Every finding on record at Fairview Nursing and Rehabilitation Community

Based on interview and record review, the facility failed to follow professional standards of nursing practice related to monitoring laboratory results for one resident (R101) of 3 residents reviewed for professional standards and quality of care, resulting in a delay of treatment for a bacterial infection, the potential for a diminished medical outcome, and the resident not maintaining or achieving their highest practical physical well-being. Findings include:Review of R101's Progress Note, dated 9/15/25 6:02 AM, indicated the Nurse Practitioner (NP) noted the resident continued to complain of low back pain the evening before and was exhibiting confusion. The confusion was said to be worse than usual. A urine sample was obtained and found to be dark and cloudy with sediment. Order was given to send a UA (urine analysis) due to the worsening mental status and low back pain. Spinal x-ray was negative for injury from fall on 9/13/25. Review of R101's Face Sheet, revealed the resident was admitted to the facility on [DATE] with diagnoses that included primary congestive heart failure and urinary tract infection (UTI). Review of R101's Care Plan revealed there was not a comprehensive focus regarding UTI with a goal or interventions to prevent or treat the resident upon admission. According to R101's Observation Detail List Report, dated 9/16/25, the resident scored 13/15 (cognitively intact) on her BIMS (Brief Interview Mental Status). Review of R101's Progress Note, dated 9/13/25 4:52 PM, indicated the resident had a fall from her bed. She complained of increasing back pain to right lower back down into her sacral area (lower back and buttocks at base of spine) with a pain score of 6 out of 10. New orders for x-rays.Review of R101's Order Summary dated 9/15/25, revealed a UA with C&S (culture and sensitivity lab test to find out what antibiotic will effectively treat the infection) was ordered to rule out a UTI.Review of R101's UA laboratory results were sent to the facility on 9/15/25 with a positive UTI infection. The C&S was completed on 9/20/25 with a sensitivity to ciprofloxacin, an antibiotic.Review of R101's Infection Tracker with McGeer's Criteria (a standardized set of definitions for identifying infections in long-term care facilities, primarily used for surveillance), dated 9/23/25 and completed by Infection Control Preventionist (IPC) I, revealed 9/19/25 was the infection onset date with new/marked increase in incontinence, urgency, and frequency. Indicating the criteria was met to start antibiotics upon the onset of symptoms, 9/15/25. The UA was positive for infection with at least 100,000 cfu/ml of no more than 2 species of microorganisms in a voided urine sample dated 9/15/25. The result of the Infection Tracker was to begin surveillance with the use of the antibiotic.Review of R101's Progress Note 9/24/25 10:35 PM revealed the IDT (interdisciplinary team) reviewed the resident's antibiotic therapy for her UTI. The resident was noted to have recent change in condition with UTI and antibiotic therapy. Resident continues with cloudy and foul odorous urine and including pain upon urination.During an interview and record review on 10/7/25 at 2:35 PM, IPC I stated while reading R101's medical chart, I am responsible for the infection control and wound care programs. There is a new form, McGeer's, in the facility's electronic medical charting for infection surveillance that the facility uses. It's a form to make sure the resident meets McGeer's criteria before starting an antibiotic. I did (R101's) McGeer's on 9/23/25 at 7:57 AM, the score indicated she met the criteria to receive an antibiotic. I do not know why I put the 9/19/25 on (R101's) McGeer's form. I do not work weekends. I do wound rounds with the wound doctor on Mondays so I cannot look for lab results until Tuesday. I try to look online at the laboratory's website for results almost everyday Tuesday through Friday. Typically, the facility tries to have labs done on weekends because I am not here to look for results online. (R101's) antibiotic was ordered on 9/23/25 after I initiated McGeer's for her. (R101's) urine sample was sent out on 9/15/25 and the facility was notified via the laboratory's online system the same day. The C&S result was completed on 9/20/25 and put in the lab's online portal the same day. It was noted the facility failed to follow up on R101's lab results until 9/23/25. According to R101's McGeer's criteria, the resident met 3 criteria and could have began antibiotic treatment when UA results showed positive on 9/15/25. During an interview on 10/7/25 at 2:57 AM, Director of Nursing (DON) B stated, (R101's) family expressed concern about her increased confusion before 9/15/25. Staff discussed the confusion with therapy and tested her for dementia. There was no documentation for increased monitoring for her increased confusion. (R101's) confusion increased enough to where a UA was ordered. Typically, I will check over the weekend online for lab results or the other on-call manager will check for lab results online while in the facility on weekends. The lab results are also faxed to the facility from the lab. The facility has had no problem with the results coming over on the fax. On Mondays, I or another manager will look for the lab results either online or on the fax because (IPC I) works with the wound doctor on that day. (R101) started symptoms of confusion about the same time her UTI was developing.During interview and record review on 10/8/25 at 1:00 PM, DON B reviewed R101 medical chart, stating, Labs are sent to the fax machine in the pantry at the nurse's station. On the weekend of September 20th, me and (ICP I) were working in the facility on the floor. Both of us should have been looking at the lab website and the fax machine for results, especially with a pending UA. DON B then reviewed the lab's portal on their website, stating, Looking on the labs website, there are UA results for (R101) posted 9/15/25 and 9/20/25. September 15 was a Monday, (IPC I) does not look at lab results on Mondays as she is doing wound rounds. It is up to me to look for lab results on Monday, especially with a pending UA. For the week of September 16-19, the ICP ( I) should have been looking at both the lab's website portal and the fax machine for (R101's) UA results. It is the expectation of (ICP I) to look for pending lab results daily and when she does not, then, me or the ADON (assistant director of nursing) would look for the results even on the weekend. I see on (R101's) McGeer's criteria sheet, (ICP I) documented the onset of the UTI was 9/19/25. The facility had no proof of that because the portal was not reviewed, and the fax results were not reviewed until 9/23/25. I do not know why 9/19 was documented as the onset of infection. (R101's) lab results were first available on 9/15/25 and no one checked for them on the portal or fax until 9/23/25.

Based on observation, interview, and record review the facility failed to 1). Maintain infection control practices, specifically the use of gloves during administration of insulin injections, 2). Sanitize or clean resident shared equipment specifically a glucometer (a portable device used to measure the concentration of glucose in the blood) for 6 (Resident #25, Resident #17, Resident #7, Resident #30, Resident #28, and Resident #22) of 6 residents reviewed for glucose monitoring during medication administration; and 3). Properly use personal protective equipment (PPE) for a resident in enhanced barrier precautions during a transfer for 1 (Resident #53) of 3 residents reviewed for transfers, resulting in the potential for the spread of infection, cross contamination, and disease transmission. Findings include: Resident #25Review of a Facesheet revealed Resident #25 was a female who originally admitted to the facility on [DATE] and had pertinent diagnosis which included: Type 2 diabetes mellitus with hyperglycemia (A condition in which the body cannot use insulin correctly and the sugar builds up in the blood causing high blood sugar.)Review of Physician Orders for Resident #25 revealed .insulin lispro insulin pen: sliding scale: if blood sugar less than 60 call MD (physician); if blood sugar is 140 to 199 give 6 units; if blood sugar is 200 to 249 give 9 units; if blood sugar is 250 to 299 give 12 units; if blood sugar is 300 to 349 give 15 units; if blood sugar is 350 to 399 give 18 units; if blood sugar is greater than 399 call MD; subcutaneous (into the layer of tissue just below the skin), before meals and at bedtime with a start date of 7/14/25. During an observation on 7/22/25 at 11:47 am, Registered Nurse (RN) S placed a glucometer into a plastic cup at the medication cart. RN S then gathered several lancets (a sharp pointed medical instrument used to puncture the skin) , alcohol prep pads, and a plastic container of glucometer test strips and placed all supplies into a second plastic cup. RN S then entered the room of Resident #25, placed the two plastic cups onto the over the bed table next to where Resident #25 was sitting in her room. RN S cleaned Resident #25's right index finger with an alcohol prep pad, used the lancet to stick the finger to obtain a blood sample, and applied the blood to the test strip in the glucometer. Once Resident #25's blood sugar reading was obtained, RN S returned to the medication cart, placed both plastic cups on top of the cart. RN S did not remove the glucometer or other supplies from the plastic cups and did not clean the glucometer. During an observation on 7/22/25 at 11:59 am, RN S prepared Resident #25's insulin lispro, 6 units (a unit is a basic measurement of the amount of insulin to administer), carried an alcohol prep pad and the insulin pen into Resident #25's room. Resident #25 lifted her shirt, exposed her abdomen, and RN S opened the alcohol prep pad, swabbed an area of Resident #25's abdomen and injected the insulin into Resident #25's abdomen. RN S did not wear any gloves during the insulin administration. Resident #17 Review of a Facesheet revealed Resident #17 was a male who was originally admitted to the facility on [DATE] and had pertinent diagnosis which included: Type 2 diabetes mellitus with hyperglycemia.Review of Physician Orders for Resident #17 revealed . aspart insulin liquid 100 units/ml (milliliter) amt 20 units subcutaneous.hold for BS (blood sugar) < (less than) 100, before meals with a start date of 6/19/2025.During an observation on 7/22/25 at 11:53 am, RN S retrieved the two plastic cups from the top of the medication cart, one containing the glucometer and the other the lancets, alcohol pads, and container of glucose test strips, and entered the room of Resident #17. As RN S entered Resident #17's room she turned to this surveyor and stated, It's okay that I do this, because I keep the glucometer in a cup to take it to another resident, but I don't clean it until the very end when I'm done checking everyone's blood sugar. RN S was observed using a lancet to obtain a blood sample from Resident #17's fingerstick and applying the blood to the test strip inserted into the same glucometer in the same plastic cup and obtained Resident #17'a blood sugar reading. RN S then returned to the medication cart, placed both plastic cups on top of the cart. RN S did not remove the glucometer or exchange the other supplies from the plastic cups and did not clean the glucometer. During an observation on 7/22/25 at 12:03 pm, RN S prepared Resident #17's aspart insulin, 20 units, carried an alcohol prep pad and the insulin pen into Resident #17's room. Resident #17 lifted his shirt, exposed his abdomen, and RN S opened the alcohol prep pad, swabbed an area of Resident #17's abdomen and injected the insulin into Resident #17's abdomen. RN S did not wear any gloves during the insulin administration. Resident #7 Review of a Facesheet revealed Resident #7 was a male who originally admitted to the facility on [DATE] and had pertinent diagnosis which included: Type 2 diabetes mellitus without complications.Review of Physician Orders for Resident #7 revealed .Novolog flex pen U-100 insulin, per sliding scale, if blood sugar is less than 60 call MD. If blood sugar is 151 to 200 give 6 units, if blood sugar is 201 to 250 give 9 units, if blood sugar is 251 to 300 give 12 units, if blood sugar is 301 to 350 give 15 units, if blood sugar is 351 to 400 give 18 units, if blood sugar is greater than 400 call MD. Subcutaneous four times a day, 8 am, 12 pm, 5:30pm, and 8:00 pm with a start date of 6/19/2025.During an observation on 7/22/25 at 11:55 am, RN S retrieved the two plastic cups from the top of the medication cart, one containing the glucometer and the other the lancets, alcohol pads, and container of glucose test strips, and entered the room of Resident #7. RN S was observed placing the cups onto Resident #7's bed side table and was observed using a lancet to obtain a blood sample from Resident #7's finger and applying the blood to the test strip inserted into the same glucometer in the same plastic cup. RN S then returned to the medication cart, placed both plastic cups on top of the cart. RN S did not remove the glucometer or other supplies from the plastic cups and did not clean the glucometer. During an observation on 7/22/25 at 12:08 pm, RN S prepared Resident #7's NovoLog 12 units, carried an alcohol prep pad and the insulin pen into Resident #7's room. Resident #7 lifted his right shirt sleeve and exposed the back of his right arm, RN S opened the alcohol prep pad, swabbed the area and injected the insulin into the back of Resident #7's right arm. RN S did not wear any gloves during the insulin administration. Resident #30Review of a Facesheet revealed Resident #30 was a male who was originally admitted to the facility on [DATE] and had pertinent diagnosis which included: Type 2 diabetes mellitus.Review of Physician Orders for Resident #30 revealed .Insulin Lispro pen 100 units/ml, per sliding scale, if blood sugar is less than 60 call MD. If blood sugar is 150 to 199 give 6 units, if blood sugar is 200 to 249 give 9 units, if blood sugar is 250 to 299 give 12 units, if blood sugar is 300 to 349 give 15 units, if blood sugar is 350 to 400 give 18 units, if blood sugar is greater than 400 call MD. Subcutaneous before meals with a start date of 6/19/2025.During an observation on 7/22/25 at 12:11 pm, RN S retrieved the two plastic cups from the top of the medication cart, one containing the glucometer and the other the lancets, alcohol pads, and container of glucose test strips, and placed a test strip into the glucometer while at the medication cart and entered the room of Resident #30. RN S was observed placing the cup containing the glucometer, alcohol pad and a lancet onto Resident #30's bed side table, applying a pair of gloves, and then used the lancet to obtain a blood sample from Resident #30's finger and applied the blood to the test strip inserted into the glucometer in the plastic cup. RN S then grabbed the cup while wearing the soiled gloves and returned to the medication cart, placed the plastic cup on top of the cart and removed her gloves. RN S did not remove the glucometer or exchange other supplies from the plastic cups and did not clean the glucometer. During an observation on 7/22/25 at 12:08 pm, RN S prepared Resident 30's insulin lispro, 12 units, carried an alcohol prep pad and the insulin pen into Resident #30's room. Resident #30 lifted his left shirt sleeve and exposed the back of his left arm, RN S opened the alcohol prep pad, swabbed the area and injected the insulin into the back of Resident #30's left arm. RN S did not wear any gloves during the insulin administration. Resident #28Review of a Facesheet revealed Resident #28 was a male who was originally admitted to the facility on [DATE] and had pertinent diagnosis which included: Type 2 diabetes mellitus.Review of Physician Orders for Resident #28 revealed .Novolin R flex pen 100 units/3 ml 20 units subcutaneous give 20 units in addition to sliding scale. Novolin R flex pen.100 units/3ml, per sliding scale, if blood sugar is less than 70 call MD. If blood sugar is 150 to 199 give 6 units, if blood sugar is 200 to 249 give 9 units, if blood sugar is 250 to 299 give 12 units, if blood sugar is 300 to 349 give 15 units, if blood sugar is 350 to 400 give 18 units, if blood sugar is greater than 400 call MD. Subcutaneous before meals and at bedtime with a start date of 6/19/2025.During an observation on 7/22/25 at 12:19 pm, RN S retrieved the two plastic cups from the top of the medication cart, one containing the glucometer and the other the lancets, alcohol pads, and container of glucose test strips, and placed a test strip into the glucometer while at the medication cart and entered the room of Resident #28. RN S was observed placing the cup containing the glucometer, alcohol pad and a lancet onto Resident #28's bed side table, applying a pair of gloves, and then used the lancet to obtain a blood sample from Resident #28's left middle finger and applied the blood to the test strip inserted into the glucometer in the plastic cup. RN S then returned to the medication cart, placed the plastic cup on top of the cart. RN S did not remove the glucometer or exchange other supplies from the plastic cups and did not clean the glucometer. During an observation on 7/22/25 at 12:23 pm, RN S prepared Resident 28's Novolin insulin, 26 units, carried an alcohol prep pad and the insulin pen into Resident #28's room. Resident #28 lifted his gown to expose his abdomen. RN S opened the alcohol prep pad, swabbed the left abdominal area and injected the insulin into Resident #28's abdomen. RN S did not wear any gloves during the insulin administration. Resident #22Review of a Facesheet revealed Resident #22 was a male who was originally admitted to the facility on [DATE] and had pertinent diagnosis which included: Type 2 diabetes mellitus with hyperglycemia.Review of Physician Orders for Resident #22 revealed .Insulin aspart pen 100 units/ml, per sliding scale, if blood sugar is less than 70 call MD. If blood sugar is 150 to 199 give 2 units, if blood sugar is 200 to 249 give 4 units, if blood sugar is 250 to 299 give 6 units, if blood sugar is 300 to 349 give 8 units, if blood sugar is greater than 349 call MD. Subcutaneous before meals and at bedtime with a start date of 7/2/2025.During an observation on 7/22/25 at 12:24 pm, RN S retrieved the two plastic cups from the top of the medication cart, one containing the glucometer and the other the lancets, alcohol pads, and container of glucose test strips, and placed a test strip into the glucometer while at the medication cart and entered the room of Resident #22. RN S was observed placing the cup containing the glucometer, alcohol pad and a lancet onto Resident #22's bed side table and then used the lancet to obtain a blood sample from Resident #22's left middle finger and applied the blood to the test strip inserted into the glucometer in the plastic cup. RN S was then observed holding the alcohol prep pad to Resident #22's left middle finger to stop the bleeding. RN S did not wear gloves during this observation. RN S then returned to the medication cart, placed the plastic cup on top of the cart. RN S did not remove the glucometer or exchange other supplies from the plastic cups and did not clean the glucometer. During an observation on 7/22/25 at 12:31 pm, RN S prepared Resident 22's insulin aspart, 4 units, carried an alcohol prep pad and the insulin pen into Resident #22's room. Resident #22 had exposed the back of his left arm. RN S opened the alcohol prep pad, swabbed the back of Resident #22's left arm and injected the insulin into Resident #22's arm. RN S did not wear any gloves during the insulin administration. During an observation on 7/22/25 at 12:33 pm, RN S was observed applying a pair of gloves while at the medication cart, retrieving a Sani-Cloth from the cart, and wrapping the glucometer in a wipe and placing it on top of the cart to sit. In an interview on 7/22/25 at 12:32 pm, RN S reported she starts about 20 minutes before a mealtime and gets all the sugars [obtains blood sugar readings for all the residents who require blood sugar readings before meals or insulin administration] and when she sees the meal carts on the hall she will begin giving insulin injections. RN S reported she should wash or sanitize her hands between every resident interaction, and she should wash with soap and water every third time. When queried, RN S reported she should wear gloves when exposure to bodily fluids was possible, and she should wash with soap and water after interactions with bodily fluids. RN S reported she should wear gloves when checking a blood sugar and when she was administering insulin. RN S confirmed that she administered insulin without wearing gloves to 6 residents (Resident #25, Resident #17, Resident #7, Resident #30, Resident #28, and Resident #22), checked Resident #22's blood sugar without wearing gloves, and did not clean the glucometer until she wrapped it in a Sani-Cloth after checking the blood sugar of 6 residents (Resident #25, Resident #17, Resident #7, Resident #30, Resident #28, and Resident #22). In an interview on 7/23/25 at 1:24 pm, Licensed Practical Nurse (LPN) N reported the glucometer should be cleaned with a Sani-Cloth between residents and after every use. LPN N reported gloves should be worn to check a blood sugar and to administer an insulin injection. In an interview on 7/23/25 at 1:24 pm, Infection Preventionist/Wound Nurse (IP/WN) D reported her expectations were that the glucometer was cleaned between resident use for two minutes per the instructions on the Sani-Cloth container. IP/WN D reported that the surface of the glucometer needed to stay wet with the Sani-Cloth solution for 2 minutes to completely disinfect the surface of the machine. IP/WN D reported that gloves should be worn during insulin administration. In an interview on 7/24/25 at 12:55 pm, Director of Nursing (DON) B reported her expectations were that gloves were to be worn during administration of insulin injections. DON B reported that RN S had been given one to one education regarding glove use during insulin injections on 7/23/25. DON B reported that her expectations were that glucometers were cleaned between residents and after each use per the instructions on the label of the Sani-Cloth wipes. DON B reported that to clean the glucometer with a Sani -Cloth wipe, her expectations were that all surfaces of the glucometer be wiped clearly wet and then the glucometer could be wrapped to maintain a wet surface for 2 minutes. Review of the label of Sani-Cloth revealed disinfects in 2 minutes and to disinfect and deodorize: disinfect nonfood contact surfaces only: unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for 2 full minutes. let air dry.Review of facility policy Glucometer Cleaning with a reviewed date of 01/2025 and provided by the facility revealed .to prevent the transmission of infections the facility requires disinfecting blood glucose meters (glucometer) between resident uses. Procedure: before and after using a blood glucose meter, disinfect the meter by cleaning the outside.the facility will note the amount of time the disinfectant solution is to be in contact with the equipment.wear gloves during finger stick blood glucose monitoring.Review of facility policy Medication Administration Procedures with a review date of 04/2020 and provided by the facility revealed .Insulin administration. Preparation: wash hands, don (put on) gloves.Resident #53Review of a Facesheet revealed Resident #53 was a male who was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: myocardial infarction (heart attack), pneumonia, and congestive heart failure.Review of Physician Orders for Resident #53 revealed .Enhanced barrier precautions. with a start date of 7/17/25.On 7/22/25 at 12:24 pm, a sign was observed posted on the wall outside of Resident #53's room indicating that Enhanced Barrier Precautions (EBP) should be used when providing high contact care activities including transferring.On 7/22/24 at 12:34 pm, RN S was observed entering Resident #53's room and assisting him to transfer from his bed into his wheelchair. RN S did not apply personal protective equipment (PPE) including gown and gloves prior to entering the room or at any time during high contact care activities including transfer from bed to wheelchair. On 7/22/25 at 12:38 pm, RN S reported she was unsure if she needed to wear PPE to transfer Resident #53. RN S confirmed that she did not wear PPE (gown and gloves) when she transferred him.In an interview on 7/23/25 at 1:24 pm, Licensed Practical Nurse (LPN) N reported she believed that EBP should be used during a transfer. In an interview on 7/23/25 at 1:24 pm, Infection Preventionist/Wound Nurse (IP/WN) D reported a gown and gloves needed to be used during high contact activities that included transferring a resident from bed to wheelchair. In an interview on 7/24/25 at 12:55 pm, Director of Nursing (DON) B reported her expectations were that EBP were used when indicated.

This citation pertains to Intake #1323219. Based on interview and record review, the facility failed to ensure incontinence care was received timely, with the appropriate number of staff assistance, and that it was documented for 1 resident (Resident #10) of 3 residents reviewed for ADL (Activities of Daily Living) care resulting in dissatisfaction with care, potential for skin breakdown and injury to occur. Findings include: Resident #10 (R10)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R10's initial admission date to the facility was on 1/3/2023 with diagnoses including hemiplegia and hemiparesis on right dominant side (muscle weakness/partial paralysis on one side of the body that can affect the arms, legs and facial muscles), reduced mobility, depression and anxiety. Brief Interview for Mental Status (BIMS) reflected a score of 14 out of 15 which indicated R10 was cognitively intact (13 to 15 cognitively intact).During an interview on 7/21/2025 at 3:35 PM, R10 stated that sometimes staff takes a while to come to her room and change her brief and asked this surveyor to come back another day to discuss details. During an interview on 7/22/2025 at 8:54 AM, Certified Nursing Assistant (CNA) BB stated that staff change R10's brief often and they check her every 1.5 to 2 hours and they document every time she was changed. CNA BB said that R10 complained about staff not changing her briefs when she was wet and soiled and especially had complaints about 2nd shift. CNA BB said that Director of Nursing (DON) B was aware of these concerns. During an interview on 7/22/2025 at 12:22 PM, CNA T stated that R10's brief was changed often usually every 2 hours, but every 1.5 hours was ideal. CNA T said that R10 doesn't refuse brief changes. CNA T stated that R10 drinks a lot of fluids and when she urinates, she urinates a lot. CNA T said R10 was a 2 person assist when changing her brief since she rolls around a lot. During an interview on 7/24/2025 at 8:23 AM, Registered Nurse (RN) S stated that R10 was a 2 person assist for bed mobility which includes changing briefs. During an interview on 7/24/2025 at 10:25 AM, CNA Z stated that R10 needs her brief changed every 2 hours since she was a heavy wetter. CNA Z said R10 was a 2 assist with brief changes but sometimes she wanted her brief changed right away and he was the only one to help her at the time so he would change her by himself. During another interview on 7/24/2025 at 12:33 PM, R10 stated that sometimes she sits in her brief for 8-10 hours depending on the CNA working that day. R10 said she worries because her bottom can get red when she lays in her wet and soiled brief for a long time. R10 said on 5/22 and 5/23 her brief wasn't changed on 1st shift, on 5/24, 5/29 and 5/30 her brief wasn't changed for 12 hours. R10 said that they need 2 staff to change her brief because she rolls too fast but sometimes only one staff member changes her. Review of R10's Resident Profile available in a book at the nurse's station for CNAs to review revealed ADLs functional status/rehabilitation potential. Start date 9/18/2023. Assist of 2 for bed mobility.Review of R10's Care Plan revealed Problem: Category: ADLs (activities of daily living) functional status//rehabilitation potential. (R10) has alteration in ADLs-self-care deficit r/t (related to) decreased mobility, right hemiparesis, and weakness. Goal: (R10) will be clean/well-groomed daily.Approach (intervention): Approach date: 9/18/2023 Assist of 2 for bed mobility. Review of R10's MDS section GG revealed Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed. Was coded as a 02 which indicated R10 was a substantial/maximal assistance. Review of R10's MDS section H revealed that R10 was always incontinent of bowel and bladder. Review of R10's vitals spreadsheet of urine and bowel movement documentation of the dates in question that R10 mentioned to this surveyor revealed:On 5/22 a brief change was completed for a bowel movement at 4:48 AM and the next brief change was completed on 5/22 at 8:21 PM. On 5/23 a brief change was completed 5/23 at 11:09 AM and the next brief change was completed on 5/24 at 5:19 AM and then on 5/24 at 9:52 PM. On 5/29 a brief change was completed at 9:30 AM and the next brief change was on 5/30 at 5:31 AM. During an interview on 7/24/2025 at 1:07 PM, DON B stated that the expectation was that staff should document each time a brief was changed whether it's for bowel or bladder and agreed if it wasn't documented then it wasn't done. DON B reported that R10 needs 1 staff for a brief change since R10 can help with rolling at times and when this surveyor stated that the resident profile stated 2 assist with bed mobility, she agreed that R10 needs to always be a 2 assist when changing her brief. Review of the Activities of Daily Living (ADLs)/Maintain Abilities Policy with a review date of 1/2025 revealed Procedure. 3. The facility will provide care and services for the following activities of daily living.c. elimination toileting. 4. A resident who is an unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview, and record review the facility failed to ensure that an assistive transfer device (gait belt) was used during a transfer for 1 (Resident #53) of 3 residents reviewed for proper transfers resulting in the potential for a fall and/or an injury.Findings include:Resident #53Review of a Facesheet revealed Resident #35 was a male who was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: myocardial infarction (heart attack), pneumonia, and congestive heart failure.On 7/21/25 at 1:35 pm, a gait belt (a safety device used to assist individuals with mobility issues, typically worn by a resident and allows for the caregiver to safely move or support a resident while walking or during transfers) was noted to be hanging over the top of the bathroom door in Resident #53's room. Resident #53 reported it was not his and the staff did not use it for him.On 7/22/25 at 12:34 pm, Registered Nurse (RN) S was observed assisting Resident #53 to transfer from his bed to this wheelchair. RN S was standing on Resident #53's left side, with the wheelchair positioned to Resident #53's right side while he was sitting on the side of the bed with his back facing the doorway of the room. RN S was observed holding Resident #53 under his left arm in the armpit area with her left hand and using her right hand to hold the back of Resident #53's pants for stability. Resident #53 was noted to hang on to the handles of the wheelchair and shuffle his feet to pivot and sit down in his wheelchair. RN S did not use a gait belt during the transfer. A gait belt was noted hanging over the bathroom door in the room.In an interview on 7/22/25 at 12:38 pm, RN S reported that Resident #53 was a one-person transfer. RN S reported that Resident #53 did not use a gait belt during transfers.Review of Care Plan for Resident #53 revealed problem/goal/approach ADLs (activities of daily living) functional ability and participation does vary and fluctuate. will participate in care to his fullest ability.TRANSFER STATUS. 1 person contact guard Assist with a GAIT BELT.On 7/23/25 at 12:45 pm, a gait belt was observed hanging over the bathroom door in Resident #53's room in the same position as the last two days.In an interview on 7/23/25 at 1:30 Certified Nurse Assistant (CNA) Y reported that a gait belt should be used for all one or two person transfers and the gait belts were kept in resident rooms.In an interview on 7/23/25 at 1:38 pm, CNA U reported all transfers not done with a mechanical lift needed a gait belt. CNA U reported there was a resident profile book that was communication between therapy and nursing staff and gave instructions on how a resident should be transferred. CNA U opened the book to Resident #53's profile page and the page was noted to reveal .TRANSFER STATUS. 1 person contact guard Assist with a GAIT BELT.In an interview on 7/23/25 at 1:34 pm CNA BB reported the resident's care plan was where transfer status was noted and that all transfers required the use of a gait belt.In an interview on 7/23/25 at 1:55 pm, Therapy Director (TD) M reported that Resident #53 was one person transfer with contact guard and a gait belt. TD M reported that gait belts should be used with all transfers unless the resident was independent or needed a mechanical lift. TD M reported that gait belts should be kept hanging on the back of the door in resident's room when not being used. In an interview on 7/24/25 at 10:39 am, Nursing Home Administrator (NHA) A reported there was no facility policy regarding transfer and the expectations were that everyone followed the recommendations for transfer status that was provided by the therapy department.In an interview on 7/24/25 at 10:40 am, Licensed Practical Nurse (LPN) N reported that gait belts were to be used for all transfers unless the resident was independent.In an interview on 7/24/25 at 1:07 pm, Director of Nursing (DON) B reported that using a gait belt with a transfer was a standard of care and the staff knew that. DON B reported that the therapy department would provide communication and direction regarding the use of a gait belt and transfer status of the residents.

Based on interview and record review, the facility failed to ensure residents received care in accordance with professional standards of nursing practice for 1 resident (Resident #6) of 5 residents reviewed for medications, resulting in the lack of physician notification of elevated blood sugar levels per physician's order, and the potential for worsening of the medical condition.Findings include: Resident #6Review of a Face Sheet revealed Resident #6 was a male, with pertinent diagnoses which included: Type 2 diabetes mellitus (a condition where the body is not able to properly use sugar from the blood) without complications. Review of an active Physician's Order for Resident #6 revealed, Check blood glucose (blood sugar) at HS (bedtime), Notify MD (medical doctor) of blood glucose less than 70 or greater than 300, At Bedtime 08:00 PM 08/02/2024Review of an active Physician's Order for Resident #6 revealed, Check blood sugar PRN (as needed) Special Instructions: PRN recheck blood sugar if over 350 at norm (normal) check Three Times A Day - PRN Morning, Mid-Day, Evening 10/02/24Review of Resident #6's Medication Administration Record (MAR) from 7/1/25 - 7/22/25 revealed blood sugar readings recorded by Registered Nurse (RN) P on 7/4/25 at 8:00 PM as 343 mg/dl (milligrams per deciliter) and by RN O on 7/19/25 at 8:00 PM as 340 mg/dl. There was no documentation that the physician had been notified of the blood glucose readings greater than 300.Review of Resident #6's progress notes for the period 7/1/25 - 7/24/25 revealed no documentation that the physician had been notified of the blood glucose readings greater than 300 on 7/4/25 and 7/19/25.In an interview on 7/23/2025 at 3:13 PM, regarding Resident #6's blood glucose level of 340 on 7/19/25, RN O reported she did not recall if she had notified Resident #6's physician of his elevated blood glucose level. RN O confirmed that the physician order for Resident #6 was for the physician to be notified of a blood glucose level over 300. RN O reported she would usually put in a progress note when the physician had been notified. In an interview on 7/24/25 at 7:20 AM, regarding Resident #6's blood glucose level of 343 on 7/4/25, RN P reported she had thought that the physician was to be notified of a blood glucose level over 350 like the prn blood sugar checks order. RN P reported she did not notify the physician of Resident #6's blood sugar level of 343 on 7/4/25 but that she should have according to the physician order.In an interview on 7/24/25 at 1:40 PM, Director of Nursing (DON) B reported it was the expectation that the nurses notify Resident #6's physician for blood glucose levels over 300 according to the physician order. DON B reported it was the expectation that a progress note is entered in the medical record to confirm the physician was notified. DON B reported if it was not documented, it was not done.

Based on observation, interview and record review, the facility failed to ensure proper label and dating of foods in the kitchen resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include: During the initial tour of the main kitchen on 8/06/2024 at 9:26 AM, the reach in refrigerator was observed to have the following: 1 lemonade pitcher had a prepare date of 8/1/2024 and a use by date of 8/3/2024. 1 plastic storage container of individual cups of mayonnaise with no label and date. 1 plastic storage container of individual cups of mustard with no label and date. 1 plastic storage container of individual cups of tartar sauce with no label and date. 1 shallow pan with individual bread slices in individual ziploc bags with no label and date. During an interview at 9:40 AM, Dietary Aide (DA) K stated that she didn't work the night before when the individual cups of mayonnaise, mustard and tartar sauce were prepared. DA K threw out the lemonade pitcher and said that it should have been tossed out on 8/3/2024. During another kitchen tour on 8/07/2024 at 9:49 AM with Certified Dietary Manager (CDM) M, the following was observed: 1) The reach in refrigerator had 1 plastic storage container of individual cups of ketchup with no label and date. 2) The shelf by the tray line had 1 plastic storage container of individual cups of brown sugar with no label or date and 1 plastic storage container of individual cups of syrup with no label and date. 3) The bread area contained 1 loaf of UDIs bread, opened with no label or date and 1 package of hamburger buns, opened with no label and date. 4) The walk-in refrigerator had 1 package of hot dogs, opened, with no label and date. During a tour of the nourishment room with CDM M, a plastic storage container was observed to have individual cups of brown sugar with no label and date. During an interview on 8/07/2024 at 10:30 AM, CDM M stated that she will reeducate her staff on making sure labels and dates are put on opened packages and when transferring items from a big container to smaller containers/individual serving cups. CDM M said there are several new staff starting and she will make sure this is included in their training. Review of the Storage Policy with a revision date of 8/2023 revealed Dry Storage of Food 5. Opened packages are to be stored in closed containers, labeled, and dated Refrigerated Storage 5. Food should be covered, dated . According to the 2017 FDA Food Code revealed: 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.

Based on interview, and record review, the facility failed to complete a significant change Minimum Data Set (MDS) assessment after a change in health status, in 1 of 13 residents (Resident #40) reviewed for a significant change in condition, resulting in the potential for unassessed physical, mental, emotional, and psychosocial needs. Findings include: Review of a Face Sheet revealed Resident #40 was a female, with pertinent diagnoses which included respiratory failure, heart failure, high blood pressure, atrial fibrillation (an irregular heart rate that results in poor blood flow), anxiety, depression, and obstructive lung disease. Noted Resident #40 readmitted to the facility on [DATE] after a hospital stay and expired on [DATE]. Review of Resident #40's Order History revealed .Hospice to evaluate and treat . with a start date of [DATE]. Review of a Licensed Nurse Progress Note for Resident #40, dated [DATE] at 5:20 PM, revealed .resident returned from (Hospital Name) with hospice order .resident (short of breath) with any activity .returning to the facility with Hospice services .(Hospice Name) will be here as soon as resident returns to evaluate . Review of a Licensed Nurse Progress Note for Resident #40, dated [DATE] at 5:30 PM, revealed .(Hospice Name) in to see resident at this time and evaluate per order . Review of a Social Services Progress Note for Resident #40, dated [DATE] at 2:47 PM, revealed .Resident is now receiving Hospice care through (Hospice Name). Start date of [DATE] . Review of Resident #40's MDS 3.0 Resident Assessments revealed no Significant Change in Status Assessment (SCSA) was completed after Resident #40 enrolled in a Hospice program on [DATE]. In an interview on [DATE] at 10:42 AM, MDS Coordinator R reported the Interdisciplinary Team (IDT) discusses changes in resident health status to determine if a Significant Change in Status Assessment needs to be completed. MDS Coordinator R reported any time a resident enrolls in a Hospice program a Significant Change in Status Assessment should be completed within 14 days. MDS Coordinator R reported she did not recall an IDT discussion after Resident #40 enrolled in Hospice on [DATE] and stated .with Hospice it should have triggered me to do one (a SCSA) . Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, v1.18.11, Chapter 2: Assessments for the Resident Assessment Instrument (RAI), revealed .Significant Change in Status Assessment (SCSA) .The SCSA is a comprehensive assessment for a resident that must be completed when the IDT (Interdisciplinary Team) has determined that a resident meets the significant change guidelines for either major improvement or decline .A significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self limiting; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan .An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD (Assessment Reference Date) must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). An SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place .

Based on observation, interview, and record review the facility failed to properly implement enhanced barrier precautions for 1 (Resident #11) of 13 residents sampled for infection control, resulting in the potential for cross contamination and spread of infection. Findings include: Review of an Admission Record revealed Resident #11, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: chronic respiratory failure with hypoxia (low oxygen levels in the blood), pneumonia, retention of urine (inability to empty the bladder), encounter for attention to tracheostomy (opening in the trachea from outside the neck). Review of a Minimum Data Set (MDS) assessment for Resident #11, with a reference date of 8/2/24 revealed a Brief Interview for Mental Status (BIMS) score of 14/15 which indicated Resident #11 was cognitively intact. Section E of the MDS revealed Resident #11 did not reject care during the 14-day assessment period. Section G of the MDS revealed Resident #11 required dependent assistance (helper does all the effort) for dressing, moderate assistance (helper lifts, holds trunk or limbs) for changing from a lying to sitting position, and dependent assistance ( helper does all the effort) for transferring from bed to chair. Section H of the MDS revealed Resident #11 had an indwelling urinary catheter. Review of a Care Plan for Resident #11, revealed problems/goals/approaches of: 1. Reference date 10/24/23: Problem: (Resident's name omitted) requires an indwelling catheter related to urinary retention. Approaches: enhanced barrier precautions . 2. Reference date 11/1/23 Problem: (Resident's name omitted) has an open old tracheostomy stoma. (Resident's name omitted) has mucus and respiratory drainage . Approaches: enhanced barrier precautions . 3. Reference date of 8/6/24, 10:24am. Problem: (Resident's name omitted) has stated he doesn't want staff to wear PPE (personal protective equipment) when caring for him. He is under enhanced barrier precautions .Goal: (Resident's name omitted) will allow staff to ear PPE while providing care .Approaches: educate on the reasons and procedures related to enhanced barrier precautions. Let him know that the procedures protect staff from exposure to bodily fluids . Review of a nursing progress note dated 8/5/24, 1:05pm, revealed resident was noted to having (sic) increased secretions through the trach stoma (opening in the neck) . During an observation on 8/6/24 at 9:31am, a sign hung next to Resident #11's door that stated: STOP. Enhanced Barrier Precautions. EVERYONE MUST: clean their hands, including before entering and when leaving the room .STAFF MUST ALSO: Wear gloves and a gown for the following high contact resident care activities: dressing .transferring .changing briefs . During an observation on 8/6/24 at 9:33am, Resident #11 sat supported in his bed. Resident #11's stoma was covered by a single ply mesh material that was saturated with yellow mucus in an area approximately 2x2. The mucus appeared wet with a shiny surface. During an observation on 8/6/24 at 9:34am, Certified Nursing Assistant (CNA) I entered Resident #11's room donned gloves and began assisting Resident #11 with personal care. CNA I did not attempt to don a gown or discuss the need for a gown prior to assisting Resident #11. In an interview on 8/6/24, at 9:51am, Certified Nursing Assistant (CNA) I reported he assisted Resident #11 with a brief change, dressing, and transferred the resident to his recliner chair during the care he provided a few minutes earlier. When further queried about the type of personal protective equipment (PPE) he used while providing care for Resident #11, CNA I reported he only used gloves, and did not realize the resident was in enhanced barrier precautions. CNA I reported he did not recall receiving training regarding enhanced barrier precautions, and that the rationale for using enhanced barrier precautions was unclear to him. In an interview on 8/8/24 at 11:04am, Director of Nursing (DON) B reported staff needed to wear a gown and gloves while providing direct care to Resident #11, and not doing so would be a breach of infection control measures. DON B reported she confirmed that CNA I did not wear the appropriate personal protective equipment during cares for Resident #11 on 8/6/24, at 9:34am. In an interview on 8/8/24 at 2:14pm, Resident #11 reported some staff wore personal protective equipment (PPE) while providing his care and others did not. When asked about his preference, Resident #11 reported he did not care if staff wore the PPE if it was just a matter of protecting him, but if it was to also protect others, he wanted them to wear it. Resident #11 reported he did not know if the PPE was recommended to protect him or to protect others. Review of Consideration for the Use of Enhanced Barrier Precautions in Skilled Nursing Facilities, published June 2021, by the Centers for Disease Control and Prevention, revealed: Residents in skilled nursing facilities are disproportionately affected by multidrug-resistant organism (MDRO) infections . Resident-to-resident pathogen transmission in skilled nursing facilities occurs, in part, via healthcare personnel, who may transiently carry and spread MDROs on their hands or clothing during resident care activities . Residents who have complex medical needs involving wounds and indwelling medical devices are at higher risk of both acquisition and colonization by MDROs.

