Every finding on record at Fenton Healthcare

This Citation pertains to intake Number 3069106.Based on interview and record review, the facility failed to ensure that safe positioning and supervision was maintained during provision of care for one resident (Resident #4) of three residents reviewed for supervision and safety with falls. This deficient practice resulted in Resident #4's fall from the bed causing the resident pain and sustaining facial contusions with a 4.5 cm hematoma on the forehead and a laceration requiring a hospital evaluation, monitoring and skin repair. Findings include: Resident #4 (R4): A record review for R4's Minimum Data Set (MDS) assessment revealed a Brief Interview of Mental status (BIMs) score of 10 that indicated moderate cognitive impairment. Further review of R4's medical record revealed medical diagnoses that included: chronic heart failure, dysphagia following cerebral infarction (stroke), hemiplegia (one-sided paralysis or weakness) and hemiparesis (one-sided muscle weakness) following cerebral infarction affecting left non-dominant side, epilepsy (seizure disorder), type 2 diabetes mellitus, vascular dementia, and required assistance with care.A record review of Intake 3069106 alleged R4 sustained injuries from a fall that required hospital evaluation and treatment when resident was under the facility's care. A record review of R4's medical record progress notes revealed: dated 5/24/2026 05:00 Nurses Notes Text: Writer heard a loud boom. Writer ran to area of noise. Upon entering room, resident on right side of bed, on her right side. Screaming in pain. Bleeding from her head, and a left forehead hematoma. Resident left alone because the cna stepped away to get more towels. Cna states that the resident fell and hit her head on tv and floor. VS assessed, ROM assessed. Pain indicated on right upper and lower extremities. Ems helped get resident off of floor due to precautions of possible fractures. 4-person assisted. Neuro checks initiated resident responding well. No change in LOC. resident sent out via ems alert. Documentation was completed by Nurse B. A record review of the facilities fall prevention program policy revealed: Policy: The facility will identify hazards and resident risk factors and implement interventions to minimize falls and risk of injury related to falls. with fall defined as: a fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not as a result of an overwhelming external force (e.g., resident pushes another resident). A record review of R4's SBAR (situation, background, appearance and review - a format for charting) communication form completed by Nurse B and dated 05/24/2026 revealed that the resident had a fall with a laceration and reported new pain at level 6 of a 10-level pain scale.A record review of R4's medical record skin assessment completed by Nurse B and dated 05/24/2026 revealed a skin issues note: Laceration to the right side of face. Hematoma to the right forehead. A record review of R4's transfer form (used when resident is being sent out for evaluation and treatment) completed by Nurse B dated 05/24/2026 revealed in key clinical information a pain level at 6 with location noted as face and according to the usual functional status before acute change in condition R4 was dependent for care with activity of daily living (ADL's) that included bathing, dressing, toileting, transfers and needs assistance with eating. Also, that R4 was incontinent for bowel and bladder at baseline. Risk alerts revealed that R4 was on anticoagulant medications (prevents clotting of blood). A record review of R4's medication orders revealed: 'Eliquis Oral Tablet 5 MG twice a day' (anticoagulant).A record review of R4's care plan revealed: Focus: (R4) is at risk for complications of right hemiplegia/hemiparesis r/t (related to) Stroke. with Interventions: Assist with ADLs/Mobility/repositioning as needed. And Focus: (R4) is at risk for fall-related injury and falls R/T: incontinence, hemiplegia, vascular dementia with Interventions: Do not leave resident unattended in bathroom; Keep the resident's environment as safe as possible with: even floors free from spills and/or clutter; adequate lighting; call light within reach, commonly used items within reach, avoid repositioning furniture and keep the bed in the appropriate position. And Focus: ADL: (R4) has a functional ability deficit and requires assistance with self-care/mobility R/T: history of stroke, CHF, dementia with Interventions: AMBULATION/WALKING: Resident is unable to ambulate and requires a wheelchair for locomotion. Resident needs to be pushed to desired locations; BATH/SHOWER: Upper Body: PARTIAL/MODERATE assistance from ONE STAFF. Lower Body: SUBSTANTIAL/MAXIMAL assistance from ONE STAFF; BED MOBILITY: Resident requires PARTIAL/MODERATE assistance from ONE STAFF. This includes rolling side to side, lying to sitting on side of bed and sitting to lying; DRESSING: Upper Body: PARTIAL/MODERATE assistance from ONE STAFF. Lower Body: DEPENDENT on ONE STAFF assistance; PERSONAL HYGIENE (combing hair, shaving, applying makeup, nail care, and washing and drying face and hands): Resident requires PARTIAL/MODERATE assistance from ONE STAFF; TRANSFER: Resident is DEPENDENT on TWO STAFF assistance and uses sit-to stand mechanical lift. And Focus: (R4) requires 24-hour care/LTC placement at this time related to care needs, dx dementia. Resident/family/legal decision maker has verbalized acceptance of plan to remain in the facility.On 07/20/2026 at approximately 1:00PM, during an interview, NHA she confirmed that R4 was no longer at the facility and had a fall on 05/24/2026. The NHA was asked for the incident & accident ([NAME]) report and soft file, and the facility's policies that correlated with the progress note for R4 that was dated 05/24/2026. The NHA advised SA that the facility had identified a deficient practice and had completed a past non-compliance (PNC) for this fall.A record review of the risk management report completed by Nurse B and dated 05/24/2026 revealed: 'Incident location: residents room with Incident description: Nursing description: Writer heard a loud boom. Writer ran to area of noise. Upon entering room, resident on left side of bed, on her right side, was calling out in pain, bleeding from her head. The CNA stated that she had just been in the room to assist the resident and stepped out to obtain towels. The risk management report also indicated that the resident was unable to give a description of incident and that the incident was unwitnessed. Under the Notes: CNA stated that they may have hit their head on the television during the fall. Laceration to right side, hematoma to the left forehead. Sent to ER for further evaluation and treatment; predisposing environmental factors: bed height not appropriate was checked; 'Other info: resident was in bed left on their side when CNA left to obtain more linen. Upon return the resident was on the floor.'On 07/20/2026 at 2:00PM, in an attempt to interview CNA C a phone message was left for with a return call requested. On 07/20/2026 at 2:13PM, during a phone interview, Nurse B reported that she was R4's nurse on shift on 05/24/2026 at the time of the fall. Nurse B said she was at the nurses' station working and around 4:30AM she heard a loud boom and immediately went running toward the direction it came from to investigate. Nurse B said she arrived at R4's room and found R4 on the ground, her bed was about 3 1/5 feet in the air, resident was on her right side, and located on the left side of her bed, the television on the ground and the resident was bleeding from her head and called out in pain. Nurse B said grabbed the towels in the room and held pressure to R4's head to stop the bleeding and that she could not leave the resident, so she called out for additional help. Nurse B said that CNA C who had been in the hall at the linen closet came in and told her that 'she had just left the resident and went to the linen closet to get more supplies' other staff arrived to help as well and Nurse B described the steps she took to send the resident out safely to the ER for evaluation and treatment. Nurse B said that afterward she asked CNA C what happened and that CNA C told her that 'she was changing R4 and needed more supplies, so she left her on her side and went to the linen closet to get them' and Nurse B said she documented in R4's chart and risk management. Nurse B said the resident should not be left on their side or with the bed elevated like that. Nurse B said that the facility gave re-education to the staff after the fall, and that fall prevention and resident safe care with ADL's, positioning and bed height, call lights were all covered. Nurse B said R4 never came back to the facility after that. On 07/20/2026 at 3:49P M, during an interview, the DON was asked about the staff education done for the PNC and she said she covered fall prevention, safety and dignity with ADL care before /during and after care, positioning of residents and beds, and the importance of all the supplies had been gathered before care begins.On 07/20/2026 at 4:20 PM, during a phone interview, CNA C was asked about R4, and she confirmed that she was the CNA on shift the night of the fall on 05/24/2026. CNA C was asked to describe what happened and she stated, I don't remember, I just remember taking care of her like I usually do and continued and then said she had left the room, could not recall for what and when she returned the resident was on the floor. CNA C could not recall other details but offered that she did not see R4 fall nor did she cause R4 to fall and stated, People fall, it was an accident; I was not in the room when she fell; I walked out and then she fell, I don't know what to tell you; I did not do anything to make her fall; I would never hurt anyone. CNA C confirmed that the facility gave re-education to the staff after the fall, and that fall prevention, resident safe care with ADL's, positioning and bed height, and call lights were all covered. CNA C said it was a good education and that what happened scared her. CNA C said the DON called me a week or so later and asked me to sign something (disciplinary action) about this that said it was my fault and said she refused to sign it. CNA C confirmed that she signed the 1:1 education.A record review of the quality assurance interview summary listed under staff interviews dated 05/27/2026 revealed: CNA C's statement: I needed to get more towels, and I went to the closet. When I got back, she was on the floor. I always raise the bed up when I am doing care. And Nurse B's statement: I was at the nurses station and I heard a boom. I saw (CNA C) going back to the room. (R4) was observed on the floor on the left side of her bed. Her bed was still up in the air. She was complaining of pain all over and she was bleeding from her head. We called 911 and waited until they got her before moving her. I asked (CNA C) what happened and she said she had to go get more towels and left her on her side and the bed up in the air.A record review of facilities policy routine resident care revealed: residents receive the necessary assistance to maintain good grooming and personal/oral hygiene. Care is taken to ensure resident safety at all times. With guidelines: 10. Staff members should observe the following safety precautions with all residents; b. beds may be raised when care is being provided. Following the provision of care the bed should be returned to the original position.On 07/21/2026 at 8:15AM, the NHA was interviewed. The soft file documentation was reviewed and the NHA said that they completed an immediate investigation and promptly had a 1:1 education with CNA C because she was in the mist of care and left the room to get supplies form the linen closet with the resident's bed elevated and resident positioned on her side. The NHA said that once they identified the deficient practice, they started the PNC to correct it. The NHA when asked said that at that time there was no camera footage to be reviewed. On 07/21/2026 at 8:26AM, during an interview, the DON reviewed the soft file and PNC documentation. The DON confirmed that the education was done for all nursing staff and that it was based off the deficient practice findings and that CNA C immediately got a 1:1 education. The DON was asked if any staff received disciplinary action, she said yes that CNA C had received a written discipline. The DON confirmed that CNA C refused to sign the discipline and did sign the education. The DON confirmed that R4 did not return to the facility and went to a different facility after being released from hospital. The DON offered that she had imagining records from the hospitalization and that R4 did not have any fractures. The DON agreed she had a laceration and hematoma. A record review of CNA C employee new hire file, competencies and license were reviewed. A review of written warning revealed: Final warning for Category II Rule #20 listed as Staff may not engage in careless behavior involving a resident's safety, health and/or physical comfort. With comment that Employee did not follow the routine resident care policy during ADL care resulting in a fall. Employee refused to sign noted and was signed by DON and witnessed/signed by another staff member on 06/04/2026.On 07/21/2026 at 10:45 AM, a phone message was left requesting a return call for medical records and was followed up by an email request for the resident's records from (hospital name). *No response was obtained by the exit of survey at 2PM. On 07/21/2026 at 11:00 AM, a record review of imagining records from (hospital name) dated 05/24/2026 and 05/26/2026. were made available by the DON that revealed a 4.5cm hematoma and laceration noted and no fractures. Unable to verify size and closure of laceration from those records and no other records had been obtained at exit of the survey. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included: Description of deficient practice. The facility CNA was performing care with the bed left in high position, and walked away to get more towels, and the resident rolled out of bed and onto the floor and received a laceration to the forehead and hematoma. Plan of correction: In depth analysis of how the deficiency occurred: The employee needed more towels for care and did not reposition the resident to the center of the bed or lower bed back down from high position before leaving the room. How the facility identified resident(s) affected and residents with potential to be affected by the same deficient practice. Audit completed by unit manager / designee of residents who are dependent of one personal care to ensure CNA does not leave room without having resident positioned in the middle of the bed, and bed in low position. Corrective action taken for resident(s) affected: The resident had a complete head to toe assessment and then was assisted back to bed with assistance of EMS and neuro checks started. Doctor was called with orders to send to ER due to complaints of pain on right upper/lower extremities. Daughter was notified of transfer to hospital. Measures or systemic changes made to ensure that deficient practice will not occur and affect others: The Facility Fall process was reviewed and deemed appropriate. The resident Routine Care Policy was reviewed and deemed appropriate. Education was completed with the Nursing staff on ensuring that they have all supplies available needed for care, resident is turned toward them when providing care with one person, that they ensure that resident is always positioned in middle of bed when done with care, and that they have bed in low position per plan of care. How a facility monitors its corrective actions to ensure deficient practice was corrected and will not recur: The UM/designee, will review nursing staff when providing personal care with residents requiring assistance with bed mobility to ensure that staff are not turning resident away from them when performing care with 1 staff member, that resident is positioned in middle of bed when done, and bed is in low position after care performed weekly x4 weeks and monthly x2 months. Any areas of non-compliance will be reviewed immediately. With findings submitted to the DON who will report findings to the QAPI committee for review and recommendation. The Administrator will be responsible for sustaining compliance. Date of compliance: 06/11/2026. The facility was able to demonstrate monitoring of the corrective actions and the maintenance of compliance.

Tis citation pertains to Intake Number 2972860.Based on interview and record review, the facility failed to provide a medication, as ordered, for one resident (Resident #4) of three residents reviewed for medication administration. Findings Include:Resident #4:A record review of the Face sheet and progress notes for Resident #4 indicated admission to the facility on 3/25/2026 with diagnoses: Respiratory failure, myelodysplastic syndrome, stem cell transplant, severe protein-calorie malnutrition, hypomagnesemia, heart failure, atrial fibrillation, depression, hypothyroidism, gout, and deep vein thrombosis. Resident #4 discharged to home on 4/4/2026.A review of the physician orders for Resident #4 identified the following: MG (magnesium) Plus Protein Oral Tablet 133 MG (Specialty Vitamins Product), Give 1 tablet by mouth one time a day for supplement, start date 3/26/2026 and discontinued date 4/4/2026.A review of the Hospital discharge orders indicated Resident #4 received Magnesium medications including MG Plus Protein tablet, while hospitalized because the resident had low magnesium levels. In addition to the oral tablet, he received IV Magnesium. He was to continue the oral MG Plus Protein tablet at the facility.A review of the March and April 2026 Medication Administration Records/MARs for Resident #4 identified the following: MG Plus Protein Oral Tablet 133 MG (Specialty Vitamins Products) Give 1 tablet by mouth one time a day for supplement, start date 3/26/2026 and discontinue date 4/4/2026.The nurses documented 5 for 5 of 6 days from 3/26/2026- 3/31/2026 on the MAR indicating the medication was held and to see the nurses' notes. On the April 2026 MAR the Nurse documented F Hold and see the nurses' notes on 4/1/2026 and for April 2nd through April 4th, 2026, there was an H documented for hold.A review of the nurses' notes for Resident #4 from 3/25/2026 to 4/4/2026 identified the following:3/26/2026 at 11:04 AM, an eMAR-Medication Administration Note, MG Plus Protein Oral Tablet 133 MG, Give 1 tablet by mouth one time a day for supplement. Unavailable.3/27/2026 at 8:00 AM, a Progress Note by Nurse Practitioner/NP B mentioned the medication MG Plus Protein Oral Tablet 133 MG, but there was no mention that the facility did not receive it for Resident #4.3/28/2026 at 10:21 AM, an eMAR- Medication Administration Note indicated the MG Plus Protein Oral Tablet 133 mg was unavailable.3/29/2026 at 10:23 AM, an eMAR- Medication Administration Note indicated the MG Plus Protein Oral Tablet 133 mg was not available.3/30/2026 at 8:00 AM, a Progress Note by NP B mentions the MG Plus Protein Oral Tablet 133 mg but does not indicate Resident #4 was not receiving it.3/30/2026 at 9:49 AM, an eMAR- Medication Administration Note said, On order for the MG Plus Protein Oral Tablet 133 mg.3/31/2026 and 4/1/2026 at 8:00 AM, Progress Notes by NP B mention the MG Plus Protein Oral Tablet 133 mg but do not mention Resident #4 was not receiving it.On 4/1/2026 at 10:53 AM, a Nurses Note provided, Contacted pharmacy concerning MG Protein Plus 133 MG supplement ordered daily. They stated they do not carry this product. Awaiting call from pharmacy to what they recommend as alternative to medication. NP informed.4/1/2026 at 11:00 AM, an eMAR-Medication Administration Note, Awaiting on new order. Pharmacy does not have this medication.4/1/2026 at 4:06 PM, a Nurses Note Call placed to (Cancer center) to review the MG PLUS Protein tablet to see if there is alternative medication that can be used. They will talk with his provider and get back with us if there is an alternative medication. This is a magnesium supplement with protein and his magnesium levels are normal at this time. They said we can put it on hold until we hear back from them. Resident and Wife aware.Resident #4 was admitted to the facility on [DATE]. He had been there 7 days before a nurse contacted the pharmacy to find out why the resident had not received his medication.4/3/2026 at 8:58 AM, A Social Services Note, Resident is choosing to waive his benefits and return home on Saturday.4/3/2026 at 2:37 PM, a Nurses Note, Received a call from (the Cancer center) about the MG protein tab. It is to help his GI symptoms. Informed them he was discharging home tomorrow and they said he can just resume taking it when he gets home. Informed Resident. The resident had been at the facility for 9 days and did not receive his necessary medication.On 4/6/2026 at 1:35 PM, Nurse A was interviewed about Resident #4's medications and she said she recalled there was a medication that was ordered but the resident did not receive it.On 4/8/2026 at 11:12 AM, Nurse Practitioner B was interviewed and she said she was not aware until 4/1/2026 that the medication MG Plus Protein Oral Tablet 133 mg had never arrived from the pharmacy and the resident did not receive it. NP B said on 4/1/2026 when she was seeing residents at the facility, a nurse mentioned to her that the medication had not arrived and the nurse had contacted the pharmacy. NP B said she recommended to the nurse to contact the resident's physician who he was seeing prior to admission to the facility, to see if there was an alternative medication for the resident. The resident did not receive an alternative medication prior to discharge on [DATE].A review of the Care Plans for Resident #4 identified the following: (Resident #4) is at nutritional and/or dehydration risk r/t (related to): reports of unintentional weight loss of >20# (lbs.) in one month with poor intake and cancer (diagnosis). Severe Protein Calorie Malnutrition with the resident having food aversions/r/t smell of foot at times. Hypomagnesium/hypokalemia (low magnesium/low potassium), date initiated 3/26/2026 and revised 3/28/2026 with Interventions including: Provide and serve supplements as ordered, date created and initiated 3/28/2026.On 4/8/2026 at 12:59 PM, Consultant Pharmacist C was interviewed about Resident #4's medication. He said the MG Plus Protein 133 mg tablet was not provided by the pharmacy. He said it was considered an over-the-counter supplement/ House stock and the facility was responsible to provide it. He said he would check with the Pharmacy to see if/when they had notified the facility that it was not going to be sent by the pharmacy.On 4/8/2026 at 3:06 pm, during an interview with Consultant Pharmacist C, he said he spoke with the Pharmacy, and the facility had been notified via a fax on 3/25/2026 that the MG Plus Protein tablet was not available.

Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing, resulting in the potential for increased risk of respiratory infection among all residents in the facility.Findings include: On 12/02/2025 at 1:15pm during the environmental tour with the Environmental Services Director I, the Environmental Services Director I tested the chlorine residual at the staff bathroom sink on the first floor and the result was undetectable on the [NAME] K-2005 chlorine test kit. The testing kit measures chlorine residual from 1 to 10 parts per million (ppm). The test kit is primarily designed to test for chlorine in swimming pools, not drinking water. When interviewed on whether there's another test kit they've been using to measure the chlorine residual since the chlorine logs have results below 1 ppm and the Environmental Services Director I answered no. On 12/02/2025 at 2:17pm during record review of the Water Management Plan, on the Legionella Environmental Assessment Form the free chlorine residual results were recorded as .1 ppm. On the Water Management Team Meeting Minutes dated 3/3/25-6/16/25, it states under chlorine residual range Were control limits acceptable? Chlorine 0.2-4.0 ppm and it was marked Yes. On 12/02/2025 at approximately 2:30pm, interviewed the Administrator on how the chlorine residual results are recorded at below 1 ppm when the chlorine test kit is not sensitive enough to measure below 1 ppm, and she answered that the Environmental Services Director I, made a mistake. According to the State Operations Manual for Water Management, Facilities must be able to demonstrate its measures to minimize the risk of Legionella and other opportunistic pathogens in building water systems . In addition, it states the water management plan must include, Measures to prevent the growth of opportunistic waterborne pathogens (also known as control measures), and how to monitor them.

Based on observation, interview, and record review, the facility failed to ensure that the advance directive status was ordered, signed by the physician, and posted in the resident's clinical record per facility policy for one resident [Resident #80 (R80)] of 5 residents reviewed for advance directives.Findings include:Resident #80 (R80)R80 was observed in her room' lying in bed on [DATE] at 11:5 am. When R80 was asked about the life vest she was wearing, R80 explained it was to monitor her heart. A review of the Electronic Medical Record revealed that R80 was [AGE] years old, admitted at the facility on [DATE], with a diagnosis of Non-ST Elevation (NSTEMI) Myocardial Infarction, Ischemic Cardiomyopathy, Right Bundle Branch Block, Paroxysmal Atrial Fibrillation, Chronic Obstructive Pulmonary Disease (COPD), Pleural Effusion, and Heart Failure in addition to other diagnoses. A review of R80's clinical record revealed that there was no Code Status specified in the Advance Directive section in the chart. Although a Code Status Form was signed by R80 on [DATE], the facility did not indicate the code status in the Code Status/Advance Directive section of the resident's chart for the staff to know her wishes. According to the Preadmission Screening (PAS Annual Resident Review (ARR) dated [DATE], R80 has a current diagnosis and is receiving treatment for Dementia. She was receiving Remeron for dementia. The physician's orders was reviewed, however, did not include Remeron in the list of current medications.A care plan for R80 included a Functional ability deficit requiring assistance with self-care and mobility, at risk for cardiac complications related to multiple cardiovascular diseases: NSTEMI, CHF, AFib, CAD, Hyperlipidemia, HTN. Right Bundle Branch Block and Ischemic Cardiomyopathy. A care plan for a full code was entered on [DATE] but did not have a physician order obtained and a Full Code was not indicated in the Advance Directive section of the resident's data.On [DATE] at 11:30 AM, the Social Worker (SW A) reviewed R80's Electronic Medical Record (EMR) and confirmed that R80 was cognitively intact and signed a full code. However, The Advanced Directive status (referring to the full code) was not written in R80's clinical record. Upon admission, on [DATE], R80 signed as full code on [DATE]. SW B revealed that she could not find the physician's order. There was no indication of a full code posted on her face sheet, in the physician's orders, nor in the resident's profile. The SW B further explained the process where the nursing staff determines the code status from the resident day one of admission. R80 was her own responsible party and was competent when she signed up for her advanced directive in [DATE], but it was not ordered. SW 'B was wondering why the resident's Advance Directive section of the resident's medical record did not reflect a full code. The resident's choice as a Full code should be followed and staff must be informed of the updated Advance Directive, so the immediate and correct action is provided without further delay.According to the Director of Nursing (DON), during an interview on [DATE] at 11:40 AM, R80's Advanced Directive full code status signed on [DATE], should have been entered in her chart. The DON admitted he order for Full code was not put in her record. I just put a doctor's order in her record as we speak. Furthermore she admitted that the Full code was not found in the resident's clinical file. However, the DON confirmed that she only entered the Full Code status order while she was talking with the surveyor during the query on [DATE] 11:45 AM. Furthermore, the DON stated that R80's Full Code status should be reflected in the electronic chart of each of the residents. There is also a Code Book in each unit. The book contains the current residents Advance Directive signed form, along with the resident's face sheet.The facility policy for Advanced Directives was reviewed on [DATE] at 3:00 PM, noted the definition of an Advance Directive is a written document that is prepared when the Resident retains capacity and in which the Resident specifies what type of medical care that the Resident wants in the future and/or whom the Resident wants to make decisions for them in the event the resident loses the ability to make decisions for him/ herself.F. Full Code. In the event of respiratory and/or cardiac arrest, 911 will be called, and the resident will receive all resuscitative measures, including but not limited to CPR, until EMS arrives.

Based on observation, interview and record review, the facility failed to ensure that oxygen humidification was provided, physician's orders for oxygen were followed and nebulizer equipment was stored according to facility policy for two residents (#51 and #69) of three residents reviewed for respiratory care. Findings include: Resident #51A review of Resident #51's medical record revealed an admission into the facility on 7/20/22 and readmission on [DATE] with diagnoses that included chronic obstructive pulmonary disease and pneumonia. On 12/2/25 at 2:05 PM, an observation was made of Resident #51 lying in bed. The Resident was interviewed, was able to answer some questions but did not engage in conversation. An observation was made of a nebulizer and mask on top of the bedside table. The nebulizer was stored in a see-through bag, and the medication chamber was observed to have liquid inside the chamber. The nebulizer was not dried prior to being stored in the bag. The Resident indicated use of the nebulizer treatment when he was sick.A review of Resident #51's orders revealed an order with a start date 11/28/25 for Ipratropium-Albuterol solution 0.5-2.5 (3) MG/3ML (milligrams per 3 milliliters), 3ml inhale orally every 4 hours as needed for SOB (shortness of breath) or Wheezing via nebulizer. Resident #69A review of Resident #69's medical record revealed an admission into the facility on 9/16/25 with diagnoses that included heart failure, and pneumonia. A review of the Minimum Data Set assessment revealed a Brief Interview of Mental Status score of 10/15 that indicated moderately impaired cognition and was dependent on a helper for toileting hygiene, bathing, dressing and transfers to chair/bed. On 12/2/25 at 10:48 AM, an observation was made of Resident #69 lying in bed. The Resident was interviewed, answered questions and engaged in conversation. An observation was made of the Resident's oxygen tubing positioned over her ears with the nasal cannula on her chin. The oxygen was on a concentrator and was set at 3 liters per minute. The concentrator was positioned between the wall and bedside table in front of the concentrator near the head of the bed. An observation was made of the humidification dry with no water or condensation in the container. The humidification container was dated 11/15/25. The date on the O2 tubing was 12/1/25. The humidification container had not been changed with tubing change. The Resident was asked about her oxygen and the Resident reported taking it off and on and that it was on most of the time. The Resident reported having nose bleeds that she attributed to the oxygen and that it would dry out her nose too much. On 12/2/25 at 3:15 PM, an interview was conducted with Unit Manager (UM), Nurse A regarding Resident #69's humidification for the oxygen. The UM reported that the nurses were responsible for changing the humidification when it was emptied on an as needed basis and that the tubing would be changed weekly. An observation was made with the UM of Resident #69 lying in bed with the nasal cannula positioned on her nose. The humidification had not been changed out and was dated 11/15/25. The UM indicated a new container should be changed when needed, took off the old one and replaced it with a new container. On 12/4/25 at 3:54 PM, an interview was conducted with Nurse D and UM A regarding Resident #69's oxygen order. An observation was made with the UM of Resident #69's oxygen concentrator set at 3 L/min as verified by the UM. A review of the physician orders indicated the oxygen was ordered for 2 L/min. Nurse D explained that the oxygen had been increased recently due to the resident being sick. A review of the orders revealed no orders to increase oxygen administration. The Nurse reported the resident should be at 2 L/min and will change the O2 while monitoring the oxygen saturation for the Resident. When asked about humidification, the Nurse reported that she thought it was changed with the tubing change. After the date on the humidification container was identified as 11/15/25, the Nurse reported that the humidification container does not last that long and should be changed out and stated, that's too long, they don't last that long I don't think. The Nurse reported the Resident also got nasal spray to help with the dryness in her nose. A review of Resident #69's Medication Administration Record revealed O2 via nasal cannula at 2L every shift with a start date 9/16/2025, documented as checked on 12-hour shift with the O2 sats (oxygen saturation). On 12/4/25 an interview was conducted with the Administrator (NHA) regarding the concern of Resident #69 lack of humidification and oxygen administration orders not followed. The NHA was informed of the concern of storage of the nebulizer treatment supplies for Resident #51. A review of the facility policy titled, Nebulizer therapy, small volume, revealed, .Rinse the nebulizer with water and allow it to air-dry. Alternatively, discard it after the treatment. Complications. Complications associated with small-volume nebulizer therapy may include: .infection from contaminated equipment. A review of the facility policy titled, Use of Oxygen, dated 2/28/25, revealed, .V. If a disposable humidifier is used, it may be used until empty.

This Citation Pertains to Intake Number MI00148563. Based on interview and record review, the facility failed to protect the resident's right to be free from misappropriation of property by facility staff for one resident (Resident #701) of three residents reviewed. Findings include: Review of Facility Reported Incident (FRI) intake documentation dated as initially received on [DATE] revealed the facility was notified on [DATE] at approximately 1:40 PM by Family Member Witness D of fraudulent charges on Resident #701's credit card. The facility submitted documentation detailing that the allegation was substantiated by the facility. An interview was completed with the facility Administrator on [DATE] at 9:30 AM. When asked if they had substantiated the allegations in the FRI involving Resident #701, the Administrator replied, Yes. The Administrator was asked what happened and verbalized that Resident #701's family member came to their office and informed them there was some unusual activity on Resident #701's card and that they had canceled the card. The Administrator stated, There was one staff member whose answers did not add up during their investigation. The Administrator was asked who the staff member was and stated, (Certified Nursing Assistant [CNA] B). When queried what did not add up in what CNA B said, the Administrator replied, There were discrepancies in their story. With further inquiry, the Administrator revealed CNA B no longer worked at the facility. The Administrator stated, (CNA B) would not come back in (to the facility) for a follow-up in person interview but told Human Resources (HR) they did it and resigned. When queried regarding CNA B's work history, the Administrator revealed CNA B had worked at the facility for six years and did not have any prior any performance issues. Record review revealed Resident #701 was admitted to the facility on [DATE] with diagnoses which included cerebral infarct (stroke) with resulting speech and language deficits, depression, diabetes mellitus, and Congestive Heart Failure (CHF). A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required set-up to moderate assistance to complete all Activities of Daily Living (ADL) with the exception of eating. A review of facility provided investigation documentation revealed the following: - Resident, Family, Employee, and Visitor Assistance Form . (Family Member D) . What is your concern about? Identified 'fraudulent' transactions on credit card and credit card is missing . When did the problem or incident occur? [DATE] and [DATE] . Who else knows about the problem or incident? No one- the bank . How can we address your issues? 'Just thought you should know.' Facility Response: Concern form initiated; Investigation initiated per facility protocol; Family states all charges were covered by the bank. Action to be Taken: Police notified on [DATE]; Concern identified- Permanently resolved; Continue routine quality rounds/education and monitoring . The form was signed by the Administrator on [DATE] and Family Member D on [DATE]. - CNA B's Workforce Background Check and hire information from 2018. - Chase Bank Transaction Statement detailing the following: Card Purchase on ,d+[DATE] at Halo Burger in [NAME] MI for $14.49 Card Purchase on ,d+[DATE] at [NAME] Ecorse MI for $2.10 Card Purchase on ,d+[DATE] at Vg's Food Center in [NAME] MI for $31.14 Card Purchase on ,d+[DATE] at Speedway in [NAME] MI for $7.35 Card Purchase on ,d+[DATE] at Speedway in [NAME] MI for $52.89 Card Purchase on ,d+[DATE] at Tips & Toes Nails in [NAME] MI for $53.50 Card Purchase on ,d+[DATE] at Panda Express in [NAME] MI for $17.75 - Incident and Accident Investigation Form . Date: [DATE] . 1:40 PM . Location: Unknown . Employee Involved in Incident: (CNA B) . Brief Description: Resident's brother stated 'fraudulent' transactions occurred on cred card- credit card is missing . (Witness D) notified (Administrator) . Investigation . Was the guest/resident . involved in the alleged incident questioned? Yes . [DATE] 11:00 AM . (Resident #701) . Conclusion . Concern seems to be substantiated. Suspect identified and no longer employed. Completed review of others that may be at risk: Yes . - Quality Assurance Interview Summary . Guest/Resident: (Resident #701) . Date of Interview: [DATE] . Not aware of wallet, could not recall last used credit card. No concerns didn't see anyone removing it. Not are of unauthorized transactions confirmed (Witness D) handles all of finances/card handling Name of Staff Member Interviewed: (Licensed Practical Nurse [LPN] C) . Date of Interview: [DATE] . I remember when (Resident #701) was admitted . (Resident #701's family) had called a few times regarding their cell phone. I did go thru their bag to look for the phone, but I never seen a wallet. (Resident #701) never mentioned a wallet and I never seen them with one. (Resident #701) wasn't even aware they had a phone . Name of Staff Member Interviewed: (LPN G) . Date of Interview: [DATE] . Was the admitting nurse for (Resident #701) on [DATE]. Was her on [DATE]. Never saw a wallet or credit card at the resident's bedside . Name of Staff Member Interviewed: (CNA J) . Date of Interview: [DATE] . Assigned CNA for (Resident #701) [DATE]. Didn't recall seeing a wallet when in resident's room. Never saw a credit card. Had they observed a credit card, the nurse would've been notified. Not aware of any concerns involving resident's possessions including credit cards . Name of Staff Member Interviewed: (CNA B) . Date of Interview: [DATE], [DATE] . [DATE]: Never observed a wallet or credit card. Not aware of the location. [DATE]: Declined to come in for a follow-up interview. - Investigation Summary/Actions Taken: (Resident #701) was originally admitted on [DATE] . transferred from the hospital via ambulance . The resident is cognitively impaired and uses a wheelchair for locomotion. On [DATE] at approximately 1:40 PM, (Witness B) notified the Administrator that they became aware of fraudulent transactions using (Resident #701's) credit card on Monday, [DATE]. (Witness D) stated that two of the transactions were in [NAME] which made them think that the card was possibly taken from [NAME] Healthcare and used in the area . (Witness D) stated immediately contacted Chase Bank who deactivated the card and has since applied credit for the charges. (Witness D) stated that the transactions appear to have occurred on Saturday, [DATE] and Sunday, [DATE]. All of the charges have been reversed by the bank, and (Resident #701) has recovered all of the funds . (Witness D) stated they came to the facility on Monday, [DATE] and observed that the resident's wallet was in a drawer next to their bed. According to (Witness D), the wallet did not have the credit card in it. According to (Witness D) the wallet had a $5.00 bill, Driver's License, Social Security Card and a Credit Union card. The last time that that (missing) credit card was physically used was on [DATE] for an ATM transaction. The resident was interviewed, (Resident #701) was unable to recall the last time the card was used and was not aware that it was missing. (Witness D) handles all of (the Resident's) finances. (Resident #701) was unaware any of the charges that (Witness D) was referring to . expressed no concerns regarding anyone's handling of belongings, and didn't seem aware. The resident's roommate is not interview-able. Facility staff interviews were initiated . (LPN G) was the assigned to the resident on the following shift from admission, and multiple times since . stated observed very little belongings, and never observed a wallet, however had no reason to go into (Resident #701's) bedside dresser. (CNA B) was scheduled to work Friday ,d+[DATE], Saturday ,d+[DATE], and Sunday ,d+[DATE], (CNA B) worked the afternoon shift and was not assigned to the resident. (CNA B) was initially interviewed on [DATE] and stated they never saw a wallet, was not aware of a wallet or a credit card. (CNA B) said they observed the family with a wallet sometime on Saturday and thought they took it home. According to the family and the nurse, the wallet was taken home on Monday. A follow-up interview was attempted to be scheduled on [DATE], due to discrepancies in the initial statement on [DATE], as well as a discussion that the employee had when they called Human Resources (HR), after the initial interview. (HR Coordinator E) stated that (CNA B) had called and inquired about what would happen if someone used a resident's debit card, and what should they do if they had taken one. Human resources thought the call was unusual and reported the conversation to the Administrator. The Administrator contacted (CNA B) via phone on [DATE] after (CNA B) called in for their scheduled shift that day, the employee stated was unable to come in for a follow-up discussion, the employee was suspended pending investigation at that time. Immediately after the call was ended with the Administrator the (CNA B) called (HR Coordinator E) and stated they resigned immediately, that they messed up, that they did it and didn't know what they were thinking. The Administrator attempted to reach the (CNA B) after the call, but there was no answer. The Administrator attempted to reach the City of [NAME] Police on [DATE] and on [DATE] with the updated information. Current interview-able residents were queried regarding any concerns with missing items, no concerns were identified. In conclusion, the allegation was substantiated. The resident has recovered all of the money for the unauthorized transactions. (CNA B) is no longer employed . The investigation documentation was reviewed with the Administrator on [DATE] at 11:00 AM. When queried regarding the location of the purchases and the facility, the Administrator revealed Halo Burger and VG's grocery store are approximately two miles from the facility. Review of CNA B address during their employment at the facility revealed the purchases completed in [NAME] were near and/or within a reasonable distance between the facility and CNA B's address. CNA B's time clock punch documentation for [DATE] to termination of employment was requested at this time. On [DATE] at 11:10 AM, a phone interview was attempted to be completed with CNA B. The phone number provided was disconnected/out of service. An interview was completed with Family Member Witness D on [DATE] at 11:29 AM. When queried regarding Resident #701, Witness D disclosed they live in Florida and stated, Since (Resident #87) had a stroke, I do their financial's as numbers confuse (Resident #701) now. Witness D revealed the Resident has two bank accounts and stated, After I pay (Resident #701's) bills, I would put the extra money in the Chase account and (Resident #701) could go to the Chase bank and take money out. Witness D stated, (Resident #701) only took out a lump sum out of the ATM and there would be $50 or $60 bucks left in the account. Witness D revealed Resident #701 was hospitalized prior to going to the facility and stated, When (Resident #701) was in the hospital, I kept putting money in (Chase account) and there was $300 or $400 in there. When queried regarding the fraudulent charges on Resident #701's card, Witness D stated, (Resident #701) went to (the facility) after the hospital. I went to see (the Resident) Monday morning and as I pulled in the driveway, my phone was going off like crazy. All the charges from the weekend dropped then. Witness D was asked what they meant and revealed they were on the Chase account with Resident #701 and had text alerts set up so they would know when money was withdrawn from the account. Witness D explained that any charges or withdrawals made from the account over the weekend, or when the bank was closed, did not drop or show on the account until Monday or when the bank reopened. Witness D stated the alerts were all for Point of sale charges (use of a credit or debit card to pay for goods) and stated, (Resident #701) never did a point of sale charge. Witness D reiterated Resident #701 only used the card to withdrawal cash. Witness D then stated, The charges were all in [NAME] and [NAME] and revealed Resident #701 lived and was in the hospital in Garden City (approximately one hour from the facility). Witness D continued, I happened to be in the parking lot of the facility when they received the bank notifications of the changes. Witness D stated, I went in and asked (Resident #701) where their wallet was, and the Chase card was missing. When asked where the Resident's wallet was, Witness D replied, In the top drawer. Witness D stated, I took (Resident #701's) wallet right then and took it home. When asked what happened, Witness D revealed they contacted the bank, canceled the card, and the bank reimbursed the account. Witness D stated, I told the Administrator on Monday or the following or next day. Witness D revealed they told the admin I think they have a problem because of the card being missing and where the charges were made. When asked what the Administrators response was, Witness D stated, The Administrator suggested I complete a police report. When asked, Witness D revealed they did file a police report. When queried what transpired following the police report, Witness D stated, Probably a week later the Administrator told me they found out who they thought it was, and they were no longer a concern. Witness D was asked the name of Police Officer who they spoke to and revealed they were unsure but that it was the City Police Department. When asked about the charges on Resident #701's card, Witness D emailed a copy of the bank account statement dated [DATE] through [DATE] with the fraud charges highlighted. When queried how Resident #701 responded to their card being stolen and the fraudulent charges, Witness D verbalized the Resident did not know until they were told. Witness D further stated the Resident was upset and becomes easily confused. Witness D verbalized they would prefer Resident #701 was not asked about the card because they focus on it. At 12:13 PM on [DATE], the City Police Department was contacted. When queried regarding the report involving Resident #701, the dispatcher revealed the Officer who responded to the incident was Officer I. A voicemail message with return phone was left at this time. Review of Resident #701's Electronic Medical Record (EMR) revealed the following: - [DATE] at 2:03 AM: Nursing Summary . Arrived via EMS . A&O x 3 (Alert and Orientated to person, place, and time) . BLE (Bilateral Lower Extremity) weakness x 1 person transfers. Incontinent B&B (Bowel and Bladder) . - [DATE] at 2:03 AM: Admission Nursing Comprehensive Evaluation . Most Recent Admission: [DATE] 22:36 (10:36 PM) . admitted From . hospital . Mode of Transport . EMS . Reason for Admission: Needs assistance with ADL's . The Assessment was completed by Licensed Practical Nurse (LPN) C. On [DATE] at 2:10 PM, Resident #701 was observed in a wheelchair. An interview was completed at this time. When asked how they were doing, Resident #701 become tearful with visible tears. Resident #701 was asked what was wrong but did not provide a response. After Resident #701 stopped crying, they were asked if any of their personal items were lost or missing while at the facility and responded, My clothes. When asked how long their clothes had been missing, Resident #701 replied, Awhile. Resident #701 was asked what clothes were missing and indicated they did not know. The Resident was confused and unable to provide meaningful responses to questions. An interview was completed with CNA F on [DATE] at 2:25 PM. When queried regarding Resident #701 becoming tearful and crying, CNA F revealed the Resident frequently cries for no obvious known reason. An interview was conducted with Licensed Practical Nurse (LPN) G on [DATE] at 2:35 PM. When queried regarding Resident #701 becoming tearful and crying when asked how they were doing, LPN G revealed it is normal for the Resident to be emotional. LPN G revealed the Resident was recently started on medication which had improved their emotional liability. When queried regarding the Resident's confusion, LPN G stated, (Resident #701) has been (confused) since they came to the the facility. When asked if they recalled and had worked with CNA B, LPN G verbalized they did and had. When asked if they had ever observed CNA B remove any personal items from a resident's room, LPN G replied they never seen (CNA B) take anything. When queried if Residents have a locked drawer and/or area in their room to secure personal items, LPN G replied, They do but have to ask about them. When asked what the process is when a resident arrives to the facility with money and/or debit/credit cards, LPN G replied, If we notice during admission then take and lock up for family to pick up. LPN G was then queried regarding the facility process/procedure pertaining to inventory of resident personal items upon admission to the facility and stated, We usually look through their stuff in front of them (resident) and another nurse and then we document everything on an inventory sheet. On [DATE] at 2:50 PM, an interview was completed with Unit Manager LPN H. When queried if they were aware of any concerns with missing resident items including Resident #701's debit/credit card, LPN H responded they were Not aware of any concerns. When asked what staff are supposed to do regarding inventory of resident personal items upon admission to the facility, LPN H stated, We have the CNA's go through their (resident) stuff and then they mark it (on inventory sheet). The CNA's let the nurse know if there is anything of value. When asked who signs the inventory form, LPN H revealed the resident's assigned nurse signs the form. When queried if the CNA signs the form, as they are completing the form, LPN H revealed they did not think the CNA signed. When queried why the nurse signs the form, if they are not actually completing the inventory, LPN H did not provide an explanation. Review of CNA B's Timecard for Terminated Employee Report for [DATE] to [DATE] revealed CNA B worked the following dates and times: - [DATE] from 3:10 PM to 11:02 PM - [DATE] from 3:15 PM to 11:01 PM - [DATE] from 11:13 AM to 11:01 PM - [DATE] from 2:56 PM to 6:04 AM - [DATE] from 3:16 PM to 11:01 PM - [DATE] from 2:59 PM to 10:08 PM - [DATE] from 2:51 PM to 9:05 PM - [DATE] from 3:19 PM to 9:09 PM The timecard specified CNA B was a Call Off 3 PM - 11 PM on [DATE]. An interview was conducted with the facility Administrator on [DATE] at 3:00 PM. When queried if they interviewed all staff who worked from when Resident #701 was admitted to when the card was used, the Administrator verbalized they did not because they identified who had taken the card and did not feel it was necessary. When queried if they spoke to/interviewed housekeeping staff, the Administrator stated they did not. CNA B's timecard was reviewed with the Administrator at this time. When asked, the Administrator confirmed CNA B's last worked shift was on [DATE]. An interview was conducted with HR Coordinator E on [DATE] at 3:52 PM. When queried if they recalled CNA B, HR Coordinator E confirmed they did. When asked if they recalled speaking to CNA B regarding their employment suspension, HR Coordinator E confirmed they did. HR Coordinator E stated, (The Administrator) and I were in their office, and we talked to (CNA B) about their suspension then via phone. When queried how the conversation went, HR Coordinator E stated, It was odd. (CNA B) was like okay and matter of fact about it. For (CNA B) it was to calm and to quick. When asked, HR Coordinator E revealed it was abnormal for CNA B to not be more boisterous and verbal. HR Coordinator E then stated, After we just hung up from talking to (CNA B), I got a phone call from them. I didn't have my phone on me, but I felt it on my I-watch. HR Coordinator E revealed they called CNA B back when they got their phone. When asked what CNA B said when they called then back, HR Coordinator E stated, (CNA B) said I quit I did it I f-ed up. When asked if they asked CNA B anything after they said that HR Coordinator E replied, (CNA B) said something about they would pay it back and I told her someone would get back to them in the near future. HR Coordinator E stated, We really didn't speak on the phone that long. When asked if CNA B was admitting to taking Resident #701's credit/debit card and were saying they would pay the Resident back, HR Coordinator E replied, That was my understanding. When queried if CNA B had any prior similar issues during their employment, HR Coordinator E replied, No, not that I am aware of. When queried if CNA B had said anything else to them regarding Resident #701's debit/credit card, HR Coordinator E stated, The day before, at the end of day, (CNA B) had been in my office. (CNA B) was saying stuff about what if somebody did that (took a Resident's credit/debit card) and I told them that if somebody did that they should talk to (the Administrator). (CNA B) called later and said if I knew who that person was what should they do, and I said do you know who did it. (CNA B) said yeah and I said you should tell to talk to (the Administrator). An interview was completed with LPN C on [DATE] at 4:40 PM. When queried regarding Resident #701's admission, LPN C verbalized they recalled the admission. When asked what occurred, LPN C stated, The family called and said they were trying to reach (Resident #701) on their cell phone. We were looking for it in some bags (the Resident) had and couldn't find it. When queried what the Resident brought with them, LPN C replied, Had clothes and a blanket. When asked if the Resident had a wallet with them, LPN C responded they did not see a wallet. When asked if they looked in the Resident's bedside dresser drawers, LPN C stated, No. LPN C was asked about Resident #701's cognitive status and stated, Pretty confused. Still pretty confused at times. When queried if they recalled working with CNA B, LPN C indicated they did and stated, (CNA B) died today. LPN C then stated, I don't know nothing about no debit card. When asked why they said that LPN C revealed they heard rumors and did not want to answer questions related to CNA B. Further review of Resident #701's EMR revealed an Inventory of Personal Effects which specified the Resident had 1 Nightgowns/pajamas and 1 cell phone, purple case with charger. The form was signed under On Admission on [DATE] but the signature was illegible. The section for Resident/Resident Representative Signature section on admission was blank. A second Inventory of Personal Effects with Additional Personal Effects Brought [DATE] handwritten on the top of the form was present. This form specified Resident #701 had the following items 6 blouses/shirts . 1 Nightshirt/pajamas . 3 Slacks/trousers . 1 pair shoes black . 1 pair hearing aid . both- No Charger . 1 Glasses (readers) . The form was signed and dated [DATE] by Witness D. The form was not signed by facility staff. Review of facility staffing/assignment sheets revealed the following CNA staff were assigned to care for Resident #701 from [DATE] to [DATE]: CNA K, CNA L, CNA B, CNA O, CNA M, CNA N, and CNA J. Review of facility staffing/assignment sheets revealed CNA K was assigned to care for Resident #701 during the midnight shift on [DATE]. An interview was completed with CNA K on [DATE] at 7:43 AM. When queried if they recalled Resident #701 and the day they were admitted , CNA K stated, Don't remember. When asked what the facility process/procedure is for documenting what resident personal items brought to the facility upon admission, CNA K stated, The nurse will give us the belonging sheet and sometimes they already have stuff put away, so we have to open the closet and then check it off on the sheet. We take the sheet back to the nurse and they sign it. CNA K was asked if they sign the Inventory sheet and responded, No. When asked if the nurse reviews they items with them, CNA K indicated they do not. When queried if they recalled working with CNA B, CNA K indicated they did. When asked, CNA K indicated they did not recall CNA B displaying any unusual behaviors. At 8:00 AM on [DATE], an interview was attempted to be completed with CNA J. A voice mail message was left with a return phone number. On [DATE] at 8:59 AM, the Administrator revealed CNA J was unavailable due to being on vacation. When queried what time Resident #701 was actually admitted to the facility, the Administrator reviewed the Resident's EMR and stated, [DATE] at 8:00 PM. When asked who signed the initial Inventory form for Resident #701 dated [DATE], the Administrator reviewed the form and responded, (Unit Manager LPN H). When queried if LPN H was working on [DATE] when the Resident was admitted , the Administrator indicated they were not sure. A second interview was completed with Unit Manager LPN H on [DATE] at 9:30 AM. When queried if they were in the facility when Resident #701 was admitted , LPN H replied they were not sure. When asked if they clock in and out when they work, LPN H stated, Yes. LPN H was asked if they went through all of Resident #701's belongings when they were admitted , as they signed the admission inventory form on [DATE], LPN H stated, If I signed, that is what I normally do. LPN H did not provide an explanation when asked why they previously said a CNA goes through the resident's belongings and not the nurse. LPN H's clock in sheet for [DATE] was requested from the facility Administrator on [DATE] at 9:35 AM. An interview was conducted with CNA N on [DATE] at 9:50 AM. When queried regarding Resident #701, CNA N confirmed they knew the Resident. When asked if they had completed and/or assisted with completing the Resident's inventory sheet when they were admitted in November, CNA N replied, Never done them on third shift. CNA N was asked to clarify and verbalized they worked third shift and had not assisted with and/or completed an inventory sheet. When asked if they recalled if Resident #701 had a wallet and/or purse when they were admitted , CNA N stated, I don't remember because I don't go in (Resident #701's) drawers for nothing. On [DATE] at 9:55 AM, an interview was completed with CNA L. When queried regarding procedure for completion of resident inventory upon admission, CNA L stated, I try not to do that, I don't like going through peoples stuff. When queried regarding if they recalled completing Resident #701's inventory when they worked the day shift on [DATE], CNA L replied, I didn't touch any of (Resident #701's) stuff. When asked if they recalled seeing a wallet or debit card in the Resident's room, CNA L stated, No, but I heard that (CNA B) took a resident's debit card and got their nails done. When asked, CNA L was unable to provide any additional information pertaining to the incident. An interview was completed with CNA M on [DATE] at 9:59 AM. When queried if they recalled completing Resident #701's inventory, CNA M revealed they did not recall. When asked if they remembered if the Resident had a wallet or a purse, CNA M stated, I don't know. CNA M was asked if Resident #701 was a two person assist and replied, I don't even remember. When queried if they worked with CNA B, CNA M confirmed they did. When queried if CNA B had taken any of Resident #701's personal belongings, CNA M revealed they heard CNA B took Resident #701's debit card. CNA M then stated, I don't know if (Resident #701) had a purse or wallet or anything. When asked why they said that CNA M stated, (Witness D) came in and said they were getting notifications. (Witness D) told us. When asked who they meant when they told us, CNA M revealed Witness D informed CNA B and themselves in the facility. A second interview was completed with Witness D on [DATE] at 10:11 AM. When asked where they last saw Resident #701's wallet/purse, Witness D stated, (Resident #701) had their wallet with them at the hospital and then the ambulance took them from the hospital to the facility. Witness D verbalized they drove to Michigan on the 14th and 15th. When queried regarding the location of Resident #701's wallet during the EMS transfer from the hospital to the facility, Witness D stated, (Resident #701) would have carried it with them. Witness D reiterated they started to get alerts on their phone related to the fraudulent charges on the card when they pulled into facility parking lot to visit the Resident. Witness D restated that they went to the Resident's room and located the wallet in the Resident's drawer. When asked what drawer, Witness D revealed it was the dresser near the bed with two drawers. Witness D stated, It (wallet) had their Medicaid and Medicare card in it. When queried if any other family members could have brought the wallet to the facility after the Resident was admitted or is another family member/friend could have visited, Witness D responded, No and revealed the Resident's other sibling was in Florida during the timeframe and no one else would have visited. Witness D indicated they considered the possibility of someone not from the facility taking the card, but it was illogical due to the location of the hospital, EMS service, and the card charges. Witness D stated, (Resident #701) had it with them and I took it with me. When queried if they were aware that the Resident's wallet and cards were not included on the initial Inventory list form, Witness D replied, They were missing multiple things on the inventory. They were missing (Resident #701's) hearing aids too and they were there with (Resident #701) when they came. Witness D was asked what happened with the hearing aids and stated, They were [NAME] (Missing In Action) until my spouse found them. They were in a cloth bag that (Resident #701) brought with them from the hospital. When queried what kind of bag, Witness D stated, Like a carry-on (bag). The wallet could have been in there originally. The staff didn't have that (bag) on their inventory either. Review of Unit Manager LPN H timekeeping clock in/out report revealed LPN H worked from 7:48 AM to 5:23 PM on [DATE] and from 6:21 AM to 4:26 PM on [DATE]. An interview was completed with the Director of Nursing (DON) and Administrator on [DATE] at 11:26 AM. The DON was asked if they were involved in the investigation involving Resident #701's debit/credit card, the DON specified they were not involved in the investigation. When queried regarding the misappropriation of Resident #701's debit/credit card and fraudulent charges while at the facility, the Administrator stated, There is no harm as the bank refunded the Resident's money and the facility did everything they were supposed to. The Administrator was then asked if the misappropriation occurred and replied they were unable to confirm CNA B took Resident #701's card. When queried regarding CNA B telling HR Coordinator E they took the card and would pay it back, the Administrator stated they were unaware CNA B had told HR Coordinator E they would pay back the charges. The Administrator was asked why they substantiated their investigation but did not provide additional explanation. The Administrator [TRUNCATED]

