Every finding on record at Fountain Bleu Health and Rehabilitation Center

Based on interview, and record review, the facility failed to complete wound care treatments for one resident (R108) out of three residents reviewed for pressure ulcers. Findings Include: This citation pertains to Intake number 3093315.A review of the electronic medical record (EMR) revealed R108 was admitted to the facility on [DATE] with medical diagnoses which included Fracture of Left Tibia (shin bone). A review of R108's MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS score (brief interview of mental status) assessment score of 15/15 indicating intact cognition. Further review of the EMR revealed an admission nurses note on 6/1/2026 documenting the following, Resident admitted to the facility from the hospital with a diagnosis of left tibia fracture. Resident alert and oriented to person, place, and time. Left lower extremity noted an immobilizer (a rigid device used to keep body part straight and still), which was intact and properly positioned. Resident reported intermittent pain to the left leg, rated 2/10 (pain assessment scoring, 1 being the least and 10 being the worse pain), and denied numbness or tingling. Skin around visible areas of the immobilizer warm, dry, and intact with no redness or breakdown.On 8/20/26 at 10:30 AM, an interview with the Wound Care Nurse (Staff C) occurred discussing R108. Staff C confirmed they were notified by a therapy staff member on 6/22/26 that R108 had a moist, open area to the skin on their left calf. Staff C stated the area was assessed, treated, and the physician was notified, ordering a new treatment.A review of R108's wound care note dated 6/22/26 revealed the area on the left calf was noted to be an in-house acquired abrasion on the left lateral calf with the following measurements: length 4.42 centimeters (cm) x width 3.83 cm and area 12.76 cm.Further review of R108's EMR reveal a 6/24/26 wound care note authored by the Nurse Practitioner (NP-Staff E) indicating, staff stated patient developed a wound on their left (calf) leg due to an immobilizer brace. Treatment ordered-Apply medihoney (ointment for wound healing), cover with dry dressing change daily.Review of R108's June (2026) Treatment Administration Record (TAR) dated 6/22/26 through 6/30/26, revealed the following treatments were not signed out as being completed (blank spaces) on 6/25/26, 6/26/26 and 6/28/26. Further review of R108's TAR for July (2026) revealed treatments were not signed out as being provided on 7/1/26 and 7/4/26.On 8/20/26 at 10:40 AM, Staff C was queried about the blank spaces on R108's Treatment Administration Records (TARs) to which they were not able to say why the treatments were not signed out as being provided. On 08/20/26 at 11:30 AM, the Director of Nursing (DON) was interviewed and queried about R108 and the incomplete treatment records for the wound on R108. The DON acknowledged the treatment record had blank holes and was unable to give a reason to why the treatments were not completed. A review of the facility's Skin and Wound Guidelines policy was reviewed and revealed the following, Policy Overview: To describe the process steps required for identification of residents at risk for the development of pressure injuries, identify prevention techniques and interventions to assist with the management of pressure injuries and skin alterations.

This citation pertains to Intake Number: 2626257 Based on interview and record review, the facility failed to ensure the safety of one sampled resident (R701) of two residents reviewed for falls resulting in hospitalization. Findings include:Review of the R701's electronic medical record (EMR) revealed that R701 was admitted to facility on 8/25/25 with diagnoses including cerebral infarction, hypertension and dysphagia. A review of the most recent Minimum Data Set assessment (MDS) dated [DATE] indicated R701 required maximum assistance with all activities of living. Further review of R701's care plan indicated that two-person assistance was needed with bed mobility. Review of an Incident/Accident report (IA) was reviewed regarding an incident involving R701 and documented the following, Date of Incident: 9/22/25. Incident description: Resident observed to have fallen out of bed while being assisted by staff Location of Incident: Resident's room.Immediate action taken Resident immediately assessed and assisted back to bed. Resident complained of pain in right elbow and hitting head during fall. Sent to (name of local hospital) for further evaluation. Review of R701's Kardex (Summary of Patient's Care Plan) revealed R701 required two-person physical assistance for bed mobility and two-person physical assistance for incontinence brief change and/or bed pan use. On 12/03/25 at 10:15 AM, Licensed Practical Nurse (LPN) A was contacted by phone and queried about the incident involving R701. LPN A stated they were at their (medication) cart and heard a loud noise. Certified Nursing Assistant (CNA) B called for them and stated a resident had fallen. CNA B had been in the room changing the bed with R701 still in it when R701 rolled off and fell on the floor hitting their head, complained of pain in their elbow, and subsequently sent to the hospital. At 1:25 PM an interview occurred with Physical Therapy Assistant (PTA) D, querying why R701 needed assistance. PTA D stated R701 was a two-person transfer due to safety, lack of mobility and weakness. At 2:55 PM, CNA B was contacted by phone and queried about the incident involving R701. CNA B stated while rounding they noticed R701 needed to be changed. CNA B said, Unfortunately, they didn't notice the 'happy feet' (a program to inform how much staff assistance is needed) sign. CNA B confirmed R701 required two-person assistance and when they went in by themselves to change the bed R701 rolled off the bed onto the floor injuring their head and elbow. At 1:35 PM, the Nursing Home Administrator (NHA) was interviewed and queried about the incident involving R701. The NHA stated, We have completed an internal investigation of the incident. A facility policy titled Fall Management Guidelines Effective Date: 12.13.23 was reviewed and stated the following, Purpose: To provide guidelines to assist with fall risk identification and fall management of residents in the facility. The facility, with the input of the attending physician, will implement a resident -centered comprehensive care plan that addresses the fall management program, the goal for fall management, individualized interventions to address the resident's modifiable fall risk factors, interventions to try to minimize the consequences of risk factors that are not modifiable, and the plan for reduction of risk. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included: 1 On 9/22/25, (R701) was being having a brief changed by (CNA B) when (R701) was rolled on the left side and the (CNA B) pulled the sheets up from under the resident to center the resident. (R701) rolled to the floor. (R701) is a 2-person bed assist; CNA did not adhere to Kardex. (R701) was assessed by the nurse; (R701) stated their elbow was hurting. The physician was notified and was sent to the hospital via 911to be further evaluated due to being on blood thinners. Incident report was completed, family and physician both aware. (R701) was transferred to the hospital on 9/22/25 and will not be returning back to the building. Review of the care plan - 2 person assist with transfers. A. CNA B has been suspended on 9/23/25 leading to termination. B. Nursing staff will be educated 100% by 9/26/25 by DON or designee on ensuring to validate transfer status prior to transferring a resident and ensuring adequate supervision with transfers. C. Current residents will be audited by 9/26/25 to ensure transfer status is accurate and updated in the Kardex/care plan. D. Unit manager / designee will complete random audits to ensure residents are being transferred according to the Kardex/care plan on 3 residents three times a week for 6 weeks. any deficiencies will be corrected immediately. Results of all audits will be submitted to QA&A for trending and review. Administrator is responsible for maintaining compliance. Date of compliance is 9/26/25. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on observation, interview, and record review, the facility failed to ensure resident rooms had signage alerting of Enhance Barrier Precaution (EBP-precautions used to reduce the spread of infection for residents with medical devices or wounds) notices for two residents (R30 and R99) reviewed for infection control. Findings include:R30A review of R30's medical record revealed that R30 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Esophagitis. A review of R30's Minimum Data Set (MDS) assessment dated [DATE] noted, R30 with an intact cognition and required assistance to complete activities of daily living. R30's MDS noted, the presence of one stage three pressure ulcer (full-thickness skin loss, exposing the fatty tissue beneath) and one venous and arterial ulcer present. A review of the physician order revealed, Cleanse Right posterior lower leg open area with normal Saline, Pat Dry, Apply Xeroform gauze and Cover with ABD pad and Paper tape every day shift every Mon, Wed, Fri for wound care. Start Date: 8/15/25 - End Date: indefinite.On 9/08/2025 10:55 AM, and on 9/09/25 at 8:39 AM, R30's door was observed without a EBP sign posted. R30 was observed lying in bed watching TV.R99A review of R99's medical record noted, R99 was admitted to the facility on [DATE] with a diagnosis of Cerebral Infraction. A review of R99's MDS noted, R99 with an impaired cognition and required total assistance with activities of daily living. R99's MDS indicated, R99 had one unstageable pressure ulcer. Further review revealed, physician order: Cleanse Open area to Coccyx with Normal Saline, Pat Dry, Apply Medihoney to wound bed, then apply A Thin layer of Triad Cream to Dark discoloration to Surrounding tissue and Cover with ABD pad and Secure with Bordered Gauze dressing. every day shift for Wound care. Start Date: 8/26/25. - End Date: Indefinite.On 9/08/25 at 10:42 AM and 9/9/25 at 9:07 AM, R99's door was observed without a EBP sign posted. On both days R99 was observed in bed on a pressure reducing mattress. R99 could not be interviewed due to impaired cognition.On 9/09/2025 at 3:06 PM, the Director of Nursing (DON) was asked about the rooms. The DON returned and reported the resident's rooms should have EBP signage, due to the residents having wounds.

Based on observation, interview, and record review the facility failed to date medication when opened in two (400B and 500B) of four medication carts reviewed for medication storage. Findings include:On [DATE] at 10:04 AM, during review of the storage in medication cart 400B with Licensed Practical Nurse (LPN) B, Latanoprost Opthalmic Solution was observed with an open date of [DATE], expired 30 days beyond the opened date. Further review of the storage in medication cart 400B, Fluticasone/ Salmeterol Diskus, and two tubes of Biofreeze Topical Gel, was observed without opened dates.On [DATE] at 10:10 AM, LPN B was queried and revealed the Latanoprost should be discarded, and the other opened medications should have been dated when opened.On [DATE] at 10:15 AM, during review of the storage in medication cart 500B with LPN C, ProSource Plus was observed with an opened date of [DATE], expired 30 days beyond the opened date. Further review observed Milk of Magnesia with an opened date of [DATE], 30 days beyond the opened date.Further review of medication cart 500B revealed an open bottle of Nystatin Suspension and Deep Sea Nasal Spray without an opened date.On [DATE] at 1:45 PM, an interview with Infection Control Practitioner (ICP) A revealed medication should be discarded after 30 days from the opened date and all multi-use medications should be dated when opened. On [DATE] at 1:45 PM, an interview with the Director of Nursing (DON) revealed all multi-use medications should be dated when opened and should be discarded after 30 days from the opened date.A review of the policy, Medication and Treatment Storage' Last reviewed on [DATE], revealed the following: Multi-use vials will be dated when the vial is first accessed. If a multi-dose vial has been opened or accessed (e.g., needle-punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. If a multi-dose vial has not been opened or accessed, (e.g., needle-punctured), it should be discarded according to the manufacturer's expiration date.

This citation pertains to Intake MI00152110. Based on observation, interview, and record review, the facility failed to implement a fall intervention for one resident (R704) out of one reviewed for falls. Findings include: On 4/15/2025 at 10:24 AM, R704 was observed laying in bed. R704 was noted to have fall mats on the side and was in a low position. R704 stated they had no complaints about the care in the facility and were about to get some sleep because they were up all night. A review of the medical record revealed R704 was admitted into the facility on [DATE] with the following medical diagnoses, Cerebral Infarction and Muscle Weakness. A review of the Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 10/15 indicating an impaired cognition. R704 also required staff assistance with bed mobility and transfers. Further review of the Incident and Accident (I/As) for R704 noted they had falls on the following days within the last six months: 11/1/2024, 11/8/2024, 12/13/2024, 1/13/2025, 2/14/2025, and 3/23/2025. Further review of the fall care plan noted an intervention dated 5/15/2024 documented R704 was supposed to have a scoop/perimeter mattress. On 4/15/2025 at 12:15 PM, R704 was observed laying in bed, on a regular mattress. Registered Nurse (RN) A. RN A was shown the bed and confirmed that R704 was not on a scoop/perimeter mattress. RN A indicated when a resident needs a scoop/perimeter mattress, the restorative team usually writes the order and informs maintenance the mattress is needed. RN A indicated the mattress may be in the facility, or they may have to order it and then maintenance puts the mattress in place. On 4/15/2025 at 1:36 PM, an interview was conducted with the Director of Nursing (DON). The DON indicated R704 is supposed to have a scoop/perimeter mattress, and they are unsure why they do not have one. The DON reported R704 has had a lot of falls in the facility. The DON reported they were going to talk to maintenance and get a scoop/perimeter mattress on the bed. A review of a facility policy titled, Fall Risk/Injury Prevention noted the following, It is the policy of this facility to assess every resident for fall risk and provide an environment that is free from accident hazards over which the facility has control, and provides supervision and assistive devices to each resident to prevent avoidable accidents.

Based on observation, interview, and record review, the facility failed to ensure safety during a transfer for one sampled resident (R26) of six reviewed for accidents, resulting in a laceration to the head and emergency transfer to the hospital. Findings include: R26 On 8/13/24 at 10:06 AM, R26 was asked about the care at the facility. R26 stated, I had a really bad fall, the sling broke. R26 explained they had a fall during a transfer using the sit to stand lift. R26 was asked if they were hurt during that fall. R26 explained, they had a head injury. R26 was asked how many staff were with her to help with the transfer. R26 stated, It may have been one person. They don't want to ask for help Because they say they are short (staff). A review of the incident and accident report noted, Incident Description. Nursing Description: Writer called in the room at approximately 10:45 am. Writer entered room, resident lying flat on [R26's] back on the floor, with Aide (Certified Nursing Assistant), two nurses, and restorative aide present. Resident observed bleeding from the back of [their] head. Laceration observed. Unable to measure due to hair, bleeding, and unable to move resident for safety. 911 called for further evaluation. Resident Description: Resident alert and oriented x3 able to make needs known. Per resident, [they] was with Aide (CNA F) and being transferred from bed to chair using a sit to stand lift. Per resident, [they] was unable to hold on, slipped under the sling, fell on [their] buttocks, then fell backwards, hitting head to the bottom corner of the bedside dresser. Immediate Action Taken: VS (vital signs) taken, Resident denies any dizziness, blurry vision. Neuro Checks initiated. ROM (Range of Motion) to BLE (bilateral lower extremities) assessed . Resident c/o (complained of) pain to back of head. Applied pressure to back of head . Resident taken to hospital? Y (yes) . A review of the hospital discharge summary dated 12/8/2023, revealed, Your evaluated in the ED (emergency department) for a fall and subsequent head laceration. Your scalp required complex sutures (stiches) and special dressing . Brusing will be anticipated near your head injury is and you might have some hair loss . A review of R26's medical record revealed, Progress notes: 12/8/2023 16:28 Nursing Progress Note: @ (at) 1620 resident returned to facility accompanied by two EMS (emergency medical service) paramedics with instructions. Instructions detail how to take care, replace, and properly maintain head bandage which can be found in the unit clerks basket. Resident is sitting upright in wheelchair watching television. No further new orders will continue to monitor and maintain safety. Further review of R26's medical record noted, R26 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Chronic Kidney Disease, Stage 4. A review of R27's Minimum Data set noted R26's ability for sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or the side of the bed: Dependent. A review of R26's care plan noted, Focus: Alteration in Mobility r/t (related to): Resident has Impaired with limited mobility/ROM (range of motion) to both lower extremities to both knees and ankle, and limited ROM to left shoulder. Date Initiated: 09/21/2020. Goal: Resident will continue to participate in ADLs within functional mobility daily x 90 days. Date Initiated: 09/21/2020. Interventions: Assess need for and provide as indicated adaptive devices for mobility. Date Initiated: 09/21/2020. Focus: Resident has A Scalp laceration on head. No treatment needed. Date Initiated: 12/09/2023. Goal: Will heal within the limits of disease process. Date Initiated: 12/11/2023. Interventions: report evidence of infection such as prurient drainage, swelling, localized heat, increase pain, etc (et cetera), Notify physician prn (as needed). On 8/15/24 at 1:57 PM, the Therapy Director was asked how many staff are required to use the sit to stand lift. The Therapy Director explained, it can be one to two but, it depends on the resident. The Therapy Director was asked for clarification and ask if one staff could transfer a resident using a sit to stand lift. The Therapy Director stated, Well I don't think we have anyone that is one a person (transfer with lift). The Therapy Director was asked R26's transfer status at the time of the fall. The Therapy Director reported, We discharged [R26] from therapy on 10/31 and they were a sit to stand with two staff. On 8/15/24 at 2:14 PM, the Director of Nursing (DON) was asked the facility's expectations for the number of staff during a transfer with a sit to stand lift. The DON explained, any staff that uses a device should have two staff. On 8/15/24 at 2:24 PM, Licensed Practical Nurse (LPN E) was asked about the fall with R26. LPN E stated, The aide had came and got me and said that she needed help because she had a fall. LPN E was asked if CNA F was alone. LPN E stated, She was alone when I walked in. LPN E stated, [R26] was laying on the floor bleeding, we didn't move [R26] we let the EMS move [R26]. I took the vitals and made sure [R26] was still alert. LPN E was asked if CNA F was required to have one or two with a sit to stand lift and explained, CNA F is required to have two people to prevent accidents and for safety. On 8/15/24 at 3:04 PM, CNA F was called via phone a error message was recevied from CNA F's phone. A review of the facility's policy titled, Activities of Daily Living (ADL) dated 8/21/2023, noted, Policy overview: Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, personal, and oral hygiene . The policy did not address the use of a mechanical lift.

Based on observation, interview, and record review, the facility failed to ensure three residents (R11, R13, R64) of three residents reviewed, call lights were accessible. Findings include: R11 A review of the facility record revealed R11 admitted into the facility on [DATE]. R11's relevant diagnoses include vascular dementia, muscle weakness, diabetes, psychotic disorder, and failure to thrive. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 00/15 indicating an severely impaired cognition. A review of R11's care plan indicated they required a two-person assist for bed mobility. On 8/13/2024 at 11:50 AM, an observation revealed the call light was hanging, tied to the left bed assist rail, touching the floor. On 8/14/2024 at 10:47 AM, an observation revealed R11's call light was tied to the left bed assist bar, hanging, touching the floor, out of resident reach. Head of bed was elevated to 90 degrees, R11 was awake and conversant. An inquiry of resident to press the call light, revealed she was unable to locate it. When queried how they would let staff know they were needed, they revealed, I yell. On 8/14/2024 at 02:12 PM, an observation revealed that R11's call light was tied to bed assist rail, hanging to the floor. Certified Nurse Assistant (CNA) A revealed they check on R11 every 2 hours and R11 does not use call light, they just check on them often. R13 A review of the facility record revealed R13 was admitted into the facility on [DATE] with diagnoses which included, dementia, frontal lobe and executive function deficit with speech and language deficits following cerebral infarction (stroke). A review of the Brief Inventory of Mental Status revealed a score of 00 indicating severely impaired cognition. A review of R13's care plan indicated a two-person assist was required for bed mobility. On 08/13/24 at 09:50 AM, upon entering R13's room meet with an individual identifying themselves as R13's family member. When queried regarding the call light, the family member looked for the device around R13's upper body and bed. They were unable to locate the light. On 8/14/2024 at 8:30 AM, 10:52 AM, and 2:00 PM, observations revealed a soft touch call light lying behind the oxygen concentrator on the floor. On 8/15/2024 at 8:55 AM an observation revealed R13 had received morning care. R13's call light was still located behind the oxygen concentrator on the floor. R34 A review of the facility record revealed R34 was admitted into the facility on [DATE]. A further review revealed the following pertinent diagnoses: vascular dementia, cerebral infarction (stroke), anxiety disorder, difficulty walking, adjustment disorder with anxiety and depression. The facility record revealed a Brief Inventory of Mental Status score to be 03/15 indicating severely impaired cognition A review of R34's care plan indicated a one-person assist was required for bed mobility. On 8/13/2024 at 11:55 AM, an observation revealed resident call light was under the bed covers at the bottom of the bed. R34 was asked if they could reach the call light and though attempted, was unable to locate it. On 8/13/2024 at 1:53 PM, an observation revealed resident was in previous position, call light under covers out of the resident's reach. On 8/14/2024 at 8:34 AM, an observation revealed R34's call light was lying on the floor at the foot of the bed. On 8/14/2024 at 10:44 AM, R34's call light was on the floor at the foot of the bed. R34 was asked if they could reach the call light. R34 attempted to locate the call light on the bed and was unable. R34 was queried how they would obtain assistance if needed and R34 revealed she would yell out for staff. 8/15/2024 at 8:21 AM, R34 revealed they had completed breakfast and was going to nap. R34's call light was within reach, lying on the bed. On 8/15/2024 at 9:24 AM, the Director of Nursing (DON) was interviewed regarding call light placement. The DON confirmed R11, R13, and R34 were all capable of using their call lights. The DON revealed the expectation is resident call lights should be within resident reach. The DON further revealed R11 and R13 tend to yell when they wanted anything. On 8/15/2024 the Restorative Nurse B was queried regarding R11, R13, and R34's ability to effectively use the call light. They indicated R11, R13, and R34 have the physical ability to activate the call light. The policy , Call Light Accessibility and Timely Response, dated 8/16/2023 under Guidance, revealed Staff will ensure the call light is plugged in, functioning, within reach of residents, and secured, as needed.

Based on observation, interview and record review, the facility failed to revise an individualized, person-centered care plan for one resident (R8) of two residents reviewed for care plans. Findings include: On 8/14/24 at 11:39 AM, R8 was observed lying in bed asleep on a perimeter mattress without heel protectors. A review of R8's medical record revealed R8 was admitted into the facility on [DATE] with diagnoses which included Alzheimer's Disease, Hypertension, and Muscle Weakness. Further review revealed the resident was significantly cognitively impaired, and required one person assistance for bed mobility. Further review of R8's medical record revealed the following care plan, Actual Pressure Ulcer Formation Related to: Resident was admitted with or has pressure ulcer, with risk for delayed wound healing secondary to progressing comorbidities, Debility and generalized weakness with decreased physical mobility and bowel/ bladder incontinence daily. Resident has pressure ulcer/ wound Left Foot. Update 11/21/22 Resident has history of PVD (peripheral vascular disease). Vascular ulcers to left lateral foot and left lateral ankle as [their] clinical status declines resident is at risk for unavoidable further skin breakdown. Date Initiated: 10/26/2022 .Interventions: bilateral heel protectors as tolerated. Date Initiated: 10/26/2022. Encourage resident to float heels and /or wear heel boots. Date Initiated: 10/26/2022. Low Air Loss mattress. Date Initiated: 10/26/2022 . Further review of R8's medical record revealed an active physician order dated 10/26/22 revealing the following, Order Summary: Air Loss Mattress. On 8/14/24 at 12:52 PM, an observation of R8's mattress did not reveal an air loss mattress in place. On 8/15/24 at 9:17 AM, an observation of R8's mattress did not reveal an air loss mattress in place. On 8/15/24 at 3:42 PM, the Director of Nursing (DON) and Licensed Practical Nurse (LPN B) explained the resident no longer needs the air loss mattress as their wound has healed. They both acknowledged the care plan should have been updated to reflect the resident's current status. A review of the facility's Care Plan-Comprehensive and Revision policy revealed the following, .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents ' conditions change. The interdisciplinary team reviews and updates the care plan: o When there has been a significant change in the resident ' s condition. o When the desired outcome is not met. o When the resident has been readmitted to the facility from a hospital stay. o At least quarterly, in conjunction with the required quarterly MDS assessment .

Based on observation, interview, and record review, the facility failed to implement dietary care plan interventions for one residents (R22) out of two reviewed for care plans. Findings include: R22 On 8/13/2024 at 12:41 PM, R22 was observed in their room eating lunch. R22's meal ticket stated, No straws. R22 was observed to have a cup of water dated 8/13/2024 with a straw in it. A review of the medical record revealed that R22 admitted into the facility on [DATE] with the following diagnoses, Dysphagia and Multiple Sclerosis. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 9/15 indicating an impaired cognition. R9 also required staff assistance with bed mobility and transfers. Further review of R22's diet order noted the following, Order: Regular diet, Mechanical Soft texture, thin consistency. Directions: No straws for nutrition. Status: Active A review of the nutrition care plan revealed the following intervention, Provide regular diet, mechanical soft texture, thin liquids. No straws per SLP (Speech Language Pathologist). Date initiated: 3/23/2023. On 8/13/2024 at 1:04 PM, R22 was observed taking a drink of water from the straw. Registered Nurse (RN) A was brought into room and shown R22 drinking out of straw. RN A stated the assigned certified nursing assistant (CNA) brought R22 the straw. RN A was noted to take the straw out of R22's water cup. On 8/14/2024 at 12:55 PM and 1:30 PM, R22 was observed eating lunch. A straw was observed in their water cup on their nightstand. On 8/15/2024 at 9:29 AM, R22 was observed up in their wheelchair. Licensed Practical Nurse (LPN) C was observed getting vital signs on R22. A straw was noted to be in the water cup. LPN C was asked if R22 should have a straw in their beverages. LPN C stated R22 should not have a straw and they told the CNA this already. LPN C was observed taking the straw out of the water. On 8/15/2024 at 9:49 AM, an interview was conducted with Registered Dietitian (RD) B. RD B stated R22 spoke with the speech therapist and the no straw order is going to stay active because of R22's long history with aspiration (choking) and the straw is just to fast, which causes R22 to choke. A review of the nutrition care plan revealed the following intervention, Provide regular diet, mechanical soft texture, thin liquids. No straws per SLP (Speech Language Pathologist). Date initiated: 3/23/2023. A review of a facility policy titled, Nutritional Management noted the following, b. Interventions will be individualized to address the specific needs of the resident. Examples include, but are not limited to: i.Diet liberalization unless the resident's medical condition warrants a therapeutic diet ii.Altered-consistency food/liquids after underlying causes of symptoms are addressed (i.e. new dentures, dental consult, dysphagia therapy) iii.Weight-related interventions iv.Environmental interventions v.Disease-specific interventions vi.Physical assistance or provision of assistive devices vii.Interventions to address food-drug interactions or medication side effects.

This citation pertains to Intake: MI00145063. Based on observation, interview, and record review, the facility failed to implement care plan interventions for two residents (R706 and R708), of four residents reviewed for falls. Findings include: R706 On 6/18/24 at 9:34 AM, R706 was observed lying in bed on a regular mattress, bed low to the floor, with one floor mat on the right side of the bed. R706's face was observed with bruising under both eyes. R706 was asked what happened to cause the bruising. R706 stated, I fell . R706 was asked how they fell and explained they fell out of bed. Further observation noted, R706's call light at the foot of the bed, hanging through the frame of the bed. On 6/18/24 at 11:52 AM, R706 was observed in the same condition as above at 9:34 AM. A review of R706's medical record noted, R706 was admitted to the facility on [DATE] with diagnoses of Cerebral infarction, unsteadiness on feet, repeated falls, and history of falling. A review of R706's care plan noted, Focus: At risk for falls due to history of falls, impaired balance/poor coordination, potential medication side effects, unsteady gait. Date Initiated: 12/11/2023. Goal: Minimize risk for injury r/t (related to) falls. Date Initiated: 12/11/2023. Interventions: Floor mats while on bed. Date Initiated: 02/05/2024. Scoop/perimeter mattress. Date Initiated: 05/15/2024. Call light within reach. Date Initiated: 12/13/2023 . On 6/18/24 at 1:46 PM, the Director of Nursing (DON) was asked to take a look at R706's mattress. R706's bed was observed to have a new mattress that was not in the room during the earlier observations. The new mattress was observed to be a perimeter mattress (for patients that are prone to exiting the bed unassisted or to falling out of bed), during this time of the observation. While in R706's room, their was a discussion about the new mattress and when it arrived on R706's bed. R706's roommate overheard the discussion and reported the mattress was just put on. On 6/18/24 at 2:37 PM, the DON was asked about the mattress. The DON explained, R706 was moved closer to the nurses station as an intervention for falls about a week ago. The DON further explained during the move the correct mattress may not have transfer to the new room with R706. The DON was asked the facility's expectations and which staff would be responsible to check R706's mattress. The DON explained, the Unit Managers are responsible for making sure the interventions are in place. R708 On 6/18/24 at 9:44 AM, R708 was observed in a bed that was not low to the floor. R708 was asleep and did not awaken for an interview. On 6/8/24 at 11:41 AM, R708 was observed in a bed that was not low to the floor. R708 was asked about falls at the facility. R708 reported they had a fall awhile ago and it was something that just happened. R708 was asked if it was during care or if they were alone. R708 stated they were alone and they did not have an injury from the fall. A review of R708's medical record noted, R708 was admitted to the facility on [DATE] with diagnoses of Seizures and Vertigo. A review of R708's care plan noted, Focus: Resident is at Risk for Falls and Potential for Injury r/t: Confusion, history of falls, muscle weakness, poor balance, potential side effects of medications used, psychotropic medication use, require assistance with Activites of Daily Living (ADL) care and transfers but is alert and chooses not to ask for assistance, unsteady gait, use of antihyertensive medication, use of opioid medications and poor safety awareness. Date Initiated: 09/02/2022. Goal: Resident will have decrease risk factors for falls with currently interventions x 90 days. Date Initiated: 04/04/2023. Interventions: Bed to be in low position when in bed. Date Initiated: 04/04/2023. Low bed. Date Initiated: 5/22/2024 . On 6/18/24 at 1:48 PM, the DON was asked to observe R708's bed and was asked if the bed was in the lowest position. The DON stated, No it's not. The DON was observed to use R708's bed remote to lower the bed and was unable to lower the bed due to the bed not functioning properly. On 6/18/24 at 2:05 PM, the DON and the Maintenance Director reported that a work order was put in this morning regarding the bed not lowering back down. A review of the facility policy titled Care Plan- Comprehensive and Revision revised date, 8/25/23 noted, Policy overview: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs is developed and implemented for each resident . Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change .

This citation pertains to Intake MI00145063. Based on observation, interview, and record review the facility failed to secure medications on three of three medication carts throughout the facility. Findings include: On 6/18/24 at 9:30 AM, an unlabeled medication cart (#1) was observed unlocked and unattended in a hallway containing resident rooms. An unknown staff member walked by and locked it 9:32 AM. On 6/18/24 at 11:42 AM, an unlabeled medication cart (#2) was observed unlocked and unattended in hallway containing resident rooms 501-509. On 6/18/24 11:45 AM, an unlabeled medication cart (#3) was observed unlocked and unattended outside resident room [ROOM NUMBER]. When an unidentified nurse was asked about the unlocked cart they stated, I know, that's my mistake. A request was made for the facility's medication cart policy. The facility provided the Centers for Medicare and Medicaid Services form (CMS-20089) titled Medication Storage and Labeling. The form noted, Medications and biologicals in medication rooms, carts, boxes, and refrigerators were maintained within: Secured (locked) locations, accessible only to designated staff; Clean and sanitary conditions; and Maintain temperatures in accordance with manufacturer specifications and monitor according to national guidelines (e.g., see CDC vaccine storage and handling) .