This citation pertains to intake #MI00142077 Based on interview and record review the facility failed to provide an environment free from abuse in 1 resident (Resident #101) of 3 residents reviewed for abuse. Findings include: Resident #101 Review of an Admission Record revealed Resident #101 had pertinent diagnoses which included: Alzheimer's disease. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of ,d+[DATE] which indicated Resident #101 was severely cognitively impaired. Resident #102 Review of an Admission Record revealed Resident #102 had pertinent diagnoses which included: Unspecified dementia. Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of ,d+[DATE] which indicated Resident #102 was severely cognitively impaired. Review of Investigation Summary provided by the facility, dated [DATE] revealed, . on ,d+[DATE] (Name Omitted) brought to my attention she found a statement in the behavior book . During an interview on [DATE] at 8:30 AM, Nursing Home Administrator (NHA) A reported that he was notified by Social Services Director (SSD) E of an incident that occurred during the overnight shift between Resident #101 and Resident #102 on [DATE] at 9:53 AM. During an interview on [DATE] at 9:13 AM., SSD E reported that NHA A instructed her to complete psychosocial assessments on Resident #101 on [DATE]. SSD E reported that Resident #101 and Resident #102 had a history of inappropriate behaviors together. SSD E reported that Resident #101 had believed in the past that Resident #102 was her (deceased ) husband. SSD E reported that Resident #102 had not had behaviors (inappropriate comments or touching) in a really long time. SSD E reported that Resident #102 was removed from behavior monitoring for inappropriate comments or touching in June of 2023. Review of Behavior Log for Resident #102 revealed . [DATE] asked me to take off my shirt/bra XXX[DATE] told me I was ballooning up said (name omitted) should have knocked me up XXX[DATE] attempting to touch/pinch nurse during med pass (twice) . targeted behaviors being disrespectful to me, calling me names, inappropriate comments . Review of Care Plan for Resident #102 revealed .Problem start date [DATE] . behavioral symptoms .has had a re-emergence of socially inappropriate behavioral symptoms as evidenced by making sexually inappropriate comments directed toward female staff XXX[DATE] .has also had a re-emergence of inappropriate touching of a female resident .Goal .will not exhibit socially inappropriate behavior . making sexually inappropriate comments about females and their body parts or clothing. Potential for inappropriate touching . Interventions .encourage to keep his hand to himself and not touch others [DATE] . Arm's length distance to be maintained between female residents [DATE] . document socially inappropriate/disruptive behaviors when around others, staff or residents[DATE] . During an observation and interview on [DATE] at 9:35 AM., Resident #101 was sitting on the side of her bed in her room, but was unable to answer direct questions appropriately, follow or engage in meaningful conversation. During a telephone conversation on [DATE] at 10:13 AM., CENA M reported she worked on the night shift on [DATE]. CENA M reported that she walked towards the nurse's station at about 1 or 2 am on [DATE] and Resident #101 and Resident #102 were standing at the nurse's station. CENA M reported that she visualized Resident #102 using his right hand to fondle Resident #101's right breast through her clothes. CENA M reported that she immediately separated the two residents, told Resident #102 that he couldn't touch Resident #101 like that, and walked with Resident #101 to her room. CENA M reported that she notified the nurse immediately. CENA M reported that the nurse met with Resident #101 in her room. CENA M reported that she did not contact the abuse coordinator of the facility. During an observation and interview on [DATE] at 12:54 PM., Resident #102 was sitting on the side of his bed in his room and could not recall touching another resident's breast when asked. Resident #102 reported he does like to flirt with the ladies in the facility. During an interview n [DATE] at 1:10 PM., Facility Resident (FR) W reported that he had heard Resident #102 flirt with female staff and make inappropriate sexual comments towards female staff. On [DATE] at 2:23 PM., telephone call made to Family Member (FM) U with no answer, left message. No return call before survey exit. During an interview on [DATE] at 3:17 PM., Licensed Practical Nurse (LPN) L reported that Resident #102 had touched her inappropriately and she had to remove his hand from her body. LPN L reported she did not know his current behavior care plan interventions. During an interview on [DATE] at 3:29 PM., Registered Nurse (RN) J reported that she was unaware of any incident between Resident #101 and Resident #102 and was not aware of any updated interventions related to Resident #102's care. RN J reported that Resident #102 had made inappropriate sexual comments to her in the past, but she did not document them in his behavior log. During an interview on [DATE] at 3:35 PM., CENA R reported that she did not know any behavior care plan interventions for Resident #102. CENA R reported that she had only been employed with the company for 2 days. During an interview on [DATE] at 3:50 PM., Director of Nursing (DON) B reported that there is a message tab in the electronic health record program that contained a list of any changes that had been made to a resident's chart including care plan updates. DON B reported that a change to a resident's care plan would be available to staff to view through the message tab in the electronic health record. During an interview on [DATE] at 10:01 AM., Activities Assistant (AA) D reported that Resident #102 had made sexually inappropriate comments to her in December of 2023and she documented them in Resident #102's behavior log. During a telephone interview on [DATE] at 10:18 AM., RN H reported that she was the nurse working on the night shift on [DATE]. RN H reported I know nothing about the incident. RN H reported that she was aware of the incident when the NHA A interviewed her. RN H reported that she is unaware of any changes to Resident #102's behavior care plan interventions. During an interview on [DATE] at 11:06 AM., RN I reported that on [DATE] she was told in nurse-to-nurse report that there was an incident between Resident #101 and Resident #102 that occurred during the previous shift. RN I reported that she is unaware of any updates to Resident #102's behavior care plan interventions. Review of SOC Summary dated [DATE] revealed . Resident #102 inappropriately touched a female resident .Care plan updated . Review of facility policy Abuse Prevention Program Policy and Procedure with a revision date of ,d+[DATE] revealed, .the facility will provide a safe resident environment and protect residents from abuse . addition to reports from resident and others that sexual abuse occurred . would require that immediate investigation by the facility . Using the reasonable person concept, though Resident #101 had decreased ability to recall past events due to her mental diagnoses, a female wound not want to be inappropriately touched in an intimate (breast) location by a stranger. The feeling of humiliation has the potential to continue well past the date of incident. The resident's representative was contacted three times to discuss Resident #101's presumed feelings but did not return call.

This citation pertains to intake #MI00142077 Based on interview and record review the facility failed to implement their abuse prevention policy in 1 resident (Resident #101) of 3 resident reviewed for abuse, resulting in the potential for abuse to go unreported and for abuse to continue. Findings include: Resident #101 Review of an Admission Record revealed Resident #101 had pertinent diagnoses which included: Alzheimer's disease. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 12/15/23 revealed a Brief Interview for Mental Status (BIMS) score of 2/15 which indicated Resident #101 was severely cognitively impaired. Resident #102 Review of an Admission Record revealed Resident #102 had pertinent diagnoses which included: Unspecified dementia. Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 1/3/24 revealed a Brief Interview for Mental Status (BIMS) score of 5/15 which indicated Resident #102 was severely cognitively impaired. Review of Investigation Summary/Witness Statements provided by the facility, dated 1/1/24 revealed, . on 1/1 (Name Omitted) brought to my attention she found a statement in the behavior book .Witness statement .it was around 2am . (Name Omitted) feeling (Name Omitted) right breast . During an interview on 2/6/24 at 8:30 AM, Nursing Home Administrator (NHA) A reported that he was notified by Social Services Director (SSD) E of an incident that occurred during the overnight shift between Resident #101 and Resident #102 on 1/2/24 at 9:53 AM. NHA A reported that he proceeded to start an investigation at that time. NHA A reported that the incident occurred at 2 AM and he was not notified at the time of incident by the facility staff. NHA A reported that his expectation was that the facility staff would notify him immediately of a suspected incident of abuse. NHA A reported that he had completed a full staff education on the timeliness of reporting suspected abuse. During a telephone conversation on 2/6/24 at 10:13 AM., Certified Nurse Assistant (CENA) M reported she worked on the night shift on 1/1/24. CENA M reported that she visualized Resident #102 using his right hand to fondle Resident #101's right breast through her clothes. CENA M reported that she immediately separated the two residents, told Resident #102 that he couldn't touch Resident #101 like that, and walked with Resident #101 to her room. CENA M reported that she notified the nurse immediately. CENA M reported that she did not contact the abuse coordinator of the facility. During an interview on 2/6/24 at 3:35 PM., Social Service Director (SSD) E reported that she recalled a vague note in the behavior log for Resident #101 that made her contact the NHA about an allegation of abuse. During an interview on 2/6/24 at 3:50 PM., Director of Nursing (DON) B reported that her expectations is that any allegations of abuse be reported immediately to either herself or the NHA. During a telephone interview on 2/7/24 at 10:18 AM., Registered Nurse (RN) H reported that she was the nurse working on the night shift on 1/1/24. RN H reported I know nothing about the incident. During an interview on 2/7/24 at 11:06 AM., RN I reported that on 1/2/24 she was told in nurse-to-nurse shift report by RN H that Resident #102 grabbed Resident #101's breast. RN I reported that she did not contact abuse coordinator. Review of facility policy Abuse Prevention Program Policy and Procedure with a revision date of 1/2024 revealed, .in addition to reports from resident and others that sexual abuse occurred . would require that immediate investigation by the facility . During an interview on 2/6/24 at 11:50 AM., NHA A provided educational materials, confirmation of all staff re-educations on the abuse prevention policy, and the dates the education was completed. NHA A reported that staff were educated on the abuse policy, with emphasis on reporting no matter what time of day it was. Review of staff sign-in sheets revealed 87 facility staff members attended training that included facility abuse prevention policy and procedures and verbal instructions of reporting timely provided by the NHA on 1/2/24 and 1/3/2024. The facility was granted Past Non-Compliance at the time of exit due to no further like incidents had occurred, the facility re-trained pertinent staff, the facility provided written materials in high visible locations for staff to reference. Therefore, no plan of correction is required. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included re-training of pertinent staff, providing written materials in high visible locations for staff to reference. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to intake MI00140159. Based on observation, interview and record review, the facility failed to maintain continuity of care according to professional standards following a change of condition related to a toe injury for 1 of 3 residents (R102) reviewed for quality of care, resulting in lack of communication, delay in assessment, treatment, and inaccurate documentation, that resulted in osteomyelitis and amputation of toes. Findings include: According to the National Library of Medicine, October 2016, Continuity of care is concerned with the quality of care over time. ideal is the delivery of a 'seamless service' through integration, coordination, and the sharing of information between different providers . https://pubmed.ncbi.nlm.nih.gov/17018200/ Review of R102's Face Sheet reported the resident had diagnoses that included hemiplegia and hemiparesis following a stroke affecting his left non-dominant side, weakness, need for assistance with personal care, and type 2 diabetes mellitus. During an interview on 11/1/2023 at 8:43 AM, Family Member (FM) G stated, I am not (R102's) DPOA. On a Friday evening 9/15/23, we got a call from the facility (R102) was going to the ER, for stitches. It was the right foot between the 4th and 5th toes. He got 4-5 stitches. He did not know how he did it. He was cognitively aware of things; he did not have a guardian. He complained of pain. We would go every couple of days to see him. He complained on 9/17/2023 of foot hurting and throbbing. His foot was wrapped with a little discharge through the bandages. This was on Sunday. We went over on Wednesday, 9/20/2023, the residents were going to the fair, he did not go because of foot pain. He said the pain was 10/10 and they were giving him pain medications. He was sent to theER on [DATE] for the throbbing pain in his foot. I went to the hospital then and he was being admitted for an infection in his foot. The hospital told me his white blood count was high. On 9/27/2023, I think, they removed his right pinky toe with an infection down to the arch of his foot. On 9/29/2023 the hospital had to do another surgery to wash out the infection and ended up removing the 4th toe because of the infection. Review of R102's Event Report reported Event Date 9/15/2023 at 12:36 PM with a Completed Date 9/19/2023 at 12:40 PM. -Description of the event: R (right) foot wedge of 4th and 5th toe. -Exact Date/Time Discovered: 9/15/2023 at 1:00 PM -Type of Injury: Other-fissure/crack in skin -Location and Size of Skin alteration: Interdigital 4th & 5th toe 0.1 cm (centimeter) x 1.3 cm x 0.1 cm -Space between 4th and 5th toe - small amount of blood loss -irregular wound edges -1/10 mild pain -Activity unknown during skin alteration occurrence -cleansed area covered with non-adherent dressing -seen by podiatry and received new order to start betadine daily for 14-days or until healed -Notification Guidelines: 9/15/2023 at 1:00 PM Medical Director and Emergency Contact -Evaluation: Wound referral made with wound specialist. Resident to follow-up with specialist on 9/19(2023). During an interview on 11/1/2023 at 3:20 PM, Registered Nurse (RN) P stated, He cut his toe on a day I was working on another unit. His nurse called me, and I came to help her. He almost severed his left pinky toe off. He told me he had felt something squishy in his shoe earlier in the day. When I took his shoe off there was nothing in it to cut him. But there was blood everywhere. He said he had transferred himself to his wheelchair earlier and wondered if he did not catch on something and cut it that way before putting his shoe on. I cleaned his foot and toe and wrapped it. I told him he had to go to the hospital because I could not do anything for the toe here. He did not want to go to the ER. A doctor was in the area and stopped by to look at (R102's) foot. There was nothing he could do here to fix the toe so the resident was sent out to the hospital. He came back with stitches holding the toe together and was to leave them in for 10 days. I cared for him about 6-7 days later and had to change the bandage because the dressing was saturated with blood and drainage. I saw the stitches were gone. (R102) told me a nurse took them out because they were not doing anything for him. I told him the stitches were keeping his toe together. The wound looked infected. I told the 1st shift nurse to assess the wound. I do not know why she did not. I told the Director of Nursing (DON B) about what I saw and he told me to keep it to myself because a nurse (Licensed Practical Nurse (LPN) N) was the one that had done it (removed the stitches) and they needed him to staff the floor. During an interview on 11/7/2023 at 7:59 AM, Registered Nurse (RN) P stated, (R102's) dressing change for his toe was daily and PRN (as needed). The order just showed up in the treatment part of his medical record. I did not have to write a progress note that I did it. I was told that I put things in my progress notes that would trigger State to investigate and would have to change my progress notes. I typed a long thing and ended up changing it. I noticed (R102's) pinky toe and told the DON and wound nurse. I looked at his toe because his dressing fell off. His sutures were missing. (R102) said the nurse before me, (LPN N), took them out the night before. (R102) told me the nurse he took them out because they weren't doing anything, I told them they were keeping his toe on. I reported to the wound nurse and the DON. The DON told me to keep it to myself because there no way of telling if that nurse did it. I told the DON that (R102) was cognitively with it and would not lie. The last time I saw the toe it looked bruised, and the sutures were gone. It did not look necrotic. I did tell the wound nurse that she needed to look at it because the sutures were missing. I felt the wound nurse should have known what was going on with his toe. During an interview and record review on 11/7/23 at 9:44 AM, Director of Nursing (DON) B stated, At some point (R102) injured his toe putting his shoe on. He should have had a care plan for toes. I do not see one. Care Plans set the guidelines for the care of that resident. I do not know who removed the sutures. It should have been documented in the MAR and the Progress Note who and when the sutures were removed. During an interview and record review on 11/7/2023 at 9:44 AM, former ADON (Assistant Director of Nursing) K stated, (R102) had an issue with his toe. The wound nurse should document in progress notes and care plan as well. While reviewing R102's medical chart, former ADON K stated, (R102) was sent out on 9/15/23 with a laceration on his right toe. He went out to theER on [DATE] and had 3 sutures and was sent back to the facility on [DATE] at 1:00 AM. Further review of R102's physician orders with former ADON K who stated, It was reported on 9/16/2023 the primary doctor at the facility was to take out the sutures or if unavailable to send to the ER to take out. It does not state when to take them out. Per our nurse in a Progress Note, the hospital note stated that the sutures should be taken out in 10 days. That was directly off the ER discharge instructions. During an interview on 11/8/2023 9:59 AM, LPN N stated, I would do dressing changes on (R102) but I did not chart that I did them. It looked infected. I guess I should have. I worked nights and it was not on my assignment. I would write on the 24-hour nurse to nurse report and put it in the doctor's communication book that he needed to see the toe as soon as possible. I could tell the doctor what was going on, but they will tell me something different or do what I did. A lot of times nurses leave messages and the doctor never calls back, that's why I did not call the doctor. I cannot remember if I documented, or I did not document. During an interview and record review on 11/7/2023 at 11:00 AM, LPN/Wound Nurse O stated, (R102) was seen by podiatry in the morning of 9/15/2023. I charted that. It was a fissure crack in the skin, between the right 4th and 5th toe. I made a wound referral that day. He was seen by the wound specialist on 9/19/2023 for the fissure. Also, on 9/15/23 at 8:00 PM a nurse, (LPN P), charted she found a laceration on the right foot between the 4th and 5th toe. She asked the resident how it happened, and he did not know. He found the blood when he took the shoe off. The resident found the blood everywhere when he took off his shoe. (LPN P) sent him to the ER. I charted on 9/19/23 when he was seen by the wound doctor, R102 said he was trying to put the shoe on the wrong foot and that is how he got the laceration. The wound doctor said it was a laceration, she looked at the sutures, there was 6 sutures in place. The order states from the ER not to remove the sutures for 10 days. The night before he left on 9/25/2023 for the ER again, I asked the resident who took the sutures out, and R102 told me the night nurse, (LPN N), took them out. I told (DON B) that (R102) the night nurse had taken them out. LPN O reviewed R102's medical chart, stating, It says (R102) on 9/26/23 took off his dressing. (LPN P) charted on 9/26/23 that (R102) told her the dressing was too tight. She replaced the dressing. I went with the wound specialist's PA on the 9/26/23, Tuesday, doing normal wound rounds, and we noticed his right 5th toe was necrotic. It was very mobile and partially detached. I didn't chart that his dressing was not on. I asked him what had happened, and he was unsure of what happened. I'm not finding that (LPN P) charted on what condition the toe was in on 9/26/23. When I saw the toe was necrotic, the PA and I went to the Medical Director, who was in the building and told him. (R102) was sent to the ER and never came back. It looked like it was reinjured. I do not think he picked at it. The last skin assessment was 9/16/23 and it said there were 3 sutures between 4th and 5th pinky toe. I know there were 6 sutures. During a telephone interview on 11/7/2023 at 11:31 AM, Licensed Practical Nurse (LPN) L stated, I do not know who removed (R102's) sutures. If they were removed, they should be documented on the TAR (Treatment Administration Record) and the Progress Notes. During an interview and record review on 11/7/2023 at 3:12 PM, LPN/Wound Nurse O stated, The reason there is no notes in the nurse's notes is because the facility charts by exception. Nurses only chart when they see a change in condition. So, in reading (R102's) notes, there was a note on 9/26/2023 at 5:42 AM and then the last note on 9/26/2023 at 9:00 AM. So I am thinking that sometime between 5:42 AM and 9:00 AM he injured that foot again which cause it to become detached and necrotic. Review of [NAME], [NAME], & [NAME] (www.journals.lww.com, July,2004) making an exception in charting revealed Charting by exception (CBE) was designed to eliminate lengthy and repetitive notes It departs from traditional systems by requiring documentation of significant or abnormal findings only. You may need to supplement your CBE documentation if you not an assessment finding that is not part of a normal assessment; document your assessment findings in a narrative progress note. During an interview and record review on 11/7/2023 at 4:38 PM, LPN L stated, Typically nurses would be documenting in Progress Notes the condition of the wound they did a dressing change on. However, (LPN O) the wound nurse, documents measurements once a week on wound rounds. Yes, I should document the decline of a wound. LPN reviewed R102's Progress Notes she had written, stating, I'm sure I worked those days. I did not document the condition of the wound and probably made a note to wound nurse (LPN O) and just gave it to her, telling her the toe was looking bad. Review of R102's Order Summary, dated 9/15/2023, Ok to transfer to hospital Once - one time 8:30 PM. Review of R102's General Emergency Department Discharge Instructions, dated 9/15/2023, reported the resident was treated for a laceration (cut) that required sutures (stitches). Follow-up with your doctor or come back here or go to the nearest Emergency Department to have your sutures take out in 10 days .You should seek medical attention immediately .at the nearest emergency department if any of the following occurs .the wound smells bad or has a lot of drainage . Review of R102's Order Summary dated 9/16/2023, Primary doctor to take sutures out. If unavailable send to (name of hospital) hospital to take out. Once - One time 12:00 PM. Review of R102's Care Plans did not reveal a person-centered treatment plan had been initiated for the right 4th and 5th toe injury. Review of R102's Order Summary dated 9/19/2023, revealed, cleanse laceration to R (right) toe with wound cleanser, pat dry, apply calcium alginate with silver then apply 4x4 gauze and wrap with Kerlix daily Once a day 06:00 AM to 2:00 PM. Review of R102's Medication Administration Record/Treatment Administration Record (MAR/TAR) 9/1/2023-9/30/2023, revealed on 9/16/2023 at 12:00 PM, a Licensed Practical Nurse (LPN) documented they had completed the order to remove the sutures, Primary doctor to take sutures out. If unavailable send to (name of hospital) hospital to take out. It was noted there was no documentation in the resident's nursing notes/progress notes or the physician notes that the sutures had been removed. Review of R102's MAR/TAR 9/1/2023-9/30/2023, reported nurses had documented they had completed the order, Cleanse laceration to R (right) 5th toe with wound cleanser, pat dry, apply calcium alginate w/(with) silver then apply 4x4 gauze & wrap with Kerlix daily. It was noted there was no documentation in the resident's progress notes of the wound's condition with dressing changes. Review of R102's Podiatry Exam Note, 9/13/2023, revealed, .small fissure in the 4th interdigital space right foot with serosanguinous drainage . Review of R102's Skin Body Assessment, observation date 9/16/2023 1:30 AM, reported skin impairment of the right pinky toe had 3 new sutures placed between the right pinky toe and the 4th toe. Review of R102's Progress Notes reported, -9/15/2023 8:01 PM, R102 was in bed with a lot of blood on the floor. Resident stated he was not sure what happened, he noticed the blood after he took off his shoes. The nurse cleaned the right foot and found bleeding between the 4th and 5th toe with a deep wound. It was suggested he be sent out (referring to a hospital emergency room ). -9/15/2023 9:49 PM, R102 was transferred to the hospital due to the laceration between the 4th and 5th toes on right foot. -9/16/2023 1:24 AM, the facility received report from the hospital stating R102 got 3 sutures between his right 4th and 5th toe. An x-ray was done with normal results. R102 returned to the facility. It was noted in the Hospital Summary dated 9/15/2023 stating the resident received 6 sutures. -9/16/2023 1:33 PM, per the hospital, R102 was to follow up with his doctor or go back to the hospital, or nearest emergency department for suture removal in 10 days. It was noted on R102's MAR/TAR 9/16/2023, documentation indicated the sutures were removed on 9/16/2023. -9/19/2023 9:40 AM ER follow-up for R102 recent ER visit where he had a foot laceration and sent toER on [DATE] where he received 3 stitches. Laceration was seen with no signs or symptoms of infection and open to air. -9/19/2023 12:44 PM, weekly wound assessment of wound between 4th and 5th on right foot with wound specialist, reconfirmed wound had 6 sutures in place with order not to remove for 10 days. There was no sign or symptoms of infection noted at that time. New orders to follow-up with wound specialist in 7 days. Will continue to monitor for any changes or concerns. -9/26/2023 5:42 AM, R102 took his right foot dressing off during the night stating It was too tight. The resident's foot was cleaned with a new bandage applied. R102 denied pain during this shift. It was noted there was no documentation of the wound's condition. -9/26/2023 9:00 AM, upon weekly wound rounds with wound specialist, R102 right 5th toe was observed to be 100% necrotic (dead tissue), very mobile, and partially detached. Wound specialist recommendation was to send resident to hospital. -9/26/2023 11:34 AM, R102 was seen by the wound medical doctor with orders to be sent to the hospital for debridement of 5th toe on right foot. The emergency medical service was called and transferred resident to hospital. -9/26/2023 2:25 PM, Nurse Practitioner note, R102 reported increased pain to left foot toe laceration and toe noted with swelling and surrounding erythema. Resident rated pain 5/10. R102 was scheduled to be seen by in-house wound provider the next day. It was noted, the wound was to the right foot and not the left foot. - 9/27/2023 09:22 AM, IDT (Interdisciplinary Team) note: Resident sent out yesterday to ER for evaluation of right little toe that was hanging half off foot. Remains at hospital for possible amputation. Review of R102's Wound Management 9/19/2023 12:42 PM, reported the wound to the right pinky toe has serosanguineous exudate (drainage), small wound tissues very moist, drainage less than 25 percent dressing, and wound healing status was stable. Review of R102's Wound Physician's Visit Report 9/19/2023 reported the information was obtained from the resident's chart and was seen for follow-up and management of the wound. History of the R102 web space between his right 4th and 5th toes identified on 9/15/2023 by a trauma. The resident complained of increased drainage. Nursing staff reported Podiatrist (foot doctor) identified a fissure between the right 4th and 5th toes on 9/15/2023. Later that evening, nursing staff noted a large area of blood on R102's bedroom floor. The resident reported to the wound physician that he accidentally tried putting his left shoe on his right foot and his right 5th toe got caught on shoe causing a large laceration between the 4th and 5th webspace. R102 was sent to the hospital ER and had sutures placed. The x-ray of the right foot while in the ER was normal. Wound specialist was re-consulted to evaluate and treat. The resident appeared to have [NAME] judgement and insight. The Wound Assessment reported the right web space between the 4th and 5th toes was a full thickness trauma wound with initial wound encounter measurements of 2.6 cm (centimeters) length x 0.8 cm width x 0.1 cm depth, with an area of 2.08 sq (square) cm and a volume of 0.208 cubic cm. There was a moderate amount of sero-sanguineous drainage (blood tinged) noted which had no odor with 50% slough (yellow/white material in wound bed). R102's wound pain level was 2/10 (2 out of 10). There were 6 sutures in place and appeared a portion of the wound was left to close by secondary intention as sutures did not span the entire length of the wound. The wound provider performed a procedure, skin/subcutaneous tissue level surgical debridement (Debridement is the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) with a total area debrided of 1.04 sq cm. Adipose (yellow layer of fat beneath the skin) and subcutaneous (full thickness tissue) were removed along with devitalized tissue (necrotic tissue (dead), exudate (fluid that leaks out of blood vessels into nearby tissues), and slough. Post debridement measurements: 2.6 cm length x 0.8 cm width x 0.7 cm depth, with an area of 2.08 sq cm and a volume of 1.456 cubic cm. The tactile feedback from the sterile scalpel used to perform the debridement suggested the wound probes to the bone. Wound Orders: cleanse wound with normal saline (NS) or wound cleanser, apply calcium alginate with silver to promote autolytic debridement, cover with gauze, secure dressing Kerlix and change dressing daily, as needed (PRN) for soiling, saturation, or accidental removal. Follow-up with wound physician within 7 days. Avoid wearing shoe on right foot. Coordination of Care: Data and history pertinent to the resident's care was obtained from the resident's chart, nursing staff, and resident. Review of R102's Wound Physician's Visit Report 9/26/2023 reported the information was obtained from the resident's chart and was seen for follow-up and management of the wound. History of the R102 web space between his right 4th and 5th toes identified on 9/15/2023 by a trauma. R102 stated his toe doesn't look like a human toe. He stated he started noticing a color change yesterday, (/25/2023. Resident denied any additional trauma to the toe since last visit, (9/19/2023). Nursing staff reports concerns for wound infection. The Wound Assessment reported the webspace between the 4th and 5th toes was a full thickness trauma wound and received a status of Not Healed. Subsequent wound encounter measurements were 2.8 cm length x 3.1 cm width x 1.2 cm depth, with an area of 9/69 sq cm and a volume of 10.416 cubic cm. There was a moderate amount of yellow drainage noted which had no odor. The wound was deteriorating. Significant deterioration with new necrosis to plantar (sole of foot), medial aspect (inner edge) of the 5th toe. Sutures were in place. Wound probes to bone. Debridement not performed due to wound not appropriate for bedside debridement, risks outweigh benefits. Deterioration due to necrosis 100 percent. Resident was transferred to the hospital ER for further evaluation. Discussed possible outcomes including amputation with resident. Informed DON (Director of Nursing B) of clinical findings. It was noted on R102's MAR/TAR dated 9/16/2023, 1 day after the resident received the sutures, they were removed. Review of R102's Hospital Notes dated 9/26/2023, revealed, .admitted : 9/26/2023 .apparently nursing home had removed the sutures and there is pus draining from the wound .It does not appear that patient (R102) has been on outpatient antibiotics for wound .resident brought into operating room .distal aspect of the right foot where the wound was assessed. There is noted to be extensive infection would per the material extruding from the wound between the fourth and fifth toes. The fifth toe was dislocated dorsally and had exposed bone at the base of proximal phalanx .the decision was made to perform a fifth reamputation, leaving it open given the extensive nature of this infection .There was an extensive amount of purulent material as well as a wound on the plantar aspect of the foot with purulent material coming out of the bottom of the foot at roughly the fifth metatarsal neck area .This is most likely the origination of the wound itself .There is an extensive amount of purulent material extending up the flexor tendon sheath which was opened appropriately. Intraoperative aerobic, anaerobic, and fungal cultures were obtained and sent for Gram stain and culture and sensitivity. At this time, the fifth metatarsal head was assessed and noted have osteomyelitic changes. The dorsal aspect of the fifth metatarsal was extremely soft and necrotic in nature. Diagnosis: Foot wound/Osteomyelitis .toe amputation . Further review of R102's Hospital Notes dated 9/26/2023, revealed, .admitted : 9/26/2023 .9/29/2023 .resident brought into operating room .attention was directed to the lateral foot (right) .there was noted to be purulence draining from the area immediately .coming from the medial proximal aspect of the plantar foot near the FHL tendon .purulence continued to be expressed from the proximal medial foot area .open a small area on the medial midfoot area .purulence was expressed from the site as well. Nonviable tissues were resected .additional portion of bone was removed. Nonviable bone die to the osteomyelitis . continued necrotic tissue to the plantar soft tissues as well as continued purulence expressed .It was felt that the infection was too extensive and this area would ultimately be nonviable, especially with the extensive soft tissue involvement and necrosis. Incision was made to remove the fourth toe .based on the persistent and extensive nature of the infection, decision was made to return to the OR (operating room) in a couple of days for repeat I&D .

This citation pertains to intake # MI00138591 Based on observation, interview and record review, the facility failed to ensure all caregivers and staff received education on dementia care to prevent staff to resident physical and verbal abuse for 1 (Resident #21) of 19 residents reviewed for dementia care, resulting in an Immediate Jeopardy when on 8/1/23 Resident #21 who was known to have dementia behaviors and required 2 person physical assistance due to the behaviors, was sworn at, suffered bruising around his neck, and received a skin tear while receiving cares from an agency employed staff member who had not received training on caring for residents with dementia. Findings include: On 8/8/23 at 12:58pm, Nursing Home Administrator (NHA) A was verbally notified and received written notification of the immediate jeopardy that began on 8/1/23 due to the facility's failure to ensure all caregivers and staff received education on dementia care to prevent staff to resident physical and verbal abuse. Review of an Admission Record dated 4/22/22 revealed Resident #21 was admitted to the facility with the following pertinent diagnoses: Psychotic disorder (loss of contact with reality) with Delusions (irrational beliefs) due to known physiological condition, need for assistance with personal care, Vascular Dementia (progressive loss of cognitive functioning) with behavioral disturbance, Alcohol dependence with alcohol-induced persisting dementia, other speech disturbances, Disorientation, Restlessness and agitation, Aphasia (loss of ability to verbalize thoughts), and Anxiety disorder. Review of a Minimum Data Set (MDS) assessment of Resident #21 dated 6/12/23 section B revealed the resident had unclear speech, sometimes made self-understood, and sometimes understood others. Section C of the MDS revealed Resident #21 was severely impaired for decision making, had continuous difficulty concentrating and organizing own thoughts. Section G of the MDS revealed that Resident #21 required extensive assistance of two staff members to complete personal hygiene and dressing. Review of a Care Plan for Resident #21, with a start date of 2/10/22 revealed a problem/goal/approach as follows: problem: (Resident #21) removes his shirt at times . Goal (Resident #21) will be dressed prior to leaving his room approaches included: Gently remind (Resident #21) that he should be dressed, offer 2 options, Assist (Resident #21) with putting clothing back on .keep a very positive tone .avoid statements like 'You have to put your shirt on' .approach from the front .avoid power struggles . Further review of the Care Plan for Resident #21 revealed a problem/goal/approach initiated on 12/22/21 as follows: problem: (Resident #21's) ADL (activities of daily living) abilities .vary and fluctuate r/t (related to) cognitive impairment. Goal: (Resident #21) will be clean .and participate in cares . Approaches: Do not rush (Resident #21) .if resistive, stop and reapproach .do not force task .provide care in pairs. During an observation on 8/7/23 at 8:56am, Resident #21 was asleep in his bed, a reddened and bruised area extended across the base of his neck and a bandaged wound was present on his upper torso. Review of a Facility Reported Incident dated 8/1/23 at 3:39pm, revealed Agency Certified Nursing Assistant (CENA) LL was overheard yelling at approximately 3:10pm, Get the f*** out of here (Resident #21's name) after providing cares to the resident while alone in the resident's room. Per the facility investigation, physical injuries were discovered on Resident #21's neck and upper torso. In an interview on 8/7/23 at 3:31pm, CENA T reported he saw Resident #21 at approximately 3:11pm on 8/1/23 as a nurse was assessing injuries to his neck and upper torso. CENA T reported Resident #21's neck was very red, and a new skin tear was present on his upper torso. CENA T described Resident #21 as upset and shaking. CENA T reported he had seen Resident #21 a few minutes before this encounter at which time Resident #21 had no injuries. CENA T reported the injuries were evident after Agency CENA LL provided cares to Resident #21. In an interview on 8/7/23 at 3:43pm, Licensed Practical Nurse (LPN) NN reported she saw Resident #21 walk out of his room on 8/1/23 at approximately 3:10pm, clutching his throat and motioning for the nurse to help him. LPN NN described Resident #21 as very distraught and reported the resident appeared fearful. LPN NN reported the front of Resident #21's neck was bright red with new bruising and new skin tear was present near his mid clavicle when she saw him in the hallway. LPN NN saw Resident #21 a few minutes before the incident and there was no redness on his neck/wound at that time. Resident #21 gestured toward his room where Agency CENA LL was at that time. LPN NN reported they asked agency CENA LL what happened, and Agency CENA LL indicated he pushed Resident #21 down because the resident became aggressive during cares. LPN NN reported several staff did not know how to care for Resident #21 because of his dementia with behaviors and that . the facility could have done more (training) to avoid this . LPN NN also stated I could see something like this was going to happen ., because they (the staff) don't know how to care for Resident #21. In an interview on 8/8/23 at 8:10am, Nursing Home Administrator (NHA) A reported he investigated the incident that occurred on 8/1/23 involving Agency CENA LL and Resident #21. NHA A confirmed that staff reported hearing Agency CENA LL yell an obscenity at Resident #21 and then found injuries on Resident #21's neck and upper torso. NHA A reported Agency CENA LL admitted to pushing Resident #21, causing him to fall on the floor but based on Resident #21's injuries, the event appeared a little more aggressive than that. NHA A indicated at the time of this interview that the facility was unsure what if Agency CENA LL had any dementia training. The facility had not provided agency staff with dementia training and was awaiting training information from the agency in which Agency CENA LL was employed. In an interview on 8/8/23 at 11:37am, NHA A reported he learned the facility wrongfully assumed the Staffing Agency (who employed all the contractual nursing staff in the facility), had provided the nursing staff with any necessary training. NHA learned the Staffing Agency provided no training of any kind, including dementia care training. In a telephone interview on 8/8/23 at 8:27am, Agency CENA LL reported he provided personal hygiene and dressing assistance to Resident #21 at approximately 3:00pm on 8/1/23. Agency CENA LL reported during cares on 8/1/23, Resident #21 was standing with his back facing his bed as Agency CENA LL attempted to assist Resident #21 with donning a shirt. Agency CENA LL threaded Resident #21's right arm through a sleeve several times, but Resident #21 unthreaded his arm from the sleeve each time. Agency CENA LL reported he continued trying to put the shirt on Resident #21. Agency CENA LL reported he kept saying to Resident #21, You've got to get your shirt on, and continued to attempt to dress Resident #21, during which time the resident became more resistant. Agency CENA LL then went behind Resident #21 and snatched (quickly pulled) the shirt over the resident's head. Resident #21 stood with a shirt over his head, his eyes covered, as Agency CENA LL came around in front of him. Resident #21 grabbed ahold of the Agency CENA's shirt. Agency CENA LL reported he placed both hands on Resident #21's upper body, near his clavicles and neck and pushed the resident backward. The resident fell back onto his bed and then bounced off the bed and landed on the floor. Agency CENA LL reported the shirt was twisted tightly around Resident #21's neck at that time and Agency CENA LL had to remove it in order redress Resident #21. Agency CENA LL then went behind Resident #21 who sat on the floor, placed his arms under Resident #21's armpits, and lifted the Resident back on his feet and Resident #21 walked out of the room. Agency CENA LL reported he .probably did swear at (Resident #21) .as the resident left his room. Agency CENA LL reported he was unsure how the bruising and redness on Resident #21's neck and the skin tear on his clavicle occurred but acknowledged it must have happened while he was providing care. Agency CENA LL reported the facility provided brief verbal instructions on caring for Resident #21 at the beginning of each shift. The instructions given on 8/1/23 were to use 2 staff members to assist the resident, no additional information was provided. Agency CENA LL stated I always just try to get it done really fast because he always fights, referring to providing care for Resident #21. Agency CENA LL reported he did not know what approaches were listed in Resident #21's care plan, other than the resident requiring assist of 2 staff. Agency CENA LL reported neither the facility, nor the agency had provided any dementia training. In an interview on 8/10/23 at 1:05pm, Assistant Director of Nursing (ADON) C reported she was asked to evaluate Resident #21 on 8/1/23 at approximately 3:30pm. ADON C reported she immediately noticed Resident #21's neck was red from one side to the other across the front of his neck. ADON C reported she asked the resident what happened, and he responded by making the universal gesture for choking by placing both hands up near his neck. ADON C also noted a new wound was present on Resident #21's mid clavicle. Review of a Resident Progress Note dated 8/1/23 at 4:46pm revealed Resident #21 was noted to have redness around his neck and a new skin tear to his upper right chest that was treated, and a dressing applied. Review of a Resident Progress Note, dated 8/2/23 at 8:37am, revealed Resident #21 had the following injuries: A 6.5cm x 3.0cm dark purple bruise noted to mid clavicle/near neck with a 1.5cm x2.0cm V-shaped skin tear to center of bruise. There is a 2.0cm x 3.5cm dark purple bruise to L clavicle near neck. Review of an Observation Detail List Report, dated 8/2/23 at 8:56am, revealed Resident #21 had the following injuries: L clavicle purple bruise 2.0cm x 3.5cm. Mid clavicle purple bruise 6.5cm x 3.0cm. Mid clavicle skin tear 1.5cm x 2.0cm x 0.1cm. Review of a list provided by the facility on 8/10/23 at 10:31am, revealed 27 Agency Staff had provided resident care since 7/26/23. The facility could not provide proof of any dementia training the agency staff had received prior to 8/2/23. In an interview on 8/10/23 at 12:19pm, Medical Records Clerk/Scheduler H reported the facility employed 34 nursing staff. Review of a list provided by the facility on 8/12/23 at 11:11am revealed 11 residents required dementia care due to a diagnosis of Dementia with Behaviors. Review of a Plan of Correction from a survey that exited on 6/27/23 revealed the facility agreed to provide all staff education on Dementia Care and Resident Aggression. The facility contacted a psychiatric service company to set up an in-person training for staff. The alleged compliance date for this training was 7/25/23. At the time of survey entry on 8/7/23, the training still had not been completed. Review of a training materials initiated by the facility on 8/2/23 revealed a Dementia/Care of Cognitively Impaired Training posttest, which only measured the trainee's most basic knowledge of dementia. The materials did not encompass how to effectively care for a Resident with dementia. The posttest questions related to basic knowledge of dementia i.e., A set routine is important for a person with Alzheimer's Dementia. True/False, The person with Alzheimer's Dementia can control their behavior. True/False. The test did not determine if staff understood that a person's behaviors might also serve as a means for the person to communicate an unmet need, rather than as an act of intentional aggression. Yelling at a distressed resident is the best way to get him or her to listen. True/False. The test did not determine if the staff understood effective ways of communicating with a person with dementia, other than knowing that yelling was not the best way to do so. Review of a Resident Aggression Pre/Post Test provided by the facility on 8/7/23 revealed a 5-question test that covered only basic information related to aggression, i.e., a question stated, If an episode of resident-to-resident aggression is abusive, it must be reported . True/False. The test did not determine if the staff understood how to avoid episodes of resident-to-resident aggression, only that if an episode occurred, it should be reported. Another question stated, At times, staff members may contribute to aggression by ignoring a resident who agitated. The test served to determine only if a staff member understood that ignoring an agitated resident would not solve the issue and did not evaluate if the staff member had any knowledge how to effectively reduce and manage aggressive behaviors. Review of Preventing The Abuse of Residents with Dementia or Alzheimer's Disease In The Long-Term Care Setting: A Systematic Review, Published by The National library of Medicine, 2019, revealed .there is an increasing rate of abuse in the long-term care setting, specifically for those individuals with either dementia or Alzheimer's. Common causes and risk factors leading to this abuse include poor training . Review of a facility policy titled Abuse Prevention Program Policy and Procedure, last revised 9/22, a section titled Training revealed the following: Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond. These symptoms, include, but are not limited to, the following . Aggressive and/or catastrophic reactions of residents .Resistance to care .Dementia Training for staff to educate on choosing the appropriate response for the Behavior using person-centered care strategies. In an email received on 8/8/23 at 4:27pm, Nursing Home Administrator (NHA) A provided an abatement plan for the immediate jeopardy. This Surveyor verified the immediacy was removed following implementation of the abatement plan as follows: Element #1: Resident #21 was assessed for injury and pain. Follow up was completed to monitor Resident #21's psychosocial well-being. Staff huddles were initiated to reinforce education of abuse prevention, care of residents with behaviors including triggers and interventions. Increased supervision of Resident #21 was provided. Element #2: Residents with dementia and/or behaviors currently residing in the facility were identified as being at potential risk. On 8/8/23 the following was completed: o Facility leadership interviewed alert and oriented residents with a BIMS score of 8 or higher regarding staff treatment. o Facility leadership reviewed skin assessments, incident reports, and grievance logs to identify potential abuse situations that require investigation and possible reporting to the state agency. o Monitoring of cognitively impaired residents for s/sx's(sic) of abuse. Element #3: Measures to ensure deficient practice will not recur: 1. Clinical managers (train the trainers) will complete the full 5-hour education utilizing the CMS hand and hand dementia training over the next 24 hours starting 8/8/23 2. Non-clinical managers will complete the full 5-hour education utilizing the CMS hand and hand dementia training over the next 5 business days starting 8/9/23 3. Direct care staff will be assigned one module of training a day utilizing the CMS hand and hand dementia training prior to the start of their next shift starting 8/9/23 i.e.: a. Module One: 8/9/23 b. Module Two: 8/10/23 c. Module Three: 8/11/23 d. Module Four: 8/14/23 e. Module Five: 8/15/23 4. Newly hired direct care staff will receive the hand and hand dementia training on hire: 8/8/23 5. Contracted staff will be provided a link to the CMS hand and hand dementia training with the expectation that they will complete one module per shift they work until the training is complete: 8/9/23 6. Comprehensive audit tool and competency testing will used for tracking completion of these modules. Element #4: Monitoring of corrective actions to ensure deficient practice will not recur: o Medical Director notified: 8/8/23 o Ad-Hoc QAPI committee meeting completed: 8/9/23 o One nurse per shift will be identified as the charge nurse and will be empowered to support and monitor staff that are providing care to residents with dementia and/or challenging behaviors Although, the Immediate Jeopardy was removed on 8/8/23, the facility remained out of compliance at a scope of actual harm and severity of isolated due to not all education had been completed and sustained compliance had not yet been verified by the State Agency.