REFER TO INTAKE NUMBER: MI00147356 Based on observation, interview, and record review, the facility failed to provide the appropriate skin care interventions to prevent the development of pressure ulcers and promote healing consistent with professional standards for three residents (R301, R302, and R304) of four sampled residents reviewed for pressure ulcers resulting in delay in treatment and healing and potential for worsening of wound, infection and further complications. Findings include: Resident 301(R301): R301 was [AGE] years old and admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Major Depressive Disorder, and Pressure Ulcer of the Sacral Region in addition to other diagnoses. On 9/12/2024, R301 was discharged to the nearby acute care hospital to evaluate and treat the wounds. R301 did not return to the facility after discharge to the urgent care on 9/12/2024. A review of R301's Treatment Administration Record (TAR) dated in July, August, and September of 2024, there were missing signatures in the treatment record. On the TAR for July 2024, the treatment order: Cleanse sacrum area and apply Chamosyn with Manuka honey cream every shift. There were missing nurse signatures on 7/2/2024, 7/6/2024, 7/9/2024, 7/18/2024, 7/23/2024, and 7/26/2024. The August 2024 TAR had a one-time order: Cleanse the sacrum area with normal saline and pat dry. Apply Medihoney and Optifoam dressing every day shift dated 8/23/24. The box for 8/23 was not signed and was left blank. Another order: Cleanse sacrum area and apply chamosyn with manuka honey cream every shift. It was noted to have blanks without a signature on the following dates: 8/1/2024, 8/3/2024, 8/4/2024, and 8/16/2024. The September 2024 TAR was reviewed. Another treatment order to apply skin prep to the discolored red area on the right buttock/hip every shift for skin care revealed that on 9/10/2024, the box was left unsigned or blank R Treatment order for the left heel was noted: Apply skin prep to left heel every shift for preventative heel care. Every shift for preventative skin care. It was noted that the treatment box was not signed on 9/2/2024 and 9/10/2024. R301's wound measurement dated 9/12/24 per Wound Consultation by a Nurse Practitioner noted the following: Date of Service: 9/12/24 Visit Type: Wound Care Consult Wound Assessment: .L89.150- Pressure Ulcer of Sacral region, unstageable: Patient will be sent to hospital for further evaluation of deteriorating sacral wound. Location: Sacrum Stage: Unstageable Measurements: Length: 9.50centimeters (cm) Width: 1.40 cm Depth: 0.10 cm Drainage Type: serosanguineous Drainage Amount: Moderate Granulation: 50 Sough 50 Date recorded: September 12, 2024 Status: Deteriorating . The EMR was reviewed on October 23, 2024, at 1:30 PM. The nurse notes for R301 dated 9/12/2024 at 11:00 AM noted that during wound rounds, wound care Nurse Practitioners (NP) ( two names mentioned, #1 NP and #2 NP) evaluated her sacral wound and recommended she go to the hospital for further evaluation of deteriorating sacral wound and recommended she go to the hospital for further evaluation of deteriorating wound . On 9/12/24 at 12:27 PM, Wound care doctor in to see the resident. Order received to send the resident to (name of Hospital mentioned) nearby hospital for eval and treatment of deteriorating sacral wound. A review of R301's care plan for at risk for impaired skin integrity date initiated on 11/7/2023 revealed: > Cue to reposition self as needed. Initiated 11/7/2023 . > Follow the facility policies /protocols for the prevention/treatment of the impaired skin integrity . Resident 302 (R302): A wound treatment performed by the Wound Nurse A for R302 was observed on 10/23/24 at. A review of R302's clinical record EMR conducted on 10/22/24 at 2:30 PM revealed R302 was admitted to the facility on [DATE] with the diagnosis of Parkinsonism, bipolar disorder, difficulty in walking, and limitation of activities in addition to other diagnoses. R302's Braden Scale score was=16, which puts R302 at risk for pressure sore. A stage 3 pressure ulcer at R302's sacral area was noted during admission assessment on 10/11/24. The treatment order specified, dated 10/12/24, was: Cleanse wound on sacrum with NS. Pack area with normal packing strip and apply calmoseptine to reddened area around wound. Cover with Optifoam every day and evening shift. R302's Treatment Administration Record (TAR) was reviewed on 10/22/24 at 2:30 PM, revealed that treatment boxes on 10/16/24 and 10/18/24 were unsigned, and no notes were indicating why the box was left empty by nurses. The Nurses Notes from 10/11/2024 up to 10/22/24 were reviewed 10/22/24 at 2:30 PM. There was no mention in the nurses' notes indicating any treatments performed or missed treatments mentioned. However, on 10/22/24 at 17:19 (5:19 PM), a late entry on 10/22/24 at 17:19 (5:19 PM) as noted stated, Late entry-10/18/24 treatment complete. An interview with Nurse B was conducted on 10/22/24 at 3:10 PM. She confirmed working that day but did not know why the treatment was left blank on 10/16/24. She stated that according to nursing protocol,if not signed, that means it did not happen. Nurse C was interviewed on 10/22/24 at 3:15 PM. She confirmed that she was working on 10/18/2024 and remembered that she had been given all medications and treatments. She stated, I must have missed signing it off that day. Resident 304 (R304): R304 was observed for treatment on 10/23/24 at 2:00 PM. The area was red, and the incontinence pad was soaked and saturated with urine. An open area was noted on the left coccyx area, described by the Wound Nurse A as a part of the skin came off. Wound Nurse A confirmed it, and measurements of the observed open area were noted. On 10/23/24 at 2:15 PM, R304 was observed for wound treatment. R304 was not one of the facility's identified in the list of residents with pressure sore submitted by the facility administrator. Wound treatment and measurement observation revealed an open area on the right sacrum, observed on 10/23/24 during the wound and incontinence care for R304. The top layer of the skin is off on the right sacrum, measured 0.2 centimeters (cm) length x 0.2 cm width and depth of 0.1 cm wound. The Wound Nurse A cleansed the area with Normal Saline and applied calmoseptine cream. The Wound Nurse A explained that this is the standard treatment until the wound nurse practitioner evaluates the area. Wound Nurse A denied receiving a report or knowledge of the open area found in the sacral area. R304 was admitted to the facility on [DATE] with the diagnosis of metabolic Encephalopathy, Type 2 Diabetes Mellitus, and Limitation of Activities due to disability. R304 was observed with Status/Post-Bilateral Above the Knee Amputation (AKA). R304's Care Plan for at-risk for impaired skin integrity was initiated on 5/20/24, with the last updated interventions dated 8/27/24. The treatment Administration Record TAR for October 2024 was reviewed. A treatment to cleanse the area on the coccyx/sacrum area with Normal Saline and apply calmoseptin every shift for wound care was ordered on 9/25/2024. An empty box with no signed-off signature was noted on 10/20/24. An interview with Wound Nurse A on 10/22/24 at 3:00 PM was conducted. She indicated that it is our protocol to make sure we sign off all treatments that were done. If it is not signed, it didn't happen. During the interview with the Director of Nursing on 10/23/24 at 2:45 PM, she stated that nurses are to provide the treatment as ordered and to document by signing off treatments when done. The facility wound care protocol, dated effective 9/19/24, was reviewed on 10/23/24 at 1:00 PM. The policy's practice guideline noted: . #3. Appropriate preventative measures will be implemented on residents identified at risk, and the interventions are documented in the care plan .#5. The licensed nurse will initiate documentation in the electronic health record, which includes a description of the skin impairment as follows: In Electronic Health Record (EHR) facilities, the licensed nurse will document the skin and wound evaluation for pressure injury and vascular ulcers. Document weekly until the area is resolved .

Based on observation, interview and record review, the facility failed to ensure a clean and safe environment for 11 residents' rooms, 2 main hallways, and 1 residential sitting area, resulting in the likelihood for resident injury (bug and spider bites and hand splinters), anger and frustration from family members and residents, and cross contamination with illnesses with increased use of antibiotics. Findings Include: During an environmental walk through done on 10/2/24 starting at 8:16 a.m., accompanied by Director of Maintenance, Housekeeping and Laundry D; the following concerns were observed: First Floor: -At 8:16 a.m., room [ROOM NUMBER], the oxygen tubing with nasal cannula was observed on the floor (not in a bag) next to his bed. The resident had no idea where his oxygen was. -room [ROOM NUMBER], the bathroom toilet had BM on the back of the seat and the floor was found dirty. -At 8:30 a.m., room [ROOM NUMBER], the window running air conditioner filter was found to have an excessive amount of dust and dirt on it. In the bathroom was found a clear plastic bag of clean linens sitting on the floor. -room [ROOM NUMBER], the window running air conditioner filter was found to have dust and dirt on it. -The first-floor shower room across from room [ROOM NUMBER], had the window open and an excessive amount of dead bugs, dirt and spider webs were found in the tract and on the window seal. -In the clean linen room, was found a dirty blue bootie sitting on clean linen and the floor had dirt and dust on it. None of the linen was covered at the time. -At 8:45 a.m., in the Therapy room was found a wheeled measuring device that was being stored behind the toilet. -In the first-floor dining room (also used for activities and council meetings), seven tables were noted to have on the edges, areas of bare wood; the venire had worn off and wood was exposed (safety and infection control concern). One light bulb was out over a dining table. -The patio off the dining room was observed; directly under the window by the door, behind two chairs was observed a medium size pile of leaves, dirt and small sticks; large spider webs were also noted behind the chairs. -At 9:19 a.m., in the laundry room, the second and third driers were found to have heavy build-up of lint on the screens. The screens themselves were not visible at the time. The running washer had both screens covered with a thick layer of lint and dust. The exhaust fan above the area where clean linens were being folded at the time had a very thick layer of black dust/dirt on all blades. Laundry Staff member G was folding white towels at the time, and they were stacked directly beneath the exhaust fan. Also, Laundry Aide G was eating food, and it was sitting on the folding table by the clean stacked towels. During an interview done on 1-/2/24 at 9:06 a.m., Laundry Aide G stated Usually once a shift I clean the filters and as needed. If screens are dirty, then it is as needed. Second Floor: -At 9:22 a.m., the walls in the hallway were observed to have several areas of black marks and scuffs. Several resident rooms on the second floor also had black marks on the walls. -A heavy smell of urine was noted across from the nurse's station, and the soiled utility room door was shut at the time. -At the end of the hall, the window was open, and the window track was very dirty with dirt, dust, spider webs and dead bugs. -At 9:35 a.m., in room [ROOM NUMBER] the running air conditioner had a large amount of black and orange colored mold-like inside the top vents, and the filter was dusty. -room [ROOM NUMBER]'s running air conditioner filter was dirty with heavy dust. -At 9:40 a.m., in room [ROOM NUMBER], the running air conditioner top and filter was found to be dirty with dead bugs and heavy dust. -room [ROOM NUMBER], the floor was found dirty. -room [ROOM NUMBER], the running air conditioner was found to have a heavy coating of dust on the front and the filter. -room [ROOM NUMBER], the air conditioner and window track and window seal were found dirty with dirt, dead bugs and dust. -room [ROOM NUMBER], the wall on the right side of the door had areas of missing paint and the window seal and tracks were found to have dust, dirt and dead bugs. -room [ROOM NUMBER], the window seal and track were observed dirty. During a interview done on 10/2/24 at 8:50 a.m., the Director of Maintenance/Housekeeping/Laundry D stated I don't have a check sheet for walk through's. During an interview done on 10/2/24 at 12:05 p.m., the Director of Nursing/Infection Control nurse stated, there is always room for improvement. Review of the facility Infection Control walk through's dated 6/24, 7/24 and 8/24, revealed under nursing all areas were marked as y, nothing was observed unclean. Review of the facility Daily cleaning and disinfecting expectations sheet (un-dated), stated Dust vent grates in bathrooms, TV's and air conditioning filters, sweep then mop-place wet floor sign until dry, dust where walls meet ceiling for spider webs. 37771 On 9/30/24 at 10:09 AM, an observation was made of the second floor of a strong urine odor halfway down the hallway. On 10/2/24 at 10:27 AM, an observation was made of room [ROOM NUMBER] that had two Residents residing in the room with one of the Residents sleeping in bed. An observation was made of a strong odor of urine in the room, upon walking into the room, the floor was sticky with each footstep around the first bed area. The bathroom had a strong smell of urine. The Nurses' station was across the hall not far from room [ROOM NUMBER]. In the hallway and by the Nurses' Station, the urine odor was detected as well. On 10/3/24 at 11:59 AM, an interview was conducted with the Director of Nursing (DON) during the Infection Control task of the survey. The DON and this surveyor were on the second floor of the facility. An odor of urine was noticed in the hallway near the Nurses' Station. The Soiled Utility room was next to the Nurses' Station and the Nurses' Station was in the vicinity of Resident rooms. An observation was made inside the Soiled Utility room with the hopper/bin that held bags of soiled linen was piled high with bags and there were multiple bags of linen laying on the floor around the filled hopper/bin. The room smelled of urine. Housekeeping staff I was asked about the overflowing dirty linen bin. The Housekeeping staff indicated that the laundry staff usually comes up and collects it, and reported he would take this one down. A review of the facility policy titled, Federal & State - Resident Rights & Facility Responsibilities, revised 5/14/24, revealed, .i. Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely .

Based on observation, interview and record review, the facility failed to ensure that residents received assistance with showering and shaving for one resident (Resident #20) and failed to use appropriate hand hygiene during ADL (activities of daily living) care for Resident #265, of five residents reviewed for ADL care and 3 of 5 confidential group of residents voicing concern of not receiving bathing activity, resulting in the potential for embarrassment, frustration, needs not meet, infection and lack of feelings of self-worth. Findings include: Resident #20: A review of Resident #20's medical record revealed an admission into the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, limitations of activities due to disability, lung cancer, muscle weakness, dementia, disorientation, and need for assistance with personal care. A review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 7/15 that indicated moderately impaired cognition, and the Resident needed partial/moderate assistance with personal hygiene. On 9/30/24 at 10:09 AM, an observation was made of Resident #20 sitting up in bed with the head of the bed elevated. The Resident was asked questions, answered simple questions and engaged in limited conversation with understanding of what the Resident was saying to take extra time. An observation was made of the Resident with facial hair covering his cheeks, chin, upper lip and neck. The Resident was asked if he liked having a beard. The Resident rubbed his cheeks, chin and indicated he didn't like it this long. When asked if he refused when they offered, the Resident reported he would not say no and stated, I don't like the beard. On 10/2/24 at 10:15 AM, an observation was made of Resident #20 lying in bed with the head of the bed elevated. The Resident continued to have facial hair that had not been shaven from the observation made on 9/30/24. The Resident was asked about his preference for having a beard and the Resident stated, Yeah, I want this off. The Resident stated, Someone was supposed to do it, rubbed his beard on his cheeks up to his ears and was talking but what was said was not completely understandable. The Resident indicated he was waiting to get a shower. On 10/2/24 at 11:03 AM, an interview was conducted with CNA K regarding facility policy for shaving. The CNA indicated that med and women should be shaved as needed as soon as the hair grows back. When asked about Resident #20 facial hair, the CNA reported she had that Resident today and he had just taken a shower and got him shaved and stated, When I have him, I try to shave him, I have not had him in a while. When asked when facial hair assistance was offered to Residents, the CNA reported that she offers on a daily basis. On 10/2/24 at 2:19 PM, an interview was conducted with the Director of Nursing (DON). When asked about facility policy of facial hair shaving, the DON reported that it depends on their preference. The DON was asked about Resident #20's preference and how would staff know what the Resident's preference was. The DON indicated that the Kardex would contain that information. When asked to look on the Kardex, the DON stated, I don't see it documented, but it could be in his care plan, and reported she would follow up with Resident #20 on his preference. The care plan was reviewed with the DON. The care plan did not have the Resident's preference for the ADL (activities of daily living) activity of shaving. When asked if the care plan should have the Resident's preference, the DON stated, Yes we usually care plan it, it should be in there. On 10/2/24 at 4:16 PM, the DON reported that she had addressed the concern of the lack of Resident preference on shaving on the care plan. The DON reported that the resident likes to be clean shaven at least every 3 days. The DON reported she had updated the care plan and had it trigger to the Kardex. 22347 Resident #265: Review of the Face Sheet, physician orders dated 9/21/24 through 10/1/24, and care plans dated 9/21/24 through 9/26/24, revealed Resident #265 was [AGE] years-old, admitted to the facility on [DATE], alert and able to make healthcare decisions, and dependent on staff for assistance with Activities of Daily Living/ADL's. The resident was dependent on oxygen at 2 liters and his diagnosis included, encephalopathy (swelling of the brain), muscle weakness, high blood pressure, Atrial Fibrillation, sepsis, anemia, heart failure, acute respiratory failure, urinary tract infection, history of lung cancer, pleural effusion, end stage renal disease and dependent on renal dialysis. Review of the resident's Respiratory and ADL care plans dated 9/24/24, revealed chronic respiratory failure with oxygen use, weakness, and the need for staff assistance with ADL's (including bathing). Observation was made on 10/1/24 at 9:02 a.m., revealed Nursing Assistant/CNA F was giving the resident a bed bath. The following are the steps done during the resident's bed bath: -Gave wash cloth to resident to wash his face. -Took brief off, washed bottom and dried bottom. -Washed peri area. -Put depends on resident, washed under his arms and top chest area. -Grabbed his shirt from closet and put on him. -After shirt put on went back to closet, got sweat pants and put them on the resident. -Touched bed controls to raise the head of the bed. -Tied the dirty linen bag, got into second drawer of bedside stand and got toothbrush, basin and tooth paste out for resident and gave it to him. -Left resident's room and walked down the hallway and went into the soiled utility room. -No cover, blanket, cover or bath blanket was on resident during the entire bed bath. During the above entire process, the same gloves were left on CNA F, she did not remove gloves, nor wash her hands the whole time she gave ADL care. Review of the facility Hand Hygiene policy dated 10/11/23, stated Hand Hygiene should be performed: Before and after contact with the resident, after contact with blood, body fluids, visibly contaminated surfaces or after contact with objects (including soiled linen bag) in the resident's room, staff involved in direct resident contact must perform hand hygiene. Gloves are to be removed and hands washed after contact with peri care and/or washing the buttock area. Resident Group Meeting: On 10/1/24 at 2:00 p.m., a confidential resident meeting was done. During the meeting, 3 of 5 confidential resident's verbalized we missed a shower because of low staffing.

Based on observation, interview, and record review, the facility 1) Failed to ensure a safe environment with adequate supervision and implement interventions to prevent a fall for three residents (Resident #2, Resident #53 and Resident #54) and failed to do a complete fall investigation for those three residents and 2) Failed to ensure that Resident #212 had their C-collar (Cervical collar or brace used to support the neck and spinal cord, often used for neck pain, spinal fractures, surgery recovery or trauma) on while out of bed as ordered by the physician of 7 residents reviewed for falls and accident hazards, resulting in potential for pain and decline in medical condition and the likelihood of repeated fall with serious injury to occur due to incomplete investigations for R2, R53 and R54 and the potential for pain or worsening/decline in medical condition for Resident #212. Findings include: Resident #2 (R2): Accidents According to the review of the Electronic Medical Records (EMR) on 10/2/24 at 3:00 PM, R2 was [AGE] years old, admitted to the facility on [DATE] with a diagnosis of Vascular Dementia, Protein Calorie Malnutrition and Cerebral Infarction in addition to other diagnoses. Brief Interview of Mental Status (BIMS) Score dated 7/02/2024 was 03. A score of 0-07 means that the person has severe cognitive impairment. Minimum Data Set (MDS) Section GG, as assessed on 7/02/2024, revealed that R2 required maximum assistance with toileting, showering, and most ADL's (Activities of Daily Living, including oral hygiene). She required partial to moderate assistance with sit-to-stand, from bed to sitting on one side of the bed, and toilet transfers. R2 is non-ambulatory and was always incontinent with bowel and bladder elimination patterns. A care plan for Falls was noted last revised on 10/1/2024 during the survey, including the history of placing self on the floor with a pillow and blanket, crawling around on the floor, self-transferring, and the intervention of communicating with hospice as needed. On 12/02/2024 at 9:45 AM' R2 was observed lying in her bed with half of her body (left shoulder and head) off to the very side of the bed. R2's eyes were closed, and she was sound asleep. When the surveyor confirmed the observation with the Nurse (LPN M), the nurse revealed that sometimes she is unpredictable with her movements. LPN M stated, It depends on the day. And that's why she is a fall risk. There are times she will not move and times when she will move. The LPN M went to find the CNA assigned to reposition R2 in the middle of the bed. In an interview with the Nurse Manager JB on 10/3/24 at 11:03 AM, she stated: R#2's mental status depends on the day. R2 does not move, and all of a sudden, she would. R2 requires assistance with transfers and is non-ambulatory. A review of R2's 3 Fall Incident Reports (I/A) Report is as follows: Fall 1: Fall #1 dated 7/8/24. Incident description revealed: Called to the resident's room per activities staff. The resident noted lying on the left side of the bed on the floor, she was lying on her left side. Resident Description: head pointed towards footboard. Resident Unable to give description. No staff witnesses were mentioned, nor were staff statements found. Some blanks were left, and checkboxes essential for the investigation were not marked. R2's I/A Report #1 was incomplete. Fall 2: Fall#2 dated 8/3/24. Incident Description revealed: Nurse was making rounds on the floor. The nurse heard resident calling out for help. Upon entering resident's room, the nurse observed the resident lying on R side between the bed and wall. Feet towards FOB, head towards HOB with head resting on the floor under her bed. W/C located at foot of bed on same side as Resident without locked wheels. Gripper socks on. Resident Description: I was trying to go to bed and fell . R2's I/A Report #2 was incomplete. No staff witnesses were mentioned, nor were staff statements found. The incident report left some blanks, and some checkboxes were not marked. Fall 3: Fall#3 dated 8/7/24. The incident Description revealed: This Nurse heard moaning coming from the resident's room, upon arrival to the resident's room, Resident was observed on the floor face down with left side of face in direct contact with the floor next to the right side of her bed, bed noted to be in low position at this time. Resident has a knot on left side of forehead. No other injuries were observed. Passive and active ROM was completed for BLE and BUE per resident's baseline without complaints of pain. Resident assisted back into bed with a 2 PA for her safety. Resident Description: When Resident was asked what she was doing before she ended up on the floor, Resident stated that she was trying to get up. When asked where she was going, Resident could not say where she was going. R2's I/A Report #3 was incomplete. No staff witnesses were mentioned, and no staff statements were found. The incident report #3 left some blanks, and some checkboxes were not marked. Resident #53 (R53): Accidents During observation and interview on 9/30/2024 at 10:15 AM, R53 was alert, awake in his room, lying in bed, and stated that the facility needed more bathrooms. They had to wait in line to get to the bathroom. According to the review of the Electronic Medical Records (EMR) on 10/2/24 at 3:00 PM, R53 was admitted to the facility on [DATE] with a diagnosis of Diabetes Mellitus, Hypothyroidism, and Wedge Compression Fracture of first lumbar vertebra, unsteadiness on feet and repeated falls in addition to other diagnoses. R53's BIMS Score is 13/15. Section GG of the Minimum Data Set (MDS), assessed on 7/24/24, revealed that mobility devices such as a walker and wheelchair were used. R53 was deemed dependent on ALL transfers (Sit-to-stand, chair transfers, and toilet transfers). This further explained R53's ability to safely come to a standing position from sitting in a chair or on the side of the bed. R53 was dependent, meaning the helper did ALL of the effort. R53 makes no effort to complete the activity. Walking 10 feet and 50 feet, assessment was not attempted due to medical condition or safety concerns. Additionally, R53 was occasionally incontinent with Bladder Elimination. However, he was always continent with bowel elimination patterns. R 53's Fall Care Plan initiated on 1/19/24 revealed to: o Encourage Resident to wear non-skid footwear when out of bed. Assist Resident as needed. o Keep the Resident's environment as safe as possible with even floors free from spills and/or clutter; adequate lighting; call light within reach, commonly used items within reach, avoid repositioning furniture, and keep the bed in the appropriate position. On 10/2/24 at 3:05 PM, a review of the Facility incident/accident (I/A) report revealed: Fall 1: Fall#1 on 6/27/24 at 23:00 (11:00 PM) described: Writer called into room by patient roommate. The roommate stated that the patient had rolled out of bed. Pt was sitting on the side of the bed. The Resident Description: getting himself off the floor, when the writer entered the room. Patient was asked what happened and he stated he fell . He was asked if he hit his head, and patient stated, No. R53's I/A Report #1 was deemed incomplete. No staff witnesses were mentioned, nor were staff statements found. The incident report #1 left some blanks, and some checkboxes were not marked. Fall 2: According to the I/A report, the fall#2 occurred on 9/15/24 at 8:15 AM. It described: 'Resident was walking in the hallway to obtain an item from breakfast cart, observed knees buckling and Resident falling slowly to the floor. The resident landed on the backside, scraping arm across the leg of mechanical lift that was located in the hallway. On assessment, Resident was noted to have sustained a 2.5 x 1.5 cm. skin tear to the left forearm. Resident Description: Walking in the hall, I didn't think I would need my walker. I felt weak and fell , I am fine. As a result, R53 sustained a skin tear to the left elbow. R53's mental status, predisposed environmental or the predisposed situation factors were not marked. No witness or staff statements were entered. Other information indicated that R53: did not use call light or walker; non-skid socks not on feet. R53's I/A Report #2 was deemed incomplete. No staff witnesses were mentioned, nor were staff statements found. The incident report #1 left some blanks, and some checkboxes were not marked. According to Nurse Manager JB on 10/03/24 at 11:34 AM, R53 is forgetful and needs reminders to use his walker. Nurse JB described R53's mental status and revealed that R53 is usually confused and forgetful. Nurse Manager JB further commented, R53 needed constant reminders to use his walker when he's up and about. R53 does not remember to use the call light either. Staff anticipates his needs, and constant supervision from Staff is essential. Resident #54 (R54): Accidents According to the review of Electronic Medical Records (EMR) on 10/2/24 at 3:30 PM, R54 was [AGE] years old and admitted to the facility on [DATE] with the following diagnoses: Hemiplegia and Hemiparesis following Cerebral Infarction affecting the left non-dominant side, difficulty in walking, syncope and collapse, hypotension and essential hypertension in addition to other diagnoses. R54's Brief Interview of Mental Status or BIMS Score assessed on 5/16/24 was 15/15. R54's Functional Limitation in Range of Motion (ROM) revealed that her Upper Extremity (shoulder, elbow, wrist, and hand) was impaired on one side. ADL's, shower, and upper and lower body dressing were substantial to max assistance. Personal hygiene (combing, shaving, washing, and drying face and hands): Partial to moderate assistance. Mobility: roll left to right: Dependent, Sit to lying: Dependent; lying to sitting on the side of the bed: Dependent; sit to stand: Dependent. Chair to bed- to chair: Dependent, Toilet transfer: Dependent, Tub/shower transfer: Dependent. Dependent means that the helper does ALL of the effort. The resident does none of the effort to complete the task. R54 is always incontinent for both bladder and bowel elimination patterns. The Fall Care Plan for R#54 was reviewed on 10/3/12:15 PM: Amongst other interventions, the facility had the following action plans: o Educate Resident on maintaining bed at wheelchair level for transfers and locking wheelchairs prior to transfers. o Encourage the Resident to wear appropriate footwear as needed. These interventions are in place for R54 to prevent falls and minimize injuries to occur and considering R54's Left sided impairment and mobility conditions. The following Fall I/A for R54 was reviewed: Fall 1: Fall #1, on 5/17/24 at 8:15 AM, Staff assisted the patient to the bathroom. R54 said she readjusted herself on the toilet and slipped off of the toilet. Staff assisted. Resident Description: (R54) stated back on the toilet and then back into bed. Resident stated that she adjusted her position on the toilet. R54's I/A Report #1, dated 5/17/24, was deemed incomplete. No staff witnesses were mentioned, nor were staff statements found. The incident report #1 left some blanks, and some checkboxes were not marked. Important details such as R54's mental status predisposing factors (Environmental and situation) were not checked or filled out. The level of pain was not assessed. Fall 2: Fall #2, on 6/13/24 at 01:00 AM, described: Staff were called to room by a roommate who had called her son to call the facility to let Staff know that this Resident was on the floor. Resident Description: The resident noted that on the floor on the right side of the bed, she was lying on her left side. No noted injuries, denied hitting the head. The resident stated, I just turned over too far and rolled out of bed. After a review of the Fall#2 I/A dated 6/13/24, it was deemed incomplete because the level of pain and the mental status were not assessed, considering that the fall was unwitnessed, there were no statements from the nursing assistant (Staff assigned), and the predisposed environmental and situation factors were left blank. Fall 3: Fall#3 occurred on 6/23/24 at 18:35 (6:35 PM). In the report,Nurse called to Resident's room. Resident was sitting on the floor next to her bed. She was sitting upright, facing the door with her legs extended. Resident said she was sitting on the side of her bed praying. She was reaching into her bedside table for a prayer book that was recently bought for her. Resident Description: Resident said she was sitting on the side of her bed praying. She was reaching into her bedside table for a prayer book that was recently bought for her. Resident also stated that the remote/cord to raise and lower the bed was tangled under the bedside table and was trying to untangle it. In the same report, the nurse wrote: Resident said she was sitting on the side of her bed praying. She was reaching into her bedside table for a prayer book that was recently bought for her. Resident also stated that the remote/cord to raise and lower the bed was tangled under the bedside table and was trying to untangle it. The I/A Report #3, dated 6/23/24, was deemed incomplete because of the following : 1.) The level of pain was not assessed. 2.) R54's Mental status was left blank 3.) Predisposed factors (environmental/ physiological/situation) were not marked or checked. There were no statements, and the incident was unwitnessed Fall 4: Fall#4 occurred in R54's room on 7/26/24 at approximately 18:35 (6:35 PM). Nursing description revealed: Called to the room and observed resident sitting on the floor with knees bent. Facing HOB (Head of Bed). Hands on Mattress of bed. The bed was in the lowest position, and the wheels were not in the lock position. Resident Description: Resident stated she had lowered the bed to get back into it. When she attempted to transfer from the w/c to the bed, the bed was not locked and slid away from her when she pushed on it. She lost her balance and fell on to her buttocks. The I/A Report dated 7/26/24 was deemed incomplete because of the following: The post-fall pain level and R54's mental status were not assessed. No statements were obtained from the Staff assigned on the day of the incident. Fall 5: Fall#5, dated 9/20/24 at 14:31 (2:31 PM), revealed R54 was observed on the floor in bathroom laying on her right side and facing the closed north side door of the bathroom. South side door open with wheelchair in the doorway. Resident had her house shoes and grippy socks on. The toilet was empty, and clothing was on. No signs of injury noted, and resident denied any pain. Resident Description: The resident reported that she slid to the floor while trying to self-transfer back to her wheelchair from the toilet. The resident states she was trying to pull her pants up all the way when she started sliding to the floor and landing on her right side. Resident denied hitting head and any injury or pain. The I/A Report dated 9/20/24 was deemed incomplete because R54's Mental Status and the level of pain were not assessed. The I/A Report noted: Resident attempted to transfer herself without assistance from toilet to wheelchair. There was no statement from the nursing assistant assigned on where the assigned Staff was during the fall and what interventions were put in place to avoid reoccurrences and prevent the potential for serious injuries to occur post-fall. During the interview with Nurse Manager JB, she indicated that most falls are caused by R54, forgetting that she needs to ask for help and assistance. Nurse JB stated that R54 needs monitoring and supervision. R54 thinks she can be independent. R54 wants to go home in assisted living. Nurse JB that they continue to educate and remind R54 to keep interventions in place. On 10/3/24 at 12:00 PM, the facility's Abuse Prohibition Policy had specified Reports and Investigations, dated 9/30/2024, was reviewed. It indicated: The facility Quality Assurance Performance Improvement Committee will investigate occurrences, patterns, and trends that may indicate the presence of abuse, neglect, or misappropriation of guest/resident property and to determine the direction of the investigation/intervention through analysis of systems, audits, and reports. 2. Identification through the safety program begins with the Incident Report. 3. The Director of Nursing and Administrator review all incident reports to identify and further investigate any suspicious incidents . The Director of Nursing and Administrator review all incident reports to identify and further investigate any suspicious incidents. E. Investigation: . 2. The Director of Nursing or designee will complete an assessment of guest(s)/resident(s) and document findings in the medical record. 3. An Incident Report (and/or grievance forms per state-specific requirements) will be completed. 4. The licensed Nurse will: a. Notify the physician if required b. Notify the family member/responsible party/emergency contact/legal guardian (not necessarily all individuals) 5. A preliminary, on-site investigation will be initiated within twenty-four (24) hours of any report. 6. The Administrator or Director of Nursing/designee shall initiate the Incident and Accident Investigation Form (or other grievance forms per state specific guidelines) and take the following actions to ensure that the investigation is conducted effectively . 37771 Resident #212: A review of Resident #212's medical record revealed an admission into the facility 9/24/24 with diagnoses that included fusion of spine lumbar region, chronic pain, polyneuropathy, cervical disc disorder with myelopathy, and fusion of spine cervical region. Further review of the medical record revealed the resident needed substantial/maximal assistance for bathing, toilet hygiene, and lower body dressing and partial/moderate assistance for upper body dressing, transfers with slide board, and toilet transfers. On 9/30/24 at 10:32 AM, an observation was made of Resident #212 propelling himself in a wheelchair and getting on the elevator. The Resident reported to people in the vicinity to be careful because he was not a pro on maneuvering the wheelchair and said it was his first time up. Staff were in the hallway and around the nurse's station. The Resident got in the elevator. The Resident was not gone long, came back up, got off the elevator, said forgot my collar, and propelled himself back to his room. Staff did not stop the Resident from leaving the unit without his cervical collar on. On 9/30/24 at 10:42 AM, an observation was made of Resident #212 sitting in his wheelchair in their room after returning to the room from the elevator. The Resident was interviewed, answered questions and engaged in conversation. The Resident reported he didn't have his neck brace on and indicated he was to wear a collar when out of bed, a cervical collar and engaged in conversation about the surgery he had on his neck. The Resident said he had gotten downstairs, and they told him he forgot his collar and came back up to have it put on. The Resident was asked how he got up into the wheelchair and he explained that staff helped him use the slide board for transfer to his wheelchair. The Resident was asked if staff had offered to put the C-collar on, and he indicated they did not, and he forgot. On 10/2/24 at 3:35 PM, an interview was conducted with the Director of Nursing (DON) regarding Resident #212's lack of having a C-collar on while out of bed and if the Resident needed assistance with care. The DON reported that the Resident did need assistance with care and that he should have the C-Collar on when out of bed. The DON reviewed the Resident's medical record and indicated the order was to encourage the C-collar when out of bed. A review of Resident #212's orders revealed an active order dated 9/24/24 C collar to be worn when out of bed, every shift for post neck surgery. The Resident's care plan revealed, Focus: ADL: (Resident's name) has a functional ability deficit and requires assistance with self care/mobility R/T (related to): multiple back surgeries. C-Collar when out of bed, initiated 9/24/24 and revision on 9/26/24. One of the Interventions included Encourage C-collar when out of bed, initiated on 9/26/24. A review of the Kardex revealed, Resident Care . Encourage C-collar when out of bed.

Based on observation, interview and record review, the facility failed to maintain the kitchen and food preparation equipment in a sanitary condition and ensure clean and ready-for-use kitchen equipment was air dried properly, resulting in an increased potential for food borne illness, potentially affecting 60 residents of a census of 62 residents who consume oral nutrition from the facility kitchen. Findings Include: Review of the U.S. Public Health Service 2009 Food Code, as adopted by the Michigan Food Law, effective October 1, 2012, directs those physical facilities shall be cleaned as often as necessary to keep them clean, food equipment was to be dried in a manner that leaves no water left inside prior to storage, and ready-to-eat foods shall be clearly marked at the time the original container is open if held for more than 24 hours. Observation was done on 10/1/24 at 10:06 a.m., accompanied by Dietary Manager/RD E. The following were observed during the initial kitchen tour done on 10/1/24: -At 10:07 a.m., the large can opener had an excessive amount of dried on food and rust-like on the blade and the surrounding area. -The plate warmer, steam table and prep table all had dried on food particles. -The oven sides were found to have dried on drippings with dried on food. -The clean and ready for use Robot Coupe food processor was found with the top on and there was an area on the top of the attachment that was wet with a dark brown substance on it. -The liquid coffee maker had dried on black thick substance on the nozzle. -The cooler had dried on drips on the sides and front. -A total of 5 stacked, clean and ready for use plate covers were found wet inside of one another. -A total of 2 black plate covers in the plate warmer were found to have dried on food particles on them. -The microwave was found to have dried on food inside on the top and sides. -The floor on the side of the oven was found to have dust and dirt on it. Review of the facility kitchen cleaning duties (un-dated), revealed the coffee pot was to be cleaned on Tuesday, the steam table on Thursday, and the stove on Tuesday. During an interview done on 10/1/24 at 10:40 a.m., Dietary Manager E said she had to get staff to clean more.

Based on observation, interview and record review, the facility 1) Failed to ensure the dignity and privacy of one resident (Resident #265) while doing a bed bath, and 2) Failed to ensure that one resident (Resident #212) had their call light within reach, resulting in the likelihood for shame, embarrassment, anger towards staff, feeling of isolation and fear of not having a readily available call light. Findings Include: Resident #265: Review of the Face Sheet, physician orders dated 9/21/24 through 10/1/24, and care plans dated 9/21/24 through 9/26/24, revealed Resident #265 was [AGE] years-old, admitted to the facility on [DATE], alert and able to make healthcare decisions, and dependent on staff for assistance with Activities of Daily Living (ADL). The resident was dependent on oxygen at 2 liters and his diagnosis included, encephalopathy (swelling of the brain), muscle weakness, high blood pressure, Atrial Fibrillation, sepsis, anemia, heart failure, acute respiratory failure, urinary tract infection, history of lung cancer, pleural effusion, end stage renal disease and dependent on renal dialysis. Review of the resident's Respiratory and ADL care plans dated 9/24/24, revealed chronic respiratory failure with oxygen use, weakness, and the need for staff assistance with ADL's (including bathing). Observation was made on 10/1/24 at 9:02 a.m., revealed Nursing Assistant/CNA F was giving the resident a bed bath. The following are the steps done during the resident's bed bath: -Gave wash cloth to resident to wash his face. -Took brief off, washed bottom and dried bottom. -Washed peri area. -Put depends on resident, washed under his arms and top chest area. -Grabbed his shirt from closet and put on him. -After shirt put on went back to closet, got sweat pants and put them on the resident. -Touched bed controls to raise the head of the bed. -Tied the dirty linen bag, got into second drawer of bedside stand and got toothbrush, basin and tooth paste out for resident and gave it to him. -Left resident's room and walked down the hallway and went into the soiled utility room. -No cover, blanket, cover or bath blanket was on resident during the entire bed bath. During the above entire process, the same gloves were left on CNA F, she did not remove gloves, nor wash her hands the whole time she gave ADL care. No cover was put on the resident at all; dignity was not protected during his bed bath while 2 people were in the room performing and observing the bed bath. Review of the facility Resident Dignity & Personal Privacy policy dated 3/28/24, stated Drape and dress residents appropriately at all times to avoid exposure and embarrassment; maintain resident privacy during toileting, bathing and other activities of personal hygiene, use a top sheet or bath blanket as a cover-up during bedside care. Review of the facility CNA orientation (un-dated), revealed new CNA's are educated on Residents Rights, Abuse, Dignity, and demonstration of bed bath. 37771 Resident #212: A review of Resident #212's medical record revealed an admission into the facility 9/24/24 with diagnoses that included fusion of spine lumbar region, chronic pain, polyneuropathy, cervical disc disorder with myelopathy, and fusion of spine cervical region. Further review of the medical record revealed the resident needed substantial/maximal assistance for bathing, toilet hygiene, and lower body dressing and partial/moderate assistance for upper body dressing, transfers with slide board, and toilet transfers. On 10/1/24 at 9:42 AM, an observation was made of the Resident sitting on the side of his bed. The Resident was interviewed, answered questions and engaged in conversation. The Resident was observed to be sitting on the side of the bed facing away from the door. The Resident had pants on that were not pulled up but positioned on his thighs and his brief he had on was exposed. The Resident could be seen from the hallway with the curtain not pulled to provide the Resident privacy. When asked the Resident reported he had been waiting for staff to come back and help him into his wheelchair. When asked how long staff had left him, the resident was unsure and stated, It hasn't been too long. Staff had not been seen exiting the room when the Resident's room was approached and there was not staff at or around the Resident's room at that time. The Resident reported he had to wait for staff to return to get into the wheelchair. An observation was made of the Resident's call light not in reach and was positioned on the floor at the head of the bed. On 10/1/24 at 9:45 AM, after the conclusion of the interview with Resident #212, Nurse M who was down the hallway at the medication cart was informed of the Resident's call light on the floor. When queried, the Nurse reported the call light should be in reach for the Resident and went to place the call light in reach for the Resident. A review of facility policy titled, Call Lights, dated 12/16/21, revealed, Policy: Call lights will be placed within the guest's/resident's reach and answered in a timely manner. Procedure: .3. When a guest/resident is in bed or confined to a chair be sure the call light is within easy reach of the guest/resident .

Based on observation, interview and record review, the facility failed to up-date person-centered comprehensive care plans to ensure that a shaving preference was identified for one resident (Resident #20) and a transfer status was updated for one resident (Resident #212) of 17 residents reviewed for care plans, resulting in the potential for Residents' needs not being met, frustration, Resident #20 not shaved to their preference and Resident #212 not assisted with getting out of bed during the weekend. Findings include: Resident #20: A review of Resident #20's medical record revealed an admission into the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, limitations of activities due to disability, lung cancer, muscle weakness, dementia, disorientation, and need for assistance with personal care. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status score of 7/15 that indicated moderately impaired cognition, and the Resident needed partial/moderate assistance with personal hygiene. On 9/30/24 at 10:09 AM, an observation was made of Resident #20 sitting up in bed with the head of the bed elevated. The Resident was asked questions, answered simple questions and engaged in limited conversation with understanding of what the Resident was saying to take extra time. An observation was made of the Resident with facial hair covering his cheeks, chin, upper lip and neck. The Resident was asked if he liked having a beard. The Resident rubbed his cheeks, chin and indicated he didn't like it this long. When asked if he refused when they offered, the Resident reported he would not say no and stated, I don't like the beard. On 10/2/24 at 10:15 AM, an observation was made of Resident #20 lying in bed with the head of the bed elevated. The Resident continued to have facial hair that had not been shaven from the observation made on 9/30/24. The Resident was asked about his preference for having a beard and the Resident stated, Yeah, I want this off. The Resident stated, Someone was supposed to do it, rubbed his beard on his cheeks up to his ears and was talking but what was said was not completely understandable. The Resident indicated he was waiting to get a shower. On 10/2/24 at 2:19 PM, an interview was conducted with the Director of Nursing (DON). When asked about facility policy of facial hair shaving, the DON reported that it depends on their preference. The DON was asked about Resident #20's preference and how would staff know what the Resident's preference was. The DON indicated that the Kardex would contain that information. When asked to look on the Kardex, the DON stated, I don't see it documented, but it could be in his care plan, and reported she would follow up with Resident #20 on his preference. The care plan was reviewed with the DON. The care plan did not have the Resident's preference for the ADL (activities of daily living) activity of shaving. When asked if the care plan should have the Resident's preference, the DON stated, Yes we usually care plan it, it should be in there. On 10/2/24 at 4:16 PM, the DON reported that she had addressed the concern of the lack of Resident preference on shaving on the care plan. The DON reported that the resident likes to be clean shaven at least every 3 days. The DON reported she had updated the care plan and had it trigger to the Kardex. Resident #212: A review of Resident #212's medical record revealed an admission into the facility 9/24/24 with diagnoses that included fusion of spine lumbar region, chronic pain, polyneuropathy, cervical disc disorder with myelopathy, and fusion of spine cervical region. Further review of the medical record revealed the resident needed substantial/maximal assistance for bathing, toilet hygiene, and lower body dressing and partial/moderate assistance for upper body dressing, transfers with slide board, and toilet transfers. On 9/30/24 at 10:42 AM, Monday, an observation was made of Resident #212 sitting in his wheelchair in their room after returning to the room from the elevator. The Resident was interviewed, answered questions and engaged in conversation. The Resident reported he didn't have his neck brace on and indicated he was to wear a collar when out of bed. The Resident reported it was his first time getting up into the wheelchair and was figuring out how to wheel his wheelchair. When asked when he had arrived at the facility, the Resident responded he had gotten here on Tuesday. The Resident was asked why this was the first time out of bed. The Resident stated, I didn't get up on the weekend because they didn't know if I could or not. The Resident reported he got up with the slide board with staff this morning and had not gotten up through the weekend. The Resident reported wanting to stand up on his own over the weekend and stated, It's hard to just lay in the bed, just couldn't take it. The resident reported they didn't have an order for what I could do. On 10/2/24 at 3:35 PM, an interview was conducted with the Director of Nursing (DON) regarding Resident #212 not getting out of bed on the weekend. The DON reported that there was a communication form that was to be provided between therapy and nursing and that she had not received the communication. The DON reported that she had asked on Monday for the form from the Therapy department regarding the transfer status. The DON indicated that the form was dated 9/26, which was a Thursday, and indicated the Resident was to be a slide board transfer and a drop arm commode toilet, nursing had not received the updated transfer status determined by the Therapy evaluation and the DON stated, We had some conversation about process improvement, and reported that once they had the conversation, they looked at the process to see how they can improve so it does not happen again. The Resident did not have the change made until Monday, 9/30/24, when the therapy evaluation determined the updated transfer status of the Resident was completed on 9/26/24 with the Resident not getting out of bed through the weekend. On 10/3/24 at 10:11 AM, an interview was conducted with the Therapy Director -- regarding Resident #212 not being assisted out of bed over the past weekend. The Therapy Director indicated that the therapy evaluations had been completed on 9/25/24 for OT (Occupational Therapy) and PT (Physical Therapy) on 9/26/24 and the interventions on transfer status was left in the DON's mailbox and also give to the MDS Nurse on Friday morning, 9/27/24. A review of Resident #20's care plan revealed a focus for ADL (Activities of Daily Living) with interventions for Transfer: Resident requires partial/moderate assistance of one staff and slideboard; and Toilet Transfer: Resident requires partial/moderate assistance of one staff with slideboard and bariatric drop arm commode, with revision dated on 9/30/24. A review of the facility policy titled, Care Planning, revised 6/24/21, revealed, Purpose: Every resident in the facility will have a person-centered Plan of Care developed and implemented that is consistent with the resident rights, based on the comprehensive assessment that includes measurable objectives and time frames to meet a residents medical, nursing, and mental and psychosocial needs identified in the comprehensive assessments and prepared by an interdisciplinary team who includes but not limited to; attending physician, .the resident or resident representative, therapy staff as required and any other ancillary staff. Additional resources will also be utilized to ensure that any additional needs or risk areas are identified . 7. The care plan must be specific, resident centered, individualized and unique to each resident .

