Every finding on record at Faith Haven Senior Care Centre

This citation pertains to Intake: 3011032Based on observation, interview, and record review the facility failed to prevent the development of pressure ulcers for one resident (R1) out of two residents with pressure ulcers reviewed, resulting in the development of R1 facility acquired stage 4 pressure ulcer that required hospital transfer for sepsis related to wound infection and surgical debridement.Review of the Face Sheet and Minimum Data Set (MDS) with Assessment Reference Date(ARD) of 5/20/26 reflected R1 was a [AGE] year old female admitted to the facility on [DATE] with recent readmission post hospital transfer 5/14/26 related to stage 4 (full thickness tissue loss with exposed muscle, tendon and or bone) pressure ulcer infection, with additional diagnoses that included hemiplegia and hemiparesis aphasia following cerebral infarction effecting non-dominant side, hypertension, protein-calorie malnutrition, vascular dementia, bipolar disorder, postural kyphosis cervicothoracic region, and anxiety . The MDS reflected R1 had a BIM (assessment tool) score of 13 which indicated her ability to make daily decisions was cognitively intact, and she was dependent on staff for repositioning in bed, transfers, dressing, hygiene, and eating. Continued review of R1 MDS reflected R1 was at risk for pressure ulcer (PU) and had one unstageable-deep tissue injury that was not present on admission, and R1 was not on turning/repositioning program.Review of R1 MDS with ARD of 3/11/26 revealed BIMS of 8 (moderate impaired) and was at risk for pressure ulcer (PU) with no unhealed PU. Continued review reflected R1 was not on turning/repositioning program.During an observation on 5/28/26 at 11:11 a.m., R1 was in bed, eyes closed, air mattress functioning, mat on floor, music playing, clean linens, bilateral blue boots on, and wedge pillow under right hip with wound vac on and in place. During an interview on 5/28/26 at 11:18 a.m., Wound Nurse (WN) D reported had been in position for about two years. WN D reported completes resident wound care every Monday, Wednesday, and Friday and floor staff complete on the other days. WN D reported weekly wound rounds with Nure Practitioner (NP) E every Wednesday. WN D reported if staff identify new skin issue they are expected to document on shower sheet, inform head nurse who then would sign shower sheet, give to unit manager and inform wound nurse. WN D reported she would then assess resident that same day or next scheduled day. During an interview on 5/28/26 at 11:50 a.m., Nursing Home Administrator (NHA) A reported had, soft file for R1 and reported staff had informed management that surveyor was asking about R1 last week (6 days prior) and wanted to know if this surveyor would like to review it. NHA A provided word document, titled, Unavoidable Pressure Injury Summary for R1. The file included a blank document titled, Unavoidable PI [pressure injury] Statement that was printed from Electronic Medical Record and completed with handwritten responses. Not completed documented electronically in EMR. Handwritten notes with no electronic date stamping. During an observation on 5/28/26 at 12:25 p.m. R1 was in bed in same position with eyes closed with slight movement of arm.During an observation on 5/28/26 at 12:28 p.m., Certified Nurse Aid (CNA) Q entered R1 room with lunch tray, placed on bedside table and exited room. During an observation on 5/28/26 at 12:35 p.m., R1 was heard repeatedly yelling out, I want something to eat with tray at bedside.During an observation on 5/28/26 @ 12:36 p.m., CNA Q returned to R1 room and overheard staff remind resident he had told her he was passing trays and would return to assist. R1 bed was heard making beeping noise.During an observation on 5/28/26 at 1:05 p.m., CNA Q exited R1 room with tray with about 50% of meal eaten and full, unopened might shake. Observed R1 in same position with wedge under right hip and continued to hear bed making beeping noise.During an observation on 5/28/26 at 1:30 p.m., R1 was observed in same position in bed with wedge under right side. (Two hours twenty minutes in same position).Review of R1 Bradon Scale for predicting risk for pressure ulcers, dated 1/2/26, reflected score of 13, which indicated high risk. Review of R1 Electronic Medical Record reflected no additional Bradon Scale assessments completed until 3/30/26 with score of 12 that indicated high risk.Review of R1 Nurse Progress Notes, dated 3/30/2026 at 11:54 a.m., reflected, New skin Location: Lower back. Issue type: Pressure ulcer / injury. Progress: New: new wound. Pressure ulcer staging: Unstageable pressure injuries presenting as deep tissue injury. Wound acquired in-house. Exact date: 03/30/2026 Signs and symptoms of infection: Erythema/edema. Painful: No. Staged by: In-house nursing. Length (cm): 2.66 Width (cm): 2.58 Depth (cm): 0 Area (cm2): 5.12 Undermining: No. Tunneling: No. Slough: 60%. Eschar: 40%. Exudate amount: Light. Seropurulent: mixture of purulent and serous, usually watery, yellow, green, tan or brown. Edema: Non-pitting edema extends > 4 cm around wound. Additional care: Turning / repositioning program. Additional care: Mattress with pump.Review of R1 wound provider notes, dated 4/1/26, reflected, Ordered keflex 500mg BID[two times daily] x 10 days for signs of wound infection.Review of R1 Skin Progress Note, dated 4/13/26, reflected, Skin issue has been evaluated. Location: Lower back. Issue type: Pressure ulcer / injury. Progress: Stable: previously deteriorating wound characteristics plateaued. Pressure ulcer staging: Unstageable pressure injuries presenting as deep tissue injury. Wound acquired in-house. Exact date: 03/30/2026 Signs and symptoms of infection: None. Painful: No. Staged by: In-house nursing. Length (cm): 6.45 Width (cm): 3.86 Depth (cm): 0 Area (cm2): 14 Undermining: No. Tunneling: No. Epithelial: 0%. Granulation: 0%. Slough: 0%. Eschar: 100%. Exudate amount: Moderate. Seropurulent: mixture of purulent and serous, usually watery, yellow, green, tan or brown.Review of R1 Wound Provider Note, dated 4/15/26 and 4/29/26, reflected wound debridement completed by provider. Continued review of 4/29/26 provider note, reflected, removed significant slough from wound bed. Base of wound appears in close proximity to spine. Requiring pt/wound to be monitored closely for s/sx [signs and symptoms] of infection.Revie of R1 Skin Progress Note, dated 4/30/26, reflected, New skin Issue. Location: Front right trochanter. Laterality / Orientation: Middle. Issue type: Other skin issue. Other skin issue description: Golf ball size lump with blanchable red mark on top Progress: New: new wound. Wound acquired in-house. It is unknown how long the wound has been present. Painful: No. Length (cm): 4 Width (cm): 4 Depth (cm): 0 Area (cm2): 16.Review of R1 Skin Note, dated 5/4/26, reflected, Location: Lower back. Issue type: Pressure ulcer / injury. Progress: Deteriorating: wound characteristics deteriorated. Pressure ulcer staging: Unstageable pressure injuries presenting as deep tissue injury. Wound acquired in-house. Exact date: 03/30/2026 Painful: Yes. Wound pain (Frequency): Intermittent. Pain description: Sharp. Pain description: Burning. Wound pain interventions: Medicate prior dressing change. Wound pain interventions: Change in position. Relief from interventions: Yes. Staged by: In-house nursing. Length (cm): 3.74 Width (cm): 3.7 Depth (cm): 2 Area (cm2): 11.24 Undermining: Yes. Undermining = 1 instance of undermining. Undermining length (cm): 2.5 Undermining location 1 from: 1 o'clock. Undermining location 1 to: 8 o'clock. Tunneling: No. Epithelial: 0%. Granulation: 20%. Slough: 50%. Eschar: 30%. Exudate amount: Moderate. Seropurulent: mixture of purulent and serous, usually watery, yellow, green, tan or brown. Other wound bed: bone. Periwound: Non-attached. Periwound: Rolled edge (Epibole). Surrounding tissue: Excoriated. Surrounding tissue: Fragile. Surrounding tissue: Scarring. Surrounding tissue: Blanching. Surrounding tissue: Erythema. Induration: None present. Edema: Non-pitting edema extends > 4 cm around wound.Review of R1 Provider Progress Note, dated 5/5/26, reflected, Pressure ulcer of left lower back, unstageable X ray of her spine reviewed. Discussed with wound NP Wound recently debrided. She has no leukocytosis and is afebrile X ray showed possible osteomyelitis/discitis.Discussed possible MRI vs hospital for evaluation of osteomyelitis, will have wound NP evaluate tomorrow then further recommendations.Review of R1 Nurse Progress Note, dated 5/6/26, reflected, Resident's Sister notified of X-ray results. Osteomyelitis in T-Spine Wound now presenting with a fever this AM. Requesting Hospital evaluation. Providers notified.Review of Hospital Documents, dated 5/6/26 through 5/14/26, reflected R1 was admitted to hospital for diagnosis of sepsis secondary to infected stage 4 lumbar pressure ulcer with deep soft tissue infection. Continued review reflected CT scan with Mild soft tissue edema posterior to the lower lumbar spine with one tiny air bubble posterior to the right margin of L3 posterior elements and may be indicative of soft tissue infection. Continued review reflected that R1 had surgical Operative debridement on 5/7/26.Review of R1 Infectious Disease Consult, dated 5/6/26, reflected, Impression: 1. Lumbar decubitus ulcer with likely spinous process erosion in the setting of inadequate offloading. 2. Leukocytosis and hypotension may represent bacteremia related to above. Recommendations 1. Likely needs debridement. 2. Would continue vancomycin, cefepime, flagyl for now. 3. Once debridement has occurred probably may benefit from placement of a wound VAC along with aggressive offloading and nutritional supplementation.Review of R1 Infectious Disease Consult, dated 5/10/26, reflected, Surgical cultures with Enterococcus and corynebacterium.Continue vancomycin with pharmacy to dose while in hospital. At time of DC[discharge], adjust to oral Zyvox 600mg twice a day and continue that until 6/30/26.Weekly CBC while on Zyvox.Review of R1 Nurse Progress Note, dated 5/15/26, reflected, [AGE] year old seen today for readmission. She is resting in bed and she was in the hospital secondary to sacral ulcer. CT showed soft tissue edema of the lower lumbar region concerning for infection. She was evaluated by general surgery and is s/p debridement. She was on antibiotics and discharged with oral Zyvox. She has wound vac in place.Review of R1 Skin Progress Note, dated 5/15/26, reflected, Location: Lower back. Issue type: Pressure ulcer / injury. Progress: Stable: previously deteriorating wound characteristics plateaued. Pressure ulcer staging: Unstageable pressure injuries presenting as deep tissue injury. Wound acquired in-house. Exact date: 03/30/2026 Signs and symptoms of infection: None. Painful: No. Staged by: In-house nursing. Length (cm): 5.59 Width (cm): 2.89 Depth (cm): 1.8 Area (cm2): 12.73 Undermining: Yes. Undermining = 1 instance of undermining. Undermining length (cm): 1 Undermining location 1 from: 12 o'clock. Undermining location 1 to: 12 o'clock. Tunneling: No. Epithelial: 0%. Granulation: 70%. Slough: 30%. Eschar: 0%. Exudate amount: None. Exudate type: Serosanguineous: mixture of serous and sanguineous fluid, typically pale, red, and watery. Odor after cleansing: None. Periwound: Rolled edge (Epibole). Periwound: Non-attached. Surrounding tissue: Intact. Surrounding tissue: Erythema. Surrounding tissue: Blanching. Surrounding tissue: Fragile. Induration: None present. Edema: No swelling or edema. Periwound temperature: Normal. Cleansing solution: Normal saline. Primary dressing: Negative pressure wound therapy.Review of R1 Provider Progress Note, dated 5/20/26, reflected, Wound Assessment: Wound- Lower back stage 4 pressure. Measurements- 4.8 x 3.2 x 1.2 3cm undermining from 8-5 o'clock. Tissue type- slough/subcutaneous. Peri Wound- fragile. Drainage- light serous exudate. Pain-moderate guarding noted. Infection- non-viable tissue. Overall Wound Condition-stable. Wound Plan Of Care- cleanse with normal saline, pat dry, apply skin prep then duoderm extra thin to picture frame wound to protect skin, promogran prisma to undermining then cut foam to fit into wound, cut strip of black foam to bridge to anterior surface so patient not laying on tubing, protect all skin under foam bridge with transparent film, cover all foam with transparent drape, place [NAME] pad, connect tubing to vac canister. Maintain NPWT [Negative Pressure Wound Therapy] @ 125mmHg continuous therapy. Wound Additional Orders- Caregiver staff to provide frequent turning and repositioning to offload wound.Review of R1 Skin Progress Note, dated 5/25/26, reflected, Location: Lower back. Issue type: Pressure ulcer / injury. Progress: Stable: previously deteriorating wound characteristics plateaued. Pressure ulcer staging: Unstageable pressure injuries presenting as deep tissue injury. Wound acquired in-house. Exact date: 03/30/2026Signs and symptoms of infection: None. Painful: No. Staged by: In-house nursing. Length (cm): 4.61 Width (cm): 3.01 Depth (cm): 1.2 Area (cm2): 11 Undermining: Yes. Undermining = 1 instance of undermining. Undermining length (cm): 3 Undermining location 1 from: 7 o'clock. Undermining location 1 to: 5 o'clock. Tunneling: No. Granulation: 50%. Slough: 50%. Eschar: 0%. Exudate amount: Moderate. Exudate type: Serous: clear watery fluid, which is separated from solid elements.Dressing saturation: Moderate 26-75%. Cleansing solution: Normal saline. Primary dressing: Negative pressure wound therapy. Secondary dressing: No secondary dressing applied. Modalities: None. frequency of treatment: 3 times a week.Review of R1 Skin Care Plan, dated 1/13/26, reflected, SKIN MANAGEMENT at risk rt [related to] Hemiplegia and hemiparesis following cerebral infarction affecting left nondominant side, HTN [hypertension], Occlusion and stenosis of right carotid artery, dementia, anxiety, venous insufficiency, CAD [coronary artery disease], HLD [elevated lipids], Bipolar, depression, insomnia. R inner heel- ruptured blister. L outer heel/ankle area- ruptured blister. Resident is often anxious and is often crossing her legs and feet back and forth continuously from one side to the other causing friction and rubbing Date Initiated: 11/28/2025.Revision on: 01/13/2026. Continued review of the Skin Care Plan reflected interventions that included, Please help me get turned and repositioned while in bed or in my wheelchair. Date Initiated: 11/28/2025.Revision on: 01/13/2026. Please help me get turned and repositioned while in bed or in my Broda chair. Date Initiated: 11/28/2025.Revision on: 05/29/2026 [During Surveyor Investigation].Place pillow behind back while in chair. Date Initiated: 03/31/2026 . I have pressure reducing device on chair/wheelchair. Date Initiated: 11/28/2025.Revision on: 01/13/2026 [same intervention updated 3/30/26] I have pressure reducing device on Broda ChairRevision on: 03/30/2026 [same day as R1 pressure injury identified].encourage me and reposition me if I allow from side to side. Date Initiated: 03/30/2026.CNA's will check my skin daily with care and report anything unusual they notice to the nurse. Date Initiated: 11/28/2025. APM. Date Initiated: 12/29/2025. Call light accessible. Date Initiated: 11/28/2025.Review of R1 MDS with ARD date of 5/20/26 reflected R1 had unstageable deep tissue injury that was not present on admission. Hospital records reflected R1 had stage 4 pressure injury on admission 5/6/26.During an observation on 5/29/26 at 8:15 R1 was in high back geri chair in Dining Room with staff assisting with meal. During an observation on 5/29/26 at 8:40 a.m. CNA E and CNA F transferred R1 from high back chair into bed with use of mechanical lift. Observed R1 air mattress pump was not functioning indicated by no lights on pump at foot of bed and mattress appeared to be deflated with R1 sunk in bed. During an observation on 5/29/26 at 8:45 a.m., CNA E reported was very familiar with R1 and routinely cared for R1 prior to room move on 5/22/26. CNA E reported R1 able to make needs known and does not refuse position changes. CNA E reported received education after wound was found on R1 on 3/30/26 under foam dressing that was not labeled or removed during bath days. CNA E reported staff were educated to report all skin changes and dressing on shower sheets and report to nurse. CNA E reported was not responsible for bathing R1 because on another shift. CNA E reported air mattress was in place prior to identifying facility acquired pressure wound. CNA E reported R1 also had documentation sheet for turning and repositioning every 2 hours now and verified was unable to locate R1s documentation at nurse station but was able to locate other residents who required repositioning documentation.During an observation and interview on 5/29/26 at 9:00 a.m. to 9:54 a.m., Wound Nurse D entered R1 room to complete dressing change. Wound vac disconnected and dressing removed over lower spine area that had been bridged on right side (foam dressing redirected to anterior body to avoid pressure from track pad and hose of suction over bony prominence). Observed soft ball size open area over R1's spine on lower back with bright red angry peri wound noted that appeared to be stage 4 pressure wound with exposed bone ligaments. WN D reported R1 prior dressing was last changed by her and provider 5/27/26. WN D cleaned wound with normal saline, pryzm applied to undermining, black foam to wound bed, skin prep peri wound and duoderm framed wound, clear drape applied, bridge to right side (appears over right iliac crest). Track pad with no foam under entire pad area only about 3/4 inch bridge with track pad suctioned down over only clear drape with potential to create pressure from track pad on health skin. Track pad and hose also appeared to be place to right side again and directly over boney prominence instead of anterior body. Observed R1 air mattress off as indicated by no lights on pump at foot of bed. R1 was transferred from bed to high back chair with back cutout foam by two staff and reported plan to go to therapy.During an interview on 5/29/26 at 10:00 a.m. WN D verified R1 wound was currently a stage 4 facility acquired pressure ulcer. During an interview and record review on 5/29/26 at about 10:20 a.m. Unit Manager (UM) G reported R1 was on a every two-hour turning and repositioning schedule and was responsible for collecting documentation. UM G provided documentation included 5/21/26 through current with several missing days with no documentation and UM G verified missing documentation days. During an interview on 5/29/26 at 10:30 a.m., Assistant Director of Nursing (ADON) H reported R1 had an Alternating Pressure Mattress (APM) since December 2025. During an interview and record review on 5/29/26 at 11:45 a.m., CNA F reported R1 every two hour turn document was located at the nurse station on a clip board and reported copy had to be made earlier so it may not have been observed at nurse station for that reason. During an interview and record review on 5/29/26 at 12:34 p.m., ADON H reported had been in position for about six months. ADON H verified the following Care Planned Interventions were in place.APM mattress initiated 12/29/25Broda chair 1/27/26.Turn and reposition initiated 3/31/26ADON H reported R1 facility acquired pressure ulcer to lower spine area was first identified on 3/30/26 and WN D assessed. ADON H reported cushion was added to back of Broda chair to offload pressure on wound related to Kyphosis. ADON H verified when R1 initially admitted was had regular wheelchair and because of Kyphosis was changed to Broda chair for safety. ADON H reported R1 was assessed by facility wound provider on 4/1/26. ADON H reported staff identified facility acquired unstageable deep tissue injury 3/30/26 after removing an unlabeled, unordered foam dressing from R1's lower spine area and investigation was started because was new open pressure wound with no physician ordered treatments. ADON H reported was unable to determine how long foam dressing had been in place and reported R1 had received showers on 3/23/26 and 3/26/26 with no changes in skin reported. Requested investigation for review.Review of the Education provided after R1 pressure ulcer identified on 3/31/26 to all nursing staff by ADON H included, If you put a treatment on a new area of concern you have to have a treatment and document what the skin issue is and notify your unit manager and DON. You cannot just put a dressing on anyone and not have treatment. Dressings need initials and dates on them, nothing else. Assure daily during rounds that treatments and other preventative measures are in place including turning and repositioning, pressure relieving devices (in good condition), dressing in place, etc. Incontinence care, offloading heels, checking skin during ADL [activity of daily living] care and showers, notification of areas of concern, documentation of decline and implementing skin prevention. Accurate completion and documentation of skin assessments, notification and documentation of new areas of concern. The facility provided above education along with facility, Wound Management Program Policy, dated 8/17/2017, and list of nursing staff with signatures with no dates.During an observation and interview on 5/29/26 at 1:05 p.m., CNA F was observed in R1 room and reported had just transferred R1 back to bed. R1 was currently on phone and CNA F reported with sister and CNA F exited room. Observed R1 positioned in bed with wedge under left side and air mattress continued to non-functioning as evidenced by no lights on pump. R1's call light was out of reach located 3 to 4 feet away from bed on nightstand. During an interview on 5/29/26 at 1:20 p.m. ADON H reported would provide R1 bath sheets and reported provided staff education 3/31/26 because non ordered foam dressing was removed from R1 lower spine that revealed open facility acquired pressure wound and facility was unsure when area was last assessed. ADON H verified R1's facility acquired pressure wound was open, had drainage, slough, and escar when first identified on 3/30/26. ADON H verified provided list of nursing staff with signatures was who was provided education and verified no dates were included on when education was completed. ADON H reported started to educate staff 3/31/26 until all staff educated.During an interview on 5/29/26 at 1:30 p.m., Director of Nursing (DON) B reported had investigation for R1 facility acquired pressure ulcer and would provide. Management team, including NHA A, DON B, Senior Executive Director (SED) J, and Regional Nurse K were present when this surveyor again requested complete investigation for R1 facility acquired pressure wound. Facility provided, soft file for R1 unavoidable pressure wound without surveyor request 5/28/26. The requested investigation was not provided. During an interview on 5/29/26 at 1:35 p.m., Confidential staff (CS) I reported had cared for R1 and was familiar with R1. CS I reported prior to R1 pressure wound staff would place foam dressing over R1 lower spine area for protection because R1 was thin and area would rub on wheelchair related to poor posture. During an interview on 5/29/26 at 1:45 p.m., Registered Nurse (RN) C reported she identified R1's new facility acquired pressure wound on 3/30/26 during weekly skin assessments after a shower. RN C reported though she completed change of condition, notified provider and facility wound nurse that day. RN C reported did not see foam dressing on at that time but had assessed R1 skin after a shower. During an interview on 5/29/26 at 2:00 p.m., Regional Nurse Consultant (RNC) K provided investigation information for R1 facility acquired pressure wound. RNC K reported staff education started 3/31/26 after complete resident sweep of facility on 3/30/26 for unidentified skin concerns or unordered treatments. RNC K reported facility investigation was unable to determine who placed R1 unlabeled, unordered foam dressing prior to identifying pressure wound.During an observation on 5/29/26 at 2:08 p.m., R1 continued to be in bed with eyes closed, call light was now in reach and air mattress continued to be non-functioning with no lights on pump noted. During an interview, observation and record review on 5/29/26 at 2:44 p.m., Director of Nursing (DON) B reported ADON H reported R1 facility acquired pressure ulcer to DON B on 3/30/26 and DON B started R1 skin incident report, notified wound nurse, pictures were taken, treatment started and pillow added to R1 Broda chair. Review of R1 lower spine pictures dated 3/30/26 and this surveyor asked why open 2.66 cm by 2.58 cm, wound with drainage, slough, and escar was not identified prior to 3/30/26. DON B asked if management had provided witness statements and surveyor verified had not been provided to surveyor after several requests for complete investigation for review. DON B reported management had statements as part of investigation. DON B reported was off on leave from April 2026 until last week, so managers took over. DON B reported would expect that staff follow care planned interventions. DON B entered R1 room with surveyor at about 3:10 p.m. and verified R1 was in bed and air mattress was not functioning and should be.During an interview on 5/29/26 at 3:39 p.m., R1 sister reported frequently visited with R1 and reported staff were not repositioning R1 while in Broda chair or in bed every 2 hours or offering position changes. R1 sister reported facility did not have cushion in Broda chair to keep pressure off R1 wound on back. R1 sister reported staff were not assisting R1 with meals and had lost weight and reported had spoken with management and feels like this has improved slightly. Review of R1, Wound Investigation Report, dated 3/30/26, provided by facility on 5/29/26 at 5:38 p.m. reflected, On 03/30/26, the resident was observed to have an open area located on the lower back along the spinal region. The wound nurse assessed the area and determined it appears consistent with deep tissue injury (DTI) that is currently unstageable. The investigation included witness statements that included:Witness statement from RN L, dated 3/31/26, reflected, On 3/26/26, I went to assess [named R1] for skin assessment. There was a patch on her back. I did not remove it to assess the underneath. It was clean, dry, and intact. There were no other issues with skin breakdown.Witness statement from Certified Nurse Aid (CNA) M, dated 3/30/26, reflected, On Saturday March 28, 2026, between 4am and 5am I did care for [named R1]. I changed her brief, washed her up, and dressed her. I did not see any sores or red areas. I did see a patch on her back, but it was intact. NHA A signed as the interviewer.Witness statement from CNA N, dated 3/30/26, reflected, I often have the assignment with [named R1] and never noticed any skin breakdown. I sometimes noticed that a spongy patch is located on her back. I don't lift the patch up and look because I thought it was for protection. The statement indicated ADON H was interviewer and NHA A was witness to statement.Witness statement from Licensed Practical Nurse (LPN) P, dated 4/1/26, reflected, On 3/9/26, I was alerted by a CNA that [named R1] redness noted to bony prominence on her back. I applied foam dressing for protection. The statement indicated ADON H was interviewer and NHA A was witness to statement.During an interview on 5/29/26 at 4:35 p.m., DON B verified R1 had care planned intervention to turn and reposition added 11/25. DON B reported would expect staff to offer to reposition every two hours. DON B reported completed facility sweep of all resident air mattresses and reported all other mattresses were functioning and had maintenance staff assesses R1 room. DON B reported that R1 air mattresses was now functioning.During an interview on 5/29/26 at 6:00 p.m., NHA A, RNC K and SED J verified had no additional documentation to provide prior to survey exit.

Based on interviews and record review, the facility failed to ensure that a substantial HS (evening) snack was consistently offered and appropriately distributed to a group of confidential residents that attended the Resident Council Meeting, potentially affecting all residents who receive meals in the facility with 14 or more hours between last evening meal and breakfast the following day, resulting in resident dissatisfaction, frustration and potential for uncontrolled blood sugars, signs and symptoms of hypoglycemia, feeling of hunger, and weight loss.Findings include:During a confidential Resident Council Meeting on 3/18/2026 at 10:00 AM, six residents actively participated. All six attendees of the confidential resident council meeting reported they were not offered or evening snacks. One of six attendees reported had observe bin of cookies at nurse station but no type of options other than cookies and residents had to go to nurse station and ask for them. Five of six residents reported did not know snack were available at all. Review of the facility, Food Council minutes, date January and February 2026, reflected when residents were asked, What are you offered for bedtime snack? residents answered, Nothing in January. Continued review of minutes reflected, when asked, What are you offered for bedtime snack? residents answered, Various but not offered in February. During an observation and interview on 3/19/2026 at 2:15 PM, Kitchen manager (KM) U reported two ways residents should get evening snacks. KM U reported if dietician orders evening snack for residents, kitchen staff delivers labeled snacks to resident nurse stations and floor staff deliver. KM U reported other way was bins are located in snack rooms on halls. KM U entered snack room on 400 hall and bin of mostly individually wrapped oatmeal cream filled and chocolate cookies and graham crackers were observed. KM U reported they can provide several other options as well and reported recent request for string cheese. KM U reported would expect staff offer each resident evening snacks and restock supplies as needed. KM U reported evening snacks are discussed at food council as well and reported planned to implement request for sting cheese.

This Citation Pertain to Intake # 2795434 Based on observation, interview and record review, the facility failed to thoroughly investigate allegations of abuse for one resident (resident #33) of two residents reviewed for abuse.Finding include:Resident #33 Review of the clinical record, including the Minimum Data Set (MDS) dated [DATE] revealed R33 was admitted to the facility on [DATE] with diagnoses that includes dementia. R33 scored 03 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS) and was not interview able. R33 was observed sitting in her wheelchair on 03/17/26 at 8:40am upon approach R33 was pleasantly confused. Review of the facility reported incident file included a word document with Licensed Practical Nurse (LPN) C's unsigned statement written on a word document. The bottom of the word document had the date of 2/01/2026, it was unclear if the 2/01/26 date was in reference to the date of the incident or the date LPN C was interviewed, the word document did not include who conducted the interview with LPN C or where LPN C was interviewed, (in person or via phone). The word document reflected LPN C was going to assist Certified Nursing Assistant (CNA) D with transferring R33 to bed using a mechanical lift. The statement reflected LPN C was a new nurse and upon entering the room R33 was mumbling and CNA D tapped R33 on the head. R33 didn't like it that and said she would report him and CNA D responded go ahead. According to the word document CNA D left the room LPN C stayed with R33 to comfort her, R33 reported she was didn't like being hit on the head and was scared. LPN C notified another Nurse, and the Nursing Home Administrator (NHA) A was notified. The statement/word document did not further query LPN C on what/how CNA D's tone of voice, inflection was used when he replied Go ahead to R33. statement included additional verbiage or the tone used. It also omitted CNA D yelling Stop at R33 while pushing R33's hands down. On 03/18/2026 at 10:10 AM during a phone Interview with LPN C stated she was a new employee and on 2/01/26 upon entering R33's room, CNA D was already in the room, R33 was agitated and mumbling and witnessed [name redacted] hit her upside the head and he then yelled Stop! LPN C stated CNA D went and retrieved R33s white board (used for communication due to R33's hearing impairment.) and wrote that LPN C was there to help her. LPN C reported R33 was still mumbling and agitated and raised her hands, at which time CNA D got in R33's face and started taunting R33, then grabbed her hands and pushed them down. R33 stated she was going to report him to the state and CNA D laughed in R33's face and said, go ahead, nobody care about you! LPN C stated she had never seen anything like that and she was very uncomfortable with CNA Ds aggressive treatment of R33. LPN C elaborated after CNA D left the room she stayed because R33 was upset stating she was afraid and didn't like being hit on the head. After R33 was settled she stated she was so uncomfortable by the interaction she told another Nurse who informed her the NHA A had to be notified. LPN C reported she informed NHA A the exact same chain of events that she just informed writer of. Review of CNA D statement located in the facility incident file, unlike LPN C's statement, CNA Ds statement was on a facility form and included the name and position of the person being interviewed, who was conducting the interview, the date of the interview, the date of the incident, and location. CNAD's statement acknowledge/agreed he hit tapped her on the side of the head as he was trying to get R33's attention because she was yelling at the new nurse. CNA Ds statement went on to say he didn't hit R33 hard enough to make a sound and he could of chosen to tap R33 on the shoulder or arm but opted not to. The statement also acknowledged R33 stated she would report CNA D's behavior and statement revealed CNA D told R33 to stop saying that. On 03/18/2026 at 11:51 AM, during a phone interview with CNA D reported he was hired at the facility on 12/02/25 and quit after the facility reported incident because he knew he'd be fired and thought it would look better to have quit then be terminated. CNA D elaborated and stated LPN C was a new employee and new Nurse and didn't understand how to work with R33. CNA D said the moment LPN C walked into R33's room R33 was upset due her dementia and LPN C was a stranger. CNA D stated he did in fact hit R33 on the head but not hard enough to hear it or leave a mark. When queried about R33 stating she was going to report him, CNA D agreed that R33 did say that, but he denied giving any response to R33. CNA D further stated that he was made aware of allegations made that he both physically and verbally abused R33. When queried how he was made aware of the allegations, CNA D stated after he was walked out /suspended on 2/01 he was panicked and called NHA A from the facility parking lot and NHA A informed him of allegations of verbal and physical abuse related to R33. On 3/18/26 at 10:25am during an interview with NHA A he offered no explanation for CNA D's tapping R33 on the head and stated he was not aware of any allegation of verbal abuse and had planned to terminate his employment, but CNA D resigned before that happened. When queried about CNA D's written statement about R33 reporting him and his written response was Go ahead did he probe further? i.e. the tone used or query LPN C about the statement. NHA A stated he knew nothing about it and was confused as to why LPN C stated she had reported it to him and was also confused as to why CNA D stated he was made aware of the allegations in detail by NHA A on 02/01/26. When queried why LPN C's interview was on a word document and not the facility form like CNA D's statement, NHA A stated he conducted the interview with LPN C from home on [DATE]. Which was why it did not have any signatures. When queried how/why CNA Ds statement was on facility form and signed by NHA A on the also on 02/01 NHA A offered no explanation. On 3/19/26 at 10:39am, during an interview with Senior Executive Director O she played voice mails from CNA D and showed text messages from CNA D to NHA A the correspondence revealed all was after 02/01/26 in which CNA D acknowledged hitting R33 on the head. Senior Executive Director O pointed out CNA D did not mention verbal abuse, and felt the statement CNA D acknowledge of go ahead possibly meant CNA D encouraged R33 to exercise her right to report him. There was no investigated pieces/documentation that the facility provided that reflected CNA D was encouraging R33's rights or investigation into LPN C' allegation that CNA D taunted, yelled and verbally abused R33. On 03/19/2026 at 11:55 AM, review of a past non-compliance (PNC) that was provided by NHA on 3/18/26 was reviewed. The PNC was related to resident-to-resident abuse and dementia care. When queried about the PNC provided, NHA A stated that was for an unrelated event. When quired if the facility had a PNC related to R33 and CNA D NHA stated there was no PNC for the incident at hand. Review of the facility's policy and procedure titled Abuse, Neglect And/or Misappropriation of Resident Funds or Property dated 5/13/14 with a revision date of 3/15/23. Page 2. defines physical abuse as includes hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment, which is physical including, but not limited to slapping of hands, flicking, or hitting with an object. The policy defines verbal abuse as any use of oral written or gestured language that willfully includes disparaging and derogatory terms to residents. Verbal abuse includes but is not limited to spoken, written or gestured language that includes insulting, offensive or disapproving terms to any resident (or within his/her hearing distance) regardless of age, disability, or ability to comprehend Page 4. Under investigative protocol read in part Interview the resident, the accused (if employee, suspend until investigation complete), and all witnesses shall include anyone who (1) witnessed or heard of the incident; (2) came in close conduct with either the resident the day of the incident (including other residents, family members, etc.); (3) employees who worked closely with the accused employee(s) and or alleged victim the day of the incident. To the extent possible, all interviews should be summarized into a written statement, which is signed and dated.

This Citation Pertains to Intake 2795434Based on observation, interviews and record review, the facility failed to protect the residents' right to be free from abuse verbal and physical from a staff member (CNA D) for one resident (resident #33) of two reviewed.Findings include: Resident #33 Review of the clinical record, including the Minimum Data Set (MDS) dated [DATE] revealed R33 was admitted to the facility on [DATE] with diagnoses that includes dementia. R33 scored 03 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS) and was not interview able. R33 was observed sitting in her wheelchair on 03/17/26 at 8:40am upon approach R33 was pleasantly confused and not able to participate in a reliable interview. Review of the facility reported incident file included, Licensed Practical Nurse (LPN) C's unsigned statement written on a word document. The bottom of the word document had the dated 2/01/2026, it was unclear if that was the date of the incident or the interview with LPN C or who interviewed LPN C. The word document reflected LPN C was going to assist Certified Nursing Assistant (CNA) D with transferring R33 to bed using a mechanical lift. The statement reflected LPN C was a new nurse and upon entering the room R33 was mumbling and CNA D tapped R33 on the head. R33 didn't like it that and said she would report him and CNA D responded go ahead. According to the word document CNA D left the room LPN C stayed with R33 to comfort her, R33 reported she was didn't like being hit on the head and was scared. LPN C notified another Nurse, and the Nursing Home Administrator (NHA) A was notified. On 03/18/2026 at 10:10 AM during a phone Interview with LPN C stated she was a new employee and on 2/01/26 upon entering R33's room, CNA D was already in the room, R33 was agitated and mumbling and witnessed [name redacted] hit her upside the head and he then yelled Stop! LPN C stated CNA D went and retrieved R33s white board (used for communication due to R33's hearing impairment.) and wrote that LPN C was there to help her. LPN C reported R33 was still mumbling and agitated and raised her hands, at which time CNA D got in R33's face and started taunting R33, then grabbed her hands and pushed them down. R33 stated she was going to report him to the state and CNA D laughed in R33's face and said, go ahead, nobody cares about you! LPN C stated she had never seen anything like that and was very uncomfortable with CNA Ds aggressive treatment of R33. LPN C elaborated after CNA D left the room she stayed because R33 was upset stating she was afraid and didn't like being hit on the head. After R33 was settled she stated she was so uncomfortable by the interaction she told another Nurse who informed her the NHA A had to be notified. LPN C reported she informed NHA A the exact same chain of events that she just informed writer. Review of CNA D statement located in the facility incident file, unlike LPN C's statement, CNA Ds statement was on a facility form and included the name and position of the person being interviewed, who was conducting the interview, the date of the interview, the date of the incident, and location. CNA D's statement acknowledge/agreed he hit tapped her on the side of the head as he was trying to get R33's attention because she was yelling at the new nurse. CNA Ds statement went on to say he didn't hit R33 hard enough to make a sound and he could of chosen to tap R33 on the shoulder or arm but opted not to. The statement also acknowledged R33 stated she would report CNA D's statement and revealed CNA D told R33 to stop saying that. On 03/18/2026 at 11:51 AM, during a phone interview with CNA D reported he was hired at the facility on 12/02/25 and quit after the facility reported incident because he knew he'd be fired and thought it would look better to have quit then be terminated. CNA D elaborated and stated LPN C was a new employee and new Nurse and didn't understand how to work with R33. CNA D said the moment LPN C walked into R33's room R33 was upset because she has dementia and LPN C was a stranger, CNA D stated he did in fact hit R33 on the head but not hard enough to hear it or leave a mark. When queried about R33 stating she was going to report him, CNA D responded that R33 did say that but he denied giving any response to R33. CNA D then elaborated that he was made aware by NHA A that it was alleged CNA D verbally abused R33, when quired about when NHA A informed him of the allegation against him for verbal abuse, CNA D stated it was the day of the incident as he was so panicked about being suspended. Stating he had called NHA A from the facility parking lot and was informed of allegations of verbal and physical abuse relating to R33. On 3/18/26 at 10:25am during an interview with NHA A he offered no explanation for CNA D's tapping R33 on the head and stated he was not aware of any allegation of verbal abuse and had planned to terminate his employment, but CNA D resigned before that happened. On 03/19/2026 at 11:55 AM, review of a past non-compliance (PNC) that was provided by NHA on 3/18/26 was reviewed. The PNC was related to resident-to-resident abuse and dementia care. When queried about the PNC provided, NHA A stated that was for an unrelated event. When quired if the facility had a PNC related to R33 and CNA D NHA stated there was no PNC for the incident at hand. Review of the facility's policy and procedure titled Abuse, Neglect And/or Misappropriation of Resident Funds or Property dated 5/13/14 with a revision date of 3/15/23. Page 2. defines physical abuse as includes hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment, which is physical including, but not limited to slapping of hands, flicking, or hitting with an object. The policy defines verbal abuse as any use of oral written or gestured language that willfully includes disparaging and derogatory terms to residents. Verbal abuse includes but is not limited to spoken, written or gestured language that includes insulting, offensive or disapproving terms to any resident (or within his/her hearing distance) regardless of age, disability, or ability to comprehend.

