Every finding on record at Father Murray, A Villa Center

Based on observation, interview, and record review, the facility failed to maintain a safe, homelike environment affecting two residents (R73 and R17) of three reviewed for environment. Findings include:R73On 06/23/26 at 9:50 AM, R73 was observed sitting in their wheelchair next to the bed. When asked about concerns, R73 pointed to areas on their wall and stated, I'm in my room most of the time and must look at this. Even when visitors come, they have to see this. R73 stated that they reported this concern to nursing months ago. Several deep nicks in the drywall and peeling paint were observed on the wall and multiple areas on wall around the room. A record review revealed that R73 was admitted on [DATE] with the following medical diagnoses of Major Depressive disorder, Anxiety and Hypertension. R73's Brief Interview for Mental Status assessment (BIMS) score was 15/15, indicating intact cognition.R17On 06/23/26 at 10:15 AM, R17 was observed lying in bed looking at television. R17 was unable to respond when asked about concerns. A large section of peeling paint and wallpaper was observed peeling off the wall behind their bed and under the television.A record review revealed that R17 was admitted on [DATE] with the following medical diagnoses of Hypertension, Cerebral Vascular Accident, and Dysphagia. R17's Brief Interview for Mental Status assessment (BIMS) score was 0/15, indicating severely impaired cognition.On 6/25/26 at 11:06 AM, a tour of the room was held with Maintenance Director (MD) F regarding room [ROOM NUMBER]. MD F was asked about areas of concern and acknowledged that the areas needed repair and that the department is working to complete several areas. The MD stated his expectation is for all the residents to be able to live in a safe, homelike environment. A review of the facility's policy titled Quality of Life - Homelike Environment policy revealed that residents are provided with a safe, clean, comfortable and home-like environment and encouraged to use their personal belongings to the extent possible.

Based on interview and record review, the facility failed to notify or provide one resident (R194) or their representative of a bed hold (a policy on how a resident's bed will be held or reserved while they are absent from the facility) upon transfer to the hospital out of two residents reviewed for hospital discharges. Findings include:Review of R194's electronic medical record (EMR) revealed progress notes regarding R194's discharge to the hospital on 6/16/26 for catheter related complications with admission back into the facility on 6/20/26. No documentation was found to indicate they or their representative was provided with the facility's bed hold policy upon this discharge to the hospital.Further review of R194's EMR revealed they were admitted to the facility 9/13/2023 with diagnoses of hypertension (high blood pressure), major depressive disorder, and obstructive and reflux uropathy (blockage of the urinary tract). R194's most recent Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition.On 06/25/2026 at 11:45 AM, an interview was conducted with the Nursing Home Administrator (NHA) who confirmed the facility's policy regarding bed hold notification is that the family of the resident is called by the receptionist to notify them of the facility's bed hold policy. The NHA then provided a document showing that R194's family was contacted on 6/19/26 (three days after resident was discharged from the facility).On 06/25/2026 at 11:48 AM, an interview was conducted with Receptionist E who stated they have a list of recently hospitalized residents they use to call the family of each resident after they have been out of the facility for over a day. Receptionist E went on to say that during the call they discuss bed holds with the resident's family and confirmed that on 6/19/26 they did speak with R194's family member and discussed the bed hold policy.On 06/25/2026 at 12:07 PM, an interview was conducted with R194's Family Member G via telephone. Family Member G stated they were called by the facility to be informed of the details of R194's hospitalization, but they were not given information about a bed hold policy.On 06/25/2026 at 1:54 PM, an additional interview was conducted with the NHA who said R194 should have been provided with a written notice of the bed hold policy, and that the expectation is for residents to be provided with one when they are discharged to the hospital.Review of a facility policy titled Bed Hold and Return Guideline with effective date of 4/25/2019 revealed Residents and their representative will be provided with bed hold and return information at admission and before a hospital transfer or therapeutic leave.

Based interview and record review, the facility failed to complete Minimum Data Set (MDS) assessments timely for two residents (R18 and R215) of 12 residents reviewed. Findings include:A review of the survey MDS task revealed 12 residents with assessments overdue by 120 days. On [DATE] at 12:18 PM, the surveyor asked the nurses in the MDS office about 12 overdue MDS assessments and requested follow-up on why they are triggering as incomplete. On [DATE] at 3:15 PM, MDS Nurse H explained that resident R18 and R215's MDS assessments had been overlooked and not completed. The other 10 were clerical errors which had previously been remedied. A review of R18's medical record revealed they were admitted into the facility on [DATE] with diagnoses of Encephalopathy and Acute Respiratory Failure with Hypoxia. Their MDS was due on [DATE] and had not been completed. A review of R215's medical record revealed they were admitted into the facility on [DATE] and discharged on [DATE] with diagnoses which included Sepsis and Diabetes. Their MDS assessment was due on [DATE] and had not been completed. On [DATE] at 3:00 PM, the Nursing Home Administrator (NHA) was asked about the MDS assessments that had not been completed and expressed that her expectation is for the assessments to be completed timely. A review of the facility's, RAI (Resident Assessment Instrument) Process Guideline revealed the following, .4) The assessment information will be encoded into the MDS within 7 days of the assessment completion. Everyone who completes a portion of the assessment will sign to certify the accuracy of that portion of the assessment. Back-dating is prohibited, though signing the assessment section with the date that section was completed is not considered back dating. Tracking records and OBRA (Omnibus Budget Reconciliation Act) assessments will be transmitted electronically, in a CMS (Centers for Medicare and Medicaid) specified format, within 14 days of the assessment completion. MDS transmission Validation Reports will be saved electronically. The facility does not release resident-identifiable information to the public .

Based on observation, interview and record review, the facility failed to implement care planned interventions for one resident (R39) of three reviewed for care plans. Findings include: A review of R39's medical record revealed they were admitted into the facility on 5/22/14, with a readmission date of 9/30/25 with diagnoses of Peripheral Vascular Disease (PVD) and Adult Failure to Thrive. Further review revealed the resident was severely cognitively impaired and required dependence with activities of daily living. A review of R39's skin integrity care plan noted the following, .The resident has actual impairment .Left outer lateral heel stage 2 (partial thickness loss of dermis), Right lateral lower leg Vascular, right lateral ankle vascular/Right heel eschar vascular, left heel eschar vascular, cognitive communication deficit, adult failure to thrive .Date Initiated: 02/20/2025. Interventions: .12. Heel protectors . On 06/23/2026 at 10:12 AM, 1:43 PM, and 3:39 PM, R39 was observed in bed on their back, their feet flat on the bed with no heel protectors in use. Due to R39's cognition, they were unable to be interviewed. On 06/24/2026 at 8:47 AM, 10:29 AM, 11:48 AM, and 1:43 PM, and 3:48 PM, R39 was observed in bed with their feet lying flat on the mattress, no heel protectors were observed in use. On 06/25/2026 at 9:04 AM, R39 was lying on back with their feet lying flat on the mattress, no heel protectors were observed in use. On 06/25/2026 at 11:48 AM, Wound Care Nurses (WCN) B and C were asked about R39's missing heel protectors. WCN C explained the heel protectors were most likely being laundered and had not been brought back to the unit. The three days of observations were discussed, and both wound care nurses and they acknowledged no direct care staff members had ensured they were on. On 06/25/2026 at 2:07 PM, the Director of Nursing (DON) was informed of R39's missing heel protection and explained the resident typically has them on but acknowledged they should have had them on during the surveyor's observations. A review of the facility's, Care Plan Standard Guideline policy did not address the implementation of care planned interventions.

Based on observation, interview, and record review, the facility failed to revise a care plan intervention for one resident (R24) out of three reviewed for care plans. Findings include: A review of the medical record revealed R24 admitted into the facility on 3/21/2022 with the following medical diagnoses, adjustment disorder and Generalized Anxiety Disorder. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 0/15 indicating an impaired cognition. R24 also required staff assistance with bed mobility and transfers. Further review of an active care plan noted the following, Focus: I speak limited English. I speak Chinese as my primary language, but can understand some English.Goal: The resident will be able to make basic needs known by.using communication board.Interventions: The resident is able to communicate by: using communication board at bedside.On 6/24/2026 at 11:50 AM, a communication board was not noted to be at R24's bedside. R24 was unable to be interviewed.On 6/25/2026 at 11:50 AM, A communication board was not noted to be at R24's bedside. On 6/25/2026 at 11:52 AM, an interview was conducted with Certified Nursing Assistant (CNA) D. CNA D reported R24 used to have a communication board when first admitted into the facility, but they have not had one in a while. CNA D reported R24 does know some English and communicates by pointing and one-word answers. On 6/25/2026 at 11:59 AM, an interview was conducted with the Activities Director (AD) A. AD A reported R24 does not need a communication board at this time, and although they do not speak much English, they can understand it well. On 6/25/2026 at 1:59 PM an interview was conducted with the Director of Nursing (DON). The DON reported that R24 can communicate their needs and has been here long and knows the staff. The DON reported the care plan needs to be updated. A request for a facility policy related to revising care plans was requested but not received by end of survey.

Based on observation, interview, and record review, the facility failed to apply soft lift heel boots for one resident (R9) out of one reviewed for physician orders. Findings include:A review of the medical record revealed R9 admitted into the facility on 2/6/2025 with the following medical diagnoses, Muscle Wasting and Atrophy and Anoxic Brain Damage. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating R9 was unable to complete the assessment. R9 also required staff assistance with bed mobility and transfer. Further review of current physician's orders revealed the following, Soft heel lift boots when up in chair and bed.Every shift for wound care management.Further review of the Treatment Administration Record (TAR) for the month of June 2026 noted a checkmark for day shift and night shift indicating the soft heel lift boots had been applied daily.On 6/23/2026 at 11:41 AM, 12:00 PM, and 3:45 PM, R9 was observed lying in bed, no soft heel lift boots were in use. On 6/24/2026 at 8:59 AM, 12:07 PM, 1:49 PM, and 3:54 PM, R9 was observed lying in bed, no soft heel lift boots were in use. On 6/25/2026 at 9:27 AM, R9 was observed lying in bed, no soft heel lift boots were in use. On 6/25/2026 at 11:55 AM, an interview was conducted with Wound Care Nurse (WCN) B and WCN C. WCN C reported R9 does not have any wounds on their heels and the soft heel lift boots order was entered as a preventative measure but aren't needed due to R9's contractures. On 6/25/2026 at 2:01 PM, an interview was conducted with the Director of Nursing (DON) who confirmed the soft heel lift boots should have been applied per the physician's orders. A review of a facility policy titled, Physician Medication Orders did not address following an order as prescribed.

Based on observation, interview, and record review, the facility failed to follow provide oversight during medication administration for one resident (R904) of one reviewed for professional standards of practice. Findings include:On 4/22/2026 at 11:27 AM, R904 was observed sitting on the side of their bed placing pills from a medication cup into their mouth. R904 was asked about the pills they were taking and was unable to identify individual pills. A review of the Electronic Medical Record (EMR) revealed R904 was admitted into the facility on 3/17/2025 with pertinent diagnosis of Adjustment Disorder with Mixed Anxiety and Hemiplegia and Hemiparesis (stroke). Further review revealed the resident had an intact cognition. A review of 904's medical record noted the following active physician orders: Amlodipine Besylate (used to treat high blood pressure) Oral tablet 10mg (milligrams) - one time a day for Hypertension (HTN). Hold if systolic blood pressure is less than 100 mmHg (millimeters of mercury, a unit of pressure) or diastolic blood pressure Is less than 60 mmHg. Metoprolol Tartrate (used to treat high blood pressure) Oral 25 mg - Give 1 tablet by mouth every 12 hours for Hypertension (HTN), hold is systolic blood pressure is less than 100mmHg, or diastolic blood pressure is less than 60mmHg.Further review of R904's April 2026 Medication Administration Record (MAR) revealed no blood pressure reading for 4/22/26. On 4/22/26 at 11:39 AM, Licensed Practical Nurse (LPN A) was asked about R904 administering their own medication. LPN A explained R904 is alert and able to self-administer their own medications. LPN A was asked about monitoring of the blood pressure parameters for the administration of R904's blood pressure medication and provided no answer. On 4/22/26 at 12:22 PM, the Director of Nursing (DON) was asked about the monitoring of blood pressure parameters prior to R904 being administered blood pressure medications, and she explained R904's blood pressure should be monitored, and vitals noted on the MAR. A review of the facility policy titled, Medication Administration dated April 2018 revealed the following: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions.

This citation pertains to Intake number 2809219.Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by facility staff for one (R900) of three residents reviewed for abuse. Findings include:An allegation of staff to resident abuse involving Certified Nursing Assistant (CNA) A and R900 was submitted to the State Agency.A review of the medical record revealed a progress note dated 3/13/25 at 10:10 PM authored by Licensed Practical Nurse (LPN) B, Observed (name of R904) looking through the personal items of their roommate without their knowledge, (name of R904) became angry pushing (name of LPN B) on the shoulder telling them to mind their own business. A progress note dated 3/14/26, documented, (Name of CNA A) attempted to redirect (name of R904) to their room when (name of R904) began swiping items off the nursing desk to the floor. (Name of CNA A) continued to attempt to redirect (name of resident R904) back to their room when the resident began throwing several full water cups on multiple staff members at the desk, including (name of CNA A). The Director of Nursing (DON) was notified as well as the local police.On 3/24/26 at 3:00 pm, in an interview with R904 they were queried regarding the incident and said, other than the blood clot in their arm they were ok. R904 declined to discuss the situation any further, stating, it was over.At 3:12 PM, an interview with CNA C revealed the beginning of R904's outburst occurred prior to shift change with LPN B. CNA C reported LPN B asked the other floor nurse to swap residents (R904 for another resident). CNA C went on to say, when CNA A was struck by two full cups of ice water they (CNA A) immediately picked up a large, insulated cup and threw it at R904 striking the resident on the hand/wrist area. Review of the medical record revealed R904 was most recently admitted to the facility on [DATE] with the following relevant diagnoses: Gunshot Wound to the Face and Lower Jaw, Major Depression, Conversion Disorder with Seizures, Dysphagia, Gastrostomy. The most recent Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status indicating intact cognition.On 3/24/26 at 3:30 PM, an interview with the DON, revealed R904 was angry from being accused of going through room-mates belongings while they were assisting the roommate in finding their remote control. The DON revealed the incident occurred close to shift change and staffs, catastrophic reactions (sudden response to a behavior) to resident behavior is unacceptable. On 3/24/26 at 2:02 PM, a phone call was made to CNA A and did not return a call by survey exit.On 3/24/26 at 2:39 PM, a phone call was made to LPN B and did not return a call by survey exit.A review of the policy titled, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, dated 11/28/2017 documented, .Residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated .

This citation pertains to Intake 2699034Based on observation, interview, and record review, the facility failed to protect one resident (R904) from sexual abuse from another resident (R903) out of five reviewed for abuse. Findings include:A review of a Facility Reported Incident (FRI) noted the following, Incident summary: During post lunch rounds, resident [R904] observed in the room of [R903]. Both residents were engaged in oral sexual contact that was interrupted by the assigned CNA [Certified Nursing Assistant]. [R904] demonstrates cognitive impairments related to [their] dx. Both residents remain in the facility. No injury. Behavior did not progress beyond this contact. [R903] is currently under enhanced supervision until investigation is complete and care plan updates can occur.On 12/22/2025 at 11:07 AM, R903 was observed lying in bed. CNA A was noted to be sitting outside the door and stated they were R903's 1:1 assigned supervision. R903 reported they were friendly with R904 in the past, and they would speak often. R903 reported R904 came in their room and laid in their roommate's bed. R903 reported they asked if they could join R904 and they told them Yes. R903 stated that when the sexual contact occurred and R904 seemed as though they were enjoying themselves. R903 reported they did not think they were doing anything wrong because R904 said yes and seemed as if they were enjoying it.A review of the medical record revealed R903 admitted into the facility with the following medical diagnoses, Muscle Weakness and Major Depressive Disorder. A review of the most recent Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 13/15, indicating an intact cognition. R903 also required staff assistance with bed mobility and transfers.On 12/22/2025 at 11:15 AM, R904 was observed lying in bed and unable to recall the incident. R904 was asked if they felt safe in the facility and they stated, Yes.A review of the medical record revealed R904 admitted into the facility with the following medical diagnoses, Schizophreniform Disorder and Major Depressive Disorder. A review of the most recent MDS assessment revealed a BIMS score of 0/15 indicating impaired cognition. R904 also required staff assistance with bed mobility and transfers. R904 was also noted to have a Legal Guardian due to being deemed incompetent by the court system.On 12/22/2025 at 11:45 AM, an interview was conducted with Social Worker (SW) F. SW F reported they conducted a psychosocial on R903 and they were open and honest about the incident. SW F reported R903 was counseled about how to contain proper consent and who they should speak to if they want to pursue a romantic relationship with another resident. SW F reported that R903 voiced their understanding.On 12/22/2025 at 12:41 PM, a phone call was attempted to CNA C with no avail. A review of a written statement from CNA C dated 12/22/2025 noted the following, Employee was conducting post-lunch rounds and entered the room of [R903] at approximately 1:25 PM. Upon entering room, employee identified [R903] standing up in between bed 1 and 2, with [their] (male private part) in [R904's] mouth, engaged in sexual contact. Employee immediately said, what are you doing? [R903] was startled and tucked [their] privates back into [their] pants. Employee called for nurse who immediately entered the room. Employee reports [R904] was not fighting but was lying in bed receiving sexual contact. Employee immediately removed [R904] from the room. Employee reports [R903] was on 1:1 supervision after that. Employee reports [R904] was returned to [their] room and behaving normally after that.On 12/22/2025 at 12:38 PM, a phone call with Licensed Practical Nurse (LPN) E was attempted with no avail.On 12/22/2025 at 1:32 PM, an interview was conducted with the Nursing Home Administrator (NHA). The NHA reported that R903 was going to remain on a 1:1 until they have a solid plan, whether that be discharge to another facility or back into the community. The NHA reported that neither resident has had an incident like this before. The NHA reported that R903 was counseled on proper consent and guardianship and that R903 voiced understanding. The NHA was asked about where staff was during this time being that R903's room is directly across from the nurse's station, and they reported they were picking up lunch trays on the floor. The NHA reported that the door was open, and the curtain was not closed during the incident according to CNA C.A review of a facility policy titled, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property noted the following, .It is the policy of the facility that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse, corporal punishment or involuntary seclusion .

This citation pertains to Intake 2609700.Based on observation, interview, and record review, the facility failed to schedule a follow up consultation appointment for one resident (R903) out one reviewed for appointments. Findings include:On 11/20/2025 at 10:38 AM, an interview was conducted with R903. R903 reported they have been trying to get to an appointment that they were referred to by their neurologist. R903 reported the follow up appointment was in their discharge paperwork from the hospital, as well as an order that was recently entered by the facility's Nurse Practitioner (NP). R903 reported they hadn't heard anything about the appointment and when they would be going, and they were starting to get worried.A review of the medical record revealed R903 admitted into the facility on 7/31/2025 with the following medical diagnoses, Spina Bifida and Presence of Cerebrospinal Fluid Drainage Device. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 15/15, which indicated intact cognition. R903 also required staff assistance with bed mobility and transfers.Further review of the medical record revealed the following neurology consultation note dated 8/30/2025, Per (neurologist) request plastics evaluation due to [R903's] chronic wound to the right temporoparietal (right side of the head) scalp. This evaluation can be done as an outpatient as well.A review of the hospital Discharge summary dated [DATE], revealed R903 was to follow up with the plastics physician within 1 to 2 weeks of discharge back to the facility.Further review of the physicians' orders revealed the following, Schedule Plastic Surgery [Physician Name and location]. Created 10/29/2025.On 11/20/2025 at 1:18 PM, an interview was conducted with R903. R903 reported they were asked about going to their plastic surgery appointment; however, they were trying to send them for their leg and not address their head. R903 reported they did not want a consultation for their leg but would go for the appointment recommended by their neurologist.On 11/20/2025 at 1:24 PM, an interview was conducted with Licensed Practical Nurse (LPN) B. LPN B reported they had asked R903 about going to a scheduled plastics appointment and they refused. LPN B reported they did tell R903 it was for their leg, because that's what they thought the appointment was for.On 11/20/2025 at 1:27 PM, LPN C asked R903 if they would like to be scheduled to go to plastics for their head. R903 stated, yes, I will go on that appointment.On 11/20/2025 at 1:32 PM, an interview was conducted with the Director of Nursing (DON). The DON stated R903 kept refusing the appointment from their understanding. The DON was informed that the only progress note related to refusing appointments referred to R903's wounds on their leg. The DON reported they would look further into refusals regarding their head wound and plastics appointment.On 11/20/2025 at 1:55 PM, an interview was conducted with the DON. The DON reported they went and spoke with the R903, and they reported they would go on the appointment if it was for their head, and not their leg. The DON reported they informed the scheduler to make the appointment and R903 would be attending it.On 11/20/2025 at 2:50 PM, an interview was conducted with Scheduler F. Scheduler F reported they were just informed about the appointment and would be getting with the facility NP to put in a new order and then would get the plastics appointment for R903's head scheduled.A review of a facility policy titled, Appointments revealed the following, It is the policy of this facility that the Nursing Department will communicate on a consistent basis with outside agencies consulted for ancillary services and/or medical appointments. Appointments include ancillary providers (such as dental, vision and audiology services) scheduled within the facility. Consultation appointments require a physician's order.

This citation pertains to 2598400 and 2609700. Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary environment in one of one bathroom on the 100 unit, and in two of four shower rooms. Findings include:On 11/20/25 at 9:20 AM, the shared bathroom between rooms [ROOM NUMBERS] was observed to have an area of built-up black soil, wall to wall on the floor behind the toilet. This had not been cleaned up prior to survey exit.On 11/20/25 at 9:40 AM and 1:04 PM, observation of the one south shower room revealed: The toilet had what looked like rust stains down from the lip of the bowl to the floor on the right side of toilet; black scratch marks also appeared on the rim of the toilet; The first stall to the left had two EKG (electrocardiogram) leads and a used Tegaderm (wound dressing) on the floor; The second stall had a soap bottle cap on the floor and the third stall had a (soap scum) soiled plastic bag attached to the left arm of the shower chair with a draw string; The shower bed in the main shower area had two pillows and a hospital style gown on the foot of the pad; The pad for the shower bed had a half dollar size dried brown substance in the center area; An approximate 1/2 to 3/4 inch cut was noted in the surface toward the foot of the pad; Black and tan soil was observed on the inside edges of the drain holes of the mat and under the mat, tan and brown soil (soap scum) rings and black soil (mildew) had formed around the drain holes; and all the drain holes for the white plastic bed surface were black with soil (mildew). The large shower chair with the brown mesh back had black soil (mildew) under the rim of the seat and around the joint connections. The shower chair with the blue mesh back had brown and black soil build up under the seat area. The white plastic shower chair had a buildup of tan, brown and black soil in the honeycomb of the back support and under the seat area. At 1:04 PM, the leads and dressing had been picked up. The rest of the items remained the same. The white plastic chair was wet, and it was noted that a resident had taken a shower.On 11/20/25 at 9:56 AM, loose dust buildup was observed in the corners behind the fire doors to one north.On 11/20/25 at 10:39 AM, a resident of the one north unit reported they did not believe the staff had any cleaner to clean the shower chairs. On 11/20/25 at 11:11 AM, the one north shower room felt stuffy and damp and had a lingering smell from the dampness (as when an area does not dry fully). A puddle of water around the size of a regulation basketball rim was observed in front of the third stall. The sink and the toilet had signs on them which stated they were out of order; The tub had mechanical items stored inside; A hospital style gown and a bath towel were on the floor next to the tub; The first stall to the left had hair left on the seat of the shower chair; The brown mesh back for the same shower chair had a buildup of tan soil (soap scum); Two razors were left on the stall divider - one had visible soil from shaving on the blades; a second and third razor were on the floor of the stall and in the hand sink respectively; The solid gray shower chair had a buildup of tan soil under the seat; The ceiling tile support grids above the shower stalls were rusted and/or separated in multiple areas over the three stalls. It appeared white spray paint had been used in places along the edges at the wall above the first stall. No cleaner was observed in the cabinets of the shower room.On 11/20/25 at 1:07 PM, a one south Certified Nursing Assistant, (CNA) D reported they had not used the shower bed in a week and was not aware of any resident who would use it to shower that day. CNA D further noted that while CNAs may sanitize the shower chairs, housekeeping would do any deep cleaning. On 11/20/25 at 1:18 PM, the one south shower room and shower chairs were observed with the housekeeping supervisor Staff G. Staff G reported the CNAs were responsible to clean the shower chairs after use and housekeeping was to do the walls and floors. On 11/20/25 at 1:26 PM, the Director of Nursing (DON) reported that after each shower the CNA was responsible for cleaning the shower rooms and chairs. This included the need to pick up trash, bag up dirty towels and clothes and put them in the soiled utility. The DON further reported they will have to find out where the disconnect between the housekeeping staff and the CNAs responsibilities is. On 11/20/25 at 2:10 PM, the observed condition of the shower rooms was reviewed with the CNA supervisor Staff H. Staff H reported the CNAs are responsible to clean all sides and underneath the shower chairs and the shower bed. Staff H reported floor care was responsible for the floors in the shower rooms. The puddle on the floor remained. A review of the facility policy titled, Quality of Life - Homelike Environment date 02/06/01, revealed, Residents are provided with a safe, clean and comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.A review of the facility policy titled, Device Cleaning dated 05/08/20, revealed, .Examples of noncritical patient care items are Blood pressure cuffs/vital sign machines, mechanical lifts that touch the skin, shower chairs/gurney . At a minimum noncritical patient care devices are disinfected when visibly soiled and on a regular basis .

This citation pertains to Intake: 2567551Based on observation, interview, and record review, the facility failed to honor one resident's self-determination rights (R701) of one reviewed for resident rights. Findings include:A review of R701's medical record revealed they were admitted into the facility on [DATE] with diagnoses which included Unspecified Dementia, Muscle Weakness, and Hypertension. Further review revealed the resident had a moderate cognitive impairment, and was independent for bed mobility, dressing, and required minimal assistance for bathing. On 8/11/25 at 10:19 AM, R701 was observed lying in bed and asked about their stay in the facility. They expressed dissatisfaction with the facility food and medication regimen, in addition to their frustration with remaining in the facility. R701 explained their son has guardianship over them and have been feeling powerless as if they are incapable of living independently. Further review of the medical record revealed the following progress notes: 11/22/2024 12:25 Social Service Note .Resident is a recent admission into the facility .admitted into the facility related to [their] mental and healthcare needs. Resident has reported that [they want] to return home however [their] son has stated [they] will remain LTC (long-term care). Resident had conversation related to [their] life and does state [they do] not feel like [R701] has family support in the lifestyle [they want] to have which is to live alone. Resident stated that [they do] feel some slight depression/mood issues related to [them] having to reside in the facility . 12/6/2024 14:27 (2:27pm) Social Service Note .spoke to resident who continues to make accusatory comments about [their] son who is [their] Legal guardian. Resident stated [they were] abused by [their] son and consistently stated he has been stealing [their] money. Resident states [they do not] want [their] son for [their] Guardian and wants a public Guardian. Resident will be assisted to have a modification of Guardianship started, after [they] has been seen by psychological services to ensure [they were] not having an intermittent episode, or if [they are] is consistent in wanting a change. Will continue to follow. A review of R701's Omnibus Budget Reconciliation Act (OBRA) assessment (used to determine a resident's level of care) dated 4/8/25 revealed the following, .1. Determination: No Nursing Facility-Specialized Mental Health Services. The individual does NOT qualify for the level of services provided by a nursing facility but requires specialized mental health/developmental disabilities services .2. Result of Determination: The individual may no longer continue to reside in a nursing facility .Recommendations: Writer recommends a No Nursing Facility placed as [R701's] medical, physical and psychiatric needs can most appropriately be met in a less restrictive community placement Any referrals needed related to discharge should be made by the NF (nursing facility) Social Worker .Writer recommends exploring the possible modification of the guardianship after a capacity exam has been completed . Further review of R701's medical record revealed a Psychological Evaluation dated 4/21/25 revealing the following, .Based on previous evaluation on 4/1/2025, client displays MILD changes in thinking and memory but RETAINS the capacity to make decision .Client would likely benefit from a LESS RESTRICTIVR ENVIRONMENT, and recommend client move outside the locked memory ward if medical team agrees. Further review revealed the following progress note, 4/11/2025 18:24 (6:24pm) Social Service Note .Writer contacted resident's son to inform him that resident had had a competency evaluation and had been deemed competent to make [their] own decisions. Resident's son was informed that resident does have the right to request [their] guardianship however [they] can wish to have [them] remain as [their] guardian. He has requested a second opinion. Writer will have psychiatrist to do an evaluation. 6/3/2025 14:28 (2:28pm) Physician/PA (physician assistant)/NP (nurse practitioner) - Progress Note.Date of Visit: 6/3/2025. Reason for visit: follow-up chronic illness. Subjective: Patient is seen today in follow-up to [their] chronic illness. [R701] is seen on memory care, complains that people are stealing from [them] including [their] family. Requesting to be moved to another unit. 6/20/2025 20:46 (8:46pm) Physician/PA/NP - Progress Note (Narrative).[R701] has been very agitated and depressed with anxiety over the last few weeks. Patient has been complaining about the fact that [their] son who is the guardian has been stealing money from [them] and not doing right by [them]. Apparently [R701] wishes to file a case in court to change guardianship. [R701] also wishes to be [their]own guardian. Patient continues to be seen by psychiatry who are managing [their] medications. Further review of the medical record did not reveal follow-up regarding R701's capacity, guardianship modification, or referrals related to discharge. On 8/11/25 at 1:35 PM, the Nursing Home Administrator (NHA) was asked if she had any information concerning follow-up regarding the resident's modified guardianship/capacity, and explained that she didn't, and was unable to provide additional information as the Director of Social Work was out of the building. A review of the facility's Resident Rights policy revealed the following, .Exercise of Rights .Residents retain the ability to exercise any rights not delegated to a representative

This citation pertains to Intake MI00153991. Based on interview and record review, the facility failed to document and inform resident representative about changes in skin integrity for one sampled resident (R901) of three residents reviewed for informed rights. Findings include: On 7/8/25 at 10:16 AM, confidential Family Member A explained that upon visiting R901 on 6/28/25, they observed the resident with bandages on their right foot. Family Member A explained they were not informed the resident had open wounds to their foot, and the wounds were not present during their last visitation on 6/9/25. A review of R901's medical record revealed they were admitted into the facility on 4/29/25 with diagnoses which included Dementia, Hypertension and Diabetes. Further review revealed the resident had a moderate cognitive impairment and required 1-2-person assistance for Activities of Daily Living. Further review of the medical record revealed the following progress note: 6/13/2025 19:01 (7:01pm) Health Status Note .Writer observed a small open sore, slightly bleeding. Writer notified Wound director. Normal Saline Pay (pat) dry apply calcium alginate with 4x4 cotton pad and gauze QD (once a day). Writer also contacted resident's DR (doctor), no new orders noted. Writer carried out ordered with applying TX (treatment). Resident tolerated TX well. Writer will continue with plan of care. Further review of the medical record of R901 revealed Active Wounds and revealed on 6/17/25, a vascular wound on the resident's right heel was identified. Further review of the medical record did not reveal documented communication the resident's representative had been contacted to inform them of the new wounds. On 7/8/25 at 1:56 PM, the Director of Nursing (DON) was asked about the missing documentation and acknowledged it is missing. A review of the facility's Resident Rights policy revealed the following, Planning and Implementing Care. Residents and/or resident representatives have the right to be fully informed of the medical condition in a language you they can understand, and to participate in your person-centered care planning and treatment, including the type of caregiver who provides services. Residents have the right to refuse and/or discontinue medications and treatments and to be fully informed of the risks and benefits, and to formulate an advanced directive, an informed decision. The right to be informed, in advance of changes to the plan of care .

Based on observation, interview, and record review, the facility failed to provide a clean, comfortable, homelike environment for one (R121) of eight residents reviewed for homelike environment. Findings include: Review of the facility record for R121 revealed an admitted [DATE] with diagnoses including Cerebrovascular Accident, Hemiplegia, and Diabetes Mellitus. On 04/07/25 at 11:12 AM, R121 was observed laying in bed. They did not respond to verbal greeting. The wallpaper under the window adjacent to the resident's right side was peeled off in a large (approx. two feet by two feet) area with a portion of the peeled paper hanging and another portion missing. There were multiple smears on the wall in the same area that appeared to be food or drink. On 04/08/25 at 9:05 AM, R121 was observed laying in bed. The wall adjacent to the bed was in the same condition as noted the previous day. R121 was asked about the condition of the room and they stated The clock doesn't work either, it needs a battery. I told them and they haven't fixed it. The clock was observed to be not working. On 04/09/25 at 9:39 AM, R121's room was observed to remain in the condition previously described and the clock was still not working. R121 stated It hasn't worked for about six weeks. R121 reported they told staff about the clock but they couldn't recall who the staff was. On 04/09/25 at 10:39 AM, R121's room was observed with the facility Administrator (NHA) present. The NHA acknowledged the condition of the wall under the window with the torn/hanging and missing wallpaper as well as the clock without a battery. The NHA reported the expectation is the condition of the wall and the function of the clock should be addressed in a timely manner. Review of the facility policy Quality of Life-Homelike Environment dated 04/14 includes under the section Characteristics of a personalized, homelike setting: .a. cleanliness and order .c. inviting colors and decor.

Based on interview and record review, the facility failed to submit a Minimum Data Set Assessment (MDS-a form to be completed for all residents Medicare/Medicaid information) in a timely manner for one (R157) of one residents reviewed for assessments. Findings include: A review of the Electronic Medical Record (EMR) revealed R157 did not have a discharge MDS assessment. The review of the EMR revealed R157 was admitted on [DATE] and was discharged on [DATE]. On 4/9/2025 at 9:29 AM, an inquiry was made regarding the submission of a discharge MDS. MDS Nurse E revealed they were unaware of a missing submission and would look into the concern. At 11:29 AM, MDS Nurse E confirmed the discharge MDS submission was overlooked. On 4/9/2025 at 12:15 PM, an interview with the Director of Nursing (DON) revealed the MDS should be submitted in a timely manner.

Based on interview and record review, the facility failed to complete an annual OBRA (Omnibus Budget Reconciliation Act) Level II Evaluation for three residents (R3, R8, R13) of eight residents reviewed for PASARR (Preadmission Screen and Resident Review). Findings include: R3 A clinical record review revealed R3 was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses of Major Depressive Disorder, Anxiety Disorder, and Congestive Heart Failure. A Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 7/15 indicating R3 was cognitively impaired. Further review of R3's medical record revealed a PASARR dated 3/25/24. R8 A clinical record review revealed R8 was originally admitted into the facility on [DATE], with a recent readmitted [DATE] and with the following diagnoses of Adjustment Disorder, Anxiety Disorder, Hoarding Disorder and Hemiplegia and Hemiparesis following cerebral infarction. A Minimum Data Set (MDS) assessment dated [DATE] and a Brief Interview for Mental Status (BIMS) score of 13/15, indicating intact cognition. Further review of R8's medical record revealed a PASARR dated 3/19/24. R13 A clinical record review revealed R13 was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses of Major Depressive Disorder, Manic Episode without Psychotic Symptoms, Developmental Disorder of Scholastic Skills and Calculus of Kidney. A Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score totaled 6/15 indicating R13 has severe cognitive impairments. Further review of R13's medical record revealed a PASARR dated 3/20/24. On 4/9/25 at 12:35 PM, an interview occurred with Social Worker J regarding missing updated PASARRs' for R3, R8, and R13 (due to previous one being completed in 2024). Social Worker J stated he thought all of the 3877s were updated for March but it appeared that some were missed. Social Worker J confirmed that PASARRs should be updated annually and when there is a change in condition. On 4/9/25 at 3:23 PM, the Director of Nursing (DON) was asked about her expectation regarding PASARR, she explained that her expectation is that PASARR assessments are completed timely as required per policy. A review of the facility policy titled, PASARR Guideline dated 12/28/17 revealed the following: This facility promotes and supports a resident centered approach to care. The purpose of this guideline is to define and set expectations regarding the appropriate preadmission assessment of all individuals with a mental disorder and individuals with intellectual disability. It is the practice of the facility to coordinate the assessment process with the preadmission screening and annual resident review (PASARR) program under Medicaid in Subpart C to the extent practicable to avoid duplicative testing and effort. This includes incorporating the recommendations from the PASARR level II determination and evaluation in the residents' assessment, care plan, and transition of care; and referring all level II residents and all residents with new or evident conditions related to Level II review upon significant change in status assessment.

Based on observation, interview, and record review, the facility failed to ensure mouth care was provided for one resident (R137) of four dependent residents reviewed for oral hygiene. Findings include: A review of the Electronic Medical Record (EMR) revealed R137 was most recently admitted on [DATE]. The EMR revealed R137 had a pertinent diagnoses of Developmental Disorder of Speech and Language, Cerebral Infarction (Stroke) affecting non-dominant side, Dysphagia (Swallowing Difficulty) and a Percutaneous Endoscopic Gastric (PEG tube) insertion for nutritional support. The EMR revealed R137 is non-verbal and on nutritional support via a tube-feeding only. R137 is not to have anything by mouth. The EMR further revealed that R137 was unable to complete the Basic Inventory for Mental Status and was also dependent for all Activities of Daily Living. On 4/7/25 at 10:13 AM, R137 was observed in bed on their back with the legs drawn up to a 90 degrees angle to body. An observation of R137's mouth revealed thick and dried mucus over their teeth which appeared thick. R137's upper lips were cracked and had some dried scabs. R137's lower lip had dry pieces of skin sticking up. R137's mouth was only open about 1/2 inch. When queried whether mouth care was done the resident would open their eyes and softly said no. On 4/07/2025 at 12:30 PM, R137 was observed with their mouth in the same condition and in the same position. On 4/8/2025 at 12:14 PM and 3:28 PM, R137 was observed with more crusty layers of mucus across their teeth. Additional observations included pinkish dried mucus around the dried wounds on R137's lips. At 3:30 PM, an interview with Licensed Practical Nurse (LPN) B indicated R137 is non-verbal, and resists care at times. At 3:34 PM, an observation with LPN B confirmed R137 was in need of mouth care and could not confirm if mouth care had been done. A review of the EMR revealed R137 is dependent for personal hygiene including oral hygiene. Further review of the EMR did not reveal R137 had refused any oral care for the past 30 days. On 4/8/2025 at 12:15 PM, an interview with the Director of Nursing (DON) revealed their expectation that residents should receive oral hygiene whenever it is needed and is often on a schedule. A review of the ADL policy, under description of ADL services include: Oral Care: clean mouth, brush teeth, provide moisture to lips .: IX: Check resident throughout the shift for care and hygiene needs; and .Report prolonged absence of ADL care or resident resistance or non0-adherence of hygiene activities to Licensed Nurse .

Based on observation, interview, and record review, the facility failed to ensure resident medications were not left at the bedside for one resident (R5) of one resident and failed to store/date medication in one of two medication carts reviewed for medication storage. Findings include: R5 On 4/7/25 at 10:46 AM, R5 was observed lying in their bed. A medication cup of seven pills were observed sitting on the resident's bedside table. At this time, the unit manager of the memory care unit, Unit Manager F was asked to enter the resident's room and explain why the medications had been left at the bedside. Unit Manager F explained that the medications should not have been left at the bedside and would talk to the administering nurse. A review of R5's medical record revealed they were admitted into the facility on [DATE] with diagnoses that included Dementia, Delusional Disorders, and Muscle Weakness. Further review revealed the resident was cognitively intact, and required minimal assistance for activities of daily living. Further review of the medical record did not reveal an assessment for the self-administration of medications. On 4/9/25 at 2:41 PM, the Director of Nursing (DON) was asked for her expectations regarding medications left at the bedside, and explained medications should not be left at the bedside. 49699 On 04/8/25 at 9:14 AM, the two south back medication cart was observed with Licensed Practical Nurse (LPN) H and a Trelegy inhaler was found with no date or resident identifier on the actual inhaler and a glucose strips container was not dated when opened. On 4/9/2025 at 2:40 PM, an interview with the Director of Nursing (DON) revealed glucose strips and medications should be appropriately labeled and dated when opened. The DON also revealed glucose strips and medications should be appropriately labeled when opened. A review of the facility's Medication Storage policy revealed the following, The facility shall store all medications and biologicals in a safe, secure, and orderly manner .

Based on observation, interview, and record review, the facility failed to store oxygen mask and tubing in a sanitary manner for one (R98) of four residents reviewed for supplemental oxygen use. Findings include: A review of the facility record revealed R98 was admitted to the facility on [DATE] with diagnoses including Respiratory Failure and Seizure Disorder. On 04/07/25 at 2:48 PM, R98's oxygen mask and tubing was observed laying on the concentrator not covered or bagged. On 04/08/25 at 8:55 AM, R98 was observed laying in bed wearing a nasal cannula. The oxygen mask/tubing and a second nasal cannula/tubing were observed laying in the open top drawer of the nightstand on top of other items uncovered and not bagged. On 04/09/25 at 10:48 AM, the facility Director of Nursing (DON) was interviewed and made aware of the observations of the oxygen mask/tubing and nasal cannula/tubing being stored uncovered and not bagged. The DON reported the expectation is that they should be bagged when not in use. A review of the facility policy Oxygen Administration dated 03/20 revealed the entry f. Oxygen tubing will be covered and stored when not in use.

Based on interview and record review, the facility failed to immunize per acceptable and/or declination for influenza immunizations for one resident (R81) of five sampled residents reviewed for immunizations. Findings Include: A review of R81's medical record revealed they were admitted into the facility on [DATE]. During a review Infection Control program, the influenza acceptance/declination for R81 was requested and revealed a consent to receive the influenza immunization dated for 10/4/24. Reviewed was a second document dated for 10/10/24 declining the influenza vaccine. A review of the resident's medical record revealed the resident received the influenza immunization on 10/14/24 (four days after declining it). On 4/8/25 at 4:19 PM, the Director of Nursing (DON) was asked about her expectation regarding immunizations being provided per consent, she explained her expectation is that immunizations are provided per acceptance/declination. A review of the facility's Influenza Vaccination Guideline did not reveal information regarding a resident receiving a vaccine after signing a declination.

This citation pertains to Intake Number MI00142477 Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from verbal and physical abuse by staff, affecting one resident (Resident #135) of five residents reviewed for abuse, resulting in R135 experiencing physical and psychosocial harm as determined by the reasonable person concept. Findings include: Resident #135 (R135): An allegation of staff-to-resident abuse involving Staff N and R135 was submitted to the state agency. On 2/27/24 at 3:49 PM, R135 was observed lying in bed. R135's room was observed to be located near the locked visitor bathrooms and near the front lobby. The resident when asked if they remembered the incident involving security guard (Staff N) on or around 1/29/24. R135 stated, No and shook their head side to side. Resident did not remember anything about the incident. On 02/28/24 at 09:25 AM, Certified Nursing Assistant (CNA L), who was a witness to the incident was interviewed. CNA L was asked to state what happened. CNA L explained, It was around 10:30 PM that I saw (Staff N) at (R135's) door. I had heard noises; [Staff N] was correcting resident about using the public bathroom. Resident has been told about that before. They [both] were at (R135's) door calling each other names. [R135] called (Staff N) names like B***, C*** and N****. (R135) was trying to close the door but (Staff Ns) foot was in the door. CNA L explained that (R135) kicked Staff N, who balled up their fist and hit R135 about 3-4 times in the face. CNA L stated, I separated them right away and called my supervisor (Nurse M) for more assistance. (Nurse M) and I made sure that (R135) was okay in the room. CNA L was asked about Staff Ns demeanor and CNA L replied, I could tell (Staff N) was irritated by their tone. [Staff N] had told (R135) that if( R135) kicked them then they would hit (R135). Even after the incident I heard [Staff N] in the hallway stating, 'I hit that M**f**'. [R135] told [Nurse M] to call the police because [Staff N] hit them. On 02/28/24 at 11:00 AM, Licensed Practical Nurse (LPN M), who was the nurse on the night of the incident, was interviewed via phone. Nurse M was asked to state what happened. Nurse M explained, I had just finished my night medication pass and I heard [CNA L] yelling my name. I jumped up and was told to come here, (R135) was just hit by a staff member. I went down the hallway and saw [Staff N] standing in the hallway. I asked what happened and [Staff N] replied, 'Nothing - (R135) is okay.' LPN M continued I went into (R135's) room, and (R135) was sitting in their wheelchair with head down. I said what happened and [R135] stated 'that B***hit me and went crazy. She hit me in my f*** face. Call the police, I want that B*** arrested.' Nurse M explained that R135's face was reddened and did a skin assessment, and the Director of Nursing and administrator were notified about the incident. Nurse M stated, The maintenance director came in and reviewed the cameras. On 2/28/24 at 12:45 PM, Staff N was interviewed via telephone. Staff N was asked to state what happened on the night of the incident involving R135. Staff N replied, (R135) is not allowed to use the visitor bathrooms because of stuffing the toilet with items. (R135) comes to the lobby to try and take the key to use the visitor toilet. When I stated 'no' [R135] called me out of my name. I went to the room to ask why was [R135] calling me out of my name. I was in the room and I used my foot in the door when (R135) was trying to close it. (R135) kicked me in my shin and I admit it, I hit them, it was a direct reaction. I stayed at work for a few hours before I was dismissed and sent home. Then I was suspended and terminated. The police came to the facility but they didn't take a statement from me. Staff N was asked if she received any training on abuse and how to handle resident behaviors? Staff N replied NO. On 2/28/24 at 11:37 AM, Maintenance Director (Staff O) was interviewed. Staff O acknowledged an awareness of the incident involving Staff N and R135 and that he had reviewed camera footage that night. When asked what he saw, Staff O replied Not too much of nothing; my officer (Staff N) stated they had words with the resident. Camera is in a 'dead spot'. Staff O indicated he could not see incident outside of the lobby. Staff O stated, (Staff N) was discharged that day. She had escalated it too far. On 2/29/24 at 11:30 AM, the Nursing Home Administrator (NHA) was interviewed in her office. When asked what were the findings of the investigation involving R135 and Staff N and how did you get to that result, NHA replied, I was informed about the incident in the middle of the night on 1/29/24 - it was reported by the nurse. Resident and (Staff N) were separated. (Staff N) was suspended that night. I interviewed [Staff N] and she denied contact but stated situation could have been handled better. We decided to terminate [Staff N] based on conduct, we don't argue with residents. I spoke with the DON, and nurse was going to do skin assessment and notify the resident's guardian. I did attempt an interview with (R135) on 1/30/24 but they could not recall incident. I interviewed the parties involved. The NHA added, The abuse was not substantiated due to (Staff N) stating that there was no contact and the resident could not recall the incident. We couldn't see anything on the cameras. The police were called, report was made, and I reported to the state. The NHA was asked what is her expectation regarding residents and abuse. The NHA replied, All residents should be free from abuse and neglect. On 2/29/24 at 2:47 PM, the Director of Nursing was interviewed. DON stated an awareness of the alleged incident between Staff N and R135. When asked what her expectation for residents and abuse. The DON replied, My expectation is that resident will be free from abuse and neglect. R135 record was reviewed and revealed the resident was admitted to the facility on [DATE] and had diagnoses of Alzheimer's disease with early onset, Dementia, Difficulty with Walking and Muscle Weakness. R135's Brief Interview for Mental status assessment dated [DATE] was a 9/15 indicating moderately impaired cognition. A review of the Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property policy dated 9/11/2020 revealed, 'it is the policy of the facility that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse, corporal punishment or involuntary seclusion. Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection.'

This citation pertains to Intake MI00132939. Based on interview and record review, the facility failed to adequately assess, monitor and document provided care to an ileostomy (last part of small intestine has an opening through the abdominal wall to collect waste) and surrounding skin for one resident (R700) of one residents reviewed for ostomy care, resulting in unmet care needs, and inadequate assessment and treatment of skin breakdown resulting in hospitalization . Findings include: A complaint filed to the State Agency was reviewed and included the following: [R700] .has a Colostomy (ileostomy) Bag .[and] was brought into the emergency room (ER) today via ambulance for Medical Device Malfunction. There was not a malfunction, [R700] has a colostomy (ileostomy) with no bag on it. [R700] has been sitting in [their] own feces for long enough to cause horrendous skin breakdowns throughout [their] abdominal area. [R700] will be kept in the hospital for at least a couple of days. Upon [their] discharge, [R700] will have a full colostomy device. A review of R700's record revealed that the resident was admitted into the facility on [DATE] and discharged to an acute care hospital on 11/16/22. R700's medical diagnoses included Ileostomy Status, Anxiety Disorder, Respiratory Failure, Protein-Calorie Malnutrition, and Metabolic Encephalopathy. Further review of R700's record revealed that the resident was cognitively intact and required the assistance of one staff for most activities of daily living (ADLs). R700 was also noted to be receiving oral antibiotic treatment for Clostridium difficile (C. Diff) infection (gastrointestinal infection causing diarrhea) upon admission into the facility. A review of R700's physician orders (typically generate to a medication (MAR)/treatment (TAR) administration record) did not include any related to ileostomy care or monitoring. The following order was found: -Skin Checks Weekly - complete Skin Evaluation in (electronic medical record system) on admission and weekly on assigned day one time a day every Mon, Thu. This order was checked off in the MAR/TAR as being completed on 11/14/22, however, no corresponding assessment nor progress note related to it was found in the record. A review of R700's care plan revealed: -Focus: The resident has actual impairment to skin integrity r/t (related to) colostomy (ileostomy) with loose stool coming in contact with surrounding skin. Date Initiated: 11/10/2022 . -Interventions: Evaluate and treat per physicians orders. Date Initiated: 11/10/2022 . Evaluate resident for S/SX (signs/symptoms) of possible infections. Date Initiated: 11/10/2022 . -Monitor skin surrounding site q/ (every) shift and complete dressing change as ordered. Date Initiated: 11/10/2022 . -Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Date Initiated: 11/15/2022 . -Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Date Initiated: 11/15/2022 . -Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration (breaking down of skin) etc. to MD (physician). Date Initiated: 11/15/2022. A review of R700's progress notes revealed the following: -11/11/22 02:09 (AM) .Skin Observation Note Text: Resident has new skin issue(s) observed. 1 Vertebrae (upper-mid) - wound to L (left) 8 or 9th rib, Sacrum - small opening to coccyx. Abdomen - RUQ (Right Upper Quadrant) iliosteomy (sic). Skin turgor with good elasticity .Skin condition is normal. -11/11/22 11:18 (AM) .Comprehensive Nutrition Assessment .General appearance is: thin, Resident is not well nourished .Resident has severe fat loss .has severe muscle loss .There is presence of skin alteration/s .Stage 3 (full thickness skin loss) PU (pressure ulcer) spine .recent total colectomy with ileostomy . -11/11/22 18:39 (6:39 PM) .Physician/PA/NP - Progress Note (Narrative) .s/p (status post) .end ileostomy, abdominal closure 9/28(/22) .Physical Examination: .Skin: Intact. No visualized rash .s/p SBO (small bowel obstruction) ileostomy. Continue to monitor output . (Written by Nurse Practitioner (NP) I). A review of R700's progress notes and assessments dated 11/12/22, 11/13/22, and 11/14/22 did not indicate that staff assessed the resident's skin nor provided ileostomy care/monitoring. Continued review of R700's progress notes revealed: -11/15/22 15:25 (3:25 PM) .Physician/PA/NP - Progress Note (Narrative) .Infectious Disease Initial Evaluation .Physical Exam: Skin: warm, dry, right upper quadrant ileostomy with surrounding erythema tenderness extending to lateral flanks no open areas or drainage . -11/15/22 16:33 (4:33 PM) .eMar - Medication Administration Note Text: Acetaminophen Capsule 500 MG (milligram) Give 2 tabled by mouth every 6 hours as needed for Mild pain c/o (complaints of) ab (abdominal) pain. -11/16/22 06:59 (AM) .Health Status Note (nurses note) .Upon arrival of shift, resident was cleaned by this writer new brief applied, and colostomy bag changed as well, resident later stated that [they] did not want to wear colostomy bag due to red irritated skin and .was going (sic) to take the bag off .this writer removed bag and cleaned area and left towel over per residents request, upon end of shift bag was reapplied. -11/16/22 10:45 (AM) .Health Status Note (nurses note) .Resident has history of refusing care to .ileostomy site. Risk vs benefits explained to resident in terms that [they] could understand. Resident was explained the benefits of allowing staff to apply barrier to peri-stoma site and what could potentially happen to skin if care is not rendered. Resident voiced understanding of receiving good skin care, will continue to monitor skin and encourage resident to allow staff to render care. Pain medication will be offered prior to care. -11/16/2022 14:43 (2:43 PM) .Physician/PA/NP (Nurse Practitioner) - Progress Note (Narrative) .SUBJECTIVE: Patient seen today as a follow up and request by staff due to ostomy not staying on and patients request to go to ER due to skin irritation .Continues to have watery diarrhea from stoma that is getting on .abdomen which is excoriated from flank to flank. Wound care and staff have been working .since admission on trying to keep the skin clean, dry and free of stool. It is reported by staff that [R700] has been picking at .dressing and loosening it causing more problems. Due the severity of the irritation requested patient be sent to ER for evaluation and wound care evaluation . -11/16/22 14:57 (PM) .Health Status Note (nurses note) .Pt (patient) transferred to [hospital] at 2:50 PM .r/t (related to) complications w/ (with) ileostomy .Pt aware of ostomy site but continues to tamper w/ (with) bag at times stating that its uncomfortable .Ostomy changed multiple times throughout shift. Skin irritated d/t (due to) fecal matter causing breakdown and constant ostomy changes . A review of R700's care plan, progress notes, and administration records did not reveal documentation indicating R700 refused ostomy care or tampered with their ostomy bag until the day the resident was discharged from the facility with skin breakdown. On 3/27/23 at 3:15 PM, wound care nurse, Licensed Practical Nurse (LPN) E was interviewed and queried regarding the expected process for caring for a resident with an ostomy in the facility. LPN E indicated that orders for ostomy care/monitoring are put into place by the floor nurses, and documentation of the provision of ostomy care would be on the MAR/TAR. When queried regarding the lack of ostomy care documentation/orders for R700, LPN E was unable to provide any further information. On 3/28/23 at 10:22 AM, NP I was interviewed via phone regarding R700. NP I stated she was familiar with the resident and followed R700's care over the course of multiple facilities. When asked if R700 came into the facility with skin irritation and breakdown on their abdomen, NP I stated, No. [R700] was having very liquid stools .makes it hard for the bag to stick .[the resident] was taking [the bag] off [themselves] .and staff was having to re-apply it almost daily. When queried regarding the lack of documentation in R700's record prior to the day of discharge to support that claim, NP I was unable to provide any further information. On 3/28/23 at 11:22 AM, the Director of Nursing (DON) was interviewed regarding R700. The DON indicated that there are normally orders put into place in the resident's record for ostomy care. The DON acknowledged the lack of documentation related to ostomy care and assessment/monitoring/treatment of R700's skin surrounding their ostomy and did not provide any further information. A review of the facility's policy/procedure titled, Colostomy, Urostomy or Ileostomy Caret dated 6/29/21, revealed, Purpose: To ensure residents who require colostomy, urostomy, or ileostomy services receive care consistent with professional standards of practice and person-centered goals and preferences .It is essential that a pouch be placed over a stoma correctly so the output from the stoma is contained, the skin around the stoma is protected and a patient free from odor or leakage .Peritoneal skin: Presence of blisters, rash and excoriated skin is abnormal .Observe pouch for leakage and length of time in place .When pouch leaks, skin damage from effluent causes more skin trauma than early removal of the wafer .