Based on observation, interview and record review, the facility failed to: (1) Ensure that infection rates were identified in the monthly infection control reports from June 2022 through August 2023, (2) Ensure that recommendations for staff education was noted on the reports (no peri-care education for trending urinary trat infections) and (3) Ensure that infection control policies and procedures were reviewed annually, resulting in the likelihood for increased rate of infections, prolonged illness and the lack of updated policies and procedure guidance for staff members. Findings include: Record review of the facility 'Infection Prevention Program Overview' policy, dated 9/9/2022, revealed the next policy review should have been on 9/9/2023. The policy revealed that the infection prevention and control program (IPCP) must include, at a minimum, the following elements: Investigates, identifies, prevents, reports and controls infections and communicable diseases. The administrator is ultimately responsible for the infection prevention program. Infection Preventionist responsibilities include collecting, analyzing, and providing infection data and trends to nursing staff and healthcare practitioners. Providing education and training; implementing evidence-based infection control practices including those mandated by regulatory and licensing agencies. Infection Prevention Committee meets on a regular basis as a component of the QAPI committee, which meets on a monthly basis and provides input and direction for the infection prevention program. Policies and procedures relating to infection prevention are approved by the committee. Reports of infections are presented to the committee which recommends actions and control measures . At the beginning of the Infection Control survey task on 9/14/2023 at 9:18 AM with the Director of Nursing (DON)/Infection Preventionist (ICP) the State surveyor requested three policies: Infection Prevention Program overview, Standard Precautions, Hand hygiene. The DON/ICP printed the policies from the policy directory off the computer. All three policies were last reviewed on 9/9/2022 and the next review date was 9/9/2023. Observation on 09/13/23 03:15 PM of room [ROOM NUMBER], a private room with single bed- bathroom across from the window with large Broda chair in front of bathroom door, with a large step on trash bin near entrance door, there was no hand sanitizer noted in room, or in the Isolation caddy over the entrance room door with gowns & gloves. In an interview and record review on 09/14/23 at 09:18 AM, the Director of Nursing (DON)/Infection Preventionist (ICP) revealed that 'yes I am all those jobs and more'. The DON/ICP revealed that she started the position on 9/19/2022, and the prior DON was also the ICP, I took over October 2022 as ICP and as DON. The state surveyor inquired about residents of concern identified by the survey team: Discussion on 09/14/23 at 09:27 AM of Resident #54 was in contact precautions for multi-drug resistance organism (MDRO), was noted with caddy over the door that had supplies, but no hand sanitizer noted in the room or in the isolation caddy. Closest hand sanitizer in the hallway was noted across and down the hall at the nursing station. Resident #3 was placed on Contact isolation due to Nurse Practitioner thought the resident had Shingles. Resident was in isolation during the weekend and then the physician saw the resident on Tues 9/12/2023 and cleared her. The Isolation was for Three and half days. The Resident #3 was on Was on Cyclovir (antiviral) medication, and the isolation was stopped, but continued the medication per physician order. Record review on 09/14/23 at 09:40 AM with the Director of Nursing (DON)/Infection Preventionist (ICP) revealed infection control monthly summaries from June 2022 (last recertification survey) through August 2023. The June 2022 infection control monthly report noted no census or infection rates for the month for urinary tract infections, respiratory infections, skin, etc Facility acquired infections (HAI), or community acquired infection (CAI) rates. Record review of the July 2022 infection control tab in the infection control binder revealed no typed-up summary notes or infection rates. The DON reviewed the binder and did not find a monthly meeting summary or sign in sheet for the meeting. Record review of the August 2022 Infection control monthly meeting summary report noted 7 (seven) residents on antibiotics for blood/staph infection, peg tube infection, and UTI's (Urinary Tract Infections). There were no in-facility acquired or community acquired infection rates identified on the monthly summary report. Infection Control education noted enhanced precautions new policy for all nursing staff. There were no educations related to peri care or hand hygiene noted. Record review of the October 2022 infection control monthly summary noted 12 infections. Seven (7) courses identified, and facility acquired, and Five (5) courses identified as community acquired, there were no infection rates identified in the summary report. Identified trends were antibiotic trends for UTI's (Urinary Tract Infections). There were no recommendations for staff education related to the UTI trend. Record review of the November 2022 infection control monthly summary report revealed fifteen (15) resident infections. Eleven (11) courses of antibiotic usage as in-facility acquired and four (4) courses of antibiotic use as community acquired. There were no in-facility acquired or community acquired infection rates identified on the monthly summary report. Identified trend for skin issues in November ranging from surgical to cellulitis. Recommended staff education was sepsis training for nurses. There were no recommendations for skin assessment or care education. Record review of the infection control meeting dated 1/19/2023 for the December 2022 infection control monthly summary report revealed eleven (11) residents received antibiotics. There were six (6) in-facility acquired infections and five (5) community acquired infections. There were no in-facility acquired or community acquired infection rates identified on the monthly summary report. Identified trends noted more skin related issues in December ranging from surgical prophylaxis to on-going treatment for slow healing. Education recommendations were Covid-19, personal protective equipment (PPE), hand hygiene and testing. Record review and interview of the infection control meeting dated 2/16/2023 for the January 2023 infection control monthly summary report revealed 10 resident received antibiotics. there were ten (10) in-facility acquired infections and four (4) community acquired infections. There were no in-facility acquired or community acquired infection rates identified on the monthly summary report. The DON/ICP was asked how she knows the rate of infection for urinary tract infection acquired within the facility from her report? and the DON stated that she would have to review her data. Record review of the infection control meeting dated 8/10/2023 for the July infection control summary report revealed eleven (11) residents received antibiotic use. five (5) were in-facility acquired and one resident received three different topical antifungal treatments. In an interview on 09/14/23 at 12:20 PM, the Director of nursing/Infection Control Preventionist was asked how much time is sent on the Infection Control program per week. The DON/ICP stated that she does work a 40-hour week and spent a least 10-20 hours a week on Infection Control program. 37771 Observation of Transmission-Based Precautions: On 9/12/23 at 4:22 PM, an observation was made in room [ROOM NUMBER]. The room was for single occupancy and had transmission-based precautions sign on the door that indicated the Resident was on contact precautions. Personal protection equipment (PPE) was available on the door. Upon entrance, an observation was made of the Resident laying in bed. An interview was conducted with the Resident. After the completion of the interview, an observation was made of the bathroom across from the Resident and was not readily accessible due to a chair and overbed table in the vicinity of the door to the bathroom. PPE was removed at the doorway to the hall and deposited in the receptacle for discarded PPE. There was no hand sanitizer accessible prior to leaving the room and the bathroom with the sink to wash hands was not readily accessible without moving resident items and their chair. Hand sanitizer was not accessible in the PPE holder on the door or directly outside the Resident's door.

Based on observation, interview and record review, the facility failed to secure a treatment cart with prescribed topical medications and refrigerated narcotic medications in an appropriate manner, resulting in the likelihood for drug diversion or ingestion of unlocked medications. Findings include: Record review of the facility 'Medication/Treatment Cart Use', dated 8/15/2023, revealed the nursing staff uses of medication/treatment cart to systematically distribute physician ordered medications to residents. Security: The medication/treatment cart and its storage bins are kept locked until the specified time of medication/treatment administration. If an emergency occurs during the medication/treatment pass, the nurse securely locks the medication/treatment cart before attending to the emergency situation . Observation and interview on 09/14/23 at 07:39 AM on the Second-floor resident living unit, the State surveyor observed the Treatment Cart to be unlocked, sitting in the hallway and accessible to the cognitively impaired residents that reside upon the unit. Registered Nurse A was in the hallway walking around and was stopped by State surveyor to observed treatment cart. State surveyor was able to access/open all drawers of treatment cart. Observation of the treatment cart revealed: prescription medications of creams and ointments. Resident #70- tube of Ketoconazole 2% cream for face and arms every shift for rash. Resident #70 was discharged [DATE] to hospital ER for eval. Active order starts 9/6/2023. Resident #33- tube of Lidocaine 2.5%/ Prilocaine cream for left upper thigh one time a day every Tues, Thurs, and Saturday dependence on dialysis. Last dose 9/14/2023@5:00 AM. Resident #48- tube of Santyl 250 unit/gram/30 grams (Collagenase) for left lateral diabetic ulcer. Resident #55- tube of Ketoconazole 2% cream to face for rash discontinued on 8/31/2023. Last dose 8/20/2023. Medication still in the treatment cart. Resident #60- tube of Nystatin 100,000 unit/gram/15 grams topical to vaginal folds every day and night. Resident #43- tube of Diclofenac Sodium 3% for right shoulder osteoarthritis pain. Observation of opened large volume Dankins solution 1/4 strength multi-dose bottle in bottom drawer, with manufactures date of 5/2024 there was no open date noted on the bottle. Observation and interview on 09/14/23 at 7:46 AM with Licensed Practical Nurse (LPN)/Unit Manager/Wound Care Nurse B approached the treatment cart and noted the surveyor reviewing prescription medication creams and ointments. The State surveyor inquired if the treatment cart should have been left unattended and unlocked? LPN A stated that the treatment cart should not be left unlocked, and that she had not used the cart yet that day. LPN A stated that the floor nurses also use the cart, any nurse can use the cart. Second floor nurses were asked about the treatment cart. At 7:48 AM Licensed Practical Nurse (LPN) C and at 7:50 AM Licensed Practical Nurse (LPN) D were both asked if they had used the treatment cart, and both denied using the cart and had just started their shifts. Was the treatment cart left unlocked since night shift??? no one knew. 37771 Narcotic Storage: On 9/14/23 at 12:18 PM, medication storage and labeling was reviewed with Nurse C of the medication room with the Omnicell that holds prescriptions medication that can be accessed by a computer to obtain necessary medications for Residents. The medication room was located behind the nurses' station and was locked. An observation was made of two vials of Ativan 2 mg (milligrams)/ml (milliliters) in a removable locked plastic box in an unlocked medication refrigerator. The locked plastic box was not secured inside the refrigerator. Nurse C was asked about the narcotic count and reconciliation of the Ativan. The Nurse reported that the Ativan was part of the Omnicell and that pharmacy takes care of that. The Nurse indicated the key to the box with the Ativan was in the Omnicell with a computer to access the contents and sign out the medication with a key from the Omnicell. When asked if the Ativan was counted between shifts, the Nurse reported they do not count the Ativan during narcotic counting between shifts. Pharmacist P was in the medication room at the time and reported that other facilities that he goes to secure the narcotic box to the refrigerator or have another lock on the refrigerator. When asked when the Ativan was monitored, the Pharmacist reported that he comes once a month to reconcile the medications which includes the narcotics and the Ativan in the refrigerator. Unit Manager, Nurse B was asked about the reconciliation of the Ativan in the refrigerator and how did the facility ensure that the Ativan was accounted for on a regular basis when the box can be removed out of the refrigerator. The Nurse reported they will address securing the box in the refrigerator or count the narcotic on the shift change and stated, I see what you mean, it is not counted and the whole box can be removed from the refrigerator. On 9/14/23 at 1:48 PM, a review of the narcotic medication Ativan in the refrigerator of the medication room and not secured or reconciled at the change of shifts was reviewed with the Director of Nursing. The Director of Nursing indicated they were securing the box that held the Ativan inside the refrigerator. A review of facility policy titled, Storage and Expiration Dating of Medications, Biological's, revision date 8/7/23, revealed, .Store all drugs and biological's in locked compartments, including the storage of Schedule II-V medications in separately locked, permanently affixed compartments, permitting only authorized personnel to have access .

Based on interview and record review, the facility failed to provide documentation of adequate notice of non-coverage for Medicare Part A benefits for two residents (Resident #174 and Resident #175) of 3 residents reviewed for notice of non-coverage of Medicare Part A benefits, resulting in the residents' inability to exercise the right to file an appeal in a timely manner. FACILITY Beneficiary Notification: Resident #174: A record review of the Face Sheet and Minimum Data Set (MDS) assessment indicated Resident #174 was admitted to the facility on [DATE] with diagnoses left femur fracture repair, weakness, heart failure, atrial fibrillation, hypertension, arthritis, GERD, anxiety and depression. A review of the progress notes revealed Resident #174 was discharged home on 1/16/2023. A review of a facility document titled Notice of Medicare Non-Coverage provided, The effective date Coverage of your current skilled stay services will end: 1/15/2023. Your Medicare provider and/or health plan have determined that Medicare probably will not pay for your current skilled nursing services after the effective date indicated above. You may have to pay for any services you receive after the above date. You have the right to an immediate, independent medical review (appeal) of the decision to end Medicare coverage . Please sign below to indicate you received and understood this notice. I have been notified that coverage of my services will end on the effective date indicated on this notice and that I may appeal this decision by contacting my QIO. The form for Resident #174 was not signed or dated that it was received and reviewed by the resident or her representative. A review of the progress notes for Resident #174 did not indicate the resident had received and signed a notification that their skilled Part A services would be discontinued. Resident #175: A record review of the Face Sheet and Minimum Data Set (MDS) assessment indicated Resident #175 was admitted to the facility on [DATE] with diagnoses: Dementia, anxiety, depression weakness, fracture of sacrum, and urinary tract infection. A review of the progress notes revealed Resident #175 was discharged home on 4/7/2023, per a facility Discharge Summary document. A review of a facility document titled Notice of Medicare Non-Coverage provided, The effective date Coverage of your current skilled stay services will end: 4/9/2023. Your Medicare provider and/or health plan have determined that Medicare probably will not pay for your current skilled nursing services after the effective date indicated above. You may have to pay for any services you receive after the above date. You have the right to an immediate, independent medical review (appeal) of the decision to end Medicare coverage . Please sign below to indicate you received and understood this notice. I have been notified that coverage of my services will end on the effective date indicated on this notice and that I may appeal this decision by contacting my QIO. The form for Resident #175 was not signed or dated that it was received and reviewed by the resident or her representative. A review of the progress notes for Resident #175 did not indicate the resident had received and signed a notification that their skilled Part A services would be ending. During an interview with the Administrator on 9/14/23 at 10:54 AM, Beneficiary Notifications were reviewed. Three residents were reviewed and 2 (#'s 174 and 175) of 3 residents did not have signed notices that skilled services would be discontinued. The Administrator said the Business office Manager was responsible for the process and was reeducated on the process to ensure the residents/representatives received the notice in the appropriated timeframe and the form was signed completed. A review of the facility policy titled, Notice of Medicare Non-Coverage (NOMNC) CMS Form 10123 and Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) Form CMS-10055, dated origination 9/1/2022 and last revised 10/17/2022 provided, It will be the policy of the facility to issue Notices of Medicare Non-Coverage )NOMNC) to all Resident on Medicare Part A Medicare Advantage Programs, and Medicare Part B/Medicare Advantage B therapies. This will give the Resident/Guest or Responsible Party advanced notice so a decision on non-coverage they must contact the Quality Improvement Organization (QIO) that is responsible for reviewing the decision. The Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) and the Advance Beneficiary Notice (ABN) will offer the Resident/Guest or Responsible Party the option of agreeing or disagreeing with the decision . Notice of Medicare Non-Coverage (NOMNC): The NOMNC, Form CMS-10123 is given by the facility to all Medicare beneficiaries at least two days before the end of a Medicare covered Part A stay or when all of Part B therapies are ending .

Based on observation, interview and record review the facility failed to implement a comprehensive care plan for one resident (Resident #70) of 19 residents reviewed for care plans, resulting in Resident #70 lacking a urinary catheter securement device. Findings Include: Resident #70: Urinary Catheter or UTI A record review of the Face Sheet and Minimum Data Set (MDS) assessment indicated Resident #70 was admitted to the facility on [DATE] with diagnoses: recent history of pulmonary embolism, diabetes atrial fibrillation, heart failure, hypertension, deep vein thrombosis left lower extremity, weakness, morbid obesity, chronic kidney disease. On 8/8/2023 diagnosis of chronic ulcer let thigh and left lower leg and on 8/32023 a diagnosis of urinary retention was added. A review of the MDS assessment date 8/3/2023 revealed the resident had full cognitive abilities with a Brief Interview for Mental Status (BIMS) score of 14/15. The MDS also revealed the resident needed assistance with all care, but was able to feed self with set up assistance. On 9/12/2023 at 2:08 PM, during a tour of the facility, Resident #70 was observed in her room lying in bed. She had an indwelling urinary catheter/ Foley catheter, with clear yellow urine in the tubing. She was asked if she had a securement device such as a leg strap to aid in preventing the catheter from pulling or dislodging and she stated, No, I don't. A review of the physician orders revealed, CATHETER: 18Fr Foley Catheter with 10cc balloon r/t (related to) acute urinary retention, dated 8/4/2023. A review of the Care Plan for Resident #70 provided: (Resident #70) is at risk for urinary tract infection and catheter-related trauma: has indwelling catheter related to acute urinary retention, date initiated 8/3/2023 and revised 8/4/2023 with Interventions: Ensure catheter tubing is secured, date initiated 8/3/2023. On 9/14/2023 at 11:57 AM, the Director of Nursing/DON was interviewed related to Resident #70's indwelling urinary catheter without a securement device. She said the resident was transferred to the hospital on 9/13/2023 for abnormal laboratory values including an elevated white blood cell count. The DON said she was looking for a larger/bariatric Foley securement device for the resident. A review of the facility policy titled, [NAME] Procedures- Indwelling urinary catheter (Foley) care and management, dated reviewed 12/02/2022 provided, . Assess the securement device daily . If a securement device isn't available, use a piece of adhesive tape to secure the catheter .

Based on observation, interview and record review, the facility failed to correctly identify an intravenous (IV) catheter to ensure appropriate care and maintenance of the catheter for one resident (Resident #15) of 3 residents reviewed for IV catheter use, resulting in the potential for Resident #15 to not receive the necessary care and services needed to prevent a decline in condition. Findings include: Resident #15: A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #15 was admitted to the facility on [DATE] with several discharges and readmissions with the most recent readmission of 9/11/2023 with diagnoses: Osteomyelitis (bone infection), pressure ulcer left buttock healed, bipolar disorder, right knee and ankle contractures, kidney stones, history of a stroke, diabetes, chronic kidney disease, peripheral vascular disease, heart failure, anxiety, depression, COPD, supra pubic catheter (a catheter through the abdomen into the bladder to drain urine). The resident was discharged to the hospital on 9/1/2023 for a change of condition with decreased responsiveness and returned on 9/11/2023 with diagnoses: SIRS (Systemic Inflammatory Response Syndrome), a new right nephrostomy (a catheter tube from the kidneys to the outside of the body). During a tour of the facility on 9/12/23 at 1:17 PM, Resident #15 was observed lying in bed watching TV. He indicated he had an IV in his right upper arm. He lifted his sleeve and showed the clear dressing and right midline IV. In large letters across the tape on the IV it said 9/6 Midline in large black letters. The resident said he was receiving IV antibiotics but he didn't know why. A review of the hospital discharge summary from the hospital indicated the resident was there from 9/1/2023 to 9/11/23 for a urinary tract infection that advanced to SIRS (systemic inflammatory response syndrome). The resident received an IV antibiotic in the hospital and was to continue the antibiotic at the facility via the midline IV catheter. Further review of the hospital discharge summary for Resident #15's stay from 9/1/2023 to 9/11/2023, identified the following: Nursing Midline Insertion Note: Date of Service September 6th, 2023 at 5:00 PM . Indication for Midline Placement: Antibiotics (intravenous) . Device Type: Bard Power Glide, 18g, Number of Lumens: Single, Total Midline length (cm): 10 . right upper arm; Vein of insertion: cephalic . A review of the physician orders for Resident #15 at the facility provided the following: Change transparent dressing to PICC (peripherally inserted central catheter) . 9/12/2023 Measure PICC catheter length . 9/12/2023 A review of the Care Plan for Resident #15 provided, (Resident #15) is at risk for complications of IV therapy: Antibiotics via PICC line; PICC line is in right upper arm, date initiated 9/11/2023 and revised 9/12/2023, with Interventions including: Observe for s/sx of infection at the PICC site: . date initiated 9/11/2023 and revised 9/12/2023. The Care Plan did not mention the resident had a Midline catheter not a PICC line. A review of the nursing progress notes did not mention what type of IV catheter Resident #15 had, including a provider progress note on 9/12/2023 at 00:00 hours (12:00 AM) or a Nursing Summary dated 9/12/2023 at 1:14 AM, . readmitted from hospital via EMS . Resident on antibiotic Meropenem . The nurses were documenting that Resident #15 had a PICC line, but he did not. He had a Midline catheter inserted for IV antibiotic therapy. PICC and Midline Catheters: What they are and what to expect- What is a PICC? A Peripherally Inserted Central Catheter (PICC) is a small flexible tube that is inserted into a vein on the inside of your upper arm. A PICC extends into the large central vein that returns blood to your heart . PICC's are used for patients who need: Long-term access to veins . What is a Midline Catheter? A Midline Catheter is a small flexible tube that is shorter than a PICC. It is inserted in the same vein location as a PICC, but it only extends to a point just below the level of your armpit. It is not a central venous catheter (CVC). A midline Catheter does not provide ongoing blood access. It cannot be used for some medicines . Midline Catheters are used for patients who need: Short-term IV access . some types of medicines . short-term IV fluids . University of [NAME] Medical Center,,, reviewed 03/2016. CDC: Centers for Disease Control and Prevention: Infection Control-Summary of Recommendations: Edited February 2017, Guidelines for the Prevention of Intravascular Catheter-Related Infections (2011); 1. Education, Training and Staffing: Educate healthcare personnel regarding the indications for intravascular catheter use , proper procedures for the insertion and maintenance of intravascular catheters . Periodically assess knowledge of and adherence to guidelines . Designate only trained personnel who demonstrate competence for the insertion and maintenance of peripheral and central intravascular catheters . Select catheters on the basis of the intended purposed and duration of use . CDC: Centers for Disease Control and Prevention: Infection Control, November 5th, 2015, Background Information: Catheter Types: Guidelines for the Prevention of Intravascular Catheter-Related Infections (2011),Table 1. Catheters Used for Venous and Arterial Access, . Midline catheters, Inserted via the antecubital fossa into the proximal basilic or cephalic veins; does not enter central veins, peripheral catheters; Length 3-8 inches . Peripherally inserted central venous catheters (PICC); Inserted into basilic, cephalic or brachial veins and enter the superior vena cava, > than or = to 20 cm (approximately 9.09 or greater inches) . On 9/13/23 at 3:17 PM, upon review of the medical record, Resident #15 had documentation that the nurse was working on a transfer for a change of condition. On 9/13/2023 at 3:55 PM, spoke with Charge Nurse Q she said she was working on sending the resident to the hospital because he threatened to harm himself and stated, That is not like him. Upon observation the resident had a nurse aide sitting with him; she said she just came into his room. The resident had his eyes half open, with pursed lip breathing. He did not respond to voice with his name called loudly. This surveyor went out and told the charge nurse, at the nurses desk/down the hallway, who was also assigned to care for the resident. She went to see him and he was awake, responding/slowly talking to the nurse. The nurse aid said she also left the room and told another nurse to come in and see him, and that nurse had just left the room. The charge nurse left the room, the resident said physically he did not feel good and stated, My gut is super sore, rubbed his stomach. The nurse aide showed his lower abdomen with supra pubic catheter site with dry gauze dressing dated 9/13/2023. The resident stated, My back, the nephrostomy is new, I've only had it a few days, it hurts. It's swollen up like a football. On 9/14/23 at 2:16 PM, interviewed the Director of Nursing/DON related to the nurses charting PICC line assessments and orders, when the resident has a Midline IV in his right upper arm. Reviewed with the DON the IV dressing had Midline written across the top of the IV dressing on 9/12/2023 and the transfer orders from the hospital on 9/11/2023 have a document detailing the type of IV Midline and when it was inserted with additional details from the nurse who inserted the IV. Also reviewed, the nurses needed to know which IV catheter Resident #15 had as Midline catheters are intended for use up to 30 days and PICC lines for longer use. Midline catheters are not appropriate for all medications and should not be used for blood draws. The DON said she was not aware that the nurses had not identified the appropriate catheter for Resident #15. A review of the facility policy titled, Midline Catheter Flushing and Locking, date revised July 1, 2012 provided, To be performed by: Licensed nurses according to state law and facility policy. The nurse is responsible and accountable for obtaining and maintaining competence with infusion therapy within his or her scope of practice . Specific flush/lock orders must be obtained, documented, and submitted to the pharmacy . The sequence of flushing, clamping, and disconnecting of the normal saline syringe should be performed according to the manufacturer of the needleless connector . A prescriber order is required to flush/lock a midline catheter . Only 10 ml barrel diameter syringes or larger will be used to flush/lock catheters .

Based on observation, interview and record review, the facility failed to prevent the development of a Stage II (blister) heel pressure ulcer for one resident (Resident #49) of 3 residents reviewed for pressure ulcers, resulting in a Stage II heel pressure ulcer, pain, discomfort, agitation, and wound treatments. Findings include: Stage two pressure ulcer is partial-thickness skin loss involving epidermis or dermis, or both. The ulcer is superficial and presents as an abrasion, shallow center, or blister. High risk resident (immobile, bed bound) should be assessed weekly, when a condition change or as needed and preventive measures should be in place including pressure relieving devices, position changes, and dietary supplements. National Pressure Ulcer Advisory Panel (NPIAP). Record review of the facility 'Skin Management' policy, dated 12/15/2023, revealed it is the policy that the facility should identify and implement interventions to prevent the development of pressure injuries. Guest/residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated, and provided appropriate treatment to promote prevention and healing. Resident #49: Record review of Resident #49's Significant Change Minimum Data Set (MDS) dated [DATE] noted an elderly female with Brief Interview of Mental Status (BIMS) of 6 out of 15, severe cognitive impairment. Section I: Active diagnosis revealed non-traumatic brain dysfunction, arthritis, osteoporosis, non-Alzheimer's dementia, anxiety, depression, difficulty walking, need for assistance with personal care, and muscle weakness. Weight was noted at 152 pounds. Section M: Skin conditions noted the Resident #49 to be at risk of developing pressure ulcers/injuries. There were no pressure ulcers/injuries noted at that time. Record review on 09/12/23 at 03:29 PM of the facility- provided CMS 802 form/document identified a facility-acquired Stage II pressure ulcer for Resident #49. Record review of Resident #49's weights for six-month review revealed that on 6/3/2023 weight of 152.4 pounds. On 7/2/2023 Resident #49's weight was taken 3 times by the registered dietitian: 138.8, 139.0, 139.0 were all a 13-pound loss in weight, with 8.9% loss. Record review of Resident #49's nutritional care plans noted no changes or added interventions to support the resident's change. Record review of Resident #49's weight log dated 9/6/2023 noted weight of 133.6 pounds another 5.25% weight loss. Record review of Resident #49's 'Wound & Skin Evaluation' assessment form, dated 9/8/2023 at 10:49 AM, revealed a new blister to the right medial heel that was in-house acquired measuring 5.1 cm (centimeter) in length and 4.6 cm in width with erythemia (bright red skin). Intervention of heels up cushion added to residents plan of care. Observation and interview on 09/13/23 at 07:19 AM with Licensed Practical Nurse (LPN)/Wound Care Nurse B noted that Resident #49 was lying in bed. Resident #49 gave consent to have right heel wound observed. There was no dressing in place. The State surveyor observed red blister area of the right heel. LPN B stated that they found the blister on Friday 9/8/23, it has not broken open and reabsorbed. LPN B Estimated measurements are weekly with photos with skin assessments. LPN B stated that the facility did not know where the wound came from, stating 'we just don't know where it came from'. An interview and record review on 09/14/23 at 01:49 PM with the Director of Nursing (DON) of Resident #49's pressure ulcer to right heel, revealed the skin injury started on 9/8/2023 and that the DON did see it (the left heel) that day, it looked like a blister fluid filled. The DON stated that the skin injury was in fact a pressure injury, staged at level II (2), and was in-house acquired. The DON stated the Resident #49 was on the radar, she had weight loss. We have spoken to family member about possible hospice and notify family of the blister and weight loss, and that the registered dietitian would review the diet. The DON stated that the pressure ulcer came from the mattress and the way she lays in the bed and not being changed in position.

Based on observation, interview and record review, the facility failed to ensure Enteral nutrition (tube feeding/nutrition through a feeding tube into the stomach or intestines) formula was provided as ordered for one resident (Resident #56) of 2 residents reviewed for enteral nutrition, resulting in the potential for Resident #56 to not receive the appropriate amount of Enteral formula. Findings Include: Resident #56: Tube Feeding A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #56 was admitted to the facility on [DATE] and discharged and readmitted several times with the most recent readmission on 1/6/2023 with diagnoses: Encephalopathy, anxiety, depression, urinary retention, gastrostomy tube for enteral nutrition, dementia, history of a stroke, GERD, hypertension, aphasia (absence of speech) and dysphagia (difficulty talking). The MDS assessment dated [DATE] revealed the resident's cognitive status could not be evaluated and he needed assistance with all care. On 9/12/23 at 1:46 PM, during a tour of the facility, Resident #56 was observed lying in bed. His bed was positioned with the head of the bed facing the wall and the resident was watching television on the nightstand. An enteral nutrition bottle/tube feeding, of Nepro 1.8 cal, was hanging on an IV pole. It was not running. The tube feeding bottle said it was hung at 0800 (8:00 AM) on 9/12/23 at 66 ml/hr. There was approximately 860 ml in the bottle. That was approximately 140 ml that the resident had received since 8:00 AM that morning. A review of the physician orders for Resident #56 provided, Enteral feed: Two times a day Nepro via PEG (feeding tube), 66 ml over 20 hours. Provides 2400 kcal, 107 g protein, 966 ml water. Total volume of 1320 ml, dated 1/6/2023. A review of the September, 2023 Medication Administration Record and Treatment Administration Record/MAR/TAR, for Resident #56 revealed, Enteral Feed Order: Two times a day Nepro via PEG, 66 ml over 20 hours. Provides 2400 kcal, 107 g protein, 966 ml water. Total volume of 1320, start date 1/6/2023. On the Hours column of the MAR/TAR it said 1300 (1:00 PM) and 1700 (5:00 PM). The nurses placed their initials at each time daily. There was no indication what 1300 and 1700 meant. It was unclear what time the tube feeding started or stopped. On 9/12/2023 at 4:29 PM the Registered Dietitian/RD G was interviewed related to the tube feeding/enteral nutrition order for Resident #56. The order was reviewed and she was asked what time the tube feeding was started and stopped. She reviewed the order specifics and said she wasn't sure, but it was to run for 20 hours. On 9/12/2023 at 4:45 PM, interviewed the Director of Nursing and RD related to the enteral nutrition/tube feeding received by Resident #56. The DON said the MAR/TAR identified the tube feeding was taken down at 1:00 PM and started at 5:00 PM for a run time of 20 hours. Reviewed that this was not written on the MAR/TAR, it simply said 1300 and 1700. Reviewed with the DON that the bottle of Nepro for Resident #56 indicated in writing that it was hung on the IV pole and started at 8:00 AM, as a new bottle of 1000 ml of Nepro. It was written on the bottle that it was to run at 66 ml/hr. Upon view at 1:46 PM, the bottle showed approximately 860 ml of Nepro remained in the bottle: approximately 140 ml. If the tube feeding was administered as ordered at 66 ml/hr, it would have run from 8:00 AM to 1:00 PM: 5 hours at 66 ml/hr was 330 ml of Nepro that the resident would have received. The DON was asked why the resident did not receive the necessary amount of nutrition and she said she would check on it. A review of the progress notes on 9/12/2023 at 4:00 PM, did not identify a note explaining why the resident did not receive the appropriate amount of nutrition. A review of the progress notes for Resident #56 on 9/13/2023 identified a late entry note written on 9/12/2023 at 4:44 PM by Nurse B for 9/12/2023 at 12:30 PM. It revealed, Changed peg tube at this time due to peg tube plug came off and needed it replaced. Resident tolerated with no complaints of pain. No signs or symptoms of distress noted. Placement checked and peg tube flushed with no difficulty. The DON did not mention or reference this when interviewed on 9/12/2023 at 4:45 PM. On 9/14/2023 at 2:00 PM, during an interview with the DON about Resident #56, she said the facility was working on clarifying the physician orders for Resident #56's tube feeding/enteral nutrition to clearly identify when the resident was to begin receiving the enteral nutrition and when it was to stop. The DON did not mention the feeding tube had been changed or how long it took to change it. She was asked for clarification related to the amount of enteral nutrition the resident received and said they were working on it. A review of the facility policy titled, Enteral Nutrition, origination 3/1/2013 and revised 6/24/2022 provided, Guests/residents maintain acceptable parameters of nutritional status . Each guest/resident is provided with sufficient fluid intake to maintain proper hydration and health. Guests/residents who are unable to feed themselves receive the necessary services to maintain good nutrition, including at times, enteral nutrition . Upon admission or after an enteral tube has been placed, the facility's clinical nutrition staff will evaluate the guest/resident for nutrition and fluid needs and recommend the appropriate enteral formula and rate to the physician . Documentation elements: Type, amount, rate of feeding formula, residual amounts, weights, patency, intolerance, condition of stoma site and oral hygiene.

Based on observation, interview and record review, the facility failed to properly identify, assess, manage, document, prevent development, and treat skin conditions for two residents ( Resident #47 and Resident #52) of five residents reviewed for pressure injury, resulting in residents developing Stage 4 pressure injuries ( Resident #47) and developing a deep tissue injury (Resident #52) and suffering pain, hospitalization s, and surgical debridement. Findings include: Resident #52: According to admission face sheet, Resident #52 was a [AGE] year-old female, admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to Minimum Data Set (MDS) dated [DATE], Resident #52 was scored 13 on the Cognition Assessment, indicating intact Cognition. According to the MDS, Resident #52 required two staff assistance with bed mobility and transfers, and one staff assistance with toileting. On 06/06/22 at 03:20 PM Resident #52 was observed in bed sleeping, positioned on her back. On 06/07/22 11:05 AM Resident #52 was observed being cleaned by staff in her bed. Heel protecting boots were noted on resident's feet. Skin and Wound evaluation dated 5/5/22 had a following assessment: pressure wound to sacrum, unstageable- obscured full-thickness skin and tissue loss (therefore depth cannot be measured), present on admission, area measures 5.3 x 14.0 x 0.1 cm (length x width x depth), with 20% granulation, present on admission. No other wounds were described. Care Plan for Resident #52 dated 5/4/22 had the following: Focus- Resident has actual impairment of skin integrity r/t pressure injury to sacrum, unstageable, present on admission, 5/25/22 noted deep tissue injury to left and right heel (initiated on 5/4/22, revision on 5/26/22). Goal- will have no complications r/t pressure injury of the sacrum through the review date (initiated on 5/4/22, revision on 5/18/22). Skin injury of the left and right heel will show signs of healing by review date (initiated on 5/26/22). Interventions: -Apply positioning pillow to offload pressure area while in bed as allows (initiated on 5/4/22, revision on 6/4/22). -Bilateral proof boots or elevate heels while in bed (initiated on 5/26/22). -Educate resident/family/caregivers of causative factors and measures to prevent skin injury (initiated on 5/5/22). - Encourage good nutrition and hydration in order to promote healthier skin, provide dietary supplement as ordered (initiated on 5/5/22). -LTC 105 mattress (initiated on 5/5/22). -Observe location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to physician (initiated on 5/5/22). -Provide incontinent care and use moisture barrier treatment as needed after incontinent episodes (initiated on 5/5/22). - ROHO in wheelchair when up as resident allows (initiated on 5/5/22). -Treatment as ordered (initiated on 5/5/22). -Turn and reposition as required and resident allows (initiated on 5/4/22). -Utilize draw sheet or pad for turning and repositioning in bed (initiated on 5/5/22). -Wound team to follow as needed (initiated on 5/5/22). Review of the treatments administered in May 2022 for Resident #52 revealed the provider skin treatment orders: Observe area to Left heel every day and PRN for increased pain, drainage, swelling, redness or change in appearance, apply lotion every day and as needed, every day shift for deep tissue injury. Start date 5/25/22, discontinued date 5/31/22 and Observe area to Right heel every day and PRN for increased pain, drainage, swelling, redness or change in appearance, apply lotion every day and as needed, every day shift for deep tissue injury. Start date 5/25/22, discontinued date 5/31/22. During interview with Nurse B on 6/14/22 at 2:30 PM she stated that Resident #52 came to facility with a sacral wound, however resident did not have heels skin issues on admission. Nurse B said Resident #52 developed deep skin injury to her heels in a facility. Policy for Skin Management revised on 7/14/22 was provided by the facility and was reviewed. Policy indicated: It is a policy that the facility should identify and implement interventions to prevent development of clinically unavoidable pressure injuries. Guests/residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated, and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation are provided to ensure optimal guest/resident outcomes. Under section Practice guidelines of the Policy the following statement was found: 13. Guest's/resident's with pressure injury and lower extremity ulcers will be evaluated, measured, and staged weekly (pressure injury and vascular ulcers only) in accordance with the practice guidelines until resolved. According to International NPUAP/EPUAP (National Pressure Ulcer Advisory Panel/ European Pressure Ulcer Advisory Panel; a group of experts who serve as the authoritative voice in pressure injuries) defined pressure injury stages. (A) Stage I-nonblanchable [CONDITION(S)]. (B) Stage II-partial thickness skin loss with exposed dermis. (C) Stage III-full-thickness skin loss. (D) Stage IV-full-thickness skin and tissue loss. (E) Unstageable pressure injury-obscured full thickness skin and tissue loss. (F) Deep tissue pressure injury-persistent non-blanchable deep red, maroon, or purple discoloration. (2016 NPUAP Pressure Injury Staging Illustrations from http://www.npuap.org/resources/educational-and-clinical-resources/pressure-injurystagingillustrations/. Used with permission of the National Pressure Ulcer Advisory Panel March 2018. © NPUAP.) Nursing and Patient Care Considerations: Prevent Pressure Ulcer Development- 1. Provide meticulous care and positioning for immobile patients. (a.) Inspect skin several times daily. (b.) Wash skin with mild soap, rinse, and pat dry with a soft towel. (c.) Lubricate skin with a bland lotion to keep skin soft and pliable. (d.) Avoid poorly ventilated mattress that is covered with plastic or impermeable material. (e.) Employ bowel and bladder programs to prevent incontinence. (f.) Encourage ambulation and exercise. (g.) Promote nutritious diet with optimal protein, vitamins, and iron. Resident #47: On 6/6/22 at 3:36 PM, Resident #47 was observed in their room in the facility, sitting in a wheelchair with both of their feet positioned on the floor. Both of Resident #47's lower extremities were dark purple- red in color. The skin on both of Resident #47's lower extremities were shiny with a taut appearance and observable [CONDITION(S)] (swelling). Their right lower extremity was visible more edematous than their left. An interview was completed with the Resident at this time. When queried regarding the reason for their admission to the facility, Resident #47 revealed they fell at home, fractured their right leg, had to have surgery, and came to the facility for therapy. When queried if they had any wounds, Resident #47 indicated they had developed a sore on their heel at the facility. Resident #47 also indicated they had an area on their bottom. Resident #47 was wearing shorts with Croc style slip on shoes and a wound dressing was not observed. When asked, Resident #47 revealed staff were no longer putting a dressing on the wound. When queried regarding the [CONDITION(S)] in their legs, Resident #47 implied their legs swell frequently because they have heart failure. Resident #47 was then queried how often they sit up in their wheelchair and revealed they sit in the chair all day. When asked if they elevate their legs, Resident #47 indicated they did not and that they did not have a chair available to recline and elevate. Record review revealed Resident #47 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact, required extensive to total assistance to perform Activities of Daily Living (ADLs) with the exception of eating, and had a stage II pressure ulcer. A review of Resident #47's prior MDS assessment submission documentation detailed the following: - 11/18/21 Admission MDS Assessment: At risk for pressure ulcer development but did not have any pressure ulcers - 12/2/21 Discharge MDS Assessment: One Unstageable pressure ulcer - 2/15/22: Quarterly MDS Assessment: One stage II and one Unstageable pressure ulcer Review of Resident #47's census and clinical admission documentation revealed the Resident was admitted to the facility from the hospital on 11/12/21, tested positive for Covid-19 and subsequently transferred to a Covid-19 hub on 12/2/21, and readmitted to the facility on [DATE]. Facility provided CMS- 802 form revealed Resident #47 had a stage II pressure ulcer but did indicate the pressure ulcer was facility acquired. Review of documentation in Resident #47's Electronic Medical Record (EMR) detailed the following: - 11/12/21 at 7:16 PM: Nursing Comprehensive Evaluation . Admission . Skin . Right knee . Dressing clean, dry, and intact with cast from heel to above knee/mid-thigh . Has cast to mid-thigh on right leg. sutures of incision site are intact, no s/s of infection noted at incision site. non weight bearing of right leg . - 11/15/21 (Physician) Progress Notes: Date of Service: 11/15/21 . Visit Type: Acute . New admit . reports discomfort where the bottom of the cast presses against Achilles tendon . right leg with rigid cast from mid-thigh to ankle, anterior portion of cast with window cut out and ACE wrap covering knee. Bottom edge of cast is pressing on Achilles tendon - no skin breakdown noted . Some irritation from cast where it presses over the right Achilles tendon . no skin breakdown or redness noted . - 11/17/21 (Physician) Progress Notes: Date of Service: 11/17/21 . Visit Type: Follow Up . continues to report that the cast is rubbing against Achilles tendon and is sore . - 11/19/21 at 6:16 PM: Total Body Skin Assessment . Number of new skin conditions: 0. Comments: Resident has no redness noted does have a long leg cast with a window by knee. toes are pink and warm and blanche well . - 11/22/21 (Physician) Progress Notes: Date of Service: 11/22/21 . Visit Type: Follow Up . continues to experience discomfort where the bottom of cast presses on right Achilles tendon .tolerating leg cast, continues to report soreness in right Achilles tendon where edge of the cast presses on the tendon . Skin: warm and dry, early skin breakdown over right Achilles tendon where cast is pressing into tendon - beginning of small ulceration noted, no drainage or evidence of infection . - 11/24/21 (Physician) Progress Notes: Date of Service: 11/24/21 . Visit Type: Follow Up . (+) skin breakdown over right Achilles tendon where cast is pressing into tendon - ulceration noted, no drainage or evidence of infection . right leg with rigid cast from mid-thigh to ankle, anterior portion of cast with window cut out and ACE wrap covering knee. Bottom edge of cast is pressing on Achilles tendon - evidence of skin breakdown . Nursing staff state they have tried to pad the cast and to support pts (patients) right heel to minimize pressure from cast. They have also attempted to have pt (patient) lie on right or left hip to offload heel and Achilles . Skin breakdown becoming more significant on exam today - facility to call ortho office to request recommendations . - 11/26/21 at 6:16 PM: Total Body Skin Assessment Late Entry . Number of new skin conditions: 0 . skin breakdown over right Achilles tendon where cast is pressing into tendon - ulceration noted, no drainage or evidence of infection-to follow up with ortho on suggestions to offload pressure . - 11/29/21: Report of Consultation . Ortho . See Wound Care. Change Ankle bandages twice a day . - 11/29/21 at 2:00 PM: Nurses Notes . Resident returned from ortho appointment . Ortho redid cast and noted a new wound on heel area. new orders noted . - 11/29/21 at 4:53 PM: Skin & Wound Evaluation . Pressure . Unstageable . Slough and/or eschar . Right heel . In-House Acquired . How long has the wound been present? Exact Date: 11/29/21 . Measurements . Length: 1.8 cm (centimeters) . Width: 2.9 cm . Depth: 0.6 cm . Undermining: 1.7 cm . Wound Bed: Slough . Exudate: Moderate . Serosanguineous . Treatment: Dressing . Intact . Notes: Resident had cast removed 11/29/21 and noted new area on right heel. Wound Dr. evaluated during wound rounds. Wound unstageable and continue with calcium alginate with silver pad and wrap . Resident needs encouragement . to keep leg elevated . Plan of care evaluated and updated. Ortho replaced the cast with a shorted (sic) cast but the bottom of cast is putting pressure on leg also. Padding applied . An image of the wound was included with the Skin and Wound Evaluation documentation. The wound bed was not obscured by the cast. - 12/9/21 at 5:02 PM: Nursing Comprehensive Evaluation . Admission . Skin . Right heel open unstageable area to heel. exposed tendon. cast is covering part of wound . - 12/10/21 at 2:07 PM: Skin & Wound Evaluation . Pressure . Unstageable . Slough and/or eschar . Right heel . Acquired . 11/29/21 . Measurements . Length: 3.4 cm . Width: 1.7 cm . Depth: 1.0 cm . Undermining: None . Wound Bed: Slough . Exudate: Moderate . Serosanguineous . readmitted and note area on right heel getting worse. Wound unstageable An image of the wound was included with the Skin and Wound Evaluation documentation. The cast was present in the image but was not obscuring the wound bed. - 12/15/21 at 2:29 PM: Skin & Wound Evaluation . Pressure . Unstageable . Slough and/or eschar . Right heel . Acquired . 11/29/21 . Measurements . Length: 4.8 cm . Width: 4.8 cm . Depth: 1.0 cm . Undermining: 1.4 cm . Wound Bed: Slough . Exudate: Moderate . Serosanguineous . Progress: Deteriorating . Cast was removed and continue with current treated . Ortho replaced the cast with a brace . An image of the wound was included with the Skin and Wound Evaluation documentation. Resident #47's Achilles tendon was visible in the wound bed image. - 1/13/22 at 7:06 AM: Skin & Wound Evaluation . Pressure . Unstageable . Slough and/or eschar . Right heel . Acquired . 11/29/21 . Measurements . Length: 4.0 cm . Width: 4.4 cm . Exudate: Moderate . Serosanguineous . -2/3/22 at 7:16 AM: Skin & Wound Evaluation . Pressure . Stage II . Right heel . Acquired . 11/29/21 . Measurements . Length: 3.2 cm . Width: 3.0 cm . Exudate: Moderate . Serosanguineous . -3/3/22 at 7:01 AM: Skin & Wound Evaluation . Pressure . Stage II . Right heel . Acquired . 11/29/21 . Measurements . Length: 1.9 cm . Width: 2.3 cm . Exudate: Light . Serosanguineous . - 5/5/22 at 7:11 AM: Skin & Wound Evaluation . Pressure . Stage II . Right heel . Acquired . 11/29/21 . Measurements . Length: 0.9 cm . Width: 1.7 cm . Area scabbed over. New treatment noted left open to air . - 5/17/22 at 3:42 PM: Resident At Risk Reviewed Clinical Indicator: Healing Pressure injury to right heel. Treatments continue as ordered, elevation of foot, continue to be followed by ortho . getting up daily in wheelchair with encouragement . - 6/2/22 at 7:39 AM: Skin & Wound Evaluation . Pressure . Stage II . Right heel . Acquired . 11/29/21 . Measurements . Length: 0.6 cm . Width: 0.5 cm . Exudate: Light . Serosanguineous . Should be resolving soon . Encouragement to keep leg elevated and noted to use pillow to elevate leg/heel . On 6/13/22 at 11:09 AM, Resident #47 was observed in their room, sitting in their wheelchair with their feet positioned on the floor. An interview was completed at this time. When queried if staff complete wound care treatments on their heel, Resident #47 replied, Sometimes. Resident #47 was asked about elevation of their right leg when they had the cast in place on their leg, Resident #47 revealed they had to be in bed to put their leg up. Resident #47 indicated it was uncomfortable when staff would place a pillow under the cast because of how long the case was and the lack of support. Resident #47 was then queried if the facility offered them a recliner and/or other adaptive devices to assist with positioning and reduce the pressure from the cast and revealed they did not. Review of Resident #47's care plans revealed a care plan entitled, (Resident #47) has an actual impaired skin integrity related Site: Right Heel pressure injury . (Initiated: 11/29/21; Created: 12/2/21). The care plan included the interventions: - Conduct skin assessment weekly and measure area(s) and document characteristics (Initiated: 11/29/21; Created: 12/2/21) - Consult wound team as ordered (Initiated: 11/29/21; Created: 12/2/21) - Elevated heel when in bed as allows (Initiated: 4/5/22) - Observe for signs of discomfort with dressing changes and administer pain medication as ordered (Initiated: 11/29/21; Created: 12/2/21) - Treatment as ordered (Initiated: 11/29/21; Created: 12/2/21) (Initiated: 11/29/21; Created: 12/2/21) (Initiated: 11/29/21; Created: 12/2/21) A second care plan entitled, (Resident #47) is at risk for impaired skin integrity/pressure injury R/T (related to) debility, surgical repair of right knee (Initiated: 12/10/21; Created: 11/12/21). The care plan included the intervention, Encourage to float heels while in bed and assist as needed (Initiated: 11/12/21; Created and Revised: 11/15/21) On 6/13/22 at 11:25 AM, an interview was completed with Registered Nurse (RN) G. When queried regarding Resident #47's pressure ulcers, RN G indicated the Resident had one ulcer on their right heel which was now open to air. RN G revealed the Resident had a cast on their leg which caused the pressure ulcer. When queried if the ulcer was visible Resident #47's cast was in place, RN G revealed it was. When queried regarding interventions in place to prevent pressure when the cast was in place, RN G indicated staff were assisting the resident to elevate their leg in bed. RN G was asked if that reduced how that reduced pressure due to the location of the wound and was unable to provide an explanation. An observation of the wound was completed with RN G at this time. RN G did not perform hand hygiene upon entering Resident #47's room. RN G donned gloves, removed the Resident's slip-on shoe, and assisted the Resident to raise their leg. A dark red colored area with a while-colored tissue was present on the back of Resident #47's right lower extremity, over the distal area of Achilles tendon. A pencil tip, open area was present in the center of the wound. When asked if the wound bed was blanchable, RN G pressed the area. No blanching was observed and confirmed by RN G. An interview was completed with Certified Nursing Assistant (CNA) H on 6/13/22 at 11:27 AM. When queried regarding Resident #47's pressure ulcers, CNA H revealed they were not aware of the Resident having any pressure ulcers. When queried regarding interventions to prevent pressure ulcer development for the Resident during their stay at the facility, CNA H revealed they were unaware of any specific interventions for the Resident. When queried if they recalled Resident #47 having a cast on their leg, CNA H indicated they did. An interview was completed with Unit Manager/Wound Care Licensed Practical Nurse (LPN) B on 6/13/22 at 3:29 PM. When queried if Resident #47's right lower extremity was facility acquired, LPN B replied, Kind of. LPN B was asked what they meant and stated, The cast was resting where the pressure was, and we couldn't get to it. When queried if nursing staff were able to visualize the pressure ulcer LPN B replied, Eventually. LPN B was asked when the wound was first identified and after reviewing Resident #47's EMR stated 11/29/22. LPN B stated, Knew about area because (Resident #47) was complaining of pain and irritation. When queried why there was physician documentation of early breakdown in the area on 11/22/21 when the wound was not assessed and identified by the facility until 11/29/21, LPN B was unable to provide an explanation. When asked about the wound progress, LPN B stated, The tendon was visible in November (2021). When queried if a pressure ulcer with a visible tendon was a stage II, LPN B stated, No, it's a stage 4. LPN B was then asked if the pressure ulcer had been surgically debrided and revealed it had not. When queried why the stage of the pressure ulcer was changed in the medical record from an unstageable to a stage II, LPN B indicated it was changed because the wound improved. When asked if they were aware that pressure ulcers always remain documented at the highest stage unless surgically debrided, LPN B revealed they were not. With further inquiry regarding the pressure ulcer and interventions implemented/actions taken by the facility, LPN B indicated the Resident's orthopedic provider was contacted when the wound was observed. When queried regarding the date the provider was contacted, LPN B revealed they did not recall and had not documented the information. LPN B revealed a shorted cast was placed when the Resident was seen in the orthopedic surgeon's office. LPN B continued that the shorten cast did not reduce pressure on the area because the cast slid down. Review of Resident #47's Treatment Administration Records (TAR) for November and December 2021 were reviewed and revealed documentation of completion of all treatments on the Resident's right heel. When queried regarding how treatments were completed if the cast had slid down, LPN B was unable to provide an explanation. When queried regarding the reason no interventions were implemented in the seven days from initial skin breakdown on 11/22/21 to open wound on 11/29/22, LPN B revealed they had attempted to contact the Resident's orthopedic surgeon. When asked why the pressure ulcer was not identified as facility acquired on the CMS-802, LPN B replied, It happened here.