This citation pertains to intake 2575924Based on interview and record review, the facility failed to protect the resident's right to be free from mental abuse and verbal abuse by a staff member. Findings Include:Review of the medical record reflected that R1 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including chronic pain syndrome, carpal tunnel syndrome, jaw pain, muscle spasms, restless legs syndrome, opioid dependence, intervertebral disc disorders (a condition that affects the disc between the vertebrae of the spine), adjustment disorder with mixed anxiety and depression, temporomandibular joint disorder (causing pain and dysfunction of the jaw), migraine, post-traumatic stress disorder, dental caries, anxiety disorder, depression, low back pain, and sciatica. The Minimum Data Set (MDS) reflected that R1 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS), a cognitive screening tool. R1 was no longer at the facility.Facility reported incident reflected on 6/30/25, RN C received a verbal order to increase R1's pain medication but did not enter it until 7/3/25. She admitted she failed to follow up with the physician in a timely manner. A physician statement dated 7/8/25 confirmed that the order for Norco was agreed upon with R1 on 6/30, but by the weekend, the changes were still not made. The Physician Assistant noted concern and intervened.Review of the facility reported incident dated 7/22/25 reflected Resident (R1) reported allegations against a staff member. R1 requested a review of a previous concern she had made that she did not feel was resolved. Upon further investigation, the NHA [covering Nursing Home Administrator] determined the need to report the allegation. A thorough investigation is being conducted. The alleged staff member will not return to work until a conclusion is made.Review of the Facility Reported Incident Report dated 7/22/25 indicated that on that date, covering NHA E reviewed two Concern Forms R1 had written on 7/5/25 along with the statements collected during the initial investigation. NHA E decided to formally report the allegations and initiate a separate investigation, as R1 continued to express unresolved concerns. R1 alleged that Registered Nurse (RN) C had threatened her life and well-being by telling her that narcotic medications would be withheld if she refused to go to the Emergency Department. R1 also alleged that RN C failed to process a physician's order dated 6/30/25 to increase her pain medication.Review of a Resident Assistance Form completed by R1 and dated 7/5/25 stated: [RN ‘C'] threatened my life and my well-being. She refused to listen to my wishes. I have a detailed EMS (Emergency Medical Service) report which backs up my claims. [RN ‘C'] also refused to put in doctor's orders on Monday. A second Resident Assistance Form contained allegations of unequal treatment from RN C. R1 again accused RN C of nearly killing her, threatening her life and well-being, and added, people like RN ‘C' do not deserve to have anyone's life in their hands. If this doesn't stop, she will definitely kill more people. The form again referenced the EMS report from a 6/25/25 hospital transfer.Review of a Nurse's Note dated 6/25/25 at 11:58 AM stated: Resident [R1] c/o (complained of) dizziness and fatigue. Pulse 45 and O2 (oxygen saturation) 70%. 2L (liters) nasal cannula applied, O2 increased to 80%. Pulse increased to 49. This writer contacted PA (Physician's Assistant) and received an order to send to ER (Emergency Department). EMT contacted and resident transferred to ER.Review of the Prehospital Care Report Summary from EMS for the 6/25/25 transfer revealed that EMS arrived at 10:33 AM. The Narrative History Text stated that EMS arrived to find R1 lying in bed. Patient (R1) was surprised they were there to transport her to the ED. Staff stated they believed her pain medication had caused her heart rate and SpO2 to drop. R1 stated she felt better and refused to go to the ED. Contact was made with the ED Physician, who confirmed that if the patient was alert and oriented (A&Ox4) and refused, she could not be forced to go. R1 continued to refuse. Staff then stated, we will not give you any kind of pain medication if you stay here. R1 responded, you will put me into DT (delirium tremors) if you do that. Staff allegedly replied, that's fine, I will make you go to the hospital when you are unconscious. Per the EMS prehospital summary, R1's vital signs were as follows on 6/25/25 at 10:41 AM (seven minutes after arrival) Blood pressure 139/75 Pulse 54 SPO2 93%. At 11:06 AM (while still at the facility) blood pressure 127/67 Pulse 77 SPO2 92%. The vitals show that R1 was hemodynamically stable.In an interview on 8/20/25 at 10:47 AM, Confidential Staff Member K described RN C as snippy and rude and reported hearing her say things like, well if you would follow what you're supposed to do, this wouldn't be happening. At 12:03 PM, LPN S stated that R1 was visibly upset over medication changes and felt she was treated differently by RN C. At 12:48 PM, LPN L stated she was present during the 6/25/25 hospital transfer. RN C reportedly said, Can you help me, [R1] is getting on my nerves and won't go to the hospital. LPN L entered the room and heard RN C tell R1, I'm not going to give you pain medication if you stay, to which R1 responded, If you withhold my medications, I'll fall over and die. RN C allegedly replied, I guess I'll send you to the hospital then and you won't be able to refuse. LPN L told RN C to stop being snippy and then exited the room.On 8/20/25 at 3:17 PM, R1 was interviewed and described feeling targeted after reporting a near-miss medication error in November 2024, which led to a nurse's termination. She said she was treated differently thereafter, especially by RN C. R1 recounted the 6/25/25 event as described in the facility reported incident and medical record.R1 became tearful, describing the experience as emotionally and verbally abusive, triggering her PTSD. She stated that RN C targeted her, labeled her a drug seeker, laughed at her, rolled her eyes, and once stood in the hallway laughing while she cried in pain. R1 stated that RN C made her feel insignificant and like her life had no value.Psychology Notes dated 4/22/25 and 5/20/25 documented R1's PTSD diagnosis and her mistrust of staff. R1 disclosed a history of childhood and domestic abuse, chronic pain, and emotional difficulties tied to her condition and environment.On 8/21/25 at 12:26 PM, LPN W confirmed that RN C was nasty to R1 and other residents. She reported being warned that R1 might get you fired, and stated RN C referred to R1 as a drug seeker who was stoned out of her [NAME]. LPN W found the comments appalling and reported them to the former NHA but was told not to worry. She also reported witnessing a conversation in which R1 asked PA T if he had discontinued her narcotics because RN C said he did. PA T denied this.On 8/20/25 at 10:18 AM, RN I stated that during the 7/1/25 meeting, RN C told R1, You're on a whole bunch of medications, you're going to die, using a condescending tone. At 3:04 PM, RN J confirmed being present during the same meeting and recalled RN C saying, You're not getting the medication list today because one doctor is trying to decrease your narcotics, but [the facility doctor] hasn't changed anything like he should have. RN J stated that RN C was a newer nurse and lacked customer service skills.Review of an Employee Corrective Action form dated 7/8/25 showed RN C was disciplined for not following through with a doctor's order. It also noted a prior written warning on 6/2/25 with no substantial improvement since. An Employee Warning Record dated 7/25/25 cited disciplinary action for the 6/25/25 incident. The summary noted that RN C communicated a verbal physician's order in a way that made the resident feel threatened, though the investigation did not find intent to threaten. It recommended better tone, body language, and communication during stressful situations. It further stated that when an order needs clarification, the provider must be contacted immediately and documentation must reflect all steps taken to process or delay a physician's order.In an interview on 8/21/25 at 10:11 AM, RN C stated that on 6/25/25, she assisted staff with addressing R1's change in condition. RN C felt that the medication that R1 was taking and her recent diagnosis of bronchitis had affected her respiratory status. RN C reported calling PA T and receiving a verbal order to hold all narcotic medication, however when asked why RN C did not document this order, RN C stated that she did not and per best standards of practice. Regarding the verbal Physician order for R1's pain medication, RN C stated that she did not put the order in timely because she felt it required provider clarification. RN C stated that she did not call back PA T after resolution of R1's symptoms and notify PA T that the acute change in condition had resolved and to inquire of holding R1's medications would still be necessary.In an interview on 8/21/25 at 10:11 AM, covering NHA E stated that after reviewing the grievances dated 7/5/25, it was clear that these concerns were allegations of abuse and should have been reported to the State Agency within the two-hour time frame. The Facility Reported Incident was not reported until 7/25/25, 20 days later.As a result of these practices, R1 stated that she experienced significant psychological distress, humiliation, and fear for her safety. She reported being targeted, made to feel insignificant, Multiple staff corroborated that RN C threatened to withhold R1's pain medications, coerced her into transferring to the hospital, told her you're going to die because of her prescriptions, and openly ridiculed her while she was crying in pain.

This citation pertains to intake 2575924Based on interviews and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act.Findings Include:Review of the medical record reflected that R1 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including chronic pain syndrome, carpal tunnel syndrome, jaw pain, muscle spasms, restless legs syndrome, opioid dependence, intervertebral disc disorders (a condition that affects the disc between the vertebrae of the spine), adjustment disorder with mixed anxiety and depression, temporomandibular joint disorder (causing pain and dysfunction of the jaw), migraine, post-traumatic stress disorder, dental caries, anxiety disorder, depression, low back pain, and sciatica. The Minimum Data Set (MDS) reflected that R1 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS), a cognitive screening tool. R1 was no longer at the facility.Facility reported incident reflected on 6/30/25, RN C received a verbal order to increase R1's pain medication but did not enter it until 7/3/25. She admitted she failed to follow up with the physician in a timely manner. A physician statement dated 7/8/25 confirmed that the order for Norco was agreed upon with R1 on 6/30, but by the weekend, the changes were still not made. The Physician Assistant noted concern and intervened.Review of the facility reported incident dated 7/22/25 reflected Resident (R1) reported allegations against a staff member. R1 requested a review of a previous concern she had made that she did not feel was resolved. Upon further investigation, the NHA [covering Nursing Home Administrator] determined the need to report the allegation. A thorough investigation is being conducted. The alleged staff member will not return to work until a conclusion is made.Review of the Facility Reported Incident Report dated 7/22/25 indicated that on that date, covering NHA E reviewed two Concern Forms R1 had written on 7/5/25 along with the statements collected during the initial investigation. NHA E decided to formally report the allegations and initiate a separate investigation, as R1 continued to express unresolved concerns. R1 alleged that Registered Nurse (RN) C had threatened her life and well-being by telling her that narcotic medications would be withheld if she refused to go to the Emergency Department. R1 also alleged that RN C failed to process a physician's order dated 6/30/25 to increase her pain medication.Review of a Resident Assistance Form completed by R1 and dated 7/5/25 stated: [RN ‘C'] threatened my life and my well-being. She refused to listen to my wishes. I have a detailed EMS (Emergency Medical Service) report which backs up my claims. [RN ‘C'] also refused to put in doctor's orders on Monday. A second Resident Assistance Form contained allegations of unequal treatment from RN C. R1 again accused RN C of nearly killing her, threatening her life and well-being, and added, people like RN ‘C' do not deserve to have anyone's life in their hands. If this doesn't stop, she will definitely kill more people. The form again referenced the EMS report from a 6/25/25 hospital transfer.Review of an Employee Corrective Action form dated 7/8/25 showed RN C was disciplined for not following through with a doctor's order. It also noted a prior written warning on 6/2/25 with no substantial improvement since. An Employee Warning Record dated 7/25/25 cited disciplinary action for the 6/25/25 incident. The summary noted that RN C communicated a verbal physician's order in a way that made the resident feel threatened, though the investigation did not find intent to threaten. It recommended better tone, body language, and communication during stressful situations. It further stated that when an order needs clarification, the provider must be contacted immediately, and documentation must reflect all steps taken to process or delay a physician's order.In an interview on 8/21/25 at 10:11 AM, covering NHA E stated that after reviewing the grievances dated 7/5/25, it was clear that these concerns were allegations of abuse and should have been reported to the State Agency within the two-hour time frame. The Facility Reported Incident was not reported until 7/25/25, 20 days later.

This citation pertains to intake 2575924Based on interview and record review, the facility failed to honor the residents right to refuse a hospital transfer in one (Resident one) out of three reviewed for resident rights. Findings include:Review of the medical record reflected that R1 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including chronic pain syndrome, carpal tunnel syndrome, jaw pain, muscle spasms, restless legs syndrome, opioid dependence, intervertebral disc disorders (a condition that affects the disc between the vertebrae of the spine), adjustment disorder with mixed anxiety and depression, temporomandibular joint disorder (causing pain and dysfunction of the jaw), migraine, post-traumatic stress disorder, dental caries, anxiety disorder, depression, low back pain, and sciatica. The Minimum Data Set (MDS) reflected that R1 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS), a cognitive screening tool. R1 was no longer at the facility.Facility reported incident reflected on 6/30/25, RN C received a verbal order to increase R1's pain medication but did not enter it until 7/3/25. She admitted she failed to follow up with the physician in a timely manner. A physician statement dated 7/8/25 confirmed that the order for Norco was agreed upon with R1 on 6/30, but by the weekend, the changes were still not made. The Physician Assistant noted concern and intervened.Further review of the facility reported incident dated 7/22/25 reflected Resident (R1) reported allegations against a staff member. R1 requested a review of a previous concern she had made that she did not feel was resolved. Upon further investigation, the NHA [covering Nursing Home Administrator] determined the need to report the allegation. A thorough investigation is being conducted. The alleged staff member will not return to work until a conclusion is made.Review of the Facility Reported Incident Report dated 7/22/25 indicated that on that date, covering NHA E reviewed two Concern Forms R1 had written on 7/5/25 along with the statements collected during the initial investigation. NHA E decided to formally report the allegations and initiate a separate investigation, as R1 continued to express unresolved concerns. R1 alleged that Registered Nurse (RN) C had threatened her life and well-being by telling her that narcotic medications would be withheld if she refused to go to the Emergency Department. R1 also alleged that RN C failed to process a physician's order dated 6/30/25 to increase her pain medication.Review of a Resident Assistance Form completed by R1 and dated 7/5/25 stated: [RN ‘C'] threatened my life and my well-being. She refused to listen to my wishes. I have a detailed EMS (Emergency Medical Service) report which backs up my claims. [RN ‘C'] also refused to put in doctor's orders on Monday. A second Resident Assistance Form contained allegations of unequal treatment from RN C. R1 again accused RN C of nearly killing her, threatening her life and well-being, and added, people like RN ‘C' do not deserve to have anyone's life in their hands. If this doesn't stop, she will definitely kill more people. The form again referenced the EMS report from a 6/25/25 hospital transfer.Review of a Nurse's Note dated 6/25/25 at 11:58 AM stated: Resident [R1] c/o (complained of) dizziness and fatigue. Pulse 45 and O2 (oxygen saturation) 70%. 2L (liters) nasal cannula applied, O2 increased to 80%. Pulse increased to 49. This writer contacted PA (Physician's Assistant) and received an order to send to ER (Emergency Department). EMT contacted and resident transferred to ER.Review of the Prehospital Care Report Summary from EMS for the 6/25/25 transfer revealed that EMS arrived at 10:33 AM. The Narrative History Text stated that EMS arrived to find R1 lying in bed. Patient (R1) was surprised they were there to transport her to the ED. Staff stated they believed her pain medication had caused her heart rate and SpO2 to drop. R1 stated she felt better and refused to go to the ED. Contact was made with the ED Physician, who confirmed that if the patient was alert and oriented (A&Ox4) and refused, she could not be forced to go. R1 continued to refuse. Staff then stated, we will not give you any kind of pain medication if you stay here. R1 responded, you will put me into DT (delirium tremors) if you do that. Staff allegedly replied, that's fine, I will make you go to the hospital when you are unconscious.In an interview on 8/20/25 at 10:47 AM, Confidential Staff Member K described RN C as snippy and rude and reported hearing her say things like, well if you would follow what you're supposed to do, this wouldn't be happening. At 12:03 PM, LPN S stated that R1 was visibly upset over medication changes and felt she was treated differently by RN C. At 12:48 PM, LPN L stated she was present during the 6/25/25 hospital transfer. RN C reportedly said, Can you help me, [R1] is getting on my nerves and won't go to the hospital. LPN L entered the room and heard RN C tell R1, I'm not going to give you pain medication if you stay, to which R1 responded, If you withhold my medications, I'll fall over and die. RN C allegedly replied, I guess I'll send you to the hospital then and you won't be able to refuse. LPN L told RN C to stop being snippy and then exited the room.On 8/20/25 at 3:17 PM, R1 was interviewed and described feeling targeted after reporting a near-miss medication error in November 2024, which led to a nurse's termination. She said she was treated differently thereafter, especially by RN C. R1 recounted the 6/25/25 event, stating that she had refused transport due to improving symptoms. She claimed RN C said, You have to go to the hospital, and if you don't, you'll never get another narcotic in this facility. R1 replied, If you do that, you'll kill me, to which RN C allegedly said, Okay, well that's a chance we are willing to take. R1 also recounted a 7/1/25 interaction in which RN C told her, You are taking too many narcotics, and you are going to kill yourself, in a rude and condescending tone. R1 became tearful, describing the experience as emotionally and verbally abusive, triggering her PTSD. She stated that RN C targeted her, labeled her a drug seeker, laughed at her, rolled her eyes, and once stood in the hallway laughing while she cried in pain. R1 stated that RN C made her feel insignificant and like her life had no value.Psychology Notes dated 4/22/25 and 5/20/25 documented R1's PTSD diagnosis and her mistrust of staff. R1 disclosed a history of childhood and domestic abuse, chronic pain, and emotional difficulties tied to her condition and environment.On 8/21/25 at 12:26 PM, LPN W confirmed that RN C was nasty to R1 and other residents. She reported being warned that R1 might get you fired, and stated RN C referred to R1 as a drug seeker who was stoned out of her [NAME]. LPN W found the comments appalling and reported them to the former NHA but was told not to worry. She also reported witnessing a conversation in which R1 asked PA T if he had discontinued her narcotics because RN C said he did. PA T denied this.On 8/20/25 at 10:18 AM, RN I confirmed that during the 7/1/25 meeting, RN C told R1, You're on a whole bunch of medications, you're going to die, using a condescending tone. At 3:04 PM, RN J confirmed being present during the same meeting and recalled RN C saying, You're not getting the medication list today because one doctor is trying to decrease your narcotics, but [the facility doctor] hasn't changed anything like he should have. RN J stated that RN C was a newer nurse and lacked customer service skills.Review of an Employee Corrective Action form dated 7/8/25 showed RN C was disciplined for not following through with a doctor's order. It also noted a prior written warning on 6/2/25 with no substantial improvement since. An Employee Warning Record dated 7/25/25 cited disciplinary action for the 6/25/25 incident. The summary noted that RN C communicated a verbal physician's order in a way that made the resident feel threatened, though the investigation did not find intent to threaten. It recommended better tone, body language, and communication during stressful situations. It further stated that when an order needs clarification, the provider must be contacted immediately and documentation must reflect all steps taken to process or delay a physician's order.In an interview on 8/21/25 at 10:11 AM, RN C stated that on 6/25/25, she assisted staff with addressing R1's change in condition. RN C felt that the medication that R1 was taking and her recent diagnosis of bronchitis had affected her respiratory status. RN C reported calling PA T and receiving a verbal order to hold all narcotic medication, however when asked why RN C did not document this order, RN C admitted that she did not and per best standards of practice, RN C should have. RN C stated that she applied 2L oxygen via nasal cannula, and R1 perked back up and returned to baseline. RN C reported that R1 repeatedly refused transport to the Emergency Department, however, RN C felt she should go because of her unstable vital signs. Regarding the verbal Physician order for R1's pain medication, RN C admitted that she did not put the order in timely because she felt it required provider clarification, however, made no timely attempts to obtain provider clarification. Of note, per the EMS prehospital summary, R1's vital signs were as follows:6/25/25 at 10:41 AM (seven minutes after arrival) Blood pressure 139/75 Pulse 54 SPO2 93%. At 11:06 AM (while still at the facility) blood pressure 127/67 Pulse 77 SPO2 92%. The vitals show that R1 was hemodynamically stable.When asked, RN C stated that she did not call back PA T after resolution of R1's symptoms and notify PA T that the acute change in condition had resolved and to inquire of holding R1's medications would still be necessary.In an interview on 8/21/25 at 10:11 AM, covering NHA E stated that after reviewing the grievances dated 7/5/25, it was clear that these concerns were allegations of abuse and should have been reported to the State Agency within the two-hour time frame. The Facility Reported Incident was not reported until 7/25/25, 20 days later. As a result of these practices, R1 stated that she experienced significant psychological distress, humiliation, and fear for her safety. She reported being targeted, made to feel insignificant, and described RN C as emotionally and verbally abusive, triggering symptoms of Post-Traumatic Stress Disorder (PTSD). Multiple staff corroborated that RN C threatened to withhold R1's pain medications, coerced her into transferring to the hospital, told her you're going to die because of her prescriptions, and openly ridiculed her while she was crying in pain.

Based on observation, interview and record review, the facility failed to provide restorative services for one residents (R67) of one residents reviewed for restorative care, resulting in the potential for all residents with Restorative Referrals, facility census 77, to decline in their current highest functioning level losing their independence and leading to withdrawal, depression and complications of immobility. Findings Include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R67 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included urinary tract infection, multiple sclerosis(chronic disease of the central nervous system that causes muscle weakness and vision changes), and anxiety disorder. The MDS reflected R67 had a BIM (assessment tool) score of 14 which indicated her ability to make daily decisions was cognitively intact, and she required one person assist with transfers, ambulation and toileting. During an observation and interview on 1/02/25 at 11:42 AM, R67 was laying in bed and appeared able to answer questions without difficulty. R67 reported had recent right shoulder replacement July 2024 with very limited range of motion and eight out of ten on pain scale and difficulty sleeping. R67 reported was unable to lift right arm off the bed from laying position more than two inches and demonstrated. R67 reported had received therapy services on admission but had to discontinue related to insurance. R67 reported physician services talked about adding medication about two weeks prior but had not heard anything yet. Review of the Hospital Orthopedic Surgery Progress Notes, dated 7/19/24, reflected R67 had right reverse total should replacement on 7/18/24. Review of R67 Hospital Occupational Therapy Progress Note, dated 10/24/24, reflected section for range of motion/strength/sensory that reflected, Guarding of the RUE[right upper extremity] at elbow and shoulder due to hx of total shoulder arthroplasty with greater tuberosity repair on 7/18/24 . Review of R67 Electronic Medical Record(EMR), dated 10/25/24 through current(1/6/25), reflected no evidence that R67 had recent right total shoulder replacement diagnosis including the MDS or Care Plans. Continued review of the EMR reflected Physician Progress Note, dated 12/13/24, that reflected, Patient with acute pain secondary to right humerus fracture and pain better managed with Norco. Following and awaiting surgical intervention or [NAME] follow up . During an interview on 1/06/25 at 11:21 AM, Therapy Director(TD) H reported R67 was not currently on therapy service related to insurance. TD H reported on admission R67 received both Occupational Therapy and Physical Therapy and was discharged from services 11/19/24. TD H verified R67 had prior history of right shoulder replacement in July 2024. During an interview on 1/06/25 at 12:28 PM, TD H reported when R67 was discharged from services on 11/19/24 therapy completed recommendation for restorative therapy and would provide evidence. Review of R67 Electronic Medical Record(EMR), dated 10/25/24 through current(1/6/25), including Care Plans, reflected no evidence that R67 had ordered/received restorative therapy between 11/19/24 and 1/6/25. Continued review of R67 EMR reflected no evidence that R67 had recent right total shoulder replacement diagnosis including the MDS or Care Plans. During an interview on 1/06/25 at 12:40 PM, Director of Nursing(DON) B reported would expect therapy to recommend restorative therapy if needed and communicate to nursing and would expect restorative therapy to be on resident Care Plans and Kardex. During an interview and record review on 1/06/25 at 1:05 PM, TM H provided R67 restorative referral, dated 11/25/24, signed and dated by two therapy staff and nursing signature line was blank. TM H reported process included that therapy would completed forms and he physically handed to the DON B to make sure nursing receives them. Review of R67, Restorative Referral form, dated 11/25/24, included R67 was a fall risk and was marked to have range of motion 2 time daily for upper extremities, Participate in ADL's (dressing/grooming) 2 times daily and ambulate two times daily with one person physical assist 2 wheel walker. During an interview on 1/6/25 at 1:25 PM, DON B reported was just provided R67 Restorative Therapy Referral today and was instructed by support staff that it was her responsibility to add to R67 plan of care including orders and care plans. DON B reported was not aware prior to today that is was her responsible to add restorative therapy orders. DON B reported had been in position for over six months. DON B verified R67 did not have orders for Restorative therapy and had not been receiving between 11/25/24 and current date and should have been. DON B reported did not recall receiving R67 Restorative Referral 11/25/24. DON B reported facility was in the process of auditing past several months of restorative therapy referrals for compliance related to surveyor investigation.

Based on observation, interview, and record review the facility failed to provide hot liquids at a palatable temperature to 4 of 5 residents in a group interview and one of one residents (R61). This deficient practice has the potential to result in decreased hydration consumption and potential for decreased satisfaction of living. Findings include: On 01/03/25 at 11:05 AM during the confidential group meeting, 4 of the 5 members reported the coffee was cold and this problem/complaint was ongoing. The group participants reported that while in the dining room you can see into the kitchen where 20 to 30 cups of coffee get poured and sit on the counter and then get placed on individual trays. The group reported there was a lid on the cups but it was to prevent spills not a thermal top and the poured coffee sits for approximately 30 minutes before it gets place on the food tray. Review of the Resident Council meeting minutes reflected residents complained of coffee temperatures being too cold on 7/23/24, 8/20/24 and 9/24/24 Review of the 12/17/24 minutes reflected no new concerns, It was explained to residents why a carafe cannot be used because of various {sic} temps. (no further explanation was documented as to why carafes cant be used.) On 01/06/25 at 09:14 AM, during an interview with NHAA reported the Resident Council Members wanted coffee kept in a carafe kept on the Nursing units, NHA A stated that would solve the coffee temperature issue but it proposed a safety issue for the dementia residents and she had no intention on implementing that suggestion. When queried what was going to be implemented to solve the coffee temperature issue NHA A stated the Dietary Manager was taking care of the issue and NHA A would attempt to get documentation from the Dietary Manager as to what efforts have been made regarding the cold coffee complaints. No such documentation was provided by the exit date. 32064 Resident # 61 (R61) Review of the medical record revealed R61 was admitted to the facility on [DATE] with diagnoses that included dementia, anxiety, and depression. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/18/24 revealed R61 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of R61's meal ticket revealed Serve fresh coffee out of machine in a 2 handled cup with lid. On 01/02/25 at 10:48 AM. R61 was observed sitting on the edge of their bed and reported they were the Resident Council President. R61 stated, All I want is a hot coffee. R61 reported the facility filled coffee cups first and by the time the meal tray was delivered to their room, the coffee was cold. R61 reported the concern with coffee temperature came up in resident council often and most of the residents agreed the coffee wasn't hot enough. R61 reported they now have a lid on their coffee, but that did not resolve the temperature issue. On 01/03/25 at 09:14 AM, Nursing Home Administrator (NHA) A reported they did not have any grievance/concern forms for R61, but there were some from resident council. All grievance/concern forms related to coffee temperatures from Resident Council was requested. NHA A provided an Assistance Form dated 6/19/24. Review of the Assistance Form dated 6/19/24 from resident council revealed Hot water isn't hot enough and the 100 hall is last, so the water is very cold. They also want soup without going in the dining room. The form revealed this was an ongoing issue. There was no mention of coffee. Resident Council Minutes dated 7/23/24 revealed WANT HOT COFFEE! [was underlined] Small carafes? Why can't the hot water from the kitchen go into a carafe? When they bring trays pour the coffee. Resident Council Minutes Dated 8/20/24 revealed Still issues w/coffee slopped on trays [and] cold. Resident Council Minutes dated 9/24/24 revealed carafe for coffee as new business. There was no Resident Council Meeting in October 2024. Resident Council Minutes dated 11/26/24 revealed Follow up .carafe cannot be temperature controlled. Resident Council Minutes dated 12/17/24 revealed It was explained to residents why a caraf [sic] cannot be used because of various temps. In an interview on 01/03/25 at 1:49 PM, Dietary Manager (DM) P reported they received concerns from resident council and recalled recent concerns regarding coffee being too cold. When asked what was being done to resolve the cold coffee concern, DM P reported there were a couple residents who were very boisterous about this. DM P reported those residents, including R61, got their coffee served out of the machine when their tray ticket came out. When asked about the process, DM P reported when the tray ticket came out, the coffee was poured, the tray and coffee were loaded on the cart, and once the cart was full, it was delivered to the unit. DM P reported tray carts held up to 18 trays and it could take approximately 10 to 15 minutes for trays to be delivered to the residents. DM P reported R61 was now using a two handled cup for their coffee because another resident told R61 that the coffee seemed hotter in that cup. DM P reported R61 still had concerns with cold coffee. DM P reported coffee temperatures were obtained in the kitchen with a goal of 160 to 170 degrees Fahrenheit. DM P reported they did not know the temperature of the coffee when it arrived to the residents because they have never obtained temperatures at that time. On 1/3/24 at 4:46 PM, NHA A reported the facility did not have a hot liquid policy. 45038 During observation of meal service on 01/02/2025 at 11:29 a.m. Culinary Specialist Q was observed temping a cup of coffee. The cup of coffee was covered with plastic wrap. After temping the cup of coffee, Culinary Specialist Q instructed the dietary staff to dump out the four cups of coffee that were pre-poured and covered with a plastic film. Culinary Specialist Q explained that the staff should not pre pour the coffee before service but should obtain the coffee directly from the coffee machine and place the coffee cup on the resident's service food tray.

Based on observations, interviews and record review, the facility failed to answer call light and provide timely care and services to one residents (R67) of one reviewed, resulting in frustration and embarrassment. Findings included: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R67 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included urinary tract infection, multiple sclerosis(chronic disease of the central nervous system that causes muscle weakness and vision changes), and anxiety disorder. The MDS reflected R67 had a BIM (assessment tool) score of 14 which indicated her ability to make daily decisions was cognitively intact, and she required one person assist with transfers, ambulation and toileting. During an observation and interview on 1/02/25 at 11:42 AM, R67 was laying in bed with call light in reach and appeared able to answer questions without difficulty. R67 complained of having her call light on for over 30 minutes and urgently needing to use the bathroom. R67 said they just do not have enough help. R67 said this happens at least 5 to 7 times a week. R67 said she knows when she has to urinate but sometimes they make her wait to long and has accidents. The red light on the wall for the call light was illuminated. This surveyor exited room and did not see or hear call light or alarms in hall. During an observation on 1/02/25 at 11:54 AM, R67 call light remained on when dietary staff entered room with meal tray. R67 overheard telling staff call light was on because she needed to be changed. Dietary staff was overheard telling R67 she would left staff know exited room and continued to pass meal trays to other resident rooms. During an interview on 1/02/25 at 11:57 AM, Certified Nurse Aid (CNA) U reported started shift at 6:00am and was assigned to R67 today. CNA U reported the facility uses a pager system for call lights that each staff have on person that sound with call lights(no sound could be heard). CNA U she did not have a pager on at the time because, and stated, I hit the floor running(current time 11:57 a.m.). CNA U reported staff can check call lights by going to 300 Nurse station and reviewing computer screen for call lights as well(300 hall nurse station was located at the end of the 300 hall.) CNA U continued to passing meal trays to other rooms. This surveyor immediately observed call light monitoring system at the 300 Nurse Station that reflected R67 call light remained on at 11:59 a.m. and was on at 11:42 a.m.(16 minutes). Dietary staff was overheard reporting to CNA U that R67 needed assistance with changing and CNA U entered R67 room and turned of call light at 12:00 p.m. Review of the Care Plans, dated 10/25/24, reflected R67 required one person physical assistance with transferring. Review of Resident Council Meeting minutes and Grievance Log, dated 6/2024 through 12/2024, reflected call light response time concerns reported in past three of six months. During an interview on 1/3/25 at 4:50 p.m., Clinical Care Coordinator (CCC) V reported oversees the 200 and 300 hall residents. CCC V reported CNA staff use pagers for resident call light system. CCC V reported would expect CNA staff to wear pagers at all times and reported was not aware staff did not have pagers on 1/2/25. CCC V reported residents occasionally complain of slow response times to call lights but nothing that she could recall in past 2 months. During an interview on 1/6/25 at about 1:35 p.m., Nursing Home Administrator (NHA) A reported facility does not ability to perform call light audits. NHA A reported facility uses pagers system to answer call lights and would expect staff to have pagers on and functioning at all times. NHA A reported was not aware that some staff were not wearing pagers on 1/2/25. Review of the new admission packet provided to all residents on admission included, KNOW YOUR RIGHTS--Your Medicaid Care and Coverage in A Nursing Facility, DCH[Department of Community Health] 0731 (10/13) . The documents included, Quality of Your Medical Care. You have the right to receive necessary nursing, medical and social services to reach and maintain the highest practicable physical, mental and social well being, as determined by the comprehensive assessment and care plan. These services must be given in a confidential and dignified manner that meets your treatment and personal needs .

Based on observation, interview, and record review, the facility failed to ensure medications were administered within parameters for one (R66) and the appropriate antibiotic was administered for one (R45) of five reviewed. Findings include: Resident #66 (R66) Review of the medical record revealed R66 was admitted to the facility on [DATE] with a diagnosis of hypertension (high blood pressure). Review of Physician's Order dated 11/10/24 revealed an order for Lisinopril (used to treat high blood pressure) 2.5 milligrams (mg) in the morning. On 11/26/24 parameters were added to the order to hold the medication for a systolic blood pressure less than 110. Review of the Medication Administration Record (MAR) revealed Lisinopril 2.5 mg was administered on 12/14/24, 12/22/24, and 12/25/24 when R66's systolic blood pressure was 108. In an interview on 01/03/25 at 11:57 AM, Unit Manager (UM) K reported R66 had a fall, and parameters were added to hold the lisinopril if R66's systolic blood pressure was less than 110. UM K reported R66's Lisinopril was administered on 12/14/24, 12/22/24, and 12/25/24 when it should have been held. UM K was not able to explain why the medication was administered when it should have been held per orders. 45038 Resident #45 (R45) Review of the medical record revealed R45 was admitted [DATE] with diagnoses that included subarachnoid hemorrhage (brain bleed-stroke), lymphedema (swelling, most often in legs and arms, caused by a lymphatic system blockage), hyponatremia (low sodium), hypertension, type 2 diabetes, dysphasia (difficulty swallowing), anemia (low red blood cells), osteoporosis (condition bones become weak and brittle), polyosteioarthritis (arthritis affecting at least five joints), gastro-esophageal reflux, hyperlipidemia (high fat content in blood), claustrophobia (fear of confined spaces), constipation, and urinary tract infection. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/10/2024, revealed R45 had a Brief Interview of Mental Status (BIMS) of 00 (indicates the most sever level of cognitive impairment) out of 15. During observation and interview on 01/02/2025 at 11:21 a.m. R45 was observed lying down in bed and appeared well groomed. R45 did not respond to verbal stimulation. R45's husband E was observed sitting in a chair at the side of R45's bed. R45's husband E explained that R45 could not respond to verbal stimulation as she had recently been tested for a urinary tract infection but explained he did not know the results of the urinary test. R45's husband E explained that he was at the facility frequently and assisted with personal grooming and incontinent care of R45. Review of R45's medical record on 01/02/2025 at 12:18 p.m. demonstrated a diagnosis of urinary tract infection that revealed a creation date of 12/26/2024. Review of 45's Order Summary Report revealed Bactrim DS oral Tablet 800-160MG (Milligrams) (Sulfamethoxazole-Trimethoprim) Give 1 tablet VIA (by) Peg-tube two times per day for urinary tract infection, with an order date of 12/26/2024 and a start date of 12/27/2024. Review of R45's medical record demonstrated that on 12/26/2024 at 10:20 pm This write was called into resident's room per CNA (Certified Nurse Aide) at approx. 1700 (07:00 p.m.) hours. Husband was at bedside and brought to this writer's attention that (name of resident) had dime size blood clots in her brief, and CNA was providing peri-care and was wiping clots that were coming from her vaginal area. Clots were dark red in color, and this writer did notify hospice. Hospice did contact this writer back and did dispatch a nurse onto site to see (name of resident). Nurse did arrive at approx. 1830 (06:30 p.m.) and did witness the clots in her brief. She did speak with this writer, and she did order Bactrim DS twice daily x7 days for UTI (urinary tract infection). First dose of antibiotic was started this evening and given via peg tube Review of documentation from laboratory services for R45 demonstrated that a urinalysis was collected on 12/27/27/2024 at 10:07 a.m. The result form the urinalysis was printed by the facility 12/28/2024 at 02:01 a.m. The urinalysis results demonstrated WBC (white blood cells) greater than 100 (should be none) and RBC (red blood cells) greater than 100 (should be none), blood -large amount (should be none), and large amount of leukocyte esterase (should be none). The same urinalysis demonstrated that a urine culture was in process. Review of R45's urine culture and sensitivity collected 12/27/2024 at 10:07 a.m. and reported to the facility on [DATE] at 03:51 p.m. Demonstrated 50,000-100,00 col/ml Proteus mirabilis and >100K col/ml Enterococcus faecalis. The same susceptibility report demonstrated Trimethoprim-Sulfamethoxazole was resistant. Review of R45's medical record on 01/02/2025 at 04:12 p.m. revealed that Bactrim DS oral Tablet 800-160MG (Milligrams) (Sulfamethoxazole-Trimethoprim) Give 1 tablet VIA (by) Peg-tube two times per day for urinary tract infection had been discontinued on 01/02/2025 at 3:42 p.m. R45's medical record also demonstrated a new antibiotic order entered 01/02/2025 Augmentin Oral Tablet 500-125 mg give one tablet via pet tube two times a day for UTI for 5 days. Review of R45's January Medication Administration Record revealed the last dose of Bactrim DS was given on 01/02/2025, in the morning, and the first dose of Augmentin was given 01/02/2025, in the evening. In an interview on 01/02/2025 at 04:31 p.m. Clinical Care Coordinator (CCC) K explained that she had called the physician assistant to have R45's antibiotic changed because the Bactrim DS was not appropriate to treat the organism identified on R45's urine culture and sensitivity results. CCC K also explained that she received an order to change the antibiotic to Augmentin as the urinary organisms were susceptible according to R45's urine culture and sensitivity results. CCC K explained that the results of R45's urine culture and sensitivity report was reported to the facility 12/31/24 but could not explain why the antibiotic had not been changed at that time and stated that this was the first day she had returned to work after the holiday. When asked to explain why she had noticed these results so late in the day, she responded that this that time was the first chance she had to review laboratory orders. In an interview on 01/03/2025 at 09:06 a.m. Corporate Director of Infection Control L explained that R45's hospice provider had requested that a urine analysis, and culture if indicated, be completed for blood in R45's urine. Corporate Director of Infection Control L was asked what other signs or symptoms had R45 exhibited, she responded only bleeding. When asked what criteria was used by the facility for screening of possible infections, she explained that it was the expectation that the facility follow the Mcgeer Criteria. Corporate Director of Infection Control L also explained that if the Mcgeer Criteria was not followed a risk benefit analysis needed to be completed by the medical provider. Corporate Director of Infection Control L could not locate a risk benefit analysis for R45 at that time. Corporate Director of Infection Control L also explained that it was the facility expectation that the nursing staff notify the medical provider of the urinary test results when the results are returned and that appropriate action be taken, for example change to the appropriate antibiotic. Corporate Director of Infection Control L could not answer why R45's antibiotic was not changed until 01/02/2025 even though urine culture and sensitivity results were received by the facility on 12/31/2024.