This citation pertains to Intake MI 832. Based on interview and record review, the facility failed to implement and operationalize policies and procedures to protect one Resident (R936) from willful Staff to Resident sexual aggressive behavior, resulting in a vulnerable resident being subjected to sexual suggestive discussions, exposure of private area, the potential of degradation, and feeling of disappointment. Findings include: Review of submitted Facility Reported Incident (FRI) intake documentation revealed the following: Investigation Summary Resident alleges that (Staff K) employee had been making sexual remarks to (R936) during (their) shift. This employee (Staff K) is an afternoon floor care service worker. Resident (R936) reports that they had been having friendly conversation for a few days, but that employee (Staff K) escalated the conversation to a sexual nature, discussing a potential sexual encounter. On 11/4/21 at 2:55 PM, (R936) was observed in their room sitting in a wheelchair, with one side of their mouth slightly drooped down. R936 was asked to recall the incident with (Staff K). R936 stated, I don't remember (Staff K's) name, but (Staff K) pulled down the front of my shirt and looked at my breast. Then (Staff K) stood at the bathroom door and showed me (their) private .he was holding it in (their) hand and shook it. R936 was asked how it made them feel. R936 stated, I was shocked. I thought (Staff K) was a nice caring person. I did not expect (Staff K) to do something like that. A review of the medical record noted R936 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R936's Brief Interview for Mental Status (BIMS) noted a score of 15 out of 15 (Intact cognitive response). On 11/8/21 at 9:58 AM, an attempt was made to contact (Staff K) via phone and email. However, their phone number was disconnected. On 11/8/21 at 10:11 AM, Staff K's employee record was reviewed with Manager N during an interview. Manager N revealed, One of my employees put in a good word for (Staff K) because (they) were looking for a job. On 11/8/21 at 11:02 AM, Nurse O was asked if they had observed any inappropriate interactions with Staff K and replied, (Staff K) was very creepy and made me feel very uncomfortable with how (they) looked at me .I've never noticed any interactions with residents. On 11/8/21 at 11:08 AM, Housekeeper P was asked if they had observed any inappropriate interactions with Staff K and stated, He would say inappropriate things like when I win a million dollars, I'm going to come back for you .I don't know why (Staff K) would say something like that .(Staff K) was strange .(Staff K) made me feel uncomfortable. On 11/9/21 at 8:51 AM, Resident Witness T was interviewed and asked if they had observed any inappropriate interactions with Staff K and stated, Something about (Staff K) made me uncomfortable. He would stare into other people rooms .I was in the dining room and (Staff K) came in there asking people for money. I did not understand because (Staff K) works and receives a check . (Staff K) ain't right. A review of the facility's Facility Reported Incident (FRI) packet Investigative Resident Interview Form dated 10/18/21 noted R936's statement: A couple of days ago the floorcare staff (Staff K) came to (R936) room. Resident states (they) told the employee I thought you were coming to see me. Resident states that employee replied, I came to see you before I left. Resident states (they) was sitting in (their) wheelchair next to foot of the bed. States (Staff K) pulled collar of my shirt outward and looked at my breasts and said Hmm. Then (Staff K) went into the bathroom and took out (their) penis and shook it a couple times. Resident states (they) told (Staff K) (they) couldn't go onto (their) stomach because (they) would need help getting off of (their) stomach. Resident states that (Staff K) said that (R936) could go on (their) side and (Staff K) would get into bed under the covers behind (R936). Resident states that the employee did not touch (them), did not get into bed with resident, nor did the employee (Staff K) finish, (they) just shook it. A review of the facility's Facility Reported Incident (FRI) packet Investigative Resident Interview Form dated 10/18/21 noted unsampled Resident Q statement: Staff K asked (Resident Q) to dig down in my pockets. You know what I have in my pocket. I just got paid. Employee (Staff K) gave resident (their) phone number and told (Resident Q) to call if (Resident Q) needed anything. A review of the facility's Facility Reported Incident (FRI) packet noted that Staff K was suspended pending investigation due to allegations of resident abuse. Staff K was called several times on 10/18/21 to discuss the allegations. Staff K's phone number was disconnected upon the facility's last call on 10/18/21. Staff K failed to answer the phone. The facility was unable to obtain a statement from Staff K On 11/8/21 at 2:39 PM the Nursing Home Administrator (NHA) was interviewed and queried about the incident with Staff K and R936. NHA stated, They had a friendship .The employee crossed the line .(R936) asked Staff K how they could have sex .We called the police and they decided that it was not a criminal act .the police took no further actions .Staff K appeared to be a nice person .I've never noticed any inappropriate behavior from (Staff K) .I think (R936) thought something bigger was going to occur with their friendship. A review of the Police Case Report Noted the following: I made contact with (936). (R936) stated to me on Thursday, 10/14/2021 a male staff member came into (their) room and began flirting. (R936) stated that (Staff K) spoke very explicitly about the sexual acts (Staff K) wanted to perform with (R936). (R936) further stated that (Staff K) went into (R936's) bathroom of (R936) room, left the door open so (R936) could see him, unzipped (their) pants and pulled (their) thing out and began stroking it. (R936) stated after (Staff K) was done, told (R936) he wanted to put it in and have sex with (R936). (R936) stated that (Staff K) put (Staff K) penis back into (Staff K) pants and left the room. (R936) said (Staff K) came back to (R936) room later but nothing occurred and he left shortly after. (R936) stated (they) saw (Staff K) again on Saturday, 10/16/2021 and he began telling (R936) that (they) wanted to put (R936) on (their) stomach and (have sex) from behind then flip (R936) onto (their) side .R936) did state, (Staff K) asked for (their) phone number and (R936) gave it to (Staff K). A review of the facility's policy Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property dated 9.11.20 noted the following: Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Abuse includes verbal abuse, sexual abuse, physical abuse and mental abuse, including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include but are not limited to: threats of harm; saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again. It is the policy of the Facility that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse, corporal punishment or involuntary seclusion. The resident will also be free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for Protection. The facility will strive to educate staff and other applicable individuals in techniques to protect all parties. Deficient Practice Statement #2 This citation pertains to intake MI 064 Based on interview and record review, the facility failed to prevent resident to resident abuse for one sampled Resident (R925) out of three reviewed for abuse, resulting in a vulnerable resident being touched in the breast area by another resident (R924), and from a reasonable persons perspective potential feelings of violation and anxiety. Findings include: On 11/08/2021, a review of a Facility Reported Incident (FRI) revealed the following: Incident Summary: [R924] was having a behavioral episode entered resident's room and attempted to put hand through neck of gown to grope breast. [R924] was immediately redirected by nursing staff and placed on a 1-1, and then petitioned out for psychiatric evaluation due to new onset to this type of behavior. [R925] remains at facility and has resumed normal activity. [R924] will remain 1-1 until alternative placement is achieved. Investigation Summary: Both residents reside on the memory care unit which is a secure unit for residents with behaviors and dementia. On 7.26.2021 [R924] BIMS (Brief Interview for Mental Status) score 0 started to experience bizarre behavior and pacing and approached [R925] to grope [R925] breast area by trying to insert hand into the top of [R925] shirt. Nursing staff immediately responded by intervening and redirecting the [R924] resident away from [R925] back to [their] room. [R924] behavior became increasingly difficult to alter. Leadership staff immediately reported to the unit and began measures to keep residents safe from this behavior. Resident was immediately placed on 1-1 monitoring during the time that a petition was completed, and resident sent out for psychiatric evaluations as this was a new onset of this type of behavior for resident. [R925] was immediately assessed for psychosocial wellbeing and has no recollection of incident and has resumed normal activity On 11/08/2021 at 10:34 AM, R924 was observed in a room across from the nurses' station, lying in bed. R924 would not answer this surveyor's questions. On 11/08/2021 at 10:40 AM, R925 was observed laying in bed. When questioned about the incident dated 7/26/21, R925 could not recall event. A review of R924 medical record review revealed that they were admitted into the facility on [DATE] with the following diagnoses, Dementia, Disorganized [CONDITION(S)], Anxiety Disorder, and Muscle Weakness. R924's most recent Minimum Data Set (MDS) dated [DATE] revealed that the resident had a Brief Interview for Mental Status score of 13 of 15 indicating intact cognition and required supervision to limited one person assist with bed mobility and transfers. A review of R925's medical record review revealed that they were admitted into the facility on [DATE] with the following diagnoses, Dementia, Anxiety Disorder, and Muscle Weakness. R925's most recent MDS dated [DATE] revealed that the resident had a BIMS score of 99 indicating R925 was unable to answer questions in the assessment and required one person extensive assist with transfers and bed mobility. A review of R924 progress notes revealed the following: Date: 07/26/2021 at 14:43 (2:43 PM) -IDT (Interdisciplinary Team Note): Called to unit as resident attempting to kick door open on the locked unit. Nurse reports [they] have been able to get it open a few times today. While I was on the unit [R924] again attempted to kick the door several attempts to redirect, finally [R924] did turn and leave the area. This writer followed [R924] to the dining room where [R924] sat at a table and began watching TV. [R924] demeanor is different today, [R924] is typically easily redirected, that did not occur today. Went and talked with Social Worker for the unit explained [their] behavior. She will take care of it. Date: 07/26/2021 at (3:10 PM)-Social Service Note: Writer informed that resident was observed trying to kiss another resident. Writer spoke with the resident about the incident, but resident did not respond. Writer completed a new BIMS and added resident to the psych list for evaluation. Writer will update res[ident] care plan. Date: 07/26/2021 at 16:00 (4:00 PM)-Behavior Narrative Note: [R924] continues to be disruptive, it is reported that [R924] kissed a woman in the hallway. Then was observed in a resident's room and nurse stated it appeared that [R924] had [their] hand on her breast area. [R924] was immediately removed from the room. [R924] was in [their] room but restless and not wanting to stay in [their] room, I asked [R924] to stay in [their] room and watch TV we together straightened [their] bed and [R924] laid down and began watching TV. Asked for 1:1 until further notice. Discussed with ADM (Administrator) and DON(Director of Nursing). ADM called Director of Soc[ial] Services. I returned to the unit to assure there was a 1:1. [R924] was still in [their] room upon my return. Male nurse present to assist with this resident. Date: 07/26/2021 at 16:29 (4:29 PM)-Behavior Narrative Note: New onset of increasingly bizarre behavior, resident accosting other residents. Sexually inappropriate, grabbing at, attempting to kiss others. Behavior is difficult to alter and without provocation. 1-1 until behavior is resolved. Safety maintained at this time. Date: 07/26/2021 at 17:18 (5:18 PM) -Behavior Narrative Note: Resident alert to self, resident was observed trying to kiss multiple residents on multiple occasions during shift. Resident was also observed in another patient room with hand under gown near chest area. Resident has been kicking the door open on unit and attempting to escape x 4 throughout shift. All parties notified. On 11/08/2021 at 10:46 AM, an interview was conducted with LPN (Licensed Practical Nurse) A. LPN A stated that they heard about the incident between R924 and R925. LPN A stated that they are agency but has been instructed if there are behaviors with R924 to put them on an 1-1 immediately. LPN A stated that they have not seen R924 display any sexual behaviors towards any residents and that R924's behaviors had really decreased. On 11/09/2021 at 9:43 AM, an interview was conducted with LPN B. LPN B stated they were assigned to R924 on the date of the incident. LPN B stated that R924 had been kicking the exit door on the locked unit and acting up all day. LPN B stated that they were told by CNA (Certified Nurse's Assistant) C that R924 had kissed an unsampled resident in the hallway and was seen standing over R925. LPN B stated that they saw R924 down the hall again trying to kiss another resident on the cheek. LPN B stated that they went and got R924 to take them to their room and thought they were following behind them. LPN B stated they turned around and realized R924 was not behind them, and they found R924 in R925's room with their hand down their gown. LPN B stated that they separated the two, walked R924 to their room and called the Concierge Director D who came up to the room with the Social Worker. LPN B stated Concierge Director D sat with R924 until the petition was complete and they were transferred to the hospital. On 11/09/2021 at 9:50 AM, an interview was conducted with CNA C. CNA C stated that they were on light duty on 07/26/2021. CNA C stated that they were standing by the exit door because it was not working due to R924 kicking it all day. CNA C stated that they were about to pass water and saw R924 walking towards an unsampled resident and kissed them on the left cheek. CNA C stated they went down the hall and separated the two and walked R924 back to their room. CNA C stated that they told the nurse what happened and walked back by the exit door. CNA C stated they walked by R924's room again and noticed they weren't in the room and found R924 standing in R925's room. CNA C stated that R924 was leaning down close to R925's face when they walked in. CNA C stated they walked R924 back to their room and reported the behaviors again. On 11/09/2021 at 11:09 AM, an interview was conducted with Concierge Director D. Concierge Director D stated that they were informed about R924's behaviors and went up to the unit. Concierge Director D stated that R924 did touch R925's breast. Concierge Director D stated they interviewed the other residents to ensure they were not affected and a 1-1 was initiated immediately. On 11/09/2021 at 1:10 PM, an interview was conducted with the Nursing Home Administrator (NHA). NHA stated that R924 was having behaviors and tried to kiss R925 and touched their breast area. NHA stated that R924 was being behavioral that day and the staff reported the incident to them. NHA stated that they petitioned R924 out and had them on a 1-1 when they returned. NHA stated that R924 was usually easily redirectable, but the usual interventions were not working for them that day. A review of a policy titled, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property revealed the following: Sexual abuse is non-consensual sexual contact of any type with a resident. It is the policy of the Facility that each resident will be free from Abuse. Deficient Practice Number Three: This citation pertains to MI 642 and MI 926. Based on observation, interview and record review the facility failed to ensure two sampled residents (R930, R932) of eleven reviewed for abuse were free from physical abuse by a resident, resulting in R930 being hit in the stomach and left flank by R929 and R932 being struck on the arms by R931 and ongoing anxiety. Findings include: Resident #929 (R929) and Resident #930 (R930) A review of the Facility Incident Summary for R929 and R930 revealed: On 08/19/2021 at 8:15 PM, while walking in the hallway, (R929) reached out and struck (R930) in the abdominal area. Staff responded immediately and separated residents. Perpetrator (R929) placed under supervision with hospitalization for psych evaluation pending. No injuries to either resident. Both residents significantly confused . Further review indicated, (R929) had a catastrophic reaction while (R929) and (R930) passed one another in the hallway. Staff responded immediately and separated the residents. (R930) was assessed, no injuries noted . No evidence of abuse, neglect nor mistreatment has been substantiated. On 11/04/21 at 11:52 AM, R930 was observed to be seated in a recliner. R930 was dressed and calmly sat in the chair. R930 was asked about the incident and reported they did not recall any fight or incident or problems with any roommates, residents, or staff. On 11/04/21 at 12:15 PM, R929 was met outside their room. R929 was dressed and seated in a wheelchair. R929 denied any incidents with other residents. Additional conversations with R929 revealed no mention of the resident to resident incident. R929 had a staff member who followed them as they moved themselves about in their wheelchair. On 11/08/21 at 12:12 PM, Nurse J was asked about R929 and R930. Nurse J reported R929 could move themselves about in their wheelchair and R930 could get up and would walk the hallways holding onto the railing. Nurse J reported R929 to be alert and oriented to person, place and time with moments of confusion and R930 was alert to self with confusion. A review of the record for R929 revealed: R929 was admitted into the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] indicated impaired cognition and the need for extensive assistance of one person with activities of daily living. The nursing care plan indicated R929 .Has a behavior problem related to multiple verbal altercations with staff and residents .date initiated 07/23/21 .has a mood problem related to [CONDITION(S)]. Date initiated 05/25/2021 .Uses [CONDITION(S)] medications .related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .has impaired cognitive function .Date initiated 04/09/21 . A review of the record for R930 revealed: R930 was admitted into the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #931 (R931) and Resident #932 (R932) A review of the Facility Incident Summary for R931 and R932 revealed: On 9/15/21 at 9:30 AM a resident-to-resident altercation occurred between R931 and R932. While in their room, R931 struck R932 on right arm without provocation. No injuries were identified. This (was) a new onset of behavior for R931 and the resident has not had any previous episodes of aggressive behaviors during stay. When queried, R931 stated (they) experienced hallucinations and hearing voices. The residents were immediately separated and (R931) was placed on one-to-one monitoring until petitioned out for psych evaluation. It was also noted in the report that an employee observed (R931) with right arm pulled back, apparently with intent to strike roommate. On 11/04/21 at 11:09 AM, R932 was observed to be dressed and seated in a wheelchair in their room. R932 was able to turn their wheelchair around and answered questions appropriately. R932 was asked about the incident and reported R931 came around their drawn curtain and started yelling and swearing and R931 stated multiple times they were going to kill them. R932 reported R931 was trying to hit them multiple times in the face but was able to block them with their arms over their head. These attempts to hit R932 occurred until a staff member pulled R931 away. R932 commented they still had a bruise on their arm from the incident. R932 reported the police arrived and asked if R932 wanted to press charges and R932 reported they did not. R932 further reported they did not know why R931 wanted to kill them and believes R931 to be crazy. R932 was asked about concerns with R931 and R932 reported R931 swore all the time while on the phone and wondered why someone like R931 was in the facility. R932 also reported R931 attempted to approach R932 to apologize but asked R931 to just stay away from them and hoped the facility would not put R931 back in the room with them. R932 reported they felt R931 was playing games with them and acting as if they didn't see them when R932 went downstairs. R932 mentioned they had casual conversations with R931 prior to the incident, but generally just kept to themselves. On 11/04/21 at 3:12 PM, R931 reported during an interview that R932 would [NAME] them, would blast the TV loud and had no regard for R931 being in the room with them. R931 reported R932 would pick their skin and throw bloody tissues on the floor under their curtain. R931 reported they had been in the room with R932 a good 4-5 months prior to the incident. R931 reported they had requested a room change to the nurse a few times and had told the nurse about the TV, tissue throwing and that R932 was belligerent. R931 reported they finally took it upon themselves and went and asked (R932) to turn down the TV. I lost it, forgot my own manner and let my temper take over. R931 reported they had been visited by Social Work before the incident for other concerns but was also spoken with after the incident. A review of the record for R931 revealed: R931 was admitted into the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] indicated intact cognition and the need for supervision or set up only for activities of daily living and locomotion. The nursing care plan indicated, .has a mood problem related to anxiety .date initiated 02/24/2021 .has a potential behavior problem related to psychological disorder/mental condition .experiences hallucinations and delusions .Date initiated: 09/15/2021. A review of the record for R932 revealed an admission into the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] indicated moderately impaired cognition and the need for supervision to extensive assistance of one person for activities of daily living. On 11/08/21 at 1:45 PM, Staff D was asked about R931 and R932 and reported neither R931 nor R932 complained about their roommates. (R932) talked about their life story and the bible and played their music loud at times. R932 was more reserved, watched TV, enjoyed snacks and kept a clean area. Staff D further noted R931 was apologetic about the incident. On 11/08/21 at 2:00 PM, Nurse H was asked about R931 and R932. Nurse H reported R931 usually comes to them if they are not having a good day. Nurse H reported that R931 told them they hear voices and at times people looked like the devil. Nurse H reported no resident-to-resident concerns or roommate concerns were identified before the incident. On 11/08/21 at 2:15 PM, Nurse I was asked about R931 and R932. Nurse I reported R931 had complaints about someone taking their stuff but nothing about any bloody tissues or messes. Nurse I noted no complaints from R932 or R931 about their roommates. Nurse I also noted both residents were able to get out of their room when up in their wheelchairs. On 11/09/21 at 8:33 AM and 1:20 PM, the Administrator was asked about the resident-to-resident incidents and reported R929 had been on a one to one for various reasons at different times during their stay. It was their understanding R930 had come up behind R929 and that R929 had yelled at R930 and subsequently hit R930 in the stomach. The Administrator reported this was a mean response toward a resident such as R930. The Administrator explained that extra staff in activities, nursing and social work are placed on the unit for resident assistance. It was reported that staff witnessed the incident. The Administrator was also queried about R931 and R932. The Administrator reported R931 generally had a [NAME] demeanor than displayed during the incident and helps out other residents and staff at times. It was also noted that R930 was a snacker but not messy. The Administrator indicated they had interacted with the residents every day and the resident had not requested any room change and not complained about their roommate. A review of the facility interview statements revealed Certified Nurse Assistant (CNA) L heard yelling and went out from behind the nurse's desk and saw R929 hit R930 in the stomach and left flank. Nurse M indicated in the nurse progress notes dated 08/19/21 at 7:41 PM that the CNA reported R929 was yelling and hit R930. A review of the facility policy, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property effective 09/11/2020, revealed: Purpose: It is the practice of the facility to encourage and support all residents, staff, families, visitors, volunteers and resident representatives in reporting any suspected acts of abuse .Definitions of Abuse and Neglect .Physical Abuse: includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment . It is the policy of the Facility that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse.

This citation pertains to intakes MI 218 and MI 221. Based on interview and record review, the facility failed to maintain an environment free of abuse for two sampled residents, R#803 and R#804, of six reviewed for abuse, resulting in 1) R#804 being pushed by R#805, which resulted in a [CONDITION(S)], pain, hospitalization , and surgical repair and 2) R#803 being hit in the face by R#801, which resulted in a cut on the lip. Findings include: R#804 and R#805 On 4/12/21 at 9:43 AM, a request for R#804's acute care hospital records from November 2020 were requested. Upon obtaining and reviewing the records, the following information was noted: Date: .Ambulance Patient Care Record, 11/23/2020 - Primary Impression: Injury of Thigh (Upper Leg); Secondary Impression: Extremity Pain; Protocol Used: Pain Control .Chief Complaint: Left Leg pain; Secondary Complaint: Pushed .Injury: Assault, Assault with bodily force .-11/23/2020 .Staff states patient was pushed down to the ground by another resident. Staff helped patient to .bed but patient has severe left thigh pain .En route patient states .pain is better after the medication . The ambulance patient care record indicated that Emergency Medical Service (EMS) staff administered 4 milligrams (mg) of intravenous [MEDICATION(S)] (opioid medication) to R#804. CT Pelvis w/o (without) Contrast (electronically signed 11/23/2020), Impression: 1. Mildly impacted fracture left femoral neck with mild varus deformity (excessive inward angulation). Comminuted fractures involving the left superior and inferior pubic rami. Also subtle nondisplaced fracture left hemisacrum, near the SI joint (sacroiliac joint - links the iliac bone (pelvis) to the sacrum (lowest part of the spine above the tailbone)). Diffuse [CONDITION(S)] and swelling soft tissues are and muscles around the left hip presumably traumatic in diffuse hematoma . The Operative Report dated 11/24/2020 indicated R#804 required surgical intervention and underwent a ORIF (Open Reduction Internal Fixation) procedure with percutaneous pinning of the left hip. R#804's hospital discharge documentation dictated on 12/19/20 read, Patient presented to the hospital after having a fall with a left [CONDITION(S)] .ended up having a left femoral neck fracture .underwent surgical intervention . On 4/12/21 at 10:02 AM, Confidential Witness H was contacted via phone and queried regarding R#804's transfer to the hospital on 11/23/2020. Witness H stated, All I know is I was on [MEDICATION(S)] to the facility to take clothes and things. Got a call and [they] said [R#804] was pushed and was at the hospital. First they wouldn't tell me what was the matter. The doctor at the hospital asked me what happened, I said I didn't know. An activity person (staff) told me that [R#804] was pushed by another resident. [R#804] went to the hospital and we didn't send [R#804] back to the facility because they were terrible to deal with, and we couldn't get anywhere with them. [R#804] was in pain at the hospital. They did tests and found out [R#804] broke [their] hip .Ended up having to have surgery to repair it. I couldn't believe someone would push [R#804] down, [R#804] is the nicest person .had no behaviors. [R#804] was able to independently walk and talk, just has dementia to where [they] forget certain things. A review of R#804's progress notes revealed the following: Effective Date: 11/24/2020 .Writer spoke with [contact person] regarding resident's incident .[Contact person] stated resident just finished with surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . Effective Date: 11/23/2020 .Created By: [Licensed Practical Nurse (LPN) J] .Resident was struck by another resident causing [them] to lose balance and fall to the floor upon assessing resident began to experience a change in condition. 911 was called immediately and DON (Director of Nursing) was notified. Resident was laid in bed began to become stable and complained about pain on .left side. [EMS] arrived and resident was sent to [hospital] at approx. 3:25pm . On 4/12/21 at 10:41 AM, Human Resources Staff H was queried if LPN J was working or available for interview. Staff H indicated that LPN J was currently on a leave of absence and not available. On 4/12/21 at 12:55 PM, Certified Nursing Assistant (CNA) I was interviewed via phone as a witness to the incident that occurred on 11/23/20 involving R#804 and R#805. When queried regarding what she witnessed between the two residents, CNA I stated, I was on 1:1 (monitoring) for [R#805], [they were] a combative resident on the dementia unit. [R#805] had been sleeping, then got up, was very aggressive. I was following behind [R#805, who] was entering another resident's room. I was trying to guide [R#805] out letting [them] know that's not [their] room. When [R#805] was coming out [they were] aggressively trying to hit us .When [R#805] was walking back out of the room, [R#804] was a newer resident trying to talk to [R#805]. [R#804] was very caring. Then [R#805] pushed [R#804]. [R#805] was already in a rage of trying to be combative, which was [their] normal behavior .Those were the type of behaviors [R#805] had, [they] wanted to be aggressive, if that's what [R#805] wanted that's what [they] did. When queried further regarding her position, and the position of the residents at the time of the incident, CNA I continued and stated, [R#805] walked in the room and I walked behind [them], me and another CNA (could not remember the name), were trying to move residents out of the way when we saw what type of mood [R#805] was in .[R#804] was standing in the doorway, and [R#805] pushed [R#804] out [of the] way. When queried if [R#804] indicated they had pain after landing on the ground, CNA I stated, Well, when [R#804] fell , I was in the midst of trying to follow [R#805] to make sure [they weren't] going to go hurt anyone else. [R#804] was [little] and the floor is hard, so I know [they were] in pain, had to be when [they fell ]. When CNA I was asked if she felt [R#805] accidentally pushed [R#804], CNA I stated, It wasn't an accident, [R#805] was trying to push people .was trying to hurt and hit staff. [R#805] was following staff trying to attack them. A review of R#805's progress notes revealed multiple notes describing aggressive/combative behaviors from September and October 2020, as well as the following: 11/15/2020 20:05 (8:05 PM) .(nurses note) Note Text: Continues on one to one. Walks to door constantly trying to get out, can become very combative at times . 11/17/2020 15:00 (3:00 PM) . (nurses note) Note Text: Resident was observed hitting CENA (CNA) repeatedly throughout the morning. Attempts at redirecting resident was mostly ineffective. Attempts at redirecting the resident from touching other residents were mostly ineffective .D.O.N and ADM (administration) made aware of the resident's behavior. Continuing to attempt to protect staff from the resident and to protect other residents from [them] . 11/19/2020 07:44 (AM) Behavior Narrative Note Note Text: [CNA] noted resident hitting another resident in [their] stomach and on [their] left hand. Resident was redirected away from the resident [they] hit . 11/19/2020 09:27 (AM) .(nurses note) Note Text: Resident wasz (sic) attemkpting (sic) to go behind the nursing station. While being redirected by nurse aide resident swung at nurse aide attempting to strike the nurse aide and struck [another resident] in the stomach and hand. Resident redirected down the hall. No further incidcent (sic) noted . 11/20/2020 19:56 (7:56 PM) .(nurses note) Note Text: Resident continued to ambulate up and down hallway, in and out of other residents room, in and out of other residents bed .resident combative during redirecting, kicking, scratching and fighting, resident allowed time to calm down and rest, while allowing rest period, resident suddenly noted walking hallway, in and out of other resident room, rambling through their personal belongings, removing blankets off beds, and upsetting other residents . 11/21/2020 09:38 (AM) Behavior Narrative Note Note Text: Received resident this AM, in bed resting. Resident awake at 8:00 am, noted ambulating quickly up and down the hallway, going into other residents room, noted hitting the walls, bumping into the footboard of bed, throwing objects, punching the doors, kicking staff, throwing drinks on staff, hitting, and punching staff . 11/23/2020 16:20 (4:20 PM) [Created by the Nursing Home Administrator] Behavior Event Note Location/Cause: 2 North Hallway, Memory Care Unit. Behavior: Resident aggressive towards another [resident]. Description of behavior: After entering room, a .peer stepped into the door way of room, staff redirect truck (sic) resident on arm who lost balance and fell . Non Pharmachological (sic) Interventions: Resident being petitioned out for psychiatric evaluation due to unsafe behaviors. Behavior/Intensity: Resident wanders aimlessly at a fast speed up and down hallway, in at racing fashion, poor safety awareness and desire to remove obstacles out direct path. Behavior is difficult to alter . 11/23/2020 16:32 (4:32 PM) .Social Service Note Note Text: Writer petitioned resident out to the hospital. Resident is verbally and physical aggressive to staff and aggressive to residents. Resident is hitting, pushing, and punching staff .a danger to .self and others . 11/23/2020 17:01 (5:01 PM) .(nurses note) Note Text: Resident was wandering hallway going in and out of residents room. Resident was being monitored closely due to combative and unsafe ways. when resident went into a room staff redirected [them], when leaving out of room another resident stood in doorway and resident struck [them] on the arm causing [them] to loose (sic) balance and fell to the floor. Resident continued to walk down hall yelling and hitting at staff . On 4/13/21 at 9:09 AM and at 9:30 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) were interviewed regarding the incident between R#804 and R#805. The DON stated, [R#805] was on a 1:1 at the time, was coming out of a room, another resident (R#804) stepped into the doorway. [R#805] pushed past [them] and the other resident, [R#804], ended up falling down and sustained an injury. The DON indicated R#804 broke their hip but was not sure which one. When queried where the assigned 1:1 staff member was at the time of the incident, the DON stated, The CNA was following directly behind [R#805]. The DON indicated that R#804 was sent to the hospital and did not return to the facility, and that R#805 was petitioned out and also did not return to the facility. The NHA stated, [R#805] was a wanderer, a pacer, and had assigned a 1:1. The NHA explained a nurse was taking care of another resident in a room to which R#805 entered into and stated, One of the CNAs followed [R#805] into the room, and on [their] way out, another resident stepped into the doorway of the room and [R#805] pushed [them] out of the way. The other [resident] tumbled and fell , it was [R#804] who fell , went to the hospital. Upon inquiry, the NHA was unsure if R#805 had had any other such incidents with peers at the facility. The NHA stated, [R#805] was a pacer, moved real fast, we had to keep people out of the way because [R#805] was a straight-line pacer. [R#805] was on 1:1 because [they walked] so fast, had pacing behavior down the hallway, our goal was to keep the other patients safe. When queried regarding the effectiveness of the 1:1 monitoring intervention, the NHA stated,[R#805] exited first but the staff did not exit first. The CNA was behind [R#805] and the other resident was in the doorway .was an obstacle for [R#805], [who] just kept on walking like [they do]. A review of R#804's Minimum Data Set (MDS) assessment dated [DATE] and medical record revealed that the resident was admitted into the facility on [DATE] (and discharged on [DATE]) with a medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R#805's MDS assessment dated [DATE] and medical record revealed that the resident was admitted into the facility on [DATE] and readmitted on [DATE] (discharged on [DATE]) with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's MDS dated [DATE] noted the resident to be moderately cognitively impaired. A review of R#805's care plan revealed: Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Date Initiated: 09/28/2020. R#801 and R#803 A review of R#801's medical record revealed, 11/12/2020 13:01 (1:00 PM) Health Status Note Text: Resident was in the PUI (Patient under Investigation) hall yelling at staff and making threats. Resident called out ethnic slurs repeatedly and made physical threats. 11/17/2020 14:54 (2:54 PM) Health Status Note Text: Doctor was called and informed about the resident's incident with hitting another resident (R#803). Doctor ordered the resident to be petitioned to (local hospital) for psych and aggressive behaviors . D.O.N. (Director Of Nursing) made aware. R#801 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R#801's MDS assessment dated , 8/28/20 and 11/27/20 noted R#801 had an impaired cognition. The MDS assessment dated , 2/27/21 revealed R#801's cognition had changed and was without impairment scoring a 15 out of 15. On 4/12/21 at 9:30 AM, R#801 was asked about their stay in the facility, and was observed to need assistance with hearing, roommate stated that (R#801) was hard of hearing. Surveyor typed on their work computer to communicate with R#801. R#801 was asked about the care at the facility and stated, They took the sheets off my bed and haven't been back. R#801 was asked about the incident with R#803 on 11/17/20 and was unable to remember that day. A review of R#801's care plan revealed, The resident is/has potential to be physically aggressive r/t (related to) territorial behavior related to belongings. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Goal: The resident will demonstrate effective coping skills through the review date Date initiated: 11/17/2020. The resident will not have conflict with roommate through next review. Date Initiated: 11/17/2020. Interventions: The resident's triggers for physical aggression are: being unable to smoke and not having access to his personal belongings. Staff must remind and assure resident is able to smoke during the allotted times and assure resident belongings are organized, in place and available to resident. Date initiated: 12/09/2020. A review of R#803's medical record revealed, that R#803 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the admission Social services evaluation noted, 11/16/2020 Reason for Evaluation Admit . Cognition Mood and Behavior: 1. Is the resident alert and orientated times three? Yes. Describe resident's mood: pleasant, shares information . Summary: Resident is pleasant and often refer to missing (R#803's spouse) and family. Talks about how bless (R#803) is to have a devoted (spouse) and misses (spouse) much. The Brief Interview Mental Status (BIMS) evaluation revealed, R#803 with a moderately impaired cognition. Further review of R#803's progress notes revealed, 11/17/2020 14:27 (2:27 PM) Health Status Note Text: Resident was standing in the hallway standing with staff. Suddenly, the resident in (R#801) rolled up in (R#801) wheelchair and punched (R#803) and hit (R#803) in the face. resident was confused to why (R#803) was hit. Examined the resident, and found a mark to (R#803's) face. will alert the resident's responsible party about the incident. DON and ADM (Administrator) made aware. will call the doctor about the incident. resident was separated from the other resident and safety maintained. will continue to monitor. A review of R#803's Incident and Accident Investigation noted, Brief description of the incident: (R#801) stuck another male peer after peer got into (R#801) bed and touched (R#801) belongings. Investigation: . Was an injury identified: Yes. Type of injury: Superficial. Action Taken: Triple antibiotic applied and band-aid. An interview was attempted with Certified Nursing Assistant (CNA G) but was informed that CNA G was at a training. CNA G's written statement revealed, While on PUI (Patient under Investigation) unit, Resident (R#803) was wandering and had to be redirected multiple times and issued face mask on an ongoing basis. Was increasingly confused (R#801) came out of (R#801's) room stating. '(R#803) keeps trying to get in my bed and stuff.' Writer request room change to address but in meantime resident (R#803) was not redirectable. Approached (R#801) who came out of room, walked up to (R#801) and became angry, writer intervened but (R#801) reached around to try and hit (R#803) and scratched (R#803's) lower lip. Writer said stop they did and administrator came and assisted (R#801) into (R#801's) room and counseled (R#801). Nursing staff completed room change . 11/7/2020. A review of R#803's care plan revealed, Focus: The resident is an elopement risk/wanderer r/t (related to) dx (diagnoses) of vascular dementia and aimless wandering. Date Initiated: 11/16/2020. Goal: The resident's safety will be maintained through the review date. Date Initiated: 11/16/2020. Interventions: Staff aware of residents wander risk Date Initiated: 11/16/2020 All staff Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Date Initiated: 11/16/2020. On 4/13/21 at 9:13 AM, the NHA was asked about the incident with R#801 and R#803 and explained, R#801 is better now and had not had any other incidents like this. The CNA was there and stopped it right away. The NHA continued and stated, I have coffee with (R#801) and we talk, (R#801) wants instant gratification and likes things right away. A review of the facility's policy/procedure titled, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, effective date 9/11/2020, revealed, .Abuse is the willful infliction of injury .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .physical abuse includes hitting, slapping, punching, and kicking .It is the policy of the Facility that each resident will be free from 'Abuse.' .residents will be protected from abuse .while they are residing at the facility .

This citation pertains to intake # MI 393. Based on interview and record review, the facility failed to develop and implement new interventions following falls for two of three residents (#702 and #704) reviewed for falls, resulting in repeated falls, pain, fractures and hospitalization . Findings include: Resident #702 A record review of the Progress Notes revealed the following for Resident #702: 9/17/2020 09:43 (AM) .Resident was found sitting on the floor with legs extended in front of (them) at beginning of the shift . 10/7/2020 04:35 (AM) .Writer returned from break and made aware by covering nurse that resident was observed on floor at around 0420 (AM) in sitting position with legs spread out next to (their) bed. Resident assisted up to bed, resident queried, states (they were) transferring from (their) bed to (their) wheelchair to go to the bathroom and slid to the floor . 10/19/2020 19:30 (7:30 PM) .8:45 pm, transferring self from restroom to bed and slid on the floor. No injuries or bruises noted, writer encouraged to call for assistance and sit in w/ (wheel) chair instead of ambulating . 12/4/2020 at 4:25 PM .sitting on the floor in the hallway. Resident stated (they) slid out of chair onto floor. 12/17/2020 13:31 (1:31 PM) .Resident observed on the floor in (their) bathroom. Resident stated (they) slipped on the floor trying to walk back to the .bed. C/o (complaints of) .pain noted to (their) right side. Small abrasion noted on left knee. Redness noted on (their) left side. Resident has unsteady gait. Resident chooses not to use wheelchair. Resident educated on safety precautions and using call light to call for assistance . 1/18/2021 13:51 (1:51 PM) .At 12:30pm Resident was noted at the foot of the bed sitting on (their) buttocks. Resident states 'I was trying to go to the bathroom.' ROM (range of motion) performed on B/L (bilateral) lower extremities, c/o pain in the right hip . 1/19/2021 07:06 (AM) Discharge/Transfer Summary Note .Xray results: fracture involving base of right femoral neck ([MEDICAL CONDITION]) with minimal displacement. The joint shows no dislocation. Pubic rami are intact. Conclusion: Recent fracture involving base of the right femoral neck . A record review of the Fall Care Plan for Resident #702 revealed the following: Focus .Resident has had an actual fall with no injury, Poor Balance .Resident had fall without injury on 10/6/20 .12/4/20 .Resident had fall with injury 1/18/21 .(Initiated 9/18/2020). Focus .Resident is at risk for falls r/t (related to) unspecified dementia with behavior disturbances .[MEDICAL CONDITION] .and Psychoactive drug use. Initiated 12/17/2020. Goal .The resident will be free of minor injury . Initiated 1/7/2021. Goal .Resident will resume usual activities without further incident . Initiated 10/7/2020. Interventions .Anticipate and meet the resident need. Revised 3/8/2021. .Ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed .needs prompt response to all requests for assistance. Initiated 9/22/2020. .Continue the interventions on the at-risk plan. Initiated 9/22/2020. .Dycem to wheelchair seat. Initiated 12/7/2020. .PT (physical therapy) to work with resident for strength and mobility. Initiated 1/18/2021. .Transfers with one person assist holding hand. Initiated 9/18/2020. .Vital signs every shift . Initiated 9/22/2020. .Bed in low position when in bed. Initiated 11/18/2020. .Encourage resident to stay properly hydrated . Initiated 5/27/2020. .Ensure bed brakes are locked. Initiated 5/27/2020. .Ensure footwear fits properly. Initiated 5/27/2020. .Ensure resident has glasses on. Initiated 5/27/2020. .Evaluate gait and ambulation capabilities, identify abnormalities. Initiated 11/18/2020. .Monitor pain and alleviate using non-pharmacological interventions and medications ordered. Initiated 5/27/2020. .Non-skid socks/footwear. Initiated 5/27/2020. .Anticipate and meet the resident's needs. Initiated 1/7/2021. .Ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Initiated 5/27/2020. .Follow facility fall protocol. Initiated 5/27/2020. .PT to evaluate and treat as ordered or PRN (as needed). Initiated 5/27/2020. .The resident needs a safe environment . Initiated 5/27/2020. A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #702 was admitted initially on 5/22/2020 with the [DIAGNOSES REDACTED]. Resident #702 had a severely impaired cognition and needed extensive hands on assistance with transfers and personal hygiene. A record review of the Rehabilitation Screen dated 10/9/2020 for Resident #702 revealed the following: Per DON (Director of Nursing) Client fell [DATE] .Patient has been assessed by physical therapist, waiting for authorization to begin treatment. Patient will benefit from skilled services. no injury or fracture noted with recent fall. On 2/3/2021 at 2:20 PM, the Nursing Home Administrator (NHA) was asked who to speak with in regard to falls within the facility. The Assistant Director of Nursing (ADON) was referred and subsequently interviewed. The ADON was queried in regard to the falls and the current interventions that were implemented for Resident #702. The ADON was asked what interventions were put into place following the falls on 10/7/2020, 10/19/2020, 12/17/2020, and 1/18/2021. The ADON explained that they had therapy screen the Resident. The ADON was asked when therapy had picked up the Resident for services and explained that PT had picked up the Resident on 12/10/2020-12/28/2020 and 1/10/2021-1/18/2021. The ADON was asked what was done in the meantime to maintain the Resident's safety while PT was waiting to be approved to initiate services. The ADON did not provide an explanation. The ADON was asked what other interventions were put into place for the Resident's safety (besides PT). The ADON did not provide an explanation. Resident #704 A record review of the Progress Notes revealed the following for Resident #704: 10/2/2020 18:21 (6:21 PM) .Resident hiself (sic) to the floor, on the floor mat was assisted by 2 staff nurses, none-injury skin intact. Resident confused thinks (they) can walk around lower (extremity) weakness. All safety measures maintained. 10/9/2020 20:17 (8:17 PM) .7:30 p.m. Writer and staff overheard a thump, upon entering room resident noted on floor, near bed back side up against the wall. writer assessed resident no noted injury, No Change in mental status, No s/s (signs and symptoms) of discomfort at this time, Vitals stabled. Resident assist back to bed, Prom (passive range of motion)demonstrated without difficulties, resident attempts to get out of bed without assist frequently . 10/19/2020 00:10 (12:10 AM) .This writer observed resident from nurses station fall back into wall hitting left side od (sic) head on room mate head board. Resident assessed with [REDACTED]. 10/28/2020 22:45 (10:45 PM) .Resident noted on the floor next to bed in prone position (lying on stomach), noted with small laceration to left eye brow and bridge of nose, slight swelling noted. ROM active in all extremities. Further record review revealed that Resident #704 had an X-ray of their facial bones and was positive for nasal fractures. A record review of Fall Care Plan for Resident #704 revealed the following: Focus .(Resident #704) has had an actual fall with no noted injury 9/9/2020 fall no injuries, 9/11/2020 fall no injuries, 10/29/2020 fall with laceration to nasal bridge and left eye, swelling association. Initiated 9/3/2019. Goal .The resident will be free of minor injury through the review date. Initiated 7/29/2020. The resident will not sustain serious injury . Initiated 7/29/2020. The resident falls will be decreased by the next review date. Initiated 7/29/2020. Interventions .Bed in low position when in bed. Initiated 9/3/2019. .Do not leave resident unattended in the bathroom. Initiated 7/29/2020. .Elastic shoelaces. Initiated 9/11/2019. .Encourage resident to stay properly hydrated . Initiated 9/11/2019. .Ensure bed brakes are locked. Initiated 9/9/2019. .Ensure footwear fit properly. Initiated 7/29/2020. .Monitor pain and alleviate using non-pharmacological intervention and medications as ordered. Initiated 11/28/2020. .Provide opportunity for physical activity . Initiated 7/29/2020. .When resident attempts to stand, ask what they would like to do, and then assist then to complete their desired task. Initiated 7/29/2020. .Anticipate and meet the resident's needs. Initiated 11/28/2018. .Assist to use restroom after meals and at bedtime. Initiated 9/3/2019. .Ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Initiated 7/29/2020. .ice application to facial bones. Initiated 10/29/2020. .Keep bed in up position, do not place bed in low position, as resident gets out of bed independently. Initiated 9/3/2019. .Resident's is noted to put self on the floors at times. Initiated 9/16/2020. .[MEDICATION NAME] (an antiaxiety medication) decreased from BID (two times per day) to once nightly . Initiated 9/10/2020. A record review of the MDS assessment dated [DATE] revealed that Resident #704 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED].#704 had a severely impaired cognition and needed hands on extensive assistance with transfers, personal hygiene and dressing. A record review of the Therapy Fall Screen dated 10/29/2020 for Resident #704 revealed the following: DON reported client fell last night, found prone on floor with laceration on face and fractured nasal bone. On 2/3/2021 at 2:20 PM, an interview was completed with the ADON in regard to the fall program of the facility. The ADON explained that falls are reviewed in the morning meetings and at the weekly at risk meetings. The ADON also explained that the facility reviews falls at the time of the incident if able to and then determines a cause of the fall and what changes need to be implemented and care planned. The ADON was queried in regard to what interventions were put in place for Resident #704 for the falls on 10/2/2020, 10/9/2020, 10/19/2020 and 10/28/2020. The ADON responded, I think we ordered a wing-tipped mattress. (Resident #704) was on hospice and hospice was to order the mattress. The ADON was asked if the mattress was ordered but was unable to verify if the mattress was ever implemented. On 2/3/2020 at 3:15 PM, an interview was completed with the Director of Nursing (DON) in regard to the fall interventions put in to place for Resident #704 and stated, The Resident was on hospice, so no aggressive measures were put in place. The DON further explained that because the resident was on hospice, they were not eligible for PT. The DON was asked what other interventions were put into place. The DON did not provide any further explanation. On 2/3/2020 at 3:37 PM, an interview was completed with the NHA in regard to the lack of interventions put in place following numerous falls for Resident #702 and #704. The NHA did not provide an explanation. On 2/3/2020 at 3:49 PM, the facility corporate representative explained that the facility had recognized a deficiency in fall intervention implementation. A review of the facility policy titled Fall Evaluation Safety Guideline dated 11/28/2017 revealed the following: Purpose: .to treat or refer for treatment appropriately .To prevent or reduce injuries related to falls. Fall prevention is achieved through an IDT approach of managing predicting factors and implementing appropriate interventions to reduce risk for falls. Procedure: .Initiate, review and revise the fall care plan as appropriate, with new or discontinued interventions .5. The IDT will evaluate the effectiveness of the individualized interventions .All residents identified as at risk for falls will be reviewed for individualized interventions .

This citation pertains to intake 1. Based on interview and record review, the facility failed to transfer a resident (R#909) to the hospital, after identifying an acute change in condition on [DATE] exhibited by lethargy and change in breathing pattern, as requested and recommended by the Nurse Practitioner, resulting in the resident being found unresponsive and subsequently dying unexpectedly on [DATE]. This deficient practice resulted in an Immediate Jeopardy (IJ). Findings include: The Immediate Jeopardy started on [DATE] and was identified on [DATE]. The Administrator was notified of the Immediate Jeopardy on [DATE] at 4:15 PM and was asked for a plan to remove the immediacy. The IJ was removed on [DATE], based on the facility's implementation of the removal plan as verified onsite on [DATE]. Although the IJ was removed, the facility's deficient practice remained isolated with actual harm that is not Immediate Jeopardy. A review of intake 1 revealed the following: Complainant states the doctor instructed staff to send (R#909) out as (they were) showing signs [MEDICAL CONDITION]. Complainant states the DON (Director of Nursing) .said not to and the resident ended up dying . A review of R#909's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was admitted into the facility on [DATE] with medical [DIAGNOSES REDACTED]. Further review of the MDS and medical record revealed that the resident was moderately cognitively impaired and required extensive assistance from staff for bed mobility, dressing, and hygiene. The record revealed that the resident passed away in the facility on [DATE]. A review of R#909's medical record revealed the following: [DATE] 14:06 (2:06 PM) *Health Status Note (nurses note) Note Text: Resident in bed lethargic and clammy. Breathing is like a panting. Meds crushed and offered, but refused. Vital signs ,[DATE] (blood pressure), Respirations 22 (normal ,[DATE] at rest), Temp(erature) 97.9, and Pluse (sic) 86. (Nurse Practitioner (NP) E) notified. Order for STAT CBC and BMP (complete blood count and basic metabolic profile - common blood tests), drug screen and 0.9 normal saline @60cc per hour. Supervisor and DON aware. -Written by Licensed Practical Nurse (LPN) F. [DATE] 16:20 (4:20 PM) *Health Status Note (nurses note) Note Text: 0.9 saline started at 4pm to run until 4pm [DATE], via picc line (a form of intravenous access that can be used for a prolonged period of time or for administration of substances that should not be done peripherally). -Written by LPN F. [DATE] 20:16 (8:16 PM) *Health Status Note (nurses note) Note Text: Resident resting in bed at this time. O2 (supplemental oxygen) at 4L/min (liters per minute) because Resident keeps removing nasal cannula. IV infusing without difficulty. In no acute distress, being monitored. Information endorsed to oncoming nurse. -Written by LPN F. No remaining progress notes were present in the resident's chart until the following: [DATE] 17:26 (5:26 PM) *Health Status Note (nurses note) Note Text: @ (at) 3:27pm OT/PT (therapy) summons nurse to room and reported resident was unresponsive. One of the therapist stated '(resident) was just up and when I looked over at (them, they were) no longer breathing.' Writer begun CPR (cardiopulmonary resuscitation) at 3:28 until ambulance arrived @3:39pm. Pulse was 44 (normal pulse is ,[DATE] beats per minute) and writer was unable to obtain blood pressure. Administered oxygen @ 15L. Reisdent (sic) was hooked to AED ( automated external defibrillator) and no shock was given. Two ambulance personal a male and female begin to assist with CPR. Resident received (sic) four rounds of EPI ([MEDICATION NAME] - [MEDICATION NAME] used for emergencies). Resident still didn't respond. CPR was given nonstop until time of death was called .@ 1558 . A review of the progress note signed on [DATE] by NP E revealed the following: Patient: (R#909) Created by: (NP E) DOS (Date of Service): [DATE] . Progress Note: .Chief Complaint / Nature of Presenting Problem: Resident is not seen in person. I did receive a call from the nurse taking care of the resident about 1420 (2:20 PM) on [DATE]. History of Present Illness: (LPN F) did call me in regards to patient having a change in status. Resident is positive for Covid and currently on IV antibiotics for a foot infection. All of (R#909's) vital signs are stable, however, nurse states that resident is lethargic and not taking any of (their) p.o. (oral) medications. (R#909) is a diabetic and blood sugar was elevated around lunchtime. (Nurse) states that the resident is clammy. Pulse ox (blood oxygen saturation) is normal with panting breathing at times. I ordered the resident to be transferred to the hospital. Nurse called me a little while after stating that the director of nursing and the nurse manager did not want to send the resident out. They wanted to do everything they could do at the facility. I expressed my concerns to the nurse that I thought it was best that the patient was transferred to the hospital due to the acute change in condition. I did contact (Physician H) to discuss the above. Stat labs including CBC, CMP, and drug screen along with IV 0.9 normal saline at 60 cc an hour were ordered. Nurse advised if no improvement or any further changes resident to be sent out . Past Medical History: Diabetes .asthma, cognitive decline . Plan: I received no further calls regarding the patient. Review of R#909's orders revealed the following: [MEDICATION NAME] HCl Solution 1000 MG (milligrams)/10 ML (milliliters) Use 1750 mg intravenously (IV) every 16 hours for antiboitics (sic) until [DATE] 23:59 -Order Date- [DATE] 0638. A review of the Medication Administration Record [REDACTED]. accucheck (blood sugar checks) AC (before meals) and HS (at bedtime), Prescriber Entered, Active [DATE]. A review of R#909's medical record, MAR, and vitals history revealed that blood glucose checks were only entered twice during the resident's stay in the facility with the following results: [DATE] 11:54 (AM) - 310 mg/dL [DATE] 11:34 (AM) - 410 mg/dL. Further review of the MAR indicated [REDACTED]. No corresponding progress notes related to the two elevated blood sugars were noted in the record. The American Diabetes Association suggests that an ideal pre-meal blood glucose result for non-pregnant diabetic individuals is 130 mg/dL or less and an ideal post-meal (,[DATE] hours after eating) blood glucose of less than 200 mg/dL. A review of R#909's pre-admission hospital documents revealed the following lab results from [DATE]: a serum blood glucose reading of 235 mg/dL, normal BUN and Creatinine levels (indicators of kidney function), normal anion gap, slightly low sodium level of 133 (normal is ,[DATE]), and slightly low chloride level of 94 (normal is ,[DATE]). A review of R#909's admitting lab results from [DATE] revealed: a serum blood glucose reading of 342 mg/dL, anion gap of 21.4 (normal is ,[DATE]), and slightly low potassium level of 3.4 (normal is 3XXX,[DATE].3). A review of R#909's STAT lab results dated [DATE] (collected [DATE]), revealed: a blood glucose level of 513 mg/dL and marked CH (critically high), BUN of 53.2 (normal is ,[DATE]), Creatinine of 1.34 (normal is 0XXX,[DATE].10), anion gap marked high 17, sodium of 150, and chloride of 109. On [DATE] at 11:06 AM, LPN F was interviewed and queried regarding R#909's change in condition that they documented on [DATE]. LPN F stated, I put in my note and assessed the patient, put (them) on the hydration. Did the STAT labs but the next day I did not work. When queried if the Nurse Practitioner (NP E) wanted to send the resident to the hospital on [DATE], LPN F stated, I called (NP E) and said, 'Maybe we need to send (R#909) out.' When asked if NP E agreed, LPN F stated, Yes at first (NP E) did and I talked to (Physician H). The facility wanted to do more. When queried who stopped the resident from being transferred out despite their assessment and the wishes of NP E, LPN F stated, I'm not sure, I got (the instructions) from (Registered Nurse (RN) Supervisor G). When queried further regarding their observation and documentation of R#909 on [DATE], LPN F stated, I thought something was off. I followed my order which was from above me. (Physician H) added the hydration. The shift supervisor said they wanted to do hydration and STAT labs before sending out. I put in for the STAT labs and started the hydration, then wasn't there the next day. It happened at the end of my shift. When queried who the oncoming nurse was, LPN F indicated they did not remember and stated, We use agency. Not sure who she was. When asked if R#909 presented on [DATE] with an obvious change in condition, LPN F stated, Yes. On [DATE] at 12:30 PM, the Director of Nursing (DON) was interviewed and queried on the facility's policy for resident change in condition. The DON indicated she needed to go pull the facility's policy and would be back. On [DATE] at 12:36 PM, the Nursing Home Administrator (NHA) was queried regarding the facility's policy for resident change in condition. The NHA stated, Should follow standards of practice, haven't reviewed it (policy) here yet though, I haven't had a chance to. Follow whatever the policy is here and standards of practice. When queried regarding transferring a resident to a higher level of care upon recommendation by a provider, the NHA stated, The nurse calls the provider and if the provider wants the resident to go out we get an order and send them out. The only time we wouldn't send them out is if the resident refuses transfer. On [DATE] at 1:12 PM, NP E was interviewed regarding R#909 and their notification of the resident's change in condition on [DATE]. NP E stated, I was very clear in my documentation. The nurse (LPN F) called me, maybe it was a Sunday. It was the afternoon. The nurse who called me is very experienced and I totally trust (their) judgment. What (LPN F) described, I said, we need to send (R#909) out and (LPN F) agreed. When asked if they gave an order to the nurse to send R#909 out to the hospital, NP E stated, Yes, the order was to send (R#909) out. They have to get it cleared, I guess, through the DON to send out. Even though I gave the order. (LPN F) said it was a huge change for the resident, (they) weren't keeping (their) oxygen on. The breathing described was not how I remembered the patient, and (the nurse) was concerned. The patient also had Covid, so we needed to send (them) out. About 20 minutes later, (the nurse) called me back and said the DON and nurse manager said they wanted to do everything they could do (at the facility), and (didn't) want to send the resident out. (The nurse asked me) about labs and an IV per the DON suggestion. I said we need to send (R#909) out, based on what you're telling me. I asked (the nurse) how fast can you get an IV and labs? I didn't feel comfortable leaving it at that. I asked the nurse to contact (Physician H). Never got called again after that. That's when I found out (R#909) passed away the next day. I don't know if the nurse ever called (Physician H). I remember saying, 'How fast can we get this done? If there's no change, (R#909) needs to get sent out.' It's not like I took my order back and said no, don't send (R#909 out). I maintained that (R#909) needed to be sent out and (Physician H) needed to be contacted. I asked (LPN F) why they (DON, manager) didn't want to send the resident out, are they there to see (R#909)? (The nurse) just told me, 'Well, you know how it is.' This nurse, (LPN F) told me, 'I don't want this resident dying on me.' I know I was pretty clear that (R#909) needed to go out, I didn't feel comfortable with the situation. I gave the orders for labs and IV but never heard anything after that. On [DATE] at 1:24 PM, Physician H was contacted and interviewed regarding R#909's change in condition on [DATE]. Physician H indicated he was contacted by LPN F and, Ordered STAT labs .never heard anything else. Physician H indicated he had spoke with NP E and stated, She had wanted to send the resident out. I talked to the nurse, (they) gave vital signs which were stable. The resident was less responsive, wanted to start a workup. From me ordering the labs I never heard anything different after that. If I got follow-up and there were changes, we would've sent (R#909) out .(gave order to) begin work-up prior to sending the patient out, but got no follow-up from that. On [DATE] at 1:52 PM, the DON indicated that she was still searching for the facility's change in condition policy/procedure. At this time, the DON was asked if she remembered R#909's change in condition that occurred on [DATE] and if she recalled the Nurse Practitioner wanting to send R#909 to the hospital. The DON stated, I do not. The DON was then asked if a practitioner wants to send a resident out for a change in condition, if the facility normally sends the resident out per the recommendation or order and responded, Absolutely. The DON was asked if she recalled any situation relating to R#909 or a request for transfer to the hospital and responded, I would need to refer to the chart. I do not recall off the top of my head. The DON was asked if she was in the facility on [DATE] and responded, No. You said it was a Sunday, correct? So no, I would not have been here on the 4th. On [DATE] at 1:57 PM, RN G was interviewed and queried regarding R#909's change in condition that occurred on [DATE] and if she recalled the Nurse Practitioner wanting to send R#909 to the hospital. RN G indicated she did not remember. When asked if she could confirm that she worked that day, RN G stated, Yes, I believe I worked that day. When queried regarding R#909's lethargy and change in breathing, RN G stated, If I was not the assigned nurse I probably would've gotten told by the assigned nurse. When queried if she handles resident transfers to the hospital, RN G responded, I don't. We go by the doctor order. If there is a change in condition, we notify physicians, they will recommend IV, labs, things that can be done in house and if the results come back that the resident needs to go out then they go out. I don't remember assessing this resident on this day. Sometimes I will assess and notify the physician. If I assess the resident myself, I do put a note in saying what I've seen and what the doctor orders and what we are doing for the resident. When queried if she expects follow-up once the labs and IV are initiated, RN G stated, Stat labs will be drawn, the oncoming nurse is made aware they need to be followed up and lab will call if there are abnormal (results). And we will follow up on the ordered treatment. If it was a Sunday, definitely would be followed up by Monday. On [DATE] at 2:55 PM, LPN I was queried regarding ordered accuchecks and where results are found in the medical record. LPN I indicated that when a nurse takes a blood sugar reading on the glucometer, they have to input it into the electronic medical record (EMR). When asked if the blood sugar checks are recorded anywhere other than the EMR, LPN I stated, No. Have to take the sugar and then manually put them into PCC (EMR) but they are not logged anywhere else. On [DATE] at 8:56 AM, the DON and NHA were interviewed. When queried regarding the Nurse Practitioner stating to send R#909 out to the hospital on [DATE] with other staff indicating the transfer was blocked, the NHA stated, That was a dictated note that was scanned in after. We reached out to the providers. The NP has the power to give order and get that going, I don't know why that didn't happen, I wasn't there. Not something the administrator should be involved in. We had a talk with the DON, had a conversation of how we will do things moving forward. Patients who need assistance must get it, and nurses must utilize nursing judgment. We've also told them they can call the medical director .We have to, as a clinical team, stay on top of actions being taken after experiencing a change in condition. We weren't on the same page here, patients can decline quickly. When queried regarding the facility's change in condition policy/procedure, the NHA stated, The policy for change in condition focused on notification. We have a change in condition policy now based on the standard of practice. The process changed for sending out. The nurse has to take steps, follow physician's orders [REDACTED]. Was not in the policy before. When queried regarding documentation of interventions implemented in the facility after a noted change in condition, the NHA stated, That's part of the education being given, that they (nurses) need to document response to the interventions being given. When asked if there was documentation of R#909's response to the interventions given in this case, the DON stated, No. The NHA responded, The follow-thought is a big thing being put into place. We should've seen some detail of follow up. When asked what is expected regarding documentation, the NHA stated, Start with vitals and follow SBAR (situation, background, assessment, recommendation - communication model). Start documentation immediately. I looked at the notes. I didn't see the follow through that I would expect for an acute change in condition. On [DATE] at 3:00 PM, the DON was interviewed and queried regarding R#909's glucose of 342 on [DATE]. When asked who followed up on that result or if it was followed up on, the DON stated, I would have to check. When asked who normally follows up on abnormal lab results, the DON stated, The nurse assigned to care for the resident. When asked if she would expect the nurse to document any interventions carried out including calling the resident's assigned doctor/NP, the DON stated, Correct. The DON was then asked if she would expect tasks, such as accuchecks for R#909, to be carried out and documented per order, the DON stated, Yes. When asked if the DON had any information to provide as to why R#909 only had their blood sugar checked twice, once on ,[DATE] and once on ,[DATE], the DON stated, No. When asked if the blood sugar checks get documented manually into the EMR, the DON stated, Correct. When asked if she would expect to see follow up from the nurse(s) who obtained the blood sugar readings of 310 on ,[DATE] and 410 on ,[DATE], the DON stated, Yes. When asked if she would like to provide any more information related to R#909's change in condition, the DON stated, My stance for every resident and communication to every nurse is that if I'm not in the building, we assess, evaluate and notify the physician. We should be utilizing and exhausting all available resources in-house including transferring out to the hospital. It's unfortunate the documentation reads as such. I have never said or tried to say that a person never needs to go to the hospital. I did not get a call from the assigned nurse. I had a missed call from facility and spoke with (RN G), who indicated that (LPN F) had a resident who wasn't doing too well. I wasn't familiar with the resident. I said to (RN G) that we need to exhaust our interventions and notify the physician and if need be, need to send the resident to the hospital. A review of the facility's policy/procedure titled, Diabetes Management, dated [DATE], revealed, .Nursing Evaluation/Symptoms .Results <70 or >400 indicate hypo or [MEDICAL CONDITION] require immediate follow up, Determine with the physician / extender if the individual has specific parameters to monitor .Additional: .Kidney function testing / impact of diabetes on GI and GU function .Injuries to feet and lower extremities .Infection signs and symptoms .Notify the physician of any findings which suggest worsening of hypo-or-[MEDICAL CONDITION] symptoms, infection, or any other complication of diabetes and / or comorbidities .Nursing Interventions: .Blood glucose monitoring including use of glucometer, reportable parameters . A review of the facility's policy/procedure titled, Notification of Changes Guideline, revised [DATE], revealed, PURPOSE The facility shall promptly notify the resident and/or the resident representative and his or her physician or delegate of changes in the resident's condition or status in order to obtain orders for appropriate treatment and monitoring and promote the resident ' s right to make choices about treatment and care preferences. PROCEDURE 1. The nurse will immediately notify the resident, resident ' s physician and the resident representative(s) for the following (list is not all inclusive). If the residents physician is not available contact the Medical Director. a. An accident involving the resident, which results in injury and has the potential for requiring physician intervention. b. A significant change in the resident ' s physical, mental, or psychosocial status that is a deterioration in the health, mental or psychosocial status in either life threatening conditions or clinical complication. c. In life threatening conditions activate the emergency response system immediately. d. A need to alter treatment significantly (a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment . A review of the facility's policy/procedure titled, Change in a Resident's Condition or Status, revised [DATE], revealed, 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: .d. a significant change in the resident's physical/emotional/mental condition; e. A need to alter the resident's medical treatment significantly .i. A need to transfer the resident to a hospital/treatment center .k. instructions to notify the physician of changes in the resident's condition .Notification - Must 'promptly notify' the physician, PA, or NP of laboratory and radiology results: l. that fall outside of the clinical reference range that would require or per physician order. m. orders- physician extenders may order and interpret labs, radiology and other diagnostic services in accordance with their physician provider agreements and state law .2. A 'significant change' of condition is a decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not 'self-limiting'), b. impacts more than one area of the resident's health status .d. ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument and 42 CFR 483.20(b)(ii) .6. The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . Immediate Jeopardy Abatement Measures for F-684 The facility failed to transfer a resident (Resident #909) to the hospital, after identifying and acute change in condition on [DATE] Steps Taken to Remove the Immediacy: o Residents in house have been evaluated for an identified change in condition that require hospitalization . The assessment included facility vital sign review and review of all laboratory tests ordered over the last 3 days for the purposes of identification of unaddressed critical lab values. Nurse Managers were assigned to each unit and completed. o Licensed Nurses on duty have been educated on the following: o Identification of changes in condition/status o Notification of physician/practitioner with acute changes in condition. Nurses are to complete associated documentation in the record that includes changes identified and steps taken for resolution. o Nurses are to contact the physician for new orders and to reach out to the Medical Director for any concerns with responsiveness or orders. o Nurses are to utilize clinical judgment for addressing acute changes in condition; including sending residents out to the hospital for any changes in condition that cannot be safely managed in the facility. o A Change in Condition Policy has been implemented to add the requirement for nurses to assess changes in condition, document those changes and resulting action, but more specifically to utilize nursing judgement in critical situations to send residents to the hospital when acute changes cannot be safely managed in the facility. o Laboratory since [DATE] have been reviewed for critical values. o 24 hours reports for the previous 72 hours have also been reviewed to assure any identified issues have been addressed. o New process implemented for clinical meetings to include daily review of audits of 24 hour reports, high priority progress notes and critical lab results will be completed during daily clinical meetings by the DON or assigned Clinical Managers.