This citation has two deficient practices. Deficient practice number one: This citation pertains to Intake number MI00135555. Based on interview and record review the facility failed to ensure timely treatments for a skin condition were initiated and documented on for one (R187) of three residents whose care and treatments were reviewed, resulting in a delay in treatment, and worsening of the skin condition prior to treatment initiation. Findings include: Review of an Intake reported concerns with medication and treatments not received timely and the amount of medication supplied for the rash was insufficient to cover all areas. Review of the facility record for R187 revealed R187 was admitted into the facility on [DATE], discharged to the hospital for a blood transfusion on 01/05/23 and readmitted to the facility on [DATE]. Diagnoses included Respiratory Failure, Anemia and Anxiety. A review of the Minimum Data Set (MDS) assessment dated [DATE] indicated intact cognition with a 15/15 Brief Interview for Mental Status score and the need for extensive assist of one or two persons for transfer, locomotion, dressing, toilet use and personal hygiene. Review of the Admission Nursing Assessment and progress note dated 01/11/23 at 9:30 PM documented .Alert and oriented time three .Admission nursing assessment completed. Resident oriented to room. Skin assessed. Skin discoloration on both upper extremities. Resident also has rashes/skin irritation all over peri area (groin/upper medial thighs) and buttocks .One person extensive assist with ADLs (activities of daily living). Continent both B/B (bowel and bladder) . The resident was reported as usually continent of both bowel and bladder but currently incontinent due to the inability to get up and out of bed because of no mobility devices and weakness. A progress note dated 01/12/23 at 10:23 AM by Nurse Practitioner (NP C) did not document the skin rash nor define any treatment. A progress note dated 01/15/23 at 12:54 by NP C documented, Note text CC (chief complaint) patient is seen to eval rash .c/o (complaint of) burning and itchiness all over, worse peri-area. Patient has red erythema all over body, worse peri-area buttocks, looks like an allergic reaction. Had blood transfusion, New medication? unaware. NKA (no known allergies). Patient states rash started the day (they) left the hospital and got worse .benadryl as needed and zinc oxide to affected areas An NP C progress note dated 01/19/23 at documented Erythema to groins/torso, arms, legs. Peeling skin on arms/hands. Itchiness, benadryl helps. Desitin (cream for rash treatment) helps when I get it .Allergic reaction, rash P (plan): Add Aquaphor ointment to affected areas on arms/legs BID (2 x's a day)-dry peeling skin Benadryl prn (as needed), Zinc oxide to affected areas TID (three times a day) monitor. A nurse progress note dated 01/23/2023 at 11:06 AM, documented writer, together with the unit manger assessed the patient's skin: redness all over (their) body except the facial area: mild swelling on the upper extremities: skin is warm to touch: writer called NP: NP ordered Methylprednisolone (steriod treatment for inflammation) 80 mg (milligrams) IM (intramuscularly) one time only. A nurse progress note dated 01/24/2023 at 11:34 AM, documented, writer assessed patient. assessment: redness all over her body and face: swelling both eyes and bilateral upper extremities, low grade fever of 98.2, itchiness and patient complaint of shivering. no shortness of breath noted. writer called MD (physician) regarding patient's assessment. MD ordered to send the patient to the hospital for further eval. A review of the January 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) documented no treatment until 01/15/23 (4 days after readmission). On 07/12/23 at 9:35 AM, following a wound care observation the wound nurse was asked to provide any wound care documentation they may have completed for R187. The wound care nurse reported they would review the chart. No wound care evaluation by the wound care nurse was provided prior to survey exit. On 07/12/23 at 11:11 AM, the Director of Nursing (DON) was asked about R187 and commented on the hospitalization and possible allergic skin reaction. The DON was asked for any documentation of treatment initiation for the rash prior to 01/15/23 and any policy related to related to this. No additional documentation of a skin rash treatment prior to 01/15/23 nor a related policy was provided prior to survey exit. 40384 Deficient practice number two. Based on observation, interview and record review, the facility failed to obtain timely radiology services (ultrasound and x-rays) for one sampled resident (R33) of two reviewed for quality of care resulting in, a delay in treatment, pain and hospitalization . Findings include: On 7/10/23 at R33 was observed in bed asleep on their back. Attempts to arouse R33 were made to no avail. A review of R33's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that include Acute Kidney Failure, Diabetes, Paraplegia, and Anxiety. Further review of the Quarterly Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition, and required extensive assistance for bed mobility, transfers, dressing, and toileting. Further review of the medical record revealed that R33 was transferred to the hospital on 7/11/23. Further review of R33's medical record revealed the following progress notes: 06/07/2023 12:12 pm Type: Nursing - Progress Note : resident complains of not feeling well generalized, (R33) had 2 large loose BMs (bowel movements) today. (R33) was seen by NP (nurse practitioner) no new orders (R33's) vitals are stable no complaining of pain, bs (blood sugar) 364, (R33) refused [their] breakfast and stated to hold [their] lunch. will continue to observe for changes. oncoming shift to be notified if condition worsen to notify NP. 06/07/2023 12:32 pm Type: Physician Team - Progress Note : CC (chief complaint): abdominal pain, paraplegia, type II DM (diabetes mellitus) Patient seen at nursing request for complaints of abdominal distention. (R33) is awake, alert and otherwise in no acute distress. He complains of a stomach ache at this time . Admits abdominal pain .Impressions: recurrent catheter-related UTI (urinary tract infection), recurrent small bowel obstruction .Plan: Continue current medications New order for abd (abdominal) US (ultrasound) . 06/08/2023 10:46 am Type: Nursing - Progress Note : resident states (they feel) better this morning than yesterday. (R33) has an order for abdominal ultrasound, date and time pending. 06/08/2023 9:30 am Type: Nursing - Progress Note : Resident, A/O X4 (alert and oriented to person, place, time and situation) SP (suprapubic) catheter in place, patent and secure Abdominal US procedure pending will call while on their way . 06/13/2023 6:40 am Type: Nursing - Progress Note : Nurse Manager on duty called several times to make client Physician and on call about client ultrasound findings 6/12/2023, Conclusion: Fatty Infiltration of liver nurse on (on coming) day shift will follow up with Physician about client and or make changes as needed. No current changes during this time client vitals were stable during night shift. A review of R33's medical record revealed that the physician order for the ultrasound to be completed was dated for 6/7/23, and the ultrasound was not completed until 6/12/23. Further review of R33's medical record revealed the following progress notes: 06/17/2023 10:09 PM Type: Nursing - Progress Note : Resident complained of abdominal pain, headache, discomfort. Blood glucose level high 381. MD (physician) notified, order for thin liquids and abdominal x-ray. Nurse do not have [mobile diagnostic services] assess to place the x-ray order, contacted the on-call nurse but voicemail was full. Resident said [they are] feeling better after eating only thin liquids for dinner. Resident alert and oriented. Will continue to monitor. 06/18/2023 12:23 pm Type: Nursing - Progress Note : resident continued on liquid diet relating to abdominal discomfort minimal complaint, waiting for abdominal x-ray to be completed. 06/19/2023 21:37 Type: Nursing - Progress Note : Resident, A/O X4 SP catheter in place, patent and secure . Abdominal Xray procedure pending [confirmation number]. Call light and personal items in reach within reach. Will continue to monitor and report any changes. 06/20/2023 11:26 pm Type: Nursing - Progress Note : resident alert and able to make needs known. continued on liquid diet relating to abdominal discomfort and for abdominal x-ray to be completed per MD . 06/21/2023 10:39 am Type: Nursing - Progress Note : resident is alert verbal able to make [their] needs made known. today (R33) had a clear liquid diet served, awaiting abdominal Xray. (R33) recently had a abdominal ultrasound. (R33) states [they feel] better no complaints of pain at this time. writer called [radiology company] to find out ETA (estimated time of arrival) for Xray which they was unable to provide but stated they will email their supervisor and try to get a ETA. writer called Dr (doctor) to update him. 06/22/2023 09:39 Type: Nursing - Progress Note : resident alert verbal able to make [their needs] made known. R33 is on a clear liquid diet waiting for abdominal Xray. residents Dr. was here today informed him of Xray not performed yet and no ETA, was informed to notify DON (Director of Nursing) resident complaining of some abdominal discomfort today . 06/22/2023 1:39 pm Type: Nursing - Progress Note : abdominal Xray completed and results are as follows: ileus type pattern favored, obstruction not excluded, recommend CT (computerized tomography, detailed images of the body). Dr. notified orders to transfer to hospital [local hospital name] for Abdominal CT with oral contrast. Effective Date: 06/22/2023 3:33 pm Type: Nursing - Transfer to Hospital Summary Note : Transportation company arrived for transfer to [local hospital] at 2:38pm. Paperwork sent along with pt (patient). Will update as needed. A review of R33's physician's orders revealed that the abdominal x-ray was ordered on 6/17/23, and was not completed until 6/22/23. A review of R33's hospital records revealed that they were admitted into the hospital on 6/22/23 for four days. Further review of R33's hospital history and physical dated for 6/22/23 revealed the following, .Presents to ED (emergency department) from nursing home with chief complaint of abdominal pain. Patient states abdominal pain started about 2 weeks ago .(R33) describes the pain as constant generalized abdominal pain, nonradiating with no aggravating or relieving factors. (R33's) last bowel movement was this morning and patient states that they are frequently constipated On arrival to the ED the CT abdomen pelvis showed very gas filled colon. The gas pattern appearance suggests sigmoid volvulus (when a portion of the intestine twists around its blood flow) GI (gastrointestinal doctor) was consulted and recommended emergent decompressive colonoscopy if patient's clinical presentation worsens . On 7/12/23 at 1:03 PM, during the Quality Assurance meeting with the Nursing Home Administrator (NHA) they were asked about the delay in diagnostic services, specifically with ultrasounds and x-rays. The NHA deferred the question to the Director of Nursing. On 7/12/23 at 2:07 PM, the DON was asked about the delay in radiography services within the facility, and explained that they began having some issues within the last four weeks, and when addressed with the mobile diagnostic company, they were told that they are short staffed of technicians. A review of the facility's Diagnostic (Radiology, Doppler, EKG) Result Reports, Reporting Of did not address a delay in the completion of diagnostic services.

Based on observation, interview, and record review, the facility failed to ensure resident food items were dated, failed to maintain kitchen equipment in a sanitary manner, and failed to ensure proper sanitization of dishware. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 7/10/23 between 8:45 AM-9:30 AM, during an initial tour of the kitchen with Dietary Manager (DM) A, the following items were observed: In the Anna's Place kitchenette, the gasket on the Aladdin reach-in cooler was observed to be heavily soiled with a black substance. DM A stated the gasket would be replaced. Inside the Aladdin reach-in cooler, there was an undated box of pizza, an undated sub sandwich, an undated container of cut fruit, an undated container of hummus, 2 stale, undated peanut butter and jelly sandwiches, and a cup of chili dated 4/2023. DM A confirmed the items should have been dated. Review of the facility's policy Safe Storage for Food Provided by Families dated 3/8/21 noted: 3. Each item will be clearly labeled with the resident's name and room number, and the current date before being refrigerated. 4. All refrigerated food is to be used within 72 hours or discarded. According to the 2017 FDA Food Code, section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. In the Anna's Place kitchenette, there was an electric stove, and the 4 drip pans located beneath the burners were observed with a heavy buildup of food debris. When queried, DM A stated the stove does not even work and is not being used. The microwave oven located in the Anna's Place kitchenette was observed with a heavily rusted and pitted interior top surface, which was no longer smooth and easily cleanable. DM A confirmed the microwave should be replaced due to it's condition. The steam table located in the Anna's Place kitchenette was observed with cloudy water inside the [NAME], with slimy, moldy clumps of debris floating on the surface. DM A confirmed the steam table [NAME] needed to be cleaned. According to the 2017 FDA food code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, .(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Dietary Staff B was observed washing dishware at the 3 compartment sink. DM A confirmed the sanitizer used in the sanitizer bin was quaternary ammonia. Dietary Staff B was observed washing items, immersing the items in the rinse compartment, and quickly dipping the items in the sanitizer bin and placing them on the drainboard to dry. During an interview on 7/10 at 3:00 PM, DM A confirmed that the clean dishware should not just be dipped in the sanitizer, but should be immersed in the sanitizer for 20 seconds. According to the 2017 FDA Food Code section 4-703.11 Hot Water and Chemical, After being cleaned, equipment food-contact surfaces and utensils shall be sanitized in: (A) Hot water manual operations by immersion for at least 30 seconds and as specified under S 4-501.111; P (B) Hot water mechanical operations by being cycled through equipment that is set up as specified under SS 4-501.15, 4-501.112, and 4-501.113 and achieving a utensil surface temperature of 71 C (160 F) as measured by an irreversible registering temperature indicator; P or (C) Chemical manual or mechanical operations, including the application of sanitizing chemicals by immersion, manual swabbing, brushing, or pressure spraying methods, using a solution as specified under S 4-501.114. Contact times shall be consistent with those on EPA-registered label use instructions by providing: (1) Except as specified under Subparagraph (C)(2) of this section, a contact time of at least 10 seconds for a chlorine solution specified under 4-501.114(A), P (2) A contact time of at least 7 seconds for a chlorine solution of 50 mg/L that has a pH of 10 or less and a temperature of at least 38 C (100 F) or a pH of 8 or less and a temperature of at least 24 C (75 F), P (3) A contact time of at least 30 seconds for other chemical sanitizing solutions, P or (4) A contact time used in relationship with a combination of temperature, concentration, and pH that, when evaluated for efficacy, yields sanitization as defined in Subparagraph 1-201.10(B). P.

Based upon observation, interview and record review, the facility failed to consistently provide evening snacks for three (R5, R34, R76) of four residents reviewed as well as seven anonymous group residents, resulting in resident dissatisfaction with snack/food service. Findings include: R5 On 07/10/23 at 11:26 AM, R5 reported that they are not offered an evening snack very often. Review of the facility record for R5 revealed an admitted [DATE] with diagnoses that included Multiple Sclerosis, Muscle Atrophy and Wasting and Breast Cancer. The Minimum Data Set (MDS) assessment dated [DATE] indicated R5 required total assistance for transfers. The Brief Interview for Mental Status (BIMS) assessment score of 15/15 indicated intact cognition. On 07/11/23 at 11:12 AM, R5 reported they were not offered a snack the previous evening. On 07/12/23 at 09:10 AM, R5 reported that they had not been offered a snack the previous evening. R34 Review of the facility record for R34 revealed an admitted [DATE] with diagnoses that included Traumatic Brain Injury, Hemiplegia and Aphasia. The MDS assessment dated [DATE] indicated R34 required total assistance for transfers. The BIMS assessment score of 15/15 indicated intact cognition. On 07/11/23 at 11:05 AM, when asked if they are offered evening snacks R34 stated once in a great while . its been at least two weeks since they did. On 07/12/23 at 8:55 AM, R34 reported that they had not been offered a snack the previous evening. R76 Reveiw of the facility record for R76 revealed an admitted [DATE] with diagnoses that included Congestive Heart Failure, Severe Protein/Calorie Malnutrition and a Pressure Ulcer. The MDS assessment dated [DATE] indicated R76 required moderate assistance for bed mobility and that transfer status was not assessed. The BIMS assessment score of 15/15 indicated intact cognition. On 07/11/23 at 11:25 AM, R76 reported that they are offered an evening snack rarely, probably less than weekly. On 07/12/23 at 8:58 AM, R76 reported that they had not been offered a snack the previous evening. On 07/11/23 at 2:19 PM, when asked if evening snacks are offered or provided to residents, seven members of an anonymous resident council meeting responded that evening snacks are either never or rarely offered or brought to them. On 07/12/23 at 09:45 AM, the facility Dietician (RD) reported that the dietary manager is primarily responsible for daily preparation and delivery of the evening snacks to the resident units. On 07/12/23 at 09:51 AM, the facility Dietary Manager (DM) reported that the dietary/kitchen staff fill the snack baskets each evening and deliver them to the units then sign-in sheets are completed that signify nursing receipt of the snacks. Regarding offering/distribution of the snacks, the DM and the RD report that the nursing department oversees the distribution of snacks. On 07/12/23 at 10:08 AM, the facility Director of Nursing (DON) reported that the expectation regarding nursing staff distribution of HS snacks is that staff offer the snacks to the residents daily and offer them directly for residents who are not able to get themselves to the snack basket at the nurses station. Review of the facility policy number 5015 titled Snack Cart Policy dated 11/1/22 revealed the following entries: It is the policy of this facility to offer a nutritious HS (Hour of Sleep) snack to every resident . It is the responsibility of the Dietary staff and supervisors to assure that the patients/residents are receiving adequate HS snacks: a. Patients/residents will be offered their choice of a snack from a snack cart. b. Nursing staff may assist resident in opening the snack, provide the necessary utensil if needed. c. Nursing staff will help patients/residents who require assistance with eating their snack.

Based on observation, interview and record review the facility failed to ensure psychotropic medication orders for Ativan (lorazepam) and Xanax (alprazolam) had a 14 day stop date for four residents (R19, R49, R54, R187) of five whose psychotropic medications were reviewed resulting in the potential for unintended use beyond 14 days, unnecessary use and decreased monitoring and assessment. Findings include: R19 R19 was observed up in a wheelchair, to eat in the dining area and sit within the social services offices on and off during the survey. A review for the record for R19 revealed R19 was admitted into the facility on [DATE]. Diagnoses included Alzheimer's, Dementia, Depression, Anxiety and Psychotic Disorder. The Minimum Data Set (MDS) assessment dated [DATE] documented severely impaired cognition with a 3/15 Brief Interview for Mental Status score. Review of the medication orders documented an active order dated 12/13/22 at 5:45 AM for Ativan 0.5 milligrams (mg), Give one tablet by mouth every six hours as need for agitation. The stop date was documented as indefinite. Review of the Medication Administration Record (MAR) for July 2023, June 2023 and May 2023 revealed no as needed administrations for Ativan. R49 A review for the record for R49 revealed R49 was admitted into the facility on [DATE]. Diagnoses included Autistic Disorder and Depression. The Minimum Data Set (MDS) assessment dated [DATE] documented severely impaired cognition with a 0/15 Brief Interview for Mental Status score. Review of the medication orders documented an active order dated 07/02/23 at 5:00 PM for Ativan 1.0 mg, Give one tablet by mouth every 12 hours as needed for agitation. The stop date was documented as indefinite. Review of the July 2023 MAR revealed ten administrations of Ativan over 11 days. R49 was observed to be up in a recliner or specialty chair bedside in their rooms most days of the survey. R49 was observed to be brought out to the common areas twice during the survey but requested to return to their room. On 07/12/23 at 2:14 PM, the social work staff commented the Ativan may have been added for agitation which had resulted in falls from the bed. R54 A review for the record for R54 revealed R54 was admitted into the facility on [DATE]. Diagnoses included Dementia, Parkinson's and Repeated Falls. The Minimum Data Set (MDS) assessment dated [DATE] documented severely impaired cognition. Review of the medication orders documented an active order dated 05/22/23 at 1:53 PM for Ativan 1.0 mg, Give one tablet by mouth every four hours as needed for agitation, anxiety. The stop date was documented as indefinite. On 07/12/23 at 2:14 PM, the social work staff reported the Ativan may have been added when the resident signed onto hospice and hospice physician would follow the medications. R54 was observed to be taken to activities, assisted to eat for meals, and resting in their room at various times during the survey. R187 A review for the record for R187 revealed R187 was admitted into the facility on [DATE]. Diagnoses included Dementia, Parkinson's and Repeated Falls. The Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition with a 15/15 Brief Interview for Mental Status score. Review of the medication orders documented a discontinued order dated 12/21/22 at 8:15 PM for Alprazolam 0.5 mg, Give one tablet by mouth every eight hours as needed for anxiety for 30 days. The end date was documented as indefinite. R187 was changed to scheduled Alprazolam on 12/27/22 during a trial for a new medication. On 07/12/23 at 1:11 PM, the Director of Nursing (DON) was asked about the use of a 14 day stop date on as needed psychotropic medications and indicated that is the expectation and that their behavioral services group visits the facility weekly and assists social services and physicians to manage the psychotropic medications. On 07/12/23 at 2:14 PM, the social work staff reported they had understood the 14 day stop date was to only apply to anti-psychotic medications. A review of the facility policy titled, Psychoactive Medication Prescribing and Behavior Management dated 11/01/19 revealed, .The facility will comply with the state operations manual as well as all other applicable law relating to psychoactive medications .An unnecessary drug is defined as any drug when used: 1. In excessive dose. 2. For excessive duration; or 3. Without adequate monitoring; or 4. Without adequate indications for its use .Monitoring .13. If the psychotropic medication is ordered PRN (as needed) there must be a physician, NP (nurse practitioner), PA (physician assistant) or Psychiatric Service documentation in the EHR (electronic health record) listing the reason for which the medication is ordered longer than a 14 day duration if applicable .14. If a PRN psychotropic medications exceeds 14 days in the EHR a task will automatically trigger in Sigma (old EHR) for the prescriber to complete a progress note to justify the medication order . A review of the Black Box Warning Details for the Xanax revealed, Warning: Risk from concomitant use with opioids. Concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death. Reserve concomitant prescribing of these drugs in patients for whom alternative treatment options are inadequate. Limit dosages and durations to the minimum required. Follow patients for signs and symptoms of respiratory depression and sedation. Abuse, misuse, and addiction: The use of benzodiazepines, including alprazolam, exposes users to risks of abuse, misuse, and addiction, which can lead to overdose or death. Abuse and misuse of benzodiazepines commonly involve concomitant use of other medications, alcohol, and/or illicit substances, which is associated with an increased frequency of serious adverse outcomes. Before prescribing alprazolam and throughout treatment, assess each patient's risk for abuse, misuse, and addiction. Dependence and withdrawal reactions: The continued use of benzodiazepines, including alprazolam, may lead to clinically significant physical dependence. The risks of dependence and withdrawal increase with longer treatment duration and higher daily dose. Abrupt discontinuation or rapid dosage reduction of alprazolam after continued use may precipitate acute withdrawal reactions, which can be life-threatening. To reduce the risk of withdrawal reactions, use a gradual taper to discontinue alprazolam or reduce the dosage.

Based on observation, interview and record review, the facility failed to prevent a fall during a transfer (by not properly applying a sling) for one sampled resident (R58) of one resident reviewed for accidents resulting in, the resident falling out of their sling during a transfer and onto the floor. Findings include: On 7/10/23 at 10:46 AM, R58 was observed in bed. They were asked about their stay in the facility, and explained that they had a fall a few months ago during a transfer. R58 explained that they were being transferred from their wheelchair to their bed, and that the sling was not all the way underneath their buttocks. R58 explained that as they were being pulled up, the sling slid from underneath them causing them to fall onto the floor. R58 denied pain, but admits that they hit their head on the side of the bed, and that they had a cut to their lip. Review of R58's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that include Heart Failure, Kidney Failure, Diabetes, and Muscle Weakness. Further review of R58's Minimum Data Set assessment dated for 4/3/23 revealed that the resident's Brief Interview for Mental Status score was a 12/15 indicating an intact cognition, and required extensive to total dependence for bed mobility, transfers and toileting. Review of R58's Incident and Accident report dated for 4/4/23 revealed the following, Resident was transferred to [their] bed from [their] chair, by using a mechanical lift, resident slide (slid) down from the sling, half way of the floor, resident head touch the edge of the bed and have a very tiny abrasion on R (right) corner of [their] lip, like a dot (2 millimeter (mm)/1mm), no bleeding, swelling no pain Description (provided by R58): I slide (slid) down from the sling. I hit my head, burst my hip (lip), I am ok On 7/12/23 at 11:51 AM, Unit Manager J was asked about the fall, and could not remember what occurred, only that they assessed the resident, and remembered them having a small abrasion to their lip. On 7/12/23 at 1:44 PM, Certified Nursing Assistant (CNA) I was interviewed regarding the fall of R58. CNA I explained that R58 was ready to be transferred to bed, and they went to obtain assistance from a CNA on another unit. CNA I explained that they observed that R58's sling was not completely underneath them and that the he and the other CNA made attempts to get the sling fully underneath the resident. CNA I explained that they cotinued with the trasnfer and as the other CNA that was assisting them was pushing the handles of the mechanical lift, they held onto the sling with the resident in the air. CNA I stated, I was keeping [R33] up with the sling in my hand, and as I'm holding it, she tells him to let go, I didn't want to let go and as soon as I let go, (R33) fell . CNA I explained that made an attempt to break R58's fall, and that they both rolled over onto the floor. On 7/12/23 at 2:10 PM, the Director of Nursing (DON) was asked about R58's fall and explained that R58 slipped out the of the sling, and that following the incident, all nursing staff were re-educated on transfers. A review of the facility's Fall Risk/Injury Prevention policy was reviewed and revealed the following, It is the policy of this facility to assess every resident for fall risk and provide an environment that is free from accident hazards over which the facility has control, and provides supervision and assistive devices to each resident to prevent avoidable accidents .

Based on observation, interview and record review the facility failed to ensure a medication cart was locked when unattended, expired medications were discarded, and biologicals were dated properly when opened for two of four medications carts and in two of three medication rooms reviewed, resulting in the potential for unauthorized access to items in the medication cart and decreased efficacy of biologicals and medication. Findings include: On 07/11/23 at 8:58 AM, a medication administration observation was conducted with Licensed Practical Nurse (LPN) D. LPN D was in a resident's room and the medication cart was unlocked. A staff member walked by and locked the cart. LPN D returned to the cart and attempted to open the drawer without the key. LPN D was then observed to prepare medications for a resident. When LPN D completed preparation of the resident's medication they left the cart and entered the resident's room. The medication cart was left unlocked. When LPN D returned to the cart, they acknowledged they had left it unlocked. On 07/11/23 at 1:00 PM, a review of the 300 low medication cart with LPN E noted one inhaler which had the date opened but not the name of the resident on the actual inhaler. On 07/12/23 at 8:55 AM, the 200 unit medication room was observed with Registered Nurse (RN) F one expired bottle of B12 vitamin dated 4/23 was found. On 07/12/23 at 9:32 AM, the 400/500 medication room was observed with LPN G one tuberculin vial had not been dated when opened. On 07/12/23 at 11:11 AM, during an interview with the Director of Nursing (DON), it was reported that the expectation was that the medication cart was locked every time staff leaves the cart and staff including the supply person and pharmacy staff work to ensure medications are properly labeled and removed when expired. A review of the facility policy titled, Medication and Treatment Cart Storage dated 05/04/22, revealed, It is the policy of this facility to ensure all supplies for treatments and medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer ' s recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security . 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. b. Only authorized personnel will have access to the keys to locked compartments (see attached listing). c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart .

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the main kitchen and in the 300 and 400 hall kitchenettes and failed to ensure clean pans and storage containers were stored appropriately. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 5/9/22 during an initial tour of the kitchen with Dietary Manager (DM) BB between 9:00 AM-9:45 AM, the following items were observed: The vent hood panels were observed with a buildup of grease and dust. DM BB was queried and stated the hood was last cleaned 1/31/22 and is cleaned every 6 months. The white tile backsplash above the drainboard at the soiled side of dish machine, was observed to be coated with a black, mildew-like substance on the tiles and in grout. In addition, the caulk along the edge where the drainboard meets the backsplash, was observed to be stained black. According to the 2013 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions, (A) Physical facilities shall be cleaned as often as necessary to keep them clean. The interior of the microwave was soiled with crumbs and splattered food debris. DM BB confirmed the soiled microwave and instructed a staff member to clean it. According to the 2013 FDA Food Code section 4-602.13 Nonfood-Contact Surfaces, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. There were clean pots and pans stored on a bottom shelf located across from the stove. There were fry pans and metal bowls stored with the opening facing up. Food debris was observed inside the clean fry pan. A shelving unit in the dish machine room with clean containers, was observed with plastic storage containers stored with the opening facing up. DM BB was queried and confirmed that clean items should be stored upside down. According to the 2013 FDA Food Code section 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, (B) Clean equipment and utensils shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted. In the 300-hall kitchenette, there was a warped gasket on the door of the Aladdin Temp-Rite reach-in cooler, and the ceiling vent cover was observed with a layer of dust. According to the 2013 FDA Food Code section 4-501.11 Good Repair and Proper Adjustment, (A) Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) Equipment components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. According to the 2013 FDA Food Code section 6-501.14 Cleaning Ventilation Systems, Nuisance and Discharge Prohibition, (A) Intake and exhaust air ducts shall be cleaned, and filters changed so they are not a source of contamination by dust, dirt, and other materials. In the 400-hall kitchenette, there were numerous dried up brown spots splattered on the ceiling, and the filter for the ice machine was dusty. According to the 2013 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.

Based on interview and record review the facility failed to establish an antibiotic stewardship program that included implementation of protocols for appropriate antibiotic use and administration and ensure that infection criteria was met prior to the admnistratoin of antibiotics., this has the potential to affect all residents prescribed an antibiotic while residing at the facility. Findings include: A review of a facility provided document titled, Antibiotic Stewardship Program, date implemented 10/17 and date reviewed/revised 10/19 was done and read, .It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Infection Preventionist-coordinates all antibiotic stewardship activities, maintains documentation, and serves as a resource for all clinical staff. On 5/11/22 at 1:20 PM, an interview was conducted with the facility's Infection Control Preventionist, Registered Nurse (RN) DD regarding the administration of antibiotics for resident infections that did not meet McGeer's criteria. RN DD shared they do not reach out to the physician's about antibiotics prescribed for infections that did not meet the McGeer's criteria in an effort to educate to either discontinue the antibiotic or have the physician explain their rationale for the antibiotic administration.