Based on interview and record review the facility failed to ensure for two of five residents (Resident 41 and 66) pharmacy medication recommendations were followed-up on by the Physician. Findings Included: Resident #41: Per R41's electronic medical record (EMR) R41 was admitted to the facility on [DATE]. Diagnosis included a fracture of the sacrum (bone at the base of the spine). Review of R41's Physician's orders revealed that on 10/5/2024 Tylenol was ordered as needed for pain, Oxycodone was ordered on 10/7/2024 for pain, and Tramadol was ordered on 11/4/2024 for pain. Review of R41's progress notes revealed a Pharmacy Recommendation dated 11/28/2024, of, PHARMACIST RECOMMENDS:: Patient is on three pain medications: Oxycodone, Tramadol and acetaminophen. Which is to be used for mild pain? _________________ Which is to be used for moderate pain? _________________ Which is to be used for severe pain? _________________ RESPONSE TO RECOMMENDATION: FOLLOW-UP REQUIRED:: yes Review of R41's EMR revealed no Physician follow-up on the Pharmacy Recommendation dated 11/28/2024, on order to identify each of the three medication's use for each level of pain. In an interview on 1/03/2025, at 12:49 PM, the Director of Nursing (DON) B stated that the Pharmacy Recommendation dated 11/28/2024, was for the Physician to document which medication was for mild, moderate, or severe pain, however DON B stated that the Physician follow-up was never done for the Pharmacy Recommendation dated 11/28/24. 32064 Resident # 66 (R66) Review of the medical record revealed R66 was admitted to the facility on [DATE] with diagnoses that included gastroesophageal reflux disease (GERD), diabetes, and chronic obstructive pulmonary disease (COPD). Review of the Physician's Order dated 11/9/24 revealed an order for Metformin HCl (used to treat high blood sugar) 1000 mg two times per day related to type 2 diabetes. The medication was scheduled to be administered between 7:00 AM and 10:00 AM and again between 7:00 PM and 10:00 PM. Review of the Physician's Order dated 11/10/24 revealed an order for glycopyrrolate 1 milligram (mg) in the morning related to COPD exacerbation. Glycopyrrolate is a medication used to treat stomach ulcers, not COPD. Review of the Pharmacy Recommendations dated 11/12/24, revealed recommendations to 1) provide a diagnosis for glycopyrrolate, and 2) Metformin was recommended to to be given with meals; consider adjusting the medication time to comply. Review of the medical record revealed an appropriate diagnosis was never added to glycopyrrolate and the timing of Metformin was not adjusted. The medical record did not include documentation from the physician as to why the recommendations were not implemented. In an interview on 01/03/25 at 11:47 AM, Director of Nursing (DON) B reported it appeared R66's pharmacy recommendations from 11/12/24 were not addressed. On 01/03/25 at 12:12 PM, DON B and Regional Clinical Director (RCD) F reported the facility had 30 days to act on pharmacy recommendations, but R66 was in the hospital from 11/26/24 to 11/29/24. RCD F reported the pharmacy review dated 12/5/24 revealed no recommendations and that was the review the facility would have considered when R66 returned from the hospital. Review of the Medication Review and Reporting policy dated 9/18 revealed Recommendations shall be acted upon within 30 calendar days.

Based on interview and record review, the facility failed to ensure that grievances were promptly resolved and/or responded to in a timely manner for 5 of 5 residents that participate in Resident Council (RC) meetings. Findings include: On 01/03/25 11:05 AM during the confidential group meeting, RC members reported management talks about fixing problems but does not put everything in writing and does correct or communicate updates on issues. When asked for the RC members to clarify they reported they talk about cold coffee month after month and offer solutions but it falls on deaf ears. One of the RC members reported that the Nursing Home Administrator (NHA) A attended the December 2024 meeting and the Council requested to discuss the coffee issue. The participants reported NHA A stated someone would start doing test trays to obtain coffee temperatures. The response of the taking a test tray added to the RC members frustration as they have consistently reported the coffee temperatures were cold, they reported they don't need NHA A to take coffee temperatures to validate their concern, they know its cold, they want a resolution. Five of 5 RC members/group participants also reported they have requested for several times for a different cable package (that includes ABC) along with a television in the main dining room. In which they reportedly were told months ago that management was waiting for big screen televisions to go on sale. Review of the facility RC minutes dated 6/18/24 reflected in part the residents requested a different cable provider, they voiced they currently were unable to receive the ABC network on their televisions and wanted additional television channel options that included the ABC network on their televisions. Review of the 7/23/24 RC Minutes reflected in part, residents had a concern related to cold coffee temperatures. Review of the 8/20/24 RC Minutes reflected in part, residents had a concern related to cold coffee temperatures. Review of the 9/24/24 RC Minutes reflected in part, residents had a concern related to cold coffee temperatures and it was requested to have a television placed in the main dining room and more television channels. The facility did not have a monthly RC Meeting in October 2024. Review of the RC minutes dated 11/26/24 revealed follow up from the 9/24/24 RC meting {sic} Mgt (Management) looking for a TV for dining room and watching holiday sales. and carafe cannot be temperature controlled. Review of the 12/17/24 minutes reflected no new concerns, It was explained to residents why a carafe cannot be used because of various {sic} temps. (no further explanation was documented as to why carafes cant be used.) A review of the grievance form responses/resolutions were reviewed and none of the responses over the 6 month time frame addressed the television in the dining room, additional television channels, or cold coffee. On 01/06/25 at 09:14 AM, during an interview with NHAA she reported the process of RC was that minutes were to be reviewed as an interdisciplinary team the day after the meeting and all concerns were transferred to resident assistance/concern forms and then given to the discipline in charge. When queried why there were zero assistance/concern forms related to cold coffee NHA A stated it was addressed in June of 2024- review of that form indicated an issue with hot water, not coffee. NHA A was asked to explain why the concern was repeated month after month and why there was no assistance/concern form the the issue, NHA A stated the Dietary Manager was to follow up and she will attempt to get the Dietary Managers documentation to that effect. When queried why there was no assistance forms to address the cable package, and the television in the dining room concerns/requests brought forth by the RC members, NHA A stated she was not sure if she wanted a television in the dining room, when queried why that was not communicated to the RC members opposed to the November minutes that reflected you were waiting for a sale NHA A did not offer an explanation, when queried about the cable provider and or cable packages - NHA A stated they were looking at cable packages currently. Of note, the RC members initially made this request (with no documented response) 7 months prior, and NHA A provided no documented responses related to the Dietary Manager following up on the chronic complaint of cold coffee temperatures. According to the facility Policy titled Resident Concern dated 8/31/15 with a revision date of 2/26/19. The policy revealed time frames in part, for responding to concerns were as soon as possible but within 15 days and a written response was to be provided as soon as possible but no later that 30 days.

Based on interview and record review, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three (R64, R66, R89) of 18 reviewed. Findings include: Resident #66 (R66) Review of the medical record revealed R66 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder. The MDS with an Assessment Reference Date (ARD) of [DATE] revealed R66 scored 12 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the Preadmission Screening/Annual Resident Review (PASARR) Level I Screening revealed no mention that R66 had a diagnosis of schizophrenia. The MDS assessments with ARDs of [DATE] and [DATE] revealed R66 was not coded as having a diagnosis of schizophrenia. Review of R66's diagnosis list revealed a diagnosis of schizophrenia was added on [DATE]. Review of the MDS with an ARD of [DATE] revealed R66 was coded with a diagnosis of schizophrenia. In an interview on [DATE] at 9:15 AM, Social Work Director (SWD) J reported R66 had a diagnosis of bipolar disorder. SWD J reported they were not sure why R66 had a diagnosis of schizophrenia listed in their medical record. In an interview on [DATE] at 11:57 AM, Unit Manager (UM) K reported they did not know why R66 had a diagnosis of schizophrenia listed in their medical record or why it was coded on the MDS. In an interview on [DATE] at 3:25 PM, Regional Clinical Director (RCD) F reported R66's diagnosis of schizophrenia and MDS coding of schizophrenia was inaccurate. 45038 Resident #64 (R64) Review of the medical record revealed R64 was admitted [DATE] with diagnoses that included peripheral vascular disease (PVD), type 2 diabetes mellitus, atherosclerotic heart disease (buildup of cholesterol plaque in artery walls), hypertension, history of heart attack, depression, osteoarthritis (type of arthritis that occurs when flexible tissue at the end of bones wears down) bilateral hips, asthma, and schizoaffective disorder bipolar type. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed R64 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview on [DATE] at 01:36 p.m. R64 was observed lying down in bed. R64 explained that she has stayed at the facility several different times and that after the previous stay she was discharged home. R64 explained that she recently returned to the facility after a hospital stay. Review of R64's medical record revealed the most recent Minimum Dat Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed section I-Active Diagnoses, subsection 15900-Bipolar had been document no and subsection I6000- Schizophrenia, had been documented as yes. Review of R64's medical diagnoses record revealed the diagnoses of schizoaffective disorder bipolar type, which had been added to the diagnoses record on [DATE]. Review of R64's hospital discharge records, dated [DATE] did not demonstrate a discharge diagnoses of schizoaffective disorder bipolar type. Review of R64's Preadmission Screening (PAS) Annual Resident Review (ARR), hospital exemption discharge date d [DATE], revealed yes-the person has a current diagnosis of mental illness, yes-the person has received treatment for mental illness, yes-the person has routinely received one or more prescribed antipsychotic or antidepressant medication within the last 14 days. The same PASARR, dated [DATE] revealed documentation that stated, explain any yes - bipolar . In an interview on [DATE] at 02:54 p.m. Social Worker (SW) J explained that she is responsible to review that residents that are receiving psychotropic medication to ensure that they have the appropriate diagnoses for the use of that type of medication. SW J explained that she is not responsible to verify the diagnoses with previous hospital records and only verifies those diagnoses by reviewing the resident's diagnoses record in the chart. SW J explained that Minimum Data Set (MDS) nurse was the person responsible to update the resident's medical diagnoses record. SW J reviewed R64's medical record and confirmed that her diagnoses record revealed the diagnoses of schizoaffective disorder bipolar type. SW J could not explain where this diagnoses had been obtained. In an interview on [DATE] at 03:01 p.m. Nursing Home Administrator (NHA) A explained that a residents diagnoses record is reviewed by the Interdisciplinary Team at morning meetings after new residents are admitted . NHA A could not answer why R64 had been given the diagnoses of schizoaffective disorder bipolar type on her diagnoses record or why R64's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], had been documented yes for Schizophrenia. NHA A explained that she would have to research R64's medial record and talk with staff to determine explanation. In an interview on [DATE] at 03:35 p.m. Regional Clinical Director (RCD) F explained that the diagnoses record for R64 was inaccurate for the diagnoses of schizoaffective disorder bipolar type and should have been given the diagnoses of bipolar disorder. RCD F explained that the computerized system automatically list schizoaffective disorder bipolar type when someone types in the diagnoses of bipolar disorder and staff would have needed to manually change the entered diagnoses. RCD F explained that R64's diagnoses record would need to be corrected and R64's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], Section I-Active Diagnoses would need to be corrected. Resident #89 (R89) Review of the medical record revealed R89 was admitted [DATE] with diagnoses that included type 2 diabetes, chronic obstruction pulmonary disease (COPD), alcohol abuse, chronic pain, major depression, gastro-esophageal reflux, hypertension, protein-calorie malnutrition, delirium (confused thinking), altered mental status, insomnia, plural effusion (a buildup of fluid between tissues that line the lungs), anemia (low number of red blood cells), abdominal aortic aneurysm, and lung cancer. R89 was discharged from the facility [DATE]. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed R89 had a Brief Interview of Mental Status (BIMS) of 11(mildly impaired cognition) out of 15. Review of R89's medical record revealed a Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE] revealed section A0310 Type of Assessment, subsection F. Entry/discharge reporting was documented as 12. Death in Facility. Review of R89's medical record progress notes revealed [DATE] 17:11 (05:11 p.m.) eMar (electronic Medication Administration Record)-Medication Administration Note, Note text: In hospital. No other progress note demonstrated that R89 had returned to the facility. In an interview on [DATE] at 12:58 p.m. Regional Clinical Director (RCD) F explained that R89 had been transferred to a physician office for a routine visit. RCD F explained that R89 became lethargic and had an altered mental status and was sent to the emergency room for evaluation. RCD F provided hospital records that demonstrated that R89 died in emergency department [DATE]. Review of the Resident Assessment Instrument (RAI) manual pg. ,d+[DATE] Leave of absence (LOA) stated hospital observation stay less than 24 hours and the hospital does not admit resident would be coded as a facility Death. In an interview on [DATE] at 01:30 p.m. Regional Clinical Director (RCD) F explained that R89's Minimum Dat Set (MDS) with an Assessment Reference Date (ARD) of [DATE] should have been coded 10. Discharge-return anticipated. RCD F demonstrated that the facility corrected the MDS.

Based on observation, interview, and record review the facility failed to develop and implement comprehensive resident-centered care plans for one out of 18 residents (R67), resulting in unmet care needs including restorative therapy within six months of right total shoulder replacement. Findings: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R67 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included urinary tract infection, multiple sclerosis(chronic disease of the central nervous system that causes muscle weakness and vision changes), and anxiety disorder. The MDS reflected R67 had a BIM (assessment tool) score of 14 which indicated her ability to make daily decisions was cognitively intact, and she required one person assist with transfers, ambulation and toileting. During an observation and interview on 1/02/25 at 11:42 AM, R67 was laying in bed and appeared able to answer questions without difficulty. R67 reported had recent right shoulder replacement July 2024 with very limited range of motion and eight out of ten on pain scale and difficulty sleeping. R67 reported was unable to lift right arm off the bed from laying position more than two inches and demonstrated. R67 reported had received therapy services on admission but had to discontinue related to insurance. R67 reported physician services talked about adding medication about two weeks prior but had not heard anything yet. During an interview on 1/06/25 at 11:21 AM, Therapy Director(TD) H reported R67 was not currently on therapy service related to insurance. TD H reported on admission R67 received both Occupational Therapy and Physical Therapy and was discharged from services 11/19/24. During an interview on 1/06/25 at 12:28 PM, TD H reported when R67 was discharged from services on 11/19/24 therapy completed recommendation for restorative therapy and would provide evidence. Review of R67 Electronic Medical Record(EMR), dated 10/25/24 through current(1/6/25), including Care Plans, reflected no evidence that R67 had ordered/received restorative therapy between 11/19/24 and 1/6/25. Continued review of R67 EMR reflected no evidence that R67 had recent right total shoulder replacement diagnosis including the MDS or Care Plans. During an interview on 1/06/25 at 12:40 PM, Director of Nursing(DON) B reported would expect therapy to recommend restorative therapy if needed and communicate to nursing and would expect restorative therapy to be on resident Care Plans and Kardex. During an interview and record review on 1/06/25 at 1:05 PM, TM H provided R67 restorative referral, dated 11/25/24, signed and dated by two therapy staff and nursing signature line was blank. TM H reported process included that therapy would completed forms and he physically handed to the DON B to make sure nursing receives them. Review of R67, Restorative Referral form, dated 11/25/24, included R67 was a fall risk and was marked to have range of motion 2 time daily for upper extremities, Participate in ADL's(dressing/grooming) 2 times daily and ambulate two times daily with one person physical assist 2 wheel walker. During an interview on 1/6/25 at 1:25 PM, DON B reported was just provided R67 Restorative Therapy Referral today and was instructed by support staff that it was her responsibility to add to R67 plan of care including orders and care plans. DON B reported had been in position for over six months. DON B verified R67 did not have orders for Restorative therapy and had not been receiving between 11/25/24 and current date and should have been. DON B reported did not recall receiving R67 Restorative Referral 11/25/24. DON B reported facility was in the process of auditing past several months of restorative therapy referrals for compliance related to surveyor investigation.

Based on observation, interview, and record review the facility failed to ensure for one out of 18 residents (Resident #41) care plan was revised as needed for changes in care needs. Findings Included: Review of R41's electronic medical record (EMR) revealed R41 was admitted to the facility on [DATE]. Record review of a wound evaluation dated 12/27/2024, revealed R41 had moisture associated skin damage (MASD) incontinence associate damage (IAD) to the sacrum (bone at the base of the spine) area. The MASD was documented to have developed in the facility. Further review of the wound evaluation dated 12/27/2024, revealed the interventions in place were a heel suspension/protection device, mattress with pump, positioning wedge, and a turning/repositioning program. Record review of a care plan in place for, Skin management initiated on 2/11/2024 and last revised on 9/26/2024 revealed, R41 was at risk for skin breakdown with one reason being from incontinence. The care plan had not been revised since 10/9/2024. The care plan was not revised to include R41's MASD/IAD issue, nor were the care plan interventions revised to include the positioning wedge and the turning/repositioning program. In an observation on 1/03/2025 at 9:26 AM, of R41's MASD/IAD area revealed three skin areas that were open skin area. In an interview on 1/03/2025 at 9:59 AM, Registered Nurse (RN) T, who was the wound nurse, stated, when a resident was identified to have any skin breakdown the one of the nurses would notified her, and the nurse would do the initial skin assessment. RN T said the assessment would go to the unit manager UM who would revise the resident's care plan. RN T said if she was in the facility at the time a resident had a new skin wounds then she would revised the resident's care plans.

Based on interview and record review, the facility failed to ensure diagnostic practices met professional standards for two (R64 and R66) of five reviewed. Findings include: Resident #66 (R66) Review of the medical record revealed R66 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder. The MDS with an Assessment Reference Date (ARD) of 12/5/24 revealed R66 scored 12 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the Preadmission Screening/Annual Resident Review (PASARR) Level I Screening revealed no mention that R66 had a diagnosis of schizophrenia. Review of R66's diagnosis list revealed a diagnosis of schizophrenia was added on 11/29/24. Review of the MDS with an ARD of 12/5/24 revealed R66 was coded with a diagnosis of schizophrenia. Review of behavioral services note dated 12/19/24 revealed no mention that R66 had a diagnosis of schizophrenia. In an interview on 01/03/25 at 9:15 AM, Social Work Director (SWD) J reported R66 had a diagnosis of bipolar disorder. SWD J reported they were not sure why R66 had a diagnosis of schizophrenia listed in their medical record. Further information was requested regarding the diagnosis of schizophrenia which was not received prior to the survey exit. In an interview on 01/03/25 at 11:57 AM, Unit Manager (UM) K reported they did not know why R66 had a diagnosis of schizophrenia listed in their medical record or why it was coded on the MDS. further information was requested regarding the diagnosis of schizophrenia which was not received prior to the survey exit. In an interview on 01/03/25 at 3:25 PM, Regional Clinical Director (RCD) F reported R66's diagnosis of schizophrenia was inaccurate. 45038 Resident #64 (R64) Review of the medical record revealed R64 was admitted [DATE] with diagnoses that included peripheral vascular disease (PVD), type 2 diabetes mellitus, atherosclerotic heart disease (buildup of cholesterol plaque in artery walls), hypertension, history of heart attack, depression, osteoarthritis (type of arthritis that occurs when flexible tissue at the end of bones wears down) bilateral hips, asthma, and schizoaffective disorder bipolar type. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/25/2024, revealed R64 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview on 01/02/2025 at 01:36 p.m. R64 was observed lying down in bed. R64 explained that she has stayed at the facility several different times and that after the previous stay she was discharged home. R64 explained that she recently returned to the facility after a hospital stay. Review of R64's medical record revealed the most recent Minimum Dat Set (MDS), with an Assessment Reference Date (ARD) of 12/25/2024, revealed section I-Active Diagnoses, subsection 15900-Bipolar had been document no and subsection I6000- Schizophrenia, had been documented as yes. Review of R64's medical diagnoses record revealed the diagnoses of schizoaffective disorder bipolar type, which had been added to the diagnoses record on 12/19/2024. Review of R64's hospital discharge records, dated 12/19/2024 did not demonstrate a discharge diagnoses of schizoaffective disorder bipolar type. Review of R64's Preadmission Screening (PAS) Annual Resident Review (ARR), hospital exemption discharge date d 12/18/2024, revealed yes-the person has a current diagnosis of mental illness, yes-the person has received treatment for mental illness, yes-the person has routinely received one or more prescribed antipsychotic or antidepressant medication within the last 14 days. The same PASARR, dated 12/18/2024 revealed documentation that stated, explain any yes - bipolar . In an interview on 01/03/2025 at 02:54 p.m. Social Worker (SW) J explained that she is responsible to review that residents that are receiving psychotropic medication to ensure that they have the appropriate diagnoses for the use of that type of medication. SW J explained that she is not responsible to verify the diagnoses with previous hospital records and only verifies those diagnoses by reviewing the resident's diagnoses record in the chart. SW J explained that Minimum Data Set (MDS) nurse was the person responsible to update the resident's medical diagnoses record. SW J reviewed R64's medical record and confirmed that her diagnoses record revealed the diagnoses of schizoaffective disorder bipolar type. SW J could not explain where this diagnoses had been obtained. In an interview on 01/03/2025 at 03:01 p.m. Nursing Home Administrator (NHA) A explained that a residents diagnoses record is reviewed by the Interdisciplinary Team at morning meetings after new residents are admitted . NHA A could not answer why R64 had been given the diagnoses of schizoaffective disorder bipolar type on her diagnoses record or why R64's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/25/2024, had been documented yes for Schizophrenia. NHA A explained that she would have to research R64's medial record and talk with staff to determine explanation. In an interview on 01/03/2025 at 03:35 p.m. Regional Clinical Director (RCD) F explained that the diagnoses record for R64 was inaccurate for the diagnoses of schizoaffective disorder bipolar type and should have been given the diagnoses of bipolar disorder. RCD F explained that the computerized system automatically list schizoaffective disorder bipolar type when someone types in the diagnoses of bipolar disorder and staff would have needed to manually change the entered diagnoses. RCD F explained that R64's diagnoses record would need to be corrected and R64's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/25/2024, Section I-Active Diagnoses would need to be corrected.

Based observation, interview and record review the facility failed to provide daily oral hygiene for one resident (Resident #5) of two residents reviewed for activities of daily living. Findings include: Review of Resident #5's (R5) clinical record, including the Minimum Data Set (MDS) dated [DATE], R5 had diagnoses that included anxiety and depression and scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Review of R5's Activities of Daily Living (ADL) care plan dated 11/18/22 reflected R5 needed assistance with oral hygiene which was to be done every shift and as needed. Review of R5's kardex (a guide for Certified Nursing Assistants) reflected oral hygiene was to be done every shift and as needed. On 01/02/25 at 11:02 AM, R5 was observed in the Activity room, R5's bottom teeth were observed to be caked with debris and R5 had severe halitosis. On 01/03/25 at 09:17 AM, R5 was observed in main dining room and again at the Resident Council Meeting at 11:00 AM. Both observations R5 had caked debris on bottom teeth and gum line. On 01/03/25 10:15 AM, during an interview with Certified Nursing Assistant (CNA) D she reported the midnight shift was responsible for getting R5 up and completing morning care. CNA D reported R5 was cooperative with care and did not refuse ADL assistance. On at 01/06/25 09:28 AM R5 was observed in the activity room, caked on debris was observed on R5's lower teeth. On 01/06/25 at 09:57 AM, during an interview with Registered Nurse/Unit Manager (RN/UM) C, reported R5's lower teeth were the natural teeth and R5 was due to be seen by the dentist the near future. When queried what the expectation was for the CNA's to provide oral care, RN/UM C stated They have to see dentist first, they make recommendations. RN/UM C then stated after all meals, at night and as needed. RN/UM C offered no explanation for R5's lack of oral care. On 01/06/25 at 10:41 AM during an Interview with R5 (bottom teeth still observed with debris along with strong halitosis) when queried if she was receiving the care needed, R5 stated Not brushing my teeth, I have been trying to get them to get me [name redacted-mouth wash] and toothpaste- I have been asking and asking and they say will and it never shows up. R5 reported being out of these items for at least two weeks, R5 further stated the bottom teeth had a partial and there was no pill to soak them in overnight. R5 stated staff do not remove the partial and her teeth have not been brushed in weeks. I don't like it! R5 stated she had requested staff to assist her with brushing her teeth and was told they don't have time. Record review reflected R5 was seen by the dentist on 10/31/24 and the consult reflected R5 had calculus and plaque build up. R5 was seen again by the dentist on 12/09/24, this consult revealed scaling was completed by hand and moderate calculus was found along with heavy plaque. Recommendations-assistance from staff for daily hygiene.

Based on observation, interview and record review the facility failed to follow a physician's order, and appropriately position two residents, (R6 and R67), of 18 reviewed for quality of care, resulting in increased likelihood of unmet care needs and potential for worsening of contractors. Findings include: Resident #67(R67) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R67 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included urinary tract infection, multiple sclerosis(chronic disease of the central nervous system that causes muscle weakness and vision changes), and anxiety disorder. The MDS reflected R67 had a BIM (assessment tool) score of 14 which indicated her ability to make daily decisions was cognitively intact, and she required one person assist with transfers, ambulation and toileting. During an observation and interview on 1/02/25 at 11:42 AM, R67 was laying in bed and appeared able to answer questions without difficulty. R67 reported had recent right shoulder replacement July 2024 with very limited range of motion and eight out of ten on pain scale and difficulty sleeping. R67 reported was unable to lift right arm off the bed from laying position more than two inches and demonstrated. R67 reported had received therapy services on admission but had to discontinue related to insurance. R67 reported physician services talked about adding medication about two weeks prior but had not heard anything yet. Review of R67 Psych Consult, dated 12/19/24, reflected recommendations to start Trazodone 25mg every night for adjustment insomnia. Continued Review of R67 Electronic Medical Record(EMR), dated 12/19/24 through 1/3/25 reflected no mention R67's consult was discussed with primary care physician or physician orders for Trazadone. During an interview on 1/3/24 4:55 pm, Director of Nursing (DON) B reported process for consult visits including Unit Managers were expected to review visit notes and consult recommendations and contact physician, and add orders to EMR. During an interview on 1/06/25 at 10:36 AM, Unit Manager(UM) V reported if residents were seen by Psych Services the facility Social Worker would review consult notes and contact Unit Manager or DON to address the recommendations. During an interview on 1/06/25 at 10:45 AM, Social Worker (SW) J reported facility psych services see residents then she reviews notes and notifies unit managers to make adjustments in orders if needed. SW J reported did not recall psych service consult visit for R67 but facility physician usually follow psych service recommendations. SW J reported would follow up. During an interview and record review on 1/06/25 at 12:57 PM, SW J verified physician order for Trazodone was not addressed after R67 psych group consult and was physician order was added today for Trazodone 25 mg every night for sleep. SW J reported that R67 consult visit was not addressed timely and planed to review all consults to verify other residents were audited. 27306 Resident #6 (R6) Review of the clinical record including the Minimum Data Set (MDS) with an assessment reference date of 12/22/24 reflected Resident # 6 (R6) was admitted to the facility on [DATE] with diagnoses that included cerebral infarction with left sided hemiparesis and hemiplegia. R6 scored 00 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). On 01/02/25 10:50 AM R6 was observed sitting in a high back wheelchair at nurses station - foot rests were attached to the wheelchair but R6's feet did not reach the foot rests and R6's feet/legs were left dangling. R6 was again observed in the same wheelchair and same position in the Tea dining room during the noon meal. On 01/03/25 at 08:40 AM, R6 was observed in Tea dining room sitting in the high back wheelchair feet dangling foot rests in place but R6's feet not on foot rests. At 8:49 R6 was observed be removed from the dining room by staff with feet/legs dangling. On 01/03/25 at 10:19 AM, R6 was observed sitting in the high back wheelchair at the nurses station outside activity room, foot rests in place, however R6's feet were still observed dangling. Same observation was made on the same date at 11:00 AM, 12:37 PM and again in the Activity room at 3:19 PM. On 1/06/25 at 08:38 AM, R6 was observed in Tea dining room eating breakfast same high back wheelchair with foot rests in place and R6's feet not reaching the foot rests and feet observed dangling. On 01/06/25 at 09:50 AM, during an interview with Registered Nurse/Unit Manager (RN/UM) C, reported she never noticed R6's feet did not touch foot rests. RN/UM C elaborated that the facility's therapy department assessed residents for their wheelchairs and therapy was responsible for issuing R6 the current wheelchair. A request was made at that time of therapy's assessment/fitting of R6's wheelchair, which was not provided by the end of the survey.

Based on observation, interview and record review the facility failed to ensure a gradual dose reduction (GDR) was attempted for one of five residents (Resident #47) in order to reduce the use a psychotropic. Findings Included: Review of Resident #47's electronic medical record (EMR) revealed R47 was admitted to the facility on [DATE]. Review of R47's medication administration record (MAR) for the month of April 2024, revealed R47 was ordered to received Prozac (a psychotropic medication) 40 mg one capsule in the morning for depression and bipolar disorder (a mental disorder of manic swings and depression). Review of behavioral notes dated 8/13/24 revealed Prozac will be attempted to be GDR and will be noted in R47's chart. Review of behavioral health services Physician's notes dated 8/13/2024, revealed R47's psychotropic medication were reviewed, and the Prozac was documented as, Prozac 40 mg (milligrams) capsule LAST GDR CONSIDERATION .8/13/2024, GDR will be Attempted: GDR will attempted and will be noted in resident's chart. Record review of R47's EMR revealed no GDR was order, and no GDR was attempted. Review of R47's Physician's order revealed R47's last Physician order for Prozac was on 4/8/2024 and the Prozac was started on 4/9/2024. As of 1/6/2025 R47's Prozac had not changed and was still being administered at 40 mg one capsule in the morning. Further review of R47's EMR revealed R47 had not been seen by behavioral health services since 8/13/2024 In an interview on 1/06/2025 at 9:30 AM, Social Worker SW (J) acknowledged that R47 remained on 40 mg of Prozac, and that the GDR had not been attempted, and also confirmed that R47 had not been seen by behavioral health services since then 8/13/2024, and stated that she did not know why. SW J said R47 should have been seen by behavioral health services. SW J was observed to add R47 to the behavioral health services list of residents to be seen on the next visit. SW J also stated that R47 should have been seen monthly by behavioral health services.

Based on observation, interview, and record review the facility failed to prevent incidents and accidents in 3 (Resident #43, #48 & #50) of 3 reviewed for incidents and accidents, resulting Resident #43 sustaining falls with a rib fracture, pain (Resident #50), and a head injury (Resident #48). Findings include: Resident #48 (R48) R48 was observed on 1/11/24 at 8:45 AM being transported from the dining room in a Broda chair (specialty wheelchair) with the footrest on chair folded up against leg rest. R48's feet were not supported. Two areas on the right side of chair were noted with white medical tape wrapped around a connection piece. R48's Minimum Data Set (MDS) assessment dated [DATE] revealed she admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS, a performance-based cognitive screener) score of 00 (00-07 Severe Cognitive Impairment). The same MDS indicated R48 was dependent on staff for activities of daily living (ADL). In review of R48's incident and accident report dated 10/25/23 at 5:30 PM, a nurse assistant was pushing R48 in a Broda chair in the hallway when R48 took a tumble out of the chair landing face first. The same report indicated R48 sustained a hematoma (blood pooling under skin) to her forehead. The same report revealed R48's Broda chair was not used correctly when R48 was transported. R48's risk for falls care plan revised 9/10/23 revealed she was at risk for falls due to Alzheimer's dementia, depression, history of stroke, impaired mobility and weakness. The same care plan indicated R48 was receiving hospice care services. R48's ADL deficit care plan, revised 9/10/23 instructed to ensure padded footrest was attached to her wheelchair. Nurses Note dated 12/31/23 at 2:01 AM revealed 3 blisters on R48's right lower extremity were noted, and the Unit Manager was notified. Nurses note dated 1/04/24 10:28 PN revealed hospice was notified of request for cushion for chair related to marks on the back of her right leg. Nurses Note dated 1/07/24 at 5:42 PM revealed three new wounds on the posterior of the R48's right lower extremity; appeared to be caused from skin rubbing on wheelchair connection that the plastic cover was missing from. The same note indicated R48's chair taped up for the moment, until assessed by maintenance. R48's incident and accident reports were requested and did not include any skin alterations due to her Broda Chair. Licensed Practical Nurse (LPN) L was interviewed on 1/11/24 at 1:07 PM and stated she was not aware of any issues with R48's chair or any skin issues due to the Broda chair. During an observation at the same time with LPN L, three reddened areas were noted on back of R48's right calf. R48's Broda chair was observed with two taped areas on chair on right side. During an interview with Certified Nurse Assistant (CNA) M on 1/17/24 at 9:55 AM she stated R48 had bruising on her leg due to her Broda chair. CNA M did not recall how long R48's chair had been taped in two areas. CNA M stated R48 did not use the footrest, she put a pillow under her legs when she was in the chair. CNA M stated R48's footrest would not stay down when adjusted. During an interview with the Director of Nursing (DON) B on 1/17/24 at 10:10 AM, she stated she was not aware of any issues with R48's Broda Chair. DON B stated she would expect an incident accident report to be generated if there were skin alterations caused from the Broda chair. Hospice Clinical Coordinator S was interviewed on 1/17/24 at 12:10 PM and stated hospice knew nothing about R48 needing a chair until 1/17/24 when the facility called her supervisor; and R48 would receive a new chair on this same day. 27306 Resident #50 According to the clinical record including the Minimum Data Set (MDS) dated [DATE], Resident # 50 (R50) was a [AGE] year old female admitted to the facility with diagnoses that include cerebral vascular accident with right side hemiparesis and hemiplegia affecting the dominant right side. R50 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). During an interview with R50 on 01/10/24 11:38 AM, it was reported she required assistance from 2 staff persons for transfers with the use of a gait belt. R50 stated a few months ago during a weekend the facility was short staffed and Certified Nursing Assistant (CNA) L transferred her to the toilet without the assistance of another CNA. R50 alleged the gait belt was not in the correct position and during the transfer she had severe pain in her ribs that lasted for weeks, and as a result of the pain R50 had missed some physical therapy sessions. When queried if her ribs were fractured, R50 stated she didn't know because there an x-ray was not done, when queried what the physician or nursing assessment determined, R50 said the physician or nursing staff never looked into it. On 01/11/24 09:22 AM during an interview with Physical Therapist (PT) K she reported being very familiar with R50, PT K stated R50 currently uses a lift for transfers but was a 2 person transfer with a gait belt a few months ago. PT K stated she was aware of R50's complaint that she was transferred by one staff opposed to two and that CNA L allegedly had the gait belt not positioned correctly and as a result R50 complained of pain in her ribs and declined therapy sessions due to the pain. PT K stated this was reported to Nursing staff, although she wasn't sure which person in nursing was notified. Review of the physical therapy notes dated 11/06/23 reflected R50 complained of pain in her ribs due to a transfer that occurred over the weekend. The progress note reflected R50 needed increased time for transfers due to pain and ended the physical therapy session early. Review of R50's care plan for activity of daily living dated 3/22 reflected R50 was to be transferred with the assist of 2 staff with a gait belt. A revision to the care plan was made by the physical therapy department on 11/07/23 for a one person assist using a mechanical lift. On 01/11/24 at 10:16 AM, during an interview with Nurse Unit Manager J, she reported she had no knowledge of the incident and if she would have been informed the proper protocol would have been to complete and incident and accident report, notify the physician, assess R50 , obtain an x-ray if ordered and provided education to CNA L as/if warranted. 46954 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], revealed Resident #43 (R43) was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (loss of function from right side after a stroke), history of falling, type 2 diabetes without complication, vascular dementia and urge incontinence. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/5/23 revealed R43 scored 9 out of 15 (cognitively impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS revealed that R43 utilized a walker and was independent with ambulation and toileting. In an observation and interview on 01/10/24 at 12:01 PM, R43 was seated in a recliner, facing the doorway of her room. R43 reported that she had a fall recently. When inquiring about the details of the fall, R43 stated that she did not know what happened, but she remembered falling to the floor and after, she got back up. R43 seemed pleasantly confused and could not elaborate further regarding the details of the fall. Review of an Incident Note dated 7/24/23 revealed Resident (R43) was trying to walk through the area by South hall nurses station. There was slight crowding, resident's walker either hit someone's wheelchair or someone's wheelchair backed into resident's walker. Resident fell on to her right side and bumped theright [sic] side of her head. There was a small bump to the rt [right] side of her head .there were no deficit's in strength between her hands or her legs . Review of an Incident Report dated 7/24/2023 at 4:15 PM revealed resident (R43) was trying to walk by the nurses station by activities room and she either hit someone's wheelchair with her walker or someone backed into her with their wheelchair. resident fell on to her right side and bumped her head. The Other Info section of the Incident Report stated resident (R43) was trying to walk through lobby area by activities and there was slight crowding. There was no Interdisciplinary Note explaining any further details regarding this fall. Review of an Incident Note dated 11/1/2023 revealed Resident (R43) was coming out of her room using her walker. The walker appeared to get caught on the edge of an easy stand (mechanical lift) that was in the hallway by her door. She tripped and fell face first onto the floor. Resident assessed. Nose bleeding resident rolled onto her side pressure applied to nose to stop bleeding [Local Ambulance Service] contacted for transport to hospital . R43 was transported to the hospital for treatment. Review of a Nurses Note dated 11/2/2023 revealed that R43 returned to the facility at 11:00 PM and was diagnosed with a left rib fracture. Review of an Incident Report dated 11/1/23 revealed resident (R43) was coming out of her room using her walker. The walker appeared to get caught on the edge of an easy stand that was in the hallway by her door. She tripped and fell face first onto the floor. There was no Interdisciplinary Note explaining any further details regarding this fall. On 01/10/24 at 2:26 PM, an observation was made of an easy stand parked outside of R43's. Additionally, a resident was parked in their wheelchair near the South Nurses station creating an obstruction of the entry/exit way of the hall which R43 resides in. On 01/11/24 at 7:46 AM, eight residents in wheelchairs were parked around the south nurse's station and near the activities room. The activities room door was closed, and the lights were off. On 01/11/24 at 7:47 AM, an easy stand was observed outside of R43's room on the right side and an additional mechanical lift was observed outside of R43's room on the left side. On 01/11/24 at 12:20 PM, a mechanical lift was observed directly outside of R43's room, parked along the wall. The left wheel of the mechanical lift was angled about approximately 80 degrees, impeding into the hallway. In an interview on 1/11/24 at 09:51 AM, Certified Nursing Assistant (CNA) F reported that she was familiar with R43's care needs. CNA F stated that R43 was independent with ambulation utilizing her walker at the time of the falls. In an interview on 01/11/24 at 10:33 AM, Registered Nurse (RN) G reported that she was working the day of the fall that occurred on 11/1/23. RN G confirmed that R43's fall occurred due to her walker getting caught on the easy lift. RN G stated that the wheel of the easy stand was kicked out to the side like at a 90-degree angle and the easy stand was in the doorway. RN G stated that employees received education about the easy stand and ensuring the wheels were flush with the legs, so the wheel did not protrude out into the hallway and into the walking path of residents. In an interview on 01/11/24 at 12:21 PM, Certified Nursing Assistant H confirmed she was working on 11/1/23 and confirmed R43 sustained the fall due to the easy lift being positioned right outside of R43's room and R43's walker catching the front wheel of the easy stand. CNA H stated that staff received education about ensuring the wheel of the easy stand was flush with the legs so the wheel did not protrude out into the hallway and into the walking path of residents. In an interview on 01/11/24 at 12:40 PM, Registered Nurse (RN) D stated that she was aware of the falls that R43 had experienced. Regarding the fall on 7/24/23, RN D stated that the Care Planned intervention for that fall was to acknowledge when the resident is carrying an item but was unsure why that intervention was implemented after that fall. When inquiring about the fall that occurred on 11/1/23, RN D stated that the easy stand was parked outside of R43's room and part of the leg of the easy stand was sticking out maybe 3 and a half inches into the doorway of R43's room. RN D stated that Physical Therapy was working with R43 after the fall, one of the goals being how to educate R43 on how to use a wheelchair. Review of Physical Therapy notes with a start of care date of 11/8/23 revealed reason for referral/Current Status: patient is a . long term care resident who had a fall involving catching walker leg on mechanical lift sitting alongside of hallway . In an interview on 01/11/24 at 2:25 PM, Director of Nursing (DON) B reported she was unsure why there was an absence of Interdisciplinary Team Notes for the two falls R43 had experienced. Concerning the fall that occurred on 7/24/23, DON B stated that the South Hall nurses station is near activity room and it's a large area that funnels into the doorway. R43 was in the middle of the pack when the fall occurred. When asked about the intervention, DON B thinks R43 was taking something to the activity room. When asked what the item was, DON B stated that she thinks it was a sweater or something thrown over her arm. Documentation of this was not found. Concerning the fall that occurred on 11/1/23, DON B stated apparently her walker leg hooked onto the platform of one of the lifts so Physical Therapy started working with the resident. When asked what the root cause of the fall on 11/1/23, DON B stated that R43's legs were very swollen and R43 was incapable of maintaining her balance. There was no additional documentation or Physician Notes provided regarding the edema in R43's legs or the altered gait. Review of a Nurses Note dated 1/11/2024 at 3:12 PM revealed late entry from 11/8/24 [sic] Residents bilateral lower legs assessed after therapy reported blister left lower leg has a blister, upon assessment both legs were light pink cool to touch there was a small scab area noted and and [sic] a darker pink area which could have been where blister was it appears dry and flakey not opened no drainage Doctor contacted on 11/9/24 stated would eval (evaluate) on 11/10/24. Review of a Nurses note dated 11/10/2023 at 11:50 PM revealed In house skin sweep conducted resident was found to have no abnormalities. Review of Skin Assessments dated 11/7/23 and 11/14/23 revealed no abnormalities of R43's skin.