This citation pertains to intake 1. Based on observation, interview, and record review, the facility failed to assist a resident (R#907) with hot coffee (per roommate, R#912), who had been assessed to require assistance with hot beverages, resulting in coffee spilling on the resident's lap. R#907 had been assessed to require assistance when handling hot liquids and sustained Second [MEDICAL CONDITION](involves the outer layer of the skin and part of the inner layer of skin) to the inner thigh and abdomen, resulting in an Immediate Jeopardy. Findings include: A second-degree burn is deeper than the top layer of skin (through epidermis to the dermis) and causes a blister to form with pink, painful skin. The blister may break and leak clear fluid, there is risk of infection. Second-[MEDICAL CONDITION] take 1 to 3 weeks to heal and can happen from contact with hot water, coffee, soup, hot surface, or hot grease. The Immediate Jeopardy started on 10/6/20 and was identified on 10/22/20. The Administrator was notified of the Immediate Jeopardy on 10/22/20 at 10:57 AM and was asked for a plan to remove the immediacy. The IJ was removed on 10/6/20, based on the facility's implementation of the removal plan as verified onsite on 10/22/20. Although the IJ was removed, the facility's deficient practice remained isolated with actual harm that is not Immediate Jeopardy. On 10/21/20 at 9:40 AM, during the initial tour, the door to R#907's room was closed. Moaning could be heard in the hallway from the room. Upon opening the door, Wound Care Nurse (WCN)/Licensed Practical Nurse (LPN) A and LPN B indicated they had just finished doing wound care on R#907. When queried regarding any new wounds R#907 had, WCN A stated, Abdomen. When asked what the wound was from, WCN A stated, I would have to look that information up. When asked the classification of the wound, LPN B stated, Burn. The nurses were then asked when the burn occurred and LPN B stated, A few weeks ago, before we got here. When asked the degree of the burn, WCN A stated, Second degree. R#907 was then asked about [MEDICAL CONDITION] the resident stated, They said I got a burn I don't know how I got it. When asked if they were able to feed themselves, R#907 stated, I used to. When asked if they drink and eat independently, R#907 stated, Sometimes. WCN A stated, We just dressed (R#907), (they were) in pain. R#907 was observed to have an uneaten breakfast tray of food at the bedside with a mug of coffee with a lid. R#907 was observed to be lying in bed on their right side with their legs curled up. The resident was asked if [MEDICAL CONDITION] be observed and agreed. WCN A moved R#907's gown to uncover their abdomen. The resident was groaning at this time. A wound dressing was in place on the resident's inner right thigh. Two pink, medium sized areas were observed on the resident's abdomen. The areas indicated a loss of the top layer of skin and revealed a healing second layer of pink skin. The same was observed on the resident's right thigh. R#907 stated, They said I dropped my coffee. R#912 was present in the room behind a drawn curtain and stated, That's not what happened. R#907 was in tears and continued to moan in pain, saying, Oh, oh, when repositioning themselves in bed. WCN A then opened the resident's milk carton and encouraged the resident to eat so, Your wounds can heal properly. WCN A asked R#907 if there were comfortable. R#907 shook their head no, and WCN A and LPN B exited the room. R#907 was left with their breakfast tray which included a mug of coffee. On 10/21/20 at 9:55 AM, R#912 was interviewed. R#912 indicated that they were in the room when R#907 sustained the coffee spill and subsequent burn. R#912 stated, The CNA (Certified Nursing Assistant) came in, gave (R#907) coffee and walked out. Then (R#907) started screaming. R#912 continued and stated, I heard the nurse come in and say 'Are you okay,' and then walked back out. I didn't see the nurse check (R#907) because she walked right back out. R#912 then stated, The burn happened Sunday or Monday, I believe. When asked who the nurse was, R#912 indicated they did not know and stated, It was an agency nurse. Almost positive it happened Sunday (10/3). If it happened Sunday, why didn't anyone say anything until Tuesday? They change and dress (R#907). When they realized this on Tuesday, there was a parade in and out. On 10/21/20 at 10:08 AM, R#907 was interviewed. When queried when the coffee had spilled on them and burned them, R#907 stated, Either Friday or Saturday. When asked if the nurse came in and checked on them, R#907 stated, I don't know. I don't remember the coffee dropping on me. R#907 stated they did not remember any of the staff's names. R#907 was unable to provide further information related to the incident. R#907's medical record was reviewed and revealed the following: 10/6/2020 10:40 (AM) *Skin/Wound Note (Narrative) Note Text: Resident skin assessed blisters to abdomen and right inner thigh. Physician notified of blisters orders transcribed and implemented. All orders transcribed and implemented .Created By: (LPN C). 10/6/2020 18:37 *Health Status Note (nurses note) Note Text: resident presents with blisters and discoloration to .abdominal area and inner thighs. Asked .multiple times how this incident happened. (R#907) repeatedly stated that (they) did not know how it happened. It appears that (they) had spilled something hot on (themselves) (coffee) due to a stained gown (they were) wearing. MGT (management) was made aware and wound care nurse was informed. Doctor was informed. Ordering PT and OT (physical therapy and occupational therapy) to help resolve issues with hand weakness. Awaiting further orders from the physician. Created By: (LPN D). A review of R#907's wound documentation revealed the resident had an, upper quadrant, (abdomen), a right thigh front, and a lower quadrant abd. (abdomen), facility-[MEDICAL CONDITION] on 10/6/20. No progress notes after 9/29/2020 until the notes on 10/6/2020 were noted in R#907's medical record. Under the evaluations section in R#907's medical record, no evaluations were completed after 9/19/2020 until 10/6/2020. A Hot Liquid Evaluation, completed on 6/2/2020 for R#907 was reviewed and revealed the following: A. Cognition: a. Safe decision making ability: 1. Yes B. Physical: a. Chair: Resident can hold cup/bowl safely while sitting in a chair: 2. No b. Bed: Resident can hold cup/bowel safely while in bed: 2. No C. Criteria: 2. If the answer is NO to ANY of the questions above the resident requires ASSISTANCE D. Determination: 1. Initial- INDEPENDENT or ASSISTANCE: 2. Assistance. A pain evaluation on 10/11/2020 for R#907 noted, Pain score out of 10 where 1 is mild pain and 10 is worst pain: (answer:) 10 .Has the discomfort changed in description or intensity in the last 7 days? Yes .If yes, describe: Per Resident 'its worst sometimes and better sometimes' .per resident, burnt area is painful . A review of R#907's care plan history revealed: AROM (active range of motion): Resident has generalized weakness related to decreased physical functioning, poor motivation) and is at risk for decline in ROM (Range of Motion). Revision Date: 9/15/2020. A review of R#907's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was admitted into the facility on [DATE] with medical [DIAGNOSES REDACTED]. Further review revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14/15 indicating an intact cognition. The MDS indicated R#907 required supervision with one person physical assist for eating, and extensive assistance from staff for mobility, transfers, dressing, toileting, and hygiene. A review of R#912's MDS assessment dated [DATE] revealed that the resident was most recently readmitted into the facility on [DATE] with a BIMS score of 15/15 indicating an intact cognition. On 10/21/20 at 11:25 AM, upon entering the 1 south nurses' station area, the Dietary Manager (DM) was present and a cart with a large coffee carafe was observed. The DM was asked to pour a coffee and obtain a temperature. The coffee was poured and visibly steaming. The DM temped the coffee on his thermometer which read 164 degrees Fahrenheit (F). When asked what he would typically like to see the coffee temped at, the DM stated, Normally 155-ish (degrees F). We just brought this down here fresh. On 10/21/20 at 11:53 AM, the DM approached with a cup of coffee and showed their thermometer reading 150 degrees F. The DM stated, That's what we serve at point of service. An observation was not made of the DM pouring this cup of coffee that he approached with. The DM continued and stated, We bring the carafes out before meal trays now and we let it sit. The aides do not pour the coffee until I tell them it's okay to. When asked when this practice was initiated, the DM stated, The 6th (of October). The coffee will not be served until right now. On 10/22/20 at 9:53 AM, LPN C was interviewed via phone regarding their progress note written on 10/6/20 for R#907. LPN C stated, They (aide) had come and got me, they were changing (R#907's) brief. They were saying (R#907) had blisters. When asked if R#907 had on a soiled gown, or if they had observed the resident wet with liquid or coffee, LPN C stated, No. LPN C indicated they did not remember the name of the aide. LPN C continued, I didn't actually see any incident happen. (R#907's) roommate (R#912) told me that it happened over the weekend. When asked if R#907 was supposed to receive assistance when drinking coffee, LPN C stated, During meal times (staff) are supposed to assist the residents. I'm guessing if (R#907) was reaching over to get coffee, no one was there. No one even knew. I found it on Tuesday and was the first person to address it. When asked if she or any other staff knew who the nurse was over the weekend assigned to R#907, LPN C stated, No, no one knows. When I did the investigation, (R#912) said the nurse walked in and walked out when it happened and didn't assess (R#907's) skin and said the resident screamed loud. (R#912 said) the nurse asked if (R#907) was okay, (R#907) said yes and the nurse walked out of the room. They weren't doing treatments to it or anything. LPN C continued and stated, The coffee was very hot, [MEDICAL CONDITION] 2nd degree .I said someone would've had to have seen it, it was old, the skin was bubbled up. My note reflects the time that I assessed it and was made aware. It did not happen the day of the note. (R#912) is alert times three. On 10/22/20 at 10:07 AM, LPN D was interviewed via phone regarding their progress note written on 10/6/20 for R#907. LPN D stated, I want to say that was a Tuesday, I was gone for four days and came back Tuesday. During the shift, a CNA came and said 'Hey, can you come look at this.' I walked into the room and was shown the resident's abdominal area and inner thigh. To me it was obvious (R#907) was burned, the resident loves coffee. Noted the area there was discoloration, some blisters, skin was darkened, 2-3 sizeable blisters on the abdomen and on the inner thigh. These blisters were sizeable. Wasn't like they had just popped up. It took some time for them to come up because of the size. When asked if R#907's gown was wet when they saw the resident, LPN D stated, No, but there was dried up coffee stain on the gown and I knew (R#907) had dropped hot coffee on (themselves) at some point. LPN D continued and stated, I went and got the wound care nurse and unit manager, everyone came to take a look. It was obvious something was going on. The nurse didn't report anything to me, looked at the notes didn't see anything .(I was asked what happened), I told them the CNA called me in and I said to them, 'This didn't happen today.' This happened over the weekend. Skin doesn't darken the very first day of a burn, usually takes a day or two and the blisters come up. I said the midnight nurse didn't say anything and no one said anything to me. They asked if the nurse reported it to me, I said no one said anything about it. I asked (R#907) what happened and (they) told me (they) didn't know. What I think was going on is that with the hot coffee evaluation thing, if you can't have coffee, they won't give it to you. I thought (R#907) was saying (they) didn't know (what happened) because (they) didn't want to lose coffee privileges .What I was upset about was that no CNAs had reported this incident happening. It looked like dried liquid was on the floor and top covers that had dried up. I got (R#907) coffee last time I worked but I told (them) I was going to be with (them) and I put a lid on it. Went in and stood there, told (R#907) to use both hands .hands shook a bit and I had to grab the cup. If I had not been there to catch it (R#907) would've done the exact same thing again .I think what possibly happened was someone put the coffee down on (R#907's) table, but just didn't know that (they) couldn't handle it. Nothing was documented over the weekend. On 10/22/20 at 10:31 AM, the Director of Nursing (DON) was interviewed and queried regarding R#907 and [MEDICAL CONDITION] sustained. The DON stated, Resident reported that (they) spilled coffee on (themselves) by mistake. Investigation ensued from there. We notified the physician that it occurred, spoke to staff, notified by (LPN C). Treated the resident accordingly. Therapy assessed the resident as well for decline in dexterity, and we checked temps of coffee. When asked when the incident occurred, the DON stated, To the best of our knowledge, it had to have occurred on 10/6 some time in the morning. When queried if they knew the resident had been assessed in June 2020 as needing assistance when handling hot liquids, the DON stated, I did not. No other incidents with the resident previously that I'm aware of. When asked what was indicative that the incident occurred on 10/6, the DON stated, We checked clothing and there appeared to be a stain on the gown. When asked if the stain was dry or wet, the DON responded, I don't recall. When asked if she had talked to any staff that had worked over the weekend, the DON stated Yes. When asked who the staff was and what they said, the DON stated, I would have to refer to the investigation. They indicated the resident didn't have evidence of burns. I would have to check. When asked if there were any documented skin assessments from the weekend staff, the DON stated, I would have to check. The DON continued and stated, The roommate (R#912) indicated it happened on 10/6. The resident said (they) made a mistake and spilled coffee. When asked if there was staff in the room with the resident when the spill occurred or if the resident had indicated staff was present, the DON stated, It seems (R#907) was drinking the coffee on (their) own independently. But I can't say there was no one there. On 10/22/20 at 11:03 AM, the Nursing Home Administrator (NHA) was queried regarding the investigation into R#907's burns. The NHA indicated they had just started their position at the time of the incident and, There was a lot to do. No further pertinent information was provided at this time. On 10/22/20 at 12:20 PM, R#907 was observed lying in bed and had not yet received their lunch tray. When interviewed and asked if they had received coffee this morning, R#907 stated, Yes. When asked if someone stayed with them while they were drinking it, the resident stated, No, why would they do that? They just brought me my coffee. On 10/22/20 at 2:45 PM, the NHA and the DM discussed interventions implemented after R#907 sustained their 2nd degree burns. The NHA stated the facility had ordered five cases of handled mugs with lids for coffee. The DM indicated that the facility had been using disposable Styrofoam cups for coffee prior to the incident. A review of the facility's policy/procedure titled, Activities of Daily Living (ADLs), effective 5/7/20, revealed, In accordance with the comprehensive assessment, together with respect for individual resident needs and choices our facility provides care and services for the following activities: .Dining: Eating, including meals and snacks .Our collaborative professional team, together with the resident and/or resident representative: 1. Will recognize and evaluate an inability to perform ADLs or a risk for decline in any ability to perform ADLs; 2. Develop and implement interventions in accordance with the resident's evaluated need, goals for care, preferences, and will address the identified limitation in an ability to perform ADLs . A review of the facility's policy/procedure titled, Serving Hot Beverages and Soup, Revised 10/6/2020, revealed, The Food Services Department will monitor the temperature of all hot liquids being prepared to ensure that hot liquids are served at a temperature that will [MEDICAL CONDITION] they should come into contact with skin. Procedure: .If coffee is above 160 (degrees F), do not serve. Cool the coffee before serving .The Food Services Director is responsible for ensuring that all hot beverages leave the kitchen at the proper temperature .hot beverages will be served to residents in insulated, lidded handled coffee mugs . Immediate Jeopardy Abatement Measures for F-689 The facility failed to assist a resident #907 with hot coffee, who has been assessed as requiring assistance with hot beverages resulting in a 2nd degree burn to the thigh and abdomen Steps Taken to Remove the Immediacy based on PNC efforts initiated post-incident: On 10/6/2020, the following steps were immediately taken to address the identified immediately Skin assessment Care plan revision for resident # 907 to include handled coffee mug and lid and assistance during meals. Therapy Screen Facility wide observations of residents conducted by IDT team to identify residents requiring assistance with hot liquids. New hot liquid screens on these identified individuals. Implementation of a Hot Liquid Protocol for kitchen service. Revision of ADL procedure to require set up support as needed for residents needing assistance with hot liquids. IDT conducted facility-wide observation of residents simulating grasping and sipping from hot-liquids to identify residents who require additional assistance. Hot liquid assessments completed on these residents. Reduction of holding coffee temperatures in the kitchen to 150 degrees and address palatability concerns on an individual basis. Assured hot liquids served with lids immediately for next meal Ordered insulated coffee mugs with lids to be used for facility wide for hot beverage

This citation pertains to Intake number MI 154. Based on observation, interview and record review the facility failed to assess the need for an indwelling urinary catheter from 9/8/20 to 10/12/20, affecting one resident (R904) of two residents reviewed for catheters resulting in prolonged pain and the potential of a preventable Urinary Tract Infection [MEDICAL CONDITION]. Findings include: On 10/21/20 at 8:01 AM, review of R904's confidential complainant's allegation revealed, The resident has been complaining of catheter pain for two weeks and nothing has been done about it. On 10/21/20 at 9:30 AM, R904 was observed and interviewed regarding having had a urinary catheter and stated, It hurt the whole time it was in. I told the nurses and one nurse said 'The hospital put it in, the hospital has to take it out.' It took them forever for them to take it out. R904 was asked about the reason the hospital put the catheter in and stated, I don't know. Review of R904's Electronic Health Record (EHR) revealed R904 was admitted into the facility on [DATE] with diagnoses that included, [MEDICAL CONDITION] Embolism (blood clot in the lung) with Acute Cor Pulmonale (enlargement of the right side of the heart) [MEDICAL CONDITION], and Arthrosclerotic [MEDICAL CONDITION] (hardening of the arteries). The most recent Minimum Data Set (MDS) assessment dated , 09/14/2020 revealed R904 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating and intact cognition and needed extensive assistance with Activities of Daily Living (ADLs). Review of R904's hospital discharge instructions revealed R904 was diagnosed with [REDACTED]. The discharge instructions did not include documentation of an indwelling urinary catheter. Review of R904's admission notes ant the facility revealed, 9/8/2020 19:31 (7:31 PM) *Nursing Evaluation (Admit, Readmit, Qtly (quarterly) Annual, Sig (significant) Change) .Catheter is indwelling . There was no assessment of the quality or quantity of the urine and there was no assessment of pain at the catheter insertion site in this admission progress note. Review of R904's Physician's History and Physical at the facility revealed, History Of Present Illness: This (resident) has a history of [MEDICAL CONDITION](stroke) [MEDICAL CONDITION] .Patient has a Foley (urinary catheter) but denies any difficulty with bowel . Past Medical History: Dementia [MEDICAL CONDITION] right lower extremity weakness History of Multiple [MEDICAL CONDITION] ([MEDICAL CONDITION] or blood clots) CKD ([MEDICAL CONDITION]) CAD ([MEDICAL CONDITION]) Heart Failure No [DIAGNOSES REDACTED]. Further review of R904's progress notes revealed, 10/12/2020 18:09 (6:09 PM) *Health Status Note (nurses note) Note Text: Res (resident) alert and responsive c/o (complains of) pain at the site of Foley insertion. Writer assessed noted cloudy urine and scant blood at the site. NP (Nurse Practitioner) notified ordered to change Foley and send urine to lab. Foley 16 Fr (size) inserted no blood noted , no pain upon insertion. Flowing light yellow urine with some sedimentation. The catheter was discontinued on 10/14/2020. Review of R904's care plan, Focus The resident has an indwelling catheter. Intervention Monitor/record/report to MD for s/sx (signs and symptoms) UTI: pain, burning . No progress notes or assessments addressing this intervention were observed until 10/12/2020. On 10/22/20 at 3:06 PM, The Director of Nursing (DON) was interviewed regarding the facility's policy and procedure for urinary catheters and stated, There would need to be an assessment of the pain and discussion on the need for the catheter. Review of the facility's policy and procedure titled, Urinary Indwelling Catheter Management Guideline dated as Effective 11.28.2017 revealed, Appropriate referrals will be made to urology specialists as directed by the physician during consultation. Medically justified indwelling catheters will require a physician [DIAGNOSES REDACTED].

This citation has two Deficient Practice Statements (DPS). DPS#1 This citation pertains to Intake number MI 910. Based on observation, interview, and record review, the facility failed to ensure appropriate infection control practices per Centers for Disease Control (CDC) guidance. The facility housed two COVID-19 positive residents in the same unit as PUI (persons under investigation who are being isolated for 14 days) residents, and residents that are COVID-19 negative. The PUI residents and COVID-19 negative residents entered in and out of one another's rooms without re-direction and/or masks. Staff failed to differentiate positive COVID-19 residents with PUI residents, initiate door closure of droplet precaution rooms, wear proper Protection Equipment (PPE) in COVID-19 positive rooms, PUI rooms and in the hallways. Staff did not properly dispose of Personal Protection Equipment (PPE), and perform hand hygiene after exiting a COVID-19 positive room. The facility did not utilize separate nursing care staff and housekeeping staff for COVID-19 positive residents, PUI residents, and non-isolation rooms. The PUI unit (2 Center) is placed in a high traffic area with access to both elevators. COVID-19 negative residents have open access to the unit and are allowed to travel through the unit and have been observed without masks. This deficient practice resulted in the likelihood of residents and staff contracting COVID-19, decline in overall health, serious illness, and/or death. The Immediate Jeopardy (IJ) started on 10/8/2020 and was identified on 10/8/2020. The Nursing Home Administrator (NHA) was notified of the Immediate Jeopardy on 10/8/20 at 4:45 PM and was asked for a plan to remove the immediacy. The IJ was removed on 10/9/2020, based on the facility's implementation of the removal plan as verified onsite on 10/9/2020. Although the immediacy was removed, the facility's deficient practice remained widespread. No actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: On 10/8/20 at 9:10AM, during an initial tour of the One-South unit, Unsampled Resident D's room door was noted with signage of Droplet Precaution with a PPE storage-rack on the door. No other room on the One-South unit was observed as Droplet Precaution. On 10/8/20 at 9:25AM, the Director of Nursing (DON) and two unidentified Certified Nurse Assistants (CNA) were observed at Unsampled Resident D's room door actively removing the precaution signage and PPE storage-rack. On 10/8/20 at 9:55AM, the DON was queried about the removal of the signage and PPE storage-rack from Unsampled Resident D's door. The DON stated, It was a mistake. I told them to remove it but realized the resident was on Droplet Precaution. On 10/8/20 at 10:05AM, an observation of the PUI unit was made which is located on the second floor immediately in front of both elevators. The Two-Center unit is open and easily accessible to residents on Two-South (non-quarantine, COVID-19 negative residents). Several residents from Two-South were observed walking through the Two-Center PUI Unit unsupervised and with masks not properly placed on their face. Unsampled Resident E was observed in a wheelchair entering the PUI Unit from Unit Two-South without a mask toward the elevator. Unsampled Resident E entered the elevator without being stopped or redirected by staff. On 10/8/20 at 10:10AM, Nurse F was observed on the Two-Center PUI unit wearing a face shield without a face mask. Nurse F was asked why they were not wearing a mask. Nurse F said, I'm sorry, I had to grab a document off the unit. On 10/8/2020 at 10:15AM, after interviewing a PUI resident in their room, there was nowhere to doff PPE, as there were no disposal bins or trash cans available in the room. Nurse N was asked where staff doff their PPE and stated, You have to go into the bathroom. The bathroom was observed in the middle of the room between the two PUI residents. On 10/8/20 at 10:40AM, during the tour of the One-North Unit, it was observed that the unit consisted of COVID-19 negative residents, PUI residents and COVID-19 positive residents. There was no signage distinguishing the residents. Several residents that were identified to be on Droplet Precaution were observed sitting in the hallway without wearing a mask or wearing it underneath their nose. Additionally, residents' doors were observed opened. Multiple PUI residents were observed exiting the unit without redirection from staff, and COVID-19 negative residents were observed entering the rooms of PUI residents. R510 (Covid-19 positive) was observed with their room door open sitting in a wheelchair. R510 was observed from the hallway with a moist cough. During this observation, other residents were seen sitting in the hallway close to R510's room as they coughed and blew their nose. One-North Unit Secretary G was observed entering the room of R511 (COVID-19 positive) without full PPE. Unit Secretary G was only wearing a surgical/procedural facemask and nothing else. Unit Secretary G was queried about the policy for entering the rooms of residents on Droplet Precaution. Unit Secretary G said, (R511) is only on precaution. (R511) is not Covid positive. We don't have to wear all the PPE for these residents. Also, Unit Secretary G did not perform hand hygiene after exiting R511's room. On 10/8/20 at 10:50AM, R512 was observed exiting their room without a facemask and leaving the One-North Unit. There were several staff in the hallway as R512 propelled down the hallway with loud vulgar music playing on their cellular phone. R512 is also on Droplet Precaution/Isolation due to being a new admission to the facility. R512 was not redirected by staff. Throughout the facility tour, staff were observed without wearing proper eye protection or correctly wearing masks. Residents were observed on the first floor near the Administrator's office, dining room, and on elevators without any type of PPE face covering. Residents that had access to a mask either wore it under their nose or under their chin. Residents were also observed not utilizing proper social distancing or performing hand hygiene. In addition, staff were not observed redirecting residents to follow COVID-19 precautions. R510 A review of R510's medical record noted that they were admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. R510's care plan noted: Interventions: Isolation measures will be implemented in accordance with the CDC requirements . Keep curtain drawn and door to room closed as able . Minimize prolonged periods of time in resident room . Per physician order: Droplet Isolation .10/6/20 every shift for 14 days. R511 A review of R511's medical record noted that they were admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. R511's care plan noted: Interventions: Isolation measures will be implemented in accordance with the CDC requirements . Keep curtain drawn and door to room closed as able . Minimize prolonged periods of time in resident room . R512 A review of 512's medical record noted that they were admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Per physician order: Droplet Precautions related to new admission .10/6/20 every shift for 14 days. Care plan intervention noted the following: Verify that proper isolation notifications are in place and appropriate protective equipment inside and outside room and follow facility policy for Droplet Precautions. On 10/8/20 at 12:14 PM, Housekeeper N was interviewed and queried regarding their cleaning assignment and if they are instructed to clean the Droplet Precaution rooms differently from rooms of residents without precautions. Housekeeper N said, I clean all the rooms on One-North. I do not do anything different. On 10/8/20 at 12:15PM, R514 was observed exiting from the door that led to the 2nd floor onto the One-North unit with their face mask underneath their chin. Throughout the survey, R514 was observed wandering throughout the facility between the first and second floors while failing to utilize social distancing. On 10/8/20 at 12:17PM, Nurse O was asked about the PUI residents on the One-North unit sitting in the hallway and intermingling with COVID negative residents, and stated, They can come out of their rooms. Nurse O was asked what their assignment was for the day, and identified COVID-19 negative resident rooms, PUI resident rooms and COVID-19 positive resident rooms. On 10/8/20 at 4:39PM, the following observations were made: -R510's room door was observed as open. -An unidentified CNA was observed going from isolation room to isolation room without full PPE delivering water. Hand hygiene was not utilized upon exiting each room. Upon entering into the COVID-19 positive rooms, they entered and exited the room into the hallway with the same gown and gloves on. On 10/9/20 at 1:10PM, Housekeeper M was observed exiting a Droplet Precaution room on unit Two-Center while wearing only a surgical/procedural mask. Housekeeper M was queried if they had received training on the proper PPE in Droplet Precaution rooms. Housekeeper M states, Oh yes, it's underneath my stuff on my cart. It's hard to breath in that N95. On 10/9/20 at 1:20PM, One-North Unit residents congregated in the hallway and exited the unit. An interview was conducted with the One-North Nurse Manager H regarding residents on Droplet Precaution gathering in the hallway and exiting the unit. Nurse Manager H stated, If they have on a mask, it's ok for them to be in the hallway and leave the unit. They are only on Droplet Precautions, they are not COVID positive. On 10/9/20 at 1:35PM, an interview was conducted with the DON regarding residents on Droplet Precaution, gathering in the hallway and exiting the unit. The DON stated, The residents are only on precaution and are not COVID positive. It's ok to leave their rooms. On 10/9/20 at 1:48PM, an interview was conducted with the NHA regarding residents on Droplet Precautions leaving their rooms and exiting the unit. The NHA stated, We cannot force this community of residents to stay in their rooms .they also have rights .All we can do is continue to redirect .But we cannot hold them in their rooms because this is not a jail. On 10/9/20 at 4:48PM, the NHA was asked about the infection control concerns within the facility and stated, We've got to communicate and make it easier for everyone .The infection control preventionist has to get more involved, and get out there and talk to the people. What we are taking away from this, is we have to engage the staff about what the expectation is because we know what we're supposed to do. A review of the facility's COVID-19 policy noted the following: It is the practice of this facility to minimize exposures to respiratory pathogens and promptly identify residents with Clinical Features and an Epidemiologic Risk for the COVID-19 and to adhere to Federal and State/Local recommendations .During the Coronavirus Disease 2019 (COVID -19) Pandemic-For the duration of the state emergency all Long-Term Care facility personnel should wear a facemask and eye protection while they are in the facility .Full PPE should be worn per CDC guidelines for the care of any resident with known or suspected COVID-19 per CDC Guidance on conservation of PPE .Residents will be placed in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19 .All recommended COVID-19 PPE should be worn during care of residents under observation which includes use of an N95 or higher-level respirator, eye protection (goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown .Residents will be reminded to practice social distancing and perform frequent hand hygiene .Only essential staff to enter rooms/wings .Implement consistent assignment of employees .Post signs on the door or wall outside of the resident room to clearly describe the type of precaution needed and required PPE .Position a waste receptacle near the exit inside any resident room to make it easy for employees to discard PPE .Hand hygiene using Alcohol Based Hand Sanitizer before and after all patient contact, contact with infectious material, and before and after removal of PPE, including gloves. Immediate Jeopardy Abatement Measures for F-880 Steps Taken to Remove The Immediacy Staff currently in the building have been re-educated on the CDC guidelines for nursing homes and transmission-based precautions. Residents have been issued masks and extras are stored at the nurse's station to be distributed as needed. Special Resident Council Meeting Held 10/9/2020 to educate residents on use of masks, and Covid-19 safety. Assignment sheet binders have been updated with easily identified rosters indicating location and indication for PUI status. Precaution signs on doors have been color coded to quickly demonstrate the status of resident. Red for positive Covid-19 status and Yellow for a person under investigation. The identified cluster of rooms dedicated to residents positive for Covid-19 have been clearly delineated through visible floor mapping and signage. Rooms identified with residents positive for Covid-19 and persons under investigation have been checked and verified to have a designated/PPE trash can for disposable of PPE. Isolation carts have been checked and verified to be stocked with appropriate PPE. Additional dispensers for alcohol based hand rub has been installed on each unit to facilitate ease of hand hygiene.19 additional dispenser have been installed. Dedicated staff (nursing & housekeeping staff) have been assigned for Covid positive residents and PUI unit per CDC guidance. 2 Center will be discontinued as a PUI Unit in 4 days when the latest resident graduates from the unit and can be moved to the 1st floor PUI area. In the meantime, assigned staff will be assigned each shift to have the responsibility to redirect, monitor and assure masks are worn by residents in this area and assure the doors to PUI rooms are closed as required. DPS#2 Based on observation, interview, and record review the facility failed to maintain contact isolation precautions for [MEDICAL CONDITION] (Infection of the large intestine caused by the bacteria [MEDICAL CONDITION].) for one resident (R516) of 17 residents reviewed for infection control practices with the likelihood of the preventable spread of infections. Findings include: On 10/08/20 at 9:09 AM, R516 is observed sitting in a wheelchair in the open doorway and on the door is an Personal Protective Equipment (PPE) caddy. R516 was asked about the isolation caddy on the door and stated, I'm doing quite well. I'm in isolation because of having an intestinal [MEDICAL CONDITION] infection and will be in isolation for two weeks. I've been in here for a week now. There is a sign on the door partially obstructed by the PPE caddy that says, STOP CONTACT ISOLATIONS Everyone Must: clean their hands, before entering and leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit. Put on a gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. Record review of R516's EHR revealed that R516 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment dated [DATE] revealed R516 had a Brief interview for Mental Status (BIMS) score of 15 out of 15 indicating an intact cognition and needed extensive assistance with Activities of Daily Living (ADLs). On 10/09/20 at 7:21 AM, R516 is observed up in a wheelchair in the doorway of the room. R516 was interviewed regarding the following of contact isolation provided by the staff and stated, I don't have a blood pressure cuff or thermometer in my room. The staff bring them in when they need to and take them away when they're done. I don't know, but I guess they clean them. R516 was asked if the staff maintain the door closed and stated, Only at night. R516 was asked about the staff using PPE and stated, They all wear masks and gloves and I would say that 90% wear gowns. On 10/09/20 at 7:51 AM, Certified Nurses Aide (CNA R) was observed serving coffee and condiments in the hallway. CNA R then poured a cup of coffee and entered R516's room without hand sanitization, donning gown or gloves and leaving the room and proceeded to serve coffee in the next room. CNA R was asked about entering the isolation room and stated, I only placed the cup of coffee on (R516's) table and the table was near the door. On 10/09/20 at 8:09 AM, the Director of Nursing asked about the facility's policy and procedure regarding contact isolation and stated, I'll have to check the policy. Review of the facility's policy and procedure titled, Guidelines for Standard and Transmission-based Precautions dated,Effective Date: 10.2.19 revealed under Contact Precautions, Gloves .Don gloves when entering the room. The policy and procedure did not address wether the door should be closed.

This citation pertains to intakes # 3 and # 9. Based on interview and record review, the facility failed to prevent verbal and physical abuse for two sampled residents (R500 and R513) of six residents reviewed for abuse, resulting in the likelihood of the resident experiencing mental anguish, fear, and shame. Findings include Resident #513 A review of intake MI 039 revealed the following, Resident stated that the staff was in the hallway outside (R513's) door with the music loud and asked (Housekeeper I) if she could turn it down twice and when she didn't (R513) closed the door. The resident stated, the housekeeping employee came into (their) room and grabbed (their) arm and stated, 'I'm not one of these (Bitc***) around here that you can mess with, you betta watch yourself!' Staff was immediately suspended. Police was contacted to do a police report. Investigation Summary: Upon completion of investigation the facility has substantiated physical and verbal abuse. The staff was terminated. The resident stated that they felt safe and declined to press charges on staff. A review of R513's medical record revealed that they were admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. R513's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had a Brief Interview for Mental Status score of 15/15 indicating an intact cognition and required supervision for some Activities of Daily Living. On 10/8/2020 at 3:23PM, an attempted phone call was made to R513 as they have since been discharged to no avail however, their statement dated 9/26/2020 regarding the incident was reviewed and revealed the following: I was in my room and (the) housekeeper was outside my room with her music very loud. I was trying to make a call to (the) front desk to get (the) supervisor about my medications .So I asked twice for her to turn (the) music down and went to shut my door and due to (the) window (being) open, she could have thought I slammed (it). So I was by the end of bed #3 and she grabbed my right arm by (my) shoulder and turned my body around and said, '(Bit**) I'm not like the ([***] **) here so you don't know who you're (Fuc****) with, I'll snap your (Fuc****) neck.' She threatened and then turned and said 'Watch yourself (Bit**)' then went out, then in about 2 mins (minutes) the pregnant CNA (Certified Nursing Assistant) from (the) other end came in my room saying don't call the police, and I said she just had no right to come at me, and she left I called the front desk for (a) supervisor . On 10/8/2020 at 3:30PM, Housekeeping Manager J was interviewed about the incident and explained that the incident took place over a weekend. They reported that they received a phone call from the Administrator and was informed of what occurred. Housekeeping Manager J stated that they contacted Housekeeper I and told them to clock out and go home. They further stated that along with the Administrator, they interviewed R513 who reported that Housekeeper I had their music up loud, and was asked to turn it down, which then led to Housekeeper I threatening R513. They further stated that the incident was referred to their bosses and corporate HR (human resources). Housekeeper I' was suspended and then terminated. On 10/9/2020 at 2:30PM, an interview was conducted with the Director of Nursing (DON) about the incident between R513 and Housekeeper I. The DON explained, It was 9/26/2020 and it was early in the afternoon. (R513) reported to staff that a housekeeper was playing music loudly while she was cleaning, and (R513) asked her two times to turn it down. (Housekeeper I) went in the room and closed the door. Housekeeper I grabbed (R513) by their arm to get their attention and (R513) reported it to staff. The housekeeper was asked to leave and (R513) gave a statement. The employee was terminated, and it was reported. The resident was followed by social work. (R513) told police and staff that they felt safe and was satisfied that (Housekeeper I) was no longer in the facility. The DON confirmed that education regarding abuse was provided to nursing staff and the IDT (Interdisciplinary Team). The education and sign-in sheets were observed and completed on 9/29/2020. On 10/9/2020 at 3:39PM, Receptionist K was contacted via phone and asked what was told to them on the date of the incident. Receptionist K stated, (R513) called and said that a housekeeper was outside their door, and (R513) was upset and scared and was asking if I could send someone to help. I was trying to get the description of what housekeeper it was. (R513) said one of the housekeepers came to the door with loud music and (R513) asked her if she could turn it down. The window was open, and the door slammed. The housekeeper came back and told (R513) that she would 'Snap (R513's) neck off.' Receptionist K was asked if R513 stated that Housekeeper I touched them, and stated, (R513) never said that they touched them, just that (R513) was a little afraid. On 10/9/2020 at 4:56PM, a phone call was made to Housekeeper I about the incident, and they stated, I went to (R513's) door and they slammed the door in my face real hard. I went in and I asked, 'What's wrong with you?' and (R513) said, 'You have your radio too loud. I told (R513) 'You could have asked me to turn it down, and they closed it (the door) again. I went back in and (R513) said to me, 'You don't do (Sh**) anyway, yall don't do (Sh** Nigg***).' CNA L came and escorted me out, and I went to the next room. Before I was able to tell on (R513) to the supervisor, the supervisor called me. I wrote a statement, that I never cussed (R513) out, or put my hand on them. I was then fired on that date, 9/26/2020. On 10/9/2020 at 5:06PM, an interview was completed with CNA L about the incident. They reported the following, I was in the dining room and I heard some back and forth. I thought it was a resident. I heard a door slam and heard the housekeeper say, 'I was just trying to clean your room.' I went into the resident's room and (R513) was going off on the housekeeper. CNA L indicated that they did not see or hear anything else. On 10/9/2020 at 4:48PM, an interview was completed with the Nursing Home Administrator (NHA) regarding abuse within the facility, and they stated, We have zero tolerance, we are the professional. We should have a higher threshold for residents with behaviors. I expect even when confronted with disagreeable residents, we do not engage residents inappropriately. If we feel we are experiencing frustration, we take a moment, step away and do not personalize it. A review of the facility policy titled Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident Property Effective Date: 9.11.2020 stated the following, An .employee .of a nursing home shall not .mentally or emotionally abuse .a resident. i. Verbal Abuse is defined as the use of oral .language that willfully includes disparaging and derogatory terms to residents . It is the policy of the facility that each resident will be free of Abuse. Abuse can include verbal, mental, sexual, or physical abuse, corporal punishment, and involuntary seclusion .Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm will be tolerated, and residents and staff will be monitored for protection. On 9/8/20 at 10:30 AM, an incident report dated 1/14/20 at 11:30 AM, indicated the following: Resident alleged that midnight Certified Nursing Assistant (CNA) A made comments construed as verbal abuse. The date of this incident was indicated to be 1/11/20. On 9/8/20 at 11:00 AM, R500 was attempted to be contacted by phone regarding the incident involving them and CNA A, resident's phone was disconnected. On 9/8/20 at 11:30 AM, a written document was reviewed which indicated that R500 alleged that on 1/11/20, CNA A was Rude, refused to make their bed, and made rude comments to them. On 9/8/20 at 11:52 AM, CNA A was attempted to be contacted by phone regarding the incident involving them and R500, CNA A's phone was disconnected. On 9/8/20 at 12:07 PM, a written document was reviewed which indicated that CNA A admitted to being frustrated with R500 and indicating to the resident that her young children do not argue with her as much as R500 does and that her children do not Pee this much in the bed. CNA A admitted to knowing that their comments were inappropriate and verbally abusive towards the resident. Further review of this documentation revealed that per the facility abuse policy, CNA A was terminated due to her actions towards R500. On 9/8/20 at 12:52 PM, Nurse B was attempted to be contacted by phone regarding the incident involving CNA A and R500. Nurse B did not answer their phone and a voice mail message was left for them. On 9/8/20 at 2:30 PM, Social Worker (SW) C was queried about the incident which occurred between R500 and CNA A. SW C stated, I do not remember anything. On 9/8/20 at 2:38 PM, the Director of Nursing (DON) was queried about their expectations for staff when interacting with residents and providing services. The DON stated, I expect staff to introduce themselves, use a level of professionalism and customer service, be respectful, and explain to the resident what care they are there to provide for them. On 9/8/20 at 3:00 PM, a review of R500's Electronic Health Record (EHR) revealed that R500 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. R500 was discharged from the facility on 10/1/20. R500's most recent Minimum Data Set Assessment ((MDS) dated [DATE] indicated that R500 had an intact cognition.

Pertaining to Intake 7 Based on observation, interview, and record review, the facility failed to implement interventions to prevent a stage two facility acquired pressure ulcer wounds (a wound that occurs as a result of direct pressure to the skin), and lack of comprehensive skin assessments for R509, resulting in the development of new pressure ulcers, the potential for delayed healing, and decline in overall health status. Findings include: On 10/8/20 at 10:13 AM, R509 was observed in bed on their back. Resident was unable to answer simple questions. The room was observed to be in disarray. R509's roommate indicated that they are always yelling out. R509 noted to be on Droplet Precaution due to readmission from the hospital. On 10/8/20 at 11:30 AM, a review of R509's medical record noted readmission to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] noted R509 required extensive to total, two persons physical assistance with all Activities of Daily Living (ADL). A review of R509's care plan noted the following: The resident is two person assist . Anticipate and meet needs . Monitor the extremities (limbs of the body) for s/sx (signs and symptoms) of injury, infection or ulcers . Monitor/document/report PRN (as needed) any s/sx of skin problems . Apply barrier cream per facility protocol to help protect skin from excess moisture. A review of R509's Skin Observation dated 9/11/20 noted the following: Reddened to Sacrum. A review of R509's Skin Observation dated 9/15/20 noted the following: Reddened area Right trochanter (hip). A review of R509's SNF to ED Handoff Form (Skilled Nursing Facility resident information for individuals being transferred to the Emergency Department) dated 9/19/20 noted the following: 9. Wounds: Are left blank by the facility. R509 was transferred to the hospital on [DATE] with the primary [DIAGNOSES REDACTED]. A review of R509's hospital admission note dated 9/19/20 noted R509 was evaluated by the wound care RN specialist: Wound care consulted for local wounds .Incontinence, debility/immobility, poor dietary intake .Injury sites are inflamed with visible moisture. Noted pigment changes to area with probable chronic moisture history .Stage 2 pressure injury to the left ischium .Wound bed pink. R509 returned to the facility on [DATE]. A review of the Nursing Evaluation dated 9/24/20 noted the following regarding wounds: Does the resident have skin integrity concerns? Answer 2. No . Left arm has discoloration to forearm. A review of R509's progress note dated 9/28/20 by Nurse O noted the following: New admit assessed area to right lateral buttocks with pale pinkish color to area. Discoloration to bil (bilateral) buttocks no open areas heels intact treatment initiated. A review of R509's order dated 9/24/20 by Physician P noted the following: Skin checks weekly every day shift every Mon (Mondays). A review of R509's Skin Observation Evaluations noted the last Skin Observation document was dated 9/15/20. As of 10/9/20, no additional Skin Observations noted since 9/15/20. On 10/9/20 at 3:00 PM, R509's coccyx wound was observed with Wound Care Nurse Q. Two opened, stage two wounds on the right side of R509's buttocks and coccyx area was observed. Wound Care Nurse Q did not measure the wounds during the observation. The wounds appeared to be about 2-3 centimeters in length and width. On 10/9/20 at 4:19pm, the DON was interviewed and asked their expectation of staff wound assessments and wound care for R509. The DON said, The expectation is that the nurses follow wound care orders. On 10/9/20 at 4:46pm, the Administrator was interviewed and asked their expectation of staff wound assessments and wound care for R509 and the Administrator stated, I will look to see if we missed anything. The facility's policy Wound Care was reviewed, however, the policy did not discuss assessing for wounds and notification of physician of wound changes.

This citation pertains to intake # 3. Based on interview and record review, the facility failed to safely navigate a food cart, affecting one sampled resident (#701) of four residents reviewed for falls, resulting in the resident being hit with the food cart, sustaining a fall with fracture, and subsequent hospitalization , surgical repair, and pain. Findings include: On 8/26/2020 at 6:15 PM, an interview was completed via telephone with Confidential Witness D. Confidential Witness D expressed concerns over Resident #701's falls within the facility, especially on 12/23/2019. Confidential Witness D stated, (Resident #701) fell seven times there (at the facility). (Resident #701) is not there anymore. The last time was in December. (Resident #701) was hit by a food cart by a Nurse Aide. They were not even going to do a XRay, I had to fight for that. They wanted us to wait for the XRay results before they sent (Resident #701) to the hospital. I demanded they send (Resident #701) to the hospital because they were in excruciating pain. I found out they were hit by a food cart by a witness who worked there. She told me. They originally told me they didn't know. (Resident #701) can't tell me what happened because of Dementia. Since all this has happened, the Dementia has gotten worse. The witness no longer works there. Right now, (Resident #701) is in a wheel chair. They can no longer walk, they were up and walking before all this. A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #701 was most recently admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #701 was severely impaired cognitively and needed limited assistance with walking. A record review of the fall care plan created 11/22/2019 for Resident #701 revealed the following: Focus-The resident is risk for falls r/t (related to) dementia Goal-The resident will not sustain serious injury . Interventions-Ensure footwear fits properly Ensure resident has glasses on Provide opportunity for physical activity (such as ambulation, self propel w/c (wheelchair), chair exercises Anticipate and meet the resident's needs Keep hallway clear of stationary chairs as much as possible . Keep left femur stabilized . A record review of the progress notes for Resident #701 revealed the following: 12/23/2019 14:40 (2:40 PM) .(nurses note) . Resident transported to the hospital with 2 EMS (Emergency Medical Services) tech via stretcher/neck collar applied by techs, tolerated transportation well. x-ray results sent with residents history and (Doctor) informed of x-ray results; results Acute Right Fracture as described. family aware and all necessary disciplines notified. Group huddles held with am/pm UAPs (certified educated nursing assistants or CENA/staff), educated on safe transportation with food cart transportation. 12/23/2019 09:36 (9:36 AM) (nurses note) .While passing Meds writer heard a loud sound looked down the hall and observed resident on their right side crying complaining of pain behind the food cart assigned Cena was pushing. A record review of the XRay report for Resident #701 dated 12/23/2019 revealed the following: Acute right [MEDICAL CONDITION] On 8/27/2020 at 1:00 PM, the CENA E that hit Resident #701 with the food cart was attempted to be interviewed via telephone, but did not recall the incident. On 8/27/2020 at 1:05 PM, another CENA F that witnessed the incident on 12/23/2019 was attempted to be interviewed via phone but did not return the phone call by the end of the survey. On 8/27/2020 at 1:10 PM, an interview was attempted to be completed with the Nurse Gon duty during the incident, however the Nurse did not return the phone call by the end of the survey. On 8/27/2020 at 1:26 PM, an interview was attempted with the Director of Nursing (DON) in regard to the 12/23/2019 incident involving Resident #701. The DON explained that she was not employed at the facility during that time frame. On 8/27/2020 at 1:44 PM, an interview was completed with the Nursing Home Administrator (NHA) in regard to the fall of Resident #701 on 12/23/2019. The NHA explained that the previous DON handled it. The NHA at that time submitted an investigation report involving the incident. A record review of the investigation report revealed the following: On 12/23/2019 during breakfast time a CNA (CENA) was pushing the tall food cart from the front of the hallway towards the back of the hallway. Due to height of the food cart the CNA was looking from side to side to steer. The CNA was unable to see (Resident #701), and (Resident #701) was bumped by the food cart resulting in (Resident #701) falling to the floor .pain to their right hip .discussed incident and decided that the intervention to prevent this from occurring again would be to not use the tall carts on 2 north sa (sic) the patient population is highly mobile with poor safety awareness .staff is being educated that 2 people must be involved in transport of the cart . Camera Timeline: 9:23 am- .The CNA pushing the cart looked left around food cart and observes a resident ambulating towards her with a walker. The CNA veers cart to the right to avoid hitting (unidentified resident). This moved the cart directly into (Resident #701) path who could not be seen from the angle. Next you see (Resident #701) fall to the floors from behind the Food cart. The CNA stopped the cart and came around the cart and staff began to rush towards the fallen resident. A review of the facility policy titled, Fall Evaluation Safety Guideline dated 11/28/2017 revealed the following: Residents who are evaluated as being a risk for falls will be identified and individualized fall precautions will be developed for each resident. Preventative measures shall be taken to decrease the number of falls whenever possible. General Preventative Strategies-Thoroughly orient to surroundings, daily routines, and staff .Provide safe, clutter free environment. Falls related to environmental hazards-Eliminate hazards that contributed to the fall .

Based on observation, interview, and record review, the facility failed to follow a physician's order and provide lab work for one sampled resident (R39) of one resident reviewed for laboratory services, resulting in delayed treatment, worsening in condition, the lack of coordinated care, and hospitalization . Findings include: On 03/03/20 at 9:46 AM, R39 was observed in their room asleep. A Peripherally Inserted Central Catheter line (PICC, used for long-term intravenous/IV medication treatment) was observed in their right upper arm. R39 was asked why they were receiving IV treatment. R39 said, I have a brain fungus. A review of R39's medical record revealed that the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. R39's medical record also revealed that the resident had a history of [REDACTED]. Further review noted that the resident required extensive assistance with activities of daily living. Additional review of R39's medical record revealed that R39 was receiving [MEDICATION NAME] B IV (used for life-threatening fungal infections. A side effect of [MEDICATION NAME] B is low potassium). A review of the medical record noted that R39 had a potassium level of 3.3 (normal level 3.5-5.0). Nurse Practitioner J ordered a Repeat potassium draw on 2/7/20. The order was implemented into the electronic medical record on 2/3/20. Upon further record review, the potassium lab result dated 2/7/2020 was not found in the electronic medical record. Further review of R39's medical record revealed, a lab result dated, 2/17/20 at 11:13 (10 days after the2/7/20 potassium order) noted the following: Potassium 2.2 .ordered to give Kdur 40 meq (potassium replacement supplement). R39's vital signs were as follows: Blood pressure 124/64, heart rate 46 (normal range for adults is 60 to 100 beats per minute; Imbalance of chemicals in the blood, such as potassium can result in a low heart rate and/or cardic arrhythmia). R39 was sent to the hospital for monitoring. R39 was admitted to the hospital on [DATE], with a [DIAGNOSES REDACTED]. On admission to the hospital, R39's potassium level was found to be 2, with a heart rate of 51. R39 was discharged from the hospital on [DATE] and readmitted to the facility. On 3/5/20 at 8:23 AM, the Director of Nursing (DON) was interviewed and queried about the Physician's order for R39's potassium to be drawn on 2/7/20. The DON stated, The lab was not drawn on 2/7/20. On 3/5/20 at 12:18 PM, a request for the facilities policy for Physician's Orders was made. The requested policy was not received from the DON prior to leaving the facility.

This Citation Pertains to Intake MI 139. Based on interview and record review, the facility failed to ensure ongoing assessment and coordination of care following a fall in the facility for one (#701) of three Residents reviewed for falls, resulting in ongoing pain, lack of ongoing care coordination, assessment, timely diagnosis, and treatment for [REDACTED]. Findings include: An interview was conducted with Confidential Witness A on 10/17/19 at 4:30 PM. When queried regarding Resident #701, Confidential Witness A revealed the Resident was no longer at the facility and stated, (Resident #701) went to the hospital on [DATE]. The facility called me on that day and told me (Resident #701's) femur was broken and that (the Resident) had been refusing to eat and was losing weight so they were going to send them to the hospital. Confidential Witness A further indicated they were the Resident's Power of Attorney and Emergency Contact. When asked if Resident #701 was able to make their own medical decisions, Confidential Witness A replied, No, they get really confused. When asked how the femur fracture occurred, Confidential Witness A stated, They (facility) said (Resident #701) feel in (MONTH) but didn't hurt themselves. Then all of a sudden, they have a really bad fracture. It doesn't make sense. How could there be nothing wrong and then it be broken? With further inquiry regarding the injury, Confidential Witness A stated, (Resident #701) was having a lot of pain after they fell . They always had pain but it got worse and then they stopped eating because of the pain but nobody even thought of that. (Resident #701) always had a very high tolerance for pain. Confidential Witness A then stated, When I went to see (Resident #701) in the hospital, I couldn't believe how much pain they were having. It was awful. I asked they what happened and all (the Resident) could tell me was they fell . (Resident #701) doesn't have the best memory. Record review on 10/22/19 revealed Resident #701 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required set-up assistance with eating and extensive assistance with other Activities of Daily Living (ADLs). Review further revealed the Resident was transferred to the hospital on [DATE]. Review of Resident #701's care plans revealed a care plan entitled, (Resident #701) has had an actual fall with no injury (Initiated 8/14/19). The care plan included the following four interventions: -Anticipate and meet the Resident need (Initiated: 9/3/19) -Ensure the Resident's call light is within reach and encourage the Resident to use it as needed. The Resident needs prompt response to all requests for assistance (Initiated: 8/14/19) -Educate and encourage Resident to use call light (Initiated: 9/9/19) -Monitor for UTI (Urinary Tract Infection) d/t due to infection (Initiated: 8/14/19) Review of Resident #701's electronic Medical Record (EMR) documentation revealed the following: -8/14/19: Fall Risk Evaluation Resident is at a HIGH risk for falls . Has Confusion . -9/9/19 at 10:04 AM: IDT (Interdisciplinary Team Note) . Team reviewed residents fall resident . Resident educated and encouraged to use call light -9/9/19 at 11:37 AM: Fall Note . Pt (patient) was observed sitting on the floor by the side of bed. Writer assessed pt. No injury. Pt was assisted back to bed by staff. Pt stated that they were trying to get in the w/c (wheelchair) to brush teeth . -9/9/19: Fall Risk Evaluation . Resident is at a HIGH risk for falls . Has no orthopedic factors . Has Confusion . -9/9/19: Health Status Note . Writer ordered a R (right_tibia/fibula X-ray 2 views for pain post fall . -9/10/19: Health Status Note . X-Ray result received result show negative readings . -9/12/19: Social Service . Therapy reported to the social work that resident stated that they wanted to kill them self. This writer assessed this resident and the resident stated that they wanted to die because of severe pain in legs and hip and mouth discomfort due to greasy food . This writer notified nursing. This writer put resident in the book for psyche . -9/27/19: Nurse to Physician/NP/PA Notification . Resident continue to complain of right leg being painful when touched and or moved . History of fall, House X-Ray done and as read no fx (fracture) . Resident need follow up with Ortho (Orthopedic) Doctor and Pain Management need to be reassess due to Tylenol nor [MEDICATION NAME] (medication to treat muscle spasms) is not effective and Resident is possible contracted and not wanted to move or even want their leg to be touch . Response: Nothing at this time . Will log in the Physician book. Will let Nurse Manager be made aware of situation . -10/3/19 at 5:45 PM: SNF to ED Handoff: Resident complaining of RT. (right) leg pain during AM med pass, writer assessed Rt. leg, Rt Knee swollen, warm to touch, with complaints of pain upon assessment pain level 10, pain meds given as ordered by physician and tolerated well, Physician notified, stat order given for Rt. Knee 2 view x-ray, and RLE (Right Lower Extremity) venous Doppler . Reason for Transfer: Distal Rt. femur FX. (fracture), Proximal Rt. Fibula Fx. with positive [MEDICAL CONDITION] . Review of Resident #701's pain level summary documentation revealed the Resident complained of the following pain levels: -October 2019: Daily complaints of pain until transferred to hospital. -10/3/19: Pain levels ranging from eight to nine out of 10 (scale of zero to 10 with 10 being the worst imaginable pain) -10/1/19 and 10/2/19: Pain levels two out of 10 -September 2019: Resident #701 complained of pain 12 days out of the month. Documented pain levels ranged from two to nine out of 10. -9/30/19: Pain levels two out of 10 -9/21/19 to 9/28/19: Pain levels ranging from two to nine out of 10 -9/17/19 to 9/19/19: Pain levels ranging from four to six out of 10 -9/12/19: Pain level at six out of 10 -August 2019: Resident #701 complained of pain 11 days during the month ranging from one to five out of 10 on scale. Review of facility provided Incident and Accident Reports for the previous six months revealed Resident #701 had falls within the facility on 8/14/19 and on 9/9/19. The incident report dated 9/9/19 revealed, Pt (patient) was observed sitting on the floor by the side of bed. Writer assessed pt. No injury. Pt was assisted back to bed by staff. Pt stated they were trying to get into the w/c (wheelchair) to brush teeth . No further c/o (complaints of) pain . Review of Resident #701's documented weights reviewed the Resident weighted 149 pounds on 8/7/19 and 140 pounds on 9/9/19. There was no documented weight for (MONTH) 2019. Review of Resident #701's Medication Administration Record [REDACTED] -[MEDICATION NAME] ([MEDICATION NAME]) Tablet 325 mg milligrams. Give 2 tablet by mouth every 6 hours for Pain (Ordered: 11/25/16) -[MEDICATION NAME] (muscle relaxer) Tablet 500 mg. Give 1 tablet by mouth every 8 hours as needed for mild pain (Ordered: 9/20/19) An interview was conducted with Physical Therapy Assistant B and Therapy Manager C on 10/22/19 at 2:10 PM. When queried regarding Resident #701, Therapy Assistant B revealed they worked with the Resident. With further inquiry regarding the Resident, Physical Therapy B stated, (Resident #701) complained of pain when I saw them. They didn't complain when it (right leg) was in a neutral position. (Resident #701) could do things (in therapy) but it hurt. When queried regarding what they did when the Resident complained of pain during therapy, Physical Therapy Assistant B replied, I let nursing staff know. Physical Therapy Assistant B then stated, It (Resident #701's right knee) was swollen. There was [MEDICAL CONDITION] around the patellar area. Therapy Manager C stated, I remember the staff talking about (the Resident's) pain. Resident #701's Physical Therapy documentation with Therapy Manager C t this time revealed the following: PT notes indicate as follows: -9/10/19: Physical Therapy (PT): PT Evaluation & Plan of Treatment . Certification Period: 9/10/19- 10/9/19 . Current Referral . fall on 9/9/19 referred to skilled therapy secondary to change in functional status per nsg (nursing) staff . Prior Level of Function . Level Surfaces = CGA (Contact Guard Assist), Distance Level Surfaces = 75 feet . pt was CGA for transfer, bed mobility and ambulation with fww (four wheeled walker) per last DC (discharge) notes 7/22/19 . History of falls . Yes . Was patient injured from fall? Yes; Injury description: right knee pain, swelling, weakness in right knee . Musculoskeletal System Assessment . RLE (Right Lower Extremity) ROM (Range of Motion) = Impaired . Right Hip = WNL (Within Normal Limits); Knee = Impaired (-10 degree knee extension passive, hamstring tightness) . Clinical Impressions . recent fall during transfer from w/c to bed and caught right foot under w/c Pt had recent x-ray for right/left tibia/fibula negative fro fracture. Pt demonstrated significant weakness in right LE . and pain in right knee 5/10 with standing, swelling right need . unable to ambulate at this time, right knee buckling , upon nurse informed about new weakness in right knee . -9/10/10: Physical Therapy Treatment Encounter Note . Response to Tx Pt has right knee weakness evaluation, pain. Nsg (nursing) informed that pt has right knee weakness, pain . -9/12/19: Physical Therapy Treatment Encounter Note . Pain . Pt c/o 7/10 pain with movement . -9/14/19: Physical Therapy Treatment Encounter Note . Precautions/Contraindications . Right knee pain and weakness from recent fall . Skilled interventions focused on static balance activities during sitting . -9/17/19: Physical Therapy Treatment Encounter Note . Precautions/Contraindications . Right knee pain and weakness from recent fall . Resident reports some pain stiffness in R knee/leg. RN aware . -9/18/19: Physical Therapy Treatment Encounter Note . Precautions/Contraindications . Right knee pain and weakness from recent fall . application of bio freeze on the R knee to minimize pain with sit to stand transfers . patient had a hard time with difficulty moving RLE with transfers . -9/23/19: Physical Therapy Treatment Encounter Note . Precautions/Contraindications . Right knee pain and weakness from recent fall . -9/25/19: Physical Therapy Treatment Encounter Note . Precautions/Contraindications . Right knee pain and weakness from recent fall . Skilled interventions focused on bed mobility training . -9/25/19: PT Therapy Progress Report . Precautions/Contraindications . Right knee pain and weakness from recent fall . -9/26/19: Physical Therapy Treatment Encounter Note . Precautions/Contraindications . Right knee pain and weakness from recent fall . Skilled interventions focused on bed mobility training . increase independence in bed mobility tasks . -9/30/19: Physical Therapy Treatment Encounter Note . Precautions/Contraindications . Right knee pain and weakness from recent fall . Collaboration with interdisciplinary nursing for pain medication for Resident's R knee . Complexities/Barriers Impacting Session: Pain levels . 10/1/19: Physical Therapy Treatment Encounter Note . Precautions/Contraindications . Right knee pain and weakness from recent fall . Pt was unable to stand for more than 10 second during 2 trials . Pain . Pt c/o 10/10 pain with movement of RLE . 10/2/19: Physical Therapy Treatment Encounter Note . Precautions/Contraindications . W/C Mngmt (management) training in wheelchair propulsion/maneuvering within patient's environment . After review of documentation review, Therapy Manager C and Physical Therapy Assistant B were queried regarding documentation. Therapy Manager C stated, They were really taking it easy on (Resident #701). With further inquiry, Therapy Manager C revealed they were unaware Resident #701 was diagnosed with [REDACTED]. Physical Therapist B then stated, That would explain the [MEDICAL CONDITION] and the pain. An interview was completed with Physician Assistant D on 10/22/19 at 3:00 PM. When queried regarding Resident #701, Physician Assistant D revealed they provided care to the Resident. When queried regarding their thought processes related to the Resident's continued pain and significant change in condition following the fall that occurred on 9/9/19 and their documentation in the Resident's medical record, Physician Assistant D reviewed the Resident's medical record and revealed their notes were focused on treatment of [REDACTED]. With further inquiry regarding the Resident's pain and ongoing assessment, Physician Assistant D stated, I was not aware of any ongoing issues. If there is a pain issue, nursing staff typically calls the doctor who then asks me to see the patient. With further inquiry regarding the X-rays completed following Resident #701's fall and if the fractures could have been missed in the X-rays completed, Physician Assistant D replied, It could have been missed. When asked if other X-rays would have been appropriate, Physician Assistant D replied, Well yeah, it (right leg injury) should have been getting better day by day and if it wasn't, then that would have been a reason to do more testing and look into it further. Physician Assistant D then stated, I don't see anywhere where I was notified (of ongoing problems with the Resident's right lower extremity). An interview was completed with the Director of Nursing (DON) on 10/22/19 at 3:40 PM. When queried regarding Resident #701, including the delay between diagnostic testing, treatment, diagnosis, and documentation of pain, the DON indicated they felt the facility followed up on the Resident's concerns. Review of facility provided policy/procedure entitled, Fall Evaluation Safety Guide (Effective:11/28/17) did not specify information pertaining to ongoing assessment and coordination of care following a fall in the facility.

This citation refers to intake # 2 Based on observation, interview, and record review, the facility failed to prevent resident to resident abuse for one (#49) sampled resident, resulting in a vulnerable resident being struck in the head with a cane by another resident (R179) causing significant bleeding, injury, and hematoma. Findings include: On 7/30/19 at 9:30 AM, a review of a progress note dated, 7/22/19 at 11:05 PM, indicated the following, Upon completing medication pass .(R179) came up to desk asked writer to get (R49) out of his nightstand. Writer walked in to room and observed (R49) standing up with injury. (R49) indicated that they hit (R179) with their cane three times because he was going in their belongings. Writer immediately removed (R179) from room and assigned staff to supervise .resident to be petitioned out due to physical aggression behavior attacking another resident. Resident self responsible and agreeable to his actions and discharge to psych evaluation. On 7/30/19 at 9:40 AM, a review of a written statement signed by R179 describing the incident which occurred on 7/22/19 involving R49 indicated the following, The man was going through my nightstand so I hit him with my cane. On 7/30/19 at 9:50 AM a review of R179's medical record indicated an admission to the facility on [DATE] which [DIAGNOSES REDACTED]. R179's Minimum Data Set Assessment (MDS) revealed an intact cognition. R179 was discharged from the facility on 7/22/19 and petitioned to the hospital for a psychiatric evaluation, following the incident involving R49. On 7/30/19 at 3:46 PM, R49 was queried regarding the incident which occurred between them and R179 on 7/22/19. R49 had no recollection of this incident and was unable to respond to any questions asked to them regarding this incident. On 7/30/19 at 3:59 PM, Unit Manager (UM) DD was queried on the incident which occurred on 7/22/19 involving R49 and R179, and stated, (R49) was going through (R179's) personal belongings and (R179) struck (R49) with their cane. UM DD indicated that they were not present when the incident occurred. On 7/30/19 at 4:15 PM, the Administrator was queried about the incident which occurred involving R49 and R179 on 7/22/19. The Administrator stated, These residents had many good days together. On 7/31/19 at 10:04 AM, Nurse JJ was contacted by phone and queried about the incident which occurred on 7/22/19, involving R49 and R179. Nurse JJ stated, (R179) reported to me that they had hit (R49) with their cane because (R49) was going through their nightstand. I went down to the resident's room and observed (R49) with blood on their face and the top of their head. I began neuro-checks, started wound care, and applied ice to (R49's) head. Both resident's were separated and placed on 1:1 supervision. (R49) was sent to the hospital for a medical examination and (R179) was petitioned out for a psychiatric evaluation. On 7/31/19 at 10:20 AM, Nurse D was contacted by phone regarding the incident involving R49 and R179 on 7/22/19. Nurse D was unable to be reached by phone and a voicemail message was left for them. On 7/31/19 at 3:04 PM, Certified Nursing Assistant (CNA) MM was contacted by phone regarding the incident which occurred involving R49 and R179 on 7/22/19. CNA MM was unable to be reached by phone and a voicemail message was left for them. On 7/31/19 at 3:37 PM, CNA N was queried regarding the incident which involving R49 and R179 on 7/22/19. CNA N stated, I walked into (R49's) room and saw the nurse in there trying to calm (R179) down. There was blood on the floor. There was a lot of blood. I cleaned blood off of (R49's) head and face. On 7/31/19 at 3:45 PM, a review of a progress noted dated 7/22/19 at 11:45 PM, indicated the following, (R49) transferred to .hospital due to roommate attacking and striking resident with cane causing visible head injury. Hematoma noted to top of head . On 7/31/19 at 3:50 PM, a review of R49's medical record indicated an admission to the facility on [DATE], with [DIAGNOSES REDACTED]. R49's MDS Assessment indicated a severely impaired cognition. On 7/31/19 at 3:55 PM, a facility policy titled, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property with an effective date of 11/28/2017 was reviewed and revealed the following, Abuse is the willful infliction of injury .Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .It is the policy of this facility that all staff monitor residents and will know how to identify potential signs and symptoms of abuse .