Based on observation, interview and record review, the facility failed to ensure medications were administered per professional standards of practice, and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: During an observation on 5/9/22 at 10:04 AM, while talking with R87 in his room, Licensed Practical Nurse (LPN) B entered the room to give R87's roommate, R94 his medications. LPN B handed a medicine cup of pills to R94 with one hand while holding an oblong plastic container in the other hand. After R94 took the medications, LPN B turned around, placed the oblong plastic container on R87's tray table, reached into the pocket of her scrub top and removed a medicine cup of pills from the pocket. LPN B handed the medicine cup to R87 and instructed him to take the pills. In the oblong plastic container was a syringe containing medication and a tube of ointment to go on R87's skin. On 5/9/22 at 10:14 AM, LPN B was interviewed and asked about having both residents' medication when she came in the room. LPN B explained she was just trying to get through the medication pass because she had a lot of residents. On 5/11/22 at 3:22 PM, the Director of Nursing (DON) was interviewed and asked about preparing two residents' medications at the same time. The DON explained medications should be prepared for one resident at a time to ensure the right medication is given to the right resident. Review of the clinical record revealed R87 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS) assessment dated [DATE], R87 had severely impaired cognition. Review of the clinical record revealed R94 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS assessment dated [DATE], R94 had severely impaired cognition. On 5/10/22 at 8:38 AM, during an observation of a medication administration for R48, LPN C was observed to place a [MEDICATION(S)] 800 mcg (micrograms) tablet into a medicine cup along with R48's other morning medications. LPN C proceeded to enter R48's room and give the medications to R48 to take. On 5/10/22 at 9:07 AM, a reconciliation of R48's medications showed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It should be noted that the amount of [MEDICATION(S)] given (800 mcg) was double the amount ordered(0.4 mg or 400 mcg), and no Vit B6 or Vit B12 were given. Review of R48's Medication Administration Records (MAR) revealed the combination medication of [MEDICATION(S)], Vit B6, Vit B12 were marked off as given for over a year since the start date of 3/27/21. On 5/10/22 at 9:47 AM, LPN C was interviewed and asked if there was a bottle or blister pack in the medication cart or medication room that contained the combination of [MEDICATION(S)], Vit B6 and Vit B12. LPN C explained she only had the bottle of [MEDICATION(S)] 800 mcg. On 5/10/22 at 9:48 AM, the DON was interviewed and asked if they had ever had the combination of [MEDICATION(S)], Vit B6 and Vit B12. The DON explained she would check into it. On 5/10/22 at 11:16 AM, the DON explained the combination medication was hard to find in over the counter bottles, so they got the medication from pharmacy in a blister pack. The DON provided a blister pack of the medication. Upon observation of the blister pack, it was noted the date on the pack was 5/10/22, and no pill had been removed from the pack. On 5/10/22 at 11:20 AM, LPN C was asked if she had ever seen R48 have a blister pack with the combination medication before. LPN C explained she had never seen that before, he would just get the [MEDICATION(S)] 800 mcg. Review of the clinical record revealed R48 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a facility policy titled, Safe Medication Administration revised 10/2021 read in part, .Follow the 5 Rs (Rights) of medication (add 2): R patient, R medications, R time /frequency, R dose, R route, R to refuse (give risk and benefits), R documentation . Observed or Identified preparation and administration of medication and biologicals in accordance to: A. Prescribers order; B. Manufacturers specifications; C. Acceptable professional standards .

This citation pertains to Intake MI 683 Based on observation, interview and record review, the facility failed to provide adequate monitoring and supervision to prevent an elopement from the facility, for one sampled resident (R901) who is severely cognitively impaired, and has diagnoses of Dementia and Muscle Weakness. R901 eloped from the facility on 12/19/2020 at approximately 5:20PM without staff being aware. The resident left their assigned unit, entered into the activities room, and exited through an alarmed door that was not heard by staff. The resident was located approximately 15-45 minutes later by police in an adjacent neighborhood from the facility after being dispatched from a concerned citizen's 911 call. The resident was found wearing a thin sweater, pants and shoes. According to the website accuweather.com, the temperature low on this date was 27 degrees, and according to google.com the sun set at 5:03pm, resulting in the likelihood for serious injury, harm, and/or death. The Immediate Jeopardy (IJ) started on 12/19/2020 and was identified on 1/5/2021. The Nursing Home Administrator (NHA) was notified of the Immediate Jeopardy on 1/5/2021 at 2:28PM and was asked for a plan to remove the immediacy. The IJ was removed on 1/6/2021, based on the facility's implementation of the removal plan as verified onsite on 1/6/2021. Although the immediacy was removed, the facility's deficient practice remained isolated with actual harm that is not immediate jeopardy. Findings include: A review of Intake MI 683 revealed the following, Incident Summary: A resident left the premises without authorization. [R901] was checked at 5:20 pm on December 19th on the unit. At 5:34 [R901] was not observed on the unit. Code W was announced overhead. Staff searched the inside of the building as well as the outside parameter (perimeter) of the building. At 5:44, 911 was called. The dispatcher explained to the nurse that they had already been called by a resident on (street parallel to building). At 5:56 resident was returned to building by the (local police) no negative outcomes noted .Wanderguard (A monitoring device to ensure safety for wandering residents) was in place at the beginning of the shift, however wanderguard was missing when resident returned . On 1/5/2021 at 9:08 AM, an interview was completed with the Nursing Home Administrator (NHA) about the incident of R901 eloping from the facility. The NHA explained that the resident left the facility at 5:20pm and subsequently 911 was called. The resident had been located by police at a home near the facility, as the resident knocked on someone's door. The NHA explained that the resident's Wanderguard was missing, and that it went missing between 2:30pm and 5:00pm. The NHA was asked how the resident was able to exit the facility, and demonstrated to the surveyor that R901 walked off of the transitional unit, past the therapy office, past a set of double doors leading to another unit, and into the activities room/dining room, out of the emergency door toward a residential area. A review of R901's medical record revealed that they were admitted into the facility on [DATE] with diagnoses of Dementia, Muscle Weakness and [CONDITION(S)]. R901's Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 4/15 indicating a severe cognitive impairment. Further review of R901's medical record revealed that an Elopement Risk Assessment was completed on 12/11/2020 in which R901 scored high as being at risk of elopement. The assessment also revealed the following, Elopement risk identified but resident has not attempted to leave the unit at this time, although verbalizes [R901] wants [family member] to pick [R901] up to go home. Needs frequent monitoring. A review of the local police department police report revealed the following, Occurrence Date/Time: 12/19/2020 17:28 (5:28pm) Call Source: 911 Verified Offense: Welfare Check 17:32 (5:32pm), [R901] was at a retreat that [R901] fled from .it was not what [R901] thought it was .wants to go home .Scared for [their] life .17:34 (5:34pm) Climbed out of window to escape the meeting .Ran to this resident where the homeowner assisted [R901] .made contact with (family member), [R901] belongs at (nursing home) .17:47 (5:47pm) Fountain Blue called 911 looking for assistance in locating their missing pt. (patient) They were advised we had located [R901] .17:53 (5:53pm)-Transporting [R901] back to (nursing home). Further review of R901's medical record revealed the following progress notes: 12/11/2020 21:30 (9:30 PM) Admission Note: Resident [identifying information] admitted to the facility from an acute care setting, recently hospitalized for mental status changes, hallucination, thinking someone was to harm [R901] .Resident is alert with confusion, knows the month and year but confused about [R901's] situation. [R901's] orientation changes, at first [R901] knew [R901] was in a nursing home, later thought [R901] was in parish .Resident walks independently in the unit . Does not remember room location or writer's name. Paces around the unit. 12/12/2020 04:34 (4:34 AM). Note Text: Resident continuously anxious asking where is [spouse] . Situation escalated to resident attempting to leave the unit. Nurse and staff asked [R901] where [R901] was going and said [R901] was 'leaving'. nurse writer and staff were able to talk to resident and calm [R901] .Social work notified of need for wander guard. 12/12/2020 20:15 (8:15 PM). Note Text: Resident is alert but confused. [R901] is able to associate with other residents and is seen wheeling another resident. [R901] still continues to wander around looking for [spouse]. the writer and other staff are alert supervising [R901] to avoid elopement. 12/14/2020 13:00 (1:00 PM). Admission Note: Resident is newly admitted to the facility r/t (related to) altered mental status. Current DX (diagnosis) includes: Dementia with Behavioral Disturbances. [R901] appears anxious and eager to return home to the community. Resident can be difficult to redirect at times and staff monitors resident to maintain safety .Resident scored a 3/15 on BIMS assessment, suggesting severe cognitive impairment. Resident does have current DX of dementia which may contribute to resident's low BIMS score .Resident's mood fluctuates, as [R901] is currently adjusting to the facility and a new environment. [Family Member] consented to psych (psychiatric) services for the resident to receive a psych evaluation and medication review for increased agitation per hospital records .Staff will continue to monitor resident for any signs of increased confusion or wandering. 12/14/2020 22:08 (10:08pm). Note Text: Resident alert, able to communicate needs but very confused. [R901] keeps asking staff why [R901] is here and wants to go home. Requesting staff to call [R901's] friend to pick [R901] up. Resident sometimes thinks [R901] is at church and is working here . Needs reminders where [R901's] room is .Wanderguard intact to L (left) ankle. 12/17/2020 21:50 (9:50pm). Note Text: Resident is alert, walking ad lib (freely) in unit .Resident remains confused at times to where [R901] is, sometimes thinks [R901] is in a rectory, or [R901's] parish. Very upset and loud at one time, angry about [family member] putting [them] in this facility .Resident refused shower, informed staff that [R901] is leaving in the morning and will shower when [R901] gets home . 12/18/2020 21:17 (9:17pm). Note Text: Resident continues to walk independently in unit. Independent with care needs, does not want assistance from staff. Resident called [family member] and became very angry after, confronted writer as to why [R901] is in the facility. Wanted to call the police. Angry at [family member] for placing [R901] in facility, insists that [they] can take care of [themselves and spouse]. Verbally aggressive, writer just listened to resident vent anger. Later [R901] went to room and said not to bother [them] until the morning . 12/19/2020 11:23 (11:23am). Note Text: received resident lying on bed, awake approx. (approximately) 6:30am. no signs of distress noted. resident is verbally rude when [R901] approach the writer. yelling that [R901] want(s) to go home. stating 'that [they're] not (to) be in this facility, [family member] is that one who put me here in the facility without consent .' writer keep monitoring [R901's] behavior, offer snack and drinks to calm [R901]. writer called the spouse about [R901's] condition, resident become calmed and crying . 12/19/2020 18:00 (6:00pm). Note Text: At approximately 1730 (5:30pm) writer was notified that resident was not observed in room. Writer search the unit. Writer unable to locate resident an Wander Alert was initiated at 1734 PM (5:34pm). All staff did a head account (count), search the building, and the outside premises. While other staff continues to search, other Nurse notified managers, while writer called 911 at approximately 1744 (5:44pm), during the call 911 informed writer that resident was safely located and was with the officers. Per staff nurse, [family member] was aware of the situation .Approximately 1756 (5:56pm) resident returned to the facility . Per resident [R901] 'wanted to go see (spouse).' Wander guard was in place at the beginning of the shift, however wander guard was missing when resident returned . On 1/5/2021 at 12:33 PM, an interview was completed with Certified Nurse Assistant (CNA) A, and asked to explain what occurred when R901 eloped from the facility and stated, R901 was sitting in one of two chairs, and I saw R901 when I began passing dinner trays which come to the unit at 6pm. CNA A explained that once they were finished delivering the other residents' trays, they went to provide R901 with their dinner tray and couldn't locate them. CNA A explained that all of the staff in the facility began looking for R901, and Nurse B contacted 911 at which time the police notified her that they already had R901. CNA A was asked what R901 was wearing when they returned to the facility and stated, a thin sweater, pants, and shoes. CNA A was asked if R901 had on a coat, and stated, No. CNA A was asked where the police located the resident, and stated, The police said R901 was knocking on people's doors asking to go home. CNA A was asked if R901 was able to explain how they exited the facility, and stated, R901 told the police that they crawled out of a window which we know isn't true. CNA A was asked how long R901 was gone, and stated, About 40-45 minutes. On 1/6/2021 at 8:17 AM, an interview was completed with Nurse B. They were asked about R901's elopement from the building and explained that R901 was in a nice mood that day, but that R901 was confused as they thought they were at a retreat. Nurse B further explained that at about 530pm, CNA A informed her that she couldn't find R901 and at that time an alert was called in the building, and everyone started to look for R901. Nurse B stated that she went outside of the building to locate R901, and that about 20-30 minutes later, she contacted 911 who informed her that R901 had been located and was safe. Nurse B was asked if R901 said anything to her once they returned and stated, [R901] hugged me and thanked me for finding them. [R901 also said that they were looking for their [spouse]. Nurse B was asked about R901's Wanderguard and explained that, it was checked at 2pm, but once R901 returned, the Wander guard was missing. Nurse B was asked if they heard any door alarms sounding, and stated, No. On 1/6/2021 at 2:32 PM, an interview was completed with the Director of Nursing (DON) in regards to R901 eloping from the building. She explained that she received a phone call at about 530pm informing her that a resident was missing, and that upon arriving to the facility, the resident had been located. The DON stated that Nurse B contacted 911 after searching for R901 and was informed that police had located them. The DON stated that the resident was back in the building between 5:50pm and 6:00pm, and that upon their return they were place on a 1:1 supervision, provided a new Wanderguard, until their discharge the following morning. The DON also explained that an in-service was provided that same evening that the facility will continue providing 30 minute checks on new admissions, ensuring that assessments and Wander guards are in place. A review of the facility's Elopement Assessment and Procedure policy was reviewed and outlined the following, POLICY: The facility will assess all residents for the potential risk of elopement and, once identified as a risk, will provide procedures and devices, including a wander alert bracelet that would deter a resident unauthorized exit from the facility. 12. The resident should be monitored frequently during the course of each shift. The frequency should be determined by the degree of risk and past elopement history. This could vary from 1:1 supervision, hourly visual checks or what has been deemed necessary for safety of resident. The frequency of the monitoring should be noted on the patient's care plan and the direct care staff should be informed for proper carry-through. 18. When an exit door alarm sounds, all staff shall automatically assume it could be a resident elopement and the staff should immediately check to see what triggered the alarm to sound. The staff should never turn off the alarm without determining what triggered it. If the staff cannot determine what triggered the alarm, an immediate search of the facility and its' surrounding property should be initiated and a quick resident census taken with special attention given to locate those residents who have been identified at risk for elopement. Plan of Correction for removal of IJ The resident R901 no longer resides in the facility. When the resident R901 returned to the facility, the resident was assessed from head to toe to ensure overt and covert symptoms has been addressed. However, the resident was having no negative outcomes. A 1:1 was assigned to the resident for the remainder of her stay. The alarm to the exit door was not heard by the staff. The facility will install an annunciator to enhance the sound of the alarm. The facility has changed the locks on the main dining room to a keypad entry to prevent the residents from having access to exit door. All other doors have digital keypad entry. The Facility's Elopement policy has been reviewed and updated on January 5, 2021. On January 6, 2021, the facility began to reassess residents who are elopement risks and care plans will be updated. There were 8 residents that have been identified as an elopement risk. All 8 residents have been reassessed. The care plans have revised and updated. The facility will address exiting seeking behaviors as needed and revise care plan. Those who are identified will have their face sheets/pictures will be put in elopement located at receptionist table and all nursing stations.

This citation pertains to intake 9. Based on interview and record review, the facility failed to accurately and consistently document skin integrity, and document wound treatment given as ordered for one sampled resident (R604) of five reviewed, resulting in inconsistent and conflicting documentation of skin status, development of wounds on the coccyx (buttocks), and the potential for development and worsening of wounds. Findings include: On 8/18/20 at 8:43 AM, Confidential Witness Z was interviewed regarding R604's care in the facility. Witness Z indicated the resident was at the facility since May 2020 and was discharged to an acute care hospital on 8/6/20. Witness Z stated the resident developed a bedsore (pressure ulcer) in the facility. Witness Z stated the resident did not have any skin problems prior to entering the facility and stated, I went to a window visit one day in July and could see [R604] was soaking wet. I stood at the window for an hour waiting for them to be changed. Now [R604] has an infected bed sore to the bone. They couldn't even do surgery on it. Witness Z stated that hospice services for the resident were being considered and that the resident was still at the acute care hospital. A review of R604's medical record and Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was admitted into the facility on [DATE] and readmitted on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the MDS dated [DATE] revealed that the resident had no existing pressure ulcers but was at risk for development of pressure ulcers; the resident was cognitively intact and required extensive assistance from staff for bed mobility, transfers, locomotion, dressing, toileting, hygiene/bathing, and was incontinent of bowel and bladder. Hospital records for R604 were requested and received on 8/18/20 and revealed the following upon review: Consult note - admitted : 8/6/20, Date of Consultation: 8/7/20 - Review of the EMR (electronic medical record) indicated presence of multiple decubiti (pressure ulcers). [Patient] has a 4 x 3 cm (centimeter) sized right heel DTI (deep tissue injury) and an unstageable (covered with slough/eschar) coccygeal (buttocks/tailbone) wound measuring 8.5 x 7.0 cm. Sorrounding (sic) skin is described to be erythematous and indurated (red and inflamed) as per wound care staff's evaluation. Gen(eral) surgery has been consulted for sharp debridement (cleaning of dead tissue off wound to promote healthy tissue growth and healing) .ID (infectious disease) consultation is obtained for evaluation of acute leukocytosis of 13.0 (elevated white blood cell count, normal is 4 to 11). On 8/18/20 at 10:14 AM, The Wound Care Nurse (WCN) was queried regarding facility policy and procedure for skin assessments. The WCN stated, Nursing is supposed to do weekly skin checks and skin checks with baths/showers. On 8/18/20 at 12:07 PM, Registered Nurse (RN) C was interviewed and queried regarding R604's skin. RN C stated, I worked with [R604] when they first got here. No skin issues that I know of. I don't remember any skin issues with them toward the beginning (of their stay). On 8/18/20 at 12:08 PM, the unit 4 nurses' station shower book full of bath/shower documentation was reviewed. A shower sheet (done on paper) titled, Bath and Skin Report, with corresponding skin assessment for R604 was present in the book and dated 8/4/20. The sheet included: Findings: Any complaint of pain or discomfort? Yes .Skin intact on feet? No .Skin intact: Yes .Reddened areas: No .Open Areas: No . The shower sheet showed a diagram of a person and on it the right heel was circled and noted Abrasion (scrab). The sheet also included a checklist under the findings and included: Licensed Nurse: I observed the resident in the shower and did a complete skin assessment. A check off list with, (1) Documented in nurses' progress notes; (2) Notified Physician; (3) Notified Wound Care Specialist; (4) Notified Dietary was present, however none of the items were checked off as completed. Licensed Practical Nurse (LPN) A signed and dated the sheet on 8/4/20. LPN A was interviewed at this time and queried regarding the shower sheet indicating no skin issues on the coccyx. LPN A stated, I put no skin issues because there were no new skin issues. A review of R604's electronic medical record (EMR) at this time revealed a skin assessment dated [DATE] that included Skin Assessment: 1. Note any skin issues (with diagram): [blank]. Problem documented on 24-Hour Report? No. Additional Comments: Pt. (patient) received shower, tolerated it well. R (right)-buttock and sacral area, tx (treatment) in progress, remaining skin is intact. No further information regarding the resident's right heel was found in the medical record. Further review of R604's paper Bath and Skin Report(s), EMR skin assessments, progress notes, treatment records, and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -R604's paper Bath and Skin report dated 7/13/20 indicated, refused shower. No corresponding skin assessment was completed in the resident's EMR. -The resident's Treatment Administration Record (TAR) for July 2020 included the task POC (Point of Care) Shower Reviewed, Shower Sheet Signed Off every evening shift every Mon, Thu I have seen and verified the C.N.A.s documentation on shower skin assessment. The task on 7/13/20 was charted as 9=Other / See Nurse Notes. No corresponding nurse's note for that date was found. -R604's paper Bath and Skin Report, and EMR skin assessment both completed and dated 7/21/20 by Registered Nurse (RN) B indicated that the resident's skin was intact with no reddened areas. No skin issues were marked on the diagram. The EMR skin assessment noted no skin issues and read, Additional Comments: Resident received shower. Skin is intact. -R604's paper Bath and Skin Report, dated 7/23/20 indicated that the resident's skin was intact with no reddened areas. No skin issues were marked on the diagram. The sheet was signed off by the Certified Nursing Assistant (CNA) and nurse. No corresponding skin assessment was completed in the resident's EMR. -A wound treatment order was initiated on 7/23/20 and read, Cleanse B/L (bilateral) buttocks open areas with Dakins, pat dry apply medinoney (sic) w/ (with) gauze cover with foam dressing change daily until resolved. every day shift for Woundcare, Order Date: 07/23/2020 0600. The TAR indicated the treatment was documented as completed on 7/23/20 but no documentation/check-off that the treatment was given was present on 7/24/20, 7/25/20, and 7/26/20. -Review of R604's medical record revealed no documentation or assessments dated 7/23/20 that noted or described the skin impairment on R604's buttocks or that corresponded with the new treatment order. No progress notes or assessments after 7/23/20 until 7/28/20 made mention of any skin impairment for R604. -A late entry (entered in in August 2020) progress note by the WCN revealed the following: Late Entry, Effective Date: 7/28/2020 16:02, Type: Skin/Wound Note, Note Text: Resident seen by wound care PA (Physician Assistant) for evaluation of Multiple buttock open areas noted while pericare provided by staff. Right gluteal abrasion measuring 4.0 x 4.0 cm with red moist wound bed and [MEDICATION(S)] tissue present. Min (minimal) s/s (signs/symptoms) odorless drainage present, no signs of infection. Treatment orders received for Dakins cleanse, pat dry apply [MEDICATION(S)] w/gauze cover with foam dressing daily until healed. Sacral abrasion measuring 5.0 x 3.0 cm with red moist wound bed and [MEDICATION(S)] tissue present. Min s/s odorless drainage present, no signs of infection . -A progress note by the WCN revealed the following: Effective Date: 8/5/2020 16:21, Type: Skin/Wound Note Note Text: Resident seen by wound care PA for follow up of right gluteal abrasion and sacral abrasion. Two open areas right gluteal and sacral now fused into one open area across sacrum, measuring 5.7 x 8.5 cm with red moist wound bed. Slough 50% present, No eschar or signs of infection. Copious s/s drainage with slight odor. New orders received for Dakins cleanse then apply dakins soaked gauze to entire wound and cover with foam dressing. Change daily and PRN (as needed). Resident tolerated treatment well with no signs of pain. Protein supplementation BID (twice a day) initiated for nutritional support . -A Report of Consultation, for R604 dated 8/4/20 revealed: [R604]'s original wounds, gluteal and sacral abrasions had progressed into one sacral Stage 3 (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed) with 50% slough (dead tissue, usually cream or yellow in color) at the time of transfer to the hospital. On 8/18/20 at 2:05 PM, all of R604's wound care documentation, braden scores, and skin assessments along with bath/shower sheets were requested from the facility. On 8/18/20 at 2:35 PM, RN B was interviewed and queried regarding R604's skin assessment dated [DATE]. RN B stated they were trying to remember the assessment but believed the sheet indicated no issues. RN B was asked if any redness or excoriation was reported to them by the aide who provided the shower and replied, No, not at the time. RN B was then asked if they as the nurse went by what the aide filled out on the shower sheet and signed off, or if they had performed their own skin assessment of R604. RN B stated, I went to the shower room and did my own assessment. I believe [R604] was in the shower chair. When asked how he performed a skin assessment of the resident's skin on the sacrococcyx region, RN B stated, Just rolled [R604] a little bit to the side to look at the bottom. On 8/18/20 at 2:45 PM, the WCN was interviewed and queried regarding R604's timeline of wound development. The WCN stated, I had had no report of any skin issues and there was an area (on the resident's bottom) that looked to be from previous pressure ulcers (healed). On 7/27, I was notified by staff there was an open area and on 7/28 they were seen by the wound care PA. There were two (open) areas. On 8/4 the areas had merged (together). Only seen by wound care twice. They called them unavoidable due to immobility and not eating. When queried where it was documented where the resident was not eating, the WCN looked in the resident's progress notes but was unable to find any notation after 7/10/20 of the resident not eating their meals well. No nutrition/dietary progress notes were found and no nutrition assessments on 7/6/20 or after were found. The WCN was then queried regarding stating that she was notified on 7/27 of the wound but put in a wound treatment order for R604's buttocks on 7/23, and asked if there was any corresponding documentation to go with the wound care order on 7/23. The WCN looked in R604's record and shook her head no and stated, No, I don't see anything. When asked if there should have been something documented when the order was put into place on 7/23, the WCN stated, Yes, I put the order in place but didn't document. I documented after wound care (team/PA) saw [R604]. The WCN was then asked if the wound care order had become active on 7/23 and confirmed that it had. When queried regarding the order not being documented as carried out on 7/24, 7/25, and 7/26, the WCN stated, It should have been done. There could have been missed communication of the order. When queried regarding the skin assessment for R604 done by RN B on 7/21/20 that indicated no skin issues, the WCN provided no further information. When asked when R604's coccyx wounds developed, the WCN indicated it seemed hard to tell and stated, If I put the order in on 7/23, but the 7/21 skin assessment says skin is intact . and provided no further information. When queried regarding R604's right heel, the WCN stated, The resident did not have a right heel DTI here but did have heel protectors. On 8/18/20 at 3:09 PM, the facility had provided the requested documentation for R604. A Bath and Skin Report dated 8/4/20 for R604 was provided by the facility, however, upon review, was noted to be different from the Bath and Skin Report dated 8/4/20 that was reviewed at the nurse's station with LPN A at 12:08 PM. The report provided by the facility noted open areas on the resident's coccyx but no area noted on the right heel. The WCN was asked to review the report in the book at the nurse's station compared with the report provided by the facility at this time and indicated she did not know why they were different. On 8/18/20 at 3:21 PM, the Director of Resident Care/Director of Nursing (DON) and the WCN were interviewed and queried regarding the two shower sheets dated 8/4/20 and the discrepancies found. The DON indicated she believed the manager may have not seen the sheet that was in the book and verified with staff to fill out another sheet when doing audits. When queried regarding the 7/23/20 Bath and Skin Report, dated 7/23/20 that indicated the resident's skin was intact with no reddened areas and had no skin issues marked on the diagram, the WCN stated, But that's the date there was the wound care order implemented. The area was open. The remaining Bath and Skin Report(s) (shower sheets) for R604 were reviewed with the DON and WCN. The reports on 6/18/20, 6/25/20 and 6/29/20 all included, Skin Intact: No. When queried regarding the sheets indicating R604's skin was not intact, the DON stated, There is no documentation of skin issues at that time, [R604] didn't have any. The WCN indicated at this time that the skin assessments on the shower sheets and the medical record were inconsistent and not reflective of each other. On 8/18/20 at 4:15 PM, the DON was interviewed and queried regarding R604's inconsistencies in skin integrity documentation and documentation present in multiple different places. The DON stated, There was an actual wound toward the end of July. When queried regarding the shower sheets indicating the resident's skin was not intact in June but with no mention of that in the EMR, the DON stated, Well, two nurses can see two different things. I know for sure the wound we treated started toward the end of July. When queried regarding the resident's skin being noted as intact on the shower sheet dated 7/23/20 but had a wound treatment initiated on the same day, the DON stated, Let me write that down I saw the documentation of the change in the skin from 7/27-7/28. We will probably have to do a teaching on how to assess skin properly. When queried regarding her expectation of ordered treatments, the DON stated, I expect them to be carried out as ordered. A review of R604's care plan revealed, Weekly nursing skin assessments with showers. Notify physician and wound care nurse of any skin changes. [Licensed Nurse,RN]. A review of the facility's policy titled, Prevention of Pressure Ulcers/Injuries, dated 10/19, revealed, Risk Assessment 1. Assess the resident on admission (within eight hours) for existing pressure ulcer/injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. 2. Conduct a comprehensive skin assessment upon admission .4. Inspect the skin on a daily basis when performing or assisting with personal care or ADLs. a. Identify any signs of developing pressure injuries (i.e., nonblanchable erythema). For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency; b. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.); .Monitoring 1. Evaluate, report and document potential changes in the skin. 2. Review the interventions and strategies for effectiveness on an ongoing basis. A review of the facility's policy titled, Pressure Ulcer/Injury Protocol, dated 10/19, revealed, POLICY: Based on the Comprehensive Assessment of a resident, the facility must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing .Procedure: When assessing an ulcer, it is important to do the following: Differentiate the type of ulcer (pressure related versus non-pressure related. Interventions may vary depending on the specific ulcer. Document the following: A. Size B. Location C. Depth & Stage of ulcer .(This comprehensive assessment should also address those factors that have been identified as having an impact on the development, treatment and/or healing of pressure ulcers, including, at a minimum; risk factors, pressure points, nutrition and hydration deficits, moisture and the impact of moisture on skin.) Identify the resident at risk of developing pressure ulcers; the level and nature of risks including specific conditions, causes and/or problems, needs and behavior; and identify the presence of pressure ulcers. The following are examples of risk factors: .impaired/decreased mobility and decreased functional ability; .Exposure of skin to urinary and fecal incontinence; .A healed ulcer. 4. Once the assessment has been completed, immediately develop a plan of care with the resident (and family, if available). In addition, if any skin breakdown is found, the responsible party must be notified immediately. Please document with whom you spoke with in the medical record 6. Monitor and evaluate the resident's response to preventative efforts .9. Weekly skin assessment will be completed on each patient regardless of Braden Scale score or skin condition. Assess skin when a new risk factor develops known to be associated with an increased risk of breakdown .10. If there is any change in the patient's skin condition, the nurse or nurse manager should review and revise the patient's care plan accordingly and consult with the director of nursing, physician and/or wound care specialist as needed 11. If an ulcer is observed or develops post admission there must be thorough documentation of the ulcer upon admission or upon its initial discovery. If there is any change in the patient's skin condition, the nurse or nurse manager should review and revise the patients care plan accordingly and consult with the Director of Nursing, physician and /or wound care specialist as needed 12. In addition, all newly acquired skin impairments and worsening of previous areas must be reported to the resident and /or their legal representative by the nursing department. Documentation of communication will be put in the progress notes by the nurse .