This citation pertains to intakes MI110044 and MI00139379. Based on observation, interview and record review, the facility failed to prevent and treat pressure ulcers, in three of three residents reviewed for pressure ulcers (Resident #1, #2, and #3) resulting in worsening of pressure ulcers (Resident #3), facility acquired pressure ulcers, pain, and unmet needs. Findings include: Resident #3 (R3) In review of R3's Admission Nurse assessment dated [DATE], she had a Stage 1 pressure ulcer (alteration of intact skin) on her coccyx (tailbone) and had an indwelling catheter. Physical Therapy Evaluation dated 6/05/23 and diagnoses list revealed R3 fell at home when walking to the bathroom with a cane and sustained a right hip fracture. R3 had the diagnoses of Dementia, diabetes, heart failure, osteoporosis, arthritis and macular degeneration (eye disease). The same evaluation revealed R3 required substantial/maximal assistance in bed mobility and weight bearing status was as tolerated. R3's Admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 6/09/23, revealed she was admitted to the facility with one Stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising; may also present as an intact or open/ruptured blister). The same MDS introduced a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener, score of 08 (08-13 Moderate Impairment). R3's MDS revealed she was at risk for pressure ulcers and a turning/repositioning program (consistent program for changing the residents' position and realigning the body; organized, planned, documented, monitored, and evaluated based on an assessment of the resident's needs) was not implemented. The same MDS indicated R3 required extensive assistance for bed mobility and was frequently incontinent of urine. Braden Assessment (tool used to determine risk of pressure ulcer development) dated 6/03/23 revealed R3 was at risk for pressure ulcers. The same assessment indicated R3's ability to change and control body position was slightly limited, able to make frequent though slight changes in body or extremity position independently. R3's Occupational Therapy (OT) Evaluation dated 6/05/23 revealed her goals were to get better and go home. The same evaluation indicated R3 demonstrated good rehab potential as evidenced by ability to follow 1-step directions. R3's pressure ulcer care plan dated 6/05/23 revealed to encourage R3 to make small, frequent shifts in position; and to assist in floating her heels. The same care plan did not include to avoid positioning on back or how often to reposition when in her bed or wheelchair. Prior to admission to the facility, hospital notes dated 5/29/23 revealed nursing orders included to reposition R3 when in chair every hour. Wound Evaluation dated 6/07/23 indicated R3 had a Stage 2 pressure ulcer on her sacrum (above coccyx, triangular-shaped bone between hip bones and positioned below the last section of the spine) and the wound bed consisted of 80 percent (%) slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, soft, stringy and mucinous in texture). The same evaluation included a picture of the sacrum and coccyx, and it appeared to have 2 separate pressure ulcer wounds on the sacrum and coccyx; it appeared the sacrum ulcer (above tailbone) was measured. The sacral ulcer was 1.42 centimeters (cm) in length by 0.82 cm in width. Centers for Medicare and Medicaid Services (CMS's) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0, Version 1.18.11, October 2023, manual, instructed: Stage 2 pressure ulcers by definition have partial thickness loss of the dermis; Granulation tissue (red tissue with cobblestone or bumpy appearance; bleeds easily when injured), slough, and eschar (dead or devitalized tissue, hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like) were not present in Stage 2 pressure ulcers. Total Body Skin assessment dated [DATE], indicated R3 had no new wounds. OT noted dated 6/12/23 revealed R3 was found lying on her back in bed with pressure sores located on both of her heels. Pillows were placed under R3's heels to decrease pressure on heels while in bed. The same note indicated the nurse was notified of R3's pressure ulcers. R3 was tearful throughout treatment and reported pain at a level of 9 (0 to 10 scale rating with 0 being no pain and 10 being the worst pain imaginable) and the nurse was notified of need for pain medication. The same note revealed R3 was dependent on staff for toileting hygiene, showers, lower body dressing and putting on and taking off footwear. Wound Evaluation dated 6/12/23 indicated R3's sacral pressure ulcer was a Stage 2 with 80% granulation tissue. The same evaluation revealed a picture that appeared R3 had 2 separate pressure ulcers; the bottom wound (coccyx) was measured according to the picture and was 3.27 cm in length and 1.04 cm in width. Skin and Wound Evaluation dated 6/12/23 revealed R3's right heel had a pressure ulcer that was staged as a deep tissue injury (DTI, persistent non-blanchable deep red, maroon or purple discoloration); and was 2.4 cm in length and 1.5 cm in width, was an intact blister, no edema or swelling were noted. Skin and Wound Evaluation dated 6/19/23 revealed R3 had an in-house acquired pressure ulcer on her left heel that presented as DTI and was 2.3 cm in length by 1.4 cm in width. Wound Evaluation dated 7/17/23 revealed R3's left heel was DTI that measured 3.39 cm in length by 2.77 cm in with. The same evaluation included a picture of the heel wound; the measurement sticker appeared to be on the inside of the left heel wound. Wound Evaluation dated 7/17/23 revealed R3's right heel presented as DTI and was 3.94 cm by 2.8 cm. The same evaluation included a picture of the heel wound; the measurement sticker appeared to be on the inside of the right heel wound. Wound Evaluation dated 7/17/23 revealed R3's sacrum pressure ulcer was a Stage 2 pressure ulcer, had 80% granulation tissue, and was 3.07 cm by 0.81 cm. MDS Coordinator (MC) D was interviewed on 11/07/23 at 3:00 PM and stated R3's she could not remember if she asked the wound nurse about the stage accuracy of R3's stage 2 sacral pressure ulcer due to documentation of slough, on R3's Admission MDS with ARD of 6/09/23. MC D stated if a resident was admitted with a Stage 2 pressure ulcer, they had to continue coding as a Stage 2, even when the pressure ulcers worsened. Registered Nurse Unit Manager (UM) O was interviewed on 11/07/23 at 4:48 PM stated R3 wore slipper socks when sitting in her wheelchair. R3 had a stage I pressure ulcer on her sacrum when she was admitted . UM O stated R3's pressure ulcers on her heels developed due to pressure from her wheelchair foot pedals. UM O stated R3's Total Body Skin assessment dated [DATE] was not investigated for accuracy. UM O stated the wound nurse had retired and was instructed she and another unit manager would take over wound management. UM O stated before the wound nurse left, they had a weekly pressure ulcer meeting, and currently did not have a weekly meeting. Director of Nursing (DON) B was interviewed on 11/08/23 at 7:55 AM and 9:50 AM and stated she was not aware of MDS coding inaccuracies DON B stated she had identified issues with accuracy of wound measurement assessments, care plans and Braden assessment accuracy, and facility nurses were educated. DON B stated unit managers were responsible for staging pressure ulcers, and if a resident was admitted on the weekend, the nurse would describe the wound; the unit managers were on-call on weekends for nursing questions. DON B stated all residents were checked and changed every 2 hours and would increase turning as needed. Physical Therapy Discharge Summary dated 7/17/23 revealed R3 was discharged home with her daughter due to exhausted benefits. Post Discharge Plan of Care, effective date 7/14/23, revealed R3 was discharged home on 7/17/23 with wound care instructions for both heels and sacrum. Hospital notes dated 7/30/23 revealed R3 was admitted to the hospital and the chief complaint was worsening of pressure ulcer wounds 38383 Resident #2 (R2): Review of the medical record reflected R2 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included dementia, chronic obstructive pulmonary disease (COPD), neuromuscular dysfunction of bladder and retention of urine. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/8/23, reflected R2 scored seven out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool), did not walk and required extensive assistance of two or more people for bed mobility and transfers. According to the same MDS, R2 was coded for an indwelling catheter and was not coded for pressure ulcers. R2 did not reside in the facility at the time of the survey. According to the Discharge Return Anticipated MDS, with an ARD of 9/15/23, R2 did not have any pressure ulcers. A Progress Note for 7/14/23 at 11:57 PM reflected R2 had open skin lesions on the sacrum and the left and right buttocks. The note reflected there were existing orders for wound care, and lotion was applied to the area. A Nutritional Progress Note for 7/17/23 reflected a monthly status update related to moisture-associated skin damage (MASD/skin impairment due to prolonged moisture exposure) to the sacrum that was improving. A Progress Note for 9/15/23 at 6:00 PM reflected R2 was sent to the Emergency Department for a change in condition. The eINTERACT Transfer Form, dated 9/15/23 at 5:24 PM, reflected a Skin/Wound Care section, which revealed documentation of Several stage 2 ulcers on both buttocks (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer). An Emergency Department Progress Note reflected R2 stated her bottom hurt. The note reflected she had .a large area of erythema [redness] over her sacrum and gluteal folds with a few 1 cm [centimeter] round ulcers proximally stage II [2] . A hospital Progress Note for 9/16/23 at 3:29 AM reflected there was a sacral wound present. There was no further descriptive information on the wound. During an interview on 11/7/23 at 4:08 PM, Registered Nurse (RN) F did not recall the documentation of R2 having several stage two ulcers on her buttocks on the transfer form dated 9/15/23. RN F reported a stage two pressure ulcer was not necessarily open, but it was reddened and broke down, deeper than just the first layer. The Skin & Wound section of R2's electronic medical record (EMR) reflected MASD was present. The last assessment on 9/12/23 reflected MASD was documented as improving. The picture on 9/12/23 had the presentation of peeling, flaking skin with underlying red/pink tissue. The picture did not appear to capture the entire area of impaired tissue, as evidenced by impaired tissue that extended to all edges of the picture. R2's Skin & Wound evaluations for 7/10/23, 7/17/23, 7/25/23, 8/1/23, 8/8/23, 8/15/23, 8/22/23, 8/29/23, 9/6/23, 9/12/23 were reflective of MASD to the sacrum, with an onset of 4/17/23. The assessments did not reflect the presence of pressure ulcers. During an interview on 11/8/23 at 10:52 AM, RN J reviewed pictures from the skin and wound section of R2's medical record for 8/1/23 to 9/12/23 and described the appearance of the skin, as seen in the pictures. Pertaining to the picture of R2's impaired skin on 8/1/23, RN J stated it looked like a stage two pressure ulcer was present, but she was not going to say it was. RN J identified excoriation and MASD and stated the wound looked worse in the pictures. She reported the larger wound in the picture looked like a stage two or stage three pressure ulcer (Full-thickness loss of skin that may have visible subcutaneous fat in the ulcer. Slough (non-viable yellow, tan, gray, green or brown tissue) and/or eschar (dead tissue that is usually black, brown or tan) may be visible but do not obscure the depth of tissue loss.). Pertaining to the 8/8/23 picture, RN J reported there were three open areas that she would probably call stage two pressure ulcers because they were open, and she could see the wound bed. She stated the larger wound appeared to have slough, but she could not be positive based on the picture. Pertaining to the 8/15/23 picture, RN J reported that because she knew what R2's skin looked like, the wound was not as deep as it looked in the picture. She stated she would call the impaired skin MASD. RN J reported the pictures were poor quality. Pertaining to the 8/22/23 picture, RN J reported two open areas appeared to be stage two pressure ulcers. Pertaining to the 8/29/23 picture, RN J stated R2's skin looked worse and awful. She stated there was no depth noted (on the assessment), but there appeared to be a stage three pressure ulcer present, as well as MASD. Pertaining to the 9/6/23 picture, RN J stated there was excoriation caused by MASD that was healing. Pertaining to the 9/12/23 picture, RN J reported there was dry, flaky tissue that was almost healed. During the same interview, RN J described a stage one pressure ulcer as being pink tissue that may or may not be blanchable. She described a stage two pressure ulcer as the top surface of the skin being open, and a wound bed being visible. RN J described a stage three pressure ulcer as wound that was deeper and could have slough. RN J described MASD as skin that was chapped, dry, excoriated and could be flaky depending on what was used for treatment. RN J stated there could be open tissue with MASD based on the appearance of R2's skin. According to the State Operations Manual, revised on 2/3/23, a stage one pressure ulcer was intact skin with an area of non-blanchable redness. A Physician's Order, with a revision date of 6/26/23, reflected R2's sacrum was to be cleansed with soap and water, patted dry, and zinc oxide was to be applied three times daily for wound care. During an interview on 11/8/23 at 12:13 PM, RN J stated she did not use zinc oxide on open areas, and it was not used on stage two pressure ulcers. 45135 Resident #01 (R01) Review of the medical record revealed Resident #01 (R01) was admitted to the facility on [DATE] with diagnoses that included major depression, anxiety, obesity, chronic pain syndrome, and Polyosteoarthritis. According to Resident #01 (R01)'s Minimum Data Set (MDS) dated [DATE], revealed R01 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R01 requires 1-2 persons for turning and repositioning, 1-2 persons for assistance with personal care and peri care due to obesity and not having the ability to reach all areas of her lower body. During an interview and observation on 11/06/23 at 12:20PM, R01 stated she had a hole in her butt. R01 then pointed to her right foot and stated she had to wear that moon boot because she has a wound there too. R01 stated the facility no longer had a wound care nurse so Registered Nurse (RN) O would come in and assess it. R01 stated they didn't have the correct dressing for the wound vac last night to put it on after her shower, so they packed the wound and covered it with a foam dressing. R01 gave writer permission to come back in and watch her wound care. During an observation and interview on 11/06/23 at 2:30PM, Registered Nurse (RN) RN O and RN P were working together on this dressing change. RN P assisted with rolling R01 toward her, so RN O could get to the wounds. Observation of a reddened are on R01's left hip the size of a sauce plate. Also observed the right gluteal was reddened and bleeding as well. R01 had red streaks across her back under the location of a bra line. R01 stated she wasn't sure if it was nail marks from scratching but unclear of the nature. RN O removed the packed dressing from the coccyx wound, washed the area with normal saline. Used a sterile Q-tip to measure the depth of the coccyx wound, while using the same q-tip to measure tunneling or underminning. RN O applied skin prep surrounding the coccyx wound and over the right gluteal wounds. As RN O continued the prep for the wound vac, she stated that R01 had an appointment at the wound clinic on 11/14/23. RN O also stated that this resident used to be down another hall, so once R01 arrived on this hall, RN O requested a wound clinic evaluation. RN O then placed green foam in the opening of the coccyx wound and across the top of the skin over the right gluteal wounds. RN O then laid a clear adhesive dressing called a drape over the coccyx and right gluteal wounds, cutting a small hole over the green foam and placed a disc/tubing over the coccyx wound, used a dressing called a bridge (connected one wound to another) attached to the wound vac. Wound vac was set at suction@ 125mmHg. RN O had to apply additional pieces of drape due to air leak in the dressing not allowing the wound vac to work properly. Once the wound vac maintained its seal, this dressing change was completed. During an interview and observation on 11/06/23 at 3:00PM, RN O stated they were doing daily dressing changes on the right heel and added the escar had come loose over the weekend, so they are now using a different dressing than what was ordered. RN O removed the dressing from the right heel using clean technique, cleaned with normal saline, a picture was taken of the wound, a dry foam dressing was put back on heel the wound bed was covered in escar tissue with bleeing coming out of the corner of it. R01 also had a red area under her right breast that was bright red and appeared to be inflamed. R01 stated it was painful when they cleaned it and put the zinc oxide on the area. The reddened area was approx 2.5 wide by 6 long. R01 had a strip of a dry wicking fabric laying between the breast and chest wall to prevent touching. Area cleaned with normal saline and the dry wicking fabric was placed back between the breast and the chest wall. RN O also stated that the wound care nurse had left in August 2023, so the unit managers were given the wound care responsibility with the DON B. During an interview on 11/07/23 at 4:40PM, RN O stated when a resident develops a new wound, she opened a new identifier in point click care (PCC) electronic record. She also stated after the wound care nurse left in august 2023, she had to go in and closed out wounds that had healed. RN O stated they had a morning meeting, and that was where she would bring up any new wounds and the orders to the whole team. RN O also stated that the DON B was certified in wound care. RN O stated that they have a product guide they used for a tool until the doctor was notified. If a wound is identified over the weekend, the nurses are instructed to call her at home, like the discovery of the skin issue under the right breast and the right heel opening. RN O stated she had not seen the doctor yet today; however, he was in the facility yesterday (11/06/23) and did not remove the dressing to the wounds to assess, reported he would look at the pictures once they were taken. When asked about the pictures that were taken of the coccyx wound, the right gluteal wound and the right heel. RN O stated some of the pictures were deleted by accident, so she had to take some new ones. RN O also stated that the picture app that they used for taking pictures on the wounds was challenging to use at times. RN O added that the nurses had this app on their personal phones and then they were given an IPad with the program on that, but also was challenging to use if you needed to get is certain places. During an interview on 11/08/23 at 07:35AM, DON B stated the wound care nurse had left in the beginning of September 2023. DON B stated she had some wound education and knew how to do what needed to be done. DON B stated she had assigned wound care to the two-unit managers. She provided wound vac training through the company itself. (name of company) came in to train on the wound care supplies and dressings. They held monthly nurses' meetings that nurses had to attend, signed in and had education provided by various vendors. Writer asked DON O what the turning and repositioning process was. DON B stated they had process called check and change, turn, and reposition. This was part of their standard of care. If a resident refused to be repositioned, the Cena was to tell the nurse and she would reapproach. DON B also stated that this was the time the cena's looked at their skin and document on a separate form all the services they provided with the skin audit. DON B stated that she met with the unit managers every morning, go over the new events, falls, new skin issues, and what needed to be followed up on. DON B also added that both doctors at the facility are engaged in the wounds but neither one touches the wounds but counts on the nurses to relay the information to them. DON B stated that the unit managers have tools to use to identify the dressing needed based on the assessment of the wounds. If the nurses need to address the wounds, then they would write an order and they have a formulary they could order from. DON B also stated that the unit managers are actively involved with the skin and wound care program, taking pictures of the wounds, treating the wounds. DON B did state that she heard that some of the pictures of the wounds were lost. Also stated she felt that was a user error. DON B stated that you should be able to reopen the previous wound identifier of a specific location and update it. It should have the same identifier as it did initially. DON B stated the minimum data set (MDS) Nurse was actively involved in the wound care program, she was present at weekly meetings to compare wounds week to week, and had to document it in the MDS documentation. She was the one who documents significant change in condition if they are getting better or worse. DON B stated they have a past noncompliance on pressure ulcers dated 10/31/23 and presented it to this writer at this time. DON B stated that she identified care plans did not match the focus, goal or interventions needed. Turn, reposition, check and change was not documented every two hours, not individualized on the care plans. During an interview on 11/08/23 at 0945AM, DON B stated that the wound identifier did not allow nurses to reopen wound assessments, so they had to identify as a new wound and was given a new wound number for identification. During an interview on 11/08/23 at 11:20 AM, RN P stated R01 was on the hall she was managing initially. Also stated that R01's skin had no issues on 09/12/23. Writer provided a picture to show skin break down, stage 2 pressure ulcer, following week R01 had aquacel with a foam dressing covering. RN P stated that within a week's time her pressure ulcers were opened up, adding that R01 refused to be repositioned and bathed. RN P also stated the nurses were using the blue dot locator correctly when they were taking pictures of these wounds. RN P stated they did not know they needed to place the blue dot in a certain position for the pictures or the measurements would be off, giving a false reading. RN P also added that wounds are not her favorite thing, but they did not have a wound care nurse. RN P stated she would ask the other unit manager for assistance with would care measurements and treatments. RN P also stated that they were educated last week on the use of zinc oxide since they had been using it on open areas, not the intended use. Record review of skin and wound assessments revealed variations in measuring and staging of the pressure ulcers. Pictures taken were not taken from the same distance from the wound, the blue dot was placed on varying locations around the pressure ulcer giving a false assessment or the picture was so blurry, you were unable to identify the body structure that was being identified. Some wounds did not have pictures attached related to pictures getting deleted. Some areas of the pressure ulcers assessment document were not filled out, leaving out important information and characteristics of the wounds. Right gluteal wounds would be marked resolved when there were visible alterations in the skin. Record review of the physician orders revealed R01 had an order for wound care for the right breast dated 10/25/23 including to cleanse under breast unilateral with wound cleaner, pat dry, apply an abd pad for excessive moisture. Complete this every day for skin management. The wound assessment on 11/06/23 stated this was a new wound, where in fact it was a previous wound with a current treatment plan in place dated 10/25/23. Record review of current orders revealed wound care to coccyx wound as follows, Coccyx wound: Remove previous dressing materials, cleanse wound with normal saline, prep peri wound with skin prep, apply drape to peri wound, fill wound cavity with green foam, secure with drape, apply bridge, apply vac head & connect to tubing. Apply continuous suction@ 125mmHg dated 10/16/23. During the observation of the wound care on 11/06/23 at 2:30PM, RN O did not perform wound care as ordered. RN O placed the green foam directly over the right gluteal wounds without a drape placed over the skin first, then the green foam should had been placed on top of this drape to protect the compromised skin. Record review of physician orders revealed R01 was ordered to wear a heel protector boot on both feet. During observations on 11/06/23 and 11/07/23 R01 was not wearing both boots, only one on the right foot. Writer could not visibly see a second boot in R01's room. During an observation on 11/08/23 R01 was wearing both heel protector boots.

This Citation Pertains To Intake#MI 865 Based on observation, interview and record review, the facility failed to ensure two residents (R18 & R19) received oral medications that included narcotics by a licensed nurse, resulting in immediate jeopardy when an unqualified staff member administered medications including controlled substances and the Director of Nursing (DON) falsified medical records and assessments prior to and after the medication administration. On 5/12/2022 at approximately 10:50am during an interview with Licensed Practical Nurse (LPN) F she reported on 1/16/2022 she worked the floor with Registered Nurse (RN) K and Director of Nursing (DON) B. LPN F stated DON B was in poor health and was not physically able to pass medications to her assigned unit (the long and middle hall) and asked for LPN F's help in completing the task. LPN F stated she was not able to assist DON B as RN K was fairly new and she was already assisting RN K. LPN F stated she observed DON B sit at the Nurses station for approximately 3 hours that day and after she declined to assist her, she observed DON B sitting on a stool in the hall next to the medication cart with Activity Director/Certified Nursing Assistant C. LPN F stated DON B was gathering medications and giving the medication cup to Activity Director/Certified Nursing Assistant C who in turn gave the medications to residents. LPN F stated she observed this repeatedly during her shift on 1/16/2022 and reported it to Nursing Home Administrator (NHA) A the following day. On 5/12/2022 on 11:15 am Regional Nurse Consultant J approached this surveyor and provided a document titled Medication administration education for [name redacted] (DON B). The form read Topics : Right Patient, Right Drug, Right Dose, Right Time, Right Route, Right to Refuse, Right Documentation. Nursing standards-Documenting the administration of only medication you personally administered to the resident. Visualizing the resident consume all medications unless said resident is authorized to self- administer. The education document was signed by DON B and dated 1/19/2022. Regional Nurse Consultant J reported she personally did the education with DON B due to a rumor of Activity Director/Certified Nursing Assistant C passing medications. When queried if there was an investigation completed, she didn't know the answer to that as she was not Human Resources and either way it did not matter as there was not a pharmacy regulation in place stating it had to be a Nurse. Regional Nurse Consultant J then reported DON B neither confirmed or denied the rumor during the education completed on 1/19/2022. Regional Nurse Consultant J stated DON B was currently on medical leave, was in poor health and she herself observed DON B's health deteriorating and elaborated that starting around December 2021, DON B could barely walk, was always short of breath and had no stamina. When queried why or how it was expected for someone in such poor health to work the floor as a Nurse, Regional Nurse Consultant J reported She didn't have to all that often. On 5/12/22 at 11:20 am, NHA A was interviewed and reported it was a rumor, a copy of an investigation into the rumor was requested, and revealed he did not substantiate any wrong doing based on an interview with DON B, Activity Director/Certified Nursing Assistant C and R18. Of note, the investigation was a total of 2 paragraphs and did not include any other interviews with staff, other residents and did not include viewing of any camera footage. NHA A was on vacation after 5/12/2022 and not available for further interviews. On 5/12/22 at 11:25 am during an interview with Activity Director/Certified Nursing Assistant C she reported DON B was currently on medical leave and was not physically capable of doing the job of a floor nurse. Activity Director/Certified Nursing Assistant C stated DON B could not walk up and down the hall, and favors started off simple by DON B texting her to walk to the fax machine to retrieve her faxes etc then it progressed into more serious favors in which she was asked by DON B to pass medications on the weekend in January. Activity Director/Certified Nursing Assistant C stated, I knew it was wrong, I trusted her, but I did it anyway. Activity Director/Certified Nursing Assistant C elaborated that R18 yelled and screamed at her when she gave her medications. When queried why R18 yelled at her, Activity Director/Certified Nursing Assistant C stated, Because she knew I wasn't a Nurse, she was furious. R19 was angry too because she was missing one of her pain pills and I had to go back and get it. Activity Director/Certified Nursing Assistant C stated after being yelled at by R18, she told DON B she no longer felt comfortable passing medications. When queried if NHA A was aware Activity Director/Certified Nursing Assistant C stated she was approached by NHA A the Monday after, I was honest with him, I told him I did it. Resident 18 According to the clinical record, including the Minimum Data Set (MDS) dated [DATE] Resident 18 (R18) was admitted to the facility on [DATE] and discharged home on 1/24/22. R18 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Further record review, including R18's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/12/2022 at 12:50 PM during a telephone interview, R18 reported without hesitation back in January [name redacted] ( Activity Director/Certified Nursing Assistant C) gave her medications. R18 stated this occurred on more than one occasion and this infuriated her. When queried if NHA A ever spoke with her about the incident she stated no, nobody ever asked her about it and after the second occurrence she yelled at Activity Director/Certified Nursing Assistant C telling her she wanted a nurse to administer her medications. On 5/12/2022 at 1:05 pm during a phone interview with Registered Nurse (RN) G she stated she became aware of the incident by R19 who reported it to her last winter. Resident #19, according to the clinical record including the MDS dated [DATE], R19 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). On 5/12/22 at 1:30pm, during an interview with R19 she stated I heard you guys were in the building, I have been waiting for someone to come talk to me. This about my medications right? When R19 was asked to elaborate about her question she proceeded to explain that on a Sunday in January of this year, she observed DON B sitting on a stool near the medication cart and Activity Director/Certified Nursing Assistant C in front of the cart pulling out drawers and medication cards. R19 stated DON B would walk her through the process of what medication card was for who and how many pills to punch out of the card and put in the cup etc . R19 stated later that day Activity Director/Certified Nursing Assistant C entered her room and gave her a cup full of pills and almost shorted her one controlled substance that she takes for pain, and stated, I know what I take, I knew I was short one so I made her go back and get it. R19 stated she was and is still very upset that this happened and very angry that Activity Director/Certified Nursing Assistant C had access to her electronic medical records and knows her medications. R19 further stated, She had no business knowing what meds I take, she's not a nurse. R19 stated this happened a couple of times and she had reported it to other nurses but nothing had come of it. When queried if NHA A had spoken to her about the incident she stated No. On 5/12/2022 at 1:50pm during an interview with Certified Nursing Assistant (CNA) E she reported she worked 1/16/2022 and was present when DON B asked Activity Director/Certified Nursing Assistant C to pass her medications on the long and middle hall. CNA E stated a short time later she observed Activity Director/Certified Nursing Assistant C give medications to several residents, CNA E stated DON B was not in good health and never saw her get up from a sitting position or enter any resident rooms entire shift. On 5/12/2022 at 2:30pm during a phone interview with CNA D she reported she worked the long hall on a Sunday in January 2022 and one of her residents asked why there was not a nurse passing out medications. CNA D stated DON B was observed sitting on a stool near the medication cart and she never got up. CNA D reported Activity Director/Certified Nursing Assistant C was observed in front of the cart. CNA D stated right after she observed Activity Director/Certified Nursing Assistant C going in resident rooms with medications in the cup and leaving with an empty cup then repeat room to room to room. CNA D stated the only time DON B left her stool was to sit at the nurses station. I never saw her go in any residents rooms that day. On 5/12/2022 at 1:43 PM during a phone interview with DON B she reported she was currently on medical leave and had been for approximately a month. DON B reported the facility was routinely short staffed and she was frequently asked to work the floor as a nurse, and had done so on all shifts. DON B further stated she hurt her back and was not physically capable of passing medications to residents and had asked the other nurses for help but they were too busy so she had Activity Director/Certified Nursing Assistant C do it. I knew it was wrong. DON B was queried who signed Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] ? DON B stated I did, it was the only way because it was on the computer, it was a bad situation. DON B stated NHA A talked to her about the situation I told him I pulled the pills and gave the cup fill to [name redacted] ( Activity Director/Certified Nursing Assistant C ) he (NHA A) said ok and then next thing I know [name redacted] (Regional Nurse Consultant J) gave me an inservice on medication pass. According to the facility policy titled Medication Administration General Guidelines. dated 01/21, Page 1. under the heading Procedures 1. Medications are prepared only by licensed Nursing, medical, pharmacy or other personnel authorized by state regulations to prepare medications. Page 3. under the heading Medication Administration 5. There person who prepares the dose for administration is the person who administers the dose. Page 6. under the heading Documentation 1.The individual who administers the medication dose, records the administration on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/17/22 at 10:34 A.M., the Covering Nursing Home Administrator BB and Regional Nurse Consultant J were verbally notified and received written notification of the Immediate Jeopardy that was identified on 5/17/22 and began on 1/16/22 due to the facility's failure to ensure medications were being administered by Licensed Nursing staff. A written plan for removal for the Immediate Jeopardy was received and accepted on 5/17/22 and the following was verified on 5/18/22: Resident #18 no longer resides at the facility. Resident #19's eMAR, progress notes and narcotic sign out sheet was reviewed for administration of the correct dose of [MEDICATION(S)] [MEDICATION(S)] 15mg and effectiveness of said pain medication. Resident's eMAR, progress notes and narcotic sign out sheet verify one 15mg dose of [MEDICATION(S)] [MEDICATION(S)] was administered at 1203 on 01.16.22 and was effective. On 5/17/22, the Activity Director/Nursing Assistant C was re-educated by the Regional Clinical Director regarding administering medications she not qualified to administer. The Licensed nurse is currently out on medical leave with the option to return to work by 05.31.22. Should she return to work, she will receive the proper education/disciplinary action. Element #2 A one-time interview of all residents was started on 05/17/2022 to ensure that all residents had not received medications by an unlicensed personnel. Re-education of all staff was started on 05/17/2022 and completed on 05/17/2022 regarding medication administration. Medications are prepared only by licensed nursing, medical, pharmacy or other personnel authorized by state regulations to prepare medications. The person who prepares the dose for administration is the person who administers the Current staff who have not signed for education prior to date of compliance have received the mandatory plan of removal education and will sign for receipt prior to working next assigned shift. Element #3 DON and Executive Director reviewed the medication administration policy on 5/17/22 and found them to be appropriate. Beginning on 5/17/22 the following System Change was implemented: DON/designee will complete 5 chart reviews weekly x 12 weeks to ensure that no residents received medication from unlicensed personnel and 5 interviews to ensure they don't verbalize it was well. This will continue until the QA committee has determined compliance. 100% of all staff received education in person or mobile text on 05/17/2022. For those who received initial re-education via email attachment or mobile text will be provided with the mandatory plan of removal education in-person prior to the start of their next scheduled shift to ensure in-person receipt and understanding. Although the Immediate Jeopardy was removed on 05/17/22, the facility remained out of compliance at a scope of pattern and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to the fact that sustained compliance had not yet been verified by the State Agency.