Based on observation, interview and record review, the facility failed to implement interventions to prevent pressure ulcer wounds, lack of infection control practices during wound care, lack of comprehensive skin assessments and/or lack of repositioning for 3 ( #41, #144, #150) sampled residents reviewed for pressure ulcers, resulting in the development of new pressure ulcer and the likelihood of the worsening of pressure wounds, infection and continued development of pressure wounds. Findings include: On 7/29/19 at 12:59 PM, observation occurred of Resident #41. The Resident in laying in bed, positioned on their back with the head of the bed flat and no pillow. The Resident unshaven with large areas of a brown colored substance noted on various areas of their skin. The Resident covered with a blanket but was not wearing undergarments and their scrotum and genital area were visible from the entryway of the room. The Resident was observed to have a left lower extremity amputation. A foul odor was noted upon entering the room which got stronger and more pungent near Resident #41. A pile of dressings and gauze were observed sitting on the table beside the Resident's bed. An interview was conducted with the Resident at this time. When asked why they were not wearing clothes, Resident #41 indicated their wound dressings come off due to being wet and they were waiting for staff to put new dressings on. With further inquiry regarding their wounds, Resident #41 stated, I just got one (wound) because they (facility staff) lost the pad for my chair (wheelchair) the first time they did a treatment when I got back from the hospital. When asked, the Resident indicated their wounds were caused by pressure. Resident #41 then pointed at their wheelchair. A roho cushion cover and a roho cushion were observed on the the chair. The cushion had multiple areas when the air pockets were collapsed. A broken, black plastic and metal wheelchair removable side arm was also observed sitting on the top of the wheelchair. When asked about the broken piece, Resident #41 indicated facility staff were aware but had not replaced the part. When asked about ambulation, Resident #41 stated, I'm paralyzed from the chest down. Record review on 7/30/19 revealed Resident #41 was admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 was cognitively intact and required limited to extensive assistance to perform Activities of Daily Living (ADLs). The MDS further revealed the Resident had two stage four (full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcers. Review of Resident #41's care plans at this time revealed a care plan entitled, The resident has actual impairment to skin integrity admitted with Stage IV Coccyx and left Ischial r/t (related to) pressure . (Initiated 1/9/19). Care plan interventions included: -Evaluate and treat per physicians orders (Initiated 1/9/19) -Evaluate resident for s/sx (signs/symptoms) of possible infections (Initiated 1/9/19) -Encourage good nutrition and hydration in order to promote healthier skin (Initiated 1/9/19) -Follow facility protocols for treatment of [REDACTED]. -Identify/document causative factors and eliminate/resolve where possible (Initiated 1/28/19) -Keep skin clean and dry . Educate Resident on leaving dressing on . and to ask for assistance if needed to reposition . to make comfortable . (Initiated 1/28/19) -Monitor/document location, size and treatment of [REDACTED]. to MD (Initiated 1/10/19) -The resident needs low air loss mattress, pillows to protect the skin while up in bed (Initiated 1/10/19) -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations (Initiated 1/10/19) Review of Resident #41's medical record documentation on 7/30/19 revealed the following WoundRound documentation: -7/24/19: Wound Assessment Detail Report: Coccyx . Stage 4 . Tissue Types: Bright Pink or Red =100%; Exudate: Amount- light; Type- Serous . Periwound: [DIAGNOSES REDACTED]; Wound Edge: Rolled . Odor: No . Size (cm -centimeters): 5.00 cm X 7.5 cm X 3.4 cm . Undermining: Present . Tunneling: Present . -7/24/19: Wound Assessment Detail Report: Sacrum . Stage 4 . Tissue Types: Pale Pink Non-granulating=50%, Bright Pink or Red=50% . Exudate: Amount - Moderate; Type - Serosanguineous . Periwound: [DIAGNOSES REDACTED]; Wound Edge: Rolled . Odor: No . Size (cm) 3.00 x 8.00 x 0.40 . Undermining: Unknown . Tunneling . Unknown . WoundRound documentation prior to 7/24/19 of Resident #41's wound measurements was able to be accessed with facility provided Surveyor Electronic Medical Record (EMR) access. Review of Resident #41's skin assessment documentation did not reveal documentation of the Resident's wound measurements. Review of Resident #41's progress note documentation revealed the following: -7/23/19: Nursing Evaluation . The Resident has skin integrity concerns. Sacrum- Sacral wound, Right iliac crest (front)- suprapubic catheter, left iliac crest (front) - Ostomy . -7/14/19: Daily Skilled Note . Skin/Wound . Pressure Ulcer . No concerns related to skin alteration evaluation . -7/26/19: Daily Skilled Note . Skin/Wound . Concerns related to skin alteration evaluation: Purulent Drainage, Increased Drainage, Bleeding. Coccyx wound increased drainage/tx (treatment) in place notified wound care for further treatment . -6/3/19: Daily Skilled Note . Skin/Wound . Pressure Ulcer . No concerns related to skin alteration evaluation . Observation of wound care for Resident #41 occurred on 7/30/19 at 2:50 PM with Nurse FF. Prior to entering the Resident's room to complete wound care, Nurse FF was asked how many pressure ulcer the Resident currently had and Nurse FF stated, (Resident #41) has two spots on their bottom and one on their leg. Nurse FF completed the wound care treatment on the Resident's right lateral leg. Nurse FF was observed washing their hands and then removing the dressing to the Resident's leg. The wound was irregularly shaped and approximately the size of a dime. The wound bed was red with an area of black, necrotic tissue on the proximal edge of the wound bed. After removing the dressing, Nurse FF cleansed the wound bed with normal saline and proceeded to measure the length and width of the wound. When asked the size of the wound, Nurse FF stated, It's 2 cm by 1.5 cm. When asked if they measured wound depth, Nurse FF stated, It doesn't really have any depth. Nurse FF then used a Q-tip to measure the depth of the wound and stated, It's 0.3 (cm). When asked if the wound size was 2 cm X 1.5 cm X 0.3 cm, Nurse FF replied, Yes. Nurse FF then changed their gloves, applied hydrogel (topical wound ointment) to four by four gauze, placed the gauze over the wound, and secured the dressing. When queried what the leg wound was caused from, Resident #41 stated, From rubbing on the wheelchair. Nurse FF shook their head in agreement with the Resident. At this time, Nurse FF performed hand hygiene and proceeded to assist the Resident to a different position in order to complete the dressing change on the Resident's sacral pressure ulcer. Upon repositioning, no dressing was in place to the Resident's sacral pressure ulcer. When asked, Resident #41 indicated the dressing got wet and had came off earlier. The wound was large with the appearance indicative of a flap and oblong in shape. The wound bed was beefy red in color with significant depth and visible tunneling and undermining. The skin surrounding the wound was red. At this time, Nurse FF was observed measuring the length of the wound in the area where the wound was observed to have the smallest length. When queried regarding facility policy/procedure and standards of care pertaining to wound measurements and if wound length is measured at the smallest or the largest area of the wound, Nurse FF stated, The largest. Nurse FF then measured the length of the wound again and stated, It's 10.5 (cm). Nurse FF then measured the width of the wound. Nurse FF was observed measuring the width at the most narrow area of the wound. When queried again regarding wound measurements, Nurse FF re-measured the wound at the widest point of the wound bed and stated, Oh, it's 5.5 (cm). Nurse FF then measured the wound depth that was not the deepest section of the wound. When queried regarding facility policy/procedure and standards of practice pertaining to wound depth measurement at the shallowest or deepest section of the wound, Nurse FF indicated wound depth should be measured at the deepest section of the wound bed. Nurse FF then measured the wound depth again and stated, It's 3.2 (cm). (Total wound size: 10.5 cm X 5.5 cm X 3.2 cm.) Nurse FF then removed their gloves, washed their hands for four seconds, and reapplied gloves. At this time, Nurse FF proceeded to apply hydrogel to 4 X 4 gauze, placed the gauze inside the wound bed, covered it with an ABD, and secured the dressing with [MEDICATION NAME] tape. Nurse FF then washed their hands and began the dressing change on the Resident's coccyx wound. The prior dressing was visually saturated. Upon removal of the dressing, a foul, permeating odor was noted. The dressing was saturated with a large amount gray/green colored, copious drainage. After removing the dressing, Nurse FF cleansed the wound bed with normal saline on gauze and obtained wound measurements. Nurse FF stated the wound was, 9.2 (cm) X 7.1 (cm) X 7.5 (cm). After measuring the wound, Nurse FF washed their hands for five seconds before donning new gloves and applying 4 X 4 gauze with hydrogel, an ABD pad, and securing the dressing with [MEDICATION NAME] tape. An irregularly shaped, dime sized area with a pink and white colored wound base was observed on the Resident's left hip. The area surrounding the open area was red in color. When queried regarding the wound, Nurse FF stated, It's a new area. When asked if the area was a pressure ulcer, Nurse FF replied, I can't say for sure but it is over a bony prominence. Nurse FF measured the wound at this time and stated, It's 1.9 (cm) by 1.5 (cm). Nurse FF proceeded to apply a dressing to the wound and indicated they would have to inform Resident #41's healthcare provider. Resident #41's wound documentation including wound measurements was requested from the facility Administrator on 7/31/19 at 11:46 AM and not received by the conclusion of the survey. An interview was conducted with Nurse FF on 7/31/19 at 3:45 PM. When queried regarding lack of hand hygiene during Resident #41's wound care, Nurse FF stated, I should have washed my hands. I didn't realize I didn't. When queried regarding wound measurements, including the increase in documented size and the method in which measurements are obtained per facility policy/procedure, Nurse FF did not provide and explanation. Record review on 7/30/19 revealed Resident #150 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required extensive assistance to perform Activities of Daily Living (ADLs). The MDS further revealed the Resident had one, stage three, pressure ulcer. Review of the MDS dated [DATE] revealed the Resident had three, stage three, pressure ulcers. Review of Resident #150's care plans on 7/30/19 revealed a care plan entitled, The resident has Recurrent pressure injury Left Glutueal/ Stage 3/ Left Heel Stage 3/ Sacrum Stage 4 r/t (related to) Hx (history) of ulcers, Immobility. Nursing update 5-3-19: Resident readmitted with Stage 4 Sacrum recurrent/ Stage 3 Left Gluteal \ Right Buttock cicatrix previous healed wound. Vaculitis Right Plantar foot with right heel cicatrix/ Left Plantar foot/Left heel cicatrix (Initiated 2/18/19). Care plan interventions included: -Administer treatments as ordered and monitor for effectiveness (Initiated 2/18/19) -Assess/record/monitor wound healing weekly Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD (Initiated 2/18/19) -Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning (Initiated 2/18/19) -If the resident refuses treatment, confer with the resident, IDT and family to determine why and try alternative methods to gain compliance. Document alternative methods (Initiated 2/18/19) -Inform the resident/family/caregivers of any new area of skin breakdown (Initiated 2/18/19) -Instruct/assist to shift weight in W/C (wheelchair) q (every) 15 minutes (Initiated 2/18/19) -Encourage resident to take frequent rest periods to offload Sacrum/ Left Gluteal. Resident prefers to be up for long periods once . out of bed (Initiated 2/18/19) Lal (Low Air Loss) mattress, soft heel lift boots as tolerated (Initiated 2/18/19) -Monitor dressing q shift to ensure it is intact and adhering. Report lose dressing to Treatment nurse. Encourage resident to offload self in bed/chair. Resident on low air loss bed . Heels elevated while in bed. Soft heel lift boots (Initiated 2/18/19) -Monitor nutritional status. Serve diet as ordered, monitor intake and record (Initiated 2/18/19) -Monitor/document/report PRN (as needed) any changes in skin status: appearance, color, wound healing, s/sx (signs/symptoms) of infection, wound size (length X width X depth), stage (Initiated 2/18/19) -The resident needs encouragement, with use of bed rails, trapeze bar, etc for resident to assist with turning (Initiated 2/18/19) The resident needs monitoring/reminding/assistance) to turn/reposition frequently or as requested. Resident in chair long periods thru out day (Initiated 2/18/19) Additional review of Resident #150's medical record revealed the Resident was transferred to the hospital on [DATE] and readmitted on [DATE]. Hospital documentation revealed the Resident was transferred to the hospital due [MEDICAL CONDITION] secondary to Urinary Tract Infection and Pressure Ulcer wound infection. Additional review of hospital documentation revealed an inpatient wound care note, dated 6/25/19, which revealed, Injuries (pressure ulcers) are present upon Hospital admission . stage 4 pressure injury to left ischium . Wound measures 2.5 cm X 2.5 cm X 1 cm Ischium . 2 cm X 6 cm X 0.1 cm . Coccyx/sacrum with healing full thickness injury . No other wounds were indicated in the provided hospital documentation. On 7/31/19 at 8:00 AM, Resident #150 was observed in bed, positioned on their back. With their heels directly on the bed mattress. At 10:00 AM on 7/31/19, observation occurred of Resident #150 in their room. The Resident was positioned on their back in bed with their heels placed directly on the mattress. On 7/31/19 at 11:30 AM, Resident #150 was observed in their room. The Resident was positioned on their back in bed with their heels directly on the mattress. An interview was completed with the Resident at this time. When asked if they sores on their skin, Resident #150 indicated they had pressure ulcers. With further inquiry regarding when the pressure ulcers developed, Resident #150 revealed the pressure ulcers developed at the facility. When asked about wound care, Resident #150 stated, (Nurse FF) does it now. Somebody else was doing it and it take longer to heal. When queried regarding getting out of bed and ability to move, Resident #150 indicated they were paralyzed from the waist down and stated, I have a motorized wheelchair. Observation of Resident #150's wheelchair at this time revealed the wheelchair did not have a pressure reduction cushion or device in place on the seat of the chair. When asked if they had a pressure reduction device or cushion for their wheelchair, Resident #150 replied, No. When asked how often and how long they are up in the wheelchair at a time, Resident #150 stated, Yesterday, I was up from noon to 5:00 (PM). When asked where they were on Monday, Resident #150 replied, I was at Doctor appointment. When asked how long they were in their wheelchair on Monday, Resident #150 stated, Oh from about 8:00 AM to 5:00 PM. I got back for lunch but I stayed up in my chair. When asked if they have pain from the pressure ulcers, Resident #150 stated, Oh yes, it hurts. Hurts a lot. When queried how often staff reposition them when they are sitting in the wheelchair, Resident #150 indicated staff do not reposition them in their wheelchair unless they request to be repositioned. When queried regarding how often staff reposition them in bed, Resident #150 indicated they had not been repositioned since around 7:30 in the morning. When queried regarding staffing at the facility, Resident #150 indicated there was not enough staff and stated, When I ring the light it takes a long time for them to answer, usually like 20 to 30 minutes. When queried if they had any pressure sores on their heels, Resident #150 indicated they did. When asked if they had heel boots or if staff elevated their heels to reduce pressure, Resident #150 stated, I used to have some but I don't know what happened to them. They (staff) haven't been putting them on. Wound care observation of Resident #150's pressure ulcers occurred on 7/31/19 at 12:19 PM with Nurse FF and Nursing Assistant BB. Resident #150's heels was positioned directly on the mattress. A dressing was observed on Resident #150's right foot. When queried if the etiology of the wound was pressure, Nurse FF replied, Yes. Resident #150 then stated, I got it (pressure ulcer) from my feet pushing on my wheelchair. As Nurse FF removed the dressing on the Resident's right foot, a foul odor was noted. Inspection of the removed dressing revealed a moderate amount of off-gray colored, thick drainage with a distinct foul odor. The wound was oblong in shape with irregular edges and was located on the pad area of the Resident's right foot. The would bed was red with white tissue and black colored, necrotic tissue noted along the medial, proximal edge. Nurse FF obtained wound measurements and when asked stated, It's (right foot pressure ulcer) is 3.5 (cm) X 3.5 (cm) X 0.3 (cm). Nurse FF then proceeded to place hydrogel on 4 x 4 gauze, placed the gauze over the pressure ulcer, and wrapped the Resident's foot with kerlix (gauze dressing). Nurse FF and Nursing Assistant BB repositioned the Resident to complete the dressing change on the Resident's coccyx and left buttocks pressure ulcers. Upon removal of the Resident's pants to complete the dressing change, an extremely unpleasant odor dispersed through the air. The Resident's brief was visually saturated with a considerable amount of urine. The dressings present on the Residents coccyx and buttocks were visually saturated with fluid. After removing the soiled brief, Nurse FF removed both dressings present on Resident #150's coccyx and buttocks. The removed dressings were fetid and completed saturated with purulent, gray/green colored drainage. The coccyx pressure ulcer was circular shaped with irregular edges and larger than a baseball. Tunneling and undermining were visible. The wound bed was red and white in color with gray and black necrotic tissue noted. Directly to the left of the open pressure area on the coccyx, a pressure ulcer was noted on the Resident's left buttocks pressure ulcer. The area was approximately the size of a softball, with a red and white colored wound base. Nurse FF measured the pressure ulcer areas at this time and stated, It's 13 (cm) X 5.5 (cm) x 4 (cm). When queried if it was one pressure ulcer or two separate pressure areas, Nurse FF indicated it is one pressure ulcer. Nurse FF covered the wound beds with hydrogel on 4 x 4 gauze and securing with a Derma dressing. After completing the dressing, Nurse FF proceeded to remove the dressing covering the pressure ulcer on the Resident's sacral pressure ulcer. The prior dressing has a moderate amount of light gray colored, foul smelling drainage. The wound was oblong shaped with irregular edges. The wound bed with red in color with white edges. Nurse FF obtained wound measurements and stated, It's 3 (cm) X 1.5 (cm) X 0.5 (cm). Nurse FF applied hydrogel to a 4 x 4 gauze and secured the gauze with a derma dressing. An interview was conducted with Nurse FF on 7/31/19 at 1:05 PM. When queried regarding Resident #150's missing wound treatments on the Treatment Administration Record (TAR), Nurse FF indicated they do not work every day. When if Resident #150's pressure ulcers were facility acquired, Nurse FF revealed they were. When asked about the size and of the wounds along with facility policy/procedure for wound measurement, Nurse FF did not provide an explanation. When queried regarding interventions in place to prevent pressure ulcers, including heel boots and frequent repositioning, Nurse FF revealed they were unsure why the Resident did not have their heel boots in place and indicated the Resident should be repositioned frequently. All Resident #150's requested wound care documentation including measurements was requested from the facility. Review on 7/31/19 revealed the facility only provided documentation pertaining to the Resident's pressure ulcer on their coccyx and their left buttocks. The provided documentation for Resident #150's coccyx pressure ulcer revealed the following: -7/30/19: Stage 3 . Tissue Types: Bright Pink or Red = 75%, Slough While [MEDICATION NAME] = 25%; Exudate: Scant- Serosanguineous; Length: 5.60 cm, Width: 3 cm, Depth: 1.2 cm . -7/24/19: Stage 3 . Tissue Types: Bright Pink or Red = 75%, Slough White [MEDICATION NAME] = 25%; Exudate: Scant- Serosanguineous; Length: 4.50 cm, Width: 1 cm, Depth: 0.3 cm . -7/10/19: Stage 3 . Tissue Types: Bright Pink or Red = 75%, Slough White [MEDICATION NAME] = 25%; Exudate: Scant- Serosanguineous; Length: 4 cm, Width: 0.6 cm, Depth: 0.2 cm . -2/15/19 (First provided documented measurement): Partial Thickness . Intact skin +50%, Non-blanchable [DIAGNOSES REDACTED]= 50%; Exudate: Scant- Serous; Length: 0.8 cm, Width: 0.5 cm, Depth: 0.00 cm . The provided documentation for Resident #150's left buttock pressure ulcer revealed the following: -7/30/19: Stage 3 . Tissue Types: Pale Pink Non-granulating = 40%, Slough loosely adherent= 60%; Exudate: Moderate- Serosanguineous; Length: 5.60 cm, Width: 3.5 cm, Depth: 2.0 cm . -7/24/19: Stage 3 . Tissue Types: Pale Pink Non-granulating = 40%, Slough loosely adherent= 60%; Exudate: Moderate- Serosanguineous; Length: 2.5 cm, Width: 3.5 cm, Depth: 2.0 cm . --2/15/19 (First provided documented measurement): Partial Thickness . Intact skin +50%, [MEDICATION NAME] (Pale Pink or Red)= 45%; Exudate: Scant - Serous; Length: 1 cm, Width: 1.5 cm, Depth: 0.2 cm . An interview was conducted with the Director of Nursing (DON) on 7/31/19 at 2:50 PM. When queried regarding Resident #41 and Resident #150's pressure ulcers including observations of wound care, lack of planned interventions, wound worsening and difficulties obtaining measurements, the DON indicated the facility is working on improving their wound care program. On 7/29/19 at 10:07 AM, Resident #144 was observed lying flat on their back in bed with their eyes closed. They appeared frail and did not respond to verbal stimuli. Resident #144's heels were resting directly on a regular bed mattress. There was a bandage observed on the right heel. The following were further observations of Resident #144 lying flat on their back in bed, with their heels resting directly on a regular mattress: 7/30/19 at 12:52 PM 7/30/19 at 3:01 PM 7/30/19 at 3:38 PM 7/31/19 at 9:02 AM 7/31/19 at 10:44 AM 7/31/19 at 11:33 AM A record review of the MDS assessment dated [DATE] revealed that Resident #144 was admitted to the facility on [DATE] and then readmitted to the facility on [DATE] with a severely impaired cognition and needed extensive to total assist with care. Resident #144 had a [DIAGNOSES REDACTED]. A record review of the Progress Notes revealed the following: 7/15/2019 19:45 (7:45 PM) *Admission Summary Note Text: .Healing abrasion to the Left Hip, dry dressing in place, open areas noted to the Sacrum, Left buttock and Right buttock. Bilateral pedal pulses noted. 2+ Pitting [MEDICAL CONDITION] noted to the Left foot. Fluid filled blister noted to the Right heel .resident will continue to be monitored. A record review of the Physician's Orders revealed that there was a Low Air Loss mattress ordered on [DATE]. On 7/31/19 at 11:27 AM, a wound observation was made with Wound Care Nurse FF and Restorative Aide BB, who was there to help position Resident #144 during the wound treatment. Resident #144 was unable to maintain a position independently and was grimacing and moaning while being turned. The following observations were made during that time: Left hip-pink area, skin closed. Sacrum/coccyx-three open areas with irregular pink borders with yellow slough (non viable tissue) in the middle of each wound. Right heel-larger than half dollar of hard, brown and black tissue covering the whole heel, the outer edge of the wound had a thick, rough surface that appeared to be cracking. During the wound treatment observation, Wound Care Nurse FF was queried in regards to Resident #144 having a heel wound, yet their heels were resting directly on the bed mattress. Wound Care Nurse FF stated, Usually they should be up (floated on a device or off the mattress with a pillow). Nurse FF and Restorative Aide BB were queried in regards to the mattress being a Low Air Loss mattress as ordered, Nurse FF was unsure but stated, Usually there would be an air pump if it was an air mattress. Restorative Nurse Aide BB stated, No, it is not an air mattress, it is just a regular mattress. A record review of the Skin Observations for Resident #144 revealed that there were no weekly comprehensive skin assessments/observations done while admitted to the facility. A record review of the Care Plans for Resident #144 revealed the following: Focus (created 6/18/19) Resident has actual for an ADL (activity of daily living) self care performance deficit r/t Dementia, Limited mobility Interventions Bed Mobility: Physical assist 2 staff Focus (created 7/16/19) Resident has actual impairment to skin Interventions Evaluate and treat per physicians orders (6/23/19) Ensure that heels has boots while resident in lying in bed as tolerated (7/19/19) Low air loss mattress (7/29/19) Monitor/document location size and treatment of [REDACTED]. Turn and reposition patient frequently (7/29/19) A record review of the wound measurements dated 7/30/19 for Resident #144 revealed the following: Wound Area Date identified Cause of wound Clinical stage Length Width Depth Coccyx 7/15/19 Pressure Unstagable 14 12 0.10 Right hip 7/15/19 Pressure Stage 1 3.10 2 L hip 7/15/19 Pressure Stage 1 3.10 2 Right heel 7/15/19 Pressure Unstagable 3.10 6.5 A request was made for the initial wound care notes and measurements for Resident #144 but not received by the end of the survey. A record review of the Braden Scale (a tool utilized to determine the risk for skin breakdown) dated 7/22/19 for Resident #144 revealed the following: Sensory-Very Limited Moisture-Very Moist Activity-Chairfast Mobility-Completely Immobile Nutrition-Adequate Friction and Shear-Problem On 7/31/19 at 12:14 PM, an interview was completed with the Director of Nursing (DON) in regards to the skin management program at the facility. The DON was queried in regards to skin assessments that are done on a routine basis. The DON explained that the nurses do the assessments weekly under the evaluations tab in the Electronic Medical Record. During the interview, the DON reviewed the medical records of Resident #2,#140 and #144 and verified that there were missing skin assessments. For Resident #144, the DON stated, They (the nurses) did a daily skilled note and it covers if there were any new skin issues. The DON was queried about the Low Aire Loss mattress that was ordered and not on Resident #144's bed. The DON stated, They (the beds) are all being used. It should be coming today. The DON was queried on the expectation of the positioning of a resident with a heel wound. The DON stated, There should be (protective) boots for them. On 7/31/19 at 3:25 PM, an interview was completed with the Administrator. The Administrator was queried about the lack of consistency of wound documentation and measurements and stated, I don't know that detail .That is why we have the regional (from the corporation) here to train them (the wound nurses). The Administrator was queried about the missing skin assessments and stated,They are supposed to be done weekly. The Administrator was queried in regards to the Heels not being floated for Resident #144 while observed during the survey and the air mattress that is not in place for Resident #144 and stated, I know the Unit Managers are monitoring for that (that interventions are put in place) and the wound team is. A review of the facility policy titled, Skin Management Guideline dated 11/28/17 revealed the following: Purpose To ensure residents that are admitted to the facility are evaluated to determine appropriate measures to be taken by the interdisciplinary care team to determine appropriate measures and individualized interventions to prevent, reduce and treat skin breakdown. It is the practice of this facility to properly identify and evaluate residents whos (sic) clinical conditions increase the risk of impaired skin integrity and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for wounds according to the industry standards of care. A complete evaluation is essential for an effective skin prevention and treatment program A comprehensive evaluation guides the: Provides an ability for the facility to develop and implement a careplan that reflects each resident's identified needs Identify interventions to stabilize, reduce or remove underlying risk factors Evaluate the effectiveness of interventions Modify the interventions as appropriate Interventions for preventing, removing and reducing predicting factors for skin may include: Pressure redistribution surface for bed and seating surfaces Elevating heels: For residents that can't turn and reposition themselves For residents that have diminished sensory perceptions of the lower extremities that may affect and independent (sic) ability to turn, reposition and off load pressure Monitoring of Skin Integrity Weekly skin observation on the bath/shower day will be performed by the Licensed Nurse 376 (TRUNCATED)

Deficient Practice Statement One: Based on observation, interview and record review, the facility failed to institute and implement person centered interventions for fall prevention for one ( #117) of six sampled residents reviewed for falls, resulting in lack of implementation of personalized care plan interventions and repeated falls including a fall resulting in a fractured arm. Findings include: On 7/29/19 at 1:13 PM, Resident #117 was observed in their room. An over bed table with multiple fast food restaurant cups and other items were noted on the table. The floor next to the bed had boxes and bags of items next to and surrounding the bed. In order to get close to the edge of the bed, an individual would have to move multiple items in order to not step on the Resident's personal items placed on the floor. The Resident was sitting in their bed, with bare feet, and a sling was observed on their left arm. When asked about their arm and why they were wearing a sling, Resident #117 stated, I fell out of my bed and broke my arm. Resident #117 indicated they were unsure of what happened when they fell and have asked staff because they do not remember but facility staff have not told them. When queried if they were having pain, Resident #117 used their right arm to point at left arm and shoulder and stated, Yeah, in my arm and shoulder. A wheelchair was observed in the room, next to the wall across from the foot end of the Resident's bed and positioned in-between Resident #117's area of the room and their roommate nearest to the window. When asked about ambulation, Resident #117 revealed they were receiving some therapy but were unsure if it was Physical Therapy or Occupational Therapy. When asked about the wheelchair, Resident #117 indicated that was their wheelchair. An interview was conducted with Nurse KK and Nursing Assistant JJ on 7/31/19 at 9:00 AM. When queried about Resident #117's left arm, Nurse KK indicated they were not sure because they do not work in that area of the facility frequently. Nursing Assistant JJ then revealed they thought the Resident had fallen. Nurse KK proceeded to review the Resident's medical record at this time and stated, They broke their humerus (the long bone in the upper arm, located between the elbow joint and the shoulder). Record review on 7/29/19 revealed Resident #117 was most recently readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact, displayed no behaviors, and required limited to extensive assistance to perform Activities of Daily Living (ADLs). The MDS further indicated Resident #117 has one fall with major injury while at the facility. Review of Resident #117's care plans on 7/30/19 revealed an active care plan titled, The resident is High risk for falls r/t (related to) limited physical mobility. Had an actual fall without injuries (Initiated 8/1/18). The care plan included the following interventions: Anticipate and meet The resident's needs (Initiated 8/1/18). Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance (Initiated 8/1/18). Non-Skid slippers/socks (Initiated 6/7/18). PT (Physical Therapy) evaluate and treat as ordered or PRN (as needed). The resident needs a safe environment with: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Slide rails as ordered, handrails on walls, personal items within reach (Revised 1/28/19). Review of Resident #117's progress note documentation in the medical record on 7/29/19 revealed the following: 5/25/19 at 4:50 PM: Fall: Resident stated they attempting to go to restroom and tipped over a cup of water and fell to the floor. Resident stated they landed on their left side. ROM (Range of Motion) performed, able to perform some pain reported. Physician notified new order for X-ray . PRN (as needed) Tylenol given. Neuro-checks in place. Vital signs stable . BS (Blood Sugar) 211 . Pain at 6 (6 out of 10) . 6/13/19 at 5:06 PM: Resident alert and verbal. No acute distress to note. Stated they wanted to get into chair . stated I thought I could do it myself (Resident) slid down to the floor stated they had a bump on their head there were no injuries to note no bleeding some pain per resident writer notified physician no new orders at this time . writer informed resident they are a non-weight bearing status and they (sic) means your not to get up and try to on your feet nor transfer . (Resident) stated they forgot . 6/13/19 at 5:36 PM: Fall Risk Evaluation . Post Fall . BS 233 . Resident is receiving [MEDICAL CONDITION] medication. Resident is receiving anti-[MEDICAL CONDITION] medication. Resident is receiving laxative and there has been changes to the medication . DX (Diagnosis) [MEDICAL CONDITION] (low blood pressure) . has decline in functional status . has decline in cognition . On 7/30/19 at 10:43 AM, Resident #117 was observed in their room, sitting at the edge of their bed with their bare feet touching the floor. A sling was in place on the Resident's left arm. The same amount of items remained on the floor and area surrounding the Resident's bed. Non-slip socks or slippers were not observed in the room. When asked again about falling within the facility, Resident #117 revealed they fell more than once but were unable to provide specific information. When queried if they use their call light when they need assistance from staff, Resident #117 indicated they do and stated, It just takes so long for them to get here. Sometimes I can't wait that long. When asked how long they have to wait after putting on their call light, Resident #117 indicated the time frame varies but stated, It's a long time. When asked how long a long time is, Resident #117 revealed the normal time is around half an hour but stated, It is worse on nights and weekends. Upon request of Resident #117's care plans of the facility, multiple care plans pertaining to falls were received. Review of facility provided care plans for the Resident on 7/31/19 revealed an additional care plan pertaining to falls titled, The resident is Moderate risk for falls r/t limited physical mobility (Initiated 11/21/18). Interventions included: -Anticipate and meet the Resident's needs (Initiated 6/7/18). -Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance (Initiated 6/7/18). -Non-Skin slipper/socks (Initiated 6/7/18). -PT evaluation and treat as order or PRN (Initiated 6/7/18). -The resident needs a safe environment with: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Slide rails as ordered, handrails on walls, personal items within reach (Initiated 6/7/18). Review of facility provided Incident and Accident Reports on 7/31/19 revealed the following: -Event Date: 5/25/19 6:50 PM . Resident state they were attempting to go to the restroom and fell to the floor. Resident stated they landed on their left side. ROM (Range of Motion) performed. Physician notified. New order for X-Ray of left tibia/Left fibula, left femur, left foot, left shoulder and left elbow. PRN Tylenol given . Description . Fall to floor: Unwitnessed . Was resident found on floor- Yes . What footwear was in use at the time of the event . Barefoot . Was the Resident injured- No . Resident initial disposition- no treatment . Possible causative factor(s) . Agitation . Floor: Wet or Slippery . A new plan of Care/Intervention has been completed to prevent further events . -Event Date: 6/13/19 4:00 PM . Resident attempted to self-transfer to w/c (wheelchair and slid down to floor . Description . Fall to floor: Unwitnessed . Was resident found on floor- Yes . Was the Resident injured- No . A new plan of Care/Intervention has been completed to prevent further events . An interview was conducted with the Director of Nursing (DON) on 7/31/19 at 2:50 PM. When queried regarding Resident #117's fall in the facility resulting in them fracturing their humerus (arm), the DON reviewed the incident report and stated, It happened on 5/25/19. We ordered an X-Ray but didn't even do it. (Resident #117) started complaining of pain and we sent (the Resident) to the hospital. With further inquiry regarding when the fall occurred and when the Resident was transferred to the hospital, the DON stated, (Resident #117) fell on [DATE] and they were sent to the hospital on [DATE]. With further inquiry regarding what occurred when the Resident fell on [DATE], the DON indicated the Resident spilled water when they were carrying it. When asked if an investigation was completed, the DON revealed the facility did not complete an investigation. With further inquiry regarding the incident report and medical record documentation indicating the Resident tipped over a glass of water, the DON reviewed the Resident's medical record documentation and stated, When I read it, it sounds like they tipped over a glass of water. When asked if the water was on the floor when it was tipped over, the DON was unable to provide an answer and indicated the water could have been on the Resident's over bed table. When asked about the amount of items and clutter on Resident #117's room floor near their bed, creating a fall risk, and if the Resident's room contained the same amount of items when they fell and fractured their arm, the DON indicated they had and stated, (Resident #117) is a bit of a hoarder. When asked if they had storage areas within the room to place their items, the DON stated, (Resident #117) doesn't want us to put it in storage. When asked if there was an additional area in the room that the Resident would be able to store their items, the DON indicated they would need to speak to maintenance staff. When queried why the incident report revealed the Resident fell on [DATE] at 6:50 PM when a note regarding the fall was documented by nursing staff on 5/25/19 at 4:50 PM, the DON did not provide an explanation. When queried regarding care plan interventions in place prior to the fall on 5/25/19 and new interventions implemented following the fall to prevent future falls, the DON reviewed the medical record and stated, (Resident #117) was reeducated on call light use. Resident #117's care plans and care plan history were reviewed with the DON at this time. When queried regarding the intervention related to a safe environment with even floors free from spills and/or clutter which was active and revised on 1/28/19, the DON stated, Yes, I see that. When asked if the Resident's room was free of clutter at the time of the fall, the DON stated, That (current condition) is how (Resident #117's) room has been. When queried regarding the Resident's second fall, after returning from the hospital due to the left arm fracture, the DON indicated the Resident was attempting to self-transfer into their wheelchair. When asked where the Resident's wheelchair was positioned in their room when they attempted to self-transfer and fell as the amount of items surrounding the Resident's bed does not allow for placement of the wheelchair in any near proximity to the bed, the DON stated, I don't know. When asked what interventions were implemented following the fall, the DON indicated the Resident was reeducated to use the call light for assistance. When queried regarding documentation of the Resident being confused at the time of the fall, blood glucose levels being elevated, and lack of new interventions not already in place, the DON indicated the Resident was alert. When asked why planned interventions on the Resident's care plan were not implemented prior to each fall, the DON did not provide an explanation. When queried if additional interventions had been attempted, the DON reviewed the medical record and indicated they did not see other interventions. Record review on 7/31/19 of facility policy titled, Fall Evaluation Safety Guideline (Effective 11/28/17) revealed, Purpose: To consistently identify and evaluate residents at risk for falls and those who have fallen to treat or refer for treatment appropriately . Guideline: Residents who are evaluated as being at risk for falls will be identified and individualized fall precautions will be developed for each resident. Preventative measures shall be taken to decrease the number of falls whenever possible . To consistently identify and evaluate residents who fall and to treat or refer for treatment appropriately . To achieve each resident's maximum potential of physical functioning . To prevent or reduce injuries related to falls . Procedure . A Fall Risk Evaluation will be completed . Upon admission/readmission to the facility; Quarterly; With a significant change of status and as needed . If the evaluation finds the resident at risk, implement resident specific interventions/precautions. Initiate, review and revise the fall care plan as appropriate, with new or discontinued interventions . All residents identified as at risk for falls will be reviewed for individualized interventions . Recommendations for Strategies on Managing Falls . General Preventative Strategies . Re-evaluate and observe closely after medication modifications or as condition(s) worsens . Provide safe, clutter free environment . Monitor high-risk medication (side effects) . Fall related to toileting needs: Provide a night light . Clear pathway to the bathroom . Footwear to prevent slipping such as socks with grippers . Assistive device within reach (but not an obstacle) . Toilet Schedule . From Bed - Unable to transfer . Contour/Perimeter Mattress in accordance with a device evaluations for positioning . Body Pillows for positioning . Call light within reach and secured; answer call light promptly . Mat beside bed as evaluation indicates for safety management . Consider bowel and bladder program and/or regular toileting schedule or offer toileting assist frequently with interactions between scheduled times . Deficient Practice Statement #2. Based on observation, interview, and record review, the facility failed to safely turn/re-position during care for two sampled residents (R#13 and R#85), resulting in a fall from the bed to the floor, and/or a laceration to the left eyebrow. Findings include: On 7/29/19 at 1:36 PM, Confidential Witness I was queried regarding any falls or injuries R#85 has had at the facility. Confidential Witness I stated, (They) fell on (MONTH) 29th this year. They (staff) said they were changing (the resident) and they fell off the bed onto the floor during changing. (R#85) got a cut above the eye. So, I insisted they put the pads down by the bed after that. It happened on the evening shift. It was just one aide changing (R#85) they are supposed to have two people for that, so that's what happened. (R#85) had to go to the ER (emergency room ), where they glued it back together and put strips on. On 7/30/19 at 8:15 AM, Certified Nursing Assistant (CNA) Q was observed going into R#85's room. When queried if they were going to change R#85, CNA Q stated they were about to. When asked if they were about to change R#85 by themselves, CNA Q stated, Yes, I'm just changing (their brief). When asked if R#85 needed two staff members for changing, CNA Q stated, No, (they're) a two-person for assist but I'm going to go get some help. When attempting to interview R#85, the resident was unable to answer any questions appropriately. Unit Manager Nurse R entered the room and was observed to have to hold R#85 on their side in bed while their gown, bedding, and brief were changed by CNA Q. R#85's bed was observed to have no assist bars on the sides of the bed and the resident appeared unable to maintain their body in a turned position without staff assistance. On 7/31/19 at 9:02 AM, Nurse L was contacted via phone for an interview and queried regarding the incident on 5/29/19 involving R#85. Nurse L stated, The CNA (CNA N) was undressing the resident in bed. I think she said she was putting a gown on them for bed. She came and got me. We went down there and (R#85) was on the floor. I asked her what happened and she said when she was taking (the resident's) pants off, (they) rolled onto the floor. When I went in there, (R#85) was lying on (their) abdomen as if (they) had rolled out of bed. (R#85) was supposed to be a two-person assist. She told me the other CNA was busy helping someone else, so she said she thought she could at least just undress the resident. (R#85) got transferred out after that, because (they) had a cut over (their) eye. I'm not sure if (they) received stitches but it was a deep cut over (their) eyebrow. When queried if the cut was actively bleeding, Nurse L stated, When I saw (R#85) on the floor, yes. Nurse L continued, There were only like two CNAs on the floor that night on midnights. I think the CNA was kind of new there. I know the other CNA that was helping her had told her (R#85) is a two-person and to wait for him to help. So why she attempted to do it herself, I have no idea, I was very confused on that part. I knew for sure (R#85) was a two-person assist. On 7/31/19 at 11:45 AM, Nurse T was queried regarding R#85's need for assistance from staff. Nurse T stated, I have always known (R#85) to be a two-person for just about everything. Definitely turning in bed, transferring, ADLs (activities of daily living), because the resident tenses up and can sometimes become resistive to care. They can be very difficult to turn and the resident does favor their left side. On 7/31/19 at 11:50 AM, the Director of Nursing was queried regarding the incident in (MONTH) with R#85. The DON stated, The resident had a laceration to the forehead, went to the ER, and came back to the facility. My understanding is that the CNA (CNA N) thought since she was dressing the resident, she only needed one person. The bed mobility instructions were for two-person assist and I believe the dressing instructions were for one. We educated everyone after that if someone is in bed, they are to refer to 'bed mobility' for how many staff. On 7/31/19 at 12:19 PM, CNA N was interviewed regarding the incident involving R#85 on 5/29/19. CNA N stated, I was by myself getting (R#85) undressed. They (facility) gave me an in-service on the resident being a two-person no matter what because (they) do get jittery. I was pulling off the residents' pants, and needed to turn (R#85) to get them all the way off. (R#85) rolled out of the bed, and I went and told the nurse. I was waiting for someone to help me change (them), so I thought I could get (the resident) undressed by myself and then have someone to help me change (them). CNA N was then queried about where she was in relation to where the resident rolled off of the bed. CNA N stated, I was on one side of the bed, pulling the pants off, and (R#85) rolled over the opposite side of the bed. CNA N indicated the resident rolled out of bed onto their abdomen, facing down. CNA N was then queried about how high the bed was when the resident rolled out of it. CNA N then stood up and placed her hands at her hip level and stated, About here, about by my hips. I'm 5'2. (They) fell out of the bed and I ran and got the nurse. There was a cut on (their) head and some blood. I didn't want to leave (R#85) like that but I did mess up because I did touch (the resident) when (they were) on the floor. I put a sheet down. I got an in-service about all of that, that you can't touch someone after they fall like that. (R#85) was making (their) normal moaning sounds when (they) were on the ground. A review of R#85's progress notes revealed the following: 5/29/2019 23:59 *Fall Note Text: CNA was undressing resident in bed and resident rolled unto the floor when was turned to pull down pants. Bed was floor level, resident was lying on back on the left side of the bed on the floor. BP (blood pressure) 124/80 P (pulse) 112 .Laceration noted to above left eye. Direct pressure applied to control bleeding. (Physician) notified and ordered to transfer resident to (acute care hospital). (Family) was notified of incident and transfer . 5/30/2019 08:15 *Health Status Note: Receive resident from (acute care hospital by ambulance) .Resident is noted with Laceration to left eyebrow. Eyebrows has two steri-strips . A review of R#85's Fall Risk Evaluation - Post Fall, dated 5/29/19 at 11:37 PM revealed: 1. Has the resident had a recent known fall? a. Yes 2. Does the resident have generalized weakness and limited/poor mobility? a. Yes .7. Neuromuscular/Functional Factors: a. Loss/Decline in use of arm/leg movement .10. Cognitive/Behavioral Factors: b. Decline in Cognition .3a. Injury Assessment: f. Laceration .A. New interventions for this fall that are being implemented: In-service provided to CNA's regarding checking care plans and 2 person assist will (sic) in bed. Care plan updated . A review of R#85's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident required total assistance from two or more staff for dressing. A review of R#85's care plan revealed: The resident has actual / potential for an ADL self-care performance deficit r/t (related to) Activity Intolerance, Confusion, Dementia AEB (as exhibited by): - requires extensive to total assist with ADLs and transfer - requires 2 person assist with transfer, hoyer - non ambulatory Revision Date: 1/14/2019 .BED MOBILITY: The resident is extensive on (2) staff for repositioning and turning in bed . Revision Date: 4/3/2019. A review of R#85's Emergency Department Discharge Instructions, dated 5/29/19-5/30/19 revealed that the resident received a [MEDICATION NAME] (Tetanus/[MEDICATION NAME]/[MEDICATION NAME]) vaccination, and included instructions for Trauma: Scalp Laceration: Sutures or Staples, and Head Injury (Adult). A review of the incident report provided by the facility titled, Report of Resident Fall, included a handwritten page with multiple signatures that revealed the following: 5/29/19 Inservice: When a resident is in the bed then we need to follow the bed mobility assist level. Even if the resident requires one person for dressing while they're in the bed we follow the bed mobility assist level because the resident does not have the strength to hold them self up while turned on their side. So if you are only using one person then the resident can roll too far and gravity will take them off the side of the bed. So always follow the care plan and use 2 person assist. A review of R#85's MDS assessment dated [DATE] revealed: The resident was admitted into the facility on [DATE], had cognitive skills for daily decision making that were Severely Impaired, with medical [DIAGNOSES REDACTED]. A review of the facility's policy titled, Fall Evaluation Safety Guideline, effective 11/28/2017 revealed: PR[NAME]EDURE: 1. A Fall Risk Evaluation will be completed at the following times: Upon admission/readmission to the facility. Quarterly. With a significant change of status and as needed. 2. If the evaluation finds the resident at risk, implement resident specific interventions/precautions. 3. Initiate, review and revise the fall care plan as appropriate, with new or discontinued interventions. A policy/procedure relating to staff assistance for bed mobility and ADLs was requested on 7/31/2019 at 9:13 AM but was not received prior to survey exit. On 7/29/19 at 2:02 PM, R13 was observed in bed watching television. R13's upper body was leaned to the right side. R13 was asked if (R13) had any falls over the last year. R13 said, I fell out of bed last week. The Certified Nurse Aide (CNA) was trying to clean me and change my brief. I told her it takes two CNAs because I can't turn, but, she kept turning me. She pushed me over and I fell out of bed. I cannot move so she had to push me over. She did not do it on purpose. (CNA) was trying to help me. I don't want anyone to get in trouble. (CNA) did not mean to push me out of bed. R13 was asked if the CNA rolled (R13) toward (CNA) or in the other direction (away) from (CNA). R13 said, She rolled me away from her, the other way. I could not hold on because my hands have arthritis and are too weak. My left leg was hurting. But I'm ok now. R13 was observed to have contractures of their hands and feet. On 7/30/19 at 10:40 AM, R13 was observed in bed with upper body leant to (R13) right side. R13 was asked if they can pull self over, more centered in bed. R13 attempted to adjust self in bed but was not able to initiate this task. On 7/30/19 at 12:04 PM, R13's medical record was reviewed and noted the [DIAGNOSES REDACTED]. The care plan dated 1/26/2019 noted the following: The resident will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury .The resident requires extensive assistance by (1) staff to turn and reposition in bed frequently. The review of the Occupational Therapy (OT) HH documentation dated 5/16/2019 Assessment Summary noted: Pt (patient) is not appropriate for skilled for OT services as (R13) is total dependent (TD) for all bed mobility, ADL completion. The progress note was reviewed and created by Nurse GGon 7/7/2019 at 10:40PM noted the following: Writer alerted by CNA that resident was noted on floor. On enter room Writer noticed bed in low position and resident laying flat on back between bed 2 and bed 3. ROM performed Resident is A&O x3 and able to make needs known. On assessing ROM (range of motion) performed pain noted to left lower extremity only. Resident stated that pain is 5 on a scale 1-10. Skin intact. Resident is able to move all other extremity without pain noted. The progress note was reviewed and created by the Director of Nursing (DON) on 7/8/19 at 2:06 PM, noted: Resident s/p (status [REDACTED]. Stated that she had fallen from the bed because she felt weak and was not able to stop herself from rolling over. New Intervention is for PT/OT (physical therapy and occupational therapy) to screen and treat as needed for balance, safety and strengthening. Upon record review of the medical record orders, did not find a new order for PT/OT. The progress note created by Nurse I dated 7/12/2019 at 4:53 indicated the following: Resident A&O x4 (alert and oriented to person, place, time, situation), pleasant (and) cooperative. Able to voice needs (and) wants, et to express pain level et [MEDICATION NAME] effectiveness level. On 7/31/19 at 8:48 AM, R13 was observed sitting in their wheelchair. R13 was queried about the fall last week and (R13) said, I did not roll out of bed by myself, the CNA was changing my brief. No, no. I cannot roll over in bed. Look at my hands. I can't even move my feet over. On 7/31/19 at 2:48 PM, a review of the Incident/Accident report noted the following: Event date 7/7.19 at 11:40 AM, Nurse GG: On enter room Writer noticed bed in low position and resident laying flat on back between bed 2 and bed 3. Arm where down by side. Resident is A&Ox3 and able to make needs known. On assessing ROM performed pain noted to left lower extremity only. Resident is able to move left leg and wiggle toes. Resident stated that pain is 5 on a scale 1-10. Skin intact. Resident is able to move all extremity without pain noted. CNA J stated on the Incident/Accident report the followingResident was in room on her side with her leg crossed over the other in the middle of the bed with the bed in low position. On 7/31/19 at 3:44 PM, the Assistant DON was interviewed and asked about R13's fall out of bed and the contradiction between the Incident report, progress notes, and R13's interview. The ADON said, The CNA said (R13) rolled out of bed. But it's hard to provide care sometimes in bed without residents not accidentally falling out of bed. Every big building like this have falls.

This citation pertains to intake MI 484 Based on interview and record review, the facility failed to provide two person assistance while rendering care per the nursing assessment and Certified Nursing Assistant (CNA) Care Guide for one (#503) of two sampled residents reviewed for falls, from a total of three, resulting in the CNA leaving Resident #503 in bed, in the highest elevation, resulting in a fall from the bed and sustaining fractures to both legs. Findings include: On 3/9/18 at 9:59 a.m., the Unit Manager (Nurse B) was interviewed regarding Resident #503's fall. Nurse B stated, I was summoned to the room by CNA A. The resident was on the floor on her right side. The resident (#503) stated that she rolled out of bed. CNA A had just provided care. She (#503) stated rolling out of bed and not being able to stop. The bed was in a low position. It's our policy to keep the beds in a low position. On 3/9/18 at 10:03 a.m., a tour of the unit 1 North accompanied by Nurse B, where Resident #503 resided revealed all residents' beds being at a normal height. There were no beds in a low position. When asked why there were no beds noted in a low position, Nurse B was unable to provide an explanation. The policy for low beds in the facility was requested at this time. On 3/9/18 at 10:09 a.m., the Director of Nurses (DON) was queried regarding a policy regarding residents' beds being in the low position. The DON stated, We don't have such a policy regarding low beds. The beds are normally in a regular position unless we have an order to have a resident's bed positioned in a low position. On 3/9/18 at 10:10 a.m., review of the facility's incident report, authored by Nurse B, regarding Resident #503, dated 1/8/18 at 14:30 (2:30 p.m.), revealed the following documentation: Summoned to room by CNA, resident lying on floor next to bed. Resident state she was laying on left side and started to roll on to right side on floor .Body assessed no [MEDICAL CONDITION] or bruising noted. 2:30 p.m. doctor notified, orders X-ray bilateral shoulders, bilateral hips knees and head . The report indicated there were no witnesses to the fall. The resident's husband and/or any other family members were informed at this time. On 3/9/18 at 10:12 a.m., an interview was conducted with the complainant (C). Complainant C stated, The CNA stepped out of the room for something while providing care. She (Resident #503) was left lying on her side without any siderails in place. The siderail was down. They were cleaning her. When she fell , she broke both of her femur bones. Her husband told me that when he got there (arrived to visit) her legs were all twisted up. He arrived there at the facility around 3:00 p.m. She (#503) was still there until 7:00 p.m. We don't know what time she fell . They never had her bed in a low position. Her bed was always in a high position. She was on an air mattress because she had bed sores. The complainant reported that Resident #503 passed away shortly after the incident. On 3/9/18 at 10:25 a.m., an attempt was made to interview CNA A by phone. There was no answer. A message was left on the answering machine for a return phone call. On 3/9/18 at 10:35 a.m., review of Resident #503's medical record revealed the following: The hospital's Surgical Progress Note/Trauma Progress Note, dated 1/11/18 indicated that Resident #503 was status [REDACTED]. The hospital's History of Present Illness, revealed the following documentation: Patient was brought in as a level 2 trauma activation after falling out of bed at her nursing home. Per the patient, she missed [MEDICAL TREATMENT] today because of diarrhea She was being cleaned at the nursing home when she rolled out of bed. She remembers the fall .She did hit the right side of her head. She was complaining of right sided head pain, as well as bilateral leg pain. Per report, she had very obvious deformity fo the right femur when EMS arrived, and she was placed in a traction splint in the right leg and a splint on the left leg. She was in the nursing home for rehabilitation related to chronic wound on the left heel and an old left knee injury. The facility's Post Fall Nursing Assessment Documentation Record, dated 1/8/18, revealed documentation of the fall that occured at 2:30 p.m. It was noted that Resident #503 had joint pain with palpation/ROM, Inability/Ability to bear weight, x-rays and a transfer to ER (emergency room ) were ordered. Per the Head Injury Documentation Record, dated 1/8/18, Resident #503 was not sent out to the hospital any sooner than 6:55 p.m. per the assessment record. Review of the face sheet indicated that the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #503's most recent quarterly Minimum Data Set (MDS) assessment, dated 1/13/18, with an assessment reference date of 1/2/18, indicated an intact cognition. Resident #503 was totally dependent upon others with the assistance of two persons for all activities of daily living (ADLs), except for eating (support of one person). Two person assistance was required for bed mobility. The Resident Care Guide indicated the requirement of two persons assisting with bed mobility. Review of a NSG-Skin Observations assessment, dated 1/8/2018 at 4:00 p.m., indicated that Resident #503 had [MEDICAL CONDITION] to bilateral lower anterior legs. The assessment also had the following documentation: At 4 p rounding noted small amount of [MEDICAL CONDITION] bilateral lower extremities. Resident state she was in pain, Initial order for x-ray. Pain noted during rom (range of motion). Doctor notified. Noroco 7.5/325 mg (milligrams) given. Orders to transfer . (to acute care). Review of the Nursing Home to Hospital Transfer Form, dated 1/8/18 at 6:02 p.m., authored by Nurse B, indicated a transfer to the hospital due to a fall. Review of the a nurse's note, (authored by Nurse B) regarding Resident #503, dated 1/8/2018 at 22:58 (10:58 p.m.), revealed the following documentation: Resident out to hospital c/o (complained of) pain noted doctor, notified new order transfer (to acute care) r/o pain and discomfort, Resident states level @ 10. The note indicate that Resident #503's husband was at the bedside. On 3/9/18 at 11:00 a.m., the DON was queried regarding Resident #503's fall. When asked if she knew the details of the incident and how Resident #503 was left positioned in bed when the CNA left the room, the DON reported not being sure how Resident #503 was positioned. The DON stated, She rolled out of bed. When asked what type of mattress she was resting on, the DON stated, She was on an air mattress. I will have to get back with you on how she was positioned. On 3/9/18 at 11:15 a.m., CNA A's employee file was reviewed and the following was noted: a Work Performance/Work Rules Disciplinary Action Record, dated 1/9/18, and authored by the DON. The disciplinary action involved the incident with Resident #503. It revealed the following documentation: Date of infraction: 1/8/2018. The description of the incident included the following: Failure to assure 2 person assistance while providing care for resident per the CNA care guide in the resident's room. CNA left resident in bed with bed in highest elevation and left room to obtain a bed sheet. While employee was out of room, resident rolled out of bed sustaining an injury, potentially a fracture to right leg. Employee was counseled on failure to provide appropriate support and supervision for resident and admitted that she left resident unattended. Employee is hereby discharged . On 3/9/18 at 11:33 a.m., the DON was queried regarding why employee A no longer works at the facility. The DON reported the facility had a high employee turn over rate and that the CNA was still in her probationary period. When asked if the CNA was terminated due to the incident that involved Resident #503, the DON stated, She was not terminated related to the incident. She had prior incidents. We did not document them. The Work Performance/Work Rules Disciplinary Action Record for employee A regarding the incident for Resident #503 was presented to the DON. The DON then stated, She was termed due to the incident. On 3/9/18 at 2:45 p.m., review of the facility's policy entitled ADL (Activities of Daily Living), Functional Mobility & Resident Care, last reviewed 8/2017, revealed the following documentation: Resident safety is to be monitored and maintained by nursing staff during each ADL activity.

Based on observation, interview and record review, the facility failed to obtain parameters for skin cleansing and assessment under a leg immobilizer (removable cast), perform accurate and complete skin assessments, and ensure that a leg immobilizer was properly fitted for one (#309) of six residents reviewed for pressure sores, out of a total sample of 30, resulting in the development of pressure sores. Findings include: On 1/14/15 at 10:30 A.M., Resident #309 was observed in bed in the room. The Resident was alert and oriented and reported that she was paralyzed on her left side due to a stroke. The resident had an immobilizer on her left leg, extending from mid thigh to just above her ankle. The resident's left foot was contracted (joint ligaments shortened through disuse, resulting in abnormal foot position) medially (bent inwards towards the center of her body), causing the edge of the immobilizer to press against the ankle of the left foot. There was a gauze dressing on the resident's left foot and ankle, extending from underneath the immobilizer to below the ankle. Resident #309 stated, "I got sores on that leg from the brace (immobilizer)." Nurse "Z", who was in the room, stated, "She's been in that immobilizer since she broke her leg last November (11/11/14). The Orthopedic Doctor didn't want us to remove that brace at all. He wanted that leg kept immobilized. Radiology took the brace off to do a follow up (f/u) X-ray on that leg last week, and we found two little dry scabs under the brace. We were assessing her foot below the brace daily. It was pink and warm, with good pulses. She had [MEDICAL CONDITION] (swelling) of that leg when she first came back from the hospital (11/14/14)." On 1/14/15 at 10:35 A.M., Nurse "Z" was asked if Resident #309 had any other pressure sores or open areas, and stated, "No". Resident #309 then stated, "I've got a sore on my right foot too. It's from my shoe. It's too tight. My podiatrist, Dr. (Name given) said that I was supposed to wear a pad over my bunion to protect it." Resident #309 then pulled the sheet off her right foot and pointed to the right side of her foot near the joint of her big toe, where she had a pencil eraser sized flat brown scab surrounded by reddened skin over the center of a bunion. Nurse "Z" was queried about this skin alteration, and stated, "I didn't see that one. There's no documentation of it. I don't know anything about a bunion pad." On 1/14/15 at 2:00 P.M., Wound Care Nurse "KK" was interviewed regarding Resident #309's left leg wounds, and stated, "The wounds are from the rod on the brace and from the edge of the brace. It happened because it (the immobilizer) slipped down. If they leave it like that, it's a problem. I was waiting for that to happen. The brace was too big once the swelling went down." On 1/14/15 at 2:05 P.M., Nurse "Z" was queried about Resident #309's immobilizer and stated, "I never saw the brace slip down. She only got up in the wheelchair two times a day, and everything was fine." When asked why she didn't see Resident #309's left ankle wounds, which were located below the level of the brace, Nurse "Z" stated, "I didn't see anything. X-ray (technician) was the first to notice." On 1/14/15 at 2:15 P.M., Nurse "Z" was requested to provide all documentation of skin assessments for Resident #309. Nurse "Z" reported that the residents' skin was assessed during the weekly shower or bed bath, and was done by a Certified Nursing Assistant (CNA) who signed the "Bathing/Skin Check Form", and then assessed again by a nurse, who also signed the form, attesting to it's accuracy. Review of Nursing notes and Treatment Records (TAR) for Resident #309 from 11/14/14 through 1/6/15 with Nurse "Z" revealed numerous nursing notes documenting that Resident #309's left foot was warm to touch and had palpable (can be felt) pedal (foot) pulses (indicative of adequate circulation/blood flow to the area). There was no documentation to indicate that the skin under or around the immobilizer was assessed for open areas or pressure sores. A Nursing Note for Resident #309, dated 1/6/15, signed by Nurse "Z" documented the discovery of two left leg wounds, "Resident splint removed for X-ray. Left leg, two small scabbed areas on ankle and calf." A "Bathing/Skin Check Form" for Resident #309, dated 1/7/15 (the day after Resident #309's two breaks in the skin were discovered) documented that the resident had intact skin, with no open areas, breaks in the skin, bruises, scrapes or blisters. When asked if this was an accurate and thorough skin assessment, as two known wounds were not documented or acknowledged as existing, Nurse "Z" turned the form over to look at the body diagrams, noted that they were blank (no areas circled as having alterations in skin condition), and stated, "There's nothing here. Both the CNA and the nurse signed, but it was the evening nurse, and I can't speak for her." On 1/15/15 at 9:00 A.M., Review of Resident #309's clinical record revealed the following information: A face sheet documented that Resident #309 was readmitted into the facility on [DATE] after a hospitalization . [DIAGNOSES REDACTED]. A Minimum Data Assessment ((MDS) dated [DATE], documented that Resident #309 had intact cognition, had no indicators of [MEDICAL CONDITION], did not walk, and needed extensive assistance for mobility in bed, transfers to the wheelchair, toileting and hygiene. The MDS also documented that Resident #309 had no pressure ulcers or vascular ulcers. Braden Scale Assessments (for Risk of Developing Pressure sores), dated 11/16/14 and 1/2/15, documented that Resident #309 was at mild risk of developing pressure sores, with a score of 17 (mild risk = 15-18, highest possible score = the lowest risk =18). A "Risk Factor For Wound Development" form for Resident #309, dated 11/15/14, documented that Resident #309 had risk factors for developing pressure sores, including, "mobility limitation, [MEDICAL CONDITION], chronic pain, fracture, and immobilizer to left (L) leg." A Nursing Care Plan for for Resident #309, initiated 11/14/14, entitled "Standard of Care for Residents with Splints", contained no parameters for monitoring or cleansing the skin under the immobilizer. A checked (activated) "Goal" was noted as, "maintain healthy skin integrity", but did not have any corresponding interventions. An activated intervention for assessment of the device, "Rehabilitation (skilled therapy services) will re-assess monthly and up-date as needed", was crossed out and "error" written next to it, with no date to indicate when this was done, or no note to indicate why. A Nursing Care Plan for Resident #309, dated 1/2/15, entitled, "Activities of Daily Living (ADL)", contained the following intervention, "Inspect skin daily during care and during showers. Report changes in skin to the nurse." A Podiatry Consultation dated 9/2/14, documented that Resident #309 was seen for, "A painful bunion bilateral (both) foot." The Plan included, "Recommendations of continued padding. She did have some bunion padding." A Physician's Progress note for Resident #309, dated 12/5/14, documented that Resident #309 had complaints about the leg immobilizer, "Is complaining about having knee immobilizer on." The Physician documented "Treatment" as, "She just does not like to be in a knee immobilizer." There was no documentation to indicate that the resident's left leg was assessed to determine the cause of the resident's discomfort. A Physician's telephone order for Resident #309, dated 1/14/15 noted, "Hold (don't use) brace of L leg until Orthopedic appointment." On 1/15/15 at 9:15 A.M., The Unit Manager (UM) Nurse "J" was interviewed regarding Resident #309's ankle wounds and stated, "There were no wearing parameters for the immobilizer. We noticed it was the rod that caused the wounds." When queried, Nurse "J" stated that Resident #309 had two wounds on the left lower leg. On 1/15/15 at 9:15 A.M., UM "J" and Wound Care Nurse"KK"were observed performing a dressing change for Resident #309's left leg wounds. Three wounds, and an additional area of skin alteration were observed on the resident's left leg, as follows: Wound 1: left (L) lower leg, in the middle of the back of the calf, approximately five centimeters (cm) above the achilles tendon was a crescent shaped open area with white curled edges around a yellow base, containing three scattered pencil eraser sized areas of dark brown eschar (dry dead tissue). Wound Care Nurse "KK" stated, "I didn't see that one." When queried, both UM "J " and Wound Care Nurse "KK" stated that this wound had not been noted by the facility. Wound 2: Over the L medial (side towards center of body) malleolus (ankle bone), there was a dime sized circular area of dark brown eschar with a bumpy, raised irregular surface, surrounded by pale, puffy edges with an outer area of pink superficial skin loss and scattered scabs. Wound 3: Over the L medial heel was a circular area of non blanchable (indicates tissue damage) red skin with a darker purple center, and a half moon shaped area of dark brown eschar with a dark red center and reddened edges. Area 4: Over the L Achilles tendon there were three areas of dark purple non-blanchable skin. When asked at this time, why Wound #1 had not been noted by the facility, Wound Nurse "KK" stated,"We didn't see it." When asked why wound #2, on the L malleolus was not discovered by the facility, despite being below the level of the immobilizer, Wound Nurse "KK" stated, The Immobilizer kept slipping down because it was too big. Her leg was contracted inward and her ankle rested against the metal rod in the immobilizer. That's what caused the wound. It's exactly where the rod was when the brace slipped down." On 1/15/15 at 9:30 A.M., per request, Resident #309's brace was reapplied by UM "J" in the presence of Wound Nurse "KK" to assess fit and position of the wounds. UM "J" stated, "The metal rods in the brace didn't slip down, but the brace did. It didn't fit properly. It kept sliding down. That accounts for the one (wound) that's right here where the rod is (wound #1 on the back of the calf). It (the immobilizer) should fit above all these wounds. The two on the L ankle and heel are due to her foot contracture. When the brace slid down, it pressed against her foot in those two spots." On 1/15/15 at 9:35 A.M., during the wound observation with UM "J" and Wound Care Nurse "KK", Resident #309 stated, "Dr (Podiatrist) wrote in the book that I was supposed to have a cover for my bunion, moleskin, right?" UM "J" replied, "I didn't know that." Wound Care Nurse "KK" stated, "I didn't, either. The Podiatrist didn't say anything to any of us. He just writes and goes without telling us." Resident #309 stated, "They never took that brace off to wash my leg or check my skin." On 1/15/15 at 9:45 A.M., the Physiatrist (Rehabilitation physician) Dr. "LL" was interviewed regarding Resident #309's immobilizer and stated, "Normally the Orthopedic Consultant sends the resident with parameters for wearing and removing immobilizers or splints. There was none of that for (Resident #309). The immobilizer was too long. The Orthopod knows it's too long. That's why he cancelled it. (phone order to hold brace on 1/14/15)." When asked who was responsible for assessing Resident #309's immobilizer for correct fit, and who's responsibility it should have been to address this, if staff were aware that the immobilizer was "too long" or "slipped down" because it did not fit correctly, Dr. "LL" stated, "Nursing and Therapy should." On 1/15/15 at 10:30 A.M., The Director of Nursing (DON) was interviewed regarding Resident #309's immobilizer and stated, "Physical Therapy, Occupational Therapy and (the Physiatrist) should be working together as a team and should be communicating." When asked who should have performed an assessment of Resident #309's immobilizer and implemented any necessary corrective measures once staff identified that the brace was "too long", and "didn't fit properly", the DON stated, "They all should have been assessing that." When asked to explain Resident #309's skin assessment of 1/7/15, which stated she had no skin alterations, and was done the day after two of the wounds were documented and noted, the DON stated, "I'll have to look in to that. I'll talk to both that nurse and that CNA who did that skin assessment." When asked why two of Resident #309's wounds were not discovered by the facility, but by the X-ray technician, despite the fact that they were both below where the immobilizer was supposed to end, and why the left calf wound and right bunion wound were not noticed by staff prior to survey inspection of the resident's skin, the DON stated, "I'm sure that they were assessing under the immobilizer. I'll ask Wound Care. They should have been documenting regular skin assessments, I'm sure they have something. I'll have to look." On 1/16/15 at 4:00 P.M., A Wound Care Consultation dated 1/16/15, was reviewed with Wound Care Manager "BB" who reported that the assessment had been done by the Wound Care Physician's Nurse Practitioner (NP). The NP documented under "vascular" that the resident had palpable pulses. Three wounds were documented as assessed for Resident #309, a L medial heel 1.2 x 0.5 cm with dry maroon base, a L medial ankle 0.3 x 0.5 cm with dry base, and a L medial leg with fragile cicatrix (scar) (no measurements noted). There were no depth measurements, or identification of type, or of any staging of the wounds. The "Diagnosis" was noted as, "L eschar, L medial heel, L medial ankle." There was no documentation that the dark purple nonblanchable area over Resident #309's left Achilles tendon or the area of eschar with redness over the right foot bunion were assessed by the NP. On 1/21/15 at 2:30 P.M., a facility policy entitled, "Splint Policy", dated 10/13/14, was reviewed and revealed no information regarding immobilizers prescribed by an outside physician. On 1/21/15 at 2:40 P.M., a facility policy entitled, "Preventative Skin", dated 9/12/14 was reviewed and revealed the following documentation, "The Charge Nurse will complete skin assessments, no less than weekly to identify any new wound concerns or changes with existing wounds." ( )