Based on observation, interview and record review, the facility failed to implement the care plan for a resident who had known dementia behaviors and required 2-person physical assistance, in 1 (Resident #21) of 19 residents reviewing for care planning, resulting in Resident #21 receiving physical injury and psychosocial harm during cares. Findings include: Review of an Admission Record dated 4/22/22 revealed Resident #21 was admitted to the facility with the following pertinent diagnoses: Psychotic disorder (loss of contact with reality) with Delusions (irrational beliefs) due to known physiological condition, need for assistance with personal care, Vascular Dementia (progressive loss of cognitive functioning) with behavioral disturbance, Alcohol dependence with alcohol-induced persisting dementia, other speech disturbances, Disorientation, Restlessness and agitation, Aphasia (loss of ability to verbalize thoughts), and Anxiety disorder. Review of a Minimum Data Set (MDS) assessment of Resident #21 dated 6/12/23 section B revealed the resident had unclear speech, sometimes made self-understood, and sometimes understood others. Section C of the MDS revealed Resident #21 was severely impaired for decision making, had continuous difficulty concentrating and organizing own thoughts. Section F of the MDS revealed that Resident #21 required extensive assistance of two staff members to complete personal hygiene and dressing. Review of a Care Plan for Resident #21, with a start date of 2/10/22 revealed a problem/goal/approach as follows: problem (Resident #21) removes his shirt at times . Goal (Resident #21) will be dressed prior to leaving his room approaches included: Gently remind (Resident #21) that he should be dressed, offer 2 options, Assist (Resident #21) with putting clothing back on .keep a very positive tone .avoid statements like 'You have to put your shirt on' .approach from the front .avoid power struggles . Further review of the Care Plan for Resident #21 revealed a problem/goal/approach initiated on 12/22/21 as follows: problem: (Resident #21's) ADL (activities of daily living) abilities .vary and fluctuate r/t (related to) cognitive impairment. Goal: (Resident #21) will be clean .and participate in cares . Approaches: Do not rush (Resident #21) .if resistive, stop and reapproach .do not force task .provide care in pairs. A problem/goal/approach dated 1/23/23 revealed the following: problem (Resident #21's name) may become aggressive when attempts are made to change his clothes . Goal (Resident #21's name) will accept assistance without hitting, shoving, scratching .Approaches: avoid power struggles with (Resident #21's name). Do not force him to change his clothes .maintain calm environment .when (Resident #21's name) becomes physically abusive, STOP and try task later. During on observation on 8/7/23 at 8:56am, Resident #21 was asleep in his bed, a reddened and bruised area extended across the base of his neck and a bandaged wound was present on his upper torso. In a telephone interview on 8/8/23 at 8:27am, agency Certified Nursing Assistant (CENA) LL reported he provided personal hygiene and dressing assistance to Resident #21 at approximately 3:00pm on 8/1/23. CENA L described caring for Resident #21 as always a struggle, a wrestling match and that he generally performed care for Resident #21 quickly because it was always a fight. CENA LL reported during cares on 8/1/23, he (CENA LL) repeatedly told Resident#21 You've got to get a shirt on and quickly pulled a shirt over Resident #21's head. When Resident #21 responded by grabbing the CENA's shirt, CENA LL felt Resident #21 was trying to restrain him. CENA LL admitted he pushed Resident #21 backward from a standing position, using both hands on Resident #21's upper body. The resident fell back onto his bed and then bounced off the bed and landed on the floor. Agency CENA reported the shirt was twisted tightly around Resident #21's neck at that time and the CENA had to remove it in order redress Resident #21. CENA LL reported he was unsure how the bruising, redness on Resident #21's neck, and the skin tear on his clavicle occurred but acknowledged it must have happened because of his actions. Agency CENA LL reported he was familiar with Resident #21 and had cared for him several times previously but did not know what care plan interventions staff were supposed to use when caring for Resident #21. Agency CENA LL indicated the only intervention he was aware of was Resident #21 required assist of 2 staff for care. CENA LL reported the staffing level on 8/1/23 was sufficient to meet resident needs on 8/1/23, but when he could not find another staff member right away, he opted to provide care alone to save time. Review of a Facility Reported Incident dated 8/1/23 at 3:39pm revealed Certified Nursing Assistant (CENA) LL was overheard yelling at approximately 3:10pm, after providing cares to the resident while alone in the resident's room. Physically injuries were discovered on Resident #21's neck and upper torso. In an interview on 8/7/23 at 3:31pm, Certified Nursing Assistant (CENA) T reported he saw Resident #21 at approximately 3:11pm on 8/1/23 as a nurse was assessing injuries to his neck and upper torso. CENA T reported Resident #21's neck was very red and new skin tear was present on his upper torso. CENA T described Resident #21 as upset and shaking. CENA T reported he had seen Resident #21 a few minutes before this encounter at which time Resident #21 had no injuries. CENA T reported the injuries were evident after agency CENA LL provided cares to Resident #21. In an interview on 8/7/23 at 3:43pm, Licensed Practical Nurse (LPN) NN reported she saw Resident #21 walk out of his room on 8/1/23 at approximately 3:10pm, clutching his throat and motioning for the nurse to help him. LPN NN described Resident #21 as very distraught and reported the resident appeared fearful. LPN NN reported the front of Resident #21's neck was bright red with new bruising and new skin tear was present near his mid clavicle when she saw him in the hallway. LPN NN saw Resident #21 a few minutes before the incident and there was no redness on his neck/wound at that time. Resident #21 gestured toward his room where Certified Nursing Assistant LL was at that time. LPN NN asked agency CENA LL what happened, agency CENA LL indicated he pushed Resident #21 down because the resident became aggressive during cares. LPN NN reported several staff did not know how to care for Resident #21 because of his dementia with behaviors and that the facility could have done more (training) to avoid this. LPN NN also stated I could see something like this was going to happen, because they (the staff) don't know how to care for (Resident #21's name). Using the reasonable person concept, though Resident #21 could not verbally express his emotional distress, he was clearly fearful and anxious following the altercation that took place during his care. According to [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing, Tenth Edition - E-Book (Kindle Location 15861 of 76897). Elsevier Health Sciences.A nursing care plan includes nursing diagnoses, goals and/or expected outcomes, individualized nursing interventions, and a section for evaluation findings .The plan promotes continuity of care and better communication because it informs all health care providers about a patient's needs and interventions and reduces the risk for incomplete, incorrect, or inappropriate care measures. Nurses revise a plan when a patient's status changes .The plan of care communicates nursing care priorities to nurses and other health care providers. It also identifies and coordinates resources for delivering nursing care .

This citation pertains to intake # MI00138591 Based on observations, interview, and record review the facility failed to provide in depth Dementia Care training to all current, newly hired and agency employed staff resulting in an incident of staff to resident abuse for Resident #21, with a potential for a decline in physical, mental, and psychosocial well- being and unmet care needs for all residents with dementia. Findings include: Review of Preventing The Abuse of Residents with Dementia or Alzheimer's Disease In The Long-Term Care Setting: A Systematic Review, Published by The National library of Medicine, 2019, revealed . there is an increasing rate of abuse in the long-term care setting, specifically for those individuals with either dementia or Alzheimer's. Common causes and risk factors leading to this abuse include poor training . Review of a facility policy titled Abuse Prevention Program Policy and Procedure, last revised 9/22, a section titled Training revealed the following: Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond. These symptoms, include, but are not limited to, the following . Aggressive and/or catastrophic reactions of residents .Resistance to care .Dementia Training for staff to educate on choosing the appropriate response for the Behavior using person-centered care strategies. Review of an Admission Record dated 4/22/22 revealed Resident #21 was admitted to the facility with the following pertinent diagnoses: Psychotic disorder (loss of contact with reality) with Delusions (irrational beliefs) due to known physiological condition, need for assistance with personal care, Vascular Dementia (progressive loss of cognitive functioning) with behavioral disturbance, Alcohol dependence with alcohol-induced persisting dementia, other speech disturbances, Disorientation, Restlessness and agitation, Aphasia (loss of ability to verbalize thoughts), and Anxiety disorder. Review of a Minimum Data Set (MDS) assessment of Resident #21 dated 6/12/23 section B revealed the resident had unclear speech, sometimes made self-understood, and sometimes understood others. Section C of the MDS revealed Resident #21 was severely impaired for decision making, had continuous difficulty concentrating and organizing own thoughts. Section G of the MDS revealed that Resident #21 required extensive assistance of two staff members to complete personal hygiene and dressing. During an observation on 8/7/23 at 8:56am, Resident #21 was asleep in his bed, a reddened and bruised area extended across the base of his neck and a bandaged wound was present on his upper torso. Review of a Facility Reported Incident dated 8/1/23 at 3:39pm, revealed Agency Certified Nursing Assistant (CENA) LL was overheard yelling at approximately 3:10pm, Get the f*** out of here (Resident #21's name) after providing cares to the resident while alone in the resident's room. Per the facility investigation, physical injuries were discovered on Resident #21's neck and upper torso. In an interview on 8/7/23 at 3:43pm, Licensed Practical Nurse (LPN) NN reported she witnessed Resident #21 as he came out of his room on 8/1/23 clutching his neck, appearing very distraught with redness, and bruising around his neck and a wound on his upper chest. LPN NN reported Resident #21 had been alone in his room with Agency Certified Nursing Assistant (CENA) LL. When asked, CENA LL reported to LPN NN that he had pushed Resident #21 down because the resident became physically aggressive during cares. LPN NN stated . I could see that something like this was going to happen .the facility should have done more . because the staff don't know how to care for Resident #21. In a telephone interview on 8/8/23 at 8:27am, CENA LL reported he frequently struggled to provide care for Resident #21 because the encounters were always . a wrestling match. CENA LL reported he felt threatened when Resident #21 grabbed his shirt during care on 8/1/23 and as a result, CENA LL pushed Resident #21, causing him to fall on the floor. CENA LL acknowledged the resident had bruising, redness, and a skin tear because of the incident. CENA LL reported the facility had not provided any training related to caring for Residents who had dementia/dementia behaviors. In an interview on 8/8/23 at 11:37am, NHA A reported he learned the facility wrongfully assumed the Staffing Agency (who employed all the contractual nursing staff in the facility), had provided the nursing staff with any necessary training. NHA learned the Staffing Agency provided no training of any kind, including dementia care training. Review of a Plan of Correction from a survey that exited on 6/27/23 revealed the facility agreed to provide all staff education on Dementia Care and Resident Aggression. The facility contacted a psychiatric service company to set up an in-person training for staff. The alleged compliance date for this training was 7/25/23. At the time of survey entry on 8/7/23, the training still had not been completed. Review of staff training materials initiated by the facility on 8/2/23 revealed a Dementia/Care of Cognitively Impaired Training posttest, which only measured the trainee's most basic knowledge of dementia. The materials did not encompass how to effectively care for a Resident with dementia. The posttest questions related to basic knowledge of dementia i.e., A set routine is important for a person with Alzheimer's Dementia. True/False, The person with Alzheimer's Dementia can control their behavior. True/False. The test did not determine if staff understood that a resident's behaviors might also serve as a means for the resident to communicate an unmet need, rather than as an act of intentional aggression. Yelling at a distressed resident is the best way to get him or her to listen. True/False. The test did not determine if the staff understood or even knew effective ways of communicating with a person with dementia, other than knowing that yelling was not the best way to do so. Review of a Resident Aggression Pre/Post Test provided by the facility on 8/7/23 revealed a 5-question test that covered only basic information related to aggression, i.e., a question stated, If an episode of resident-to-resident aggression is abusive, it must be reported . True/False. The test did not determine if the staff understood how to avoid episodes of resident-to-resident aggression, only that if an episode occurred, it should be reported. Another question stated, At times, staff members may contribute to aggression by ignoring a resident who agitated. The test served to determine only if a staff member understood that ignoring an agitated resident would not solve the issue and did not evaluate if the staff member had any knowledge how to effectively reduce and manage aggressive behaviors. 41424 Review of Facility assessment dated [DATE], revealed, . For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired . No mention of behavioral health services education to be provided to all staff and agency staff. Review of the spreadsheet of course completions received 8/14/23, revealed, 14 employees out of 75 employees and 51 agency staff had not completed the education for Behavioral Health Services for the previous 12 months. Review of Annual Education Calendar revealed, Behavioral Health Services education was provided November 2022. In an interview on 08/09/23 02:54 PM, Regional Director of Nursing GG reported the education and training was monitored by the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) prior to the implementation of the vendor education program which started in May 2023. In an interview on 08/10/23 at 2:22 PM, Administrator A reported we have some work to do on monitoring education completion.

This citation is linked to intake # MI00138591 This citation contains 2 Deficiency Practice Statements, DPS #1 and #2. DPS #1 Based on observations/interviews/record review, the facility failed to protect the resident's right to be free from staff to resident verbal and physical abuse for 1 (Resident #21) of 19 residents reviewed for abuse, resulting in Resident #21 sustaining a reddened and bruised area extended across the front of his neck and a bandaged wound was present on his upper torso. Findings include: Review of a facility Abuse Prevention Program Policy and Procedure document revised on 9/22, revealed the intent states: Each resident has the right to be free from abuse .of any type by staff or anyone. The facility will provide a safe resident environmnet and portect residents from abuse. Review of an Admission Record dated 4/22/22 revealed Resident #21 was admitted to the facility with the following pertinent diagnoses: Psychotic disorder (loss of contact with reality) with Delusions (irrational beliefs) due to known physiological condition, need for assistance with personal care, Vascular Dementia (progressive loss of cognitive functioning) with behavioral disturbance, Alcohol dependence with alcohol-induced persisting dementia, other speech disturbances, Disorientation, Restlessness and agitation, Aphasia (loss of ability to verbalize thoughts), and Anxiety disorder. Review of a Minimum Data Set (MDS) assessment of Resident #21 dated 6/12/23 section B revealed the resident had unclear speech, sometimes made self-understood, and sometimes understood others. Section C of the MDS revealed Resident #21 was severely impaired for decision making, had continuous difficulty concentrating and organizing own thoughts. Section F of the MDS revealed that Resident #21 required extensive assistance of two staff members to complete personal hygiene and dressing. Review of a Care Plan for Resident #21, with a start date of 2/10/22 revealed a problem/goal/approach as follows: problem: (Resident #21) removes his shirt at times . Goal (Resident #21) will be dressed prior to leaving his room approaches included: Gently remind (Resident #21) that he should be dressed, offer 2 options, Assist (Resident #21) with putting clothing back on .keep a very positive tone .avoid statements like 'You have to put your shirt on' .approach from the front .avoid power struggles . Further review of the Care Plan for Resident #21 revealed a problem/goal/approach initiated on 12/22/21 as follows: problem: (Resident #21's) ADL (activities of daily living) abilities .vary and fluctuate r/t (related to) cognitive impairment. Goal: (Resident #21) will be clean .and participate in cares . Approaches: Do not rush (Resident #21) .if resistive, stop and reapproach .do not force task .provide care in pairs. During on observation on 8/7/23 at 8:56am, Resident #21 was asleep in his bed, a reddened and bruised area extended across the front of his neck and a bandaged wound was present on his upper torso. Review of a Facility Reported Incident dated 8/1/23 at 3:39pm revealed Certified Nursing Assistant (CENA) LL was overheard yelling at approximately 3:10pm, Get the f*** out of here (Resident #21's name) after providing cares to the resident while alone in the resident's room. Physically injuries were discovered on Resident #21's neck and upper torso. Review of Statement Form dated 8/1/23 at 3:10pm revealed Resident #21 verbalized two words, choked and pushed when asked what happened when CENA LL cared for him a few minutes prior to the interview. In an interview on 8/7/23 at 3:31pm, CENA T reported he saw Resident #21 at approximately 3:11pm on 8/1/23 as a nurse was assessing injuries to his neck and upper torso. CENA T reported Resident #21's neck was very red and new skin tear was present on his upper torso. CENA T described Resident #21 as upset and shaking. CENA T reported he had seen Resident #21 a few minutes before this encounter at which time Resident #21 had no injuries. CENA T reported the injuries were evident after agency CENA LL provided cares to Resident #21. In an interview on 8/7/23 at 3:43pm, Licensed Practical Nurse (LPN) NN reported she saw Resident #21 walk out of his room on 8/1/23 at approximately 3:10pm, clutching his throat and motioning for the nurse to help him. LPN NN described Resident #21 as very distraught and reported the resident appeared fearful. LPN NN reported the front of Resident #21's neck was bright red with new bruising and new skin tear was present near his mid clavicle when she saw him in the hallway. LPN NN saw Resident #21 a few minutes before the incident and there was no redness on his neck/wound at that time. Resident #21 gestured toward his room where CENA LL was at that time. LPN NN asked agency CENA LL what happened, agency CENA LL indicated he pushed Resident #21 down because the resident became aggressive during cares. LPN NN reported several staff did not know how to care for Resident #21 because of his dementia with behaviors and that the facility could have done more (training) to avoid this. LPN NN also stated I could see something like this was going to happen, because they (the staff) don't know how to care for (Resident #21's name). In an interview on 8/8/23 at 8:10am, Nursing Home Administrator A reported he investigated the incident that occurred on 8/1/23 involving agency CENA LL and Resident #21. NHA A confirmed that staff reported hearing agency CENA LL yell an obscenity at Resident #21 and then found injuries on Resident #21's neck and upper torso. NHA A reported agency CENA LL admitted to pushing Resident #21, causing him to fall on the ground but based on Resident #21's injuries, the event appeared a little more aggressive than that. NHA A indicated at the time of this interview that the facility was unsure what if any dementia training agency CENA LL had. NHA A reported the facility had not provided agency staff with dementia training and was awaiting training information from the agency in which CENA LL was employed. In a telephone interview on 8/8/23 at 8:27am, agency Certified Nursing Assistant (CENA) LL reported he provided personal hygiene and dressing assistance to Resident #21 at approximately 3:00pm on 8/1/23. CENA L described caring for Resident #21 as always a struggle, a wrestling match. CENA LL reported during cares on 8/1/23, Resident #21 was standing with his back facing his bed as he attempted to assist Resident #21 with donning a shirt. Agency CENA LL threaded Resident #21's right arm through a sleeve several times, but Resident #21 removed his arm from the sleeve each time. CENA LL reported he continued trying to put the shirt on Resident #21 and did so as quickly as possible. CENA LL reported he kept saying You've got to get your shirt on and continued to attempt to dress Resident #21, during which time the resident became more resistant. Agency CENA LL then went behind Resident #21 and snatched (quickly pulled) the shirt over the resident's head. Resident #21 stood with a shirt over his head, his eyes covered, as CENA LL came around in front of him. Resident #21 grabbed ahold of the CENA's shirt. Agency CENA LL stated he felt Resident #21 was trying to restrain him. Agency CENA LL reported he placed both hands on Resident #21's upper body, near his clavicles and neck and pushed the resident backward. The resident fell back onto his bed and then bounced off the bed and landed on the floor. Agency CENA reported the shirt was twisted tightly around Resident #21's neck at that time and the CENA had to remove it in order redress Resident #21. Agency CENA LL then went behind Resident #21 who sat on the floor, placed his arms under Resident #21's armpits, and lifted the Resident back on his feet. Agency CENA LL then asked the resident Why are you trying to hurt me? Resident #21 walked out of the room. Agency CENA LL reported he probably did swear at (Resident #21) as the resident left his room. CENA LL reported he was unsure how the bruising and redness on Resident #21's neck and the skin tear on his clavicle occurred but acknowledged it must have happened while Agency CENA was providing care. Agency CENA LL reported the facility provided brief verbal instructions on caring for Resident #21 at the beginning of each shift. The instructions given on 8/1/23 were to use 2 staff members to assist the resident, no additional information was provided. Agency CENA LL reported he was familiar with Resident #21 and had cared for him several times previously. Agency CENA LL stated I always just try to get it done really fast because he always fights, referring to providing care for Resident #21. Agency CENA LL reported he did not know what approaches were listed in Resident #21's care plan, other than the resident requiring assist of 2 staff. CENA LL reported the staffing level on 8/1/23 was sufficient to meet resident needs but when he could not find another staff member right away, he opted to provide care alone to save time. Agency CENA LL reported the facility, nor the agency had not given him any dementia training. In an interview on 8/10/23 at 1:05pm, Assistant Director of Nursing (ADON) C reported she was asked to evaluate Resident #21 on 8/1/23 at approximately 3:30pm. ADON C reported she immediately noticed Resident #21's neck was red from one side to the other across the front of his neck. ADON C reported she asked the resident what happened, and he responded by making the universal gesture for choking by placing both hands up near his neck. ADON C also noted a new wound was present on Resident #21's mid clavicle. In an interview on 8/8/23 at 11:37am, Nursing Home Administrator (NHA) A reported he learned the facility wrongfully assumed the staffing agency (who employed all the contractual nursing staff in the facility), had provided the nursing staff with any necessary training. NHA learned the agency provided no training of any kind, including dementia care training and abuse training. Review of a Resident Progress Note dated 8/1/23 at 4:46pm revealed Resident #21 was noted to have redness around his neck and a new skin tear to his upper right chest that was treated, and a dressing applied. Review of a Resident Progress Note dated 8/2/23 at 8:37am revealed Resident #21 had the following injuries: A 6.5cm x 3.0cm dark purple bruise noted to mid clavicle/near neck with a 1.5cm x2.0cm V-shaped skin tear to center of bruise. There is a 2.0cm x 3.5cm dark purple bruise to L clavicle near neck. Review of an Observation Detail List Report dated 8/2/23 at 8:56am revealed Resident #21 had the following injuries: L clavicle purple bruise 2.0cm x 3.5cm. Mid clavicle purple bruise 6.5cm x 3.0cm. Mid clavicle skin tear 1.5cm x 2.0cm x 0.1cm. Using the reasonable person concept, though Resident #21 had decreased ability to verbally express his own thoughts due to his mental diagnoses, he was clearly angry and fearful following the verbal and physical abuse that occurred on 8/1/23. This fear has the potential to continue well past the date of the incident based on the reasonable person concept. As the resident had a court appointed guardian, no family was available to interview as to the presumed feeling of Resident #21. Review of a facility policy titled Abuse Prevention Program Policy and Procedure, section titled Staff to Resident Abuse revealed the following: (Facility Name) will not consider striking a combative resident an appropriate response in any situation. It is also not acceptable for any staff members to claim his/her action was reflexive . This portion of the citation pertains to intakes #MI00138589 and #MI00138592 DPS #2 Based on observations, interviews and record review, the facility failed to prevent resident to resident physical abuse for 2 (Resident #32 and Resident #13) of 19 residents by Resident #21 reviewed for abuse, resulting in feelings of fear of Resident #21. Findings include: Resident #32 Review of an Admission Record dated 5/2/22 for Resident #32 revealed the resident was admitted to the facility with the following pertinent diagnoses: Major Depressive Disorder, Unspecified Dementia (progressive loss of cognitive abilities), Weakness. Review of a Care Plan dated 5/4/22 for Resident #2 revealed problem/goal/approaches as stated: Problem (Resident #32's name) can no longer safely care for self at home . Goal (Resident #32's name) will reside at (facility name) while maintaining her dignity and highest level of functioning as possible Approaches Staff to provide 24-hour supervision. Review of a Minimum Data Set (MDS) assessment for Resident #32 dated 5/2/23 revealed a Brief Interview for Mental Status (BIMS) score of 9/15 which indicated Resident #32 was cognitively impaired. Review of Section E of the MDS revealed Resident #32 had no episodes of delusions (irrational beliefs). Section F revealed Resident #32 used a wheelchair for mobility and could not walk. Review of a Facility Reported Incident revealed on 7/24/23 at 4:15pm, Resident #32 was sitting in the dining room when staff heard her yell He pulled my hair!. Staff responded, found Resident #21 standing next to Resident #32. Resident #32 reported that Resident #21 grabbed her soda and when she told Resident #21 No, he grabbed her ponytail and pulled. In an interview on 8/10/23 at 9:52 am, Resident #32 was lying in bed but reported she wanted to talk. Resident #32 reported she felt afraid of (Resident #21's name) when he pulled her hair. Resident #32 stated He's too much for me. I'm definitely afraid of him and don't want him close to me. Resident #32 reported she continued to go to the dining room but was worried she might have another stressful interaction with Resident #21. Resident #13 Review of an Admission Record dated 3/29/22 for Resident #13 revealed the resident was admitted with the following pertinent diagnoses: Mood Disorder, Dementia (progressive loss of cognitive abilities), Aphasia (impaired ability to verbalize thoughts) and Weakness. Review of a Care Plan dated 7/21/22 revealed problem/goal/approaches as follows: problem (Resident #13's name) can no longer safely care for self at home . Goal (Resident #13's name) will reside at (facility name) .while maintaining her dignity and highest level of functioning possible Approaches Staff to provide 24-hour supervision. Review of a Minimum Data Set (MDS) assessment dated [DATE] for Resident #13 revealed the resident scored 4/15 on a Brief Interview for Mental Status (BIMS) assessment which indicated Resident #13 was severely cognitively impaired. Section D of the MDS revealed Resident #13 expressed feeling down, depressed, or hopeless. Section E of the MDS revealed Resident #13 had no hallucinations (perception of something that is not present) or delusions (false beliefs about reality). Review of a Facility Reported Incident dated 7/27/23 at 7:49pm revealed Resident #13 was sitting near the nurse's station when a staff member observed Resident #21 grab Resident #13 by the forehead and hair. In an interview, Certified Nursing Assistant (CENA) U reported she witness Resident #21 grabbing Resident #13 by the forehead on 7/27/23. Resident #21 had his right hand on Resident #13's forehead and pulled head back. Resident #21 immediately stopped when CENA U intervened. CENA U described Resident #13 as scared, crying, and hysterical for a few minutes. Using the reasonable person concept, though Resident #13 had decreased ability to verbally express her thoughts, she was clearly frightened and emotional upset by the Resident #21's actions of grabbing her forehead and forcefully pulling her head back.

Based on observation, interview, and record review, the facility failed to employ a dietary manager with appropriate training and certifications to provide oversight of kitchen and clinical nutritional services resulting in the potential to result in food service sanitation failures, food borne illness, among all 41 vulnerable residents. Findings include: During observation and interview on 8/7/2023 at 9:20 AM Dietary Manager (DM) K stated, I am not a certified dietary manager. I have the information for the classes, but I have not started and do not know when I will start. I have been in this kitchen for 1 year. Review of an email received from the Nursing Home Administrator (NHA) A 8/14/2023 at 12:40 PM stated, 4/18/2022 is when she (DM K) started at (name of the facility).

Based on observation, interview, and record review, the facility failed to: 1. Properly date and discard food products, 2. Maintain cleanliness of food and non-food contact surfaces, and 3. Consistently monitor temperatures of the walk-in refrigerator, resulting in the potential of an increased risk of contaminated foods and food borne illnesses that could affect the vulnerable population of 41 residents who consume food from the kitchen. Findings include: During the initial tour of the kitchen, interview, and record review on 8/7/2023 at 9:20 AM with Dietary Manager (DM) K: -Observed upon entering the kitchen the floor to have a sticky film covering it. Dirt and debris covered floor, along kick plates, and converging in corners. -Observed a white plastic pipe ran from the coffee pot to lying on the floor next to a floor drain. Around the drain was accumulation of dirt and debris. The walls above the drain next to the table holding the coffee maker were splattered with a dried brown substance resembling coffee. -Observed on the floor next to the coffee maker's table in the path of this surveyor, was a rodent trap. -Observed with DM K taped to the Reach-In refrigerator was the Record of Refrigeration Temperatures dated July and August (2023). -Review of the July Record of Refrigeration Temperatures reported the AM (morning) temp was not documented for 8 days from July 15-17 and July 27-31. -Further review of the July Record of Refrigeration Temperatures reported the PM (afternoon) temp was not documented for 20 days from July 11-17 and July 19-31. -Review of the August Record of Refrigeration Temperatures reported the PM temp was not documented for 8 days from August 1-8. -DM K stated, The temperatures need to be checked and documented every shift. Night shift (PM) does not do this. Staff does not listen to me that the temperatures need to be checked and documented. I am here on days and responsible to have this done. During an interview on 8/7/2023 at 9:25 AM DM K excused herself and DM returned to continue the tour at 9:30 AM. -Observed with DM the smaller individual plate warmer to have dried substance resembling food. DM stated, That should be cleaned. -Observed with DM the larger plate warmer that held multiple plates, to have dried substance on it resembling food. Plates had been loaded in the warmer. DM stated, That should be cleaned. -Observed on a metal rack containing metal pans and bowls, and various kitchen utensils, 4 bags of dry cereal all opened with the tops folded closed, with no dates on them. Seven individual bowls of cereal were on a tray each covered with clear plastic wrap. DM stated, The bags of cereal are not dated. They have been used every morning since being opened. I do not know the date they were opened. Food should be dated when it is received, the day it is opened, and when it expires. The facility does not go by the manufacturer's expiration date. If a food is opened on say 8/2/23 then it is good for 1 month minus 1 day because not all months have 30 days. -Observed the toaster to be full of crumbs and dust on the outside of the it. DM K stated, This toaster is used every day. It should be wiped down. Again, I've not had time to clean. -Observed 2 opened loaves of bread not dated next to the toaster. DM stated, The bread is not dated. It was used yesterday and today. -Observed the meat slicer to have food debris on the edges of the tray. DM stated, Staff has not been using it much. It does have dust on it. It should be washed before and after each use. -Observed a bag of flour on the lower shelf of the food prep table. It was dated 7/19/23. DM stated, The flour should be good for 3 months after it was opened. The expiration date was put on it. -Observed the microwave to have dried food on the inside of it. DM stated, It is used daily to heat chicken noodle soup for the residents. It does need to be cleaned. Staff that cleans it are on break. No chicken noodle soup has been heated yet today. -Observed a metal cart with multiple shelves holding clean baking sheets and cupcake pans. Crumbs were on the shelves. DM stated, Staff is trying to find a way to take this rack outside to clean it. Maybe it could be power washed. -Observed on bottom shelf of metal rack sterno warmers. On the shelf was dust and debris. -Observed a free-standing steamer oven. DM stated, It does not work. It was given to the facility not working. It needs to be gotten rid of. -Observed the gas stove burners and flat top. On the wall behind the burners and flat top was streaks of grease running down from the ceiling . DM stated, Maintenance knows the schedule that a company comes in to clean this area. I clean everything else when I have time. I have not had time yet to day to clean because we are on this tour. I was trying to clean the steam table, but you came in here. It will have to wait until after lunch. I must order food for this week soon today. If it is not done by 2 PM today it will not be delivered on Wednesday. -Observed on the food prep counter: -1 peanut butter jar that was opened with peanut butter visibly used, with no dates -1 package of refried beans, gravy mix, biscuit mix, and cheese sauce with no dates marked on them. The packages were opened with no clips on them exposing the contents. -2 boxes of Cream of Wheat with tops opened exposing the contents. -1 bag of flour opened exposing the contents with no dates -1 bag of powdered sugar opened with no dates -3 packages of pasta that were opened with no dates. -winged insects were flying around the table and contents -a box of crackers that were opened with no dates -opened packages of food including 2 bags of chips, box of donuts, and bottled drinks. DM K stated, These packages of food belong to kitchen staff. -Observed on the bottom shelf of the food prep table were various spices with lids opened exposing the contents. Observed the air gap even with the floor drain underneath the food prep sink. Observed underneath the food prep sink was an aerosol can of Carbon Off lying on its side. DM picked up the aerosol can, looked at it and placed it back on the floor. Next to the can was a rodent trap in the foot path in front of the sink. Observed the walk-in refrigerator to have no thermometer inside during the tour. On a Record of Refrigeration Temperatures was documentation the temperature had been monitored daily for August 2023. Observed the walk-in refrigerator: -on the bottom of a 4-shelf rack were cartons of eggs with boxes of tomatoes, and ham slices on the shelf directly above them on the 3rd shelf. -on the 3rd shelf were resealable bags of chopped onions, cheddar cheese, and white cheese with no dates -on the 2nd shelf were boxes of meat in packaging and a tray of hamburger covered with loose parchment paper Observed the walk-in freezer: -on the top of a 4-shelf rack was a large slab of meat in packaging underneath the compressor. The compressor was leaking water that was dripping and making ice chunks that were on and next to the meat and with some of the water that had dropped through the shelf and frozen on top of boxes of food on the 2nd shelf -on the back wall was a 4-shelf rack with an opened package of pie shells that were exposed on the top shelf. DM stated, Those belong to the Administrator. He put those in here. Observed the dishwasher to have corrosion build- up on sides and edges of a white substance, dirt, and grime. DM K stated It is lime and dishwasher stuff built up. Maintenance knows about it. Observed on the floor underneath the dishwasher around the drain and spreading out from underneath was a build-up of corrosion, rust, grime, and dishwasher drain run-off approximately 1/4 of inch thick. Observed the 3-compartment sink to have a puddle of water on the floor, and drainage overflowing out of the drain onto the floor. DM stated, The garbage disposal is not working. When the water is let out of the sink too fast it back splashes on the floor causing the puddle. No one has had time to clean it up yet today. Observed the pH strips used to test the sanitizer with DM K. The expiration date was 5/15/2023. DM stated, The strips have run out and I will have to order more. Observed there to be strips available for use. DM stated, I did not know these strips had an expiration date. Observed the dry stock storage to have an opened bag of powdered sugar on the 3rd shelf with an open date of 12/29/2021. DM stated, That needs to be thrown away. It has been there for 2 years. Observed an open package of hamburger buns with no dates. During an interview on 8/9/2023 at 10:10 AM Nursing Home Administrator (NHA) A stated, The Dietary Manager is not certified. She has been doing the job for 1 year. During a re-tour and interview on 8/10/2023 at 12:15 PM of the kitchen with Maintenance Supervisor (MS) J, observed the dishwasher and the floor underneath it. MS J stated, There was about a 1/4 inch of lime, and gunk built up on the floor underneath the dishwasher. I had to scrape it off the floor. It should have been cleaned more regularly. Observed the dishwasher with MS J to have lime build up around the seams and drip edge. MS J stated, I got some of it off. I'm going to have to use a wire brush to try and get the rest of it off. I got some of it off already. During a tour and interview on 8/9/2023 at 10:15 AM of the kitchen with DM K, observed on food prep table to have a half a block of butter wrapped in its original covering on the counter. The butter was not dated. DM stated, That was used for lunch and has not been dated yet. The staff is on break. On the bottom shelf of the food prep table was a box of corn starch with the bag inside of it and the top of it open exposing the contents. Also on the bottom shelf were 10 containers of various spices with the tops open exposing contents. Review of a facility policy Storage Procedures with a revised date of 4/21 revealed, POLICY: Food shall be properly stored to preserve flavor, nutritive value, and appearance. PROCEDURE: DRY STORAGE OF FOOD: . 4. Routine cleaning and pest control procedures are to be developed and followed. 5. Opened packages are to be stored in closed containers, labeled, and dated . REFRIGERATED STORAGE: 1. Refrigerated storage temperatures should be at 36-41 degrees F (Fahrenheit). 2. Thermometers are to be placed to be easily visible for checking. Temperatures will be recorded on freezer/cooler temperature record on a regular basis, as no less than twice per day . 3. Refrigeration equipment is to be routinely cleaned and defrosted . According to the 2013 FDA Food Code section 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is appropriately marked with a date or day that exceeds a temperature and time combination as specified in 3-501.17(A). According to the 2013 FDA Food Code section 4-602.11 Equipment Food-Contact Surfaces and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be cleaned: . (5) At any time during the operation when contamination may have occurred. According to the 2013 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Non-FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

Based on interview and record review, the facility failed to ensure all staff, including contractual staff were trained in the facility expectations on caring for residents in the facility which inclueded training in communication, resident rights, abuse, neglect, and exploitation, quality assurance, infection control, and ethic training, resulting in the potential for decreased resident safety. Findings include: Review of Facility assessment dated [DATE], revealed, .Training Topics: Communication - effective communications for direct care staff .Resident's rights and facility responsibilities - ensure that staff members are educated on the rights of the resident and the responsibilities of a facility to properly care for its residents .Abuse, neglect, and exploitation - training that at a minimum educates staff on-(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property; (2) Procedures for reporting incidents, of abuse, neglect, exploitation, or the misappropriation of resident property; and (3) Care/management for persons with dementia and resident abuse prevention .Infection control - a facility must include as part of its infection prevention and control program mandatory training that includes the written standards, policies, and procedures for the program .Culture change (that is, person-centered and person-directed care} .Required in-service training for nurse aides. In-service training must: Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year .Include dementia management training and resident abuse prevention training, o Address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff .For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired .Identification of resident changes in condition, including how to identify medical issues appropriately, how to determine if symptoms represent problems in need of intervention, how to identify when medical interventions are causing rather than helping relieve suffering and improve quality of life .Cultural competency (ability of organizations to effectively deliver health care services that meet the social, cultural, and linguistic needs of residents) .Corporate Compliance and HIPPA .Falls management, incident reporting, alert charting .Infection Control standards and practices . Review of the spreadsheet provided by the facility on 8/14/23, revealed, 21 certified nursing assistants (CNAs) had not completed the required 12 hours of annual training in the last 12 months. In an interview on 08/08/23 at 01:20 PM, CNA M reported she did not receive new employee education prior to going on the floor and she had been working on the floor the last two weeks. CNA M was observed to be providing mentoring to a new Non Certified Nursing Assistant O who just started yesterday. Review of the education spreadsheet provided on 08/14/23, revealed, CNA M had not completed education prior to working on the unit with residents. In an interview on 08/10/23 at 12:45 PM, Certified Nursing Assistant (CNA) Q reported the monthly education was placed in the CNA room in the file cabinet. There was a folder for each education, we would review, take the test and then the Assistant Director of Nursing (ADON) C would come and check the folder and take the tests out of the folder. In an interview on 08/09/23 02:54 PM, Regional Director of Nursing GG reported the new employee education was documented on paper until about three months ago when they switched over to an electronic system for education. Regional Director of Nursing GG reported there were checks and balances to ensure the monthly completion of education by the facility. At the corporate level there was a score card and the completion of education was tracked, and if the facility fell below a certain percentage or had a low percentage of completion, corporate would have a conversation with the facility. In an interview on 08/08/23 at 03:35 PM, Hospitality Aide PP reported she received a tour of the facility, she was informed of who the residents were and what she needed to know about the residents but she reported she did not receive any education prior to working on the floor around and with residents. Review of the education spreadsheet provided on 08/14/23, revealed, Hospitality Aide PP had not completed education prior to working on the unit with residents. In an interview on 08/09/23 at 10:23 AM. Human Resources W reported the facility currently had three hospitality aides working at the facility. In an interview on 08/14/23 at 10:47 AM, Human Resources W reported the expectation would be the new staff members would complete the required trainings prior to starting at the facility. Review of Agency Staff List from May 7, 2023, revealed, 27 CNAs and 24 Nurses did not complete a comprehensive nursing orientation program to ensure agency staff competency prior to working independently with residents at the facility. In an interview on 08/09/23 at 10:06 Am, Scheduler H reported she was assigned to oversee the completion of the required education with the agency staff beginning on 8/2/23. Scheduler H reported she was not sure who was or if that was being completed prior to her being assigned to complete it. Scheduler H reported human resources, Director of Nursing and the Assistant Director of Nursing were the responsible individuals to monitor the completion of education for the facility staff. In an interview on 8/8/23 at 11:37am, Nursing Home Administrator (NHA) A reported he learned the facility wrongfully assumed the staffing agency (who employed all the contractual staff in the facility), had provided the staff with any necessary training. NHA learned the agency provided no training of any kind to the agency staff. In an interview on 08/10/23 at 10:49 AM, [NAME] President of Clinical Services H reported the facility was not following (Corporate) protocol for staff education. The facility received a corporate calendar with the educations in January, which needed completed each month. This building had its challenges and not every staff member completed education. [NAME] President of Clinical Services H reported she would have to complete a root cause analysis as to the reason there were so many agency staff in the building and what had happened. [NAME] President of Clinical Services H reported there had been 27 agency staff who had worked in the building since 7/26/23. Review of the spreadsheet of course completions received 8/14/23, revealed, 53 employees out of 56 direct care employees had not completed the education for Effective Communication for the previous 12 months. Review of the spreadsheet of course completions received 8/14/23, revealed, 16 employees out of 75 employees had not completed the education for Residents Rights for the previous 12 months. Review of the spreadsheet of course completions received 8/14/23, revealed, 10 employees out of 75 employees and 51 agency staff had not completed the education for Abuse, Neglect, Exploitation, and Misappropriation of resident property for the previous 12 months. Review of Annual Education Calendar revealed, QAPI was to be completed in December 2022 per the monthly calendar of education. Review of the spreadsheet of course completions received 8/14/23, revealed, 63 employees out of 75 employees and 51 agency staff had not completed the education for Quality Assurance Performance Improvement (QAPI) education for the previous 12 months. Review of the spreadsheet of course completions received 8/14/23, revealed, 20 employees out of 75 employees and 51 agency staff had not completed the education for Infection Control for the previous 12 months. Review of Annual Education Calendar revealed, Infection Control education was to be completed in January -Antibiotic Stewardship Policy review, February -PPE Use, March - Blood Borne Pathogens, and October - Basics of Hand Hygiene. Review of Facility assessment dated [DATE], revealed, no mention of Compliance and Ethics education to be provided to staff. Review of Annual Education Calendar revealed, no education listed for Compliance and Ethics training. Review of policy, Standards of Nursing Practices revised on 5/2018, revealed, .1. All newly hired licensed nurses and direct care givers will be provided a meaningful job specific orientation according to company guidelines prior to filling an open position .2. All newly hired licensed nurses or direct care givers will be competency tested .3. Competencies will be performed by the employee in the presence of a supervising nurse. Competencies are valid only when witnessed for correct procedure by the supervising nurse. Competency testing is also completed annually. (Michigan - skills checks will be completed on all newly hired nursing assistants prior to them accepting an independent assignment) .