Based on observation, interview, and record review, the facility failed to implement interventions, including timely toileting and increased supervision, consistent with residents needs and care plan to prevent falls in 2 of 5 sampled residents (Resident #5 & #7) reviewed for falls, in a total sample of 15 residents, resulting in multiple falls and a nasal fracture for Resident #5 and including fractures. Findings include: Resident #5 On 11/15/17 at 8:25 AM, Resident #5 was observed sitting in a wheelchair in the Holliday dining room eating breakfast. During the same time, another resident in the dining room was yelling out in nonsensical speech; Resident #5's face grimaced and she yelled out shut-up in response. In review of the physician's Progress Record dated 5/1/17, Resident #5 was a [AGE] year old with Alzheimer's disease, chronic kidney disease, and generalized anxiety disorder. Resident #5's care plans with a revision date of 11/14/17, indicated she had the [DIAGNOSES REDACTED]. Resident #5's Minimum Data Set (MDS) 3.0 dated 8/24/17, introduced the Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents, score was 2 (00-07 indicated a severe impairment). The same MDS assessment revealed a Patient Health Questionnaire-9 (PHQ-9), a multipurpose instrument for screening, monitoring and measuring the severity of depression, and had a look-back period of 14 days; Resident #5 scored 13, indicating moderate depression. Resident #5's PHQ-9 questionnaire, included in the MDS assessment dated [DATE], indicated she had symptoms of feeling or appearing down, depressed or hopeless; feeling tired or having little energy; felt bad about self, was a failure, or had let self or family down; and trouble concentrating on things for the past 12 to 14 days. The same assessment indicated Resident #5 had felt down, depressed or hopeless the last 2 to 6 days. Resident #5's prior MDS assessment dated [DATE], revealed a PHQ-9 score of 8, indicating she had mild depression during this assessment and her depression had worsened over the quarter. According to Centers for Medicare and Medicaid Service's (CMS), Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, Version 1.14, October 2016, Section D; depression could be associated with decreased functional status and poorer outcomes. Resident #5's most recent MDS dated [DATE], revealed Resident #5 required limited assistance of one person for ambulation. The same MDS indicated Resident #5 was frequently incontinent of urine (7 or more episodes of urinary incontinence, but at least one episode of continent voiding) and always incontinent of bowel (no episodes of continent bowel movements) during the 7 day look-back period and had never had a trial toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) attempted since urinary or bowel incontinence was noted in the facility. Resident #5's activities of daily living care plan, revised on 9/6/17, indicated she required 1 person assist with toileting and to assist her to the toilet every 2 hours and as needed. In review of Resident #5's medical record, she fell on 22 occasions since February 2017: Resident #5 fell 14 out of 22 times on the 3:00 PM to 11:00 PM shift; 10 out of 22 of Resident #5's falls were unwitnessed; 13 out of 22 falls occurred while Resident #5 was in her room. In review of the incident report (no title), dated 2/20/17 at 6:30 AM, Resident #5 was observed on the floor at the nurses station and her wheelchair seat cushion was pushed against the backrest of the chair. A bruise was noted on her right elbow on the same report. The same report indicated Resident #5 was able to ambulate with a walker until she fractured her clavicle. The same report indicated at times she .forgets her limitations, which are caused by her memory loss and chronic pain issues. In review of the incident report (no title), dated 2/20/17 at 6:30 PM, Resident #5 was observed sitting on the floor with her wheelchair approximately 3 feet away and reported she slid out of her chair. In review of the incident report (no title), dated 3/15/17 at 8:15 AM, Resident #5 was observed on the floor in her room wearing a shirt without a brief or slacks and stated she was trying to go the the bathroom. The same incident report indicated, under Notes, dated 3/17/17, that Resident #5's care plan was updated to provide toileting every 2 hours. In review of the incident report (no title), dated 3/18/17 at 6:15 PM, Resident #5 was observed sitting on the floor with her wheelchair behind her and sustained a laceration on her right index finger that resulted in a visit to the emergency room . The same report indicated Resident #5 likely cut her finger on the door. There were no interventions on this report to prevent reoccurrence of falls for Resident #5. 3/24/17 at 6:15 PM, the incident report (no title), revealed Resident #5 was observed lying on her back in her room with a spilled cup of water noted on the floor. The same report revealed Resident #5 sustained a hematoma (a solid swelling of clotted blood within the tissues) on the back of her head. The same report indicated that previous to the fall, Resident #5 was combative in the dining room, and the nurses assistant took her to her room in which she fell approximately 15 minutes later. The same report, under other info (information) indicated Resident #5 had poor safety awareness and attempted to ambulate on her own frequently. Certified Nurse Assistant (CNA) V was interviewed on 11/15/17 at 11:15 AM and stated she was on the schedule on 3/24/17, on the afternoon shift and did not recall Resident #5's fall or her being combative in the dining room prior to the fall. CNA V stated in the same interview that there was not always enough help in the dining room, and at times, they were the only staff in the dining room on the afternoon shift. In review of the incident report (no title), dated 4/28/17 at 5:25 AM, Resident #5 was observed on a floor mat, next to her bed, with only a pull up (adult brief) on, that was partially off and stated she was trying to get up. The same report revealed Resident #5 was incontinent. The same report did not indicate the last time Resident #5 was assisted to the toilet. There were no noted interventions on this report to prevent future falls for Resident #5. In review of the incident report (no title), dated 5/4/17 at 3:20 PM revealed Resident #5 fell from her wheelchair at the nurses station. Resident #5 hit the back of her head, sustained a 4 centimeter bump, and was transferred to the hospital for further evaluation. Resident #5 was incontinent as noted on the same report. The same report did not indicate the last time Resident #5 was assisted to the toilet. The were no noted interventions on this report to prevent future falls for Resident #5. In review of Resident #5's incident report (no title), dated 5/24/17 at 1:12 AM, Resident #5 fell on [DATE] at 6:15 PM, and was observed lying on her back in the dining room next to another resident; it appears that they possibly ran into one another after both got up from their wheelchairs during diner. The only witness listed on the report was a resident. In review of the incident report (no title), dated 5/25/17 at 6:00 PM, Resident #5 was observed sitting in her room on the floor and reported she fell . The same report indicated Patient (Resident #5) forgets she is weak and unable to ambulate without falling. Educated her many times d/t (due to) many falls with no injuries. D/t (due to) dementia she just can not remember to use call light. 6/8/17 at 3:19 PM, Resident #5's incident report (no title) revealed she was agitated and yelling at her roommate, the nurses assistant attempted to intervene as Resident #5 was approaching her roommate and she grabbed the nurses assistant; Resident #5 fell after the nurses assistant removed her arm from Resident #5's grasp. Resident #5 then lost her balance and fell back onto her buttocks onto a mat in her room. The same report revealed Resident # 5 sustained an abrasion on her right arm. 6/25/17 at 8:30 AM Resident #5's incident report (no title) was observed on the floor, lying between the bed and the bathroom. Resident #5 stated she hit her head and complained of pain behind her right ear and right hip. Resident #5 was incontinent at the time of the fall and was transferred to the hospital for an evaluation. The same report revealed Resident #5 had new store bought slippers on her feet that were removed and slipper socks were placed. The same report indicated the care coordinator was to educate the family on purchasing footwear with appropriate non-skid properties. The same report did not indicated the last time Resident #5 was assisted to the toilet. 6/27/17 at 7:55 PM, Resident #5's incident report (no title) revealed she fell from her wheelchair at the nurses station. Resident #5 was incontinent and wearing the inappropriate slipper's from the previous fall. The same report indicated there were no witnesses to the fall. The same report indicated they were unable to determine when Resident #5 was last changed or toileted. In review of the incident report (no title), dated 7/9/17 at 6:36 PM, Resident #5 was incontinent, agitated in the dining room and fell on the floor when ambulating in an attempt to hit staff. The same report indicated she was transferred to the hospital and returned with a [DIAGNOSES REDACTED]. The same report did not indicate the last time Resident #5 was assisted to the toilet. In review of the incident report (no title), dated 7/23/17 at 3:30 PM, Resident #5 was observed sitting on the floor in the dining room. The same report indicated Resident #5 became combative when activities staff attempted to get her to sit back in chair prior to the fall. In review of the incident report (no title), dated 7/30/17 at 8:00 PM, Resident #5 was observed lying on her back and stated she went to the bathroom. Resident #5 was incontinent and sustained a skin tear to her left arm during the incident. The same report indicated interventions at this time were to keep bed at lowest setting, frequent visual checks and for staff to anticipate resident needs. The same report did not indicate the last time Resident #5 was assisted to the toilet. In review of Resident #5's risk for falls care plan, revised on 11/14/17, during the standard survey, increased visual checks for safety was initiated on 10/28/2016. The same care plan did not specify how often to visually check Resident #5. The CNA care plan, print date of 11/14/17, indicated the same intervention without specifying how often to visually check Resident #5. In an interview on 11/15/17 at approximately 3:00 PM, Director of Nursing (DON) B was not able to specify how often visual checks were completed for Resident #5 and stated visual checks were documented on Resident #5's Neurological Assessment Flow Sheet. During the same interview, DON B presented Frequent Visual Checks Log that was completed for Resident #5 from 4/4/17 to 4/5/17, 4/5/17 to 4/6/17, and 4/7 through 4/8, that indicated a frequency of checks every 15 minutes, without a duration listed, however, no other more recent checks were documented on these forms. In review of Resident #5's medical record, she did not fall from 4/4/17 through 4/8/17, during the 15 minute visual checks. In review of Resident #5's Neurological Assessment Flow Sheet, dated 7/30 to 8/1, vital signs and neurological assessments were completed following a fall with the instructions to assess every 15 minutes times 4, then every 1 hour times 4, then every 2 hours times 4, then every 4 hours times 3; then every 8 hours for 48 hours. There was no documentation of frequent visual checks after 8/1/17. 8/5/17 at 12:39 PM, Resident #5's incident report revealed she slid out of the shower chair onto her buttocks after attempting to kick a nurses assistant. 8/24/17 at 11:15 PM, Resident #5's incident report revealed she was observed lying on the floor mat next to her bed. The same report indicated Resident #5 was placed on frequent visual checks when in bed, the same intervention following the fall on 7/30/17. Frequent Visual Checks Log was requested from DON B on 11/15/17 at 2:20 PM and was not provided prior to the exit conference. 8/25/17 at 4:30 AM, Resident #5's incident report revealed she was observed lying on a floor mat next to her bed on her right side next to her night stand. The same report revealed blood was observed coming from Resident #5's nose and a skin tear on the right side of the nose. The same report revealed bruising and swelling of Resident #5's nose was also noted. In review of a Ear, Nose, and Throat consult, dated 8/29/17 at 11:00 AM, Resident #5 was seen for a closed fracture of the nasal bone. 9/11/17 at 5:33 PM, Resident #5's incident report (no title) revealed she pushed staff away when attempting to ambulate independently in the activity room and fell on to her buttocks. The same report revealed Resident #5 was incontinent at the time of the incident and did not indicate the last time she was assisted to the toilet. On the same report an interdisciplinary note dated 9/13/17 revealed she was no longer able to walk with a walker or cane, as both could become weapons during her agitation. In review of the incident report (no title), dated 9/27/17 at 10:00 AM, Resident was observed sitting on the floor in her room. Plan was to discuss with provider lidocaine patch or muscle rub for painful areas. There were not orders observed for a lidocaine patch or muscle rub on the medication or treatment administration records. Information regarding orders or information from the physician for consideration of a lidocaine patch or muscle rub for Resident # 5, was requested from DON B on 11/15/17 at 2:20 PM and was not provided prior to the exit conference. In review of the incident report (no title), dated 10/3/17 at 7:03 PM, Resident #5 was found lying in the dining room at 6:15 PM with tender raised areas noted to her scalp. There were no witnesses noted on the incident report, but a note on the same report, dated 10/4/17 indicated Resident #5 was agitated and striking out at staff prior to the fall. In review of the incident report (no title), dated 11/10/17 at 5:04 PM, Resident #5 was observed on the floor in her room and reported that her head hurt. The same incident report revealed Resident #5 was incontinent at the time of the incident. The same report indicated Resident #5 was on a toileting schedule, but not what time she was last toileted. Resident #7 Resident #7's MDS 3.0 admission assessment, dated 8/31/17, introduced the BIMS score of 5 (00-07 indicated Severe Cognition Impairment). The same MDS revealed Resident #7 was [AGE] year old admitted to the facility on [DATE]. The same MDS assessment revealed Resident #7 required oversight to limited assistance of one person for transfer and ambulation. The same MDS assessment revealed Resident #7 was occasionally (less than 7 episodes of incontinence during a 7 day look-back period) incontinent of urine and frequently (2 or more episodes of bowel incontinence, but at least one continent bowel movement during a 7 day look-back period) incontinent of bowel. The same MDS assessment indicated a trial of a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) had not been attempted on admission. Resident #7's care plan with goal to be free of hip fracture complications, revised on 11/14/17, revealed he had the [DIAGNOSES REDACTED]. In review of the incident report (no title), dated 10/4/17 at 1:45 PM, Resident #7 was observed lying on his back with his walker near the bathroom door. Resident #7 was documented as stated that he was going to help his brother and the walker was too far behind him. The same report revealed Resident #7 had no injuries related to the fall and was using his over-bed table for balance instead of using his walker. The same report included an interdisciplinary team (IDT) note that indicated a stationary television (TV) tray would be provided for Resident #7, instead of a rolling over-bed table. The same note did not address placement of Resident #7's walker, consideration of a staff alerting device to notify staff when he transfers in his room without assistance, or consideration for increased visual checks. In review of the incident report (no title), dated 10/14/17 at 6:30 PM, Resident #7 was observed on the floor on his left side in the activity room. The same report revealed prior to the fall Resident #7 had been sitting in a chair watching TV. The same report indicated Resident #7 reported that he stood and his shoes were slippery, causing him to fall. The same report revealed Resident #7 sustained a bruise on top of his scalp. The IDT note, in the same report, did not include any additional interventions for Resident #7, but indicated resident has a medical history that includes Parkinson's which can cause fatigue and that he declined to lay down prior without a time indicated. There was no mention on this report or in the progress notes that Resident #7's shoes were inspected for appropriateness. In review of the incident report (no title), dated 10/30/17 at 8:35 AM, Resident #7 was observed sitting on the floor next to his bed and was naked from the waist down. The same report indicated Resident #7 was incontinent and was attempting to get up from bed to go to the bathroom. The same report revealed Resident #7 would be scheduled for a neurology consult and a therapy screen. The IDT note did not indicate a plan to complete bowel and bladder assessment. In review Resident #7's incident report (no title), dated 11/3/17 at 7:01 PM, he was observed by the nursing assistant lying outside the bathroom door. The IDT note did not indicate any new interventions were implemented, such as a bowel and bladder assessment. In review of the incident report (no title), dated 11/8/17 at 3:45 AM, Resident #7 was observed lying on his right side in his room and reported to the nursing assistant I had to pee, so I stood up, and my legs came out from underneath me, and I fell on the floor. The same report revealed Resident #7 had an x-ray that revealed a fracture and was transferred to the hospital for treatment. In review of the incident report (no title), dated 11/11/17 at 5:50 PM, Resident #7 was found on the floor at the foot of his bed, lying on his right side with his walker lying on top of him. The same report revealed Resident #7 was complaining of pain to the right hip and leg area and stated he was going to the bathroom when he lost his balance and fell , and hit his head against the bottom drawer of his nightstand. The same report revealed Resident #7 had just returned from the hospital earlier the same day following hip replacement surgery. The same report revealed Resident #7 was provided with a high-back wheelchair with elevating leg rests. The same report did not indicate a plan to complete bowel and bladder assessment. During an interview on 11/15/17 at 9:15 AM, DON B stated Resident #7 had been good with using a urinal, that a bedside commode had not considered and she didn't believe a bowel and bladder patterning assessment was indicated upon admission, that they had just put one on his door yesterday to track patterning. During the same interview, DON B stated she was not sure if an alarm that would activate the call light was ever considered for Resident #7. During an interview on 11/15/17 at 2:20 PM, DON B stated a Medication Regime Review by the pharmacist was not initiated for Resident #7 due to his falls. In review of the Fall Reduction Program policy revised on 9/25/17, the interdisciplinary team (IDT) was to review each incident and complete a root cause analysis, evaluate trends and/or patterns and notify pharmacist via request for Medication Regime Review (MRR) form, as applicable. In a interview on 11/15/17 at 11:15 AM, Certified Nursing Assistant (CNA) V stated Resident #7 had a poor memory and did not use his call light. During the same interview CNA V stated an device/alarm that would activate Resident #7's call light would be helpful. CNA V stated in the same interview, Resident #7 was walking without assistance/supervision and was half-way down the hall looking for the bathroom, earlier on this same day. According to CMS's, Long-Term Care Facility RAI User's Manual, Version 1.14, October 2016, Section J, A fall should stimulate evaluation additional monitoring (e.g., toileting, to avoid incontinence). The same source revealed previous falls, especially recurrent falls and falls with injury, were the most important predictor of future falls and injurious falls; and a leading cause of morbidity and mortality among nursing home residents. In review of Resident #7's Medication Admin Audit Report and medication administration record, dated 11/1/17 to 11/15/17, Carbidopa-Levodopa 25-100 milligrams (mg) was ordered twice daily at 8:00 AM and 5:00 PM. There were no instructions on the medication administration record of potential food interactions. The same report revealed Carbidopa-Levodopa was administered on 11/15/17 at 8:30 AM. In review of Faith Haven Meal Time Schedule (no date), the Holliday Dining Room has breakfast at 7:45 AM, Lunch at 11:30 AM, and Dinner at 5:30 PM. Licensed Practical Nurse (LPN) X was interviewed on 11/15/17 at 1:20 PM and stated that she administers Resident #7's Carbidopa-Levodopa a half hour after he eats because she said she knew it affected digestion. On 11/15/17 at approximately 2:30 PM, DON B stated LPN X had discussed what she had told this writer regarding her rationale for the timing of Carbidopa-Levodopa, and DON B stated she disagreed with LPN X and educated her that Carbidopa-Levodopa should be administered prior to meals. The National Parkinson Foundation website (http://www.parkinson.org/understanding-parkinsons/treatment/Medications-for-Motor-Symptoms/Carbidopa-levodopa) recommended to take Carbidopa-Levodopa 30 to 60 minutes before eating a meal to allow the medication to be quickly absorbed before the food could interfere with absorption. The same reference indicated Levodopa, after converted into dopamine was stored in the neurons (cells) until needed by the body for movement.

This citation has two deficient practice statements DPS A and DPS B. DPS A) This citation pertains to complaint number MI 875. Based on interview and record review the facility failed to ensure that wounds were accurately assessed, identified, and treated according to physician's orders [REDACTED].#50), resulting in the worsening/development of new wound(s), the reoccurrence of [MEDICAL CONDITION] (MRSA) infection and maggot infestation of the skin graft site for Resident #50. Findings include: According to Legal and Ethical Issues in Nursing, 4th Edition, (Guido, G, 2006), A major responsibility of all health care providers is that they keep accurate and complete medical records. From a nursing perspective, the most important purpose of documentation is communication. The standards for record keeping attempt to ensure, patient identification, medical support for the selected diagnoses, justification of the medical therapies used, accurate documentation of that which has transpired and,,,Documentation must show continuity of care, interventions used, and patient responses. Nurses' notes are to be concise, clear, timely, and complete. A review of the text book, Legal and Ethical Issues in Nursing by G. Guido (2001), reflected on page 171, Documentation must show continuity of care, interventions that were used, and patient responses to the therapies implemented. Nurse ' s notes are to be concise, clear, timely, and complete. A jury can infer that no observation of the patient was conducted if there is no documentation. According to the Fundamentals of Nursing, 6th edition (Potter-Perry, Mosby, 2005, page 419), The physician is responsible for directing medical treatment. Nurses are obligated to follow physicians' orders unless they believe the orders are in error or would harm clients. The reference goes on to indicate that all orders must be assessed and further clarification from the physician retrieved if necessary. The physician should write all orders, and the nurse must make sure that they are transcribed correctly. Resident #50 According to the facility's electronic medical records, Resident #50 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. left foot, [MEDICAL CONDITION], muscle weakness, depression, anxiety, multiple chronic ulcers of the left and right foot, osteo[DIAGNOSES REDACTED] of the left ankle, multiple courses of intravenous antibiotic and multiple surgeries of both feet; most recently, surgical insertion of pins and the application of a supportive cage to stabilize the left ankle for healing, and surgical grafts to the left heel and ankle. Resident #50 was not a resident in the facility at the time of the survey. According to the 5-day Minimum Data Set (resident assessment), Resident #50 weighed over 300 pounds, was alert and oriented and could make his own decisions, could feed himself and perform hygiene after set-up, required the assist of 2 staff persons for bed mobility, transfers, and toileting, and required the assist of 1 staff person for walking with his walker with no-weight-bearing on his left foot, bathing and dressing. Resident #50 chose to not follow a diet to help regulate/lower his blood sugars, and would refuse showers or bed baths at times. According to the facility's Admission Assessment, dated 6/30/16, Resident #50 had the following listed in the Skin Integrity section on page 8, Skin graft sites L (left) upper thigh/healed/pink in color. Missing 2nd and 3rd toes L foot/healed. Appx (approximately) 1 cm (centimeter - about one half inch) round area R (right) inner ankle. Appx 2 cm round area R outer ankle. 9 pins with halo L toes/ankle area. 4+ pitting (dent in skin remains for or more than 4 seconds when pressed with a finger tip) [MEDICAL CONDITION] LLE (left lower extremity) (surgical side). A review of the admission orders [REDACTED]Wound Care: 1. LLE (left lower extremity) - gently remove dressing, gently cleanse c (with) wound cleanser, cover c 1-2 layers (non-adherent dressing), cover c 4 X 4 (gauze), secure c (brand name) tape. - change daily. 2. Pin Care - cleanse c saline, wrap c (non-adherent dressing), wrap c fluffs. - change daily (sic) 3. RLE (right lower extremity) - cleanse c wound cleanser, (product to remove dead tissue) to necrotic areas, (non-adherent dressing), cover c fluffs, wrap c gauze. - change daily (sic) 4. Keep pts (patient's) feet elevated @ all times. The orders failed to identify the location and number of wounds. A review of the discharge summary from the transferring facility, dated 6/30/16 and dictated by Nurse Practitioner (NP) J mentioned that Resident #50's pins and cage were, clean, dry and intact, and that the pin care would continue. NP J stated, The patient was admitted [DATE] and he has had a prolonged stay at (transferring facility) secondary to complex wound, which now is just pin care. A review of the history and physical, dated 7/1/16 and performed by Facility Physician K, reflected a history of multiple surgeries, infections and Charcot joint of the left foot. The document failed to reflect that Resident #50 had pins and a cage on his left foot, and the location/number of wounds on both of his lower extremities. Hard [MEDICAL CONDITION] (well established [MEDICAL CONDITION]) was noted, and Facility Physician K wrote, We will continue the wound care per care planning of the right foot. No mention was made of the left foot. A review of the facility's Order Review Report for 7/2016 reflected that Resident #50's dressing changes and pin care were scheduled on the midnight shift. The pin care order, dated 7/1/16 and written by Facility Physician K, was unchanged from the admission orders [REDACTED]. There was no order to monitor/change dressings to the left foot. A review of the transferring facility's Wound Assessments for Resident #50's foot wounds reflected the following documentation: On 6/6/16 - left foot plantar (bottom of heel), was a graft, 32 cm (centimeters) long by 4.8 cm wide by 0.5 cm deep (approximately 12.5 inches by 1.75 inches by 1/4 inch). A second location was described as, LLE calf (left lower extremity), was a skin graft, 5 cm long by 1.3 cm wide by 1 cm deep. The 2 open areas on the right ankle, labelled as RLE medial (right lower extremity, inner ankle) and RLE lateral (outside ankle) were documented in a similar manner. On 6/13/16 - left foot plantar, graft, 19 cm long by 5 cm wide by 0.3 cm deep (approximately 7.6 inches by 2 inches by 1/8 inch). LLE calf, 6.8 cm long by 2.8 cm wide by 1 cm deep (approximately 2.5 inches by 1 inch by 1/4 inch ). The 2 open areas on the right ankle were documented in a similar manner. On 6/21/16, there was no documentation of the area previously labelled left foot plantar. LLE posterior was a new location label (back of leg or ankle, not specified), 8 cm long by 3 cm wide (approximately 3 inches by 1 inch). A second new location, LLE lateral (outside area of leg), was a graft site, was 20% necrotic tissue (dead) and 80% granulation (newly healed tissue), 6.5 cm long by 2 cm wide (approximately 2.5 inches by 3/4 inch). A third new location, L heel (without documenting exactly which part of the heel, the bottom that was walked on or the back, against a shoe), graft site, 7 cm long by 5 cm wide by 0.3 cm deep (approximately 2.75 inches by 2 inches by 1/8 inches). the RLE had 2 different locations assessed and documented, RLE lateral (to one side) and RLE anterior (to the front). There was no documentation for other wound assessments, done weekly, after the assessment dated [DATE], 10 days before Resident #50 was transferred. All of the photocopied assessment documents were faxed to the admitting facility prior to Resident #50's transfer, and included indistinct photos of each wound. A review of Resident #50 's undated plan of care for skin management reflected, at risk for breakdown due to diabetes, impaired mobility due to foot/leg halo, obesity, [MEDICAL CONDITION]. The existing wounds on the right and left ankle were not included in the diagnoses. The goal was that interruptions in skin integrity will resolve without complications. Interventions included, CNA will check my skin daily with care and report anything unusual to the nurse, float heels as patient allows, treatments/medication as ordered, treatment to halo site as ordered-observe for signs of infection, float left heel as patient allows. No mention was made of the location or nature of wound care, nor was the intervention to elevate legs at all times, as ordered by the surgeon, planned. A review of the facility's CNA care guide also failed to include to keep his legs elevated at all times. A review of the progress note dictated by facility Physician K, dated 7/5/16, for Resident #50 reflected, Nurse asked me to evaluate the patient about his right foot ulcer along with his left foot status [REDACTED]. The patient's bilateral foot has swellings with mild redness with chronic skin changes without any signs of acute severe drainages (sic). Right foot ulcer, slowly healing. I have recommended to follow up with Infectious Disease Physician and also check (labwork). No observation of wounds was documented. A review of the progress note dictated by facility Physician K, dated 7/8/16, for Resident #50 reflected, We are sending this laboratory results to the infectious disease for further workup. Again, no observation of the wounds was documented. A Review of the POS [REDACTED]Assessment, clinically there is no evidence of pin tract infection. No drainage or signs of infection at this time. [DEVICE] is well maintained. I reviewed the patient's x-rays: stable. Severe [MEDICAL CONDITION] of the left ankle. There was no documentation concerning the grafted site on the left lower extremity, performed on 4/10/16, or the wounds on the right lower extremity. A CT scan was ordered of the left ankle. A review of the CT scan report of the left ankle, dated 7/15/16, reflected the following, The extent of [MEDICAL CONDITION] at the ankle level appears slightly increased since 3/22/16. No discrete abscess identified. Postsurgical soft tissue wound involving the posterior mid aspect of the distal left lower leg (back of lower leg, above heel)his (sic-has) again demonstrated, appears less deep and less of (sic) thin than on the prior exam. (Previously seen open wound in the distal medial foot is also substantially improved in appearance. Wound involving the anterior lateral distal leg above the ankle (just above ankle and slightly toward toes) actually appears slightly more prominent than on the prior exam). A review of a skin assessment recorded in the nurse's note, dated 7/18/16 and written by Wound Registered Nurse (RN) C, reflected the following about Resident #50, Left lateral incision appears intact no s/s (signs/symptoms) of infections. No drainage noted. Skin graft on foot remains intact & healed. No mention was made about the left lateral incision being healed. A review of the Visit Type: Post Op Visit note for Resident #50 from Podiatrist P, dated 7/19/16, reflected that Resident #50 reported a fall to his knees at the facility, and that a nurse told him that some of the pins had scabbed over. Podiatrist P documented, No pin tract infections. No drainage or signs of infection at this time. Serous (clear or blood-tinged, watery) drainage on the posterior aspect of the left incision. The lateral incision has fibrotic tissue with serous drainage but appears to be healing within normal limits. The patient has severe [MEDICAL CONDITION] of the left foot and warmth noted I would like to continue pin care with gauze and H2O2 (hydrogen peroxide). The assessment impression stated, Maggot infestation, Active. The patient has maggots in the lateral left ankle wound. The patient was sent to the ED and a washout will be performed tonight. A review of the Surgical/Procedure Operative Report for Resident #50 from Podiatrist P, dated 7/19/16, reflected, post-operative [DIAGNOSES REDACTED].>1. Full-thickness wound, lateral ankle with maggot infestation lateral left ankle. The wound is through subcutaneous tissue. 2. Full-thickness ulceration at the posterior left ankle to subcutaneous tissue. .Operative findings: Wound measurements at the lateral ankle were 15cm x 3cm with no purulence noted. On 8/4/16 at 12:25 p.m., Director of Nurses (DON) B was interviewed. When asked, DON B said that she was not aware of any wounds on the left lower leg except for the pins and halo. When asked how nurses document dressing changes, DON B said that the nurses initialed the electronic Treatment Administration Record (TAR ) next to the physician's orders [REDACTED]. When asked if nurses documented by exception (only document unusual or abnormal findings), and DON B said that they did. On 8/3/16 at 3:35 p.m., Physical Therapy Assistant (PTA) H was interviewed. PTA H said that Resident #50 would still attempt to bear weight on his left leg while doing therapy, or he would grab the cage/pins to lift his left leg if he couldn't move it himself. When asked about the presence of wound dressings, PTA H said there was gauze all around the base of all the pins, and she noticed gripper socks on Resident #50's feet, but does not recall seeing a dressing on the left foot/ankle. On 8/3/16 at 3:45 p.m., Certified Occupational Therapy Assistant (COTA) G was interviewed about Resident #50. When asked, COTA G said that she noticed drainage from the left foot dripping onto the floor when Resident #50 had his left leg propped up while using a therapy machine. She would call the nurse to fix it. When asked about a dressing on the right foot/ankle, COTA G said that she knew Resident #50 wore grippy socks, but couldn't remember a dressing. When asked which nurse changed the dressing, COTA G answered, Nurse F. On 8/4/16 at 2:00 p.m., RN C was interviewed. When asked, RN C was not able to say why staff only initial that a treatment was done on the TAR, and don't write in nurse's progress notes. RN C said that the nurses contacted her with questions or changes, and there had been no questions/changes for Resident #50. When asked to list what dressings Resident #50 had when he arrived at the facility, RN C said that she recalled the gauze on the pins, a dressing on the right foot, scarring on the left outer lower leg, a healed graft to the left heel, a healed site where the skin was removed for the graft on the left thigh. RN C mentioned that Resident #50 liked to sit outside, on the facility porch and visit with other residents and family during the past few weeks of his stay. On 8/5/16 at 9:00 a.m., RN E was interviewed via phone. RN E recalled changing dressings to the bottom of the left heel and the inner and outer right ankle, using wound cleanser, a non-adherent dressing and gauze. RN E said that he cleansed the pins with half-strength hydrogen peroxide and sterile water and applied the dressings as ordered. When asked, RN E recalled no dressings around the left calf or ankle. RN E went on to describe that he would remove all the dressings from both feet before doing the wound care. When asked when he changed gloves and performed hand hygiene, RN E said that he did so before he began cleansing wounds. When asked about hand hygiene/glove changes between wound sites, RN E paused for a moment, and said, I didn't think about that, but I'll remember. When asked abut any wound drainage, RN E said that there was occasional drainage from the left heel, but light-colored, never green or yellow, and no odor. When asked why he didn't document the condition of the wounds for every dressing change, RN E mentioned charting by exception, and said that he considered the wounds, Normal for him (Resident #50). RN E mentioned that Resident #50's lower legs were very [MEDICAL CONDITION], and added that he liked to sit out on the facility porch in the afternoon. RN E believed that the dumpsters were only about 20 yards from the porch, and it had been hot and humid recently. I've never even seen a fly in that hallway, RN E said. On 8/5/16 at 11:45 a.m., Podiatrist D was interviewed at the surgeon's office. Podiatrist D said that she was with Podiatrist P and saw the wound with maggot infestation. When asked, Podiatrist D said that no pictures were taken before the procedure, but she showed post-procedure pictures that reflected a long wound with hardly any width, but appeared deep. When asked if the maggots were counted, or how big they were, Podiatrist D drew a representation on this Surveyor's notes, which was a tight oval, approximately 5/8 inch long. When asked, Podiatrist D said that the wound culture done during the procedure [MEDICAL CONDITION]. On 8/5/16 at 3:05 p.m., facility Physician K was interviewed. When asked if he observed Resident #50's wounds on his left lower leg, Dr. K said that the area on the left foot where the graft was placed was healed, and there was no drainage. When asked, Physician K said that he did not see dressings on the left leg graft site, just around the pins. There was no redness, he said. On 8/5/16 at approximately 3:30 p.m., the wound nurse from the transferring facility, RN I was interviewed via phone. When asked, RN I said that she gave a verbal report to the facility wound RN C, and remembered saying that the left foot wounds were healing well. He had small openings in the heel and lateral legs, and his left heel drained a large amount, said RN I. On 8/5/16 at 3:45 p.m., DON B was interviewed. When asked, DON B said the following; when she noticed that the dressing orders were dated 6/10/16 for Resident #50's 6/30/16 admission to the facility, she asked Wound RN C to contact the transferring facility to verify the orders and enter them into the computer. RN O completed the admission assessment, including looking at Resident 350's wounds. On 8/5/16 at 4:00 p.m., Wound RN C was interviewed. When asked when she contacted the wound nurse from the transferring facility to clarify Resident #50's wound care orders and referenced DON B's request to do so, RN C said that she asked about the pin care but doesn't remember being asked to clarify wound orders, nor did she remember when she contacted the wound nurse at the other facility. RN C stated recall of being told that Resident #50 had 2 grafts that they had been, Working several months to heal', and that they were, Healing well. When asked about seeing a dressing on the left heel, RN C said that she didn't recall seeing a dressing. When asked when she first observed Resident #50's wounds, RN C did not recall, but would see if she could find any of her notes. RN C did not recall entering Resident #50's treatment orders into the computer. RN C was asked how she verified the transferring physician's orders [REDACTED]. When asked what the nurse was to do if treatment orders written by a physician don't fit the number and location of observed wounds, RN C said she wasn't writing orders, she was just trying to get information on how Resident #50's wounds were doing. RN C said that she would check to see if she did enter Resident #50's treatment orders into the computer. The only response to these questions was a handwritten paper, dated 7/1/16 with several entries written randomly on it, including, (Resident #50's name) [DEVICE] L (left) wash pins c N/S (normal saline) (non-adherent dressing) 4 X 4 (gauze) not wt (weight) bearing L. On 8/9/16 at 9:30 a.m., Wound RN I from the transferring facility was interviewed. RN 'I last evaluated Resident #50's wounds on 6/28/16, and provided the following documentation: LLE lateral - graft, 6.5 cm long by 2.2 cm wide by 0.6 cm deep (approximately 2.5 inches by 3/4 inch by 1/8 inch). L heel - 9 cm long by 3 cm wide by 0.6 cm deep (approximately 3.5 inches by 1.2 inches by 1/8 inch). LLE posterior - closed. R heel - 1.3 cm long by 0.5 cm wide (approximately 1/2 inch by 1/8 inch) R foot medial - 1.5 cm long by 2.3 cm wide (approximately 5/8 inch by 1 inch). R foot lateral - 2.4 cm long by 2.5 cm long (approximately a little less than 1 inch by 1 inch). R foot mid -0.5 cm long by 2.5 cm wide (approximately 1/8 inch by 1 inch). When asked, RN I said that there was no other documentation of Resident #50's wounds that she knew of. Only the nurse's initials in the treatment record. When asked, RN I said that the wound assessment from 6/28/16 was not sent to the facility with the discharge paperwork. When asked about the changing locations of wounds on Resident #50's feet, RN I said that she was documenting the remaining open areas of each area on a weekly basis, but could see how this could lead to confusion, especially since photocopies of the wound pictures attached to the wound assessments that are faxed are always of poor quality. Copies of the color photos on the wound assessments dated 6/28/16 were provided for this Surveyor, and were easily interpreted. When asked if staying with the same location names, but specifying that particular areas of the wound were healed, RN I felt that her way was more specific. On 8/9/16 at 2:30 p.m., RN F was interviewed. When asked, RN F said that she retaped a thick gauze pad over Resident #50's left arch and heel for the therapy department, but did not recall if she changed a dressing to the left foot. RN F thought for a minute and said that she had removed all the dressings from Resident #50's lower legs upon his admission on 6/30/16. RN F said that she was still in training and was calling out her observations to RN O, who was entering information into the computer. I know I mentioned the wound on his left heel, RN F said, Maybe she didn't hear me. RN F said that the wound looked like a sore right at the edge of his left heel, and there was no old dressing above the heel base. The wound was dressed with a border dressing and was, gradually getting better. RN F said that she may have replaced the dressing one time, but Resident #50 urinated in his bed and the urine ran down and actually soiled the dressings on the pins and heel on his left leg a few times, but would not allow the the wounds to be cleansed and new dressings applied. When asked about the size of the wound on Resident #50's left heel, RN F held up her fingers to demonstrate and conveyed that the wound was about the size of a small hen's egg. On 8/9/16 at approximately 4:00 p.m., RN O was interviewed via phone. When asked about dressings to Resident #50's lower legs, she only recalled the gauze wrapped around the pins on the left leg. RN O also recalled that Resident #50 had a few toes amputated and those areas were healed. RN O said that she would have documented whatever she saw, bruise, reddened, whatever, and would have said so if she removed dressings. For wounds, she would have measured them or got Wound Nurse C. On 8/9/16 at approximately 4:30 p.m., when asked, DON B said that the consult appointment for infectious disease was scheduled on 8/15/16. When asked if Podiatrist P or facility Physician K ordered the consult, DON B said the consult was ordered by Dr. P on 8/3/16. When asked why the infectious disease consult was not scheduled when facility Physician K mentioned it in his progress notes dated 7/5/16 and 7/8/16, DON B could not say. ( ) DPS B) Based on observation, interview and record review the facility failed to ensure the current standards of practice for hand hygiene and glove changes were followed for 2 sampled residents (#51, #52) out of 3 evaluated for wounds from a total sample of 6 resulting in the potential for non-healing and infection of wounds for Residents #51 and #52. Findings include: According to an article published in Healthcare Infection, 3/28/2015 edition, and found online at, <http://www.publish.csiro.au/paper/HI >, Nurses uniforms are in frequent close contact with multiple patients and thus a likely source of HAI (health-acquired infection) . According to the CDC Guidelines for Hand Hygiene in Health-Care Settings, 10/25/02 found online at <http://www.cdc.gov/HAI/pdfs/ppe/PPEslides6-29-04.pdfgloves>, remove gloves after caring for a patient. Do not wear the same pair of gloves for the care of more than one patient . Change gloves during patient care if moving from a contaminated body site to a clean body site. Decontaminate hands before having direct contact with patients, after contact with a patient's intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient, after contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings if hands are not visibly soiled. Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient), after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient and after removing gloves. Limit opportunities for touch contamination - protect yourself, others and environmental surfaces. A review of the facility procedure titled, Dressing Change, dated 7/1/08, reflected the following; 6. Remove soiled dressing and discard in plastic bag. 7. Dispose of gloves .8. Wash hands with soap and water and re apply gloves. After the dressing was completed, 12. Remove gloves and discard with any contaminated supplies in plastic bag .14.Wash hands with soap and water A review of the facility's Wound Management Program, revised on 7/15/15, reflected, Process (Management of Pressure Ulcers/Non Pressure wounds): the following process is completed by the designated Nurse, unless otherwise specified .1.2 Develop an individualized plan of care/Kardex .3. Complete the following daily (Charge Nurse): 3.1. Verify that resident-specific Care Plan interventions are in place . Resident #51 According to the electronic medical record, Resident #51 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set, dated dated [DATE], Resident #51 was alert, oriented and could make his own decisions, was non-weight bearing on both feet and required the assist of 1 staff person for dressing, hygiene, bathing and toileting, was continent of bowel and bladder and had constant pain that he described as 7 out of 10 with 10 being the most severe pain imaginable. A review of the 7/2016 Treatment Administration Record (TAR) for Resident #51 reflected the following orders for dressing changes to both feet: cleanse with wound cleanser, [MEDICATION NAME] (antiseptic) on a dressing and apply, dry gauze to cover, wrap with gauze, do every day. A review of the care plan for skin integrity for Resident #51, revised on 7/21/16, reflected frostbite to both feet that caused gangrene and [MEDICAL CONDITION] and surgical intervention. The goal was dressings to both feet according to doctor's orders. Interventions included, daily skin observation during care, report anything unusual to the nurse, foot cradle add to bed, encourage to elevate feet and wear blue boots when in bed, elevate feet on pillows when doesn't want to wear the blue boots, notify nurse if dressings are loose or falling off my feet, treatment to bilateral feet per physician orders. The treatment intervention was not person-centered, nor was the location and nature of the treatments stated. On 8/4/16 at 9:55 a.m., Licensed Practical Nurse (LPN) N was observed as she changed the dressings on Resident #51's feet in his room. After assembling supplies for the dressing change and placing them on a barrier on Resident #51's over-bed table, RN N placed a barrier beneath Resident #51's feet, closed the privacy curtain, turned on the light and donned gloves without performing hand hygiene. No foot cradle was visible in the room. LPN N repositioned the overbed table with her gloved right hand and opened and placed a trash bag on the bed beside Resident #51's feet. Without performing hand hygiene and donning new gloves, LPN N removed bandage scissors from her right uniform pocket and cut the gauze wrap from both feet, without first cleansing the scissors (ex. no use of an alcohol wipe). Without performing hand hygiene, LPN N sprayed wound cleanser on the non-adherent dressings of both feet to loosen them, and without performing hand hygiene and changing gloves between, removed both old dressings and dropped them into the garbage bag. Without performing hand hygiene and donning gloves, LPN N poured [MEDICATION NAME] into 2-1 ounce medication cups, sprayed the wound areas on each foot with wound cleanser, patted each foot dry and applied new non-adherent gauze soaked in [MEDICATION NAME] to each foot. Again, LPN N did not perform hand hygiene and don new gloves between feet. ( ) Resident #52 According to the electronic medical record, Resident #52 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set, dated dated [DATE], Resident #52 has moderate memory loss, still makes his own decisions, rejects cares, requires the assist of 1 staff person for pushing his wheelchair, dressing and hygiene, and requires the assist of 2 staff persons for bed mobility, transfers with a sit to stand lift, bathing and toileting, and was frequently incontinent of bowel and bladder. According to the facility's Order Summary Report for 6/2016, Resident #52 was to have daily dressing changes as follows: Left heel wound, clean wound and surrounding with normal saline. Apply (brand name) 2% (numbing gel) to wound and surrounding skin. After 5 minutes, apply a protective cream to the skin surrounding the wound, avoiding the wound bed. Apply a [MEDICATION NAME] gel to the base of the wound bed. Apply a non-adherent dressing, then a border dressing. Apply gauze wrapping over all. Apply blue boots daily. A review of Resident #52's care plan for wounds, revised on 5/19/16, reflected the focus as a left heel ischemic (no oxygen) vascular ulcer due to my fluid overload with [MEDICAL CONDITION] of the lower extremities and end stage [MEDICAL CONDITION]. I refuse to lay in bed and elevate my feet. The

This citation has two deficient practice statements (A and B): DPS A) Based on observation, interview, and record review, the facility failed to provide adequate supervision for 1 (Resident #7) of 6 reviewed for falls, from a total sample of 17, resulting in Resident #7 sustaining a fall with a hip fracture. Findings include: Review of the Minimum Data Set ((MDS) dated [DATE], revealed Resident #7 was a [AGE] year old female, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS revealed Resident #7 had modified independence (some difficulty in new situations only) with her cognitive skills for daily decision making. The MDS revealed that Resident #7 had a memory problem with short term and long term memory. The MDS revealed Resident #7 transferred, walked in her room, and used the toilet with one person physical assist. Review of Resident #7's fall care plan initiated on 9/18/14, revealed "I am at risk for falls and have a history of falls. I am very unsteady and unaware of my limitations. I get very anxious at times and feel like I need to be up and moving..." Interventions included: anticipate needs, offer and assist to the bathroom hourly while awake, call light in reach, appropriate non-skid footwear, sensor pad alarm on bed and wheelchair, safe environment, floor mat while in bed, and stay with her when she was anxious. Review of the Unusual Occurrence dated 12/18/14 at 4:10 pm, revealed Resident #7 was observed on the floor in her room and her leg was externally rotated and shortened. Review of the Investigation of Unusual Occurrence revealed that staff was alerted about the occurrence because they "heard screams". In a telephone interview on 1/30/15 at 10:20 am, Nursing Staff "N" reported that she was on lunch break when Resident #7 fell . Nursing Staff "N" stated that Resident #7 was "her usual self (that day), trying to get up every few minutes. She was a little unsteady, but had been that way for a few days, even that wasn't really out of the ordinary." Nursing Staff "N" reported that when staff is scheduled to work on middle hall, their assignment wraps around to the other room by the therapy hall. Nursing Staff "N" stated "when they do that, it is so hard to hear an alarm go off on the middle hall." In an interview on 1/30/15 at 2:35 pm, Licensed Nursing Staff "P" reported that Resident #7 "would get up every 5 to 10 minutes, she set off her alarm all the time." Licensed Nursing Staff "P" reported that if one Certified Nursing Assistant (CNA) was on break, that left 1 CNA on the hall. Licensed Nursing Staff "P" reported that she was at the nurse's station when Resident #7 fell . Licensed Nursing Staff "P" stated "I heard screams and tried to find where they were coming from. I found her (Resident #7) on the floor. I know she had the gripper socks on and the alarm was sounding." When queried if she was able to hear the alarm sounding from the nurses' station, Licensed Nursing Staff "P" stated "no", but she heard it sounding when she entered Resident #7's room. When queried what other interventions were in place, Licensed Nursing Staff "P" reported that she kept her cart right outside Resident #7's door, but she was not at her cart during the time of the fall. In an interview on 1/30/15 at 3:05 pm, Nursing Staff "O" reported that prior to the fall, Resident #7 got up unassisted several times per day. Nursing Staff "O" reported she was working when Resident #7 fell and the other Nursing Staff member assigned to Resident #7 was on break. Nursing Staff "O" reported she was around the corner in room 303, assisting another resident. Nursing Staff "O" stated "When I had come back around, we had carolers in the building. I heard screaming and (Resident #7) was on the floor." When queried if she heard the alarm sounding, Nursing Staff "O" stated, "It was going off when I came into the room." When queried if she heard the alarm sounding while in room 303, Nursing Staff "O" stated "Nope, like I said there were carolers in the building." In an interview on 1/30/15 at 3:37 pm, Director of Nursing (DON) "B" stated "prior to the fall, (Resident #7) was always trying to go to the bathroom, up frequently throughout the day. I was here that day, in my office and heard the God awfulest scream. I went to her room, she was on th floor in a lot of pain, one leg shorter than the other...we sent her out to the hospital.." When queried if she heard Resident #7's alarm from her office, DON "B" stated she could not recall if she heard an alarm sounding or not. Review of the Nurse's Notes dated 12/21/14, revealed Resident #7 was readmitted to the facility after hospitalization for a hip fracture. Review of Resident #7's care plan initiated 1/7/15, revealed "I recently fell and fractured my right hip and had to have surgery. I have been having right hip pain due to healing hip fracture. I scream out in pain with movement at times and my anxiety gets worse with transfers and walking." In an interview on 1/28/15 at 2:30 pm, Licensed Nursing Staff "M" reported that Resident #7 got up unassisted that morning and took herself to the bathroom. An observation on 1/28/15 at 2:10 pm, 1/28/15 at 3:45 pm, 1/30/15 at 10:00 am, and 1/30/15 at 3:30 pm, revealed Resident #7 was lying in bed and a floor mat was not in place. On 1/30/15 at 3:30 pm, Resident #7's alarm box was on her bed, within Resident #7's reach, not attached to anything, and the volume was set on "low". There were two options for volume, low and high". ( ) DPS B) The facility failed to ensure exits were free from snow and ice for 2 (therapy hall exit door and 300 hall exit door) of 13 exits reviewed for safety, from a total of 17 exits, resulting in the potential for a delay in safe resident exit; and failed to secure a room off of the Main dining room with potential safety hazards each potentially affecting all 79 residents. Findings include: On 2/5/15 at 4:00 pm, the #4 (physical Therapy) exit side walk was covered with ice and the exit door was unable to open freely due to the build up of ice. The walkway to the #5 and #6 exits were snow covered and the exit at #7 leading off the sidewalk was snow covered preventing a quick exit in the event of an emergency. At 4:05 pm, Maintenance supervisor "D" reported he had not kept up with the sidewalks and exits due to the weather. On 1/30/15 at 3:15 pm, There was an unidentified resident observed unattended in the dining room. In the dining room there was a room with an open door. There was a sign on the door to leave the door open so the ice machine would not stop working. This room was further observed on 2/5/15 at 9:15 am, during the environmental tour with Maintenance Supervisor (MS) "D" and Housekeeping Manager (HM) "E". The room had an exit window that was unsecured with an opening large enough for a resident to exit the window, there was a thermostat on the wall with capped wires and no cover and there was no lock on the door to secure the area. ( )