Based on observation, interview and record review, the facility failed to ensure that one (#309) of twelve residents reviewed for accidents, out of a total sample of 30, was provided with a wheelchair with a seat depth appropriate for the resident's height, and a wheelchair cushion that was the correct size, resulting in a fall with fracture (broken bone). Findings include: On 1/15/15 at 9:00 A.M., Review of Resident #309's clinical record revealed the following information: A face sheet documented that Resident #309 was readmitted into the facility on [DATE] after a hospitalization . [DIAGNOSES REDACTED]. A Minimum Data Assessment ((MDS) dated [DATE], documented that Resident #309 had intact cognition, had no indicators of delirium, did not walk, and needed extensive assistance for mobility in bed, transfers to the wheelchair, toileting and hygiene. The MDS also documented that Resident #309 had impaired balance. A Nursing Care Plan for Fall prevention for Resident #309, initiated 2/26/13, and last updated on 7/24/14, documented that Resident #309 was at risk for falls. Interventions added on 2/26/13 to prevent falls from the wheelchair, "Dycem (an anti slip pad) to wheelchair", and "wheelchair assessment", indicated that Resident #309 was at risk for sliding out of the wheelchair. Review of facility "Incident Investigation Reports" for Resident #309 revealed the resident fell on [DATE], and on 7/24/14 during staff assisted transfers (to or from wheelchair) because her legs "gave out". A "Resident Incident/Accident Report" for Resident #309, dated 11/11/14 at 9:20 P.M., documented that Resident #309 fractured the proximal shaft of the tibia and the fibula after a fall from the wheelchair. The report documented, "Resident fall to floor against wall from wheelchair. Foot slip from foot rest while repositioning herself." A Nursing Note, dated 11/11/14 at 9:30 P.M., documented Resident #309's fall from the wheelchair, noting, "Resident observed on the floor against the wall on her right side, her left leg folded under her. Her wheelchair was at the foot of the bed. States while she was repositioning herself, her left foot (paralyzed side) slipped from the leg rest and she fell ." A Nursing Note for Resident #309, dated 11/12/14 at 3:05 A.M., documented that Resident #309 was sent to the hospital emergency room after post fall X-ray results showed fractures of the left fibula and tibia. A hospital Computerized Tomography (CT scan - a computerized multi-image X-ray) Report for Resident #309, dated 11/12/14 at 5:42 A.M., documented the following results, "Acute comminuted fractures (A fracture in which the bone is splintered, crushed, or broken into pieces) of the proximal left tibia and fibula." On 1/16/15 at 9:10 A.M., Resident #309 was interviewed in the room. The resident was alert and oriented, and was able to recall names, dates and details of past events and her medical history in detail. Resident #309 had left side paralysis, and had contractures of the left foot and ankle (ligament shortening causing the the foot to be stuck in an abnormal position). Resident #309 stated, "I fell because they had me in a wheelchair that wasn't deep enough. When I came back here after the fall, I was seen by Physical Therapy (PT) and Occupational Therapy (OT), and the girl from OT said that I fell out of my wheelchair because the seat wasn't deep enough for me. I'm five foot ten (5 ' 10"). They gave me a chair with a deeper seat after the fall. I was reaching across to my bed for something, and I slipped out of the wheelchair seat. My leg came out of the foot rest because it was too short too, and I fell . " On 1/16/15 at 9:50 A.M., Resident #309's old wheelchair ( used at the time of the fall), and new wheelchair were measured and inspected by Maintenance Employee "CC", in the presence of Resident #309. Resident #309 recognized her previous wheelchair, which was in the hallway outside the door of the room, and had unusual coloration, "That's my old one, the one I was in when I fell and broke my leg." The previous wheelchair was observed to be labeled with the resident's name and a pressure reduction cushion, also labeled with Resident #309's name, was observed on the seat. A lumbar cushion was observed to be attached to the backrest of Resident #309's previous chair, and was also measured at this time. The pressure reduction cushion on the previous chair was observed to extend several inches beyond the edge of the seat. Per request, Maintenance Employee "CC" pushed his hand down on the end of the cushion and the entire cushion was observed to compress to a 45 degree downward slope off the edge of the seat. When queried about this, Maintenance Employee "CC" stated, "That doesn't look too good." Measurements taken by Maintenance Employee "CC" at this time were: Wheelchair used at the time of Resident #309's fall on 11/11/14: seat depth: 18 inches (") Lumbar support thickness: 2" (Making actual depth of seat for resident's hips and thighs = 16") Seat width: 20" Seat Height: 22" Wheelchair cushion seat length: 19.5 " (extending 1.5" beyond front edge of seat) Resident #309's current wheelchair: Seat depth: 20" Seat width: 20" Seat height 20" wheelchair cushion seat length: 21.5" (extending 1.5" beyond front edge of seat) On 1/16/15 at 10:00 A.M., Maintenance Employee "CC" stated, "They wanted to put her in a deeper chair. She (Resident #309) was having a hard time keeping herself back in the chair. Therapy had assessed her after the fall and said she needed a deeper chair so they switched it out on 11/18/14. We didn't have that size in the storeroom, so we had to order it." Resident #309 stated, " I need to get that lumbar support back. Do you know how eight hours in that chair hurts your back?" On 1/16/15 at 11:15 A.M., OT "FF" was interviewed regarding Resident #309's wheelchairs. OT "FF" stated that she performed a wheelchair evaluation for Resident #309 after she returned to the facility after the fall with fracture on 11/11/14. OT "FF" stated, "We evaluated her (Resident #309) when she came back after the fall, because her hips weren't in alignment and the leg rest wasn't long enough. Her hips and legs were too far forward in the chair because she's really tall. We didn't give her back that lumbar cushion in the new wheelchair, because it would push her too far forward in the chair. She would slip forward if her hips weren't all the way to the back (of the seat)." When asked if it would increase the risk of a resident sliding out of the wheelchair if the pressure reduction cushion extended out beyond the front edge of the seat, OT "FF" stated, "It would be a problem. The cushion should be the same size as the seat. It wouldn't be good if it hung over the edge of the seat." When asked if she knew that the pressure reduction cushion in both Resident #309's previous wheelchair, and the current wheelchair extended 1.5 inches beyond the edge of the seat, OT "FF" stated, "I didn't know that. We didn't provide those cushions. They came with the wheelchairs, as far as I know." On 1/16/15 at 12:00 P.M., Review of an OT Evaluation and Plan of treatment for [REDACTED].M., revealed the following, "sitting balance: Fair. Patient's hip/knee/ankle alignment is at 90 degrees in wheelchair = No. (Patient is currently in standard wheelchair with lumbar support which causes hips to sit towards edge of wheelchair and pelvis to tilt.) Requested 20 by 20" wheelchair to trial in order to improve hip and lower extremity (leg) positioning. New wheelchair to be ordered since facility is unable to provide needed size." On 1/16/15 at 12:35 P.M. the Director of Nursing (DON) was interviewed regarding Resident #309's wheelchair and pressure reduction cushion and stated, "I can see where you wouldn't want the cushion extending beyond the edge of the wheelchair. It's supposed to be a team process where everyone, the entire team collaborates to make sure the equipment is the right size." The DON was requested to provide documentation of wheelchair assessments for Resident #309, prior to the fall on 11/11/14, but was unable to provide documentation that this had been done since 2/26/13. On 1/20/15 at 3:00 P.M., Review of the facility policy entitled "Falls", dated 6/16/14, provided no additional information. Review of a policy entitled, "Rehab Screening", revised 12/6/13, contained the following statement, "The quarterly screen (done every three months) has three primary purposes. The third purpose of the quarterly screen is to determine the continued need or modification of assistive devices that the resident is currently using or needs." A policy on fitting and/or assessing wheelchairs for correct fit was requested but not provided. ( )

Based on observation, interview, and record review, the facility failed to provide adequate supervision, and implement appropriate, timely safety interventions for one resident (#323), who had been assessed at high risk, out of 17 sampled residents reviewed for accidents from a total of 30, resulting in falls, a fracture, hematomas, bruising, and pain. Findings include: On 12/6/13 at 9:20 AM, resident #323 was observed lying in bed. The resident was confused, did not respond to verbal stimuli, and required staff for turning and repositioning. The resident lived in a room on the secured, dementia unit. The residents on this unit were observed to be closely and constantly monitored for their whereabouts by staff. On 12/6/13 at 3 PM, the clinical record and incident/accident (I/A) reports for resident #323 were reviewed with the director of nursing (DON) and the assistant DON (ADON). The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The minimum (MDS) data set [DATE] noted that the resident had severe cognitive impairment, was physically abusive, non-ambulatory, and required extensive assistance for transfers. Review of fall risk assessments for resident #323 dated 12/10/12, 1/10/13, 1/14/13, 3/26/13, 4/29/13, 5/15/13, and 5/24/13 noted that the resident was at high risk. Per review of I/A reports and nurses notes for resident #323, the following occurred: 1. On 1/14/13, the resident was observed lying on the floor in the hallway. There was redness to the left shoulder and the resident complained of pain to bilateral shoulders. The I/A report and nurses notes both documented: "Safety devices were in place and functional at the time of incident." When asked to specify the type of devices and how they functioned, the ADON reported the resident, "always had alarms and they were working when the incident occurred." There was no documentation indicating that the resident had a fall safety alarm and that it sounded to notify staff of an attempt to rise from the wheelchair without assistance. Review of the January 2013 monthly physician order [REDACTED]. There was no available care plan for January 2013 that noted fall safety alarms as interventions. Review of an x-ray report dated 1/14/13 for resident #323 revealed: Chronic right humeral dislocation "without fracture" and "extensive chronic rotator cuff damage without acute fracture or dislocation" of the left shoulder. Bilateral humerus were "without fracture." 2. Review of a "Potential for injury and trauma" care plan with a start date of 3/26/13, noted that on 1/29/13, resident #323 "fell getting up out of wheelchair (laceration to back of head)." There was no documentation provided regarding the incident and whether safety interventions were in place at the time (all I/A reports and investigations for the resident, had been requested twice during the survey). There was no mention of this incident in nurses notes. Review of resident #323's February 2013 monthly physician order [REDACTED]." 3. Nurses notes dated 2/19/13 documented: "Noted resident standing in her room with several (nurse aides) attempting to keep resident safe related to unsteady gait. Resident enraged physically fighting, hitting, and attempting to bite (aide) and supervisor....informed to allow resident to calm herself. Noted facial swelling, mouth bleeding, and lips and left wrist swollen....(aide) reported during attempts to render care, resident (was ambulating without assistance). Attempt to re-direct and assist....gait unsteady...." The I/A report dated 2/19/13, noted the resident "lost her balance hitting her facial area (on the bed footboard)." The nurses notes and I/A report both indicated that the resident was agitated during care, sustained the injuries in the presence of at least three staff, and staff was not instructed to allow the resident space and time to calm until after the injuries had already occurred, rather than before the accident. When queried, the DON and ADON were unable to provide further documentation of the sequence of the events. Per nurses notes dated 2/21/13, resident #323 had bruising from the "upper facial" area down to the lower neck. 4. The I/A report noted that on 4/29/13, resident #323's wheelchair alarm sounded. The resident was observed on the floor in her room with a laceration and bleeding to the back of the head. The fall was noted to be unwitnessed, however the report noted, "Got up out of wheelchair trying to get into closet." The report did not indicate that the resident made this statement. The resident was transported to the hospital on [DATE] and returned, per review of a body assessment sheet dated 4/30/13, with three staples to the head. Per nurses notes dated 4/30/13, the resident was then transferred to the secured, dementia unit. 5. The I/A report and nurses notes documented that on 5/7/13 at 3:45 PM, resident #323 was in the back of the dining room, stood up from the wheelchair, and fell to the floor. There was no mention that a safety alarm sounded to alert staff of a transfer attempt. The resident sustained [REDACTED]." The incident investigation forms noted that the fall was witnessed by another resident's visitor, who stated that resident #323 was bending down to pick up something from the floor and fell . Investigation forms also noted that there were four nurse aides present, but they were all located on opposite side of the room and did not observe the incident. Per review of "Employee Fall/Incident Educational Opportunity" forms, the four nurse aides received training after the incident: "As caregivers, we are responsible to ensure the safety and well-being of our residents....(each nurse aide)....was positioned on the opposite side of the dining room with (his/her) back towards the incident....therefore (he/she) did not observe the incident....educated to space (him/herself) and other staff throughout the dining room....to ensure all residents can be monitored." Per nurses notes, prior to the incident, beginning at 8 AM on 5/7/13, resident #323 was "very upset today, standing by self....resisting care, slapping staff, refusing safety directions....still running chair into staff...." Per the notes, the resident received oral ativan (for anxiety) at 8 AM followed by an additional ativan injection at 9:30 AM. At 1 PM, the resident was still "becoming more restless." When queried, the DON and ADON did not respond why the resident, who had been agitated all morning leading up to the fall on 5/7/13, was not adequately supervised in the dining room. (When interviewed earlier at 12:30 PM on 12/6/13, the DON stated that the facility identified in "August (2013)" that falls were occurring in the dining room and felt that the cause "was related to a lack of supervision.)" 6. The I/A report noted that on 5/17/13, resident #323 attempted to stand from the wheelchair and slid down to the floor before staff could reach her. There was no mention that an alarm sounded to alert staff of an attempt to self transfer. 7. The I/A report noted that on 5/30/13, resident #323 was observed on the floor mat in the room. There was no mention that an alarm sounded. 8. The I/A report noted that on 6/24/13, resident #323 was on the floor in the hallway in front of the wheelchair. The resident sustained [REDACTED]." The incident was "unwitnessed," but per nurses notes, "resident leaning (prior to fall) forward reaching for something on floor tumbled out of wheelchair. Observed on floor....large hematoma noted to right side of head." Interventions included a self release seatbelt. There were no further documented nurses notes until 6/30/13. Per nurses notes dated 6/30/13, the resident had bruising of the right shoulder and complained of shoulder pain. An x-ray was taken of the right shoulder on 6/30/13. Per review of the report: Anterior dislocation of the head of the right humerus "with avulsion (torn away) fracture...." Nurses noted on 6/30/13 at 11:40 PM, that the resident's primary care physician (PCP) was notified of the fracture and the PCP stated, "I'm aware." Per review of physician progress notes [REDACTED]. The examiner noted, "x-ray result discussed with (the PCP)...anterior dislocation of the head of the right humerus with avulsion....head of humerus of the right has been said to be chronically dislocated prior to recent fall....right humeral head anterior dislocation." The examiner did not address in the notes that, in addition to the chronic dislocation, a fracture had occurred, a fracture that was not present on the 1/14/13 x-ray. The examiner did not indicate that the PCP addressed the "fracture" during their discussion of the x-ray. When queried regarding how and when the fracture occurred, the DON indicated that she did not know. When queried whether the fracture was documented and investigated, the DON and ADON indicated that they did not know and left the room. 15 minutes later at approximately 3:45 PM on 12/6/13, the DON and ADON returned. The DON stated, "It was determined that the fracture occurred during the fall on 6/24/13" without providing an I/A report and investigation linking the fracture to the fall on 6/24/13. (On 12/9/13 at 2:50 PM, the PCP stated by phone that he did not recall the circumstances of the fracture and deferred to the resident's chart for information.) On 12/6/13 at 3:50 PM, per review of the facility's policies on "Falls/Fall Risk, Fall Prevention, Guidelines for Evaluation of" dated 2/2013 and "Supervision" dated 5/2013: -Incident reports must be completed upon any fall. -Information from incident reports will be used to identify patterns, causes, and trends. -Investigations must be initiated for any injury of unknown origin. -Determine causes of falls and re-evaluate the resident's care plan. -"Should falling occur despite initial interventions, other interventions will be progressively attempted until an appropriate resolution is achieved." -"Nursing staff are required to provide adequate supervision to any resident identified as "at risk"....This included the dining rooms....hallways...." ( ) ( )

THIS CITATION PERTAINS TO INTAKE #MI 172. BASED ON INTERVIEWS AND RECORDS REVIEW, THE FACILITY FAILED TO SUPERVISE AND PROVIDE THE NECESSARY SAFETY DEVICES REQUIRED TO PREVENT FALLS FOR 2 OF 3 SAMPLED RESIDENTS (#104 AND #105) REVIEWED FOR SAFETY, FROM A TOTAL OF 11, RESULTING IN FALLS WITH INJURIES, A LEFT HIP FRACTURE FOR RESIDENT #104 AND A FRACTURED NECK FOR RESIDENT #105. FINDINGS INCLUDE: RESIDENT #104 RESIDENT #104 WAS NOT AT THE FACILITY DURING THE ABBREVIATED SURVEY. REVIEW OF THE FACE SHEET DATED 4/29/2013 REVEALED RESIDENT #104 WAS A [AGE] year OLD MALE admitted TO THE FACILITY 11/19/2012, WITH [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM (MDS) data set [DATE] REVEALED RESIDENT #104 HAD AN UNSTEADY GAIT THAT REQUIRED STAFF SUPERVISION DURING AMBULATION. REVIEW OF FALL RISK ASSESSMENTS DATED 3/08, 3/16, 3/22, 3/23, AND 4/14/2013, REVEALED STAFF FOUND RESIDENT #104 AT RISK FOR INJURY AS EVIDENCED BY RECENT FREQUENT FALLS, IMPAIRED COGNITION, INCONTINENCE, REQUIRED ASSISTIVE DEVICES, IMPAIRED AMBULATION, IMPAIRED BALANCE, HIGH RISK HEALTH CONDITIONS AND SIDE EFFECTS ASSOCIATED WITH HIS PRESCRIBED MEDICATIONS. REVIEW OF THE RESIDENT CARE GUIDE DATED 3/08/2013 REVEALED RESIDENT #104 WAS NOT ORIENTED TO PLACE OR TIME, "PREFERRED TO AMBULATE IN NON-SKID SOCKS...NOT TO WEAR SHOES..." AND HE REQUIRED MINIMALLY ONE STAFF MEMBER TO SUPERVISE/ASSIST HIM WITH AMBULATION. REVIEW OF THE "SAFETY" CARE PLAN INITIALLY DATED 2/07/2013 AND UNDATED 3/25/2013, REVEALED THAT RESIDENT #104 REQUIRED HIPSTERS TO BE APPLIED AROUND THE CLOCK, WITH "FOOTWEAR TO INCLUDE WELL-FITTING SHOES, STURDY SLIPPERS AND NON-SKID SOCKS." THE "COMPREHENSIVE CARE PLAN" FOR FUNCTION AND SAFETY WHILE AMBULATING DATED 3/08/2013 NOTED THAT RESIDENT #104 HAD THE POTENTIAL FOR BOTH INJURY AND TRAUMA, ASSOCIATED WITH HIS "HEIGHTENED FALL RISK...LOSS OF BALANCE...POOR SAFETY AWARENESS...(AND) WANDERING" BEHAVIORS. THIS CARE PLAN ALSO DOCUMENTED RESIDENT #104 PREFERRED NOT TO WEAR SHOES AND INSTEAD WORE NON-SKID SOCKS. REVIEW OF THE INCIDENT AND ACCIDENT INVESTIGATION DATED 4/12/2013 AT 7:20 P.M., REVEALED RESIDENT #104 fell WHILE AMBULATING IN THE HALLWAY. ON 4/22/2013 AT 2:00 P.M., THE SURVEYOR REVIEWED THE SECOND FLOOR, NORTH SIDE SECURITY VIDEO FOOTAGE, DATED 4/12/2013 BETWEEN 7:34 P.M. AND 7:37 P.M. THE ADMINISTRATOR WHO WAS PRESENT, IDENTIFIED RESIDENT #104 IN THE VIDEO FOOTAGE, WHO INDEPENDENTLY WALKED THROUGHOUT THE HALL WEARING SOCKS ON HIS FEET. AS RESIDENT #104 TRANSITIONED FROM THE CARPETED HALLWAY ONTO NEWLY INSTALLED LAMINATE FLOORING, THE VIDEO FOOTAGE REVEALED HE SLIPPED, fell AND LANDED ON HIS LEFT SIDE. NO OTHER CONTRIBUTING FACTORS WERE IDENTIFIED DURING THE VIDEO FOOTAGE REVIEW. REVIEW OF NURSING NOTES DATED 4/12/2013 AT 7:20 P.M., REVEALED STAFF FOUND RESIDENT #104 ON THE HALLWAY FLOOR AND THEY ASSISTED HIM BACK INTO HIS BEDROOM WHERE LICENSED PRACTICAL NURSE (LPN) #1 "NOTED ...(HIS) WORN OUT NON-SKID SOCKS." REVIEW OF NURSING NOTES DATED 4/13/2013 AT 6:00 A.M. REVEALED RESIDENT #104 CONVEYED PAIN EVIDENCED BY FACIAL GRIMACING WHEN STAFF MOVED HIS LOWER EXTREMITIES, AND HE COULD NO LONGER STAND. REVIEW OF THE RADIOLOGY REPORT DATED 4/13/2013 REVEALED RESIDENT #104 HAD AN ACUTE LEFT HIP FRACTURE. REVIEW OF A TRANSFER FORM DATED 4/13/ REVEALED RESIDENT #104 WAS TRANSFERRED TO A LOCAL AREA HOSPITAL FOR A SURGICAL CONSULT. DURING A TELEPHONE INTERVIEW ON 4/22/2013 AT 2:00 P.M., LPN #1 SAID THAT AFTER RESIDENT #104 fell , SHE IMMEDIATELY ASSESSED HIS CONDITION, DETERMINED HE WAS NOT WEARING HIS REQUIRED HIPSTERS AND THAT HIS NON-SKID SOCKS HAD INADEQUATE TREAD FOR SAFETY. LPN #1 SAID THE WORN-OUT SOCKS WERE IMMEDIATELY REPLACED FOR THOSE WITH AN ADEQUATE TREAD, BUT THE HIPSTERS WERE NOT APPLIED BECAUSE THE RESIDENT HAD REFUSED TO WEAR THEM FOR WEEKS. DURING AN INTERVIEW 4/22/2013 AT 3:00 P.M., ADMINISTRATOR (ADM) #1 AND DIRECTOR OF NURSING (DON) #1 REMAINED SILENT WHEN TOLD STAFF PERMITTED RESIDENT #104 TO AMBULATE UNASSISTED, WITHOUT HIS REQUIRED HIPSTERS, WHILE IN UNSAFE FOOTWEAR, ON A LAMINATE FLOOR THE EVENING OF 4/12/2013. THE ADMINISTRATOR SAID SHE BELIEVED THE FOOTWEAR WORN BY RESIDENT #104 HAD ADEQUATE TREAD, BUT DENIED EVALUATING THE SOCKS INVOLVED. RESIDENT #105 REVIEW OF THE FACE SHEET DATED 3/01/2013 REVEALED RESIDENT #105 WAS A [AGE] year OLD FEMALE admitted TO THE FACILITY 2/27/2013, WITH [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM (MDS) data set [DATE] REVEALED RESIDENT #105 HAD MODERATELY IMPAIRED COGNITION, BOTH LONG AND SHORT TERM MEMORY LOSS, COULD NOT BALANCE, AND REQUIRED MINIMALLY ONE STAFF MEMBER TO ASSIST WITH ALL TRANSFERS. REVIEW OF FALL RISK ASSESSMENTS DATED 1/20, 2/27, AND 2/28/2013, REVEALED RESIDENT #105 WAS A FALL RISK AS EVIDENCED BY RECENT FREQUENT FALLS, VISUAL IMPAIRMENTS, IMPAIRED COGNITION, INCONTINENCE, REQUIRED ASSISTIVE DEVICES, IMPAIRED AMBULATION, IMPAIRED BALANCE, HIGH RISK HEALTH CONDITIONS AND SIDE EFFECTS ASSOCIATED WITH HER PRESCRIBED MEDICATIONS. REVIEW OF PHYSICIAN ORDERS [REDACTED]. REVIEW OF THE "IMPAIRED PHYSICAL MOBILITY" CARE PLAN DATED 12/28/2012 REVEALED RESIDENT #105 REQUIRED A RESTRAINT WHILE SEATED BECAUSE SHE had a history of [REDACTED]. THE "FALLS" CARE PLAN DATED 1/20/2013 REVEALED RESIDENT #103 REQUIRED MINIMALLY ONE STAFF MEMBER TO ASSISTANCE WITH ALL TRANSFERS. REVIEW OF NURSING NOTES DATED 2/12/2013 REVEALED RESIDENT #105 WAS UNABLE TO MAKE HER NEEDS KNOWN, WHILE THE NOTES DATED 2/26/2013 DOCUMENTED SHE REQUIRED "...EXTENSIVE ASSISTANCE..." WITH ALL TRANSFERS. ON 2/27/2013, NURSING DOCUMENTED THE CERTIFIED NURSING ASSISTANT (CNA) #2 LEFT RESIDENT #105 UNSUPERVISED, SITTING ON THE EDGE OF HER BED, IN ORDER TO MOVE FLOOR MATS, "...WHEN THE RESIDENT LOST (HER) BALANCE AND fell FORWARD HITTING HER HEAD ON THE CORNER OF THE DRESSER." REVIEW OF THE "INCIDENT AND ACCIDENT REPORT" DATED 2/27/2013 REVEALED RESIDENT #105 SUSTAINED A LACERATION ABOVE HER LEFT EYE AND WAS SENT TO THE LOCAL AREA HOSPITAL FOR EVALUATION AND TREATMENT. REVIEW OF RADIOLOGY REPORTS DATED 2/27/2013 REVEALED RESIDENT #105 HAD A BROKEN NECK AND DISPLACED C2 (CERVICAL 2) BONE. DURING AN INTERVIEW 4/22/2013 AT 3:00 P.M., DON #1 REVIEWED THE FALL AND SAID STAFF FAILED TO PROVIDE THE NECESSARY SUPERVISION RESIDENT #105 REQUIRED WHEN PLACED IN A SITTING POSITION ON THE EDGE OF HER BED.

THIS CITATION REFERS TO INTAKE NUMBER MI 928 BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE CARE NECESSARY FOR 1 (#102) OF 7 RESIDENTS REVIEWED FOR ASSESSMENT, FROM A TOTAL SAMPLE OF 8, TO REACH THEIR HIGHEST PRACTICABLE PHYSICAL WELL-BEING WHEN FACILITY STAFF DID NOT MONITOR OR ASSESS FOR A CHANGE IN CONDITION, PRIOR TO DISCHARGE, RESULTING IN A DELAY OF MEDICAL EVALUATION AND TREATMENT. FINDINGS INCLUDE: ACCORDING TO THE CLOSED CLINICAL RECORD, RESIDENT #102 WAS AN [AGE] year OLD MALE WHO WAS admitted to the facility on [DATE] AND WAS discharged TO AN ASSISTED LIVING FACILITY ON 9/14/12. DURING A PHONE INTERVIEW, THE COMPLAINANT STATED THAT RESIDENT #102 ARRIVED AT THE ASSISTED LIVING FACILITY "SLUMPED OVER IN THE WHEELCHAIR, LETHARGIC WITH A BLOOD PRESSURE OF 80/45 (VERY LOW) AND FOUL SMELLING STOOL IN HIS BRIEF." HE WAS IMMEDIATELY TRANSFERRED TO AN ACUTE CARE HOSPITAL AND FOUND TO BE HYPOTENSIVE (LOW BLOOD PRESSURE), [MEDICAL CONDITION] (WHOLE BODY [MEDICAL CONDITION] STATE) AND DEHYDRATION (SEVERE LOSS OF BODY FLUID). FURTHER REVIEW OF THE CLINICAL RECORD REVEALED THAT RESIDENT #102'S [DIAGNOSES REDACTED]. PER THE MINIMUM DATA SET (MDS) assessment dated [DATE], HE HAD MODERATELY IMPAIRED COGNITION, AND WAS ABLE TO MAKE HIMSELF UNDERSTOOD AND TO UNDERSTAND OTHERS. RESIDENT #102 REQUIRED EXTENSIVE ASSISTANCE OF 1 PERSON FOR TRANSFERS AND TOILET NEEDS AND LIMITED ASSISTANCE OF 1 FOR ALL OTHER ACTIVITIES OF DAILY LIVING. FURTHER REVIEW OF THE CLOSED CLINICAL RECORD REVEALED DAILY SKILLED NURSING NOTES DATED FROM 9/1/12 TO 9/13/12. THE RECORD DID NOT HAVE A SKILLED NURSING NOTE OR NURSE'S PROGRESS NOTE FOR 9/14/12, THE DATE OF RESIDENT #102'S DISCHARGE. THE 9/13/12 SKILLED NURSING NOTE FOR THE 7:00 A.M. TO 7:00 P.M. SHIFT WAS BLANK UNDER THE AREA TITLED "VITAL SIGNS." THE 7:00 P.M. TO 7:00 A.M. SKILLED NURSING NOTES DOCUMENTED RESIDENT #102'S VITAL SIGNS AS B/P (BLOOD PRESSURE) 114/66; PULSE 82; RESPIRATIONS 20 AND TEMPERATURE 97.6. THE NURSING DISCHARGE SUMMARY WAS INCOMPLETE WITH NO DOCUMENTATION OF VITAL SIGNS. THE DISCHARGE SUMMARY ONLY NOTED THAT RESIDENT #102 WAS ALERT, SKIN INTACT AND STABLE AND WAS SIGNED BY LICENSED PRACTICAL NURSE (LPN) #18. ON 11/16/12 AT 1:10 P.M., LPN #18 STATED THAT SHE WAS ASSIGNED TO RESIDENT #102 ON 9/13 AND 9/14/12 BUT WAS NOT FAMILIAR WITH HIM. SHE STATED THAT ON 9/14/12 HE WAS discharged FROM THE FACILITY TO AN ASSISTED LIVING FACILITY AND LEFT THE FACILITY BY AMBULANCE. WHEN QUERIED BY THE SURVEYOR, LPN #18 SAID SHE DID NOT ASSESS RESIDENT #102'S VITAL SIGNS PRIOR TO DISCHARGE AND WAS UNAWARE OF WHAT HIS VITAL SIGNS WERE. LPN #18 SAID RESIDENT #102 WAS SITTING UP IN HIS WHEELCHAIR AND APPEARED SLEEPY, BUT SHE THOUGHT HE WAS STABLE. WHEN ASKED IF IT WAS FACILITY PROTOCOL TO DOCUMENT A NURSE'S NOTE, WITH ASSESSMENT AND VITAL SIGNS PRIOR TO DISCHARGING A RESIDENT, LPN #18 SAID "YES." WHEN ASKED IF SHE DOCUMENTED A NURSING NOTE, LPN #18 SAID "NO." LPN #18 SAID SHE FILED OUT THE NURSING DISCHARGE SUMMARY. A REVIEW OF THE NURSING DISCHARGE SUMMARY DATED 9/14/12 AT 2:30 P.M. REVEALED RESIDENT #102 WAS ALERT, SKIN INTACT AND STABLE. THE SECTION TITLED "VITAL SIGNS AT DISCHARGE" WAS BLANK. WHEN ASKED IF SHE HAD ASSESSED THE RESIDENT, LPN #18 SAID SHE BELIEVED SHE DID A SKIN ASSESSMENT. ON 11/16/12, CERTIFIED NURSING ASSISTANT (CNA) #19 SAID HE WAS ASSIGNED TO RESIDENT #102 ON 9/14/12. CNA #19 SAID THAT HE (#19) WAS VERY FAMILIAR WITH RESIDENT #102 AND PROVIDED CARE FOR HIM OFTEN PRIOR TO 9/14/12. HE (#19) SAID THE RESIDENT HAD PREVIOUS BEEN diagnosed with [REDACTED]. CNA #19 SAID THAT RESIDENT #102 DID HAVE LOOSE STOOL STAINS IN HIS BRIEF AT THE TIME OF MORNING CARE ON 9/14/12. ACCORDING TO CNA #19, AS RESIDENT #102 WAITED FOR THE AMBULANCE TO TAKE HIM TO THE ASSISTED LIVING FACILITY, HE (#19) NOTICED THAT RESIDENT #102 HAD DARK COLORED DIARRHEA AND APPEARED LETHARGIC. RESIDENT #102 HAD SLUMPED OVER IN THE WHEELCHAIR AND REQUIRED REPOSITIONING SEVERAL TIMES. CNA #19 SAID THAT HE DID NOT TAKE RESIDENT #102'S VITAL SIGNS. CNA #19 SAID THAT WHEN THE AMBULANCE ARRIVED, HE (#19) TOLD THE TRANSPORTER TO "WATCH HIM (#102)" BECAUSE HE KEPT SLUMPING OVER IN THE WHEELCHAIR. ON 11/16/12, A REVIEW OF THE FACILITY STAFF ASSIGNMENT SHEET FOR 1 NORTH REVEALED THAT CNA #24 WAS ASSIGNED TO RESIDENT #102 ON THE 3PM TO 11PM SHIFT ON 9/13/12. VITAL SIGNS WERE DOCUMENTED ON THE BACK OF THE ASSIGNMENT SHEET FOR 1 NORTH RESIDENTS. RESIDENT #102'S VITAL SIGNS WERE DOCUMENTED AS B/P 81/44; PULSE 88; RESPIRATIONS 24 AND OXYGEN SATURATION 94 %. ON 11/19/12, CNA #24 WAS INTERVIEWED, AND REVIEWED THE ASSIGNMENT SHEET. CNA #24 SAID THAT THE DOCUMENTATION OF VITAL SIGNS WAS HERS. WHEN ASKED ABOUT RESIDENT #102'S BLOOD PRESSURE, SHE SAID, "THAT (BLOOD PRESSURE) IS VERY LOW AND I WOULD HAVE REPORTED IT TO THE NURSE, (NAME OF NURSE)." CNA #24 SAID THAT SHE DID NOT DOCUMENT THAT SHE NOTIFIED THE NURSE OF THE VITAL SIGNS, NOR COULD SHE RECALL RESIDENT #102. ON 11/16/12 AT 2:16 P.M. THE SURVEYOR REVIEWED THE CLINICAL RECORD DOCUMENTATION FOR RESIDENT #102 WITH THE DIRECTOR OF NURSING (DON) #3. DON #3 SAID SHE WAS AWARE LPN #18 HAD FAILED TO DOCUMENT ASSESSMENT AND VITAL SIGNS FOR RESIDENT #102'S DISCHARGE ON 9/14/12. DON #3 SAID SHE HAD CALLED LPN #18 INTO THE FACILITY AT THE TIME AND SHE WAS TOLD TO DOCUMENT THE INFORMATION AND DID NOT. THE DON #3 SAID SHE WAS UNABLE TO LOCATE A CENA (CNA) CARE GUIDE OR CENA (CNA) ADL (ACTIVITIES OF DAILY LIVING) SHEET FOR RESIDENT #102. DON #3 CONFIRMED RESIDENT #102'S CLINICAL RECORD DID NOT CONTAIN DOCUMENTATION OF ASSESSMENT OR VITAL SIGNS PRIOR TO DISCHARGE. PER THE ASSISTED LIVING ADMISSION NOTE DATED 9/14/12 AT 7:03 P.M., "RESIDENT (#102) ARRIVED FROM THE NURSING HOME, UNABLE TO RESPOND TO VERBAL STIMULI. OPENS EYES SLIGHTLY SPONTANEOUSLY. FOUL LIQUID BROWN STOOL FOUND IN BRIEF WITH CONTINUED LARGE AMOUNTS OF LIQUID BROWN STOOLING. B/P 80/45 HEART RATE 80. PHYSICIAN NOTIFIED AND RESIDENT (#102) TRANSPORTED VIA AMBULANCE TO ACUTE CARE HOSPITAL." A REVIEW OF THE HOSPITAL emergency room RECORD DATED 9/14/12 AT 1755 (5:55 PM), DOCUMENTED THAT RESIDENT #102 ARRIVED LETHARGIC AND HYPOTENSIVE (LOW BLOOD PRESSURE). THE emergency room PHYSICIAN NOTED AN IMPRESSION AND PLAN FOR [DIAGNOSES REDACTED].M.) ACCORDING TO THE HOSPITAL INPATIENT ADMISSION HISTORY AND PHYSICAL, RESIDENT #102 WAS admitted to ICU for [REDACTED]. RESIDENT #102 WAS FOUND TO HAVE ACUTE KIDNEY INJURY AND METABOLIC ACIDOSIS (TOO MUCH ACID IN THE BODY WHICH CAN BE CAUSED WHEN KIDNEYS ARE NOT REMOVING ACID). RESIDENT #102 WAS PLACED IN ISOLATION AND PROVIDED AGGRESSIVE VOLUME RESUSCITATION (FLUID REPLACEMENT TO RESTORE HEMODYNAMIC STABILITY). PER THE HOSPITAL DISCHARGE SUMMARY DATED 10/1/12, RESIDENT #102'S DISCHARGE [DIAGNOSES REDACTED]. STOPPED) AMONG OTHER DIAGNOSIS. RESIDENT #102 WAS discharged on HOSPICE CARE BACK TO THE ASSISTED LIVING FACILITY. AT THE EXIT CONFERENCE, DON #3 PROVIDED A COPY OF LPN #18'S DISCIPLINE EMPLOYEE REPORT DATED 10/5/12 WHICH READ, "ON 9/13/12 ASSOCIATE FAILED TO DOCUMENT RESIDENT'S (#102) VITAL SIGNS ON SKILLED MEDICARE CHARTING. ADDITIONALLY ON 9/14/12 ASSOCIATE discharged THIS SAME RESIDENT TO AN ASSISTED LIVING FACILITY WITHOUT A DISCHARGE ORDER, DID NOT OBTAIN VITAL SIGNS FOR THE NURSING SUMMARY PORTION OF THE DISCHARGE FORM AND FAILED TO COMPLETE SKILLED MEDICARE DOCUMENTATION FOR THE RESIDENT. SUBSEQUENTLY, THIS RESIDENT (#102) WITHIN 12 HOURS OF DISCHARGE TO THE ASSISTED LIVING FACILITY WAS TRANSFERRED TO THE HOSPITAL WITH [MEDICAL CONDITION]. THIS IS IN VIOLATION OF (NAME OF FACILITY) POLICIES, VIOLATION OF PROFESSION STANDARDS PERTAINING TO RESIDENT CARE AND CUSTOMER SERVICE." ( )

THIS CITATION REFERS TO INTAKE NUMBER MI 753. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE A SAFE ENVIRONMENT FOR 1 (#101) OF 7 SAMPLED RESIDENTS REVIEWED FOR SAFETY, FROM A TOTAL SAMPLE OF 8 RESIDENTS, WHEN RESIDENT #101, WHO HAD BEEN ASSESSED AS REQUIRING TWO-PERSON ASSIST FOR TRANSFER WAS IMPROPERLY TRANSFERRED BY A SINGLE STAFF MEMBER, RESULTING IN FRACTURES TO HER LEFT TIBIA AND LEFT FIBULA, PAIN AND A DECREASE IN FUNCTIONAL STATUS. FINDINGS INCLUDE: RESIDENT #101 WAS AN [AGE] year OLD FEMALE WHO WAS ORIGINALLY admitted to the facility on [DATE] AND REadmitted on [DATE] AND 10/26/12. RESIDENT #101 HAD [DIAGNOSES REDACTED]. PER THE MINIMUM DATA SET (MDS) ASSESSMENT, DATED 8/15/12, RESIDENT #101 HAD MODERATELY IMPAIRED COGNITION AND REQUIRED 2 PERSON ASSISTANCE WITH TRANSFERS AND 1 PERSON ASSISTANCE WITH ALL OTHER ACTIVITIES OF DAILY LIVING. FURTHER REVIEW OF RESIDENT #101'S CLINICAL RECORD REVEALED A CERTIFIED NURSING ASSISTANT (CENA) CARE GUIDE WHICH DOCUMENTED THAT RESIDENT #101 WAS TOTALLY DEPENDENT ON STAFF AND REQUIRED TWO PERSON ASSIST FOR TRANSFERS. PER THE FACILITY INVESTIGATIVE REPORT INCIDENTS/UNUSUAL OCCURRENCES SHEET, DATED 9/20/12 AT 5:00 P.M., RESIDENT #101 WAS NOTED TO HAVE KNEE SWELLING AND PAIN. THE PHYSICIAN WAS NOTIFIED AND ORDERS WERE RECEIVED FOR MEDICATIONS (COLCHICINE AND PREDNISONE) AND PAIN MEDICATION WAS PROVIDED. ON 9/21/12, WHEN RESIDENT #101 WAS EXPERIENCING INCREASED PAIN, THE PHYSICIAN WAS NOTIFIED AND THE RESIDENT WAS SENT TO AN ACUTE CARE HOSPITAL. PER THE HOSPITAL X-RAY AND COMPUTED TOMOGRAPHY (CT) SCAN, DATED 9/21/12, RESIDENT #101 WAS diagnosed with [REDACTED]. THE FACILITY INVESTIGATIVE FINDING CONCLUDED RESIDENT #101 SUSTAINED AN INJURY TO HER LEFT TIBIA. A REVIEW OF THE HOSPITAL X-RAY DATED 9/21/12, REVEALED THAT RESIDENT #101 SUSTAINED A COMMINUTED FRACTURE OF THE LATERAL TIBIA WITH SOME DEGREE OF IMPACTION, AND AN IMPACTION TYPE FRACTURE OF THE FIBULAR NECK. THE CT SCAN NOTED THAT MULTIPLE FRACTURE LINES WERE SEEN ON THE TIBIA. THE CT SCAN ALSO NOTED A NONDISPLACED FRACTURE OF THE NECK OF THE FIBULA. ON 11/15/12 AT 12:00 NOON, RESIDENT #101 WAS OBSERVED IN HER ROOM CLEAN AND DRESSED. SHE WAS IN BED WITH HER FEET ELEVATED, WHILE WEARING BILATERAL HEEL BOOTS AND AN IMMOBILIZER TO HER LEFT LEG. HER BED WAS IN THE LOWEST POSITION AND THERE WAS A FLOOR MAT ON THE LEFT SIDE OF THE BED. RESIDENT #101 WAS ALSO WEARING A YELLOW FALL RISK BRACELET. THE CALL LIGHT AND THE BED ALARM WERE IN PLACE. RESIDENT #101 DID NOT RESPOND VERBALLY TO QUESTIONS BUT DID MAKE EYE CONTACT AND REACHED FOR SURVEYOR'S HAND. ON 11/15/12 AT 2:25 PM, PHYSICAL THERAPIST (PT) #7 SAID THAT ON 9/20/12, SOMETIME BETWEEN 1:00 PM AND 2:00 PM, SHE ENTERED THE DINING ROOM TO GET RESIDENT #101 FOR HER THERAPY SESSION AND "FOUND HER IN A GERI (RECLINER) CHAIR, WITH HER LEFT LEG DANGLING OFF THE FOOT REST." PT #7 STATED THAT SHE LIFTED RESIDENT #101'S LEFT LEG TO POSITION IT, BUT RESIDENT #101 SAID, "OUCH" AND GRABBED HER LEG. PT #7 SAID SHE RAISED RESIDENT #101'S PANT LEG AND OBSERVED THAT HER LEFT KNEE WAS SWOLLEN AND WARM TO THE TOUCH. SHE DENIED SEEING ANY BRUISING OR MARKS. PT #7 SAID SHE INFORMED THE NURSE WHO ASSESSED THE LEG AND STATED SHE WOULD CONTACT THE PHYSICIAN. PT #7 SAID SHE TOOK RESIDENT #101 TO THERAPY FOR 50 MINUTES TO AN HOUR BUT DID NOT ENGAGE THE LEFT LEG. PT #7 SAID RESIDENT #101 WAS ONLY OBSERVED TO SHOW SIGNS OF PAIN WITH MOVEMENT INVOLVING THE LEFT LEG. ON 11/15/12 AT 2:55 P.M. CERTIFIED NURSING ASSISTANT (CNA) #8 WAS INTERVIEWED AT THE FACILITY. CNA #8 SAID SHE HAD PROVIDED CARE FOR RESIDENT #101 OFTEN DURING THE FIRST ADMISSION, WHEN SHE HAD BEEN ON THE 2 NORTH UNIT. CNA #8 SAID SHE WAS ASSIGNED TO RESIDENT #101 ON THE DAY SHIFT ON 9/20/12. SHE SAID THAT RESIDENT #101 HAD DECLINED OVERALL SINCE HER FIRST ADMISSION ON 2 NORTH. CNA #8 SAID THAT ON 9/20/12 SHE PROVIDED MORNING CARE AND DRESSED RESIDENT #101. AT APPROXIMATELY 2:30 P.M., CNA #8 "STOOD AND PIVOTED" RESIDENT #101 INTO THE GERI CHAIR. CNA #8 SAID THAT SHE PLACED HER (#101) IN THE HALLWAY. CNA #8 SAID THAT RESIDENT #101 WAS MOANING AND GRIMACING WITH MOVEMENT AND HAD NOT EARLIER WHEN SHE HAD DRESSED HER. WHEN QUERIED BY THE SURVEYOR ABOUT RESIDENT #101'S TRANSFER STATUS, CNA #8 SAID SHE WAS UNSURE OF THE TRANSFER STATUS AT THE TIME. ACCORDING TO CNA #8, SHE DID NOT RECALL IF THE CARE GUIDE WAS AVAILABLE AND HAD NOT REFERRED TO IT TO DETERMINE THE TRANSFER STATUS FOR RESIDENT #101. CNA #8 SAID THAT SHE (#101) HAD BEEN A ONE PERSON ASSIST FOR TRANSFER IN THE PAST, "SO THAT'S WHAT I DID." CNA #8 DENIED HAVING ANY CONCERNS DURING THE ONE PERSON TRANSFER. ON 11/15/12 AT 4:25 P.M., LICENSED PRACTICAL NURSE (LPN) #12 SAID SHE TOOK OVER CARE FOR RESIDENT #101 ON 9/20/12 ABOUT 3:00 P.M. WHEN ANOTHER NURSE LEFT EARLY. LPN #12 SAID SHE WAS INFORMED ABOUT 4:00 P.M. BY A FACILITY PHYSICAL THERAPIST THAT RESIDENT #101'S LEFT KNEE WAS RED, INFLAMED AND WARM TO THE TOUCH. LPN #12 SAID SHE ATTEMPTED RANGE OF MOTION AND FOUND RESIDENT #101 TO BE "GUARDED." LPN #12 CONTACTED THE PHYSICIAN WHO SAID IT WAS A GOUT FLARE UP AND ORDERED COLCHICINE, PREDNISONE AND TYLENOL (MEDICATIONS). LPN # 12 SAID SHE GAVE THE TYLENOL AND SENT THE ADDITIONAL ORDERS TO THE PHARMACY. LPN #12 STATED THE DAY SHIFT CNA LEFT AT 3:00 P.M. AND HAD NOT INFORMED HER OF ANY CONCERNS. LPN #12 SAID RESIDENT #101 WAS TRANSFERRED TO 2 SOUTH LATER THAT EVENING AND SHE INFORMED THE RECEIVING NURSE OF THE LEFT LEG PAIN AND PHYSICIAN ORDERS. ON 11/15/12 AT 3:30 AND 3:45 P.M. RESPECTFULLY, CNAS #10 AND #11, WHO PROVIDED CARE FOR RESIDENT #101 WHEN SHE MOVED TO 2 SOUTH ON 9/20/12 AT APPROXIMATELY 6:30 P.M. WERE INTERVIEWED BY THE SURVEYOR. CNAS #10 AND #11 BOTH SAID THAT RESIDENT #101 REQUIRED 2 PERSONS FOR TRANSFER AND HAD PAIN WHEN THEY TRANSFERRED HER ON 9/20/12. CNA #11 SAID THAT RESIDENT #101 "WAS IN PAIN FROM THE MINUTE WE SAW HER." SHE WAS MOANING AND HAD FACIAL EXPRESSION OF PAIN. BOTH CENAS (#10 & #11) SAID THEY ASSUMED IT WAS FROM THE WOUND ON HER FOOT. BOTH CNA #10 AND CNA #11 SAID TWO NURSES WERE IN THE ROOM AND DID A FULL BODY ASSESSMENT OF RESIDENT #101. ON 11/16/12 AT 8:55 A.M., LPN UNIT MANAGER (UM) #13 SAID THAT A NURSE ON 2 NORTH INFORMED HER THAT RESIDENT #101 WAS HAVING PAIN IN HER LEFT LEG. UM #13 SAID SHE SPOKE WITH LPN #12 WHO INFORMED HER PAIN MEDICATION HAD BEEN GIVEN AND THE PHYSICIAN ORDERS [REDACTED]. THE UM #13 SAID THE PHYSICIAN WAS CONTACTED AGAIN AND NEW ORDERS WERE RECEIVED FOR AN X-RAY WHICH SHOWED NO FRACTURE AT THE TIME. THE UM #13 SAID SHE LEFT THE FACILITY AND REQUESTED THE NURSING STAFF TO LET HER KNOW IF THERE WERE ANY FURTHER CONCERNS. ON 11/16/12 AT 11:34 A.M., THE DIRECTOR OF NURSING (DON) #3 SAID, RESIDENT #101'S IN-HOUSE X-RAY ON 9/20/12 WAS NEGATIVE FOR FRACTURE. DON #3 SAID THAT ON 9/21/12, RESIDENT #101 CONTINUED TO HAVE COMPLAINTS OF PAIN AND THE PHYSICIAN WAS CONTACTED. THE PHYSICIAN THEN SENT RESIDENT #101TO THE HOSPITAL WHERE SHE WAS FOUND TO HAVE FRACTURES. DON #3 SAID THAT RESIDENT #101 WAS A TWO PERSON TRANSFER AND COULD NOT SAFELY BE TRANSFERRED BY ONE PERSON. WHEN THE SURVEYOR INFORMED DON #3 THAT CNA #8 HAD TRANSFERRED RESIDENT #101 BY HERSELF ON 9/20/12, THE DON SAID, "I WASN'T AWARE (THAT CNA #8 TRANSFERRED RESIDENT #101 BY HERSELF) BUT SEE THE CONCLUSION YOU ARE COMING TO." ADDITIONAL NURSING STAFF CNA #9, CNA #15 AND LPN #14, WHO HAD ALL PROVIDED CARE FOR RESIDENT #101 WERE QUESTIONED. ACCORDING TO THESE STAFF MEMBERS, RESIDENT #101 WAS A 2 PERSON TRANSFER. THE CNAS SAID THAT THE CARE GUIDES WERE ALWAYS AVAILABLE AND UP TO DATE. LPN #14 SAID RESIDENT #101 WOULD NOT BE SAFE FOR A 1 PERSON TRANSFER. CNA #11 SAID THAT RESIDENT #101 WAS "FEARFUL AND WOULD GRAB THINGS. I DON'T THINK ANYONE COULD TRANSFER HER ALONE. THAT WOULD BE AN ACCIDENT WAITING TO HAPPEN BECAUSE SHE GRABBED ON. SOMEONE, YOU OR HER, WOULD GET HURT." ( )

THIS CITATION HAS TWO DEFICIENT PRACTICES. DEFICIENT PRACTICE #1. BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW THE FACILITY FAILED TO PROVIDE TIMELY INTERVENTIONS TO PREVENT A DELAY IN NECESSARY TREATMENT FOR ONE (#407) OF ONE SAMPLED RESIDENT WITH A [MEDICAL CONDITION] (AN OPENING IN THE THROAT TO PROVIDE AN AIRWAY AND TO REMOVE SECRETIONS) OUT OF A TOTAL OF 32, WHO WAS IN ACUTE RESPIRATORY DISTRESS FROM AN OBSTRUCTION, RESULTING IN PROLONGED SHORTNESS OF BREATH, INCREASED RESPIRATORY RATE, AND MENTAL ANGUISH AND RESULTING IN AN IMMEDIATE JEOPARDY (IJ) TO THE HEALTH AND SAFETY OF THE RESIDENT. THE IJ BEGAN ON 9/27/12 AND WAS IDENTIFIED ON 10/3/12. THE ADMINISTRATOR WAS NOTIFIED OF THE IJ ON 10/4/12 AT 9:10 AM. A PLAN OF CORRECTION WAS REQUESTED TO REMOVE THE IJ. THE IJ WAS REMOVED ON 10/4/12 BASED ON THE FACILITY'S IMPLEMENTATION OF CORRECTIVE ACTIONS ON 10/4/12, AS VERIFIED ONSITE BY THE SURVEY TEAM ON 10/4/12. FINDINGS INCLUDE: ON 9/25/12 AT 9:30 A.M., RESIDENT #407 WAS OBSERVED IN BED WITH A [MEDICAL CONDITION]. THE RESIDENT WAS ALERT AND ABLE TO MOUTH RESPONSES TO QUESTIONS APPROPRIATELY. UNIT MANAGER "F" STATED, "SHE HAD JUST RETURNED TO THE FACILITY A COUPLE OF DAYS AGO AFTER HAVING THE [MEDICAL CONDITION] REPLACED (ON 9/6/12)." ON 9/25/12 AT 1:45 P.M., REVIEW OF THE ADMISSION FACE SHEET NOTED THAT RESIDENT #407 WAS readmitted INto the facility on 9/7/12 WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE] NOTED THAT THE RESIDENT WAS COGNITIVELY INTACT AND REQUIRED LIMITED ASSISTANCE FOR MOST ACTIVITIES OF DAILY LIVING. ON 9/27/12 AT 8:40 A.M., RESIDENT #407 WAS OBSERVED IN HER ROOM SITTING ON THE SIDE OF THE BED BREATHING 24 TO 26 BREATHS PER MINUTE (NORMAL RANGE=12-20). THE RESIDENT WAS HAVING DIFFICULTY BREATHING TO THE POINT WHERE ACCESSORY MUSCLES (IN SHOULDERS AND STOMACH), WERE USED. RESPIRATORY THERAPIST (RT) "K" WAS AT THE RESIDENT'S BEDSIDE AND STATED, "THE MIDNIGHT (SHIFT) NURSE CALLED ME AT 8:00 A.M. AND TOLD ME THAT HE HAD MET WITH SOME RESISTANCE PUTTING A NEW CANNULA IN (THE RESIDENT'S THROAT). THEY (THE FACILITY) HAVE A NEW NURSE. THIS WILL BE A GOOD OPPORTUNITY TO LISTEN TO SOMEONE WITH A MUCOUS PLUG (THROAT OBSTRUCTION). I'M WAITING FOR THE NURSE TO GET FINISHED CHECKING BLOOD SUGARS (ON OTHER RESIDENTS)." AT APPROXIMATELY 8:47 A.M., RT "K" LEFT THE ROOM LEAVING THE RESIDENT UNATTENDED WHO WAS EXPERIENCING SHORTNESS OF BREATH. THE RESIDENT WAS OBSERVED SITTING UP, LAYING DOWN, CONSTANTLY CHANGING POSITIONS TO TAKE IN AIR, RUBBING HER HANDS THROUGH HER HAIR, SITTING ON THE SIDE OF THE BED, AND ATTEMPTING TO CATCH HER BREATH. AT 8:50 A.M., TEN MINUTES AFTER RESIDENT #407 WAS INITIALLY OBSERVED HAVING DIFFICULTY BREATHING. THE RESIDENT CONTINUED TO USE HER ACCESSORY MUSCLES TO BREATHE, HELD HER HANDS TO HER THROAT, AND MOUTHED, "I CAN'T BREATHE." THE RESIDENT'S EYES OPENED WIDER AND SHE BEGAN TO CRY. HER RESPIRATORY RATE HAD INCREASED TO 28 BREATHS PER MINUTE. THE RESIDENT WAS RESTLESS AND CONTINUED TO LAY DOWN AND SIT UP IN THE BED. THE RESIDENT WAS SPITTING OUT MODERATE AMOUNTS OF ORAL SECRETIONS INTO A NEAR BY TRASH CAN. AT 9:05 A.M., RT "K" RETURNED TO THE RESIDENT'S BEDSIDE. THE RT "K" LOOKED AT THE RESIDENT AND BEGAN TO OPEN THE STERILE SUPPLIES NEEDED TO CHANGE THE RESIDENT'S [MEDICAL CONDITION]. RT "K'" THEN LEFT THE ROOM AGAIN LEAVING THE RESIDENT, WHO WAS IN ACUTE RESPIRATORY DISTRESS, UNATTENDED. AT 9:16 A.M., RESIDENT #407 WAS OBSERVED SITTING ON THE SIDE OF THE BED, CRYING, PLACING HER TREMBLING HANDS THROUGH STRANDS OF HER HAIR SEVERAL TIMES. HER RESPIRATORY RATE INCREASED FURTHER TO 30 TO 34 BREATHS PER MINUTE. THERE WAS NO STAFF IN ATTENDANCE. AT 9:20 A.M., 40 MINUTES AFTER RESIDENT #407 WAS INITIALLY OBSERVED USING ACCESSORY MUSCLES TO BREATHE AND CONSTANTLY CHANGING POSITIONS IN ORDER TO TAKE IN AIR. THIS SURVEYOR ASKED THE DIRECTOR OF NURSING (DON) WAS ASKED TO COME TO THE RESIDENT'S ROOM. WHEN THE DON ARRIVED, SHE STATED, "SHE'S (THE RESIDENT) IN DISTRESS!" THE DON ASKED RT "K," "WHAT ARE YOU DOING?" RT "K" RESPONDED, "SHE (RESIDENT #407) HAS A MUCOUS PLUG." THE RESIDENT WAS ASKED HOW SHE WAS DOING? THE RESIDENT BEGAN SHAKING HER HEAD AND MOUTHING "NOT GOOD." RT "K" SUCTIONED COPIOUS AMOUNTS OF SECRETIONS FROM INSIDE AND AROUND THE RESIDENT'S [MEDICAL CONDITION]. RT "K" THEN REMOVED THE OLD [MEDICAL CONDITION] AND REPLACED IT WITH A NEW ONE. RT "K" SUCTIONED THE RESIDENT AGAIN. THE RESIDENT LAID BACK IN BED ON TWO PILLOWS, TOOK A DEEP BREATH, AND SIGHED. AT 9:30 AM, THE DON STATED, "IF A RESIDENT HAS A MUCOUS PLUG, THE THERAPIST SHOULDN'T LEAVE HER. HE (RT "K") NEEDS TO TAKE CARE OF THAT." AT 10:20 A.M., THE DON AND RT "K" WERE QUERIED CONCERNING THE DELAY IN CARE FOR RESIDENT #407. "RT "K" STATED, "SHE (RESIDENT #407) WAS IN MODERATE DISTRESS WHEN I FIRST CHECKED HER (AT 8:40 AM)." THE DON THEN REPLIED, "SHE (RESIDENT #407) WAS IN DISTRESS. I SAW IT." AT 10:45 A.M., RESIDENT #407 WAS OBSERVED RESTING IN BED, BREATHING AT 20 BREATHS PER MINUTE. THE RESIDENT COVERED THE OPENING OF [MEDICAL CONDITION] STATED, "I WAS SCARED. I COULDN'T BREATHE." AT 11:45 A.M., RESIDENT #407 WAS SITTING NEAR THE NURSES STATION AND MOUTHED, "I THOUGHT I WAS GOING TO DIE." REVIEW OF RESPIRATORY THERAPY NOTES BY RT "K" DATED 9/27/12 AT 10 AM, WERE REVIEWED THAT DOCUMENTED THE FOLLOWING ACCOUNT: "CALLED AWAY (FROM RESIDENT #407'S ROOM) FOR ANOTHER PATIENT IN ACUTE DISTRESS. UPON RETURN TO (RESIDENT #407'S) room [ROOM NUMBER] MINUTES LATER, PATIENT VERY UPSET (WITH) INCREASED DIFFICULTY IN BREATHING...." HOWEVER, WHEN QUERIED FURTHER ON 9/28/12 12:35 PM, THE DON STATED, "A RESIDENT WITH AN ACUTE CHANGE IN CONDITION SHOULD NOT BE LEFT ALONE. HE (RT "K") SHOULD HAVE LET ONE OF THE NURSES KNOW. BESIDES, WE (REFERRING TO A UNIT MANAGER) HAD THAT OTHER RESIDENT (WHO WAS IN DISTRESS) COVERED." ON 10/4/12 AT 1:20 PM, THE MEDICAL DIRECTOR, WHO WAS ALSO THE RESIDENT'S PRIMARY CARE PHYSICIAN (PCP), WAS ASKED BY PHONE ABOUT THE DELAY IN REMOVING THE MUCOUS PLUG WHICH LEAD TO THE RESIDENT EXPERIENCING RESPIRATORY DISTRESS AND MENTAL ANGUISH ON 9/27/12, THE PCP DID NOT EXPLAIN OR RESPOND. PER THE WEBSITE: WWW INC/JOURNAL ARTICLE: OBSTRUCTED [MEDICAL CONDITION]: CLEARING THE AIR, 1/10 "A COMMON COMPLICATION ASSOCIATED WITH [MEDICAL CONDITION] IS OBSTRUCTION. OBSTRUCTION OF THE [MEDICAL CONDITION] IS A LIFE-THREATENING EMERGENCY, SO IF YOU SUSPECT YOUR PATIENT HAS OR IS DEVELOPING A [MEDICAL CONDITION] OBSTRUCTION, YOU'LL NEED TO INTERVENE IMMEDIATELY. CLOSELY MONITOR YOUR PATIENT FOR SIGNS AND SYMPTOMS OF RESPIRATORY DISTRESS SUCH AS SHORTNESS OF BREATH, TACHYPNEA ( RAPID BREATHS), LABORED BREATHING, AGITATION AND USE OF ACCESSORY MUSCLE. " PER REVIEW OF THE FACILITY'S POLICY TITLED "CHANGE IN CONDITION: NURSING ASSESSMENT" DATED 3/10/12, IF THE CHANGE OR SYMPTOM IS SIGNIFICANT, SUCH AS RESPIRATIONS GREATER THAN 28 BREATHS PER MINUTE, THE PHYSICIAN MUST BE NOTIFIED IMMEDIATELY. THE POLICY DID NOT ADDRESS REMAINING WITH A RESIDENT WHO WAS HAVING AN ACUTE CHANGE IN CONDITION. THE IJ WAS REMOVED ON 10/4/12 WHEN THE FOLLOWING PLAN OF CORRECTION WAS SUBMITTED. ALTHOUGH THE IJ WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE WAS NOT CORRECTED AND REMAINED AS ISOLATED, NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY. ELEMENT #1 RESIDENT # 407 CONTINUES TO RESIDE AT THE FACILITY WITHOUT INJURY OR HARM. RESIDENT PRESENTS WITHOUT SIGNS OR SYMPTOMS OF RESPIRATORY DISTRESS. RESIDENT CONTINUES TO HAVE [MEDICAL CONDITION] IN PLACE. RESIDENT ' S PULSE OXIMETRY HAS RANGED FROM 96%- 99% FROM 9/27/2012 THROUGH TODAY 10/4/2012 ON ROOM AIR PER CURRENT NURSING NOTES. RESIDENT HAS EXHIBITED NO CHANGES IN HER OVERALL CONDITION AND APPEARS STABLE. ALL MEDICATION ADMINISTERED AS ORDERED BY THE PHYSICIAN AND RESIDENT TOLERATED ADMINISTRATION WITHOUT DIFFICULTY ON OCTOBER 4, 2012. RESIDENT WAS RE-ASSESSED BY THE UNIT NURSE AND THE DIRECTOR OF NURSING FOR SIGNS AND SYMPTOMS OF RESPIRATORY DISTRESS, DIMINISHED BREATH SOUNDS, TACHYPNEA, DYSPNEA, GURGLING, CRACKING AND OR WHEEZING UPON INSPIRATION, CYANOSIS DECREASED BREATH SOUNDS, DECREASED OXYGEN SATURATION, RESTLESSNESS AGITATION AND OR CONFUSION AS WELL AS DROOLING, SECRETIONS OR VOMITUS IN MOUTH. RESIDENT SHOWED NO SIGNS OR SYMPTOMS OF DISTRESS AND OXYGEN SATURATION WAS NOTED AT 98% AT APPROXIMATELY 11:15 AM ON OCTOBER 4, 2012. RESIDENT # 407 WAS RE-ASSESSED BY RESPIRATORY THERAPIST ON OCTOBER 4, 2012 AT APPROXIMATELY 3:45 PM AND NOTED COLOR GOOD AND SKIN WARM AND DRY WITH BREATH SOUNDS CLEAR AND PULSE OXIMETRY 96% ON ROOM AIR. RESIDENT PRESENTED NO SIGNS OR SYMPTOMS OF RESPIRATORY DISTRESS DURING ASSESSMENT ON OCTOBER 4, 2012. RESPIRATORY CARE PLAN REVIEWED ON OCTOBER 4, 2012. RESIDENT # 407 WAS [MEDICAL CONDITION] ON OCTOBER 4, 2012 USING PROPER TECHNIQUE AND TOLERATED WELL. RESIDENT WAS SEEN BY PSYCH SERVICES ON OCTOBER 2, 2012 FOR ROUTINE TREATMENT AND FOLLOW UP FOR DECREASED MOOD, CONFUSION, ANXIOUSNESS AND DEPRESSION. RESIDENT OVERALL APPEARS STABLE NO NOTED CHANGES IN BEHAVIOR OR APPETITE OR DAILY TASKS SHE WILL CONTINUE BEING FOLLOWED BY PSYCH SERVICES TO ASSIST WITH MOOD STABILIZATION IN RELATION TO HER OVERALL CONDITION. SOCIAL WORKER ASSESSED RESIDENT ON OCTOBER 4, 2012 AT APPROXIMATELY 5:15 PM AND RESIDENTS MOOD WAS PLEASANT AND VERY INVITING. RESIDENT EXPRESSED HAVING A GOOD MOOD AND STATED HER OVERALL CARE WAS GOOD. RESIDENT STATED SHE WAS NOT IN ANY TYPE OF DISTRESS AT THIS TIME. SOCIAL WORKER WILL VISIT WITH RESIDENT DAILY X ' S ONE WEEK, THEN AT LEAST WEEKLY X ' S ONE MONTH TO ENSURE MOOD REMAINS STABLE AND RESIDENT ' S PSYCHO SOCIAL NEEDS ARE BEING MET AND ADDRESSED APPROPRIATELY. ELEMENT #2 ON OCTOBER 4, 2012 THERE WERE 12 RESIDENT ' S IDENTIFIED WITH POTENTIAL FOR RESPIRATORY DISTRESS RELATED TO OXYGEN THERAPY. THE 12 RESIDENT ' S IDENTIFIED WERE RE-EVALUATED ON OCTOBER 4, 2012 BY THE UNIT NURSE. THE IDENTIFIED RESIDENTS WERE ASSESSED FOR SIGNS AND SYMPTOMS OF RESPIRATORY DISTRESS AND WERE EVALUATED FOR SYMPTOMS SUCH AS DIMINISHED BREATH SOUNDS, TACHYPNEA, DYSPNEA, GURGLING, CRACKING AND OR WHEEZING, CYANOSIS, DECREASED BREATH SOUNDS, DECREASED OXYGEN SATURATION, RESTLESSNESS AGITATION, CONFUSION, DROOLING AND OR VOMITUS IN THE MOUTH. THE 12 RESIDENT ' S IDENTIFIED APPEARED STABLE AND DID NOT EXHIBIT SIGNS OR SYMPTOMS OF RESPIRATORY DISTRESS ON OCTOBER 4, 2012 DURING THE ASSESSMENT. ON OCTOBER 4, 2012 CARE PLANS FOR THE 12 RESIDENTS IDENTIFIED WERE REVIEWED BY THE NURSE TO ENSURE POTENTIAL SYMPTOMS OR SIGNS OF DISTRESS WERE IDENTIFIED APPROPRIATELY. ELEMENT #3 EMERGENCY QUALITY ASSURANCE MEETING WAS HELD ON OCTOBER 4, 2012 AT 5:30 PM TO DISCUSS AND IDENTIFY AREAS OF CONCERN AS IT RELATES TO RESPIRATORY CARE, IDENTIFYING SIGN AND SYMPTOMS AND APPROPRIATE TREATMENT FOR IDENTIFIED SYMPTOMS. MEMBERS OF THE INTERDISCIPLINARY TEAM WERE PRESENT TO ASSIST WITH PROVIDING INPUT AND CORRECTIVE ACTIONS TO MAINTAIN SYSTEMS AND ENSURE COMPLIANCE. THE POLICY AND PROCEDURE ON RECOGNIZING THE SIGNS AND SYMPTOMS OF RESPIRATORY DISTRESS WAS REVIEWED AND REVISED ON OCTOBER 4, 2012 BY THE ADMINISTRATIVE STAFF. LEAD RESPIRATORY THERAPIST REVIEWED AND REVISED [MEDICAL CONDITION] POLICY ON OCTOBER 4, 2012. LEAD RESPIRATORY THERAPIST PROVIDED 1:1 IN-SERVICE TO FACILITY RESPIRATORY THERAPIST ON NEWLY REVISED [MEDICAL CONDITION] POLICY ON OCTOBER 4, 2012. FACILITY RESPIRATORY THERAPIST WAS IN-SERVICED ON IDENTIFYING THE SIGNS AND SYMPTOMS OF RESPIRATORY DISTRESS AND HOW TO PROVIDE AND TREAT SYMPTOMS APPROPRIATELY. [MEDICAL CONDITION] CARE POLICY AND PROCEDURE WAS REVIEWED AND UPDATED OCTOBER 4, 2012 BY THE ADMINISTRATIVE STAFF. ON OCTOBER 4, 2012, 20 OF 72 (FULL, PART TIME AND CONTINGENT) LICENSED NURSING STAFF WERE IN-SERVICED BY THE IN-SERVICE NURSE BY 1:30 PM ON THE REVISED [MEDICAL CONDITION] POLICY. LICENSED NURSES WERE IN-SERVICED ON IDENTIFYING SIGNS AND SYMPTOMS OF DISTRESS WITH INTERVENTIONS AS THEY APPLY TO SYMPTOMS IDENTIFIED. THERE WERE 47 LICENSED NURSING STAFF IN-SERVICED ON APPROPRIATE [MEDICAL CONDITION], OXYGEN CARE, AND PERFORMING APPROPRIATE TECHNIQUE BY THE IN-SERVICE DIRECTOR BY 7 PM ON OCTOBER 4, 2012. THE MIDNIGHT SHIFT SUPERVISOR PROVIDED IN-SERVICE TO 7 ADDITIONAL STAFF ON RESPIRATORY DISTRESS, RECOGNIZING SIGNS AND SYMPTOMS, ADDRESSING TIMELY [MEDICAL CONDITION] BY 7 AM OCTOBER 5, 2012. THE REMAINING 17 NURSES WERE CONTACTED VIA PHONE ON OCTOBER 4, 2012 BY THE HUMAN RESOURCE DEPARTMENT AND THE STAFFING COORDINATOR AND WERE MADE AWARE THEY WOULD NOT BE PERMITTED TO WORK UNTIL THE IN-SERVICE ON RESPIRATORY DISTRESS IS COMPLETED. RESIDENT # 407'S CARE PLANS WERE REVIEWED AND UPDATED BY NURSING STAFF OCTOBER 4, 2012. AUDITS WILL BE CONDUCTED DAILY ON ALL RESIDENTS IDENTIFIED AS HAVING POTENTIAL FOR RESPIRATORY DISTRESS UTILIZING NURSING NOTES TO MONITOR SIGNS AND SYMPTOMS OF DISTRESS ALONG WITH APPROPRIATE TREATMENT BASED ON IDENTIFIED SYMPTOMS FOR ONE WEEK TO ENSURE COMPLIANCE AND THEN AUDIT WEEKLY X ' S 4 WEEKS THEREAFTER. THE NURSING NOTES REGARDING RESPIRATORY STATUS WILL BE MONITORED BY THE DON/DESIGNEE BEGINNING OCTOBER 4, 2012 TO ENSURE COMPLIANCE AND ENSURE PROCEDURES ARE BEING FOLLOWED CORRECTLY. AREAS OF NON- COMPLIANCE WILL BE ADDRESSED IMMEDIATELY AND CONCERNS FORWARDED TO QA FOR REVIEW AND MONITORING AT LEAST MONTHLY FOR 3 MONTHS. ELEMENT #4 THE ADMINISTRATOR IS RESPONSIBLE FOR ENSURING ON-GOING COMPLIANCE. ( ) ( ) ( ) ( ) ( ) ( ) DEFICIENT PRACTICE #2. BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PERFORM [MEDICAL CONDITION] CARE FOR ONE OF ONE SAMPLED RESIDENT (#425) REVIEWED WITH A [MEDICAL CONDITION] OUT OF A TOTAL OF 32, RESULTING IN BLEEDING AT THE AREA SURROUNDING THE [MEDICAL CONDITION] WHEN THE RESIDENT PERFORMED SELF-CARE OF THE [MEDICAL CONDITION] AND THE POTENTIAL FOR DEVELOPMENT OF INFECTION. FINDINGS INCLUDE: ON 9/27/12 AT 9:45 A.M., RESIDENT #425 WAS OBSERVED IN A ROOM CLEANING HIS STOMA ( THE END OF THE BOWEL THAT PROTRUDES THROUGH THE ABDOMINAL WALL) WITH 4 X 4 GAUZE DRESSINGS. THE STOMA HAD A LARGE AMOUNT OF BRIGHT RED (FRESH) BLOOD COMING FROM IT. THE RESIDENT USED SEVERAL 4 X 4'S AND WIPED THE AREA THREE TIMES TO REMOVE THE BLOOD COMING FROM THE STOMA. THE RESIDENT DID NOT HAVE GLOVES ON. THE RESIDENT PLACED THE POUCH (USED TO COLLECT THE WASTE) ONTO THE AREA SURROUNDING THE STOMA. RESIDENT #425 WAS ASKED WHY HE WAS DOING HIS OWN [MEDICAL CONDITION] CARE AND WHERE WERE THE GLOVES. THE RESIDENT RESPONDED, "I'VE BEEN DOING IT FOR SIX YEARS. I ASKED FOR GLOVES BUT THEY DIDN'T BRING THEM." CERTIFIED NURSING ASSISTANT (CNA) "M" ENTERED THE ROOM AND HANDED THE RESIDENT A BOX OF GLOVES. CNA "M" WAS ASKED IF THE RESIDENT DID HIS OWN [MEDICAL CONDITION] CARE. CNA "M" REPLIED, " YES, HE DOES HIS OWN." AT 10:00 A.M., THE CLINICAL RECORD FOR RESIDENT #425 WAS REVIEWED. THE ADMISSION FACE SHEET NOTED THAT THE RESIDENT WAS readmitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE] INDICATED THE RESIDENT WAS SEVERELY COGNITIVELY IMPAIRED AND REQUIRED EXTENSIVE ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING. ON 9/27/12 AT 11:55 A.M., UNIT MANAGER "F" WAS QUERIED CONCERNING RESIDENT #425 PERFORMING HIS [MEDICAL CONDITION] CARE AND WHETHER HE WAS EVER ASSESSED TO PERFORM IT. MANAGER "F" WAS ASKED WHEN DID STAFF ASSESS THE RESIDENT'S [MEDICAL CONDITION] TO ENSURE THAT IT WAS BEING CARED FOR PROPERLY AND THAT THERE WAS NO SKIN TRAUMA. UNIT MANAGER "F" REVIEWED THE RESIDENT'S CHART AND WAS UNABLE TO FIND AN ASSESSMENT AND OR CARE PLAN THAT DOCUMENTED THE RESIDENT COULD PERFORM HIS OWN [MEDICAL CONDITION] CARE. UNIT MANAGER "F" WAS ALSO UNABLE TO FIND NURSES NOTES DOCUMENTING THAT STAFF HAD ASSESSED THE RESIDENT'S [MEDICAL CONDITION] SITE. SHE WAS UNABLE TO EXPLAIN WHY. ON 9/27/12 AT 3:30 P.M., UNIT MANAGER "F" DEFERRED TO MDS NURSE "L" CONCERNING RESIDENT #425'S ASSESSMENT FOR PERFORMING [MEDICAL CONDITION] SELF-CARE. MDS NURSE "L" STATED, "SINCE THE FALL (THAT OCCURRED 7/2012 RESULTING IN A [MEDICAL CONDITION]) HE (RESIDENT #425) HAS HAD AN ACUTE CHANGE IN CONDITION. HE SHOULD NOT BE DOING HIS [MEDICAL CONDITION] CARE. ON 8/8/12, AFTER DOING HIS MDS ASSESSMENT, I TOLD STAFF AND THE UNIT MANAGER THAT HE CAN'T DO HIS [MEDICAL CONDITION] ANYMORE." ON 9/28/12 AT 10:00 A.M., RESIDENT #425'S BEDSIDE TABLE WAS OBSERVED WITH UNIT MANAGER "F." THE RESIDENT HAD TWO BOXES OF [MEDICAL CONDITION] SUPPLIES ON HIS BEDSIDE TABLE. UNIT MANAGER "F" LOOKED AT THE SUPPLIES, SHOOK HER HEAD, AND LEFT THE ROOM. WHEN ASKED IF THE RESIDENT SHOULD HAVE THOSE SUPPLIES AT HIS BEDSIDE, UNIT MANGER 'F" REPLIED "NO." SHE WAS UNABLE TO EXPLAIN WHY THE SUPPLIES WERE THERE AND WHY THE RESIDENT WAS STILL PERFORMING SELF-CARE OF THE [MEDICAL CONDITION]. PER REVIEW OF THE FACILITY'S UNDATED POLICY TITLED [MEDICAL CONDITION] AND [MEDICAL CONDITION] CARE: "RESIDENTS WITH A [MEDICAL CONDITION] OR [MEDICAL CONDITION] WEAR AN EXTERNAL POUCH TO COLLECT EMERGING FECAL MATTER, CONTROL ODOR, AND TO PROTECT THE STOMA AND [MEDICATION NAME] AREA... A NURSE PERFORMS THIS PROCEDURE. CNA'S WITH PROPER TRAINING MAY ALSO PERFORM [MEDICAL CONDITION] CARE UNDER THE SUPERVISION OF A LICENSED NURSE." ( )