Based on observations, interviews, and record reviews, the facility failed to prevent the development of a Stage IV pressure ulcer for one resident (Resident #33) of three residents reviewed for pressure ulcers and care, resulting in the development of a Stage IV pressure ulcer of the sacrum for Resident #33, which required multiple treatments to the area. Findings include: The facility 'Skin Management' Policy, dated as revised 10/2019, documented: It is the policy that the facility should identify and implement interventions to prevent the development of clinically unavoidable pressure injuries. Guests and residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated, and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluations provided to ensure optimal guest/resident outcomes . Resident #33: According to admission face sheet, Resident #33 was an [AGE] year-old female who was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set ( MDS) indicator, Resident #33 had Brief Interview for Mental Status (BIMS) score of 13, indicating minimal cognition impairment. The facility- developed care plan for Activities of Daily Living (ADL), indicated Resident #33 required an extensive two-person assist from staff for bed mobility, transfers, dressing, personal hygiene, bathing and toileting needs. On 3/30/21 at 10:24 AM, during the initial screening of Resident #33, Resident #33 appeared to be laying flat on her back. Upon further observation, Resident #33 was noted to have a pillow placed under her left hip area, but the pillow appeared to raise Resident #33 off the bed only slightly. The pillow appeared to be flattened down significantly. Resident #33 did have her heels up on a pillow. Resident #33 was asked if she got the wound while in the facility or was admitted with it. Resident #33 said that she had a wound along time ago, but it had been healed for a long time, and this one happened after she got real sick with Covid around May 2020. A second observation was made on 3/30/21 at approximately 2:10 PM. Resident #33 appeared to be resting in the exact same position. A third observation was made on 3/30/21 at 4:10 PM. Resident #33 appeared to be in the same position as observed on the previous two occasions. Observation of wound care was done on 3/31/21 at 10:30 AM, with Licensed Practical Nurse T. LPN T entered the room, sanitized her hands, supplies were set up, washed her hands again, donned gloves and proceeded to do the wound care to the sacral area for Resident #33. LPN T removed the old dressing to sacral area. Resident #33 was observed to have a large open wound to the sacrum with, what appeared to be, an area of muscle and bone exposed. The wound base appeared to have about 10-20 percent of scattered yellowish/white stringy slough noted. The surrounding skin had old scar tissue from previous pressure ulcers, which was pink in nature. There was some moderate drainage noted to the old dressing which had been packed into the wound base. LPN T cleansed the wound, applied the treatment as ordered, covered the dressing with an ABD pad, and secured it with border foam. Resident #33 had been pre-medicated with pain medications prior to wound care and she tolerated the procedure. LPN T put barrier cream around the surrounding tissue during the dressing change. After care was completed, Resident #33 was positioned onto her right side by LPN T and another staff member. Review of the MDS, dated [DATE], documented No to pressure ulcers, Stage I or higher, and that Resident #33 was at risk for developing pressure ulcers. Review of the MDS, dated [DATE], documented No to pressure ulcers, Stage I or higher, and that Resident #33 was at risk for developing pressure ulcers. Review of the MDS, dated [DATE], documented Yes to pressure ulcers, and listed one Stage III pressure ulcer. Review of the MDS, dated [DATE], documented Yes to pressure ulcers, and listed one Stage III pressure ulcer. Review of the MDS, dated [DATE], documented Yes to pressure ulcers, and listed one Stage III pressure ulcer. Review of the MDS, dated [DATE], documented Yes to pressure ulcers, and listed one Stage III pressure ulcer. According to the Skin Observation Tool in Point Click Care (PCC), used to document weekly skin checks by nurses, the PCC Skin Assessment, dated 4/7/20, documented No to open areas. Review of the PCC Skin Assessments dated 4/14/20, 4/21/20, 4/28/20, 5/5/20, and 5/12/20, documented that Resident #33's skin was intact with no new skin issues. Review of the PCC Skin Assessment, dated 5/19/20, documented No new skin issues, treatment to coccyx ongoing. Review of the Treatment Acceptance Record (TAR), dated 4/28/20, documented Apply [MEDICATION(S)] cream to coccyx and buttocks twice daily every shift. Review of the TAR, dated 5/08/20, documented a treatment initiated for the coccyx/sacral wound: Cleanse with normal saline, dry, apply skin prep to periwound, apply [MEDICATION(S)] to wound bed, pad and protect daily q shift and prn. This treatment was discontinued 5/19/20. Review of the TAR, dated 5/22/20, documented a treatment initiated for the coccyx/sacral wound: Cleanse with normal saline, dry, skin prep to periwound, apply silverabsorb gel and collagen to wound bed, pad and protect daily q shift and prn. This treatment was discontinued 5/28/20, and a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the TAR, dated 1/02/21, documented a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the TAR, dated 3/19/21, documented a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This was the treatment that LPN T had followed upon observation of the wound by the Surveyor. Review of facility care plans for Resident #33 revealed a 'Skin' care plan, created on 5/8/2020, with a revision on 3/11/21, which documented: Resident has an actual impaired skin integrity related to Stage 4 pressure injury to coccyx/sacrum. One intervention was to: Turn and reposition as required, and When resident chooses not to reposition as often as needed, explain consequences and continue to attempt to get to comply. Review of a Physician's Progress note, dated 3/16/21, documented Skin, warm and dry to touch. No staff available to assist. Unable to turn pt (patient) to examine sacral wound. Pressure Ulcer sacral Region Stage 4, Sacral wound progressed from a Stage III to IV last week and continues to appear breaking down. An addendum was added to end of the progress note, This Stage 4 sacral wound has a large amount of malodorous sanguineous drainage. There is 60 percent black and yellow with undermining from 6-3 o'clock measuring 2.3 cm (centimeters). Depth is 2.5 cm. There is also a tunnel today at 8:00 measuring 3.4 cm; there is palpable bone to this area. Remaining wound is pink and granular in appearance. The wound has gotten worse. Review of a nurse's progress note, dated 3/17/21, documented, Resident declined to participate in evening social distance group program as she was in bed and did not want to get back up Review of other nurses' progress notes for a six-month period did not reveal any documentation that Resident #33 refused to be repositioned while in bed. An interview was conducted with the Director of Nursing on 4/1/21, at 2:36 PM regarding the wound to the sacrum for Resident #33. The DON stated that Resident #33 was admitted to the facility back in 2016, with pressure ulcers and the facility had healed them. The DON indicated the area on the sacrum opened sometime in November 2019, was a Stage II and then healed. The DON stated that the wound is currently now a Stage IV. The DON stated that Resident #33 was possibly going onto Hospice Services soon. The DON stated that Resident #33, at times, refused to let staff roll her. The DON indicated Resident #33 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] The DON was shown that, according to the MDS data going back 10 months prior to the wound re-opening in May of 2020, Resident #33's skin was documented as intact and no pressure ulcers were noted. The DON indicated that when Resident #33 got sick with Covid-19 in May of 2020, her skin re-opened and that she was aware that Resident #33's skin had been closed for almost a year. The DON was asked how it could be that the skin was documented as being intact on the MDS, dated [DATE], and on the PCC Skin Assessments dated 4/14/20, 4/21/20, 4/28/20, 5/5/20, the skin was documented as being intact with no new skin issues. On the MDS, dated [DATE], a Stage III pressure ulcer to the sacrum was noted In a time period of 14 days Resident #33's skin went from intact skin to a Stage III pressure ulcer. The DON stated that she was not sure. The DON stated that Resident #33 had Macerated Associated Skin Damage caused by incontinence from urine. The DON was asked that if the wound progressed to a Stage III pressure ulcer and was being macerated by urine, why the facility did not get a doctor's order to insert a Foley Catheter to protect the wound from urine. The DON indicated she just was not comfortable with Foley catheters. The DON was asked if they attempted to use a wound vacuum to the area when it was getting worse. She stated, No, the facility did not attempt that as well. The DON indicated that it (the pressure ulcer) was unavoidable due to Resident #33's noncompliance and conditions. The DON was asked to provided documented refusals from the front lines that Resident #33 was refusing care. The DON only provided a couple of notes that Resident #33 was refusing her breakfast and a couple of dietary notes of Resident #33 only accepting few bites here and there and liquids at times. At the end of the survey, The DON provided a large stack of documents and asked the Surveyor to review them. The documents did not refute the assertion that Resident #33 refused to be repositioned by nursing staff. The National Pressure Ulcer Advisory Panel/European Pressure Ulcer Advisory Panel (NPUAP/EPUAP), a group of experts who serve as the authoritative voice in pressure injuries, defines pressure ulcer stages as follows: (A) Stage I-nonblanchable [CONDITION(S)]. (B) Stage II-partial thickness skin loss with exposed dermis. (C) Stage III-full thickness skin loss. (D) Stage IV-full thickness skin and tissue loss. (E) Unstageable pressure injury-obscured full thickness skin and tissue loss. (F) Deep tissue pressure injury-persistent non-blanchable deep red, maroon, or purple discoloration. (2016 NPUAP Pressure Injury Staging Illustration from http://www.npuap.org/resources/educational-and-clinical-resources/pressure-injury-stagingillustrations/. Used with permission of the National Pressure Ulcer Advisory Panel March 2018. NPUAP.) Nursing and Patient Care Considerations: Prevent Pressure Ulcer Development-1. Provide meticulous care and positioning for immobile patients. (a.) Inspect skin several times daily. (b.) Wash skin with mild soap, rinse, and pat dry with a soft towel. (c.) Lubricate skin with a bland lotion to keep skin pliable. (d.) Avoid poorly ventilated mattresses that is covered with plastic or impermeable material. (e.) Employ bowel and bladder programs to prevent incontinence. (f.) Encourage ambulation and exercise. (g.) Promote nutritious diet with optimal protein, vitamins, and iron.

This Citation pertains to Intake Number MI 408. Based on observation, interview and record review, the facility is placed in Immediate Jeopardy due to the facility's failure to 1) Ensure adequate supervision to prevent recurring falls for one resident (Resident #3), 2) Identify the root cause of falls and implement or maintain effective interventions to reduce the risk for falls for two residents (Resident #3 and Resident #4), 3) Identify a change of condition and modify safety interventions, as necessary, to prevent falls for one resident (Resident #3), 4) Assess and treat one resident (Resident #4) in a timely manner after a fall, and 5) Investigate a fall for one resident (Resident #1) of four residents reviewed for falls, resulting in 1) hospitalization for a closed head fracture and subsequent death for Resident #3, 2) delayed identification and treatment of [REDACTED].#4 and 3) and an injury of unknown origin for Resident #1. Immediate Jeopardy The Immediate Jeopardy started on [DATE]. The Immediate Jeopardy was identified on [DATE]. The facility was notified of the Immediate Jeopardy in writing on [DATE] at 2:15 PM. The Immediate Jeopardy was removed on [DATE] Findings include: This Immediate Jeopardy began on [DATE] at 5:00 PM, when Resident #3 had an unwitnessed fall at the facility, after an unidentified change of condition, and was transferred to the hospital where he it was reported he had [MEDICATION NAME] force trauma to his head and a closed head fracture. Resident #3 was pronounced deceased at the hospital on [DATE] at 12:20 AM, 7 hours and 20 minutes later. Resident #3 fell at least five times prior to [DATE]. He fell on [DATE], [DATE], [DATE], [DATE], and [DATE]. After each fall, the facility failed to assess and identify the root cause of those falls and failed to implement effective interventions. Resident #3's progress notes on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] all describe Resident #3's poor safety awareness, self-transferring habits, and concern for falls. During an interview with the Director of Nursing (DON) on [DATE] at 2:24 PM his risk for falls was discussed. When asked if Resident #3 would have benefited from 15-minute checks or one on one supervision the DON said, He wasn't a safety risk and said he had been having difficulty breathing. When asked if Resident #3 had any other falls during his stay the DON said she was not sure and would need to check. It was alleged via complaint on [DATE] that a resident recently passed away after a fall when staff failed to assist him and it was alleged the facility is not adequately staffed to ensure residents are provided with proper care. The complaint said, The nursing unit manager and CNA's (certified nursing assistant's) were saying the resident was getting on their nerves and they wouldn't assist him. The complainant did not leave a phone number for contact and did not respond to email. Upon review of facility residents hospitalized in [DATE] that did not return, it was noted that Resident #3 was hospitalized post fall on [DATE] at 17:00 and passed away at the hospital. Late Entry Nurses Note written by the Director of Nursing (DON) on [DATE] at 14:25 (4 days after Resident #3's death) and dated [DATE] at 14:19: (Resident) having difficulties sitting up in wheel chair today, he needs oxygen on at all times now or he gets very short of breath using all exessary mussels to breath. (Resident) assisted with lunch only at a few bits. Had to be assisted multiple times from bed to wheel chair as (Resident) was very confused and continued to attempt to self transfer. Family and physician notified of (Residents) declining health condition. Note did not include details regarding physician response or new orders. Late Entry Nurses Note written by Unit Manager D on [DATE] at 14:33 (4 days after Resident #3's death) and dated [DATE] at 15:21: Resident calling out in room for help several times this afternoon. He reported that he was not breathing well, O 2 (oxygen) was applied per nasal cannula with saturations at 93%, he appeared short of breath and stated that the belt around his waist was making it so he could not breathe and he kept attempting to stand up and remove his belt. Resident was wearing sweat pants without a belt and informed him of this many times, but resident was insistent. Physician and guardian notified, will continue to reorient resident as needed. Note did not include details regarding physician response or new orders. Total Body Skin Assessment progress note written by Unit Manager D on [DATE] at 17:00: .1 bleeding abrasion with large hematoma noted above right eye, physician notified, resident sent to er Nurses Notes written by Unit Manager D on [DATE] at 17:00: Was notified by staff that resident had fallen in room and was bleeding. Observed resident lying on right side, face pointing towards wall and located in entryway of room. Bleeding abrasion noted above right eye as well as a large bump/hematoma. Pupils were not reactive and resident was not responding but awake appearing lethargic, unable to follow simple commands which is not his baseline. Vital Signs obtained, unable to determine pain, resident was sat up x 2 staff assist, ROM (range of motion) intact at baseline and no voiced pain while moving extremities however baseline cognition was abnormal. Physician notified of occurrence with orders to send to ER (emergency room ) for further evaluation. Family/guardian notified. Resident #3's ED (emergency department) Provider's Note (dated [DATE] at 18:39) said Resident #3 arrived to the emergency room 17:36. History of Present Illness (HPI) notes said the chief complaint was fall head injury. The HPI note explained that Resident #3 was brought in by ambulance after falling forward. The note stated, Patient had an unwitnessed fall that resulted in him having [MEDICATION NAME] force trauma to his right forehead. Unknown loss of consciousness. Patient has been weak the last few days. Full history and review of systems cannot be obtained as patient has a decreased GCS (Glasgow Coma Scale). A GCS score can be indicative of how critically ill a patient is. Resident #3's GCS score was documented in the ED as 14. Resident #3's hospital Death Pronunciation Note (singed [DATE] at 00:21) said, Paged by nursing to evaluate patient for increased work of breathing, combativeness, and inability to obtain adequate vitals. Patient was recently transferred to the floor from the ED admitted for closed head fracture, PNA (pneumonia) episode of [DIAGNOSES REDACTED] (low blood sugar) .On arrival to the patient's room at 12:03, RN (registered nurse) notified house staff that patient had passed and was asystole .The patient was pronounced dead on [DATE] at 12:03 AM . Resident #3's hospital Record of Death said he expired [DATE] at 00:14 and autopsy was not requested and No was marked for, Was an infectious agent present? Resident #3's incident and accident reports for all six falls were reviewed to determine injuries, gain perspective on what he was doing when he fell , and ascertain what new interventions staff implemented to prevent future falls. It was noted for three out of six falls that Resident #3 stated he was trying to use the bathroom prior to falling. Resident #3 was incontinent at the time of three of the six falls. Two of the six falls did not assess incontinence as a contributing factor. Appropriate toileting interventions were not implemented after four of the six falls. Orthostatic blood pressures were not obtained for Resident #3 after all six falls. Resident #3 was on high-risk medications that could have caused orthostatic [MEDICAL CONDITION] and contributed to his falls. Resident #3 had the following physician orders [REDACTED]. 1) Monitor resident for the following side effects related to anti-anxiety medication use and contact practitioner if indicated Confusion .restlessness, .weight changes .orthostatic [MEDICAL CONDITION] . 2) Monitor resident for the following side effects related to antipsychotic medication use and contact practitioner if indicated Confusion . restlessness, .weight changes .orthostatic [MEDICAL CONDITION] . ([DATE]) 3) ([DATE]) and Orthostatic blood pressure three times a day on [DATE] related to [MEDICAL CONDITION]. On four out of six post fall evaluations, Blood Sugar check is required for diabetic resident). Was resident's blood sugar significant? was marked Not Applicable. Resident #3 was diabetic and on scheduled insulin at the time of all six falls. Two of the six post fall evaluations did not ask/document whether blood sugar was checked. Only one blood sugar was documented ([DATE] at 00:41 a.m.) in Resident #3's electronic heath record during his entire stay at the facility. Resident #3's Incident Reports/Post-Fall evaluations indicated he was not thoroughly assessed for factors that likely contributed to his falls. At the time of Resident #3's last fall (Friday [DATE] at 17:00) Unit Manager D, Nurse E, Certified Nursing Assistants (CNA's) F, G, H, and I were working on Resident #3's floor. All staff were interviewed on [DATE]-[DATE] to determine where they were at the time Resident #3 fell . ,[DATE] staff were occupied with other residents/tasks. The 6th staff member was not available for interview and the incident report/post fall evaluation did not assess where staff were at the time of the fall. The Immediate Jeopardy was identified on [DATE]. The Nursing Home Administrator (NHA) was notified on [DATE] at 2:15 p.m. of the Immediate Jeopardy that began on [DATE] at 17:00 p.m., and the need for immediate action to ensure the facility is able to provide adequate supervision for residents, who are at risk for falls and identify, implement and monitor for effective interventions to prevent falls through thoroughly investigating and analyzing the root cause of residents' falls. Additional Findings Include: Resident #3: According to Admission Record, printed [DATE], Resident #3 was an 87-year- old male admitted to the facility on [DATE] (original admission date of [DATE]) with [DIAGNOSES REDACTED]. According to Resident #3's admission Brief Interview for Mental Status (BIMS) assessment on [DATE], his cognition was moderately impaired. According to Resident #3's most recent Minimum Data Set (MDS) Resident Assessment Tool (dated [DATE]) he did not have any indicators of [MEDICAL CONDITION] such as hallucinations and delusions and had no behavioral symptoms (Section E). The assessment said Resident #3 required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weigh bearing assistance) for bed mobility, transfers, walking, dressing, toileting and personal hygiene (Section G). The assessment said Resident #3 was occasionally incontinent, defined as less than 7 episodes of incontinence (Section H). According to Section J of the MDS, Resident #3 did not have a condition or chronic disease that may result in life expectancy of less than 6 months. Section J said he did not have shortness of breath, pain, fever, vomiting, dehydration, or internal bleeding. The MDS said resident had two falls since admission/entry or reentry that resulted in injury (skin tears, abrasions, lacerations, superficial bruises, hematoma's and sprains, or pain) and no falls with major injury (bone fracture, joint dislocations, closed head injuries with altered consciousness and subdural hematoma). According to Section N of the MDS, Resident #3 was on antipsychotic, antidepressant and anticoagulant medications seven days a week. Section P of the MDS said Resident #3 did not have any physical restraints or alarms. According to Resident #3's physician orders [REDACTED]. The medications included: two anti-depressants ([MEDICATION NAME] and [MEDICATION NAME]), an antipsychotic ([MEDICATION NAME]), a blood thinner (apixaban), insulin ([MEDICATION NAME]), an anti-anxiety medication ([MEDICATION NAME]), and a medication to treat his abnormal heart rhythm ([MEDICATION NAME]). Additionally, Resident #3's as needed inhaler for shortness of breath was discontinued no [DATE] due to hospitalization and not reordered upon readmission. It was noted that Resident #3's [MEDICATION NAME] order significantly increased on [DATE]. Resident #3 was prescribed [MEDICATION NAME] 25 mg by mouth at bedtime for [MEDICAL CONDITION] (from [DATE] - [DATE]) then his dose increased to 50 mg twice daily on [DATE]. It was also noted that on [DATE] a chest x-ray and oxygen via nasal cannula at 2 liters as needed every shift for shortness of breath and low oxygen saturation was ordered. No labs were ordered according to Resident #3's order summary report. Progress Notes: According to Resident #3's progress notes he fell at least five times prior to [DATE]. He fell on [DATE], [DATE], [DATE], [DATE], and [DATE]. After each fall, the facility failed to assess and identify the root cause of those falls and failed to implement effective interventions. Resident #3's progress notes on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] all describe Resident #3's poor safety awareness, self-transferring habits, and concern for falls. The notes did not specify whether Resident #3's plan of care was reviewed or revised with changes of condition or whether the physician had new orders when he was notified of changes of condition. Changes in Resident #3's accident risk were not clearly identified or communicated in his progress notes to include interventions attempted and whether they were successful each episode Nurses Note written [DATE] at 05:35: .a loud thud was heard from down the hall .heard the resident yell help me please! .resident in his restroom laying on the floor on his right side. In front of him was his wheelchair with the brakes unlocked a small abrasion ws found on his upper back/cervical spine area .no mental status changes noted .his neuro assessment was not significant for any abnormalities from baseline 15 minutes after the fall he complained of lower back and left shoulder pain that was sharp and ,[DATE] . Social Services Note written [DATE] at 14:58: .Resident was admitted with severe anxiety/agitation and [MEDICAL CONDITION]/delusion during evening hour, repeated calling out .resistant to care and screaming .family reported long history of psychological distress in the evening during sleep that started in his 20's following a head injury sustained during his time I the navy .had long periods of resolution of his symptoms throughout his life. Behaviors of aggression, yelling and [MEDICAL CONDITION] initiated again aprox one month prior to his admission to this facility. Non pharmacological interventions were attempted and ineffective: Anticipate resident needs and provide assist, 1:1 reassurance and supportive listening, redirection, offer drink/snack, ensure comfort of environment (light, noise, temperature). Resident was referred to (psychological services) for evaluation, medical management and psychological supportive services . Nurses Note written [DATE] at 02:39: Resident observed on floor next to bed on his back at 01:25. Stated that he got up to go to the bathroom. He used call light, but did not wait for assistance. Had regular socks on and slipped on dry floor .no injury noted. Nurses Note written on [DATE] at 02:15: Resident observed on floor in another resident room next to bed on his right side with right arm raised up beneath him, upper half of body under bedside table. Resident stated he was going to the bathroom. He had on regular sock on and one regular sock off and didn't have his wheelchair breakes locked, it was noted to be next to him and the bed. He slipped on the floor when he was attempting to self transfer from wheelchair to the bed .no injuries were noted upon initial assessment . Nurses Note written [DATE] at 14:51: .continues to make progress in PT and OT .He continues to have poor safety awareness and transfers without assistance . Nurses Note written [DATE] at 00:09: Resident had a change in neuro checks, pupils are uneven and not reactive to light, (blood pressure) is elevated ,[DATE], (elevated heart rate) 102, temp 99.1, altered mental status, unable to follow simple commands . Resident sent to the hospital at 0019. Nurses Note written [DATE] at 07:38: Resident returned from .hospital with new orders . Nurses Note written [DATE] at 10:18: Observed on the floor at 1000 by staff, writer in to assess, skin intact .no complaints of pain, range of motion within normal limits, unsure of how he got on the floor, was incontinent of bowel and bladder at the time of fall, assisted by 2 people up to bed, able to stand well, appears slightly weak . Nurses Note written [DATE] at 10:55: .new orders to send resident back to (hospital) for mental status changes, non reactive and uneven pupils, lethargy . Nurses Note written [DATE] at 15:57: Resident returned from the hospital.very lethargic . Nurses Note written [DATE] at 21:35: Resident observed on floor between bed and wall with back up against wall/register and head leaned on right side of nightstand, resident has abrasion noted on outer right knee and lower back, no (signs or symptoms) or (complaint of) pain at this time Room rearranged for safety placing nightstand at (head of bed) and resident has scoop mattress . Nurses Note written [DATE] at 23:56: Resident laying in bed very restless, he makes sudden jerking movements and yellows out frequently and makes squeaking sounds and hums loudly, nonsensical speech and when asked if he needs anything he randomly bursts out singing loudly. Yells out hey when asked questions then says I'm sorry and flops his head down and closes his eyes. Several attempts to get out of bed and sits himself up on bedside. Singing hey baby baby. No new or revised fall prevention interventions documented. Nurses Note written [DATE] at 01:27: Resident has been laying in bed nonstop yelling out, [MEDICATION NAME], singing, and making noises. Confused per baseline and is pleasant with staff. Very restless attempting to get self out of bed requiring constant staff supervision. Nurses Note written [DATE] at 04:18: .extremely restless and fidgety .will attempt to self transfer when in room/bed and when self propels in wheelchair goes into other room and attempts to transfer to other beds . Nurses Note written [DATE] at 09:55: Resident attempting to get our of bed at this time, note easily redirected. Writer finally assisted resident into bed . Nurse Note written [DATE] at 1700: Resident in bed turning from side to side and restless .this nurse sat with him for approx 30 min . Nurses Note written [DATE] at 23:37: Resident is very restless tonight, moaning out and swinging his legs out of bed .is lethargic . Nurses Note written [DATE] at 01:21: Resident has been up through lunch and dinner yesterday, he has not napped or rested in bed .increase in agitation occurring as the night goes on, hallucinating believing his wife has fallen on the floor and is under his bed, he has pulled the fire alarm and has tried to contact 911 several times during the evening. Safety reassured to him. With each event has not been able to reorient, pupil sizes are not equal, right pupil smaller than left, they do react to light, staff have attempted to lay him down multiple times however he chooses to get himself out of bed, food and fluids provided and offered through the shift. Nurses Note written [DATE] at 06:56: Resident has been up and down all night with very small naps .some delusional thoughts noted. He was looking for his wife and trying to call her on his cell phone and would talk on the phone like someone was on the other end but it wasn't on. And then few minutes later talk about how she is dead. Then talk about how she is trapped under his bed . Nurses Note written [DATE] at 16:31: .up walking in room with two photos of wife in hand. Nurse was able to intervene before falling .he stated he was cleaning up his room .fidgety with things is room watching t.v Nurses Note written [DATE] at 02:48: Up at night. Pacing from (wheelchair) to bed and back. When in bed lays across it. Wheels himself to the hallway and was in elevate twice just sitting there . Nurses Note written [DATE] at 03:48: Resident pulled fire alarm box causing alarm to sound. Nurses Note written [DATE] at 01:23: .restless and get up in just a few minutes. Nurses Note written [DATE] at 10:37: .will try and self transfer if not watched . Nurse Note written [DATE] at 07:00: Resident is extremely restless at night, only laying down for twenty minute periods, he is up and down all night long and is not sleeping .will continue to monitor. Nurses Note written [DATE] at 00:32: Resident pulled box cover off fire alarm sounding alarm several times used elevator to go downstairs and has been redirected back upstairs . Nurses Note written [DATE] at 01:15: Resident used elevator to go to first floor, he held door handle down to get into lobby sounding alarm .stated he has to go to the bathroom .assisted back to his room to toilet and wanderguard placed on right ankle due to attempting to leave thru front doors . Nurses Note written [DATE] at 05:51: Resident up all night. Pacing in hallway, dining room and getting into the elevator . Nurse Note written [DATE] at 00:08: .Alarm on elevator sounded. Resident stated he was going downstairs to get some pop . Nurses Note written [DATE] at 01:07: on [DATE] midnight resident setting in wheelchair by elevator alarm going off in elevator. Resident stated he was looking for head boss . Nurses Note written [DATE] at 03:18: Resident has been up and down from bed to wheelchair all night long. Reports being restless and unable to get comfortable in bed .Will only rest for short periods of time, less than 10 min, the gets back up .Continues to go to elevator pushing buttons to go downstairs, but alarms sounds . Nurse Note written [DATE] at 00:10: Resident .is very restless, won't stay in bed despite staff sitting with him to provide reassurance . Nurses Note written [DATE] at 01:42: Resident restless. Getting to and out of bed continuously. Complained of not being able to breath when in bed. Head of bed up. O 2 via nasal cannula applied, but resident took it off in just a few minutes . Nurses Note written [DATE] at 11:21: .complaining of runny nose .showing signs of restlessness . Nurses Note written [DATE] at 11:43: (physical therapy, occupational therapy and speech therapy) continues. He remains very confused especially at night .Ambulating with rolling walker and assist of one .Extensive assist for (activities of daily living) . Nurses Note written [DATE] at 10:00: Resident up awake all night per the staff. He was having increased anxiety and upset about things that weren't there. Point at people that weren't there. Needed one on one redirect and he calmed down but still was antsy. Unable to get him to rest. Nurses Note written [DATE] at 14:16: Resident calling for help in his room reporting he couldn't breathe, O 2 sats on room air were at 98% but he demanded oxygen, reassured him he needed to deep breathe, he had no clothes on and was sitting at the edge of his bed stated he could not breathe because his underwear were too tight. I assisted him with getting new clothes did not appear tight and they seemed to fit properly . [DATE] at 05:31: Resident was up all night. He was agitated .constantly switching from bed to wheelchair and back again .As patient continued to exert himself with repetitive behaviors, his DIB (difficulty in breathing) became more pronounced . [DATE] at 05:35: Resident was up all night. He was agitated and at times confrontational .still using O 2 .as patient continued to exert himself with repetitive behaviors, his DIB became more pronounced . [DATE] at 15:01: patient was complaining of tightness in chest and very high anxiety with breathing out his mouth (oxygen saturation) is 97 on room air placed nasal canal for comforted. Dr (doctor) ordered chest x ray . [DATE] at 06:33: Resident xray returned with no acute cardiopulmonary process . [DATE] at 20:29: Resident presented with complaints of difficulty breathing. Sitting upright on the edge of bed. SAT (saturation) 89% on )2 at 2.5 via nasal cannula. Increased to 3.5, then to 4 LPM (liters per minute) with SAT drop to 65% and resident becoming drowsy and lowing to bed with eyes closed, becoming non-responsive. Called second nurse for help, switched to tank 02, 6 LPM. SAT increased to 97%. Resident reminds drowsy. Respirations 24 . It was not documented if the physician was notified. [DATE] at 13:46: Resident participated in therapy this afternoon and while exercising O 2 was removed several times and oxygen saturation obtained while on room air and each reading was (greater than) 92% and he denied feeling short of breath . Resident stated he feel less short of breath with oxygen on while he is in his room, physician notified. [DATE] at 17:03: .He does continue to have a cough and post nasal drip . Late Entry Nurses Note written by the Director of Nursing (DON) on [DATE] at 14:25 (4 days after Resident #3's death) and dated [DATE] at 14:19: (Resident) having difficulties sitting up in wheel chair today, he needs oxygen on at all times now or he gets very short of breath using all exessary mussels to breath. (Resident) assisted with lunch only at a few bits. Had to be assisted multiple times from bed to wheel chair as (Resident) was very confused and continued to attempt to self transfer. Family and physician notified of (Residents) declining health condition. Note did not include details regarding physician response or new orders. Late Entry Nurses Note written by Unit Manager D on [DATE] at 14:33 (4 days after Resident #3's death) and dated [DATE] at 15:21: Resident calling out in room for help several times this afternoon. He reported that he was not breathing well, O 2 (oxygen) was applied per nasal cannula with saturations at 93%, he appeared short of breath and stated that the belt around his waist was making it so he could not breathe and he kept attempting to stand up and remove his belt. Resident was wearing sweat pants without a belt and informed him of this many times, but resident was insistent. Physician and guardian notified, will continue to reorient resident as needed. Note did not include details regarding physician response or new orders. Total Body Skin Assessment progress note written by Unit Manager D on [DATE] at 17:00: .1 bleeding abrasion with large hematoma noted above right eye, physician notified, resident sent to er Nurses Notes written by Unit Manager D on [DATE] at 17:00: Was notified by staff that resident had fallen in room and was bleeding. Observed resident lying on right side, face pointing towards wall and located in entryway of room. Bleeding abrasion noted above right eye as well as a large bump/hematoma. Pupils were not reactive and resident was not responding but awake appearing lethargic, unable to follow simple commands which is not his baseline. Vital Signs obtained, unable to determine pain, resident was sat up x 2 staff assist, ROM (range of motion) intact at baseline and no voiced pain while moving extremities however baseline cognition was abnormal. Physician notified of occurrence with orders to send to ER (emergency room ) for further evaluation. Family/guardian notified. Nurses Note written [DATE] at 16:12: On [DATE] at 1145 am daughters .came in to facility to collect their Dad's personal effects as he had passed away at the hospital the night before . Incident and Accident Reports: Resident #3's incident and accident reports were reviewed to determine injuries, gain perspective on what he was doing when he fell , and ascertain what new interventions staff implemented to prevent future falls. It was noted for three out of six falls that Resident #3 stated he was trying to use the bathroom prior to falling. Resident #3 was incontinent at the time of three of the six falls. Two of the six falls did not assess incontinence as a contributing factor. Appropriate toileting interventions were not implemented after four of the six falls. Orthostatic blood pressures were not obtained for Resident #3 after all six falls. Resident #3 was on multiple high-risk medications that could have caused orthostatic [MEDICAL CONDITION] and had the following physician orders: 4) Monitor resident for the following side effects related to anti-anxiety medication use and contact practitioner if indicated Confusion .restlessness, .weight changes .orthostatic [MEDICAL CONDITION] . 5) Monitor resident for the following side effects related to antipsychotic medication use and contact practitioner if indicated Confusion . restlessness, .weight changes .orthostatic [MEDICAL CONDITION] . ([DATE]) 6) ([DATE]) and Orthostatic blood pressure three times a day on [DATE] related to [MEDICAL CONDITION]. On four out of six post fall evaluations, Blood Sugar check is required for diabetic resident). Was resident's blood sugar significant? was marked Not Applicable. Resident #3 was diabetic and on scheduled insulin. Two of the six post fall evaluations did not ask/document whether blood sugar was checked. Only one blood sugar was documented ([DATE] at 00:41 a.m.) in Resident #3's electronic heath record during his stay at the facility. Resident #3's Incident Reports/Post-Fall evaluations indicated he was not thoroughly assessed for factors that likely contributed to his falls. Incident Report/ Post Fall Evaluation dated [DATE] at 05:00 a.m. said Resident #3 fell in his bathroom and obtained an abrasion to his upper back (measurements not included). Resident #3 was noted to be incontinent at the time of the fall and stated he was trying to urinate in toilet. The evaluation said it was unknown when Resident #3 last toileted. The post fall huddle asked, What was different this time?, transferring self to toilet was documented. Toileting Status was marked as a contributing factor to the fall. The intervention initiated post-fall was anti roll backs on Resident #3's wheelchair and did not address his incontinence or statement of what he was doing at the time of the fall. Under describe initial intervention to prevent future falls, a handwritten intervention was crossed out that said, Care planned no longer being able to take self to the toilet he must be assisted to the restroom. And was changed to, Anti-roll backs applied to w/c (wheelchair). Incident Report/ Post Fall Evaluation dated [DATE] at 01:25 a.m. said Resident #3 fell on the floor next to his bed. No injury was noted. The report/evaluation did not note if Resident #3 was incontinent at the time of the fall or not, or when he was last toileted. The report said Resid (TRUNCATED)

Based on observation, interview and record review the facility failed to ensure appropriate measures were in place to promote wound healing for 1 resident (#55) of 3 residents reviewed for wounds, resulting in Resident #55 experiencing an opened wound, hospitalization , pain and prolonged healing. Findings Include: On 4/23/19 at 11:53 AM, Nurse M and Physician N were observed entering Resident #55's room to change an abdominal incision dressing. When the surveyor asked to view the dressing change and wound, the nurse said the resident refused. Per Nurse M the wound dehisced (Reopening of a surgical incision or breakdown of an incision in the abdominal area, Agency for Healthcare Research and Quality, 2019). A record review of the Face Sheet and Minimum Data Set (MDS) assessment indicated Resident #55 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS assessment dated [DATE] indicated the resident had mild cognitive impairment-Brief Interview for Mental Status (BIMS) score of 11/15 and was able to transfer and walk independently, needed supervision with dressing, and hygiene and 1-person assistance with bathing and toileting. The quarterly MDS dated [DATE] revealed the resident's cognitive abilities had decreased with a BIMS score of 6/15 and a Significant Change MDS dated [DATE] revealed the resident had severe cognitive deficits (Memory Problem) that could not be evaluated with a BIMS test and needed extensive to total assistance with all care. The resident was no longer able to walk on her own. The MDS dated [DATE] also indicated the resident had experienced multiple falls while at the facility. The record review further revealed Resident #55 was transferred to the hospital on [DATE] and returned on 1/22/19 after having an abdominal surgery to remove excess skin after weight loss. The resident was transferred to the emergency roiagnom on [DATE] because the abdominal wound was opened and draining foul discharge and transferred to the hospital on [DATE] for a deteriorating wound. A review of the Incident and Accident reports for Resident #55 (MONTH) 2019 through (MONTH) 13, 2019 indicated the resident had fallen 11 times, between (MONTH) 1st, 2019 and (MONTH) 13, 2019. On 1/22/19 the day of return from the procedure, the resident removed one of the abdominal drains placed after surgery. A review of the physician progress notes [REDACTED]. 1/13/19- .She can ambulate, but is confused .no rash or itch, but there was overhanging skin from her abdominal fold . 2/6/19- .she had recent surgery in which an abdominal skin fold was removed .she has had some weight loss . came back on [MEDICATION NAME] briefly . has significant dementia . has slight pain in the area . there are large sutures vertically and horizontally Discharge left lower abdomen . (drain site) . 2/17/19- .further opening of abdominal wound it dehisced .was started on Keflex (antibiotic) with possibility of infection . she pulled out her Jackson-Pratt (JP) drains. Since then, the wound has opened significantly .there is a plan for wound vac tomorrow . A review of the Skin Evaluations, for Resident #55 revealed the following: 2/1/19- This was the first documented Skin Evaluation, after 12/28/18 and the first since the surgical procedure on 1/21/19. It said, Surgical incision to abdomen, skin intact. 2/7/19- Surgical wound, open. 2/12/19- surgical wound, open, with a drawing of an opened area on the abdomen. 3/2/19- Post-fall, surgical wound, picture with a larger open area (no measurements.) 3/3/19- Post-Fall, surgical wound, picture with open abdominal wound. 3/5/19- Related to observed on floor, surgical wound, knot on head, (circled on picture. 3/6/19- Related to observed on floor, surgical wound, open surgical wound with wound vac. 3/8/19- Post- surgical wound, with 2 large areas wrapping around the side of the abdomen indicated on the pictures. A review of the progress notes and assessments from (MONTH) 22, 2019 to (MONTH) 25, 2019 indicated the resident had multiple instances of attempting to transfer self, wandering in the hallway (prior to a decline in the ability to walk) and pulling at the dressings on her abdomen, including the [DEVICE] (vac), once they were present. There was repetitive documentation that the resident was educated not to transfer self or take off the dressings, drains or wound vac. During that timeframe the resident's cognitive status greatly declined. Progress Note: 1/25/19, Resident returned from follow-up with plastic surgeon .surgeon wanted a follow-up CT scan due to resident pulling out own JP drain on 1/22/19 .right side and left side JP site shows no abnormalities . 1/30/19: Appointment scheduled for abdominal CT scan, (1/31/19- 6 days after the surgeon's recommendation). 2/1/19 at 4:00 AM, Resident observed sitting on buttocks on floor . 'It's slippery,' coming from bathroom . The resident took herself to the bathroom. 2/1/19 at 11:00 PM, Nurse educated patient not to touch JP drain . 2/3/19 at 3:00 PM, .abdominal sutures intact and dry . 2/4/19 at 2:00 AM, .noted resident touching surgical site, reeducated to not touch site . 10:30 PM, Anxiety and crying . 2/6/19 at 10:00 AM, .(resident) kept trying to make adjustments to her wound area-many times is asked to please keep her hands out of wound area. She is very forgetful with fidgeting with drains . 2/7/19- Resident returned from visit to surgeon who removed 3 sutures. 2/8/19 at 10:00 PM, .wandering in hallway .frequent outbursts of crying. Medicated for pain . 2/12/19 at 7:35 PM, .wound noted to have a foul odor and large amount of purulent drainage, incision site deteriorating . 2:00 PM . transport resident to hospital .7:35 PM . arrived back to facility . 2/13/19 at 5:30 AM, . nurse attempted to change old dressing and was unable .resident became angry, stated it hurts for her to move . 2/14/19 at 6:00 PM, Resident is sitting on side of bed eating dinner, complains of pain at incision site . 2/16/19 at 3:00 PM, .open area approximately 12-14 cm (centimeters) around, approximately 5-7 cm deep. Foul odor .resident continuously reminded to leave area alone . 2/27/19 at 10:15 AM, Resident has shown signs and symptoms of increased pain at surgical wound site in abdomen. Resident has verbalized increase of pain . Per the Incident and Accident reports, the resident fell on ce on 3/5/19 and twice on 3/6/19. After falling the 2nd time on 3/6/19 the progress note provided, .found on floor .complains of abdominal pain 9/10 .1:1 with staff at bedside . A review of the progress notes indicated there was no additional documentation of 1:1 monitoring after 3/6/19. The resident fell 4 more times after that. A review of the progress notes indicated the resident had returned to the surgeon for approximately 5 revisits and was transferred to the emergency roiagnom on [DATE] and readmittance to the hospital on [DATE]) for complications related to the abdominal surgical wound. From 2/1/19 to 4/13/19 the resident had fallen 11 times; Each fall with the potential to decrease the ability of the wound to remain intact and heal. As identified in the progress notes the resident was confused and reeducation was ineffective in decreasing Resident #55 from touching the abdominal wound or removing the dressings. A review of the physician orders [REDACTED]. A review of the resident's Care Plans titled: At risk for complications from surgical wound . date initiated 1/23/19 and revised 2/13/19 with Interventions: Avoid tension at surgical incision site, dated 1/23/19, revised 2/13/19. There was no mention of distraction or attempting to hide the dressing/tubing to decrease the chance of removal. At Risk for pain . date initiated 11/20/18 and revision 3/29/19 with Interventions: Observe and report to Nurse as needed any signs/symptoms of non-verbal pain: .vocalizations (grunting, moans, yelling out, silence), Mood/behavior changes ( more irritable, restless, aggressive, squirmy, constant motion) .Face (sad, crying, worried, scared, clenched teeth, grimacing), dated 11/20/18, Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease range of motion, withdrawal or resistance to care. Dated 11/20/18. At risk for falls . date initiated 11/20/18 with Interventions: Provide resident with activities that minimize the potential for falls while providing diversion and distraction, dated 11/20/18, revised 2/13/19. There was no mention of 1:1 monitoring as mentioned in the progress notes on 3/6/19. During an interview with Nurse K on 4/25/19 at 10:39 AM, she said With her Dementia she was not aware that she even had surgery. She pulled out both of her drains about a week apart and would not leave her dressing on. The surgeon initially opened up a few of the sutures to allow the fluid buildup to drain. Nurse K was asked about the resident's pain at the surgical site and stated, When she came back to us, (after she went to the hospital from 2/21/19-2/26/19, because the wound had dehisced) she had an order for [REDACTED]. On 2/27/19 the [MEDICATION NAME] 5/325 mg was discontinued, and [MEDICATION NAME] was increased to 10/325 mg every 6 hours as needed. On 3/19/19 routine pain medication was started- [MEDICATION NAME] 10/325 mg 3 times a day, with [MEDICATION NAME] x 1 10/325 mg as needed. On 3/27/19 the resident started [MEDICATION NAME] 10/325 mg 1 every 4 hours routine, She is not complaining, wincing, guarding as much with care. She kept trying to self-transfer and she was connected to a wound vac. We tried regular and portable wound vac. Fanny pack or with her on the wheelchair. She seems better now. Sometimes she plays with it. We try to keep it out of her sight. Policies related to Wound Care and Pain management, were requested during this interview and not received prior to exit on 4/25/19 at 5:45 PM.

Based on observation, interview and record review, the facility failed to ensure appropriate interventions were in place and enacted to ensure resident safety for 2 residents (#55 and 56) of 5 residents reviewed for falls, resulting in Resident #55 experiencing multiple falls with injury and a dehisced (opened) surgical wound and neurological examinations not completed post-fall for a resident with a head injury (#56). Findings Include: Resident #55: A record review of the Face Sheet and Minimum Data Set (MDS) assessment indicated Resident #55 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS assessment dated [DATE] indicated the resident had mild cognitive impairment-Brief Interview for Mental Status (BIMS) score of ,[DATE] and was able to transfer and walk independently, needed supervision with dressing, and hygiene and 1-person assistance with bathing and toileting. The quarterly MDS dated [DATE] revealed the resident's cognitive abilities had decreased with a BIMS score of ,[DATE] and a Significant Change MDS dated [DATE] revealed the resident had severe cognitive deficits (Memory Problem) that could not be evaluated with a BIMS test and needed extensive to total assistance with all care. The resident was no longer able to walk on her own. The MDS dated [DATE] also indicated the resident had experienced multiple falls while at the facility. A review of the progress notes indicated the resident had abdominal surgery on [DATE] and returned to the facility on [DATE]. In addition, the progress note dated [DATE] provided, .found on floor .complains of abdominal pain ,[DATE] .1:1 with staff at bedside . A review of the progress notes indicated there was no additional documentation of 1:1 monitoring after [DATE]. The resident fell 4 more times after that. Further review of the progress notes and assessments from (MONTH) 22, 2019 to (MONTH) 25, 2019 indicated the resident had multiple instances of attempting to transfer self and wandering in the hallway (prior to a decline in the ability to walk). There was repetitive documentation that the resident was educated not to transfer self. During that timeframe the resident's cognitive status greatly declined. From [DATE] to [DATE] the Incident and Accident reports revealed the resident fell 11 times: Falls: [DATE]-observed sitting on floor by the bed, [DATE]- found on floor next to bed, [DATE]- observed on floor next to bed, [DATE]- lying flat on back next to bed, [DATE]- observed on floor near bed, [DATE]- found lying on back on floor at the foot of the bed, [DATE]- observed on back next to bed, [DATE]- on floor be bed, [DATE]- lying on floor be bed, [DATE]- observed on floor next to bed. During that time, the resident's abdominal surgical incision dehisced (opened) from one side of the abdomen to the other. The Incident and Accident reports said the resident injured her head 3 times during the falls: [DATE] Knot on left side back of head,[DATE] Lump on back of head, and [DATE] Small closed, round area noted to posterior head. A review of all of the physician progress notes [REDACTED]. There was no mention of assessment related to the falls with injury or a plan for prevention of further falls. A review of post-fall Skin Evaluations, for Resident #55 revealed the following: [DATE]- Post-fall, surgical wound, picture with a larger open area at the surgical wound site (no measurements.) [DATE]- Post-Fall, surgical wound, picture with open abdominal wound. [DATE]- Related to observed on floor, surgical wound, knot on head, (back of head circled on picture). [DATE]- Related to observed on floor, surgical wound, open surgical wound with wound vac. [DATE]- Post- surgical wound, with 2 large areas wrapping around the side of the abdomen indicated on the pictures. A review of the physician orders related to pain management indicated the resident did not receive routine pain medication after readmission from the hospital on [DATE] until [DATE] when a routine pain medication was added to the As needed medication that the resident had been receiving. A review of the resident's Care Plans titled: At Risk for pain . date initiated [DATE] and revision [DATE] with Interventions: Observe and report to Nurse as needed any signs/symptoms of non-verbal pain: .vocalizations (grunting, moans, yelling out, silence), Mood/behavior changes ( more irritable, restless, aggressive, squirmy, constant motion) .Face (sad, crying, worried, scared, clenched teeth, grimacing), dated [DATE], Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease range of motion, withdrawal or resistance to care. Dated [DATE]. At risk for falls . date initiated [DATE] with Interventions: Provide resident with activities that minimize the potential for falls while providing diversion and distraction, dated [DATE], revised [DATE]. There was no mention of 1:1 monitoring as mentioned in the progress notes on [DATE]. The Fall, Care Plan was not reviewed or updated after the resident fell on [DATE] or [DATE]. The resident fell again on [DATE] and [DATE]. With both falls on [DATE] and [DATE] the resident hit and injured her head. During an interview with Nurse K on [DATE] at 10:39 AM, she said With her Dementia she was not aware that she even had surgery. Nurse K was asked about the resident's pain at the surgical site and said the resident has routine pain medication now . She kept trying to self-transfer and she was connected to a wound vac The nurse was asked about the resident's multiple falls and said, We tried 1:1. When queried on how long was 1:1 monitoring in place, Nurse K said she did not know. On [DATE] at 2:00 PM, the Administrator was asked about Resident #55's numerous falls, which included several head injuries and a dehisced surgical wound and said, We try to educate her. The Administrator said the facility had tried 1:1 monitoring with the resident but was not able to identify the amount of time the resident received 1:1 monitoring or if it was effective. A review of the facility policy titled, Fall Management, dated revised ,[DATE] provided . Each resident is assisted in attaining/maintaining his or her highest practical level of function by providing the resident adequate supervision, assistive devices and/or functional programs as appropriate to minimize the risk of future falls . Residents identified at risk for falls will have a care plan developed and implement appropriate fall prevention interventions . When a fall occurs, the licensed nurse will complete: . review and/or revise care plan and resident Kardex . Resident #56: According to electronic admission face sheet, Resident #56 was a [AGE] year old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to Resident #56 Care Plans and Kardex, Resident #56 was independent with most Activities of Daily Living and required limited assistance with ADL care. Resident #56 was alert and oriented and able to make her needs known. Review was done of Fall Management' Policy dated as revised ,[DATE], documented The facility will identify hazards and resident risk factors and implement interventions to minimize falls. Under 'Practice Guidelines' number 5: If a potential head injury is present, complete Neurological Record. Review of Incident report dated [DATE] at 0230 (2:30 AM), Resident #56 was 'observed in her bathroom, on left side propped on left elbow wiping blood from her head with toilet paper'. Under the section 'Type of Injury' documented: bump, S.T. (skin tear), and hit head. Under the section of 'Interventions Implemented' documented Site cleansed, non-adherent dressing applied, affixed with Kerlix (dry dressing), ice applied. Review of 'Fall Description Details documented under the question 'What did the Resident say they were trying to do' documented Got off the toilet and slipped. In the box to check for 'witnessed' was checked 'No'. Review of 'Interventions' documented offer and provide Gripper socks while in bed. There was also a set of vital signs documented on the incident report, along with responsible party and physician notification. The Incident report was signed by the Administrator, Director of Nursing, and physician as reviewed. During an Interview, the Administrator indicated it was the expectation of the facility for any unwitnessed falls and those with head injured that a Neurological Assessment be completed. The Administrator was asked to provide the Neurological Assessment for the incident on [DATE]. The Administrator provided a document 'Neurological Assessment Flow Sheet' dated [DATE] 0245 (2:45 AM), with instructions to 'Complete checks' Every 15 minutes for 1 hour, Every 4 hours for four hours, Every 4 hours for 19 hours that had been completed for Resident #56. Review of the Neurological Assessment Flow Sheet, documented Neuro checks on [DATE] at 0245, 0300, 0315, 0330, 0345, 0445, 0545, 0645, 0745, 1145, 1545,1945, 2345. On [DATE], at 0345, was the last documentation of Neuro checks performed. (It was a total of 24 hours of Neuro checks). The Administrator was asked if there was any additional documents to go with the Neuro checks she had provided and said No. The Administrator was asked why the Neurological Assessment only was completed for 24 hours with a head injury, and indicated that they had recently updated the Neurological Flow sheet to continue for 72 hours, and that staff were following the old flow sheet at that time, and provided documentation that extended Neurological Assessments for 72 hours. The document instructed to perform Neurological Assessment every 15 minutes times 3, every 30 minutes times times 4, every 1 hour times 4, every 4 hours times 4, and every 8 hours times 2 days. Review was done of Fall Management' Policy dated as revised ,[DATE], documented The facility will identify hazards and resident risk factors and implement interventions to minimize falls. Under 'Practice Guidelines' number 5: If a potential head injury is present, complete Neurological Record. According to www.ncbi.nlm.nih.gov 'The clinical practice guideline for falls and fall risk' documented Falling is a significant cause of injury and death in frail older adults. Residents in long-term care (LTC) facilities fall for a variety of reasons and are more likely to endure injuries after a Fall. According to www.hcpro.com 'Neurological checks for head injuries LTC Clinical Pearls: Powered by HCPRO's Long Term Care Nursing Library, (MONTH) 8, 2013, documented Assess the resident for changes in level of consciousness, which is a cardinal sign of untoward pathology. Assess resident immediately after the fall, then frequently throughout the shift. Assessment should continue for minimum of 72 hours. Perform frequent neurological exam: every 15 minutes for 2 hours, every 30 minutes for 2 hours, every 60 minutes for four hours, every 8 hours for 16 hours, every 8 hours for at least 72 hours have elapsed, and the resident is stable. The neurological assessment includes: pulse, respirations, blood pressure measurements, assessment of pupil size, equality of hand grasps, which helps keep the findings objective. The neurological exam is the assessment of sensory neuron and motor responses, reflexes to determine whether the nervous system is impaired.