This citation pertains to MI 502. Based on interview and record review the facility failed to ensure a resident received the necessary care and services to maintain the highest practicable well-being by not providing post operative wound care in 1 of 5 residents (#4) reviewed for quality of care, from a total sample of 6 residents, resulting in surgical wound dehiscence (separation of the layers of a surgical wound) and the potential for infection. Findings Include: Review of the closed medical record revealed Resident #4 was a [AGE] year old male admitted to the facility on [DATE] for rehabilitation following a multiple vehicle accident and suffering multiple rib fractures, [MEDICAL CONDITION], pelvic fractures, vertebral fractures and had multiple surgical interventions completed, Resident #4 no longer resides at the facility. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #4 had clear speech, was understood, understands and had no cognitive impairments. Review of the Prehospital Care Report Summary (ambulance run sheet) dated 4/8/14, revealed, "Transported patient (Resident #4) to neurology appointment...patient physician advised at this point that (Resident #4) would need to be taken directly to (the) wound clinic. Review of the wound clinic consultation report dated 4/9/14, revealed that per a family member, the facility, "never changed the bandage since the day (Resident #4) left the hospital (3/19/14)...The dressing was taken off yesterday (4/8/14 at Resident #4's neurology appointment). The wound fell apart at that point...The wound is 7.5 centimeters (cm) long x 2.5 cm wide x 2.5 cm deep with undermining (deep tissue damage around the wound edge) of about 6.2 cm...There is some exposed hardware (device that was used to fuse two vertebrae together) at the very base of the wound...We may very well have to do a debridement (surgical removal of dead, damaged or infected tissue), but we would do that in conjunction with his neurosurgeon...The only surgical reconstruction for this that would be possible on an acute basis would be a...muscle flap (removal of a piece of muscle from a part of the body to be used to place over the open wound)...That would be a long 7 to 8-hour operation that would be too much for (Resident #4) considering his cardiac status. Review of the hospital "After Visit Summary" dated 3/19/14 revealed Resident #4 was discharged from the hospital 6 weeks after suffering multiple pelvic fractures, rib fractures and vertebral fractures, related to a multiple vehicle accident. The summary revealed that during the hospital stay, Resident #4 underwent surgery for [REDACTED]. Review of the hospital "Transfer Report" dated 3/19/14 revealed upon discharge, Resident #4 was to be assisted to turn every 2 hours, Resident #4's old pin sites were to be cleaned with a 1:1 peroxide/saline solution, and antibiotic cream was to be applied. The report also revealed that Resident #4's pelvis and back dressing was to be changed as needed and the dressing on the resident's chest was to be discontinued on 3/23/14. Review of the facility's "Admission Data Collection" form dated 3/19/14, under the "Skin Assessment" section, revealed Resident #4 was admitted to the facility with an approximately 8-10 inch surgical incision on his back, two 1 inch long chest tube incisions, one on each side of his chest and two 1 centimeter long incisions, one on each side of his groin. Review of the facility's "Wound Management Program" policy dated 7/1/08 and revised 10/8/10 revealed that under the "Process (Management of pressure ulcers/non pressure wounds): section of the policy the designated Wound Nurse is to develop an individualized plan of care based on assessment and update the Resident Care Guide with new interventions. The policy revealed the following was to be completed daily: 1. Verify that resident-specific Care Plan interventions are in place. 2. Inspect dressing to assure it is intact. 3. Inspect skin surrounding (the wound). The policy further revealed the following forms were to be completed weekly: 1. Weekly Non-Pressure wound documentation. 2. Weekly Non-Pressure wound log Review of Resident #4's physician's admission orders [REDACTED]. Review of Resident #4's medical chart from 3/19/14 thru 4/8/14, failed to reveal that weekly non-pressure wound documentation or logs were completed. Review of the Medication Administration Record [REDACTED]. Review of the Nurse's Notes dated 3/19/14 thru 4/7/14 failed to reveal that any type of wound care, assessment or treatment was completed for Resident #4's back, chest or groin wounds. Review of physician progress notes [REDACTED].#4's back, chest or groin wounds were assessed, or plan of treatment was put into place. Review of the "Admission Care Plan" dated 3/20/14 failed to reveal interventions were put into place to care for Resident #4's back, chest or groin wounds. The plan did did have an intervention of "turn and reposition every 2 hours while in bed and every 1 hour while in a chair", but review of the undated Resident Care Guide, the guide that Certified Nursing Assistants (CNAs) use to determine what care is to be completed each shift, failed to reveal that these interventions were put into place for the CNAs. Review of Resident #4's physician's admission orders [REDACTED]"Weekly Hydration and Skin Assessment" sheets for March and April revealed that skin assessments were not completed on 4/1/14 or 4/8/14, only after the resident returned from the wound clinic on 4/9/14 was a second skin assessment completed. In an interview on 6/19/14 at 10:06 a.m., Licensed Practical Nurse (LPN) "M" stated that when Resident #4 was admitted to the facility, she completed the initial admission assessment. When asked who was responsible for Resident #4's initial wound plan of care, LPN "M" stated, "Our unit managers are in charge of wound care. LPN "M" further stated, "(Resident #4's wounds) were extensive, so I didn't feel comfortable writing wound care orders, so I left it for the manager (Registered Nurse (RN) "Q") to complete...they are supposed to follow up on all admissions". This surveyor provided Resident #4's medical record and asked if she was able to find in the record where any type of wound care orders or treatments were documented, LPN "M" stated, "Nope, just the skin assessment that was completed on March 25th". This surveyor asked who was responsible for the initial care plan, LPN "M" stated, "we have up to 24 hours to get it in place. With admissions, we just get to the important stuff and then pass on the other stuff, I didn't do the care plan, looks like it was 3rd shift that started the care plan...that day I wasn't working the floor, just came in to do admissions, so I didn't pass report to the oncoming nurse". In an interview on 6/19/14 at 11:25 a.m., this surveyor provided Resident #4's medical chart and asked what the facility was doing for Resident #4's wounds, Unit Manager, RN "Q" responded, "nothing...I totally agree (there was no care given to his wounds while he was here)". This surveyor asked why resident #4 transferred to another facility RN "Q" stated that after they wound clinic appointment on 4/9/14, "(The family) was very upset, the (surgeon) called me and he was very upset (about the condition of the untreated wound). I talked to the daughter (of Resident #4), I told her I could apologize but that is not going to change anything, I asked her what we could do to make things better, she (Resident #4's daughter) said transfer him to another facility, so that is what we did". In an interview on 6/24/14 at 10:40 a.m., DON "B" stated that there were no treatments for Resident #4's wound until the resident returned from the wound clinic on 4/9/14. DON "B" further stated that after Resident #4 returned from the wound clinic "we looked through the entire chart and had concerns". ( )

This citation pertains to MI 502. Based on interview and record review, the facility failed to provide the necessary care and services that met professional standards by not properly assessing and implementing interventions for wound care and not following it's wound management program policy for 1 of 2 residents (#4) reviewed for wound care from a total sample of 6 sampled residents, resulting in surgical wound dehiscence (separation of the layers of a surgical wound) and the potential for infection. Findings Include: According to an article posted by the United States National Institutes of Health (http://www.ncbi.nlm.nih.gov/pubmed/ 43), "Wound management is a crucial aspect of patient care and the nurse often is faced with the question of which approaches to use to provide an environment that supports healing and prevents complications". Review of the closed medical record revealed Resident #4 was a [AGE] year old male admitted to the facility on [DATE] for rehabilitation following a multiple vehicle accident and suffering multiple rib fractures, [MEDICAL CONDITION], pelvic fractures, vertebral fractures and had multiple surgical interventions completed, Resident #4 no longer resides at the facility. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #4 had clear speech, was understood, understands and had no cognitive impairments. Review of the Prehospital Care Report Summary (ambulance run sheet) dated 4/8/14, revealed, "Transported patient (Resident #4) to neurology appointment...patient physician advised at this point that (Resident #4) would need to be taken directly to (the) wound clinic. Review of the wound clinic consultation report dated 4/9/14, revealed that per a family member, the facility, "never changed the bandage since the day (Resident #4) left the hospital (3/19/14)...The dressing was taken off yesterday (4/8/14 at Resident #4's neurology appointment). The wound fell apart at that point...The wound is 7.5 centimeters (cm) long x 2.5 cm wide x 2.5 cm deep with undermining (deep tissue damage around the wound edge) of about 6.2 cm...There is some exposed hardware (device that was used to fuse two vertebrae together) at the very base of the wound...We may very well have to do a debridement (surgical removal of dead, damaged or infected tissue), but we would do that in conjunction with his neurosurgeon...The only surgical reconstruction for this that would be possible on an acute basis would be a...muscle flap (removal of a piece of muscle from a part of the body to be used to place over the open wound)...That would be a long 7 to 8-hour operation that would be too much for (Resident #4) considering his cardiac status. Review of the hospital "After Visit Summary" dated 3/19/14 revealed Resident #4 was discharged from the hospital 6 weeks after suffering multiple pelvic fractures, rib fractures and vertebral fractures, related to a multiple vehicle accident. The summary revealed that during the hospital stay, Resident #4 underwent surgery for [REDACTED]. Review of the hospital "Transfer Report" dated 3/19/14 revealed upon discharge, Resident #4 was to be assisted to turn every 2 hours, Resident #4's old pin sites were to be cleaned with a 1:1 peroxide/saline solution, and antibiotic cream was to be applied. The report also revealed that Resident #4's pelvis and back dressing was to be changed as needed and the dressing on the resident's chest was to be discontinued on 3/23/14. Review of the facility's "Admission Data Collection" form dated 3/19/14, under the "Skin Assessment" section, revealed Resident #4 was admitted to the facility with an approximately 8-10 inch surgical incision on his back, two 1 inch long chest tube incisions, one on each side of his chest and two 1 centimeter long incisions, one on each side of his groin. Review of the facility's "Wound Management Program" policy dated 7/1/08 and revised 10/8/10 revealed that under the "Process (Management of pressure ulcers/non pressure wounds): section of the policy the designated Wound Nurse is to develop an individualized plan of care based on assessment and update the Resident Care Guide with new interventions. The policy revealed the following was to be completed daily: 1. Verify that resident-specific Care Plan interventions are in place. 2. Inspect dressing to assure it is intact. 3. Inspect skin surrounding (the wound). The policy further revealed the following forms were to be completed weekly: 1. Weekly Non-Pressure wound documentation. 2. Weekly Non-Pressure wound log Review of Resident #4's physician's admission orders [REDACTED]. Review of Resident #4's medical chart from 3/19/14 thru 4/8/14, failed to reveal that weekly non-pressure wound documentation or logs were completed. Review of the Medication Administration Record [REDACTED]. Review of the Nurse's Notes dated 3/19/14 thru 4/7/14 failed to reveal that any type of wound care, assessment or treatment was completed for Resident #4's back, chest or groin wounds. Review of physician progress notes [REDACTED].#4's back, chest or groin wounds were assessed, or plan of treatment was put into place. Review of the "Admission Care Plan" dated 3/20/14 failed to reveal interventions were put into place to care for Resident #4's back, chest or groin wounds. The plan did did have an intervention of "turn and reposition every 2 hours while in bed and every 1 hour while in a chair", but review of the undated Resident Care Guide, the guide that Certified Nursing Assistants (CNAs) use to determine what care is to be completed each shift, failed to reveal that these interventions were put into place for the CNAs. Review of Resident #4's physician's admission orders [REDACTED]"Weekly Hydration and Skin Assessment" sheets for March and April revealed that skin assessments were not completed on 4/1/14 or 4/8/14, only after the resident returned from the wound clinic on 4/9/14 was a second skin assessment completed. In an interview on 6/19/14 at 10:06 a.m., Licensed Practical Nurse (LPN) "M" stated that when Resident #4 was admitted to the facility, she completed the initial admission assessment. When asked who was responsible for Resident #4's initial wound plan of care, LPN "M" stated, "Our unit managers are in charge of wound care. LPN "M" further stated, "(Resident #4's wounds) were extensive, so I didn't feel comfortable writing wound care orders, so I left it for the manager (Registered Nurse (RN) "Q") to complete...they are supposed to follow up on all admissions". This surveyor provided Resident #4's medical record and asked if she was able to find in the record where any type of wound care orders or treatments were documented, LPN "M" stated, "Nope, just the skin assessment that was completed on March 25th". This surveyor asked who was responsible for the initial care plan, LPN "M" stated, "we have up to 24 hours to get it in place. With admissions, we just get to the important stuff and then pass on the other stuff, I didn't do the care plan, looks like it was 3rd shift that started the care plan...that day I wasn't working the floor, just came in to do admissions, so I didn't pass report to the oncoming nurse". In an interview on 6/19/14 at 11:25 a.m., this surveyor provided Resident #4's medical chart and asked what the facility was doing for Resident #4's wounds, Unit Manager, RN "Q" responded, "nothing...I totally agree (there was no care given to his wounds while he was here)". This surveyor asked why resident #4 transferred to another facility RN "Q" stated that after they wound clinic appointment on 4/9/14, "(The family) was very upset, the (surgeon) called me and he was very upset (about the condition of the untreated wound). I talked to the daughter (of Resident #4), I told her I could apologize but that is not going to change anything, I asked her what we could do to make things better, she (Resident #4's daughter) said transfer him to another facility, so that is what we did". In an interview on 6/24/14 at 10:40 a.m., DON "B" stated that there were no treatments for Resident #4's wound until the resident returned from the wound clinic on 4/9/14. DON "B" further stated that after Resident #4 returned from the wound clinic "we looked through the entire chart and had concerns". ( )

Based on observation, interview and record review, the facility failed to identify, monitor and evaluate pressure ulcers for 1 of 5 residents (#1) reviewed for concern with pressure ulcers from a total 16 sampled residents, resulting in an unstageable lumbar spine pressure ulcer. Findings include: The physician's orders [REDACTED]. The most recent minimum data set (MDS) care area assessment (CAA) dated 1/21/14 reflected resident #1 was alert and oriented to self with unclear speech, making it difficult to express her needs. Resident #1 needed total assistance with her activities of daily living (ADL), transferred with a "Hoyer" lift and was incontinent of bladder. Under pressure ulcer CAA section resident #1 was documented as having an unstageable pressure (undetermined depth of tissue destruction due to slough or necrosis) area on her back due to slough. The laboratory tests such as [MEDICATION NAME], protein, blood urea nitrogen, creatinine and complete blood count dated 12/4/13 pertinent to pressure ulcer development and healing were all documented as being within normal range. The skin care plan last revised 12/22/12 (over 1 year ago) reflected resident #1 had a potential for pressure ulcer development due to her immobility, incontinence and fragile skin subject to easy bruising. The interventions included 1) turn and reposition frequently while in bed and chair, 2) pressure reducing mattress to bed and chair, 3) follow facility policy/protocol for treatment of [REDACTED]. On 1/31/14 at 11:00 a.m., resident #1's lumbar spine pressure ulcer wound was observed assisted by the unit manager, (staff "C") in the resident's room. The wound was round with measurement of approximately quarter size and it was located slightly right of her protruding spinal column close to lumbar bony prominence. The wound bed was covered with 100 % yellow slough and the surrounding tissues were bright red. The resident was being uncooperative and attempted to move away from staff "C," making the inspection difficult. Resident #1 was showing discomfort with the maneuvering. The "Wound Assessment Details Report" dated 1/17/14 documented resident #1 had this lumbar spine pressure ulcer first identified on 1/13/14. The measurement at that time was 1.00 x 1.10 x 0.00 (L x W x D) in centimeters. However, staff "C" stated she was not sure where the date 1/13/14 came from. Staff "C" stated the first time she found out about the wound was on 1/17/14, thus she had started to measure the wound and monitor. The wound was also documented as a stage 2 (partial loss of outer skin layer). Staff "C" was directed to resident #1's MDS pressure ulcer CAA documentation. On 1/31/14 at 11:30 a.m., the unit manager, (staff "C") was asked exact onset date of resident #1's lumbar spine pressure ulcer. Staff "C" stated she started her position on 1/2/14. Staff "C" stated the nursing unit did not have a manager for a couple of months and she was not sure which staff was overseeing the unit. The nursing note dated 12/10/13 reflected, "clean with saf clens, apply [MEDICATION NAME] foam, change 3 days as needed of small red spot, middle of back lower until healed, pressure point." This was the first documentation that had identified resident #1's lumbar spine pressure ulcer. There were no skin assessments or wound assessment detail reports, thus there was no monitoring or evaluation of the wound. On 1/31/14 at 11:30 a.m., the unit manager, (staff "C") stated she ordered alternating air pressure mattress as soon as she found the wound on 1/17/14. The Annual Nutritional assessment dated [DATE] reflected resident #1 was at high risk of nutritional status. Resident #1's most current weight was 89.2 pounds with her usual body weight of 95 pounds (quarterly nutrition assessment dated [DATE] recorded the resident's usual body weight as being 105-110 pounds). This insidious weight loss combined with a lack of early assessment, monitoring and evaluation may have contributed resident #1's development of avoidable pressure ulcer. ( )

Based on interview and closed record review, the facility failed to transfer 1 of 1 resident (#16) with an acute infection to the hospital in a timely manner from a total 19 sampled residents, resulting in the quickly deteriorating clinical outcome and death; the facility also failed to coordinate hospice care for one (#10) of one residents reviewed for hospice care, resulting in the potential for resident #10 become anxious and decreased self worth. Findings include: The admission Care Area Assessment (CAA) dated [DATE] revealed resident #16, " is a [AGE] year old male admitted to the facility on [DATE] with a recent hospitalization due to swelling and redness of his left wrist. He has a history of hypertension, non-insulin dependent diabetes mellitus, previous intracranial cerebral hemorrhage that left him with lower extremity weakness. He is currently requiring extensive assistance with most of his activities of daily living (ADL) related to weakness. He is working with physical therapy and occupational therapy, but has had some issues with low blood pressure as well as with diarrhea so he has had limited time with them ...stool sample was sent to check for [MEDICAL CONDITION] and was negative ...resident is alert and oriented with some forgetfulness ... " The hospital history and physical dated [DATE] reflected resident #16 had been placed on intravenous antibiotic ([MEDICATION NAME]) for his [MEDICAL CONDITION] of left wrist. The Advance Directives dated [DATE] for resident #16 included "No" cardiopulmonary resuscitation, ventilators, [MEDICAL TREATMENT], artificial nutrition, major surgery, invasive diagnostic testing and [MEDICAL CONDITION]. Advance directives reflected "Yes" included transfer to acute care hospital for 1) inpatient treatment of [REDACTED]. The nursing notes dated [DATE] through [DATE] reflected resident #16 was weak with low blood pressures, not having a good appetite and he was having nausea, vomiting and diarrhea. Resident #16 required high flow oxygen (6 liters) to relieve symptoms of [MEDICAL CONDITION] (low oxygen). Resident #16 required blood pressure medications adjusted. Resident #16 required intravenous fluid therapy for 7 days (from [DATE] to [DATE]) to relieve symptoms of dehydration. The nursing notes dated [DATE] through [DATE] reflected resident #16's clinical status was improving to the point that he required low oxygen flow (2 liters) to maintain tissue perfusion, had a good appetite and attended therapy regularly. His vital signs were also stable including temperatures ranging 97.4 Fahrenheit to 98.7 Fahrenheit. The nursing note dated [DATE] at 1800 (6:00p) reflected, "resident complaining of being sweaty and shaking, no pain, doctor was called and said to monitor." There were no vital signs recorded. The next nursing note entry was at 2230 (10:30p) reflected, " resident at 2145 (9:45p) was unresponsive and oxygen saturation 52% on 2 liters, pulse was faint and shallow respirations. Doctor was called but no response. On call manager was called and said for resident to be on comfort care. Family was called and gave permission to release body to funeral home. " On [DATE] at 1:15 p.m., the on-call manager nurse, (staff "U" ) was interviewed about the incident involving resident #16's death. Staff "U" had vague recall of the events related to resident #16's death and spoke very little. Staff "U" stated she was in bed sleeping when the staff from the facility had called her. Staff "U" stated the situation was too late to do anything by the time she got a call, thus she did not provide any advice. Of note, after the death of resident #16 on [DATE] the nursing notes contained one and one-half pages of late entries dated [DATE] and [DATE], detailing the events prior to resident #16's death. On [DATE] at 2:00 p.m., Director of Nursing, (staff "B" ) stated she found out about resident #16's passing on Monday when she came to work. After reviewing the incident including the nursing notes she felt that the information leading to the resident's death was sketchy, thus she asked the nurse who was on duty that evening to fill in the gaps. Director of Nursing stated the nurse (staff "T" ) resigned after the incident. The late entry dated [DATE] reflected, at " 1200 hr resident complained of ache in his left shoulder. Vitals were ,[DATE], P.71, RR 18, Oxygen saturation 85%, resident expressed he felt tired. Doctor notified. Orders for [MEDICATION NAME] (diuretic) today ...weights twice a week. [MEDICATION NAME] treatment three times daily for 3 weeks. This information was already documented on the physician's visit dated [DATE]. The physician's assessment included 1) [MEDICAL CONDITION] with diastolic dysfunction ...will start [MEDICATION NAME] ...2) [MEDICAL CONDITION], 3) hypertensive [MEDICAL CONDITION], 4) acute [MEDICAL CONDITION] with mild [MEDICAL CONDITION] ...will start [MEDICATION NAME] ... " The late entry dated [DATE] reflected, at 1430 (2:30p) on [DATE] resident was given "[MEDICATION NAME]" for back pain. At 1500 (3:00p) vitals; ,[DATE], temperature 101 degrees Fahrenheit, pulse 70 respiration 18, oxygen saturation 92 % on 2 liters per nasal cannula, denies pain, resident complaining of shaking and sweating. [MEDICATION NAME] given. Lungs clear pre and post treatment. Tylenol 2 tabs given. At 1800 (6:00p) vitals ,[DATE]. T 98.5 Pulse 74, RR 18. Doctor was called and reported elevated temperature, chills and sweaty, responded to Tylenol, said he didn't feel good. Doctor said to check and monitor. The late entry for [DATE] reflected, at 2000 (8:00p) vitals; T 98.3, P 70, RR 18, blood sugar 194, continues to complaining of shaking, sweating, didn't feel good ...complaining of nausea, denies pain. At 2100 (9:00 p) vitals ,[DATE], T 98.4, P 70, RR 18, denies pain. Resident alert and oriented. [MEDICATION NAME] given. At 2145 (9:45p) CNA (certified nursing assistant) came and told me resident was unresponsive. Vitals; pulse 40, RR 8, Oxygen saturation 52%. Blood pressure could not be obtained. Doctor called x2 with no response. POA (power of Attorney) called and told resident deteriorating rapidly ... " On [DATE] at 2:30 p.m., the licensed practical nurse, (staff "T") was called for an interview, but staff "T" did not return the call. On [DATE] at 2:40 p.m., Director of Nursing, (staff "B") stated staff "T" was new and inexperienced and had never been involved in an actual emergency. Staff "B" continued to state she educated staff "T" regarding SBAR (situation, background, analysis, response) for gathering information, leading to her critical thinking as well as use of emergency equipment and re-breather mask ( was not utilized for resident #16 during acute hypoxic period). Resident #16 had a change of condition that required prompt hospitalization per his advance directives that was not honored, potentially contributing to the resident's death on [DATE]. ( ) According to the facility admission record dated [DATE], resident #10 was a [AGE] year old female with [DIAGNOSES REDACTED]. A significant minimum data set assessment was done on [DATE] and reflected resident #10 scored a "5" on the brief interview for mental status, which indicated cognitive impairment. Resident #10 was signed up for hospice services on [DATE] due to her declining condition. Resident #10 care guide under the special instructions section reflected "No male caregivers." The nursing care plan with a revision date of [DATE] reflected "I do not want male caregivers. Please assign females only to assist me with my care." On [DATE] at 1:00 p.m., during a confidential family interview with resident #10's family, it was reported that resident #10 was never married, never dated, disliked and was fearful of men throughout her lifetime. On [DATE] at 11:20 a.m., during an interview with the hospice nurse "F" she was not aware of resident #10's care guide and care plan that specifically requested no male caregivers and reported none of the facility staff have conveyed this to her. A review of the hospice documentation reflected that hospice had assigned a male caregiver to resident #10 whom provided personal care including bathing on ,[DATE], ,[DATE], ,[DATE] and [DATE]. On [DATE] at 10:30 a.m. during an interview with nurse manager "C" she reported that she had not conveyed or coordinated this preference about resident #10 with the hospice team. On [DATE] at 10:35 a.m., during an interview with the Director of Nursing "B" she reported that she had spoken with the hospice nurse "F" yesterday and hospice was going to adjust the schedule so that resident #10 would no longer have a male providing personal care. ( )

This citation pertains to MI 832, MI 883, and MI 886 Based on observation, interview, and record review, the facility failed to implement adequate safety interventions for 2 (Resident #1 and Resident #5) of 4 residents reviewed for falls, from a total sample of 5 resulting in: 1) Resident #1 sustaining a skin tear after an improper transfer, 2) Resident #1 sustaining a laceration requiring 15 sutures to the forehead after a fall where the wheelchair cushion was not in place and the wheelchair foot pedals were attached, and 3) the potential for injury for Resident #5 who was transferred without the use of a gait belt. Findings include: Resident #1 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #1 was an [AGE] year old female, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed that a Brief Interview for Mental Status (BIMS) was not completed and Resident #1 transferred with extensive assistance. Review of the Fall Care Plan dated 3/1/13, revealed that as of 7/3/13, Resident #1 required the use of the EZ stand (sit to stand mechanical lift) for transfers and as of 7/15/13, needed a wedge cushion in her wheelchair. Review of the ADL (Activities of Daily Living) Care Plan dated 3/1/13, revealed that as of 3/14/13, staff was to remove Resident #1's wheelchair foot pedals to allow her to self-navigate her wheelchair. Review of the Potential for Pressure Ulcer Care Plan dated 3/1/13, revealed staff was to remove Resident #1's wheelchair foot pedals to allow for self-navigation and reduce risk of hitting her leg. Review of the Resident Care Guide (undated) that was in Resident #1's closed chart, revealed "remove w/c (wheelchair) foot pedals when self-navigating" and "wedge cushion to w/c". The Resident Care Guide did not mention the use of an EZ stand. Review of the facility's investigation, revealed an additional undated Resident Care Guide that revealed Resident #1 transferred with an EZ stand. Review of Skil-Care Corporation's manufactures guidelines for the wheelchair wedge, revealed "wedges are recommended when you want to lean your resident back in the wheelchair in order to promote better sitting posture ans reduce sliding". Review of the Unusual Occurrence report dated 9/21/13, revealed Resident #1 sustained a laceration to her left leg during a 2 person transfer from her bed to wheelchair. Review of the facility's Investigation of Unusual Occurrence revealed that Resident #1's care was not in compliance with her plan of care at the time of the incident. The investigation revealed the explanation was that Resident #1's care plan stated she was an EZ stand transfer and that she also had her wheelchair pedals on during the transfer. The investigation revealed "due to improper transfer and foot pedal placements, Resident (Resident #1) obtained 2-3 cm (centimeter) laceration to left lower leg". In an interview on 10/9/13 at 2:35 PM, Certified Nursing Assistant (CNA) "E" reported that she and CNA "H" transferred Resident #1 on 9/21/13. CNA "E" stated "All I saw on the care guide was 2 person. I didn't look farther down and see EZ stand. When we transferred her, her leg got caught on the foot pedal. The other aide left the foot pedals on". When queried if she agreed that she transferred Resident #1 improperly, CNA "E" stated "yes". ( , ) This surveyor attempted to contact CNA "H", but no return call was received prior to the survey exit date. ( ) Review of the facility's investigation revealed a witness statement written by CNA "H". The statement revealed "transferring resident with two person transfer..." In a telephone interview on 10/9/13, Licensed Practical Nurse (LPN) "G" reported that on 9/21/13, Resident #1 was transferred to the hospital because "it (the skin tear) looked really deep." ( ) Review of the Hospital Records dated 9/21/13, revealed Resident #1 was transferred to the hospital because "they (the facility) felt that it was deep enough to require an evaluation". The Emergency Department Chart Physical Exam revealed "Primary closure of the 10 cm skin tear on the left calf...was performed using skin adhesive and Steri-strips. The Emergency Department Progress Notes revealed "due to the integrity of the skin...wound cannot be sutured". Review of the Unusual Occurrence report dated 9/22/13, revealed Resident #1 was observed on the floor at 5:45 PM and had a skin tear to her right shoulder and a laceration to her forehead. The section titled "Items witnessed and in place at time of event. Check all that apply", revealed that Resident #1 transferred independently and the box for "wedges in place" was not checked. There was no mention of wheelchair foot pedals. Review of the Emergency Department Chart dated 9/22/13, revealed Resident #1 had a laceration located over the middle and left side of her forehead that measured 17 centimeters in length. The Procedure report revealed "laceration repair took a total of one hour...closed with 15 sutures". In an interview on 10/9/13 at 10:42 AM, CNA "D" reported that she and CNA "F" took Resident #1 to the bathroom and then put her back in the wheelchair. CNA "D" stated that she was the last staff member to see Resident #1 prior to her fall on 9/22/13. CNA "D" reported that Resident #1 did not have a cushion in her wheelchair and had her wheelchair pedals attached to the wheelchair. When queried what it meant when the Resident Care Guide indicated wedge cushion to wheelchair, CNA "D" stated "I'm not really sure". When queried if wedges or other positioning devices were ever used in wheelchairs, CNA "D" stated "Not that I know of. Not that I have seen". ( , ) In an interview on 10/9/13 at 2:00 PM, CNA "F" reported that on 9/22/13, she assisted CNA "D" with Resident #1's care prior to her fall on 9/22/13. CNA "F" reported that she left Resident #1's room before CNA "D". When queried if Resident #1 had a cushion in her wheelchair, CNA "F" stated "nope". CNA "D" reported that she was in Resident #1's room after the fall and could not remember if the foot pedals were on the wheelchair. ( , ) In a telephone interview on 10/9/13 at 2:35 PM, CNA "E" reported that she was the staff member who observed Resident #1 on the floor on 9/22/13. CNA "E" stated "don't recall the foot pedals being on. I was focused on her (Resident #1)" . CNA "E" reported there was a black and yellow cushion in Resident #1' s wheelchair. When queried as to what type of cushion it was, CNA "E" stated "I don't know..." When queried if Resident #1 was to have wheelchair foot pedals in place while in her room, CNA "E" stated "No because she would take her feet off of them..." ( , ) In a telephone interview on 10/9/13 at 3:25 PM, LPN "G" reported that she was the nurse on duty when Resident #1 fell on [DATE]. LPN "G" stated that Resident #1 had "just a pressure reduction cushion "in her wheelchair. When queried what the wedges in place section in the Unusual Occurrence report was for, LPN "G" stated "I don't know". LPN "G" reported that Resident #1 was not to have wheelchair foot pedals in place unless staff was propelling her. ( ) In an interview on 10/10/13 at 9:50 AM, MDS Coordinator "C" reported that she was the Interim Director of Nursing (DON) on 9/22/13. When queried if Resident #1 should or should not have had her wheelchair foot pedals on, MDS Coordinator "C" stated "according to (Resident #1's) care plan, it says to remove my foot pedals to allow me to self-navigate". ( , ) Resident #5 Review of the Face Sheet and MDS dated [DATE], revealed Resident #5 was an [AGE] year old female, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed Resident #5 used 1 person physical assistance for transfers and she was not steady and only able to stabilize with staff assistance when she moved on and off the toilet. Review of Resident #5's Fall Care Plan dated 11/7/13, revealed as of 4/30/13, she needed one person assist for transfers. Review of the Resident Care Guide (undated) revealed Resident #5 transferred with 1 person assistance. An observation on 10/8/13 at 11:25 AM, revealed that CNA "K" transferred Resident #5 from the wheelchair to the toilet without the use of a gait belt. When CNA "K" was queried if she should have used a gait belt during the observed transfer, CNA "K" stated "I'm not sure about that". ( ) In an interview on 10/8/13 at 11:35 AM, MDS Coordinator "C" reported that a gait belt should be used for 1 person assist transfers. ( ) Review of the facility's Transfer Techniques Policy and Procedure dated 7/1/08, revealed "General Instructions: 5. Use gait belt". ( , )

This citation pertains to MI 092. Based on observation, interview, and record review, the facility failed to provide adequate supervision and/or assistive devices for 1 of 3 residents (Resident #102) reviewed for accidents, from a total of 3 sampled residents, resulting in a fall with fracture for Resident #102. Findings include: Per the Facility Investigation Report -5 Working Days, dated 11/14/12, "Summary of Incident of 11/6/12, and reported 11/8/12, (Resident #102) was observed sitting on the floor in our activities room. Initial assessment was negative for any identified injury. However, ongoing assessments, noted favoring of left leg during ambulation assistance. Subsequent x-ray was inconclusive with further x-ray ordered. This x-ray revealed a recent non-displaced fracture of the left femoral neck (hip) with sclerosis, of undetermined age as of 11/8/12. ..It was identified that after being toileted 5 minutes before the incident, the CNA (Certified Nurse Aide) who completed the toileting could not recall that the tab alarm was in place...It has been identified that our care plan was not followed as the tab alarm was not on (Resident #102)..." Per the Minimum Data Set, dated dated [DATE], Resident #102 had severe cognitive impairment, and [DIAGNOSES REDACTED]. Per Resident #102's care plan, dated 2/10/12, "I am at high risk for falls r/t (related to) my [DIAGNOSES REDACTED]. I am incontinent at times and take medication that may contribute to my falls...I use a sensor pad electronic alarm on my bed and in my wheelchair. Ensure the device is in place and turned on at all times because I try to transfer myself and do not ask for assistance and don't understand hto (how to) use call light". Nurses' Notes, dated 9/21/12, revealed Resident #102's daughter #11 requested Resident #102 have both a sensor alarm and a tab alarm for safety. Per physician orders [REDACTED]. On 11/15/12 between 12:01-12:09, Resident #102 was observed with her eyes closed, sitting in a wheelchair at a table in the Activity Room; there were no staff present in the Activity Room. There was a tab alarm on the back of the wheelchair and there was a pressure alarm on the seat cushion, under Resident #102. At 12:09, nurse aide #4 and Activities Director #6 entered the Activities Room, and then nurse aide #4 wheeled Resident #102 out of the Activity Room. In an interview, on 11/15/12 at 2:00 PM, nurse aide #1 identified herself as a nurse aide who assisted Resident #102 on 11/06/12. Nurse aide #1 stated, "I did not realize (Resident #102) did not have her tab alarm on but she had a pressure sensor (alarm) on". When asked who was watching Resident #102 while she was in the Activity Room, nurse aide #1 stated, "We're all supposed to watch them (residents) when they are in there (Activity Room)". In an interview, on 11/16/12 at 11:29 AM, Unit Manager #14 reported working second shift on 11/06/12, and (at 8:00 PM) she assisted with walking Resident #102 to the bathroom when she heard a "popping/cracking noise" and immediately put Resident #102 into bed. Unit Manager #14 reported she immediately assessed Resident #102 and stated, "There was no rotation seen or crepitus (crackling sound) heard during range of motion. (Resident #102) kept trying to set up. I called the doctor for x-rays...later sent to ER (emergency room ) where they saw a fracture of (Resident #102's) femur (hip)". Unit Manager #14 reported that Resident #102's alarms did not sound at the time of the fall because "the sensor pad clip was broken...they (both alarms: tab alarm and pressure alarm) failed. It was the perfect storm". In an interview, on 11/16/12 at 1:00 PM, LPN/Licensed Practical Nurse #12 identified herself as the nurse assigned to Resident #102 on 11/06/12, and as the nurse that performed a physical assessment on Resident #102 immediately after she was observed sitting on the floor of the Activity Room. LPN #12 stated, "There was no alarm sounding...A visitor alerted (nurse aide #13). I was paged. I did not see a tab alarm on (Resident #102). The pressure alarm tab (on the pressure alarm cord that fits into the pressure alarm pad) was not in the pad. I didn't notice that it was broken...(Resident #102) had a tab alarm and a pressure alarm because she tries to get up and move more than other residents. (Nurse aide #13) was on then (assigned to Resident #102)". LPN #12 reported she did a complete head to toe assessment on Resident #102 and found no impairments and no complaints of pain before she and nurse aide #13 placed Resident #102 into her wheelchair and took her to her bathroom to toilet her. In a telephone interview, on 11/07/12 at 2:10 PM, nurse aide #13 stated, "I didn't think I was assigned to (Resident #102). I didn't work with (Resident #102) all day. When she fell , she was supposed to be my resident. A visitor approached me and I went in there (Activity Room). (Resident #102) was lying on the floor and trying to get up. There were not any alarms going off". ( )