Deficient Practice Statement One: Based on observation, interview and record review, the facility failed to implement and individualize interventions to prevent repeated falls with injury for two (#'s 39 and 51) of five Residents reviewed for falls resulting in lack of documentation and investigation of falls, lack of timely implementation of interventions following falls, Resident #39 experiencing multiple falls with two hip dislocations, Resident #51 experiencing a fall with a fractured humeral head, unnecessary pain, and the likelihood for decline in overall function and health status. Findings include: Resident #39 On 1/14/19 at 10:30 AM, Resident #39 was observed in their room, in bed with their eyes closed. One fall mat was noted in-between Resident #39's bed and their roommates' bed, on the right side. An interview was conducted with Nurse J on 1/14/30 at 10:46 AM. When asked if Resident #39 had fallen within the facility, Nurse J replied, Yes, (Resident #39) fell and has a hip brace. Nurse J revealed the Resident had to wear the hip brace as a result of the fall but was unable to provide detailed information pertaining to what occured when the Resident fell or the indication for the brace when queried. On 1/14/20 at 12:30 PM, Resident #39 was observed in their room. The Resident was laying in bed, positioned on their back. One fall mat was noted in-between Resident #39's bed and their roommates' bed, on the right side. An interview was attempted to be completed with the Resident at this time. When asked questions, Resident #39 did not make eye contact and did not respond to all questions. Record review revealed Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired, displayed wandering behaviors, and required limited to total assistance to perform Activities of Daily Living (ADLs). On 1/15/19 at 1:45 PM, Resident #39 was observed in their bed. One fall mat was in place on the right side of the Resident's bed, between the two beds in the room. An interview was attempted to be completed with the Resident at this time. When asked questions, the Resident would respond with one-word answers and then close their eyes. On 1/15/19 at 1:50 PM, an interview was conducted with Nursing Assistant Q. When queried regarding Resident #39 communication and level of care, Nursing Assistant Q replied, (Resident #39) used to be talkative and walk. With further inquiry Nursing Assistant Q stated, (Resident #39) kept getting out of bed. I know they hurt themselves. When asked how they had hurt themself, Nursing Assistant Q indicated they did not know the specific injury and stated, Now they have to wear the protective (hip) brace. With further inquiry, Nursing Assistant Q revealed Resident #39's level of functioning had declined since their injury in the facility. Upon walking down the facility hallway on 1/15/19 at 1:52 PM, Resident #39 was heard yelling, Help repeatedly. Upon entering their room, Resident #39 was observed in bed, positioned on their back. The Resident was visibly restless and was squirming their body in bed. When asked what was wrong, Resident #39 stopped yelling but did not provide a meaningful response. When spoke to, the Resident was calm. When not speaking to the Resident and upon walking to the room door, they would begin loudly yelling, Help repeatedly. Nursing Assistant Q entered the Resident's room at this time. When queried regarding the Resident's brace, Nursing Assistant Q removed Resident #39's blankets and revealed a Hip Abduction Orthosis brace on the Resident's left side. The brace was a hard-white plastic and metal brace which surrounding their left thigh and was connected by a metal rod to a hard-white plastic and metal section which surrounding the Resident's chest. The entire brace was twisted to the side and the upper part of the brace was over the Resident's breast area. A section of white plastic was noted to be unattached on one side and positioned vertically to the rest of the brace. When queried regarding the positioning of the brace, Nursing Assistant Q replied, The nurses put it on. Upon request, Nurse M entered Resident #39's room. When queried regarding the positioning of the brace including the brace being twisted, the unattached plastic section, and upper part of the brace being over the Resident's breast area, Nurse M adjusted the brace and indicated the upper part of the brace is always positioned over the Resident's breast area. After the brace was adjusted and repositioned by Nurse M, Resident #39 stopped yelling Help loudly and repeatedly. An interview was conducted with Unit Manager Nurse N on 1/15/20 at 1:55 PM. When queried regarding Resident #39's injuries within the facility, Nurse N stated, (Resident #39) fell here. They went to the hospital and came back on Hospice. Nurse N then revealed the Resident was recieving Hospice services prior to the fall. With further inquiry, Unit Manager N stated, We did an x-ray on 11/25/19 which showed a separation of the femoral hip prosthesis. Then we sent (Resident #39) out (to the hospital) on 11/26/19. When queried regarding Resident #39's hip brace and orders, Unit Manager N reviewed the Resident's medical record and stated, The hospital information is brace at all time. Review of the hospital discharge documentation with Nurse N further revealed the Resident was supposed to Follow up with ortho in two weeks. When queried regarding the follow up orthopedic care appointment and Health Care Provider recommendations, Nurse N reviewed the Resident's medical record and revealed there was no documentation that a follow up appointment was made and/or that the Resident was seen by an orthopedic provider for follow up care. Review of Resident #39's Hospice documentation with Nurse N at this time did not indicate the Resident was seen for follow up care. However, review of Hospice note documentation revealed Resident #39 fell within the facility again on 11/29/19. When queried regarding the second fall, Nurse N indicated they would need to review the Resident's medical record further. Review of Resident #39's medical record revealed the following note documentation: -11/16/19 at 1:22 PM, Health Status Note: At 11:45 AM, Resident ambulatory in hallway close to the wall near nurses station when tripped over the footrest of another resident w/c (wheelchair) . Resident fell forward to the floor and hit forehead on floor. Resident was assessed and transferred to w/c . Resident difficult to direct. Making several attempts to redirect resident to remain in w/c at nurses station while being closely monitored. Skin assessment noted redness with a lump present, skin abrasion, no bleeding. (Family) called and spoke to about fall . MD, unit mgrs (managers) . DON notified of incident/fall. -11/24/19 at 10:29 AM, Health Status Note: Resident was c/o (complain of) pain in left leg pain . Writer contacted (Hospice) regarding order for [MEDICATION NAME] sulfate (narcotic medication for severe pain) . administered medication . -11/24/19 at 9:56 PM, Health Status Note: Received resident in bed sleeping. Resident INA day 1 from a fall. At 1800 (6:00 PM) writer notified that L (left) hip sensitive to touch causing resident to refuse care. PRN [MEDICATION NAME] administered and effective. Left hip x-ray ordered . (Hospice) notified . -11/25/19 at 7:54 AM, Health Status Note: X-ray results . Acute separation of the femoral and acetabular components of the hip prosthesis with mild superior migration of the femoral portion . Conclusion: Acute separation femoral and acetabular components of the hip prosthesis as described. Recommend orthopedic consultation. (Hospice notified) . -11/26/19 at 3:34 PM, Health Status Note: Resident transferred to (Hospital) r/t (related to) left hip fx (fracture) from unwitnessed fall . -11/26/19 at 9:58 PM, Health Status Note: Resident arrived at facility via 2 EMT techs on stretcher. (Hospice) Hospice nurse in person to assess resident upon return from (Hospital) . -11/29/19 at 10:00 AM, Health Status Note: Writer called to room by another unit nurse. Writer went to room to observe resident lying on the floor on left side . transferred . back to bed. Resident assessed for injuries, none noted. Resident had c/o pain to left leg. Resident medicated with prn [MEDICATION NAME] per physician order [REDACTED]. -11/29/19 at 7:37 PM, Health Status Note: X-ray results received with conclusion a superior dislocation of the hip . -12/3/19 at 2:25 PM, Health Status Note: Resident re-admit from (Hospital) via EMS accompanied by 2 EMTs. admitted to Hospice . Received A+O x 1 (Alert and Oriented to self) at normal baseline. Brace in place to left extremity r/t hip dislocation dx (diagnosis) . -12/7/19 at 5:38 AM, Health Status Note: Resident observed on the floor on the right side of bed sitting on the floor mat on buttock, resident confused and unable to tell writer what happened . Review of diagnostic testing results for Resident #39 revealed the following: -11/25/19, Hip X-Ray 1 View, Left: Results: Acute separation of the femoral and acetabular components of the hip prosthesis with mild superior migration of the femoral portion . Conclusion: Acute separation femoral and acetabular components of the hip prosthesis as described. Recommend orthopedic consultation . -11/29/19, Femur 2 View X-Ray: Results: Left femur . There is superior dislocation of the femur in relation to the prosthetic acetabulum . Conclusion: A superior dislocation of the hip . An interview was completed with Nurse M on 1/15/20 at 2:50 PM. When queried regarding Resident #39's brace, Nurse M revealed the Resident wears the brace 24 hours a day. When asked if the brace is ever removed, Nurse M stated, No. When queried regarding how the Resident's skin integrity is monitored and assessed and how hygiene is provided if the brace is never removed, Nurse M indicated the brace is not tight. Review of Hospital discharge documentation, dated 12/3/19, for Resident #39 revealed the Resident was admitted to the hospital on [DATE] for a dislocated hip as a result of a fall. The History and Physical, dated 12/1/19, included in the Hospital documentation revealed, Presented to ED (Emergency Department) yesterday with left hip dislocation sp (status [REDACTED]. Left hip dislocations . last week requiring closed reduction in OR (Operating Room) . ED attempted closed reduction yesterday without success . LLE (Left Lower Extremity) internally rotated and shortened . Plan for closed reduction in OR today . The documentation also included an Orthopedic Consultation which revealed, F/U (follow up) in office in two weeks . An interview was conducted with Hospice Nurse K on 1/15/19 at 3:54 PM. When queried regarding Resident #39, Nurse K stated, I admitted (Resident #39) to Hospice at home and then we transitioned them to a facility. When asked why the Resident was admitted to Hospice, Nurse K replied, Their primary [DIAGNOSES REDACTED]. When queried if the Resident had fallen in the facility, Nurse K replied, Yes. Two times (falls) resulted in dislocation of their hip. When asked how the Resident had fallen, Nurse K stated, We don't know. The falls were unwitnessed. With further inquiry regarding the falls, Nurse K stated, Both times, (Resident #39) had to go to ER but they couldn't put it back in and it (reduction) had to be done under sedation. When asked how the falls and dislocations had affected the Resident, Nurse K stated, (Resident #39) used to walk. It definitely contributed to their decline. When queried regarding documentation in the medical record indicating the Resident's was supposed to follow up with an orthopedic provider, Nurse K stated, We had a conversation (with the facility) regarding following up with ortho. The facility would need to complete coordination of care for that. With further inquiry regarding the brace including how often the Resident is supposed to wear it and monitoring skin integrity under the brace, Nurse K replied, I thought they (facility staff) were taking it off at night but then they called me today and told me they weren't. On 1/15/20 at 3:50 PM, Resident #39 was observed in their room in bed. A fall mat was in place in the right side of the bed. The Resident was yelling out, Help, help repeatedly and was observed attempting to move their legs off the left side of the bed. On 1/15/20 at 4:50 PM, an interview was completed with the Director of Nursing (DON). When queried regarding how many fall mats Resident #39 is supposed to have in place, the DON replied, Two. An observation of Resident #39's room was completed with the DON at this time. One fall mat was in place on the right side of the Resident's bed. When asked if there were two fall mats in place, the DON replied, No. When queried why only one fall mat was observed in the Resident's room on 1/14/20 and 1/15/20, the DON was unable to provide an explanation. Facility policy/procedure pertaining to falls and fall prevention was requested from the DON at this time. An interview was conducted with the Facility administrator on 1/15/19 at 5:28 PM. When queried regarding Resident #39's history of falls with injury and observations of not having two fall mats in place, the Administrator stated, I can't disagree. Review of facility provided fall Incident and Accident Reports for Resident #39 revealed the following: -11/16/19 at 11:45 AM: Description . Resident ambulatory in hallway . fell forward and hit head. Forehead noted with redness and a lump, skin abrasion, and no bleeding . Predisposing Physiological Factors . Confused . Predisposing Situation Factors . Wanderer . -11/29/19 at 9:45 AM: Description . Resident was on the floor in room . on the floor on left side . Level of Pain . Numerical: 10 . Mental Status: Orientated to Person . Injuries Report Post Incident: No Injuries Observed Post Incident . Predisposing Physiological Factors . Impaired Memory . Confused . Witnesses: No Witnesses Found . -12/7/19 at 5:45 AM: Description . Resident observed on the floor on the right side of bed sitting on the floor mat on buttocks . Mental Status: Orientated to Person . Predisposing Physiological Factors . Gait Imbalance . Impaired Memory . Confused . Witnesses: No Witnesses Found . An interview was completed with Hospice Staff K, Hospice Staff L, and Hospice Staff R on 1/16/20 at 11:52 AM. When queried regarding the dates Resident 39 had fell within the facility, Staff K reviewed the Resident's Hospice medical record documentation and stated, 11/23/19, 11/29/19, and 12/7/19. When queried regarding facility documentation indicating the Resident's also fell on [DATE], Staff K reviewed the Resident's Hospice documentation and stated, We were not aware of that fall, but I will note it in the record. When asked about Resident #39's injuries resulting from the falls, Hospice Staff K, L and R all revealed they had concerns regarding the Resident having repeated, unwitnessed falls within a short time span and the injuries the resident sustained [REDACTED]. Staff L then revealed the facility has had a large turnover of nursing staff. When queried regarding the Residents hip brace including lack of follow up care and monitoring of skin integrity under the brace, Staff K revealed they were not aware facility staff were not removing the brace and stated, It is not a Hospice related injury and we would not have even written an order for [REDACTED]. Hospice Staff K, L and R further revealed Hospice would have addressed the concern if they would have been made aware the facility staff did not obtain an order for [REDACTED].>An interview was conducted with the facility Director of Nursing (DON) and Nurse O on 1/16/20 at 1:49 PM pertaining to Resident's #39's falls with injury in the facility. When asked why three Incident and Accident Reports were provided when progress note documentation in the Resident's medical record indicated the Resident had fallen four times, the DON revealed they did not have any other Incident and Accident Reports for the Resident. Resident #39's progress note documentation was reviewed with the DON and Nurse O at this time. When queried regarding the note dated 11/24/19 which stated, Day 1 from a fall . The DON replied, I was not notified. They (Resident #39) must have fell on [DATE]. Review of documentation for 11/23/19 for Resident's #39 with the DON revealed the only note documentation dated 11/23/19 was a Social Services Note pertaining to psychiatric services. When queried if there should be documentation in the medical record as well as an Incident and Accident Form, the DON replied, Yes. When asked why there was no documentation of the fall on the day it occurred and/or detailing what had happened, the DON did not provide an explanation and indicated they would address the lack of notification and documentation with staff. At this time, Unit Manager Nurse N joined the interview. When queried regarding Resident #39's falls within the facility and interventions implemented to prevent further falls and injury, Nurse O revealed they updated the care plan after a fall. Review of Resident #39's care plans with the DON, Nurse O, and Nurse N at this time revealed a care plan entitled, Risk for Fall (s) and Potential for Injury, related to: cognitive impairment, dementia with impaired decision making skills and poor safety awareness, [MEDICAL CONDITION] medication use, unsteady gait (Initiated: 11/12/19). The care plan included the interventions: -Monitor for increased confusion, if observed monitor for attempts to ambulate or transfer impulsively and assist as needed (Initiated: 11/18/19) -Place Resident in Highly Visible areas for safety (Initiated: 11/29/19) -Orientate to surroundings and use of call-light, answer call light promptly (Initiated: 11/29/19) -Offer and encourage to be toileted q (every) two hours and as needed to prevent unassisted transfers (Initiated: 12/7/19) -Bilateral Floor Mats while in bed (Initiated: 12/9/19) -Concave Mattress (Initiated and Revised: 12/11/19) When queried why the Resident had not been observed out of their bed, when an intervention to prevent falls dated 11/29/19, was to place the Resident in a highly visible area for safety, Nurse N indicated the hip brace makes it uncomfortable for the Resident to sit in a wheelchair comfortably. When queried why the interventions of bilateral floor mats and a concave mattress were not implemented until after the Resident had two falls with injuries, an explanation was not provided. When asked why no interventions were implemented following the Resident's fall on 11/23/19 after they had to go to the hospital to have their dislocated hip reduced under anesthesia and prior to falling again and requiring further medical intervention in the hospital, the DON and Nurse O indicated they were not notified of the fall. No further explanation was provided. Resident #51 On 1/14/20 at 12:40 PM, Resident #51 was observed in their room with the door closed. The Resident was laying in bed at an angle with their feet hanging off the side of the bed and a blanket covering their head. An untouched food tray was observed on a table next to their bed. Record review revealed Resident #51 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required limited assistance to perform Activities of Daily Living (ADL). The medical record further revealed the Resident had been deemed incompetent and had a legal Guardian. Review of Resident #51's medical record documentation revealed the following: -1/3/20 at 10:28 PM: Health Status Note . Resident on floor in room at 6:15 pm calling out for help face down on the ground near the window. A set of vitals were gathered BP (Blood Pressure) 141/110 . Resident has a lump and red spot on rt (right) side of forehead complains of pain in rt (right) hip and rt (right) shoulder. Rt shoulder was bulging and swollen. ROM (Range of Motion) was assessed. Residents ROM was very limited but was able to wiggle fingers but not able to lift arm or move it without yelling out in pain. Ice was applied to the affected shoulder and resident was given PRN (as needed) pain meds. Physician was contacted order was given to send the resident to the hospital, transferred . at 7:15pm. Guardian service was contacted no answer a message was left. DON messaged via Tiger text. -1/5/20 at 1:11 PM: Health Status Note . Resident arrived from Hospital around 13.30 via EMS. Resident dx (diagnosis): Fracture to R (right) humeral. Patient alert, denies pain on assessments . On 1/14/20 at 1:50 PM, Resident #51's room door was closed. Upon knocking and entering the room, Resident #51 was observed in bed with a blanket over their head. The Residents feet were hanging sideways off the bed at an angle. Record review of facility provided Incident and Accident Reports for Resident #54 revealed the Resident had four unwitnessed falls in their room since (MONTH) 2019. Detailed review revealed the following: -1/3/20 at 6:04 PM: Location: Resident's Room . Description: Resident on floor face down next to bathroom calling out for help. Resident complained of pain in right shoulder and right hip. Right shoulder was bulging and swelling . Resident Description: ' fell please help me up' Predisposing Physiological Factors . Gait Imbalance . Ambulating without assist . -9/23/19 at 1:50 PM: Location: Resident's Room . Description: Nurse was called into Residents private room, nurse writer observed patient sitting on the floor, one shoe appeared close by on the floor and walker adjacent . -4/30/19 at 6:45 PM: Location: Resident's Room . Description: writer was called to room. Resident was lying on the floor . right side, facing the fall . -4/14/19 at 9:00 PM: Location: Resident's Room . Description: Observed the client on the floor at the foot of bed, rolling walker was behind them . Resident Description: Resident Unable to give description . On 1/16/20 at 1:00 PM, Resident #51 was observed in the hallway of the facility in a wheelchair. The Resident's right arm was positioned in a sling. An interview was conducted with the Resident at this time. When queried what happened, Resident #51 revealed they fell in their room. When queried if they were having pain, Resident #54 replied, It really hurts. An interview was conducted with the facility Director of Nursing (DON) and Nurse O on 1/16/20 at 2:37 PM. When queried regarding Resident #51's fall within the facility and interventions in place to prevent falls, Nurse O indicated Resident # care plans are updated following incidents. Resident #51's care plan was reviewed with the DON and Nurse O at this time. The care plan was titled, Resident has a history of falls r/t (related to) balance problems (Initiated: 9/21/17; Revised: 10/16/18). The care plan included the following interventions: -Anticipate and meet Resident's needs (Initiated and Revised: 10/16/18) -Be sure call light in within reach and encourage Resident to use it for assistance as needed (Initiated: 4/16/18; Revised: 11/2/18) -Ensure Resident is wearing appropriate footwear, non-skid socks when ambulating (Initiated: 4/16/18; Revised: 10/16/18) -Ensure well-lit, clutter free environment (Initiated: 1/4/20) -Resident re-educated on the use of walker (Initiated: 4/16/18; Revised: 10/16/18) -Visual checks Q (every) 30 minutes (Initiated: 1/7/20) When queried regarding the conditions and/or circumstances surrounding the Resident's fall on 1/3/20 and if planned interventions were in place, Nurse O and the DON revealed they did not complete an investigation pertaining to the fall. When queried how they were able to implement meaningful interventions to prevent falls if they did not know the circumstances surrounding the fall, Nurse O and the DON did not provide an explanation. When asked about interventions implemented following the Resident's previous unwitnessed falls within the facility when the care plan interventions and revision dates did not correlate with the falls, Nurse O indicated interventions are implemented that best fit the Resident. Review of facility provided policy/procedure entitled, Care Plan (Dated: 10/19) revealed, Our facility develops a comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs . The comprehensive care plan has been designed to: a. Incorporate identified problem areas .d. Reflect treatment goals and objectives in measurable outcomes . f. Prevent declines in the resident's functional status and/or functional levels . 6. Care plans are revised as changes in the resident's condition dictate . A policy/procedure pertaining to falls was requested on 1/15/20 but not received by the conclusion of the survey. Deficient Practice #2. Based on observation, interview, and record review, the facility failed to ensure adequate supervision of an ambulatory and confused resident (R#69), of eight reviewed for accidents/hazards, resulting in the resident acquiring a box cutter from an unknown source and the potential for accidental or intentional harm of self or others. Findings include: On 1/14/20 at 12:10 PM, R#69 was observed independently wandering in the 300 dining room area. The resident presented with a frustrated look on their face, mumbled something to themselves, and proceeded to wander to the 300 hallway of rooms. A review of R#69's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was admitted into the facility on [DATE], and was severely cognitively impaired with medical [DIAGNOSES REDACTED]. Further review revealed the resident was independently ambulatory with staff oversight and required limited assistance from staff for activities of daily living (ADLs), and the resident was noted to have wandering behaviors. A review of R#69's medical record revealed the following: 6/2/2019 10:21 (AM) Behavior Note Behavior Observed: Writer was coming out of another residents room when resident (R#69) walked up to writer and pulled a box cutter out. Resident was swinging (their) arm yelling you (expletive), I'm white. Writer then shouted for help and went behind resident and pulled the box cutter .from residents hand. Resident continued to scream stay out of (their) room. Writer was able to remove box cutter from resident hands with no injuries present. Antecedent to Behavior: Non-pharm. Interventions/Effectiveness: Pharm. Interventions/Effectiveness: (blank) Interventions Attempted: (blank) Residents' Response to Interventions: (blank) Additional Information: (blank). Signed by Nurse [NAME] 6/4/2019 13:32 (1:32 PM) Social Service Note D[NAME]UMENT QUARTERLY/ANNUAL NOTE, RESIDENT ISSUES/CONCERNS and FOLLOW-UP, ROOM CHANGES: This writer followed up with IDT (interdisciplinary team) today and observed the item that resident had in (their) possession. It was unsure of where resident had obtained the item but (they were) unable to open it. Per staff, resident had appeared agitated because (they were) worried about some of (their) items. (R#69) reacted poorly and staff reported they kept checking .after the incident and (R#69) did not recall lashing out or even having the item that was retrieved from (them). Staff reported resident was not in any distress after and was cooperative. This writer will follow up with family to discuss behavior. Signed by Social Worker (SW) C. 6/5/2019 21:04 (9:04 PM) Social Service Note: This writer contacted resident's (family) today and reviewed information obtained from IDT about resident's behavior over the weekend. This writer notified (them) that it is unsure where resident obtained the item but that (R#69) has not been in much distress since that time and that (they) forgot about the incident 10 minutes after . On 1/15/20 at 3:14 PM, SW C and SW D were interviewed regarding the incident involving R#69 on 6/2/19. SW C stated, We don't know where they got a hold of the box cutter. I honestly don't know if it was one from the facility, it was a smaller one, about an inch wide. SW D stated, (R#69) has had episodes of behaviors up and down, they like to wander through rooms and search through items. The difficult part is the resident has no ability to recall and no sense of understanding what they're doing. (R#69) is redirectable, but 5-10 minutes passes and they will be unable to recall anything that happened and will go about something different in a very pleasant way. On 1/16/20 at 8:57 AM, the Director of Nursing (DON) was interviewed regarding R#69 obtaining a box cutter and threatening staff. The DON stated, I wasn't here because it was the weekend. The nurse (A) called me and said the resident got the box cutter, it was not opened, it was just regular one that they picked up. It wasn't open but (R#69) was holding it and I'm not sure if they were swinging it, but the nurse was able to take it away from them. The patient was calling the staff (derogatory terms). When asked if the resident got the box cutter from another resident's room, the DON stated, (R#69) did not get it from another resident's room. When I did the investigation, it was on a tray somewhere on the nurse's station. The resident is ambulatory all over the place and sometimes just walks around. The DON was then asked if the box cutter was left out somewhere in the open and responded, I'm not sure where the location was of that. I just know that when the nurse called me they said (R#69) had a box cutter but wasn't open. And they got it away from (the resident) and nothing happened. (R#69) had it and was yelling (expletives). On 1/16/20 at 9:20 AM, an attempt was made to contact Nurse A, however the number was non-working. Another contact number was unable to be obtained as the nurse no longer works at the facility. On 1/16/20 at 10:48 AM, Nurse Supervisor B and Nurse H were queried regarding the incident involving R#69. Nurse B stated, I want to say it was a weekend, I was up in the front in the main dining area, then I was informed about this box cutter. Apparently (R#69) pulled it out and I don't remember if they were actually coming after the nurse with it, but the nurse got it away. I went with (R#69) into their room after to see if they had anything else, any other kind of weapon, and the resident went with me. They were fine after that and didn't even recall the incident. I have no idea where the box cutter came from. Nurse H added, I don't know where the box cutter came from. I didn't see the resident take it but I saw the act of the nurse taking the box cutter out of the resident's hand. The blade wasn't out and the box cutter looked rusty and old. On 1/16/20 at 10:56

Based on observation, interview and record review, the facility failed to ensure that foot care and proper footwear were provided for one resident (R50), resulting in the resident having continued pain in both the left and right feet and the potential for further decline in mobility. Findings include: On 11/8/18 at 10:00 AM, during a Confidential Group Meeting, R50 stated that both of their feet were hurting due to not having Orthopedic shoes. The resident stated that their feet are flat, and as a result of their shoes not fitting correctly, they have, Red ridges on their toes, from trying to hold on to their shoes while they walk. The resident also reported that they have a history of falling as a result of their improperly fitting shoes. R50 was observed to be using a walker to ambulate throughout the facility. On 11/8/18 at 10:50 AM, The Social Services Manager was asked about R50's complaint about foot pain, and the need for better fitting shoes. The Social Services Manager stated, The guardian stated that R50 doesn't have any money for shoes, and the podiatrist will not prescribe R50 orthopedic shoes because they are not Diabetic. We'll have to look into other resources. On 11/8/18 at 3:00 PM, a review of the Electronic Health Record (EHR) revealed that R50 was admitted into the facility on [DATE] with the following Diagnoses: [REDACTED]. On 11/9/18 at 9:49 AM, R50 was asked how they were doing and stated, My feet hurt. I have corns and calluses because the shoes are too big. I complain all the time about my feet but no one listens. I've told the nurses, everybody. I cry so much because they are so painful. I have put paper in my shoes to prevent them from sliding back and forth but it didn't work. My previous guardian would not assist me with new shoes because they said that I didn't have any money. R50's shoes did appear too large for their feet, and when they voluntarily took off their shoes and socks, their feet appeared red in color as if they had been rubbing against their shoes, the soles of their feet appeared flat, with obviousy bony prominences at the arches of their feet. Their toes appeared abnormally bent and crooked. On 11/9/18, further review of the EHR was conducted and revealed the following, On 7/19/18, Resident c/o (complained of) 10/10 pain at left foot anterior. MD (Medical Doctor) notified in-person. A physician note stated that on 7/23/18, Pt (patient) seen per pt report of left foot pain . Upon assessment, pt admits to pain in left great toe. (R50) states that they always had 'trouble' with their feet. Fall risk: 6/2018 (high). Pt with corns at great toes bilaterally. Left posterior crease of great toe with skin split. D/W (discussed with) social work, pt is on list to be seen by podiatry at next visit. On 7/30/2018, a Physician note stated, Pt seen in follow-up for multiple medical problems and to assess management of pain . Pt also c/o pain in the arches of feet and soreness of toenails. R50's was seen over a month later from their admitted for their Podiatrist appointment. The Podiatrist Visit Summary stated, Musculoskeletal Right: Abnormal-Decreased ROM (Range of Motion) and muscle strength, contracted digits, Hallux Valgus (Bunion). Musculoskeletal Left: Same as Right. Care Plan: S/S (signs and symptoms) of [MEDICAL CONDITION] ([MEDICAL CONDITION], blocked blood vessels which may cause foot pain). Discussed with patient/nurse importance of proper diet and exercise, and proper footcare/footware. Further review of the EHR revealed that on 8/27/2018, Pt seen in follow-up for multiple medical problems. (R50) states the top of left foot is hurting. On 10/25/2018, (R50) c/o pain in feet, knees, hands and back. (R50) shoes are too big and rubbing against toes when (R50) walks. (R50) has not taken anything for pain yet Called social work regarding pt's orthopedic shoes being too large. They will work on getting (R50) a smaller pair. On 10/16/2018, R50 was seen for Podiatry Services. The need for R50 to obtain better footware was not addressed. Continued review of the the EHR revealed that on 10/30/2018, a Nursing Skin Assessment described the following findings: Red area on all four toes on (R) foot. Interventions and preventative measures: lotion applied and had resident change shoes. On 11/6/2018, A Health Status Note Text stated, Resident complains of both feet hurting relating to bunion on feet, (R50) states their shoes don't fit comfortably, S.S (social services) notified via tiger text. On 11/6/2018, another Nursing Skin Assessment described their findings, Pt states that they have some redness on toes, it was reported to S.S. (social services) to follow up with for shoes. On 11/09/18 at 11:34 AM, The Director of Nursing (DON) was asked what steps should be taken if a resident is complaining of foot pain, and stated, When a resident complains of pain, I call the podiatrist as needed, and whatever they recommend we get it. When asked about residents not having the necessary funds to purchase orthopedic shoes, the DON stated, We would usually just get it. Central supply will get it from our own funds. On 11/09/18 at 12:54 PM, The Administrator was asked how the facility handles a resident complaining of foot pain, and stated, It should be assessed right away, and if a referral needs to be made to a podiatrist, it should be made. Review of the facility's Podiatry Services policy revised 10/18 revealed, Residents will receive podiatry care as needed to help promote optimal health.