This citation pertains to MI 443. Based on observation, interview, and record review, the facility failed to implement interventions to prevent the development of a deep tissue injury on the heel of one resident (#11) out of three residents reviewed for pressure ulcers resulting in Resident #11 developing an unstageable pressure ulcer (deep tissue injury) on her right heel. Findings include: According to the Admission Record, dated 8/13/2018, Resident #11 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Resident Assessment (MDS), dated [DATE], indicated that Resident #11 did not walk, required extensive physical assistance of two staff members to move around in her bed, and had no pressure ulcers, but was at risk of developing pressure ulcers. The MDS, dated [DATE], indicated that Resident #11 had no memory problems and was cognitively intact with a score of 15 out of 15 on the brief interview for mental status (BIMS). Resident #11 had a care plan for the risk for a skin breakdown/pressure ulcers related to her decreased mobility and the [DIAGNOSES REDACTED] of her lower extremities that had been initiated on 10/9/2018. An intervention to prevent the development of pressure ulcer, initiated on 10/9/2018, included to float her heels, which meant to elevate her legs so her heels did not touch the bed. Another intervention was the use of a low air loss mattress. A third intervention, listed on her activities of daily living care plan, initiated on 10/9/2018, and on the undated Kardex that was used by the nursing assistants to guide care, was to alternate the use of prafo and prevalon boots every eight hours to prevent heel pressure. Prevalon boots are a brand name of puffy slipper-like boots that use a Velcro to strap around the foot and come up to the ankles to provide a cushion for the heel. Prafo boots come further up the leg and have a metal frame that suspends the heel inside the boot so there is no pressure on the heel. Resident #11 had no care plan that indicated she was not cooperative with the interventions on the care plan. The MDS, dated [DATE], indicated that Resident #11 did not reject care. On 12/5/2018 at 10:25 AM, an observation was made of Resident #11's room. Resident #11 was not in the room. Prafo boots were observed in the room. The pump for the air mattress hung on the foot of the bed. The pump ensures the air flow to the mattress. There were no lights on. On 12/5/2018 at 2:45 PM, Certified Nursing Assistant (CNA) M was asked about the pump not having lights on to indicate if it was functioning. CNA M felt the air mattress and said its deflated, it should have lights. At 2:50 PM, Registered Nurse (RN) F, who was newly hired with one of her duties to be wound care, entered the room, looked at the air mattress and the pump and said she did not know how the air mattress functioned. At about 2:55 PM, RN F stated that the air mattress had been unplugged and it was functioning with lights on the pump display. On 12/6/2018 at 8:45 AM, Resident #11 was visited in her room. Resident #11 stated that the air mattress had been beeping last night and some nights it is hard. The lights on the pump indicated the mattress was functioning at that time. Resident #11 complained of pain and burning in her heels. CNA M left the room and when she reentered, she stated she had informed the RN of Resident #11's complaint and had been told by the RN that he would check her pain medication. Resident #11 was observed to have her heels resting directly on the mattress and to be wearing fluffy blue heel booties, the Prafo boots were sitting near the closet. As CNA's M and J removed Resident #11's heel booties and turned Resident #11 in her bed to perform care, her feet were observed. Both of Resident #11's feet were dry with flaky skin. Resident #11's right heel was covered with a hard crusty flake and was black/dark blue under the crust. When felt, the heel was slightly mushy toward the side and the bottom of the crusty dark flake and the dark area was non-blanchable (meaning the color did not change when it was pushed). CNA's M and J put the heel booties back on Resident #11 and prepared to transfer her to her wheel chair with a mechanical lift. RN I entered the room while Resident #11 was still in the bed and gave her some pain medication. Resident #11 informed RN I about her heels burning and he said he would check her pain meds. RN I started to leave the room and was asked if he was going to look at Resident #11's heels. RN I did look at Resident 11's heels and then left the room. When asked, CNA M, who had cared for Resident #11 the last two days, stated that she had not ever put the Prafo boots on Resident #11. During an interview on 12/6/2018 beginning at 10:55 AM, the Therapy Department Program Manager, Staff T stated that the Prafo boots had been fit by the therapy staff who had given the recommendation to the nursing department for them to be worn for eight hours and off for eight hours. Staff T provided the Therapy Communication Care Plan form to Nursing which indicated that on 11/26/2018 the therapy department had requested that the Prafo boots be used, every eight hours, to increase Resident #11's ankle range of motion and prevent heel pressure. Therapy Manager T stated that nursing was to write an order for [REDACTED]. 11/27 to 27/2018, did not identify the communication from therapy or an order for [REDACTED].>According to the National Pressure Ulcer Advisory Panel (NPUAP) (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/), A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. A Deep Tissue Pressure Injury is described by the NPUAP as Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. RN F had documented a skin assessment for Resident #11 on 12/6/2018 at 2:15 PM that read in part, Resident reported that when she is in bed at night her right heel burns. Area assessed, . right heel has a flat darker area noted to right heel that blanched when assessed. On 12/6/2018 at 3:15 PM, RN F was interviewed. RN F stated she was unsure if she could call the area on Resident #11's heel a Deep Tissue Pressure Injury because she was unsure if that would be a [DIAGNOSES REDACTED]. RN F did agree that the area looked like it was an injury from pressure.

This Citation pertains to Intake# MI 965 Based on observation, interview and record review, the facility failed to ensure appropriate interventions were in place and care plans were reviewed to prevent falls with injury for 1 (#12) resident and complete neurological (neuro) assessments (checks) post fall for 2 (Resident #4 and Resident #12) of 2 residents reviewed for falls and abuse from a total sample of 16 residents, resulting in Resident #12 sustaining facial contusions after falling and neither Resident #'s 4 or Resident #12 received a completed neurological assessment to aid in determining if serious injuries were present. Findings Include: On [DATE] at 10:00 am, during a tour of the facility, Resident #12 was observed walking in the facility's 2nd floor hallway independently. The resident had a large yellow/green bruise covering the right side of her cheek, eye and forehead. On her right forehead was a large, protruding lump raised about 1 inch from the forehead and 1 inch in circumference. A review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment, dated [DATE], revealed that the resident had a severe memory problem and was independent with transfers and ambulation, but needed 1-person assistance with dressing, eating, hygiene, bathing and toileting. A review of the Incident and Accident reports and Progress Notes for the resident from admission on [DATE] to [DATE], indicated the resident had fallen 8 times: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and twice on [DATE]. The resident injured her forehead and face on [DATE] at 12:15 PM and fell again on [DATE] at 11:10 PM. A review of the Neurological Assessment Flow Sheets for 1.) [DATE]- [DATE], 2.) [DATE]-[DATE] and 3.) [DATE]-[DATE], revealed the nurses did not perform the post-fall Neurological assessments as required for Resident #12, for any of the 3 sets of assessments. Assessment components included: Level of Consciousness, Pupil Response, Motor Functions, Pain Response, Vital Signs (Blood pressure, pulse, respirations and temperature) and observations (ex. [MEDICAL CONDITION], headaches vomiting etc.) and assessments were to be completed Every 15 minutes (after the fall) for 1 hour, Every hour for 4 hours and every 4 hours for 19 hours. A review of the professional Nursing Journal Lippincott Williams and Wilkins, dated March-[DATE], Volume 8, Issue 2, Simplifying neurological assessment, revealed, .The value of a solid neurological assessment can't be overstated-small change in the assessment is indicative of a neurological injury, and early intervention can prevent permanent damage . On the #1 Neurological Assessment Flow Sheet-5 assessments, including all components were missing. The #2 Neurological Assessment Flow Sheet was missing 7 assessments with all components and the #3 Neurological Assessment Flow Sheet- was missing 1 assessment with all components. The resident had a history of [REDACTED].#12's Fall, Care Plan, indicated that it was not initiated until [DATE], after the resident had fallen twice ([DATE] and [DATE]) and had no interventions listed until [DATE] which included: Ensure the resident is wearing appropriate footwear, Assess the risk level for falls on admission and as needed and put the resident's call light in reach. The Fall Care Plan was not reviewed or updated with new preventive measures after the resident fell on [DATE], [DATE] or [DATE]. After Resident #12 fell 3 times on [DATE]-[DATE], the Care Plan was updated on [DATE] with the following intervention: Contact husband for better fitting shoes. On [DATE] at 4:00 PM, during an interview, Nurse E was queried on Resident #12's falls and stated, The falls that she was having was because of her shoes. A (confidential person) brought the wrong size. They were too small and then too big. She wears a 9 ½ . We tried slip-on and she fell right out of them. Now she has tie-shoes. On [DATE] at 8:45 am, Activities Person Q was observed assisting Resident #12 to lay down in bed after breakfast. The resident was observed wearing blue lace-up tennis shoes. When they were removed the resident said, Ahhh. There was 1 gray size 10 lace-up tennis shoe on the dresser and 2 slip-on pairs of shoes in the closet- one sized 10 and one open heel sized ,[DATE]. During an interview with Confidential Family Member S on [DATE] at 9:04 am, it was revealed, She fell and had a bump on her head a couple months ago. Now she has another one. She has fallen a few times in the last few months. She has cuts and abrasions on her back too. I think it was last week she fell a few times too. When queried about the resident's shoes, the Confidential person replied, I bought 2 or 3 pairs. They asked me to bring a slip-on. She wears a 10 ½, but they only had a 10, so I bought an 11 and they were too big. She fell ([DATE]). She has a blue pair of tie shoes that are too tight. Do I need to bring in different shoes for her? No one there has talked to me about it since then. An interview with the Director of Nursing and Nurse C on [DATE] at 10:45 am, about Neurological assessments after a head injury, revealed They are supposed to complete the Neuro checks on the times that are documented on the forms. We began re-education. On [DATE] at 1:30 PM, during an interview with Nurse I, the nurse was queried on what measures were in place to assist in preventing Resident #12 from additional falls and injury and stated, We are supposed to follow the policy. The Administrator was interviewed on [DATE] at 2:30 PM about the Care Plan and interventions not being reviewed or updated after many of the resident's falls. The Administrator stated, I will look into that. The Administrator was also queried about the Fall Care Plan intervention dated [DATE] Contact Husband for better fitting shoes. There was no documentation in the medical record to indicate the intervention had been followed-up on and the resident had not received any better fitting shoes. The Administrator said, I will address that. On [DATE] at 2:35 PM, the Administrator was queried about the lack of Neurological assessments after Resident #12 had fallen and sustained a head and facial injury The Administrator stated, I heard about that. We started working on education. A review of the facility policy titled, Fall Management, released ,[DATE] and revised ,[DATE] provided, The facility will identify hazards and resident risk factors and implement interventions to minimize falls .Residents identified at risk for falls will have a care plan developed and implement appropriate fall prevention interventions .If a potential head injury is present, complete the Neurological Record .the IDT (interdisciplinary team) will review/modify the plan of care to minimize repeat falls and update the resident care plan . According to admission face sheet, Resident #4 was an [AGE] year-old female admitted to the facility on [DATE], and readmitted [DATE], with [DIAGNOSES REDACTED]. According to Minimum Data Set (MDS), dated [DATE], Resident #4's cognition assessment was scored at a 3 indicating severe cognitive impairment. According to the MDS, Resident #4 was independent with ambulation and required limited assistance with Activities of Daily Living care. Review of an Incident/Accident report, dated [DATE], documented that Resident #4 had an unwitnessed fall, and was observed on the floor. Pt (patient) observed lying on floor between her bed and bathroom, lying on her back, flat on the floor. According to the report, Resident #4 sustained a skin tear to the left eyebrow (laceration), and bruising to right hand. The attending physician was informed of the incident and ordered Neurological Assessment to be performed on Resident #4. (Neurological assessments involve assessing level of consciousness, pupil response, hand grasps, motor function of extremities, pain response, vital signs, and observations for headaches, [MEDICAL CONDITION], vomiting, or paralysis, indicating serious changes in neurological status which determines the type of interventions needed for the Resident, Neurological disease, or Injury). A Review was completed of the Neurological Flow sheet, dated [DATE], and it revealed incomplete neurological assessment by staff. According to the Neurological Assessment Flow sheet, neurological checks were supposed to be completed every 15 minutes for 1 hour, every 1 hour for 4 hours, every 4 hours for 19 hours. Review of the flow sheet indicated that on [DATE], neurological checks were started at 5:45 (no indication of AM or PM), completed again at 6:00, 6:15, 6:30, 7:30, and 8:30. At 9:30 (no indication of AM, or PM), neurological checks were not completed, and again at 10:30 not completed. The flow sheet was left blank for 9:30 and 10:30 time periods. The neurological assessment was not completed again until 0230 (2:30 AM). Review of Facility 'Fall Management' Policy dated as released revised ,[DATE], documented If a potential head injury is present, complete the Neurological record. According to www.hcpro.com., Neurological checks for head injuries Long Term Care Clinical Pearls': Powered by HCPRO's Long Term Care Nursing Library, (MONTH) 8, 2013., documented to Assess the resident for changes in level of consciousness, which is a cardinal sign of untoward pathology. Assess the resident immediately after the fall, then frequently through the shift, and should continue for a minimum of 72 hours. Observe the resident for obvious injuries to the scalp, including lacerations, bruising, contusions, confusion, memory loss, difficulty speaking, gait balance, pupils of unequal size or reactions, headache, vomiting, and must continue monitoring for a minimum of 72 hours. An interview was conducted with Administrator A on [DATE], related to incomplete neurological assessment for Resident #4. Administrator A said, The nurses should have completed all of the neurological checks, and I see they left some holes in the flow sheet and checks were not completed.

Based on observation, interview and record review, the facility failed to 1) implement infection control practices per policy and procedure and standards of practice to prevent the spread of infection for 4 of 9 sampled residents (#'s 1, 4, 8, 9) and 29 supplemental residents ( #'s 2, 5, 9, 10, 17, 19, 23, 25, 28, 35, 40, 41, 42, 43,46, 54, 58, 60, 61, 62, 64, 65, 68, 71, 76, 77, 78, 82, 84), who all exhibited sings and symptoms of a highly contagious gastrointestinal Illness and 2) implement transmission based precautions to protect all residents from the highly infectious Gastrointestinal Illness, resulting in an Immediate Jeopardy when on [DATE] residents began having signs and symptoms of a Gastrointestinal illness and no preventive measures, including transmission based precautions, nor notification of the Health Department of a disease outbreak, testing of the residents stools or appropriate cleaning to prevent or diminish the spread of infection, was implemented. The deficient practice resulted in 33 of 84 facility residents developing signs and symptoms positive for a Gastrointestinal Illness and placing all residents, staff and visitors at risk for serious harm, injury and/or death. Findings Include: On [DATE] the facility was entered for an abbreviated survey. During an interview with Resident #1, at 10:00 am, the resident was repeating in unclear speech, I need help. I pooped. The resident was observed lying in bed and had brown stains on her fingernails on both hands. Certified Nursing Assistant (CNA) V, entered the room and stated, She needs help, and pulled back the blanket. The resident was lying in a pool of runny diarrhea. An interview with CNA M, on [DATE] at 10:20 am, revealed Almost all of the residents on the 2nd floor have had diarrhea. Nurse L, at 10:40 am, stated, We have had about 5 cases on the 2nd floor with diarrhea. On [DATE] at 11:00 am, an interview with Infection Control (IC) Nurse I indicated, I have a Line Listing. IC Nurse I could not locate the Line Listing. The Director of Nursing (DON) stated, It hasn't been reported. There have been about 5 cases. Both the DON and IC Nurse said there had been no precautions put in place to prevent the spread of the illness. At 11:30 am on [DATE], the IC Nurse provided a Line List (Calendar for (MONTH) and (MONTH) (YEAR)) with 19 resident names on it who had nausea, vomiting and/or diarrhea and stated, I did not report the loose stools. I would report if I had at least 3 cases. I should have reported it. I will call the Health Department now. Neither the nurse or DON contacted the Health Department. The following residents were on the Line List for [DATE], Sampled Residents #4 and Supplemental Residents #'s 2, 5, 19, 60 and 65. All of the residents were residing on the 1st floor of the facility. The Line List also included 12 residents with signs and symptoms of Gastrointestinal Illness from [DATE]-[DATE]: #'s 1, 8, Sampled 9, and Supplemental #9, 10, 23, 25, 41, 42, 58, 68, 71, 78 and 82. The residents resided on both the 1st and 2nd floors. An interview with 2nd floor Environmental Services (EVS) worker, X at 11:35 am revealed, No one told me to clean differently. The EVS worker was using a Quaternary ammonia based disinfect cleaner. The DON further stated, We have had several cases over a 2 week period. The symptoms didn't last very long, about ,[DATE] hours. I haven't tried to limit the resident's or staffs movements. None of the residents on the list were observed to be in Transmission Based Precautions. A policy related to Gastrointestinal outbreaks, Surveillance and Transmission Based Precautions was requested, on [DATE] at 11:40 am. At 1:08 pm, the DON stated, I cannot find a policy on Isolation or Gastrointestinal symptoms. At 1:28 pm, the 1st floor Environmental Services Worker (EVS) W, stated No one told me about loose stools. The IC Nurse was interviewed again at 1:28 pm on [DATE] and stated, To my knowledge, they (cases of nausea, vomiting and diarrhea) started on [DATE]. I was notified mostly by word of mouth. Sometimes in the morning meetings. On the 31st (January), I realized there was an issue, especially when the employees started calling in. I believe it was a resident that started with the diarrhea. It started to die down and then came back a couple days ago. On [DATE] at 1:30 pm, IC Nurse I was queried what measures were put in place once an issue was identified and responded, Universal Precautions (basic hand hygiene and standard use of gloves and personal protective equipment-nothing new) was the emphasis. We discussed the Flu (Influenza), but there were no respiratory symptoms. To my knowledge nothing was tested . No stools. It wasn't [MEDICATION NAME] very long. Patients were bouncing right back. We still did activities and residents ate in the dining room. We encouraged them to eat in their rooms, but we didn't make them. Three residents (including sampled Resident #'s 8 and 9) were hospitalized , but not for loose stools. A record review of face sheets, Minimum Data Set (MDS) assessment, Daily Skilled Nurses Notes, SBAR Communication Form, Interdisciplinary Team (IDT) Notes and physician progress notes [REDACTED]. Resident #1 The resident was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS, dated [DATE], indicated the resident was confused and needed extensive to total assistance with all care. The Daily Skilled Nurses Note, dated, [DATE], indicated Resident #1 had 1 episode of emesis (vomiting) and 2 episodes of diarrhea including malodorous diarrhea on the night shift. The SBAR Communication Form, dated [DATE] indicated the resident had 1 emesis (vomiting) and 1 episode of diarrhea. The physician was not notified. The last time the physician had examined the resident was on [DATE]. The Line Listing provided by IC Nurse I indicated Resident #1 began having loose stools from [DATE]-[DATE] and again on [DATE]. Resident #4 The resident was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS dated [DATE] indicated the resident needed assistance with all care and had full cognitive abilities. The Daily Skilled Nurses Notes dated [DATE], indicated the resident had 1 emesis and was propelling herself in her wheelchair in the facility. The SBAR Communication Form dated [DATE], indicated the nurse attempted to contact the physician 3 times, but was unsuccessful. A Physicians Progress Note dated [DATE] did not mention the resident had recent vomiting. The Line Listing, provided by IC Nurse I, indicated the resident had vomiting and loose stools on [DATE]. Resident #8 The resident was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS dated [DATE], indicated the resident needed assistance with all care and had mild cognitive impairment. The resident was discharged to the hospital on [DATE] with a change of condition with stroke symptoms, including facial drooping and readmitted on [DATE] with Hospice services. The resident expired on [DATE]. The Daily Skilled Nurses Note dated [DATE], indicated the resident had nausea, emesis and diarrhea. The SBAR Communication Form dated [DATE] indicated the resident had emesis and yellow diarrhea. There was no physician progress notes [REDACTED]. The Line Listing, provided by IC Nurse I indicated the resident had nausea, vomiting and diarrhea. Resident #9 The resident was admitted to the facility on [DATE] and discharged on [DATE], readmitted on [DATE] with Diagnoses: [REDACTED]. The MDS dated [DATE] indicated the resident was independent with all care except for bathing and had full cognitive abilities. The resident was discharged to the hospital again on [DATE] with difficulty breathing and increased abdominal girth with unstable vital signs. Blood Pressure ,[DATE], Pulse 116, Respiratory Rate 14 with oxygen saturation of 89%. The Daily Skilled Nurses Notes revealed the following: [DATE], returned from [MEDICAL TREATMENT] states has the flu, nausea, vomiting and diarrhea . [DATE], Resident difficult to arouse repeating, I'm just so tired .complaining the room is hot .not answering questions appropriately .complains of feeling the need to vomit, stating, I need to throw up but I can't .abdominal pain .(EMS) called to take resident to the hospital . [DATE], Patient stated she had a couple gooey stools today. The Line Listing provided by IC Nurse I indicated the resident had nausea and vomiting on [DATE]. The Line Listing also indicated the following Supplemental resident information: #2: Nausea and vomiting on [DATE] #5: Vomiting and loose stools on [DATE] #19: Vomiting and loose stools on [DATE] #60: Vomiting and loose stools on [DATE] #65: Vomiting and loose stools on [DATE] #9: Nausea, vomiting and loose stools on [DATE]-[DATE] #10: Nausea and vomiting on [DATE] #23: Nausea, vomiting and loose stools on [DATE] #25: Nausea, vomiting and loose stools on [DATE] #41: Nausea and vomiting on [DATE]-[DATE] #42: Nausea, vomiting and loose stools on [DATE] #58: Nausea and vomiting on [DATE] #68: Loose stools on [DATE]-[DATE] #71: Nausea, vomiting and loose stools on [DATE]-[DATE] #78: Nausea, vomiting and loose stools on [DATE] #82: Nausea, vomiting and loose stools on [DATE]-[DATE] On [DATE] the following interviews occurred: 3:50 pm- Doctor S revealed, I know gastroenteritis is going around. I was informed of a couple patients. I didn't know the scope of the number of residents with diarrhea. 4:40 pm- Doctor R the Medical Director stated, They told me about a couple cases, but not about that many. It might be best to keep them isolated. I'll call them and find out how many we have right now. Maybe we can keep them isolated and test them to see just what we have. 4:53- The Director of Nursing was queried if she had contacted the Health Department to report the outbreak of Gastrointestinal Illness, the DON stated, I'll do that now. At 4:56 pm, the DON contacted the Health Department and stated, They're sending an email with resources. On [DATE] the nursing home administrator was informed of the immediate jeopardy that was identified on [DATE] and had began on [DATE]. The facility staff did the following to remove the immediate jeopardy: [DATE]: Line listing for residents with GI symptoms completed. [DATE]: 2 active resident cases. [DATE]: Line listing for staff members completed. [DATE]: Health Department notified. [DATE]: Health Department visited facility, recommendations provided; requested follow up 7 days; left containers/instructions for stool samples. [DATE]: Stool Samples sent to Health Department. [DATE]: No current confirmation of Norovirus [DATE]: Signage to inform visitors of an outbreak posted at facility entrances, elevators and nursing stations as indicated for incoming visitors. [DATE]: Contact isolation initiated for residents exhibiting GI Illness symptoms. Contact isolation to remain in place until resident asymptomatic x 72 hours [DATE]: Consistent Staffing in place and maintained. [DATE]: Second Floor Dining Room closed. [DATE]: Second Floor Dining Room remains closed. [DATE]: First Floor Dining Room closed. [DATE]: First Floor Dining Room re-opened. No active cases. [DATE]: Activities held to individual rooms. [DATE]: Cleaning solution utilized bleach solution. [DATE]: Cleaning solution switched to Virex [DATE]: Cleaning solution switched to Virasept (due to Virex not on health department approved list for killing Gastrointestinal outbreak) [DATE]-[DATE]: No admissions and/or re-admissions. [DATE]: Restricted admissions to second floor. [DATE]: Quality Review conducted utilizing Stop & Watch, SBAR, 24 hour report and resident interviews. Follow up based on findings. [DATE]: Facility re-education initiated regarding Infection Control Standards, Housekeeping Standards initiated. (Staff required completing education prior to next scheduled shift). [DATE]: Facility Housekeeping department- education initiated regarding use of new cleaning solution Virasept. [DATE]: Ad Hoc QAPI Committee held to include Root Cause Analysis. [DATE]: Ongoing Quality Monitoring of Infection Control Program initiated and to continue to be reviewed through monthly QAPI Committee Meeting. Modifications based on findings. On [DATE] at 9:05 am, the DON provided an updated Line List titled, Resident Symptom Line Listing, dated [DATE]-[DATE]. There were 13 new cases of Gastrointestinal Illness during that timeframe; bringing the total to 33 of 84 residents. The DON stated, We're keeping them in Contact Precautions for 72 hours after the last symptom. The updated Line Listing included date of onset, type of symptoms and when the Contact Precautions would be discontinued. The DON was again asked for policies related to Infection Surveillance, Outbreaks, Gastrointestinal illness and Transmission Based Precautions and said she could not locate them. The DON was also asked for a copy of the documents sent by the Health Department and stated, We had a call with them last week. We went over what we are supposed to do. They are picking up 3 stool samples today to send them in for testing of Norovirus. She did not provide the documents. At 11:40 am, on [DATE], 11 residents were observed to have Contact Precautions in place, including a sign on the door and a cart containing personal protective equipment (gowns and gloves) outside the door. Staff were observed entering the rooms to provide care without wearing Personal Protective Equipment (PPE), including gowns and gloves. On [DATE] the following observations and interviews occurred: 11:45 am, EVS Staff AA stated, We have a new cleaning product. 11:50 am, Staff Y was observed entering Resident #62's room without donning (putting on) PPE. When Staff Y was queried about the resident being in Contact Precautions, she responded, I would wash my hands in between each resident (there were 3 in the room). I use the hand sanitizer. Staff Y was not aware of the need to wear PPE. 11:55 am, Nurse L was observed exiting Resident #62's room and when queried about the resident being in Contact Precautions, stated, I'm not sure who's in precautions. 11:57 am, CNA K exited Resident #62's room and stated, I had on a mask and gloves. I wore the gown the first time I went in the room, but not this time. The CNA indicated she was providing care to all of the residents in the room. 12:05 pm, Hospice Nurse Z was observed entering Resident #40's room without donning PPE and then set her bag on the floor and proceeded to assess the resident. When queried about the resident being in Contact Precautions, Nurse Z stated, I did not know. They didn't let the office know. 12:15 pm, Nurse Manager H was queried about the staff and visitors not being aware of the necessity to follow Contact Precautions for the residents with Gastrointestinal Illness and responded, We're instructing them on what precautions to use-Gowns, gloves, masks and dispose of them in a red bag. Hand Hygiene is with soap and water and a paper towel to dry their hands. We will continue our education. 3:26 pm, Health Department Staff BB provided an overview of their discussion with the facility on [DATE] and indicated a review of the resource materials concerning a Gastrointestinal Outbreak that was provided to the facility on [DATE] at 9:12 am. 4:15 pm, EVS Director F was queried about the new product and stated, I was directed to use it. We used bleach for one day ([DATE]) and then switched to the new product the next day ([DATE]). 4:40 pm, Health Department Staff CC was interviewed via phone and stated, We had a conference call with the facility and reviewed all of the recommendations with them, including the most up to date list of cleaning products. If it's not on there it's not approved. They're supposed to perform increased cleaning. It's important to use the right cleaner. A sign on the front door should alert visitors to the outbreak. The following 8 documents were sent to the facility by the Health Department and reviewed with them on [DATE]: 1. Norovirus Control Recommendations (from the Centers for Disease Control-CDC), Key Infection Control Recommendations 2. Environmental Protection Agency (EPA)- List G EPA Registered Hospital Disinfectants Effective Against Norovirus (Norwalk- [MEDICAL CONDITION]) 3. Line List for Outbreak in Long Term Care Facilities- Health Department 4. Health Department Fact Sheet-Norovirus dated ,[DATE] 5. General Fact Sheet for Norovirus ([MEDICAL CONDITION] gastroenteritis)- Michigan Department of Community Health (MDCH) 6. Guidelines for Environmental Cleaning -Norovirus -MDCH, [DATE] 7. Guidelines for the Control of a Suspected or Confirmed Outbreak of [MEDICAL CONDITION] Gastroenteritis in a Nursing Home 8. Norovirus Illness: Key Facts, CDC Several recommendations from the CDC's Norovirus Control Recommendations, included: -Place patients with norovirus gastroenteritis on Contact Precautions for a minimum of 48 hours after the resolution of symptoms. - Actively promote adherence to hand hygiene among healthcare personnel, patients, and visitors in patient care areas affected by outbreaks of norovirus gastroenteritis. - During outbreaks, use soap and water for hand hygiene after providing care or having contact with patients suspected or confirmed with norovirus gastroenteritis. - If norovirus infection is suspected, adherence to PPE use according to Contact and Standard Precautions is recommended for individuals entering the patient care area (i.e., gowns and gloves upon entry). -Consider the closure of wards to new admissions or transfers as a measure to attenuate the magnitude of a norovirus outbreak. - In the absence of clinical laboratory diagnostics or in the case of delay in obtaining laboratory results, use Kaplan's clinical and epidemiologic criteria to identify a norovirus gastroenteritis outbreak. Kaplan's Criteria: 1. Vomiting in more than half of symptomatic cases, and 2. Mean (or median) incubation period of 24 to 48 hours, and 3. Mean (or median) duration of illness of 12 to 60 hours, and 4. No bacterial pathogen isolated from stool culture - Consider submitting stool specimens as early as possible during a suspected norovirus gastroenteritis outbreak and ideally from individuals during the acute phase of illness (within ,[DATE] days of onset). -Increase the frequency of cleaning and disinfection of patient care areas and frequently touched surfaces during outbreaks of norovirus gastroenteritis (e.g., increase ward/unit level cleaning twice daily to maintain cleanliness, with frequently touched surfaces cleaned and disinfected three times daily using EPA-approved products for healthcare settings). -Exclude ill personnel from work for a minimum of 48 hours after the resolution of symptoms. Once personnel return to work, the importance of performing frequent hand hygiene should be reinforced. -Notify appropriate local and state health departments if an outbreak of norovirus gastroenteritis is suspected. Guidelines for the Control of a Suspected or Confirmed Outbreak of [MEDICAL CONDITION] Gastroenteritis in a Nursing Home, indicated the following: - If visitation is allowed, visitors should go directly to the person they are visiting and not spend time with anyone else. - Signs should be posted to warn visitors of the outbreak, so individuals do not put themselves at risk. - Visitors should wash their hands upon entering and leaving the room or facility. The facility had posted a sign on the outside of the front door to the facility that did not mention or indicate the facility had an outbreak of a Gastrointestinal Illness. It suggested visitors not enter if they had been ill. On [DATE] at 5:25 pm, the DON, Administrator, Nurses C and D and EVS Director F were interviewed regarding the cleaning product placed into use on [DATE], as it was not on the EPA approved list of products effective against Norovirus, provided by the Health Department. There was no response. The facility also did not have a sign posted to alert visitors that the facility was experiencing an outbreak of a Gastrointestinal Illness. The DON stated, We don't want to panic people. The DON provided a copy of a new sign mentioning Gastrointestinal Illness, but did not indicate it was at the facility. When queried if the facility was still accepting new admissions the DON stated, Yes, we will have a new admission today ([DATE]). On [DATE] at 10:50 am EVS Director F was queried about the facilities cleaning product and stated, I haven't had a chance to do anything different. We talked about it last night, but haven't done anything different. At 11:30 am, Nurse C provided several Infection Control policies. On [DATE] at 4:45 pm, EVS Director F indicated the facility had chosen a new cleaning product from the EPA approved list, effective against Norovirus. The staff were being educated on use of the new product. [DATE] at 10:30 am, the Director of Nursing provided a list of admissions to the facility for the past 30 days. 1 resident had been newly admitted on [DATE] and 1 re-admitted on [DATE], to the facilities 2nd floor, which was the current location of the Gastrointestinal Illness outbreak. The last resident to become symptomatic with diarrhea was on [DATE] on the 2nd floor. At 11:45 am, on [DATE] the DON and Nurse E reviewed the Infection Control Program. From (MONTH) (YEAR) until (MONTH) (YEAR) there was no summarized surveillance data. The prior Infection Control Nurse had performed surveillance, but did not summarize, trend or report or implement interventions to respond to findings of the surveillance. This included the surveillance data from the outbreak of the Gastrointestinal Illness from (MONTH) (YEAR)-February (YEAR). The Director of Nursing was unaware the surveillance data was incomplete. At 1:30 pm, a review of several facility provided Infection Control policies revealed the following: Surveillance for Infections, dated [DATE] indicated, The Infection Preventionist will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcomes and that may require transmission-based precautions and other preventative interventions .The purpose of surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and (HAI) to guide appropriate interventions and to prevent future infections . Isolation-Categories of Transmission-Based Precautions, dated [DATE] provided, .Transmission-Based Precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others .Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's room .Wear a disposable gown upon entering the Contact Precautions room . Norovirus Prevention and Control, dated [DATE] revealed, The facility will implement strict infection control measures to prevent the transmission of norovirus infection .Place residents on Contact Precautions .The following may be considered .Minimizing resident movements within the unit .Suspending group activities (including dining events) .During outbreaks, use soap and water for hand hygiene .During outbreaks of Norovirus gastroenteritis, unit level cleaning will be increased to twice daily, with frequently touched surfaces cleaned and disinfected three times daily using EPA-approved products .Ill personnel will be excluded from work for a minimum of 48 hours after the resolution of symptoms .Non-essential visitors will be restricted from affected areas of the facility during outbreaks of norovirus gastroenteritis . Although the immediate jeopardy was removed on [DATE], the facility remained out of compliance with a scope of pattern and severity of No actual harm with the potential for more than minimal harm that is not immediate jeopardy due to all staff had not received inservice education and sustained compliance had not been verified by the state agency.

Based on observation, interview and record review, the facility failed to document consistent weekly Pressure Ulcer Records, document weekly measurements on facility acquired pressure ulcers (PU), perform timely incontinence care, and turn/reposition, at a minimum, every two hours, for one (#501) of two sampled residents reviewed for pressure ulcer, from a total of 15, resulting in the development and worsening of facility acquired PU and the potential for additional pressure ulcers. Findings include: On 3/6/2017 at 9:30 a.m., during the initial tour of facility, accompanied by the Unit Manager (Nurse B), Resident #501 was observed lying in bed on his left side, facing the window. The head of the bed was elevated at 30 degrees. A [MEDICAL CONDITION] was in place with oxygen infusing. Nurse B reported that Resident #501 was receiving hospice services, not responsive, and that he has been in this condition since his overdose. On 3/6/17 at 11:35 a.m., Resident #501 was observed still lying on his left side and facing the window. The head of the bed was elevated at 30 degrees. Resident #501 was alert but not responsive to verbal stimuli. On 3/6/17 at 2:00 p.m., Resident #501 was still in the same position. An observation of Resident #501's pressure ulcer wound treatments was requested. Treatment Nurse (Nurse A) was informed. On 3/6/17 at 2:40 p.m., Nurse A entered Resident #501's room to perform wound care on Resident #501. Again, Resident #501 was lying on his left side. Nurse A attempted to start wound care to Resident #501's pressure ulcers when she noted that he was incontinent of urine and stool. Nurse A stated, We have to clean him up first. When Resident #501 was observed turned onto his right side from his left side, large copious amounts of loose stool/diarrhea and urine were noted. The incontinence pad, top sheet, fitted sheet, and mattress along with Resident #501's brief were saturated with stool and urine. The stool had spread half way up Resident #501's back and as low as mid-thigh. When asked who was Resident #501's assigned Certified Nursing Assistant (CNA), Nurse A reported that she was busy taking care of another resident. After Resident #501 was cleaned up, the treatments to Resident #501's wounds revealed the following: Area #1: Resident #501's pressure ulcer treatment to the left lower leg was observed with Nurse A. Nurse A removed the dressing. The pressure ulcer was noted with pink tissue and exposed hardware. Nurse A reported that it started out as a pressure ulcer initially until the hardware was noted in the wound bed. Now it is a surgical wound. Area #2: Resident #501's right hip pressure ulcer was also observed at this time. When asked for the stage of the pressure ulcer, Nurse A stated, I don't think it's a pressure ulcer. I think it was from shearing. The area was superficial in depth with the first layer of the skin not intact. Nurse A then cleansed the area with normal saline (NS), applied [MEDICATION NAME] and dry dressing. Area #3: Pressure ulcers were noted on Resident #501's bilateral buttocks and coccyx area. Nurse A reported that the areas were identified as stage II pressure ulcers (partial thickness loss of dermis presenting a shallow open ulcer with red-pink wound bed) prior to the current observation. There were no dressings on the wounds. The areas were noted to have yellow slough (non-viable, dead, yellow, tan gray, green or brown tissue) and scattered necrotic (dead tissue) tissue throughout. Nurse A stated, It is now hard to determine the stage of the pressure ulcers. I think we consider the pressure ulcers now as one area. They look connected. It is now unstageable (Unable to stage due to slough and/or eschar, the wound cannot be visualized therefore it cannot be staged). We are just applying [MEDICATION NAME] (skin protective cream) to the areas. The doctor does not want any dressings to the areas. Area #4: Nurse A then treated Resident#501's left elbow pressure ulcer. Nurse A reported the area was identified as a stage II pressure ulcer. Nurse A removed the dressing and the pressure ulcer was observed to have areas of eschar and some areas of yellow slough Nurse A stated, We now have to call it unstageable. On 3/6/17 at 3:37 p.m., Resident #501's assigned CNA (CNA E) was interviewed regarding his care for the day. CNA E stated, I cleaned him up around 8:40 a.m. I got here late. I have not had a chance to turn him. I know I should turn him at least every two hours. I have not been back to care for him since then. The nurse was pressing me to take care of other residents. On 3/8/17 at 10:10 a.m., The Director of Nurses (DON) was informed of the concerns regarding Resident #501's lack of turning and repositioning, incontinence care, and inconsistent documentation/assessments of PU. The DON did not provide an explanation other than stating, That ADLs is a standard of care. We will talk to the CNA. On 3/8/17 at 3:50 p.m., review of Resident #501 clinical record revealed the following: The face sheet indicated an original admission into the facility on [DATE] and a re-admission on 6/4/16 with [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set (MDS) assessment, dated 1/15/17, indicated a severely impaired cognition (vegetative state) and that Resident #501 was dependent upon staff for all activities of daily living (ADLs), including turning and repositioning. Resident #501's care plan titled Potential for alteration in skin integrity r/t (related to) immobility,[MEDICAL CONDITION], feeding tube, dependent for all care, initiated on 9/17/15, revealed the intervention to turn and reposition as clinically indicated. Peri (perineal) care after each incont. (incontinence) episode. Anticipate all needs, unable to use call light system. Weekly and prn (as necessary) skin assessment. Review of the Pressure Ulcer Records revealed the following facility acquired pressure ulcers: Area #1: Left ankle. Developed on 9/17/15. Currently, a stage four (IV) and measured last on 3/2/17 at 3.2 centimeters (cm) width by 1.2 cm in width. There were missing weekly Pressure Ulcer records between the time period of 2/20/17 - 3/2/17. Area #2: Right hip. Developed on 12/29/16. Currently, a stage two ( II). There was no documentation of Weekly Skin Integrity Reviews on the PU. A Pressure Ulcer Record was initiated by the Unit Manager (Nurse B) on 3/8/17. The PU was measured on 3/8/17 at 1.0 cm by 0.6 cm. On 3/8/17 at 1:40 p.m., Nurse B stated, There is no documentation of the right hip PU after 12/29/17. The PU sheet was started today. Area #3: Right buttock/coccyx. Developed on 1/5/17. Currently a stage II and measured last on 3/2/17 at 7.0 cm by 3.8 cm. There was a missing weekly Pressure Ulcer between the time period of 2/20/17 - 3/2/17. The PU size was increased from the 2/20/17 - 3/2/17. The wound on 2/20/17 was measured at 6.4 cm width by 4.0 length. Area #4: Left elbow. Developed on 2/18/17. The facility did not have documentation of the stage and description of the PU. Review of the Pressure Ulcer records, dated 2/18/17 and 3/2/17, only included measurements. The measurement of the PU on 2/18/17 was 1.5 cm by 1.4 cm. The measurement on 3/2/17 only had the measurement of the width as 1.0 cm. The length of the PU was not documented. The weekly wound note for 2/25/17 was missing. Area #5: Left Buttock. Facility reported having no documentation of the area and considered it as a part of the, now called, right buttock/coccyx PU. Yet, upon review of the Pressure Ulcer Records, dated 1/30/17 and 2/16/17, a PU was noted on Resident #501's left buttock. The initial measurement was done on 1/30/17 and indicated it was a stage II that measured at 1.0 cm by 0.4 cm. On 2/16/17 it measured at 1.0 cm by 0.6 cm. There was no further documentation beyond 2/16/17 regarding the left buttock PU. On 3/9/17 at 11:20 a.m., review of the facility's policy titled Pressure Ulcer Record, revised 1/30/15, revealed the following documentation: To document the presence of skin impairment related to pressure when first observed and weekly thereafter until the site is healed. One site will be recorded per page. Resident will have a Pressure Ulcer Record completed for each skin impairment that is related to pressure. Review of the facility's policy titled Skin Evaluation - Weekly, revised 1/30/15, revealed the following documentation: A licensed nurse will complete a total body evaluation on each resident weekly, paying particular attention to any skin tears, bruises, stasis ulcers, rashes, pressure ulcers, [MEDICAL CONDITION], abrasions, reddened areas and skin problems.

Based on observation, interview and record review, the facility failed to identify, assess, develop and implement interventions to prevent a decrease in range of motion (ROM) for one (#710) of five sampled residents reviewed for ROM, out of a total of 18, resulting in an actual right knee/leg contracture with the potential for the worsening of it and the development of additional contractures. Findings include: On 4/12/16 at 1:25 p.m., Resident #710 was observed receiving a bed bath by his Certified Nursing Assistant (CNA). During that time a right leg (knee joint) contracture was noted for Resident #710. The right leg was completely flexed, without any extension of the leg. Resident #710 was alert, but was unable to answer simple questions. On 4/13/16 at 2:55 p.m., The Director of Nursing (DON) was queried regarding the onset date of Resident #710's contracture. At this time the clinical record was reviewed and revealed that there was no care plan for the right leg contracture nor was there any documentation of it. The DON stated, You would have to talk to therapy about that. On 4/13/16 at 3:05 p.m., the Director of Rehabilitation (Staff G) was interviewed regarding any therapy services received at the facility for resident # 710. Staff G stated, He was screened by occupational therapy, physical therapy, and by speech. He was ambulating on 4/9/15 (second day of admission into the facility). There were no therapies recommended at that time. He was never screened again. He never received therapy from us. I was not aware of his (#710) contracture. He was admitted into the facility on [DATE] and he never went out for any hospitalization s. Staff G indicated that he has remained in the facility from 4/8/15 - present time. Staff G then presented a form titled Interdisciplinary (IDT) Therapy Screen, dated 4/9/15, that indicated the reason for the screen was because Resident #710 was a new admit and the assessment identified him as having no contractures nor any deficits with walking, balance, bed mobility, bathing, dressing nor any other activities of daily living (ADLs). This IDT screen further indicated Patient at baseline, completes ADLs, transfers, requires some set up .No skilled PT therapy services recommended at this time. On 4/13/16 at 3:35 p.m., the Director of Nursing (DON) was queried regarding Resident #710's right leg contracture. The DON stated, I think it was unavoidable. I wish that we would have documented interventions. He received passive ROM while receiving care. That is a standard of practice. The contracture was unavoidable because he declined and he had other health conditions that were poor. On 4/13/16 at 4:10 p.m., review of Resident #710's clinical record revealed the following: Resident #710's face sheet indicated an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment, dated 4/20/2015, indicated that Resident #710 was severely cognitively impaired and was independent with ambulation (walking), balance was steady at all times. He was also assessed for having no ROM impairments, no contractures. The most current MDS assessment (quarterly), dated 2/22/2016, indicated that Resident #710 was severely cognitively impaired and was not ambulating. He was assessed for having no ROM impairments, no contractures. On 4/14/16 at 9:10 a.m., a skin assessment was conducted on Resident #710 with the Unit Manager (Nurse F). Resident #710's right leg was completely flexed (bent at knee). Nurse F was unable to provide a time frame as to when the contracture developed for Resident #710. On 4/14/16 at 9:23 a.m., the Physical Therapist (PT E) assessed Resident #710's right leg. PT E attempted to extend Resident #710's right leg. Resident #710 began to grimace in pain. PT E stated, It's very tight (muscles/tendons) and contracted. This is my first time seeing it. When I saw him on admission he walked independently, totally with good balance. He used to pace the halls constantly. I am surprised to see this. We (therapy dept.) were never informed of a contracture. PT E measured Resident #710's knee contracture and obtained the following measurements: Knee joint measured 25 degrees. PT reported the normal measurements are 0 - 140 degrees. It is contracted at 120 degrees, when stretched (leg) it is 115 degrees. The left leg is fine. There was no communication to us regarding this. The first time I saw him (on admission) I had no recommendations for him. He now has a fixed contracture. On 4/14/16 at 10:36 a.m., the MDS nurse (Nurse D) was queried regarding Resident #710's assessment of his ROM. Nurse D stated, I did all of his MDS (assessments) for the entire time he has been here. I physically assessed him for the MDS assessments. I did not notice that he had a right leg contracture. The last time I saw him was around 2/23/16 .both of his feet were down, both legs were extended. Nurse D was queried as to whether she thought that he was assessed for being at risk for developing contractures. Nurse D responded, Yes. Nurse D was then asked if there was a plan of care in place for the prevention of contractures. Nurse D then reviewed the care plan binder and reported, No, there is no care plan for the prevention of contractures. Nurse D offered no explanation other than stating, He was at risk. Any contracture can be avoided or the risk of one developing can be decreased. He was at risk. This is the first time I heard of his contracture. On 4/14/2016 at 12:25 p.m., review of the facility's policy titled, Contractures, Prevention, dated 11/30/2014, revealed the following documentation: Each resident must be assessed for need of contracture prevention procedures on admission and as needed. Residents with inactive extremities should have range of motion exercises done to those extremities as part of daily care. ( )

This citation is related to Intake #MI 638. Based on observation, interview and record review the facility failed to ensure that 1 of 4 sampled residents (#33) was free from verbal abuse and withholding of candy as a punishment resulting in psychosocial harm and deprivation of candy as punishment which was not part of the care plan. Findings Include: The face sheet for Resident #33 reflected she was an [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) completed on 7/22/15 reflected the following for Resident #33: Brief Interview for Mental Status (BIMS) score of 7 out of 15 (0-7 severe impairment), required extensive assistance of one person for transfers, hygiene, bathing, dressing and locomotion on the unit. The facility reported on 8/5/15 at 12:54 PM, that on 8/2/15 at 6:30 PM Resident #33 has an verbal disagreement with Licensed Practical Nurse (LPN G). Below are staff who were working the day of the reported incident 8/2/15 along with a summary of their written statements: On 8/4/15 at 2:38 PM facility staff called Nursing Assistant (NA H) regarding the incident. NA H revealed that on the day in question Resident #33 wanted to go outside, but it was too hot so LPN G informed the resident she would have staff take her out later when it had cooled down. Resident wanted to go outside immediately, got out of bed and put herself on the floor. LPN G was notified and encouraged NA H to leave Resident #33 on the floor and let her calm down. Later LPN G entered and told Resident #33 she would tell the NA who normally brought her candy not to bring her anymore and took Resident #333's candy. Also, that she would not get it back until she acted correct. Resident #33 became very angry, but LPN G did not give the resident her candy back. Resident #33 called LPN G a B*tch and got of floor like she was going to fight and LPN G said, Come on come on. After Resident #33 calmed down LPN G asked her if would stay of the floor and Resident #33 said yes and apologized. On 10/7/15 at 12:58 PM a phone call was attempted for NA H, but she had a non-functioning number. The facility staff stated NA H was not on the schedule to work while writer was there and had no way of contacting her. NA (I) written statement dated 8/4/15 reflected LPN G had Resident #33 standing by the nursing station, holding Resident #33's gait belt with her forearm (normally held by ones hand). LPN G asked Resident #33 multiple times, Are you going to stay of the Fu*king floor. Resident #33 then called LPN G a B*tch and asked LPN G to let her go. LPN G then took Resident #33's candy out of her drawer and was not going to give it back until Resident #33 answered her question. Resident #33 got tired of LPN G swearing at her and said she would staff off the floor. LPN G then gave Resident #33 her candy back after we took her back to her room. Resident #33 asked NA I to take her outside, and NA I stated she would. Then LPN G told NA I, I wouldn't because Resident #33 was being punished. LPN G written statement dated 8/5/15 reflected Resident #33 wanted to go outside, but she explained to her that it was too hot and she have a NA take her out when it cooled down. Resident #33 then began calling her the B-word. LPN G told Resident #33 she would tell the NA on third shift not to bring her candy. LPN G then picked up Resident #33's candy, walked down the hall several times as Resident #33 called her derogatory name, and took her to her room and placed her in bed. Later a NA took Resident #33 outside. LPN G was called on 10/7/15 at 3:29 PM, and asked to recall incident occurred around 8/4/15. LPN G revealed, Resident #33 had candy all over her bed and drawers and they thought I took it. She wanted to go outside and I told her it was too hot to go outside and she cursed me out and called me everything but a child of God. We walked down the hall with a gait-belt on. I told her the sitter would be able to take her out when it cooled off. I put her candy back in her drawer. I was going to tell the person who brought her the candy not to bring her anymore candy because she was cutting up. She flopped in the bed. LPN G Denied using a harsh tone or curse words with Resident #33. LPN G stated, She cursed me and I told her to call me Ms. B*tch was the only curse word I used. My hand was under her gait-belt. Her gait was unstable. LPN G denied that she refused to give Resident #33 her candy and denied exhibiting abuse toward the resident. LPN G stated, Resident #33 later came back and apologized. LPN G revealed she had worked at the facility for a year. When asked when her last abuse training was, LPN G replied, I think maybe 3 months ago before that happened. NA (J) written statement dated 8/7/15 at 11:30 AM reflected she saw LPN G standing at th nurses station with Resident #33. LPN G asked Resident #33 why she was acting up, and could not wait to go outside. Resident #33 asked for her candy back and called LPN G a B*tch. LPN G responded, No way because of the way your acting. Resident #33 cursed at LPN G again, and NA J walked away. NA J was called on 10/7/15 at 3:27 PM, but did not have a functioning phone number or additional number to call. NA (K) written statement dated 8/7/15 at 11:45 AM reflected Resident #33 was acting up at the nurses station and called LPN G a B*tch. LPN G was supporting Resident #33 with her gait belt, had Resident #33's candy and would not give it to her. LPN G had a bad attitude, she was rude to Resident #33. Kind of like verbal abuse rude. NA K was called on 10/7/15 at 3:22 PM, a friend answered the phone who stated she was at a doctor's appointment. The friend was asked to let the phone pickup voicemail for re-peat call. He stated no voicemail was available, so the writer's name and number was left for friend for return call. Registered Nurse (RN L) written statement dated 8/8/15 reflected that upon walking out of the break room, she observed Resident #3 standing in the hall with her fail belt loosely on her and LPN G holding Resident #33 with her right arm. LPN G was withholding Resident #33's candy from her, and she told the resident she could have her candy back if she stayed off the floor. Resident #33 stated, Give me my fu*king candy and LPN G stated, you can have your candy back when you say you are going to stay off the floor. Resident #33 called LPN G a B*tch. LPN G stated, That's is Mrs. [***] if you're going (sic) calling me a B*tch, then I will act like a B*tch. After Resident #33 said she would staff of the floor the interaction ended, she was returned to her room and her candy was returned. On 10/7/15 at 3:13 PM RN L was interviewed. She stated she had been working at the facility for 3 months. When asked when her last abuse training was RN L replied, My last abuse training was after the incident. I didn't have abuse training upon hire or prior 8/2/15. My date of hire is 7/8/15. RN L was given her statement to read and asked if it was accurate. She replied that it was pretty accurate. RN L was asked why she did not intervene with the incident between Resident #33 and LPN G. RN L replied, I did not know what to do intervene. I was hesitant that the nurse would retaliate against me. I was shocked and had not experienced anything like that before, and I did not do justice to intervene. I did not know the proper manner in what to do or how to handle the situation. The nurse had more of a domineering personality, and was probably around 18 inches from the resident. The resident was aggravated and frustrated. Now I understand what I should do. I did not contact any of the first floor nurses, I don't believe they were notified. When asked about the gait belt placement. RN L revealed that the nurse walking holding it with her arm. The gait-belt was in the bend of the nurse's arm. None of the above staff reported the incident immediately to the authorities, the Administrator (A) or Interim Director of Nursing (ADON B). Documentation of knowledge related to the incident reflected 8/4/15 with investigation documents, with the incident occurring around 8/1/15 or 8/2/15. Resident #33's Care Plan related to the problem of displaying socially inappropriate/disruptive behavior reviewed 7/22/15 reflected the following approaches: Do not argue with Resident #33, redirect as needed. Discuss Resident #33's option for appropriate channeling of anger with resident. Talk with Resident #33 in a calm voice when behavior is disruptive Social Services to evaluate and visit with Resident #33 as needed. Resident #33 Falls care plan reviewed 7/22/15 reflected, .Keep items in reach .Involve resident in decision making regarding daily choices . The facility's Policies and Procedures related to Resident Abuse revised on 3/20/15 reflected the following: .Employees of The Company are charged with a continuing obligation to treat residents so they are free from abuse, neglect, mistreatment, and/or misappropriation of property. No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatment, and /or misappropriation of property against any resident . Verbal Abuse .Any use of oral, written or gestured language that includes cursing, disparaging and derogatory term to other residents or visitors within hearing range, to describe residents, regardless of their age, ability to comprehend, or disability. Misappropriation of Personal Property .Inappropriate us of resident funds or property . Training Employees of The Company will receive education and training on Residents Rights, Resident Abuse, and Abuse Reporting during orientation and annually thereafter .An employee shall be deemed to have violated his obligation in paragraph A (above) if he does any of the following: Fails to report an incident of abuse witnessed by or known to him/her . Procedure for Reporting Abuse All incidents of resident abuse are to be reported immediately to the Clinical Nurse in Charge, Director of Clinical Services, and the Executive Director. Once reported to one of those three officials, the prescribed forms are to be completed and delivered to the Abuse Coordinator or his/her designee for an investigation. The incident was discussed with Administrator A and DON B on 10/8/15. Administrator A revealed that when she found out the incident had not been reported in 2 days she was in shock. She revealed that, Upon investigating I realized there was a huge lack of education in this building. I took it upon myself to address how severe an issue it was. I did all of the abuse in-services myself on all shifts. I ensured that all employee ' s understood what abuse was. I had many in-serves provided by all shifts. All of the staff interviewed, denied having had abuse training prior to the incident. They have not had much education in years. ( )