This citation pertains to MI 159, MI 655, and MI 161. Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices for 3 of 4 Sampled Residents (Resident #101, Resident #102, and Resident #104) who were at high risk of falls, from a total of 4 Sampled Residents (who were at high risk for falls), resulting in a fall with injury for Resident #101, a fall with injury for Resident #102, a fall with the potential for injury for Resident #104, and the potential for falls for an additional 24 residents with care planned alarm devices. Findings include: Per the facility "Alarm Devices - Use of" Policy and Procedure, dated [DATE], "The purpose of alarm devices is to alert staff to aid in the prevention and/or reduction of resident accidents and falls...Charge nurses to ensure proper application of the alarm device, and that the devices with the on/off switch are turned to the 'On' position when applicable..." Per the "Attendant" Pressure Pad Alarm product information guide,"...The warranty period and our obligations under the warranty will end before one year after shipment...Inspect the product for damage before each use and do not us it if the product appears to be damaged or is not functioning properly..." Per the "Lesson B: Resident Care Devices and Products/in-service training materials," dated [DATE], "...Demonstrate resetting the alarm. Identify any process for battery charging or changing..." The in-service training material did not include information regarding inspecting Pressure alarm pads for damage or expiration, or information as to who was responsible for dating Pressure pads. In an interview, on [DATE] at 10:50 AM, DON #8 stated, "Whoever puts it (the pressure alarm pad) on (the bed or wheelchair) dates it. DON/Director of Nursing #8 stated, "The CNAs (nurse aides) are responsible to check the (Pressure and Tab) alarms every shift; the nurses check the wanderguards (departure alert system)...I don't know if the CNAs check for frayed wires." When Surveyor # asked DON #8 what the blinking light on the alarm boxes indicated and whether the nurse aides were educated regarding the blinking light, DON #8 replied that she was unaware that the alarm boxes had a blinking light. In an interview, on [DATE] at 1:00 PM, LPN/Licensed Practical Nurse #18 stated, "No," she had not been in-serviced on the use of Pressure/Tab alarms lately, and LPN #18 stated she did not remember being educated about alarms in orientation. LPN #18 stated she had worked at the facility for 1 year and 3 months. Resident #101 Resident #101 no longer resided at the facility at the time of the investigation. Per the MDS/Minimum Data Set, dated dated [DATE], Resident #101 was admitted to the facility on [DATE], needed extensive assistance with transfers, and scored ,[DATE] on "Cognitive Patterns" (memory problems). Per the physician progress notes [REDACTED]. According to "Nurse's Notes," dated [DATE], Resident #101 "turned (alarm) unit off and put unit in her bag." Per Resident #101's "FALL" care plan, dated [DATE], "I have a hx (history) of multiple times at home before I went to the hospital and I have fallen since my admission to this facility. I have multiple risk factors that put me at a high risk for falling again... ([DATE]) Sensor (Pressure) and Tab alarms on w/c (wheelchair)." Review of Resident #101's Care Guide did not indicate that Resident #101 was to have a Tab alarm while in the wheelchair. According to Resident #101's "Nurse's Notes," Resident #101 sustained falls without injury on [DATE] at 2:15 PM, [DATE] at 7:45 PM, [DATE] at 9:15 AM, [DATE] at 10:00 AM, [DATE] at (no time indicated), and [DATE] at 7:30 AM (the same day she later fell and sustained injury). Per the facility "Unusual Occurrence" report, written by LPN/Licensed Practical Nurse #14, dated [DATE], Resident #101 had a fall at 7:00 PM, and sustained a "left lateral (outer) side of face, 2 cm long bruise; 1.5 cm long by 0.6 cm wide left arm skin tear; left elbow 2 cm by 0.5 cm and 0.4 cm laceration (cut) , (and) laceration over left eye 0.8 cm by 0.1 cm wide...After this investigation the following conclusion was drawn: NO harm occurred..." According to this "Unusual Occurrence" report, there were no alarms sounding. Per the "Emergency Department Chart" dated [DATE], regarding Resident #101, "...Left upper extremity tenderness over the left elbow without joint effusion (fluid in the joint) and 1 cm laceration on the lateral aspect of the elbow...5 mm laceration over the left temple without active bleeding...There is an uncomplicated horizontal laceration located over the left side of forehead which is 0.5 cm in length. This wound will require surgical closure to stabilize wound edges and ensure optimal healing. There is an uncomplicated laceration located over the left elbow which is 1 cm in length. This wound will require surgical closure to stabilize wound edges and ensure optimal healing..." In an in interview, on [DATE] at 1:36 PM, nurse aide #4 stated there were no alarms sounding when she found Resident #101 walking out of her room on [DATE] with blood on her face. In an interview, on [DATE] at 1:43 PM, nurse aide #3 stated, "I saw (Resident #101) come out of her room and go across the hall...I went to her....(Resident #101) went back into her room and sat on the bed." Nurse aide #3 stated she did not hear an alarm sounding and that she did not check the Pressure alarm afterwards, but stated she was "200% positive" she turned it "ON" prior to the incident, at the time she toileted Resident #101. In an interview on [DATE] at 3:30 PM, DON #8 revealed that there was no Tab alarm on Resident #101's wheelchair on [DATE] at 7:00 PM, and that Resident #101's Pressure alarm was not checked to determine the reason it did not sound after Resident #101 fell on [DATE] at 7:00 PM. DON #8 stated, "No one told me if it was OFF or ON." Per the "Supervisor/Manger's Investigation, dated [DATE], DON/Director of Nursing #8 wrote, "...Poor safety awareness and very impulsive...Sensor (Pressure) alarm box placed low behind w/c (wheelchair) where (Resident #101) can't reach." The investigation did not include an examination of the "OFF/ON" switch, and the Pressure alarm pad and box were not examined to rule out why the alarm had malfunctioned. ( and ) Resident #102 According to the MDS/Minimum Data Set, dated dated [DATE], Resident #102 had [DIAGNOSES REDACTED]. Per Resident #102's "FALLS" care plan, dated [DATE], Resident #102 was to have a "Sensor alarm on bed and w/c (wheelchair)." On [DATE] at 3:30 PM, DON/Director of Nursing #8 stated that although Resident #102's wheelchair Pressure alarm was not sounding when she sustained an unwitnessed fall and was found on the floor on [DATE] at 9:45 AM, DON #8 was present and "assessed the scene," and "based on how (Resident #102) looked (at the time), everything pointed to a cardiac event." In an interview, on [DATE] at 11:40 AM, nurse aide #17 stated she was assigned to Resident #102 on [DATE], took Resident #102's vital signs at approximately 7:40 AM, and had left Resident #102 sitting in her wheelchair at her bedside at approximately 9:40 AM, after having just toileted her; at which time Resident #102 was smiling and talking. Nurse aide #17 told Surveyors ( and ) that she remembered turning OFF Resident #102's wheelchair Pressure alarm when she was toileting Resident #102, but she could not remember if she turned it back ON. In an interview, on [DATE] at 12:00 PM, nurse aide #6 stated she found Resident #102 lying on the floor at 9:55 AM. Nurse aide #6 stated, "I didn't hear an alarm going off." In an interview, on [DATE] at 9:09 AM, LPN/Licensed Practical Nurse #15 stated she was called to Resident #102's room, on [DATE] at 9:45 AM by nurse aide #6, who was standing in the hallway looking into room #204 and saying, "Oh my god, she's (Resident #102) on the floor." LPN #15 stated she did not remember hearing an alarm sounding, and when she entered room #204 she saw Resident #102 lying on the floor, with her face turned to the left "in a pool of blood." LPN #15 stated she found Resident #102 without a pulse or respirations, and that she was unable to get Resident #102 to respond when she called her name. LPN #15 stated she applied pressure to "a 1 ,[DATE] inch cut over (Resident #102's) eye" and ordered nurse aide #6 to get help. According to LPN #15, Registered Nurse (RN) #16 arrived within seconds and "took over." In an interview, on [DATE] at 9:52 AM, RN #16 stated, "When I got to the room (Resident #102) was on her right side lying on the floor. (LPN #15) was with her, and there was a pool of blood under (Resident #102's) head, approximately 7 inches by ,[DATE] inches. I bent down and checked (Resident #102) for pulse and respirations. (Resident #102's) face was cyanotic (blue); very shallow respirations. I did feel a radial pulse in her left arm. I felt her last heart beats and saw her last breaths." RN #16 stated she was ACLS (Advanced Cardiac Life Support) trained and that she ordered the crash cart, vital signs, machine gauze pads, and 911 called because, "Even though (Resident #102) was No CPR (no cardiopulmonary resuscitation), No CPR doesn't mean don't treat. We knew we weren't going to do chest compression because of her wishes. I don't want to lose my nursing license for coding someone who is a documented legal NO CODE. We did emergency procedures required for the situation given her wishes." According to RN #16, Resident #102's responsible party and Physician #13 were aware that Resident #102's pulse had been running higher than expected for someone with a pacemaker for the past few days, and it was well known that Resident #102 had life-threatening cardiac issues; it was decided between them not to intervene. RN #16 stated that "One - two minutes" elapsed between the time she was unable to find any vital signs on Resident #102 and when the EMS (Emergency Medical System) responders arrived on the scene. When asked if there was a possibility that abuse was involved, RN #16 stated, "Seems outlandish to me given our resident population." According to the "Prehospital Care Report Summary," dated [DATE], "Call Received: 10:00:49 ...On Scene: 10:06:39 ...On (July) 16 2012 we find a [AGE] years old female patient presenting with cardiac arrest which started on (July) 16 2012." Per the "Medical Certificate of Death", "date of death : [DATE]. Time Pronounced Dead: 10:15 AM...Cause of Death: a. Cardio [DIAGNOSES REDACTED] (dysfunction); b. Acute Cardiac Arrest (heart attack)." Per the "Supervisor/Manger's Investigation, dated [DATE], written by DON/Director of Nursing #8, there was no investigation as to why the Pressure alarm on Resident #102's wheelchair was not sounding at the time she was found on the floor on [DATE]. ( and ) Resident #104 Per the MDS/Minimum Data Set, dated dated [DATE], Resident #104 was admitted to the facility on [DATE], had no mental impairments, was totally dependent upon staff for transfers, and had weakness on one side of her upper and lower body. Per Physician #13's progress notes, dated [DATE], "(Resident #104) had dementia with old CVA (stroke) with left hemiparesis (weakness)..." Per Resident #104's "FALLS" care plan, dated [DATE], "I am at risk for falls because I recently had a stroke and have left sided weakness... Chair and bed Tab alarm(s) (added [DATE])." On [DATE] at 10:02 AM, the Surveyors ( and ) observed Resident #104 lying in bed. There was a winged perimeter mattress on the bed, a Pressure alarm under the resident and one in her wheelchair, and there was a cushioned mat lying on the floor next to the bed. The bed was in a low position, but there was no Tab alarm on Resident #104. Review of "Unusual Occurrence" reports revealed that Resident #104 fell on [DATE] at 7:00 PM (without injury), [DATE] 6:50 AM (without injury), and on [DATE] (without injury). Per "Nurse's Notes", dated [DATE], "(Resident #104) observed on floor at (8:45 PM)..." Per the "Facility Investigation Report - 5 Days," dated [DATE], "Date of Incident: [DATE] ... (Resident #104) sustained a fall on [DATE] at (8:45 PM)...There was no injury noted. The fall was reported to the state on [DATE], as it appeared there was no tab alarm on this resident as was the plan of care ...(Resident #104) denied having turned off or moved the tab alarm...Tab alarm was at bedside...(Nurse aide #1) found resident on floor in front of closet. Admits to not knowing that (Resident #104) needed a Tab alarm, not reading the care guide, and thus not following the plan of care..." On [DATE] at 9:55 AM, Surveyors ( and ) accompanied nurse aide #2 to Resident #104's room and asked nurse aide #2 to explain the meaning of the date marked on the Pressure alarm in Resident #104's wheelchair. Nurse aide #2 replied, "I can't tell ya, to be honest." Nurse aide #2 left the room and when she returned a minute later, nurse aide #2 stated, "(Unit Manager #9) told me that the date is when it (the Pressure pad) was put on the bed, and it is good for one year (expires one year after dated)." ( and )

This citation pertains to intake number MI 601 Based on observation, interview, and record review, the facility failed to prevent the elopement and ensure the safety in 1 of 5 sampled residents (Resident #101), from a total of 6 sampled residents, resulting in an Immediate Jeopardy (IJ) when Resident #101, who was identified as an elopement risk and at risk for falls, exited the facility at approximately 7:50 PM on 6/2/12, unbeknownst to facility staff. Resident #101 was found at approximately 8:00 PM in the employee parking lot, walking with her walker approximately 100 feet from a 55 MPH (miles per hour) 2-lane county road. Findings include: Review of the Unusual Occurrence, dated 6/2/12 at 8:00 PM revealed, Resident #101 eloped outside the facility and was observed in the staff parking lot. Observations on 6/14/12 at 9:20 AM, revealed that 2 of 16 exit doors were wanderguard- alarmed (an alarm that beeps with an overhead announcement indicating which door is open when a resident wearing a wanderguard bracelet attempts to exit the door). In addition, the 2 entrances had key pad alarms that were turned on between 9:00 PM and 6:00 AM, when these doors were locked. The alarms were functioning properly. The employee entrance had a key pad lock to enter and exit with an additional key pad door to the resident area in the facility. The remaining exit doors had key pad exits which were in place and functioning properly. All exit doors were key pad locked and were observed to have an alarm that beeped and had an overhead voice alarm which announced the location of the open door. Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], revealed Resident #101 was an [AGE] year-old female, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated Resident #101 was severely cognitively impaired for daily decision-making skills and had a history of [REDACTED]. In an interview on 6/14/12 at 2:00 PM, Licensed Practical Nurse (LPN) #3 reported she observed Resident #101 on 6/2/12 at approximately 7:50 PM. LPN #3 reported she thought she heard a door alarm sound (the overhead voice alarm that informs staff of which door is open) on 6/2/12 a little before Certified Nursing Assistant (CNA) #6 informed her that Resident #101 had been found outside the facility at 8:00 PM. In interviews on 6/15/12 at 9:55 AM and 2:20 PM, CNA #6 reported Resident #101 was observed at 8:00 PM outside the employee door in the parking lot going towards a 55 MPH 2-lane county road. CNA #6 reported Resident #101 was moving fast with her walker in a straight line towards the 55 MPH 2 lane county road when CNA #6 just happened to glance at the North Employee Exit and see her. CNA #6 stated she did not notice anyone in the employee parking area except Resident #101 and had not heard the overhead voice alarm or the beeping alarm sound until she brought Resident #101 back into the facility. CNA #6 stated Resident #101 was very confused, unsteady when ambulating and swaying from side to side. CNA #6 stated that she did not know from which door Resident #101 exited the facility. CNA #6 stated that before Resident #101 eloped on 6/2/12 the overhead voice alarms could barely be heard. In an interview on 6/14/12 at 5:05 PM, CNA #9 reported that on 6/2/12 Resident #101 was on the couch at the South Hall Nursing Station at approximately 7:30 PM. CNA #9 stated Resident #101 was usually a stand by assist when she was up with her walker because she was not steady. CNA #9 stated she did not hear any door alarms sound until 8:00 PM when CNA #6 was bringing Resident #101 back into the building from outside. CNA #9 stated that if she was in a resident's room doing care and the television was on, she would not hear an overhead alarm going off. In an interview on 6/14/12 at 3:00 PM, LPN #27 stated on 6/2/12 she noted Resident #101 at approximately 7:40 PM down the hall outside the therapy room, LPN #27 then entered a resident's room two doors from the employee entrance/exit, LPN #27 stated that she heard the employee entrance/exit door alarm beep (but not the overhead voice alarm), stepped in the hallway about one minute after she had heard the beep, looked towards the employee parking area, but did not see anyone so she resumed resident care. In an interview on 6/14/12 at 3:16 PM, CNA #28 stated that on 6/2/12 she was working 2nd shift and heard one alarm (the overhead voice alarm and not the beeping alarm) at approximately 8:00 PM while she was in a room doing care. CNA #28 stated the alarm was a man's muffled unclear voice and only sounded once so she did not respond. Review of the Rehab Services Screening Form, dated 4/9/12, revealed Resident #101 "lacks any safety awareness or ability to carry over safety techniques. Require SBA (stand by assist) for all transfers and ambulation to ensure safety". In an interview on 6/21/12 at 11:28 AM, Occupational Therapist (OT) #19 stated Resident #101 was a SBA when she was ambulating with her walker, because she was "easily distractible and cognitively impaired". In an interview on 6/19/12 at 3:55 PM, LPN #29 stated Resident #101 was unsteady on her feet and leaned off to one side when she was up for too long and was forgetful and confused. In an interview on 6/14/12 at 3:40 PM, Administrator #1 stated she did not know which door Resident #101 had eloped from. Review of the Treatment Record for June 2012, revealed from 6/1/12 through 6/2/12, Resident #101's wanderguard bracelet was checked for placement every shift and functionality once a day on the 10:00 PM-6:00 AM shift. On 6/14/12 at 10:15 AM, this surveyor observed Resident #101 in a wheelchair in the Therapy Room groomed and dressed appropriately for the day- leg supports were in place, with her feet up on foot peddles and shoes on. Resident #101 had tab alarm attached to the wheelchair and a wanderguard bracelet was noted to be on her left ankle. Both were functioning properly. Resident #101 was observed at other times during the on-site investigation from 6/19-6/22/12 in her wheelchair on the South Hall, eating in the main dining room, participating in activities, and working with therapist. Resident #101 was unable to tell this surveyor about the elopement on 6/2/12. Observations on 6/14/12 at 10:20 AM, during a tour of the residents' living areas, revealed 22 of 22 residents, assessed to be at risk for elopement, had wanderguard bracelets in place and functioning properly. On 6/19/12 at 3:45 PM, the Administrator was notified of the Immediate Jeopardy that began on 6/2/12 and was identified on 6/14/12, when the facility failed to prevent the elopement and ensure the safety of Resident #101, who had been identified as an elopement risk and who eloped from the facility on 6/2/12 at approximately 7:50 PM, unbeknownst to facility staff. Resident #101 was found at approximately 8:00 PM in the employee parking lot walking with her walker approximately 100 feet from a 55 MPH (miles per hour) 2-lane county road. On 6/20/12, this surveyor confirmed that the facility staff implemented the following to remove the Immediate Jeopardy: 1. On 6/2/12, Resident #101 was assessed by the Nurse Supervisor and and no injury was noted. 2. On 6/2/12, Resident #101's wanderguard bracelet was checked for functioning, a new wanderguard bracelet was applied even though Resident #101's was found to be functioning properly. 3. On 6/2/12, Resident #101 was placed on 15 minute checks. 4. On 6/2/12, nine exit doors were checked for proper functioning. 5. On 6/2/12, signs were posted on all entrance/exit doors which alerted visitors not to assist residents outside. 6. On 6/3/12, the Director of Maintenance checked all door alarms for proper functioning. 7. On 6/4/12, 76 of 76 residents were audited for identification of wandering or exit seeking behaviors by Social Services and Unit Managers. 20 of 76 residents were identified at risk for elopement. 8. On 6/4/12, the 20 residents identified at risk for elopement were audited: Plans of Care, Elopement risk assessments, and Resident Care Delivery Guides were updated as needed by Social Services and Unit Managers. 9. On 6/4/12, audits of the Treatment Administration Records (TAR) to ensure documentation for placement and function checks of the wanderguard bracelets were completed by the Unit Managers for the 20 residents identified at risk for elopement. 10. On 6/4/12, the Elopement Book was audited by the Social Service Director to ensure the data was current for the 20 residents identified at risk for elopement. 11. On 6/4/12, staff and visitors were no longer permitted use of the North and Elm Hall entrance/exit doors and signs were posted to alert them of the change. 12. On 6/4/12, Policies and Procedures for Elopement and Missing Residents were reviewed and deemed appropriate by the Administrator and Director of Nursing. 13. On 6/4/12, weekend exit door audits were added to the Weekend Manager rounds. 14. On 6/5/12, mag locks were reactivated on the North and Elm Hall exit doors, an outside contractor audited all doors for proper function, and the Director of Maintenance increased the volume of the overhead announcements to alert staff when an exit door is opened. 15. 108 of 125 employees received inservicing on facility Elopement and Missing Residents policies between 6/4/12 and 6/6/12 from the Staff Development Director. Employees not available received the inservice prior to returning to work. 16. On 6/6/12, the Administrator and Director of Maintenance did employee door alarm audits. 17. On 6/6/12, the Administrator and Director of Social Services completed missing resident drills. Although the Immediate Jeopardy was removed on 6/6/12, the facility remained out of compliance at a scope of isolated and a severity of no actual harm with potential for than minimal harm that is not Immediate Jeopardy due to the fact that sustained compliance had not yet been verified by the State Agency. (# )