Based on observation, interview and record review, the facility failed to implement and make operational a planned Restorative Nursing Program and failed to provide appropriate assessment, services, documentation, and treatment to maintain or improve mobility for 2 (#'s 12 and 41) of 5 sampled residents reviewed for Range of Motion (ROM), from a total sample of 27, resulting in lack of documentation of contractures, lack of Restorative Nursing Services to prevent functional decline, diminished mobility, and unnecessary, increased pain. Findings include: Resident #12 On 2/13/18 at 6:54 AM, Resident #12 was observed sitting their wheelchair in their room. A blue colored lower extremity brace was observed in the Resident's room. The brace was sitting on top of a stationary chair in the room and not on the Resident. An interview was attempted to be completed at this time. The Resident was pleasant but experienced difficulty with effective verbal communication. The Resident indicated Yes or No when asked questions and occasionally repeated words and sounds in an attempt to communicate. On 2/13/18 at 10:45 AM, Resident #12 was observed in their room. The Resident was lying in bed, positioned on their back. The blue colored lower extremity brace was in the same position on top of the stationary chair in the room and not on the Resident. On the wall, near the right side of the head of the Resident's bed, documents were observed clipped on the wall. Review of the documents revealed instructions for the Resident's nursing assistants to apply the lower extremity leg brace in the morning and remove in the afternoon when the Resident was in bed. Record review on 2/13/18 at 1:30 PM revealed Resident #12 was initially admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired, required extensive to total assistance to perform Activities of Daily Living (ADL's), and had functional limitation in ROM in one side of both their upper and lower extremities. Review of Resident #12's care plans at this time revealed the following care plans related to the Resident's ROM: I have an ADL Self Care Performance Deficit r/t (related to) right side weakness (Initiated: 12/13/16; Revised: 12/14/16). Care plan interventions included: -My RUE sling is to be worn for transfers only (Initiated: 3/24/17) -TRANSFER: I require 1 person for transfer from bed to chair and back again on modified scoot/sit transfer with arm rest swung back; 2nd person to hold the right leg due to [DIAGNOSES REDACTED] (Initiated: 1/24/18) I have limited physical mobility r/t right sided weakness/[DIAGNOSES REDACTED] (Initiated: 5/31/17; Revised: 1/30/18). Care plan interventions included: -I wear a right knee brace in the morning while in bed and when seated in my w/c (wheelchair). Remove brace for all transfers. After noon shift to remove brace for the day. Check skin integrity and report any abnormalities to the Nurse (Initiated: 1/30/18) On 2/14/18 at 1:25 PM, Resident #12 was observed in their room. The Resident was lying in bed, positioned on their back. The blue colored lower extremity brace was in the same position on top of the stationary chair in the room and not on the Resident. An interview was completed with the Director of Nursing (DON) on 2/15/18 at 9:14 AM. When queried regarding the Restorative Nursing program within the facility, the DON stated, Restorative starts as a referral from PT (Physical Therapy) or OT (Occupational Therapy). The Restorative CNA (nursing assistant) does the documentation). The floor (staff) weren't doing it. We are working on education. There is definitely a knowledge deficit related to active, passive, and active assist ROM. When queried if Resident #12 was receiving Restorative Nursing, the DON reviewed the medical record and stated, No. With further inquiry regarding Resident #12's lower extremity brace and observations of the brace not being in place, the DON reviewed the medical record and indicated (Nurse E) would be able to provide additional information. An interview was completed with the DON and Nurse E at this time. With inquiry regarding Restorative Nursing services and Resident #12's lower extremity brace, Nurse E stated, (Resident #12) just has it on the TAR (Treatment Administration Record) for the brace. Observation of Resident #12 in their room occurred on 2/15/18 at 10:24 AM. The Resident was lying in bed and positioned on their back. The Resident had a splint in place to their right hand and arm. The splint was observed to be positioned incorrectly with the Resident's hand noted to be outside of the brace securement strap on the lateral side. The blue colored lower extremity brace was noted on top of the stationary chair in the room and not on the Resident. Nursing Assistant F entered the Resident's room at this time and an interview was completed. When queried regarding Resident #12's lower extremity brace, Nursing Assistant F stated, We (staff) can't put the brace on because (Resident #12) cries out in pain. Nursing Assistant F proceeded to uncover the Resident enabling observation of their leg. The Resident was positioned in bed on their back. Their right leg was positioned with the knee bent at approximately a 130 degree angle. When Nursing Assistant F touched the Resident's right lower leg in an effort to reposition their leg, the Resident began yelling out No, no, no and displaying facial grimacing. When queried if the Resident's leg had a contracture, Nursing Assistant F replied, Yes. When asked if the contracture to the Resident's leg had gotten worse, Nursing Assistant F stated, Oh yes. Nursing Assistant F proceeded to state, They (Facility Administration) said we are getting a cite for not putting the brace on (Resident #12) but it's too painful (for the Resident) to put it (brace) on. (Resident #12's) leg won't bend that far. At 10:51 AM on 2/15/18, observation of Resident #12's wound care treatment occurred with Nurse G. Prior to the treatment, the Resident was observed positioned on their back in bed. A brace was noted on their right hand and arm. The blue colored lower extremity brace was noted on top of the stationary chair in the room and not on the Resident. The Resident's right leg was positioned with the knee bent at approximately a 130 degree angle. Nurse G was observed turning the Resident onto their right side to complete the treatment. Resident #12 yelled out and facial grimacing was observed when they were repositioned with movement to their right upper and lower extremities. The Resident's right leg remained bent at the knee at approximately a 130 degree angle when lying on their side for the treatment. After the treatment was completed, Nurse G repositioned the Resident so they were lying on their back with their right leg bent at approximately a 130 degree angle at their knee. During repositioning, Resident #12 was observed yelling out and displayed facial grimacing with movement to their right upper and lower extremities. An interview was completed with Nurse G at this time. When queried regarding Resident #12's leg, Nurse G stated It is contracted. With further inquiry, Nurse G stated, Yes, it's gotten worse. With inquiry regarding the Resident's pain management, Nurse G indicated the Resident receives Tylenol. Review of Resident #12's Medication Administration Record (MAR) on 2/15/18 at 12:05 PM revealed the Resident was receiving the following medications for pain: -[MEDICATION NAME] (medication used to treat nerve pain) 300 milligrams (mg); Three times a day (Start Date: 1/23/18) -Tylenol 650 mg; Every 6 hours (Start Date: 12/11/17) Additional review of the MAR at this time revealed an area of documentation entitled, Check skin under right knee brace when brace is removed. Notify Doctor and Treatment Nurse of any abnormalities. Every evening shift for skin care (Start Date: 1/31/18). No documentation indicating brace removal was completed on 2/5/18, 2/10/18, and 2/11/18. On 2/15/18 at 12:10 PM, record review revealed Resident #12's Treatment Administration Record (TAR) did not include any Restorative Nursing and/or brace application/removal treatment. An interview was completed with Therapy Manager Speech Therapist H on 2/15/18 at 1:12 PM. When queried regarding Resident #12, Speech Therapist H stated, (The Resident) was picked up in August 2017 for decreased functional ability, decreased mobility, pain, and increased assistance with transfers. Speech Therapist H further stated, (Resident #12) was discharged (from therapy) on 1/24/18 to Restorative with an active ROM plan and a brace. When queried regarding Resident #12 having contractures and documentation of degree of flexion and/or extension in the Resident's extremities, Speech Therapist H stated measurements were not completed. Review of PT (Physical Therapy) Daily Treatment Note documentation for Resident #12 at this time revealed, -1/23/18: Pt (Patient) completed omni cycle for 15 mins (minutes) for joint mobility. Strength; prolonged stretch to the right knee flexor for knee brace application. LLE (Left Lower Extremity) strengthening with 2 pounds weight X 20 reps all planes; no signs of pain today as brace was taken off and donned before and after the omni cycle. -1/31/18: Pt has tolerated knee brace with 20 degrees extension and/or knee flexion. Therapy notes further indicated education was provided to facility staff regarding brace application. On 2/15/18 at 2:00 PM, an observation of Resident #12 and an interview was completed with Physical Therapist I and Occupational Therapist J. Upon entering the Resident's room, the Resident was lying in bed positioned on their back. The Resident no longer had the splint in place on their right upper extremity. The blue colored lower extremity brace was noted on top of the stationary chair in the room and not on the Resident. When queried regarding the brace, Therapist J stated, (The Resident needs to wear it. It only takes two or three days to become tight again. The Resident's right leg was observed bent at the knee at approximately a 130 degree angle. At this time, Therapist I then slowly stretched the Resident's leg and was able to extend the Resident's right lower leg to approximately 45 degrees. On 2/15/18 at 2:34 PM, an interview was completed with Therapy Manager Speech Therapist H. When queried regarding Resident #12 and Restorative, Speech Therapist H stated, (Resident #12) was supposed to be working with Restorative. Record review at this time of facility provided documentation for Resident #12 entitled Restorative Orders revealed two order sheets, one dated 1/26/18 and one dated 1/26/17. When queried regarding the Restorative Orders sheet dated 1/26/17, Speech Therapist H indicated the date written on the order form was an error and stated, These were the orders for Restorative when (Resident #12) was discharged from therapy on 1/24/18. Reveal of the Restorative Orders occurred with Speech Therapist H at this time. The Restorative Orders indicated the following: -Restorative Nursing Plan: . Problem/Need: Joint range and strength. Goal: 3 X wk X 8 wks (three times a week for eight weeks). Intervention: 1. Omni cycle for 15 minutes at level 0 to 1; 2. LLE strengthening exercises with 2 pound weights x 3 reps all planes; 3. PROME (Passive Range Of Motion Exercises) x 20 reps all planes; 4. Right knee flexors stretching with 5 seconds hold to repeat 10 times. -Problem/Need: Right knee [DIAGNOSES REDACTED]. Goal: Maintain RLE (Right Lower Extremity) knee extension via knee brace, in order to enhance ROM and maintain joint integrity. Intervention: Resident to wear right knee brace in morning while in bed and seated in wheelchair. Remove brace for all transfers. Afternoon shift to remove brace for the day. Resident #41 On 2/13/18 at 6:45 AM, Resident #41 was observed in lying in bed in their room. The Resident was positioned on their back. The Resident's left hand and fingers were observed to be in a contorted shape with limited ROM. Both of the Resident's feet were pointed downward and away from the Resident's head at approximately a 170 degree angle. The Resident was pleasantly confused and did not provide meaningful answers to all questions but did move their fingers small amounts when asked. When asked if they could move their toes, the Resident did not move their move toes. On 2/13/18 at 10:38 AM, Resident #41 was observed sitting in a broda chair (wheeled, reclining, high back chair with rest/base for lower extremities). The Resident's hands were contorted and their feet were pointed away from their head at approximately a 170 degree angle. Record review on 2/13/18 at 2:20 PM revealed Resident #41 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 was severely cognitively impaired, had functional limitation in ROM in both lower extremities, and required extensive to total assistance to perform Activities of Daily Living (ADL's). The MDS further indicated the Resident had not received Restorative Nursing. Additional Review of Resident #41's facesheet revealed the following additional [DIAGNOSES REDACTED]. -Contracture, unspecified joint (8/12/14- During Stay) -Contracture, Left knee (1/9/16) -Unspecified . Fracture of humerus, right arm .Fracture with malunion (5/3/16) -Contracture, left elbow (6/1/16) -Stiffness of right hand, not elsewhere classified (3/1/17) Resident #41's care plans were reviewed at this time. Review revealed the following care plans related to ROM and contractures: I am potential for pain related to [DIAGNOSES REDACTED]. Care plan interventions included: -Assist with ADLs when needed related to limited ROM secondary to contractures of left side (Initiated: 3/14/17) I have an ADL Self Care Performance Deficit r/t (related to) Dementia and limited mobility (Initiated: 12/20/11; Revised 1/19/18). Care plan interventions included: -I am positioned with the hip abductor pillow while in supine in bed and in the Broda Chair (Initiated: 8/2/16; Revised 1/19/18). Review of Resident #41's MAR and TAR at this time revealed no areas of documentation related to Restorative Nursing activities. On 2/14/18 at 4:43 PM, Resident #41 was observed in their room. The Resident was lying in bed in their room, positioned on their back. The Resident's left hand and fingers were observed to be in a contorted shape. When asked, the Resident was able to open and extend the fingers with limited ROM observed. Both of the Resident's feet were pointed downward and away from the Resident's head at approximately a 170 degree angle. An interview was completed with Nursing Assistant P at this time. When queried if Resident #41 was receiving restorative services, Nursing Assistant P stated, (Resident #41) is not getting restorative. With further inquiry regarding staff performance of Passive Range Of Motion (PROM) exercises with the Resident, Nursing Assistant P indicated the Resident was not receiving restorative services. An interview was completed with the Director of Nursing (DON) on 2/15/18 at 8:38 AM. When queried if Resident #41 was receiving Restorative Nursing services, the DON stated, No, they are not on Restorative. When queried regarding the Resident's limited ROM in their hands and feet, the DON indicated they were unaware. An observation of the Resident occurred at this time with the DON. The Resident was sitting in their Broda chair next to a table in the dining room of the facility. The Resident's feet were pointing downward, away from their head, at approximately a 170 degree angle. An abductor pillow (wedge shaped foam pillow typically utilized following surgery to maintain proper alignment of the hip joint) was observed between the Resident's legs and strapped tightly in place preventing the Resident from moving their legs. When asked, the Resident moved their fingers but did not move their toes. An interview was conducted with Therapy Manager Speech Therapist H on 2/15/18 at 12:45 PM. When queried regarding Resident #41, Speech Therapist H stated, (Resident #41) was discharged from therapy last on 5/12/17. Speech Therapist H then stated, (The Resident) was picked up (by Therapy) for transfers. With further inquiry, Therapist H indicated Resident #41 was discharged to Restorative Nursing. Therapy documentation entitled, PT (Physical Therapy) - Therapist Progress & Discharge Summary dated 5/12/17, was reviewed with Speech Therapist H at this time. Documentation revealed the following: -End of Goal Status as of 5/12/17: Goal Met . The patient transfers bed to/from wheelchair with total assist/dependent with mesh sling; awaiting proper sling to arrive. -Goal: Goal Met on 5/12/17. The patient will perform passive range of motion as functional maintenance program with trained caregivers according to physical therapy written instructions . -Precautions: . At risk for progression of contractures . post fracture status for RUE (Right Upper Extremity) needs clarification. UE passively ranged at 50 % of range with no complaints of pain or facial grimacing while patient supine in bed. When queried regarding the abductor pillow, Speech Therapist H stated, We (Therapy) picked the Resident up in 2015 because of chair positioning. Documentation entitled, PT (Physical Therapy) - Therapist Progress & Discharge Summary dated 9/11/15 was reviewed with Speech Therapist H at this time. Therapy documentation revealed: -End of Goal Status as of 9/11/15. Goal Met. The patient exhibit hip flexion and adductors in better position while seated in geri chair during mealtimes about 60 minutes utilizing abductor pillow. -Goal: Goal Met on 9/11/15. The patient will perform passive range of motion functional maintenance program with trained caregivers according to physician therapy written instructions . When queried regarding the abductor pillow and strapping the pillow in place, Speech Therapist H stated, Therapy usually do not strap the abductor pillows for that. When queried regarding reevaluation of the abductor pillow use, Therapist H indicated the Resident was also seen by Therapy in 2016 and the pillow use was evaluated at that time. When queried if the use of the abductor pillow was evaluated when the Resident received Therapy in 2017, Therapist H stated, It is not included in the last evaluation. An interview was completed with the DON on 2/15/18 at 3:30 PM. When queried why Resident #12 and Resident #41 had not been receiving Restorative Nursing services, the DON was unable to provide and explanation. When queried regarding a facility/policy pertaining to Restorative Nursing, the DON stated, We don't have one. No further explanation was provided. A facility policy/procedure pertaining to Restorative Nursing was requested but unavailable for review.

This citation pertains to intake #MI 110. Based on interview and record review the facility failed to prevent staff to resident neglect in one of seven sampled Residents (Resident #701) reviewed for abuse/neglect, from a total sample of seven Residents resulting in an Immediate Jeopardy (IJ) when, on [DATE] at approximately 8:00 a.m., Director of Nursing (DON D) informed facility staff to not perform CPR (cardio [MEDICAL CONDITION] resuscitation) for Resident #701, who was a full code (desired all life sustaining measures), and was found to be unresponsive without vital signs. Resident #701 died on [DATE] at 8:00 a.m. The IJ was identified on [DATE] at 1:00 p.m. Although the facility removed the Immediacy on [DATE] at 4:30 p.m., based on the facility's implementation of the plan of removal as verified by the Surveyor, the facility remained out of compliance at the scope of isolated and severity of actual harm that is not immediate jeopardy. Findings include: Per the American Red Cross First Aid and Safety Handbook (2011), A person in [MEDICAL CONDITION] is unconscious, not breathing, and has no heartbeat. The Handbook revealed that a person in [MEDICAL CONDITION] will have the greatest chance of survival if there is: 1). Early access to the emergency medical services (EMS) system, 2). Early CPR, 3). Early defibrillation, and 4). Early advanced medical care. The Handbook also revealed that without early CPR and defibrillation, the chance for survival is greatly reduced. According to the State Operations Manual - SOM Appendix PP (42 CFR 488.301), Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. On [DATE] at 8:00 a.m., review of a facility reported incident filed with the State Agency documented, It was reported the resident was found unresponsive in her bed. Further documentation revealed that although R#701 was found unresponsive and without vitals, with physician orders and advance directives of Full Code, CPR was not provided and the Resident died . Review of the clinical record revealed R#701 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident had been admitted for short term skilled nursing care and therapy, with a discharge plan to return home to the community. According to the admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of [DATE], R#701 was cognitively intact (scored ,[DATE] on brief mental status exam), and participated in interviews which pertained to her care. There was no indication that the Resident was declared incompetent, which meant the Resident was competent to sign for advance directives and treatment decisions. Review of the facility form titled, Advance Care Planning Form documented with a check mark next to Yes for CPR. This form was signed by the R#701 on [DATE], and co-signed by the Attending Physician/Medical Director (Physician K) on [DATE]. Review of an Incident/Accident Report - Unusual Occurrence Form dated Sept. 12, 2017 Tuesday 8:00 AM which was completed by the Director of Nursing (Nurse D) included: .8:00 AM - A stat page was announced overhead as I entered the building. I went to 300 unit to (R#701's room). I observed R#701 in a supine position in bed with her mouth open and unresponsive to all stimuli. I assessed for a pulse, respirations and blood pressure with no vitals obtained. EMS confirmed findings. No CPR was initiated . Review of the facility's investigation included: On [DATE] at 7:50 am, resident (#701) was observed in bed in a semi-fowlers position, unresponsive to verbal/tactile stimuli and without a pulse, respirations or blood pressure by nurse (name of Licensed Practical Nurse - LPN B) with the assistance of (name of Registered Nurse - RN C). Nurse C checked the resident's code status (she was a full code), paged overhead for all nurses to respond Stat to (R#701's room) and then began to prepare transfer paperwork. (Name of Nurse D), DON was entering the facility at this time, such that she heard the overhead Stat page as she walked in and proceeded immediately to (R#701's room) where the other licensed nurses in the facility were responding to the Stat page. Nurse D assessed the resident, found that she had no pulse, respirations or blood pressure and pronounced death at 8am, which was later confirmed by EMS when they arrived . On [DATE] at 8:54 a.m., an interview was conducted with LPN B. When asked to recall the events that occurred on [DATE], LPN B responses included: R#701 was probably the fourth patient I saw. When I went in, she was sitting up in bed approximately ,[DATE] degrees, had oxygen on but I can't recall if in nose, or on face. When I saw she was slumped over, called name and no response. I stuck my head out the door and saw RN C and yelled to come down. She (RN C) rushed in and asked what was code status, and left the room. Must've called Stat cause everyone rushed in .No one said what code status was. CPR was never done. When asked what the facility's procedure is if a Resident is found unresponsive, LPN B reported, You yell for help, have to check advance directives - if see full code immediately start CPR, don't stop until 911 arrives. On [DATE] at 10:03 a.m., an interview was conducted with RN C via phone. When asked to recall the events that occurred on [DATE], RN C reported, LPN B asked to come in to R#701's room due to non-responsive. I did quick assessment before approaching - she was sitting up in bed slumped over, phone next to her on bed, phone was off hook. Nasal cannula was on (not in) nose. I put the nasal cannula back and did sternal rubs, called name, no response and directed LPN B to stay. I checked code and was full code. I paged overhead - Nurses STAT to room such and such, proceeded to print out paperwork to go with her to hospital. I asked housekeeper to go to the room to check to see if I should call 911. The reason I asked is in the event the other nurses could arouse - see if back to life. DON was walking from room and directed me not to call 911. RN C was unable to explain why CPR had not been initiated per advance directives for full code. On [DATE] at 10:15 a.m., an interview with the DON (Nurse D) was conducted. When asked about why CPR had not been provided to R#701 per physician orders and advance directives, and if any other staff had questioned her decision to withhold performing CPR, Nurse D reported, It was questioned afterwards when I left out of room. Some staff remained to do post mortem care and questioned why no CPR was started. Nurse D further reported, I do recall LPN B handed the phone to me (while on phone with 911) and was asked by EMS if CPR was done and they asked why not. I told her (EMS staff) who I was and that I had pronounced her. Nurse D was unable to explain why the decision was made to not provide CPR to R#701 per her directives. On [DATE] at 1:58 p.m., a phone interview was conducted with Physician K who confirmed he was the facility's Medical Director as well as R#701's Attending Physician. When asked about the facility's practice of emergency response when Residents are found unresponsive, Physician K reported This was the first incident I'm aware of. CPR should've been done. Physician K was unable to offer any further explanation as to why CPR had not been initiated for R#701 as required. Review of undated documentation provided by the facility titled, Section H: End of Life Care and Emergency Procedures included: .Emergency Scenario #1: The resident has No Pulse and No Respiration. This requires immediate action by implementing the following procedure - 1. Check the resident's Advance Directive/Code Status. If Do Not Resuscitate is not checked off, they are considered a Full Code .The resident's nurse is responsible for running/directing the code with the assistance of the other nurses .Initiate CPR .Continue CPR until EMS arrives and assumes responsibility for life support interventions. Once CPR has been initiated, efforts cannot be ceased by the nurses until EMS relieves them . Review of the facility policy titled, CPR-Cardiopulmonary Resuscitation dated May, 2017 documented: .Nurses and other care staff are educated to initiate CPR, as recommended by the American Heart Association (AHA) unless: A valid Do Not Resuscitate order is in place . The facility submitted the following plan to remove the immediacy on [DATE]: Element #1 Resident #701 no longer resides in the facility. Nurse B, C, D, and nurse managers have been re-educated on the CPR Policy and Emergency Procedures and the Abuse and Neglect Policy by RN Corporate nurse consultant. Debriefing regarding the incident was done on [DATE], at approx. 12:15 pm by Administrator, DRC (Director of Resident Care - Director of Nursing), RN Corporate Nurse Consultant and Medical Director. Element #2 All resident advance directives were reviewed to confirm current code status. Facility will follow all physician orders for advance directives. All Licensed Nurse files were audited to ensure they have provided proof of their current CPR certification. Element #3 The CPR Policy and Emergency Procedures were reviewed and deemed appropriate. All licensed nursing staff were re-educated on CPR Policies and Emergency Procedure by nursing management and all other nursing staff will be re-educated. Upon hire and annually all nursing staff will receive training on the facility CPR Policy and Emergency Procedures. DRC has received a memo regarding the standard of practice. Element #4 Mock codes for the licensed nurses were conducted on the day shift on [DATE] and on the afternoon and midnight shift on [DATE], by nurse managers. Mock codes for all nursing staff will be conducted weekly x 3 more weeks (rotating shifts) and monthly thereafter. Any identified issues will be corrected immediately. The Administrator/designee will be responsible for sustaining compliance and will present findings to the Quality Assurance Committee. The QA committee will receive report and direct actions as appropriate. Element #5 The Administrator is responsible to ensure these corrective measures will be fully implemented by [DATE].

This citation pertains to intake #MI 110. Based on interview and record review the facility failed to follow professional standards of nursing practice in one of seven sampled Residents (Resident #701) reviewed for code status and CPR needs, from a total sample of seven Residents resulting in an Immediate Jeopardy (IJ) when staff failed to follow physician's orders to provide CPR (cardio [MEDICAL CONDITION] resuscitation) to a Full Code (perform all life saving measures) for Resident #701 when she was found unresponsive and without vitals on [DATE] at approximately 7:50 a.m. Resident #701 died on [DATE] at 8:00 a.m. The IJ was identified on [DATE] at 1:00 p.m. Although the facility removed the Immediacy on [DATE] at 4:30 p.m., based on the facility's implementation of the plan of removal as verified by the Surveyor, the facility remained out of compliance at the scope of isolated and severity of actual harm that is not immediate jeopardy. Findings include: According to the Code of Ethic for Nurses (American Nurses Association, 2001, pg. 14), the nurse's primary commitment is to the health, well-being, and safety of the patient. The nurse must take appropriate action regarding any instances of incompetent, unethical, illegal, or impaired practice by any member of the health care team. The Code of Ethics for Nurses (pg. 17) goes on to state the nurse is accountable to the quality of nursing care given to patients and the delegation of nursing care activities of other health care workers. The nurse is responsible for monitoring the activities of these individuals and evaluating the quality of the care provided. On [DATE] at 8:00 a.m., review of a facility reported incident filed by the State Agency documented, It was reported the resident was found unresponsive in her bed. Further documentation revealed that although R#701 was found unresponsive and without vitals, with physician orders and advance directives of Full Code, CPR was not provided and the Resident died . Review of the clinical record revealed R#701 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident had been admitted for short term skilled nursing care and therapy, with a discharge plan to return home to the community. According to the admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of [DATE], R#701 was cognitively intact (scored ,[DATE] on brief mental status exam), and participated in interviews which pertained to her care. There was no indication by two Physicians that the Resident was declared incompetent, which meant the Resident was competent to sign for advance directives and treatment decisions. Review of the facility form titled, Advance Care Planning Form documented with a check mark next to Yes for the following choices CPR, Artificial Hydration, Artificial Nutrition, and Diagnostic Testing. This form was signed by the R#701 on [DATE], and co-signed by the Attending Physician/Medical Director (Physician K) on [DATE]. Review of an Incident/Accident Report - Unusual Occurrence Form dated Sept. 12, 2017 Tuesday 8:00 AM which was completed by the Director of Nursing (Nurse D) included: 8:00 AM - A stat page was announced overhead as I entered the building. I went to 300 unit to (R#701's room). I observed R#701 in a supine position in bed with her mouth open and unresponsive to all stimuli. I assessed for a pulse, respirations and blood pressure with no vitals obtained. EMS confirmed findings. No CPR was initiated . On [DATE] at 10:15 a.m., during an interview with the Director of Nursing (Nurse D), when asked if she believed she was working in the scope of practice for nursing when she directed staff to not perform CPR, Nurse D did not answer the question but responded, If it makes it any better I feel real bad. No further explanation was provided when asked to clarify why CPR had not been provided for a Resident unresponsive and without vitals, and had advance directives for full code. On [DATE] at 11:00 a.m., review of the documentation provided by the Administrator included re-education to Nurse D on the facility's CPR Policy and Emergency Code Procedure on [DATE] and a written statement dated [DATE] signed by Nurse D which documented, I entered the building at 8:00 am and as I was entering my office, a stat page was announced overhead. I immediately went to the 300 unit to room (R#701's room). Upon entering the room, Resident (name of R#701) was observed to be unresponsive in bed in a supine position. The HOB (head of bed) was slightly elevated to a 30 degree angle. The resident's mouth was open and skin color was a yellow hue in appearance. I lifted the residents head slightly to center it as it was turned to the side. There was no carotid or radial pulse, unable to obtain respirations as I placed my hand over the resident's chest to monitor for chest rise and fall, also unable to obtain a blood pressure. This was confirmed when EMS arrived; however CPR was not initiated. Review of the facility policy titled, CPR-Cardiopulmonary Resuscitation dated May, 2017 documented: .Nurses and other care staff are educated to initiate CPR, as recommended by the American Heart Association (AHA) unless: A valid Do Not Resuscitate order is in place . Review of additional undated/untitled documentation provided by the facility identified: .Emergency Care and Treatment without a DNR Order - If the resident does not have a DNR Order and a medical emergency arises, we will initiate measures to assure the resident receives the emergency medical care necessary, which may include: 1. Initiate CPR if the resident has stopped breathing or has other indicators of the need for CPR. 2. Call 911 and transfer to acute care hospital without prior notice to family of physician if condition is life threatening . The facility submitted the following plan to remove the immediacy on [DATE]: Element #1 Resident #701 no longer resides in the facility. Nurse B, C, D, and nurse managers have been re-educated on the CPR Policy and Emergency Procedures and the Abuse and Neglect Policy by RN Corporate nurse consultant. Debriefing regarding the incident was done on [DATE], at approx. 12:15 pm by Administrator, DRC (Director of Resident Care - Director of Nursing), RN Corporate Nurse Consultant and Medical Director. Element #2 All resident advance directives were reviewed to confirm current code status. Facility will follow all physician orders for advance directives. All Licensed Nurse files were audited to ensure they have provided proof of their current CPR certification. Element #3 The CPR Policy and Emergency Procedures were reviewed and deemed appropriate. All licensed nursing staff were re-educated on CPR Policies and Emergency Procedure by nursing management and all other nursing staff will be re-educated. Upon hire and annually all nursing staff will receive training on the facility CPR Policy and Emergency Procedures. DRC has received a memo regarding the standard of practice. Element #4 Mock codes for the licensed nurses were conducted on the day shift on [DATE] and on the afternoon and midnight shift on [DATE], by nurse managers. Mock codes for all nursing staff will be conducted weekly x 3 more weeks (rotating shifts) and monthly thereafter. Any identified issues will be corrected immediately. The Administrator/designee will be responsible for sustaining compliance and will present findings to the Quality Assurance Committee. The QA committee will receive report and direct actions as appropriate. Element #5 The Administrator is responsible to ensure these corrective measures will be fully implemented by [DATE].