This citation is related to Intake# MI 638 (Resident #33). Based on observation, interview and record review the facility failed to timely report and investigate abuse occurring for 1 of 4 sampled residents (#33), resulting in the resident being exposed to verbal abuse, misappropriation of property and delayed advocacy related to abuse exposure. Findings Include: The face sheet for Resident #33 reflected she was an [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) completed on 7/22/15 reflected the following for Resident #33: Brief Interview for Mental Status (BIMS) score of 7 out of 15 (0-7 severe impairment), required extensive assistance of one person for transfers, hygiene, bathing, dressing and locomotion on the unit. The facility reported on 8/5/15 at 12:54 PM, that on 8/2/15 at 6:30 PM Resident #33 has an verbal disagreement with Licensed Practical Nurse (LPN G). Below are staff who were working the day of the reported incident 8/2/15 along with a summary of their written statements: On 8/4/15 at 2:38 PM facility staff called Nursing Assistant (NA H) regarding the incident. NA H revealed that on the day in question Resident #33 wanted to go outside, but it was too hot so LPN G informed the resident she would have staff take her out later when it had cooled down. Resident wanted to go outside immediately, got out of bed and put herself on the floor. LPN G was notified and encouraged NA H to leave Resident #33 on the floor and let her calm down. Later LPN G entered and told Resident #33 she would tell the NA who normally brought her candy not to bring her anymore and took Resident #333's candy. Also, that she would not get it back until she acted correct. Resident #33 became very angry, but LPN G did not give the resident her candy back. Resident #33 called LPN G a B*tch and got of floor like she was going to fight and LPN G said, Come on come on. After Resident #33 calmed down LPN G asked her if would stay of the floor and Resident #33 said yes and apologized. On 10/7/15 at 12:58 PM a phone call was attempted for NA H, but she had a non-functioning number. The facility staff stated NA H was not on the schedule to work while writer was there and had no way of contacting her. NA (I) written statement dated 8/4/15 reflected LPN G had Resident #33 standing by the nursing station, holding Resident #33's gait belt with her forearm (normally held by ones hand). LPN G asked Resident #33 multiple times, Are you going to stay of the Fu*king floor. Resident #33 then called LPN G a B*tch and asked LPN G to let her go. LPN G then took Resident #33's candy out of her drawer and was not going to give it back until Resident #33 answered her question. Resident #33 got tired of LPN G swearing at her and said she would staff off the floor. LPN G then gave Resident #33 her candy back after we took her back to her room. Resident #33 asked NA I to take her outside, and NA I stated she would. Then LPN G told NA I, I wouldn't because Resident #33 was being punished. LPN G written statement dated 8/5/15 reflected Resident #33 wanted to go outside, but she explained to her that it was too hot and she have a NA take her out when it cooled down. Resident #33 then began calling her the B-word. LPN G told Resident #33 she would tell the NA on third shift not to bring her candy. LPN G then picked up Resident #33's candy, walked down the hall several times as Resident #33 called her derogatory name, and took her to her room and placed her in bed. Later a NA took Resident #33 outside. LPN G was called on 10/7/15 at 3:29 PM, and asked to recall incident occurred around 8/4/15. LPN G revealed, Resident #33 had candy all over her bed and drawers and they thought I took it. She wanted to go outside and I told her it was too hot to go outside and she cursed me out and called me everything but a child of God. We walked down the hall with a gait-belt on. I told her the sitter would be able to take her out when it cooled off. I put her candy back in her drawer. I was going to tell the person who brought her the candy not to bring her anymore candy because she was cutting up. She flopped in the bed. LPN G Denied using a harsh tone or curse words with Resident #33. LPN G stated, She cursed me and I told her to call me Ms. B*tch was the only curse word I used. My hand was under her gait-belt. Her gait was unstable. LPN G denied that she refused to give Resident #33 her candy and denied exhibiting abuse toward the resident. LPN G stated, Resident #33 later came back and apologized. LPN G revealed she had worked at the facility for a year. When asked when her last abuse training was, LPN G replied, I think maybe 3 months ago before that happened. NA (J) written statement dated 8/7/15 at 11:30 AM reflected she saw LPN G standing at th nurses station with Resident #33. LPN G asked Resident #33 why she was acting up, and could not wait to go outside. Resident #33 asked for her candy back and called LPN G a B*tch. LPN G responded, No way because of the way your acting. Resident #33 cursed at LPN G again, and NA J walked away. NA J was called on 10/7/15 at 3:27 PM, but did not have a functioning phone number or additional number to call. NA (K) written statement dated 8/7/15 at 11:45 AM reflected Resident #33 was acting up at the nurses station and called LPN G a B*tch. LPN G was supporting Resident #33 with her gait belt, had Resident #33's candy and would not give it to her. LPN G had a bad attitude, she was rude to Resident #33. Kind of like verbal abuse rude. NA K was called on 10/7/15 at 3:22 PM, a friend answered the phone who stated she was at a doctor's appointment. The friend was asked to let the phone pickup voicemail for re-peat call. He stated no voicemail was available, so the writer's name and number was left for friend for return call. Registered Nurse (RN L) written statement dated 8/8/15 reflected that upon walking out of the break room, she observed Resident #3 standing in the hall with her fail belt loosely on her and LPN G holding Resident #33 with her right arm. LPN G was withholding Resident #33's candy from her, and she told the resident she could have her candy back if she stayed off the floor. Resident #33 stated, Give me my fu*king candy and LPN G stated, you can have your candy back when you say you are going to stay off the floor. Resident #33 called LPN G a B*tch. LPN G stated, That's is Mrs. [***] if you're going (sic) calling me a B*tch, then I will act like a B*tch. After Resident #33 said she would staff of the floor the interaction ended, she was returned to her room and her candy was returned. On 10/7/15 at 3:13 PM RN L was interviewed. She stated she had been working at the facility for 3 months. When asked when her last abuse training was RN L replied, My last abuse training was after the incident. I didn't have abuse training upon hire or prior 8/2/15. My date of hire is 7/8/15. RN L was given her statement to read and asked if it was accurate. She replied that it was pretty accurate. RN L was asked why she did not intervene with the incident between Resident #33 and LPN G. RN L replied, I did not know what to do intervene. I was hesitant that the nurse would retaliate against me. I was shocked and had not experienced anything like that before, and I did not do justice to intervene. I did not know the proper manner in what to do or how to handle the situation. The nurse had more of a domineering personality, and was probably around 18 inches from the resident. The resident was aggravated and frustrated. Now I understand what I should do. I did not contact any of the first floor nurses, I don't believe they were notified. When asked about the gait belt placement. RN L revealed that the nurse walking holding it with her arm. The gait-belt was in the bend of the nurse's arm. None of the above staff reported the incident immediately to the authorities, the Administrator (A) or Interim Director of Nursing (ADON B). Documentation of knowledge related to the incident reflected 8/4/15 with investigation documents, with the incident occurring around 8/1/15 or 8/2/15. Resident #33's Care Plan related to the problem of displaying socially inappropriate/disruptive behavior reviewed 7/22/15 reflected the following approaches: Do not argue with Resident #33, redirect as needed. Discuss Resident #33's option for appropriate channeling of anger with resident. Talk with Resident #33 in a calm voice when behavior is disruptive Social Services to evaluate and visit with Resident #33 as needed. Resident #33 Falls care plan reviewed 7/22/15 reflected, .Keep items in reach .Involve resident in decision making regarding daily choices . The facility's Policies and Procedures related to Resident Abuse revised on 3/20/15 reflected the following: .Employees of The Company are charged with a continuing obligation to treat residents so they are free from abuse, neglect, mistreatment, and/or misappropriation of property. No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatment, and /or misappropriation of property against any resident . Verbal Abuse .Any use of oral, written or gestured language that includes cursing, disparaging and derogatory term to other residents or visitors within hearing range, to describe residents, regardless of their age, ability to comprehend, or disability. Misappropriation of Personal Property .Inappropriate us of resident funds or property . Training Employees of The Company will receive education and training on Residents Rights, Resident Abuse, and Abuse Reporting during orientation and annually thereafter .An employee shall be deemed to have violated his obligation in paragraph A (above) if he does any of the following: Fails to report an incident of abuse witnessed by or known to him/her . Procedure for Reporting Abuse All incidents of resident abuse are to be reported immediately to the Clinical Nurse in Charge, Director of Clinical Services, and the Executive Director. Once reported to one of those three officials, the prescribed forms are to be completed and delivered to the Abuse Coordinator or his/her designee for an investigation. The incident was discussed with Administrator A and DON B on 10/8/15. Administrator A revealed that when she found out the incident had not been reported in 2 days she was in shock. She revealed that, Upon investigating I realized there was a huge lack of education in this building. I took it upon myself to address how severe an issue it was. I did all of the abuse in-services myself on all shifts. I ensured that all employee ' s understood what abuse was. I had many in-serves provided by all shifts. All of the staff interviewed, denied having had abuse training prior to the incident. They have not had much education in years. ( )

This citation pertains to intake number(s) MI 400, MI 408 Based on observation, interview and record review, the facility failed to assess and implement interventions based on assessment and provide supervision and stand-by assistance during ambulation as recommended by physical therapy to prevent falls and minimize injury from falls for one (#503) of three sampled residents reviewed for falls from a total of four sampled residents resulting in Resident #503 falling multiple times with potential for serious injury, culminating in a fall in which the resident sustained [REDACTED]. Findings include: On 1/21/15 at 10:29 a.m., Resident #503 was observed in her room laying in bed with her head near the foot of the bed. Resident #503 was observed with bilateral orbital (eye) bruising and swelling to her forehead with a visible healing laceration. Resident #503 had a cast on her left wrist/forearm. Certified Nursing Assistant (CNA "E") was interviewed at this time and stated, "She (Resident #503) fell Saturday (1/17/15). Her left wrist is broken. CNA "E" further reported, that (Resident #503) "fell in the dining room. There was no nurse in there with her. CNAs were in the dining room but they were busy taking residents out to their rooms because the residents had just finished eating dinner. No one was watching her. Her (Resident #503) hand was so swollen and blood was all over the dining room floor. This happened about 6:30 in the evening." A review of the clinical record was conducted on 1/21/15 at 11:00 a.m. revealed that Resident #503 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The "Admission/Readmission Data Collection - New Admission" assessment dated [DATE] revealed that Resident #503 had a history of [REDACTED]." The most recent Minimum (MDS) data set [DATE] revealed that Resident #503 had severely impaired cognitive skills for decision making, had a history of [REDACTED]. Resident #503's most recent "Fall Risk Assessment" dated 10/1/14 revealed a score of "15" (At risk for falls). According to facility Incident and Accident reports Resident #503 fell five separate times between 8/10/14 and 1/17/15, while ambulating, unassisted. The most recent fall, that occurred on 1/17/15 resulted in a forehead laceration and broken left wrist. There was no evidence Resident # 503 was assessed after each fall and based on assessment, individualized interventions were put in place to minimize and prevent additional falls. Resident #503's most significant fall with injury occurred on 1/17/15 at 6:05 p.m. in the dining room where she was "observed on the floor" and noted with a cut above her right eye and swollen left hand. The intervention identified to "avoid repetition" of this fall was: "Monitor every 2 hours while in bed and if resident gets up." The resident was eating in a supervised dining area at the time of this fall. A physician's orders [REDACTED]." According to a "Radiology Report" dated 1/18/15 Resident #503 was diagnosed with [REDACTED]. There is soft tissue swelling." According to "Nursing Home to Hospital Transfer Form" dated 1/18/15, Resident #503 was transferred due to a hematoma and swollen hand. "...observed on floor on 1/17/15. Head laceration to forehead steri-stripped but still bleeding and resident picks it. Left hand edematous...middle finger has a ring on it and no capillary refill on fingertip." The resident was "wincing" due to pain. According to the "ED (Emergency Department) Patient Discharge Summary" dated 1/18/15 indicated the resident was assessed in the emergency department for an acute superficial laceration to scalp and an acute left differential metacarpal fracture." On 1/21/15 at 12:24 p.m., an interview was conducted with the Physical Therapy Assistant/Therapy Program Manager (PTA). When asked if Resident #503 required supervision during ambulation, the PTA reported, "She (Resident #503) is a fall risk and will place herself on the floor anywhere. I've caught her numerous times on the floor. She is a fall risk more so due to cognitive deficits and poor judgement. She also has generalized muscle weakness. When she ambulates, she's hunched over and tends to lean forward. The last few times I've seen her, she's been holding on to the rails in the hallways. She was discharged from Physical therapy on 8/30/14. She requires supervision and stand by assistance (SBA) of staff during ambulation for safety. These are discharge recommendations, but they carry on until she is reevaluated, and should be followed." The PTA went on to say, "I mean, she can ambulate independently so she doesn't need a walker, but because of her poor safety awareness and cognitive issues, she needs stand by assist and supervision." The PTA reviewed Resident #503's care plans and there was no evidence stand by assistance was put into place to address ambulation. Additional I/A reports were reviewed and revealed the following falls, assessments, and interventions to prevent repetition: 8/10/14 at 10:20 a.m. Resident #503 was "observed on the floor" and sustained a small abrasion on her right hand palm area. Corrective measures identified: "Resident is independent while ambulating. Ensure proper footwear". A care plan "Problem/Concern" was written and dated 8/10/14 and identified the following problem: "observed on floor..." The care plan goal was "Resident will have no complications related to the fall. Interventions included to redirect the resident from entering other resident's rooms, obtain vital signs, provide treatment, notify the family and the physician, and observe the resident for change of condition. The care plan did not include the above corrective measure--to ensure the resident was wearing proper footwear. 10/01/14 at 7:15 a.m. Resident fell in hallway witnessed tripping over transfer lift. No injuries. Fall risk assessment score 15. There was no update to the care plan. 10/5/14 at 5:00 p.m. Resident #503 was observed "walking fast and tripped and fell to the floor". The corrective measure to prevent the incident from reoccurring was "Ensure proper footwear". This was not included in the care plan. The resident fall risk score was 15. An "Interdisciplinary Progress Notes" dated 11/24/14 documented, "Doctor in to see resident. No new orders at this time. Resident continues to ambulate with unsteady gait often at a fast pace, poor safety awareness continues." 12/9/14 at 4:00 p.m. Resident # 503 was observed on the ground at the bottom of the steps on the second floor back stairwell. Corrective measures included to keep the resident away from exit doors at all times. In addition, it was identified the door alarm was not working. Recommendations included safety checks every 15 minutes. These interventions were not identified on the care plan. On 1/21/15 at 1:02 p.m., an interview was conducted with the Director of Nursing (DON). When queried about Resident #503's fall that occurred on 1/17/15, the DON reported, "I became aware on 1/18/15 that she had fallen and they were obtaining X-rays of her left hand. She fell on the afternoon shift in the dining room. Staff observed her on the floor. She went to the ER (emergency room ) later related to swelling and concern for her finger which had a ring on it. She returned a few hours later. Resident #503 was walking in the dining room when she fell ." When asked about supervision or stand by assistance for Resident #503 during the time of the fall, the DON reported, "There were no staff members with her when she fell . The residents were done with dinner and staff were taking residents out of the dining room and back to their rooms. As for supervision, to monitor her (Resident #503) constantly , it would require 15 minute checks. By then she could be in someone else's room so it wouldn't help. I wasn't aware that her Therapy Discharge Summary said stand by assist and supervision." When asked what facility personnel had been designated to provide supervision during dining, the DON reported, "The CNAs were to be in the dining room providing supervision. There should also be a nurse in the dining room during all meals." On 1/22/14 at 1:04 p.m., the Assistant Director of Nursing (ADON) was interviewed. When queried about Resident #503's falls history and current interventions, the ADON reported, "When she first came here to the facility, she was trying to climb on tables and trying to get out of windows. on 12/9/14 she was found in the stairwell on the landing just sitting there. She got out behind staff. She had a wanderguard so we added the intervention to keep her away from exit doors at all times. I think she's going to have to have one to one supervision." When asked why one to supervision had not been implemented after Resident #503 was discovered in a stairwell, the ADON reported, "I can't give you an answer." Although the above documentation acknowledged that Resident #503 had an unsteady gait and poor safety awareness, no additional interventions or orders had been implemented to prevent falls. A review of the facility's Fall Policy revealed the following: "Resident Incident/Accident Reports" policy (undated) "It is the policy of the company that resident incidents/accidents are recorded, reviewed, and trended..." "A document provided by the DON on 1/22/15 at 3:00 p.m. was reviewed and documented: "Falls Toolkit" (undated) Steps to follow when a fall occurs - Have an immediate team meeting with current staff members to determine an intervention to prevent further falls....Establish new interventions and document on the care plan and nurse tech kardex...Implement safety checks as needed." The DON was asked whether the policy identified above, was used to assess and manage Resident #503's falls and reported that it was not used. A "Resident Safety Checks" document (undated) documented "Resident safety checks can be initiated by a physician or Clinical Nurse who deems a resident to be at risk to self or others."

This citation refers to intake number M 8240. Based on observation, interview, and record review, the facility failed to appropriately respond to an acute crisis situation when one (#501) of three sampled residents reviewed for abuse, from a total of three sampled residents, experienced extreme agitation, combative behaviors, and posed a danger to herself and others, resulting in mistreatment of [REDACTED]. Findings include: An anonymous complaint was received on 9/17/14 alleged that staff pinned Resident #501 to the ground on 9/17/14. During a tour of the facility on 9/18/14 at approximately 1:45 P.M., Resident #501 was observed lying in bed. There was a "sitter" assigned to Resident #501 who was at the bedside. The sitter reported that Resident #501 had behaviors that consisted of pulling the fire alarm, ambulating without assistance, and hitting and kicking at people because she wanted to leave and be transferred from the facility. An interview was conducted with Certified Nursing Assistant (CNA) "A" on 9/18/14 at 2:30 P.M. CNA "A" reported that on 9/17/14 around 10:00 or 11:00 A.M. she heard commotion in the hallway of the 2nd floor unit while caring for another resident on the same unit. CNA "A" reported that she observed Resident #501 "acting out" and observed the unit manager, a nurse, and an aide on the floor with the resident. CNA "A" stated, "(Resident #501) was kicking and fighting. The DON got down on the ground on top of her (Resident #501)...pinning her down and holding her around her wrists." When asked to describe what CNA "A" meant by "on top of her", CNA "A" stated, "straddling her--sitting on her." CNA "A" reported that the nurse gave Resident #501 an injection. CNA "A" further reported that around 2:00 P.M., in the hallway near the DON's office, Resident #501 became "out of control" and was grabbing stuff, clawing at stuff, pulling the fire alarm and grabbing for the fire extinguisher. The DON sat on top of the resident and pinned her down to the ground (CNA "A" demonstrated that Resident #501's arms were crossed across her chest and wrists held to prevent her from moving). CNA "A" further stated, "She was on the floor for so long, probably about 20 minutes. They eventually got her a pillow, but the DON was still sitting on top of her and holding her wrists and said 'You're not going to win (Resident #501)'. It made me feel very uncomfortable. There were other residents and visitors in the area. When I asked Resident #501 if (the DON) hurt her, Resident #501 said, 'yes' and grabbed her arms." On 9/18/14 at approximately 2:20 P.M., Resident #501 was observed standing and ambulating on foot on the 2nd floor unit with four staff members nearby. Resident #501 appeared extremely agitated and was grabbing at the fan in the hallway and kicking her legs at staff. Eventually, staff was able to redirect Resident #501 into her room to sit on the bed. At approximately 2:30 P.M., Resident #501 became extremely agitated and combative in the hallway of the 2nd floor unit. Staff attempted to walk with Resident #501, however, she was kicking and hitting at staff while other residents were in the hallway. Staff assisted Resident #501 into a wheelchair and attached a seatbelt. Resident #501 detached the seatbelt and stood up and began walking and hitting and kicking again. Resident #501 was redirected into the DON's office and the door was closed. An observation was made at approximately 2:45 P.M. and Resident #501 was on the floor of the DON's office with staff attempting to calm her down. According to Licensed Practical Nurse (LPN) "C" at approximately 2:50 P.M., the physician was contacted and orders were given to send Resident #501 to the emergency room via ambulance. An interview was conducted with CNA "D" on 9/18/14 at 3:12 P.M. and reported that on 9/17/14 around 11:00 or 11:30 A.M., Resident #501 presented with agitated and aggressive behaviors and stated, "She (resident #501) knocked me, the unit manager, and another nurse on the ground. She (Resident #501) kicked the nurse in the nose." An interview was conducted with the social services staff at 3:30 P.M. on 9/18/14. The social services staff reported that Resident #501 had a [DIAGNOSES REDACTED]. Social services staff reported that her behaviors appeared purposeful. When queried about triggers for the behaviors exhibited by Resident #501, the social services staff reported that they fluctuate and have escalated this past week, usually in relation to talking about discharge and arrangements for transferring to another facility in another state closer to family. When queried about interventions, the social services staff reported that she will receive a [MEDICATION NAME] injection or talk with social services or activities staff and she is working on getting her transferred. Social services staff also reported that Resident #501 currently had a guardian and was in the process of facilitating a transfer to another facility, however, due to her behaviors and documented history of multiple suicide attempts, facilities have denied to accept Resident #501. An interview was conducted with CNA "F" on 9/19/14 at 10:20 A.M. who reported that she had never seen Resident #501 have behaviors as bad as yesterday (9/18/14). CNA "F" reported that there were two episodes of Resident #501 being agitated and hitting and kicking at staff on 9/17/14, one before lunch time and the other after lunch around 1:00 P.M. or 2:00 P.M. CNA "F" explained that around 1:00 P.M. or 2:00 P.M. on 9/17/14, Resident #501 was observed on the ground by the DON's office and break room in the hallway with the DON "on top of her (Resident #501). (The DON) pinned her down for about fifteen minutes...She (Resident #501) was really upset. I'm not sure what they should have done, but I don't think it should have happened like that...There were other residents, guests, and staff around." An interview was conducted with Resident #501 on 9/19/14 at 11:00 A.M. Resident #501 was observed seated in a wheelchair with a seatbelt attached. Resident #501 stated, "I was upset" when queried about going to the hospital on [DATE]. When asked if anyone had ever hurt her when she was upset, Resident #501 stated, "yes" and grabbed her arms. Resident #501 did not give any additional information. On 9/19/14 at 11:45 A.M., CNA "H" was interviewed. CNA "H" reported that she worked on 9/17/14 on the 2nd floor but was not assigned to Resident #501. CNA "H" reported that on 9/17/14, Resident #501 was "acting wild, hitting, kicking, and punching...They put her on the ground and she was still swinging. The DON had to restrain her and was on top of her, holding her hands down. As soon as he let go she started hitting and kicking again. I heard him say, 'When you calm down, I'll let you go.'...I was by the nurse's station and they were in the hallway by the break room." CNA "H" stated, "She wouldn't stop kicking and hitting and they just had her on the ground...I didn't know you could do that here...I hope she stays calm today. I don't want to see her down on that floor anymore. All that holding her down. That's just crazy!" On 9/19/14 at 12:00 P.M., Licensed Practical Nurse (LPN) "G" was interviewed. LPN "G" stated, "(Resident #501) can be fine one second, but then have behaviors the next. Her movements are so fast and jerky from [MEDICAL CONDITION]'s Disease. Since her first day here, it has been bad. She punched me a couple weeks ago. She is always combative and she is very strong. She will try to keep walking, even if you are trying to redirect her. I couldn't believe she hit me." When queried about any behaviors Resident #501 had on 9/17/14, LPN "G" reported that she was not assigned to Resdient #501, but Resident #501 had pulled the fire alarm once or twice, but "I left her alone because she tries to punch me...(The DON) was trying to keep her from hitting and kicking and kind of held her on the floor. It took three people to hold her to calm her." On 9/19/14 at 12:15 P.M., the Assistant Director of Nursing (ADON) was interviewed regarding behavioral interventions for Resident #501. The ADON reported that staff usually tried to calm her down by talking to her, but all of a sudden she began kicking, pushing off the wall. The ADON stated, "She has been more defensive when she has seen me. Her behaviors have been worse for the past two days." When queried about behavioral interventions implemented on 9/17/14, the ADON stated, "We called the doctor and got an order for [REDACTED]. When (the DON) would let go, (Resident #501) would start kicking again. We can't use any restraints anymore so we were just trying to keep her safe." The ADON reported that this happened in the afternoon in the hallway between the far side of the nurse's station after Resident #501 tried to grab the pill crusher from the medication cart. When queried about what the facility would do when residents were in a crisis situation and their process for obtaining emergency psychiatric care, the ADON stated, "She was seen by psych initially. I don't know the process for petitioning." When asked about the reason Resident #501 was transferred to theER on [DATE], the ADON stated, "Extreme agitation and to achieve enough calm for her to be safe. It's pretty scary with the other residents around. We have to make sure we keep the other residents safe." When queried about why Resident #501 was not sent to the hospital on [DATE] when she first exhibited escalated behaviors, the ADON stated, "She calmed down after she received [MEDICATION NAME] and her behaviors (on 9/17/14) lasted for a shorter period of time than yesterday (9/18/14)." The DON was interviewed on 9/19/14 at 12:00 P.M. and reported that Resident #501 had a one to one sitter due to impulsive and unpredictable behaviors and was unsafe to be by herself. The DON further reported that Resident #501 did not want to be at the facility and became frustrated and acted out in the past which was described as "getting up and pulling the fire alarm." The DON reported that Resident #501 had two "outbursts" on Wednesday (9/17/14). "by my office" where Resident #501 was "acting up aggressively, kicking, scratching, hitting. The CNAs were trying to verbally intervene, but it got to the point where it was becoming unsafe for the CNAs and (Resident #501) so I told staff to help her to the floor. Resident #501 was unable to be redirected so we had her by both arms and laid her down and tried to hold her legs down." When queried about procedures for residents with combative behaviors, the DON stated, "We make sure we are protecting other residents and minimizing harm to the resident having behaviors." When asked if Resident #501 was ever at risk of harming her self of others, the DON stated, "She was a danger to herself, especially yesterday (9/18/14). She eventually deescalated on Wednesday (9/17/14)." When questioned about why Resident #501 was sent to theER on [DATE] and not on 9/17/14, the DON reported that Resident #501 was able to calm down eventually on 9/17/14 and did not have any further episodes that day after she received oral and IM (intramuscular) medications. Resident #501's clinical record was reviewed on 9/19/14 at various times and revealed the following: The Medication Administration Record [REDACTED].M. The face sheet revealed that Resident #501 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #501 usually made herself understood, had severely impaired cognition, and had physical behaviors toward others. An "SBAR Communication Form" (a form completed and used to report a change in condition to the physician) dated 9/17/14 documented vital signs under the "background" section. Under the "Assessment (RN)" section it was documented that "Resident voices to SW (social work) post incident that she wants to go home." Under the "Nursing Notes (for additional information on the Change in Condition)" section it was documented at 2:00 P.M., "Resident (#501) became extremely agitated while sitting in wheelchair, accompanied by 1:1 sitter. Resident attempting to stand up while seat-belted in wheelchair. Refusing to state in words what she needs or wants to do. Seatbelt released as resident raising wheelchair off floor. Resident kicking and swinging arms at staff with closed fists. 5 staff member attempting to keep resident sage and prevent injury to staff and other residents. Resident lowered to floor and arms and legs secured by staff." The SBAR form documented that the physician was documented, but did not document a time. The SBAR form was not signed by any staff member and other than the above information, the form was blank." A "Daily Skilled Nurse's Note" dated 9/17/14 at 2:00 P.M. documented, "Res. increased agitation. Trying to hit staff..." A History and Physical dated 7/10/14 documented that Resident #501 had a psychiatric history that included aggressive behavior, auditory hallucinations, and multiple suicide attempts. There were no other progress notes by the physician in the clinical record. The ADON was interviewed on 9/19/14 at 1:40 P.M. regarding the last physician visit for Resident #501 and confirmed that it had been after admission on 7/10/14. When queried about how often the residents should be seen by a physician, the ADON did not know. An "Admission/Readmission Data Collection" form dated 7/8/14 documented Resident #501's admitting [DIAGNOSES REDACTED]. The "Physical Restraint Evaluation" section documented that Resident #501 was exit seeking, ambulatory, leaned sideways when walking, and was agitated. The "Mood and Behaviors" section documented that Resident #501 had a history of [REDACTED]. An Activities plan of care dated 7/15/14 documented that Resident #501 "can be impulsive...will act out behaviorally if unable to get her thought voiced...very little family support." Approaches documented were "Assist (resident #501) with thoughts PRN (as needed) to help avoid behavioral outbursts...Respect her right to choose and refuse..." A Nursing plan of care dated 7/8/14 documented that Resident #501 "displays social inappropriate/disruptive behavior...disrobes and walks in hallway...exit seeking behaviors...pulls fire alarm/fire extinguisher." Approaches documented included, "Social services to evaluate and visit...monitor and document behavior...Discuss options for appropriate channeling of anger...Praise for demonstrating desired behavior...Administer behavior medications as ordered by physician...Talk in calm voice when behavior is disruptive...Notify (physician) with any condition changes/needs/wants...1:1 supervision..." An initial psychiatric evaluation dated 7/15/14 documented that Resident #501 was referred for a psychiatric evolution due to behaviors that included exit seeking and was sent to the ER and returned to the facility. A follow up psychiatric evaluation dated 8/12/14 documented that Resident #501 was referred to evaluate for behaviors that included pulling the fire alarm, undressing self, and agitation. A follow up psychiatric evaluation dated 9/16/14 documented that Resident #501 had impulsiveness at times and that Resident #501 reported that her movements have gotten worse over the last couple of days and she is more depressed. Social Services Progress Notes were reviewed from 7/2014 through the present date and did not document anything regarding behaviors. A Social Service Evaluation dated 7/12/14 documented that Resident #501 was timid, fearful, and impulsive; had a history of [REDACTED]. The evaluation documented, "Approach resident in very calm non-threatening manner...will act out behaviorally if unable to get thoughts..." Incident and Accident (I&A) Reports were reviewed on 9/19/14 at 1:00 P.M. for Resident #501 for September 2014 and revealed the following: An I&A Report dated 9/17/14 at 14:00 (2:00 P.M.), location: hallway. Description of incident: Escalation of aggressiveness and combativeness. Cause of incident: Unknown cause. Paged (physician). Treatment: No new orders for treatment. Calm approach, redirecting toward toom, attempting to keep safe from self and keep from harming others. There was no I&A report from the other behavior incident reported earlier in the day (before lunch) on 9/17/14. An I&A Report dated 9/18/14 at 14:55 (2:55 P.M.). Description of incident: escalating aggressiveness/combativeness. Treatment orders were left blank. Calming voices/redirection/keep safe from harming self or others. A "Nursing Home to Hospital Transfer Form" dated 9/17/14 (in error), but signed and dated 9/18/14 at 2:45 P.M., documented that Resident #501 had increase in agitation, combative with staff, unable to decipher what she wants. Risk Alerts had a check mark next to "harm to self or others". The social services staff was interviewed on 9/19/14 at 1:36 P.M. regarding when a resident would be petitioned for hospitalization and the social services staff stated, "We would first work with the behavior. If it is out of control and the resident is going to harm themselves or others and if all interventions including chemical are not working." When queried about why Resident #501 was not petitioned to the hospital on [DATE], the social services staff stated, "She calmed down by the time I talked to her." The facility's policy titled "Resident Abuse" with a revision date of 1/1/12 was reviewed on 9/19/14 at 1:45 P.M. and documented the following: "No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatment, and/or misappropriation of properly against any resident... ...Definition of Resident Abuse:...Any action that may cause or causes actual physical, psychological or emotional harm, which is not caused by simple negligence, constitutes abuse. Action, such as...restraining a resident improperly without authorization, and other such actions which can be seen as causing physical pain to a resident are strictly forbidden... ...Non-action, which results in emotional, psychological, or physical injury, is viewed in the same manner as that caused by improper or excessive action...All actions in which employees engage with resident must have as their legitimate goal, the healthful, proper, and humane care and treatment of [REDACTED].

This citation pertains to intake MI 270. Based on interviews and record review, the facility failed to act in a timely and appropriate manner consistent with the resident's documented wishes for 1 (Resident #500) of 10 sampled residents, from a total sample of 10 residents, resulting in an immediate jeopardy when Resident #500, who was a full code, was found unresponsive with no pulse or respirations on [DATE] at approximately 12:25 p.m. and facility staffs failed to initiate Cardiopulmonary Resuscitation (CPR) for 22 minutes and did not activate Emergency Medical Services (EMS) for 30 minutes. Resident #500 subsequently died . These deficient practices placed 74 residents, identified as a full code status, at the facility at risk for serious harm, injury and/or death. Findings Include: Review of the Face Sheet, Minimum Data Set (MDS, resident assessment tool) dated [DATE], Physician orders [REDACTED].# 500 was a [AGE] year old female, admitted to the facility on [DATE], alert and able to make her needs known, dependent on staff for assistance with all activities of daily living (ADL's) and had decreased mobility. Resident # 500's [DIAGNOSES REDACTED]. Review of Resident # 500's clinical record revealed a plastic green divider at the beginning of the chart that stated in large letters "Full Code" and an advance directive document with Resident #500's full name and "Full Code" status dated "[DATE]". The clinical record also had a "green dot" (sticker) on the end of the chart, indicating she was a full code. Per interview done on [DATE] at 10:00 a.m., with the Director of Nursing (DON) #1, he said the facility's code status policy included "green dot" (do CPR) and "red dot" (do not do CPR/do not resuscitate) stickers on the ends of the residents' charts and on their name plates outside of their room doors. An interview was done on [DATE] at 1:00 p.m., with Certified Nursing Assistant (CNA) #1. CNA #1 stated "The last time I saw her (Resident #500) alive was at 11:30 a.m., I did care on her, she was sick and throwing-up, I did tell the nurse (LPN #2). I went on break at 12:00 p.m. and I was back at 12:30 p.m. When I came back at 12:30 p.m., the nurses (RN #1 and LPN #2) were running down to her room, it was like no one took her being sick seriously". Review of CNA #1's hand written statement dated [DATE], said "I did her care at 11:30. When I seen she was sick I let the nurse (LPN #2) know this morning, she had threw up all day yesterday and she responded that it was not in the notes". Review of Resident #500's Nurses note's dated [DATE] are as follows: "1100 (11:00 a.m.), Resident resting in bed, asked how she was feeling, Resident stated fine". "1233, I was called to resident room by staff (RN #1), stated therapy (Physical Therapist/PTA #1) said we need to assess resident, resident assessed, absent of v/s (vital signs), (RN #1) stated I will call the time of death at 1235 (12:35 p.m.)". "1238, Discussed with (DON #1) that resident was a full code, repeated x 2 that absent at 1235, was told by (DON #1) to call (Primary Physician #1) and then call back". "1245, Call (Primary Physician #1) cell phone, message left return call to (DON #1). Was told by (DON #1) to not do anything until return call". "1254, Return call, stated start CPR, CPR started at 1255 (12:55 p.m.) with (RN #1)". "1256, 911 called by (Social Worker/SW #1)". "1310, EMT on site". "1332, Resident time of death". "1310, Late entry, notified family (Family Member #1) of CPR being performed will call with more info". Per interview done on [DATE] at 1:00 p.m., with LPN #2, she stated "I put late entry on the 6 th line from the bottom of the notes because I missed a line; my times were out of order". "1335, Notified family and Guardian (Guardian #1, Attorney At Law) of resident demise". Review of the EMS record dated [DATE], revealed the facility called 911 at "13:03:00 (1:03 p.m.) Sunday, [DATE]". EMS arrived at the facility and took over Resident #500's care at "13:08:22 (1:08 a.m. and 22 seconds), Sunday, [DATE]". EMS unit cancelled time at "13:45:00 (1:45 a.m.), Sunday, [DATE]". Review of the EMS narrative report dated [DATE], stated "Per staff, Pt. had last been seen alive at approx 1230 (12:30 p.m.). At approx 1255 (12:55 p.m.), staff came in to attend to Pt. and found her pulseless and apneic (without oxygen). Staff immediately initiated CPR. Pt's. jaw was firmly clenched, intubation attempted unsuccessfully. At 1332 (1:32 p.m.), (Hospital) was contacted and (Hospital Physician) provided permission to terminate resuscitative efforts". Review of Physician order [REDACTED]. Review of the Certificate of Death dated [DATE], stated Resident #500's "immediate underlying or contributing cause of death" was "Cardio Respiratory Arrest". Review of the nurses 24 Hour Report dated [DATE], stated "1332 (1:32 p.m.) demise". An interview was done on [DATE] (at 9:05 a.m. and 10:55 a.m.), with DON #1. DON #1 said on [DATE], he had received a phone call at 12:39 p.m., from LPN #2 who had told him the "resident had expired at 11:30 a.m.", she was a full code and they did not do CPR. When DON #1 asked her why she (RN #1) did not do CPR and she also had said "I don't know". DON #1 stated "she (LPN #2) let me talk with (RN #1), I asked why she did not do CPR and she said "I don't know". I did not tell them to start CPR or call 911 because it had been over an hour". DON #1 said he was initially told by both nurses that the resident was found not breathing without a pulse at "11:30 a.m.", then both nurses changed it to "12:30 p.m.". DON #1 called and informed Administrator #2. DON #1 stated "I called back to the facility and (LPN #2) said she died at 12:30 p.m., not 11:30 a.m., so I said go start CPR and call 911". Review of the DON #1's "Time Line for Occurrence [DATE]", regarding Resident #500's death is as follows: At "1239 (12:39 p.m.): Called by (LPN #2) and informed that resident (#500) had expired. Stated it was reported to (RN #1) that a person from therapy (PTA #1) had reported to her that the resident appeared that she was not breathing. When I asked if the resident was a no code, (LPN #2) stated the resident was a full code. I asked what time this resident expired and she stated 1130 (11:30 a.m.). I asked why she did not initiate CPR and she stated she did not know. She put (RN #1) on the phone. Again (RN #1) stated that the resident was found unresponsive at 1130. I told them to call the physician and I would call them right back". At "1248 (12:48 p.m.): Returned call to facility and asked again what time the resident had been found with no pulse or respirations was it really 1130. At this point (LPN #2) stated no it was 1230 (12:30 p.m.). I stated that they needed to initiate CPR and call 911 immediately". At "1254 (12:54 p.m.): Call placed to (Administrator #2, Administrator at the time of the incident on [DATE]), Administrator informing him of situation". At "1610 (4:10 p.m.): Interview conducted with (RN #1), she stated that a "girl from therapy (PTA #1)" had notified her that something was wrong with (Resident #500). She stated that the therapy person thought that she may not be breathing. (RN #1) went right down to the room and the resident (#500) was not breathing and the resident had no pulse. She instructed (LPN #2) to call (DON #1), the DON at 1238 (12:38 p.m.). When asked why she did not perform CPR immediately she stated that she could not answer why not and stated that she just "freaked out" once she saw that the patient was a full code". At "1630 (4:30 p.m.): Interview conducted with (LPN #2). She stated that she was in the room at 1135 and was told by (RN #1) that the patient (Resident #500) was not breathing and had no pulse. She stated that (RN #1) had told her that she was an RN and could pronounce so she pronounced and asked (LPN #2) to notify (the DON #1). When asked why she did not perform CPR she stated because (RN #1) had told her that she could pronounce-when asked again why she did not perform CPR she stated she did not know". An interview was done on [DATE] at 6:15 p.m. with PTA #1. PTA #1 stated on [DATE] "at 12:20 p.m., I went in the room (Resident #500's room), I was working with the roommate and I looked at the resident, she was not breathing and her eyes were half open. Then I went up to (RN #1) and said I think (Resident #500) is gone, then I went and told (LPN #2) she was gone". PTA #1 said she informed RN #1 and LPN #2 "between 12:29 p.m. and 12:30 p.m.", that Resident #500 "was gone". Resident #500's roommate was not able to be interviewed due to decreased memory. An interview was done on [DATE] at 6:00 p.m., with Social Worker (SW) #1. SW #1 stated "They (RN #1 and LPN #2) called me on the phone (SW #1 was at the facility on Sunday [DATE], in her office) and said they needed me. They wanted me to call the Code Blue and call 911. The Police came first, then Fire Department, then EMS, they asked me what time was CPR started and I said 12:55 p.m. I don't recall (LPN #2) and (RN #1) letting the first responders know there was a delay in CPR". SW #1 said she was the one who documented the time RN #1 and LPN #2 started CPR on the resident and confirmed there was a 22 minute delay in initiating CPR on Resident #500. Review of the Code Blue Documentation Nurses Note dated [DATE], stated "Time Code Blue was called (time CPR started):1255" and was signed by SW #1. Per interview done on [DATE] at 1:00 p.m. and per review of written statement (un-dated), LPN #2 revealed the following information. LPN #2 stated "(PTA #1) told (RN #1) that we need to go check on (Resident #500) right now, and that she was dead, at 12:33 p.m. I told the DON #1 that at 12:35 p.m. (RN #1) had pronounced the resident dead. We went to her room, I was crying and I felt very sad, we both assessed her, she had no pulse and no lung sounds. (RN #1) called the time (time of death) which was 12:35 p.m., at 12:38 p.m. we called (the DON #1). I thought she was a Do Not Resuscitate (DNR), she (RN #1) said she thought she was a DNR also. I did not look at her name plate (outside Resident #500's room); I just didn't think to look at the dot (green dot). I know the DNR policy program. We went to the desk, picked up her chart and I said, she's a full code what do we do? (RN #1) yelled at me and said, "call (DON #1), call (DON #1) now". I called (DON #1); I told him 12:30 p.m. she died . Then (RN #1) took the phone and then gave it back to me, (DON #1) said, "call the Doctor, don't do anything else and call me right back". I did not ask him if he meant not to do CPR. I should of done CPR. I called (Primary Physician #1), I called 2 times and left a message that (Resident #500) was absent of vital signs. Then I called (DON #1) back at 12:45 p.m. and he said "don't do anything until I call you back". I turned to (RN #1) and said (DON #1) said do not do anything until he calls you back. At 12:54 p.m., (DON #1) called back and stated "you and the other nurse are suspended and go down there and start CPR". I told (RN #1) we are suspended and go start CPR now, (SW #1) called 911. We went to the room with the crash cart, (SW #1) came in and started writing things down on the paper, Code Blue document. The sheriff came in and another gentleman that said he was an intern with the Sheriff. At 10 after 1:00 p.m., the Fire Department came in, we did not tell them, the Police, EMS and Fire Department, that we delayed CPR. (DON #1) told me I had to chart on them, I charted at 5:00 p.m., the DON told me to. I had post-it's and I was writing it down, I threw them away after I charted". The Police report (#,[DATE]), was not available for review at the time of the investigation ([DATE] to [DATE]). An interview was done on [DATE] at 12:00 p.m., with RN #1. RN #1 stated "She was a full code. I don't remember looking at her code status; I was not assigned to her. The PTA girl (PTA #1) came to me and said "something's wrong with (Resident #500), I think she might be dead". I ran in the resident's room and checked for vital signs and there were none. I ran to the door and yelled (LPN #2), (LPN #2), come in here, I looked at my watch it was 12:35 p.m. I said you check too, she checked too. She said "she's gone there is nothing we can do for her", then she became hysterical and started crying. I asked her if (Resident #500) was a DNR, she said "yes" and then I said are you sure? She said "I don't know", so we ran up to the desk and after going through the chart, she said "Oh my God, she's a full code; we need to call the DON". Then I began to panic and I was frozen and I was crying and I said to myself I need to grab the crash cart and do CPR. She (LPN #1) called (the DON #1), I was standing there and I was frozen, he (DON #1) said do nothing until he calls us back. I didn't take the phone because I was panicking. We both were at the nurses station, she was sitting in the chair and I was standing there, maybe about 4 minutes. She made 2 phone calls, to the family and the doctor. She informed the family that (Resident #500) had died . When (DON #1) called back, he said go start CPR. I did the compressions and she (LPN #2) did the bagging, (SW #1) called the ambulance (911 call). We continued CPR until EMS and the Fire Department came. The sheriff and a lawyer both came, I did not get any names. I feel bad about it, I did not react fast enough, I did not chart, I did not get any names of 1st responders. I told her (LPN #2) I feel terrible, I trusted her. We were inserviced on what to do in a code, about 2 weeks before this. We are so under pressure with corporate, I was exhausted after the last time the State was in". RN #1 said the facility had been recently given an IJ level citation because of the "same kind of issue". Review of the facility IJ Notification given on [DATE] at 9:20 a.m., reveled there had been a 20 minute delay in summoning EMS after a resident was found unresponsive and not breathing. Review of the Mandatory In Service Training Attendance Roster dated [DATE], revealed signatures of Charge Nurses RN #1 and LPN #2, confirming they had attended the training given by DON #1 which covered CPR and the facility Code Blue Policy N-305. A phone interview was done on [DATE] at 9:04 a.m., with Administrator #2. Administrator #2 stated "The nurses (RN #1 and LPN #2) and one therapy person (PTA #1) said the resident was not breathing. (RN #1) went into the resident's room and she was not breathing, she was warm to the touch. They called (DON #1) and asked if they should perform CPR, then (DON #1) said start CPR. The facility called 911. (Corporate VP #1) ordered me not to report this (to the State Agency)". A Phone call made on [DATE] at 10:07 a.m., to Corporate VP #1, revealed Administrator #2 was told by VP #1, "we have 24 hours to report, we haven't investigated yet". Per review of a faxed memo from Guardian #1 dated [DATE] (requested by surveyor), Guardian #1 (Attorney at Law) revealed per voice mail recording from the facility on [DATE] regarding Resident #500, and per notes taken from the voice mail recording dated [DATE], stated "a call from (the facility) at around 12:20 p.m. asking for a return call and advising that (Resident #500) was not responding to others. Then my note is they called at 2:38 p.m. to explain that they had been doing CPR because they did not think that clear from the first message. The caller beat around the bush but it was clear to me that CPR was not successful. It was also clear to me that the nurse did not have a time of death to report". An interview was done on [DATE] at 1:30 p.m., with Primary Physician #1. Primary Physician #1 revealed the facility had called his cell phone the first time at "12:56 p.m." on [DATE]. Primary Physician #1 revealed he had not been made aware by the facility that there had been a delay in the initiation of Resident #500's CPR and EMS until "[DATE]" (the day of the interview with the surveyor). On [DATE] at 1:30 p.m., the surveyor observed and confirmed the saved first phone call from the facility (incoming phone call) dated [DATE], was at "12:56 p.m." on Primary Physician #1's cell phone. An interview was done on [DATE] at 3:20 p.m., with Medical Director #1. Medical Director #1 revealed he had not been made aware of the delay in Resident #500's CPR and EMS until "[DATE]" (the day of the interview with the surveyor). Review of LPN #1's Facility Personnel File revealed a "Certificate of Completion" in "Basic Life Support Adult CPR, Child CPR and Infant CPR, #,[DATE]" and it was dated "[DATE]" with an expiration date of "June, 2015". This certificate was given the day after Resident #500 had deceased . Review of the facility Licensed Practical Nurse Job Description, signed by LPN #2 and dated [DATE], stated that LPN's had to have a "Valid CPR certificate". Per interview done on [DATE] at 1:45 p.m., Charge Nurse LPN #2 stated "I took the class on [DATE]". Review of the facility's Cardiopulmonary Resuscitation Policy N-302 dated [DATE], stated "Cardiopulmonary Resuscitation is initiated on all residents except those with a "No Code" order and appropriate documentation. In the case of Cardiac and/or [MEDICAL CONDITION] Arrest, CPR is initiated immediately". Review of the facility's Code Blue Policy N-305 dated [DATE], stated "CPR will be provided to all residents who are found in Cardio [MEDICAL CONDITION] Arrest unless such resident has a DNR order written by a Physician on their medical records. In the event that he resident is identified as a Full Code and the person finding the resident is trained in CPR they will: 1. Call for help and state "Code Blue" 2. Initiate CPR. If the first person finding the resident is not trained in CPR, they will immediately call over the intercom a "Code Blue" identifying the specific floor and area". The Administrator was notified of the Immediate Jeopardy on [DATE] at 3:00 p.m. that began 0n [DATE] at 12:33 p.m. when Resident #500 was found by staff in her bed unresponsive, without a pulse and not breathing. Resident #500 was identified in her clinical record as being a full code status and staff did not initiate CPR until 12:55 p.m., a delay of 22 minutes. Staff did not call 911/EMS until 1:03 p.m., a delay of 30 minutes, placing 74 other residents, identified as a full code status, at the facility at risk for serious harm and/or death. The surveyor verified that the facility implemented the following to remove the Immediate Jeopardy: 1. On [DATE], the nurses who did not immediately initiate CPR had been suspended pending investigation. 2. On [DATE], The Director of Clinical Services (Director of Nursing/DON #1), Executive Director and Social Worker reviewed all residents clinical records, a total of 104 for proper code status information, with any discrepancies corrected, there were 30 residents with a "No Code" status and 74 with "Full Code" status. 3. On [DATE], the Director of Clinical Services and Nurse Manager in serviced 17 of 26 licensed nursing staff on the following: -The facility's CPR policy, N-302 and Code Blue policy, N-305 which included immediately activating Emergency Medical Services (EMS). -The nurses verbalized they will perform CPR as indicated on a resident with a Full Code status including with a terminal [DIAGNOSES REDACTED]. Mock codes were and will continue to be conducted randomly, so nurses can demonstrate an appropriate response to initiate CPR on a full code "mock resident" or not perform CPR on a Do Not Resuscitate (DNR). -Nurses verbalized that they will not withhold emergency treatment from a resident with a DNR, to include basic first aid. 4. On [DATE], the Director of Clinical Services, Executive Director and Social Worker began Quality Improvement (QI) monitoring five residents medical records to ensure the code status was in place and was without discrepancy. 5. On [DATE], the Director of Clinical Services began interviewing five Licensed Nurses per day to ensure proper understanding of facility CPR policy, Full Code status, when to perform CPR, including on residents with a terminal [DIAGNOSES REDACTED]. Nurses will verbalize they will not withhold emergency treatment from a resident with a DNR status, to include basic first aid. QI monitoring will be conducted five times per week for four weeks, then three times per week for four weeks, then one time weekly for four weeks, then one time per month for nine months using a sample size of five nurses. 6. On [DATE] the Director of Clinical Services started conducting random mock codes daily, until staff responds per facility policy. If discrepancies are noted, the staff will immediately be re-educated by the Director of Clinical Services or Nurse Manager. After it has been determined that staff responded appropriately, the Director of Clinical Services will then conduct random mock codes two times per week for four weeks, then one time weekly for four weeks and then one time monthly for four months. 7. The Director of Clinical Services will report results of the QI monitoring to the Quality Assurance committee monthly for twelve months for continued substantial compliance and/or revision. While Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of pattern and severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to facility has not completed all education and sustained compliance had not been verified by the State Agency. ( )