THIS CITATION PERTAINS TO MI 503 BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT THE ELOPEMENT AND ENSURE THE SAFETY IN 1 OF 10 SAMPLED RESIDENTS FROM A TOTAL SAMPLE OF 13 RESIDENTS, RESULTING IN AN IMMEDIATE JEOPARDY (IJ) WHEN RESIDENT #501, WHO HAD BEEN IDENTIFIED AS AN ELOPEMENT RISK, ELOPED FROM THE FACILITY ON 8/7/11 AT APPROXIMATELY 3:30 PM, UNBEKNOWNST TO FACILITY STAFF. RESIDENT #501 RETURNED TO THE FACILITY AT APPROXIMATELY 3:55 PM, ESCORTED BY NEIGHBORS AND STAFF. THIS DEFICIENT PRACTICE PLACES TEN OTHER RESIDENTS, WHO ARE IDENTIFIED AS ELOPEMENT RISKS, AT RISK FOR SERIOUS HARM, INJURY, AND/OR DEATH. FINDINGS INCLUDE: REVIEW OF THE FACE SHEET IN THE MEDICAL RECORD, DATED 6/14/11, REVEALED RESIDENT #501 WAS AN [AGE] year OLD FEMALE admitted to the facility on [DATE]. REVIEW OF THE [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM DATA SET (MDS), dated [DATE], REVEALED RESIDENT #501 HAD MODERATE COGNITIVE IMPAIRMENTS. REVIEW OF THE "ELOPEMENT RISK ASSESSMENT," DATED 3/9/10, REVEALED RESIDENT #501 WAS IDENTIFIED AS AN ELOPEMENT RISK AS EVIDENCED BY "EXIT SEEKING, ASKING TO CALL FAMILY MEMBER TO COME AND GET HER, WANDERING, AND LOOKING FOR A WAY OUT." REVIEW OF AN ELOPEMENT CARE PLAN, DATED 6/22/11, REVEALED RESIDENT #501 HAD A WANDERGUARD IN PLACE. REVIEW OF AN ACTIVITIES DAILY LIVING (ADL'S) CARE PLAN, DATED 6/22/11, REVEALED RESIDENT #501 USED A WALKER. THE ADL CARE PLAN INDICATED FACILITY STAFF WERE TO MONITOR RESIDENT #501 DURING AMBULATION. REVIEW OF THE TREATMENT ADMINISTRATION RECORD (TAR) DATED 8/2011 REVEALED RESIDENT #501'S WANDERGUARD WAS CHECKED FOR PLACEMENT EVERY SHIFT AND FOR FUNCTION DAILY. REVIEW OF A NURSE'S NOTE, DATED 7/24/11, REVEALED RESIDENT #501 ATTEMPTED TO EXIT THE FACILITY. REVIEW OF AN UNUSUAL OCCURRENCE DOCUMENT, DATED 8/7/11, WRITTEN BY LICENSED PRACTICAL NURSE (LPN) #6, REVEALED RESIDENT #501 EXITED THE FACILITY. THE DOCUMENT REVEALED RESIDENT #501 HAD NO INJURIES. IN AN INTERVIEW ON 8/15/11 AT 10:40 AM AND IN A WRITTEN STATEMENT DATED 8/7/11, CERTIFIED NURSING ASSISTANT (CNA) #9 REPORTED ON 8/7/11 AT 3:25 PM, SHE ASSISTED RESIDENT #501 TO THE BATHROOM. CNA #9 REPORTED RESIDENT #501 HAD A SHIRT, PANTS, AND TENNIS SHOES ON AT THAT TIME. CNA #9 REPORTED AT 3:30 PM, SHE OBSERVED RESIDENT #501 WALKING IN THE HALLWAY WITH HER WALKER AND INFORMED CNA #8 THAT SHE WAS GOING ON HER LUNCH BREAK. CNA #9 REPORTED WHEN SHE CAME BACK FROM LUNCH AT 3:50 PM, SHE DID NOT SEE RESIDENT #501 IN THE HALLWAY. CNA #9 STATED SHE AND CNA #8 BEGAN SEARCHING FOR RESIDENT #501 THEN NOTIFIED LPN #6 THAT SHE WAS UNABLE TO FIND RESIDENT #501. IN AN INTERVIEW ON 8/15/11 AT 10:30 AM, CNA #8 REPORTED ON 8/7/11 AT APPROXIMATELY 3:30 PM, SHE SAW RESIDENT #501 WALKING WITH HER WALKER DOWN THE HALLWAY. CNA #8 REPORTED SHE WAS ASSISTING OTHER RESIDENTS TO THE BATHROOM AND ANSWERING CALL LIGHTS BETWEEN 3:32 PM AND 3:50 PM. CNA #8 REPORTED SHE DID NOT HEAR ANY ALARMS SOUNDING BETWEEN 3:30 PM AND 3:50 PM. CNA #8 REPORTED AT APPROXIMATELY 3:50 PM, CNA #9 TOLD HER SHE DID NOT SEE RESIDENT #501 WALKING IN THE HALLWAY. CNA #8 STATED SHE AND CNA #9 BEGAN SEARCHING FOR RESIDENT #501. IN AN INTERVIEW ON 8/15/11 AT 11:00 AM AND IN A WRITTEN STATEMENT DATED 8/7/11, HOUSEKEEPER #12 REPORTED ON 8/7/11 AT APPROXIMATELY 3:55 PM, SHE WAS DRIVING TO THE FACILITY WHEN SHE NOTICED RESIDENT #501 WITHOUT HER WALKER ON THE LAWN OF THE HOUSE NEXT TO THE FACILITY. HOUSEKEEPER #12 REPORTED SHE PULLED INTO THE VISITOR'S PARKING LOT AND NEIGHBOR #14 TOLD HER RESIDENT #501 WAS COMING OUT OF HER BATHROOM. HOUSEKEEPER #12 REPORTED SHE, NEIGHBOR #14, AND NEIGHBOR #15 ESCORTED RESIDENT #501 BACK TO THE FACILITY THROUGH DOOR #2. HOUSEKEEPER #12 REPORTED DOOR #2'S WANDERGUARD ALARM SOUNDED WHEN RESIDENT #501 WAS BROUGHT BACK INTO THE FACILITY. IN AN INTERVIEW ON 8/15/11 AT 11:25 AM AND IN A WRITTEN STATEMENT DATED 8/7/11, LPN #6 REPORTED SHE DID NOT HEAR ANY ALARMS GO OFF ON 8/7/11 BETWEEN 3:30 PM AND 3:50 PM. LPN #6 REPORTED ON 8/7/11 AT APPROXIMATELY 3:55 PM, CNA #9 TOLD HER THAT SHE WAS UNABLE FIND RESIDENT #501. LPN #6 REPORTED AS SHE WAS GOING TO INITIATE THE "MISSING PERSON" PROTOCOL, SHE SAW HOUSEKEEPER #12, NEIGHBOR #14, AND NEIGHBOR #15 IN THE VISITOR'S PARKING LOT ESCORTING RESIDENT #501 BACK TO THE FACILITY. LPN #6 REPORTED AT APPROXIMATELY 4:00 PM, SHE CHECKED RESIDENT #501'S WANDERGUARD FOR FUNCTION AND PLACEMENT, PERFORMED A HEAD-TO-TOE ASSESSMENT, AND INITIATED 15 MINUTE CHECKS. LPN #6 STATED THE DIRECTOR OF NURSING (DON) #2 WAS NOTIFIED AT APPROXIMATELY 4:06. LPN #6 STATED SHE NOTICED THE MAIN THERAPY DOOR AND DOOR #4 (THE THERAPY DOOR THAT LEADS OUT TO THE VISITOR'S PARKING LOT) WAS OPEN. LPN #3 REPORTED SHE tested DOOR #4 WITH A WANDERGUARD AT THAT TIME, BUT THE ALARM DID NOT SOUND. IN AN INTERVIEW ON 8/15/11 AT 10:30 AM, CNA #8 REPORTED ON 8/7/11, AFTER RESIDENT #501 RETURNED TO THE FACILITY, SHE FOUND RESIDENT #501'S WALKER IN THE THERAPY BATHROOM. IN AN INTERVIEW ON 8/12/11 AT 2:00 PM, MAINTENANCE DIRECTOR #7 REPORTED ON 8/8/11, HE NOTED DOOR #4'S ALARM HAD BEEN DISENGAGED, WHICH PREVENTED THE ALARM FROM SOUNDING WHEN RESIDENT #501 EXITED THE FACILITY. REVIEW OF DAILY MAINTENANCE LOGS FOR THE MONTHS OF 7/11-8/11 REVEALED ALL EXIT DOOR ALARMS (14 DOOR ALARMS AND 3 WANDERGUARD DOOR ALARMS) WERE CHECKED AND FUNCTIONED PROPERLY. AN OBSERVATION ON 8/12/11 AT 2:00 PM, REVEALED ALL EXIT DOOR ALARMS (14 DOOR ALARMS AND 3 WANDERGUARD DOOR ALARMS) AND WANDERGUARD BRACELETS (11 WANDERGUARD BRACELETS) FUNCTIONED PROPERLY. ON 8/16/11 AT 3:30 PM, THIS SURVEYOR OBSERVED RESIDENT #501 WANDERING IN THE HALLWAY WITH HER WALKER. RESIDENT #501 WAS WEARING PANTS, A SHIRT, JACKET, AND TENNIS SHOES. RESIDENT #501 HAD A WANDERGUARD ON HER LEFT ANKLE. ON 8/16/11 AT 1:15 PM, THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY THAT BEGAN ON 8/7/11 WHEN THE FACILITY FAILED TO PREVENT THE ELOPEMENT AND ENSURE THE SAFETY OF RESIDENT #501, WHO HAD BEEN IDENTIFIED AS AN ELOPEMENT RISK AND WHO ELOPED FROM THE FACILITY ON 8/7/11 AT APPROXIMATELY 3:30 PM, UNBEKNOWNST TO FACILITY STAFF. RESIDENT #501 RETURNED TO THE FACILITY AT 3:55 PM ESCORTED BY NEIGHBORS AND STAFF. THIS DEFICIENT PRACTICE PLACES TEN OTHER RESIDENTS, WHO ARE IDENTIFIED AS ELOPEMENT RISKS, AT RISK FOR SERIOUS HARM, INJURY, AND/OR DEATH. ON 8/17/11 AT 2:30 PM, THE SURVEYOR CONFIRMED THAT THE FACILITY STAFF IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. ON 8/7/11, THE CHARGE NURSE ASSESSED RESIDENT #501 FOR INJURIES AND NONE WERE NOTED. 2. ON 8/8/11, THE PUSH BUTTON DOOR ALARM DISENGAGEMENT OPTION THAT ELIMINATED THE ALARM ACTIVATION AT THE OUTPATIENT THERAPY EXIT DOOR WAS REMOVED BY MAINTENANCE STAFF. 3. ON 8/8/11, RESIDENT #501'S CARE PLANS FOR ELOPEMENT, COGNITION, AND TOILETING WERE REVIEWED AND UPDATED. RESIDENT #501'S CARE GUIDE WAS UPDATED. RESIDENT #501'S WANDERGUARD WAS CHECKED BY THE MAINTENANCE DIRECTOR AND THE DON AND WAS DEEMED IN OPERATING ORDER. 4. ON 8/8/11, THE DON CONDUCTED AN AUDIT OF FACILITY RESIDENTS FOR ELOPEMENT RISK. 11 RESIDENTS WERE IDENTIFIED AS AN ELOPEMENT RISK. 5. AS OF 8/8/11, MAINTENANCE STAFF WILL MONITOR DOOR ALARMS DAILY (MON-SUN) INCLUDING THE WANDERGUARD SYSTEM AND REPORT FINDINGS TO THE ADMINISTRATOR AND THE QUALITY ASSURANCE COMMITTEE MONTHLY FOR REVIEW AND NECESSARY ACTION. 6. ON 8/8/11, ALL 5 THERAPY STAFF WERE IN-SERVICED ON DOOR SECURITY AND SAFETY SYSTEMS. 7. ON 8/9/11, THE MAINTENANCE DIRECTOR EVALUATED ALL 17 FACILITY EXIT DOORS FOR FUNCTIONALITY. THREE OUT OF THE 17 DOORS CURRENTLY HAVE A WANDERGUARD ALARM SYSTEM INSTALLED. 8. ON 8/9/11, THE INTERDISCIPLINARY TEAM REVIEWED AND DEEMED THE ELOPEMENT POLICY AND PROCEDURES APPROPRIATE. 9. ON 8/9/11, THE FACILITY UPDATED THE PICTORIAL ELOPEMENT BINDER FOR RESIDENTS IDENTIFIED AS AN ELOPEMENT RISK. 10. ON 8/10/11, THE FACILITY UPDATED ELOPEMENT AND COGNITIVE CARE PLANS FOR THOSE IDENTIFIED AS AN ELOPEMENT RISK. ALL RESIDENTS AT RISK FOR ELOPEMENT WERE REVIEWED BY THE INTERDISCIPLINARY CARE TEAM AT THE BEHAVIOR MANAGEMENT MEETING. 11. ON 8/10/11, THE MAINTENANCE DIRECTOR AND UNIT MANAGERS REVIEWED THE WANDERGUARD LIST TO ENSURE ALL WERE OPERATIONAL. 12. AS OF 8/10/11, 94 OUT OF 98 EMPLOYEES WERE IN-SERVICED ON ELOPEMENT POLICIES AND PROCEDURES AS WELL AS THE INITIATION OF THE ELOPEMENT ARM BAND PROGRAM FOR THOSE RESIDENTS UNABLE TO COMMUNICATE, HAVE ALZHEIMER'S, AND ARE AT RISK FOR ELOPEMENT. THE 4 EMPLOYEES ON VACATION AND MEDICAL LEAVE WILL NOT REPORT TO THE UNITS UNTIL IN-SERVICE EDUCATION IS COMPLETED. 13. RESIDENTS IDENTIFIED AS AN ELOPEMENT RISK WILL BE MONITORED UPON ADMISSION BY THE DON AND/OR VIA THE RAI PROCESS. THE ELOPEMENT AND COGNITIVE CARE PLANS WILL BE REVIEWED BY THE I-TEAM QUARTERLY OR AS NEEDED. IN ADDITION, RESIDENTS AT RISK FOR ELOPEMENT WILL BE REVIEWED AT THE BEHAVIOR MANAGEMENT MEETING WEEKLY BY THE I-TEAM AND MEDICAL DIRECTOR. ALTHOUGH IMMEDIATE JEOPARDY WAS REMOVED ON 8/10/11, THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF ISOLATED AND A SEVERITY OF NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY DUE TO ALL IN-SERVICES HAD NOT 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 PROVIDE ADEQUATE SUPERVISION AND FAILED TO EVALUATE APPROPRIATENESS OF THE ALARM DEVICE FOR 1 OF 1 RESIDENT WITH FALLS (#10) FROM A TOTAL SAMPLE OF 15 RESIDENTS, RESULTING IN AN INTERNAL BRAIN INJURY (SUBARACHNOID HEMORRHAGE) AND A LARGE SCALP HEMATOMA. FINDINGS INCLUDE: RESIDENT #10 WAS A [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE NOTE ALSO INCLUDED THE RESIDENT AS HAVING EYE INFECTION AND SIGNIFICANT POSTURAL BLOOD PRESSURE CHANGES WITH SYMPTOMS OF DIZZINESS. THE LIST OF MEDICATIONS INCLUDED MULTIPLE BLOOD THINNERS (ASPIRIN, PLAVIX, LOVENOX), MULTIPLE BLOOD PRESSURE MEDICATIONS (ATENOLOL, COZAAR, IMDUR) AND MULTIPLE PSYCHOTROPICS (ATIVAN, NAMENDA, REMERON, ATIVAN). ALL THESE MEDICATIONS WOULD HAVE PUT THE RESIDENT AT RISK OF FALL. ON 4/1/11 AT 10:30 A.M., THE DIRECTOR OF NURSING, (STAFF "F") STATED THAT THE RESIDENT HAD BEEN RESIDING IN AN ADULT FOSTER CARE HOME PRIOR TO COMING TO THE FACILITY. SHE WAS FOUND HAVING FREQUENT FALLS AND INCREASED SIGNS OF DEMENTIA, THUS SHE WAS SENT TO THE HOSPITAL. THE DIRECTOR OF NURSING "F" WAS NOT SURE WHY THE RESIDENT WAS RECEIVING MULTIPLE BLOOD THINNERS THAT MAY HAVE INCREASED THE RISK OF INJURY. HOWEVER, SHE STATED THE FACILITY PHYSICIAN HAD DISCONTINUED SEVERAL OTHER MEDICATIONS (TENORMIN ON 11/15/10, COZAAR AND NEMANDA ON 12/3/10) THAT MAY HAVE AFFECTED THE RESIDENT'S BLOOD PRESSURE CHANGES. THE NURSING NOTE DATED 11/19/10 REFLECTED, " ...OBSERVED ON FLOOR BESIDE BED AT 1900...RES ROOMMATE ALERTED WRITER TO COME TO ROOM...C/O SMALL AMOUNT OF PAIN WITH RANGE OF MOTION (ROM)...BRUISING NOTED ON RIGHT HIP AND RIGHT SCAPULA... " THE X-RAY RESULT WAS NEGATIVE FOR FRACTURES. THE INVESTIGATION OF THIS FALL CONCLUDED THE RESIDENT ATTEMPTED TO GET UP BY HERSELF, THUS THE TAB ALARM WAS PLACED TO ALERT THE STAFF. THE UNUSUAL OCCURRENCE REPORT DATED 11/21/10 REFLECTED, " ...THE ALARM SOUNDING IN THE REST ROOM IN THE TEA-ROOM...RES WAS FOUND SITTING ON THE FLOOR... " THE INVESTIGATION OF THIS FALL CONCLUDED THE RESIDENT HAD WHEELED SELF INTO BATHROOM IN TEA-ROOM AND SELF TRANSFERRED...HAD REMOVED TAB ALARM... " THE URINE WAS ALSO CHECKED FOR POSSIBLE URINARY TRACT INFECTION (UTI). THE URINE TEST WAS NEGATIVE FOR UTI. NO EVALUATION OR INTERVENTIONS ABOUT THE USE OF TAB ALARM COULD BE FOUND. THE UNUSUAL OCCURRENCE REPORT DATED 11/26/10 REFLECTED, " ...HEARD RES TAB ALARM SOUNDING...OBSERVED RES SITTING ON FLOOR IN FRONT OF WHEEL CHAIR... " THE INVESTIGATION OF THIS FALL CONCLUDED NO CHANGES OF INTERVENTIONS. THE NURSING NOTE DATED 11/28/10 REFLECTED THE RESIDENT'S EYE LIDS AS BEING RED AND COMPLAINING OF FEELING DIZZY. THE NURSING NOTES DATED 11/29/10 THROUGH 12/20/10 REFLECTED THE RESIDENT AS HAVING CONTINUED EYE IRRITATIONS AND OBSERVED RUBBING HER EYES. THE RESIDENT ALSO WAS REPORTED COMPLAINING OF DIZZINESS ON 12/12/10 AND WAS AGAIN CHECKED FOR POSSIBLE URINARY TRACT INFECTION. THE URINE TEST WAS AGAIN NEGATIVE FOR UTI. THE UNUSUAL OCCURRENCE REPORT DATED 12/21/10 AT 8:10 P.M., REFLECTED, " ... THE RESIDENT WAS OBSERVED LYING FACE DOWN ON FLOOR IN SOUTH HALL...SHE HAD LARGE HEMATOMA ON LEFT SIDE OF HEAD WITH SMALL ABRASION...ABRASION TO LEFT ELBOW AND KNEE... " THE INVESTIGATION OF THIS FALL CONCLUDED THE RESIDENT FREQUENTLY ATTEMPTED TO GET UP FROM WHEEL CHAIR AND THE ALARM WAS NOT SOUNDING...FOUND THE ALARM STRING WAS UNCLIPPED FROM GOWN. THE RESIDENT WAS SENT TO THE HOSPITAL. ON 4/1/11 AT 10:30 A.M., THE DIRECTOR OF NURSING, (STAFF "F") THOUGHT THE RESIDENT HAD REMOVED ALARM, BUT SINCE THERE WAS NO WITNESS FOR THE INCIDENT IT EITHER HAD NEVER BEEN PLACED BY THE NURSING STAFF OR THE RESIDENT MAY HAVE REMOVED. THE HOSPITAL RECORD DATED 12/22/10 REFLECTED, " ...CAT SCAN OF THE HEAD SHOWS ACUTE SUBARACHNOID HEMORRHAGE SEEN ALONG THE PARENCHYMA OF THE LEFT FRONTOPARIETAL AND TEMPORAL LOBES...LARGE SCALP HEMATOMA MEASURING 9 X 2 CM...POSSIBLE CONTUSION OF BRAIN... " THE RESIDENT DID NOT UNDERGO NEUROSURGICAL INTERVENTION BUT ANTI-PLATELETS (ASPIRIN, PLAVIX) AND ANTICOAGULANT (LOVENOX) WERE HELD. THE RESIDENT RETURNED TO THE FACILITY AFTER 2 DAYS OF OBSERVATION. THE NURSING NOTES DATED 12/25/10 THROUGH 2/6/11 REFLECTED THE RESIDENT AS HAVING CONTINUED EPISODES OF UNSUPERVISED FALLS (12/25/10, 12/ 29/10, 12/ 30/10, 1/29/11 AND 2/6/11). THE UNUSUAL OCCURRENCE REPORTS INDICATED THAT THE RESIDENT WAS OBSERVED REMOVING TAB ALARMS ON 12/25/10, 12/30/10 AND 2/6/11. HOWEVER, NO INTERVENTIONS TO CURVE THE RESIDENT'S BEHAVIOR OF REMOVING TAB ALARMS COULD BE FOUND. THE NURSING NOTE DATED 12/30/10 REFLECTED THE SENSOR ALARM, A PAD THAT RESPONDS TO THE WEIGHT OF RESIDENT, WAS PLACED UNDER THE WHEEL CHAIR CUSHION. THE SENSOR ALARM WAS IMPLEMENTED AFTER 6 FALLS INCLUDING THE FALL WITH INJURY AND 4 FALLS WHERE THE RESIDENT WAS REPORTED AS REMOVING THE ALARM. ON 3/31/11 AT 3:30 P.M., THE RESIDENT WAS OBSERVED BEING TRANSFERRED FROM A WHEEL CHAIR TO HER BED WITH ASSISTANCE FROM THE NURSING AIDE, (STAFF "L"). THE NURSING AIDE "L" CLIPPED THE TAB ALARM TO THE RESIDENT'S SHIRT BY THE FRONT PART OF HER NECK AFTER SHE WAS LAID ON BACK IN BED. THE NURSING AIDE "L" WAS QUESTIONED WHETHER THE RESIDENT MIGHT REMOVE THE ALARM. SHE SAID, "NO, SHE WON'T REMOVE IT. THE ONLY TIME THE RESIDENT WOULD REMOVE THE ALARM IS WHEN SHE HAS A URINARY TRACT INFECTION." ON 4/1/11 AT 10:30 A.M., THE DIRECTOR OF NURSING "F" STATED IF THE RESIDENT WAS REMOVING THE ALARM IT SHOULD HAVE BEEN PLACED WHERE THE RESIDENT COULD NOT REACH IT. HOWEVER, THE NURSING CARE PLAN DATED 11/21/10 AND UPDATED 1/29/11 REFLECTED NO SUCH MODIFICATIONS. INSTEAD, THE RESIDENT WAS PLACED WITH A LAP BUDDY ON 1/4/11. ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 211 BASED ON INTERVIEWS AND RECORD REVIEWS, THE FACILITY FAILED TO MAINTAIN THE HIGHEST PRACTICABLE PHYSICAL, MENTAL, AND PSYCHOSOCIAL WELL-BEING FOR ONE (#505) OF SEVEN SAMPLED RESIDENTS RESULTING IN RESIDENT #505 NOT RECEIVING NURSING SERVICES AS REQUESTED WHEN SHE COMPLAINED OF SHORTNESS OF BREATH WHICH RESULTED IN RESIDENT #505 EXPERIENCING RESPIRATORY DISTRESS AND SUBSEQUENTLY BEING TRANSFERRED TO A NEARBY HOSPITAL WHERE SHE SUFFERED A [MEDICAL CONDITION]. FINDINGS INCLUDE: REVIEW OF THE ADMISSIONS FACE SHEET INDICATED THAT RESIDENT #505 WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM (MDS) data set [DATE] INDICATED THAT RESIDENT #505 HAD INDEPENDENT COGNITIVE SKILLS FOR DECISION MAKING, HAD NO SHORT OR LONG TERM MEMORY PROBLEMS AND REQUIRED EXTENSIVE TO TOTAL ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING INCLUDING BED MOBILITY, TRANSFERS, DRESSING, TOILETING, PERSONAL HYGIENE AND BATHING. A COMPLAINT ON FILE ALLEGED THAT ON 7/22/10 A CERTIFIED NURSING ASSISTANT (CNA) REFUSED TO GET THE NURSE FOR RESIDENT #505 WHO REPORTEDLY COMPLAINED OF SHORTNESS OF BREATH (SOB) AND REQUESTED TO SEE THE NURSE. IT WAS FURTHER REPORTED THAT THE CNA TOLD RESIDENT #505 THAT THERE WAS NOTHING WRONG WITH HER AND TO STOP ACTING LIKE A BABY. DURING THE COMPLAINT INVESTIGATION, THE ALLEGATION REGARDING THE CNA TELLING RESIDENT #505 TO STOP ACTING LIKE A BABY COULD NOT BE SUBSTANTIATED. ACCORDING TO RESIDENT #505'S RESIDENT TRANSFER FORM DATED 7/22/10, RESIDENT #505 EXPERIENCED PAIN AT LEVEL 6/10, SHORTNESS OF BREATH WITH AN OXYGEN SATURATION LEVEL OF 82%. RESIDENT #505'S SKIN WAS CLAMMY AND SWEATY AND SHE COMPLAINED OF A SORE THROAT AND HAD A SWOLLEN GLAND TO HER RIGHT NECK. RESIDENT #505 WAS THEN TRANSFERRED OUT TO A NEARBY HOSPITAL FOR EVALUATION AND TREATMENT. ACCORDING TO RESIDENT #505'S EMS (EMERGENCY MEDICAL SYSTEM) RUN SHEET DATED 7/22/10, RESIDENT #505 WAS TRANSFERRED TO A NEARBY HOSPITAL FOR COMPLAINTS OF SHORTNESS OF BREATH, RIGHT SIDED NECK PAIN AND PAIN TO HER CHEST. THE EMS RUN SHEET DOCUMENTED THE FOLLOWING: "...ON THURSDAY, JULY 22 WE FIND A [AGE] year OLD FEMALE PATIENT PRESENTING WITH SHORTNESS OF BREATH SINCE THIS MORNING COMPLAINING OF RIGHT SIDED NECK PAIN AND A SORE THROAT. SHE HAS SOME SWELLING AND TENDERNESS ON THE RIGHT SIDE OF HER NECK..." "...STATES IT HURTS IN HER CHEST WHEN SHE BREATHS..." "...INITIAL ASSESSMENT: PALE IN COLOR, LEFT SIDE DIMINISHED LUNG SOUNDS, RIGHT WET DIMINISHED LUNG SOUNDS..." RESIDENT #505 WAS GIVEN OXYGEN AT 4 LITERS PER MINUTE. CARDIAC MONITORING WAS INITIATED AND RESIDENT #505 WAS TRANSFERRED TO A NEARBY HOSPITAL VIA AN ADVANCED LIFE SUPPORT UNIT. A HOSPITAL HISTORY AND PHYSICAL NOTE DATED 7/22/10 DOCUMENTED: "...THE PATIENT REPORTEDLY AWOKE THIS MORNING TO SHORTNESS OF BREATH..." "...THE PATIENT REPORTED EXPERIENCE SOME FEVER AND CHILLS LAST NIGHT..." "...THE PATIENT WAS BROUGHT INTO THE emergency room , HAD A CHEST X-RAY WHICH SHOWED A D-DIMER (The d-Dimer test, which is used to rule out blood clots). CT SCAN (Computed tomography x-ray imaging) INDICATED A LARGE PLEURAL EFFUSION BILATERALLY AS WELL AS CONSOLIDATION OF THE LUNGS BILATERALLY INDICATING A NOSOCOMIAL PNEUMONIA. (Facility-acquired pneumonia or Nosocomial pneumonia refers to any pneumonia contracted after at least 48-72 hours of being admitted to a healthcare facility or hospital)..." "...IN SHORT, IT APPEARS THAT THE PATIENT IS PRESENTING WITH ACTUALLY FOUR ACTIVE PROBLEMS..." "...SHE HAS AN ELEVATED TROPONIN, INDICATIVE OF LIKELY NON-ST-ELEVATION [MEDICAL CONDITION] INFARCTION..." (Proteins from cardiac muscle that indicate a [MEDICAL CONDITION]; when blood vessels that supply blood to the heart are blocked, preventing enough oxygen from getting to the heart). "...IT APPEARS THAT SHE HAS A NEW ONSET [MEDICAL CONDITION]" "...URINARY TRACT INFECTION..." "...NOSOCOMIAL PNEUMONIA..." A CARDIOLOGY CONSULTATION NOTE DATED 7/22/10 DOCUMENTED THE FOLLOWING: "...SHE (#505) DESCRIBES FEELING SHORT OF BREATH AND DIAPHORETIC (excessive sweating) THIS AFTERNOON..." "...THE PATIENT IS AN ELDERLY ILL APPEARING LADY IN MILD RESPIRATORY DISTRESS..." "...RESULTS OF THE CT SCAN SHOWED COMPRESSIVE ATELECTASIS AND CONSOLIDATION FOR BOTH LOWER LUNGS. CHEST X-RAY REVEALS [MEDICAL CONDITIONS]" "...EVALUATION IN THE emergency room SHOWED MARKEDLY ELEVATED BNP (B-type Natriuretic Peptide blood test shows changes in pressure that occur when heart failure develops) AND MILDLY ELEVATED TROPONIN. (Proteins- used as a test of several different heart disorders, including [MEDICAL CONDITION] infarction ([MEDICAL CONDITION])..." "...THE PATIENT WAS THEN admitted ..." REVIEW OF THE FACILITY'S ADMINISTRATIVE INVESTIGATION (UNDATED) DOCUMENTED THE FOLLOWING: "IN EARLY JULY NURSE #1 WORKED WITH CNA #1 N HER COMMUNICATION WITH RESIDENTS AND HOW SOMETIMES CNA #1 APPEARS BOSSY AND ABRUPT. THIS ONE ON ONE COACHING WAS DESIGNED TO CURB THIS NEGATIVE PRESENTATION BY MAKING CNA #1 CONSCIOUS OF HER TONE AND TEMPERAMENT... " " ...ON 7/30/10 (INCORRECT DATE AS INCIDENT OCCURRED ON 7/22/10), RESIDENT #505 ASKED CNA #1 TO GET HER NURSE AS SHE WAS EXPERIENCING DIFFICULTY BREATHING. ACCORDING TO RESIDENT #505, CNA #1 TOLD RESIDENT #505 THAT SHE WAS FINE ..." " ...LATER, CNA #1 REPORTED TO THE NURSE THAT RESIDENT #505 WAS SHORT OF BREATH. RESIDENT #505 WAS DISPLAYING SIGNS AND SYMPTOMS OF RESPIRATORY DISTRESS... " " ...LATER, NURSE #1 HAD A DISCUSSION WITH CNA #1 INDICATING IT WAS NOT HER RESPONSIBILITY TO DECIDE IF A RESIDENT NEEDED MEDICAL ATTENTION... " " ...NURSE #1 REPORTED TO THE DIRECTOR OF NURSING (DON) THAT RESIDENT #505 INFORMED HER (NURSE #1) THAT CNA #1 WAS MEAN SPEAKING AND KEPT SAYING SHE (#505) WAS FINE AND TO LAY DOWN... " " ...IT WAS DECIDED TO REASSIGN CNA #1 ON ANOTHER UNIT UNTIL THE INVESTIGATION WAS COMPLETE... " THERE WAS NO DOCUMENTED EVIDENCE THAT CNA #1 WAS SUSPENDED PENDING INVESTIGATION. ON 10/18/10 AT 12:08 P.M., DURING AN INTERVIEW, NURSE #1 REPORTED THE FOLLOWING: "...I WAS MADE AWARE THAT THE CNA (CNA #1) REFUSED TO GET THE NURSE WHEN RESIDENT #505 COMPLAINED Of SOB AND I IMMEDIATELY SPOKE WITH HER (CNA #1) ABOUT THIS..." NURSE #1 ACKNOWLEDGED THAT SHE COULD NOT REMEMBER THE DATE OF THE OCCURRENCE. NURSE #1 WENT ON TO STATE "...SHE (#505) WAS CRYING AND SHE SAID THAT THE CNA (CNA #1) REFUSED TO GET THE NURSE WHEN SHE WAS HAVING SOB..." "...I SPOKE TO HER (CNA#1) AND COUNSELED HER ABOUT NOT COMING TO GET ME WHEN THE RESIDENT COMPLAINED OF SHORTNESS OF BREATH (SOB), AND SHE (CNA #1) INFORMED ME THAT SHE THOUGHT THE RESIDENT WAS FINE..." "...SHE (CNA #1) INFORMED ME THAT SHE THOUGHT THAT RESIDENT #505 WAS JUST PLAYING AROUND BY ASKING FOR HELP JUST BECAUSE SHE (#505) WANTED TO BE BABIED..." NURSE #1 FURTHER STATED THAT RESIDENT #505 WAS "...QUITE SICK AND HAD TO BE SENT TO THE HOSPITAL..." AND "...I NEVER WANT A RESIDENT TO HAVE TO WAIT FOR CARE..." "...SHE COMPLAINED OF EXTREME SHORTNESS OF BREATH AND CHEST PAIN. SHE WAS DIAPHORETIC, AND HER HAIR WAS DRIZZLING WITH SWEAT. I CHECKED HER OXYGEN SATURATION AND IT WAS 80%..." "...I YELLED AT HER (CNA #1) AND SAID "THIS IS WHY YOU NEVER MAKE THAT DECISION FOR ME"..." "...IF I HAD BEEN CONTACTED IMMEDIATELY, SHE (#505) WOULDN'T HAVE BEEN IN SUCH DISTRESS..." WHEN ASKED IF THERE WAS ANY DOCUMENTATION OF THIS INCIDENT AVAILABLE FOR REVIEW, NURSE #1 SAID "...NOT IN THE CHART BUT I'M THE ONE WHO SENT HER (#505) TO THE HOSPITAL..." ON 10/18/10 AT 12:31 P.M., DURING AN INTERVIEW, LPN #1 REPORTED THAT RESIDENT #505 COMPLAINED OF PAIN EARLIER THAT EVENING, BUT DIDN'T SPECIFY A LOCATION. WHEN ASKED ABOUT RESIDENT #505'S TRANSFER TO THE HOSPITAL, LPN #1 SAID "...I THINK SHE (#505) WENT OUT BECAUSE OF PAIN..." ON 10/18/10 AT 3:52 P.M., AN INTERVIEW WAS CONDUCTED WITH CNA #1. WHEN ASKED IF RESIDENT #505 REQUESTED TO SEE THE NURSE ON THE DATE IN QUESTION WHEN SHE (#505) COMPLAINED OF SOB, CNA #1 SAID, "...YES, SHE ASKED QUITE OFTEN..." "...IT WAS BUSY. I WAS TAKING VITALS AND I TOLD THE NURSE SHE (#505) HAD A HARD TIME BREATHING..." WHEN ASKED IF SHE (CNA#1) INFORMED THE NURSE OF RESIDENT #505'S COMPLAINTS OF SOB RIGHT AWAY, CNA #1 SAID "...I COULDN'T FIND THE NURSE RIGHT AWAY. I WENT OUTSIDE TO LOCATE HER..." WHEN ASKED OF RESIDENT #505'S CONDITION DURING THE START OF THE SHIFT, CNA #1 SAID "...I DIDN'T THINK SHE (#505) WAS THAT BAD AT THE TIME I FIRST CHECKED HER..." " ...I CHECKED HER VITALS (BLOOD PRESSURE, PULSE, TEMPERATURE, and OXYGEN SATURATION) AT THE START OF MY SHIFT (10:00 P.M.) AND I THOUGHT SHE WAS FINE... " "...SHE WAS UPSET AND NERVOUS BECAUSE SHE WAS IN PAIN. SHE TOLD ME SHE WAS SOB BUT SHE DIDN'T APPEAR TO BE. HER OXYGEN SATURATION LATER WENT DOWN TO BETWEEN 78% AND 82%..." "...WE HEARD A COUPLE OF HOURS LATER THAT SHE (#505) DID HAVE A [MEDICAL CONDITION]" CNA #1 FURTHER SAID THAT DURING THE NIGHT IN QUESTION, SHE (CNA#1) HAD RECEIVED COUNSELING FOR THE TONE OF VOICE SHE USED WITH RESIDENT #505. ADDITIONALLY, CNA #1 STATED "...SHE (#505) WAS SENT TO THE HOSPITAL BECAUSE SHE DIDN'T GET THE HELP SHE NEEDED..." WHEN ASKED IF SHE (CNA #1) DID IN FACT TELL RESIDENT #505 THERE WAS NOTHING WRONG WITH HER, CNA #1 REPLIED, " ...I DIDN'T TELL HER TO STOP ACTING LIKE A BABY... " CNA #1 HAD NO RESPONSE TO WHETHER SHE TOLD RESIDENT #505 THAT THERE WAS NOTHING WRONG WITH HER. ADDITIONALLY, ALTHOUGH CNA #1 STATED THAT SHE HAD ASSESSED RESIDENT #505'S VITAL SIGNS, REVIEW OF RESIDENT #505'S VITAL SIGN FLOW SHEET REVEALED NO DOCUMENTED EVIDENCE THAT CNA #1 HAD ASSESSED RESIDENT #505'S VITAL SIGNS AT THE BEGINNING OF THE SHIFT AS PREVIOUSLY INDICATED. THE VITAL SIGNS FLOW SHEET REVEALED THAT RESIDENT #505'S VITAL SIGNS HAD NOT BEEN ASSESSED UNTIL SHE WENT INTO DISTRESS AND HER (#505) VITALS SIGNS HAD NOT BEEN TAKEN UNTIL 12:00 A.M., AND HAD BEEN DOCUMENTED BY NURSE #1. ON 10/18/10 AT 4:30 P.M., DURING AN INTERVIEW WITH CNA #2, SHE REPORTED: "...CNA #1 LATER CAME TO THE NURSE'S STATION TO REPORT THAT RESIDENT (#505) NEEDED ASSISTANCE. I WENT DOWN TO CHECK ON HER AND I'M THE ONE WHO INFORMED HER (#505'S) NURSE. SHE (#505) SAID THAT CNA #1 WAS RUDE TO HER..." CNA#2 FURTHER STATED "...THE CALL LIGHTS WERE CONSTANTLY GOING ON SO I WENT DOWN THERE AND PULLED HER (#505) UP IN BED..." "...SHE (#505) SAID THAT CNA#1 WASN'T TAKING HER SERIOUSLY WHEN SHE KEPT ASKING FOR HELP..." ON 10/19/10 AT 12:13 P.M., DURING AN INTERVIEW, NURSE #2 STATED THAT CNA #1 WAS SUSPENDED PENDING INVESTIGATION. "...WE DISCUSSED WHAT CONSTITUTES ABUSE AND WE DISCUSSED THE TONE OF VOICE SHE USED WHEN SPEAKING WITH THE RESIDENTS..." ON 10/20/10 AT 11:14 A.M., DURING AN INTERVIEW, THE DIRECTOR OF NURSING (DON) REPORTED THAT RESIDENT #505 WAS "...SENT OUT TO THE hospital on [DATE] AT 12:35 A.M. BECAUSE SHE (#505) HAD SOB, DECREASED OXYGEN AND HER SKIN WAS CLAMMY AND SWEATY..." WHEN ASKED IF RESIDENT #505 HAD BEEN MEDICATED PRIOR TO HER BEING SENT OUT TO THE HOSPITAL, THE DON SAID THAT RESIDENT #505 WAS GIVEN HER PRESCRIBED PAIN MEDICATION JUST PRIOR TO BEING SENT OUT TO THE HOSPITAL. WHEN ASKED IF CNA #1 WAS SUSPENDED PENDING INVESTIGATION, THE DON STATED " ...NO, SHE WAS NOT SUSPENDED... " WHEN QUERIED ABOUT RESIDENT #505'S DECLINE WITH RESULTANT hospitalization , THE DON STATED "...HER NEEDS WEREN'T BEING MET..." THE DIRECTOR OF NURSING (DON) COULD NOT EXPLAIN WHY RESIDENT #505'S NEEDS WERE NOT MET AND WHY SHE DID NOT RECEIVE MEDICAL ATTENTION WHEN SHE COMPLAINED OF SHORTNESS OF BREATH WHICH LED TO RESPIRATORY DISTRESS AND hospitalization WITH RESULTANT [MEDICAL CONDITION] INFARCTION ([MEDICAL CONDITION]). ADDITIONALLY, THE DON COULD NOT EXPLAIN WHY CNA #1 WAS NOT SUSPENDED PENDING INVESTIGATION.

THIS CITATION PERTAINS TO INTAKE NUMBER MI 211 BASED ON INTERVIEWS AND RECORD REVIEWS, THE FACILITY FAILED TO ENSURE THAT ONE (#505) OF SEVEN SAMPLED RESIDENTS WAS FREE FROM ABUSE AND NEGLECT RESULTING IN RESIDENT #505 NOT RECEIVING NURSING SERVICES AS REQUESTED WHEN SHE COMPLAINED OF SHORTNESS OF BREATH WHICH RESULTED IN RESIDENT #505 EXPERIENCING RESPIRATORY DISTRESS AND SUBSEQUENTLY BEING TRANSFERRED TO A NEARBY HOSPITAL WHERE SHE SUFFERED A [MEDICAL CONDITION]. FINDINGS INCLUDE: REVIEW OF THE ADMISSIONS FACE SHEET INDICATED THAT RESIDENT #505 WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM (MDS) data set [DATE] INDICATED THAT RESIDENT #505 HAD INDEPENDENT COGNITIVE SKILLS FOR DECISION MAKING, HAD NO SHORT OR LONG TERM MEMORY PROBLEMS AND REQUIRED EXTENSIVE TO TOTAL ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING INCLUDING BED MOBILITY, TRANSFERS, DRESSING, TOILETING, PERSONAL HYGIENE AND BATHING. A COMPLAINT ON FILE ALLEGED THAT ON 7/22/10 A CERTIFIED NURSING ASSISTANT (CNA) REFUSED TO GET THE NURSE FOR RESIDENT #505 WHO REPORTEDLY COMPLAINED OF SHORTNESS OF BREATH (SOB) AND REQUESTED TO SEE THE NURSE. IT WAS FURTHER REPORTED THAT THE CNA TOLD RESIDENT #505 THAT THERE WAS NOTHING WRONG WITH HER AND TO STOP ACTING LIKE A BABY. DURING THE COMPLAINT INVESTIGATION, THE ALLEGATION REGARDING THE CNA TELLING RESIDENT #505 TO STOP ACTING LIKE A BABY COULD NOT BE SUBSTANTIATED. ACCORDING TO RESIDENT #505'S RESIDENT TRANSFER FORM DATED 7/22/10, RESIDENT #505 EXPERIENCED PAIN AT LEVEL 6/10, SHORTNESS OF BREATH WITH A LOW OXYGEN SATURATION LEVEL OF 82% (NORMAL 90% TO 100%). RESIDENT #505'S SKIN WAS CLAMMY AND SWEATY AND SHE COMPLAINED OF A SORE THROAT AND HAD A SWOLLEN GLAND TO HER RIGHT NECK. RESIDENT #505 WAS THEN TRANSFERRED OUT TO A NEARBY HOSPITAL FOR EVALUATION AND TREATMENT. ACCORDING TO RESIDENT #505'S EMS (EMERGENCY MEDICAL SYSTEM) RUN SHEET DATED 7/22/10, RESIDENT #505 WAS TRANSFERRED TO A NEARBY HOSPITAL FOR COMPLAINTS OF SHORTNESS OF BREATH, RIGHT SIDED NECK PAIN AND PAIN TO HER CHEST. THE EMS RUN SHEET DOCUMENTED THE FOLLOWING: "...ON THURSDAY, JULY 22 WE FIND A [AGE] year OLD FEMALE PATIENT PRESENTING WITH SHORTNESS OF BREATH SINCE THIS MORNING COMPLAINING OF RIGHT SIDED NECK PAIN AND A SORE THROAT. SHE HAS SOME SWELLING AND TENDERNESS ON THE RIGHT SIDE OF HER NECK..." "...STATES IT HURTS IN HER CHEST WHEN SHE BREATHS..." "...INITIAL ASSESSMENT: PALE IN COLOR, LEFT SIDE DIMINISHED LUNG SOUNDS, RIGHT WET DIMINISHED LUNG SOUNDS..." RESIDENT #505 WAS GIVEN OXYGEN AT 4 LITERS PER MINUTE. CARDIAC MONITORING WAS INITIATED AND RESIDENT #505 WAS TRANSFERRED TO A NEARBY HOSPITAL VIA AN ADVANCED LIFE SUPPORT UNIT. A HOSPITAL HISTORY AND PHYSICAL NOTE DATED 7/22/10 DOCUMENTED: "...THE PATIENT REPORTEDLY AWOKE THIS MORNING TO SHORTNESS OF BREATH..." "...THE PATIENT REPORTED EXPERIENCE SOME FEVER AND CHILLS LAST NIGHT..." "...THE PATIENT WAS BROUGHT INTO THE emergency room , HAD A CHEST X-RAY WHICH SHOWED A D-DIMER (The d-Dimer test, which is used to rule out blood clots). CT SCAN (Computed tomography x-ray imaging) INDICATED A LARGE PLEURAL EFFUSION BILATERALLY AS WELL AS CONSOLIDATION OF THE LUNGS BILATERALLY INDICATING A NOSOCOMIAL PNEUMONIA. (Facility-acquired pneumonia or Nosocomial pneumonia refers to any pneumonia contracted after at least 48-72 hours of being admitted to a healthcare facility or hospital)..." "...IN SHORT, IT APPEARS THAT THE PATIENT IS PRESENTING WITH ACTUALLY FOUR ACTIVE PROBLEMS..." "...SHE HAS AN ELEVATED TROPONIN, INDICATIVE OF LIKELY NON-ST-ELEVATION [MEDICAL CONDITION] INFARCTION..." (Proteins from cardiac muscle that indicate a [MEDICAL CONDITION]; when blood vessels that supply blood to the heart are blocked, preventing enough oxygen from getting to the heart). "...IT APPEARS THAT SHE HAS A NEW ONSET [MEDICAL CONDITION]" "...URINARY TRACT INFECTION..." "...NOSOCOMIAL PNEUMONIA..." A CARDIOLOGY CONSULTATION NOTE DATED 7/22/10 DOCUMENTED THE FOLLOWING: "...SHE (#505) DESCRIBES FEELING SHORT OF BREATH AND DIAPHORETIC (excessive sweating) THIS AFTERNOON..." "...THE PATIENT IS AN ELDERLY ILL APPEARING LADY IN MILD RESPIRATORY DISTRESS..." "...RESULTS OF THE CT SCAN SHOWED COMPRESSIVE ATELECTASIS (COLLAPSE OF THE AIR SACKS IN THE LUNGS) AND CONSOLIDATION FOR BOTH LOWER LUNGS. CHEST X-RAY REVEALS [MEDICAL CONDITIONS] (FLUID IN THE LUNGS)..." "...EVALUATION IN THE emergency room SHOWED MARKEDLY ELEVATED BNP (B-type Natriuretic Peptide blood test shows changes in pressure that occur when heart failure develops) AND MILDLY ELEVATED TROPONIN. (Proteins- used as a test of several different heart disorders, including [MEDICAL CONDITION] infarction ([MEDICAL CONDITION])..." "...THE PATIENT WAS THEN admitted ..." REVIEW OF THE FACILITY'S ADMINISTRATIVE INVESTIGATION (UNDATED) DOCUMENTED THE FOLLOWING: "IN EARLY JULY NURSE #1 WORKED WITH CNA #1 AND HER COMMUNICATION WITH RESIDENTS AND HOW SOMETIMES CNA #1 APPEARS BOSSY AND ABRUPT. THIS ONE ON ONE COACHING WAS DESIGNED TO CURB THIS NEGATIVE PRESENTATION BY MAKING CNA #1 CONSCIOUS OF HER TONE AND TEMPERAMENT... " " ...ON 7/30/10 (INCORRECT DATE AS INCIDENT OCCURRED ON 7/22/10), RESIDENT #505 ASKED CNA #1 TO GET HER NURSE AS SHE WAS EXPERIENCING DIFFICULTY BREATHING. ACCORDING TO RESIDENT #505, CNA #1 TOLD RESIDENT #505 THAT SHE WAS FINE...". "...LATER, CNA #1 REPORTED TO THE NURSE THAT RESIDENT #505 WAS SHORT OF BREATH. RESIDENT #505 WAS DISPLAYING SIGNS AND SYMPTOMS OF RESPIRATORY DISTRESS... ". " ...LATER, NURSE #1 HAD A DISCUSSION WITH CNA #1 INDICATING IT WAS NOT HER RESPONSIBILITY TO DECIDE IF A RESIDENT NEEDED MEDICAL ATTENTION... ". "...NURSE #1 REPORTED TO THE DIRECTOR OF NURSING (DON) THAT RESIDENT #505 INFORMED HER (NURSE #1) THAT CNA #1 WAS MEAN SPEAKING AND KEPT SAYING SHE (#505) WAS FINE AND TO LAY DOWN...". "...IT WAS DECIDED TO REASSIGN CNA #1 ON ANOTHER UNIT UNTIL THE INVESTIGATION WAS COMPLETE..." THERE WAS NO DOCUMENTED EVIDENCE THAT CNA #1 WAS SUSPENDED PENDING INVESTIGATION. ON 10/18/10 AT 12:08 P.M., DURING AN INTERVIEW, NURSE #1 REPORTED THE FOLLOWING: "...I WAS MADE AWARE THAT THE CNA (CNA #1) REFUSED TO GET THE NURSE WHEN RESIDENT #505 COMPLAINED OF SOB AND I IMMEDIATELY SPOKE WITH HER (CNA #1) ABOUT THIS..." NURSE #1 ACKNOWLEDGED THAT SHE COULD NOT REMEMBER THE DATE OF THE OCCURRENCE. NURSE #1 WENT ON TO STATE "...SHE (#505) WAS CRYING AND SHE SAID THAT THE CNA (CNA #1) REFUSED TO GET THE NURSE WHEN SHE WAS HAVING SOB..." NURSE #1 SAID, "...I SPOKE TO HER (CNA#1) AND COUNSELED HER ABOUT NOT COMING TO GET ME WHEN THE RESIDENT COMPLAINED OF SHORTNESS OF BREATH (SOB), AND SHE (CNA #1) INFORMED ME THAT SHE THOUGHT THE RESIDENT WAS FINE..." "...SHE (CNA #1) INFORMED ME THAT SHE THOUGHT THAT RESIDENT #505 WAS JUST PLAYING AROUND BY ASKING FOR HELP JUST BECAUSE SHE (#505) WANTED TO BE BABIED..." NURSE #1 FURTHER STATED THAT RESIDENT #505 WAS "...QUITE SICK AND HAD TO BE SENT TO THE HOSPITAL..." AND "...I NEVER WANT A RESIDENT TO HAVE TO WAIT FOR CARE..." "...SHE COMPLAINED OF EXTREME SHORTNESS OF BREATH AND CHEST PAIN. SHE WAS DIAPHORETIC, AND HER HAIR WAS DRIZZLING WITH SWEAT. I CHECKED HER OXYGEN SATURATION AND IT WAS 80%..." NURSE #1 SAID,"...I YELLED AT HER (CNA #1) AND SAID "THIS IS WHY YOU NEVER MAKE THAT DECISION FOR ME"..."; "...IF I HAD BEEN CONTACTED IMMEDIATELY, SHE (#505) WOULDN'T HAVE BEEN IN SUCH DISTRESS..." WHEN ASKED IF THERE WAS ANY DOCUMENTATION OF THIS INCIDENT AVAILABLE FOR REVIEW, NURSE #1 SAID "...NOT IN THE CHART BUT I'M THE ONE WHO SENT HER (#505) TO THE HOSPITAL..." ON 10/18/10 AT 12:31 P.M., DURING AN INTERVIEW, LPN #1 REPORTED THAT RESIDENT #505 COMPLAINED OF PAIN EARLIER THAT EVENING, BUT DIDN'T SPECIFY A LOCATION. WHEN ASKED ABOUT RESIDENT #505'S TRANSFER TO THE HOSPITAL, LPN #1 SAID "...I THINK SHE (#505) WENT OUT BECAUSE OF PAIN..." ON 10/18/10 AT 3:52 P.M., AN INTERVIEW WAS CONDUCTED WITH CNA #1. WHEN ASKED IF RESIDENT #505 REQUESTED TO SEE THE NURSE ON THE DATE IN QUESTION WHEN SHE (#505) COMPLAINED OF SOB, CNA #1 SAID, "...YES, SHE ASKED QUITE OFTEN..." CNA #1 SAID, "...IT WAS BUSY. I WAS TAKING VITALS AND I TOLD THE NURSE SHE (#505) HAD A HARD TIME BREATHING..." WHEN ASKED IF SHE (CNA#1) INFORMED THE NURSE OF RESIDENT #505'S COMPLAINTS OF SOB RIGHT AWAY, CNA #1 SAID "...I COULDN'T FIND THE NURSE RIGHT AWAY. I WENT OUTSIDE TO LOCATE HER..." WHEN ASKED OF RESIDENT #505'S CONDITION DURING THE START OF THE SHIFT, CNA #1 SAID "...I DIDN'T THINK SHE (#505) WAS THAT BAD AT THE TIME I FIRST CHECKED HER..." " ...I CHECKED HER VITALS (BLOOD PRESSURE, PULSE, TEMPERATURE, and OXYGEN SATURATION) AT THE START OF MY SHIFT (10:00 P.M.) AND I THOUGHT SHE WAS FINE... " CNA #1 SAID, "...SHE WAS UPSET AND NERVOUS BECAUSE SHE WAS IN PAIN. SHE TOLD ME SHE WAS SOB BUT SHE DIDN'T APPEAR TO BE. HER OXYGEN SATURATION LATER WENT DOWN TO BETWEEN 78% AND 82%..." CNA #1 STATED, "...WE HEARD A COUPLE OF HOURS LATER THAT SHE (#505) DID HAVE A [MEDICAL CONDITION]" CNA #1 FURTHER SAID THAT DURING THE NIGHT IN QUESTION, SHE (CNA#1) HAD RECEIVED COUNSELING FOR THE TONE OF VOICE SHE USED WITH RESIDENT #505. ADDITIONALLY, CNA #1 STATED "...SHE (#505) WAS SENT TO THE HOSPITAL BECAUSE SHE DIDN'T GET THE HELP SHE NEEDED..." WHEN ASKED IF SHE (CNA #1) DID IN FACT TELL RESIDENT #505 THERE WAS NOTHING WRONG WITH HER, CNA #1 REPLIED, " ...I DIDN'T TELL HER TO STOP ACTING LIKE A BABY... " CNA #1 HAD NO RESPONSE TO WHETHER SHE TOLD RESIDENT #505 THAT THERE WAS NOTHING WRONG WITH HER. ADDITIONALLY, ALTHOUGH CNA #1 STATED THAT SHE HAD ASSESSED RESIDENT #505'S VITAL SIGNS, REVIEW OF RESIDENT #505'S VITAL SIGN FLOW SHEET REVEALED NO DOCUMENTED EVIDENCE THAT CNA #1 HAD ASSESSED RESIDENT #505'S VITAL SIGNS AT THE BEGINNING OF THE SHIFT AS PREVIOUSLY INDICATED. THE VITAL SIGNS FLOW SHEET REVEALED THAT RESIDENT #505'S VITAL SIGNS HAD NOT BEEN ASSESSED UNTIL SHE WENT INTO DISTRESS AND HER (#505) VITALS SIGNS HAD NOT BEEN TAKEN UNTIL 12:00 A.M., AND HAD BEEN DOCUMENTED BY NURSE #1. ON 10/18/10 AT 4:30 P.M., DURING AN INTERVIEW WITH CNA #2, SHE REPORTED: "...CNA #1 LATER CAME TO THE NURSE'S STATION TO REPORT THAT RESIDENT (#505) NEEDED ASSISTANCE. I WENT DOWN TO CHECK ON HER AND I'M THE ONE WHO INFORMED HER (#505'S) NURSE. SHE (#505) SAID THAT CNA #1 WAS RUDE TO HER..." CNA#2 FURTHER STATED "...THE CALL LIGHTS WERE CONSTANTLY GOING ON SO I WENT DOWN THERE AND PULLED HER (#505) UP IN BED..." "...SHE (#505) SAID THAT CNA#1 WASN'T TAKING HER SERIOUSLY WHEN SHE KEPT ASKING FOR HELP..." ON 10/19/10 AT 12:13 P.M., DURING AN INTERVIEW, NURSE #2 STATED THAT CNA #1 WAS SUSPENDED PENDING INVESTIGATION. "...WE DISCUSSED WHAT CONSTITUTES ABUSE AND WE DISCUSSED THE TONE OF VOICE SHE USED WHEN SPEAKING WITH THE RESIDENTS..." ON 10/20/10 AT 11:14 A.M., DURING AN INTERVIEW, THE DIRECTOR OF NURSING (DON) REPORTED THAT RESIDENT #505 WAS "...SENT OUT TO THE hospital on [DATE] AT 12:35 A.M. BECAUSE SHE (#505) HAD SOB, DECREASED OXYGEN AND HER SKIN WAS CLAMMY AND SWEATY..." WHEN ASKED IF RESIDENT #505 HAD BEEN MEDICATED PRIOR TO HER BEING SENT OUT TO THE HOSPITAL, THE DON SAID THAT RESIDENT #505 WAS GIVEN HER PRESCRIBED PAIN MEDICATION JUST PRIOR TO BEING SENT OUT TO THE HOSPITAL. WHEN ASKED IF CNA #1 WAS SUSPENDED PENDING INVESTIGATION, THE DON STATED " ...NO, SHE WAS NOT SUSPENDED... " WHEN QUERIED ABOUT RESIDENT #505'S DECLINE WITH RESULTANT hospitalization , THE DON STATED "...HER NEEDS WEREN'T BEING MET..." THE DIRECTOR OF NURSING (DON) COULD NOT EXPLAIN WHY RESIDENT #505'S NEEDS WERE NOT MET AND WHY SHE DID NOT RECEIVE MEDICAL ATTENTION WHEN SHE COMPLAINED OF SHORTNESS OF BREATH WHICH LED TO RESPIRATORY DISTRESS AND hospitalization WITH RESULTANT [MEDICAL CONDITION] INFARCTION ([MEDICAL CONDITION]). ADDITIONALLY, THE DON COULD NOT EXPLAIN WHY CNA #1 WAS NOT SUSPENDED PENDING INVESTIGATION.