This citation pertains to intake #MI 110. Based on interview and record review the facility failed to follow physician's orders and advanced directives to provide CPR (cardio [MEDICAL CONDITION] resuscitation) in one of seven sampled Residents (Resident #701), reviewed for advanced directives, from a total sample of seven residents, resulting in an Immediate Jeopardy (IJ) when staff failed to provide CPR to Resident #701, who was deemed a full code (provide CPR if a patient's heart stops beating or if the patient stops breathing), on [DATE] at approximately 7:50 a.m., when Licensed Practical Nurse (LPN B) found Resident #701 to be unresponsive and CPR was not performed. Resident #701 died on [DATE] at 8:00 a.m. The IJ was identified on [DATE] at 1:00 p.m. Although the facility removed the Immediacy on [DATE] at 4:30 p.m., based on the facility's implementation of the plan of removal as verified by the Surveyor, the facility remained out of compliance at the scope of isolated and severity of actual harm that is not immediate jeopardy. Findings include: According to the Fundamentals of Nursing (Potter and Perry, 6th ed., 2005), [MEDICAL CONDITION] is characterized by an absence of pulse and respiration. If the nurse determines that the client has had a [MEDICAL CONDITION], cardiopulmonary resuscitation (CPR) must be initiated. CPR is a basic emergency procedure of artificial respirations and manual external cardiac massage. Nurses must obey the orders of the physician in charge of a patient, unless an order would lead a reasonable person to anticipate injury if it were carried out, according to Creighton in Law Every Nurse Should Know, 5th Edition, page 98. On [DATE] at 8:00 a.m., review of a facility reported incident filed with the State Agency documented, It was reported the resident was found unresponsive in her bed. Further documentation revealed that although R#701 was found unresponsive and without vitals, with physician orders and advance directives of Full Code, however CPR was not provided and the Resident died . Review of the clinical record revealed R#701 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident had been admitted for short term skilled nursing care and therapy, with a discharge plan to return home to the community. According to the admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of [DATE], R#701 was cognitively intact (scored ,[DATE] on brief mental status exam), and participated in interviews which pertained to her care. There was no indication that the Resident was declared incompetent, which meant the Resident was competent to sign for advance directives and treatment decisions. Review of the facility form titled, Advance Care Planning Form documented with a check mark next to Yes for CPR. This form was signed by the R#701 on [DATE], and co-signed by the Attending Physician/Medical Director (Physician K) on [DATE]. Review of an Incident/Accident Report - Unusual Occurrence Form dated Sept. 12, 2017 Tuesday 8:00 AM which was completed by the Director of Nursing (Nurse D) included: .8:00 AM - A stat page was announced overhead as I entered the building. I went to 300 unit to (R#701's room). I observed R#701 in a supine (lying facing upward) position in bed with her mouth open and unresponsive to all stimuli. I assessed for a pulse, respirations and blood pressure with no vitals obtained. EMS confirmed findings. No CPR was initiated . Review of the facility's investigation included: On [DATE] at 7:50 am, resident (#701) was observed in bed in a semi-fowlers position (position of a person who is lying in bed in a semi-upright position), unresponsive to verbal/tactile stimuli and without a pulse, respirations or blood pressure by nurse (name of Licensed Practical Nurse - LPN B) with the assistance of (name of Registered Nurse - RN C). Nurse C checked the resident's code status (she was a full code), paged overhead for all nurses to respond Stat to (R#701's room) and then began to prepare transfer paperwork. (Name of Nurse D), DON was entering the facility at this time, such that she heard the overhead Stat page as she walked in and proceeded immediately to (R#701's room) where the other licensed nurses in the facility were responding to the Stat page. Nurse D assessed the resident, found that she had no pulse, respirations or blood pressure and pronounced death at 8am, which was later confirmed by EMS when they arrived . On [DATE] at 8:54 a.m., an interview was conducted with LPN B who was currently working in the facility. When asked to recall the events that occurred on [DATE], LPN B reported, Got here (at facility) about 6:30, 6:35 (a.m.) and got report from the day nurse (LPN H) .Started med pass approximately 7:15, 7:30 ish (name of R#701) was probably the fourth patient I saw. When I went in, she was sitting up in bed approximately ,[DATE] degrees, had oxygen on but I can't recall if in nose, or on face. When I saw she was slumped over, called name and no response. I stuck my head out the door and saw RN C and yelled to come down. She (RN C) rushed in and asked what was code status, and left the room. Must've called Stat cause everyone rushed in .No one said what code status was. CPR was never done. When asked what the facility's procedure is if a Resident is found unresponsive, LPN B reported, You yell for help, have to check advance directives - if see full code immediately start CPR, don't stop until 911 arrives. When asked why CPR had not been initiated per physician order and advance directives, LPN B reported, Nurse 'D' came in and said she's gone. No one else said anything regarding resuscitation. After I called 911, wasn't more than ,[DATE] minutes (after finding R#701 unresponsive) EMS came quick maybe seven minutes or less. I wasn't in the room when they arrived. Nurse D pronounced her death. I called her family - husband, daughters and granddaughter. On [DATE] at 10:03 a.m., an interview was conducted with RN C via phone. When asked to recall the events that occurred on [DATE], RN C reported, I was getting Residents ready for breakfast. LPN B asked me to come into R#701's room due to non-responsive. I did quick assessment before approaching - she was sitting up in bed slumped over, phone next to her on bed, phone was off the hook. Nasal cannula was on (not in) nose. I put the nasal cannula back and did sternal rubs, called name, no response and directed LPN B to stay. I checked code and was full code. I paged overhead - Nurses STAT to room such and such, proceeded to print out paperwork to go with her to hospital. I asked housekeeper to go to the room to check to see if I should call 911. The reason I asked is in the event the other nurses could arouse - see if back to life. DON (Nurse D) was walking from room and directed not to call 911. RN C was unable to explain why CPR had not been initiated per physician orders and advance directives. Review of the facility policy titled, CPR-Cardiopulmonary Resuscitation dated May, 2017 documented: This facility will provide basic life support, including CPR .when a resident requires such emergency care, prior to the arrival of emergency medical services, subject to a physician order and resident choice indicated in the resident's advance directives . Review of additional undated/untitled documentation provided by the facility identified: .Emergency Care and Treatment without a DNR Order - If the resident does not have a DNR Order and a medical emergency arises, we will initiate measures to assure the resident receives the emergency medical care necessary, which may include: 1. Initiate CPR if the resident has stopped breathing or has other indicators of the need for CPR. 2. Call 911 and transfer to acute care hospital without prior notice to family of physician if condition is life threatening . The facility submitted the following plan to remove the immediacy on [DATE]: Element #1 Resident #701 no longer resides in the facility. Nurse B, C, D, and nurse managers have been re-educated on the CPR Policy and Emergency Procedures and the Abuse and Neglect Policy by RN Corporate nurse consultant. Debriefing regarding the incident was done on [DATE], at approx. 12:15 pm by Administrator, DRC (Director of Resident Care - Director of Nursing), RN Corporate Nurse Consultant and Medical Director. Element #2 All resident advance directives were reviewed to confirm current code status. Facility will follow all physician orders for advance directives. All Licensed Nurse files were audited to ensure they have provided proof of their current CPR certification. Element #3 The CPR Policy and Emergency Procedures were reviewed and deemed appropriate. All licensed nursing staff were re-educated on CPR Policies and Emergency Procedure by nursing management and all other nursing staff will be re-educated. Upon hire and annually all nursing staff will receive training on the facility CPR Policy and Emergency Procedures. DRC has received a memo regarding the standard of practice. Element #4 Mock codes for the licensed nurses were conducted on the day shift on [DATE] and on the afternoon and midnight shift on [DATE], by nurse managers. Mock codes for all nursing staff will be conducted weekly x 3 more weeks (rotating shifts) and monthly thereafter. Any identified issues will be corrected immediately. The Administrator/designee will be responsible for sustaining compliance and will present findings to the Quality Assurance Committee. The QA committee will receive report and direct actions as appropriate. Element #5 The Administrator is responsible to ensure these corrective measures will be fully implemented by [DATE].

This citation pertains to intake #MI 990. Based on observation, interview and record review, the facility failed to thoroughly document, conduct a timely assessment and implement appropriate, timely post-fall interventions for one (#207) of eight sampled residents reviewed for physical, mental, psychosocial well-being from a total of eight, resulting in delay in evaluation and treatment of [REDACTED]. Findings include: The complainant reported to the State agency that residents at the facility were not being monitored and were not assessed for acute change in condition. On 3/29/17 at 10 AM, resident #207 was observed asleep in the facility chapel with a walker by her side, awaiting a religious service. At 11 AM, the resident's clinical record, Incident/Accident (I/A) Reports and hospital records were reviewed. The resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum (MDS) data set [DATE] noted that the resident was cognitively impaired and required supervision for transfers and ambulation. Nursing notes for resident #207 revealed the following: 10/24/16-at 3:40 AM, staff observed resident sitting on buttocks with walker turned over next to bathroom door, urine on the floor, skin tear right elbow, steri-strips applied. 10/24/16 at 9:43 PM (physician note)-seen at request of nursing (staff) regarding skin tear right elbow no witnessed or reported trauma 2-3 centimeter (cm) partial thickness tear right elbow. 10/26/16 at 4:12 PM (nurse practitioner note)-Resident seen at request of nursing. Caregiver noted a hematoma on right forehead of 'unknown origin'. Resident does not recall any fall, bump or bang approximately 5 cm by 5 cm by 2 cm elevated circular mildly tender hematoma. 10/26/16 at 8:18 PM-Writer observed a hematoma to right side of forehead. Resident states she doesn't know what happened unit manager notified, voicemail left for DON (Director of Nursing). 10/26/16 at 9:08 PM-hematoma on right side of forehead. 10/28/16 at 1:37 PM-Resident observed unresponsive in dining room during breakfast 911 called, resident transported via ambulance to (hospital). 10/28/16 at 2 PM- to hospital related to an unresponsive episode hematoma to forehead after being observed on floor on 10/24/16 An I/A report dated 10/24/16 at 3:40 AM noted the fall. When the resident was asked what happened, she said that she was trying to go to the bathroom and slipped. The report was signed by the DON and the Administrator on 10/25/16. An I/A report dated 10/26/16 at 4:05 PM noted: She (resident #207) doesn't know what happened. Writer observed hematoma on right side of her head. The report was signed by the DON on 10/31/16 and by the Administrator on 11/4/16. Both I/A reports were signed by the physician on 10/31/16 with the notation in hospital. There was no documented link made between the two I/A reports by the DON, Administrator or physician. There was no documented I/A report or acute change in condition form (SBAR report) provided that addressed the resident developing a hematoma and being found unresponsive on 10/28/16 related to a fall that occurred four days prior. Hospital records for resident #207 noted the following: 10/28/16 CAT scan report-Fall with both eyes black and blue 2 days ago. (The CAT scan was negative for brain hemorrhage.) 10/29/16 consultation report-The patient was presented from her nursing home following an unwitnessed fall. On talking to the patient this morning, she is extremely confused She has no idea of events that led to her hospital admission. She does visibly have extensive bruising around her eyes and on the right side of her forehead. On questioning about falls, she denies any recent falls Ecchymosis (bruising) noted around bilateral orbits as well as the right temporal region. The resident was transferred back to the facility on [DATE]. On 3/30/17 at 2:30 PM, the two I/A reports were reviewed with the DON and she said, These two are related. When it was mentioned that the resident had extensive bruising around the eyes when she arrived at the hospital and asked why this obvious bruising was not documented and reported to the physician by nursing staff prior to finding the resident unresponsive, the DON did not respond. She did not respond when asked why a more thorough evaluation of resident #207 was not conducted sooner. The I/A report and nursing notes for 10/24/16 did not mention the resident being asked if she had hit her head during the unwitnessed fall. Nursing notes documented that neurological (neuro) checks began on 10/26/16 (a series of assessments for 24 hours or more for motor dysfunction, verbal response, sensation, reflexes, reaction of pupils to light that should begin immediately following head injuries). At 3 PM, nurse unit manager 'A' was asked to provide documented verification that the neuro checks were performed. She looked in the resident's electronic record and said that they were not there. She then said that the records were kept on the nursing unit and left to look for them. She returned at 3:30 PM with the DON and said that there were no records. During the survey exit at 3:45 PM, the DON and Administrator were asked to provide any additional information, such as neuro checks and SBAR reports, but were not received by the end of the survey. On 3/31/17 at 8 AM, per review of the facility's policy on Change in Condition dated 8/2012: It is the facility's policy to enable staff to evaluate and manage residents and avoid transfer to a hospital or emergency room by recognizing an acute change of condition and identify its nature, severity and causes. A nurse should complete an SBAR of the resident for signs of marked changes from the usual, notify the physician and document findings in the resident's clinical record.

This citation pertains to intakes #MI 051 and #MI 990. Based on observation, interview and record review, the facility failed to properly document, assess and implement appropriate preventive interventions for one (#202) of two sampled residents reviewed for urinary tract infections (UTIs) from a total sample of eight, resulting in the resident being found unresponsive and requiring emergency hospitalization for treatment of [REDACTED]. Findings include: The complainant reported to the State agency and reported during a phone interview on 3/30/17 at 1:30 PM: Resident #202 was found one evening layered in two incontinence briefs, totally saturated with urine and lying on wet linen. The resident was crying and uncomfortable. The urine was dark colored and the resident had loose stool going up into her vagina. The complainant said that she asked staff for assistance, but help was unavailable, so she got fresh linen, a basin of soap and water, removed the soiled briefs and began washing the resident when help arrived that she could not identify. Several days later, the resident was found in bed unresponsive and was transported to the hospital for a UTI due to the facility failing to provide proper care and monitoring of the resident. Resident #202 was observed lying in bed earlier in the day on 3/30/17 at 11:30 AM. The resident was alert, confused and had very limited mobility. A nurse aide entered the room, turned the resident over and opened her incontinence brief, which was found to be wet and needed to be changed. When asked, the aide said that the resident was last checked for incontinence and changed two hours prior. At 11:45 AM, the resident's clinical record was reviewed. The resident was admitted into the facility on [DATE] with diagnosed that included stroke, [MEDICAL CONDITION], diabetes, heart failure, [MEDICAL CONDITION] and dementia. The minimum (MDS) data set [DATE] noted that the resident had severe cognitive impairment, was non-ambulatory, required extensive assistance for bed mobility, hygiene and bathing and was always incontinent of bowel/bladder. Per nursing notes dated 12/8/16, resident #202 was alert, confused and had a good appetite that day. The next note was dated 12/11/16. On that date nurses noted: (Nurse aide) entered room to check resident and called nurse to check resident, resident lie in bed unresponsive call 911 at 4 AM rub chest, resident open eyes once and close it 911 ambulance staff come at 4:06 AM and took resident to hospital ER at 4:11 AM (The nurse who wrote the note was unavailable for comment.) The hospital transfer form noted: Reason for transfer-unresponsive. Hospital records for resident #202 were reviewed and revealed the following: History and Physical dated 12/11/16-The resident was admitted into the hospital on [DATE] with chief complaint-UTI presented with burning on urination. Patient's family stated that on Tuesday (12/6/16), they noticed her grimace when she would need to urinate and that she would reach for her groin. Family noticed a decreased level in cleanliness at the facility and have noticed her in dirty briefs more [MEDICAL CONDITION] secondary to UTI. physician progress notes [REDACTED]. Coli (escherichia coli-a bacteria normally found in feces) UTI.[MEDICAL CONDITION] (severe) Per the website, 'webmd.com': You get an E. coli infection by coming into contact with the feces. A hospital urinalysis report dated 12/11/16 noted that the resident's urine was cloudy with 4+ (large amount) bacteria (normally should be clear with no bacteria). The urine culture report dated 12/11/16 noted: 100,000-3,000,000 colonies of E. coli and that E. coli is a confirmed ESBL (extended spectrum beta lactamase) producer, meaning a bacteria with the capability of breaking down commonly used antibiotics, such as [MEDICATION NAME], rendering them ineffective. The culture noted that the resident was resistant to common antibiotics including, [MEDICATION NAME], Cipro, [MEDICATION NAME] and seven others. Resident #202 returned to the facility on [DATE]. At 12:40 PM, when asked if transfer orders included a prescription for antibiotics, the Director of Nursing (DON) said, I don't think she was on antibiotics. However, per the hospital discharge summary, the orders included Bactrim (antibiotic). When asked why and how the resident was found unresponsive on 12/11/16, what were the events and where documented nursing notes were indicating that she was being monitored prior to finding her in that state, the DON did not respond. When asked how that much E. coli ended up in the resident's urine, if the resident had received prompt, thorough incontinence care from staff, the DON did not respond. There was no documented care plan specific to bowel/bladder incontinence for the resident. When asked if there should have been one, especially after finding the resident unresponsive, the hospitalization and the large amount of E. coli in the urine, the DON said, I don't know. I have to look at her situation and get back to you. The DON was asked if there were any complaint forms documented for resident #202. She presented a Resident Assistance Form written by nurse unit manager 'A', dated 1/12/17, which noted that she had received a list of complaints from the resident's family including, the resident not being checked and changed every two hours and that two briefs were found on the resident the previous month. There was an attached investigation dated 12/12/16 by the DON. There was no explanation why the Resident Assistance Form was written one month later. Per the investigation: The complainant reported to the social worker that the resident was hosptalized on [DATE] with a UTI and felt it was caused by not changing her timely and that she was double briefed. The complainant asked a nurse aide (aide 'B') for help, but was told that the resident's assigned aide (aide 'C') was helping another resident at the time and would assist afterwards. The complainant said that the incident occurred during the first week of 12/2016 and did not know the names of the aides involved. The DON interviewed aide 'B', who recalled the complainant coming to the desk asking her for assistance at dinner time and telling the complainant that staff were caring for other residents, but would come when they were done. The DON concluded however, Unable to substantiate concerns of the (complainant). Spoke with staff and no one recalls being asked to assist with caring for (the resident). At 2 PM, Aide 'B' was queried about the complainant's allegations. The aide said that the complainant asked her for help during dinner time and that aide 'C' was busy with another resident at the time. Aide 'B' said that she left the unit and did not assist in cleaning and changing the resident. She did not know who may have assisted or how long it took for help to arrive. At 3 PM, aide 'C' was interviewed by phone regarding the resident being left soiled and initially said, I did not talk to (the complainant) then said, It was a long time ago. I can't remember anything that far back. By survey exit, there was no additional information provided, such as an incontinence care plan. A facility policy on incontinence care was requested from the DON, but instead, she provided a procedure on application and handling of Briefs and Underpads, which did not address ensuring prompt incontinence care and that females were thoroughly cleaned and wiped in a backward motion from the labia (skin covering the vaginal opening) toward the rectum.

This citation has two deficient practices. Deficient Practice #1 pertains to intake #MI 569. Based on observation, interview and record review, the facility failed to properly transfer a Resident that required two person assist with a lift machine for one (#904) of ten sampled Residents reviewed for abuse/neglect in a total sample of 17, resulting in the Resident sustaining an acute spiral fracture with slight lateral and ventral angulation of distal tibia following an improper transfer which required hospitalization for further treatment. Findings include: On 6/27/16 at 4:20 p.m., a discussion with the Director of Nursing (DON) was conducted. When asked about the facility reported incident involving Resident #904's fracture identified on 5/2/16, the DON reported that she was out of town at the time of the incident but stated, I believe the staff did a pivot transfer. (Pivot indicates that the Resident puts at least some weight on one or both legs and spins to move their bottom from one surface to another.) When asked what the Resident's transfer status was prior to the injury the DON reported, Resident #904 has always been two person assist with hoyer (a mechanical lift which allows a person to be lifted and transferred with minimal effort). On 6/27/16 at 4:30 p.m., Resident #904 was observed seated in a reclined gerichair with a bright pink cast that encased most of the left leg. Resident #904 appeared slightly agitated (restless with non-sensical verbalizations). At that time, Resident #904's responsible party whom was visiting reported, She went to the ortho doctor today and it (fractured tibia) is still not healing, so they put another cast on. Review of the incident/accident report dated 5/2/16 6:20 a.m. documented, Writer was called into resident's room by assigned CNA (Certified Nursing Assistant) reporting resident was expressing pain when getting her dressed and involving left leg. Writer observed redness, swelling, and popping/clicking when moving left foot and ankle .Writer notice grimacing only when moving left leg . Resident #904 was transferred to the hospital per Physician order [REDACTED]. Review of the radiology report dated 5/2/16 12:37 p.m. documented, TIBIA/FIBULA AP and LAT, LEFT Results: Osteopenia. Acute spiral fracture with slight lateral and ventral angulation of distal tibia. Offset oblique fracture proximal and middle third junction of fibula . According to the facility's investigation, interviews were conducted with staff and family. Resident #904 was unable to provide a statement due to significant cognitive impairment. The report further identified that the Resident's plan of care was reviewed and it was identified that her plan of care was not followed and may have contributed to the fracture. Review of the witness statements included: An undated, handwritten statement from CNA C who worked on the midnight shift of 5/1 which read, .I (name of CNA) had gave care for resident on 5/1/16 at 7:3 am .I was getting her dressed and ready for breakfast when I had gotten finish transferring Resident #904 in her chair which I had transferred her with a one assist transferred I notice she was making a noises. I had pivot her in her chair also I then pushed Resident #904 to the dining area in her chair . CNA C was contacted by phone for interview, however there was no returned call by the end of the survey. Review of the clinical record revealed Resident #904 was initially admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the significant change Minimum Data Set (MDS) assessments dated 2/26/16 and 5/11/16, Resident #904 had significant cognitive deficits, and required extensive assistance with transfers of two persons. Review of the ADL (activities of daily living) care plan dated 5/5/16, revised 5/12/16 documented and an interventions initiated on 5/12/16 which read, TRANSFER: I am transferred to bed/Geri chair and Geri Chair/Bed by jasmine hoyer lift with gray/green size sling with 2 people. LE (lower extremity) needs to be supported. The DON was requested to provide documentation of Resident #904's transfer status prior to the fracture identified on 5/2/16, however no such documentation was provided by the end of the survey. On 6/28/16 at 8:00 a.m., an interview was conducted with Nurse Manager F. When asked about the concern regarding CNA Cs transfer of Resident #904 without use of a lift machine and one other staff person as care planned, Nurse Manager F reported, She (CNA C) was newly off orientation and her normal schedule is midnights but she was orientating on days. She (Resident #904) is a two person transfer with hoyer and has been prior to that (recent fracture). When asked how staff become aware of the Residents' care needs, Nurse Manager F reported, For a new person there is orientation and nursing staff have access to the Kardex (specific documented needs of the Residents). Nurse Manager F discussed the Resident's [DIAGNOSES REDACTED]. According to the facility's Mechanical Lift Transfer policy dated 10/2012, .Review the Resident Plan of Care to assess for any special needs of the Resident; Gather equipment - portable lift and sling as stated in the Resident Plan of Care; Depending on the individual Resident Plan of Care, one or two nursing assistants may be required for safe resident transfer . ( ) Deficient Practice #2 Based on observation, interview and record review, the facility failed to prevent the use of a slow cooker in a Resident's room for one (#903) of 14 sampled Residents whose environment was observed in a total sample of 17, resulting in the potential for burns, equipment malfunction and electrical fires. Findings include: On 6/27/16 at 9:58 a.m., observation of Resident #903's room revealed a slow cooker set on a small table which was plugged in but set to off, located just inside the room to the right. Additionally, there was a sign taped to the dresser just above the placement of the slow cooker which read, Please give (first name of Resident #904) soup from crockpot (slow cooker). At that time, there was no soup contained inside of the slow cooker. Further observation of the 500 hall unit revealed several Residents were observed self propelling in wheelchairs throughout the unit. On 6/27/16 at 4:30 p.m., observation of Resident #903's room revealed the slow cooker was on, set to warm, and filled with soup. Upon touching the side of the slow cooker, it was warm to touch. On 6/28/16 at 7:50 a.m., the Director of Nursing (DON) was asked to observe Resident #903's room. At that time, the DON acknowledged the slow cooker which was plugged in as earlier observation on 6/27/16 and set to off. When asked about the facility's use of similar items that had heating elements, the DON reported they were not allowed and that the Resident's family had been informed multiple times not to bring in the slow cooker. When asked why the slow cooker had not been identified by any other staff as a concern, the DON stated, Between housekeeping or nursing someone should've seen it and reported it. On 6/28/16 at 8:00 a.m., Nurse Manager F was asked about the observation of the slow cooker in Resident #903's room and stated, The daughter requests to have it in her room. She's (Resident #903) surviving on liquid diet for months and recently started to decline. Nurse Manager F could not recall any education provided to the family in regards to not using the slow cooker. Review of the clinical record revealed Resident #903 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE], Resident #903 was cognitively intact (scored 14/15 on mental status exam), and required supervision and set up with eating. ( )