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented per the standard of practice 1.) during a wound dressing change for 1 resident (R392) of 2 residents reviewed for wound dressing changes, 2.) in an resident common area, and 3.) for the use of personal protective equipment (PPE) during laundry services, resulting in the potential for the spread of infection, cross-contamination, and disease transmission. Findings include: R392 According to the Minimum Data Set (MDS) dated [DATE], R392 scored 9/15 (moderately cognitively intact) on her BIMS (Brief Interview Mental Status), was independent in her ability to ambulate via wheelchair in the facility with medically complex conditions that included MDRO (multidrug-resistant organism), aphasia (difficulty expressing and communicating), and peripheral vascular disease in both lower legs. Review of R392's Orders revealed, Enhanced Barrier Precautions which includes the use of gowns and gloves for high contact resident care activities start date 7/31/2023. Review of R392's Orders reported LLL (left lower leg) wounds and RLL (right lower leg) wounds to be cleansed with wound cleanser, patted dry, oil emulsion gauze applied to wounds, covered with an ABD pad, wrapped with kerlix and ace wraps applied with light compression twice a day start date 8/9/2023. During an observation and interview on 8/7/23 at 9:39 AM, R392 had signage on her room's door indicating she was on Enhanced Barrier Precautions. The signage stated staff were to wear gown and gloves when providing direct resident cares. Infection Control Preventionist, (ICP) V was observed kneeling in front of the resident changing her wound dressings while not wearing a gown. The floor was wet beneath R392's legs where they had seeped liquid onto the floor. ICP V stated, I entered R392's room to do Ambassador Rounds. The resident wanted her wound dressings changed. There were dressing supplies in the room, and I just changed them. Honestly, I just did not think about putting on PPE. (R392) is on Enhanced Barrier Precautions and gown and gloves are to be worn when changing her wound dressings. Review of R392's Progress Note 8/7/2023 9:31 AM revealed, Upon morning rounds at approx (approximately) 0815 (AM) this nurse checked in on resident .When speaking with resident she demanded this nurse to change her dressings to BLL (bilateral lower legs) as they were leaking onto the floor and she c/o (complained of) dressings being too tight. This nurse was able to provide wound care with supplies at hand . Observed 8/9/2023 at 1:02 PM, with Licensed Practical Nurse (LPN) OO, R392 sitting in her room in a wheelchair without a barrier under her feet. Her legs were seeping clear drainage out of the ends of the wraps onto the floor. There was a puddle of clear drainage with blood from two of her toes from her right foot mingling with it. During an observation and interview on 8/9/2023 at 1:02 PM regarding R392, LPN OO stated, The wound nurse did an assessment earlier today and thought it was her heel that was bleeding, but it looks like her toes are bleeding. Observed with LPN in the corner of R392's room, a wet and soiled blue pad. LPN OO stated, That pad is soaked with fluids. Why would staff not take care of it. LPN bagged the pad without wearing gloves and put it in the dirty linen tub in the soiled utility room. 41424 During an observation on 08/08/23 at 01:50 PM, this writer observed a clear, shiny trail of dried liquid from in front of the nurse's station to Resident #392's room. In Resident #392's room she was seated in her wheelchair (with her legs not elevated) and her roommate, Resident #36, was present. Resident #392 reported she had been to see the vascular doctor earlier today. Observed Resident #392 with her legs wrapped with unaboots with what appeared to be like a [NAME] hose over them. Resident #36 reported Resident #392 had been to the doctors this morning and she was sitting here, and her legs were seeping on to the floor. Resident #392 reported the doctor told me to cover them if took a shower, as the doctor didn't want them taken off. Resident #392 reported no one had come to speak to her or look at her legs to see why they were seeping. Resident #392's roommate reported the doctor did not think they would start seeping this fast. Resident #392 reported she had left her room to see about getting a cup of coffee. Facility staff were contacting housekeeping to come and clean up the dried liquid streak on the floor. In an interview on 08/08/23 at 01:57 PM, Housekeeping Supervisor (HS) Y reported the housekeepers were contacted to come to the hallway to clean up the trail of the shiny, dried fluid leading to Resident #392's room. HS Y reported the housekeeping staff would remove the mop heads between rooms when cleaning, place them in a plastic bag and were placed in melt away bags and laundered by facility laundry staff. During an observation on 08/08/23 at 2:00 PM, Infection Preventionist (IFP) V and License Practical Nurse (LPN) D entered Resident #392's room without donning personal protective equipment (PPE) even though the door had a sign for Enhanced Barrier precautions. During an observation and interview on 8/08/2023 at 3:09 PM, Resident #392 was in her room, awake, sitting in a wheelchair with both of her lower legs wrapped in bandages. R392 stated, I went to the doctor. He cleaned my legs and wrapped them. About 1.5 hours after I came back, they started leaking fluid all over the floors. The floors had to be mopped. Nurses (ICP V and LPN D) came in to look at my legs and said they did not think it was my legs, but I told them to look at the tracks I left. In an interview 08/10/23 12:36 PM CNA Z reported Resident #392's leg was always leaking, and the facility had tried different interventions to stop the leaking but nothing was working, her legs leak all the time. CNA Z reported when Resident #392 returned from her doctor's appointment her legs were leaking and she reported they said it wouldn't leak through, but it did. In an interview on 08/09/23 at 02:21 PM, Director of Nursing (DON) B reported with Enhanced isolation would require the staff members entering to don appropriate personal protective equipment (PPE). In an interview on 08/10/23 at 11:33 AM, Infection Preventionist (IFP) V reported Resident #392 does have a history of MRSA. IFP V reported staff had paged me down to the nurse's station due to Resident #392's legs draining, and she reported she attempted to contact the provider to obtain orders and direction on treatment as the resident came back with none. IFP V reported she and LPN D went into Resident #392's room to perform an assessment on her. IFP V reported there was wetness on the covering panty hose on the bottom of her unaboots around the bottom of her feet. IFP V reported Resident #392 was recently hospitalized two times in the last month with left lower extremity (LLE) wound infection and had been on IV antibiotics. In an interview on 08/10/23 at 01:12 PM, LPN D reported she and the IFP V went into the Resident #392's room as there was a dried streak on the floor leading to her room. LPN D reported the streak on the floor appeared to be approximately about the width of a hand or heel maybe a little bit smaller than a heel, and the dried fluid was clean/clear with no additional matter or fluids in it. LPN D reported the streak appeared to have a thin streak on each side of the dried streak at various spots about footstep length along the way to Resident #392's room. 47955 During an interview on 8/9/23 at 12:57 PM, Laundry Supervisor (LS) Y reported all rags and mops are bagged on the housekeeping carts and washed together, regardless of which room they were used in. LS Y reported any visibly soiled linen was sent to laundry in a melt away bag (a bag that dissolves in hot water). LS Y reported there was no order that rooms were cleaned. LS Y reported linen from all rooms, non-isolation rooms, enhanced barrier rooms, and contact isolation room was sent to laundry in a clear plastic bag unless visibly soiled. LS Y reported that laundry staff should use universal precautions when separating linens and laundry staff should place melt away bags directly into washer. During an interview on 8/9/23 at 1:01 PM, certified nurse assistant (CNA) BB reported she placed potentially infectious linens into a bag and walked the bag directly to laundry. CNA BB reported she is to place visibly soiled linen into a melt away bag. During an interview on 8/10/23 at 11:20 AM, LS Y reported the laundry attendant has no indication if the linens are from a contact isolation room. LS Y reported all linen is received the same in the laundry room. LS Y reported only visibly soiled linen is placed into a melt away bag. LS Y reported that the laundry attendant has never worn a gown while sorting laundry. During an observation and interview on 8/10/23 at 12:23 PM, Laundry Tech (LT) S did not apply a gown or apron before sorting laundry. LT S brushed the front of her shirt against the soiled linen barrel while sorting laundry. LT S removed a blue blanket from the dryer, balled it up in her arms and against her shirt while moving linen to the table to fold. LT S touched her sleeves to the clean blanket while holding the blanket against her body to fold. LT S reported she does not wear a gown when she sorts laundry. During an interview on 8/10/23 at 2:05 PM, Licensed Practical Nurse/Infection Control Prevention (LPN/ICP) V reported she thought the laundry tech was wearing a gown and gloves when they sorted laundry. LPN/ICP V reported she found out on Tuesday that the laundry tech did not have wear a gown and gloves when sorting laundry. During an interview on 8/10/23 at 4:00 pm CNA F and CNA CC reported visibly soiled linen is to be placed into a melt away bag and placed into the general soiled linen area. Review of facility policy Washing Infectious Laundry with a review date of 1/2023 revealed .soiled linen will be sorted in the soiled laundry areas before washing. Gloves and gown/aprons Personal Protective Equipment (PPE) should be worn by laundry personnel while sorting soiled linen .

Based on interview and record review, the facility failed to allow resident room visitations for 3 of 3 residents (R4, R37, and R26), reviewed for resident choice resulting in visitation privileges inconsistent with resident preferences and potential for increased social isolation, depression, and anxiety. Findings include: Resident #4 (R4) According to the Minimum Data Set (MDS) dated [DATE], R4 scored 10/15 (moderately cognitively impaired) on her BIMS (Brief Interview Mental Status) requiring the use of a wheelchair with supervision while in the facility due to a hip fracture and replacement. During an interview on 8/9/2023 at 12:42 PM Confidential Informant (CI) BB stated, Staff is told not to tell surveyors things like residents are not allowed to go into other resident rooms to visit. Residents say this place feels like a prison. During an interview and observation on 8/9/23 at 12:50 PM R4 was lying in her bed awake, stating I like to have my friends that live here to come into my room to visit. It is not always easy for me to get out of my bed to go out into the facility and find a place to visit. I do not mind the other residents coming into my room. I was told by staff that my friends that live here cannot come into my room. I feel like I'm blocked here, like it is a prison. I live here why can't I visit where I want with others. 46999 Resident #37 Review of an Admission Record for Resident #37 dated 3/6/23, revealed the resident was admitted with the following pertinent diagnoses: Major Depressive Disorder, Anxiety Disorder. Review of a Minimum Data Set (MDS) assessment dated [DATE] for Resident #37 revealed a Brief Interview for Mental Status (BIMS) score of 13/15 which indicated Resident #37 was cognitively intact. Section D of the MDS revealed Resident #37 had feelings of hopelessness. In an interview on 8/7/23 at 8:19am, Resident #37 reported approximately 2 weeks ago, another resident was visiting her in her in room when staff came in and told them they were not allowed to visit each other in their rooms. The resident visiting Resident #37 left the room. Resident #37 reported she enjoyed visiting with the resident, who was also experiencing health issues but had gotten well enough to return home, and doing so was . good for her mood. Resident #37 reported she felt frustrated and helpless because she could not choose to visit with other residents in her room. In a telephone interview on 8/9/23 at 4:06pm, former resident II reported he went to visit Resident #37 while he was residing at the facility and was told to leave her room because the facility was no longer allowing residents to visit each other in their rooms. Former resident II reported he asked for an explanation, but none was given. Former resident II confirmed that he ended his visit with Resident #37 after a staff member told him to do so. Former resident II reported 2 staff members confirmed that room visits were no longer allowed. In an interview on 8/8/23 at 2:27pm, Certified Nursing Assistant (CENA) BB reported she was instructed by the facility to ensure residents were not visiting each other in their rooms. CENA BB reported it was the staff's responsibility to enforce not allowing residents to visit each other in their rooms, regardless of a resident's preference. Resident #26 Review of an Admission Record for Resident #26 dated 6/12/23 revealed the resident was admitted with the following pertinent diagnoses: Major Depressive Disorder, recurrent, Anxiety Disorder, and Adult Failure to Thrive (syndrome of weight loss .inactivity .depressive symptoms . Review of a Minimum Data Set (MDS) assessment for Resident #26 dated 6/18/23, revealed a Brief Interview for Mental Status (BIMS) score of 14/15 which indicated Resident #26 was cognitively intact. In an interview on 8/7/23 at 8:19am, Resident #26 reported a fell ow resident who had since returned home had been told to leave her room because residents were not allowed to visit each other in their rooms. Resident #26 reported she felt like she . was in jail . because she was not allowed to visit with others in a place of her choosing. Resident #26 indicated staff told her that if another resident entered her room to visit, she was expected to turn on her call light to alert staff because visiting in resident rooms was no longer allowed. Review of facility policy, Resident Rights updated 9/2022, revealed, Policy: It is the policy of this facility to ensure residents have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside of this facility . The resident has a right to receive visitors of his or her choosing at the time of his or her choosing .

This citation pertains to intakes: MI00132446, MI00136322, MI00136324, MI00136326, MI00136328, MI00136330, MI00137222, MI00137224, MI00137540, MI00137886 Based on observation, interview, and record review the facility failed to protect the resident ' s right to be free from resident to resident physical abuse by Resident #100 in 8 of 9 residents (Resident #113, Resident #109, Resident #106, Resident #111, Resident #108, Resident #105, Resident #107, Resident #110) reviewed for abuse, resulting Resident #113 feeling unsafe in her home, Resident #109 sustaining a head laceration, Resident #106 being slapped in the face leaving redness, Resident #111 sustaining minor injuries with continued anger, Resident #108 feeling as if Resident #100 was out to get her, Resident #107 having her arm twisted, and Resident #'s 105 and 110 being abused by Resident #100. Findings include: In an interview on 6/20/23 at 1:23 PM, the Ombudsman reported in regard to Resident #100 that there were concerns at that time that he was wandering and doing his own thing at the facility without interventions from staff. Ombusman stated, I know they have sent him out for psych evals and he just gets sent back. I have had multiple conversations with the NHA that staff need to know where (Resident #100) is at all times if they are not going to do one on ones with him and staff seems to go about their day and not have any clue where he is half the time. Residents are afraid of him. If you get in (Resident #100's) way, he gets very aggressive and violent and I am afraid a resident is going to get hurt. In an interview on 6/21/23 at 9:37am, Resident #113 reported there was a resident at the facility named Wandering (Resident Name omitted) (Referring to Resident #100) who stood at their (Resident #113 and her roommate) doorway and they (Resident #113 and her roommate) had to yell at him to get away. Resident #113 reported did not feel safe with (Resident #100) at the facility. Resident #100 Review of an Admission Record revealed Resident #100 was a male, originally admitted to the facility on [DATE] with the following pertinent diagnoses: Vascular Dementia (general term describing problems with reasoning, planning, judgement, and memory caused by impaired blood flow to the brain) with behavioral disturbance, Alcohol-induced persisting Dementia, Disorientation (state of mental confusion), Restlessness and Agitation, Anxiety Disorder, Weakness. Review of a Minimum Data Set (MDS) assessment for Resident #100 dated 6/12/23, revealed Resident #100 entered the facility from a psychiatric hospital on 12/20/21. Resident #100 was sometimes able to make self-understood and sometimes understood others. A Brief Inventory of Mental Status (BIMS) assessment was not attempted due to Resident #100's severe cognitive impairment. Section D (Mood) of the MDS revealed Resident #100 displayed trouble falling asleep or sleeping too much, trouble concentrating on things such as reading or watching television and several days of being short tempered, easily annoyed. Section E (Behavior) of the MDS revealed Resident #100 rejected care 1 to 3 days during the assessment period and wandered daily. Section G (Functional Status) revealed Resident #100 walked independently but was unsteady and required extensive assistance of 2 staff to transfer from one surface to another, i.e., from sitting to standing. Review of a current Care Plan for Resident #100 revealed a problem initiated on 5/25/23 He becomes extremely restless and agitated which may escalate into physical aggression toward others. Approaches for this problem included: Assess if (Resident #100's) behavioral/mood symptoms present a danger to himself and/or others. Intervene as needed Engage (Resident #100) in brief conversation, redirect to an activity, offer food/drink . Separate (Resident #100) from other residents immediately with any display of anger or irritability . Review of Facility Reported Incidents from 10/14/22-5/23-23 revealed Resident #100 was involved in 12 Resident to Resident altercations, all 12 took place in the afternoon or early evening, 7 occurred in the dining room, 5 involved Resident #100 reaching for or taking another Residents' cup. All incidents occurred in the common areas of the facility. 10 of the 12 incidents involved other Residents who also had a diagnosis of dementia with behaviors. 8 of the incidents were unwitnessed by staff. 4 incidents involved Resident #100 either touching or pulling another Resident's hair. I incident involved Resident #100 grabbing another Resident's personal belongings. During the altercations, Resident's #109, #111 and #100 had minor injuries. Review of an Observation Detail List Report dated 5/22/23 at 6:32pm revealed Resident #100 had scratches on his right arm following an altercation with Resident #111. Report stated Nurse walked in to see chocolate milk thrown at resident (Resident #100) by another resident (Resident #111) and both resident were throwing fists and grabbing and scratching each other. In an interview on 6/21/23 at 2:57pm, Certified Nursing Assistant (CENA) H reported it was not possible to provide enough supervision for Resident #100. CENA H found Resident #100 and another Resident in an altercations by the nurse's station on 6/20/23, both were trying to gain possession of a filled coffee cup with no other staff present. CENA H reported there was no opportunity to intervene before both Residents were upset, physically grabbing for the cup and at risk for having a hot beverage spill on them. CENA H also reported that Resident #100 was often up all-night walking, and no staff were available to supervise him. CENA H confirmed she witnessed the altercations between Resident #100 and Resident #109 and Resident #100 and Resident #110( 2 seperate altercations). CENA H reported she did not observe the events leading up to the altercations, the Residents were unsupervised at that point, but heard yelling and arrived to find the Residents in physical altercations involving a coffee cup. In an interview on 6/21/23 at 4:14pm Licensed Practical Nurse (LPN) O reported Resident #100 had periods in which he did not sleep for up to 3 days at a time and when that occurred, Resident #100 became manic (exhibiting extreme behaviors). LPN O reported that Resident #100 wandered the halls for hours at times, became extremely fatigued, looked exhausted and could not be constantly supervised. Review of the electronic medical record revealed on 6/22/23 Resident #100 was transferred to a chair in the sunshine room at 5:39am. During an observation on 6/22/23 at 8:14am, Resident #100 remained in the Sunshine Room near a dining table, seated on a metal folding chair. Resident #100 was alone in the room. A breakfast tray sat on the table near Resident #100 who sat facing the middle of the room. The food on the tray was neatly placed in sections of the tray, no indentations were present to indicate Resident #100 had tried to eat it. A spilled bowl of oatmeal was on the floor, with approximately 75% of the content on Resident #100's pants, socks and right foot dressing. Resident #100's feet had edema (swelling which can be associated with legs being in a dependent position for long periods of time), the right foot was bandaged, reddened swollen exposed skin was evident just above the dressing. A spoon rested on the floor between Resident #100's feet. Resident #100 was awake, sat flexed at the waist at 80 degrees, attempted to pick up the spoon between his feet. Mucus, approximately 4 in length, hung from Resident #100's nose. Resident #100 licked oatmeal residue off his fingers as his torso remained in the forward flexed 80 degree angle for the next 19 minutes. At that time Registered Nurse (RN) T was heard outside the door of the Sunshine Room saying Did anyone know this man was down here? Certified Nursing Assistant (CENA) J responded and stated No, I did not. CENA J entered the room and began cleaning the oatmeal of Resident's pants. During an observation on 6/21/23 between 2:35pm-2:51pm, Resident #100 wandered from a crowded area across from the nurse's station to the end of the hall, entered the Sunshine Room for 30 seconds, then returned down the hall to the nurse's station. Resident carried 3 empty coffee cups as he completed this route twice, unobserved by staff. In an interview on 6/27/23 at 9:22am Housekeeper FF reported a schedule was initiated for housekeeping staff to check the floor of the Sunshine Room after each meal because Resident #100 frequently urinated there when unsupervised. Housekeeper FF reported she found urine on the floor in the Sunshine Room several times a week and that Resident #100 was the only Resident who had this behavior. In an interview on 6/27/23 at 10:02 am with Laundry Supervisor/Certified Nursing Assistant (CENA) K, it was revealed that Resident #100 regularly urinated on the floor of the Sunshine Room when he was unsupervised. When asked about the frequency of this happening, CENA K reported it had happened as often as daily. CENA K reported it was likely urine had seeped under the tiles due to the frequency in which Resident #100 urinated on the floor and the smell was difficult to resolve as a result. During an observation on 6/21/23 at 10:21am, a strong smell of urine was present in the Sunshine Room. The room was empty at the time. During an observation on 6/26/23 at 4:15pm, a strong smell of urine was present in the Sunshine Room. The room was empty, floor appeared clean. During an observation on 6/27/23 at 8:43am, a strong smell of urine was present in the Sunshine Room. The room was empty at the time. Resident #109 Review of an Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #109 scored 4 of 15 on a Brief Inventory of Mental Status (BIMS) assessment which indicated the Resident was severely cognitively impaired. Resident #109 had episodes of disorganized thoughts but did not display aggressive behaviors toward others. Resident #109 was independent with using a wheelchair for mobility and did not ambulate. Review of a Facility Reported Incident report dated 4/11/23 revealed Resident #109 was struck in the head twice with a coffee cup by Resident #100 at 4:00pm in the dining room of the facility. Resident #109 was heard screaming and reported the incident to Licensed Practical Nurse (LPN) W who responded. Resident #109 had a 1.5 cm laceration on her head. In an interview on 6/21/23 at 2:57pm, Certified Nursing Assistant (CENA) H reported she observed the altercation involving Resident #109 and Resident #100 and said she did not know what triggered Resident #100, but it often seemed to involve cups. CENA H felt it was impossible to monitor Resident #100 all the time and impossible to predict the altercations that could arise. In an interview on 6/26/23 at 10:02am Licensed Practical Nurse (LPN) W reported she heard Resident #109 screaming on 4/11/23 and found her in the dining room with a laceration on her head. Resident #100 was standing near Resident #109 and was removed from the room. LPN W reported Resident #100 had frequent altercations with others. In an interview with Resident #109 on 6/22/23 at 10:52am, the resident could not recall the incident. Based on a reasonable person concept, Resident #109 would not have wanted to be hit twice in the head causing head trauma and would likely have had lingering pain due to the resident to resident abuse that occurred. Resident #106 Review on an Admission Record dated 10/21/16 revealed Resident #106 was admitted to the facility with the following pertinent diagnoses: Dementia with Agitation, Diffuse Traumatic Brain Injury, Major Depressive Disorder, Anxiety Disorder and Muscle Weakness. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #106 scored 6 of 15 on a Brief Interview for Mental Status (BIMS) assessment which indicated she was severely cognitively impaired. Resident #106 expressed feelings of depression during 7-11 days during the 14-day assessment period. Review of a current Care Plan for Resident #106 revealed problem/goal/approaches stated, Diagnosis of depression .sadness may also display as anger when confusion is increased . Interventions for this problem included avoid over-stimulation .other physically aggressive Residents, assess whether behaviors endanger (Resident's Name), intervene if necessary . Review of a Facility Reported Incident dated 12/19/22 at 6:42pm, revealed Resident #106 was involved in an unwitnessed Resident to Resident altercation. A former Resident who had a Brief Interview for Mental Status score of 15 (cognitively intact) reported that Resident #106 was hit in the face by Resident #100. Resident #106 was found screaming and crying hysterically and reported she had been hit in the face. Staff observed that Resident #106 had a reddened area on her face that extended from her cheek to her forehead. Resident #100 was agitated, used profanity, and verbalized threats toward staff as they removed him from the area. In an interview on 6/21/23 at 11:14am, Resident #106 was unable to recall the altercation that took place with Resident #100. Based on the reasonable person concept, Resident #106 would not have wanted to be slapped in the face so hard it left a reddened area on her face leaving her screaming and crying hysterically. Resident #111 Review of an Admissions Record dated 11/16/14 revealed Resident #111 was admitted to the facility with pertinent diagnoses that included: Vascular Dementia with behavioral disturbances(a disease causing a progressive decline in cognitive skills), Major Depressive Disorder, Anxiety Disorder, Post Concussive Syndrome (symptoms that occur after a brain injury which may include physical, cognitive, behavioral or emotional in nature), and Receptive-Expressive Language Disorder(decreased ability to understand others and express own thoughts). Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #111 scored 4 of 15 on a Brief Interview for Mental Status (BIMS) assessment which indicated he had a severe cognitive impairment. Review of a current Care Plan for Resident #111 revealed a Problem, Goal and Approaches as follows: Problem: behavioral disturbance .flipping people off, yells, says curse words Goal: Maintain behavioral functioning and management of symptoms Approaches: Avoid other physically aggressive Residents, Assess whether behavior endangers (Resident name) or others, Intervene. Resident #111's current Care Plan also revealed a Problem, Goal, Approaches which stated: Problem Does not like others around his personal space in the dining room, Goal Will exhibit decreased agitation, Approaches Attempt to keep in calm environment and away from large groups of people if he appears agitated, Remind (Resident Name) not to use profanity, use finger gestures or call others names, Remove from common areas as needed. Review of a Facility Reported Incident report dated 5/22/23 revealed Resident #111 and Resident #100 were unsupervised in the dining room when an altercation occurred between them. The altercation took place after Resident #100 attempted to take a cup from Resident #111. When a nurse arrived, Resident #111 threw the cup at Resident #100 and both Residents were punching and grabbing each other. Both Residents had abrasions on their arms. On 5/24/23 Resident #111 remained angry about the incident and yelled when he discussed it with the Social Services Director. During on observation on 6/22/23 at 9:11am, Resident #100 was standing in the hallway near the nurse's station. Resident #111 sat nearby in a wheelchair and pointed his hand in a gun shape at Resident #100 and made 2 shooting sounds while bending his thumb in a trigger motion. Resident #111 then gestured with his thumb, in a motion used by baseball officials to indicate out and pointed at Resident #100. Using the reasonable person concept, though Resident #111 had decreased ability to verbally express his own thoughts, he was clearly still angry with Resident #100 as identified by the threatening behavior of pretending to shoot Resident #100 and indicated he was going to be taken out. Resident #108 Review of an Admission Record dated 9/15/21 revealed Resident #108 was admitted to the facility with the following pertinent diagnoses: Hemiplegia (paralysis on one side), Hemiparesis (loss of strength on one side), Major Depressive Disorder, and Generalized Anxiety Disorder. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #108 scored 15/15 on a Brief Interview for Mental Status (BIMS) assessment which indicated the Resident was cognitively intact. Resident #108 had no symptoms of delusions (misconceptions contrary to reality), no behaviors or episodes of aggression toward others. Resident #108 was independent with wheelchair mobility. Review of a current Care Plan revealed a problem/goal/approaches initiated on 8/19/21which stated: Problem (Resident Name) .requires 24-hour care/supervision .Goal (Resident Name) will reside at (facility name) for 24-hour care/supervision while maintaining her dignity and highest level of functioning .Approaches Staff to provide 24-hour supervision. Review of a Facility Reported Incident report dated 2/18/23, 4:34pm, revealed Resident #108 was heard saying ouch and reported she had been kicked in the leg by Resident #100 while in the hallway. Review of a Facility Reported Incident report dated 3/13/23 revealed Resident #108 was attending an activity in the Sunshine Room when Resident #100 approached her with a raised arm while holding a coffee cup and appeared as though he was going to hit Resident #108. Resident #100 was removed from the room. Resident #108 was fearful after this incident and called the police due to being fearful. In an interview on 6/21/23 at 2:42pm Resident #108 reported Resident #100 kicked her in the leg on 2/18/23. Resident #108 reported she believed Resident #100 was stressed after being told to leave the Sunshine Room (activity room near Resident #108's room) and acted out when he encountered Resident #108 in the hallway. Resident #108 reported she was not injured when Resident #100 kicked her, but it did hurt, and thought the Resident was out to get her. Resident #105 Review of an Admission Record dated 5/23/22 revealed Resident #105 was admitted to the facility with the following pertinent diagnoses: Unspecified Dementia (progressive disease resulting in loss of cognitive skills) with behavioral disturbance, Major Depressive Disorder, Anxiety Disorder. Review of a Minimum Data Set (MDS) for Resident #105 dated 5/23/23 revealed a Brief Interview for Mental Status (BIMS) score of 2/15 which indicated Resident #105 was severely cognitively impaired. Resident #105 experienced disorganized thinking (rambling or irrelevant conversation), had episodes of feeling badly about herself, feeling depressed, and wandered. Section E of the MDS revealed Resident #105 wandered during 1-3 days of the assessment period. Review of Facility Reported Incidents revealed Resident #105's hair was pulled by Resident #100 on 10/28/22 and 5/23/23. Both incidents occurred in common areas of the facility, one was witnessed by a staff member, the other was reported by a resident. The unwitnessed incident occurred across from the nurse's station where staff were working nearby. The staff looked up after being alerted of the situation by another Resident and observed Resident #100 walking away. In an interview on 6/22/23 at 9:42am, Certified Nursing Assistant (CENA) I reported she witnessed Resident #100 tug on Resident #105's hair as he walked by on 5/23/23. Both residents were near the nurse's station in the hallway. Resident #105 was calling out that day. CENA I reported Resident #100's behaviors, such as pulling Resident #105's hair, were triggered by other residents who call out and although the staff try to keep a distance between Resident #100 and others, they could not always supervise the common areas. During an observation on 6/21/23 at 1:56pm, Resident #105 was in the common area near the nurse's station calling out and reaching for those who passed by. During an observation on 6/21/23 at 4:07pm, Resident #105 was in her wheelchair near the doorway in her room, appeared frustrated and called her roommate a pain in the a** in a loud tone. No staff were present to intervene. During an observation on 6/22/23 at 1:56pm, Resident #105 propelled her wheelchair in the hallway, approached a room where another resident was calling out, Resident #105 yelled loudly Shut up, shut up Dam .t. No staff were present to intervene. Resident #107 Review of an Admission Record dated 8/20/18 revealed Resident #107 was admitted to the facility with the following pertinent diagnoses: Bipolar Disorder (mental condition marked by alternating periods of elation and depression), Dementia (a progressive disease causing decline in cognitive skills), Generalized Anxiety Disorder, Schizophrenia, and Moderate Intellectual Disabilities. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #107 scored 9 of 15 on a Brief Interview for Mental Status (BIMS) assessment which indicated he had a moderate cognitive impairment. Resident #107 showed no evidence of delusions (misconceptions contrary to reality) and had episodes of aggressive behavior during the assessment period. Review of a current Care Plan for Resident #107 revealed problem/goal/approach as follows: (Resident #107) requires 24-hour supervision .Goal (Resident #107) will reside at (facility name) for 24-hour supervision while maintaining his dignity .Approaches . Provide 24 hour supervision. Review of a Facility Reported Incident report dated 1/12/23 at 4:35 pm revealed Resident #107 was involved in a Resident to Resident altercation in his arm was grabbed and twisted by Resident #100. Resident #100 tried to take Resident #107's coffee cup. Per the report, the incident was not initially witnessed by staff but upon entering the dining room, staff observed Resident #100 twisting Resident #107's arm. Resident #110 Review of an Admission Record dated 11/28/22 revealed Resident #110 was admitted to the facility with pertinent diagnoses that included: Mood Disorder with Depressive Features, Dementia with Moderate Mood Disturbance, and Anxiety Disorder. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #110 scored 4 of 15 on a Brief Interview for Mental Status (BMS) assessment which indicated she had a severe cognitive impairment. Resident #110 had episodes of verbal and physical aggression 4 to 6 days during the 14-day assessment period. Resident #110 was not able to walk and was dependent on staff for moving her wheelchair. Review of a current Care Plan for Resident #110 revealed a Problem/Goal/Approach of Problem: Displays extreme restlessness and agitation, verbal and physical Goal Will not harm self or others Approaches Avoid over-stimulation .other physically aggressive Residents, Keep away from other Residents when extremely agitated. Review of a Facility Reported Incident report dated 5/10/23 revealed on 5/9/23 at 7:55pm Resident #110 was sitting in a common area displaying verbal behaviors, yelling out and disturbing others. Staff attempted to redirect without success and did not remove Resident #110 from the area. Resident #100 who was known to be triggered by noise, walked by, and pulled Resident #110's hair. Review of a Facility Reported Incident dated 5/22/23 revealed on 5/21/23 at 6:35pm, Resident #110 was sitting near the nurse's station with a cup of coffee. Per the report, Resident #110 yelled at Resident #100 as he walked by, and Resident #100 grabbed Resident #110's arm. In an interview on 6/21/23 at 2:57pm, Certified Nursing Assistant (CENA) H reported she observed an altercation involving Resident #110 and Resident #100 and said she did not know what triggered Resident #100, but it often seemed to involve cups. CENA H reported during the most recent incident, both Resident #110 and Resident #100 were in the area across from the nurse's station. No other staff were present. CENA H arrived to find Resident #100 trying to take a cup out of Resident #110's hands. Both Residents were struggling for possession of the cup. CENA H felt it was impossible to monitor Resident #100 all the time and impossible to predict the altercations that could arise. During an observation on 6/21/23 at 4:00pm, Resident #110 was sitting in her wheelchair near the nurse's station calling out to others as they passed by. The common area was congested with several residents in wheelchairs, 2 were calling out as Resident #100 ambulated between their wheelchairs. In an interview on 6/27/23 at 11:48am, Director of Nursing (DON) B reported the area around the nurse's station should be kept clear to avoid additional incidents of Resident #100 becoming overwhelmed and acting out toward other residents. In an interview on 6/27/23 at 9:28am, Certified Nursing Assistant (CENA) G revealed a nurse was supposed to supervise residents in the dining room during each meal. CENA G reported this supervision was usually provided during the day shift but was inconsistent during the afternoon shift. CENA G expressed concern about the lack of supervision in the dining room because anything could happen. Review of Resident Council minutes dated 5/18/23 revealed Residents expressed a concern which stated A nurse needs to help feed (assist Residents who cannot eat independently) and be in the dining room for safety.

This citation pertains to Intake # MI 729. Based on interview, and record review, the facility failed to ensure pain management was provided for a resident with severe pain in 3 residents (Resident #110, #105, #111) reviewed for pain management resulting in unrelieved pain that impacted the resident's functional status, quality of life, and increased their mental anguish. Findings include: Resident #110 Review of an Admission Record revealed Resident #110 was a male, with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Safety Events - Fall Events document completed on 9/30/21, revealed, .Exact Time Event Discovered: 09/30/21 06:55 PM .Pain Observation: Does resident exhibit or complain of pain related to the fall? If so, describe location .Yes, right knee .On a scale of 0-10, how does the resident rate intensity of pain if able, or indicate based on observation .5 .(4-Moderate Pain-Distressing Miserable, 7-Severe pain-horrible, intense) .What intervention(s) did yo provide to provide comfort to resident post fall .Repositioning (Other Option to select: Pharmacological (Medications, include topicals) .Did the fall result in an injury? .Bruise, Right Knee .Pain w/ROM (range of motion)-right knee (Other Option to select: Fracture) .Range of Motion findings: ROM Painful/Limited in Lower Extremity - right knee .Positioning of Extremities: Rotation/Deformity/Shortening of Right Lower Extremity .Describe: When attempting to turn to side noted knee stays but lower shin area moves, swelling to knee .Lower Right Extremity Movement: Unable to do - painful to move .Does resident exhibit or complain of any of the following since the fall .Pain .Interventions: Other: Educate staff regarding making sure resident put to bed before leaving floor .Notification: 09/20/21 07:35 PM, name of MD/NP/PA notified (Medical Doctor PP) .Notification to Director of Nursing/Clinical Leader: 09/30/21 07:38 PM .Orders: (Note: No orders noted under this section) . In an interview on 11/16/21 at 2:12 PM, Certified Nursing Assistant (CNA) U reported after Resident #110 had the fall and broke his leg and the immobilizer was placed, .It was horrible during cares as he was in so much pain .We couldn't roll him to provide care without him screaming in pain .He was crying out for Jesus .I was so upset for him because he was in so much pain .It took 3 staff members to take care of him . In an interview on 11/16/21 at 4:22 PM, Certified Nursing Assistant (CNA) I reported she worked the night Resident #110 broke his leg. CNA I stated, .He (Resident #110) fell sometime after dinner .He was in a lot of pain .Staff could barely touch it and he was in pain .The nurse doing the meds who worked that night .didn't do an accurate assessment on him .She was yelling at the other girl to come and assess him .The nurse was rude and yelling at the aides .He didn't get sent out (to the ER) when I was there .They called for the x-ray to come in .They didn't come when I was there .Terrible how he was treated . In an interview on 11/17/21 at 07:30 AM, Certified Nursing Assistant (CNA) J stated, .From what I was told he was given Tylenol at 7-8 o'clock that night (9/30/21) and they said they couldn't send him out because the x-rays were inconclusive .He was in bed when I came in at 10:00 PM .He hadn't been changed .They were told not to touch him .Was told not to touch him for the rest of the night .He was crying and yelling out in pain .He couldn't even move and he was in pain .and they didn't send him out .I left at 06:00 AM and he was still at the facility when I left . In an interview on 11/17/21 at 09:40 AM, Licensed Practical Nurse (LPN) M reported she completed an additional assessment and range of motion indicating Resident #110 had an obvious displacement. LPN M stated .When I went in as a second set of eyes, (Resident #110) was laying in his bed .He was in a lot of pain .If I was his nurse and responded initially, I would have left him on the floor and contacted the doctor and stressed to him the condition of his leg and how painful the resident was .If the doctor didn't indicate the resident should be sent out . LPN M stated .I would use the, When in doubt, Send out .And send the resident to the hospital . In an interview on 11/17/21 at 9:52 AM, Certified Nursing Assistant (CNA) T stated, .I was on break and got a call on my phone from my hall partner, CNA H stating 911 in (Resident #110's room) .I was running down the hall .I told (ADON C) something happening in that room .I get into the room and he is on the floor screaming grabbing his leg .(ADON C) comes in and asks us to move him and get him in the bed .I told her that we can't move him until she assesses him .We would get into trouble if we moved him and she didn't assess him first .She briefly looked at his leg and said that he was fine that he just bumped it on the dresser and he would be okay .She told us to get the hoyer and get him off the floor .We told her that she needs to take another look at his leg as I thought there was something really wrong with it .We asked his roommate what happened and he said that he was leaning in his night stand and slid out of his wheelchair .She told us to get him up and in the hoyer .He was in so much pain .We tried to stabilize his leg when moving him to the bed .Once he was in bed, she told us to remove his clothing so she could assess him more .She left the room .He was screaming in pain .I didn't see her give him anything for the pain .When she came back after we removed his clothing .I told her that he was ready (when we removed his clothing) and it took 10-15 minutes or more for her to come back and assess him further .When she came back his knee was twice the size it was when we first responded .His leg was starting to turn colors from the bruising .She was very rough with him .Trying to move his leg this way and that way .He was in excruciating pain .I didn't want to move him because you don't move someone who has fallen as you never know if someone has a spinal injury .They never sent him out while I was there and x-ray hadn't come either . In an interview on 11/17/21 at 11:57 AM, Certified Nursing Assistant (CNA) H stated, .I reported to the ADON that I had made eyes on my group and (Resident #110) was in the dining room as he was still eating .He likes to take his time to eat .I pass the dining room again and he was still in there eating .When I came back towards the nurse's station .And I heard someone screaming from down the hallway .I start walking fast down the hallway and the (ADON C)was asking who it was .Didn't take long to figure out it was (Resident #110) .I go in the room and he has slipped out of his wheelchair and he is like sitting on his foot pegs .He is holding his right knee and he is screaming, yelling, swearing .I told him to stay still so the nurse can assess you .I poked my head out the door and yelled for the nurse .waited .Still no one . yelled again .That is when I called my hallway partner with 911 .CNA T running into the room .Still no nurse .She stayed with him and I went out of his room to get the nurse .She came in and told us to get him up .Can't move him without you assessing him first .She was trying to ask him what happened .He is yelling and holding his knee .Told us to pick him up .I know not to move him until she has assessed him and she hadn't assessed him yet .said she can't assess unless he is on the bed .We get the wheelchair out from under him .It was only a few inches as he was on the foot pedals .Guided him to the floor .Now he is laying flat on the floor .She asked if anything hurt and he replied, Yes, my [OBSCENITY] ing knee .She is assessing him and she is grabbing on his knee, one hand on the top and then underneath she pushes up and she forcibly straightens his leg .He yelled out in pain .She directed us to get him in the bed .Told her if we use the hoyer it is going to put pressure on his leg and it is going to hurt him more .She said he needs to get off the floor and into the bed .We were asking the roommate what happened and he said he was looking in his night stand and slipped out of his chair .We were trying to figure out how to get him in the bed .We had to use the hoyer .and he as crying in pain and the other aide was supporting his leg if anything was broken .We got him in the bed and got his pants off .We were trying to be really careful but he was screaming in pain .It took her awhile to come back and complete her assessment .By the time she got there his knee was swelling up and bruising was happening .We suggested to her that he should be sent out .That it is swollen that fast and it doesn't look good .She told us to leave the wet brief under him, unstrapped and got a clean, dry on e and placed on the front part of him and tucked it so when he urinated it wouldn't go all over .She told me to do that .Told 3rd shift to do that as well as not to move him in case it was broken .She said the xray people were coming to xray it .By the time I left, xray had not been there yet .When I came back the next day and asked about him, I was told that he was sent out this morning and he was back with a knee brace .It took us like 2-3 people to change him .It was bad .Told him if he wanted to squeeze my hand that he could .He was hitting, yelling, screaming .He had tears in his eyes .He is a tough guy and for him to have tears .I know that he was hurting . This writer spoke with the Director of Nursing (DON) B and she informed this writer the ADON no longer works for the facility. This interviewer attempted to contact ADON C prior exit and did not hear from her prior to exit. On 11/17/21 at 12:36, tried to contact facility physician regarding Resident #110 left a message with Medical assistant VV, no calls returned by exit. In an interview on 11/17/21 at 3:39 PM, Director of Nursing (DON) B notify the physician and provide them with a clear story of what is going on and what you are observing. They should suggest to send the resident out. You are the eyes for the physician and if there is an obvious displacement you are to inform them of that. DON B reported if the physician doesn't give the order to send out and as the nurse you deem that the resident requires additional care, as in this case, you would send the resident out. Review of Standards of Nursing Practices reviewed on 01/2021, revealed, .Pain Management: The licensed nurse will strive to minimize and manage the residents pain. Residents will be assessed for pain .after a fall .The licensed nurse will communicate with the physician regarding the resident's potential need for routine pain medication . Review of Fall Prevention and Management Program reviewed 01/2021, revealed, .6. If the resident has sustained injuries that require transfer to an acute care setting then a INTERACT hospitalization Transfer form will be completed and copy sent with resident upon transfer . Review of Care Standards reviewed on 01/2021, revealed, .4. DO NOT MOVE THE RESIDENT IF IT MAY RESULT IN FURTHER INJURY .5. Notify the primary physician immediately for orders, if a suspected injury has occurred request transfer order to an Emergency Care Center . Review of Notification of Change reviewed 7/2021, revealed, .NOTIFY THE PHYSICIAN IMMEDIATELY IF THE RESIDENT REQUIRES IMMEDIATE ACTION .CALL 911 IN EMERGENCY SITUATIONS such as fall with head or neck injury, and or other traumatic injury .3. When a situation is emergent or becomes emergent the licensed nurse may initiate the 911 system .7. Once the Physician calls back, describe resident's condition. Document physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . automatic transfer of the resident to the emergency room or admission to the hospital . Review of the policy/procedure Pain Management, dated 1/2021, revealed .(Company Name) believes pain is a personal experience that, if left undertreated or mismanaged, can radically change a residents quality of life and impact their overall well-being. A residents pain is best treated and managed by an interdisciplinary team that actively engages the resident in the development of an effective treatment plan. Our pain management program will utilize a combination of methods, encompassing a holistic, person-centered approach .Each member of the Interdisciplinary Team has the responsibility to advocate for the residents comfort and to take in account their benefits, preferences, burdens of treatment, risks of potential adverse effects, while providing the resident with options to all appropriate interventions, including; medications, nonpharmacological approaches, and complementary therapies in the development of the residents individualized pain management plan .It is the responsibility of all direct care staff to be vigilant for sign and symptoms suggesting pain during the resident daily activities .Prior to any medication administered to the resident, the residents physician or practitioner will be consulted to select the appropriate classification, dose, route of delivery and time frame for administration . Resident #105 Review of a Face Sheet revealed Resident #105 was a female, with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #105, with a reference date of 10/4/21, revealed a Brief Interview for Mental Status (BIMS) score of 12, out of a total possible score of 15, which indicated moderate cognitive impairment. Review of a current Care Plan for Resident #105 revealed the problem .has actual pain r/t (related to) pressure ulcers, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident #105) complains of pain on daily basis, she has no outward FLACC scoring (a measurement used to assess pain) showing pain and she is able to be redirected with simple conversations and will deny pain when asked details regarding pain. (Resident #105) is prescribed routine [MEDICATION(S)] for pain management . with interventions which included .Administer pain medication(s) as ordered . with a start date of 7/6/18. In an observation on 11/9/21 at 10:48 a.m., Resident #105 was noted in bed in her room. Noted visible loose, yellow-brown bowel movement on her buttocks and sheets. Observed Resident #105 tapping her bed remote on the edge of her tray table, repeatedly yelling .I'm burning! I'm burning! and asking for help. Observed Certified Nursing Assistant (CNA) W and CNA AA respond, after notification by surveyor, to assist Resident #105 with incontinence care. Resident #105 continued to call out, yelling .I hurt! I burn! Observed a padded dressing on Resident #105's buttocks, dated 11/8/21, saturated with bowel movement. Observed CNA W and CNA AA remove the soiled dressing and perform incontinence care. Resident #105 was tearful, and stated .it hurts bad . Noted buttocks appeared reddened/irritated and sensitive. Observed a whiteboard beside the bed, which contained notes written by Resident #105. Observed a note which stated .I hurt . CNA AA notified the nurse of Resident #105's increased pain and need for pain medication and a new wound dressing. Review of the current Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Chronic pain Three Times A Day 08:00 AM, 02:00 PM, 08:00 PM . with a start date of 7/24/21 and no end date, and .[MEDICATION(S)] Immediate release .15 mg .Twice A Day 08:00 AM, 08:00 PM . with a start date of 8/23/21 and no end date. In an observation on 11/9/21 at 11:32 a.m., Registered Nurse (RN) C prepared medications for Resident #105 at the medication cart in the hallway, outside Resident #105's room. Observed RN C prepare [MEDICATION(S)] 150 mg and [MEDICATION(S)] 15 mg for Resident #105, along with the remainder of Resident #105's scheduled morning medications. RN C then administered the medications to Resident #105, in the resident's room. Note both pain medications were scheduled for 8:00 a.m. (late administration). Resident #111 Review of a Face Sheet revealed Resident #111 was a female, with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #111, with a reference date of 9/16/21, revealed a Brief Interview for Mental Status (BIMS) score of 12, out of a total possible score of 15, which indicated moderate cognitive impairment. Review of a current Care Plan for Resident #111 revealed the problem .has potential for / actual pain r/t (related to) decreased mobility, [CONDITION(S)] (an eye condition that can cause [CONDITION(S)]), depression, CHF (congestive heart failure), DM (diabetes), OA (arthritis), PVD (peripheral vascular disease). At times (Resident #111) will have complaints of pain to her knees and lower back . with interventions which included .Administer pain medication(s) as ordered . with a start date of 12/30/16. Review of the current Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .every morning arthritis pain Once A Morning 08:00 AM . with a start date of 1/31/19 and no end date. In an observation and interview on 11/9/21 at 11:51 a.m., Registered Nurse (RN) C prepared morning medications for Resident #111 at the medication cart in the hallway, outside Resident #111's room. RN C reported there were no 500 mg Acetaminophen tablets available at this time, so the medication would not be administered. RN C initialed and circled the initials in the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . RN C then finished preparation of the remainder of Resident #111's medications, and administered the medications to Resident #111, in the resident's room. No scheduled 8:00 a.m. Acetaminophen was administered to Resident #111 at this time. In an interview on 11/17/21 at 4:19 p.m., Director of Nursing (DON) B reported medications should be administered within one hour before to one hour after the scheduled administration time.