THIS CITATION PERTAINS TO INTAKES MI 755 AND MI 966. BASED ON OBSERVATION, INTERVIEWS AND RECORDS REVIEW, THE FACILITY FAILED TO ENSURE THAT 12 OF 12 RESIDENTS (#101, #102, #103, #104, #105, #106, #107, #108, #109, #110, #111 AND #112) REVIEWED FOR ELOPEMENT, FROM A TOTAL SAMPLE OF 34, RECEIVED ADEQUATE ASSISTIVE DEVICES AND THE APPROPRIATE LEVEL OF SUPERVISION TO ENSURE A SAFE LIVING ENVIRONMENT, RESULTING IN IMMEDIATE JEOPARDY FOR RESIDENT #101, WHEN STAFF FAILED TO FOLLOW THE FACILITY'S ELOPEMENT POLICY AND/OR PHYSICIAN ORDERS, PERMITTING RESIDENT #101 ACCESS TO MOVE FROM A SECURED SECOND FLOOR, INTO AN OPERATING ELEVATOR, ONTO THE FIRST FLOOR AND INTO THE FRONT LOBBY WITHOUT ACTIVATION OF THE ELOPEMENT SENSORS AND/OR SECURITY SYSTEMS ALARMS IN EACH AREA. IN THE LOBBY, FACILITY STAFF THEN OPENED AN OTHERWISE LOCKED FRONT DOOR AND WATCHED RESIDENT #101, A COGNITIVELY IMPAIRED RESIDENT, LEAVE THE BUILDING, UNSUPERVISED, DURING THE EVENING HOURS OF 5/22/2012. THIS DEFICIENT PRACTICE ALSO RESULTED IN THE POTENTIAL FOR ELOPEMENT AND SUBSEQUENT POTENTIAL FOR SERIOUS HARM, INJURY AND/OR DEATH FOR RESIDENTS #102, #103, #104, #105, #106, #107, #108, #109, #110, #111 AND #112 AS WELL AS FOR 5 NON-SAMPLED RESIDENTS, IDENTIFIED AS AT RISK FOR ELOPEMENT. FINDINGS INCLUDE: THE FACILITY'S POLICY FOR "ELOPEMENT: ASSESSMENT, PREVENTION AND RESPONSE," LAST UPDATED 11/2011, WAS REVIEWED FOR COMPLIANCE WITH SAMPLED RESIDENTS. THIS FACILITY POLICY REQUIRED 1) A NURSING ASSESSMENT ON ADMISSION AND, AS NEEDED, FOR ALL RESIDENTS AT RISK OF ELOPEMENT; 2) CARE PLANS IMPLEMENTED FOR ALL RESIDENTS ON ELOPEMENT PRECAUTIONS; 3) THE PLACEMENT OF A WANDERGUARD/BRACELET TRANSMITTER DEVICE (A DEVICE THAT TRANSMITS A SIGNAL WHICH ACTIVATES AN ALARM WHEN THE SIGNAL IS RECEIVED, USUALLY AT A DOORWAY) ON AT-RISK RESIDENTS; 4) DOCUMENTATION THAT THE BRACELET TRANSMITTER WAS APPLIED; 5) BRACELET TRANSMITTERS SCANNED EVERY MORNING TO ENSURE FUNCTION WITH DOCUMENTATION OF THE SAME ON THE MEDICATION ADMINISTRATION RECORD (MAR); 6) FACILITY WIDE SENSORS MONITORED FOR APPROPRIATE FUNCTION WHEN BRACELET TRANSMITTERS NEARED THEM; 7) A THOROUGH AND IMMEDIATE INVESTIGATION OF ALL TRIGGERED ALARMS, TO FIND (THAT IS, IDENTIFY THE) TRIGGER AND SECURE RESIDENTS; AND 8) STAFF TO RESET THE ALARM AFTER #7 IS COMPLETE; 9) NAMES AND PICTURES OF ALL RESIDENTS AT RISK FOR ELOPEMENT MAINTAINED AT THE LOBBY DESK; 10) STAFF EDUCATED ON ELOPEMENT PRECAUTIONS; 11) RESIDENTS ON ELOPEMENT PRECAUTIONS MONITORED BASED ON INDIVIDUAL NEEDS, RESIDENT BEHAVIORS AND NURSING JUDGMENT; 12) AN INCIDENT REPORT GENERATED WITH EACH ELOPEMENT; AND 13) NOTIFICATION OF MDCH (MICHIGAN DEPARTMENT OF COMMUNITY HEALTH, NOW KNOWN AS MICHIGAN DEPARTMENT OF LICENSURE AND REGULATORY AFFAIRS) BY ADMINISTRATION. ACCORDING TO THE POLICY, ACTIVATED ALARMS PREVENTED ELEVATORS FROM OPERATING UNTIL THEY WERE RESET. RESIDENT #101: ACCORDING TO THE FACE SHEET DATED 5/31/2012, RESIDENT #101 WAS AN [AGE] year OLD FEMALE WHO LIVED AT THE FACILITY SINCE 10/04/2011. HER [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM DATA SET assessment dated [DATE], RESIDENT #101 HAD SEVERELY IMPAIRED COGNITION, INATTENTION, TROUBLES CONCENTRATING WITH BOTH LONG AND SHORT TERM MEMORY LOSS. STAFF SUPERVISION WAS REQUIRED WHEN RESIDENT #101 WALKED DUE TO HER EXTENSIVE DAILY WANDERING. THE ADMISSION ELOPEMENT ASSESSMENT, DATED 10/04/2011, REVEALED RESIDENT #101 ARRIVED TO THE FACILITY AMBULATORY, CONFUSED, AND WITH A HISTORY OF WANDERING AT HER PRIOR FACILITY/HOSPITAL AND HOME. IT WAS DETERMINED RESIDENT #101 WAS AN ELOPEMENT RISK AND STAFF DOCUMENTED THAT A WANDERGUARD BRACELET WAS APPLIED. ON 10/28/2011, A PHYSICIAN ORDERED RESIDENT #101 TO WEAR A WANDERGUARD BRACELET AT ALL TIMES. THE PHYSICIAN ORDERED STAFF TO FOLLOW THE ELOPEMENT PROTOCOL AND COMPLETE DAILY FUNCTION TESTS ON THE BRACELET. THE ELOPEMENT CARE PLAN WAS UPDATED ON 2/01/2012, BUT NO NEW INTERVENTIONS WERE IMPLEMENTED. A CNA (CERTIFIED NURSING ASSISTANT) CARE GUIDE DATED 2/16/2012 IDENTIFIED THAT RESIDENT #101 WAS AT RISK FOR ELOPEMENT AND REQUIRED STAFF TO ENSURE A WANDERGUARD BRACELET WAS ON HER BODY AT ALL TIMES. A REVIEW OF MEDICATION ADMINISTRATION RECORDS, DATED 4/02/2012, 4/03/2012, 4/04/2012 AND 4/05/2012, FAILED TO PROVIDE ANY DOCUMENTED EVIDENCE STAFF HAD COMPLETED THE REQUIRED DAILY FUNCTION TESTS ORDERED BY HER PHYSICIAN AND REQUIRED BY FACILITY POLICY FOR WANDERGUARD BRACELETS. NURSING NOTES, DATED 4/06/2012, AT NOON DOCUMENTED THAT RESIDENT #101 WAS UNSUPERVISED WHEN SHE WENT FROM THE SECOND FLOOR, DOWN TO THE FIRST FLOOR, AND WAS NEAR THE FRONT LOBBY, BEFORE STAFF LOCATED HER. ON 4/06/2012, THE PHYSICIAN AGAIN ORDERED STAFF TO APPLY A WANDERGUARD TO RESIDENT #101, "TO PREVENT ELOPEMENT." AGAIN, THE PHYSICIAN REQUIRED STAFF TO CHECK THE FUNCTION OF THE BRACELET DAILY. AN ELOPEMENT ASSESSMENT, DATED 4/06/2012, DOCUMENTED THAT RESIDENT #101 WAS AT RISK FOR ELOPEMENT BECAUSE SHE WAS CONFUSED, DISORIENTED, INDEPENDENTLY AMBULATED, AND had a history of [REDACTED]. NURSES DOCUMENTED THAT RESIDENT #101 HAD CONSTANT EXIT SEEKING BEHAVIOR. THESE BEHAVIORS WERE DOCUMENTED IN THE NURSING NOTES ON 4/06/2012 AT NOON, WHEN STAFF APPLIED A WANDERGUARD ON RESIDENT #101'S LEFT ANKLE; ON 4/07/2012, WHEN RESIDENT #101 EXPERIENCED INCREASED ANXIETY AND AGITATION AFTER STAFF REJECTED HER DESIRE TO LEAVE THE FACILITY; ON 4/08/2012, WHEN STAFF FOUND RESIDENT #101 "DIFFICULT TO REDIRECT" WITH "INCREASED AGITATION AND ANXIETY NOTED;" ON 4/11/2012 AND 4/23/2012, WHEN RESIDENT #101 WAS "ANXIOUS" AS SHE WALKED THE UNIT; ON 4/26/2012, WHEN RESIDENT #101 WANTED TO LEAVE THE FACILITY TO WAIT FOR A BUS; AND ON 4/29/2012, WHEN STAFF DOCUMENTED RESIDENT #101 COULD NOT BE REDIRECTED AND WAS VERBALLY ABUSIVE AND PACED THE HALLS LOOKING FOR A DOOR TO EXIT. PSYCHIATRIC NOTES, DATED 5/22/2012, DOCUMENTED THAT RESIDENT #101 HAD DEMENTIA WITH RECENTLY INCREASED BEHAVIORS OF "ANGER (AND) EXIT-SEEKING." THE PSYCHIATRIC PRACTITIONER DOCUMENTED THAT RESIDENT #101 HAD POOR KNOWLEDGE, POOR JUDGMENT, POOR INSIGHT, IMPAIRED ATTENTION, IMPAIRED CONCENTRATION, IMPAIRED RECENT AND IMPAIRED REMOTE MEMORY. THE PRACTITIONER DOCUMENTED THAT RESIDENT #101 WAS "VERY CONFUSED ...RESTLESSNESS ...DISORIENTED, INSISTS SHE CAN GO HOME ALONE" AND WAS "UNABLE TO BE REDIRECTED OR DISTRACTED EFFECTIVELY." ALTHOUGH NURSING STAFF DOCUMENTED THESE OBSERVATIONS AND ASSESSMENTS, THERE WAS NO EVIDENCE THAT THEY UPDATED RESIDENT #101'S ELOPEMENT CARE PLAN. DURING AN INTERVIEW ON 8/07/2012 AT 11:10 A.M., A STAFF MEMBER WISHING TO REMAIN ANONYMOUS (ANN #1) SAID SHE WAS PRESENT THE EVENING OF 5/22/2012, WHEN RESIDENT #101 ELOPED FROM THE FACILITY, UNSUPERVISED. DURING AN INTERVIEW ON 7/27/2012 AT 2:30 P.M., A STAFF MAINTENANCE MEMBER (EMPLOYEE #3) SAID HE TOO WAS PRESENT DURING THE EVENING SHIFT RESIDENT #101 SUCCESSFULLY ELOPED FROM THE FACILITY, UNSUPERVISED. DURING AN INTERVIEW ON 7/27/2012 AT 3:00 P.M., RECEPTIONIST #1 (REC #1) SAID A WELL-DRESSED FEMALE (RESIDENT #101), WHO APPEARED TO BE A VISITOR, NOT A RESIDENT, RODE THE ELEVATOR TO THE FIRST FLOOR AND ENTERED THE FIRST FLOOR LOBBY. REC #1 SAID SHE TOLD RESIDENT #101 TO HAVE A GOOD DAY AND THEN, "...BUZZED HER OUT." REC #1 SAID WHEN SHE PRESSED THE BUZZER, THE OTHERWISE LOCKED FRONT DOORS OPENED AND RESIDENT #101 WALKED OUTSIDE INTO THE PARKING LOT, UNSUPERVISED. REC #1 WATCHED RESIDENT #101 LEAVE THE FACILITY BEFORE AN UNIDENTIFIED MALE VISITOR INFORMED HER (REC #1) THE WOMAN JUST RELEASED WAS LIKELY A CONFUSED RESIDENT FROM THE SECOND FLOOR. REC #1 SAID IT TOOK APPROXIMATELY ONE MINUTE FOR HER TO UNDERSTAND EXACTLY WHO AND WHAT THE UNIDENTIFIED MALE VISITOR MEANT, AND THEN SHE IMMEDIATELY NOTIFIED THE NURSING SUPERVISOR, AND CALLED A "CODE PINK." ACCORDING TO REC #1, A CODE PINK SIGNIFIED A RESIDENT WAS MISSING. REC #1 SAID THE SENSOR ALARMS DID NOT SOUND WHEN RESIDENT #101 EXITED THE ELEVATOR OR ENTERED THE LOBBY. RECEPTIONIST #1 SAID SHE DID NOT IDENTIFY RESIDENT #101 AS A RESIDENT OR AS AN ELOPEMENT RISK BECAUSE "SHE LOOKED LIKE A VISITOR . . .I DIDN'T REVIEW THE ELOPEMENT BOOK." DURING AN INTERVIEW ON 7/30/2012 AT 10:00 A.M., NURSING SUPERVISOR (NS #1), A REGISTERED NURSE (RN), SAID THAT WHEN THE CODE PINK WAS CALLED SHE (NS #1) IMMEDIATELY WENT INTO THE LOBBY, DISCUSSED THE SITUATION WITH REC #1 AND THEN STEPPED OUTSIDE THE FRONT DOORS. NS #1 SAID SHE SAW RESIDENT #101 RUNNING, UNSUPERVISED, THROUGH THE PARKING LOT, TOWARD THE STREET. INITIALLY, NS #1 SAID RESIDENT #101 WORE A WANDERGUARD WHEN SHE ELOPED FROM THE FACILITY, BUT IT "DIDN'T WORK." NS #1 LATER SAID, "TO BE HONEST," RESIDENT #101 MAY NOT HAVE HAD A WANDERGUARD BRACELET ON WHEN SHE ELOPED ON 5/22/2012. ACCORDING TO MEDICATION ADMINISTRATION RECORDS, DATED 5/22/12, IN THE SECTION WHERE NURSING STAFF WERE TO DOCUMENT THE WANDERGUARD FUNCTION TEST FOR RESIDENT #101, THE NURSE CIRCLED HER INITIALS ON THE MEDICATION ADMINISTRATION RECORD TO INDICATE THE TASK WAS NOT COMPLETED. NURSING NOTES DATED 5/22/2012 AT 3:30 P.M. DOCUMENTED THAT RESIDENT #101 REFUSED THE PLACEMENT OF HER WANDERGUARD THREE TIMES AND IT WAS "NOT APPLIED AT THIS TIME." DESPITE THE ELOPEMENT OF RESIDENT #101, STAFF FAILED TO DOCUMENT ANY NEW INTERVENTIONS IMPLEMENTED TO ENSURE RESIDENT #101 REMAINED SAFE UNTIL HER DISCHARGE TO A LOCAL AREA HOSPITAL 5/23/2012 AT 4:30 P.M. ON 5/30/2012, RESIDENT #101 RETURNED TO THE FACILITY, WAS ASSESSED AND DETERMINED TO BE AN ONGOING ELOPEMENT RISK. A NURSING ENTRY, DATED 7/23/2012 AT 10:30 P.M., REVEALED RESIDENT #101 HAD NO WANDERGUARD IN PLACE WHEN STAFF ATTEMPTED TO REMOVE THE DEVICE FOR TEMPORARY DISCHARGE TO A LOCAL HOSPITAL. DESPITE THIS ASSESSMENT, STAFF FAILED TO DOCUMENT ANY ADDITIONAL SAFETY INTERVENTIONS IMPLEMENTED TO ENSURE HER FUTURE SAFETY AFTER SHE RETURNED TO THE FACILITY, HOURS LATER. DURING AN INTERVIEW ON 7/27/2012 AT 3:15 P.M., THE DIRECTOR OF NURSING (DON #1) SAID THAT RESIDENT #101 SHOULD NOT HAVE BEEN ABLE TO GO UNSUPERVISED, FROM THE FACILITY'S SECOND FLOOR DOWN TO THE FIRST FLOOR ON 4/2/06/2012. DON #1 WENT ON TO SAY THAT RESIDENT #101 SHOULD NOT HAVE BEEN ABLE TO SUCCESSFULLY ELOPE ON 5/22/2012. ACCORDING TO THE DON, RESIDENT #101 COULD HAVE ONLY ACHIEVED THESE MOVEMENTS IF THE FACILITY'S WANDERGUARD AND/OR ELOPEMENT SYSTEM FAILED TO FUNCTION, IF UNIDENTIFIED VISITORS KNEW THE ALARMS CODES AND RESET THEM, OR IF THE ORDERED WANDERGUARD BRACELET WAS NOT IN PLACE. DON #1 SAID THAT NO MATTER THE CAUSE, RESIDENT #101 WAS AT RISK FOR HARM AND SUBSEQUENT INJURY, WHEN THE SYSTEM AND/OR STAFF FAILED TO PREVENT HER ELOPEMENT. DON #1 FURTHER SAID THAT RESIDENT #101 WAS KNOWN FOR FREQUENTLY REMOVING HER WANDERGUARD BRACELET. DON #1 FAILED TO EXPLAIN WHAT ADDITIONAL SAFETY DEVICES AND/OR SUPERVISION WERE IMPLEMENTED TO KEEP RESIDENT #101 SAFE, AFTER SHE (#101) LEARNED TO REMOVE HER OWN WANDERGUARD BRACELET. DURING AN INTERVIEW ON 7/31/2012 AT 1 P.M., THE ADMINISTRATOR (ADM #1) SAID, "VISUAL CHECKS ARE NEVER GOOD ENOUGH. WE ALL KNOW..." THAT THE WANDERGUARD BRACELET MAY NOT HAVE BEEN FUNCTIONAL, EVEN IF IT WAS PRESENT. ADM #1 SAID THAT IF A SECOND FLOOR RESIDENT WITH A WANDERGUARD MADE IT TO THE FIRST FLOOR, THE SYSTEM TO PREVENT ELOPEMENT FAILED. ON 8/07/2012 AT 3:40 P.M., ADM #1 AGREED WITH A CORPORATE NURSE CONSULTANT #1 (CNC #1) WHO SAID, "WE KNOW THE ELOPEMENT HAPPENED. THAT'S ON US." ON 7/27/2012 AND 7/31/2012 RESIDENT #101 WAS OBSERVED PACING THROUGH THE HALLWAYS ON SECOND FLOOR WITH A FUNCTIONAL WANDERGUARD ATTACHED TO HER LEFT ANKLE. ON 8/03/2012 AT 10:25 A.M., THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY THAT BEGAN ON 5/22/2012, WHEN THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION AND/OR ASSISTIVE DEVICES TO PREVENT A COGNITIVELY IMPAIRED INDIVIDUAL, RESIDENT #101, FROM AN UNSUPERVISED FACILITY ELOPEMENT. THIS DEFICIENT PRACTICE PLACED 16 OTHER RESIDENTS IDENTIFIED AS AT RISK FOR ELOPEMENT, AT RISK FOR SERIOUS HARM, INJURY, AND/OR DEATH. ON 8/03/2012 THE SURVEYOR ENSURED THE FACILITY HAD IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. AS OF 8/03/2012, RESIDENT #101 REMAINED AT THE FACILITY WITHOUT INJURY AND/OR HARM. 2. AS OF 8/03/2012 RESIDENT #101 HAD NO OTHER IDENTIFIED ELOPEMENT ATTEMPTS. 3. AS OF 8/03/2012 RESIDENT #101'S WANDERGUARD FUNCTIONED WHEN tested . 4. AS OF 8/03/2012, 16 RESIDENTS WERE IDENTIFIED BY THE FACILITY AT RISK FOR ELOPEMENT. 5. AS OF 8/03/2012, 16 OF 16 RESIDENTS ON ELOPEMENT RISKS HAD UPDATED CARE PLANS AND ELOPEMENT ASSESSMENTS. 6. AS OF 8/03/2012, 16 OF 16 ELOPEMENT PRECAUTION RESIDENT HAD FUNCTIONAL WANDERGUARD BRACELETS IN PLACE WHEN tested . 7. AS OF 8/03/2012, 4 OF 4 ELEVATOR SENSORS FUNCTIONED WHEN tested . 8. AS OF 8/08/2012, 8 OF 8 DOOR SYSTEMS FUNCTIONED WHEN tested . 9. AS OF 7/25/2012, RECEPTIONIST #1 HAD DOCUMENTED ELOPEMENT INSERVICE TRAINING. 10. AS OF 7/25/2012, THE ELOPEMENT BOOK WAS UPDATED AND PLACED AT THE FRONT DESK. 11. AS OF 8/03/2012, 277 OF 294 EMPLOYEES HAD RECEIVED EDUCATION ON ASSESSMENTS, CARE PLANS, THE SECURITY SYSTEM, MONITORING, SEARCHING FOR MISSING RESIDENTS AND DOCUMENTATION OF ELOPEMENTS. 12. AS OF 8/03/2012, 9 RECEIPTS FOR CERTIFIED LETTERS WITH THE SAME EDUCATION REQUIREMENTS WERE AVAILABLE FOR REVIEW, SENT TO EMPLOYEES ON CURRENT LEAVE OF ABSENCES. 13. AS OF 8/03/2012, STAFF WILL NOT BE ALLOWED TO WORK UNTIL THE REQUIRED EDUCATION IS RECEIVED. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED ON 8/03/2012, 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 AS SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY. RESIDENT #102: ACCORDING TO THE FACE SHEET DATED 6/20/2012, RESIDENT #102 WAS AN [AGE] year OLD MALE WHO LIVED AT THE FACILITY SINCE 12/19/2011. HIS [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM DATA SET assessment dated [DATE], RESIDENT #102 HAD SEVERELY IMPAIRED COGNITION WITH BOTH LONG AND SHORT TERM MEMORY LOSS. AN ELOPEMENT assessment dated [DATE] DOCUMENTED RESIDENT #102 WAS CONFUSED AND DISORIENTED BUT NOT AT RISK FOR ELOPEMENT AND HE DID NOT REQUIRE A WANDERGUARD BRACELET. NURSING NOTES DATED 7/17/2012 FOR RESIDENT #102, DOCUMENTED THAT HE (#102) WAS UNSUPERVISED AND TOOK "THE ELEVATOR TO THE 1ST (FIRST) FLOOR." PHYSICIAN ORDERS [REDACTED]. NURSING DOCUMENTED THE APPLICATION OF THE WANDERGUARD BRACELET ON HIS RIGHT ANKLE 7/17/2012 AT 12:00 A.M. ACCORDING TO MEDICATION ADMINISTRATION RECORDS DATED 7/17/2012, 7/18/2012, 7/19/2012, 7/20/2012, 7/21/2012, 7/22/2012, 7/23/2012, 7/24/2012, 7/25/2012, 7/26/2012, 7/27/2012, 7/28/2012 AND 7/29/2012 STAFF FAILED TO DOCUMENT COMPLETION OF THE DAILY WANDERGUARD FUNCTION TESTS FOR RESIDENT #102. DURING AN INTERVIEW ON 7/31/2012 AT 2:15 P.M., THE UNIT MANAGER (UM #4), A LICENSED PRACTICAL NURSE (LPN), FOR RESIDENT #102 SAID EMPTY BOXES ON THE MEDICATION ADMINISTRATION RECORD INDICATED THAT STAFF FAILED TO FOLLOW FACILITY POLICY AND/OR PHYSICIANS ORDERS. UM #4 REVIEWED THE MEDICATION ADMINISTRATION RECORD FOR "WANDERGUARD TO PREVENT ELOPEMENT; CHECK TRANSMISSION ON A DAILY BASIS (A.M. SHIFT)" AND FOUND THAT IN JULY 2012 STAFF FAILED TO FOLLOW THE FACILITY POLICY/PHYSICIAN ORDERS [REDACTED].#102 AT RISK FOR ELOPEMENT AND SUBSEQUENT HARM BUT FAILED TO EXPLAIN WHY THE DAILY FUNCTION TESTS WERE NOT PERFORMED. UM #4 COULD NOT IDENTIFY ANY ADDITIONAL SAFETY DEVICES/SUPERVISION IMPLEMENTED TO ENSURE RESIDENT #102 REMAINED SAFE. RESIDENT #103: ACCORDING TO THE UNDATED FACE SHEET RESIDENT #103 WAS A [AGE] year OLD MALE WHO LIVED AT THE FACILITY SINCE 6/02/2011. HIS [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM DATA SET assessment dated [DATE], RESIDENT #103 HAD SEVERELY IMPAIRED COGNITION WITH BOTH LONG AND SHORT TERM MEMORY LOSS. HE REQUIRED MINIMALLY ONE STAFF MEMBER TO PROVIDE ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING. ELOPEMENT ASSESSMENTS DATED 7/11/2011, 9/13/2011, 6/29/2012 AND 7/23/2012 DOCUMENTED THAT RESIDENT #103 REQUIRED A WANDERGUARD BRACELET AT ALL TIMES BECAUSE OF HIS DEMENTIA, CONFUSION, DISORIENTATION, HISTORY OF WANDERING AND ELOPEMENTS. AN ELOPEMENT CARE PLAN DATED 7/11/2011, UPDATED ON 7/14/2011, 12/07/2011, AND 7/23/2012, REQUIRED STAFF TO ENSURE RESIDENT #103 HAD A FUNCTIONAL WANDERGUARD BRACELET ON AT ALL TIMES. ACCORDING TO MEDICATION ADMINISTRATION RECORDS FOR RESIDENT #103, STAFF FAILED TO DOCUMENT ANY DAILY WANDERGUARD FUNCTION TESTS IN MAY 2012 AND JUNE 2012. REVIEW OF MEDICATION ADMINISTRATION RECORDS FOR JULY 2012 REVEALED THAT STAFF OMITTED THE SAME SAFETY CHECKS ON 7/01/2012, 7/02/2012, 7/03/2012, 7/04/2012, 7/05/2012, 7/06/2012, 7/07/2012, 7/08/2012, 7/09/2012, 7/10/2012, 7/11/2012, 7/12/2012, 7/13/2012, 7/14/2012, 7/15/2012, 7/16/2012 AND 7/17/2012. DURING AN INTERVIEW ON 7/31/2012 AT 12:15 P.M. THE UNIT MANAGER (UM #2), AN RN, FOR RESIDENT #103 SAID EMPTY BOXES AND/OR CIRCLED INITIALS ON A MEDICATION ADMINISTRATION RECORD INDICATED THAT STAFF HAD NOT FOLLOWED FACILITY POLICY AND/OR PHYSICIANS ORDERS. UM #2 THEN REVIEWED THE MEDICATION ADMINISTRATION RECORD FOR "WANDERGUARD TO L (LEFT) ANKLE TO PREVENT ELOPEMENT; SCAN TRANSMITTER EVERY MORNING" AND FOUND THAT IN JULY 2012, STAFF FAILED TO FOLLOW THE FACILITY POLICY/PHYSICIANS ORDER 17 TIMES. UM #2 SAID THIS PRACTICE LEFT RESIDENT #103 AT RISK FOR ELOPEMENT AND SUBSEQUENT HARM BUT FAILED TO EXPLAIN WHY THESE DAILY FUNCTION TESTS WERE NOT PERFORMED. UM #2 FAILED TO IDENTIFY ANY ADDITIONAL SAFETY DEVICES AND/OR SUPERVISION IMPLEMENTED TO ENSURE RESIDENT #103 REMAINED SAFE. RESIDENT #104: ACCORDING TO THE FACE SHEET DATED 7/31/2012, RESIDENT #104 WAS AN [AGE] year OLD FEMALE WHO LIVED AT THE FACILITY SINCE 4/17/2012. HER [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM DATA SET assessment dated [DATE], RESIDENT #104 HAD SEVERELY IMPAIRED COGNITION WITH BOTH LONG AND SHORT TERM MEMORY LOSS. SHE REQUIRED MINIMALLY ONE STAFF MEMBER TO PROVIDE SUPERVISION WHEN SHE WALKED. ELOPEMENT ASSESSMENTS DATED 4/17/2012, 4/19/2012, AND 7/24/2012, REVEALED RESIDENT #104 REQUIRED A WANDERGUARD BRACELET ON HER BODY AT ALL TIMES BECAUSE OF HER DEMENTIA, CONFUSION, DISORIENTATION, DESIRE TO LEAVE THE FACILITY, HISTORY OF WANDERING AND HISTORY OF ELOPEMENTS. AN ELOPEMENT CARE PLAN DATED 4/18/2012 AND UPDATED ON 7/19/2012, REQUIRED STAFF TO ENSURE RESIDENT #104 HAD A FUNCTIONAL WANDERGUARD BRACELET ON HER BODY AT ALL TIMES. MONTHLY RENEWAL ORDERS DATED 5/2012, 6/2012 AND 7/2012, REQUIRED RESIDENT #104 TO WEAR A WANDERGUARD BRACELET "FOR SAFETY," WITH DAILY WANDERGUARD FUNCTION TESTS COMPLETED BY STAFF TO ENSURE IT FUNCTIONED. ACCORDING TO MEDICATION ADMINISTRATION RECORDS STAFF FAILED TO DOCUMENT THE COMPLETION OF THE DAILY WANDERGUARD FUNCTION TESTS 84 OF THE 92 REQUIRED DAYS IN MAY 2012, JUNE 2012 AND JULY 2012. DURING AN INTERVIEW ON 7/31/2012 AT 12:15 P.M., UM #4 SAID EMPTY SPACES ON THE MEDICATION ADMINISTRATION RECORD INDICATED STAFF HAD NOT FOLLOWED POLICY AND/OR THE PHYSICIANS ORDER. UM #4 THEN REVIEWED THE MEDICATION ADMINISTRATION RECORD FOR "WANDERGUARD TO PREVENT ELOPEMENT; CHECK TRANSMISSION EVERY MORNING" AND FOUND THAT IN MAY, JUNE AND JULY OF 2012, STAFF FAILED TO FOLLOW THE FACILITY POLICY/PHYSICIAN ORDERS [REDACTED].#104 AT RISK FOR ELOPEMENT AND SUBSEQUENT HARM BUT FAILED TO EXPLAIN WHY THESE DAILY FUNCTION TESTS WERE NOT PERFORMED. UM #4 FAILED TO IDENTIFY ANY ADDITIONAL SAFETY DEVICES AND/OR SUPERVISION IMPLEMENTED TO ENSURE RESIDENT #104 REMAINED SAFE. UM #4 SAID, "OF ALL PEOPLE," RESIDENT #104 REQUIRED A WANDERGUARD BRACELET TO ENSURE HER SAFETY. UM #4 SAID RESIDENT #104 WALKED THE SECOND FLOOR HALLWAYS CONSTANTLY, WITH PURSE HER IN HAND. SHE SAID RESIDENT #104 WALKED QUICKLY AND A FUNCTIONAL WANDERGUARD ENSURED SHE REMAINED ON THE UNIT AND WITHIN THE FACILITY FOR APPROPRIATE SUPERVISION. DURING AN INTERVIEW ON 7/31/2012 AT 2:00 P.M., LICENSED PRACTICAL NURSE (LPN) #1SAID, "I'M SUPPOSED TO" PERFORM DAILY WANDERGUARD FUNCTION TESTS FOR ALL ASSIGNED RESIDENTS AT RISK FOR ELOPEMENT. LPN #1 THEN SAID THAT RESIDENT #104 WAS IN HER ASSIGNMENT, AT RISK FOR ELOPEMENT, BUT DAILY WANDERGUARD FUNCTION TESTS WERE NOT NECESSARY. LPN #1 SAID BECAUSE RESIDENT #104 WANDERED SO MUCH, THE ALARM ON THE UNSUPERVISED ELEVATORS WOULD DEMONSTRATE THE BRACELET'S FUNCTION. LPN #1 FAILED TO IDENTIFY POTENTIAL OUTCOMES IF RESIDENT #104 APPROACHED THE UNSUPERVISED ELEVATORS AND HER WANDERGUARD BRACELET DID NOT FUNCTION OR IF RESIDENT #104 WAS NOT WEARING THE WANDERGUARD BRACELET. LPN #1 SAID STAFF FOUND NO WANDERGUARD BRACELET ON RESIDENT #104 TODAY (7/31/12). LPN #1 SAID THAT WHEN RESIDENTS LEAVE THE BUILDING FOR APPOINTMENTS, THEIR WANDERGUARDS ARE REMOVED AND OFTEN NOT RE-APPLIED WHEN THEY (RESIDENTS) RETURN. RESIDENT #105: ACCORDING TO THE FACE SHEET DATED 7/31/2012, RESIDENT #105 WAS A [AGE] year OLD MALE WHO LIVED AT THE FACILITY SINCE 9/13/2011. HIS [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM DATA SET assessment dated [DATE], RESIDENT #105 NO COGNITIVE IMPAIRMENTS BUT REQUIRED SUPERVISION TO AMBULATE WITH A WALKER. PHYSICIAN ORDERS [REDACTED].#105 WITH DAILY FUNCTION TESTS COMPLETED TO ENSURE IT FUNCTIONED. ELOPEMENT ASSESSMENTS DATED 9/13/2011, 9/17/2011, 9/30/2011, 5/04/2012, AND 7/23/2012, DOCUMENTED RESIDENT #103 REQUIRED A WANDERGUARD BRACELET AT ALL TIMES TO ENSURE HIS SAFETY, AS HE EXPRESSED A DESIRE TO LEAVE. DESPITE RESIDENT #105'S POTENTIAL FOR ELOPEMENT, STAFF DID NOT IMPLEMENT ANY ELOPEMENT CARE PLANS UNTIL 7/23/2012. ACCORDING TO MEDICATION ADMINISTRATION RECORDS FOR 7/2012 STAFF FAILED TO DOCUMENT THE COMPLETION OF DAILY WANDERGUARD FUNCTION TESTS ON 7/05/2012 AND 7/10/2012. DURING AN INTERVIEW ON 7/31/2012 AT 1:40 P.M. THE UNIT MANAGER (UM #2), A RN, FOR RESIDENT #105 SAID EMPTY BOXES AND/OR CIRCLED INITIALS ON A MEDICATION ADMINISTRATION RECORD INDICATED THAT STAFF FAILED TO FOLLOW POLICY AND/OR PHYSICIAN ORDERS. UM #2 THEN REVIEWED THE MEDICATION ADMINISTRATION RECORD FOR "WANDERGUARD TO PREVENT ELOPEMENT; CHECK TRANSMISSION ON A DAILY BASIS (AM SHIFT)" AND FOUND THAT IN JULY 2012, STAFF FAILED TO FOLLOW THE FACILITY'S POLICY/PHYSICIAN ORDERS [REDACTED].#105 AT RISK FOR ELOPEMENT AND SUBSEQUENT HARM BUT FAILED TO EXPLAIN WHY THESE DAILY FUNCTIONAL TESTS WERE NOT PERFORMED. UM #2 FAILED TO IDENTIFY ANY ADDITIONAL SAFETY DEVICES AND/OR SUPERVISION IMPLEMENTED TO ENSURE RESIDENT #105 REMAINED SAFE. RESIDENT #106: ACCORDING TO THE FACE SHEET DATED 7/31/2012, RESIDENT #106 WAS AN [AGE] year OLD FEMALE WHO LIVED AT THE FACILITY SINCE 1/09/2012. HER [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM DATA SET assessment dated [DATE], RESIDENT #106 HAD COGNITIVE IMPAIRMENTS WITH BOTH LONG AND SHORT TERM MEMORY LOSS. SHE REQUIRED MINIMALLY ONE STAFF MEMBER TO ASSIST WITH ALL AMBULATION HOWEVER, IN A WHEELCHAIR SHE COULD MOVE THROUGHOUT THE FACILITY. ELOPEMENT ASSESSMENTS DATED 1/11/2012, AND 3/07/2012, DOCUMENTED THAT RESIDENT #106 REQUIRED A WANDERGUARD BRACELET AT ALL TIMES BECAUSE OF HER DEMENTIA, ABILITY TO MOVE THROUGHOUT THE FACILITY, HISTORY OF WANDERING AND EXPRESSED DESIRE TO LEAVE. DESPITE RESIDENT #106'S POTENTIAL FOR ELOPEMENT, STAFF DID NOT IMPLEMENT ANY ELOPEMENT CARE PLANS UNTIL 4/01/2012. PHYSICIAN ORDERS [REDACTED]. ACCORDING TO MEDICATION ADMINISTRATION RECORDS, STAFF FAILED TO DOCUMENT THE COMPLETION OF ANY DAILY WANDERGUARD FUNCTION TESTS TO KEEP RESIDENT #106 SAFE ON 6/10/2012, 6/20/2012, 6/23/2012, 6/24/2012, 6/27/2012, 6/28/2012, 7/07/2012, 7/11/2012, 7/12/2012, 7/22/2012, AND 7/25/2012. ADDITIONALLY, STAFF CIRCLED THEIR INITIALS ON 6/02/2012, 6/03/2012, 6/04/2012, 6/07/2012, 6/11/2012, 6/21/2012, 6/22/2012, 6/25/2012, 6/26/2012, 7/01/2012, 7/09/2012, 7/10/2012, 7/13/2012, 7/14/2012, 7/15/2012, 7/16/2012, 7/17/2012, 7/18/2012, 7/19/2012, 7/20/2012, AND 7/21/2012. DURING AN INTERVIEW ON 7/31/2012 AT 1:40 P.M. THE UNIT MANAGER (UM #3), A RN, FOR RESIDENT #106 SAID EMPTY BOXES AND/OR CIRCLED INITIALS ON A MEDICATION ADMINISTRATION RECORD INDICATED THAT STAFF FAILED TO FOLLOW POLICY AND/OR PHYSICIANS ORDER. UM #3 THEN REVIEWED THE MEDICATION ADMINISTRATION RECORD, "WANDERGUARD TO PREVENT ELOPEMENT; CHECK TRANSMISSION ON A DAILY BASIS (AM SHIFT)," AND FOUND THAT IN JUNE AND JULY 2012, STAFF FAILED TO FOLLOW THE FACILITY'S POLICY/PHYSICIAN ORDERS [REDACTED].#106 AT RISK FOR ELOPEMENT AND SUBSEQUENT HARM BUT FAILED TO EXPLAIN WHY THESE DAILY FUNCTIONAL TESTS WERE NOT PERFORMED. UM #3 FAILED TO IDENTIFY ANY ADDITIONAL SAFETY DEVICES AND/OR SUPERVISION IMPLEMENTED TO ENSURE RESIDENT #106 REMAINED SAFE AT THE FACILITY. UM #3 SAID NURSING STAFF ON HER UNIT FOLLOWED THE ELOPEMENT POLICY AT THEIR DISCRETION AND WHEN RESIDENTS EXHIBITED ACTIVE ELOPEMENT BEHAVIORS. RESIDENT #107: ACCORDING TO THE FACE SHEET DATED 7/31/2012, RESIDENT #107 WAS AN [AGE] year OLD FEMALE WHO LIVED AT THE FACILITY SINCE 4/08/2009. HER [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM DATA SET assessment dated [DATE], RESIDENT #107 HAD MODERATELY IMPAIRED COGNITION WITH BOTH LONG AND SHORT TERM MEMORY LOSS. SHE WANDERED DAILY AND REQUIRED SUPERVISION WHEN SHE WALKED. ELOPEMENT ASSESSMENTS DATED 9/30/2011, 11/16/2011, AND 7/24/2012, DOCUMENTED THAT RESIDENT #107 REQUIRED A WANDERGUARD BRACELET AT ALL TIMES BECAUSE OF HER DEMENTIA, ABILITY TO MOVE THROUGHOUT THE FACILITY AND HISTORY OF WANDERING. AN ELOPEMENT CARE PLAN DATED 11/13/2011, UPDATED ON 3/06/2012 REQUIRED RESIDENT #107 TO WEAR A WANDERGUARD BRACELET AT ALL TIMES, tested DAILY TO ENSURE IT FUNCTIONED. FACILITY STAFF WERE TO THEN DOCUMENT THE TESTING ON THE MEDICATION ADMINISTRATION RECORD (MAR). PHYSICIAN ORDERS [REDACTED].M. SHIFT)" TO ENSURE THE DEVICE FUNCTIONED AND RESIDENT #107 WAS SAFE. ACCORDING TO MEDICATION ADMINISTRATION RECORDS FOR MAY 2012 AND JUNE 2012, STAFF FAILED TO DOCUMENT THE COMPLETION OF DAILY WANDERGUARD FUNCTION TEST FOR 60 OF THE 61 REQUIRED DAYS. DURING AN INTERVIEW ON 7/31/2012 AT 1:40 P.M. THE UNIT MANAGER (UM #3), A RN, FOR RESIDENT #107 SAID EMPTY BOXES IN MEDICATION ADMINISTRATION RECORDS INDICATED THAT STAFF FAILED TO FOLLOW POLICY AND/OR PHYSICIAN ORDERS. UM #3 THEN REVIEWED THE MEDICATION ADMINISTRATION RECORD FOR RESIDENT #107, "WANDERGUARD TO PREVENT ELOPEMENT; CHECK TRANSMISSION ON A DAILY BASIS (AM SHIFT)," AND FOUND THAT IN MAY AND JUNE 2012, STAFF FAILED TO FOLLOW THE FACILITY POLICY/PHYSICIAN ORDERS [REDACTED].#107 AT RISK FOR ELOPEMENT AND SUBSEQUENT HARM BUT FAILED TO EXPLAIN WHY THESE DAILY FUNCTIONAL TESTS WERE NOT PERFORMED. UM #3 FAILED TO IDENTIFY ANY ADDITIONAL SAFETY DEVICES AND/OR SUPERVISION IMPLEMENTED TO ENSURE RESIDENT #107 REMAINED SAFE. UM #3 SAID THE NURSING STAFF ON HER UNIT FOLLOWED THE ELOPEMENT POLICY AT THEIR DISCRETION, WHEN RESIDENTS EXHIBITED ACTIVE ELOPEMENT BEHAVIORS. RESIDENT #108: ACCORDING TO THE FACE SHEET DATED 7/31/2012, RESIDENT #108 WAS AN [AGE] year OLD FEMALE WHO LIVED AT THE FACILITY SINCE 5/02/2012. HER [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM DATA SET assessment dated [DATE], RESIDENT #108 HAD SEVERELY IMPAIRED COGNITION WITH BOTH LONG AND SHORT TERM MEMORY LOSS. DESPITE FACILITY POLICY, STAFF FAILED TO PERFORM AN ADMISSION ELOPEMENT ASSESSMENT FOR RESIDENT #108. PHYSICIAN ORDERS [REDACTED]. AN ELOPEMENT ASSESSMENT COMPLETED ON 6/26/2012, DOCUMENTED THAT RESIDENT #108 WAS FOUND IN THE FACILITY'S ELEVATOR, AND WHERE TOLD THE NURSING STAFF, "I'M GOING OUT." STAFF COMPLETED HER INITIAL ELOPEMENT ASSESSMENT 55 DAYS AFTER ADMISSION AND ESTABLISHED RESIDENT #108 WAS AT RISK FOR ELOPEMENT. STAFF DOCUMENTED A WANDERGUARD BRACELET WAS APPLIED. DESPITE THIS ASSESSMENT RESIDENT #108 DID NOT HAVE AN ELOPEMENT CARE PLAN UNTIL 7/24/2012. MEDICATION ADMINISTRATION RECORDS REVIEWED BETWEEN 6/26/2012 AND 7/23/2012 FAILED TO DOCUMENT THE COMPLETION OF ANY DAILY WANDERGUARD FUNCTION TESTS FOR RESIDENT #108. DURING AN INTERVIEW ON 7/31/2012 AT 1:40 P.M. THE UNIT MANAGER (UM #3) FOR RESIDENT #108 SAID EMPTY BOXES IN MEDICATION ADMINISTRATION RECORDS INDICATED THAT STAFF FAILED TO FOLLOW POLICY AND/OR PHYSICIAN ORDERS. UM #3 THEN REVIEWED THE MEDICATION ADMINISTRATION RECORD FOR RESIDENT #108 AND FOUND STAFF FAILED TO FOLLOW THE FACILITY'S POLICY/PHYSICIAN ORDERS [REDACTED].#108 AT RISK FOR ELOPEMENT AND SUBSEQUENT HARM BUT FAILED TO EXPLAIN WHY THESE DAILY FUNCTIONAL TESTS WERE NOT PERFORMED. UM #3 FAILED TO IDENTIFY ANY ADDITIONAL SAFETY DEVICES AND/OR SUPERVISION IMPLEMENTED TO ENSURE RESIDENT #108 REMAINED SAFE. UM #3 SAID THE NURSING STAFF ON HER UNIT FOLLOWED THE ELOPEMENT POLICY AT THEIR DISCRETION AND WHEN RESIDENTS EXHIBITED ACTIVE ELOPEMENT BEHAVIORS. RESIDENT #109: ACCORDING TO THE FACE SHEET DATED 7/31/2012, RESIDENT #109 WAS AN [AGE] year OLD FEMALE WHO LIVED AT THE FACILITY SINCE 8/16/2011. HER [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM DATA SET assessment dated [DATE], RESIDENT #109 HAD MODERATELY IMPAIRED DECISION MAKING WITH BOTH LONG AND SHORT TERM MEMORY LOSS. SHE REQUIRED LIMITED ASSISTANCE TO MOVE THROUGHOUT THE FACILITY IN HER WHEELCHAIR. ELOPEMENT ASSESSMENTS DATED 8/16/2011, 9/14/2011, 11/08/2011, 11/16/2011, 2/16/2012, AND 7/24/2012 DOCUMENTED THAT RESIDENT #109 REQUIRED A WANDERGUARD BRACELET AT ALL TIMES BECAUSE OF DEMENTIA, CONFUSION, DISORIENTATION, ABILITY TO MOVE THROUGHOUT THE FACILITY, PRIOR ELOPEMENT ATTEMPTS AND DESIRE TO LEAVE THE FACILITY. AN ELOPEMENT CARE PLAN FOR RESIDENT #109 DATED 9/14/2012 AND UPDATED ON 9/22/2011, 11/08/2011, 2/15/2012, AND 7/24/2012, REQUIRED STAFF TO APPLY AND MAINTAIN A FUNCTIONAL WANDERGUARD BRACELET AT ALL TIMES. A physician's orders [REDACTED]. THE PHYSICIAN NEVER DISCONTINUED THIS ORDER. HOWEVER, MONTHLY RENEWAL ORDERS FROM PHARMACY DATED MAY 5012, JUNE 2012, AND JULY 2012, FAILED TO TRANSCRIBE AND/OR LIST THIS ORDER. ACCORDING TO MEDICATION ADMINISTRATION RECORDS FOR 5/2012, 6/2012, AND 7/2012, STAFF FAILED TO DOCUMENT ANY WANDERGUARD FUNCTION TESTS COMPLETED FOR 84 OF THE 92 REQUIRED DAYS. DURING AN INTERVIEW ON 7/31/2012 AT 1:40 P.M. THE UNIT MANAGER (UM #3) FOR RESIDENT #109 SAID MEDICATION ADMINISTRATION RECORDS WERE PREPRINTED BASED ON ORDERS RECEIVED BY THE PHARMACY. UM #3 SAID THOUGH THE WANDERGUARD ORDER FOR RESIDENT #109 REMAINED ACTIVE IN MAY 2012, JUNE 2012 AND JULY 2012, IT WAS NOT TRANSCRIBED ONTO MONTHLY ORDER FORMS AND THEREFORE NOT LISTED ON THE MEDICATION ADMINISTRATION RECORDS AS A REQUIRED TASK. UM #3 SAID WHEN IT ORDER fell OFF THE PRINTED MEDICATION ADMINISTRATION RECORDS, STAFF SHOULD HAVE MANUALLY TRANSCRIBED IT AND RE-FAXED THE ORDER TO PHARMACY FOR INCLUSION THE FOLLOWING MONTH. SHE SAID STAFF STOPPED DOING THE DAILY FUNCTION TESTS FOR RESIDENT #109 BECAUSE IT WAS NOT DOCUMENTED AS A TASK ON THE MEDICATION ADMINISTRATION RECORD. UM #3 SAID THIS PRACTICE LEFT RESIDENT #109 AT RISK FOR ELOPEMENT AND SUBSEQUENT HARM BUT FAILED TO EXPLAIN WHY THESE DAILY FUNCTIONAL TESTS WERE NOT PERFORMED. UM #3 FAILED TO IDENT