This citation pertains to MI 793. This citation has multiple Deficiency Practice Statements, A & B. A. Based on observation, interview, and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being (not immediately initiating Emergency Medical Services and not adequately assess and monitor a change of condition) in 2 of 15 sampled residents (Resident #103 and Resident #104) reviewed for acute change of condition, resulting in: 1.) an Immediate Jeopardy when on [DATE] at 3:20 PM, Resident #104 was found unresponsive, without respirations, and Emergency Medical Services (EMS) was not notified for 20 minutes after CardioPulmonary Resuscitation (CPR) was initiated. Resident #103 subsequently died ; and 2.) and an Immediate Jeopardy for Resident #104 when [DATE] at 2:30 PM, Physician #22 ordered Resident #104 to be transferred to the hospital due to an acute change of condition and facility staffs did not transfer Resident #104 for 2 hours due to lack of permission by the Corporate Office. These deficient practices placed all 94 resident, at risk for an acute change of condition, at risk for serious harm, injury, and/or death. Findings include: Review of the Facility Policy "Nursing N-105," dated [DATE] revealed, "Policy, The clinical Nurse will recognize and appropriately intervene in the event of a change in resident condition." Procedure: "In the event of an emergency situation,, 911 will be called and the Physician /Family /Responsible Party will be notified as soon as possible." According to the Facility policy "Policies and Procedures, Nursing N-305" dated [DATE], revealed "Policy, CPR will be provided to all residents who are found in Cardio [MEDICAL CONDITION] arrest unless such resident has a DNR (do not necessitate) order written by a physician on their medical records." Procedure, 6. The Nurse Manager/Supervisor/Clinical Nurse will assume responsibility for the code and delegate the following: 1. Summon emergency equipment to the room 2. Activate the EMS system 3. Assign a person to document the ongoing code 4. Notify the doctor 5. Complete a Transfer Form 6. Call emergency room and give a report to Admitting Nurse ." Resident #103 Review of the Face Sheet revealed Resident #103 was [AGE] year-old male, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Nurse's note dated [DATE], documentation by Licensed Practical Nurse (LPN) #10, revealed that at 3:20 PM, Resident #103 was found with no respirations, his fingertips were purplish in color, and CPR was started with two nurses. The note indicated that at 3:35 PM, the physician was notified by an unknown facility staff member and at 3:40 PM, 911 was called by an unknown facility staff member. The note revealed CPR continued. In an interview on [DATE] at 9:45 AM, LPN #10 stated, "I immediately wrote notes, they are accurate." LPN #10 reported she was unsure who was responsible for or who made the call to 911 but that she did not call EMS. LPN #10 reported that she recalled seeing most of the nurses on shift as it was shift change (between 3:00 and 3:30 PM) and all nurses were required to respond to a Code. LPN #10 reported that LPN #12 had assisted with "pumping" (cardio resuscitation) during the code. Review of the EMS Run Sheet, dated [DATE], revealed the call was received at 3:42 PM (22 minutes after Resident #103 was found unresponsive) and EMS arrived at the facility at 3:45 PM. According the the Run sheet, upon arrival, facility staff informed the EMS crew that Resident #103 had been checked on at 3:40 PM and was found pulseless and apneic. EMS sheet indicated Resident #103 was "pulseless and apneic, warm to touch". In an interview on [DATE] at 11:03 AM, Unit Manager #6, responsible for organizing the code, responded, "everybody was doing something." Unit Manager #6 reported she had responded to Resident #103's code. When asked asked who called EMS, Unit Manager #6 stated, "One of the nurse. It was mass confusion, residents in the hall, everyone wanted to see." In an interview on [DATE] at 7:05 PM, DON #5 reported "did not know the exact time Resident was found". DON #5 reported that she was "not involved in the Code at all. I was sitting at the desk working on another resident's paper work." DON #5 stated, "the person on the scene takes charge and calls EMS." DON #5 was asked if she had called EMS and she stated, "no". In an interview on [DATE] at 3:35 PM, Administrator (ADM) #1 stated, "The nurses should have called immediately for EMS." In an interview on [DATE] at 2:55 PM, LPN #9 reported she had responded to Resident #103's "code blue" and had inquired if EMS had been notified and was informed 911 had already been called. ( ) Resident #104 Review of the Face Sheet revealed Resident #104 was a [AGE] year-old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #104 had a recent history of abdominal wall [MEDICAL CONDITION] (skin infection) and debility, secondary to [MEDICAL CONDITION]. On [DATE] Resident #104 was documented to have had a 102 degree (Fahrenheit) temperature and was given an antibiotic pursuant to a physician's order. Review of the Physician's Progress note dated [DATE], Resident #104's deteriorating change of condition was reported by Nurse Practitioner (NP) #3 to Physician #22 and Physician #22 ordered that Resident #104 be transported to the hospital due to lethargy, her face was flushed, and she was diaphoretic (excessive sweating associated with a medical emergency), had labored respirations (difficulty breathing), and bilateral rhonchi (coarse, rattling breath sounds) throughout her lung fields. In an interview on [DATE] at 11:07 AM, NP #3 reported that she saw Resident #104 on [DATE] at no later than 2:30 PM and reported she was "taken back by her condition". NP #3 reported that Resident #104 "was delirious, lungs were full of fluid, she was burning up". NP #3 reported an order was given to Registered Nurse (RN) #5 to send Resident #104 to the hospital at 2:30 PM on [DATE]. Review of the EMS Run Sheet revealed EMS was called for dispatch to the facility at 4:28 PM approximately 2 hours after NP #3 ordered Resident #104 to the hospital. In an interview on [DATE] at 6:57 PM, Director of Nursing (DON) #5 reported that the delay of Resident #104's transport from the facility to the hospital was a result of telephone calls to the Corporate Consultant (CC) #20 to inform/obtain permission, because "it was not an emergency situation". DON #5 was instructed by CC #20 to try other" interventions" prior to Resident #104 being sent out to the hospital. DON #5 reported that another call was then placed to Physician #22, who again ordered that Resident #104 be sent to the hospital for an evaluation. In an interview on [DATE] at 11:15 AM, Licensed Practical Nurse (LPN) #7 reported Resident #104 had requested to go to the hospital at 1:30 PM because "she didn't feel good." LPN #7 reported that DON #5 was notified at that time. LPN #7 stated, "the policy is to notify the DON before notifying the doctor, she has to call corporate before we call the doctor or send her out to the hospital." In an interview on [DATE] at 11:37 AM, Physician # 22 stated that he expected residents to leave the facility and for the staff to have called for an ambulance within ,[DATE] minutes of the time he gave an order for [REDACTED].#104's situation, "the sooner the better." According to Resident #104's hospital admission on [DATE] at 5:06 PM, "The patient has a history of [MEDICAL CONDITION] who presents with acute shortness of breath lethargy and hypoxic [MEDICAL CONDITION]." A review of admission documentation indicated that Resident #104 suffered from hypercarbic [MEDICAL CONDITION] (increased carbon [MEDICATION NAME] levels) [MEDICAL CONDITION] (acute infection). According to Resident #104's Discharge Summary dated [DATE], Discharge [DIAGNOSES REDACTED]. In an interview on [DATE] at 10:10 AM, LPN #8 reported, "there were several situations that had to be run by the DON, who then had to call the Regional clinical nurse before we could call the physician, we had to follow these procedures or there was a certain implication we would lose our jobs and we always felt our judgement of acute care was questioned." In an interview on [DATE] at 12:30 PM, Administrator (ADM) #1 reported he was instructed on multiple occasions to "come into the facility to work weekends to prevent hospitalization s". ADM #1 reported he was directed to have the nurses call DON #5 prior to hospitalization s, and DON #5 was instructed to work weekends, and to call Regional clinical nurse for guidance from Regional Director of Clinical Services prior to calling the physician. Review of a copy of instructions (provided by anonymous person) to the facility by the corporate Regional Clinical Nurse Consultant #20 revealed, "I wanted to take a moment to discuss RTH's (return to hospitals). It is no secret that we have had many returns to hospital, as of late. We are in crisis mode with our total census for District 2. With that being said, there are some things that are already in place, and I have a few more ideas that we need to put in place as follows.....: 2. Facility nursing staff must notify the DCS (Director of Nursing) PRIOR to calling the MD to send a resident out to the hospital (unless the resident is in cardiac or respiratory distress/arrest, they need to call 911). The DCS needs to call me to discuss this resident PRIOR to the MD being notified. The DCS and I will converse about the resident and I will offer suggestions. The DCS will then notify the Nurse at the facility with these suggestions After all discussion, the MD will be called, if needed, further orders. When calling the MD, the Nurse Supervisor (if they have one available) on the shift needs to make the call. 3. DCS's need to be present in the building for some time over the course of the weekend. The DCS can offer guidance, support and suggestions to the nursing staff to optimize resident care in the facility. The DCS needs to call during the weekend on each shift to check on the residents and offer guidance and support. The DCS needs to make it clear what the expectation is and drive home the focus on managing resident's care within the facility. I will assist the DCS with these tasks, by making phone calls to the facilities to offer support over the course of the weekend, etc." The document had CC #20 name and credentials at the bottom of the form with her phone number listed. On [DATE] at 10:55 AM, Regional Director Clinical Services (CC) #20 denied giving directions to be notified prior to calling the physician being notified, was questioned several times for clarification and continued to deny the staff were given any directives and stated, "the Director of Nursing did not understand the process, it was not the policy of the facility, I would not dispute an order of a physician. That would be [MEDICATION NAME] outside the scope of practice, if you did not follow a physician order." On [DATE] at 6:00 PM CC #20 reported the Vice President of Clinical Services suggested the directive to prevent unnecessary returns to the hospital and was meant as an "aide to the nurses and DON." CC #20 continued to deny any directive was given to the staff to call her prior to calling the physician. In an interview on [DATE] at 1:00 PM the Administration (ADM) reported he was "instructed to stop returns to the hospital due to the low census." On [DATE], Administrator #1 was notified of the Immediate Jeopardy that was identified on [DATE] and began on [DATE] for both Resident #103 and Resident #104 due to not immediately initiating Emergency Medical Services and not adequately assess and monitor a change of condition resulting in a serious delay in treatment for [REDACTED]. On [DATE] the surveyor confirmed that the facility implemented the following to remove the Immediate Jeopardy: 1. As of [DATE], Resident #103 no longer resided in the facility. Resident #104 was admitted to the hospital on [DATE] and remained there for 7 days. 2. On [DATE], all 99 residents were reassessed by nursing staff for any current change of condition. 3. On [DATE], the crash cart check list was re-initiated. 4. On [DATE], the N-305 Code Blue Policy and Procedure was reviewed by the DON and educator and deemed appropriate. 5. On [DATE], DON/nurse manager re-educated 16 of 26 current licensed nursing staff on the facility's policy and procedure for emergency services related to conducting a code of a resident to include immediate notification of 911 for further treatment and/or transfer to the hospital. 6. On [DATE], N-305 Code Blue, N-315 Emergency Equipment Check, At-a-Glance -105 Change in Resident Condition, Resident Transfer to Hospitals which include Policies changes in Resident Condition N-105, Change in Resident Condition AG-140, Interact II-SBAR, Early Warning, Change in Condition, Resident Transfer Form, Acute Care Transfer Document Checklist, and Acute Transfer Log Policy and Procedures were all reviewed and deemed appropriate. 7. As of [DATE], 24 of 26 licensed nurses were re-educated. 8. The DON will QA (quality assurance) any resident code situation to ensure that the nursing staff responded appropriately and notified 911 immediately for further treatment and/or transfer to the hospital. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity of actual harm due to additional residents identified with a delay in treatment that did not rise to the level of Immediate Jeopardy. ( ) B. Based on observation, interview, and record review the facility's failed to maintain the highest practical physical well-being (timely notify the physician for transport to the hospital after an acute change of condition) in 2 of 15 sampled residents (Residents #105 and #106) reviewed for changes in condition, from a total of 15 sampled residents, resulting in Resident #105 having a delay in medical treatment for [REDACTED]. Findings include: Resident #105 According to Resident #105's Minimum Data Set (MDS) assessment dated [DATE], Resident #105 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the SBAR (Situation Background Assessment Request Physician Communication Progress) note dated [DATE] at 6:00 PM, LPN #16 documented Resident #105 had an elevated temperature of 103.8 degrees Fahrenheit and lethargy. The note indicated that Tylenol was as administered, physician was notified and an order for [REDACTED]. According to the SBAR dated [DATE] at 7:00 AM, LPN #16 documented that Resident #105 was lethargic, had generalized weakness, poor skin turgor (indication of dehydration), was taking liquids poorly, and was short of breath. The note indicated Resident #105's oxygen level (SPO2) was measured at 85% (normal greater than 95%) and that a breathing treatment was given that brought Resident #105's SPO2 up to 91%. LPN #16 documented that an order was received for intravenous (IV) fluids from Physician # 22 and the IV was started at 7:30 AM. LPN #16 documented that at 8:00 AM, Resident #105's color remained pale. According to the nurse progress notes dated "[DATE] at 8:20 AM, LPN # 10 documented, "notified DON, dr (doctor) orders to send (Resident #105) to ER for treatment. 8:35 AM, EMS called for transport to ER at 8:50 AM (EMS) here to transport to hospital, skin assessment completed, BP ,[DATE], P 97, R 28, BS 180. Lethargic at this time." In an interview on [DATE] at 2:15 PM, LPN #10 reported Resident #105 had been really sick on the previous day ([DATE]) and stated she made up her mind prior to going to work on [DATE] that if Resident #105 was still sick, "if it caused me my job she (Resident #105) was going to the hospital." LPN #10 reported Resident #105 was first assessed at 7:00 AM, with oxygen saturation at 80 percent, physician was called by LPN #16 and requested to start and IV on Resident #105. LPN #10 reported the physician was called again at 8:20 AM and Resident #105 left the facility at 8:50 AM at which time her respirations were "very shallow, she was lifeless. I did not think she was going to make it. Her color didn't look good." LPN #10 reported Resident #105 had not been transferred on Saturday due to the facility policy of, "can't always call the doctor first, you had to call the DON, who called corporate nurse, who then calls back to the DON before the doctor can be notified." According to the hospital admission documentation dated [DATE], revealed Resident #105 was admitted with the [DIAGNOSES REDACTED]. ( ) Resident #106 According to Resident #106's Minimum Data Set assessment dated [DATE], and Hospital Admission assessment dated [DATE], Resident #106 was an [AGE] year old female with [DIAGNOSES REDACTED]. Review of the SBAR (Situation Background Assessment Request Physician Communication Progress note) dated [DATE] at 8:15 AM, revealed Resident #106 complained of left sided weakness, slurred speech numbness to her face and left arm and leg. In an interview on [DATE] at 2:05 PM, LPN #10 reported on [DATE] at 7:00 AM, Resident #106's roommate's family member requested assistance and at that time she had noted Resident #106 had slurred speech, her arm was weak, and suspected she was having a stroke. LPN #10 reported Director of Nursing (DON) #5 was notified and that DON #5 called Corporate Consultant (CC) #20 before the physician was called to request a transport to the hospital. LPN #10 reported the physician was not notified until 8:15 AM, 45 minutes after the call to DON #5. LPN #10 reported she was taught in nursing school that treatment for [REDACTED]." Review of the Emergency Medical Sheet (EMS) dated [DATE], revealed Resident #106 was transported at 8:17 AM and arrived at the hospital at 8:22 AM. The EMS report revealed Resident #106 was "positive for Cincinnati stroke scale with facial droopage to left side of face and lower and upper extremities, pt (patient) had slurred speech. Pt was alert and oriented times 2 with a GCS (Glasgow scale) of 15. O2 (oxygen) sats at 88%, Cardiac monitoring showed sinus [MEDICAL CONDITION](fast heart rate). Transferred Priority 1." According to the Hospital admission documentation dated [DATE] at 1:00 PM, "Clinical Impression: Chronic [MEDICAL CONDITION] with hypercapnia (high carbon [MEDICATION NAME] levels). Acute [MEDICAL CONDITION] with [MEDICAL CONDITIONS] and speech deficit. TPA (Total [MEDICATION NAME] Nutrition) was considered but not administered because exclusion criteria were present and symptoms onset was greater than 3 hours prior to arrival." ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE COMFORT AND ADEQUATE PAIN RELIEF AS ORDERED FOR 1 RESIDENT (#502) OF 3 SAMPLED RESIDENTS RESULTING IN PAIN SCORE LEVEL OF 8/10 AND FAILURE TO ATTAIN AND MAINTAIN THE HIGHEST PRACTICABLE PHYSICAL, MENTAL AND PSYCHOSOCIAL WELL-BEING IN ACCORDANCE WITH THE COMPREHENSIVE ASSESSMENT AND PLAN OF CARE. FINDINGS INCLUDE: RESIDENT #502 HAD BEEN REadmitted to the facility on [DATE] AND WAS RECEIVING HOSPICE CARE. SHE WAS ALERT, ORIENTED AND ABLE TO MAKE HER NEEDS KNOWN. RESIDENT #502'S BRIEF INTERVIEW OF MENTAL STATUS SCORE WAS 9, INDICATING IMPAIRED COGNITION. ACCORDING TO THE history and physical examination [REDACTED]'S ESOPHAGUS AND [MEDICAL CONDITION] IN ADDITION TO OTHER DIAGNOSES. THE MINIMUM DATA SET (MDS) assessment dated [DATE], NOTED THAT RESIDENT #502 REQUIRED EXTENSIVE ASSISTANCE WITH ACTIVITIES OF DAILY LIVING WITH ONE PERSON ASSISTANCE. A CARE PLAN WAS REVIEWED FOR ACTIVITIES OF DAILY LIVING AND ALTERATION IN COMFORT/PAIN. REVIEW OF THE CLINICAL RECORD REVEALED PHYSICIAN ORDERS [REDACTED]. [MEDICATION NAME]-[MEDICATION NAME] 5-500, GIVE ONE TABLET BY MOUTH 3 TIMES A DAY AS NEEDED. THE ORDER FOR THE [MEDICATION NAME]-[MEDICATION NAME] WAS CHANGED ON 11/20/12 AT 10:30 AM, TO [MEDICATION NAME]-[MEDICATION NAME] 5-500, 1 TABLET 3 TIMES A DAY AROUND THE CLOCK WITH 1 ADDITIONAL DOSE PRN (AS NEEDED). OBSERVATION ON 11/20/12 AT 2:50 PM REVEALED RESIDENT #502 LYING IN BED. WHEN RESIDENT #502 WAS INTERVIEWED, SHE STATED THAT SHE DID NOT FEEL WELL AND THAT SHE WAS IN PAIN. WHEN THE SURVEYOR ASKED RESIDENT #502 TO DESCRIBE HER PAIN LEVEL, RATED FROM 1 TO 10 (10 BEING THE MOST), RESIDENT #502 STATED THAT HER PAIN INTENSITY WAS 8 OUT OF 10. SHE POINTED OUT THAT THE PAIN WAS FELT ON BOTH LOWER LEGS. SHE STATED THAT SHE DID NOT HAVE HER PAIN PATCH ON AND FURTHER EXPLAINED THAT SHE DID NOT REMOVE IT BECAUSE SHE KNOWS THAT THE PATCH IS FOR HER PAIN. RESIDENT #502 DID NOT KNOW WHEN THE PATCH WAS REMOVED. RESIDENT #502 RECALLED THAT THE PATCH HAD BEEN PLACED ON HER RIGHT UPPER BACK. RESIDENT #502 DEMONSTRATED TO THE SURVEYOR THE EXACT PLACEMENT, PUTTING HER LEFT HAND ON THE AREA. THE SURVEYOR DID NOT SEE THE [MEDICATION NAME] PATCH ON HER BACK. RESIDENT# 502 RECALLED GETTING SOMETHING FOR PAIN IN THE MORNING (ON 11/20/12) BUT NOT SINCE. AT 3:00 PM, THE SURVEYOR OBSERVED THAT RESIDENT #502 DID NOT HAVE A [MEDICATION NAME] PATCH APPLIED TO HER BODY AND WAS COMPLAINING OF SEVERE PAIN TO HER LOWER EXTREMITIES AND WITH THE LAST DOSE OF PAIN MEDICATION ON 11/20/12 AT 9:00 AM (6 HOURS PREVIOUS). ACCORDING TO THE Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]#14 MEANT). LICENSED PRACTICAL NURSE (LPN) #3 INITIALED THE MAR indicated [REDACTED]. PLEASE NOTE THAT THE SURVEYOR REVIEWED THE MAR indicated [REDACTED]. THE MAR FURTHER DOCUMENTED THAT ON 11/20/12, AT 9:00 AM, [MEDICATION NAME]-[MEDICATION NAME] 5-500 1 TABLET WAS GIVEN BY LPN #3, WHO NOTED THE MEDICATION WAS EFFECTIVE AND THAT RESIDENT #502'S PAIN LEVEL WAS "0." ON 11/20/12, AT 2:00 PM (1400), LPN #3 AGAIN RECORDED RESIDENT #502'S PAIN RATED AS "0." LPN #3 VERIFIED ON 11/20/12 AT 3:10 PM, THAT IT WAS HER INITIALS IN THE MAR indicated [REDACTED]. LPN #3 DID NOT HAVE AN EXPLANATION AS TO WHY HER INITIALS WERE ON THE MAR BEFORE THE TIME SCHEDULE AT 2:00 PM AND 3:00 PM. LPN #3 STATED THAT SHE HAD CHECKED THE [MEDICATION NAME] PATCH PLACEMENT EVERY HOUR TODAY (11/20/12) AND SAW THE [MEDICATION NAME] PATCH ON RESIDENT #502 EVERY HOUR FROM 8:00 AM THROUGH 3:00 PM. LPN #3 COULD NOT EXPLAIN WHAT HAPPENED TO THE PATCH AND WHY IT WAS NOT PRESENT AT 2:45 PM. LPN #3 CONFIRMED THAT SHE ONLY ADMINISTERED PAIN MEDICATION TO RESIDENT #502 AT 9:00 AM. CERTIFIED NURSE AIDE (CNA) #4 WAS INTERVIEWED ON 11/20/12 AT 3:00 PM. CNA #4 STATED THAT ON 11/20/12, AFTER BREAKFAST, AT AROUND 9:00 AM, SHE (#4) PROVIDED MORNING CARE TO RESIDENT #502 AND SHE (#4) WAS SURE THAT THERE WAS NO [MEDICATION NAME] PATCH ON THE RESIDENT. CNA #4 STATED THAT SHE (#4) WASHED RESIDENT #502'S WHOLE BODY, STARTING ON HER BACK, TO HER CHEST, PERI-AREA, THEN TO HER LEGS. ACCORDING TO CNA #4, RESIDENT #502 DID NOT HAVE ANYTHING ON HER LIKE A TAPE, CLEAR PLASTIC OR DRESSING. CNA #4 SAID THAT SHE THEN APPLIED LOTION TO RESIDENT #502'S SKIN BEFORE SHE PUT THE RESIDENT'S CLEAN CLOTHES ON. RESIDENT #502 DID NOT HAVE A PATCH ON ANYWHERE. RESIDENT #502 COMPLAINED OF PAIN WHEN SHE WAS TURNED DURING CARE AND TOLD THE NURSE. THE HOSPICE NURSE #5 WAS INTERVIEWED ON 11/20/12 AT 3:15 PM BY PHONE. HOSPICE NURSE #5 STATED THAT SHE HAD BEEN IN TO SEE RESIDENT #502 AT AROUND 9:45 AM THAT MORNING (11/20/12). RESIDENT #502 COMPLAINED OF PAIN IN HER LOWER LEGS. ACCORDING TO HOSPICE NURSE #5, RESIDENT #502 COULD NOT RATE HER PAIN FROM 0-10 BUT SHE SAID IT WAS CONSTANT ON BOTH LOWER EXTREMITIES. SHE (#5) ASSUMED THAT THE [MEDICATION NAME] PATCH WAS ON RESIDENT #502. HOSPICE NURSE #5 SAID THAT SHE DID NOT VISUALLY CHECK RESIDENT #502 TO SEE IF THE [MEDICATION NAME] PATCH WAS ON THE RESIDENT AND DID NOT REMOVE THE PATCH. SHE FURTHER EXPLAINED THAT IT IS THE FACILITY STAFF'S RESPONSIBILITY TO APPLY AND REMOVE THE PATCH. HOSPICE NURSE #5 WENT ON TO SAY THAT THEY (FACILITY) HAVE A SYSTEM IN PLACE FOR CHECKING THE PATCH ON AN HOURLY BASIS. HOSPICE NURSE #5 STATED THAT SHE CALLED THE DOCTOR AND OBTAINED THE NEW ORDER TO GIVE [MEDICATION NAME] 3 TIMES A DAY PLUS 1 ADDITION DOSE IF NEEDED FOR BREAKTHROUGH PAIN. HOSPICE NURSE #5 STATED SHE WROTE THE ORDER AT 10:30 AM AND DISCUSSED THE NEW ORDERS WITH LPN #3 BEFORE SHE LEFT AT APPROXIMATELY 10:45 AM ON 11/20/12. DIRECTOR OF NURSING (DON) #1 AND REGISTERED NURSE (RN) #6 ON 11/20/12 AT 4:25 PM STATED THAT THEY FOUND A [MEDICATION NAME] PATCH IN ONE OF THE CLEAR TRASH BAG WITH THE SOILED INCONTINENCE PAD. ACCORDING TO RN #6, THEY COULD NOT CONCLUSIVELY IDENTIFY NOR PROVE THAT IT WAS THE PATCH REMOVED FROM RESIDENT #502 BECAUSE IT WAS SOILED WITH FECES. THE DON COULD NOT EXPLAIN WHY THE PATCH WAS OFF WHEN THE FACILITY HAS A SYSTEM IN PLACE TO CHECK THE PLACEMENT OF [MEDICATION NAME] PATCHES EVERY HOUR. ( )

Based on observation, interview, and record review, the facility failed to prevent the development of a pressure Ulcer for a Resident Identified at risk for developing a Pressure Ulcer and failed to implement interventions according to the care plan for 1 of 5 sampled residents (#103) reviewed for Incontinence and repositioning from a total sample of 5 residents, resulting in the development of (2) Stage II Pressure Ulcers to the Right Ischium. Findings Include: According to the Annual Minimum Data Set assessment dated [DATE] Resident #103 was a [AGE] year old male with [DIAGNOSES REDACTED]. Section M0150 reflected, "Resident is at risk for developing a pressure ulcer Yes." Section M 0210 reflected, "Resident has Stage I or higher pressure ulcers No." Section M1200C reflected "Skin/Ulcer treat: turning/repositioning Checked." According to Resident #103's Quarterly Minimum Data Set assessment dated [DATE], Section M0150 reflected, "Resident is at risk for developing a pressure ulcer Yes." Section M 0210 reflected, "Resident has Stage I or higher pressure ulcers No." Section M1200C reflected, Skin/Ulcer treat: turning/repositioning Checked." On 10/29/12 at 10:50 AM, during the initial tour, Resident was observed lying on his left side with his feet bent toward his chest. There were no pillows observed on Resident #103's bed to support any bony prominences. Resident was asked if he had been repositioned recently and Resident #103 stated "NO." On 10/30/12 at 1:00 PM, 10/31/12 at 9:31 AM, 10/31/12 at 12:30 PM, and on 10/31/12 at 1:30 PM, Resident #103 was observed lying on his left side with his feet bent toward his chest. There were no pillows observed on Resident #103's bed to support any bony prominences. On 10 30/12 at approximately 9:00 AM, Registered Nurse (RN) #2 reported that she had been on call over the weekend and had received a call from one of the Charge Nurses that Resident #103 had a Pressure Ulcer. RN #2 stated, "it should be healed by now it was a weekend thing." On 10/30/12 upon receipt and during review of the Facility's Resident census and condition it was noted that the form failed to reflect Resident #103's Pressure Ulcers. On 10/30/12 at 11:25 AM, Certified Nurse Aide (CNA) # 6 reported there were no concerns identified with Resident #103 on 10/30/12 when CNA #6 was assigned to provide care for Resident #103. CNA #6 reported Resident #103 wore briefs, was incontinent of bowel and bladder and was changed and repositioned maybe every 2-3 hours. CNA #6 reported that the area on the "cheek" of the buttock had been reported open but the area was "observed" healed and a cream had been applied to the area on the buttocks. On 10 30/12 at 12:20 PM, CNA # 1 reported she was assigned to provide care for Resident #103 on 10/29/12 and 10/31/12. CNA #1 reported Resident #103's buttocks were reddened and had applied a "cream" to the area on buttock with each incontinent episode during both shifts. CNA #1 reported Resident #103 was incontinent of bowel and bladder. CNA #1 reported Charge Nurse instructed on 10/31/12 Resident #103 was to be repositioned every 2 hours. CNA reported applying cream to area of pressure ulcer 10/29/12-10/31/12. Review of Nurse Progress note dated 10/9/12 at 1800 (6:00 PM, reflected "family made aware of wound to R (right) ischium and Dr. (doctor) aware." There was no treatment or any other documentation for monitoring of the development of the Pressure Ulcer. Review of Resident #103's Care Plan "Alteration in Skin Integrity R/T (Related/To) Open area to Posterior Upper Thigh, dated 10/30/12, reflected "1. Cleanse area...Cover with 4 x 4...2 assess weekly ...5. Reposition every 2 hours as needed to enhance healing..." Review of Resident #103's treatment record reflected a treatment was started on 10/28/12 to the right ischium with skin integrity spray then apply moisture barrier to the wound edges and hydrogel to wound bed. The treatment was discontinued on 10/30/12. The treatment was only recorded as being provided on 10/28/12. Review of Resident #103's Treatment Record reflected a treatment was initiated on 10/30/12 to "cleanse area to right Posterior Upper Thigh with skin integrity spray, apply hydrogel to wound bed moisture barrier to surrounding wound and cover with 4 x 4 ABD to pad Hydroflex to secure daily and as needed." Review of Weekly Skin Impairment/Suspected Deep Tissue Injury check dated 9/6/12, reflected no skin impairments, 9/13/12 reflected no skin impairments, 9/20/12 reflected no skin impairments, 10/3/12 reflected no skin impairments, 10/10/12 reflected no skin impairments, 10/17/12 reflected no skin impairments, 10/28/12 reflected (1) "3 cm x 2 cm" (centimeter) (Area marked near the Right Ischium). The documentation failed to determine any of the Pressure Ulcer's characteristics, including the stage, color of the wound bed, drainage, depth or the wound, color of surrounding skin, temperature or any [MEDICAL CONDITION]. Review of the Weekly Skin integrity check dated 10/30/12 reflected Skin Clear, no change of condition assessed. On 10/31/12 at 3:10 PM, Resident was observed lying on his left side with his feet bent toward his chest upon entering Resident #103's room for observation of Resident #103's treatment of [REDACTED].#4. There were no pillows observed on Resident #103's bed to support any bony prominences. Two Stage II Pressure Ulcers were observed on the right Ischium approximately 3 centimeters (cm) in diameter and approximately 3-4 cm apart. Both Stage II Pressure Ulcers were observed reddened around the edges with the surrounding area also red. Resident #103 was not on any type of pressure reducing mattress. Following the treatment RN #4 placed a leg separator to the lower legs according to the care plan. The leg separator had not been observed to have been implemented all week until RN #4 put in place following the treatment. There was no documentation in the clinical record to support (2) Stage II Pressure Ulcers on the Right Ischium as observed. On 10/31/12 at 4:40 PM, RN #4 reported I could have checked the other box "Wound/Skin condition Present/No new change of condition. Documentation already established on all existing Wound/Skin conditions. There was no documentation in the clinical record to reflect the development of (2) Stage II Pressure Ulcers on the Right Ischium. The Facility's Policy "Change in Resident Condition" dated 3/12, reflected "The Clinical Nurse will recognize and appropriately intervene in the event of a change in resident condition. The Physician/Family/Responsible Party will be notified as soon as possible." The Policy included a Procedure that included "4. With a change of resident status, the Nurse is responsible to complete an assessment of the resident's condition to include vital signs, level of consciousness and any other symptoms related to the condition and make any judgement calls regarding the course of action to be taken. The need to contact the agent/surrogate/contact person and or physician and must document the date, time party's notified, findings and details of the notification in the Nurse Notes. ..." 6. Document in medical record. 7. The nurse manager/supervisor will communicate to the MDS coordinator and care manager (if appropriate) any significant changes in condition, which may warrant a reassessment." The Policy included "Attachment M Change in Condition" reflected an assessment that included the most recent findings, mental status, vital signs, wound status (describe, drainage, appearance, treatment) with instructions for the form to be completed before contacting the physician. According to the facility policy the facility failed assess, monitor, and document on 10/9/12 and 10/28/12 with the development of the (2) Stage II Pressure Ulcers to document according to the Facility Policy. The Facility's Policy "Resident Abuse" dated 3/12, reflected "5. Neglect d. Failure to provide services that result in harm to the resident, such as not turning a bedfast resident or leaving a resident in a soiled bed." The facility failed to follow their policy in the prevention of the development of (2) Stage II Pressure Ulcers for Resident #103. Documentation of the the original occurrence, number and the site of the Stage II Pressure Ulcers (Right upper thigh, Ischium) and type of treatment that was provided (CNAs reported a cream) were inconsistent. #

2 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE COMFORT AND ADEQUATE PAIN RELIEF AS ORDERED FOR 1 RESIDENT (#502) OF 3 SAMPLED RESIDENTS RESULTING IN PAIN SCORE LEVEL OF 8/10 AND FAILURE TO ATTAIN AND MAINTAIN THE HIGHEST PRACTICABLE PHYSICAL, MENTAL AND PSYCHOSOCIAL WELL-BEING IN ACCORDANCE WITH THE COMPREHENSIVE ASSESSMENT AND PLAN OF CARE. FINDINGS INCLUDE: RESIDENT #502 HAD BEEN REadmitted to the facility on [DATE] AND WAS RECEIVING HOSPICE CARE. SHE WAS ALERT, ORIENTED AND ABLE TO MAKE HER NEEDS KNOWN. RESIDENT #502'S BRIEF INTERVIEW OF MENTAL STATUS SCORE WAS 9, INDICATING IMPAIRED COGNITION. ACCORDING TO THE history and physical examination [REDACTED]. THE MINIMUM DATA SET (MDS) assessment dated [DATE], NOTED THAT RESIDENT #502 REQUIRED EXTENSIVE ASSISTANCE WITH ACTIVITIES OF DAILY LIVING WITH ONE PERSON ASSISTANCE. A CARE PLAN WAS REVIEWED FOR ACTIVITIES OF DAILY LIVING AND ALTERATION IN COMFORT/PAIN. REVIEW OF THE CLINICAL RECORD REVEALED PHYSICIAN ORDERS [REDACTED]. [MEDICATION NAME]-[MEDICATION NAME] 5-500, GIVE ONE TABLET BY MOUTH 3 TIMES A DAY AS NEEDED. THE ORDER FOR THE [MEDICATION NAME]-[MEDICATION NAME] WAS CHANGED ON 11/20/12 AT 10:30 AM, TO [MEDICATION NAME]-[MEDICATION NAME] 5-500, 1 TABLET 3 TIMES A DAY AROUND THE CLOCK WITH 1 ADDITIONAL DOSE PRN (AS NEEDED). OBSERVATION ON 11/20/12 AT 2:50 PM REVEALED RESIDENT #502 LYING IN BED. WHEN RESIDENT #502 WAS INTERVIEWED, SHE STATED THAT SHE DID NOT FEEL WELL AND THAT SHE WAS IN PAIN. WHEN THE SURVEYOR ASKED RESIDENT #502 TO DESCRIBE HER PAIN LEVEL, RATED FROM 1 TO 10 (10 BEING THE MOST), RESIDENT #502 STATED THAT HER PAIN INTENSITY WAS 8 OUT OF 10. SHE POINTED OUT THAT THE PAIN WAS FELT ON BOTH LOWER LEGS. SHE STATED THAT SHE DID NOT HAVE HER PAIN PATCH ON AND FURTHER EXPLAINED THAT SHE DID NOT REMOVE IT BECAUSE SHE KNOWS THAT THE PATCH IS FOR HER PAIN. RESIDENT #502 DID NOT KNOW WHEN THE PATCH WAS REMOVED. RESIDENT #502 RECALLED THAT THE PATCH HAD BEEN PLACED ON HER RIGHT UPPER BACK. RESIDENT #502 DEMONSTRATED TO THE SURVEYOR THE EXACT PLACEMENT, PUTTING HER LEFT HAND ON THE AREA. THE SURVEYOR DID NOT SEE THE [MEDICATION NAME] PATCH ON HER BACK. RESIDENT# 502 RECALLED GETTING SOMETHING FOR PAIN IN THE MORNING (ON 11/20/12) BUT NOT SINCE. AT 3:00 PM, THE SURVEYOR OBSERVED THAT RESIDENT #502 DID NOT HAVE A [MEDICATION NAME] PATCH APPLIED TO HER BODY AND WAS COMPLAINING OF SEVERE PAIN TO HER LOWER EXTREMITIES AND WITH THE LAST DOSE OF PAIN MEDICATION ON 11/20/12 AT 9:00 AM (6 HOURS PREVIOUS). ACCORDING TO THE Medication Administration Record [REDACTED]#14 MEANT). LICENSED PRACTICAL NURSE (LPN) #3 INITIALED THE MAR indicated [REDACTED]. PLEASE NOTE THAT THE SURVEYOR REVIEWED THE MAR indicated [REDACTED]. THE MAR FURTHER DOCUMENTED THAT ON 11/20/12, AT 9:00 AM, [MEDICATION NAME]-[MEDICATION NAME] 5-500 1 TABLET WAS GIVEN BY LPN #3, WHO NOTED THE MEDICATION WAS EFFECTIVE AND THAT RESIDENT #502'S PAIN LEVEL WAS 0. ON 11/20/12, AT 2:00 PM (1400), LPN #3 AGAIN RECORDED RESIDENT #502'S PAIN RATED AS 0. LPN #3 VERIFIED ON 11/20/12 AT 3:10 PM, THAT IT WAS HER INITIALS IN THE MAR indicated [REDACTED]. LPN #3 DID NOT HAVE AN EXPLANATION AS TO WHY HER INITIALS WERE ON THE MAR BEFORE THE TIME SCHEDULE AT 2:00 PM AND 3:00 PM. LPN #3 STATED THAT SHE HAD CHECKED THE [MEDICATION NAME] PATCH PLACEMENT EVERY HOUR TODAY (11/20/12) AND SAW THE [MEDICATION NAME] PATCH ON RESIDENT #502 EVERY HOUR FROM 8:00 AM THROUGH 3:00 PM. LPN #3 COULD NOT EXPLAIN WHAT HAPPENED TO THE PATCH AND WHY IT WAS NOT PRESENT AT 2:45 PM. LPN #3 CONFIRMED THAT SHE ONLY ADMINISTERED PAIN MEDICATION TO RESIDENT #502 AT 9:00 AM. CERTIFIED NURSE AIDE (CNA) #4 WAS INTERVIEWED ON 11/20/12 AT 3:00 PM. CNA #4 STATED THAT ON 11/20/12, AFTER BREAKFAST, AT AROUND 9:00 AM, SHE (#4) PROVIDED MORNING CARE TO RESIDENT #502 AND SHE (#4) WAS SURE THAT THERE WAS NO [MEDICATION NAME] PATCH ON THE RESIDENT. CNA #4 STATED THAT SHE (#4) WASHED RESIDENT #502'S WHOLE BODY, STARTING ON HER BACK, TO HER CHEST, PERI-AREA, THEN TO HER LEGS. ACCORDING TO CNA #4, RESIDENT #502 DID NOT HAVE ANYTHING ON HER LIKE A TAPE, CLEAR PLASTIC OR DRESSING. CNA #4 SAID THAT SHE THEN APPLIED LOTION TO RESIDENT #502'S SKIN BEFORE SHE PUT THE RESIDENT'S CLEAN CLOTHES ON. RESIDENT #502 DID NOT HAVE A PATCH ON ANYWHERE. RESIDENT #502 COMPLAINED OF PAIN WHEN SHE WAS TURNED DURING CARE AND TOLD THE NURSE. THE HOSPICE NURSE #5 WAS INTERVIEWED ON 11/20/12 AT 3:15 PM BY PHONE. HOSPICE NURSE #5 STATED THAT SHE HAD BEEN IN TO SEE RESIDENT #502 AT AROUND 9:45 AM THAT MORNING (11/20/12). RESIDENT #502 COMPLAINED OF PAIN IN HER LOWER LEGS. ACCORDING TO HOSPICE NURSE #5, RESIDENT #502 COULD NOT RATE HER PAIN FROM 0-10 BUT SHE SAID IT WAS CONSTANT ON BOTH LOWER EXTREMITIES. SHE (#5) ASSUMED THAT THE [MEDICATION NAME] PATCH WAS ON RESIDENT #502. HOSPICE NURSE #5 SAID THAT SHE DID NOT VISUALLY CHECK RESIDENT #502 TO SEE IF THE [MEDICATION NAME] PATCH WAS ON THE RESIDENT AND DID NOT REMOVE THE PATCH. SHE FURTHER EXPLAINED THAT IT IS THE FACILITY STAFF'S RESPONSIBILITY TO APPLY AND REMOVE THE PATCH. HOSPICE NURSE #5 WENT ON TO SAY THAT THEY (FACILITY) HAVE A SYSTEM IN PLACE FOR CHECKING THE PATCH ON AN HOURLY BASIS. HOSPICE NURSE #5 STATED THAT SHE CALLED THE DOCTOR AND OBTAINED THE NEW ORDER TO GIVE [MEDICATION NAME] 3 TIMES A DAY PLUS 1 ADDITION DOSE IF NEEDED FOR BREAKTHROUGH PAIN. HOSPICE NURSE #5 STATED SHE WROTE THE ORDER AT 10:30 AM AND DISCUSSED THE NEW ORDERS WITH LPN #3 BEFORE SHE LEFT AT APPROXIMATELY 10:45 AM ON 11/20/12. DIRECTOR OF NURSING (DON) #1 AND REGISTERED NURSE (RN) #6 ON 11/20/12 AT 4:25 PM STATED THAT THEY FOUND A [MEDICATION NAME] PATCH IN ONE OF THE CLEAR TRASH BAG WITH THE SOILED INCONTINENCE PAD. ACCORDING TO RN #6, THEY COULD NOT CONCLUSIVELY IDENTIFY NOR PROVE THAT IT WAS THE PATCH REMOVED FROM RESIDENT #502 BECAUSE IT WAS SOILED WITH FECES. THE DON COULD NOT EXPLAIN WHY THE PATCH WAS OFF WHEN THE FACILITY HAS A SYSTEM IN PLACE TO CHECK THE PLACEMENT OF [MEDICATION NAME] PATCHES EVERY HOUR. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE THE NECESSARY TREATMENT AND SERVICES TO PROMOTE HEALING AND PREVENT INFECTIONS OF THE EXISTING PRESSURE ULCERS FOR 1 OF 2 RESIDENTS (#2) WITH PRESSURE ULCERS FROM A TOTAL SAMPLE OF 18 RESIDENTS, RESULTING IN MULTIPLE NON-HEALING UNSTAGEABLE RIGHT FOOT PRESSURE ULCERS AND THE DEVELOPMENT OF RECURRENT INFECTION AND PAIN. FINDINGS INCLUDE: RESIDENT #2 WAS AN ALERT, EMACIATED (69 INCHES TALL, 111 POUNDS) AND RARELY COMMUNICATIVE [AGE] year OLD MALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE RESIDENT WAS UNDER HOSPICE CARE BEFORE HE WAS admitted . THIS WAS DISCONTINUED ON 9/17/10 DUE TO A LACK OF MEETING SUFFICIENT CRITERIA FOR CONTINUED SERVICES. THE ADMISSION "NURSING DATA COLLECTION" DATED 9/14/10 REFLECTED THE resident had a history of [REDACTED]. THE "WEEKLY SKIN SWEEP" DATED 9/14/10 DESCRIBED THE RESIDENT AS HAVING 2 NECROTIC UNSTAGEABLE PRESSURE ULCERS ON HIS RIGHT HEEL AND THE AREA NEAR THE 5 TH TOE (REFERRED TO AS RIGHT SUPERIOR LATERAL). THE RESIDENT ALSO HAD A REDDENED AREA BETWEEN THE 2 NECROTIC AREAS (REFERRED TO AS RIGHT MID LATERAL SIDE). ACCORDING TO THE "SKIN GRID- PRESSURE" FORM DATED 9/14/10, THE RIGHT HEEL WOUND MEASURED 5 CM X 3 CM, RIGHT SUPERIOR LATERAL WOUND MEASURED 2.5 CM X 2 CM AND THE RIGHT MID LATERAL WOUND MEASURED 2.5 CM X 2 CM. ALL 3 PRESSURE ULCERS WERE LABELED AS AN UNSTAGEABLE AND HAD NO MEASUREMENT OF DEPTH. ALL 3 PRESSURE ULCERS WERE MARKED AS HAVING ESCHAR (DEAD TISSUE) WITHOUT DRAINAGE AND THEIR WOUND EDGES WERE RED. THE "SKIN GRID-PRESSURE" FORM DATED 4/20/11 DESCRIBED THE RIGHT MID LATERAL WOUND AS A STAGE 4 (FULL THICKNESS SKIN LOSS WITH EXTENSIVE DESTRUCTION, TISSUE NECROSIS, OR DAMAGE TO MUSCLE, BONE, OR SUPPORTING STRUCTURES SUCH AS TENDON, JOINT CAPSULE) WITH SMALL AMOUNT OF SEROUS DRAINAGE. IT MEASURED 2.3 CM X 1.6 CM X 0.1 CM. THE "SKIN GRID-PRESSURE" FORM DATED 4/27/11 DESCRIBED THE RIGHT SUPERIOR LATERAL WOUND AS A STAGE 4 WITH A MEASUREMENT OF 3.1 CM X 3.1 CM X 0.1 CM. THE RIGHT HEEL WOUND HOWEVER REMAINED AS AN UNSTAGEABLE (REFER TO STAGE 4 DUE TO COVERING OF DEAD TISSUE) WITH FLUCTUATIONS OF SIZES. THE LARGEST SIZE WAS 9.2 CM X 9.4 CM ON 5/10/11 (ORIGINAL SIZE WAS 5 X 3). ON 5/23/11 AT 10:00 A.M., THE RESIDENT WAS OBSERVED LYING ON HIS LEFT SIDE WITH 2-3 PILLOWS BETWEEN HIS KNEES. HOWEVER, BOTH HEELS RESTED ON THE BED BECAUSE HIS LEGS WERE DRAWN UP TO HIS TRUNK DUE TO CONTRACTURES. THE HEELS WERE NOT FLOATED ON THE PILLOWS. AT 12:30 P.M. ON SAME DAY THE RESIDENT WAS OBSERVED TO BE IN THE SAME POSITION WITH HEELS TOUCHING THE BED. AT 1:00 P.M., THE RESIDENT WAS OBSERVED COVERING HIS FACE WITH A PILLOW. BOTH HEELS STILL RESTED ON THE BED. AT 2:00 P.M., THE NURSE AIDE, (STAFF "E") CAME INSIDE THE ROOM TO ASSIST WITH A BED BATH. SHE WAS ASKED WHETHER THE RESIDENT HAD BEEN TURNED SINCE 10:00 A.M. THE STAFF "E" STATED SHE HAD TURNED HIM AROUND 11:30 A.M. WHEN SHE WAS ASKED WHY THE RESIDENT'S HEELS WERE STILL TOUCHING THE BED STAFF "E" STATED THAT THE RESIDENT MAY HAVE KICKED THE PILLOW OUT OF POSITION. HOWEVER, ALL 3 PILLOWS WERE TUCKED IN BETWEEN THE RESIDENT'S KNEES WHILE HE REMAINED IN THE SAME POSITION (ON HIS LEFT SIDE) AS HE HAD BEEN OBSERVED AT 10:00 A.M. LYING ON HIS LEFT SIDE DID NOT APPEAR HE WAS TURNED OR REPOSITIONED. ON 5/24/11 AT 10:00 A.M., THE DRESSING CHANGE BY THE TREATMENT NURSE, (STAFF "C") TO ALL 3 WOUNDS WAS OBSERVED IN THE RESIDENT'S ROOM. THE RIGHT HEEL WOUND WAS COVERED WITH BLACK ESCHAR. THERE WAS LOOSE, YELLOW BROWNISH SLOUGH IN THE PROXIMAL CORNER OF THE BLACK SCAB WITH PURULENT DRAINAGE AND AN UNPLEASANT ODOR. (THESE ARE SIGNS OF AN INFECTION). THE MEASUREMENT OF THE RIGHT HEEL WOUND WAS 7.6 CM X 7.6 CM. THE RIGHT SUPERIOR PRESSURE ULCER LOOKED LIKE A DRIED SCAB AND MEASURED 1.8 CM X 1.5. THE RIGHT MID LATERAL WOUND HAD SMALL AMOUNT OF SEROUS DRAINAGE AND MEASURED 2.0 CM X 2.5 CM. STAFF "C" APPLIED [MEDICATION NAME] (ANTIMICROBIAL) CREAM TO THE OPEN AREAS OF THE RIGHT HEEL AND THE RIGHT MEDIAL LATERAL WOUND. SHE THEN COVERED THE WOUNDS WITH 4 X 4 GAUZE, SECURED IT WITH "HYPOFIX" TAPE AND WRAPPED THE FOOT WITH ROLLS OF "KERLIX." THE RESIDENT MADE SLIGHT FACIAL GRIMACING WHEN THE WOUNDS WERE CLEANED WITH SALINE SOLUTION. HOWEVER, THE TREATMENT NURSE "C" STATED SHE NOTICED THE RESIDENT AS HAVING MORE PAIN WITH DRESSING CHANGES ABOUT 2 WEEKS AGO THAN TODAY. THE RESIDENT'S BOTH LEGS WERE BONY AND CONTRACTED. WHEN THE RESIDENT WAS TURNED TO HIS LEFT SIDE THERE WERE 3 RED MARKS OBSERVED ON HIS BACK FROM A WRINKLED DRAW SHEET. ALSO THERE WAS A DARK RED SPOT ON HIS RIGHT HIP OVER THE BONY PROMINENCE. STAFF "C" ADDED THAT THE RESIDENT COULD NOT FREELY MOVE HIS LEGS. THE "RESIDENT CARE PLAN" DATED 4/21/11 REFLECTED THE RESIDENT HAD AN ALTERATION IN SKIN INTEGRITY AS EVIDENCED BY FRAIL TISSUE, PAPER THIN SKIN, MULTIPLE AREAS OF BRUISING ON UPPER ARMS AND SKIN TEARS. THE APPROACHES INCLUDED; TREATMENT AS ORDERED, WEEKLY SKIN ASSESSMENT, PREVENTIVE SKIN AREA (NO SPECIFIC LOCATION OR MEASURES DOCUMENTED), MAINTAIN ADEQUATE NUTRITION AND HYDRATION, NOTIFYING PHYSICIAN OF ALL CONCERNS AND CHANGES, AND USING CAUTION WITH TURNING AND REPOSITIONING. NO SUPPORTIVE SURFACES SUCH AS A PRESSURE RELIEVING MATTRESS OR HEEL PROTECTORS WERE INCLUDED IN THE RESIDENT'S CARE PLAN. IN ADDITION, UNDER THE SKIN CARE IN THE "RESIDENT INFORMATION SHEET," A CARE PLAN UTILIZED BY THE NURSING AIDES, DATED 2/16/11 DID NOT CHECK AS PROVIDED ANY PRESSURE RELIEVING INTERVENTIONS (BED, CHAIR, FLOAT HEELS). THE NURSING NOTES DATED 9/14/10 THROUGH 5/20/11 REFLECTED THE RESIDENT HAD BEEN TREATED WITH AN ANTIBIOTIC THREE TIMES (11/21/10, 1/19/11, 4/21/11) FOR SIGNS AND SYMPTOMS OF INFECTION (PURULENT DRAINAGE AND ODOR) ON RIGHT FOOT. THE PODIATRY NOTES DATED 9/22/10, 11/24/10 AND 2/3/11 FAILED TO DESCRIBE SPECIFIC VASCULAR OR ORTHOPEDIC ABNORMALITIES RELATED TO THE RESIDENT'S PRESSURE ULCERS. THE LABORATORY TESTS NECESSARY TO BE MONITORED FOR WOUND HEALING INCLUDED THE HEMOGLOBIN A1C AS 5.7 % (NORMAL RANGE: 4-6 %) AND [MEDICATION NAME] LEVEL OF 3.5 G/L (3.6-5.6) DATED 3/29/11. THE [MEDICATION NAME] LEVEL DROPPED TO 2.8 G/L ON 4/5/11 WHICH REFLECTED A LOW LEVEL OF PROTEIN STORES NEEDED FOR WOUND HEALING. ON 5/24/11 AT 11:30 A.M., STAFF "C" WHO STATED THAT SHE HAD BEEN WORKING AS A TREATMENT NURSE FOR ABOUT 2 YEARS WAS ASKED WHAT MIGHT BE THE POTENTIAL CAUSES OF THE RESIDENT'S NON-HEALING (DEFINED BY AN ARTICLE, "STATE OF SCIENCE IN WOUND CARE MANAGEMENT" CENTER FOR MEDICARE AND MEDICAID SERVICES, MULTIMEDIA BROADCAST APRIL 23, 2004, AS THE WOUND THAT FAILS TO SHOW MEASURABLE PROGRESS TOWARD HEALING FOR 2-4 WEEKS DESPITE APPROPRIATE MANAGEMENT) RIGHT FOOT PRESSURE ULCERS OVER THE PAST 9 MONTHS. STAFF " C" STATED THE RESIDENT WAS ELDERLY, NOT TAKING ADEQUATE NUTRITION AND HE WAS A DIABETIC (DIET CONTROLLED). FURTHER DISCUSSION WITH STAFF "C" REVEALED THAT SHE DID NOT RECEIVE ANY SPECIAL TRAINING IN WOUND CARE, BUT ENJOYED DOING DRESSING CHANGES. SHE BELIEVED SHE POSSESSED A DEEPER KNOWLEDGE AND SKILLS THAN THE OTHER STAFF. STAFF "C" ADDED THAT SHE WROTE MOST TREATMENT ORDERS (NEW TREATMENT ORDERS WERE WRITTEN NEARLY ON A DAILY BASIS ON OCCASIONS WITHOUT GIVING SUFFICIENT TIME TO EVALUATE EFFECTIVENESS OF THE PREVIOUS TREATMENT) AND HAD THE PHYSICIAN SIGN ORDERS AT A LATER TIME. STAFF "C" WAS ASKED WHAT WAS HER RATIONALE FOR USING ONLY "[MEDICATION NAME]" CREAM WHEN THE WOUND HAD NECROTIC OPEN AREAS THAT NEEDED TO BE DEBRIDED. SHE STATED [MEDICATION NAME] CONTAINED ANTIMICROBIAL PROPERTY. THE physician's orders [REDACTED]. PAD WITH 4 X 4 WRAP AND HYPOFIX TO SECURE QD (DAILY)". THE "PRESSURE ULCERS, GUIDELINES FOR PREVENTION AND MANAGEMENT," THIRD EDITION, AUTHORED BY JOANN MAKLEBUST AND MARY SIEGGREEN STATED THAT ANTISEPTICS SUCH AS [MEDICATION NAME]-IODINE, ACETIC ACID, SODIUM HYPOCHLORITE, AND HYDROGEN PEROXIDE ARE HIGHLY REACTIVE CHEMICALS THAT INDISCRIMINATELY DESTROY CELL FUNCTION (CYTOTOXIC FIBROBLAST). THEIR USE TO DECREASE THE BACTERIAL COUNT IN OPEN WOUNDS IS CONTRAINDICATED, BECAUSE THEY INDISCRIMINATELY DAMAGE TISSUE, INTERFERE WITH TISSUE FUNCTION, INCREASE INJURY, AND DELAY WOUND HEALING (P. 106). THE GUIDELINE REFERENCE ALSO STATES THAT THE USE OF TOPICAL ANTIMICROBIALS WAS HIGHLY CONTROVERSIAL BECAUSE SEVERAL STUDIES REPORTED ADVERSE EFFECTS. ALL PRODUCTS THAT GO ON OR INTO A WOUND SHOULD BE NONTRAUMATIC. (P. 39). THE RESIDENT CARE PLAN DATED 4/21/11 HAD NO UPDATED, REASSESSMENT OF THE CURRENT RISK FACTORS RELATED TO THE DETERIORATION OF THE WOUND AND NO RE-EVALUATION OF THE INTERVENTIONS TO IMPROVE WOUND HEALING OF THE RIGHT FOOT PRESSURE ULCERS. IN ADDITION, NO WOUND CARE SPECIALIST HAD BEEN CONSULTED TO FIND NEW STRATEGIES NOR WAS THERE EVIDENCE OF A CONSISTENT INTERDISCIPLINARY DIALOGUE TO SEEK AN EFFECTIVE WOUND CARE PLAN. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE APPROPRIATE AND CONSISTENT RANGE OF MOTION (ROM) EXERCISES FOR 1 OF 7 RESIDENTS (#2) REVIEWED FOR ROM FROM A TOTAL SAMPLE OF 18 RESIDENTS, RESULTING IN CONTRACTURES, LOSS OF INDEPENDENCE IN HIS ACTIVITIES OF DAILY LIVING AND DECLINE IN ROM FOR UPPER AND LOWER EXTREMITIES. FINDINGS INCLUDE: RESIDENT #2 WAS AN ALERT, EMACIATED (69 INCHES TALL, 111 POUNDS) [AGE] year OLD MALE admitted TO THE FACILITY 9/14/10 WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE] REFLECTED THE RESIDENT HAD NO IMPAIRMENT OF FUNCTIONAL LIMITATION IN RANGE OF MOTION IN BOTH UPPER EXTREMITIES THAT INCLUDED SHOULDER, ELBOW, WRIST AND HAND AND LOWER EXTREMITIES THAT INCLUDED HIP, KNEE, ANKLE AND FOOT (CODED AS "0"). HOWEVER, THE MDS dated [DATE] AND 3/7/11 REFLECTED THAT THE RESIDENT HAD IMPAIRMENT OF FUNCTIONAL LIMITATION IN RANGE OF MOTION ON BOTH SIDES OF UPPER AND LOWER EXTREMITIES (CODED AS "2"). ON BOTH QUARTERLY ASSESSMENT PERIOD THERE WAS NO EVIDENCE THAT THE RESIDENT HAD BEEN REFERRED TO THE REHABILITATIVE SERVICES FOR HIS RESTORATIVE OR MAINTAINING ACTIVITIES OF DAILY LIVING (ADL) FUNCTION. THE NURSING NOTE DATED 10/26/10 REFLECTED THE RESIDENT FED HIMSELF BUT THE NURSING NOTE DATED 5/6/11 REFLECTED THE RESIDENT WAS BEING FED BY STAFF. IT WAS NOT CLEAR SINCE WHAT TIME PERIOD THE RESIDENT LOST HIS ABILITY TO FEED HIMSELF. DURING THE SURVEY FROM 5/23/11 THROUGH 5/25/11 THE RESIDENT WAS OBSERVED NEVER GETTING OUT OF THE BED, BEING FED BY STAFF AND ASSISTED FOR ALL ASPECTS OF ACTIVITIES OF DAILY LIVING (ADL). THE NURSING NOTES DATED 4/28/11 REFLECTED, "RESIDENT NOTED WITH INCREASINGLY MORE DIFFICULTY STRENGTH BILATERAL KNEE JOINTS AND DIFFICULTY WITH HIP FLEXION". ON 5/25/11 AT 3:00 P.M., THE PHYSICAL THERAPIST, (STAFF "AA") STATED THAT HE WAS TOLD BY THE NURSING STAFF DURING HIS WEEKLY ROUNDS THE RESIDENT WAS HAVING DECREASED ROM. STAFF "A" THEN EVALUATED THE RESIDENT AND FOUND THAT THE RESIDENT HAD HIP AND KNEE HAMSTRING CONTRACTURES. HE FIRST RECOMMENDED USING A HIP ABDUCTOR BUT OPTED TO TRAIN NURSING STAFF TO POSITION BY USING PILLOWS AND PERFORM PASSIVE RANGE OF MOTION EXERCISES TO BOTH LOWER EXTREMITIES 10 REPETITIONS FOR 2 SETS ON RESIDENT #2. HE STATED THAT THE TRAINING WAS STARTED ON 4/29/11. HOWEVER, THE "RESIDENT INFORMATION SHEET," UTILIZED BY THE NURSE AIDES, DATED 2/16/11 HAD NO CHECK ON ROM AND THE RESIDENT DID NOT RECEIVE ANY ROM EXERCISES THROUGHOUT THE SURVEY WEEK. HIS OVERALL DECLINE WAS PREVENTABLE. ( )