This citation pertains to Intake # MI 729. Based on observation, interview, and record review the facility failed to provide adequate supervision for 2 residents (Resident # 112, #110) of 22 residents reviewed for accidents/hazards resulting in the potential for residents to sustain a fall injury which have the potential to negatively affect the residents highest practicable physical, mental, and psychosocial well-being. Findings include: According to Potter and Perry, (2017) The patient's mobility problem is an obvious priority because of its influence on risk for falls and skin integrity. Plan individualized interventions on the basis of the severity of risk factors and the patient's developmental stage, level of health, lifestyle, and cultural needs (Box 27-7). Planning involves an understanding of the patient's need to maintain independence within physical and cognitive capabilities. Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Fundamentals of Nursing - Ninth Edition - E-Book (Kindle Locations - ). Elsevier Health Sciences. Kindle Edition. Review of Fall Prevention and Management Program reviewed 01/2021, revealed, .A key component in reducing fall reoccurrences is the program's in-depth investigation to determine contributing factors that places the resident at risk and the root cause(s) of the fall event. Considerations: Why is it important? There are several reasons: * .About 1 in 3 who fall will fall two or more times in a year .* Falls often have serious consequences, especially in fail older residents. Fall-related injuries decrease the residents quality of lie and ability to function .One in every 10 residents who fall has a serious related injury and about 65,000 residents suffer a [CONDITION(S)] each year .*Adverse consequences of falls for residents can include: Reduced quality of life, increase fear of falling, restriction of activities, decrease ability to function, serious injuries, and increase risk of death . Resident #112: Review of an Admission Record revealed Resident #112 was a male, with pertinent diagnoses which included dementia with behavioral disturbances, repeated falls, Alzheimer's disease, [CONDITION(S)] with delusions, abnormalities of gait and mobility, lack of coordination, history of falls, attention and concentration deficit, difficulty in walking, adult failure to thrive, weakness, fracture of neck of left femur, pain in right knee, reduced mobility, pain in left knee, depression, unsteadiness on feet, traumatic brain injury, and joint replacement surgery. Review of a Minimum Data Set (MDS) assessment for Resident #112, with a reference date of 9/16/21, revealed a Brief Interview for Mental Status (BIMS) score of 6, out of a total possible score of 15, which indicated severe cognitive impairment. Further review of this MDS assessment, dated 9/16/21, revealed Resident #112 was totally dependent on two staff for transfers. Review of a Minimum Data Set (MDS) assessment for Resident #112, with a reference date of 9/16/21, revealed, .Locomotion on unit - how resident moved between locations in his/her room and adjacent corridor on same floor. If in wheelchair, self-sufficiency once in chair .Supervision - oversight, encouragement or cueing .One person physical assist . Review of Review of a Minimum Data Set (MDS) assessment for Resident #112, with a reference date of 9/16/21, .Section P: Alarms: Bed alarm used daily .Chair alarm .Used daily . Review of current Care Guide provided on 11/15/21 at 3:56 PM revealed, .Pressure alarm chair/bed, toilet upon rising, before/after meals .padded fall mat when in bed . Review of a current Care Plan for Resident #112 revealed the focus .At risk for falls and subsequent injury related to: impaired mobility weakness, and cognitive deficits .Diagnosis of Dementia, Seizures, Diabetes, [CONDITION(S)], [CONDITION(S)] (high blood pressure), GERD .(Resident #112) will self transfer from wheelchair to floor mat to lay himself down . with the interventions of .Locate bed controls and alarms out of reach of (Resident #112) as he has h/o (history of) turning alarms off and altering his bed height .Keep w/c (wheelchair) alarms under seat of wheelchair for safety as he will disable if within reach .Ensure pressure pad alarm to bed and check for functioning every shift and PRN (as needed) .Increase supervision, give additional reminders to call, ask, and await for assistance . Review of Orders dated 9/14/21 revealed, .Check placement and function of pressure sensor alarm to bed q (every) shift .Special Instructions: Ensure pressure sensor alarm is on, functioning and in appropriate position to be effective . Review of Orders dated 9/14/21, revealed, .Check placement and function of pressure sensor alarm to bed q (every) shift; Every shift: Days, Evenings, Nights, Start Date: 9/14/21 - Open ended . Review of Safety Events - Fall Events dated 9/27/21, revealed, .Exact time Event Discovered: 09/27/21 06:32 PM .No witness to the fall .No pain .No injury .Possible Contributing Factors: Balance problem, Cognitive impairments, Noncompliance .[MEDICATION(S)] given at 1445 .Risk Factors: Appliances and Devices: An alarm was used and did NOT sound: Battery low light on; This was not on when Resident placed in bed . Review of Progress Notes dated 9/27/21 at 6:32 PM, revealed, .Responded to call light which roommate activated to find Resident lying on floor length ways beside bed on fall mat; ROM to all extremities completed with no deformities, increase in pain, or malformation of any extremities; No areas of injury or pain noted; Resident assisted up in wheelchair x2 assist and taken to dining room for supper; Resident's bed alarm had not sounded with noted that battery was low; (DON B) ,DON and (Medical Doctor PP) made aware at this time; Message left with guardian . Review of Safety Events - Fall Events dated 10/12/21, revealed, .Exact time Event Discovered: 10/12/21 07:30 PM .Sitting in wc in room .Describe the fall in the resident's word if able .I slid out of chair .No witnesses to the fall .No pain .Possible Contributing Factors: Balance problem .Medications: Antidepressant, Antianxiety, Narcotic - [MEDICATION(S)] .Risk Factors: Appliances and Devices: None . Review of Progress Notes dated 10/12/21 at 11:58 PM, revealed, .730 pm CNA requested to come to resident's room due to found on floor. Resident sitting up on floor. Asked resident I slide out of chair. Full ROM all joints without any pain, alert and oriented to self. no injuries noted at this time. 2 assist resident into bed. 1140p (Medical Doctor PP) contacted regarding fall. 1150pm (Resident #112's Guardian) called and message left regarding fall . Review of Safety Events - Fall Events dated 10/17/21 at 03:00 PM, revealed, .Exact time Event Discovered: 10/17/21 03:00 PM .In bed resting .Assigned nurse walked past observed resident in room sitting on the floor mat in front of his bed .Unwitnessed fall .No Pain .Possible Contributing Factors: Incontinence, Balance problem, Joint pain, Cognitive impairments, Non compliance, [CONDITION(S)] disorder .Medications: Antipsychotic, Antidepressant, Antianxiety, Narcotic-[MEDICATION(S)], [MEDICATION(S)] .Risk Factors: Appliances and Devices: An alarm was used and did NOT sound: Reason Unknown . Review of Progress Notes dated 10/17/21 at 03:00 PM, revealed, .Assigned nurse walking by room observed resident sitting in front of his bed on his bottom on top of the cushioned floor mat in his room. no injuries noted. assigned nurse completed resident full assessment. Vitals taken and neuros started. All appropriate parties notified including (Resident #112' guardian) message left . Review of Progress Notes dated 10/20/21 at 03:47 PM, revealed, .No injuries related to recent fall. fall intervention continue as directed. denies pain related to recent fall. ROM WNL. Neuro's WNL. Vitals remain WNL. no further concerns noted voiced or reported. safety maintained. Continues to attempt to self transfer and removes his own alarms. fluids and call light in reach. Will monitor for any changes . Review of Orders dated 9/14/21, revealed, .Padded fall mat to open side of bed; Every shift: Days, Evenings, Nights; Start Date: 9/14/21 -Open Ended . Review of Treatment Administration Record (TAR) dated 9/22/21 revealed, .Check placement and function of pressure sensor alarm to bed q (every) shift; Every shift: Ensure pressure sensor alarm is on, functioning and in appropraite position to be effective, Start date: 9/14/21 - Open ended . Note: No check was completed during the Day shift. Review of Treatment Administration Record (TAR) dated 9/22/21 revealed, .Padded fall mat to open side of bed; Every shift, Start Date: 9/14/21 - Open ended . Note: No check was completed during the Day shift. Review of Treatment Administration Record (TAR) dated 9/23/21 revealed, .Check placement and function of pressure sensor alarm to bed q (every) shift; Every shift: Ensure pressure sensor alarm is on, functioning and in appropraite position to be effective, Start date: 9/14/21 - Open ended . Note: No check was completed during the Day shift, Evening shift, and Night shift. Review of Treatment Administration Record (TAR) dated 9/23/21 revealed, .Padded fall mat to open side of bed; Every shift, Start Date: 9/14/21 - Open ended . Note: No check was completed during the Day shift and Night shift. Review of Treatment Administration Record (TAR) dated 9/24/21 revealed, .Check placement and function of pressure sensor alarm to bed q (every) shift; Every shift: Ensure pressure sensor alarm is on, functioning and in appropraite position to be effective, Start date: 9/14/21 - Open ended . Note: No check was completed during the Day shift. Review of Treatment Administration Record (TAR) dated 9/24/21 revealed, .Padded fall mat to open side of bed; Every shift, Start Date: 9/14/21 - Open ended . Note: No check was completed during the Day shift. Review of Treatment Administration Record (TAR) dated 9/25/21 revealed, .Check placement and function of pressure sensor alarm to bed q (every) shift; Every shift: Ensure pressure sensor alarm is on, functioning and in appropraite position to be effective, Start date: 9/14/21 - Open ended . Note: No check was completed during the Day shift. Review of Treatment Administration Record (TAR) dated 9/25/21 revealed, .Padded fall mat to open side of bed; Every shift, Start Date: 9/14/21 - Open ended . Note: No check was completed during the Day shift. In an interview on 11/8/21 at 4:27 PM, Certified Nursing Assistant (CNA) WW reported a resident with an alarm was Resident #112. Resident #112 has an alarm on his wheelchair and on his bed. During an observation on 11/9/21 at 10:36 AM, Resident #112 was observed in bed with an alarm attached to the side of resident's bed hanging from side of the bed near shoulder are in view and reach of resident. During an observation on 11/15/21 at 12:45 PM, Resident #112 was observed in bed with an alarm attached to the side of resident's bed hanging from side of the bed near shoulder are in view and reach of resident. In an interview on 11/17/21 at 9:52 AM, Certified Nursing Assistant (CNA) T reported the alarms used of residents have regular batteries. CNA T stated, .The alarms sometimes do not go off .they are faulty .Don't stay turned on .Resident will have a fall and we won't even know it as it won't alarm . In an interview on 11/17/21 at 1:22 PM, Registered Nurse (RN) N stated .When the box is changed out and moved over to the bed .check to make sure it is always in place .When turn it on, it will beep .If the batter is low, the low battery light will turn on .If the batteries are low, when the staff member turns it on, they would be able to see that the batteries are low . During an observation on 11/17/21 at 1:30 PM, Resident #112 was in his room sitting in his wheelchair with the alarm clipped to the back of his shirt. The box was attached to the top right back side of the wheelchair in resident's reach. Indicator for low battery was in the center of the box in view and it was not illuminated. In an interview on 11/17/21 at 1:54 PM, Licensed Practical Nurse (LPN) M reported the box will beep I the battery was getting low. LPN M stated, .The nurses document in the Treatment Administration Record (TAR) to note the alarm is in place and in working order . In an interview on 11/17/21 at 2:19 PM, Certified Nursing Assistant (CNA) Y stated, .When we take him to the bathroom is it taken off and it is our responsibility to put it back on or when he goes to bed we are responsible for hooking it back up and turning it on .When you turn it on, it will beep .When the battery is low the light blinks . In an interview on 11/17/21 at 1:41 PM, Licensed Practical Nurse (LPN) P stated, .The nurses are responsible for ensuring the alarms are in working order and are on the resident/equipment .The batteries are in the medication room for us to replace the dead batteries .the CNAs would turn them off when transferring the resident and it is there responsibility to turn them back on when transfer is complete . Resident #110: Review of an Admission Record revealed Resident #110 was a male, with pertinent diagnoses which included nondisplaced [MEDICATION(S)] fracture of shaft of right tibia, nondisplaced [MEDICATION(S)] fracture of shaft of right fibula, stroke, dementia with behavioral disturbances, muscle weakness, abnormal posture, chronic pain, lack of coordination, [CONDITION(S)] of right lower extremity, postconcussional syndrome (physical and emotional disturbances occurring after a traumatic brain injury), speech and language deficits, and lack of coordination. Review of a Minimum Data Set (MDS) assessment for Resident #110, with a reference date of 10/8/21, revealed a Brief Interview for Mental Status (BIMS) score of 99, out of a total possible score of 15, which indicated Resident #110 was unable to complete the interview. Further review of this MDS assessment, dated 7/12/21, revealed Resident #110 was totally dependent on two staff for transfers. Review of current Care Plan for Resident #110 revealed the focus dated 11/16/2014 .At risk for falls and subsequent injury related to impaired balance, [CONDITION(S)], incontinence, [CONDITION(S)] disorder, TBI (traumatic brain injury), HOH (hard of hearing), [CONDITION(S)], behaviors, cognitive impairment, and dementia . with the interventions of .Offer to lay resident down after meals (7/5/21) , Dycem to w/c (wheelchair) to prevent slipping (7/3/21), antiroll back to wheelchair (3/4/16), back of wheelchair lowered for proper seating (2/12/16) . Review of Progress Notes dated 9/30/2021 at 11:07 PM, revealed, .09/30/2021 655 pm Call from CNA resident on the floor. When entered room resident round sitting on foot pedals of wc (wheelchair), right knee up next to night stand. 3rd dresser drawer 1/3 open, hoyer pad under him. Able to move wheelchair out from under resident, able to position knee straight without any discomfort, hoyer used to lift resident up off floor into bed. once in bed, noted swelling to right knee. Had another nurse come with me to check right knee. With attempting to turn resident observed knee stays in place but shin area moves out of place, neuro check and vital signs completed. 725 pm (Medical Doctor called and informed of knee/shin area changes, order to get x-ray of knee. Order written and call to medical diagnostic regarding stat x-ray. requested to fax order, order faxed. 735pm .(Guardian for Resident #110) called and message left regarding fall and x-ray ordered. 1030 medical diagnostic in and did x-ray . Review of Safety Events - Fall Events document completed on 9/30/21, revealed, .Exact Time Event Discovered: 09/30/21 06:55 PM .Pain Observation: Does resident exhibit or complain of pain related to the fall? If so, describe location .Yes, right knee .On a scale of 0-10, how does the resident rate intensity of pain if able, or indicate based on observation .5 .(4-Moderate Pain-Distressing Miserable, 7-Severe pain-horrible, intense) .What intervention(s) did yo provide to provide comfort to resident post fall .Repositioning (Other Option to select: Pharmacological (Medications, include topicals) .Did the fall result in an injury? .Bruise, Right Knee .Pain w/ROM (range of motion)-right knee (Other Option to select: Fracture) .Range of Motion findings: ROM Painful/Limited in Lower Extremity - right knee .Positioning of Extremities: Rotation/Deformity/Shortening of Right Lower Extremity .Describe: When attempting to turn to side noted knee stays but lower shin area moves, swelling to knee .Lower Right Extremity Movement: Unable to do - painful to move .Does resident exhibit or complain of any of the following since the fall .Pain .Interventions: Other: Educate staff regarding making sure resident put to bed before leaving floor .Notification: 09/20/21 07:35 PM, name of MD/NP/PA notified (Medical Doctor PP) .Notification to Director of Nursing/Clinical Leader: 09/30/21 07:38 PM .Orders: (Note: No orders noted under this section) . Review of Fall Statement completed by Certified Nursing Assistant (CNA) H dated 9/30/21, revealed, .7. Roommate states he (Resident #110) was messing with his night stand and slide out of his wheelchair .8. Resident sitting on the foot pegs of wheelchair screaming holding his right knee with bottom drawer of nightstand open . Review of X-ray Right Knee performed 9/30/2021, Reported Date Time: 09/30/2021 21:27:49, revealed, .A subtle nondisplaced fracture of the neck of the fibula is difficult to rule out on these images .Impression: [CONDITION(S)], which may prevent detection of a nondisplaced fracture. A subtle nondisplaced fracture of the neck of the fibula is difficult to rule out .Moderately severe [CONDITION(S)] of the medial compartment of the knee .Moderate arthrosis of the patellofemoral joint. Pretibial soft tissue swelling . Review of Progress Notes dated 10/01/2021 at 06:50 AM, revealed, .Rec'd call from DON (Director of Nursing) stating to transfer patient to hospital secondary to fracture. VM left for (Guardian for Resident #110) to return call to facility . Review of INTERACT Nursing Home to Hospital Transfer Form dated 10/1/21 at 06:57 AM, revealed, .How long has resident had illness? .fell at 1855 on 9/30/21 . Note: 12 hours since fall. Review of Progress Notes dated 10/1/2021 at 07:25 AM, revealed, .EMS arrived to transport pt to hospital. Documents sent with EMS . Review of Progress Notes dated 10/01/2021 at 10:42 AM, revealed, .Rec'd call from (ER Nurse) at (Community hospital ER) States pt (patient) will be returning to facility. Reports pt was dx (diagnosed ) with fib (fibular) and tib (tibial) fractures and was placed in a knee immobilizer by (ortho doctor UU). Pt is to f/u (follow up) with (Ortho Doctor UU) ASAP in his office. Non weight bearing. Also rx'd (received) pain medication and stool softener . Review of Radiology Detail dated 10/01/2021, revealed, .Findings: BONES: Nondisplaced oblique fracture of the proximal tibial metadiaphysis. Nondisplaced fracture at the neck of the proximal fibula . Review of General Emergency Department Discharge Instructions revealed, .You have been diagnosed with a tibial fracture .Limit use of the injured body part .Ice: By applying ice to the affect area, swelling and pain can be reduced. Apply the ice bag to the affect areas for at least 20 minutes. Do this at least 4 times per day . Elevate the injured part .You have been given a splint for your fracture. This is to reduce pain and keep the injured area immobilized (still) .Prescription written: [MEDICATION(S)]-Acetaminophen Oral Tablet 5-325 mg, Take 0.5-1 tablet by mouth every 4-6 hours when necessary pain . Review of Physician Orders dated 10/01/2021 - 10/24/2021 (DC Date) revealed, .[MEDICATION(S)]-acetaminophen - Schedule II tablet; 5-325 mg; amt: one tab; oral [DX: Other chronic pain] Every 6 Hours - PRN; PRN 1, PRN 2, PRN 3, PRN 4 . Review of Medication Administration Record (MAR) dated 10/1/2021, revealed, .Pain Assessment using 0-10 or FLACC Every Shift, 05/26/2019-Open ended .Nights .10 . Note: No pain assessment was completed for Day Shift or Evening Shift on 10/1/2021 in the MAR. Review of Progress Notes dated 10/02/2021 at 01:46 PM, revealed, .Pt alert and oriented to person; able to make needs known. Immobilizer in place to RLE; CMS present. VS stable. Pt verbalizes 10/10 pain to RLE; PRN pain pill ineffective. Pt in bed all of this shift. screams with cares. Accepts ADL care with the assist of two care givers. Incontinent of bowel and bladder . Review of Progress Notes dated 10/03/2021 at 01:24 PM, revealed, .Pt alert and oriented to person; able to make needs known. Immobilizer in place to RLE(right lower extremity); CMS present. VS (vital signs) stable. Pt verbalizes 10/10 pain to RLE; PRN pain pill ineffective. Pt in bed all of this shift. screams with cares. Accepts ADL care with the assist of two care givers. Incontinent of bowel and bladder . Review of Progress Notes dated 10/04/2021 at 10:35 AM, MD in to see resident with new orders for STAT ortho consult needed and new orders for [MEDICATION(S)] 7.5mg every 4 hours . In an interview on 11/17/21 at 09:40 AM, Licensed Practical Nurse (LPN) M reported she completed an additional assessment and range of motion indicating Resident #110 had an obvious displacement. LPN M stated .When I went in as a second set of eyes, (Resident #110) was laying in his bed .He was in a lot of pain .If I was his nurse and responded initially, I would have left him on the floor and contacted the doctor and stressed to him the condition of his leg and how painful the resident was .If the doctor didn't indicate the resident should be sent out . LPN M stated .I would use the, When in doubt, Send out .And send the resident to the hospital . In an interview on 11/17/21 at 9:52 AM, Certified Nursing Assistant (CNA) T stated, .I was on break and got a call on my phone from my hall partner, CNA H stating 911 in (Resident #110's room) .I was running down the hall .I told (ADON C) something happening in that room .I get into the room and he is on the floor screaming grabbing his leg .(ADON C) comes in and asks us to move him and get him in the bed .I told her that we can't move him until she assesses him .We would get into trouble if we moved him and she didn't assess him first .She briefly looked at his leg and said that he was fine that he just bumped it on the dresser and he would be okay .She told us to get the hoyer and get him off the floor .We told her that she needs to take another look at his leg as I thought there was something really wrong with it .We asked his roommate what happened and he said that he was leaning in his night stand and slid out of his wheelchair .She told us to get him up and in the hoyer .He was in so much pain .We tried to stabilize his leg when moving him to the bed .Once he was in bed, she told us to remove his clothing so she could assess him more .She left the room .He was screaming in pain .I didn't see her give him anything for the pain .When she came back after we removed his clothing .I told her that he was ready (when we removed his clothing) and it took 10-15 minutes or more for her to come back and assess him further .When she came back his knee was twice the size it was when we first responded .His leg was starting to turn colors from the bruising .She was very rough with him .Trying to move his leg this way and that way .He was in excruciating pain .I didn't want to move him because you don't move someone who has fallen as you never know if someone has a spinal injury .They never sent him out while I was there and x-ray hadn't come either . In an interview on 11/17/21 at 11:57 AM, Certified Nursing Assistant (CNA) H stated, .I reported to the ADON that I had made eyes on my group and (Resident #110) was in the dining room as he was still eating .He likes to take his time to eat .I pass the dining room again and he was still in there eating .When I came back towards the nurse's station .And I heard someone screaming from down the hallway .I start walking fast down the hallway and the (ADON C)was asking who it was .Didn't take long to figure out it was (Resident #110) .I go in the room and he has slipped out of his wheelchair and he is like sitting on his foot pegs .He is holding his right knee and he is screaming, yelling, swearing .I told him to stay still so the nurse can assess you .I poked my head out the door and yelled for the nurse .waited .Still no one . yelled again .That is when I called my hallway partner with 911 .CNA T running into the room .Still no nurse .She stayed with him and I went out of his room to get the nurse .She came in and told us to get him up .Can't move him without you assessing him first .She was trying to ask him what happened .He is yelling and holding his knee .Told us to pick him up .I know not to move him until she has assessed him and she hadn't assessed him yet .said she can't assess unless he is on the bed .We get the wheelchair out from under him .It was only a few inches as he was on the foot pedals .Guided him to the floor .Now he is laying flat on the floor .She asked if anything hurt and he replied, Yes, my f***ing knee .She is assessing him and she is grabbing on his knee, one hand on the top and then underneath she pushes up and she forcibly straightens his leg .He yelled out in pain .She directed us to get him in the bed .Told her if we use the hoyer it is going to put pressure on his leg and it is going to hurt him more .She said he needs to get off the floor and into the bed .We were asking the roommate what happened and he said he was looking in his night stand and slipped out of his chair .We were trying to figure out how to get him in the bed .We had to use the hoyer .and he as crying in pain and the other aide was supporting his leg if anything was broken .We got him in the bed and got his pants off .We were trying to be really careful but he was screaming in pain .It took her awhile to come back and complete her assessment .By the time she got there his knee was swelling up and bruising was happening .We suggested to her that he should be sent out .That it is swollen that fast and it doesn't look good .She told us to leave the wet brief under him, unstrapped and got a clean, dry on e and placed on the front part of him and tucked it so when he urinated it wouldn't go all over .She told me to do that .Told 3rd shift to do that as well as not to move him in case it was broken .She said the xray people were coming to xray it .By the time I left, xray had not been there yet .When I came back the next day and asked about him, I was told that he was sent out this morning and he was back with a knee brace .It took us like 2-3 people to change him .It was bad .Told him if he wanted to squeeze my hand that he could .He was hitting , yelling, screaming .He had tears in his eyes .He is a tough guy and for him to have tears .I know that he was hurting . This writer spoke with the Director of Nursing (DON) B and she informed this writer the ADON no longer works for the facility. This interviewer attempted to contact ADON C prior exit and did not hear from her prior to exit. On 11/17/21 at 12:36, tried to contact facility physician regarding Resident #110 left a message with Medical assistant VV, no calls returned by exit. In an interview on 11/17/21 at 3:39 PM, Director of Nursing (DON) B notify the physician and provide them with a clear story of what is going on and what you are observing. They should suggest to send the resident out. You are the eyes for the physician and if there is an obvious displacement you are to inform them of that. DON B stated if the physician doesn't give the order to send out and as the nurse you deem that the resident requires additional care, as in this case, you would send the resident out.

This citation pertains to Intake # MI 729. Based on observation, interview, and record review, the facility failed to ensure skin protection interventions were implemented per plan of care and failed to ensure wound treatments were completed per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: According to Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Fundamentals of Nursing - E-Book (Kindle Locations - ). Elsevier Health Sciences. Kindle Edition.The health care provider (physician or advanced practice nurse) is responsible for directing medical treatment. Nurses follow health care providers' orders unless they believe that the orders are in error, violate agency policy, or are harmful to the patient . According to Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Fundamentals of Nursing - E-Book (Kindle Locations - ). Elsevier Health Sciences. Kindle Edition.A health care provider's order for changing a dressing indicates the dressing type, the frequency of changing, and any solutions or ointments to be applied to the wound . According to Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Fundamentals of Nursing - E-Book (Kindle Locations - ). Elsevier Health Sciences. Kindle Edition.Nurses are responsible for performing all procedures correctly and exercising professional judgment as they carry out health care providers' orders . Review of the policy/procedure Pressure Injury Prevention and Care, dated 3/2021, revealed .This policy is intended to supplement the clinical staff's knowledge and provide a resource to guide on wound prevention and management procedures. The procedures and information contained herein are not intended to replace a licensed nurse's clinical judgment and experience and may not pertain to each individualized pressure injury occurrence .Purpose: To promote and facilitate pressure injury prevention and implement appropriate interventions and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .Interventions will be implemented, and care planned to prevent pressure injury development or to promote pressure injury resolution . Review of the policy/procedure Skin Program Foot Care, dated 3/2021, revealed .To promote treatment and care to maintain good foot health for residents and prevent complications .Facility will provide foot care and treatment in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) .Residents will be provided with preventive care to avoid the development of and alert to any podiatric complications in residents with comorbidities that place them at higher risk, such as diabetes and circulatory disorders .The facility will .Minimize pressure on heels and malleoli while resident is in bed or in position that may cause pressure to these areas . Review of a Face Sheet revealed Resident #105 was a female, with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #105, dated 10/4/21, revealed a Brief Interview for Mental Status (BIMS) score of 12, out of a total possible score of 15, which indicated moderate cognitive impairment. Further review of this MDS assessment, dated 10/4/21, revealed Resident #105 had two stage 4 pressure ulcers, with one of those two present on admission. Review of a current Care Plan for Resident #105 revealed the problem .has pressure ulcer to sacrum with potential for infection and discomfort to area. Increase risk for skin breakdown r/t (related to) impaired mobility weakness, and incontinence. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . (history) of DVT (blood clots), HLD ([CONDITION(S)]), [CONDITION(S)] (Resident #105) at times will be resistant to following ordered treatments for wounds. Foley catheter placed for wound healing . with interventions which included .Treatment as ordered . and .Use pressure reduction devices for elevation of lower extremities and heels . both with a start date of 7/6/18. Review of the current Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Cleanse area to sacrum with dakins solution and pat dry, apply skin prep to periwound, apply collagen into wound bed then cut to fit [MEDICATION(S)] sheet to wound bed, cover with foam dressing and secure with pink tape. Change daily and PRN (as needed) .Once A Day . with a start date of 11/2/21 and no end date. Review of the current Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Cleanse R (right) iliac crest with dakins solution, pat dry, apply collagen pwd (powder) then cut [MEDICATION(S)] sheet and place into wound bed, cover with foam and secure with pink tape .Once A Day . with a start date of 10/1/21 and no end date. In an observation on 11/9/21 at 10:48 a.m., Resident #105 was noted in bed in her room. Noted visible loose, yellow-brown bowel movement on her buttocks and sheets. Observed Resident #105 tapping her bed remote on the edge of her tray table, repeatedly yelling .I'm burning! I'm burning! and asking for help. Observed a dressing on the inner aspect of Resident #105's right foot. Noted her right foot was bare, and observed a padded green boot on the floor near Resident #105's bed. Observed Certified Nursing Assistant (CNA) W and CNA AA respond, after notification by surveyor, to assist Resident #105 with incontinence care. Observed a padded dressing on Resident #105's buttocks, dated 11/8/21, saturated with bowel movement. Observed CNA W and CNA AA remove the soiled dressing and perform incontinence care. Resident #105 was tearful, and stated .it hurts bad . Noted buttocks appeared reddened/irritated and sensitive. CNA AA notified the nurse of Resident #105's increased pain and need for pain medication and a new wound dressing. In an observation on 11/9/21 at 12:41 p.m., noted Resident #105's call light was activated. Observed CNA G respond, at which point Resident #105 asked when the nurse would be in to apply a new dressing to her sacral/buttock wounds. Note Resident #105 has not had any dressings in place to her sacral/buttock wounds since the soiled dressings were removed at 10:48 a.m. In an observation on 11/9/21 at 12:54 p.m., Registered Nurse (RN) C entered Resident #105's room to complete wound care. RN C prepared supplies on Resident #105's tray table. Observed significant scarring to Resident #105's buttocks/sacral area from previously healed wounds. Observed RN C cleanse Resident #105's sacral wound, which was about the size of a [NAME], with Dakin's solution and apply skin prep around the wound. RN C then applied collagen to the wound bed, and covered with a sheet of [MEDICATION(S)]. Note RN C did not cut the [MEDICATION(S)] sheet to fit the wound bed. Observed RN C place a foam dressing over the top of the treatment, and cover with pink tape. Noted Resident #105 was barefoot in bed at this time, with no padded boot in place. No dressing applied to Resident #105's right right iliac crest wound at this time. Note Resident #105 was in bed for over two hours with no sacral/iliac crest wound dressings in place. In an observation on 11/9/21 at 4:08 p.m., Resident #105 was noted in bed in her room. Observed CNA T assist Resident #105 with oral care at this time. Noted Resident #105's right foot was bare, with no padded boot in place. Observed a wound dressing in place on the inner aspect of Resident #105's right foot. Noted Resident #105's foot was laying directly on the surface of the mattress, with no pillows or positioning devices in use. In an observation on 11/10/21 at 10:48 a.m., Resident #105 was in bed in her room, laying on her left side. Noted Resident #105's right foot was bare, with no padded boot in place. Observed a wound dressing in place on the inner aspect of Resident #105's right foot. Noted Resident #105's foot was laying directly on the surface of the mattress, with no pillows or positioning devices in use. In an interview on 11/10/21 at 11:13 a.m., Wound Nurse KK reported Resident #105 admitted to the facility with Stage 4 pressure ulcers to her sacrum and right ischium. Wound Nurse KK reported the right ischium wound had healed, but later reopened. Wound Nurse KK reported the wound on Resident #105's inner aspect of her right foot is a venous ulcer. Review of a Weekly Pressure Ulcer Progress Report for Resident #105, dated 11/4/21, revealed .sacrum .Date of Initial Discovery 07/06/2018 .admitted with wound .Stage 4 .4.0cm x 5.0cm x 0.2cm . Review of a Weekly Pressure Ulcer Progress Report for Resident #105, dated 11/4/21, revealed .R (right) iliac crest .Date of Initial Discover 05/20/2021 .In House Acquired .Stage 4 .2.4cm x 1.0cm x <0.2cm . Review of a Physician Note for Resident #105, dated 11/4/21, revealed .Asked to see patient for spine on the right in the foot. Recall that the patient had circulation evaluation of the right lower extremity and she does have mild to moderate disease. She also has toward skin of the foot. Now the patient has an area of redness in the medial aspect of the right great toe. Patient is certainly at risk for breakdown of the skin in part because of decreased circulation. In addition the patient has taut skin she has osteoarthritic changes of the joints including hammertoe formation as well as joint bony prominence. There is also some pressure on the area because of foot positioning . In an observation on 11/10/21 at 11:21 a.m., Resident #105 was in bed in her room, laying on her left side. Noted Resident #105's foot was bare, with no padded boot in place. Observed a wound dressing in place on the inner aspect of Resident #105's right foot. Noted Resident #105's foot was laying directly on the surface of the mattress, with no pillows or positioning devices in use. In an observation on 11/10/21 at 11:24 a.m., Licensed Practical Nurse (LPN) M administered pain medication to Resident #105, in the resident's room. Observed Resident #105 in bed, laying on her left side. Noted Resident #105's foot was bare, with no padded boot in place. Observed a wound dressing in place on the inner aspect of Resident #105's right foot. Noted Resident #105's foot was laying directly on the surface of the mattress, with no pillows or positioning devices in use. In an observation and interview on 11/10/21 at 2:41 p.m., Resident #105 was in bed in her room, laying on her left side. Observed LPN M and LPN E perform wound care at this time. Noted a blue padded boot in place to Resident #105's right foot. LPN M stated staff .try to always encourage her to wear (the blue padded boot) when in bed . Review of a Skin Incident Event assessment for Resident #105, dated 11/3/21, revealed .1.5cm x 1.5cm open area to R (right) inner aspect of foot .appears as venous stasis ulcer . Review of a Skin Incident Event assessment for Resident #105, dated 11/10/21, revealed .R great hammer toe 0.5cm x 0.5cm x <0.2cm .appears like venous stasis ulcer . Review of a Physician Note for Resident #105, dated 11/11/21, revealed .Examination of the right lower extremity shows that the patient has contracture about the knee. The skin of the distal leg and foot is taut and stretched. She has hammertoe formation of the second and third toes. The great toe is deviated laterally. There is an ulcer on the medial aspect of the great toe is about a centimeter in size no signs of infection. There is a small subcentimeter ulcer on the knuckle of the great toe where the skin is taught. There is also a (sic) an area of [CONDITION(S)] on the knuckle of the second toe with decreased blanching. Overall the lower extremity has toward skin with discoloration (arterial studies done earlier showed mild to moderate disease but no obstruction). Foot skin makes it easy for skin breakdown on pressure points .Discussion Notes .Boot for heel and other pressure-point protection . In an interview on 11/17/21 at 4:19 p.m., Director of Nursing (DON) B reported if a wound dressing becomes soiled or is accidentally removed, it should be replaced .quite soon, because we don't want to leave (the wound) exposed . DON B reported the expectation would be for the CNA staff to notify the nurse as soon as possible. DON B stated .if (the nurse) couldn't change it (they) should ask for help .