REFER TO INTAKE #MI 752 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE ONE (#101) OF 4 SAMPLED RESIDENTS, ALL REVIEWED FOR ABUSE PROHIBITION FROM A TOTAL SAMPLE OF 4 THE RIGHT TO BE FREE FROM PHYSICAL ABUSE, RESULTING IN ACTUAL PHYSICAL ABUSE WHEN RESIDENT #101 WAS ENGAGED IN A PHYSICAL ALTERCATION BY A FACILITY EMPLOYEE. FINDINGS INCLUDE: RESIDENT #101 WAS [AGE] years OLD AND HAD BEEN admitted to the facility on [DATE]. ACCORDING TO THE NEW ADMISSION INITIAL PSYCHIATRIC DIAGNOSTIC EVALUATION DATED 5/16/12, RESIDENT #101 HAD HISTORY OF DEPRESSION, AND MULTIPLE MEDICAL ISSUES ARISING FROM [MEDICAL CONDITION] (LOWER BODY PARALYSIS) SECONDARY TO A GUNSHOT WOUND. THE MINIMUM DATA SET (MDS) ASSESSMENT, DATED 5/23/12, DOCUMENTED THAT RESIDENT #101 HAD INTACT MEMORY AND COGNITION. RESIDENT #101 WAS HIS OWN RESPONSIBLE PARTY. HOWEVER, DUE TO [MEDICAL CONDITION], RESIDENT #101 REQUIRED LIMITED TO EXTENSIVE ASSISTANCE WITH HIS DAILY ACTIVITIES. ACCORDING TO THE INCIDENT REPORT DATED JUNE 4, 2012, RESIDENT #101 ENTERED THE FRONT LOBBY APPROXIMATELY AT 6:30 AM, REQUESTING TO LEAVE THE BUILDING IN ORDER TO GO OUT TO AN APPOINTMENT. SECURITY OFFICER #3 ASKED RESIDENT #101 IF HE (#101) HAD SIGNED OUT FROM HIS (#101) NURSING UNIT. RESIDENT #101 THEN CAME TO THE DESK AND SAID TO THE SECURITY STAFF, "B----- LET ME OUT THE DOOR OR I WILL BREAK THIS M-----F--- GLASS." SECURITY OFFICER #3 WAS NOT ABLE TO RE-DIRECT RESIDENT #101. SECURITY OFFICER #3 GOT BEHIND RESIDENT #101'S WHEELCHAIR TO PREVENT THE RESIDENT FROM MOVING AND CALL OUT FOR ASSISTANCE. RESIDENT #101 REMOVED THE WHEELCHAIR LEG REST AND PROCEEDED TO HIT SECURITY OFFICER #3. SECURITY OFFICER #3 THEN WRESTLED RESIDENT #101 OUT OF HIS (#101) WHEELCHAIR, AND PINNED RESIDENT #101 ON THE FLOOR. A VIDEO OF THE ALTERCATION WAS REVIEWED BY THE SURVEYOR DURING THE ONSITE INVESTIGATION. AT TIME STAMP 6:00 AM, THE VIDEO FOOTAGE SHOWED THAT THE SECURITY OFFICER #3IN THE FACILITY LOBBY. STARTING AT TIME STAMP 6:01 AM, SECURITY OFFICER #3 COULD BE SEEN ROUGHLY MANEUVERING RESIDENT #101 OUT OF HIS WHEELCHAIR TO THE FLOOR AND PINNING HIM DOWN OF THE FLOOR. SECURITY OFFICER #3 COULD BE SEEN ON TOP OF RESIDENT #101, AT AROUND TIME STAMP 6:05 AM, SECURITY OFFICER #3 COULD BE OBSERVED GIVING SEVERAL PUNCHES TOWARDS RESIDENT #101. THIS WAS VALIDATED BY NURSE AIDE #5 AND NURSE SUPERVISOR #4 DURING INTERVIEWS CONDUCTED BY THE SURVEYOR. AT LEAST 7 NURSING STAFF WERE IN AND OUT OF THE SCENE BUT DID NOT SEPARATE SECURITY OFFICER #3 FROM RESIDENT #101. LOCAL POLICE CAME AT 6:11 AM AND FOUND RESIDENT #101 AND SECURITY ON THE FLOOR. RESIDENT #101 WAS HANDCUFFED BY THE POLICE OFFICER. CHARGE NURSE #6 WAS INTERVIEWED ON 6/25/12 AT 3:30 PM. ACCORDING TO CHARGE NURSE #6, RESIDENT #101 CAME TO HER (#6) ON 6/4/12 AND TOLD HER (#6) THAT HE (#101) HAD A COURT HEARING AT 8:00 AM AND NEEDED TO CATCH THE BUS BY 6:30 AM AT THE BUS STOP. CHARGE NURSE #6 CALLED THE DOCTOR TO GET LEAVE OF ABSENCE (LOA) PERMISSION FOR THE RESIDENT AND RESIDENT #101 WAS APPROVED TO LEAVE AT 6:00 AM. A DOCTOR'S ORDER WAS WRITTEN AND DOCUMENTED IN THE NURSE'S NOTES. CHARGE NURSE #6 HOWEVER, STATED THAT SHE DID NOT CALL THE LOBBY TO INFORM SECURITY OFFICER #3 OR CALL THE MIDNIGHT SUPERVISOR, BECAUSE SHE (#6) GOT TOO BUSY. CHARGE NURSE #6 WAS NOT AWARE THAT THE ALTERCATION UNTIL AFTER THE POLICE ARRIVED. RESIDENT #101 LIVED AT THE SECOND FLOOR AND THE INCIDENT OCCURRED IN THE FIRST FLOOR LOBBY. CHARGE NURSE #6 DENIED RECEIVING A CALL FROM SECURITY OFFICER #3, ASKING IF RESIDENT #101HAD LOA PERMISSION. CHARGE NURSE #6 ALSO DENIED RECEIVING AN INQUIRY FROM ANY OTHER NURSING STAFF ABOUT RESIDENT #101'S LOA. NURSE #6 ACCEPTED THAT SHE FAILED TO COMMUNICATE TO SECURITY OFFICER #3 IN THE LOBBY THAT RESIDENT #101 WAS ALLOWED TO LEAVE THE FACILITY AT 6:00 AM. NURSE AIDE #5 WAS INTERVIEWED BY TELEPHONE ON 6/26/12 AT 1:09 PM. NURSE AIDE #5 STATED SHE HEARD RESIDENT #101 YELLING PROFANITIES IN THE LOBBY, SO SHE (#5) CALLED THE MIDNIGHT SUPERVISOR IMMEDIATELY. RESIDENT #101 WAS SWINGING HIS WHEELCHAIR LEG-REST AT SECURITY OFFICER #3 AND AT NURSE SUPERVISOR #4. NURSE AIDE #5 STATED SHE (#5) COULD NOT TELL IF RESIDENT #101 MADE CONTACT WITH THE SECURITY OFFICER OR THE NURSE WITH THE LEG-REST. NURSE AIDE #5 STATED THAT SHE (#5) OBSERVED SECURITY OFFICER #3 GET RESIDENT #101 DOWN TO THE FLOOR BY TILTING HIS (#101) WHEELCHAIR AND SAW BOTH OF THEM ON THE FLOOR. SHE (#5) STATED THAT SHE (#5) GRABBED THE LEG-REST AWAY FROM RESIDENT #101 WHILE THE SECURITY OFFICER HAD HIM (#101) PINNED TO THE FLOOR. NURSE AIDE #5 THEN HEARD THE SECURITY OFFICER SAY, "HE (#101) BIT ME." SECURITY OFFICER #3 THEN SAID, "CALL 911." NURSE AIDE #5 THEN SAID, "I SAW THE SECURITY OFFICER (#3) HIT (RESIDENT #101) MORE THAN ONCE AND REPEATEDLY. NO ONE SEPARATED THEM." NURSE AIDE #5 FURTHER STATED THAT RESIDENT #101WAS YELLING "STOP! GET OFF ME." NURSE AIDE #5 EXPLAINED, "WE SHOULD HAVE CALLED CODE BLACK. CODE BLACK IS THE CODE THAT SHOULD BE CALLED OVERHEAD IF THERE IS A THREAT OR SOMEONE IS VIOLENT. EVERYTHING HAPPENED SO FAST, NO ONE CALLED FOR CODE BLACK." NURSE SUPERVISOR #4 WAS INTERVIEWED ON 6/26/12 AT 11:05 AM. NURSE SUPERVISOR #4 SAID THAT SHE (#4) WAS CALLED BY NURSE AIDE #5 BECAUSE SHE (#5) HEARD THAT RESIDENT #101 WAS USING PROFANE LANGUAGE TO THE SECURITY OFFICER IN THE LOBBY. NURSE SUPERVISOR #4 SAID THAT SHE (#4) IMMEDIATELY WENT TO THE LOBBY AND "SINCE I DID NOT KNOW ABOUT THE RESIDENT'S LOA STATUS, I TOLD SECURITY OFFICER #3 THAT I DID NOT KNOW (RESIDENT #101'S STATUS)." NURSE SUPERVISOR #4 admitted SHE DID NOT KNOW THE RESIDENT AND DID NOT KNOW ABOUT HIM HAVING PERMISSION TO LEAVE THE BUILDING AT 6:00 AM THAT MORNING. SUPERVISOR #4 STATED THAT SECURITY OFFICER #3 WRESTLED RESIDENT #101 DOWN TO THE FLOOR AND RESTRAINED HIM (#101) BY PINNING HIM TO THE FLOOR. DURING THE ALTERCATION, NURSE SUPERVISOR #4 SAW RESIDENT #101 BITE SECURITY OFFICER #3 ON THE CHEST AND SAW THE SECURITY OFFICER #3 PUNCHED RESIDENT #101 ABOUT 3 TIMES. SECURITY OFFICER #3 WAS ON TOP OF RESIDENT #101 THE ENTIRE TIME. THE POLICE CAME AND HANDCUFFED RESIDENT #101. THE NURSE FROM THE 2ND FLOOR LATER STATED THAT RESIDENT #101 DID HAVE A DOCTOR'S ORDER FOR A LEAVE OF ABSENCE AT 6:00 AM BUT DID NOT INFORM HER (#4) OR THE SECURITY OFFICER (#3). NURSE SUPERVISOR # 4 FURTHER COMMENTED, "ALL OF THIS COULD HAVE BEEN PREVENTED IF THE CHARGE NURSE (#6) COMMUNICATED WITH US THAT THE RESIDENT (#101) HAD PERMISSION TO LEAVE THE FACILITY AT 6:00 AM." RESTORATIVE NURSE #8 WAS INTERVIEWED ON 6/26/12 AT 12:24 PM. RESTORATIVE NURSE #8 RECALLED THAT SHE (#8) WAS COMING INTO THE BUILDING FOR THE MORNING SHIFT BUT WAS APPROACHED OUTSIDE THE BUILDING BY STAFF AND HEARD ABOUT THE STAFF-RESIDENT ALTERCATION. RESTORATIVE NURSE #8 ASSESSED RESIDENT #101. RESIDENT # 101 EXPLAINED THAT THE SECURITY OFFICER WOULDN'T LET HIM OUT FROM THE BUILDING. RESTORATIVE NURSE #8 REPORTED THAT RESIDENT #101 SAID THAT HE WAS "HURTING." RESIDENT #101 HAD A SWOLLEN KNOT ON THE RIGHT CHEEK AND A COUPLE OF SKIN ABRASIONS. RESTORATIVE NURSE #8 SAID THAT SHE (38) APPLIED ICE PACK TO RESIDENT #101 AND THAT THE 2ND FLOOR NURSE BROUGHT HIM (#101) A PAIN PILL. SOCIAL WORKER #7 WAS INTERVIEWED ON 6/26/12 AT 12:00 PM. SOCIAL WORKER #7 SAID THAT SHE (#7) DID NOT WITNESS THE STAFF TO RESIDENT ALTERCATION, BUT THAT RESIDENT #101 NO LONGER RESIDED AT THE FACILITY. AFTER THE ALTERCATION, RESIDENT #101 HAD HAD SIGNED OUT AGAINST MEDICAL ADVICE (AMA). ACCORDING TO SOCIAL WORKER #7, SHE (#7) GOT A CALL FROM RESIDENT #101 SOME TIME AFTER THE INCIDENT AND HE (#101) WANTED TO RETURN. SOCIAL WORKER #7 EXPLAINED TO RESIDENT #101 THAT HE (#101) HAD SIGNED OUT AMA AFTER THE ALTERCATION AND COULD NOT RETURN. RESIDENT #101 TOLD SW #7 THAT HE HAD SIGNED THE AMA BUT DID NOT EXACTLY UNDERSTAND WHAT IT WAS FOR. THE SOCIAL WORKER #7 DID NOT KNOW WHERE RESIDENT #101 WENT AFTER SIGNING OUT AMA. ACCORDING TO THE ADMINISTRATOR ON 6/27/12 AT 12:00 PM, SECURITY OFFICER #3 WAS NO LONGER EMPLOYED AT THE FACILITY. THE SECURITY STAFF #3 WAS discharged /TERMINATED ON 6/6/12, DUE TO THE ALTERCATION INCIDENT WITH RESIDENT #101. THE ADMINISTRATOR admitted THAT SECURITY OFFICER #3 HAD NOT ATTENDED THE ANNUAL IN-SERVICE FOR ABUSE HELD ON 9/30/11, BUT WAS GIVEN A PHONE IN-SERVICE BY HIS SUPERVISOR. THE ATTENDANCE RECORD FOR ABUSE IN-SERVICE WAS REVIEWED AND SHOWED THAT IT WAS NOT SIGNED BY SECURITY OFFICER #3. SEVERAL UNSUCCESSFUL ATTEMPTS WERE MADE TO CONTACT SECURITY OFFICER #3. THE FACILITY ' S ABUSE PROTOCOL, REVISED JULY 2011 WAS REVIEWED. ACCORDING TO THE FACILITY ABUSE POLICY, STAFF SHOULD NOT HIT BACK. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT TWO (#'S 411 AND 426) OF 13 SAMPLED RESIDENTS AND ONE (#13) OFF SAMPLED RESIDENT, REVIEWED FOR ABUSE OUT OF A TOTAL OF 30 SAMPLED RESIDENTS WERE FREE FROM VERBAL THREATS AND VERBAL ABUSE, RESULTING IN ACTUAL PSYCHOSOCIAL DISTRESS, AS EVIDENCED BY VERBALIZATIONS OF FEAR AND INTIMIDATION. FINDINGS INCLUDE: ON 12/6/11 AT 8:50 A.M. INITIAL TOUR OF THE FACILITY WAS CONDUCTED BY UNIT MANAGER "B". RESIDENT #411 BEGAN TAPPING OUT A MESSAGE ON HER LETTER BOARD AS SHE LAYED IN HER BED. THE RESIDENT SPELLED OUT " I HAVE A COMPLAINT. " ON 12/6/11 AT 1:35 P.M. RESIDENT #411 WAS INTERVIEWED. USING HER COMMUNICATION BOARD, SHE SPELLED OUT THE FOLLOWING: " I DON ' T LIKE CERTIFIED NURSING ASSISTANT (CNA) "Z". SAID SHE KILL ME. " QUERIED RESIDENT AS TO WHEN THIS OCCURRED. SHE SPELLED OUT FRIDAY THREE WEEKS AGO." RESIDENT WAS QUERIED AS TO WHETHER CNA "Z" WAS WORKING TODAY. SHE SPELLED OUT " YES. " ON 12/6/11 AT 2:00 P.M., CLINICAL RECORD REVIEW REVEALED RESIDENT #411 WAS admitted INto the facility on [DATE] AND REadmitted [DATE] WITH [DIAGNOSES REDACTED]. ACCORDING TO THE RESIDENT'S MOST RECENT QUARTERLY MINIMUM DATA SET ((MDS) dated [DATE], RESIDENT #411 WAS INDEPENDENT IN DECISION MAKING. SHE WAS TOTALLY DEPENDENT ON STAFF FOR ALL ACTIVITIES OF DAILY LIVING AND REQUIRES A ONE PERSON ASSIST FOR ALL TRANSFERS, DRESSING, BATHING AND HYGIENE. RESIDENT #411 WAS BED-BOUND. THE RESIDENT WAS ABLE TO MAKE HER NEEDS KNOWN BY USING A LETTER BOARD. SHE TAPS THE LETTERS WITH HER LEFT HAND TO COMMUNICATE ON THE BOARD. A REVIEW OF THE MOST RECENT SOCIAL SERVICE NOTES, DATED 11/23/11 DID NOT INDICATE ANY CONCERNS REGARDING VERBAL THREATS TO RESIDENT. ON 12/7/11 AT 9:15 A.M., RESIDENT #411 WAS OBSERVED TO BE AWAKE AND ALERT. SHE WAS QUERIED AS TO WHETHER OR NOT SHE TOLD ANYONE ABOUT CNA "Z"'S THREAT. SHE WROTE ON HER LETTER BOARD SOCIAL WORKER "A". RESIDENT #411 WAS QUERIED AS TO WHAT SHE TOLD SOCIAL WORKER, AND SHE SAID "SAME THING I TOLD YOU." ON 12/9/11 AT 12:30 P.M. THE SOCIAL WORKER (SW) DIRECTOR "A" AND THE ADMINISTRATOR WERE QUERIED REGARDING RESIDENT #411'S ALLEGATIONS OF VERBAL THREATS MADE TO RESIDENT #411 BY CNA "Z" . SW "A" STATED "I HAVE NOT PUT ANY OF THE DOCUMENTATION ON THE CHART." SW "A" STATED THAT RESIDENT #411 WANTED TO SEE HER ON NOVEMBER 28 TH. RESIDENT #411 SPELLED OUT "SCARED". STAFF "A" STATED, "I MADE THE MISTAKE OF ASKING MORE QUESTIONS, THEN THE RESIDENT SPELLED OUT, CNA "Z" SAID SHE WOULD KILL ME. I BROUGHT IT TO THE UNIT MANAGER "B" ATTENTION RIGHT AWAY." SW "A" STATED "I DID NOT THINK OF HER (RESIDENT #411) BEING IN ANY HARM OR DANGER SINCE BEING SCARED IS A SUBJECTIVE THING AND SHE HAS A HISTORY OF ATTENTION SEEKING BEHAVIORS AND SUICIDAL TENDENCIES." WHEN QUERIED WHETHER OR NOT A CARE PLAN WAS DEVELOPED FOR THIS BEHAVIORS, SW "A" STATED, "THERE WAS NO CARE PLAN. SW "A" STATED "I FOUND THIS NOTE THAT I HAD NOT FILED (IN THE MEDICAL RECORD) YET. " SW " A THEN PRESENTED AN UNSIGNED SOCIAL WORK NOTE DATED 11/28/11, SUBJECT: CONVERSATION WITH RESIDENT. THE NOTE READ: " SOCIAL WORKER MET WITH RESIDENT AT BEDSIDE PER RESIDENT REQUEST. RESIDENT STATED THAT SHE NEEDS TO TRANSFER TO ANOTHER FACILITY BEFORE DECEMBER 5 TH. RESIDENT STATED THAT CNA " Z " THREATENED HER. SOCIAL WORKER ASKED FOR ELABORATION, RESIDENT SPELLED OUT ' KILL ME. ' RESIDENT SPELLED OUT " SCARED. " SOCIAL WORKER ASKED IF THE CNA "Z" THREATEN TO KILL HER, RESIDENT POINTED TO "YES ". RESIDENT WAS UNABLE TO RECALL WHEN THE EVENT OCCURRED. SOCIAL WORKER ENSURED THAT THE RESIDENT IS SAFE AND WILL FOLLOW UP WITH CLINICAL UNIT MANAGER (STAFF "B") REGARDING THE SITUATION. SOCIAL WORKER SPOKE WITH CLINICAL UNIT MANAGER ("B") WHO STATED RESIDENT HAS BEEN MAKING DIFFERENT STATEMENTS TO STAFF SINCE LAST WEEK. SHE STATED THAT RESIDENT HAD ISSUES WITH A FEW CNA'S RECENTLY. UNIT MANAGER ("B") STATED THAT THE RESIDENT NO LONGER HAS CNA "Z" AS HER CNA, AND WILL WRITE A STATEMENT. " STAFF "A" PROVIDED NO OTHER DOCUMENTATION AT THIS MEETING. ON 12/7/11 CNA "Z" WAS OBSERVED TO BE WORKING ON UNIT 2 SOUTH WHERE RESIDENT #411 RESIDED. ON 12/9/11 AT 12:30 P.M., THE ADMINISTRATOR WAS QUERIED REGARDING THE INCIDENT AND STATED "THIS WAS BROUGHT TO MY ATTENTION ON WEDNESDAY (12/7/11). THE CNA HAS BEEN REASSIGNED AND IS NO LONGER PROVIDING CARE TO THE RESIDENT (#411). THIS SHOULD HAVE BEEN KICKED UP TO THE DIRECTOR OF NURSING (DON) OR MYSELF." ON 12/9/11 AT 1:15 P.M. UNIT MANAGER "B" WAS QUERIED AS TO WHETHER SHE HAD KNOWLEDGE OF THE ALLEGED THREAT TO RESIDENT #411. UNIT MANAGER "B" STATED "YES, I TOLD STAFF "A" THAT THE DAY BEFORE THANKSGIVING OR THE DAY AFTER RESIDENT (#411) CALLED ME INTO HER ROOM TO COMPLAIN ABOUT CNA ("Z"). I TOLD HER I WOULD ARRANGE TO HAVE SOMEONE ELSE WORK WITH HER AND WOULD TALK TO CNA "AA" WHO DOES THE CNA ASSIGNMENTS. RESIDENT #411 THEN TOLD MANAGER "B" , "I WANT TO LEAVE (TRANSFER)." MANAGER "B" MADE NO COMMENT TO THE RESIDENT. WHEN MANAGER "B" WAS QUERIED AS TO WHETHER AN INCIDENT REPORT WAS WRITTEN, MANAGER "B" STATED "NO. NOT ON MY PART BECAUSE IT WAS KIND OF IN SW "A" BALLPARK, BEING THE SOCIAL WORKER. I (MANAGER "B") MET WITH CNA "Z" AND TOLD HER TO WRITE A STATEMENT. THE STATEMENT WAS WRITTEN AND GIVEN TO STAFF "A" ALONG WITH MY STATEMENT. "MANAGER "B" WAS QUERIED AS TO WHERE THE STATEMENTS WERE AS NO STATEMENTS WERE RECEIVED FROM SW "A." MANAGER "B" STATED "I DON'T KNOW." ON 12/9/11 AT 2:44 P.M., INTERVIEW WITH THE FACILITY ' S ADMINISTRATOR, DON, MANAGER B, SW DIRECTOR, AND ASSISTANT DIRECTOR OF NURSING (ADON) REGARDING THE ALLEGATIONS OF VERBAL ABUSE BY CNA "Z" TO RESIDENT #411. THE ADON STATED " I LEARNED ABOUT THIS AT THE INTERDISCIPLINARY MEETING ON WEDNESDAY (12/7/11). UNIT MANAGER "B" HAD A RECENT CONVERSATION WITH ME ABOUT RESIDENT #411 AND SAID NOTHING ABOUT VERBAL ABUSE OR VERBAL THREAT. " UNIT MANAGER "B" WAS QUERIED ABOUT THE PROTOCOL FOR REPORTING ABUSE WHEN ABUSE IS SUSPECTED, SHE STATED "REPORT TO DIRECT SUPERVISOR, DON, AND ADMINISTRATOR WHEN ABUSE IS SUSPECTED." ON 12/9/11 REVIEW OF UNIT 2 SOUTH ASSIGNMENT SHEETS DATED 11/19/11 TO 12/6/11 PROVIDED BY UNIT MANAGER "B" SHOWED THAT CNA "Z" WAS ASSIGNED TO RESIDENT #411 TO PROVIDE CARE ON FOUR OCCASIONS SUBSEQUENT TO THE INCIDENT, ON 11/27/11 P.M. SHIFT; 12/2/11 P.M. SHIFT; 12/3/11 A.M. AND P.M. SHIFT; AND ON 12/6/11 P.M. SHIFT. ON 12/7/11 AT 10:00 A.M., DURING A GROUP INTERVIEW, RESIDENT #426 STATED, "I WOULD LIKE TO TALK TO YOU IN PRIVATE ABOUT MIStreatment of [REDACTED]. ON 12/8/11 AT 2:00 P.M., DURING AN INTERVIEW, RESIDENT # 426 STATED," I HEARD THE MIDNIGHT CERTIFIED NURSING ASSISTANT (CNA) TELL RESIDENT #13, YOU WEAR A DIAPER AND PISS IN IT ALL THE TIME AND DON'T USE THE COMMODE WHAT'S THE DIFFERENCE. IT TAKES OVER AN HALF HOUR FOR THEM TO ANSWER RESIDENT #13'S CALL LIGHT. THE CLOCK IS RIGHT IN FRONT OF ME. "I TOLD MY THERAPIST, (EMPLOYEE "BB"). EMPLOYEE "BB" WAS INTERVIEWED AND STATED," I DON'T RECALL YOU (RESIDENT# 426) TELLING ME ANYTHING." RESIDENT #426 STATED, "YOU KNOW I TOLD YOU HOW SHE (RESIDENT #13) WAS MISTREATED." EMPLOYEE "BB" MADE NO VERBAL COMMENTS. THIS INCIDENT HAPPENED JUST A FEW NIGHTS AGO." THE NURSING ADMISSION SHEET DATED 11/21/11 DOCUMENTED RESIDENT #426 WAS ALERT AND ORIENTED TO PERSON, PLACE, TIME AND SITUATION. ON 12/9/11 AT 10:30 A.M., DURING AN INTERVIEW RESIDENT #13 STATED, "YES, CNA "CC" WAS MEAN AND NOT PROFESSIONAL. SHE TOLD ME I WAS TOO LAZY TO GO TO THE BATHROOM, I WOULD RATHER WET IN MY PANTS." I DID TELL SOMEONE, CAN'T REMEMBER THE NAME." THIS HAPPENED JUST A FEW NIGHTS AGO. REVIEW OF THE MIDNIGHT ASSIGNMENT SCHEDULE REVEALED CNA "CC" WAS ASSIGNED TO RESIDENT #13 ON THE FOLLOWING MIDNIGHT SHIFTS: 12/1/11 - 12/2/11; 12/2/11-12/3/11; 12/5/11-12/6/11; 12/7/11- 12/8/11 ;12/8/11- 12/911; RECORD REVIEW REVEALED RESIDENT #13 WAS admitted INTO THE FACILITY 10/7/11 WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE] DOCUMENTED THE RESIDENT REQUIRED EXTENSIVE ASSISTANCE WITH TOILETING AND ACTIVITIES OF DAILY LIVING. REVIEW OF A CARE PLAN DATED 10/7/11, ENTITLED, INCONTINENCE BLADDER AND BOWEL CARE PLAN DOCUMENTED, "TOILET AT REGULAR INTERVALS, SUCH AS FOLLOWING MEALS." ON 12/9/11 REVIEW OF THE FACILITY ' S POLICY DATED 9/2010, ENTITLED; "ABUSE PREVENTION PROGRAM ", DOCUMENTED "THE FACILITY MAINTAINS AN ENVIRONMENT FREE OF ABUSE AND NEGLECT. THE RESIDENT HAS THE RIGHT TO BE FREE FROM VERBAL, SEXUAL, PHYSICAL AND MENTAL ABUSE, CORPORAL PUNISHMENT AND INVOLUNTARY SECLUSION... VERBAL ABUSE : THE USE OF ORAL, WRITTEN, OR GESTURED LANGUAGE THAT WILLFULLY INCLUDES DISPARAGING AND DEROGATORY TERMS TO RESIDENT OR THEIR FAMILIES, OR WITHIN THEIR HEARING DISTANCE, REGARDLESS OF THEIR AGE, ABILITY TO COMPREHEND, OR DISABILITY". ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO CONSISTENTLY PERFORM SKIN ASSESSMENTS, CARE PLAN, AND IMPLEMENT INTERVENTIONS TO PREVENT PRESSURE ULCERS FOR TWO ( #'S 417 AND 422) SAMPLED RESIDENTS OF THIRTEEN SAMPLED RESIDENTS REVIEWED FOR PRESSURE ULCERS, OUT OF A TOTAL SAMPLE OF 30, RESULTING IN THE DEVELOPMENT OF FACILITY ACQUIRED PRESSURE ULCERS. FINDINGS INCLUDE: ON 12/7/11 AT 3:30 P.M., WOUND CARE BY TREATMENT NURSE "L" , ASSISTED BY LICENSED PRACTICAL NURSE (LPN) "M" WAS OBSERVED FOR RESIDENT #417. THE RESIDENT WAS LYING IN BED ON A LOW AIR LOSS MATTRESS (PRESSURE REDUCTION DEVICE), WITH HEELS BRIDGED (ELEVATED OFF THE BED) BY A SPECIALIZED CUSHION PLACED ACROSS THE FOOT OF THE BED. RESIDENT #417 WAS ALERT AND ORIENTED, AND WAS ABLE TO RESPOND TO QUESTIONING, BUT NEEDED STAFF ASSISTANCE TO REPOSITION IN BED. THE TREATMENT NURSE PERFORMED WOUND CARE ON RESIDENT #417 ' S LEFT HEEL STAGE THREE (III) PRESSURE ULCER (FULL THICKNESS SKIN LOSS WITH DAMAGE TO UNDERLYING TISSUES). BOTH FEET WERE NOTED TO BE PALE AND SWOLLEN ([MEDICAL CONDITION]) WITH PITTING [MEDICAL CONDITION] (A RISK FOR PRESSURE ULCERS). THE WOUND WAS OBSERVED TO BE CIRCULAR WITH YELLOW MOIST SLOUGH AT THE BASE, PINK GRANULATION TISSUE AT THE MARGINS, AND A HARD, DRY BROWN CRESCENT SHAPED SCAB ON THE LOWER MARGIN. THE WOUND NURSE RECORDED THE SIZE OF THE OPEN AREA AS MEASURING 1.5 CENTIMETERS (CM) LONG, BY 1.5 CM WIDE BY 0.3 CM DEEP. THE RESIDENT STATED, "OH THAT'S SORE!" TREATMENT NURSE "L" THEN REPOSITIONED RESIDENT #417 TO CHANGE THE DRESSING ON THE RESIDENT'S BUTTOCK PRESSURE ULCER. THE RESIDENT WAS NOTED TO BE SOILED WITH DRY CLAY LIKE FECES, OVERFLOWING THE RESIDENT'S BRIEF, AND EXTENDING FROM THE RESIDENT'S UPPER THIGHS TO THE RESIDENT'S MID BACK. WHEN QUERIED, THE RESIDENT WAS UNSURE WHEN HE HAD LAST RECEIVED INCONTINENCE CARE, AND STATED THAT HE HAD DECREASED SENSATION IN THE LOWER BODY, AND COULD NOT FEEL WHETHER OR NOT HE WAS INCONTINENT. LPN "M" CALLED IN CNA "N" TO PERFORM INCONTINENCE CARE PRIOR TO THE DRESSING CHANGE. THE DRESSING ON THE RESIDENT'S LEFT BUTTOCK PRESSURE SORE WAS NO LONGER OCCLUSIVE (TIGHTLY SEALED) AND WAS NOTED TO BE FILLED WITH FECES. THE RESIDENT COMPLAINED THAT HIS "BOTTOM" WAS "SORE." RESIDENT #417'S LEFT BUTTOCK PRESSURE ULCER WAS NOTED TO BE A FLAT, CIRCULAR OPEN AREA OF MOIST RED TISSUE, MEASURING 0.5 CM BY 0.3 CM, WITH NO DEPTH. NURSES "M" AND "L" THEN BAGGED SUPPLIES AND PREPARED TO LEAVE THE ROOM. UPON REQUEST, RESIDENT #417'S RIGHT SOCK WAS REMOVED, AND REVEALED A PREVIOUSLY UNDETECTED WOUND ON THE RIGHT LATERAL (SIDE) OF THE RIGHT HEEL. THIS NEW WOUND MEASURED 2.0 CM BY 4.0 CM, WITH NO DEPTH. THE WOUND WAS COVERED WITH A LAYER OF MOIST YELLOW TISSUE, WITH DARK REDDISH BROWN TISSUE VISIBLE UNDERNEATH. THERE WERE TWO SMALL OPEN AREAS, WHICH WERE NOT MEASURED BY THE WOUND NURSE. THE DAMAGED TISSUE WAS BOGGY (MUSHY) TO PALPATION (TOUCH). WHEN QUERIED, CNA "N" STATED SHE HAD NOT SEEN THE WOUND ON RESIDENT #417'S RIGHT HEEL BEFORE, AND WAS UNABLE TO STATE WHEN THE RESIDENT'S RIGHT SOCK WAS LAST REMOVED AND THE SKIN UNDERNEATH INSPECTED. WHEN QUERIED, THE TREATMENT NURSE AND LPN "M" STATED THE WOUND WAS NEW, AND MUST HAVE JUST DEVELOPED THAT DAY. WHEN QUERIED, NEITHER LPN "M" NOR TREATMENT NURSE "L" COULD PROVIDE DOCUMENTATION THAT RESIDENT #417 HAD RECEIVED A FULL BODY SKIN ASSESSMENT FOR THE PAST FOUR DAYS, SINCE 12/3/1. THREE DRIED BLOOD SPOTS WITH THE FOLLOWING , MEASUREMENTS, (1) 3.5 CM BY 1.7 CM (2) 1.0 CM BY 0.5 CM AND (3) 0.8 CM BY 0.4 CM, WERE NOTED ON THE BEDSHEETS UNDERNEATH RESIDENT #417'S RIGHT FOOT, BUT NO BLOOD WAS NOTED ON THE RESIDENT'S SOCKS. WHEN QUERIED, NEITHER THE TWO NURSES, NOR THE CNA COULD EXPLAIN HOW THE SHEETS WERE STAINED WITH BLOOD IN AN AREA COVERED BY THE HEEL BRIDGE DEVICE, IF THE DEVICE WAS CONSISTENTLY APPLIED AS ORDERED. ON 12/11/11 AT 4:00 P.M., RESIDENT #417'S CLINICAL RECORD AND TREATMENT RECORD WERE REVIEWED WITH THE TREATMENT NURSE. WHEN QUERIED HOW RESIDENT #417'S WOUNDS WERE FIRST DETECTED, THE TREATMENT NURSE STATED THAT " A CERTIFIED NURSING ASSISTANT (CNA) HAD NOTICED BLOOD ON THE RESIDENT ' S BED SHEETS, AND THEN NOTICED THAT THE RESIDENT HAD PRESSURE ULCERS ON THE LEFT HEEL AND THE LEFT BUTTOCK. THE TREATMENT NURSE WAS QUERIED ABOUT RESIDENT #417'S FIRST TWO FACILITY ACQUIRED PRESSURE ULCERS, ON THE LEFT HEEL AND THE LEFT BUTTOCK, AND STATED WOUND CARE WAS FIRST NOTIFIED OF THE LEFT HEEL STAGE III PRESSURE ULCER AND THE LEFT BUTTOCK STAGE TWO (II) PRESSURE ULCER ON 11/18/11. THE WOUND NURSE STATED THAT TREATMENT WAS INITIATED, PRESSURE ULCER PREVENTION INTERVENTIONS AND A PRESSURE ULCER CARE PLAN WERE IMPLEMENTED ON 11/18/11, ONCE SHE WAS INFORMED ABOUT THE FACILITY ACQUIRED PRESSURE ULCERS. WHEN QUERIED, THE TREATMENT NURSE STATED THAT RESIDENT #417'S RISK OF DEVELOPING PRESSURE ULCERS INCREASED ON 11/13/11 DUE TO WEAKNESS AND DEBILITY FROM [MEDICAL CONDITION] DISEASE, SEVERE DIARRHEA WITH INCONTINENCE, POOR NUTRITION DUE TO LACK OF APPETITE FROM THE [MEDICAL CONDITION], AND CONFINEMENT TO BED. WHEN QUERIED WHETHER A NURSING CARE PLAN AND INTERVENTIONS FOR PREVENTION OF PRESSURE ULCERS SHOULD HAVE BEEN INITIATED AT THIS TIME, THE TREATMENT NURSE STATED, "I KNOW THEY DID ONE ON ADMISSION. THEY CERTAINLY SHOULD HAVE REVISED IT AND ADDED NEW INTERVENTIONS ONCE HE GOT SICK." RECORD REVIEW REVEALED THERE WERE NO NURSING CARE PLANS OR INTERVENTIONS FOR THE PREVENTION OF PRESSURE ULCERS BEFORE RESIDENT #417 DEVELOPED THE PRESSURE ULCERS ON 11/18/11. WHEN QUERIED, THE TREATMENT NURSE WAS UNABLE TO EXPLAIN THIS. ON 12/7/11 AT 1:45 P.M., RESIDENT #417'S CLINICAL RECORD WAS REVIEWED WITH NURSE "G", THE MANAGER OF THE UNIT WHERE RESIDENT #417 RESIDED ON 11/18/11, WHEN THE LEFT HEEL AND LEFT BUTTOCK PRESSURE ULCERS WERE FIRST DETECTED. WHEN QUERIED, NURSE "G" WAS UNABLE TO FIND NURSING NOTES DOCUMENTING THE DISCOVERY OF RESIDENT #417'S PRESSURE ULCERS ON 11/18/11. WHEN QUERIED, NURSE "G" WAS UNABLE TO FIND A NURSING CARE PLAN FOR PREVENTION OF PRESSURE ULCERS FOR RESIDENT #417, BUT STATED THERE SHOULD HAVE BEEN ONE INITIATED UPON ADMISSION, AND COULD NOT EXPLAIN WHY THIS HAD NOT BEEN DONE. WHEN QUERIED, NURSE "G" STATED THAT RESIDENT #417'S RISK OF DEVELOPING PRESSURE ULCERS INCREASED WHEN HIS HEALTH DETERIORATED DUE TO [MEDICAL CONDITION] INFECTION. THE NURSE NOTED THAT SEVERE DIARRHEA WITH INCONTINENCE WAS ALSO AN ADDITIONAL RISK FACTOR FOR THE DEVELOPMENT OF BUTTOCK AND COCCYX PRESSURE ULCERS, AND THUS, RESIDENT #417 SHOULD HAVE BEEN REASSESSED, SHOULD HAVE RECEIVED AN UPDATED NURSING CARE PLAN FOR PRESSURE ULCER PREVENTION, AND PRESSURE ULCER PREVENTATIVE INTERVENTIONS SHOULD HAVE BEEN PUT IN PLACE. WHEN QUERIED, UNIT MANAGER "G" COULD NOT EXPLAIN WHY THIS HAD NOT BEEN DONE, BUT NOTED THAT THE RESIDENT HAD MOVED SEVERAL TIMES AND HAD RESIDED IN MULTIPLE NURSING UNITS. ON 12/7/11 AT 3:00 P.M., RESIDENT #417'S CLINICAL RECORD WAS REVIEWED WITH NURSE "B", THE MANAGER OF THE UNIT WHERE RESIDENT #417 RESIDED. REVIEW OF A FACE SHEET DOCUMENTED RESIDENT #417 WAS admitted INto the facility on [DATE]. [DIAGNOSES REDACTED]. REVIEW OF A MINIMUM DATA SET ASSESSMENT FOR RESIDENT #417, DATED 9/25/11 REVEALED RESIDENT #417 HAD NO COGNITIVE IMPAIRMENTS (NO SIGNIFICANT DEMENTIA), AND NEEDED EXTENSIVE ASSISTANCE OF ONE STAFF FOR MOBILITY IN BED AND WAS DEPENDENT FOR TRANSFERS TO THE WHEELCHAIR, DID NOT WALK, WAS DEPENDENT FOR TOILETING AND HYGIENE, AND HAD NO PRESSURE ULCERS PRESENT UPON ADMISSION. REVIEW OF A BRADEN SCALE SKIN ASSESSMENT (TO ASSESS RISK OF DEVELOPING PRESSURE ULCERS), DATED 9/19/11 REVEALED THAT RESIDENT #417 WAS NOT HIGH RISK FOR THE DEVELOPMENT OF PRESSURE ULCERS WITH A SCORE OF 17 ON THAT DATE. WHEN QUERIED, NEITHER UNIT MANAGER "G" NOR "B" COULD PROVIDE DOCUMENTATION RESIDENT #417 RECEIVED A BRADEN SCALE REASSESSMENT AFTER HE DEVELOPED [MEDICAL CONDITION] DISEASE AND SUFFERED A DECLINE IN HEALTH AND MOBILITY. REVIEW OF A MULTIDISCIPLINARY CARE CONFERENCE SUMMARY DATED 10/5/11 REVEALED RESIDENT #417 WAS AT "RISK/CONSEQUENCE" FOR "PRESSURE ULCER". REVIEW OF NURSING CARE PLANS FOR RESIDENT #417 REVEALED THE FOLLOWING: 1. AN INTERIM (ADMISSION) CARE PLAN DATED 9/19/11 HAD THE SECTION TITLED, "SKIN INTEGRITY" LEFT BLANK (UNCOMPLETED), WITH NO PREVENTION OF PRESSURE ULCERS CARE PLAN OR INTERVENTIONS ACTIVATED. 2. A CARE PLAN DATED 9/19/11 FOR "IMPAIRED MOBILITY" HAD NO PRESSURE ULCER PREVENTION INTERVENTIONS ACTIVATED. 3. A NURSING CARE PLAN DATED 11/18/11, TITLED "IMPAIRED SKIN INTEGRITY" DOCUMENTED RESIDENT #417 HAD A STAGE III LEFT HEEL PRESSURE ULCER AND AN UNCATEGORIZED LEFT BUTTOCK WOUND. INTERVENTIONS INCLUDED "MONITOR HIGH RISK AREAS SUCH AS HEELS DAILY", AND "HEELS UP WITH POSITIONING DEVICE WHEN IN BED." REVIEW OF UNDATED "DAILY CHECK BODY FORMS FOR RESIDENT #417 REVEALED EITHER NO DOCUMENTATION (BLANK, UNCOMPLETED) OR NO DOCUMENTATION OF ANY WOUNDS, EXCEPT FOR ONE NOTATION ON DAY 15, "SORE ON BOTTOM". WHEN QUERIED WHERE THE DAILY MONITORING OF RESIDENT #417'S HEELS WAS DOCUMENTED PER THE SKIN INTEGRITY CARE PLAN, NURSE "B" STATED IT WOULD BE DOCUMENTED IN THE NURSING NOTES, HOWEVER, THE UNIT MANAGER "B" WAS UNABLE TO PROVIDE ANY DOCUMENTATION OF THIS IN THE NURSING NOTES UPON REQUEST, EXCEPT FOR THE WEEKLY DOCUMENTATION BY THE TREATMENT NURSE. UNIT MANAGER "B" THEN STATED THAT THE UNDATED DAILY BODY CHECK FORMS FOR RESIDENT #417, FOR DAYS 1 THROUGH 31, WERE THE DAILY SKIN ASSESSMENTS FOR RESIDENT #417 FOR NOVEMBER, IMPLEMENTED PER THE CARE PLAN ON 11/18/11. NURSE "B" THEN DATED ALL THE FORMS WITH "NOVEMBER 2011", AND INITIALED THE DATE. WHEN QUERIED ABOUT THE ACCURACY OF THE SKIN ASSESSMENTS DOCUMENTED ON THESE FORMS, AS THE FORMS CONTAINED NO DOCUMENTATION OF WOUNDS ACTUALLY PRESENT (AFTER 11/18/11) (LEFT BLANK, "RED BOTTOM", OR "SAME FINDINGS"), NURSE "B" WAS UNABLE TO ANSWER. UNIT MANAGER "B" STATED THAT THE SKIN ASSESSMENTS WERE ALSO DOCUMENTED TWICE WEEKLY ON "SHOWER SHEETS". UNIT MANAGER "B" WAS REQUESTED TO PROVIDE ALL DOCUMENTATION OF SKIN ASSESSMENTS FOR RESIDENT #417. WHEN QUERIED, THE TREATMENT NURSE STATED THAT FULL BODY SKIN ASSESSMENTS WERE PERFORMED TWICE WEEKLY, ON SHOWER DAYS. REVIEW OF "BATHING SKIN ASSESSMENT FORMS FOR RESIDENT #417 REVEALED THE FOLLOWING SKIN ASSESSMENTS: 1. 11/12/11 (NO OPEN AREAS), 2. 11/14/11 NO OPEN AREAS, 3. 11/15/11 TO 11/23/11 AND 11/25/11 TO 12/7/11 NO DOCUMENTATION (LEFT BLANK), 4. 11/24/11 NO OPEN AREAS ( SIX DAYS AFTER RESIDENT #417'S LEFT HEEL AND LEFT BUTTOCK PRESSURE ULCERS WERE IDENTIFIED), 5. DECEMBER 2011 (NO DATE IDENTIFIED) OPEN AREAS. HOWEVER, THE BODY MAP FOR LOCATION AND DESCRIPTION OF OPEN AREAS WAS LEFT BLANK ( NOT COMPLETED). UNIT MANAGER "B" WAS UNABLE TO PROVIDE ADDITIONAL DOCUMENTATION OF TWICE WEEKLY BATHING SKIN ASSESSMENTS FOR RESIDENT #417 UPON SECOND REQUEST. THE UNIT MANAGER THEN STATED THAT THERE WOULD BE DOCUMENTATION IN THE SHOWER BOOK THAT THESE WERE DONE PER FACILITY POLICY FOR THE MISSING DATES IN DECEMBER. HOWEVER, REVIEW OF THE SHOWER BOOK REVEALED NO ADDITIONAL DOCUMENTATION FOR RESIDENT #417. ON 12/8/11 AT 9:00 A.M., THE DIRECTOR OF NURSING (DON) WAS QUERIED ABOUT RESIDENT #417'S THREE FACILITY ACQUIRED PRESSURE ULCERS, THE LACK OF SKIN RISK REASSESSMENT, PREVENTATIVE SKIN CARE PLAN AND INTERVENTIONS AFTER RESIDENT #417'S CHANGE IN HEALTH AND MOBILITY, AND PROVIDED NO FURTHER INFORMATION. THE DON WAS ALSO UNABLE TO EXPLAIN HOW RESIDENT #417 HAD BLOOD STAINS ON THE BEDSHEETS UNDERNEATH THE HEEL ELEVATION DEVICE IF THE DEVICE WAS CONSISTENTLY USED. THE DON WAS ALSO UNABLE TO EXPLAIN THE INCONSISTENT AND INACCURATE SKIN ASSESSMENTS FOR RESIDENT #417. WHEN QUERIED ABOUT THE NEW FACILITY ACQUIRED RIGHT HEEL WOUND IDENTIFIED ON 12/7/11, THE DON WAS UNABLE TO STATE HOW LONG IT HAD BEEN PRESENT BEFORE DETECTION DURING A SURVEYOR REQUESTED SKIN ASSESSMENT. ( ) ON 12/9/11 AT 09:30 A.M., RESIDENT #422 WAS OBSERVED IN BED ASLEEP ON A SPECIALTY MATTRESS WITH OXYGEN VIA NASAL CANNULA. THE RESIDENT'S RIGHT LEG WAS ELEVATED ON A HEEL LIFT WITH FOOT FLAT AGAINST THE FOOTBOARD. THE LEFT LEG WAS SEVERELY CONTRACTED WITH THE KNEE BENT UP TOWARD THE STOMACH AND THE FOOT LAYING ON THE RIGHT ANKLE AND CALF. AT 9:40 A.M., THE ACTIVE CLINICAL RECORD FOR RESIDENT #422 WAS REVIEWED. THE ADMISSION FACESHEET INDICATED THE RESIDENT WAS MOST RECENTLY admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM (MDS) data set [DATE] INDICATED THE RESIDENT'S COGNITIVE SKILLS FOR DECISION MAKING WAS SEVERELY IMPAIRED AND EXTENSIVELY RELIED ON STAFF FOR ALL CARE NEEDS. THE ADMISSION NOTE DATED 4/8/11 DOCUMENTED THE RESIDENT HAD A "STAGE FOUR SACRAL DECUBITUS" ( FULL THICKNESS TISSUE LOSS WITH . SLOUGH OR ESCHAR MAY BE PRESENT) ONLY. THE RESIDENT HAD NO OTHER AREAS OF SKIN BREAK DOWN DOCUMENTED. ON DATED 12/2/11, THE WOUND CARE NOTE DOCUMENTED THE RESIDENT HAS WOUNDS TO SACRUM, LOWER EXTREMITIES, TOE AND EAR. NURSE '"E" WAS QUERIED CONCERNING THE DEVELOPMENT OF WOUNDS TO RESIDENT#422'S LOWER EXTREMITIES, TOE AND EAR. NURSE "E" STATED " SHE CAME IN WITH THE WOUND TO THE COCCYX. THE LEFT FOOT AND HEEL CAME BECAUSE OF THIS RUBBING UP AND DOWN MOTION. SHE HAS PARKINSON DISEASE. THE TUBING FROM THE OXYGEN PROBABLY CAUSED THE ONE BEHIND HER EAR." AT 12:30 P.M. WOUND CARE FOR RESIDENT #422 WAS OBSERVED WITH NURSE PRACTITIONER "DD". THE RESIDENT HAD THREE FACILITY ACQUIRED WOUNDS. NURSE "L" WITH GLOVED HANDS REMOVED THE OLD DRESSING FROM THE LEFT LATERAL ASPECT OF THE FOOT WAS A STAGE III . THE WOUND WAS A CIRCULAR SHAPE WITH A DARK RED TO PINK WOUND BED, MEASURING 1.7 X 2.5 CM. A STAGE II WOUND ON THE LEFT GREAT TOE WHICH APPEARED TO BE A FLAT BLISTER, HAD A SMALL AMOUNT OF BLOODY DRAINAGE. THE WOUND MEASURED 1.1 X 1.0 CM. THE FOURTH WOUND WAS LOCATED BEHIND THE LEFT EAR WHERE THE TUBING TO THE OXYGEN WAS PLACED. THE REDDENED STAGE II WOUND HAD A SMALL AMOUNT OF BLOODY DRAINAGE AND MEASURED 0.8 X 0.5 CM. AT 11:00 A.M., RESIDENT #422 ACTIVE CLINICAL RECORD WAS REVIEWED WITH UNIT MANAGER "B", THE 4/7/11, ADMISSION BRADEN SCALE (PRESSURE SORE RISK SCALE) WAS A 12, AT HIGH RISK FOR DEVELOPMENT. UNIT MANAGER "B" . UNIT MANAGER "B" WAS ASKED TO FIND AN ADMISSION IMPAIRED SKIN INTEGRITY CAREPLAN FOR THE RESIDENT, SINCE THE RESIDENT HAD A STAGE IV SACRAL WOUND ON ADMISSION AND WAS AT HIGH RISK FOR DEVELOPMENT OF PRESSURE ULCERS. UNIT MANAGER "B' WAS UNABLE TO FIND AN ADMISSION CAREPLAN FOR SKIN INTEGRITY OR ANY WRITTEN INTERVENTIONS TO PREVENT THE DEVELOPMENT OF NEW PRESSURE ULCERS. UNIT MANAGER "B" STATED "SHE ( THE RESIDENT) SHOULD HAVE HAD A 14 DAY CAREPLAN, IT MUST HAVE GOTTEN OVERLOOKED. BUT IT WAS CAUGHT ON THE QUARTERLY WHICH WAS 4 MONTHS LATER ON 8/26/11. ON 8/05/11, BEFORE A SKIN INTEGRITY CAREPLAN WAS WRITTEN. WOUND CARE NOTES DOCUMENTED, RESIDENT #422 HAD THE FOLLOWING TWO FACILITY ACQUIRED WOUNDS. A LEFT LATERAL FOOT BLOOD BLISTER, CAP MEASURING 1.8 X 1.6 CM AND THE LEFT METATARSAL HEAD HAD A BLOOD BLISTER WITH THE CAP MEASURING 2.8 X 1.6 CM, BOTH 75% DESICCATED (DRIED OUT). ACCORDING TO THE WEBSITE FOOT AND ANKLE HEALTH. COM; "MOST BLOOD BLISTERS OCCUR AFTER THE SKIN HAS BEEN PINCHED OR SQUEEZED. " ( )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ORDER A POST SKILLED THERAPY PLAN OF CARE TO MAINTAIN RANGE OF MOTION AND PROPER BODY ALIGNMENT FOR ONE (#413) OF FOUR SAMPLED RESIDENTS REVIEWED FOR RANGE OF MOTION FROM A TOTAL OF 30, RESULTING IN THE DEVELOPMENT OF A LEG CONTRACTURE. FINDINGS INCLUDE: ON 12/7/11 AT 9:40 AM, NURSE 'M' ASSISTED IN ASSESSING RESIDENT #413'S SKIN. THE RESIDENT WAS IN BED ON HER RIGHT SIDE WITH HER LEFT KNEE FLEXED (BENT) TO THE POINT WHERE HER LEFT HEEL WAS IN CONTACT WITH THE BACK OF HER LEFT THIGH. WHEN SHE TURNED ONTO HER BACK, HER LEFT FOOT WAS FIRMLY PLANTED ON THE MATTRESS DUE TO FLEXION OF THE KNEE. THE RESIDENT IMMEDIATELY CROSSED HER RIGHT LEG OVER THE TOP OF THE FLEXED LEFT KNEE. NURSE 'M' ASKED THE RESIDENT, WHO WAS ALERT AND ABLE TO RESPOND TO QUESTIONS, TO UNCROSS THE RIGHT LEG. THE RESIDENT WAS ABLE TO SLOWLY LIFT THE RIGHT LEG OFF OF HER LEFT KNEE. NURSE 'M' THEN ASKED THE RESIDENT TO LIFT HER LEFT HEEL TO OBSERVE THE SKIN ON THE HEEL. THE RESIDENT WAS UNABLE TO EXTEND (STRAIGHTEN) HER LEFT LEG ENOUGH TO LIFT THE HEEL FROM THE MATTRESS. NURSE 'M' PROCEEDED TO MANUALLY LIFT THE HEEL FROM THE BED WHILE ATTEMPTING TO STRAIGHTEN THE LEFT LEG. THE RESIDENT CLUTCHED HER LEFT THIGH AND GRIMACED AS THE LEG WAS BEING MOVED. THE NURSE WAS ONLY ABLE TO EXTEND THE KNEE ENOUGH TO LIFT THE HEEL A FEW INCHES FROM THE MATTRESS. ON 12/7/11 AT 1 AND 3 PM, ON 12/8/11 AT 1:15 PM, AND ON 12/9/11 AT 12 NOON, RESIDENT #413 WAS OBSERVED SITTING IN HER WHEELCHAIR WITH HER LEFT KNEE FLEXED. A REVIEW OF RESIDENT #413'S RECORD REVEALED THAT THE RESIDENT WAS admitted on [DATE] FOLLOWING SURGICAL REPAIR OF A LEFT [MEDICAL CONDITION]. SHE ALSO HAD [MEDICAL CONDITION] REQUIRING [MEDICAL TREATMENT] PER THE ADMISSION FACE SHEET. THE MINIMUM DATA SET ((MDS) dated [DATE] NOTED THAT THE RESIDENT HAD IMPAIRED RANGE OF MOTION (ROM) TO THE LEFT LEG. THE MDS dated [DATE] NOTED THAT THE RESIDENT HAD IMPAIRED ROM TO BOTH LEGS. RESIDENT #413'S INITIAL PHYSICAL THERAPY (P.T.) EVALUATION AND CARE PLAN DATED 7/20/11 WRITTEN BY PT ASSISTANT (PTA) 'V', NOTED THAT THE RESIDENT'S EXTENSION OF THE LEFT HIP AND KNEE WERE WITHIN FUNCTIONAL LIMITS, IE, 0-30 DEGREES FOR THE HIP AND 120-0 DEGREES FOR THE KNEE. THERE WAS NO MENTION IN THE EVALUATION OF MAINTAINING PROPER POSITIONING OF THE LEFT LEG. ON 12/9/11 AT 1 PM, PTA 'V' PRESENTED ALL P.T. RECORDS FOR RESIDENT #413, INCLUDING A P.T. DISCHARGE SUMMARY WRITTEN BY HER DATED 8/30/11. ON 8/30/11, PTA 'V' WROTE THAT THE RESIDENT'S P.T. WAS DISCONTINUED BECAUSE "PATIENT HAS REACHED PLATEAU IN THERAPY." THE DISCHARGE RECOMMENDATION: "REFER TO RESTORATIVE (NURSING CARE)." THE RESIDENT WAS NON-AMBULATORY WHEN P.T. WAS DISCONTINUED BUT HER KNEE EXTENSION WAS WITHIN FUNCTIONAL LIMITS AND HIP EXTENSION WAS WITHIN NORMAL RANGE. ON 12/9/11 AT 2:15 PM, RESTORATIVE THERAPY RECORDS FOR RESIDENT #413 WERE REQUESTED FROM RESTORATIVE AIDE 'S'. AIDE 'S' LOOKED THROUGH THE RESTORATIVE THERAPY BOOK, BUT WAS UNABLE TO LOCATE ANY RECORDS INDICATING THAT THE RESIDENT RECEIVED RESTORATIVE THERAPY AFTER DISCHARGE FROM P.T. SHE WAS UNABLE TO RESPOND WHY. THERE WAS NO DOCUMENTED CARE PLAN AVAILABLE FOR RESTORATIVE THERAPY. ON 12/9/11 AT 2:30 PM, AFTER THREE REQUEST WERE MADE TO HAVE A PHYSICAL THERAPIST ASSESS RESIDENT #413'S LEFT LEG, PTA 'Q' ARRIVED TO TAKE JOINT MEASUREMENTS. AGAIN, THE RESIDENT'S KNEE WAS FLEXED AND SHE CROSSED THE RIGHT LEG OVER THE LEFT KNEE. WHEN PTA 'Q' ATTEMPTED TO GENTLY STRETCH AND EXTEND THE RESIDENT'S HIP AND KNEE, THE RESIDENT BEGAN TO GRIMACE, CLUTCH HER LEFT HIP, AND CRY AS IT WAS BEING STRETCHED. AFTER PTA 'Q' STRETCHED THE LEG AS FAR AS THE RESIDENT COULD TOLERATE, HE TOOK MEASUREMENTS. THE RESIDENT'S LEFT HIP AND KNEE EXTENSION DECLINED TO MINUS 30 DEGREES, INDICATING A DECLINE IN ROM (CONTRACTURE). PTA 'Q' STATED THAT THE RESIDENT COULD POSSIBLY BENEFIT FROM RESTORATIVE THERAPY OR APPLICATION OF A BRACE IF ALLOWED. ON 12/9/11 AT 2 :45 PM, RESTORATIVE NURSE 'P' PRESENTED NOTES FROM A FAMILY DISCUSSION OF CONCERNS DURING A CARE CONFERENCE ON 10/18/11. THE FAMILY INQUIRED AS TO WHY THE RESIDENT WAS NOT RECEIVING THERAPY. PER THE NOTES, THE RESIDENT WAS "discharged (ON 8/30/11) FROM P.T. WITH NO ORDER FOR RESTORATIVE PROGRAM. ORDER WRITTEN 10/24/11 FOR P.T. TO RE-EVALUATE RESIDENT....P.T. STATED THEY WILL RE-EVALUATE DURING EVENING OF 10/26/11 OR 10/27/11." AN ORDER WAS WRITTEN ON 10/24/11 FOR A P.T. EVALUATION. ON 11/4/11, THERE WAS an order written [REDACTED]. EVALUATION. THE EVALUATION WAS NOT DONE. WHEN ASKED WHY, NURSE 'P' AND NURSE MANAGER 'B' WERE UNABLE TO STATE WHY. NURSE 'P' STATED THAT THE RESIDENT NEVER RECEIVED RESTORATIVE THERAPY "BECAUSE THERE WAS NO ORDER WRITTEN." THEY WERE UNABLE TO EXPLAIN WHY. THEY WERE UNABLE TO EXPLAIN WHY THE RESIDENT'S LEG WAS NOT MAINTAINED IN PROPER ALIGNMENT TO PREVENT DEVELOPMENT OF A CONTRACTURE. NURSE 'P' SAID, "I WILL GET HER A BRACE." AFTER THREE REQUESTS FOR AN INTERVIEW, PTA 'V' WAS UNAVAILABLE FOR COMMENT REGARDING DISCONTINUING P.T. FOR RESIDENT #413 WITH NO FURTHER ORDERS OR INTERVENTIONS. PER THE FACILITY'S "RESTORATIVE: RANGE OF MOTION ASSESSMENT" POLICY REVISED 3/2010: -RESIDENTS WITH LIMITED ROM SHOULD NOT EXPERIENCE A REDUCTION IN ROM UNLESS THE RESIDENT'S CLINICAL CONDITION DEMONSTRATES THAT A REDUCTION IS UNAVOIDABLE. -ALL RESIDENTS WITH LIMITED ROM SHOULD RECEIVE APPROPRIATE TREATMENT AND SERVICES TO INCREASE ROM AND/OR REDUCE POTENTIAL FOR FURTHER DECLINE. -UPON DISCHARGE FROM P.T., FURTHER DISCHARGE RECOMMENDATIONS SHOULD BE ADDRESSED. IF APPROPRIATE FOR A RESTORATIVE PROGRAM, A physician's orders [REDACTED]. -RESIDENT'S WHO ARE AT RISK FOR CONTRACTURES SHOULD RECEIVE RECOMMENDATIONS FROM THE THERAPIST FOR TREATMENT TO INCREASE OR MAINTAIN ROM. ( )

BASED ON INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO PROPERLY MONITOR AND CARE PLAN NUTRITIONAL PARAMETERS FOR TWO (#'S 402 AND 414) OUT OF 10 RESIDENTS REVIEWED FOR WEIGHTS CHANGES OF A TOTAL OF 30 SAMPLED RESIDENTS, RESULTING IN UNINTENDED SEVERE WEIGHT CHANGES. FINDINGS INCLUDE: ON 12/7/11 AT 2:50 P.M., RECORD REVIEW REVEALED RESIDENT #414 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MOST RECENT MINIMUM DATA SET ((MDS) dated [DATE] DOCUMENTED THE RESIDENT WAS INDEPENDENT IN DECISION MAKING AND REQUIRED ASSISTANCE WITH ACTIVITIES OF DAILY LIVING. REVIEW OF THE physician's orders [REDACTED]. ON 8/2/2011 AN ORDER WAS WRITTEN FOR "[MEDICATION NAME] 80 MILLILITER (ML)/HOUR FROM 5:00 P.M. UNTIL DOSE DELIVERED. TOTAL ML'S OF FORMULA IN 24 HOURS 1280 ML/TOTAL KCAL (CALORIES) IN 24 HOURS 1920 ML." ON 8/16/11 an order for [REDACTED].M. UNTIL DOSE DELIVERED. TOTAL ML'S FORMULA IN 24 HOURS 640/TOTAL KCAL IN 24 HOURS 960. CONDUCT WEEKLY WEIGHTS. 2 CAL MED PASS SUPPLEMENT 2 CAL HIGH NITROGEN (HN) 60 ML AT 9:A.M., 1:00 P.M., 5:00 P.M. AND 9:00 P.M." A REVIEW OF WEEKLY ENTERAL INTAKE DOCUMENTED THE FOLLOWING INTAKE VOLUMES BY DATE: 8/18/2011-582 ML 8/19/2011-200 ML 8/20/2011- 360 ML 8/21/2011- 560 ML 8/22/2011- 531 ML 8/23/2011- 560 ML 8/24/2011- 1280 ML 8/25/2011- 209 ML 8/27/2011- 1280 ML 8/28/2011- 1280 ML 8/29/2011- 1280 ML 8/30/2011- 1280 ML 8/31/2011- 640 ML 9/1/2011 - 1280 ML 9/2/2011- 1280 ML 9/3/2011- 1280 ML 9/5/2011-680 ML 9/6/2011- 680 ML 9/7/2011- 680 ML 9/8/2011- 487 ML 9/10/2011- 680 ML 9/11/2011- 1280 ML 9/12/2011 -610 ML 9/13/2011- 650 ML 9/14/2011-1280 ML 9/15/2011- 1280 ML 9/16/2011- 1280 ML 9/17/2011- 1280 ML 9/18/2011- 1280 ML 9/19/2011- 120 ML 9/20/2011- 1280 ML 9/21/2011- 1280 ML 9/22/2011- 620 ML 9/23/2011- 175 ML 9/24/2011- 661 ML 9/25/2011-BLANK THE REVIEW REVEALED THAT 22 OF 36 DAYS THE RESIDENT RECEIVED MORE TUBE FEEDING THAN ORDERED BY THE PHYSICIAN. ON 12/9/11 AT 1:50 P.M., NURSE 'E' WAS QUERIED REGARDING WHY RESIDENT #414 HAD NOT CONSISTENTLY RECEIVED THE PRESCRIBED TUBE FEEDING ORDER FROM 8/16/2011 THROUGH 9/25/2011 NURSE' E' SAID, "I DON'T KNOW". REVIEW OF THE NUTRITION CARE PLAN DATED 10/19/2011 DOCUMENTED," WEIGHT LOSS RISK POOR ORAL INTAKE, RISK FOR DEHYDRATION AND TUBE FEEDING. GOALS INCLUDED, NO WEIGHT LOSS IN 90 DAYS. APPROACHES INCLUDED RECORD AND MONITOR WEEKLY WEIGHTS FOR TRENDS. HOLD TUBE FEEDING DURING TRIAL WEAN. DIET AS ORDERED, CONTINUE TO HOLD TUBE FEEDING AS LONG AS WEIGHT STABLE. REVIEW OF WEIGHT RECORDS REVEALED THE FOLLOWING: 8/19- 130 LBS (POUNDS) 8/29- 130 LBS 9/4- 131 LBS 9/13- 133 LBS 9/20- 134 LBS 9/21- 136 LBS 10/4- 138 LBS 10/10- 140 LBS 10/18- 141 LBS 10/25- 142 LBS 11/1 143.2 LBS 11/7- 147 LBS 11/15- 147.3 LBS 11/23- 148.3 LBS 11/29- 144.2 LBS 12/1- 145 LBS REVIEW OF NUTRITION PROGRESS REVEALED THE FOLLOWING: ON 8/16/2011, " PATIENT AND NURSING REQUEST TUBE FEEDING TO BE CUT BACK TO ALLOW GREATER PO (ORAL) INTAKE. TUBE FEEDING CHANGED TO 640 ML TOTAL VOLUME AND ADDED 2 CAL HN 60 ML QID (FOUR TIMES A DAY)." ON 9/30/2011, " WEIGHT INCREASED 8 LBS. PO INTAKE 75% OVERALL. HOLD TUBE FEEDING FOR 7 DAYS AND MONITOR ORAL INTAKE FOR POSSIBLE TUBE FEEDING WEAN. " ON 10/6/2011, "NUTRITIONAL ASSESSMENT, USUAL BODY WEIGHT NOTED TO BE 125-128. CONTINUE TO HOLD TUBE FEEDING AS LONG AS WEIGHT STABLE." ON 10/19/2011, " WEEKLY WEIGHTS STABLE TO SLIGHTLY INCREASED. CONTINUE TUBE FEEDING HOLD SECONDARY TO POSITIVE OUTCOME " . ON 11/15/2011" CURRENT BODY WEIGHT 147 LBS AND STABLE WITH TUBE FEEDING HELD. ON 11/22/2011, PER NURSING VERBAL REPORT TO RD (REGISTERED DIETITIAN) " 2 CAL HN CAUSING GAS PER RESIDENT " WILL RECOMMEND CHANGE TO ENSURE 60 ML QID. RESIDENT WEIGHT RECORD INDICATED A 11% WEIGHT GAIN (SEVERE) IN PAST 3 MONTHS. WEIGHT 9/4 131 LBS. WT. 12/1 145 LBS. UBW 125-128 LBS HEIGHT 63 INCHES PER NUTRITION ASSESSMENT. QUERIED RD REGARDING RESIDENT. RD STATED, " RESIDENTS USUAL WEIGHT HAD BEEN BETWEEN 125-128 LBS. HER GOAL WAS WEIGHT MAINTENANCE ." WHEN QUERIED REGARDING CONTINUED SUPPLEMENT USE AND SIGNIFICANT WEIGHT GAIN THE RD STATED, " I DID NOT SEE THE ORDER TO CUT BACK ON ORAL INTAKE. I WAS NOT AWARE THE RESIDENT WAS GETTING SUPPLEMENTS THROUGH THE FEEDING TUBE. I WOULD HAVE PROBABLY DISCONTINUED THE SUPPLEMENT NEXT MONTH WHEN I REVIEWED HER " . REVIEW OF THE FACILITY'S REVISED POLICY DATED, OCTOBER, 2011, ENTITLED; "ENTERAL FEEDING PROTOCOL" DOCUMENTED, TUBE FEEDING REDUCTION MAY OCCUR WHEN THE RESIDENT IS RECEIVING A TRAY AND EATING 75% OF THEIR THREE MEALS A DAY. WEEKLY WEIGHTS WILL BE MONITORED , FOOD ACCEPTANCE REPORTS WILL BE KEPT. NURSING AND CLINICAL DIETITIANS WILL MAKE RECOMMENDATIONS TO THE PHYSICIANS." ( ) DEFICIENT PRACTICE #2: BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ADEQUATELY MONITOR, EVALUATE, AND IMPLEMENT INTERVENTIONS REGARDING NUTRITIONAL PARAMETERS FOR ONE (#409) OF 10 SAMPLED RESIDENTS REVIEWED FOR WEIGHT CHANGES FROM A TOTAL OF 30, RESULTING IN SEVERE WEIGHT LOSS FOLLOWED BY SEVERE WEIGHT GAIN. FINDINGS INCLUDE: ON 12/9/11 AT 10:50 AM, RESIDENT #409'S WEIGHT RECORDS WERE REVIEWED WITH NURSE AIDE 'U', WHO WAS RESPONSIBLE FOR WEIGHING RESIDENTS. FROM 5/2/11 THRU 10/24/11, THE RESIDENT WEIGHED 217-220 POUNDS. AIDE 'U' STATED THAT THE RESIDENT WAS WEIGHED ON THE SAME SCALE EACH TIME FOR SAKE OF CONSISTENCY. ON 10/24/11, THE RESIDENT'S WEIGHT WAS RECORDED AS 220 POUNDS. ON 11/24/11, THE RESIDENT'S WEIGHT WAS 191 POUNDS, A SEVERE 13% WEIGHT LOSS IN ONE MONTH. THERE WERE NO FURTHER WEIGHTS RECORDED FOR RESIDENT #409. WHEN ASKED, AIDE 'U' STATED THAT THE WEIGHT DECLINE WAS REPORTED TO NURSE MANAGER 'G'. AIDE 'U' STATED THAT THERE WAS NO RE-WEIGH ON 11/24/11 OF THE RESIDENT TO CONFIRM THE WEIGHT. WHEN ASKED WHY, SHE WAS UNABLE TO EXPLAIN. AIDE 'U' WAS QUERIED REGARDING WHEN THE RESIDENT WAS DUE TO BE WEIGHED AGAIN. THE AIDE STATED, "I WASN'T TOLD TO WEIGH HIM. HE IS NOT DUE UNTIL NEXT WEEK," EVEN THOUGH THE RESIDENT'S WEIGHT HAD SEVERELY DROPPED IN NOVEMBER. AN IMMEDIATE WEIGHT WAS REQUESTED ON RESIDENT #409. WHEN HE STOOD ON THE SCALE THAT HE WAS USUALLY WEIGHED ON, HIS WEIGHT REGISTERED AT 231.4 POUNDS, A SEVERE, 17% INCREASE SINCE 11/24/11. AFTER RESIDENT #409 WAS WEIGHED, THE RESIDENT'S WEIGHT RECORD WAS REVIEWED WITH MANAGER 'G'. SHE INDICATED THAT SHE DID NOT RECALL BEING TOLD BY AIDE 'U' IN NOVEMBER THAT THE RESIDENT HAD LOST WEIGHT. THERE WAS NO INDICATION THAT THE WEIGHT LOSS WAS DISCUSSED WITH THE PHYSICIAN OR DIETARY STAFF. ON 11/2/11, DIETARY STAFF NOTED THAT THE RESIDENT WEIGHED 220 POUNDS. ON 12/2/11, DIETARY STAFF NOTED THAT THE RESIDENT'S WEIGHT WAS "STABLE." THERE WAS NO REFERENCE TO THE 13% WEIGHT LOSS ON 11/24/11. MANAGER 'G' WAS UNABLE TO EXPLAIN WHY THERE WAS NO RE-WEIGH TO CONFIRM THE WEIGHT IN NOVEMBER AND WAS UNABLE TO COMMENT ON THE SEVERE WEIGHT INCREASE TO 231.4 POUNDS. A REVIEW OF RESIDENT #409'S CLINICAL RECORD REVEALED THAT THE RESIDENT WAS admitted on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SETS DATED 5/3/11 AND 11/15/11 NOTED THAT THE RESIDENT WAS AMBULATORY, WEIGHED 218 POUNDS AND 220 POUNDS AND WAS 74 INCHES IN HEIGHT. THE RESIDENT WAS PRESCRIBED A REGULAR, CONSISTENT CARBOHYDRATE DIET. INTERVENTIONS ON THE RESIDENT'S "ALTERATION IN NUTRITION" CARE PLAN DATED 8/4/11 THRU 12/2/11 AND A NUTRITION assessment dated [DATE] INCLUDED: "MAINTAIN CURRENT WEIGHT WITHIN 3%" AND CONTINUE TO MONITOR WEIGHT. PER THE FACILITY'S "WEIGHT LOSS" AND "WEIGHING RESIDENTS" POLICIES DATED 10/2011: -THE FACILITY MUST ENSURE THAT A RESIDENT MAINTAINS ACCEPTABLE PARAMETERS OF NUTRITIONAL STATUS, SUCH A BODY WEIGHT. A WEIGHT LOSS OR GAIN OF GREATER THAN 5% IN ONE MONTH IS DETERMINED TO BE SEVERE. -NURSING AND DIETARY STAFF SHOULD ASSESS RESIDENTS MONTHLY FOR ACTUAL WEIGHT LOSS OR RISK FACTORS FOR WEIGHT LOSS. -RESIDENTS SHOULD BE RE-WEIGHED IF THE NEW WEIGHT IS PLUS OR MINUS FIVE POUNDS FROM THE PRIOR WEIGHT. THE NURSE MANAGER SHOULD REVIEW THE WEIGHTS AS SOON AS POSSIBLE AND DETERMINE IF THE RESIDENT NEEDS TO BE RE-WEIGHED. -IF THERE IS A DIFFERENCE OF MORE THAN FIVE POUNDS FOR RESIDENTS WITH HEART FAILURE, THE WEIGHT SHOULD BE REPEATED. IF CONFIRMED, IT SHOULD BE REPORTED TO THE NURSE. -THE PHYSICIAN SHOULD EVALUATE THE RESIDENT FOR WEIGHT LOSS. RECOMMENDATIONS SHOULD BE MADE BY DIETARY STAFF AND A physician's orders [REDACTED].