THIS CITATION HAS TWO DEFICIENT PRACTICES: DEFICIENT PRACTICE #1 BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE HOT WATER TEMPERATURES WERE WITHIN THE SAFE RANGE BETWEEN 105 AND 120 DEGREES FAHRENHEIT. HOT WATER TEMPERATURES RANGED FROM 122.0 DEGREES FAHRENHEIT TO 132.0 DEGREES FAHRENHEIT AT THE HAND SINKS IN 12 OF 48 RESIDENT ROOMS AND THREE OF THREE COMMUNITY SHOWER ROOMS. THE HOT WATER TEMPERATURES HAD THE POTENTIAL TO AFFECT THREE SAMPLED RESIDENTS (#S 604, 609, AND 614) OUT OF 19 REVIEWED FOR HOT WATER TEMPERATURES AND 10 (#S 34, 35, 37, 39, 40, 65, 66, 67, 72, AND 73) SUPPLEMENTAL SAMPLED RESIDENTS CAPABLE OF ACCESSING THE HANDWASHING SINKS, RESULTING IN AN IMMEDIATE JEOPARDY (IJ) AND THE POTENTIAL FOR HARM, SERIOUS INJURY AND/OR DEATH FROM SERIOUS BURNS AND SCALDING. THE IMMEDIATE JEOPARDY (IJ) WAS IDENTIFIED ON 8/13/13 AT 10:00 A.M. THE ADMINISTRATOR WAS NOTIFIED OF THE IJ ON 8/13/13 AT 2:00 P.M. THE ADMINISTRATOR WAS REQUESTED TO PROVIDE A PLAN OF CORRECTION TO REMOVE THE IMMEDIATE JEOPARDY. THE IMMEDIATE JEOPARDY WAS REMOVED ON 8/13/13; BASED ON THE PROVIDER'S IMPLEMENTATION OF CORRECTIVE ACTIONS ON 8/13/13 AS VERIFIED ON SITE ON 8/14/13. ALTHOUGH THE IJ WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE REMAIN AS ISOLATED, WITH NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY. FINDINGS INCLUDE: DURING THE INITIAL TOUR OF THE FACILITY ON 8/13/13 AT 10:00 A.M., HOT WATER TEMPERATURES WERE MEASURED AT BATHROOM HAND SINKS ON THE FOURTH AND FIFTH UNITS AND WERE FOUND TO BE ABOVE A SAFE RANGE OF 105 AND 120 DEGREES FAHRENHEIT FOR RESIDENTS (#S 604, 609, 614, 34, 35, 37, 39, 40, 65, 66, 67, 72, AND 73). THE HOT WATER TEMPERATURES RANGED FROM 122.0 TO 132.0 DEGREES FAHRENHEIT. THE HOT WATER TEMPERATURE AT THE HAND SINK LOCATED IN THE RESTROOM FOR RESIDENT #604 WAS 130.0 DEGREES FAHRENHEIT. ACCORDING TO RESIDENT #604'S FACE SHEET, REVIEWED 8/16/13 AT 3:30 P.M., THE RESIDENT WAS admitted INto the facility on [DATE] WITH A [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM DATA SET, (MDS), dated [DATE], RESIDENT #604 HAD SEVERELY IMPAIRED COGNITION FOR DAILY DECISION-MAKING. THE HOT WATER TEMPERATURES AT THE HAND SINK LOCATED IN THE RESTROOM FOR RESIDENT #609 MEASURED 127.4 DEGREES FAHRENHEIT. ON 8/13/13 AT 1:30 P.M., RECORD REVIEW FOR RESIDENT #609 REVEALED THE RESIDENT WAS readmitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MOST RECENT MINIMUM (MDS) data set [DATE], REVEALED RESIDENT #609 WAS SEVERELY IMPAIRED IN COGNITIVE SKILLS FOR DAILY DECISION MAKING. THE HOT WATER TEMPERATURE AT THE HAND SINK LOCATED IN THE RESTROOM FOR RESIDENT #614 REGISTERED 129 DEGREES FAHRENHEIT. ON 8/13/2013 AT 11:45 AM, REVIEW OF THE ADMISSION FACE SHEET REVEALED THE RESIDENT WAS readmitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE HOT WATER TEMPERATURE AT THE HAND SINK LOCATED IN THE RESTROOM FOR SUPPLEMENTAL SAMPLED RESIDENT #34 WAS 130.0 DEGREES FAHRENHEIT. ACCORDING TO RESIDENT #34'S FACE SHEET, REVIEWED 8/16/13 AT 3:30 P.M., THE RESIDENT WAS admitted INto the facility on [DATE] WITH A [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM DATA SET (MDS), dated [DATE], RESIDENT #34 HAD SEVERELY IMPAIRED COGNITION FOR DAILY DECISION-MAKING. THE HOT WATER TEMPERATURES AT THE HAND SINK LOCATED IN THE RESTROOM FOR RESIDENT #35 MEASURED 127 DEGREES FARENHEIT. ON 8/13/2013 AT 2:00 PM, RECORD REVIEW REVEALED THAT RESIDENT #35 WAS RE-admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MOST RECENT MINIMUM (MDS) data set [DATE] REVEALED THAT RESIDENT #35 WAS SEVERELY COGNITIVELY IMPAIRED. THE HOT WATER TEMPERATURES AT THE HAND SINK LOCATED IN THE RESTROOM FOR RESIDENT #37 MEASURED 132 DEGREES FARENHEIT. ON 8/13/2013 AT 2:00 PM, RECORD REVIEW REVEALED THAT RESIDENT #37 WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MOST RECENT Minimum Data Set, dated dated [DATE], REVEALED THAT RESIDENT #37 HAD SEVERE COGNITIVE IMPAIRMENT. THE HOT WATER TEMPERATURE AT THE HAND SINK LOCATED IN THE RESTROOM FOR RESIDENT #39 REGISTERED 130.4 DEGREES FAHRENHEIT. ON 8/13/2013 AT 11:15 AM, REVIEW OF THE ADMISSION FACE SHEET REVEALED THE RESIDENT WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM DATA SET (MDS), dated [DATE], INDICATED RESIDENT #39 HAD SEVERELY IMPAIRED COGNITION FOR DECISION MAKING. THE HOT WATER TEMPERATURE AT THE HAND SINK LOCATED IN THE RESTROOM FOR RESIDENT #40 REGISTERED 130.4 DEGREES FAHRENHEIT. ON 8/13/2013 AT 11:15 AM, REVIEW OF THE ADMISSION FACE SHEET REVEALED THE RESIDENT WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM DATA SET (MDS), dated [DATE], INDICATED RESIDENT #40 HAD SEVERELY IMPAIRED COGNITION FOR DECISION MAKING. THE HOT WATER TEMPERATURES AT THE HAND SINK FOR RESIDENT #66 MEASURED 127 DEGREES FARENHEIT. ON 8/13/2013 AT 2:00 PM RECORD REVIEW REVEALED RESIDENT #66 WAS admitted on [DATE] WITH [DIAGNOSES REDACTED]. THE MOST RECENT Minimum Data Set, dated dated [DATE], REVEALED RESIDENT #66 HAD SEVERELY IMPAIRED COGNITIVE STATUS. THE HOT WATER TEMPERATURES AT THE HAND SINK FOR RESIDENT #65 MEASURED 125.4 F. ON 8/13/13 AT 1:35 P.M., RECORD REVIEW FOR RESIDENT #65 REVEALED THE RESIDENT WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MOST RECENT Minimum Data Set, dated dated [DATE], REVEALED RESIDENT #65 WAS SEVERELY IMPAIRED IN COGNITIVE SKILLS FOR DAILY DECISION MAKING. THE HOT WATER TEMPERATURES AT THE HAND SINK FOR RESIDENT #67 MEASURED 127 F. ON 8/13/13 AT 1:40 P.M., RECORD REVIEW FOR RESIDENT #67 REVEALED THE RESIDENT WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE FACILITY'S ADMIT/READMIT SCREENER FORM, DATED 8/10/13, REVEALED RESIDENT #67 WAS ALERT TO PERSON ONLY. THE HOT WATER TEMPERATURES AT THE HAND SINK FOR RESIDENT #72 MEASURED 122.9 DEGREES FARENHEIT. ON 8/13/2013 AT 2:00 PM, RECORD REVIEW REVEALED THAT RESIDENT #72 WAS readmitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MOST RECENT MINIMUM (MDS) data set [DATE] REVEALED THAT RESIDENT #72 WAS SEVERELY COGNITIVELY IMPAIRED. THE HOT WATER TEMPERATURES AT THE HAND SINK FOR RESIDENT #73 WAS 122.9 DEGREES FARENHEIT. ON 8/13/2013 AT 2:00 PM, A REVIEW OF THE RESIDENT'S RECORD REVEALED THAT RESIDENT #73 WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MOST RECENT Minimum Data Set, dated dated [DATE], REVEALED THAT RESIDENT #73 HAD SEVERELY IMPAIRED COGNITIVE SKILLS IN DAILY DECISION MAKING. ON 8/13/13 AT 9:15 AM, DURING THE INITIAL TOUR, THE HOT WATER TEMPERATURE IN THE HAND SINK IN THE 300 UNIT SHOWER ROOM WAS 130.5 DEGREES FARENHEIT. THERE WAS NO LOCK ON THE SHOWER ROOM DOOR. ON 8/13/13 AT 9:20 AM, IN THE PRESENCE OF THE MAINTENANCE DIRECTOR, DURING THE TOUR OF THE MAIN SHOWER ROOMS ON UNITS 400 AND 500, THE HOT WATER TEMPERATURES AT THE HAND SINK LOCATED IN THE SHOWER ROOMS REGISTERED 127.2 AND 131.6 DEGREES FAHRENHEIT RESPECTIVELY. IN AN INTERVIEW WITH THE MAINTENANCE TECH ON 8/13/13 AT 10:05 AM, HE OFFERED NO EXPLANATIONS AS TO THE REASON FOR HIGH WATER TEMPERATURES AT THE RESIDENT SHOWER ROOMS. IN AN INTERVIEW WITH THE UNIT MANAGER ON THE 400 UNIT ON 8/13/2013, AT 12:38 PM, SHE INDICATED THAT RESIDENTS #604, 614, 34, 35, 37, 39, AND 40 HAD IMPAIRED COGNITION, WERE VERY CONFUSED, AND UNABLE TO MAKE THEIR NEEDS KNOWN. WHEN QUERIED ABOUT RESIDENT #'S 39 AND 40, SHE REVEALED THEY WERE VERY CONFUSED, UNABLE TO MAKE SAFE DECISIONS RELATING TO CARE, BUT WERE ABLE TO ACCESS THE HAND SINK. DURING AN INTERVIEW ON 8/13/2013 AT 12:20 PM, THE UNIT MANAGERS FOR THE 500 UNIT REVEALED THAT RESIDENTS # 609, 65, 66, 67, 72, AND 73, WERE CONFUSED BUT ABLE TO ACCESS THE HAND SINKS INDEPENDENTLY. DURING A TOUR OF THE BOILER ROOM FOR THE 400 AND 500 UNITS, ON 8/13/13 AT 12:00 P.M., WITH MAINTENANCE TECHNICIAN "A", THE OUTLET LINE (LINE SUPPLYING WATER TO RESIDENT ROOMS) TO THE THE MIXING VALVE (A VALVE THAT MIXES COLD WATER WITH THE HOT WATER FROM A BOILER SYSTEM TO ACHIEVE A LOWER DESIRED TEMPERATURE) WAS OBSERVED, REGISTERED AT 125 DEGREES FAHRENHEIT. WHEN ASKED HOW THE HOT WATER TEMPERATURES WERE MONITORED THROUGHOUT THE FACILITY, MAINTENANCE TECHNICIAN "A" RESPONDED, "WE TAKE TEMPERATURES HERE MONTHLY AND AT THE ENDS OF THE UNITS." ON 8/13/2013 AT 12:30 PM, A REVIEW OF THE FACILITY'S UNDATED POLICY TITLED "WATER TEMPS" STATED, "WATER TEMPS READING HAVE TO BE TAKEN ONCE PER MONTH...WATER TEMPERATURE RANGES SHOULD BE ACCORDING TO THE STATE REGS OF 105 TO 120 DEGREES." THE IMMEDIATE JEOPARDY WAS REMOVED ON 8/13/13 WHEN THE FOLLOWING INTERVENTIONS WERE IMPLEMENTED BY THE FACILITY AND WERE VERIFIED: ELEMENT #1 A SKIN ASSESSMENT WAS DONE ON RESIDENTS #33, 34, 35, 39, 40, 42, 62, 64, 65, 66, 67, 69, 72, AND 73. NO SKIN ISSUES ARE IDENTIFIED. THE MEDICAL DIRECTOR IS CONTACTED BY PHONE AND MADE AWARE OF WATER TEMP NON-COMPLIANCE AND HE ORDERED NURSING STAFF TO ACCESS REMAINING 69 RESIDENTS. THE WATER TEMPERATURE WAS IMMEDIATELY LOWERED BY THE MAINTENANCE STAFF AND RANDOM TEMPS WERE TAKEN. TEMPERATURES RANGED FROM 100 TO 188. ALL REMAINING SCHEDULED SHOWER WERE PUT ON HOLD UNTIL WATER TEMPERATURES WERE WITHIN NORMAL RANGE. ELEMENT #2 THE ADMINISTRATOR MEET WITH THE INTERDISCIPLINARY TEAM (IDT) TO MAKE THEM AWARE OF THE WATER NONCOMPLIANCE. THE IDT REVIEWED AND UPDATED THE "WATER TEMPERATURES" POLICY. STAFF ARE INFORMED TO HOLD SHOWERS AND BATHS UNTIL FURTHER NOTICE. A NOTICE IS POSTED ON ALL SHOWER/BATHING ROOMS TO ALERT STAFF, RESIDENT AND FAMILIES. LIKE RESIDENTS ASSESSED AND NO SKIN ISSUES IDENTIFIED. RESIDENTS WHO ARE INTERVIEWABLE WERE QUERIED REGARDING WATER TEMPERATURES AND ALL DENIED EVER FEELING THAT THE WATER WAS TOO HOT. THE STAFF IS PROVIDED HAND SANITIZER AND DISPOSABLE ADULT WASH CLOTHES TO ENSURE PROPER BODY CARE. THE MAINTENANCE STAFF IS IMMEDIATELY INSERVICED ON THE UPDATED POLICY. A PLUMBING REPAIR COMPANY WAS CALLED AND ARRIVED IMMEDIATELY. ASSESSMENTS OF THE WATER SYSTEM INCLUDING THE MIXING VALVES ARE COMPLETED. IT WAS IDENTIFIED THAT A MIXING VALVE NEEDED TO BE REPLACED. THE PROJECT WAS IMMEDIATELY COMPLETED BY THE PLUMBING COMPANY AND WATER TEMPERATURES WERE WITHIN REQUIRED RANGE. AFTER MIXING VALVE IS REPLACED, ALL AREAS WITH A WATER FLOW ARE CHECKED AND TEMPS ARE APPROPRIATE. WATER TEMPERATURES WERE RANDOMLY CHECKED ON THE AFTERNOON AND MIDNIGHT SHIFT TO ENSURE THE TEMPERATURES OF THE WATER WAS IN ACCEPTABLE RANGE. ELEMENT #3 ALL FULL TIME AND PART TIME STAFF IS INSERVICED ON THE UPDATED "WATER TEMPERATURES" POLICY. THE FOLLOWING DEPARTMENTS ARE INSERVICED: ACTIVITY, DIETARY, MAINTENANCE, LAUNDRY, HOUSEKEEPING, ADMINISTRATION, SOCIAL SERVICES, THERAPY, AND NURSING. THE POLICY IS REVIEWED AND REVISED TO INCLUDE MORE FREQUENT MONITORING OF WATER TEMPERATURE GAUGES AND WATER TEMPERATURES IN RESIDENT ROOMS AND SHOWER ROOMS. ELEMENT #4 WATER TEMPERATURE GAUGES WILL BE CHECKED DAILY BY MAINTENANCE DIRECTOR/DESIGNEE AND DOCUMENTED ON THE WATER TEMPERATURE LOG TO ENSURE THAT THE NEW MIXING VALVE IS FUNCTIONING PROPERLY. RANDOM WATER TEMPERATURES WILL BE CHECKED IN ROOMS THROUGHOUT THE FACILITY TWICE WEEKLY BY MAINTENANCE DIRECTOR/DESIGNEE AND DOCUMENTED ON THE WATER TEMPERATURE LOG. SHOWER ROOM WATER TEMPERATURES WILL BE CHECKED DAILY, BEGINNING 8-14-13 FOR 10 DAYS BY MAINTENANCE DIRECTOR/DESIGNEE. ANY ISSUES OR CONCERNS WILL BE ADDRESSED IMMEDIATELY. THE ADMINISTRATOR WILL AUDIT THE WATER TEMPERATURE LOG DAILY TIMES 10 DAYS AND THEN TWICE PER MONTH TO ENSURE COMPLIANCE WITH THE POLICY. ELEMENT #5 THE FACILITY IS CONFIDENT THESES CORRECTIVE MEASURES WILL BE FULLY IMPLEMENTED BY AUGUST 14, 2013. ( , , , , ) DEFICIENT PRACTICE #2 BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT OXYGEN TANKS WERE STORED IN A SAFE MANNER TO PREVENT INJURY OR DEATH FROM EXPLOSIONS. FINDINGS INCLUDE: ON 8/14/13 AT 11:30 A.M., DURING THE GENERAL TOUR OF THE FACILITY WITH MAINTENANCE TECHNICIAN "A", THREE EMPTY OXYGEN TANKS WERE OBSERVED STORED IN THE OXYGEN STORAGE ROOM UNSECURED. WHEN ASKED IF THE TANKS SHOULD BE STORED THAT WAY, MAINTENANCE TECHNICIAN "A" STATED, "NO." ON 8/16/13 AT 3:00 P.M., REVIEW OF THE FACILITY'S "OXYGEN STORAGE AND ASSEMBLY POLICY", DATED DECEMBER 2008, REVEALED: STORE ALL OXYGEN IN AN UPRIGHT POSITION IN "RACKS" IF "RACKS" ARE NOT AVAILABLE, OXYGEN TANKS ARE SECURED WITH CHAINS THAT FIT SNUGGLY AROUND THE CYLINDERS AND ARE SECURED TO AN EXTERIOR STATIONARY WALL. ( )

THIS CITATION PERTAINS TO INTAKE MI 537 BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT 1 OF 3 SAMPLED RESIDENTS (#101) OF A TOTAL SAMPLE OF 3 RESIDENTS ALL REVIEWED FOR ACCIDENTS, RECEIVED ADEQUATE SUPERVISION AND ASSISTIVE DEVICES TO REMAIN FREE OF ACCIDENTS WHEN CARE PLAN INTERVENTIONS FOR FALL RISK PREVENTION WERE NOT IMPLEMENTED BY NURSING STAFF RESULTING IN AN AVOIDABLE LEFT FEMORAL HIP FRACTURE FOR RESIDENT #101. FINDINGS INCLUDE: REVIEW OF THE CLOSED CLINICAL RECORD FOR RESIDENT #101 REVEALED ON THE "ADMISSION RECORD" FORM PRINTED ON 6/17/13, [DIAGNOSES REDACTED]. THE COMPREHENSIVE assessment dated [DATE], INDICATED THAT RESIDENT #101 REQUIRED MINIMAL ASSISTANCE WITH TRANSFERS AND REQUIRED A WHEELCHAIR FOR MOBILITY. THE COMPREHENSIVE ASSESSMENT FURTHER INDICATED THAT RESIDENT #101 EXHIBITED IMPULSIVITY AND DEMONSTRATED POOR SAFETY AWARENESS BY ATTEMPTING TO AMBULATE UNASSISTED THAT RESULTED IN ACCIDENTS. FURTHER REVIEW OF THE CLOSED CLINICAL RECORD FOR RESIDENT #101 REVEALED THAT NURSING STAFF INITIATED A CARE PLAN ON 3/12/13, THAT ADDRESSED THAT RESIDENT #101 WAS A "HIGH FALL RISK". THE CARE PLAN STIPULATED INTERVENTIONS TO BE IMPLEMENTED TO MINIMIZE INJURIES AND PROMOTE SAFETY TO PREVENT ACCIDENTS. INTERVENTIONS FOR FALL RISK PREVENTION INCLUDED:BED ALARM TO BE APPLIED EVERY SHIFT INITIATED ON 3/12/13; AND FLOOR MATTS AT BEDSIDE AT ALL TIMES WHILE IN BED INITIATED ON 6/17/13. REVIEW OF THE CLOSED CLINICAL RECORD FOR RESIDENT #101 REVEALED IN THE "NURSE'S PROGRESS NOTES" A TOTAL OF THREE ACCIDENTS THAT OCCURRED ON 5/27/13; 6/16/13; AND 6/21/13. REVIEW OF AN "INCIDENT AND ACCIDENT REPORT" FORM DATED 5/27/13, INDICATED THAT AT 11:50 P.M., "RESIDENT (#101) WAS OBSERVED ON THE FLOOR NEXT TO HIS BED. resident sustained [REDACTED]. ALARM SOUNDING UPON ENTERING THE ROOM." THE INCIDENT REPORT INDICATED THAT A CORRECTIVE ACTION WOULD BE FOR "PT (PHYSICAL THERAPY) AND OT (OCCUPATIONAL THERAPY) EVALS (EVALUATIONS)." REVIEW OF AN "INCIDENT AND ACCIDENT REPORT" FORM DATED 6/16/13, INDICATED THAT AT 6:05 A.M., "RESIDENT (#101) WAS OBSERVED SITTING ON THE FLOOR WITH A LACERATION TO LEFT ELBOW. ALARM SOUNDING UPON ENTERING ROOM." THE INCIDENT REPORT INDICATED THAT A CORRECTIVE ACTION WOULD BE, "FLOOR MATS AT BEDSIDE." REVIEW OF AN "INCIDENT AND ACCIDENT REPORT" FORM DATED 6/21/13, INDICATED THAT AT 9:45 A.M., "RESIDENT (#101) OBSERVED ON FLOOR IN HIS ROOM BY EMPLOYEE #1. THE INCIDENT REPORT INDICATED THAT THE RESIDENT (#101), "ATTEMPTED TO GET OUT OF HIS BED UNASSISTED AND HAD A FALL. RESIDENT (#101) COMPLAINED OF PAIN TO LEFT HIP AND WAS TRANSFERRED TO AN AREA HOSPITAL FOR FURTHER EVALUATION." THE INCIDENT REPORT WAS COMPLETED BY THE DIRECTOR OF NURSING KNOWN, AS EMPLOYEE #2. REVIEW OF A HOSPITAL RADIOLOGICAL REPORT DATED 6/21/13, INDICATED THE DIAGNOSTIC IMPRESSION OF A "LEFT FEMORAL NECK FRACTURE." ON 7/24/13, AT 10:30 A.M., INTERVIEW WITH EMPLOYEE #2 REVEALED THAT RESIDENT #101 WAS INITIALLY ASSESSED BY THE UNIT 300 DAY SHIFT CHARGE NURSE, KNOWN AS EMPLOYEE #3. EMPLOYEE #2 FURTHER REPORTED THAT THE DAY SHIFT CERTIFIED NURSING ASSISTANT ASSIGNED TO RESIDENT #101 WAS EMPLOYEE #4. ON 7/24/13, AT 11:00 A.M., INTERVIEW WITH EMPLOYEE #1 REVEALED THAT AT APPROXIMATELY 9:45 A.M., ON 6/21/13, SHE WAS WORKING AS A HOUSEKEEPER ON THE 300 UNIT WHEN SHE HEARD RESIDENT #101 YELLING LOUDLY "HELP ME." EMPLOYEE #1 STATED THAT SHE OBSERVED RESIDENT #101 IN HIS ROOM LAYING ON THE LEFT SIDE OF HIS BED ON THE TILED FLOOR. EMPLOYEE #1 STATED THAT SHE IMMEDIATELY SUMMONED FOR EMPLOYEE #2 TO ASSIST RESIDENT #101. EMPLOYEE #1 STATED THAT SHE WAS CERTAIN THAT SHE DID NOT HEAR AN ALARM SOUNDING IN THE RESIDENT'S ROOM NOR DID SHE OBSERVE A FLOOR MAT NEXT TO THE RESIDENT'S BED AT THE TIME OF HER OBSERVATION OF RESIDENT #101. ON 7/24/13, AT 11:30 A.M., INTERVIEW WITH EMPLOYEE #3 REVEALED THAT AT APPROXIMATELY 9:45 A.M., ON 6/21/13, SHE WAS SUMMONED BY EMPLOYEE #1 TO THE ROOM OCCUPIED BY RESIDENT #101. EMPLOYEE #3 STATED THAT SHE OBSERVED RESIDENT #101 ON THE LEFT SIDE OF HIS BED ON THE TILED FLOOR AND HE WAS YELLING OUT LOUDLY FOR HELP. EMPLOYEE #3 STATED THAT SHE OBSERVED THE RESIDENT'S LEFT LEG TO BE EXTERNALLY ROTATED AND HE IMMEDIATELY COMPLAINED OF PAIN IN THE REGION OF HIS LEFT HIP. EMPLOYEE #3 STATED THAT SHE AND OTHER NURSING STAFF ELEVATED RESIDENT #101 OFF THE FLOOR AND ONTO HIS BED FOR COMFORT. EMPLOYEE #3 FURTHER REPORTED THAT SHE IMMEDIATELY NOTIFIED THE PHYSICIAN WHO ORDERED FOR THE RESIDENT TO BE TRANSFERRED TO AN AREA HOSPITAL FOR FURTHER TREATMENT AND EVALUATION. WHEN EMPLOYEE #3 WAS QUERIED IF SHE RECALLED IF THERE WAS A FLOOR MAT NEXT TO THE RESIDENT'S BED SHE REPLIED, "NO." WHEN EMPLOYEE #3 WAS ASKED IF SHE RECALLED HEARING THE RESIDENT'S BED ALARM SOUNDING AT THE TIME SHE ENTERED THE ROOM SHE REPLIED, "IF THE ALARM WAS SOUNDING IT WAS FAINT. HE (RESIDENT #101) WAS YELLING OUT LOUDLY." EMPLOYEE #3 FURTHER REPORTED THAT THE DAY SHIFT CERTIFIED NURSING ASSISTANT, KNOWN AS EMPLOYEE #4 IS REQUIRED TO CHECK THE BED ALARM AT THE START OF THE SHIFT TO ENSURE THAT THE ALARM IS FULLY FUNCTIONAL. ON 7/24/13, AT 12:00 NOON., INTERVIEW WITH EMPLOYEE #4 REVEALED THAT ON 6/21/13, SHE WAS ASSIGNED AS THE PRIMARY CAREGIVER DURING THE DAY SHIFT FOR RESIDENT #101. EMPLOYEE #4 STATED THAT AT APPROXIMATELY 6:00 A.M., DURING HER INITIAL ROUNDS SHE OBSERVED RESIDENT #101 SLEEPING IN HIS BED. EMPLOYEE #4 STATED THAT SHE RECALLED OBSERVING THE RESIDENT'S BED ALARM BOX ATTACHED TO BE BED FRAME AND RECALLED SEEING A GREEN LIGHT ON THE BOX FLASHING. HOWEVER, EMPLOYEE #4 STATED THAT SHE DID NOT CHECK THE VOLUME LEVEL ON THE ALARM TO DETERMINE IF IT WAS SET ON HIGH OR LOW VOLUME AND ENSURE THAT THE ALARM WAS FULLY FUNCTIONING. EMPLOYEE #4 FURTHER EXPLAINED THAT THERE WAS NO FLOOR MAT ON THE LEFT SIDE OF THE RESIDENT'S BED DESPITE THE FACT THAT THE RESIDENT'S CARE PLAN INDICATED FLOOR MATS AT BEDSIDE AT ALL TIMES. EMPLOYEE #4 STATED THAT SHE WAS ON HER BREAK AT THE TIME OF THE ACCIDENT FOR RESIDENT #101. REVIEW OF THE HOSPITAL RECORD "PHYSICIAN CONSULTATION REPORT" DATED 6/24/13, INDICATED THAT RESIDENT #101 DID NOT RETURN TO THE FACILITY SUBSEQUENT TO HIS treatment of [REDACTED].

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO DEVELOP AND IMPLEMENT INTERVENTIONS TO PREVENT THE DEVELOPMENT OF A NEW FACILITY ACQUIRED SKIN ULCER/WOUND FOR ONE RESIDENT (#509) OF 15 SAMPLED RESIDENTS, FROM A TOTAL OF 15 SAMPLED RESIDENTS, RESULTING IN THE DEVELOPMENT OF A NEW SKIN ULCER/WOUND AND THE POTENTIAL FOR A DELAY IN TREATMENT AND HEALING. FINDINGS INCLUDE: A TOUR OF THE 300 NURSING UNIT WAS CONDUCTED ON 7/25/12 AT 9:30 A.M., WITH NURSE (C). RESIDENT (#509) WAS OBSERVED LYING IN BED IN A LOW SEMI-FOWLER'S POSITION, (LYING ON BACK SIDE, HEAD SLIGHTLY ELEVATED APPROXIMATELY 30 DEGREES). NURSE (C) REPORTED RESIDENT #509 HAD NO FACILITY ACQUIRED WOUNDS. AT 12:30 P.M., RESIDENT #509 WAS OBSERVED IN BED, IN THE SAME LOW SEMI-FOWLER'S POSITION. AT 2:00 P.M., RESIDENT #509 WAS STILL IN THE SAME POSITION. AT 4:00 P.M., RESIDENT #509 WAS STILL IN THE SAME POSITION, AND AN INTERVIEW WAS CONDUCTED WITH RESIDENT #509. RESIDENT #509 STATED NO STAFF MEMBER HAD OFFERED TO ASSIST THE RESIDENT INTO ANOTHER POSITION TO HELP ALLEVIATE PRESSURE ON THE BONY PROMINENCE SUCH AS THE COCCYX.. ON 7/25/12 AT 2:15 P.M., REVIEW OF RESIDENT #509'S CLINICAL RECORD REVEALED THE FOLLOWING: THE "PHYSICIAN ORDER" (MONTHLY RENEWAL SHEET), DATED 7/01/12 THROUGH 7/31/12, AND A PHYSICIAN ORDER [REDACTED]. THE PHYSICIAN ORDER [REDACTED]. (SANTYL OINTMENT- USED TO REMOVE NECROTIC TISSUE FROM WOUNDS.) ON 7/26/12 AT 11:30 A.M., A DRESSING CHANGE AND WOUND CARE OBSERVATION WAS REQUESTED FOR RESIDENT #509 WITH TREATMENT NURSE (A). TREATMENT NURSE (A) REPORTED RESIDENT #509 HAD BEEN treated for [REDACTED]. (SHEARING OCCURS WHEN LAYERS OF THE SKIN RUB AGAINST ANOTHER OR THE SKIN REMAINS STATIONARY AND THE UNDERLYING TISSUE MOVES AND STRETCHES AND ANGULATES OR TEARS THE UNDERLYING CAPILLARIES AND BLOOD VESSELS CAUSING DAMAGE). DURING THE DRESSING CHANGE AND WOUND CARE OBSERVATION AT 11:30 A.M., IT WAS OBSERVED THAT RESIDENT #509 HAD A SKIN ULCER/WOUND TO THE COCCYX. THAT MEASURED 3.5 CENTIMETERS (CM) X 2.75 CM. THE BASE OF WOUND AND WOUND BED WERE NOT VISIBLE AND COVERED WITH YELLOW AND BROWN SLOUGH. (SLOUGH, THE NECROTIC /AVASCULAR TISSUE IN THE PROCESS OF SEPARATING FROM THE VIABLE PORTIONS OF THE BODY, AND IS USUALLY YELLOW BROWN., GRAY-GREEN). WOUNDS WITH SLOUGH ARE NOT STAGEABLE UNTIL THE WOUND BASE IS VISIBLE. TREATMENT NURSE (A) CLEANSED THE WOUND WITH NORMAL SALINE, PATTED THE WOUND DRY, APPLIED SANTYL OINTMENT AND COVERED THE WOUND WITH A DRY GUAZE. AFTER THE DRESSING CHANGE AND WOUND CARE OBSERVATION HAD BEEN COMPLETED, AN INTERVIEW WAS CONDUCTED WITH TREATMENT NURSE (A), AT 12:00 P.M. TREATMENT NURSE (A) WAS UNABLE TO IDENTIFY WHEN THE "UNSTAGEABLE" SKIN ULCER/WOUND WAS FIRST IDENTIFIED ON RESIDENT #509'S COCCYX AREA. AT 12:15 P.M., NURSING NOTES WERE REQUESTED FROM THE DIRECTOR OF NURSING AND TREATMENT NURSE (A) TO DETERMINE WHEN THE SKIN ULCER/WOUND WAS FIRST IDENTIFIED. HOWEVER, THE NURSING NOTES WERE NOT PROVIDED BY THE END OF THE SURVEY ON 7/27/12.. THE ADMISSION FACE SHEET RECORD DATED 7/26/2012, INDICATED RESIDENT #509 WAS ORIGINALLY admitted INto the facility on [DATE] AND readmitted INto the facility on [DATE]. RESIDENT #509 HAD [DIAGNOSES REDACTED]. THE ANNUAL MINIMUM DATA SET (MDS), DATED 10/19/11, AND THE CARE AREA ASSESSMENT (CAA) DATED 10/19/11, INDICATED RESIDENT #509 WAS "...AT HIGH RISK FOR SKIN BREAKDOWN BECAUSE SHE IS TOTAL CARE WITH HER BED POSITIONING... HER SKIN IS INTACT AT THIS TIME.." THE QUARTERLY MINIMUM DATA SET 7/19/12 INDICATED RESIDENT #509 REMAINED "AT RISK" FOR THE DEVELOPMENT OF PRESSURE SORES AND SKIN BREAKDOWN AND THE MDS INDICATED RESIDENT #509 HAD AN OPEN LESION (LOCATION NOT SPECIFIED). RESIDENT #509 WAS COGNITIVELY INTACT FOR DAILY DECISION MAKING (SCORED 14- 15 ON THE BIMS (BRIEF INTERVIEW FOR MENTAL STATUS) . RESIDENT #509 RECEIVED NUTRITION VIA BOTH, GASTROSTOMY TUBE ( TUBE INSERTED DIRECTLY IN TO THE STOMACH) AND ORALLY. REVIEW OF RESIDENT # 509'S PLAN OF CARE (ADL'S) ACTIVITY OF DAILY LIVING, LAST UPDATED 6/26/12, INDICATED RESIDENT #509 WAS BEDFAST, TOTALLY DEPENDENT ON STAFF FOR BED MOBILITY (REQUIRED TWO PERSON ASSISTANCE), PERSONAL HYGIENE AND TRANSFERS. THE PLAN OF CARE ALSO INDICATED RESIDENT #509'S SKIN WOULD BE INSPECTED DAILY DURING CARE AND BATHS TO IDENTIFY REDNESS, OPEN AREAS, SCRATCHES, CUTS, BRUISES AND ANY CHANGE WOULD BE REPORTED TO THE NURSE. A PLAN OF CARE, LAST UPDATED 6/04/12, "I HAVE POTENTIAL FOR PRESSURES ULCER DEVELOPMENT RELATED TO MOBILITY", INCLUDED NURSING INTERVENTIONS TO "...TURN /REPOSITION RESIDENT #509 AT LEAST EVERY TWO HOURS, MORE OFTEN AS NEEDED OR REQUESTED..." THE WAS NO PLAN OF CARE THAT ADDRESSED THE WOUND ON RESIDENT #509'S COCCYX. THERE WERE NO SPECIFIC AND INDIVIDUALIZED INTERVENTIONS WITH MEASURES IN PLACE FOR THE WOUND ON RESIDENT#509'S COCCYX TO HELP PREVENT WORSENING OF THE COCCYX ULCER/WOUND. THERE WERE NO SPECIFIC AND/OR INDIVIDUALIZED INTERVENTIONS IN THE PLAN OF CARE TO HELP PREVENT SHEARING ON RESIDENT#509'S COCCYX OR TO HELP PREVENT WORSENING OF THE SHEARING OR WOUND ON RESIDENT #509'S COCCYX. ON 7/27/12 AT 11:45 A.M., A DRESSING CHANGE AND WOUND OBSERVATION WAS CONDUCTED FOR RESIDENT #509 WITH TREATMENT NURSE (A) AND THE DON. WHEN THE PROCEDURE HAD BEEN COMPLETED, THE DIRECTOR OF NURSING ADDED, RESIDENT #509 HAD BEEN treated for [REDACTED].#509'S COCCYX HAD GOTTEN WORSE. HOWEVER, THE DON WAS UNABLE TO EXPLAIN WHEN THE WOUND HAD WORSENED OR WHEN THE WOUND WAS FIRST IDENTIFIED. THE WOUND MEASURED 3.5 CENTIMETERS (CM) X 2.75 CM. THE BASE OF WOUND AND BED WAS NOT VISIBLE AND COVERED WITH YELLOW AND BROWN SLOUGH. THE DIRECTOR OF NURSING WAS UNABLE TO PROVIDE ANY EVIDENCE THAT NURSING INTERVENTIONS WERE IN PLACE TO HELP PREVENT THE DEVELOPMENT OF THE COCCYX WOUND. I N ADDITION , THE DON WAS UNABLE TO EXPLAIN WHY THERE WERE NO CURRENT NURSING INTERVENTIONS IN PLACE TO HELP PREVENT WORSENING OF THE COCCYX WOUND /ULCER. THERE WAS NO EXPLANATION PROVIDED TO EXPLAIN WHY THE PLAN OF CARE HAD NOT BEEN REVISED OR UPDATED WITH NURSING INTERVENTIONS FOR THE UNSTAGEABLE WOUND ON RESIDENT #509'S COCCYX . IN ADDITION, THE DON WAS UNABLE TO EXPLAIN WHY RESIDENT #509 HAD NOT BEEN OFFERED OR ASSISTED TO CHANGE POSITIONS IN BED ON 7/25/12. THE DON WAS UNABLE TO EXPLAIN WHY NURSING INTERVENTIONS HAD NOT BEEN PUT IN PLACE TO HELP PREVENT SHEARING ON RESIDENT #509'S COCCYX.. THE DON WAS UNABLE TO PROVIDE EVIDENCE THAT RESIDENT #509' SKIN HAD BEEN INSPECTED DAILY DURING CARE AND BATHS TO IDENTIFY REDNESS, OPEN AREAS , SCRATCHES, AND ANY CHANGE REPORTED TO NURSE. FURTHER REVIEW OF RESIDENT #509'S WOUND CARE physician progress notes [REDACTED].. AN INCIDENT AND ACCIDENT REPORT DATED 1/13/12 STATED "...CALLED INTO RESIDENT'S ROOM BY ASSIGNED CENA (COMPETENCY EVALUATED NURSE ASSISTANT) WHILE SHE WAS CLEANING UP RESIDENT AFTER INCONTINENT EPISODE. RESIDENT NOTED TO HAVE OPEN AREA LEFT PERI (PERINEUM) COCCYX, MORE TO THE LEFT MEASURES 2.0 CM X 1.5 CM HAS UNSTAGEABLE SLOUGH 1.0 CM X 1.0 CM, ANOTHER AREA ALSO NOTED DENUDED SKIN (L) (LEFT) BUTTOCKS OPEN AREA WITH SOME SKIN MISSING MEASURES 4.5 CM X 1.75 CM. WOUND CARE physician progress notes [REDACTED].# 509 HAD BEEN treated for [REDACTED]. THE FACILITY'S POLICY, "SKIN MANAGEMENT FACILITY GUIDELINES" DATED 12/2012, STATED, "... RESIDENTS WILL BE IDENTIFIED FOR THEIR RISK FOR SKIN BREAKDOWN... A CARE PLAN IS DEVELOPED UPON ADMISSION AND ADDRESSES: IDENTIFYING THE CONTRIBUTING RISK FOR BREAKDOWN; PREVENTATIVE DEVICES;POSITION REQUIREMENTS; PHYSICAL ACTIVITY; EDUCATION-WHEN APPROPRIATE.." ( )