This citation pertains to Intake # MI 729. Based on record review and interview, the facility failed to ensure 1 of 22 residents (Resident #110) was provided appropriate assessment and failed to transfer the resident with a significant change in condition to the hospital in a timely manner after an unwitnessed fall, which resulted in a fracture, resulting in severe pain impacting the resident's functional status and quality of life and impaired their physical, mental, and psychosocial well-being. Findings include: Review of an Admission Record revealed Resident #110 was a male, with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #110, with a reference date of 10/8/21, revealed a Brief Interview for Mental Status (BIMS) score of 99, out of a total possible score of 15, which indicated Resident #112 was unable to complete the interview. Further review of this MDS assessment, dated 7/12/21, revealed Resident #110 was totally dependent on two staff for transfers. Review of current Care Plan for Resident #110 revealed the focus dated 11/16/2014 .At risk for falls and subsequent injury related to impaired balance, [CONDITION(S)], incontinence, [CONDITION(S)], TBI ([CONDITION(S)]), HOH (hard of hearing), [CONDITION(S)], behaviors, cognitive impairment, and dementia . with the interventions of .Offer to lay resident down after meals (7/5/21) , Dycem to w/c (wheelchair) to prevent slipping (7/3/21), antirollback to wheelchair (3/4/16), back of wheelchair lowered for proper seating (2/12/16) . Review of a current Care Plan for Resident #110 revealed the focus .(Resident #110) has potential for actual pain r/t (related to) impaired mobility, weakness. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Does have cognitive deficits with inability to communicate effectively . with interventions which included .Provide repositioning as needed for comfort, Sufficient uninterrupted rest periods, address status of his pain with pain assessment, handle gently and try to eliminate environmental stimuli, observe for nonverbal signs of pain; grimacing, moaning, increased vital signs, guarding areas of body . Review of Progress Notes dated 9/30/2021 at 11:07 PM, revealed, .09/30/2021 655 pm Call from CNA resident on the floor. When entered room resident round sitting on foot pedals of wc (wheelchair), right knee up next to night stand. 3rd dresser drawer 1/3 open, hoyer pad under him. Able to move wheelchair out from under resident, able to position knee straight without any discomfort, hoyer used to lift resident up off floor into bed. once in bed, noted swelling to right knee. Had another nurse come with me to check right knee. With attempting to turn resident observed knee stays in place but shin area moves out of place, neuro check and vital signs completed. 725 pm (Medical Doctor PP) called and informed of knee/shin area changes, order to get x-ray of knee. Order written and call to medical diagnostic regarding stat x-ray. requested to fax order, order faxed. 735pm .(Guardian for Resident #110) called and message left regarding fall and x-ray ordered. 1030 medical diagnostic in and did x-ray . Review of Safety Events - Fall Events document completed on 9/30/21, revealed, .Exact Time Event Discovered: 09/30/21 06:55 PM .Pain Observation: Does resident exhibit or complain of pain related to the fall? If so, describe location .Yes, right knee .On a scale of 0-10, how does the resident rate intensity of pain if able, or indicate based on observation .5 .(4-Moderate Pain-Distressing Miserable, 7-Severe pain-horrible, intense) .What intervention(s) did yo provide to provide comfort to resident post fall .Repositioning (Other Option to select: Pharmacological (Medications, include topicals) .Did the fall result in an injury? .Bruise, Right Knee .Pain w/ROM (range of motion)-right knee (Other Option to select: Fracture) .Range of Motion findings: ROM Painful/Limited in Lower Extremity - right knee .Positioning of Extremities: Rotation/Deformity/Shortening of Right Lower Extremity .Describe: When attempting to turn to side noted knee stays but lower shin area moves, swelling to knee .Lower Right Extremity Movement: Unable to do - painful to move .Does resident exhibit or complain of any of the following since the fall .Pain .Interventions: Other: Educate staff regarding making sure resident put to bed before leaving floor .Notification: 09/20/21 07:35 PM, name of MD/NP/PA notified (Medical Doctor PP) .Notification to Director of Nursing/Clinical Leader: 09/30/21 07:38 PM .Orders: (Note: No orders noted under this section) . Review of Fall Statement completed by Certified Nursing Assistant (CNA) H dated 9/30/21, revealed, .7. Roommate states he (Resident #110) was messing with his night stand and slide out of his wheelchair .8. Resident sitting on the foot pegs of wheelchair screaming holding his right knee with bottom drawer of nightstand open . Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of X-ray Right Knee performed 9/30/2021, Reported Date Time: 09/30/2021 21:27:49, revealed, .A subtle nondisplaced fracture of the neck of the fibula is difficult to rule out on these images .Impression: [CONDITION(S)], which may prevent detection of a nondisplaced fracture. A subtle nondisplaced fracture of the neck of the fibula is difficult to rule out .Moderately severe [CONDITION(S)] of the medial compartment of the knee .Moderate arthrosis of the patellofemoral joint. Pretibial soft tissue swelling . Review of Progress Notes dated 10/1/21 at 04:01 AM, revealed, .Writer able to speak with (Medical Doctor (MD) PP) on phone at approx. 0100. writer read xray results RLE (right lower extremity) word for word to MD and faxed results to MDs office. NO (new order): [MEDICATION(S)] 5/325mg PO Q6H PRN pain. MD states he will follow up in AM and call in [MEDICATION(S)] script ASAP. resident RLE elevated and iced for pain, considerable amount of swelling observed, pedal pulses present. writer called pharmacy 3 times and each time was informed that [MEDICATION(S)] script was unavailable . Review of Progress Notes dated 10/1/21 at 05:54 AM, revealed, .0300 - followed up with MD (MD PP) regarding writer being unable to pull narcotics. MD states he will send in script again . Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)]-Acetaminophen - Schedule II tablet; 5-325 mg; amt: half to 1 tablet; oral; Every 6 hours - PRN, PRN1, PRN2, PRN3, PRN4 In an interview on 11/17/21 at 8:29 AM, Licensed Practical Nurse (LPN) L reported the x-ray results came back pretty late .When I spoke to Medical Doctor PP he indicated the result was not a fracture and indicated Resident #110 did not need to be sent to the hospital .I read him the results I received word for word so there was no question .Resident #110 was in a lot of pain and I expressed that to the doctor .the Doctor stated to give the resident the medication he prescribed and he would be in to check on him in the morning .On my next shift the Director of Nursing (DON) spoke to me and informed me that if something like this happens again, I can send the resident to the hospital .I did give him [MEDICATION(S)] from the backup medications . Review of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #110 on 10/1/2021. Review of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .Tylenol (acetaminophen) [OTC] tablet; 325 mg; Amount to Administer: 650; oral Twice a Day; prn for left arm pain; prescribed on 01/09/2020 - Open ended . was dispensed to Resident #110 between 07:00PM - 11:00 PM. Review of Individual Statement written by Director of Nursing (DON) B dated 10/1/21, revealed, .Received call from Midnight nurse regarding X-ray results. Resident had fallen on PM shift 9/30/21. Results revealed a nondisplaced fracture of the right fibula. Nurse stated that she was awaiting call back from physician to inform of results. Instructed her to send to hospital along with copy of x-ray results .Spoke with ADON who was the nurse on duty when resident was observed on the floor. Stated that resident was observed self-propelling in wheelchair down the hallway. Later observed on the floor in his room with right knee up (flexed position) next to nightstand. Unable to straighten leg. Doctor was notified and X-ray ordered. Guardian notified .Per resident's roommate-A & O x 4, resident was bent over trying to get something out of his nightstand and fell out of wheelchair .Staff interviews-Staff responded to yelling coming from the long hall. Observed resident sitting on foot pedals of his wheelchair holding his right knee . Review of Progress Notes dated 10/01/2021 at 06:50 AM, revealed, .Rec'd call from DON (Director of Nursing) stating to transfer patient to hospital secondary to fracture. VM left for (Guardian for Resident #110) to return call to facility . Review of INTERACT Nursing Home to Hospital Transfer Form dated 10/1/21 at 06:57 AM, revealed, .How long has resident had illness? .fell at 1855 on 9/30/21 . Note: 12 hours since fall. Review of Progress Notes dated 10/1/2021 at 07:25 AM, revealed, .EMS arrived to transport pt to hospital. Documents sent with EMS . Review of Progress Notes dated 10/01/2021 at 10:42 AM, revealed, .Rec'd call from (ER Nurse) at (Community hospital ER) States pt (patient) will be returning to facility. Reports pt was dx (diagnosed ) with fib (fibular) and tib (tibial) fractures and was placed in a knee immobilizer by (ortho doctor UU). Pt is to f/u (follow up) with (Ortho Doctor UU) ASAP in his office. Non weight bearing. Also rx'd (received) pain medication and stool softener . Review of hopsital Radiology Detail dated 10/01/2021, revealed, .Findings: BONES: Nondisplaced oblique fracture of the proximal tibial metadiaphysis. Nondisplaced fracture at the neck of the proximal fibula . Review of General Emergency Department Discharge Instructions revealed, .You have been diagnosed with a tibial fracture .Limit use of the injured body part .Ice: By applying ice to the affect area, swelling and pain can be reduced. Apply the ice bag to the affect areas for at least 20 minutes. Do this at least 4 times per day . Elevate the injured part .You have been given a splint for your fracture. This is to reduce pain and keep the injured area immobilized (still) .Prescription written: [MEDICATION(S)]-Acetaminophen Oral Tablet 5-325 mg, Take 0.5-1 tablet by mouth every 4-6 hours when necessary pain . Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)]-acetaminophen - Schedule II tablet; 5-325 mg; amt: one tab; oral [DX: Other chronic pain] Every 6 Hours - PRN; PRN 1, PRN 2, PRN 3, PRN 4 . Review of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .Pain Assessment using 0-10 or FLACC Every Shift . Note: No pain assessment was completed for Day Shift or Evening Shift on 10/1/2021 in the MAR. Review of Progress Notes dated 10/02/2021 at 01:46 PM, revealed, .Pt alert and oriented to person; able to make needs known. Immobilizer in place to RLE; CMS present. VS stable. Pt verbalizes 10/10 pain to RLE; PRN pain pill ineffective. Pt in bed all of this shift. screams with cares. Accepts ADL care with the assist of two care givers. Incontinent of bowel and bladder . Review of Progress Notes dated 10/03/2021 at 01:24 PM, revealed, .Pt alert and oriented to person; able to make needs known. Immobilizer in place to RLE(right lower extremity); CMS present. VS (vital signs) stable. Pt verbalizes 10/10 pain to RLE; PRN pain pill ineffective. Pt in bed all of this shift. screams with cares. Accepts ADL care with the assist of two care givers. Incontinent of bowel and bladder . Review of Progress Notes dated 10/04/2021 at 10:35 AM, .MD in to see resident with new orders for STAT ortho consult needed and new orders for [MEDICATION(S)] 7.5mg every 4 hours . Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)]-acetaminophen - Schedule II tablet; 7.5-325 mg; amt: 1 tablet; oral; Special Instructions: Give when available from pharmacy; Every 4 Hours; 12:00 AM, 04:00 AM, 08:00 AM, 12:00 PM, 04:00 PM, 08:00 PM . In an interview on 11/8/21 at 3:20 PM, Resident #110 reported this was the first broken bone he has had in [AGE] years. When asked how it happened, Resident #110 reported he is not sure how it happened. In an interview on 11/16/21 at 2:12 PM, Certified Nursing Assistant (CNA) U reported after Resident #110 had the fall and broke his leg and the immobilizer was placed, .It was horrible during cares as he was in so much pain .We couldn't roll him to provide care without him screaming in pain .He was crying out for Jesus .I was so upset for him because he was in so much pain .It took 3 staff members to take care of him . In an interview on 11/16/21 at 4:22 PM, Certified Nursing Assistant (CNA) I reported she worked the night Resident #110 broke his leg. CNA I stated, .He (Resident #110) fell sometime after dinner .He was in a lot of pain .Staff could barely touch it and he was in pain .The nurse doing the meds who worked that night .didn't do an accurate assessment on him .She was yelling at the other girl to come and assess him .The nurse was rude and yelling at the aides .He didn't get sent out (to the ER) when I was there .They called for the x-ray to come in .They didn't come when I was there .Terrible how he was treated . In an interview on 11/17/21 at 07:30 AM, Certified Nursing Assistant (CNA) J stated, .From what I was told he was given Tylenol at 7-8 o'clock that night (9/30/21) and they said they couldn't send him out because the x-rays were inconclusive .He was in bed when I came in at 10:00 PM .He hadn't been changed .They were told not to touch him .Was told not to touch him for the rest of the night .He was crying and yelling out in pain .He couldn't even move and he was in pain .and they didn't send him out .I left at 06:00 AM and he was still at the facility when I left . In an interview on 11/17/21 at 09:40 AM, Licensed Practical Nurse (LPN) M reported she completed an additional assessment and range of motion indicating Resident #110 had an obvious displacement. LPN M stated .When I went in as a second set of eyes, (Resident #110) was laying in his bed .He was in a lot of pain .If I was his nurse and responded initially, I would have left him on the floor and contacted the doctor and stressed to him the condition of his leg and how painful the resident was .If the doctor didn't indicate the resident should be sent out . LPN M stated .I would use the, When in doubt, Send out .And sent the resident to the hospital . In an interview on 11/17/21 at 9:52 AM, Certified Nursing Assistant (CNA) T stated, .I was on break and got a call on my phone from my hall partner, CNA H stating 911 in (Resident #110's room) .I was running down the hall .I told (ADON C) something happening in that room .I get into the room and he is on the floor screaming grabbing his leg .(ADON C) comes in and asks us to move him and get him in the bed .I told her that we can't move him until she assesses him .We would get into trouble if we moved him and she didn't assess him first .She briefly looked at his leg and said that he was fine that he just bumped it on the dresser and he would be okay .She told us to get the hoyer and get him off the floor .We told her that she needs to take another look at his leg as I thought there was something really wrong with it .We asked his roommate what happened and he said that he was leaning in his night stand and slid out of his wheelchair .She told us to get him up and in the hoyer .He was in so much pain .We tried to stabilize his leg when moving him to the bed .Once he was in bed, she told us to remove his clothing so she could assess him more .She left the room .He was screaming in pain .I didn't see her give him anything for the pain .When she came back after we removed his clothing .I told her that he was ready (when we removed his clothing) and it took 10-15 minutes or more for her to come back and assess him further .When she came back his knee was twice the size it was when we first responded .His leg was starting to turn colors from the bruising .She was very rough with him .Trying to move his leg this way and that way .He was in excruciating pain .I didn't want to move him because you don't move someone who has fallen as you never know if someone has a spinal injury .They never sent him out while I was there and x-ray hadn't come either . In an interview on 11/17/21 at 11:57 AM, Certified Nursing Assistant (CNA) H stated, .I reported to the ADON that I had made eyes on my group and (Resident #110) was in the dining room as he was still eating .He likes to take his time to eat .I pass the dining room again and he was still in there eating .When I came back towards the nurse's station .And I heard someone screaming from down the hallway .I start walking fast down the hallway and the (ADON C)was asking who it was .Didn't take long to figure out it was (Resident #110) .I go in the room and he has slipped out of his wheelchair and he is like sitting on his foot pegs .He is holding his right knee and he is screaming, yelling, swearing .I told him to stay still so the nurse can assess you .I poked my head out the door and yelled for the nurse .waited .Still no one . yelled again .That is when I called my hallway partner with 911 .CNA T running into the room .Still no nurse .She stayed with him and I went out of his room to get the nurse .She came in and told us to get him up .Can't move him without you assessing him first .She was trying to ask him what happened .He is yelling and holding his knee .Told us to pick him up .I know not to move him until she has assessed him and she hadn't assessed him yet .said she can't assess unless he is on the bed .We get the wheelchair out from under him .It was only a few inches as he was on the foot pedals .Guided him to the floor .Now he is laying flat on the floor .She asked if anything hurt and he replied, Yes, my [OBSCENITY] ing knee .She is assessing him and she is grabbing on his knee, one hand on the top and then underneath she pushes up and she forcibly straightens his leg .He yelled out in pain .She directed us to get him in the be .Told her if we use the hoyer it is going to put pressure on his leg and it is going to hurt him more .She said he needs to get off the floor and into the bed .We were asking the roommate what happened and he said he was looking in his night stand and slipped out of his chair .We were trying to figure out how to get him in the bed .We had to use the hoyer .and he as crying in pain and the other aide was supporting his leg if anything was broken .We got him in the bed and got his pants off .We were trying to be really careful but he was screaming in pain .It took her awhile to come back and complete her assessment .By the time she got there his knee was swelling up and bruising was happening .We suggested to her that he should be sent out .That it is swollen that fast and it doesn't look good .She told us to leave the wet brief under him, unstrapped and got a clean, dry on e and placed on the front part of him and tucked it so when he urinated it wouldn't go all over .She told me to do that .Told 3rd shift to do that as well as not to move him in case it was broken .She said the xray people were coming to xray it .By the time I left, xray had not been there yet .When I came back the next day and asked about him, I was told that he was sent out this morning and he was back with a knee brace .It took us like 2-3 people to change him .It was bad .Told him if he wanted to squeeze my hand that he could .He was hitting , yelling, screaming .He had tears in his eyes .He is a tough guy and for him to have tears .I know that he was hurting . This writer spoke with the Director of Nursing (DON) B and she informed this writer the ADON no longer works for the facility. This interviewer attempted to contact ADON C prior exit and did not hear from her prior to exit. On 11/17/21 at 12:36, tried to contact facility physician regarding Resident #110 left a message with Medical assistant VV, no calls returned by exit. In an interview on 11/17/21 at 3:39 PM, Director of Nursing (DON) B notify the physician and provide them with a clear story of what is going on and what you are observing. They should suggest to send the resident out. You are the eyes for the physician and if there is an obvious displacement you are to inform them of that. DON B stated if the physician doesn't give the order to send out and as the nurse you deem that the resident requires additional care, as in this case, you would send the resident out. .The health care provider (physician or advanced practice nurse) is responsible for directing medical treatment. Nurses follow health care providers' orders unless they believe that the orders are in error, violate agency policy, or are harmful to the patient . Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Fundamentals of Nursing - E-Book (Kindle Locations - ). Elsevier Health Sciences. Kindle Edition. Review of Fall Prevention and Management Program reviewed 01/2021, revealed, .A key component in reducing fall reoccurrences is the program's in-depth investigation to determine contributing factors that places the resident at risk and the root cause(s) of the fall event. Considerations: Why is it important? There are several reasons: * .About 1 in 3 who fall will fall two or more times in a year .* Falls often have serious consequences, especially in fail older residents. Fall-related injuries decrease the resident's quality of lie and ability to function .One in every 10 residents who fall has a serious related injury and about 65,000 residents suffer a hip fracture each year .*Adverse consequences of falls for residents can include: Reduced quality of life, increase fear of falling, restriction of activities, decrease ability to function, serious injuries, and increase risk of death .6. If the resident has sustained injuries that require transfer to an acute care setting then a INTERACT hospitalization Transfer form will be completed and copy sent with resident upon transfer . Review of Care Standards reviewed on 01/2021, revealed, .4. DO NOT MOVE THE RESIDENT IF IT MAY RESULT IN FURTHER INJURY .5. Notify the primary physician immediately for orders, if a suspected injury has occurred request transfer order to an Emergency Care Center . Review of Notification of Change reviewed 7/2021, revealed, .NOTIFY THE PHYSICIAN IMMEDIATELY IF THE RESIDENT REQUIRES IMMEDIATE ACTION .CALL 911 IN EMERGENCY SITUATIONS such as fall with head or neck injury, and or other traumatic injury .3. When a situation is emergent or becomes emergent the licensed nurse may initiate the 911 system .7. Once the Physician calls back, describe resident's condition. Document physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . automatic transfer of the resident to the emergency room or admission to the hospital .

This citation pertains to intake #MI 600, #MI 591 & MI 803. Based on observation, interview and record review the facility failed to provide adequate care to prevent to prevent skin breakdown and worsening of pressure ulcers in 2 of 18 residents (Resident #111 & #107) reviewed for pressure ulcers, resulting in actual skin breakdown and worsening of pressure ulcers due to inadequate repositioning and incontinence care. Findings include: Resident #111 Review of a Face Sheet revealed Resident #111 was originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #111, with a reference date of 4/5/21 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #111 was cognitively intact. Review of the Functional Status revealed that Resident #111 required maximum assistance for bed mobility. Review of Resident #111's Pressure Ulcer Care Plan revealed, .start date 7/6/2018 . pressure ulcer to coccyx with potential for infection and discomfort to area. Increased risk for skin breakdown related to impaired mobility weakness, and incontinence, .12/29/20: foley catheter (a tube inserted into the bladder to drain urine) placed for wound healing. APPROACH: .keep clean and dry as possible. Minimize skin exposure to moisture start date 7/6/2018 .keep linen clean, dry and wrinkle free. Start date 7/6/2018 .keep (Resident #111) off affected area as much as possible. Start date 7/6/2018 .maintain the head of the bed at the lowest degree of elevation possible. Start date 7/6/2018 .Provide incontinence care after each incontinent episode. Use moisture barrier product to peri-area. Start date 7/6/2018 .Turn and reposition every two hours and PRN (as needed) as (Resident #111) will allow. Start date 7/6/2018. Use pressure reduction devices for elevation of lower extremities and heels. Start date 7/6/2018. Review of Resident #111's Braden Scale for Prediction of Pressure Sore Risk dated 5/5/21 revealed a score of 15 which indicated Resident #111 was at risk. During an observation on 5/4/21 at 1:22 P.M., Resident #111 was observed with eyes closed lying in bed, leaning to the right, positioned on her right buttock. The HOB (head of bed) was approximately 45 degrees. During an interview on 5/4/21 at 3:53 P.M. Licensed Practical Nurse (LPN) F reported that Resident #111 did not have a pressure ulcer, but was being treated with a topical cream for preventative measures. This information was inconsistent with the documentation in the medical record. Review of Resident #111's Treatment Administration Record on 5/10/21 indicated orders for a weekly skin assessment every Tuesday on first shift. There was no documentation to indicate this had yet been completed. Review of Resident #111's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .topical .small amount . apply to buttock twice daily . 8:00 A.M. and 8:00 P.M. start date 4/9/21. There were no other medications or documented treatments/dressings ordered for Resident #111's wounds. Review of Resident #111's Weekly Pressure Ulcer Progress Report dated 4/29/21 revealed, Sacrum . Stage 4 . 4 cm x 5.5 cm x 0.1 cm . continue order for [MEDICATION(S)] . Review of Resident #111's Weekly Pressure Ulcer Progress Report dated 5/7/21 revealed, Sacrum . Stage 4 . 9 cm x 7 cm x 2 cm . foul odor . Deteriorated . [MEDICATION(S)] for wound . During an observation and interview on 5/6/21 at 12:05 P.M., Resident #111 was sitting in her wheelchair in the hall outside of her room, a blue wedge at her right side. Resident #111 reported that she had a sore on her bottom and stated, .it hurts so bad to sit on my right side .there's no bandage on it .it's like someone is ripping my flesh apart . During an interview on 5/6/21 at 12:05 P.M., Occupational Therapy Assistant (OTA) KK reported that Resident #111 had been in her chair for about 2 hours and stated .she can tolerate 2-4 hours usually .she knows enough to ask when she wants to lay down .we are working on her positioning while she is up in her wheelchair .that's what the blue wedge is for . During an observation on 5/6/21 at 2:34 P.M. Resident #111 was sitting in her wheelchair in the dining room, leaning heavily to her right side and the blue wedge was no longer at her side assisting with her positioning. During an interview on 5/6/21 at 2:50 P.M., Certified Nursing Assistant (CNA) W reported that Resident #111 had been in her wheelchair since before lunch and stated, .she doesn't need to be changed .she has a catheter .she will lay down after dinner . During an observation on 5/6/21 at 3:26 P.M. Resident #111 was sitting in her wheelchair in the dining room, slumped over to her right side. During an observation and interview on 5/6/21 at 4:15 P.M. Resident #111 was sitting in her wheelchair in the dining room, slumped over to her right side. Resident #111 stated, .oh my back side is hurting so bad .I want to lay down .it does no good to ask . It was noted that Resident #111 had been in her wheelchair for approximately 6 hours. During an observation and interview on 5/10/21 at 10:38 A.M. Resident #111 was lying in her bed with the HOB at approximately 45 degrees. Resident #111 reported that she has a catheter so that she doesn't have wetness all over herself and stated, .I have a sore on my bottom .and the acid [CONDITION(S)] .oh it hurts so bad right now . During an observation and interview on 5/10/21 at 11:23 A.M. Resident #111 was lying in bed on her back with the HOB approximately 30 degrees. Resident #111 stated, .I would like to get out of this bed .my backside feels just awful . During an interview on 5/10/21 at 11:28 A.M., CNA E reported that she emptied Resident #111's catheter bag about an hour ago. CNA E stated, .she doesn't want to get up .she has a wound on her bottom . During an observation and interview on 5/10/20 at 11:30 A.M. CNA E in Resident #111's room preparing to get her up for lunch. Resident #111 stated, .yes I would like to get up .can you do that .I am miserable . Observation of Resident #111's brief heavily saturated with urine, feces caked on her rectum and the under pad was wet and discolored. Observation of a large open wound on Resident #111's coccyx, a small open area with surrounding scar tissue on the right gluteal fold (bottom on buttocks) and a small area that was actively bleeding on the right upper buttocks. The surrounding skin was macerated and bright red. CNA E stated, .your catheter must be leaking . Resident #111 stated, .my catheter always leaks .my backside is hurting! CNA E reported that she applied [MEDICATION(S)] (a thick white topical medication for minor skin irritation) to Resident #111's bottom earlier today. CNA E was observed to look through Resident #111's drawers and was not able to find the [MEDICATION(S)] at this time. It was noted that Resident #111's buttocks did not have any evidence of residual [MEDICATION(S)] during the observation. At 12:00 P.M. LPN II entered the room to assess Resident #111's new wound on Resident #111's right upper buttock, reported measurements of the wound were 3 cm x 2 cm and covered the wound with an adhesive dressing and stated, .the doctor will be here later to do wound rounds . Resident #111's was then transferred into her wheelchair for lunch. There was no observation of [MEDICATION(S)] topical being applied to Resident #111's wounds and no observation of a dressing applied to the wounds. During an observation on 5/10/21 at 1:38 P.M. Resident #111 was sitting in her wheelchair in the dining room, leaning to her right, with no blue wedge observed to assist in repositioning. During an interview on 5/10/21 at 2:03 P.M., Regarding Resident #111's order for [MEDICATION(S)] order, LPN II stated .No I didn't do that this morning .I don't know if the CNA did .the nurse is supposed to do it .I am new and haven't been trained on treatments . LPN II was then looking for [MEDICATION(S)] in the treatment carts and was not able to find any. LPN II asked LPN HH for assistance. During an interview on 5/10/21 at 2:10 P.M. LPN HH reported that [MEDICATION(S)] is in a jar and we scoop it into a cup for treatments. LPN HH was not able to locate any [MEDICATION(S)] in the treatment carts or the medication carts. LPN HH stated, .I will go see if I can find some in the supply room . Review of Resident #111's Treatment Administration Record for 5/1/21-5/10/21 indicated that [MEDICATION(S)] topical had not been administered in 9 out of 19 opportunities. During an observation on 5/10/21 at 2:28 P.M. Resident #111 was observed sitting in her wheelchair in the dining room. During an observation on 5/10/21 at 3:05 P.M. Resident #111 was observed sitting in her wheelchair, leaning to her right with no observation of a blue wedge on her right side to assist with repositioning. During an interview on 5/10/21 at 3:07 P.M. Registered Nurse (RN) R reported that she assessed Resident #111's coccyx wound on 5/7/21 and stated, .she was laying on her right side .I don't remember seeing a wound on her right butt crease .it has never been mentioned in clinical meetings .(LPN LL) may know more she usually does the wounds . RN R reported that she was specifically assessing the known wound and did not perform a full skin assessment on 5/7/21. RN R reported that Resident #111 has orders for [MEDICATION(S)] Cream to be applied to her wounds and she is supposed to be repositioned frequently and have incontinence care frequently and stated, .she needs frequent incontinence care because she has [CONDITION(S)] and has frequent bowel movements . During an interview on 5/10/21 at 3:17 P.M. LPN LL reported that she saw Resident #111 last on 4/29/21 for the wound on her coccyx and stated, .she has had a pressure ulcer on her right gluteal crease in the past .but I thought that was just scar tissue now . LPN LL reported that she had discovered last week that the wound treatments were not being done as ordered. During an observation on 5/10/21 at 3:44 P.M. Resident #111 was sitting in her wheelchair in the hallway by her room, slumped to her right side and stated, .my right backside hurts be so bad . During an observation on 5/10/21 at 4:23 P.M. Resident #111 was sitting in her wheelchair in the doorway to her room, leaning heavily to her right side and stated, .I've been waiting and waiting .my back side feels bad .I am getting fed up! . Resident #111 had been up in her chair for greater than 4 hours. Resident #107 Review of a Face Sheet revealed Resident #107 was originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #107, with a reference date of 3/22/21 revealed a Staff Assessment for Mental Status indicating that Resident #107 was severely cognitively impaired. Review of the Functional Status revealed that Resident #107 required extensive assistance of 1 person for bed mobility. Review of Resident #107's Pressure Ulcer Care Plan revealed, .has wounds to bilateral buttocks/coccyx area and foot. Start date 4/14/2021. APPROACH: .continue to turn and reposition (Resident #107) every two hours. Start date 4/14/2021.Deliver prescribed treatment. Start date 4/14/2021.Keep heels elevated with pillows. Start date 4/14/2021.Measure and assess wound weekly for progression of healing. Start date 4/14/2021. Provide weekly skin checks per licensed nurse for other weakened skin areas . start date 4/14/2021. Use draw sheet to lift. Start date 4/14/2021 . Review of Resident #107's Braden Scale for Prediction of Pressure Sore Risk dated 5/5/21 revealed a score of 14 which indicated that Resident #107 was at moderate risk. During an observation and interview on 5/6/21 at 3:28 P.M., Resident #107 was in his room sitting in his wheelchair and stated, .I have been in my chair since 6:00 A.M I am ready to lay down .I have a big sore on my bottom . my bottom hurts a lot . when can I lay down . During an observation and interview on 5/6/21 at 4:15 P.M., CNA H and CNA W were in Resident #107's room and preparing to get him into bed, using the hoyer lift (a mechanical lift to assist with transferring). CNA H reported that he did not know how long Resident #107 had been up in his chair today and stated, .he was in the activity room when I got here at 2:00 P.M .yes he has wounds on his bottom . Following the transfer into bed, Resident #107's stated, .my bottom is still burning . Observation of Resident #107's buttocks during his incontinence brief change, it was noted that the entire surface area of Resident #107's buttocks were bright pink, with 2 open areas on the right middle buttock and no dressings observed. It was noted that Resident #107 had a foley catheter, but the incontinence brief was wet. CNA H did not perform incontinence care (cleaning the skin) and stated, .I am going to give him a shower after supper . Review of Resident #107's most recent Weekly Pressure Ulcer Report dated 4/29/21 at 3:08 P.M. revealed, .right gluteus .discovered 4/10/21 .buttocks .Stage 2 .9 cm x 3.5 cm .beefy red .macerated tissue .Deteriorated . Review of Resident #107's document titled Determination of Unavoidable Pressure Wound dated 4/29/21 at 8:59 A.M. revealed, .stage 2 open area on coccyx . The document was not completed and reflected a different body location. During an interview on 5/6/21 at 4:19 P.M., LPN F reported that Resident #107 has orders for [MEDICATION(S)] topical on his bottom and stated, .I haven't done that yet .he is due for a pressure ulcer report today too, so I will do a progress note on that after I see it . Review of Resident #107's Treatment Administration Record for 5/1/21-5/10/21 revealed orders for a weekly pressure ulcer report on Thursdays and it was noted to not have been performed on Thursday 5/6/21. Also orders for [MEDICATION(S)] topical that had not been administered in 4 of the 19 opportunities. Review of Resident #107's Progress Notes from 5/6/21-5/10/21 revealed no documentation of pressure ulcer assessment. During an observation on 5/10/21 at 10:46 A.M., Resident #107 was sitting in his wheelchair in the hallway. During an observation on 5/10/21 at 11:13 A.M., Resident #107 was sitting in his wheelchair in the activity room. During an interview on 5/10/21 at 11:15 A.M., CNA E reported that Resident #107 got up into his chair this morning at about 9:00 A.M. and he will lay back down this afternoon after activities. During an observation on 5/10/21 at 12:28 P.M., Resident #107 was sitting in his wheelchair in the activity room. During an observation on 5/10/21 at 2:18 P.M., Resident #107 was sitting in his wheelchair in the hallway. Resident #107 was observed asking several staff members if they would lay him down. During an observation on 5/10/21 at 2:26 P.M., Resident #107 was sitting in his wheelchair in the hallway. Resident #107 was observed verbalizing, .I want to lay down .I am ready to lay down . Resident #107 had been sitting in his wheelchair for greater than 5 hours. During an observation and interview on 5/10/21 at 2:42 P.M., Resident #107 was transferred into his bed using a hoyer lift. Regional Nurse Consultant (RNC) MM and CNA Y encouraging Resident #107 to scoot himself down in bed. CNA Y was positioned on the right side bottom half of the bed, holding onto Resident #107's arms, pulling and asked him to move down from the HOB. Resident #107 was observed to scoot down while being assisted by CNA Y. It was noted that this technique puts the resident at risk for shearing of the skin. RNC MM covered the resident with his blanket. Resident #107 was left lying on his back. RNC MM then reported that she did not know anything about Resident #107's wounds on his bottom and stated, .we can take a peek . Observation of Resident #107's buttocks revealed 2 open wounds on the right buttock and the surrounding skin was bright pink, there was no dressing in place. RNC MM then positioned Resident #107 on his left side and Resident #107 stated, .that feels good . There was no incontinence care or topical treatments applied to the skin during this observation. Review of a facility policy Pressure Ulcer Prevention/Supportive Approaches dated 4/2018 revealed, .if resident requires wedge or pommel cushion when in chair, utilize pressure reduction wedge or pressure reduction pommel cushion . Keep the skin clean and dry . Avoid positioning on bony prominences . When assisting the resident with transfers, positioning, or lifting avoid friction and or skin shear . apply moisture barrier: a. During a.m. and p.m. care and or bathing activities. b. Following each incontinent episode . Establish a 1 or 2 hour repositioning schedule as appropriate to meet the resident's needs, continue to turn and reposition regardless of the support surface in use as no support surface provides complete pressure relief . It is preferable practice to float residents heals as a preventative measure to pressure wound development . Review of a facility policy Skin Condition Discovery and Documentation dated 4/2018 revealed, .A complete wound assessment and documentation will be conducted on all skin conditions upon discovery and weekly there after until they are healed . Weekly assessments of skin conditions will be documented in the resident's electronic medical record using . weekly pressure ulcer progress report . Review of Fundamentals of Nursing (Potter and Perry) 9th edition revealed, Usually the time that a patient sits uninterrupted in a chair is limited to 1 hour. This interval is shortened in patients who are at very high risk for skin breakdown. Reposition patients frequently because uninterrupted pressure causes skin breakdown . The presence and duration of moisture on the skin increases the risk of ulcer formation. Moisture reduces the resistance of the skin to other physical factors such as pressure and/ or shear force. Prolonged moisture softens skin, making it more susceptible to damage. Immobilized patients who are unable to perform their own hygiene needs depend on nurses to keep the skin dry and intact. Skin moisture originates from wound drainage, excessive perspiration, and fecal or urinary incontinence.

This citation pertains to intake #MI 024 & #MI 416. Based on observation, interview and record review the facility failed to ensure residents received care in accordance with treatment orders and professional standards in 1 of 18 residents (Resident #114) reviewed for quality of care, resulting in Resident #114 having dysuria (pain with urination) for approximately 4 weeks, sustaining 5 straight catheterizations (insertion of a tube through the urethra into the bladder to obtain a urine sample) due to the facility mishandling the specimens and a significant delay in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of a facility policy Laboratory Test dated 1/2021 revealed, The licensed nurse receiving the order for any Laboratory test will transcribe the order .notify the lab .for specimen pick-up . Review of a Face Sheet revealed Resident #114 was originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #114, with a reference date of 2/12/21 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #114 was cognitively intact. Review of Resident #114's Care Plan did not indicate history of and/or problems with UTI's. During an interview on 5/4/21 at 3:27 P.M., Resident #114 reported that it was very painful when she urinated and that the facility staff had collected 4 urine specimens from her using a straight catheter over the past few weeks and stated, the last one was very painful .and I still don't have results .they won't prescribe any medication until they have results .I know what the symptoms are .I've had UTI's all my life . Resident #114 reported that the facility staff told her that the reason for the repeated urine specimens was because of the lab not picking up the specimens. During an interview on 5/6/21 at 12:25 P.M., Resident #114 tearfully reported that the nurse had to do a 5th straight catheterization today and stated, .it isn't right .it hurts so bad up inside of me .there is something wrong with this picture .I don't know who to trust anymore .they just come in and do straight catheters like its no big deal .the last 2 have hurt so bad .I am not on an antibiotic yet, they gave me that medicine that turns your pee orange .that didn't help anything .I am having painful urination and low back pain .it's worse now with all the straight catheters being done . During an interview on 5/6/21 at 12:38 P.M., Medical Doctor (MD) EE reported that he was not aware of Resident #114's painful urination. During an interview on 5/6/21 at 12:51 P.M. Licensed Practical Nurse (LPN) O reported that Resident #114 began having painful urination about a month ago and Nurse Practitioner (NP) FF ordered a urinalysis (lab test for urine) with C & S (culture and sensitivity: a test to indicate what medication would be best to treat an infection) to be obtained by means of straight catheterization. LPN O reported that the initial order did not get transcribed correctly and therefore required that another specimen be obtained and stated, .then the second order did not get put in the system .then the third and fourth specimens didn't get picked up so we did another one and it got picked up today . LPN O reported that it is the responsibility of the nurse manager to ensure that the specimen is picked up by the lab and that did not happen. LPN O reported that NP FF was in the facility on 5/4/21 and was upset that we still didn't have any test results. LPN O reported that Resident #114 was no longer taking the [MEDICATION(S)] (medication used for painful urination that is known to turn the urine orange) or any medication for a urinary tract infection and stated, .she isn't complaining of burning anymore .we haven't gotten the urine culture results back to know what antibiotic to prescribe . Review of Resident #114's Lab Orders indicated a 1 time order on 4/13/21 at 9:00 P.M. for urinalysis; urine culture. There were no further orders entered in the electronic medical record. During an interview on 5/6/21 at 2:10 P.M. Nursing Home Administrator (NHA) A reported that lab specimens and orders should be reviewed in the morning by the managers to ensure that they were obtained and picked up by the lab and stated, .I found out about (Resident #114's) urine specimen issues just today . During an interview on 5/10/21 at 9:59 A.M., NP FF reported that Resident #114 first started complaining of painful urination in mid April and stated, .it had been going on for a couple weeks .I ordered a straight catheter urine specimen with C & S .multiple times .urine results would come back but not the C & S .then when I was there last week I said let's do it again .every Tuesday when I came in I would discover that it wasn't done again . NP FF reported that it was her understanding that the lab orders were not getting transcribed accurately from what the actual order was and to what was written on the lab slip, and then a couple times the lab didn't pick up the specimens. NP FF reported that she had prescribed [MEDICATION(S)] initially, but that did not help Resident #114's pain. NP FF reported that repeated straight catheterizations can increase the risk for infection. NP FF reported that MD EE would be the person notified of the results and not NP FF. During an interview on 5/10/2021 at 1:00 P.M., Laboratory Staff (LS) GG reported that three urine specimens had been received for Resident #114. LS GG reported that on 4/13/21 a urinalysis was ordered and a specimen was received, on 5/2/21 a urinalysis was ordered and a specimen received and on 5/5/21 a urinalysis and culture & sensitivity was ordered and a specimen was received, and stated, .all of the results have been reported to the facility . LS GG reported that there was no record of specimens not being picked up from the facility. During an interview on 5/10/21 at 1:42 P.M., LPN HH reported that Resident #114 is doing much better since she has started an antibiotic for her UTI and stated, .she isn't having as much pain .her urine is a lot lighter . LPN HH reported that the results had came back last week from the urine specimen that was obtained on 5/2/21 and stated, .we didn't even need to take those other specimens .the results were just not back yet . Review of Resident #114's lab test result Urine Culture with a collected date of 5/2/21 and a reported date of 5/6/21 indicated, >100,000 CFU/ML Escherichia Coli (specific bacteria of the infection), sensitive to [MEDICATION(S)] (antibiotic) with written notes [MEDICATION(S)] 100mg BID (twice a day) 7 days .5/6/21 per (MD EE). It was noted that [MEDICATION(S)] is in the [MEDICATION(S)] class of antibiotics. Review of Provider Communication Binder revealed the following notes regarding Resident #114, On 4/13/21: c/o (complains of) pain when urinating, dysuria for 2 weeks, UA (urinalysis) with Culture and sensitivity straight catheter specimen. [MEDICATION(S)] 100mg TID (3 times a day) for 2 days for painful urination and spasms. On 4/15/21: dysuria, with no treatment orders or findings. On 4/27/21: frequency, urgency, suprapubic (lower abdominal area) painful urination, ongoing, order not entered as ordered by provider on 4/13 culture not done, repeat UA and urine culture & sensitivity, catheter specimen stat (immediately). Review of Resident #114's Progress Note dated 4/13/21 at 6:41 P.M. revealed, NP in to see resident. New orders are UA with culture and sensitivity-straight catheter specimen. [MEDICATION(S)] 100 mg TID x two days for painful urination/spasms. Review of Resident #114's Progress Note dated 4/24/2021 at 9:41 P.M. revealed, Resident stated she was having burning and urgency when she urinates. This nurse asks if she's been drinking water as she was taking a drink of pop. This nurse educated resident that water is the best to flush out bacteria not pop. Resident didn't complain any further this shift. Will continue to monitor. Review of Resident #114's Progress Note dated 4/27/2021 at 8:43 P.M. revealed, NP in to see resident on first shift. New order for a repeat UA and urine culture and sensitivity-catheter specimen STAT, this nurse obtained urine. Awaiting lab to pick up. Review of Resident #114's Progress Note dated 4/30/2021 at 10:51 P.M. revealed, This nurse called the on-call provider to report the findings of dark urine noted during personal care. the provider ordered straight catheter. For further urine culture. The order is in the lab tab and urine in the fridge. Review of Resident #114's Progress Note dated 5/6/2021 at 6:20 P.M. revealed, UA returned, positive E. coli >100,000. C & S received, MD notified and ordered [MEDICATION(S)] 100 mg BID x 7 days. Order entered . Review of Resident #114's Progress Note dated 5/7/2021 at 9:59 A.M. revealed, Resident began [MEDICATION(S)] 100 mg BID x 7 days today for E. coli in urine . Resident did complain of soreness around urethra area cleansed well and patted dry .