THIS CITATION PERTAINS TO INTAKE NUMBER MI 077 BASED ON INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE APPROPRIATE POST FALL CARE FOR ONE OF FIVE SAMPLED RESIDENT (#501), ALL REVIEWED FOR APPROPRIATE CARE, WHEN DIRECT CARE STAFF MOVED RESIDENT #501 AFTER HE (#501) HAD FALLEN FROM HIS BED, SUSTAINING A [MEDICAL CONDITION], BEFORE LICENSED STAFF HAD ASSESSED HIM FOR INJURIES, RESULTING IN RESIDENT #501 BEING ALLOWED TO LAY ON THE FLOOR IN PAIN AS STAFF LOOKED ON, AND RESULTING IN A DELAY IN PAIN RELIEF, DELAY IN IDENTIFICATION OF INJURIES, HUMILIATION, AND THE POTENTIAL FOR FURTHER INJURIES. FINDINGS INCLUDE: ACCORDING TO THE "PROFILE FACE SHEET" RESIDENT #501 WAS ORIGINALLY admitted to the facility on [DATE] AND REadmitted on [DATE]. A REVIEW OF THE physician's orders [REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE] REVEALED THAT RESIDENT #501 REQUIRED LIMITED ASSISTANCE WITH ONE PERSON PHYSICAL ASSIST WITH TRANSFERS, EXTENSIVE ASSISTANCE OF ONE PERSON PHYSICAL ASSIST FOR DRESSING, PERSONAL HYGIENE AND WAS TOTALLY DEPENDENT ON STAFF FOR TOILETING, LOCOMOTION OFF THE UNIT AND BATHING. THE MDS INDICATED THAT RESIDENT #502 WAS "...NOT STEADY, ONLY ABLE TO STABILIZE WITH HUMAN ASSISTANCE WITH MOVING FROM SEATED TO STANDING POSITION, WALKING, TURNING AROUND, MOVING ON AND OFF TOILET AND SURFACE TO SURFACE TRANSFERS (TRANSFER BETWEEN BED AND CHAIR OR WHEELCHAIR)..." ACCORDING TO THE "ADMISSION NURSING ASSESSMENT" DATED 5/27/11, RESIDENT #501 WAS ALERT BUT DISORIENTED TO TIME AND PLACE RESIDENT #501'S "FALL RISK EVALUATION" REVEALED THAT RESIDENT #501 WAS IDENTIFIED AS A FALL RISK ON ADMISSION WITH AN ADMISSION SCORE OF 23. ACCORDING TO THE EVALUATION, "...A RESIDENT WHO SCORES A 10 OR HIGHER IS AT RISK..." RESIDENT #501'S FALL RISK SCORE ON 9/16/11 WAS 24. A "FACILITY INCIDENT REPORT" DATED 10/5/11, DOCUMENTED "...IT WAS DISCOVERED THAT ON OCTOBER 3, 2011, (RESIDENT #501) SLID OUT OF HIS BED IN HIS ROOM ON TO THE FLOOR SAFETY MAT." IT WAS REPORTED THAT THE CNA (CERTIFIED NURSING ASSISTANT) (CNA #4) ASSISTED THE RESIDENT ONTO HIS BED WITH THE ASSISTANCE OF CNA #5 AND CNA #2. "X-RAY TAKEN, FRACTURE DISCOVERED, CURRENTLY hospitalized ..." A REVIEW OF THE "FACILITY INVESTIGATION REPORT" DATED 10/10/11 REVEALED "...ON 10/3/11 AT 11:43 P.M., RESIDENT #501 WAS OBSERVED ON THE FLOOR ON A MATT NEXT TO HIS LOW BED. AT 5:00 A.M., RESIDENT #501 COMPLAINED OF PAIN IN HIS LEFT KNEE AND RECEIVED MEDICATION FROM THE LICENSED NURSE. (LPN #2) DURING THE AM SHIFT OF 10/4/11 THE RESIDENT WAS ASSESSED BY LPN #2 WHO DID NOT OBSERVE ANY BRUISING, SWELLING OR REDNESS. RESIDENT #501 CONTINUED TO COMPLAIN OF PAIN, THE PHYSICIAN ORDERED AN X-RAY. THE X-RAY REVEALED THAT A FRACTURE HAD OCCURRED..." A REVIEW OF RESIDENT #501'S X-RAY REPORT DATED 10/4/11 REVEALED, "...LEFT HIP AND FEMUR: EXAMINATION REVEALS WHAT APPEAR TO BE AN IMPACTED INTERTROCHANTERIC AND BASOCERVICAL [MEDICAL CONDITION] FEMUR WITH SLIGHT VARUS DEFORMITY AND NO SIGNIFICANT DISPLACEMENT.." ON 12/1/11 AT 3:08 P.M., DURING AN INTERVIEW, CNA #2 REPORTED, "...I HEARD AN ALARM SO I RAN TO IT. I SAW (CNA #4) ALREADY IN THE ROOM. SHE (#4) WAS JUST STANDING THERE LOOKING AT HIM (#501). (CNA #5) CAME IN RIGHT BEHIND ME. SHE JUST STOOD THERE AND LOOKED AT HIM TOO. THEN SHE (CNA #5) SAID "LET'S JUST PUT HIM BACK IN THE BED." I QUESTIONED THAT. I SAID, PUT HIM BACK IN THE BED?..." CNA #2 WENT ON TO SAY, "THEN CNA #5 CALLED OUT THE DOOR, SOMEBODY BRING ME (#5) A WHEELCHAIR, SO I (#2) LEFT TO GO GET A WHEELCHAIR. I (#2) BROUGHT IT TO THEM (#4 AND #5) AND THEN I (#2) LEFT TO CARE FOR MY PATIENTS. WHEN I (CNA #2) GOT BACK WITH THE WHEELCHAIR, THE OTHER TWO CNAS (CNA #4 AND CNA #5) WERE JUST STANDING THERE TALKING TO EACH OTHER..." WHEN ASKED WHAT RESIDENT #501 WAS DOING AT THIS TIME, CNA #2 SAID, "...HE WAS STILL ON THE FLOOR YELLING, HELP ME, HELP ME UP!...THERE WERE MATS ON HIS FLOOR AND HE WAS LAYING ON HIS SIDE..." THE DIRECT CARE STAFF' DID NOT REPORT RESIDENT #501'S FALL TO THE ASSIGNED NURSE (LPN #2). ON 12/5/11 AT 12:55 P.M., A REVIEW OF THE FACILITY'S VIDEO SURVEILLANCE CAMERAS SHOWED MULTIPLE DIRECT CARE STAFF GOING INTO AND COMING OUT OF RESIDENT #501'S ROOM AFTER HE HAD FALLEN. AT TIMES, DIRECT CARE STAFF WERE SHOWN (PER SURVEILLANCE VIDEO) JUST STANDING IN THE DOORWAY OF RESIDENT #501'S ROOM, TALKING AMONGST THEMSELVES. ON 12/5/11 AT 3:15 P.M., DURING AN INTERVIEW WITH THE FACILITY ADMINISTRATOR AND THE DIRECTOR OF NURSING (DON), THE ADMINISTRATOR REPORTED, "...I WAS SURPRISED TO LEARN OF WHAT HAPPENED. I'M SURE THEY (DIRECT CARE STAFF/CNAS) WERE TRAINED NOT TO MOVE A PATIENT WHO IS INJURED BEFORE THEY HAVE BEEN ASSESSED BY THE NURSE..." ON 12/5/11 AT 11:25 A.M., DURING AN INTERVIEW, LPN #2 REPORTED, "...I LEARNED HE (#501) HAD FALLEN THE NEXT DAY. THE ASSISTANT DIRECTOR OF NURSING (ADON) SAID HE WAS GOING OUT TO THE HOSPITAL BECAUSE HE KEPT COMPLAINING OF PAIN AND THAT HIS (#501) ROOMMATE SAID HE fell . THE FACILITY ORDERED AN X-RAY AND IT REVEALED A FRACTURE SO THEY SENT HIM OUT..." LPN #2 FURTHER REPORTED, "...I FIRST SAW HIM AT ABOUT 11:45 P.M. I LAST SAW HIM (#501) AROUND 5:00 A.M. THE NEXT MORNING WHEN I HAD TO DO HIS STRAIGHT CATH (CATHETERIZATION) RELATED TO HIS HISTORY OF [MEDICAL CONDITION]" WHEN ASKED OF THE LAST TIME SHE (LPN #2) SAW RESIDENT #501 PRIOR TO 5:00 A.M., LPN #2 SAID, "I SAW HIM THAT ONE OTHER TIME BETWEEN 11:45 P.M. AND MIDNIGHT BECAUSE I HAD GIVEN HIS ROOMMATE HIS MEDICATIONS AND IT WAS AROUND MIDNIGHT. HE (#501) COMPLAINED OF KNEE PAIN THE NEXT MORNING (10/4/11) SO I ASSESSED HIM FOR KNEE PAIN BUT I DIDN'T SEE ANY BRUISING. I WAS OFF THE UNIT FOR ABOUT AN HOUR AND A HALF THE PREVIOUS EVENING BECAUSE I HAD TO SUPERVISE DURING THAT TIME..." A REVIEW OF THE FACILITY'S EVENTS TIMELINE REVEALED THAT LPN WENT INTO RESIDENT #501'S ROOM FOR COMPLAINTS OF PAIN AT MIDNIGHT, HOWEVER, DURING THE INTERVIEW, LPN #2 REPORTED THAT SHE WENT IN AT THAT TIME TO MEDICATE RESIDENT #501'S ROOMMATE. A REVIEW OF RESIDENT #501'S "MEDICATION RECORD" (MR) FOR THE MONTH OF OCTOBER, REVEALED THAT NO MEDICATION HAD BEEN ADMINISTERED TO RESIDENT #501 AT MIDNIGHT. THE MR FURTHER REVEALED THAT RESIDENT #501 RECEIVED A NARCOTIC PAIN MEDICATION ([MEDICATION NAME]) ON 10/3/11 AT 7:00 P.M. PRIOR TO THE FALL AND DID NOT RECEIVE ANY OTHER PAIN MEDICATIONS UNTIL 10/4/11 AT 4:30 A.M., WHEN HE WAS AGAIN ADMINISTERED THE NARCOTIC PAIN MEDICATION. WHEN ASKED IF SHE (LPN #2 NOTIFIED THE PHYSICIAN OF RESIDENT #501'S COMPLAINTS OF KNEE PAIN, LPN #2 SAID, "...NO, BECAUSE HE'S COMPLAINED OF JOINT PAIN BEFORE..." LPN #2 FURTHER REPORTED, "...IT WAS WEIRD THAT HE COMPLAINED OF KNEE PAIN..." A REVIEW OF THE FACILITY'S "FALLS/FALL RISK/FALL PREVENTION, GUIDELINES FOR EVALUATION OF" POLICY REVIEWED 10/11 REVEALED: "...PURPOSE: TO PROVIDE GUIDELINES FOR THE CONSISTENT IDENTIFICATION AND MONITORING OF RESIDENTS AT RISK FOR FALL/FALLS AND TO IMPLEMENT INTERVENTIONS FOR RESIDENT SAFETY..." "...ALL RESIDENT FALLS OR OBSERVED ON THE FLOOR INCIDENTS SHOULD BE REPORTED, ASSESSED BY A LICENSED NURSE PRIOR TO MOVING AND A WRITTEN INCIDENT/OCCURRENCE REPORT IS COMPLETED..."

THIS CITATION PERTAINS TO INTAKE NUMBER MI 077 BASED ON INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION TO PREVENT A FALL FOR ONE RESIDENT (#501), OF TWO RESIDENTS REVIEWED FOR FALLS, FROM A TOTAL OF FIVE SAMPLED RESIDENTS, RESULTING IN RESIDENT #501 FALLING FROM HIS BED SUSTAINING A HIP FRACTURE. FINDINGS INCLUDE: ACCORDING TO THE "PROFILE FACE SHEET" RESIDENT #501 WAS ORIGINALLY admitted to the facility on [DATE] AND REadmitted on [DATE]. A REVIEW OF THE physician's orders [REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE] DOCUMENTED THAT RESIDENT #501 REQUIRED LIMITED ASSISTANCE WITH ONE PERSON PHYSICAL ASSIST WITH TRANSFERS, EXTENSIVE ASSISTANCE OF ONE PERSON PHYSICAL ASSIST FOR DRESSING, PERSONAL HYGIENE AND WAS TOTALLY DEPENDENT ON STAFF FOR TOILETING, LOCOMOTION OFF THE UNIT AND BATHING. THE MDS INDICATED THAT RESIDENT #502 WAS "...NOT STEADY, ONLY ABLE TO STABILIZE WITH HUMAN ASSISTANCE WITH MOVING FROM SEATED TO STANDING POSITION, WALKING, TURNING AROUND, MOVING ON AND OFF TOILET AND SURFACE TO SURFACE TRANSFERS (TRANSFER BETWEEN BED AND CHAIR OR WHEELCHAIR)..." ACCORDING TO THE "ADMISSION NURSING ASSESSMENT" DATED 5/27/11, RESIDENT #501 WAS ALERT BUT DISORIENTED TO TIME AND PLACE RESIDENT #501'S "FALL RISK EVALUATION" REVEALED THAT RESIDENT #501 WAS IDENTIFIED AS A FALL RISK ON ADMISSION WITH AN ADMISSION SCORE OF 23. ACCORDING TO THE EVALUATION, "...A RESIDENT WHO SCORES A 10 OR HIGHER IS AT RISK..." RESIDENT #501'S FALL RISK SCORE ON 9/16/11 WAS 24. A "FACILITY INCIDENT REPORT" DATED 10/5/11, DOCUMENTED "...IT WAS DISCOVERED THAT ON OCTOBER 3, 2011, (RESIDENT #501) SLID OUT OF HIS BED IN HIS ROOM ON TO THE FLOOR SAFETY MAT." IT WAS REPORTED THAT THE CNA (CERTIFIED NURSING ASSISTANT) (CNA #4) ASSISTED THE RESIDENT ONTO HIS BED WITH THE ASSISTANCE OF CNA #5 AND CNA #2. "X-RAY TAKEN, FRACTURE DISCOVERED, CURRENTLY hospitalized ..." A REVIEW OF THE "FACILITY INVESTIGATION REPORT" DATED 10/10/11 REVEALED "...ON 10/3/11 AT 11:43 P.M., RESIDENT (#501) WAS OBSERVED ON THE FLOOR ON A MAT NEXT TO HIS LOW BED. AT 5:00 A.M., (RESIDENT #501) COMPLAINED OF PAIN IN HIS LEFT KNEE AND RECEIVED MEDICATION FROM THE LICENSED NURSE (LPN #2). DURING THE AM SHIFT OF 10/4/11, THE RESIDENT WAS ASSESSED BY LPN (#2) WHO DID NOT OBSERVE ANY BRUISING, SWELLING OR REDNESS. (RESIDENT #501) CONTINUED TO COMPLAIN OF PAIN, THE PHYSICIAN ORDERED AN X-RAY. THE X-RAY REVEALED THAT A FRACTURE HAD OCCURRED..." A REVIEW OF RESIDENT #501'S X-RAY REPORT DATED 10/4/11 REVEALED, "...LEFT HIP AND FEMUR: EXAMINATION REVEALS WHAT APPEAR TO BE AN IMPACTED INTERTROCHANTERIC AND BASOCERVICAL FRACTURE OF THE PROXIMAL FEMUR WITH SLIGHT VARUS DEFORMITY AND NO SIGNIFICANT DISPLACEMENT.." THE DIRECT CARE STAFF' DID NOT REPORT RESIDENT #501'S FALL TO THE ASSIGNED NURSE (LPN #2). ON 12/5/11 AT 12:55 P.M., A REVIEW OF THE FACILITY'S VIDEO SURVEILLANCE CAMERAS SHOWED MULTIPLE DIRECT CARE STAFF GOING INTO AND COMING OUT OF RESIDENT #501'S ROOM AFTER HE HAD FALLEN. AT TIMES, DIRECT CARE STAFF WERE SHOWN (PER SURVEILLANCE VIDEO) JUST STANDING IN THE DOORWAY OF RESIDENT #501'S ROOM, TALKING AMONGST THEMSELVES. ON 12/1/11 AT 3:08 P.M., DURING AN INTERVIEW, CNA #2 REPORTED, "...I HEARD AN ALARM SO I RAN TO IT. I SAW (CNA #4) ALREADY IN THE ROOM. SHE (#4) WAS JUST STANDING THERE LOOKING AT HIM (#501). (CNA #5) CAME IN RIGHT BEHIND ME. SHE JUST STOOD THERE AND LOOKED AT HIM TOO. THEN SHE (CNA #5) SAID "LET'S JUST PUT HIM BACK IN THE BED." I QUESTIONED THAT. I SAID, PUT HIM BACK IN THE BED?..." CNA #2 WENT ON TO SAY, "THEN CNA #5 CALLED OUT THE DOOR, SOMEBODY BRING ME (#5) A WHEELCHAIR, SO I (#2) LEFT TO GO GET A WHEELCHAIR. I (#2) BROUGHT IT TO THEM (#4 AND #5) AND THEN I (#2) LEFT TO CARE FOR MY PATIENTS. WHEN I (CNA #2) GOT BACK WITH THE WHEELCHAIR, THE OTHER TWO CNAS (CNA #4 AND CNA #5) WERE JUST STANDING THERE TALKING TO EACH OTHER..." WHEN ASKED WHAT RESIDENT #501 WAS DOING AT THIS TIME, CNA #2 SAID, "...HE WAS STILL ON THE FLOOR YELLING, HELP ME, HELP ME UP!" ON 12/5/11 AT 11:25 A.M., DURING AN INTERVIEW, LPN #2 REPORTED, "...I LEARNED HE (#501) HAD FALLEN THE NEXT DAY. THE ASSISTANT DIRECTOR OF NURSING (ADON) SAID HE WAS GOING OUT TO THE HOSPITAL BECAUSE HE KEPT COMPLAINING OF PAIN AND THAT HIS (#501) ROOMMATE SAID HE fell . THE FACILITY ORDERED AN X-RAY AND IT REVEALED A FRACTURE SO THEY SENT HIM OUT..." A REVIEW OF RESIDENT #501'S CLOSED CLINICAL RECORD REVEALED THE FOLLOWING CARE PLANS: 5/27/11, "...POTENTIAL FOR FALLS/INJURY RELATED TO COGNITIVE DEFICIT, FALL RISK ASSESSMENT SCORE..." 7/8/11 "...FUNCTIONAL DEFICIT IN SELF CARE RELATED TO A [DIAGNOSES REDACTED]. RESIDENT CANNOT RECOGNIZE HE REQUIRES ASSISTANCE WITH SOME TASK AS WELL AS SUPERVISION WITH OTHERS..." 7/30/11 "...POTENTIAL FOR FALLS/INJURY RELATED TO WEAKNESS, HISTORY OF FALLS. INTERVENTIONS: 1:1 (ONE-ON-ONE SUPERVISION)..." UPDATED 8/9/11 "...PSYCHOSOCIAL WELL-BEING IMPAIRED RELATED TO NEW ENVIRONMENT, MEMORY LOSS, CONFUSION, AS EVIDENCED BY WANDERS. FREQUENTLY ON SECOND FLOOR. DOES NOT REMEMBER WHERE TO GO OR ROOM NUMBER..." UPDATED 9/19/11 "SAFETY ....NO NEED FOR WANDER GUARD AT THIS TIME, DECREASE 1:1 FOR PM SHIFT ONLY..." UPDATED 9/24/11 "...SAFETY-FROM FALL RISK ASSESSMENT, CONFUSED, ONE TO ONE SITTER FOR INTENSIVE SUPERVISION, WHEELCHAIR PLACED CLOSE TO NURSES STATION FOR MONITORING. ROUTINE NURSING CARE WILL INCLUDE: TOILETING ASSISTANCE, PAIN RELIEF AND COMFORT..." ACCORDING TO THE CNA CARE GUIDE (USED TO INFORM DIRECT CARE STAFF OF THE NEEDS OF THE RESIDENTS), REVISED 9/14/11, RESIDENT #501 REQUIRED ONE PERSON LIMITED ASSISTANCE WITH TRANSFERS, A WHEELCHAIR FOR MOBILITY AND had a history of [REDACTED]. A REVIEW OF A "SOCIAL WORK NOTE" DATED 9/22/11 REVEALED, "...RESIDENT #501 WAS SEEN BY PHYSICIAN'S ASSISTANT FOR INITIAL PSYCHIATRIC DIAGNOSTIC EVALUATION DUE TO CHANGE IN CONDITION. RESIDENT #501 HAS BECOME INCREASINGLY AGITATED, VERBALLY AGGRESSIVE, AND HAS REQUIRED 1:1 SUPERVISION, DIAGNOSIS, DEMENTIA WITH BEHAVIORAL DISTURBANCE, ANXIETY..." A SOCIAL WORK NOTE DATED 8/15/11 REVEALED, "...HE (#501) IS NOTED TO BE CONFUSED AND FORGETFUL,. RESIDENT IS CURRENTLY ON A 1:1 FOR SAFETY. RESIDENT HAS NOT HAD ANY FALLS OR CONCERNS SINCE BEING ON 1:1..." A SOCIAL WORK NOTE DATED 8/23/11 REVEALED, "...RESIDENT HAS BEEN DOING WELL ON THE DAY SHIFT AND HAS NOT HAD ANY FALLS IR SHOWING ANY UNUSUAL BEHAVIORS TO CONTINUE NEED FOR 1:1 FOR DAY SHIFT. RESIDENT (#501) WILL CONTINUE 1:1 FOR AFTERNOON AND MIDNIGHT FOR CONTINUED TIME..." THERE WAS NO DOCUMENTED EVIDENCE THAT RESIDENT #501 HAD 1:1 (ONE-ON-ONE) SUPERVISION ON 10/3/11, AS INDICATED IN THE PLAN OF CARE. ON 12/5/11 AT 1:41 P.M., DURING AN INTERVIEW, THE DIRECTOR OF NURSING (DON) WAS QUERIED ABOUT RESIDENT #501'S FALL. THE DON REPORTED, "...HE (#501) HAD A ONE-TO-ONE (1:1) ORDER DUE TO SAFETY MEASURES. IT WAS A NURSING JUDGMENT FOR SAFETY REASONS. IT WAS THE FAMILY'S REQUEST INITIALLY..." A REVIEW OF THE FACILITY'S BEHAVIORAL LOGS REVEALED NO DOCUMENTED EVIDENCE THAT RESIDENT #501 HAD 1:1 SUPERVISION ON THE EVENING OF 10/3/11 WHEN HE fell . FURTHER, THERE WAS NO BEHAVIORAL LOG DOCUMENTATION FOR THAT EVENING. THE DON WAS UNABLE TO EXPLAIN WHY RESIDENT #501 DID NOT HAVE 1:1 SUPERVISION ACCORDING TO THE PLAN OF CARE IN ORDER TO PREVENT RESIDENT #501'S FALL WITH SUBSEQUENT HIP FRACTURE. A REVIEW OF THE FACILITY'S "FALLS/FALL RISK/FALL PREVENTION, GUIDELINES FOR EVALUATION OF" POLICY REVIEWED 10/11 REVEALED: "...PURPOSE: TO PROVIDE GUIDELINES FOR THE CONSISTENT IDENTIFICATION AND MONITORING OF RESIDENTS AT RISK FOR FALL/FALLS AND TO IMPLEMENT INTERVENTIONS FOR RESIDENT SAFETY..."

THIS CITATION PERTAINS TO INTAKE NUMBER MI 712 BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO REPORT TO THE STATE SURVEY AND CERTIFICATION AGENCY AN ELOPEMENT INCIDENT INVOLVING 1 OF 8 SAMPLED RESIDENTS REVIEWED FOR ELOPEMENT (RESIDENT #101) FROM A TOTAL SAMPLE OF 9 RESIDENTS, RESULTING IN IMMEDIATE JEOPARDY AND THE POTENTIAL FOR HARM, INJURY OR DEATH FOR RESIDENT #101, WHEN HE ELOPED FROM THE FACILITY ON 3/16/2011 WITHOUT STAFF OR GUARDIAN KNOWLEDGE, WHICH CAUSED RESIDENT #101 TO BE UNSUPERVISED OUTSIDE IN A PARKING LOT FOR AN UNKNOWN PERIOD OF TIME, POSSIBLY "MINUTES." THE FACILITY'S FAILURE TO REPORT THIS INCIDENT OF ELOPEMENT AS WELL AS ITS FAILURE TO THOROUGHLY INVESTIGATE THE CIRCUMSTANCES LEADING UP TO THE ELOPEMENT AND FAILURE TO CONSISTENTLY IMPLEMENT CORRECTIVE ACTIONS FURTHER RESULTED IN A SECOND ELOPEMENT OF RESIDENT #101 FROM THE FACILITY ON 9/20/2011, WHICH ALSO RESULTED IN IMMEDIATE JEOPARDY. FINDINGS INCLUDE: RESIDENT #101: ACCORDING TO THE FACE SHEET, DATED 9/02/2011, RESIDENT #101 WAS A [AGE] year OLD MALE WHO LIVED AT THE FACILITY SINCE 04/09/2003. HIS [DIAGNOSES REDACTED]. ACCORDING TO THE Minimum Data Set, dated dated [DATE], RESIDENT #101 HAD IMPAIRED COGNITIVE FUNCTION WITH SHORT-TERM MEMORY LOSS. RESIDENT #101 HAD RESTRICTED RANGE OF MOTION IN HIS LOWER EXTREMITIES. HE COULD NOT AMBULATE, REQUIRED STAFF ASSISTANCE WITH ALL TRANSFERS AND USED A MOTORIZED WHEELCHAIR TO MOVE THROUGHOUT THE FACILITY. REVIEW OF A COMPETENCY DECLARATION FORM SIGNED BY TWO PHYSICIANS, DATED 11/14/2003, REVEALED RESIDENT #101 WAS UNABLE TO PARTICIPATE IN HIS MEDICAL TREATMENT DECISIONS. A FORM FROM THE STATE OF MICHIGAN PROBATE COURT OF MACOMB COUNTY, DATED 7/27/2011, DEEMED RESIDENT #101 A LEGALLY INCAPACITATED PERSON. HE WAS APPOINTED A FULL GUARDIAN FROM THE COURT WHEN HIS PRIOR GUARDIAN (BROTHER), WHO HAD SERVED FOR EIGHT YEARS, RESIGNED. THE FACILITY'S LICENSED SOCIAL WORKER DOCUMENTED IN A "SOCIAL WORK NOTE," DATED 3/15/2011, THAT RESIDENT #101 HAD A LEGAL GUARDIAN BECAUSE HE DISPLAYED PERIODS OF CONFUSION AND IMPAIRED JUDGEMENT. REVIEW OF CURRENT COGNITIVE LOSS CARE PLANS FOR RESIDENT #101, WHICH STAFF INITIATED ON 3/15/2011, REVEALED RESIDENT #101 HAD IMPAIRED JUDGEMENT, INSIGHT AND DECISION MAKING. IN THIS CARE PLAN, STAFF ASSESSED RESIDENT #101 TO HAVE "POOR IMPULSE CONTROL" AND THE NEED FOR "ASSISTANCE...(WITH) MAKING DECISION... " REVIEW OF CURRENT ELOPEMENT CARE PLANS FOR RESIDENT #101, WHICH STAFF INITIATED ON 8/31/2010, REVEALED RESIDENT #101 HAD PRIOR ELOPEMENT ATTEMPTS FROM THE FACILITY. TO KEEP RESIDENT #101 SAFE, STAFF WERE TO MONITOR HIS "WHEREABOUTS FREQUENTLY, AT LEAST EVERY 2 HOURS." PHYSICIAN ORDERS, DATED 2/1/2011 THROUGH 9/20/2011, REQUIRED STAFF TO PLACE A WANDERGUARD (A DEVICE THAT CAUSES AN ALARM TO SOUND WHEN THE WANDERGUARD IS IN CLOSE PROXIMITY TO THE ALARM) ON RESIDENT #101 TO PREVENT HIS ELOPEMENT FROM THE FACILITY. IN AN INTERVIEW ON 9/28/2011 AT 2:00 P.M., THE UNIT MANAGER (UNIT MANAGER #5) SAID DESPITE THE physician's orders [REDACTED]. REVIEW OF AN UNEXPECTED OCCURRENCE REPORT, DATED 3/16/2011, REVEALED RESIDENT #101 DID NOT HAVE HIS PHYSICIAN-ORDERED WANDERGUARD IN PLACE, WHEN HE EXITED THE FACILITY ON 3/16/2011 AT 3:30 P.M. AND PROCEEDED UNSUPERVISED INTO THE FACILITY'S "BACK PARKING LOT" WITHOUT STAFF KNOWLEDGE. ON 9/28/2011 AT 2:00 P.M., UNIT MANAGER #5 WAS INTERVIEWED AND SAID RESIDENT #109 LEFT THE FACILITY WITHOUT STAFF KNOWLEDGE BECAUSE HE WAS NOT WEARING HIS ORDERED WANDERGUARD. UNIT MANAGER #5 SAID, "IT WAS NOT SAFE" FOR RESIDENT #101 TO BE OUTSIDE, "ESPECIALLY IN MARCH." IN AN INTERVIEW ON 9/30/2011 AT 11:35 A.M., THE ADMINISTRATOR SAID RESIDENT #101 WAS "ONLY IN THE BACK PARKING LOT FOR MINUTES," WHEN HE ELOPED FROM THE FACILITY ON 3/16/2011. THE ADMINISTRATOR COULD NOT QUANTIFY THE NUMBER OF "MINUTES" RESIDENT #101 SPENT UNSUPERVISED IN THE BACK PARKING LOT. THE ADMINISTRATOR SAID THE FACILITY DID NOT REPORT THIS ELOPEMENT TO THE STATE AGENCY. ON 9/28/2011 AT 2:00 P.M. UNIT MANAGER #5 WAS INTERVIEWED. ACCORDING TO UNIT MANAGER #5, AS OF 3/16/11, TO PREVENT FUTURE ELOPEMENTS, A WANDERGUARD ALARM WAS PLACED BEHIND OR UNDERNEATH RESIDENT #101'S WHEELCHAIR TO KEEP HIM FROM REACHING IT. THE UNIT MANAGER SAID IT WAS DECIDED THAT PLACEMENT OF THIS SAFETY DEVICE ON RESIDENT #101'S PERSON WOULD HAVE PERMITTED TAMPERING AND POSSIBLE REMOVAL OF THE DEVICE AND, THEREFORE, IT WAS NOT CONSIDERED A SAFE OPTION. HOWEVER, ON 9/19/11, WHEN RESIDENT #101 VERBALIZED HIS INTENT TO LEAVE THE FACILITY, STAFF WORKING ON THE EVENING SHIFT (3:00 P.M. TO 11:00 P.M.), MOVED THE RESIDENTS WANDERGUARD ALARM FROM THE WHEELCHAIR TO RESIDENT #101'S ANKLE. UNIT MANAGER #5 STATED THAT SHE WAS UNAWARE THAT THE NURSING STAFF HAD MADE THIS DECISION AND WAS NOT ABLE TO EXPLAIN THE REASONING BEHIND THIS DECISION. IN AN INTERVIEW ON 9/28/2011 AT 1:30 P.M., RESIDENT #101 SAID THAT ON 9/20/11, AFTER LUNCH, HE USED A BUTTER KNIFE TO "SAW" OFF THE WANDERGUARD ALARM ON HIS ANKLE, AND LEFT THE FACILITY THROUGH THE BACK PARKING LOT DOOR, THE SAME DOOR HE HAD USED WHEN HE LEFT THE BUILDING IN MARCH. ON 9/30/2011 AT 3:20 P.M., THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY THAT BEGAN ON 3/16/2011 AND WAS IDENTIFIED ON 9/28/2011 WHEN THE FACILITY FAILED TO ENSURE THAT ALL ALLEGED VIOLATIONS INVOLVING MISTREATMENT AND NEGLECT WERE REPORTED IMMEDIATELY TO THE STATE SURVEY AND CERTIFICATION AFTER STAFF FAILED TO PROVIDE THE NECESSARY SUPERVISION AND ASSISTIVE DEVICES ORDERED BY HIS PHYSICIAN TO PREVENT HIS SUCCESSFUL ELOPEMENT ON 3/16/2011, WHICH LEFT RESIDENT #101 UNSUPERVISED OUTSIDE IN THE FACILITY'S PARKING LOT. ON 10/03/2011, THIS SURVEYOR CONFIRMED THE FACILITY IMPLEMENTED THE FOLLOWING BY 10/01/2011 TO REMOVE THE IMMEDIATE JEOPARDY: 1. THE ADMINISTRATOR AND DIRECTOR OF NURSING REVIEWED THE POLICY AND PROCEDURE FOR REPORTING EVENTS TO THE STATE AGENCY AND DEEMED IT APPROPRIATE. 2. THE ADMINISTRATOR AND DIRECTOR OF NURSING HAVE SAID ALL EVENTS THAT MEET REPORTING REQUIREMENTS WILL BE REPORTED TO THE STATE AGENCY. 3. INSERVICE TRAINING FOR ALL STAFF ON THE PREVENTION OF ABUSE AND NEGLECT BEGAN AND ADMINISTRATION DETERMINED ALL STAFF WILL RECEIVE THIS MANDATORY EDUCATION BEFORE RETURNING TO DUTY. AS OF 10/02/2011 188 OF 245 STAFF MEMBERS HAD RECEIVED THIS EDUCATION. 4. THE ADMINISTRATOR AND DIRECTOR OF NURSING MET WITH THE REGIONAL DIRECTOR FOR THEIR FACILITY AND ACKNOWLEDGED UNDERSTANDING OF STATE REPORTING REQUIREMENTS. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED ON 9/23/2011, 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 AS SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY.

THIS CITATION PERTAINS TO INTAKE NUMBER MI 712 BASED ON OBSERVATIONS, INTERVIEWS, AND RECORD REVIEWS, THE FACILITY FAILED TO PROVIDE THE NECESSARY SUPERVISION AND/OR ASSISTIVE DEVICES IN 2 OF 8 SAMPLED RESIDENTS REVIEWED FOR ELOPEMENT (RESIDENT #101 AND RESIDENT #109) FROM A TOTAL SAMPLE OF 9 RSEIDENTS, RESULTING IN: 1) IMMEDIATE JEOPARDY FOR RESIDENT #101 WHEN THE FACILITY FAILED TO PROVIDE THE NECESSARY SUPERVISION AND ASSISTIVE DEVICES TO PREVENT TWO SUCCESSFUL ELOPEMENTS BY RESIDENT #101. THE FIRST ELOPEMENT OCCURRED ON 3/16/2011 WITHOUT STAFF OR GUARDIAN KNOWLEDGE, WHICH CAUSED RESIDENT #101 TO BE UNSUPERVISED OUTSIDE IN A PARKING LOT FOR AN UNKNOWN PERIOD OF TIME, POSSIBLY "MINUTES." THE SECOND ELOPEMENT OCCURRED ON 9/20/2011 WITHOUT STAFF OR GUARDIAN KNOWLEDGE, WHICH CAUSED RESIDENT #101 TO BE UNSUPERVISED OUTSIDE THE FACILITY, FOR FOUR HOURS AND THREE MINUTES, APPROXIMATELY 3 MILES FROM THE FACILITY, HAVING CROSSED MANY HIGH-TRAFFIC-VOLUME STREETS IN THE URBAN ENVIRONMENT OF METROPOLITAN DETROIT AND 2) THE POTENTIAL FOR RESIDENT #109 TO ELOPE FROM THE FACILITY DUE TO A LACK OF SUPERVISION AND/OR ASSISTIVE DEVICES TO PREVENT ELOPEMENT. THIS DEFICIENT PRACTICE PLACED 15 RESIDENTS, IDENTIFIED AT RISK FOR ELOPEMENT, AT RISK FOR SERIOUS HARM, INJURY, AND/OR DEATH. FINDINGS INCLUDE: RESIDENT #101 ACCORDING TO THE FACE SHEET, DATED 9/02/2011, RESIDENT #101 WAS A [AGE] year OLD MALE WHO LIVED AT THE FACILITY SINCE 04/09/2003. HIS [DIAGNOSES REDACTED]. ACCORDING TO THE Minimum Data Set, dated dated [DATE], RESIDENT #101 HAD IMPAIRED COGNITIVE FUNCTION WITH SHORT-TERM MEMORY LOSS. RESIDENT #101 HAD RESTRICTED RANGE OF MOTION IN HIS LOWER EXTREMITIES. HE COULD NOT AMBULATE, REQUIRED STAFF ASSISTANCE WITH ALL TRANSFERS AND USED A MOTORIZED WHEELCHAIR TO MOVE THROUGHOUT THE FACILITY. ACCORDING TO THE CARE AREA ASSESSMENT SUMMARY, DATED 3/06/2011, SIGNED BY THE ASSISTANT DIRECTOR OF NURSING, RESIDENT #101 SUFFERED FROM DELIRIUM. IN THIS ASSESSMENT, THE FACILITY DOCUMENTED IMPAIRED JUDGEMENT AS THE PRIMARY REASON THAT RESIDENT #101 NEEDED ASSISTANCE FROM STAFF AND/OR HIS GUARDIAN TO MAKE DECISIONS. THIS DOCUMENT FURTHER INDICATED THAT RESIDENT #101 NEEDED STAFF TO PROVIDE DIRECTION AND CUEING. REVIEW OF A COMPETENCY DECLARATION FORM SIGNED BY TWO PHYSICIANS, DATED 11/14/2003, REVEALED THAT RESIDENT #101 WAS UNABLE TO PARTICIPATE IN HIS MEDICAL TREATMENT DECISIONS. DOCUMENTS FROM THE STATE OF MICHIGAN PROBATE COURT OF MACOMB COUNTY DATED 7/27/2011, DEEMED RESIDENT #101 A LEGALLY INCAPACITATED PERSON AND APPOINTED A FULL GUARDIAN FROM THE COURT WHEN HIS PRIOR GUARDIAN (BROTHER), WHO HAD SERVED FOR EIGHT YEARS, RESIGNED. THE FACILITY'S LICENSED SOCIAL WORKER DOCUMENTED IN A "SOCIAL WORK NOTE," DATED 3/15/2011, THAT RESIDENT #101 HAD A LEGAL GUARDIAN BECAUSE HE DISPLAYED PERIODS OF CONFUSION AND IMPAIRED JUDGEMENT. THE ELOPEMENT ASSESSMENT, COMPLETED FOR RESIDENT #101 ON 8/31/2010, IDENTIFIED RESIDENT #101 AT RISK FOR ELOPEMENT BASED ON HIS DIAGNOSIS, "MENTAL SYNDROME PSYCHOSIS," HIS ABILITY TO USE A SELF PROPELLED POWER WHEELCHAIR, HIS INTERMITTENT CONFUSION, HIS INTERMITTENT DISORIENTATION, AND A PRIOR ELOPEMENT ATTEMPT FROM THE FACILITY. REVIEW OF CURRENT COGNITIVE LOSS CARE PLANS FOR RESIDENT #101, WHICH STAFF INITIATED ON 3/15/2011, REVEALED RESIDENT #101 HAD IMPAIRED JUDGEMENT, INSIGHT AND DECISION MAKING. IN THIS CARE PLAN, STAFF ASSESSED RESIDENT #101 TO HAVE "POOR IMPULSE CONTROL" AND THE NEED FOR "ASSISTANCE...(WITH) MAKING DECISION... " REVIEW OF CURRENT ELOPEMENT CARE PLANS FOR RESIDENT #101, WHICH STAFF INITIATED ON 8/31/2010, REVEALED RESIDENT #101 HAD PRIOR ELOPEMENT ATTEMPTS FROM THE FACILITY. TO KEEP RESIDENT #101 SAFE, STAFF WERE TO MONITOR HIS "WHEREABOUTS FREQUENTLY, AT LEAST EVERY 2 HOURS." PHYSICIAN ORDERS, DATED 2/1/2011 THROUGH 9/20/2011, REQUIRED STAFF TO PLACE A WANDERGUARD BRACELET (A DEVICE THAT CAUSES AN ALARM TO SOUND WHEN THE WANDERGUARD IS IN CLOSE PROXIMITY TO THE ALARM) ON RESIDENT #101 TO PREVENT HIS ELOPEMENT FROM THE FACILITY. THE PHYSICIAN ORDERED STAFF TO CHECK THE FUNCTION OF RESIDENT #101'S WANDERGUARD EVERY SHIFT AND WEEKLY AT THE ELEVATOR. IN AN INTERVIEW ON 9/28/2011 AT 2:00 P.M., THE UNIT MANAGER (UNIT MANAGER #5) FOR THE UNIT, WHERE RESIDENT #101 RESIDED, SAID STAFF REMOVED RESIDENT #101'S WANDERGUARD ALARM IN FEBRUARY OF 2011, WITHOUT CONSULTING A PHYSICIAN OR OBTAINING A physician's orders [REDACTED]. SHE SAID THE DECISION TO REMOVE RESIDENT #101'S WANDERGUARD CAME BECAUSE "STAFF FELT RESIDENT #101 HAD NO RECENT ELOPEMENT ATTEMPTS." THE UNIT MANAGER COULD NOT DEFINE THE FACILITY'S CRITERIA FOR "NO RECENT ELOPEMENT ATTEMPTS." REVIEW OF AN UNEXPECTED OCCURRENCE REPORT, DATED 3/16/2011, REVEALED THAT ON 3/16/11, AT 3:30 P.M., RESIDENT #101 PROCEEDED FROM INSIDE THE BUILDING UNSUPERVISED OUT INTO THE FACILITY'S "BACK PARKING LOT" WITHOUT STAFF KNOWLEDGE. RESIDENT #101 DID NOT HAVE HIS PHYSICIAN-ORDERED WANDERGUARD IN PLACE. IN AN INTERVIEW ON 9/30/2011 AT 11:35 A.M., THE ADMINISTRATOR SAID RESIDENT #101 WAS "ONLY IN THE BACK PARKING LOT FOR MINUTES," WHEN HE ELOPED FROM THE FACILITY ON 3/16/2011. THE ADMINISTRATOR COULD NOT QUANTIFY THE NUMBER OF "MINUTES" RESIDENT #101 SPENT UNSUPERVISED IN THE BACK PARKING LOT. THE ADMINISTRATOR SAID ACTIVITY AIDE #2 FOUND RESIDENT #101 IN THE BACK PARKING LOT WHEN HE REPORTED FOR DUTY ON 3/16/2011, AT WHICH POINT STAFF REDIRECTED RESIDENT #101 BACK INTO THE FACILITY. (ATTEMPTS TO REACH ACTIVITY AIDE #2 FOR A STATEMENT WERE UNSUCCESSFUL.) ACCORDING TO THE ELOPEMENT CARE PLAN FOR RESIDENT #101, INITIATED ON 8/31/2010, STAFF DOCUMENTED RESIDENT #101 "ATTEMPT(ED) AND SUCCEEDED...," IN GETTING "OUT TO (THE) BACK PARKING LOT... " ON 9/28/2011 AT 2:00 P.M. UNIT MANAGER #5 WAS INTERVIEWED AND SAID THAT AS A RESULT OF THE 3/16/2011 ELOPEMENT, AS OF 3/16/2011, RESIDENT #101 WAS TO HAVE A WANDERGUARD BRACELET PLACED BEHIND OR UNDERNEATH RESIDENT #101'S WHEELCHAIR TO KEEP HIM FROM REACHING IT. THE UNIT MANAGER SAID IT WAS DECIDED THAT PLACEMENT OF THIS SAFETY DEVICE ON RESIDENT #101'S PERSON WOULD HAVE PERMITTED TAMPERING AND POSSIBLE REMOVAL OF THE DEVICE AND, THEREFORE IT WAS NOT CONSIDERED A SAFE OPTION. UPON REVIEW OF THE CLINICAL RECORD, UNIT MANAGER #5 AGREED THAT THERE HAD BEEN NO DOCUMENTATION OF THE DECISION TO PLACE THE WANDERGUARD ON THE RESIDENT'S WHEELCHAIR. ON 9/19/2011, STAFF WORKING THE EVENING SHIFT (3:00 P.M. TO 11:00 P.M.), MOVED THE RESIDENTS WANDERGUARD ALARM FROM THE WHEELCHAIR TO RESIDENT #101'S ANKLE WHEN RESIDENT #101 VERBALIZED HIS INTENT TO LEAVE THE FACILITY. UNIT MANAGER #5 STATED THAT SHE WAS UNAWARE THAT THE NURSING STAFF HAD MADE THIS DECISION AND WAS NOT ABLE TO EXPLAIN THE REASONING BEHIND THIS DECISION. ACCORDING TO UNIT MANAGER #5, THIS DECISION TURNED OUT BADLY. IN AN INTERVIEW ON 9/28/2011 AT 1:30 P.M., RESIDENT #101 SAID HE RETAINED A BUTTER KNIFE FROM HIS MEAL TRAY ON 9/20/2011 AND USED IT TO "SAW" OFF THE WANDERGUARD ALARM, WHICH STAFF HAD PLACED ON HIS ANKLE. RESIDENT #101 SAID HE THREW THE WANDERGUARD IN HIS GARBAGE. RESIDENT #101 SAID, "THE STAFF WERE TOO BUSY TO NOTICE ME LEAVING." ACCORDING TO AN INVESTIGATIVE REPORT INCIDENT/UNUSUAL OCCURRENCES REPORT, DATED 9/20/2011 AT 6:00 P.M., RESIDENT #101 "LEFT THE BUILDING." A REVIEW OF THE FACILITY'S SECURITY TAPE FOOTAGE ON 9/28/2011 AT 2:50 P.M., REVEALED THAT RESIDENT #101 LEFT THE FACILITY UNSUPERVISED THROUGH THE BACK PARKING LOT DOOR ON 9/20/2011 AT 1:57 P.M. AND PROCEEDED IN A NORTHERLY DIRECTION. IN AN INTERVIEW ON 9/28/2011 AT 2:00 P.M., UNIT MANAGER #5 SAID STAFF DID NOT MONITOR THE WHEREABOUTS OF RESIDENT #101 EVERY TWO HOURS AS REQUIRED BY HIS CARE PLAN. SHE SAID HER INVESTIGATION DETERMINED RESIDENT #101 WAS LAST SEEN BY THE ASSISTANT DIRECTOR OF NURSING ON 9/20/2011, JUST PRIOR TO 2:00 P.M. NEAR THE SECOND FLOOR ELEVATORS. UNIT MANAGER #5 SAID STAFF DID NOT KNOW THAT RESIDENT #101 HAD LEFT THE BUILDING UNTIL 5:20 P.M. ACCORDING TO NURSING NOTES DATED 9/20/2011 AT 10:30 P.M., STAFF INITIATED A SEARCH AT 5:20 P.M. AFTER THE FACILITY RECEIVED AN ANONYMOUS OUTSIDE CALL REPORTING RESIDENT #101 MISSING. STAFF DID NOT LOCATE RESIDENT #101 IN THE FACILITY. NURSING DOCUMENTED THAT UNIT MANAGER #5 LEFT THE FACILITY BY CAR AND TEN MINUTES LATER FOUND RESIDENT #101, TWO AND A HALF MILES AWAY FROM THE FACILITY, NEAR THE INTERSECTION OF 2 BUSY, URBAN THOROUGHFARES, APPROXIMATELY 3 MILES FROM THE FACILITY. AN UNTITLED DOCUMENT, DATED 9/20/2011, REPORTED RESIDENT #101 RETURNED to the facility on [DATE] AT 6:00 P.M. A COMPREHENSIVE REVIEW OF THE MEDICAL RECORD COVERING THE TIME PERIOD BETWEEN 3/01/2011 AND 9/20/2011, REVEALED NO DOCUMENTED EVIDENCE STAFF HAD COMPLIED WITH THE ORDERED WANDERGUARD CHECKS FOR RESIDENT #101, EVERY SHIFT AND WEEKLY AT THE ELEVATOR. IN AN INTERVIEW ON 9/28/3011 AT 2:00 P.M., UNIT MANAGER #5 REVIEWED THE MEDICAL RECORD FOR RESIDENT #101 AND SAID SHE COULD NOT FIND ANY STAFF DOCUMENTATION TO SHOW THAT THE ORDERED WANDERGUARD CHECKS HAD BEEN COMPLETED DURING THE TIME PERIOD BETWEEN 3/01/2011 AND 9/20/2011. ON 9/30/2011 AT 3:20 P.M., THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY THAT BEGAN ON 3/16/2011 AND WAS IDENTIFIED ON 9/28/2011 WHEN THE FACILITY FAILED TO PROVIDE THE NECESSARY SUPERVISION AND ASSISTIVE DEVICES TO PREVENT TWO SUCCESSFUL ELOPEMENTS BY RESIDENT #101. THE FIRST ELOPEMENT OCCURRED ON 3/16/2011, WITHOUT STAFF OR GUARDIAN KNOWLEDGE, WHICH CAUSED RESIDENT #101 TO BE UNSUPERVISED OUTSIDE IN A PARKING LOT FOR "MINUTES." THE SECOND ELOPEMENT OCCURRED ON 9/20/2011, WITHOUT STAFF OR GUARDIAN KNOWLEDGE, WHICH CAUSED RESIDENT #101 TO BE UNSUPERVISED OUTSIDE THE FACILITY, FOR FOUR HOURS AND THREE MINUTES, APPROXIMATELY 3 MILES FROM THE FACILITY, HAVING CROSSED MANY HIGH-TRAFFIC-VOLUME STREETS IN THE URBAN ENVIRONMENT OF METROPOLITAN DETROIT. ON 10/03/2011, THIS SURVEYOR CONFIRMED THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. ON 9/20/2011 THE CLINICAL MANAGER LOCATED RESIDENT BY 5:30 P.M. AND REMAINED WITH HIM UNTIL HE RETURNED TO FACILITY. 2. ON 9/20/2011 RESIDENT #101 WAS REVIEWED FOR INJURY. NONE WERE FOUND. 3. ON 9/20/2011 LICENSED NURSES COMPLETED ANOTHER ASSESSMENT TO DETERMINE RESIDENT #101'S ELOPEMENT RISK. 4. BY 9/22/2011 THE INTERDISCIPLINARY TEAM REVIEWED AND UPDATED RESIDENT #101'S CARE PLANS TO INCLUDE: a. GUARDIAN'S WRITTEN PERMISSION FOR RESIDENT #101 TO TAKE SHORT LEAVE OF ABSENCES UNACCOMPANIED FOR UP TO TWO HOURS. b. PHYSICIAN ORDERS [REDACTED]. c. ADMINISTRATION AND SOCIAL WORK MET WITH RESIDENT #101. THE FACILITY PROVIDED HIM WITH EDUCATION ON THE LOA (LEAVE OF ABSENCE) POLICY AND SIGN OUT POLICY. RESIDENT #101 AGREED TO FOLLOW THE FACILITY'S PROCEDURES FOR THE SAME. d. THE CLINICAL MANAGER, SOCIAL WORKER, PHYSICIAN GUARDIAN AND RESIDENT REVIEWED AND UPDATED THE RESIDENT'S CARE PLAN SO THAT THE RESIDENT MAY LEAVE THE BUILDING FOR UP TO TWO HOURS. 5. ON 9/20/2011 MANDATORY STAFF INSERVICE BEGAN ON THE FACILITY'S ELOPEMENT POLICY. ON 9/22/2011 109 OF 245 EMPLOYEES HAD RECEIVED THIS EDUCATION AND ALL ADDITIONAL STAFF WERE NO LONGER PERMITTED TO RETURN TO WORKING DUTIES WITHOUT THE EDUCATION. 6. ON 9/21/2011, THE MAINTENANCE SUPERVISOR VERIFIED THAT THE FACILITY'S WANDERGUARD MECHANISMS FOR THE DOORS WERE OPERATING PROPERLY. 7. ON 9/21/11, THE NURSING STAFF VERIFIED THAT EACH OF THE 15 RESIDENTS IDENTIFIED AT RISK FOR ELOPEMENT HAD A WANDERGUARD IN PLACE THAT FUNCTIONED. 8. ON 9/22/2011, 214 RESIDENTS RESIDING AT THE FACILITY WERE ASSESSED FOR POTENTIAL ELOPEMENT RISKS. THE INTERDISCIPLINARY TEAM IDENTIFIED 15 RESIDENTS AT RISK AND UPDATED THEIR CARE PLANS WHEN NECESSARY. 9. ON 9/22/2011, THE ADMINISTRATOR AND DIRECTOR OF NURSING REVIEWED THE POLICY AND PROCEDURE FOR ELOPEMENT AND DEEMED IT APPROPRIATE. 10. ON 9/22/2011 THE INTERDISCIPLINARY TEAM DISCUSSED THE ELOPEMENT ASSESSMENT FOR RESIDENTS, WHEN A BRACELET IS TO BE PLACED OR REMOVED, THEIR ASSESSMENT, THE RATIONALE FOR CHANGE, THE MODIFICATIONS NECESSARY TO THE CARE PLAN, THE CRITERIA THAT INCLUDED DIAGNOSIS, MOBILITY, COGNITION, BEHAVIOR, AND ANY OTHER IDENTIFIED ISSUES. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED ON 9/23/2011, 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 AS SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY. RESIDENT #109 ACCORDING TO THE FACE SHEET, DATED 8/29/2011, RESIDENT #109 WAS A [AGE] year OLD MALE WHO LIVED AT THE FACILITY SINCE 3/17/2008. HIS [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM DATA SHEET, DATED 2/19/2011, RESIDENT #109 HAD IMPAIRED DECISION MAKING WITH BOTH LONG AND SHORT TERM MEMORY LOSS. HE AMBULATED WITHOUT ASSISTANCE AND EXHIBITED WANDERING BEHAVIORS DAILY. THE COGNITIVE LOSS/DEMENTIA CARE PLAN FOR RESIDENT #109, INITIATED ON 2/09/2011, IDENTIFIED RESIDENT #109 AT RISK FOR IMPAIRED DECISION MAKING, JUDGEMENT AND INSIGHT. THE ELOPEMENT CARE PLAN FOR RESIDENT #109, WHICH STAFF INITIATED ON 4/30/2010, IDENTIFIED RESIDENT #109 AT RISK FOR ELOPEMENT. THIS CARE PLAN REQUIRED STAFF TO MONITOR RESIDENT #109'S WHEREABOUTS, AT LEAST EVERY TWO HOURS AND APPLY A WANDERGUARD TO HIS BODY. RESIDENT #109'S WANDERGUARD PLACEMENT WAS TO BE CHECKED BY STAFF EVERY SHIFT AND AS NEEDED. ON 10/03/2011 AT 2:00 P.M., THE ASSISTANT DIRECTOR OF NURSING SAID RESIDENT #109 REMOVED HIS WANDERGUARD ALARM AT LEAST WEEKLY AND RECENTLY VOICED HIS DESIRE TO LEAVE THE FACILITY, SO RESIDENT #109 WAS PLACED ON 1:1 (ONE ON ONE) MONITORING. REVIEW OF THE ELOPEMENT CARE PLAN FOR RESIDENT #109 VERIFIED ON 9/21/2011 STAFF INITIATED "1:1 MONITORING UNTIL (THE) RESIDENT NO LONGER VERBALIZED (A) DESIRE TO GO HOME OR OUTSIDE." ON 10/03/2011 AT 2:00 P.M., THE ASSISTANT DIRECTOR OF NURSING (ADON) WAS INTERVIEWED AND SAID THAT RESIDENT #109 DID NOT RECEIVE MONITORING BETWEEN THE HOURS OF 11:00 P.M. AND 7:00 A.M. THE ADON STATED, "I DON'T FEEL" THAT RESIDENT #109 "WOULD LEAVE THE FACILITY AT NIGHT, WHEN IT WAS DARK OUTSIDE." FURTHER, SHE SAID RESIDENT #109 MAY BE ABLE TO GET HIS WANDERGUARD OFF BUT WOULD NEVER BE ABLE TO GET PAST ALL OF THE STAFF ON SECOND FLOOR, ONTO THE ELEVATOR, DOWN TO FIRST FLOOR AND OUT OF THE BUILDING WITHOUT BEING NOTICED. SHE SAID, "HE JUST WOULDN'T." THE ASSISTANT DIRECTOR OF NURSING PROVIDED NO DOCUMENTED EVIDENCE THAT RESIDENT #109 WAS SAFE WITHOUT SUPERVISION DURING THE HOURS BETWEEN 11:00 P.M. AND 7:00 A.M. THE SURVEYOR THEN ASKED THE THE ASSISTANT DIRECTOR OF NURSING TO REVIEW A BEHAVIOR MANAGEMENT NURSING NOTE, DATED 5/26/2011 AT 10:35 P.M., THAT REPORTED RESIDENT #109 HAD REMOVED HIS WANDERGUARD, LEFT THE SECOND FLOOR, UNSUPERVISED, GOT TO THE FIRST FLOOR AND WENT OUTSIDE ONTO THE RESIDENTS' GATED PATIO, BEFORE ANY STAFF NOTICED HIM. THE ASSISTANT DIRECTOR OF NURSING WAS NOT ABLE TO EXPLAIN HER CONCLUSIONS ABOUT RESIDENT #109'S ABILITY TO LEAVE THE SECOND FLOOR OF THE FACILITY AND HIS SAFETY WHEN HE HAD ALREADY PROVEN HIMSELF CAPABLE OF SUCH EVENTS. THE DIRECTOR OF NURSING THEN SAID, "IT'S JUST MY OPINION." ON 10/03/2011 AT 1:00 P.M., RESIDENT #109 WAS OBSERVED LYING IN HIS BED WITHOUT A WANDERGUARD ON HIS BODY. RESIDENT #109 HAD MANAGED TO REMOVE HIS WANDERGUARD DEVICE AND PLACE IT UNDER HIS PILLOW, UNBEKNOWNST TO STAFF, WHILE HE RECEIVED 1:1 MONITORING FROM CERTIFIED NURSING ASSISTANT (CNA) #5. WHEN ASKED ABOUT THE WANDERGUARD, CNA #5 STATED THAT SHE DID NOT REALIZE THAT THE RESIDENT HAD REMOVED IT (THE WANDERGUARD). ON 10/03/2011 AT 1:05 P.M. THE ASSISTANT DIRECTOR OF NURSING WAS INTERVIEWED AND SAID RESIDENT #109 REMOVED HIS WANDERGUARD ALARM AT LEAST ONCE A WEEK. ON 10/03/2011 AT 2:00 P.M. THE ASSISTANT DIRECTOR OF NURSING REVIEWED THE MEDICAL RECORD FOR RESIDENT #109 AND FOUND NO DOCUMENTED EVIDENCE TO SUGGEST STAFF EVER EVALUATED THE PLACEMENT OR FUNCTION OF RESIDENT #109'S WANDERGUARD DEVICE BETWEEN 5/01/2011 AND 9/20/2011. BEHAVIOR/INTERVENTION MONTHLY FLOW RECORDS USED TO TRACK SPECIFIC BEHAVIORS AND DRIVE INDIVIDUALIZED CARE PLANS, LISTED THE BEHAVIOR OF WANDERING FOR RESIDENT #109 BETWEEN 8/01/2011 AND 8/31/2011. THIS FORM REQUIRED STAFF TO DOCUMENT EACH SHIFT ON THE NUMBER OF WANDERING EPISODES EXPERIENCED BY RESIDENT #109, THE INTERVENTIONS TAKEN, OUTCOMES TO THOSE INTERVENTIONS AND THE ASSOCIATED SIDE EFFECTS. A REVIEW OF THIS DOCUMENT REVEALED STAFF FAILED TO DOCUMENT THEIR ASSESSED FINDINGS FOR RESIDENT #109'S WANDERING BEHAVIOR 57 OF THE 93 SHIFTS WORKED DURING THE MONTH OF AUGUST. ADDITIONALLY, THERE WAS NO DOCUMENTATION RELATED TO RESIDENT #109'S ABILITY TO REMOVE THE WANDERGUARD DEVISE. ON 10/03/2011 AT 2:00 P.M., THE ASSISTANT DIRECTOR OF NURSING REVIEWED THE MEDICAL RECORD FOR RESIDENT #109. THE ASSISTANT DIRECTOR OF NURSING SAID THE NURSING DOCUMENTATION FOR RESIDENT #109'S WANDERING WAS NOT COMPLETE AND DID NOT PROVIDE AN ACCURATE ILLUSTRATION OF THIS BEHAVIOR. SHE SAID THAT THE STAFF KNEW RESIDENT #109 TOO WELL, THEREFORE FAILED TO CONSISTENTLY DOCUMENT THE NUMBER OF EPISODES, INTERVENTIONS, OUTCOMES OR SIDE EFFECTS ASSOCIATED WITH HIS WANDERING. ON 10/03/2011 AT 12:45 P.M., THE DIRECTOR OF PLANT OPERATIONS SAID HIS DEPARTMENT MADE DAILY ROUNDS TO ENSURE THAT THE FACILITY'S WANDERGUARD SYSTEMS FUNCTIONED AT EACH EXIT POINT. HE THEN REVIEWED THREE MONTHS OF THE FACILITY'S "WANDERGUARD/CODE LOCK DAILY ROUNDS CHECK SHEET(S)" AND SAID HIS STAFF DOCUMENTED ON 7/5/2011, 7/13/2011, 7/16/2011, 7/17/2011, 7/19/2011, 7/20/2011, 8/24/2011 AND 9/19/2011 THAT AT LEAST ONE OF THE WANDERGUARD ALARMS DID NOT FUNCTION. THE DIRECTOR OF PLANT OPERATIONS SAID HE "DID NOT KNOW" WHAT, IF ANY, ACTIONS THE FACILITY TOOK TO RESOLVE THESE CONCERNS. HE SAID, "WE PROBABLY ORDERED A PART OR SOMETHING." HE WAS NOT ABLE TO EXPLAIN HOW RESIDENTS WERE KEPT SAFE WHEN THESE NON-FUNCTIONING ALARMS WERE IDENTIFIED. HE PROVIDED NO DOCUMENTED EVIDENCE TO SUPPORT HIS COMMENTS.