THIS CITATION PERTAINS TO INTAKE MI 608. BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE SUPERVISION TO PREVENT ACCIDENTS FOR 1 OF 7 SAMPLED RESIDENTS (#500), RESULTING IN IMMEDIATE JEOPARDY FOR RESIDENT #500 WHO SUSTAINED SECOND DEGREE BURNS ON THE RIGHT HIP AND ABDOMEN FROM HOT COFFEE, RESULTING IN SERIOUS HARM AND PLACING 16 RESIDENTS ASSESSED TO NEED ADAPTIVE DRINKING EQUIPMENT AT HIGH RISK FOR SERIOUS HARM. FINDINGS INCLUDE: REVIEW OF THE FACE SHEET, NURSES NOTES DATED 10/18/10 THROUGH 1/6/11, SOCIAL WORKER NOTES DATED 8/27/10 THROUGH 1/3/10, physician progress notes [REDACTED].#500 WAS admitted to the facility on [DATE], AFTER A FALL AT HOME RESULTING IN A RIGHT HIP FRACTURE REQUIRING SURGERY. REVIEW OF THE MDS dated [DATE], REVEALED THE RESIDENT WAS INCONTINENT, HAD MEMORY LOSS, REQUIRED ASSISTANCE WITH ADL'S (ACTIVITIES OF DAILY LIVING) AND WAS A SET-UP FOR MEALS. THE RESIDENT WAS RECOVERING FROM PNEUMONIA AND HER [DIAGNOSES REDACTED]. REVIEW OF THE SPEECH THERAPY PLAN OF TREATMENT (DATED 9/17/10) AND TREATMENT LOG (DATED 9/21/10), REVEALED RESIDENT #500 WAS diagnosed with [REDACTED]. REVIEW OF RESIDENT #500'S FUNCTIONAL MAINTENANCE PROGRAM DATED 9/27/10, STATED "DECREASED SAFETY AWARENESS". REVIEW OF THE REHAB CARE PLAN DATED 8/27/10, STATED "DEMENTIA WITH FLUCTUATIONS IN COGNITIVE ABILITIES AS SHE CAN BECOME CONFUSED AT TIMES, ALERT X 3". REVIEW OF SOCIAL SERVICE NOTE DATED 8/27/10, STATED "RES HAS DX OF DEMENTIA BUT IS ALERT X3 (TO PERSON, PLACE AND TIME) WITH PDS (PERIODS) OF CONFUSION AND FLUCTUATIONS IN HER COGNITIVE ABILITIES REQUIRING CUES AND SUPERVISION FROM FAMILY AND STAFF". REVIEW OF THE DIETARY PROGRESS NOTES DATED 11/22/10, STATED "SHE GEN (GENERALLY) REQUIRES A LOT OF ENCOURAGEMENT TO EAT". REVIEW OF THE FACILITY INCIDENT AND ACCIDENT REPORT (DATED 1/2/11) AND INVESTIGATION REPORT (DATED 1/7/11), REVEALED ON 1/2/11 AT 8:30 A.M. RESIDENT #500 WAS GIVEN HOT COFFEE AND SHE SPILLED IT. RESIDENT #500 RECEIVED BURNS TO HER ABDOMEN AND RIGHT HIP. THE PHYSICIAN WAS INFORMED AND SILVADENE CREAM (A MEDICATION FOR BURNS) WAS ORDERED. RESIDENT #500 SAID ON 1/2/11 HER HAND GOT SHAKY AND THE CUP fell OUT OF HER HAND. THE INVESTIGATION REPORT STATED "8:00 A.M. RESIDENT OBSERVED TO BE AWAKE AND ALERT, SITTING UP IN BED EATING BREAKFAST, HUSBAND AT BEDSIDE WITH RESIDENT. 8:30 A.M. STAFF ENTERED RESIDENTS ROOM TO PICK UP BREAKFAST TRAY AND OBSERVED THAT SHE HAD SPILLED HER COFFEE, DENIED DISCOMFORT. (RESIDENT #500) HAD NOT PRESENTED WITH ANY COMPLICATIONS OR SHAKING WHEN THE BREAKFAST TRAY WAS DELIVERED AND SET-UP BY STAFF. THE RESIDENT HAD NOT BEEN OBSERVED HAVING ANY DIFFICULTY WITH HOT BEVERAGES OR MANAGEMENT OF HER COFFEE CUP. COMPLETION OF THE INVESTIGATION INDICATES THAT THE EVENT COULD NOT HAVE BEEN PREVENTED". REVIEW OF THE NURSES NOTES DATED 1/2/11 AT 7:30 A.M., STATED "8:00 A.M. AWAKE AND ALERT SITTING UP IN HER (RESIDENT #500) BED EATING BREAKFAST. HUSBAND AT BEDSIDE. 8:30 A.M. WHEN CNA PICKED UP BREAKFAST TRAY SHE NOTICED COFFEE ON SHEET AND BLANKET. SHE REPORTED THIS TO ME; I IMMEDIATELY CHECKED HER BODY AND FOUND AREA ON R (RIGHT) ABD (ABDOMEN) RED WITH R HIP RED. BOTH AREAS WERE IMMEDIATELY TREATED, WITH ICE APPLIED. WATER FILLED VESICLES APPEARED ONE ON R ABD AND 2 ON R HIP, BOTH TREATED WITH SILVADENE AND DRESSING. DR CALLED. 10:00 A.M. HUSBAND WAS CALLED AND STATED "YES I NOTICED SHE HAD SPILLED HER COFFEE BUT SHE NEVER SAID IT HURT, I DIDN'T THINK SHE BURNED HERSELF". REVIEW OF THE PHYSICIAN ORDER [REDACTED].#500'S BURNS AND GAVE an order for [REDACTED]. OBSERVATION OF RESIDENT #500 WAS DONE ON 1/5/11 AT 8:05 A.M.; SHE WAS IN BED SITTING UP, ALERT TO NAME AND PLACE. RESIDENT #500 WAS UNABLE TO RECALL HOW SHE WAS BURNED. WHEN ASKED IF HER BURN HURT, RESIDENT #500 STATED "YES IT HURTS". A SECOND DEGREE BURN (A PARTIAL-THICKNESS BURN, DESTRUCTION OF THE OUTER AND UNDERLINING SKIN LAYERS) ON HER ABDOMEN WAS MEASURED BY NURSE #1 (ON 1/2/11, ASSIGNED TO THE UNIT THE RESIDENT WAS ON) TO BE 1.8 INCHES IN LENGTH AND .5 INCHES IN WIDTH, WITH A REDDENED AREA AROUND IT MEASURING 7 INCHES IN LENGTH, AND 2.5 INCHES IN WIDTH. AN IRREGULAR SHAPED SECOND DEGREE BURN WAS ON THE RIGHT OUTER HIP AREA AND WAS MEASURED TO BE 10.5 INCHES IN LENGTH AND 8 INCHES IN WIDTH, WITH A REDDEN AREA AROUND THE MIDDLE OF THE BURN MEASURING 11 INCHES IN LENGTH AND 5 INCHES IN WIDTH, AND A REDDENED AREA AT THE TOP OF THE BURN, NEAREST THE ABDOMEN WAS 8 INCHES IN LENGTH AND 8 INCHES IN WIDTH. BOTH OF THE BURNS HAD RED EDGES, AND WERE LIGHT YELLOW IN THE MIDDLE WITH DARK PINK COLOR UNDERNEATH THE YELLOW. THE HIP BURN ALSO AND HAD 2 SMALL BLISTERS APPROXIMATELY 1 INCH IN DIAMETER EACH AT THE TOP LEFT SIDE OF THE BURN, NEAREST THE ABDOMEN. AN INTERVIEW WAS DONE ON 1/10/11 AT 9:20 A.M., WITH RESIDENT #500'S ROOMMATE. REVIEW OF THE MDS dated [DATE], REVEALED THE ROOMMATE WAS ALERT AND ABLE TO MAKE HER SELF UNDERSTOOD. THE ROOMMATE STATED "I WAS COMING OUT OF THE BATHROOM (ON 1/2/11), AND I HEARD HER (RESIDENT #500) SCREAM, I YELLED FOR HELP AND THEN THEY (STAFF) CAME IN. HER HUSBAND CAME IN AFTER SHE SPILLED HER COFFEE". AN INTERVIEW WAS DONE ON 1/5/11 (AT 12:15 P.M.) AND ON 1/6/11 (AT 9:00 A.M.), WITH CNA #1 (ON 1/2/11, A NURSING ASSISTANT ASSIGNED TO THE UNIT THE RESIDENT WAS ON). CNA #1 STATED "I HAVE BEEN CARING FOR THE RESIDENT (RESIDENT #500) FOR 1 YEAR, HER HUSBAND IS ALWAYS HERE IN THE MORNING, THAT DAY (1/2/11) HE WAS LATE. SHE GOT THE COFFEE FIRST BEFORE THE TRAY THAT DAY. ALL THE PATIENTS EAT (BREAKFAST) IN THEIR BEDS BECAUSE THERE'S NO TIME TO GET THEM UP. THE TRAYS COME BETWEEN 7:20 A.M., AND 7:30 A.M. (FIRST SHIFT STARTS AT 7:00 A.M.). SHE WAS SITTING UP IN BED, SHE WAS CONFUSED, SHE IS ALWAYS CONFUSED. I GAVE HER THE COFFEE ABOUT 7:30 A.M., THEN I PASSED OUT TRAYS TO RESIDENTS. I WALKED BY HER ROOM AND (THE RESIDENT'S ROOMMATE) CALLED ME BACK IN ABOUT 7:45 A.M., SHE WAS YELLING WE NEED HELP. I SAW HER SITTING UP AND THE COFFEE WAS SPILLED ON HER GOWN AND HER SHEET AND UNDER HER DEPENDS. I TOOK OFF THE SHEET AND GOWN, WHEN I PULLED HER GOWN UP, I SAW A RED MARK ON HER STOMACH, A SMALL ONE. THEN I TOOK OFF THE SHEET AND GOWN. HER SKIN DID COME OFF WHEN I LIFTED HER SHEET (SKIN CAME OFF OF THE HIP BURN). I OPENED HER BRIEF AND SAW HER STOMACH AND UPPER THIGH WAS RED. THERE WAS A BIG MARK ON RIGHT HIP. I WENT AND GOT THE NURSE (NURSE #2, ON 1/2/11, ASSIGNED TO THE UNIT THE RESIDENT WAS ON). THE WHOLE CUP OF COFFEE WAS SPILLED IN THE BED. IT STARTED TO BLISTER IN 30 MINUTES WE HAD 3 AIDES (CNA'S WORKING ON 1/2/11, FIRST FLOOR), WE ARE SUPPOSE TO HAVE 4 TO 5, IT WAS BUSY, VERY DEMANDING, NO ONE CALLED ANYONE IN. (THE DIRECTOR OF NURSING, DON) CUT STAFF, WE HAVE TRIED TO TELL HER WE NEED MORE HELP, AND SHE WILL SAY 'I DON'T WANT TO HEAR IT'. WE EVEN TALKED TO THE ADMINISTRATOR ABOUT 2 MONTHS AGO; HE SAID 'IT'S THE BUDGET'. REVIEW OF THE WRITTEN STATEMENT SIGNED BY CNA #1 DATED 1/10/11, STATED "PASSED COFFEE TO (RESIDENT #500), LEFT OUT TO CONTINUE TO PASS TRAYS. PASSING ROOM AND HEARD (ROOMMATE) CALL OUT. OBSERVED THAT (RESIDENT #500) HAD SPILT COFFEE. I TOOK OFF THE SHEETS AND GOWN. THERE WERE NO OTHER VISITORS OR STAFF TO WITNESS THE SPILL. WHEN I PULLED BACK THE SHEETS SOME OF THE SKIN CAME OFF WITH THE SHEETS. EVERY RESIDENT EATS IN THEIR ROOM FOR BREAKFAST. (RESIDENT #500) STATED HER HAND STARTED SHAKING". AN INTERVIEW WAS DONE 1/6/11 AT 10:10 A.M., WITH CNA #2 (ON 2/1/11, ASSIGNED TO THE UNIT RESIDENT #500 WAS ON). CNA #2 STATED "(THE ROOMMATE) SAID THIS LADY NEEDS HELP. (CNA #1) AND I WENT IN. SHE (RESIDENT #500) SEEMED MORE CONFUSED, SHE HAD A FACIAL EXPRESSION OF PAIN, BUT SHE COULDN'T FIGURE IT OUT. IF I WOULD OF GIVEN HER COFFEE THAT MORNING (1/2/11), I WOULD OF GIVEN HER HALF A CUP WITH A STRAW. SHE EATS REAL SLOW. ON 1/2/11, THE NURSES TOLD US TO KEEP AN EYE ON HER, SHE MAY NEED HELP. IF SHE IS IN A DAZE WE GO IN THERE AND HELP HER. IT COULD OF BEEN PREVENTED". AN INTERVIEW WAS DONE ON 1/5/11 (AT 1:10 P.M.) AND ON 1/10/11 (AT 9:25 A.M.), WITH NURSE #2 (ON 1/2/11, ASSIGNED TO THE UNIT RESIDENT #500 WAS ON). NURSE #2 STATED "I WAS HER NURSE ON 1/2/11, (CNA #1) NOTICED COFFEE ON HER BLANKET AND CAME AND TOLD ME AND WE WENT AND LOOKED AT IT. THE HUSBAND CAME AFTER COFFEE SPILLED; HE NOTICED THAT SHE HAD SPILLED HER COFFEE BECAUSE IT WAS ON HER BEDDING. ABOUT 8:30 A.M. I CALLED THE DOCTOR; I PUT ICE AND SILVADENE AND A LIGHT DRESSING, GAUZE ON IT. I USED ANOTHER RESIDENTS WHO HAD SILVADENE ORDERED. IT WAS RED AT 8:30 A.M., AND ABOUT A HALF AN HOUR LATER IT STARTED TO BLISTER. NURSE #2 REVEALED RESIDENT #500 WAS SERVED HER COFFEE ON 1/2/11, IN A REGULAR, ONE HANDLE COFFEE CUP WITHOUT A LID. NURSE #2 STATED "SHE DIDN'T HAVE A SIPPY CUP (A CUP WITH A LID AND 2 HANDLES) FOR LUNCH (ON 1/2/11); I WOULD NOT KNOW WHERE TO GET ONE. SHE HAD COFFEE FOR LUNCH IN A REGULAR COFFEE CUP WITH NO LID; SHE GOT THE LID ON IT AFTER YOU (THE SURVEYOR) CAME IN. SHE DENIED PAIN BUT SHE IS CONFUSED. SHE DOESN'T SIT UP FOR TOO LONG, SHE GETS SO TIRED". AN INTERVIEW WAS DONE ON 1/10/11 AT 9:40 A.M., WITH THE ASSISTANT DIRECTOR OF NURSING (ADON). THE ADON REVEALED SHE WAS THE ON-CALL SUPERVISOR FROM 1/1/11 AND 1/2/11, AND NURSE #1 CALLED HER AT HOME ON 1/2/11, AND INFORMED HER OF RESIDENT #500'S BURN. THE ADON STATED "I DID NOT TELL THEM TO GET HER A CUP WITH A LID, I DID NOT THINK OF IT". REVIEW OF THE PHYSICIAN ORDERS [REDACTED]. REVIEW OF THE MEDICATION ADMINISTRATION RECORD DATED 1/11, REVEALED DOCUMENTATION THAT RESIDENT #500 RECEIVED BENADRYL ON 1/2/11 AT 6:00 A.M. (APPROXIMATELY 1 1/2 HOURS PRIOR TO RECEIVING HOT COFFEE). BENADRYL MAY CAUSE SEDATION, OR SLEEPINESS. DRUG INFORMATION HANDBOOK FOR NURSING, TURKOSKI, LANCE, BONFIGLLO, 2007. INTERVIEWS WERE DONE ON 1/5/11 (AT 8:40 A.M.), ON 1/6/11 (AT 8:00 A.M.) AND ON 1/10/11 (AT 9:05), WITH FAMILY MEMBERS #1 AND #3. FAMILY MEMBER #1 STATED "IT WAS ABOUT 10 (MINUTES) TO 8 ON SUNDAY (1/2/11). HER (RESIDENT #500) BREAKFAST TRAY WAS THERE WHEN I GOT THERE. NOTHING WAS ON HER BUT A DIAPER, THE BLANKET WAS WADDED-UP AT THE END OF THE BED WET. HER ROOMMATE TOLD ME SHE SPILLED HER COFFEE. HER DIAPER HELD THE COFFEE IN. THE AIDE (CNA #1) KNEW SHE SPILLED THE COFFEE. THE AIDE HAD GONE TO GET A BLANKET. I LEFT AROUND 8:45 A.M. THAT MORNING, I DID NOT SEE THE NURSE (NURSE #2) COME IN BEFORE I LEFT. NO ONE TOLD ME ANYTHING ABOUT THE BURN UNTIL 2:00 P.M., (NURSE #2) CALLED ME AT 2:00 P.M. AND TOLD ME (RESIDENT #500) HAD BEEN BURNED AND THERE WAS SOME BLISTERING. NO ONE TALKED TO ME ABOUT IT AFTER THAT. THE DIETITIAN (DIETARY MANAGER) TOLD ME (ON 1/3/11) THE COFFEE WAS 165 (DEGREES FAHRENHEIT) WHEN IT LEFT THE KITCHEN (ON 1/2/11) AND 140 WHEN IT GOT TO HER. I DON'T KNOW HOW SHE KNEW IT WAS 140". FAMILY MEMBER #1 REVEALED HE IS AT THE FACILITY EVERY DAY TO ASSIST RESIDENT #500 TO EAT HER BREAKFAST (BETWEEN 7:30 A.M., AND 8:00 A.M.), AND HE DENIED EVER SEEING STAFF TAKE THE TEMPERATURE OF THE COFFEE ON THE UNIT. ON THE (1/2/11) WHEN I GOT IN HERE, ANYTHING SHE DRANK I HELD FOR HER. SHE HAS BEEN HAVING THE TREMORS (SHAKING) ON AND OFF. THEY BRING HER TRAY AND LEAVE (AT BREAKFAST). FAMILY MEMBER #3 STATED "SHE SHAKES NOW AFTER HER PNEUMONIA, SHE HAS BEEN SHAKING, EVEN HER FOOT SHAKES. SHE WOULD REACH FOR HER COFFEE AND SHE WOULD SLIDE IT OFF THE TABLE AT DINNER (IN THE DINING ROOM). WE SIT BY HER, WE FEED HER NOT THE STAFF". A PHONE INTERVIEW WAS DONE ON 1/19/11 AT 5:50 P.M., WITH NURSE #5 (A SECOND SHIFT NURSE). NURSE #5 STATED "SHE (RESIDENT #500) MUMBLES, SHE WAS CONFUSED ON AND OFF (PRIOR TO 1/2/11). IF SHE WAS NOT EATING, WE (STAFF) WOULD TRY TO ENCOURAGE HER. A LOT OF THE TIME HER FAMILY WILL COME IN TO HELP FEED". REVIEW OF THE FACILITY DIETARY TEMP LOG DATED JANUARY 2011, REVEALED ON 1/2/11, THE COFFEE WAS "169" DEGREES FAHRENHEIT. ON 1/6/11, THE SURVEYOR REQUESTED DOCUMENTATION FROM THE DIETARY MANAGER OF THE TEMPERATURE OF THE COFFEE ON 1/2/11, ON THE NURSING UNIT. THERE WAS NO DOCUMENTATION AVAILABLE. REVIEW OF THE DEPARTMENT OF COMMUNITY HEALTH ALERT ON SCALDING INJURIES CAUSED BY EXCESSIVE HOT WATER, FOOD AND HOT BEVERAGE TEMPERATURES DATED 11/3/06; REVEALED WATER TEMPERATURE OF 150 DEGREES FAHRENHEIT TAKES LESS THEN 1 SECOND TO RECEIVE A SECOND DEGREE BURN. REVIEW OF NURSES NOTES DATED 12/23/10 (NO TIME) REVEALED RESIDENT #500 WAS A TOTAL ASSIST FOR BREAKFAST, LUNCH AND DINNER, AND STATED "RESIDENT ALERT TODAY BUT NOT EATING, HAD TO BE FED". REVIEW OF NURSES NOTES DATED 12/26/10 AT 6:00 P.M., STATED "ATTEMPTED TO FEED BY THIS NURSE, ATE POOR". REVIEW OF THE NURSE'S NOTE DATED 12/29/10 REVEALED RESIDENT #500 WAS ASSISTED BY STAFF TO EAT DINNER. REVIEW OF THE CARE PLAN FOR "INFREQUENT EPISODES OF HAND SHAKING DATED 1/2/11, REVEALED NO DOCUMENTATION OF A DISCONTINUED OR RESOLVED DATE, AND STATED "STAFF WILL PROVIDE ASSIST WITH MEALS AND BEVERAGES PRN (AS NEEDED)". A SECOND INTERVIEW WAS DONE ON 1/10/11 AT 7:55 A.M., WITH CNA #1. CNA #1 STATED "WHEN WE GO IN THERE, THE HUSBAND WILL LET US KNOW IF SHE NEEDS TO BE FED". WHEN ASKED, HOW DID SHE KNEW RESIDENT #500 DID NOT NEED TO BE FED OR ASSISTED WITH HER COFFEE ON THE MORNING OF 1/2/11, CNA #1 STATED "BECAUSE SHE SAID GOOD MORNING TO ME, AND SHE SAID SHE WANTED HER COFFEE". CNA #1 REVEALED SHE HAD NOT BEEN INSTRUCTED OR IN-SERVICED BY THE FACILITY ON HOW TO ASSESS IF RESIDENT #500 NEEDED ASSISTANCE WITH HER MEALS OR BEVERAGES. REVIEW OF RESIDENT #500'S CNA RESIDENT INFORMATION SHEET (UNDATED), REVEALED NO GUIDANCE OR INSTRUCTIONS ON HOW TO ASSESS IF RESIDENT #500 NEEDED ASSISTANCE WITH HER MEALS AND/OR BEVERAGES, AND NO DOCUMENTATION WAS FOUND INSTRUCTING STAFF TO ASSIST RESIDENT #500 WITH HER MEALS AS NEEDED. OBSERVATIONS WERE MADE ON 1/5/11, 1/6/11, AND 1/10/11 BETWEEN 7:30 A.M. AND 9:00 A.M., OF FIRST AND SECOND FLOOR RESIDENTS. ALL RESIDENT'S WERE OBSERVED EATING IN THEIR ROOMS, NOT EATING AT ALL, OR IN THE HALLWAYS. THE DINING ROOMS ON BOTH FLOORS HAD THE MAIN LIGHTS TURNED OFF, NO FACILITY RESIDENT WAS OBSERVED EATING BREAKFAST IN A DINING ROOM. AN INTERVIEW WAS DONE ON 1/10/11 AT 8:20 A.M., WITH THE DIRECTOR OF NURSING (DON). THE DON STATED "RESIDENTS EAT IN THEIR ROOMS BECAUSE IT'S THEIR PREFERENCE". UPON REQUEST, THE DON WAS UNABLE TO LOCATE DOCUMENTATION IN RESIDENT #500'S CLINICAL RECORD OF HER OR HER POWER OF ATTORNEYS (POA) PREFERENCE FOR EATING LOCATIONS. ON 1/10/11 THE DON GAVE THE SURVEYOR A COPY OF THE CNA RESIDENT INFORMATION SHEET (CARE GUIDE) FOR RESIDENT #500. REVIEW OF RESIDENT #500 INFORMATION SHEET STATED "PREFERS BREAKFAST IN ROOM" WITH NO DATE WRITTEN NEXT TO IT. REVIEW OF SAME RESIDENT INFORMATION SHEET OBTAINED BY THE SURVEYOR ON 1/5/11, REVEALED NO DOCUMENTATION OF RESIDENT #500 PREFERENCE FOR EATING LOCATIONS ANYWHERE ON IT. DURING AN INTERVIEW DONE ON 1/11/11 AT 8:00 A.M., FAMILY MEMBER #1 STATED "NO WAY, NO ONE ASKED ME ANYTHING (REGARDING WHERE RESIDENT #500 WANTED TO EAT BREAKFAST)". AN INTERVIEW WAS DONE ON 1/6/11 AT 2:15 P.M., WITH THERAPIST #1. THERAPIST #1 STATED "DIFFERENT DAYS SHE (RESIDENT #500) ACTS DIFFERENTLY, TODAY (1/6/11, DURING BREAKFAST) SHE WAS IN LA LA LAND. I AM TRYING TO TEACH HER TO BRING HER HEAD BACK AND TIP THE CUP TO HER MOUTH. YOU HAVE TO INSTRUCT HER EACH TIME". AN INTERVIEW WAS DONE ON 1/10/11 AT 9:50 A.M., WITH THERAPIST #2. THERAPIST #2 REVEALED ON 1/4/11, SHE SCREENED RESIDENT #500 TO ASSESS HER NEEDS IN HANDLING A CUP SAFELY. THERAPIST #2 STATED "I DID HER SCREEN ON THE 4 TH, AROUND 7:30 A.M. I WENT TO THE KITCHEN ON THE 4TH WITH (DIETARY MANAGER) TO GET A SIPPY CUP, (A 2 HANDLED CUP WITH A LID) WITH THE SIPPY CUP SHE NEEDED MORE CUEING ON ARMS AND HEAD BACK, WE SWITCHED HER TO A SPOUT CUP (A CUP WITH A LID ON, WITHOUT HANDLES). (RESIDENT #500) HAS SENILE DEMENTIA, THERE IS MORE SEQUENCING INVOLVED WHEN USING A 2 HANDLED CUP. THE THERAPIST DENIED BEING AWARE OF A FACILITY POLICY FOR SCREENING RESIDENTS FOR SAFE HANDLING OF CUPS, OR FOR THE ABILITY TO SAFELY HANDLE HOT LIQUIDS. A PHONE INTERVIEW WAS DONE ON 1/21/11, WITH THERAPIST #3. THERAPIST #3 STATED "WE ALWAYS HAD AN ISSUE WITH HER (RESIDENT #500) SAFETY BECAUSE OF HER CONFUSION". ON 1/5/11 AT 9:30 A.M., WHEN THE SURVEYOR REQUESTED THE FACILITY POLICY FOR EVALUATING RESIDENTS FOR SAFE HANDLING OF HOT LIQUIDS, OR EVALUATING RESIDENTS FOR HANDLING CUPS, THE DON STATED "WE DON'T HAVE ONE". ON 1/5/11 AT 9:20 A.M., THE DIETARY MANAGER CONFIRMED THE FACILITY DID NOT HAVE A POLICY FOR EVALUATING RESIDENTS FOR HOT BEVERAGES OR HANDLING CUPS. REVIEW OF RESIDENT #500'S ADL (ACTIVITIES OF DAILY LIVING) EVALUATION FORM FOR ADAPTIVE EQUIPMENT SIGNED BY NURSE #1 DATED 1/4/11, STATED "RESIDENT COULD BENEFIT FROM USE OF NOSEY CUP (A CUP WITH A CUT-OUT FOR THE NOSE)". AN INTERVIEW WAS DONE ON 1/12/11 AT 11:50 A.M., WITH NURSE #1. NURSE #1 REVEALED SHE SCREENED RESIDENTS FOR HANDLING HOT BEVERAGES AND CUPS ON TUESDAY (1/4/11), BECAUSE SHE HAD MONDAY (1/3/11) OFF. NURSE #1 REVEALED THIS WAS THE FIRST TIME THE FACILITY EVER SCREENED ALL THE RESIDENTS FOR SAFE HANDLING OF HOT LIQUIDS OR CUP USE, AND SHE SCREENED THE RESIDENTS DUE TO RESIDENT #500'S SPILL ON 1/2/11. AN INTERVIEW WAS DONE ON 1/5/11 AT 9:25 A.M., WITH THE DIETARY COOK #1 (ASSIGNED IN THE KITCHEN ON 1/2/11). COOK #1 STATED "I WAS HERE ON SUNDAY (1/2/11) WHEN SHE (RESIDENT #500) GOT BURNED. WE (DIETARY STAFF) TOOK IT (COFFEE) OUT OF THE SILVER POT (COFFEE MAKER/URN) AND TEMPED IT. THE TEMPERATURE WAS 178, THAT'S THE USUAL. WE POUR SOME COFFEE FROM THE URN INTO THE POT USED FOR COFFEE, THEN WE TEMP. IT, BEFORE BREAKFAST, LUNCH AND DINNER, WE USE A DIGITAL THERMOMETER. WE PUT THE COFFEE ON A CART AND THE CART GOES BY THE NURSE'S STATION AND THE AIDE (CNA) POURS THE COFFEE. THEY DIDN'T TEMP ON THE FLOOR (THE UNITS) BEFORE THIS HAPPENED; NOW THE RD (REGISTERED DIETITIAN) TEMPS IT. I DON'T KNOW IF WE HAVE AN ACTUAL POLICY ON IT, I DON'T KNOW WHERE THE POLICY IS, I DON'T HAVE ONE IN THE KITCHEN. THERE'S NOT A SIGN OR POLICY IN THE KITCHEN (REGARDING TEMPS, OR TEMPING OF HOT BEVERAGES/FOODS). WE JUST VERBALLY TELL PEOPLE HOW TO TEMP., WHO EVER IS TRAINING (DIETARY AIDE) THAT DAY DOES THE ORIENTATION TRAINING ON TEMPING. I HAVE BEEN HERE [AGE] years". OBSERVATION OF DIETARY STAFF TEMPING COFFEE WAS DONE ON 1/5/11 AT 8:55 A.M., IN THE FACILITY KITCHEN. COOK #1 WAS UNABLE TO LOCATE A POLICY ON THE TEMPING HOT BEVERAGES OR FOODS IN THE ADMINISTRATIVE MANUAL OF CLINICAL DIETETICS MANUAL OR THE NUTRITION SERVICES POLICY BOOK, BOTH FOUND IN THE KITCHEN. COOK #1 STATED "I HAVE NEVER SEEN THESE BOOKS BEFORE. WE DON'T KEEP ANY POLICY BOOKS IN HERE, THEY ARE KEPT IN THE DIETARY OFFICE. THE OFFICE IS CLOSED AT 4:30 P.M., AND THE DOOR IS LOCKED. WE (DIETARY STAFF ON 1/2/11) WERE NOT TOLD SHE (RESIDENT #500) GOT BURNED UNTIL LUNCH. THEY SAID SOMEONE SPILLED THEIR COFFEE, THEY DIDN'T SAY WHO IT WAS". ON 1/5/11 AT 10:35 A.M., WHILE OBSERVING THE TEMP TAKEN ON THE COFFEE, THE YELLOW DIGITAL THERMOMETER SHUT OFF COMPLETELY, AND COOK #1 HAD TO STOP, AND TURN IT BACK ON TO FINISH TEMPING THE COFFEE. DURING AN INTERVIEW WITH THE DIETARY MANAGER ON 1/6/11 AT 12:45 P.M., WHEN THE SURVEYOR INFORMED HER THAT THE YELLOW DIGITAL THERMOMETER SHUT OFF IN THE MIDDLE OF TEMPING COFFEE, SHE STATED "WE DON'T USUALLY USE THAT THERMOMETER, WE USE A DIFFERENT ONE". DURING AN INTERVIEW WITH FAMILY MEMBERS #1 AND #3 ON 1/11/11 AT 8:15 A.M., FAMILY MEMBER #1 STATED "THE ADMINISTRATOR CALLED ME AT 5:00 P.M. LAST NIGHT (ON 1/10/11), HE SWITCHED ON SPEAKER PHONE, HE DIDN'T TELL ME, IT ECHOED. HE WANTED TO KNOW IF I WAS IN THE ROOM WHEN SHE (RESIDENT #500) SPILLED HER COFFEE. HE SAID HIS INITIAL REPORT WAS THAT I WAS IN THE ROOM, I SAID I WAS NOT. HE ASKED ME IF SHE WAS IN PAIN AND I TOLD HIM SHE WAS. HE ASKED ME SEVERAL TIMES, HE WANTED ME TO CHANGE MY STATEMENT, BUT I WOULDN'T. THIS IS THE FIRST TIME I EVER TALKED TO HIM. AT 2:00 P.M., (NURSE #2) CALLED ME. NO ONE CAME IN WHILE I WAS HERE; I STAYED UNTIL 9:00 A.M. (ON 1/2/11). IF I DON'T COME IN SHE WOULD GET BURNED, AND SHE DID. FAMILY MEMBER #3 STATED "SATURDAY NIGHT (1/8/11), THE NURSE FED MY MOTHER AND HAD TO STOP. WHEN THE NURSE ASKED AN AIDE TO FEED HER, THE AIDE NEVER CAME BACK". FAMILY MEMBER #1 AND #3, REVEALED NO ONE FROM THE FACILITY CONTACTED THEM OR TALKED TO THEM AFTER THE INCIDENT OR DURING THE INVESTIGATION. REVIEW OF THE WRITTEN STATEMENT DATED 1/12/11, SIGNED BY FAMILY MEMBER #1 STATED "ON 1/2/11, I CAME INTO (RESIDENT #500'S) ROOM AT THE FACILITY AFTER SHE HAD SPILLED HER COFFEE ON HERSELF. (RESIDENT #500) SAID IT DID HURT HER, IT BURNED HER". AN INTERVIEW WAS DONE ON 1/10/11 AT 10:45 A.M., WITH RESIDENT #500'S PRIMARY PHYSICIAN. THE PHYSICIAN REVEALED RESIDENT #500 RECEIVED A SECOND DEGREE BURN AND STATED "I THINK IT'S HER DEMENTIA, SOMETIMES SHE KNOWS IT HURTS". A SECOND INTERVIEW WAS DONE ON 1/12/11 AT 7:40 A.M., WITH NURSE #2. NURSE #2 STATED "WHEN I CALLED HIM (RESIDENT #500'S HUSBAND ON 1/2/11) I CAN'T BE REAL CERTAIN ON THE TIME. I CAN'T BE CERTAIN ON THE TIME HE ENTERED THE ROOM, I WAS BUSY WITH MY MED PASS. I CHARTED EVERYTHING AT ONE TIME (BLOCK CHARTING)". REVIEW OF THE FACILITY ABUSE PREVENTION PROGRAM OVERVIEW DATED 2/05, STATED "NEGLECT, FAILURE TO PROVIDE GOODS AND SERVICES NECESSARY TO AVOID PHYSICAL HARM, MENTAL ANGUISH, OR MENTAL ILLNESS. TRAINING WILL INCLUDE HOW TO PROVIDE PROTECTION FOR RESIDENTS. IDENTIFY, CORRECT, AND INTERVENE IN SITUATIONS WHERE ABUSE, NEGLECT AND/OR MISTREATMENT ARE MOST LIKELY TO OCCUR". ON 1/5/11 AT 11:15 A.M., THE ADMINISTRATOR STATED TO THE SURVEYOR, "WE DON'T FEEL THERE WAS ANY DEFICIENT PRACTICE HERE". RESIDENT #500 WAS ASSESSED BY THE FACILITY ON 8/27/10, TO HAVE FLUCTUATIONS IN HER COGNITIVE ABILITIES AND SHE BECAME CONFUSED AT TIMES. RESIDENT #500 WAS ASSESSED ON 9/17/10 AND 9/21/10, TO HAVE LANGUAGE AND COGNITIVE IMPAIRMENTS, ON 9/27/10, TO HAVE DECREASED SAFETY AWARENESS, AND ON 9/12/10, TO HAVE PERIODS OF CONFUSION, REQUIRING CUEING FROM STAFF. ON 1/2/11 AT 7:30 A.M., RESIDENT #500 WAS LEFT ALONE SITTING IN HER BED WITH HOT COFFEE IN A REGULAR ONE HANDLED COFFEE CUP WITHOUT A LID. RESIDENT #500'S HAND STARTED SHAKING AND SHE DROPPED HER COFFEE CUP, SPILLING THE HOT COFFEE ON HER ABDOMEN AND RIGHT HIP. RESIDENT #500 SUSTAINED TWO SECOND DEGREE BURNS, ONE SMALL ONE ON HER ABDOMEN AND ONE LARGE ONE ON HER RIGHT OUTER HIP AREA. RESIDENT #500 WAS NOT ASSESSED BY THE FACILITY FOR HER ABILITY TO BE LEFT UNSUPERVISED WITH HOT LIQUIDS USING A REGULAR COFFEE CUP WITHOUT A LID PRIOR TO BEING BURNED ON 1/2/11. THE COFFEE WAS DOCUMENTED BY STAFF TO BE 169 DEGREES WHEN IT LEFT THE KITCHEN ON 1/2/11. RESIDENT #500 WAS LEFT UNSUPERVISED WITH HOT COFFEE IN A REGULAR CUP WITH NO LID, PUTTING HER IN DANGER OF SERIOUS INJURY. ON 1/10/11 AT 2:07 P.M., NOTIFICATION OF IMMEDIATE JEOPARDY WAS GIVEN TO THE ADMINISTRATOR THAT BEGAN ON 1/2/11 AT 8:30 A.M., AS A RESULT OF THE FACILITY'S FAILURE TO PREVENT BURNS AND ENSURE THE SAFETY OF RESIDENT #500, WHO SUSTAINED TWO SECOND DEGREE BURNS FROM HOT COFFEE, AND PLACING 16 ADDITIONAL RESIDENT'S ASSESSED TO NEED ADAPTIVE EQUIPMENT AT HIGH RISK FOR SERIOUS HARM. ON 1/12/11, THE SURVEYOR CONFIRMED THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY. 1. ON 1/3/11, RESIDENT #500 WAS PROVIDED WITH A TWO-HANDLED SIPPY CUP. 2. ON 1/4/11 AN EVALUATION WAS COMPLETED BY OCCUPATIONAL THERAPY, ORDERS WERE OBTAINED FOR THERAPY, AND RESIDENT #500 RECEIVED A SPOUT CUP. 3. ON 1/11/11, RESIDENT #500 ORDERS WERE TO BE TREATED BY OCCUPATIONAL THERAPY FOR 6 VISITS IN 2 WEEKS, FOR TRAINING IN USE OF AN INSULATED CUP. 4. IN-SERVICES ON HOT BEVERAGES AND SERVING TEMPERATURES WERE DONE 1/4/11 THROUGH 1/10/11, FOR 122 OUT OF 126 STAFF. THE REMAINING 4 STAFF WERE MAILED THE IN-SERVICE ON 1/12/11, AND WILL BE IN-SERVICED BY THE DON AND ADON WHEN THEY RETURN TO WORK. 5. ON 1/3/11, ALL RESIDENTS (102) WERE OBSERVED BY NURSING TO IDENTIFY PROBLEMS WITH MANAGING HOT BEVERAGES, AND 24 RESIDENTS WERE REFERRED TO THERAPY. DOCUMENTATION REVEALED RESIDENTS ON FIRST FLOOR WERE OBSERVED BY NURSING TO IDENTIFY PROBLEMS WITH MANAGING HOT BEVERAGES ON 1/4/11. 6. ON 1/2/11, 1/3/11, AND 1/4/11, RESIDENT #500'S CARE PLANS WERE UP-DATED. 7. ON 1/3/11, RESIDENTS CARE PLANS WERE UP-DATED FOR RESIDENTS WHO WERE IDENTIFIED AS NEEDING ADAPTIVE CUPS. 8. ON 1/3/11, 24 RESIDENT'S WERE IDENTIFIED TO HAVE DIFFICULTY WITH THE MANAGEMENT OF HOT BEVERAGES AND WERE REFERRED TO THERAPY. ON 1/7/11, THERAPY SCREENED 24 RESIDENTS FOR POSSIBLE INTERVENTIONS AND ON 1/10/11, EVALUATED 4 RESIDENTS FOR FURTHER INTERVENTIONS. THE INTERDISCIPLINARY TEAM WILL BE ADVISED OF THE RESULTS FOR FURTHER INTERVENTIONS, AND CARE PLANS WILL BE UP-DATED AS NEEDED. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED ON 1/4/11, THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF A PATTERN AND SEVERITY OF ACTUAL HARM THAT IS NOT IMMEDIATE JEOPARDY DUE TO SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY. ( )