This citation pertains to intake MI 978 and MI 518. Based on interview and record review, the facility failed to implement a care plan to assess, monitor and document care interventions following a change in condition in 1 resident (#9); follow protocols for treatment of [REDACTED].#18), out of three reviewed for quality of care resulting in pain and a rapid decline in condition for #9, severe low blood sugars and an unnecessarily painful and anxious death for #18 and the failure to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and residents' choices. Findings include: Resident #9 (R9): R9's annual Minimum Data Set (MDS) assessment, dated [DATE], introduced the Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents, score was 11 (scale ,[DATE] Moderate Impairment). R9's oxygen therapy care plan dated [DATE] revealed she had the [DIAGNOSES REDACTED]. Confidential staff (CS) was interviewed during the survey between [DATE] and [DATE], and stated R9's pain symptoms on her right side began at the end of March or beginning of [DATE]. Same CS stated when R9 came back from the hospital, she was in so much pain they were unable to roll her. Two weeks before R9 went out to the hospital, she reported R9's pain to NHA A and was told R9's complaints were due to behaviors. Same CS stated in the same interview, R9 refused to be turned, had emesis when they would try and get her to drink fluids; and after R9's surgery she didn't eat due to her pain. Same CS stated she did not offer R9 a supplement when she refused her meals. CS was interviewed during the survey and stated she did not offer R9 supplements when she refused her meals. Same CS stated she advised R9's daughter to take her to the hospital on [DATE] because she was in excruciating pain. Same CS stated she didn't know if intravenous fluids, were discussed with the R9 or R9's daughter. Same CS stated she did not have access to policies. R9's nurses notes indicated she had an emergency room (ER) visit on [DATE], due to increased complaints of abdominal pain. R9's ER record dated [DATE], revealed she had gallstones and a kidney infection. R9's ER instructions revealed to follow a low-fat diet and was prescribed an antibiotic for the kidney infection. R9's care plans were not updated with interventions to address the gallstones, pain or her kidney infection. R9's cholecystectomy (surgical procedure to remove gallbladder) postoperative (post-op) instructions dated [DATE] revealed to start liquids and a bland diet, then progress to a general diet. The same instructions indicated it was important to remain hydrated and to drink plenty of fluids. The same instructions indicated to use an ice pack to the incision for pain. The same instructions revealed R9 had a Jackson Pratt (JP) drain (used to remove fluids that build up in body after surgery) to remain in place until one-week follow-up appointment. JP instructions included to strip tubing, empty, and record output daily; and to bring the information to the follow-up appointment. R9's care plan was not updated with her post-op instructions. A physician order for [REDACTED]. R9's Critical Admission Assessment was dated [DATE], and the completion date and time was [DATE] at 11:39 AM, after she had expired. The same assessment under skin comments revealed she had 3 incisions on her lower abdomen from surgery, there was no mention in the assessment or progress notes dated [DATE] that she was admitted with a pressure ulcer. R9's same admission assessment indicated she had frequent pain that was rated as 7 out of 10, with 10 being the worst pain she had ever experienced. The same assessment revealed the pain made it difficult to sleep at night, daily activities were limited because of pain, and pain affected R9's appetite. R9's pain goal was to be at a 5 out of 10, making it tolerable. The assessment indicated approaches were to be reviewed, added to R9's plan of care and documented in R9's record. There were no updates to R9's care plan. R9's potential for actual pain care plan related to decreased mobility, [MEDICAL CONDITIONS] reflux disease (GERD), [MEDICAL CONDITION], chronic right shoulder pain, knee pain, and numbness of hands and fingers dated [DATE] and was last updated on [DATE]. R9's pain care plan did not include her recent surgery, personal pain goal of a 5 out of 10 rating, or difficulty sleeping interventions. R9's Medication Administration Record (MAR) instructed to assess pain every shift, three times a day. Pain assessment on R9's record was not recorded on the MAR from [DATE] through her death on [DATE]. R9's [DATE] MAR and controlled substance record indicated she received [MEDICATION NAME] and [MEDICATION NAME] for pain on 12 occasions following her readmission from [DATE] through [DATE]. Progress notes dated [DATE] at 4:00 PM revealed R9's JP drain (on right side of abdomen and was draining well. The same note did not indicate how much fluid was emptied from the drain. Progress notes dated [DATE] at 1:56 PM revealed R9 refused to get out of bed, had little to no intake, and needed strong encouragement to get up and eat anything; JP drain intact draining light red drainage. The same note did not indicate how much fluid was emptied from the drain. Progress notes dated [DATE] at 5:51 AM indicated she had slight amount of drainage from the JP drain. There was no consistent record keeping of R9's JP drain amount emptied per shift. Director of Nursing (DON) B was interviewed on [DATE] at 10:40 AM, and stated pain and JP drain output was documented in R9's progress notes. DON B was not able to provide accurate JP drain output based on data in R9's progress notes. DON B did not have an explanation as to why pain was not documented on the MAR or consistently in R9's progress notes from [DATE] through R9's death on [DATE]. R9's last Braden assessment (risk of skin breakdown) was completed on [DATE], and indicated her score was 19 (score of 19 or greater indicated no risk and no interventions were necessary). R9's physician orders indicated to complete a Braden assessment monthly, no assessment for [DATE] was found in R9's medical record. R9's Event Report dated [DATE], indicated it was recorded on [DATE] at 3:28 PM, and was admitted with a Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed) on her coccyx. R9's [DATE] Treatment Record did not indicate treatments were completed for any pressure ulcer. Physician orders did not include treatment for [REDACTED]. R9's at risk for skin breakdown care plan dated [DATE], noted under problem that on [DATE], she returned to facility with Stage III pressure ulcer (full thickness tissue loss) to the coccyx. R9 was re-admitted to the facility on [DATE]. The same care plan revealed R9's goal was her skin would remain intact through the next review. There were no updated care plan approach's or goals on R9's skin care plan. There were no other care plans that addressed R9's pressure ulcer. R9's nurses notes dated [DATE] at 9:26 AM reflected she expired at 9:05 AM. Resident #18 (R18) A review of the electronic medical record reflected that R18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of care plans for R18 reflected fluctuating cognitive ability and hallucinations. R18 declined further intravenous antibiotic therapy and was admitted to hospice services on [DATE]. A review of a facility document titled, Medical Treatment Decisions of Residents, reflected R18 checked I wish to have medication for comfort. R18 signed the document on [DATE]. According to physician's orders, on [DATE] R18 was prescribed [MEDICATION NAME] concentrate (opioid) solution; 100 milligrams (mg)/5 milliliters (ml); 0.25 ml every two hours as needed for pain and difficulty breathing. On [DATE] R18 was prescribed [MEDICATION NAME] 5 mg; one tablet every four hours as needed for pain. A review of electronic progress notes, dated [DATE] at 9:37 AM, R18 was tearful and indicated having a high pain level. On [DATE] at 8:09 AM, Registered Nurse (RN) N reported R18 crying in pain. On [DATE] at 7:52 AM, progress notes reflected that Hospice RN o assessed R18 during the night shift and increased the dose of [MEDICATION NAME] concentrate to 0.5 mg every two hours as needed until the daytime hospice nurse arrived. On [DATE] at 10:05 AM, documentation reflected that Hospice RN W assessed R18 for jerky motions. R18 said he didn't know where he was, and was unable to answer any other questions. Resident Advocate U was at R18's bedside. On [DATE] at 8:31 AM, RN S documented that R18 was showing intense signs of distress and discomfort, thrashing crying out, etc. RN S notified Dr. C, and he increased the [MEDICATION NAME] concentrate to 1 ml every two hours, and he was given a dose. At 10:45 AM on [DATE], R18 passed. A review of the June Medication Administration Records (MAR) for R18 reflected he received [MEDICATION NAME] 0.5 ml at 7:00 PM and 11:45 PM, and one time earlier in the day (illegible time) on [DATE]-020. On [DATE], R18 received [MEDICATION NAME] 0.5 ml at 3:45 AM and 5:45 AM. On [DATE] at 9:40 AM, Hospice Administrator (ADM) I was interviewed via phone. ADM I was aware that Advocate U was upset about the delayed pain medications and that we don't use care packs (back up supply of strong pain and anxiety meds maintained where the hospice resident lives) or have our own 24-hour pharmacy. We have a local pharmacy, but it is closed at nigh, ADM I said. On [DATE] at 1:00 PM, Advocate U was interviewed via phone, and stated she was in to visit with R18 the day before he passed. I told Dr. C that [MEDICATION NAME] had caused hallucinations and restlessness before for R18. By the time R18 passed, he had been in pain, restless and hallucinating through the night. He looked uncomfortable, she said, And I was told by RN N that it could take up to four hours to get a stat med delivered from the pharmacy in Grand Rapids. He (R18) had 20 minutes of relief before he died . Later, the hospice director admitted they did not have their own pharmacy. On [DATE] at 10:00 AM, Hospice RN O was interviewed via phone as followed: RN o came to the facility to assess R18 early on the morning of [DATE]. R18 was lying down, twitching, his eyes were rolling back in his head. I suspected he was septic, RN o said. R18 had difficulty swallowing and couldn't swallow his pain medications. He looked very uncomfortable. RN o called Doctor C at 2:10 am and received orders to stop the [MEDICATION NAME] pills and increase the [MEDICATION NAME] concentrate dose. On [DATE] at 9:56 AM, RN N was interviewed as followed: Hospice Nurse W waited at R18's bedside all day on [DATE] for Dr. C to evaluate him. Doctor C finally ordered the [MEDICATION NAME] concentrate around noon. We don't keep [MEDICATION NAME] concentrate in the back-up medication box, RN N said. On [DATE] at 10:58 AM, Pharmacist O provided a timeline pertaining to the delivery of [MEDICATION NAME] concentrate on [DATE] for R18 as follows: orders for [MEDICATION NAME] 100mg/5ml were electronically received at 12:26PM. The orders where released by the pharmacist at 12:58 PM, and dispensed as STAT (right away). The pharmacy driver picked up the delivery at 2:18 PM and delivered the drugs to the facility at 5:02 PM. A review of the May and June MAR and Treatment Administration Record (TAR) reflected there was no order for blood glucose checks for R1. The MARs reflected that R18 was prescribed [MEDICATION NAME] FlexTouch Insulin pen 100 units/ml 12 units once a morning since [DATE]. According to the Geriatric Dosage Handbook, 21st edition, page 827, [DIAGNOSES REDACTED] (low blood glucose) is the most common adverse effect of insulin .Use of long-acting insulin preparations (eg. [MEDICATION NAME]) may delay recovery from [DIAGNOSES REDACTED]. Profound and prolonged episodes of [DIAGNOSES REDACTED] may result in convulsions, unconsciousness, temporary or permanent brain damage or even death. Insulin requirements may be altered during illness, emotional disturbances or other stressors. On page 829, monitoring parameters included blood glucose (finger stick) and HbA1c (blood test that measures average blood glucose control over the previous three months). Íntensive glucose control (HgbA1c less than 6.5) in the geriatric population has been related to cardiovascular mortality, [DIAGNOSES REDACTED] requiring treatment. An HbA1c less than 7.5% is an acceptable goal for a healthy older adult while less than 8% is acceptable for frail elderly patients. A review of laboratory results reflected R18's most recent HgbA1c of 6.6 on [DATE]. A review of electronic progress notes for R18 reflected as followed: [DATE] at 5:45 PM, observed resident lying in bed, seizing and eyes rolled back. Blood glucose was 38. Gave glucose gel (extremely sweet, thick product to raise low blood glucose, especially in someone who was unable to swallow as it absorbs via mucous membranes in the mouth). Rechecked blood glucose in 15 minutes and it was 45. Doctor C called and ordered recheck blood glucose at 7:15 AM. Hospice nurse notified. Blood glucose at 8:00 PM was 101. Resident still having tremors and eyes still rolling back, but responsive to staff. On [DATE] at 5:30 AM, Resident continued to have tremors and eyes rolling back in head. Only responsive to painful stimuli. At 5:30 AM, blood glucose was 39. [MEDICATION NAME] was given intramuscularly. Fifteen minutes later the blood glucose was 49. Second [MEDICATION NAME] given and blood sugar was 55. Doctor C called and ordered orange juice. Fifteen minutes after 80 to 100 ml of milk, the blood glucose was 61. Doctor C was called and said he would be in to see R18 in the morning. On [DATE] at 9:14 AM, Licensed Practical Nurse (LPN) p was interviewed via phone as followed: LPN p said she helped LPN q with R18's low blood glucose on [DATE]. At approximately 6:00 PM, R18's blood glucose was 39 and he was seizing. R18e had no orders to check blood sugars, but every Monday, the evening nurses check blood glucose on a list of residents, and LPN p was sure R18 was on that list. Although requested, this list was not provided by end of survey on [DATE]. I told LPN Q to get the [MEDICATION NAME] based on the protocol in the front of the MAR binder, but she could only find glucose gel, said LPN p. LPN q stayed with him, rechecked BS 49, and gave R18 a second glucose gel. This was 2nd shift on Sunday between dinner to about 10pm. Doctor C wanted orange juice, but we were out. I was able to get in about 100 ml of milk by dripping it into his mouth with a straw. On [DATE] at 9:35 AM, LPN q was interviewed via phone as followed: R18's blood glucose went really low around dinner time on [DATE]. I followed the protocol on R18's MAR for glucose gel because that's what Doctor C told me to do', said LPN q. When asked about using [MEDICATION NAME], LPN q said she was unsure about the injections and when to use them. I would have called the doc before using that, LPN q said. On the next shift (11PM to 7am) on [DATE], LPN p checked R18's blood glucose to be 39 at 5:30 AM, and I gave him a [MEDICATION NAME] injection. Fifteen minutes later, it was 49 and I gave a second [MEDICATION NAME] injection. His blood glucose was 55 after. Doctor C said to hold all his meds and he would be in in the morning. A review of the June MAR reflected no entries that [MEDICATION NAME] injections were administered to R18, nor were physician's orders located. A review of an undated, laminated facility document, titled Hypo/[MEDICAL CONDITION] Protocol, kept in the MAR book on short hall, reflected the following: Call MD if blood glucose level is less than 60 mg/dl. Make sure to treat first then call). Accucheck (sic - blood sugar finger stick test machine), blood sugar levels 20milligrams/deciliter (mg/dl) or less: Give [MEDICATION NAME] 1 mg by IM (into muscle) or SQ (into fatty tissue) injection. Repeat accucheck blood sugar level in 15 minutes to validate that glucose level has reached 79 mg/dl. If blood sugar level fails to reach 70 mg/dl in 15 minutes. Blood sugar levels that fail to rise to 70 mg/dl after second [MEDICATION NAME] injection, physician notification is required for further orders. Accucheck blood sugar levels ,[DATE] mg/dl: Give an alert resident six ounces of orange juice or instant glucose . If unresponsive give [MEDICATION NAME] 1 mg IM or SQ. Repeat accucheck (sic) blood sugar level in 15 minutes to validate that glucose level has reached 70 mg/dl. If blood sugar level fails to reach 70 mg/dl in 15 minutes, repeat either orange juice or [MEDICATION NAME] injection and recheck in 15 minutes. Blood sugar levels that fail to rise to 70 mg/dl after second [MEDICATION NAME] injection, physician notification is required for further orders.

This citation pertains to intake MI 978 and MI 332. Based on interview and record review, the facility failed to implement interventions following a weight loss, in two of three reviewed for weight loss (Resident #9 & #10), resulting in a severe weight loss (Resident #9) and a significant weight loss (Resident #10). Findings include: Resident #9 (R9): R9's annual Minimum Data Set (MDS) assessment, dated [DATE], introduced the Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents, score was 11 (scale ,[DATE] Moderate Impairment). The same MDS identified a 5 percent (%) weight loss in 30 days or a 10 % loss over 6 months, and R9 was not on a physician-prescribed weight-loss regimen. R9's Nutritional Status care plan dated [DATE], indicated she was at nutritional/hydration risk related to heart and kidney disease. R9's care plan goal was she would have adequate intake and hydration. The same care plan indicated R9 had a regular diet, instructed to monitor food acceptance record, observe labs, offer substitutions if consumed less than 50 percent (%) of meals. R9's Laboratory Report dated [DATE] revealed an [MEDICATION NAME] (protein that keeps fluid from leaking out of blood vessels and nourishes tissues) of 3.0 grams/deciliter (g/dL) (normal 3XXX,[DATE].7 g/dL). R9's care plan did not address the deficiency. In review of R9's electronic medical record (EMR), under vital signs, her weight on [DATE] was 174.6 pounds (lbs.); R9's weight on [DATE] was 156.8 lbs., a 10 percent (%) weight loss over six months. Registered Dietician progress note dated [DATE] at 11:18 AM, revealed R9 was on a Regular diet and ate independently. R9's intake was 75% for breakfast and dinner and lunch was variable. R9's estimated needs were ,[DATE] kilocalorie's (kcal) using 25 kcal/kilogram (kg) of adjusted ideal body weight (IBW) range, protein ,[DATE] grams (g) using ,[DATE].3 g/kg of the same and fluids ,[DATE] milliliters (mL) using 30 mL/kg of the same. The same note indicated no changes and no concerns at this time. Care Conference notes dated [DATE] did not indicate R9 had a 10 % weight loss in 6 months or any new nutritional interventions. In review of R9's [DATE] Food Acceptance (FA), there were 8 meals not documented for breakfast and lunch on ,[DATE], ,[DATE], ,[DATE], and [DATE]. The same record reflected for breakfast and lunch meals R9 consumed ,[DATE] % of the meals and ,[DATE] % of the dinner meal. On [DATE], R9's EMR reflected her weight was 146.2 lbs., a 7 % weight loss in 30 days. R9's nurses notes indicated she had an emergency room (ER) visit on [DATE], due to complaints of increased abdominal pain. R9's ER record dated [DATE], revealed she had gallstones and a kidney infection. R9's ER instructions revealed to follow a low-fat diet and was prescribed an antibiotic for the kidney infection. There were no changes made to R9's nutrition care plan or changes made to her diet. R9's cholecystectomy (surgical procedure to remove gallbladder) postoperative (post-op) instructions dated [DATE] revealed to start liquids and a bland diet, then progress to a general diet. The same instructions indicated it was important to remain hydrated and to drink plenty of fluids. R9's care plan was not updated with her post-op instructions. A physician order [REDACTED]. R9's [DATE]'s FA record revealed she had refused or ate less than 25% for 26 meals, along with no charting completed for 8 meals through [DATE]. There was no indication on the record or in the nurse's notes that a supplement was offered. The same FA record revealed on [DATE] R9 had no fluids with dinner; [DATE] no documentation of fluids for breakfast and lunch, and she refused dinner fluids. On [DATE] no fluid acceptance was documented for breakfast and lunch, and R9 refused dinner; On [DATE] R9 refused fluids at breakfast, fluid acceptance was 120 cubic centimeters (cc) with lunch, and she refused fluids with her dinner. On [DATE] fluid acceptance was documented all 3 meals totaling 450 cc, in which she did not meet her minimum fluid needs. On [DATE] the same FA record revealed her fluid acceptance was only 120 cc total. R9 refused fluids for all 3 meals on [DATE]. On [DATE] R9 refused fluids for breakfast. R9's oxygen therapy care plan dated [DATE] revealed an approach start date dated [DATE], to if ordered for possible dehydration, administer IV (intravenous) hydration as ordered. R9's medical record did not reflect IV hydration was offered to R9 or R9's daughter in [DATE]. Registered Dietician (RD) h was interviewed on [DATE] at 9:30 AM, and stated she documented R9's 2 lb. weight loss she had in April, but was not notified of R9 having emesis, nausea, or the low [MEDICATION NAME] from [DATE]. The Dietary Manager completed R9's annual nutrition assessment [DATE] and did not include her low [MEDICATION NAME] lab result. RD h stated in the same interview, the dietary manager was no longer employed at the facility. RD h stated if she would have been notified of R9's weight loss on [DATE], she would have asked for a re-weight. In review of the Weight Monitoring Policy dated ,[DATE], residents that trigger for a significant weight loss greater than 5 % from the previous month would be placed on weekly weights, resident would be reviewed by the interdisciplinary team committee and appropriate interventions would be put into place. Registered Nurse (RN) N was interviewed on [DATE] at 11:20 AM and stated she did not offer R9 a supplement when she refused to eat meals; and supplements were to be given if they have a physician's orders [REDACTED].>R9's nurses notes dated [DATE] at 9:26 AM reflected she expired at 9:05 AM. Resident #10 (R10) R10's MDS assessment, dated [DATE], indicated a BIMS score of 03 (scale ,[DATE] Severe Impairment). The same MDS assessment revealed R10 had the [DIAGNOSES REDACTED]. The same MDS indicated R10's Patient Health Questionnaire (PHQ-9, depression screen tool) score was 8 (scale ,[DATE] mild depression), and during the 14-day look-back period, he had a poor appetite or overeating, for 7 to 11 days, half or more of the days during the look-back period. R10's annual MDS assessment dated [DATE], reflected no issues with poor appetite or overeating during the 14-day look-back period. According to R10's EMR, his weight on [DATE] was 231.4 lbs. and his weight on [DATE] was 206.4, in which revealed he had a 10% weight loss in 180 days. In review of R10's nutrition/hydration care plan dated [DATE], his only goal was to have adequate intake and hydration, R10 had not had any new approaches added to his nutrition/hydration care plan since [DATE]. RD h' was interviewed on [DATE] at 11:57 AM and stated she was having issues getting accurate weights, R10 was on a no added salt, carbohydrate controlled, regular diet. RD h stated R10 did not have a nighttime snack that was documented and was offered items from the pantry. RD h stated she planned to review R10's record and make recommendations. R10's Food Acceptance Records (FAR) were reviewed from [DATE] through [DATE]. R10 did not have a [DATE] FAR. R10's [DATE] FAR indicated an intake of 75 to 100 % for most meals. R10's March, April, May and [DATE] FAR's reflected 50 to 100 % of meals accepted. Infection Control (IC) nurse O was interviewed on [DATE] at 1:10 PM and stated R10 was slow to wake up in the morning, needed help with set up and encouragement to get started. IC nurse O stated in the same interview R10 was started on a supplement twice a day on [DATE]. On [DATE] at 11:49 PM, Nurse Aide Q returned a telephone called placed on [DATE] at 1:44 PM, Nurse Aide Q reported, I'm a night shift aid and just wanted to report we are having trouble getting our residents snacks at night. Also, we almost never have thickener so we are not able to make thickened water for the ones that need it. This has been an issue for a while now and has been brought up in the past and nothing has been done about it. Nurses and aids have been supplying snacks for residents. However, when this has been brought to our administrator's attention, she has told us 'there are plenty of snacks'.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and interventions to prevent falls for one (Resident #26) of three reviewed for falls, resulting in repeated falls and a [MEDICAL CONDITION] requiring hospital transfer and sutures. Findings include: Review of the medical record revealed R26 was a [AGE] year old male, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Discharge return anticipated MDS dated [DATE], revealed R26 had moderately impaired cognitive skills for daily decision making, evidence of an acute change in mental status, inattention present and fluctuated (comes and goes, changes in severity), disorganized thinking present and fluctuated, required extensive assistance for transfers, walking, locomotion, and toilet use, and had two or more falls with injury since admission/entry or prior assessment. The 14 day MDS dated [DATE], revealed R26 scored 12 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS), had evidence of an acute change in mental status, inattention present and fluctuated, disorganized thinking present and fluctuated, transferred with supervision of one staff, walked with limited assistance of one staff, and required supervision of one staff for toilet use toilet use. R26 expired in the facility on [DATE]. Review of the Progress Note dated [DATE], revealed CNA notified this nurse at 2150 (9:50 PM) that resident had fallen. This nurse entered room and observed resident sitting on floor next to bed and wheelchair bed side table was in front of him .Checked resident's head and observed a small contusion to back of his head with a small laceration on top of it .Resident thought it was Saturday and that he was still at (name of hospital) but once reassured resident knew where he was .Interventions are fall mat, bed alarm and 15 min checks. This nurse put cool compress to head and gave PRN (as needed) Tylenol for pain . Review of physician's progress note dated [DATE], revealed chief complaint increase confusion, weight loss, tremor, shaking, frail, increase sleep .Patient seen because he looks frail and confused. he was propelling himself in a wheelchair and this behavior was new to me. Usually the patient ambulates on his own. I asked the patient how he was doing he stated that he was doing fine. He said he was using the wheelchair for some support sometimes he feels tired .I am concerned that he is using a wheeled walker chair to assist with ambulation and him (sic) concerned that he is failing. Review of the Progress Note dated [DATE] at 3:40 AM, revealed This nurse called to residents room. Resident observed laying on his back with feet facing doorway to hall and head facing roommates side. Resident wearing only a t shirt, BM on floor and on residents legs, blanket from bed on floor. Call light is on. Noted blood dripping down residents face and on to the floor, blood droplets on tv stand and on the floor next to it. resident confused, unable to state what he was doing, stated I fell .Roommate stated resident was standing up and then fell down. It all happened so fast. Compress to laceration on rt (right) side of forehead applied and held pressure to stop bleeding .Noted rt knee has abrasion, no bleeding .Unable to stand at this time. 911 called . Review of the Fall Statements revealed R26 did not have his alarm in place or sounding. In a telephone interview on [DATE] at 09:49 AM, CNA AA reported she was assigned to care for R26 when he fell on [DATE] at 3:40 AM. CNA AA reported her shift started at 10:00 PM. When asked what fall interventions were in place when her shift started, CNA AA stated he had the pull tab bed alarm, fall mat, bed was lowered all the way down as low as it would go. CNA AA reported at one point (she could not recall the time) she assisted R26 to the bathroom and when he went back to bed, she put his alarm on him. CNA AA reported R26 used his call light a couple times for assistance. CNA AA reported she went on break between 2:00 AM and 2:30 AM and when she came back, R26 was asleep in bed. When asked how she was alerted to his fall, CNA AA stated his call light went off and I went to check. When I opened the door and turned on the light, he was on the floor. There was a big puddle of blood. His roommate was sitting on the edge of his bed. He (the roommate) was the one who pushed his call light. CNA AA reported the alarm box was on the floor next to R26 and the tab was attached to R26's shirt. CNA AA reported the alarm was not sounding. CNA AA reported she put the alarm back together, pulled it apart and it sounded. CNA AA reported they changed the batteries in the alarm just in case that was the problem. CNA AA reported she was aware R26 had a history of [REDACTED]. I would make sure I saw the flashing light and it was clipped to him. Review of the Progress Note dated [DATE] at 8:30 AM, revealed This nurse was called to resident's room, where aide found resident crawling out of the bathroom, covered with feces. Unknown if fell in bathroom, resident stated yes, when asked if he fell in bathroom. Checked resident over, neuro's were positive for confusion, unable to tell me where he was . Did know fist (sic) and last name. 15 minute vitals continued from previous fall and return to building. Cleaned and dressed resident, transferred to wheelchair, and placed resident on one on one supervision at nurses station. [MEDICAL TREATMENT] notified that resident unable to dialyze due to confusion. Review of the Fall Statements revealed R26 did not have an alarm in place or sounding. In an interview on [DATE] at 08:32 AM, Registered Nurse (RN) J reported R26 was pretty much independent for transfers. When asked if he was care planned to be independent with transfers, RN J stated I believe so. RN J reported she worked first shift on [DATE] when R26 came back from the hospital after his fall on night shift. RN J reported R26 came back to the facility around 7:30 or 8:00 AM and stated it wasn't too long before that second fall happened. RN J reported she checked R26 over at the nurse's station and from there someone else took him to his room and put him to bed. RN J was unsure who took R26 to his room. When asked what interventions were in place upon readmission, RN J stated frequent rounding .every hour .he should have had a bed alarm on and for some reason I don't' think that was in place or connected because we did not hear it go off .I did not specifically see the alarm on the bed. He always has one on there, but it was just disconnected for the most part because he was independent for the most part .when I made his bed several weeks before, it was there, but not being used. When asked if the alarm was tested after the fall, RN J stated I don't think anyone did. I personally did not. RN J reported R26 was supposed to go to [MEDICAL TREATMENT] that day, but was too confused and impulsive. RN J reported R26 was then transferred to the emergency department for [MEDICAL TREATMENT]. The medical record revealed R26 was readmitted on [DATE] with sutures above his right eyebrow, a bruise to the right side of his forehead, and a bruised right knee. On [DATE] at 10:52 AM, R26 was observed lying in bed. He had a tab alarm box sitting on the mattress, next to his pillow, however the alarm was not clipped to R26. R26 was wearing gripper socks, his wheelchair was locked at his bedside, the left side of the bed was against the wall, and there was a fall mat on the right side of the bed. R26 had bruising around his right eye and sutures above his right eyebrow. When asked what happened, R26 reported he fell the other day and hit his head. R26 seemed confused and reported he was having trouble remembering. On [DATE] at 11:29 AM, R26 was now in his wheelchair, propelling in the hallway. He had shoes on and his alarm box was on his wheelchair and clipped to the back of his shirt. On [DATE] at 12:44 PM, R26 was observed self transferring from his wheelchair to bed. There was a wheelchair alarm in place that did not sound. R26 then took his shoes off and placed them on the fall mat beside his bed and took his bed tab alarm and placed it on top of his shoes. On [DATE] at 02:40 PM, R26 was transported by staff back to his room from therapy. Therapy staff transferred R26 from his wheelchair to his bed. R26 removed his own shoes. The therapist picked up the tab alarm off the floor. She then exited the room at 2:43 PM. At 02:44 PM, R26 was observed lying in bed. His tab alarm was connected to right sleeve, towards the front of his shirt. The alarm box was sitting on the bed next to him. On [DATE] at 04:22 PM, R26 was observed in the dining room in his wheelchair. There was no alarm present. R26 was observed self transferring to a dining room chair. No alarm sounded. On [DATE] at 07:54 AM, R26 was observed in expired in bed. Review of the Fall Event dated [DATE] at 12:35 AM, revealed time event discovered was 12:20 AM and resident stated he rolled out of bed .resident went into [MEDICAL CONDITION] after stating he rolled out of bed .resident passed away after [MEDICAL CONDITION] .mental status: unresponsive .an alarm was not used and did NOT sound: explain why resident had removed. The Progress Note dated [DATE], revealed resident observed on floor next to bed on fall mat at 1220am this nurse asked resident what happened and if he was hurting anywhere? resident stated I rolled out of bed resident then started to twitch from head to toe. this nurse ran down long hall to get help from the CNA's and was away from resident for ,[DATE] minutes while getting help and vital equipment. this nurse instructed CNA's to get vitals while this nurse called (name of physician) to transfer him to the Emergency department due to resident seizing. the [MEDICAL CONDITION] lasted 2 minutes this nurse instructed the CNA's to keep resident on his left side and to protect his head and neck. this nurse came out to get paperwork done for the EMS team when CNA came to say she thinks resident has passed. This nurse assessed resident to have blue lips no respirations and no palpable pulses, instructing the CNA's to stay with the resident this nurse called (name of physician) to tell him about the resident, then this nurse called ADON (Assistant Director of Nursing) to come to the building, as this nurse was on the phone with ADON EMS arrived, hooked resident up to the ECG machine and pronounced with ECG strip reading time of death for resident to be 1233am . In an interview on [DATE] at 02:26 PM, Licensed Practical Nurse (LPN) V reported when R26 fell on [DATE], she was on the end of long hall (R26 resided on short hall) helping the CNAs with a new resident. LPN V reported the two CNAs were finishing up with that resident and then headed to the four bedroom wards to finish check and change while the other two aides were running trash outside. LPN V reported she always sent two staff to take trash out because it was dark and unsafe outside. LPN V reported she was walking and doing her checks when she observed R26 on his back, looking at the ceiling. LPN V reported R26 looked at her, said he rolled out of bed and then started twitching from head to toe. LPN V reported she ran back down to long hall, got the two CNAs and the vitals cart. She instructed the CNAs to place R26 on his left side while she went to call 911 and the physician. LPN V reported R26's [MEDICAL CONDITION] lasted approximately two minutes and the CNA came out of his room and said she thought R26 was dead. LPN V reported R26's lips were blue and he had no respirations. R26 was a do not resuscitate. When EMS arrived, they hooked R26 up to the EKG and pronounced him dead. LPN V reported R26 had some cognitive changes over the last few weeks. When asked what fall interventions were in place, LPN V stated fall mat, low bed, tab alarms and stated now he had removed his tab alarm which is why we didn't know he either rolled out of bed, got out of bed, however that may have went. LPN V stated apparently he has been pulling his shirt to take his alarm off so the alarm doesn't go off. When asked if she was aware of that prior to the fall on [DATE], LPN V stated well me and therapy had been talking about the possibility of re-evaluating him for the necessity of the alarms .it was this past weekend he was pulling his alarms off. LPN V reported she checked the alarm after the fall and it functioned properly. LPN V reported R26 was also 15 minute checks at the time of the fall and she had just laid eyes on him. In an interview on [DATE] at 10:54 AM, Director of Nursing (DON) B reported R26 had his first fall at the facility in (MONTH) and was independent with transfers and ambulation at that time. When asked what intervention was put into place after that fall, DON B reported she thought that's when the tab alarm was initiated, but he hated it. DON B reported R26 remained independent after that fall, even though he had an alarm in place. Regarding the first fall on [DATE], DON B reported R26 did not have his tab alarm in place because he had taken it off and was carrying it with him. DON B reported on [DATE] around 3:30 AM, R26 fell and hit his head, resulting in a laceration, transfer to the emergency department, and sutures. DON B reported R26 returned to the facility around 7:30 AM on a stretcher. DON B reported herself and Registered Nurse (RN) J got R26 settled into bed. When asked if R26 had an alarm in place at that time, DON B stated to be honest, I don't remember. We got him off the cot, into bed, and I went back to short hall. I'm assuming it went back on him since it was an intervention in place before he went out. I did not personally do it (put the alarm in place). DON B reported R26 then sustained another fall around 8:30 AM and an alarm did not sound. When asked why not, DON B stated I don't know. I'm assuming he unclipped it again. Most of the time he thought it was his wallet and would unclip it and carry it around. When asked if anyone tested the alarm when R26 returned from the hospital, DONB reported she was not sure. DON B reported R26 was always confused during the long stretch of Saturday to Tuesday of no [MEDICAL TREATMENT]. R26 received [MEDICAL TREATMENT] on Tuesdays, Thursdays, and Saturdays. Regarding the second fall on [DATE], DON B reported R26 got up, went to the bathroom in bare feed and had poopy footprints back to his room. DON B reported R26 had taken his bandage off his head, folded it up, and placed it on his bed. DON B reported she was trying to get R26's [MEDICAL TREATMENT] figured out because she knew he was going to spiral out of control. DON B reported [MEDICAL TREATMENT] wanted R26 sent to the hospital to receive [MEDICAL TREATMENT] and that was when R26 was admitted to the hospital for metabolic [MEDICAL CONDITION]. DON B reported R26 readmitted to the facility on [DATE]. When asked what interventions were in place upon readmission, DON B reported R26 had a fall mat, but he kept picking it up and moving it. DON B reported R26 did not want alarms going off when he stood up. When asked about the fall on [DATE], DON B reported shortly after midnight, she believed R26 began seizing and rolled out of bed onto the fall mat. DON B stated again, it was Monday night, long [MEDICAL TREATMENT] stretch, where was he at medically. When asked if R26 had his fall alarm in place, DON B stated he removed it and put it on his mat. DON B stated he hated his alarm. DON B reported R26 had been on 15 minute checks after the fall on [DATE] and the checks were discontinued on [DATE] and never implemented again. When asked what was being done as an additional intervention, knowing R26 removed his alarm, DON B stated to be honest when he wasn't at [MEDICAL TREATMENT], he came to meals independently, came to activities independently. He was one of our fall risk people so eyes on all the time. On [DATE] at 01:03 PM, when asked why the facility had an alarm on R26 if they say he was independent, DON B stated more to alert us. Review of R26's care plans, revealed the fall care plan had not been updated since R26's admission to the facility. There was no mention of a fall mat, alarms, increased confusion during his long stretch of non-[MEDICAL TREATMENT] days (Saturday to Tuesday), or that R26 had a history of [REDACTED]. The care plan was not updated with new interventions after each fall. Review of the CNA Care Guide dated [DATE], revealed R26 required one assist with ADLs. No alarms or increased supervision was identified on the Care Guide.

This citation pertains to MI 958. Based on interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for 1 of 5 residents reviewed for quality of care (Resident #101), resulting in continued falls and delay in assessment and treatment after a fall with head injury that resulted in death for Resident #101. Findings include: According to the MDS, dated [DATE], Resident #101 (R101) was a [AGE] year old who was admitted to the facility on [DATE], scored 13 out of 15 on the Brief Interview for Mental Status (cognitively intact), needed limited assistance with one staff member for transfers, walking, locomotion, dressing and toilet use, was taking and antidepressant, diuretic, and antibiotic, was always continent of urine, had a history of [REDACTED]. Review of R101's Medication Administration Records (MAR) revealed he was administered Aspirin 81 mg (blood thinner) every day, [MEDICATION NAME] 75 mg (blood thinner), [MEDICATION NAME] 10 mg (antidepressant) and [MEDICATION NAME] 50 mg (antidepressant) by mouth at bedtime every evening since he was admitted . Review of a Pharmacy Consultation for R101, dated [DATE], revealed the Pharmacist stated there was no [DIAGNOSES REDACTED]./Medical Director M; therefore no reduction had been made. According to National Center for Biotechnology Information, (YEAR), [MEDICATION NAME] is associated with increased fall risk . Orthostatic [MEDICAL CONDITION] is an unfortunate consequence of antihypertensive therapy . <https://www.ncbi.nlm.nih.gov> According to an article entitled Drug-related Falls in Older Patients by SAGE (academic) publications, (YEAR), Antidepressants have long been recognized as a contributory factor to falls . < https://www.ncbi.nlm.nih.gov> According to WebMD, (YEAR), side effects of [MEDICATION NAME] include, . serious bleeding in the . brain . To lower the chance of getting . injured .avoid activities such as contact sports . <https://www.webmd.com/drugs/2/drug-5869/[MEDICATION NAME]-oral/details> Review of R101's care plan, dated [DATE], revealed, Potential for bleeding r/t (related to) aspirin and [MEDICATION NAME] (blood thinners) therapy . Protect (R101) from injury/trauma. Review of R101's advance directives, dated [DATE], revealed he was full code status. Review of an Admission - Critical Admission Assessment, dated [DATE], revealed Licensed Practical Nurse (LPN) I completed a Fall Risk Assessment on R101 and determined his Fall Risk Level: Not high risk. In an interview, on [DATE] at 5:00 PM, LPN D reported she was assigned to the care of R101 on third shift on [DATE] when R101 fell around midnight (see details below). LPN D reported, (R101) ended up with a goose egg (bump) on his right forehead . (R101) was on the floor. I told him not to move, checked range or motion and neuro (logical) checks were within normal limits. (R101) was not on 1:1 (one staff member to watch one resident). I left at 6:30 AM. The last time I checked (R101) was at 4:00 AM. He was asleep, but his pupils (neuro checks) were fine . (R101) fell all the time. He fell a lot. I would think one of the interventions would have been 15-minute checks. He should have been on 1:1 all the time he was here with all the falls that he had. R101's Medication Administration Record [REDACTED]. Review of (R101's) Incident reports from ([DATE] - [DATE]) revealed R101 had 9 falls in 25 days. (1). On [DATE] at 1:20 PM - unwitnessed fall without injury; call light on. (2). On [DATE] at 2:15 PM, (R101) resting in recliner, tried to ambulate to the bathroom; an unwitnessed fall with no injury. (3). On [DATE] at 1:30 AM, resting in recliner tried to ambulate to the bathroom; unwitnessed fall with no injury. (4). On [DATE] at 3:30 PM, attempting to take pants off and sit back in recliner; unwitnessed fall with no injury. (5). On [DATE] at 4:00 AM, self-transfer to and from bathroom and he fell ; unwitnessed and sustained an abrasion to the head. (6). On [DATE] at 7:30 AM, slid out of recliner, caught up on sheets tangled in feet, trying to self-transfer; unwitnessed fall with no injury. (7). On [DATE] at 8:22 AM, slid out of chair, 2 pillows behind him in his chair, trying to reach his pillows; witnessed by Nurse Aide (CNA) J and no injuries. (8). On [DATE] at 9:35 PM, got out of bed and fell ; unwitnessed fall with no injury. (9). On [DATE] at 8:30 PM, fell while trying to stand to untangle his call cord; hit head on wheelchair. Review of R101's Falls Care Plan, dated [DATE], revealed a lack of meaningful/effectual interventions to reduce falls, At risk for falls and subsequent injury related to decreased mobility, weakness, and visual impairment. Resident removes footwear and gripper socks, res (resident) attempts to ambulate independently even after education (reminders), resident hates walker, at times refused to use, unsteady gait at times, knocks blankets on floor and ambulates on to of blankets, becomes argumentative with staff education for safety. Goal . To prevent or reduce the occurrence of falls and subsequent injury related to falls . Interventions: ([DATE]) encourage to wear proper footwear, ([DATE]) educate on the importance of call light, ([DATE]) night light in room, offer every one hour toileting in the daytime and every four hours at night, ([DATE]) signage to remind to call for help, ([DATE]) assure items are in reach, ([DATE]) remind/educate to make sure floor is free of items when standing/ambulating and to call for assistance, ([DATE]) encourage to sleep in bed, (on [DATE]) urinal provided to resident, ([DATE]) sensor pad alarm to bed, and [DATE]) refer to optometry, and ([DATE]) replace sensor pad. In a letter, dated [DATE] at 9:32 PM, Administrator A stated 1:1 could not have been done for R101 because he was argumentative with staff education for safety, that R101 did not like 1:1 Activities in his room, Psychiatric recommendations were for him to be in the least restrictive environment, and (R101) had a history of [REDACTED]. However, R101's Falls Care Plan did not reflect it was R101's choice not to have increased supervision. On [DATE] at approximately 7:00 PM, Interim Director of Nursing (IDON) B reported she had been pulled from a sister facility (a nursing home owned by the same corporation) to assist the facility who did not have a DON. According to IDON B the facility recorded 5 resident falls in (MONTH) (YEAR), 8 falls in (MONTH) (YEAR), 16 falls in (MONTH) (YEAR), 19 falls in (MONTH) (YEAR) and 19 falls so far in (MONTH) (YEAR). IDON B said most of the falls in the past 3 months occurred on second shift. This Surveyor requested R101's falls since the facility's last annual Survey, dated [DATE], and was presented with three additional falls since [DATE]: (10). According to Nursing Progress Notes, dated [DATE] at 8:21 PM, (R101) set alarm off multiple times this shift trying to get out of recliner himself . According to an Observation Detail List Report, R101's blood pressure on [DATE] at 11:30 PM was ,[DATE]. On [DATE] at 11:58 PM, rolled out of bed to knees; no injury. Resident's bed alarm did not go off . According to a Nursing Progress Note, dated [DATE] at 10:26 AM, R101's blood pressure was ,[DATE] (significantly lower than on [DATE]). According to Healthy Living, (YEAR), Orthostatic blood pressure is more correctly known as orthostatic [MEDICAL CONDITION] ([MEDICAL CONDITION] is low blood pressure). It is a condition in which a person's blood pressure drops significantly when changing positions from lying down or sitting to standing up. <https://healthyliving.azcentral.com/what-is-orthostatic-blood-pressure- 577.html> (11). On [DATE] at 11:19 AM, unwitnessed fall in room; no injury. (12). On [DATE] at 12:56 AM, unwitnessed fall with injury. According to Nursing Progress Notes, dated [DATE] at 12:50 AM, At (12:21 AM) this nurse heard bed alarm going off down the hall. Call light was on. This nurse (LPN D) ran down to room. (R101) observed on right side on the floor next to bed. Right side of head has small goose egg (bump) and it was bleeding. (R101) stated his head was hurting. This nurse gave (R101) Tylenol and applied ice to head. VS (vital signs) ,[DATE] (blood pressure), 89 (pulse), 16 (respirations), 97.5 (temperature. Neuros (lack of pupil reaction indicates potential bleeding in the brain) started and are WNL (within normal limits), ROM (range of motion) also WNL . will continue to monitor. In an interview, on [DATE] at 7:02 PM, IDON B reported the staff at the facility had not been using the form for neuro (neurological) checks the Corporate Office had issued more than 2 years ago. The Neurological Checklist, not dated, used by LPN D for R101's fall on [DATE] did not contain the scheduled every 4-hour checks per professional standards; it skipped from q 1 hr. x 2 (every one-hour checks times two) directly to q 8 hour checks once a day. Therefore, no neuro checks were performed on R101 after 4:01 AM; the next scheduled check on the form was timed for noon on [DATE]. IDON B stated she realized staff were using the wrong forms when she arrived at the facility approximately two weeks ago and brought the new forms in and told some of the staff about them. In addition, IDON reported she had reviewed R101's physician progress notes [REDACTED]. falls to find a root cause. IDON B also she reviewed R101's Medical Record for orthostatic blood pressures but found none had been done to assess the possibility that R101 was falling due to sudden drops in his blood pressure. IDON B initially said any resident that has a cardiac condition or that has high blood pressure should have an orthostatic blood pressure taken monthly and that is what staff were doing at her home facility for at least the last two years. However, she said the facility's Corporate policies only required orthostatic blood pressures to be done on residents who are taking antipsychotic medications. IDON B reported she began a Night Owl program on [DATE] and explained the program as something she created/instituted for 6 -7 of the facility's residents who are restless in the evening; they are placed in the dining room with activities and a staff member until each can be placed into bed by another staff and when all the residents have been laid down, the staff member who was sitting with them can go home. Review of R101's 12 falls revealed none of them occurred between 4:30 PM - 8:00 PM, but all occurred unwitnessed by staff in R101's room. Review of the Neurological Assessment form IDON B stated the staff should have been using revealed it was not dated. According to the form, This checklist should be completed at the following intervals for follow up for all unwitnessed falls or falls in which head was struck . Vital signs and Neuro Checks - Initial assessment followed by: q (every) 15 min (minutes) x (times) 8 q 30 min x 4 q hour x 4 q 8 hrs x 2 The form contained a warning box: Notify Physician IMMEDIATELY of signs & symptoms of Intracranial Pressure and Level of Consciousness: 1. Fully conscious: awake, aware, no change in orientation; 2. Lethargic: responds slowly to verbal stimuli; 3. Obtund: very drowsy, responds to touch stimuli; 4. Stupor: responds only to painful stimuli; 5. coma: absent response to stimuli. Review of R101's vital signs, dated [DATE] at 3:37 PM (five hours after R101 left the building) records revealed LPN I documented: Temperature 98.4, Pulse 119 beats per minute (high), Respirations 24 per minute, blood pressure ,[DATE]. There was no evidence in R101's medical record that any neuro checks were performed on R101 on [DATE] by LPN I. In an interview, on [DATE] at 7:12 PM, Administrator A said I don't think 1:1 supervision for residents like R101 would be necessary and . because there is not enough staff to do that. On [DATE] at 8:30 PM, Administrator A said, R101's Responsible Party placed R101 in the facility because he was falling all the time at home. Administrator A said a fall committee was just recently formed. In a telephone interview, on [DATE] at 9:33 AM, Nurse Aide (CNA) N reported she was the day shift nurse aide assigned to care for R101 on [DATE] and arrived to work at 6:00 AM that day. CNA N stated the night shift CNA took her to see R101's bruise on his right forehead. CNA N said R101, had a black and blue bump the size of a golf ball. CNA N said around 8:00 AM and rolled R101 to change him while he was sleeping and took vital signs, but not the neuro checks because only the nurses do the neuro checks, and placed them on a clipboard at the desk. CNA N said she didn't have contact with R101 after that, but another CNA (name unknown) brought his breakfast tray in for him and she must have told the nurse he wasn't doing well. In a telephone interview, on [DATE] at 10:45 AM, LPN I revealed she did not immediately alert a physician or IDON B of R101's altered level of consciousness. LPN I stated she arrived to work around 6:00 AM on [DATE], and a CNA told her R101 was sleeping and didn't want to eat. LPN I said she was told in report R101 fell and hit his head, was up until 4:00 AM and when she went in to get a blood sugar reading around 7:00 AM, R101 moaned at me. LPN I said around 8:00 AM, she went to give R101 his medications, yelled his name, gave him a sternal rub and he moaned so she told him she would come back later. LPN I said, I don't know why my boss (IDON B) went in there around 9:00 AM, (R101) was not moving, she gave him a strong sternal rub and he didn't move. LPN I said she was aware there were 2 different Neurological Checklists in the drawer at the nurses' station, but said she used the old one because no one told her not to and she didn't think they were very much different. LPN I stated she did not have to check R101's pupils because they weren't scheduled to be checked. LPN I revealed the entry time reflected in the medical record entries did not necessarily reflect the time her observation/assessments actually happened. LPN I said she must have documented R101's vital signs at the end of her shift but could not remember at what time the vital signs were actually taken, or by whom. In a returned telephone call, on [DATE] at 2:23 AM, CNA O reported she was assigned to care for R101 on the midnight shift on [DATE]. CNA O reported R101 began to decline around 4:00 AM when she observed him to be very lethargic and wouldn't assist with her turning him as he usually did. CNA O said the goose egg had stopped bleeding, but he was very lethargic. CNA said, I told (LPN D) around 5:00 AM he wasn't talking to me when I talked to him, wasn't acting normal, and that he was like dead weight. According to an article by the Med League, [DATE], entitled, Patient Falls: The Critical Role of Post Fall Assessment in a Head Injury, When a patient falls within a healthcare environment, the actions of the staff members can be critical. They can make the difference between life and death, between the patient getting a prompt evaluation for injuries or a delay in treatment, and between normal function and paralysis . The nurse should watch for signs of deterioration: a headache, change in the level of consciousness . Vital signs and neurological observations should be performed hourly for 4 hours and then every 4 hours for 24 hours, then as required. The attending physician should be notified immediately if there is any change in observations . The last part of the post-fall assessment is to review the plan of care and to add more fall prevention strategies. The biggest risk factor for another fall is a history of a prior fall <https://www.medleague.com/patient-falls-the-critical-role-of-post-fall-assessment-in-a-head-injury-slip/> Review of a Nursing Progress Note, dated [DATE] at 9:30 AM, revealed LPN I documented, Went in (R101's) room to administer AM meds and resident appeared to be sleeping and when gave resident tactile stimuli resident grimaced and while pinching resident nailbed resident jerked arm. In 20 (minutes) came back to attempt another try to administer meds and (R101) not responding to tactile stimuli. Notified (IDON B). Review of a Nursing Progress Note, dated [DATE] at 9:53 AM, revealed LPN I documented, (R101) not responding to stimuli verbally or tactile. (IDON B) assisted in assessing resident. (Physician M) notified and gave order to send to (hospital). EMS (ambulance) called . EMS arrived at (10:12 AM) . According to a hospital discharge summary, R101 arrived to the emergency room with fixed pupils, the imaging report showed a large subdural hematoma (bleed in the brain) with a significant midline shift (accumulated blood in the brain) likely extensive bleeding due to ASA (aspirin) and [MEDICATION NAME] (blood thinner) use; R101 was placed on comfort care by his Durable Power of Attorney and subsequently died on [DATE] (16 hours after being admitted ).

Based on observation, interview, and record review, the facility failed to provide adequate supervision and/or assistive devices to prevent falls for 2 of 3 residents reviewed for falls (Resident) R51 and R39, resulting in a fall with major injury (fracture) and continued falls for R51 and continued falls with minor injuries for R39. Findings include: Resident #51 According to the Minimum Data Set (MDS), dated [DATE], R51 was a [AGE] year old who was admitted to the facility on [DATE], was moderately cognitively impaired, needed extensive assistance with transfers, walking, locomotion, dressing and toilet use, was taking antipsychotic, antidepressant, diuretic and opioid (narcotic) medications, had 2 or more falls with injuries and 1 fall with major injury since the last assessment, was occasionally incontinent of urine and had [DIAGNOSES REDACTED]. In an interview with Assistant Director of Nursing (ADON) C, on 10/18/18 at 10:35 AM, R51's falls (12 falls since 10/26/17) were reviewed. ADON C reported: (1.) On 10/26/17 at 5:30 PM, (R51) in her room, fell from her wheelchair onto her to knees; not witnessed by staff, no apparent injury. Intervention: Physical Therapy referral, encourage for her to be in high traffic locations. (2.) On 11/25/17 at 8:00 PM, (R51) found lying on floor at nurses' station with wheelchair located behind (R51); unwitnessed, complaint of pain in right hip. Intervention: self-releasing seatbelt reapplied, and coin alarm added to wheelchair. (3.) On 12/08/17 at 8:35 PM, (R51) fell out of wheelchair in her room trying to get to doorway to call for help to the bathroom. unwitnessed. Injuries: bruise to l hand, l shoulder and l side of face. Intervention: hourly toileting. (4.) On 1/26/18 at 9:45 PM, (R51) was found in room her room lying on right side with wheelchair behind (R51), she was trying to get to bed; unwitnessed fall with complaint of moderate right hip pain/x-ray showed no fracture or dislocation. Intervention: assist to bed after shower. This intervention was discontinued on 4/02/18. (5.) On 5/01/18 at 5:30 PM, (R51) fell from her wheelchair in the dining room reaching for something on the floor onto her left side; staff witnessed and sustained a small bruise to left elbow. Intervention: Therapy referral. (6.) On 5/19/18 at 5:07 PM, (R51) caught wheelchair in doorway, fell face first; unwitnessed fall and sustained contusion on right side of forehead. Intervention: assist through doorways. (7.) On 5/29/18 at 11:52 AM, (R51) stood up from her wheelchair, tripped on anti-trippers; unwitnessed with complaint of mild pain, left shoulder abrasion and laceration above left eye. Intervention: therapy assessment for anti-tippers. (8.) On 6/30/18 at 8:50 PM, fell out of chair in room trying to get to bed; unwitnessed and sustained mild-moderate pain and skin tear to right knee and laceration to top of head. Intervention: placed a night light in her room and alarming seat belt applied to chair. (9.) On 8/21/18 at 3:19 PM, (R51) fell out of wheelchair in bathroom getting personal items; unwitnessed and sustained moderate pain and bruise on left hip. Intervention: removed items from bathroom. Offer toileting. I'm not sure why that was added, (R51) was doing personal care; unwitnessed with no injuries. (10.) On 8/23/18 at 3:14 PM, (R51) in Broda (low reclining) chair witnessed in dining room during lunch, leaning forward reaching for something on the floor and slid out; witnessed by staff and no apparent injury. (The Incident Report did not explain why staff did not intervene.) Intervention: Dycem (anti-slip) to Broda chair cushion and to set at a low table in the dining room. (11.) On 8/29/18 at 10:45 PM, (R51) self-transferring trying to go the bathroom, slid out of Broda chair in bathroom; unwitnessed and sustained mild pain but no apparent injury. Interventions: Assure resident has gripper socks after shower. Had just had a shower and toileted. She likes to go to bed between 9 and 10 PM. X-ray done 8/30/18. During the investigation it was found that the alarm on her chair was not sounding. (Nurse Aide/CNA L) did not turn the alarm on after her shower. Interventions: (CNA L) was educated. Encourage to lay down after shower. The next day, when they were ambulating (R51) in therapy, heard the pop and sat her down in (R51) chair. The x-ray was dated 5:05 at PM 8/30/18; x-ray called and said no fracture. They called back on 8/31/18 (time unknown) and said (R51) had a subacute fracture to trochanter (hip). Review of Nursing Progress Notes, dated 9/24/2018 at 02:20 PM, revealed, (R51) left via (ambulance) . 9/24/2018 at 11:05 AM, (Medical Director H) informed of x-ray results. Ordered resident to be sent to (emergency) for evaluation and (treatment) . 9/21/2018 at 1:22 PM, Therapy reported that during (therapy) (R51) was ambulating and while transferring weight onto left leg an audible pop was heard. (R51) immediately stated she did not wish to continue and was put back into her Broda chair. (R51) was monitored for increased pain which she did report about 1 hr. (hour) later . According to R51's x-ray, dated 9/21/18, of her pelvis and left hip, left femur and left knee, findings included: [MEDICAL CONDITION] .a comminuted fragmented displaced fracture is seen in the region of the greater trochanter of the proximal left femur with increased displacement of the bony fragments compared to the last examination of 8/30/18 . (12.) On 10/01/18 at 12:00 AM (midnight), (R51) was found sitting on floor near her closet. Stated she tried to stand up and walk to her closet, was lost and tired; unwitnessed and complained of pain in her head with severity level of 3 out of 10. Intervention: lay down between 9:00 PM - 10:00 PM. On 10/17/18 02:38 PM, LPN F reported she was R51's full time nurse on the day shift. LPN F said, (R51) is noncompliant. When she fell in the bathroom when she broke her hip, she was put on 1/2-hour checks. Happy feet. (R51) has had many falls but most from her putting herself out of her chair. In an interview, on 10/18/18 10:45 AM, Therapy Director I spoke about R51 saying, We have been working on various things to keep her safe since she's been here. Her transfer status: does not walk; she is always 1-person extensive assist. In an interview, on 10/18/18 at approximately 11:00 AM, Licensed Practical Nurse (LPN) M was interviewed about the incident on 9/24/18 and asked specifically when he assessed R51 after the pop was heard, if he did range or motion, and if she was complaining of pain, but LPN M did not say whether his assessment was done immediately after the pop was heard or an hour later. LPN M only said, No Incident Report was done for (the pop) but I did the assessment on (R51). It looks like I didn't' document it. Resident #39 According to the MDS, dated [DATE], R39 was a [AGE] year old who was admitted to the facility on [DATE], scored 13 out of 15 on the Brief Interview for Mental Status (cognitively intact), needed limited assistance with one staff member for transfers, walking, locomotion, dressing and toilet use, was taking and antidepressant, diuretic, and antibiotic, had was always continent of urine, had a history of [REDACTED]. During an observation/interview, on 10/16/18 at 10:53 AM, R39 reported, The last time I fell was 4 days ago. I dropped something on the floor and was bending over to get it, I tipped over backwards. I didn't have the (call) light handy. It was hidden under the covers. According to Healthy Living, (YEAR), Orthostatic blood pressure is more correctly known as orthostatic [MEDICAL CONDITION] ([MEDICAL CONDITION] is low blood pressure). It is a condition in which a person's blood pressure drops significantly when changing positions from lying down or sitting to standing up. <https://healthyliving.azcentral.com/what-is-orthostatic-blood-pressure- 577.html> In an interview with Assistant Director of Nursing (ADON) C, on 10/18/18 at 10:35 AM, R39's falls were reviewed with this Surveyor. ADON C was interviewed about the post fall nursing assessments and she said, No one has thought to do orthostatic blood pressures on (R39). That is very interesting. It could be the reason for all of his falls. ADON reviewed each of R39's falls in his room since his admission on 8/25/18 (9 falls in 36 days) and reported: (1). On 9/07/18 at 1:20 PM, (R39) wanted to sit in recliner after lunch. It was an unwitnessed fall in room, a self-transfer; He was educated to wear proper footwear. He was wearing slippery socks. Ambulation status was independent or standby; ambulation status not on Fall Care Plan. (R39) is one assist with transfers. There was no injury. (Review of Licensed Practical Nurse L Progress Notes revealed R39's, Call light was on. (2). On 9/09/18 at 2:15 PM, (R39) resting in recliner, tried to ambulate to the bathroom; an unwitnessed fall with no injury. Intervention: educate on call light for safety until stronger. Yes, we educate them upon admission on using the call light. (3). On 9/10/18 at 1:30 AM, resting in recliner tried to ambulate to the bathroom; unwitnessed fall with no injury. Intervention: nightlight in his room; did not have one at that time. And offer toileting four times at night and every one hour during the day. (4). On 9/13/18 at 3:30 PM, attempting to take pants off and sit back in recliner; unwitnessed fall with no injury. Intervention: signage placed in room to use call light and ask for assistance. (A Physician order [REDACTED]. (5). On 10/03/18 at 4:00 AM, self-transfer to and from bathroom and he fell ; unwitnessed and sustained an abrasion to the head. Intervention: place items within reach . the intervention doesn't stop him from self-transferring. (6). On 10/05/18 at 7:30 AM, slid out of recliner, caught up on sheets tangled in feet, trying to self-transfer; unwitnessed fall with no injury. Intervention: remind and call for assistance and keep floor clear. Encourage to sleep in bed. He is now sleeping in his bed at night. (7). On 10/06/18 at 8:22 AM, slid out of chair, 2 pillows behind him in his chair, trying to reach his pillows; witnessed by Nurse Aide (CNA) J and no injuries. Intervention: encourage to sleep in bed, room change to better observe resident (was in a private room where staff could not see his recliner). (8). On 10/11/18 at 9:35 PM, got out of bed and fell ; unwitnessed fall with no injury. Intervention: urinal was provided to resident; initially he did not want to use one. (9). On 10/12/18 at 8:30 PM, sitting in recliner tried to stand and untangle his call cord, but call cord was not tangled. Did a referral to optometry. Sensor pad added to bed. (10/13/18). Sensor to recliner was placed in Sept, but the date is not on the care plan . ADON C commented further, Therapy recommendations are not on (R39's) care plan. (R39) came in with a cane. Therapy wants (R39) to use his walker. When self- transferring, (R39) is not using his walker. (R39) is not a Happy Feet (1/2-hour check). Happy Feet is the Elopement policy, not the Fall policy. He is not an elopement risk. (R39) could be checked on 1/2 hr. check, but it is not on his care plan. He is on hourly toileting. ADON C reported, to her knowledge, R39 had not been assessed for prostate or bladder problems and said, If his Admission MDS says he was always continent of urine when he first got here, that is not correct. I will have to check into that. Review of R39's care plan, dated 9/01/18, revealed, currently being treated for [REDACTED]. Review of R39's care plan, dated 9/06/16, revealed, Potential for bleeding r/t (related to) aspirin and [MEDICATION NAME] (blood thinners) therapy. In an interview, on 10/18/18 at 02:22 PM Therapy Director I reported R39 had poor decision making and was still in Therapy and R51 has been on therapy six times in the last year to prevent falls. However, Therapy Director I said he was not on a Fall Prevention Committee, did not know if the facility had a Falls Committee or whether Fall prevention was a Quality Assurance project. Therapy Director I said he did not attend Quality Assurance meetings but, We discuss each fall after they happen in morning meeting.

This citation pertains to intake MI 116 Based on observation, interview and record review the facility failed to ensure prescribed interventions related to fall prevention was in place for 2 of 4 residents reviewed for falls (Resident #103 and #104) from a total sample of 4 resulting in Resident #103's right hip fracture, pain and subsequent death after falling from an elevated bed and resident #104 potentially falling due to incorrect staff transfer. Findings include: Resident #103 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected Resident #103 was a [AGE] year of female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS reflected Resident #103 had a BIM (assessment tool) which indicated her ability to make daily decisions was severely impaired, and she was totally dependant on one person physical assist with bed mobility, transfers, locomotion on unit, dressing, toileting, hygiene, and bathing and required extensive assistance with eating. Review of the facility Incident/Accident Report, dated [DATE] at 4:00 a.m., reflected Resident #103 had an unwitnessed fall out an elevated bed by the window in room 36. In an observation on [DATE] at 4:00 p.m., this surveyor entered room #36 and observed bed 2, located by the window, was in a low position, about knee level. The manufacturer label located on the bed frame reflected, Joerns, # [DATE] EZCRBED. In an interview on [DATE] at 4:02 p.m., Resident #103's roommate C reported she was in the room in bed one on [DATE] when Resident #103 fell from bed two. Resident #103's roommate C reported she heard a sound like Resident #103 had fallen out of bed during the night and pushed the call bell and Certified Nurse Assistant CNA D arrived and found Resident #103 on the floor. Resident #103's roommate C reported CNA D had assisted her about 1.5 hours prior to Resident #103's fall in the room while CNA E assisted Resident #103 and no one else had been in the room until Resident #103's fall. Resident #103's roommate C reported it seemed unusual that Resident #103 fell from the bed because she had not seen Resident #103 move on her own for several months and required staff to assist her with everything including moving in bed. In an interview on [DATE] at 10:00 a.m., Assistant Director of Nursing (ADON) F reported Resident #103 was a very demented older lady who required maximum assist with all care needs including bed mobility. ADON F reported Resident #103 would occasionally talk but wound usually mumble. ADON F reported it was her expectation that after providing care to a resident in bed staff are expected to ensure the bed is in the lowest position. ADON reported it was her expectation that staff check the care guides prior to providing care. In an interview on [DATE] at 11:25 a.m., CNA G reported prior to Resident #103 fall on [DATE] Resident #103 required 2 person assist and required assistance with repositioning in bed. I an interview on [DATE] at 12:00 p.m., CNA H reported she cared for Resident #103 routinely on days for several months including the morning of [DATE] after the 4:00 a.m. fall. CNA H reported she was told by 3rd shift on [DATE] that Resident #103 had fallen out of bed. CNA H reported she provided morning care and transferred Resident #103 from the bed to the wheelchair on the morning of [DATE] with no concerns. CNA H reported Resident #103 grimaced slightly with position changes but though it was related to being sore from recent fall and muscle aches. CNA H reported husband visited every day and was concerned Resident #103 was up in wheelchair sleeping upon arrival considering recent fall and requested Resident #103 remain in the bed. CNA H reported Resident #103 was non verbal and required assistance with all activities of daily living including position changes in bed prior to fall. CNA H reported Resident #103's husband was in all day on [DATE] however was not providing assistance with meals and drink on that day because resident refused. CNA H reported Resident #103's urine output, went way down, and informed Licensed Practical Nurse I. CNA H reported she did not report signs of pain to the nurse until [DATE] after Resident #103 continued to show signs of pain on the right side with position changes in bed with two staff assisting because had thought Resident #103 was just sore from fall on [DATE], however when Resident #103's pain appeared to worsen with moaning on [DATE] she notified nursing staff and stopped positioning Resident #103 on the right side. CNA H reported Resident #103 remained in bed after until Resident #103 passed away on [DATE]. CNA H reported several months prior to Resident #103's fall on [DATE] she recalled entering Resident #103's room on 2 occasions around 6:00 a.m. finding the bed, way too high. CNA H reported Resident #103's bed was around hip level from floor and lowered bed on both occasions after observing. CNA H reported she did not address bed height with night shift and stated, because they get defensive and did not report to anyone because nothing ever changes. CNA H reported Administrator advised staff to document on behavior charting even though not a resident behavior but a staff issue. In an interview on [DATE] at 12:56 p.m., CNA J reported she had cared for Resident #103 since her admission and was familiar with Resident #103 care needs. CNA J reported she was not working at the time of Resident #103's fall on [DATE]. CNA J reported Resident #103 required extensive assist with everything and was not able to make position changes on own including in bed and was non-verbal. In a telephone interview on [DATE] at 1:21 p.m., CNA D reported she was working the night of Resident #103 fall and was on her second night of orientation with CNA E. CNA D reported there were 3 CNA's and 1 nurse working the 3rd shift from 10:00 p.m. to 6:00 a.m. shift on [DATE] including herself. CNA D reported she had completed her CNA training the second week of October. CNA D reported CNA K had the short hall and CNA E had the long hall. CNA D reported both herself and CNA E entered room 36(Resident #103's) for rounds around 2:30 a.m. and CNA E performed incontinence care for Resident #103 and CNA D helped the resident in bed 1 to the bathroom. CNA D reported the curtain was pulled between the two beds but was able to see Resident #103's bed was located against window wall and Resident #103 was covered facing the window with bed about thigh to hip height when they exited the room after care. CNA D reported both her and CNA E were providing care to another resident close by when CNA D heard someone in room 36 knock on the wall and the call light was on for Resident #103's roommate and immediately went to room 36 and found Resident #103 on the floor by the bed with the bed in a high position between thigh and hip level and CNA D lowered bed about 4 inches before stopping. CNA D reported Resident #103 was on floor in left side in fetal position mumbling words but not able to understand and reported she called for help. CNA D verified witness statements times 3. In an interview on [DATE] at 2:04 p.m. CNA K reported she did not work the night of Resident #103's fall, however reported Resident #103 was usually assigned to her. CNA K reported Resident #103 usually slept though the night prior to the fall on [DATE] and reported both legs were contracted and stated, did not move at all on own. CNA K reported she did care for Resident #103 after the fall on [DATE] and reported Resident #103 would hold right hip and cry out during position changes and was instructed not to position on right side. CNA K reported staff are expected to check Care Guide prior to providing care. In a telephone interview on [DATE] at 2:09 p.m., CNA E reported the facility was short staffed the evening of [DATE] with one CNA on short hall and she(CNA E) was assigned to the long hall with a trainee CNA D and about 40 residents. CNA E reported she normally worked with residents on the odd side of the hall and another CNA would work with the residents on the even side and reported she was not familiar with the residents on the even side including Resident #103. CNA D reported during second rounds about 2:30 a.m. both herself and CNA D entered room 36 and CNA E performed care for Resident #103 while CNA D assisted the resident in bed one to the bathroom. CNA E reported after performing care Resident #103 was positioned on the right side facing the window with a pillow between her knees and covered and reported lowering bed till it stopped which was just below waist height. CNA E reported she did not know bed went lower because she had not cared for Resident #103 in past. CNA E reported she entered Resident #103 after finishing with another resident when CNA D was heard stating a resident had fallen about 4:00 a.m. CNA E reported Resident #103 was on the floor on her right side in a fetal position facing the window with the blankets folded up at the foot of the bed with the bed at about waist height and Resident #103 was mumbling bit did not appear to be in pain. CNA E reported 3 staff assisted Resident #103 back to bed after being able to lower bed with no signs of pain from Resident #103. CNA E verified several witness statements and reported she had to do several to add more details. CNA E reported she did not provided care again that night. Review of Death Certificate, dated [DATE] at 2:00 p.m., reflected Resident #103 died at nursing home. In a telephone interview on [DATE] at 10:30 p.m., LPN M reported she was working the night of [DATE] when Resident #103 fell out of bed. LPN M reported she was familiar with Resident #103 because she was her routine 3rd shift nurse. LPN M reported there was 1 CNA on the short hall and 1 CNA on the long hall and 1 CNA trainee on the long hall for the [DATE] 3rd shift and she was the only nurse. LPN M reported she was at the nursing station when she heard the trainee CNA D call for help from room 36. LPN M entered Resident #103's room and CNA D was with Resident #103 who was on the floor in the fetal position one her right side facing the bed. LPN M reported she did an assessment that included range of motion with no signs of pain and reported Resident #103 was non verbal but was smiling and laughing with assessment. LPN M reported Resident #103's bed height was about hip level from floor. LPN M reported Resident #103 was transferred to the bed after moved around and lowered and Resident #103 tolerated with no signs or symptoms of pain. LPN M reported the Director of Nursing was notified as well as the Guardian and the doctor who reported to monitor. LPN M reported she completed the fall packet, progress note, post fall pain assessment and fall SBAR. In an interview on [DATE] at 10:45 a.m., Therapy Program Manager L reported he had been contacted by the facility for about 7 years. Therapy Program Manager L reported that in his professional opinion that beds should be in the lowest position when residents are in bed unless staff are providing care especially if resident is dependant on care. Therapy Program Manager L reported Resident #103 was dependant on care. Review of the Maintenance Inspection Report, undated, reflected room 36 space 2 resident bed actuation was completed and reflected, Upon request for inspection of the Resident's bed hydraulic actuators were all correctly connected and functioning. The bed was able to operate in an up and down fashion, as well as the foot and head inclines. The bed showed no hesitation in the communication from the remote to the bed controls and the hydraulics functioned smoothly and quickly. Review of the ADL and Fall Care Plans, dated [DATE] through [DATE], reflected Resident #103 was as risk for fall and subsequent injury related to problems that included impaired balance, CVA, incontinence, visual impairment, behaviors, cognitive impairment, and Alzheimer dementia. The Care plans interventions that included: sign to remind resident to use call light(visually impaired), call light in reach([DIAGNOSES REDACTED]. No intervention added since [DATE] that were mats to floor, sensor alarm to bed (DC [DATE]) and low bed discontinued on [DATE]. In an interview on [DATE] at 12:45 p.m., Business Office Manager(BOM) N reported the facility provided orientation to new CNA by providing the first day as classroom setting, ,[DATE] days on the floor following other CNA who has been with facility for awhile. BOM N reported for the first ,[DATE] days on floor the CNA trainee can not be alone and after ,[DATE] days they get own assignment after check list completed. BOM N reported CNA D started with Long Term Care on [DATE] and passed call [DATE] and had not taken certification class yet. In an interview and record review on [DATE] at 4:40 p.m., Maintenance staff O reported Resident #103's bed manufacture recommendations for Joerns, # [DATE] EZCRBED were 14.5 inches in lowest position to bottom of frame. Reviewed manufacturer recommendations and verified bed heights. In an interview on [DATE] at 5:00 p.m., Administrator reported it was determined the root cause of Resident #103's fall on [DATE] was Resident #103 independently got out of bed and bed was too high, therefore education was provided to staff related to lowering beds and checking Care Guides prior to caring for residents and physician notification. Resident #104 Review of the Face Sheet dated [DATE], reflected Resident #104 was a [AGE] year of male admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. In an observation on [DATE] at 3:00 p.m., this surveyor received permission to observe transfer of Resident #104 from bed to wheelchair. CNA P was observed placing gait belt around Resident #104 sitting in very low bed. CNA P performed a 1 person pivot transfer from bed to wheelchair with maximum assist. Resident #104 appeared very unsteady and complained of some discomfort in back during transfer. Review of the facility Care Guide, dated [DATE], reflected Resident #104 was a fall risk and required, Two person extensive sit to stand, for transfer assistance. In an interview on [DATE] at 10:30a.m., ADON F reported Resident #104 had a fall on [DATE] during a transfer with 2 staff. ADON F reported Resident #104 transfer status on [DATE] was 2 person extensive assist sit to stand and reported therapy changed transfer status to 1 person extensive assist with walker on [DATE]. In an interview on [DATE] at 6:00 p.m., CNA P reported the facility policy and procedure is to check the care guide prior to resident care. CNA P reported she did not check Resident #104's care guide prior to his observed transfer from bed to wheelchair on [DATE] and reported she should have because the care guide indicated Resident #104 required a 2 person transfer. CNA P reported she incorrectly transferred Resident #104, as a one person transfer and reported to the ADON F.

This citation pertains to MI 440. Based on observation, interview and record review the facility failed to ensure that 1 resident (#50) out of 6 assessed for elopement from a total sample of 6 was provided supervision to prevent 2 separate elopements from the facility, unbeknownst to staff; all staff were trained on how to respond to an elopement upon hire; a thorough investigation was done for each elopement and the elopements were immediately reported to the state agency resulting in the potential for 9 residents assessed as being at risk for elopement to be at high risk for physical harm, injury and/or death. Findings include: According to the facility's electronic medical record, Resident #50 was a [AGE] year-old male, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), a resident assessment tool, dated 3/14/17, Resident #50 scored a 7 out of 15 indicating moderate-to-severe cognitive impairment and required the assistance of 1 staff person for transfers, but ambulated independently with a walker. A review of the plan of care for elopement, dated 11/6/14, reflected the following for Resident #50: at risk for exit-seeking behavior, risk assessment to be done on admission, quarterly and as needed, use conversation/distraction when he appears to be exit seeking, lingering near or attempting to open exit doors, reinforce compliance, keep picture and in formation current in the elopement book, 60-minute checks, ID bracelet, seek needs behind activities and attempt to meet, reinforce supervision. A review of the facility's progress notes, dated 7/19/16, documented Resident #50's elopement, and mentioned that increased confusion was noted. This was written after the event occurred, and there were no other notes prior to the elopement about confusion, nor was the nature of the increased confusion documented. A review of the facility's incident/accident report reflected the following on 7/19/16 at 7:00 a.m., Alarm at front door sounded Staff CNA went to front door noted resident in foyer (area between inside and outside front doors) beginning to step outside. When I got door open he stepped onto sidewalk stated, 'Im going to Sheriffs office to see my son'. A review of the facility documents titled, Reportable Event/Root Cause Analysis, were attached to the incident/accident report and reflected as follows: A question on page 1 indicated that the staff did, follow policy and procedure immediately following this event. On page 2, the staff person (CNA D) that found Resident #50 was, Pushing a resident into dining room. Another question on page 2 about adequate staffing during the unit at the time of the incident was answered, Yes, Two (2) nurses in building. Seven (7) nurse aides & Director of Nursing. On page 3, no facility wide problem that may have contributed to this incident was recorded. The root cause was determined to be Resident #50's increased confusion. No new interventions were developed because, system worked, although all residents were re-assessed for elopement risk and the elopement books, kept by the main entrance and the nurse's station, were updated. In an interview on 4/18/17 at 8:50 a.m., Housekeeper Staff G said that they were newly hired in July 2016, and was cleaning the bathroom by the administrator's office (on 7/19/16). She heard an alarm, but believed it was set off by another housekeeper working by the main entrance/offices. She did not know what the alarm meant, and did not respond to it. The alarms sound funny, echo-y in the bathrooms when they go off, said Staff G, You can't tell where or what they are. When asked, Staff G did not recall receiving education about elopements when hired. During an interview on 4/18/17 at 1:00 p.m., CNA (Certified Nurse Assistant) D said that on Tuesday, 7/19/16 at approximately 7:00 a.m., they saw Resident #50 walking south from the facility, toward a highway with a 40 mph speed limit. By the time CNA D caught up with Resident #50, he had traveled 210 feet from the building. A review of the facility's incident report, dated 9/20/16 at 7:30 a.m., reflected that Resident #50, Was noted standing on the sidewalk outside to the right of the front door by CNA. CNA & Nurse retrived (sic) resident without difficulty. The fact that the main entrance door alarm had not sounded was not documented in the incident/accident report, nor could the Reportable Event/Root Cause Analysis documents be located for this elopement. During an interview on 4/18/17 at 1:00 p.m., CNA D said that she was outside (on 9/20/16 at approximately 7:30 a.m.), on the (west) side of the building and saw Resident #50 in the staff parking lot. CNA D said, He said he was looking for his car. Resident #50 was not happy about returning to the building, so CNA D called the nurse's station on her cell phone to request assistance. Licensed Practical Nurse E met her about half way to the door, and assisted Resident #50 back into the building. During an interview on 4/18/17 at 11:30 p.m., LPN E confirmed what CNA D said, and identified the area where she met up with CNA D and Resident #50. In an interview on 4/18/17 at approximately 2:00 p.m., Housekeeper Staff H said that they saw Resident #50 at the main entrance that morning (9/20/16), and he was looking outside. Staff H greeted him, he returned the greeting and Staff H began to clean the bathroom located behind the business office. When asked, Staff H said that they did not hear or reset the alarm, but did hear the front door open and close. I figured his ride came, and he left, said Staff H. According to Maintenance Director F, all doors in the facility are wired to alarm and remain locked if a code is not entered. After 15 seconds, the door unlocks and will open if the person continues to push on the door. Staff F measured the distance from the front door to the signage by the highway, where Resident #50 was recovered on 7/19/16, as being 215 feet. It was only 25 additional feet to the edge of the busy highway. This surveyor measured the approximate distance as 190 feet from the main entrance to the area of the employee parking lot where CNA D first observed Resident #50 on 9/20/16. Resident #50 and CNA D were approximately ½ the distance between the main entrance and the employee lot, where LPN E met them and walked back into the facility with them. A review of elopement drill records, with no names listed, nor if non-nursing staff participated, reflected that drills were held on the following dates: 10/10/16, 2nd shift; 12/15/16, 1st shift; 1/7/17, 1st shift; 2/12/17, all 3 shifts; 3/17/17, 2nd shift and 3/18/17, 1st and 3rd shifts. A review of the course information for the on-line elopement education required for all newly-hired staff reflected a 30-minute course that included the following topics: What you need to know about your facility's emergency preparedness plan; Direction, Control, and Communication; Utility Outages and Emergency Services; Bomb and Terrorist Threats; Hazardous Materials Incidents; Evacuation and Elopement. A review of employee files reflected the following: Housekeeper H was hired on 5/13/16, but did not complete the on-line education about elopement until 10/11/16, 5 months later. Housekeeper G was hired on 7/13/16, but did not complete the on-line education about elopement until 9/14/16, 2 months later. On 4/18/17 at 3:50 p.m. DON B was interviewed as follows: When asked the nature of instructions given her by corporate to investigating elopements or an allegation of neglect, DON B answered that it was her responsibility, and staff statements were to be kept simple, without the use of dramatic words. When asked, DON B identified the statements of staff for the 2 elopements of Resident #50 on 7/19/16 and 9/20/16 as her own hand-handwriting. When asked where the written statements by staff were, DON B said that she didn't think there were any. DON B added that she had been new at investigating elopements in July 2016. When asked, DON B was not aware that, on 7/19/16, Housekeeper G heard the alarm, but did not know further action was required,and that, on 9/20/16, Housekeeper H did not recognize that Resident #50 was lingering near the main entrance, where he was not supposed to be, and redirect him back to the dining room. On 4/19/17 at approximately 2:00 p.m. Adm (Administrator) A was interviewed. When asked about initial training for elopement after hire, Adm A said that they were given an introduction to elopements by the DON in the first few days, and, then, received on-line training. Adm A was unaware that the on-line training for elopement did not occur until 10/2016 for Housekeepers G and H. When asked if they reviewed the incident/accident reports for Resident #50's elopements, Adm A said that they had. When asked if they noticed that not all the information was accurately filled in, Adm A said, Our system worked (to prevent elopements). When asked, Adm A was not aware that Resident #50 was almost to the highway on 7/19/16, and that Housekeeper G heard the alarm, but did not know further action was required. Adm A was also not aware that Housekeeper H did not recognize that Resident #50 was lingering near the main entrance and redirect him back to the dining room. When asked if they were aware that elopements were to be immediately reported to the state agency, Adm A said, Well, yes, and nodded without making eye contact. When asked why the total of 4 elopements by Resident #50, 51 and 52 were not reported, Adm A said, Because our system (to prevent elopements) worked. When asked whether Resident #50 was given an opportunity to demonstrate that he could or could not key in the correct code at the main entrance after the elopement. Adm A said, No, but I've personally seen Resident #50 messing with the key pad at a back entrance. On 4/19/17 at approximately 3:15 p.m., DON B was interviewed. When asked what was the information on elopement that she talked about during orientation of new employees, DON B said that she defined what elopement was and briefly reviewed it's importance and what the facility did if a resident eloped. NHA A was presented with Immediate Jeopardy Notification on 4/18/17 as a result of the facility's failure to prevent the elopement and ensure the safety of one resident (Resident #50), who eloped from the facility on 2 occasions, unbeknownst to facility staff. On Tuesday, 7/19/16 at approximately 7:00 a.m., Resident #50 was observed by Certified Nurse Assistant (CNA) D walking south from the facility, toward a highway with a 40 mph speed limit. By the time CNA D caught up with Resident #50, he had travelled 210 feet from the building. On Tuesday, 9/20/16 at approximately 7:30 a.m. Resident #50 was observed in the west employee parking lot by CNA D at a distance of approximately 200 feet from the building. Immediate Jeopardy was removed on 4/19/17 when the facility had the following in place: 1. Complete head count of residents was conducted, 58 of 58 residents were accounted for in the facility plus one on LOA. 2. All residents were assessed for elopement risk and 9 determined to be at risk for elopement. Elopement risk list was accurately reflective. 4-18-17. 3. Updated care plans to reflect elopement precautions. 4-19-17. 4. All door alarms were checked for proper functioning. 4-18-17. 5. Education begins* in regards to: Elopement policy and procedure to include response to alarms, immediate alert of resident missing within, the facility, taking the search outside, safety checks and documentation verified for those at risk by the Director of Nursing. ( 4-18-17) and Doors checked daily for proper locking and functioning. 6. Staff working were immediately in-serviced regarding the elopement procedure, remaining staff called and verbally educated. Those who did not return calls will not be allowed to work until they have received the education. 4-18-17. 7.Signage will be place on the exit doors alerting visitors to be aware to not let residents follow them out of the facility. 4-18-17 8. Elopement books reviewed to ensure current. 4-18-17 9. Elopement drills in-service for current staff and next 3 shifts. 4-18-17 10. Quality Assurance committee met and agreed that this is a sustainable corrective action plan with monitoring to include daily checks of all items listed by the DON, Administrator or designee. Although the Immediate Jeopardy was removed on 4/19/17, the facility remained out of compliance at the scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, due to the fact that sustained compliance could not be verified by the State Agency.