THIS CITATION PERTAINS TO REVISIT KS9Y12 BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE SENSOR ALARMS WERE FUNCTIONAL IN 3 OF 12 SAMPLED RESIDENTS (RESIDENT #201, RESIDENT #202, RESIDENT #203), OUT OF A TOTAL SAMPLE OF 12 RESIDENTS WHO HAD SENSOR ALARMS, RESULTING IN THE POTENTIAL FOR SERIOUS INJURIES FROM FALLS ON RESIDENTS IDENTIFIED AS NEEDING THE ALARMS. FINDINGS INCLUDE: REVISIT INITIAL ROUNDS WERE ON 7/16/12 FROM 9:00 AM TO 11:30 AM WITH ADMINISTRATOR #1 DOING THE HANDS ON CHECKING OF SENSOR ALARMS. SENSOR ALARMS CONSIST OF TWO PARTS. A CONTROL BOX AND A PAD THE RESIDENT SITS OR LIES ON. THE CONTROL BOX HAS A LIGHT THAT BLINKS, SIGNALING THAT THE APPARATUS WAS WORKING. THE CONTROL BOX WAS CONNECTED BY A CORD TO A SENSOR PAD. WHEN WORKING CORRECTLY THE SENSOR PAD HAD AN ALARM THAT SOUNDED IF THE RESIDENT ROSE OFF THE PAD, THUS ALERTING STAFF THAT A RESIDENT WAS ATTEMPTING TO GET UP. SENSOR PADS WERE UTILIZED WHEN RESIDENTS HAD A RISK OF FALLING. ON 7/16/12 AT 9:10 AM DURING INITIAL ROUNDS THE CONTROL BOX ON THE SENSOR ALARM FOR RESIDENT # 201, WHO WAS LYING IN BED, WAS NOT BLINKING. ADMINISTRATOR #1 USED THE CALL LIGHT TO GET A STAFF PERSON TO STAY WITH THE RESIDENT WHILE OTHER STAFF REPLACED THE BATTERY IN THE SENSOR DEVICE. ON 7/16/12 AT 10:00 AM RESIDENT #202 WAS IN HER ROOM SITTING IN HER WHEELCHAIR. THERE WAS A SENSOR CONTROL BOX ON HER WHEELCHAIR. THE SIGNAL LIGHT WAS NOT BLINKING. ADMINISTRATOR #1 DISCOVERED THE SENSOR PAD CORD WAS NOT PLUGGED INTO THE CONTROL BOX. ADMINISTRATOR #1 PLUGGED IT IN AND IT BEGAN BLINKING. CERTIFIED NURSING ASSISTANT (CNA) # 3 WAS ASKED TO STAND RESIDENT #202 TO ASSESS THE ALARM OF THE SENSOR. CNA #3 CORRECTLY UTILIZED THE GAIT BELT AND RESIDENT #202 STOOD. THE ALARM SOUNDED. ON 7/16/12 AT 10:15 AM RESIDENT #203 WAS IN A WHEELCHAIR WITH A SENSOR ALARM CONTROL BOX ON HIS CHAIR. THE CONTROL BOX WAS NEITHER BLINKING NOR SOUNDING. ON 7/16/12 AT 2:00 PM THE SENSOR FOR RESIDENT #201 WAS tested AND WAS WORKING. ON 7/16/12 AT 2:05 PM THE SENSOR FOR RESIDENT #202 WAS tested AND WAS WORKING. ON 7/16/12 AT 2:06 PM THE SENSOR FOR RESIDENT #203 WAS tested AND WAS WORKING. REVIEW OF "CNA CHEAT SHEETS" DATED 7/4/12, 7/6/12, 7/7/12, 7/10/12, 7/12/12, AND 7/13/12 REVEALED SENSOR ALARMS HAD BEEN CHECKED FOR PLACEMENT AND FUNCTION BY A MEMBER OF THE MANAGEMENT TEAM. ADMINISTRATOR #1 SAID, ON 7/16/12 AT 9:20 AM, THAT MUCH EFFORT HAD BEEN EXPENDED IN AN EFFORT TO MAKE SURE THE SENSOR ALARMS WERE PROPERLY WORKING. ADMINISTRATOR #1 SAID SHE WOULD FIND OUT WHY THOSE ALARMS WERE NOT FUNCTIONING PROPERLY. ( )

This Citation pertains to MI 479 and MI 569 Based on observation, interview, and record review the facility failed to: 1.) ensure the safe transfer of residents by not using a gait belt in 1 of 5 residents (#103) from a total sample of 5 residents resulting in Resident #103 sustaining a leg laceration and pain after a transfer, and 2.) ensure sensor alarms were in working order for 1 of 5 residents (#104), from a total sample of 5 residents, resulting in the potential for elopement or fall to Resident #104. Findings include: Resident #103 Resident #103 was a admitted to the facility on [DATE] and according to the facility face sheet with a medical history of [REDACTED]. According to the Minimum Data Set ((MDS) dated [DATE] Resident #103 was usually able to express herself and able to understand others, was moderately impaired with limited vision and moderately impaired with cognitive daily decision making skills and displayed no behavioral issues. Resident #103 required limited one person assistance with transfers, walking in the corridor, dressing, toileting and personal hygiene, extensive one person assistance moving about the facility and totally dependent on staff for bathing and was occasionally incontinent of both bladder and bowel. Resident #103 was observed in her room on 6/12/12 at 10:22 AM sitting in her wheelchair. The resident was sitting in front of the TV, the call light on the bed approximately 6 feet from the resident. The sensor alarm attached to the wheelchair was blinking and noted on both support legs of the wheelchair where both foot pedals were absent was black tape wrapped covering soft padding. Resident #103 stated that "they didn't protect me I screamed my leg I'm not sure what happened it's a blur now". Noted on both legs were soft padded beige colored "derma sleeve" devices "they make me wear them they are a nuisance". During an interview with the Unit Manager C while in Resident #103's room on 6/12/12 at 10:35 AM she stated "the young lady who was involved from the wheelchair to bed transfer gave us an awful description about what happened, there was no gait belt used during the transfer and somehow the resident lacerated her left leg". During the observed dressing change on 6/12/12 at 10:50 AM with Treatment Nurse #9 a laceration approximately 13 cm long by 2.5. cm wide with 15 skin sutures counted. The laceration was well approximated (edges together healing) no areas of skin breakdown were noted, scant drops of light red drainage noted on the removed dressing. Treatment Nurse #9 cleansed the area with Normal Saline, applied Bacitracin, 4 X 4 dressing and wrapped the wound with Kerlix gauze. During the dressing change Resident #103 denied pain stating "the pain pills help me". Inspection of Resident #103's bed and wheelchair no sharp areas were felt on either piece of equipment. The wheelchair leg rests connections were padded with black tape and soft padding as described above. During a phone interview with Certified Nursing Assistant (CNA) #4 on 6/13/12 at 12:37 PM she stated on 5/29/12 she was working on the 300 unit and at approximately 8:45 PM on the evening shift (2-10 PM) of 5/29/2012 she had taken Resident #103 to the bathroom and had toileted the resident and was getting her pajamas on. The resident was taken from the bathroom to the bedside in the wheelchair, CNA #4 picked Resident #103 up by placing her arms (CNA #4) around the resident's waist, the resident placed her arms around the CNA's neck CNA #4 stated without using a gait belt lifted the resident to place her into bed. "I did a body lift she (resident #103) was holding onto everything during the transfer, and I don't know what hit her leg I got her to the edge of the bed and saw it was bleeding, the Resident was yelling my leg, my leg, I looked down and there was blood all over the floor, I put a towel around it and rang and got the nurse, I held pressure until help got there and she was sent to the hospital". During an interview with Staff Nurse LPN #5 on 6/13/12 at 1:40 PM she stated she was working the 2-10 PM shift on 5/29/12 on Unit 400, "the nurse came to our unit for assistance, when I went into the room the resident (#103) was sitting on the edge of the bed not doing or saying anything, I saw blood on the floor and a big laceration on her left leg, I cleaned the open wound, wrapped it in a towel and when the other nurse (#7) got there we cleaned it, and put the edges together, put 2-3 ABD's (large bandages) and one roll of Kerlix on the wound, it was just a few minutes and the EMS people were there, my main concern was for the resident. I can't answer yes or no about the gait belt my initial thought was oh my gosh, I asked the CNA what happened and she said I don't know". During an interview with Staff Nurse RN #7 on 6/13/12 at 2:10 PM she stated she was working the 2-10 PM shift on 5/29/12 and was called for help to the 300 unit for a "skin tear" "when I got to the room it was more than a skin tear the other nurse (LPN #5) and I began to clean the laceration it was pretty deep, bleeding but not gushing, we wrapped the wound and held pressure until EMS got there. The resident was sitting on the bed, I asked the CNA what happened and she said I don't know I looked and there was blood". During an interview on 6/13/12 at 2:34 PM with CNA #3 he stated he was working the 400 unit on 5/29/12 on the 2-10 PM shift. He stated that while doing rounds around 8:30-8:45 PM he heard a page for help and went to see if he could help the nurses there. Upon entering the room he saw a laceration "a hugh gash on her leg I thought it looked painful and that maybe it was a scar that had opened up, the nurses were cleaning and covering it everyone seemed to be doing what they needed to do so I left". Review of Facility Incident/Accident Reports regarding Resident #103 dated 4/24/12 at 8:20 PM section "what did resident state they were doing, "I hit my leg when resident stood up to transfer to bed". Section "describe what occurred; "resident was being transferred from wheelchair to bed when she yelled my leg, my leg. CNA turned resident to sit on bed, then laid her down, went to find nurse". Equipment involved; wheelchair/bed frame. Type of injury; purplish raised area. Location of injury; left leg. Pain assessment; 4-7 moderate pain (grimacing). Immediate interventions initiated; ice pack applied ASAP, stat x-ray to left lower leg (tibia) Tylenol given, requesting pads for wheelchair and bed frame. Physician notified 4/24/12 at 8:55 PM and responsible party notified on 4/24/12 at 9 PM. During a phone interview on 6/18/12 at 9:15 AM CNA #11 stated that during the transfer on 4/24/12 between 8-9 PM she was using a gait belt and transferring Resident #103 from the wheelchair to the bed. While standing and pivoting the resident yelled out "ouch my leg, my leg". "I looked there was a bump bruised area it was below the knee above the ankle on her left leg she had ted hose on which were removed at night, I don't recall the size but I did see a bump". Review of the Facility Treatment Administration Records dated 4/12 to 6/12 revealed no further evaluation, assessment, treatments or outcome from the "bruise" of 4/24/12. Review of the facility Nursing Care Plans dated 1/6/12 "potential for skin integrity related to fragile skin; use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surface". No further information regarding the nursing assessments/treatments/care plan related to the "bruise" from 4/24/12 was recorded in the medical record. Review of Facility Incident/Accident Report regarding Resident #103 dated 5/29/12 at 8:45 PM section "what did resident state they were doing; did not say". Describe what occurred and what was observed "called to patient's room by CNA. She said the patient left leg was bleeding. When I got inside the room I found the patient sitting on the side of the bed. I saw a very deep laceration with blood coming out of a 6 inch laceration on her left lower leg front". Equipment involved; wheelchair. Incident occurred; resident room. Type of injury; laceration. Location of injury; left leg front LLE (left lower extremity). Pain assessment 4-7 moderate pain (grimacing). Interventions; wrapped left leg with clean towels and had CNA apply pressure to area to contain the bleeding while I proceeded to call 911". Physician Assistant notified on 5/29/12 at 8:50 AM and the responsible party was notified on 5/29/12 at 8:55 PM. During a phone interview on 6/15/12 at 12:35 PM with Staff Nurse LPN #10 he stated he was working the 300 unit the night of 5/29/12 on the 2-10 PM shift, and at approximately 8:45 PM he was at the nurses station when CNA #4 approached him and in a "matter of fact" manner asked that he come and look at Resident #103's leg that it was bleeding, as they walked approximately 75 feet from the nurses station in an "unhurried" pace to the room upon entering the room "a big gash" was noted on the resident's leg. "I thought it looked like it just spilt wide open, blood was gushing out I got a towel and told the CNA to hold it tight and went to get help, I knew by the way it was bleeding we had to get her out immediately to the hospital, blood was squirting. The CNA seemed confused about what happened it didn't make much sense to me when I told her to write out what happened it really did not tell me anything something about she was putting the resident to bed, was in the bathroom, noticed paper in the toilet, had pajama pants on her, she lifted the resident up, noticed leg bleeding, you would have thought she would have noticed she bumped the resident's leg and it was bleeding. I don't remember if I saw a gait belt I was concerned about the resident, sometimes I see them use them (gait belts) I know it's a policy at the facility to use them but not all the time do I see them doing that". Review of Facility physician progress notes [REDACTED]. On exam awake no acute distress. Admits to tenderness and "a bump" to left leg. Extremities warm and general edema bilateral lower extremities left lateral leg with hematoma (mild) 4 X 4 CM. no [DIAGNOSES REDACTED]/heat or signs and symptoms of infection. Impression: left leg hematoma cool compress X 24 hours then will request warm compress X 20 min every shift to facilitate reabsorption. Review of Facility physician progress notes [REDACTED]. Review of Facility Nursing Notes dated 4/24/12 revealed "resident seen by NP (nurse practitioner) this am related to bump on left lower extremity. New orders for cool compress X 20 min every shift then warm compress every shift X 48 hours continue ted hose (compression stockings) as tolerated. X-ray results negative observed by NP. No further entry regarding the left lower leg is recorded until the laceration on 5/29/12. Review of Facility Nursing Care Plans reveal no care plan related to the "bump" from 4/24/12. Review of the Facility CNA care guide updated 12/15/11 revealed shower days as Wednesday and Saturday on the PM shift. Review of Facility Shower/Skin sheets dated 4/25/12 "bump" was indicated on the left lower leg anterior (front of leg) and on 4/28/12 "bruise" was noted on the left lower leg. No other documentation was recorded in the medical record related to description or status of the "bruise" noted on 4/28/12. ( ) Resident #104 Resident #104 was admitted to the facility on [DATE] and according to the facility face sheet with a medical history of [REDACTED]. According to the Facility MDS dated [DATE] Resident #104 usually was able to make himself understood and to understand others, was moderately impaired for daily decision making skills, required limited one person assistance with transfers and ambulation, extensive one person assistance with dressing, personal hygiene, bathing and incontinent of both bowel and bladder. Balance during transition from seated to standing position, off and on the toilet, surface to surface was not steady and only able to stabilize with staff assistance. During the initial tour on 6/12/12 at 9:50 AM Resident #104 was observed in his wheelchair located by Exit Doorway #8 vigorously shaking the door. After several attempts to open the door the door opened and Resident #104 was able to exit through the door and was outside onto the sidewalk beyond the door opening before staff responded to the audible alarm and retrieved the resident. Noted present on the wheelchair was a wanderguard device (security monitoring tool) attached to the right arm rest of the wheelchair not on the resident's person. Resident #104 was observed again on 6/12/12 at 12 PM lying in bed. Noted present was a wheelchair next to the bed and hanging from the bed was a blinking monitoring device connected to a pad located under the resident under the bed sheet, visible under the sheet was the pad/plug connection bent under the pad itself. Still present on the wheelchair was the wanderguard device on the right arm of the wheelchair. Upon this surveyor entering the room Resident #104 rose from a lying to sitting position at the side of the bed bent over placed his shoes on, tied them stood at the bedside and walked 3 steps to the dresser, no alarm sounded. Resident #104 then went to to the wheelchair sat in the wheelchair and exited the room at 12:09 PM, no alarm had yet sounded. The resident had left the room for 3 minutes before the alarm sounded at 12:12 PM and rang for 1.5 minutes (12:14 PM) before staff entered the room to investigate. While waiting for staff response it was noted the volume switch was in the "hi" position. The staff member entered the room silenced the alarm it was noted no lights blinked on the device. When asked if the light was to blink the staff member replied "I will have to check with the manager" and exited the room. At 12:15 PM Unit manager B entered the room, inspected the sensor pad and alarm box. Unit manager B replaced the pad and still noting the light on the box was not blinking. When asked how were alarms checked for function Unit Manager B replied that the CNA check alarms to ensure they are plugged in, physically touch the alarm to make sure they sound, "we have a problem with families turning the volume down from high. We really don't keep track of when batteries are changed I will get a new battery to see if that's the problem with this". A new battery was placed and the light blinked and the alarm sounded. Review of the Facility physician progress notes [REDACTED]. Dizziness resolved after patient was lying in bed. physician progress notes [REDACTED]. Review of the Facility Nurses Notes dated 6/6/12 Resident #104 was found unresponsive outside with family members, refused hospital treatment and was treated at the facility. Also noted in the Nurses Notes dated 6/14/12 a wanderguard device was placed on Resident #104's right leg. ( )

THIS CITATION PERTAINS TO INTAKE: MI 857 BASED ON STAFF INTERVIEWS AND RECORDS REVIEW THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION AND THE APPLICATION OF AN APPROPRIATE TYPE OF ALARM TO PREVENT A FALL IN 1 OF 6 SAMPLED RESIDENTS ( RESIDENT #102) REVIEWED FOR FALLS OF A TOTAL SAMPLE OF 6, RESULTING IN RESIDENT #102 REMOVING HER TAB ALARM, FALLING OUT OF HER WHEELCHAIR AND SUSTAINING A HIP FRACTURE. FINDINGS INCLUDE: ACCORDING TO THE FACILITY'S INCIDENT REPORT DATED 5/8/11, ON 5/7/11 AT APPROXIMATELY 7:30 P.M., CERTIFIED NURSE ASSISTANT (CNA) #2 AND REGISTERED NURSE (RN) #6 RESPONDED TO RESIDENT #102'S CALL FOR HELP AND FOUND HER LAYING ON THE FLOOR, IN HER ROOM, BETWEEN HER BED AND THE HEAT REGISTER. RESIDENT # 102 WAS TRANSFERRED TO THE HOSPITAL AND diagnosed with [REDACTED]. ON 5/25/11 AT 11:00 A.M., RN # 6 SAID ON 5/7/11 SOME TIME AFTER DINNER, WHILE STILL IN THE DINING ROOM, HE SAW RESIDENT #102 REMOVE HER PERSONAL TAB ALARM AND ATTEMPT TO SELF TRANSFER HERSELF OUT OF THE WHEELCHAIR. RN #6 SAID HE RE-APPLIED THE RESIDENT'S PERSONAL TAB ALARM AND REMINDED HER TO LEAVE THE ALARM IN PLACE AND ASK FOR ASSISTANCE BEFORE TRANSFERRING OUT OF THE WHEELCHAIR. RN #6 SAID RESIDENT #102 HAD BEEN NON-COMPLIANT IN THE PAST WITH SELF-TRANSFERS AND REMOVING HER ALARM. HE ATTEMPTED TO KEEP RESIDENT #102 IN THE COMMON AREA SO HE COULD VISUALLY OBSERVE HER AND PREVENT ANY ADDITIONAL SELF-TRANSFERS. AT APPROXIMATELY 7:30 P.M., RN # 6 SAID HE RESPONDED TO RESIDENT #102 YELLING "HELP ME" FROM HER ROOM AND FOUND HER ON THE FLOOR BETWEEN THE BED AND THE WINDOW. RESIDENT #102 SAID SHE WAS TRYING TO CLOSE THE WINDOW BLINDS. RN # 6 COULD NOT SAY FOR CERTAIN IF THE ALARM WAS SOUNDING, BUT IT WAS NOT CONNECTED TO RESIDENT #102 WHEN HE FOUND HER ON THE FLOOR. RN #6 COULD NOT RECALL WHERE HE RE-ATTACHED RESIDENT #102'S PERSONAL ALARM AFTER SHE REMOVED IT EARLIER IN THE SHIFT. RN #6 COULD NOT EXPLAIN ANY ADDITIONAL INTERVENTIONS UTILIZED BY STAFF TO PREVENT RESIDENT #102 FROM FALLING OR FROM REMOVING HER ALARM. RN #6 DID NOT EXPLAIN WHY A PRESSURE SENSOR ALARM WAS NOT UTILIZED ON RESIDENT #102 INSTEAD OF CONTINUING TO USE THE TAB ALARM, AFTER STAFF KNEW RESIDENT #102 WAS ABLE TO REMOVE THE TAB ALARM. DURING AN INTERVIEW ON 5/25/11 AT 2:40 P.M., CNA #2 SAID ON 5/7/11 AT APPROXIMATELY 7:30 P.M., SHE HEARD RESIDENT #102 CALL OUT FOR HELP, WENT INTO HER ROOM AND FOUND HER ON THE FLOOR BETWEEN THE BED AND THE WINDOW. CNA #2 COULD NOT BE CERTAIN IF THE ALARM WAS SOUNDING. CNA #2 SAID THAT RN #6 IMMEDIATELY ASSESSED AND REPOSITIONED RESIDENT #102 INTO BED AND CALLED THE DOCTOR. CNA #2 SAID RESIDENT #102 HAD BEEN NON-COMPLIANT WITH SELF-TRANSFERS AND REMOVING THE PERSONAL ALARM ALL THAT EVENING. CNA #2 SAID SHE HEARD RN #6 TELL RESIDENT #102 TO KEEP THE TAB ALARM IN PLACE, USE THE CALL LIGHT, AND ASK FOR ASSISTANCE BEFORE GETTING UP SEVERAL TIMES. CNA #2 COULD NOT IDENTIFY ADDITIONAL INTERVENTIONS TO PREVENT RESIDENT #102 FROM REMOVING HER PERSONAL ALARM OR ATTEMPTING SELF-TRANSFERS. A CLOSED MEDICAL RECORD REVIEW REVEALED THAT RESIDENT #102 WAS admitted to the facility on [DATE] FOR MULTIPLE [DIAGNOSES REDACTED]. THE MINIMUM (MDS) data set [DATE] INDICATED THAT RESIDENT #102 HAD SHORT AND LONG TERM MEMORY LOSS AND COGNITIVE IMPAIRMENT RELATED TO HER DEMENTIA. A FALL RISK assessment dated [DATE] IDENTIFIED RESIDENT #102 AS BEING AT "HIGH RISK" FOR FALLS. A REVIEW OF THE THERAPY EVALUATION DATED 4/25/11 REVEALED THAT RESIDENT #102 HAD A SIGNIFICANT SHORT TERM MEMORY DEFICIT AND "WOULD BENEFIT FROM A PERSONAL TAB ALARM." A REVIEW OF THE CNA NOTES REVEALED THAT CNA #7 WAS ASSIGNED TO RESIDENT #102 ON A REGULAR BASIS. ON 5/25/11 AT 1:50 P.M., CNA #7 WAS INTERVIEWED ABOUT RESIDENT #102 AND THE INCIDENT THAT OCCURRED ON 5/7/11. CNA #7 SAID THAT RESIDENT #102 ALWAYS TOOK HER PERSONAL TAB ALARM OFF AND ATTEMPTED TO SELF-TRANSFER BECAUSE SHE WAS VERY FORGETFUL. CNA #7 SAID THAT SHE WOULD CLIP THE PERSONAL ALARM ONTO RESIDENT #102'S BACK WHERE SHE COULD NOT REACH IT. CNA #7 SAID A PRESSURE SENSOR ALARM WOULD HAVE WORKED BETTER FOR RESIDENT #102, BUT COULD NOT PROVIDE AN EXPLANATION AS TO WHY THE PERSONAL TAB ALARM WAS NOT SWITCHED TO A PRESSURE SENSOR TYPE. A CARE PLAN FOR FALL PREVENTION DATED 4/28/11 INCLUDED THE FOLLOWING INTERVENTIONS: "MONITOR FOR PERCEPTUAL CHANGES, OBSERVE FOR DECREASE IN FUNCTIONAL STATUS." ON 5/7/11, "PERSONAL TAB ALARM" WAS ADDED TO THE INTERVENTIONS. THERE WAS NO MENTION OF ANY SPECIAL PLACE TO ATTACH THE PERSONAL TAB ALARM. A REVIEW OF THE RESIDENT CARE GUIDE CARD DID NOT DOCUMENT THAT RESIDENT #102 UTILIZED AN ALARM, NOR DID IT PROVIDE ANY INSTRUCTIONS FOR SPECIAL NEEDS OR DIVERSIONAL ACTIVITES. ON 5/31/11 AT 1:00 P.M., THE ADMINISTRATOR SAID THE FACILITY WAS IN THE PROCESS OF CHANGING FROM PERSONAL TAB ALARMS TO PRESSURE SENSOR ALARMS FOR ALL RESIDENTS WHO WERE ASSESSED TO BENEFIT FROM ALARMS. THE ADMINISTRATOR COULD NOT PROVIDE AN EXPLANATION FOR WHY RESIDENT #102 STILL HAD A PERSONAL TAB ALARM IN USE ON 5/7/11. ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 064 AND MI 079. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROTECT 1 OF 4 RESIDENTS (#101) FROM ACCIDENTS BY NOT SECURING SEATBELT RESULTING IN FRACTURED LEFT HUMERUS (LONG BONE IN THE ARM THAT RUNS FROM THE SHOULDER TO THE ELBOW). FINDINGS INCLUDE: RESIDENT #101'S MEDICAL RECORD CONTAINS [DIAGNOSES REDACTED]. RESIDENT #101'S MEDICAL RECORD CONTAINS A MINIMUM DATA SET ((MDS) dated [DATE] THAT SAID RESIDENT #101 IS A [AGE] year OLD FEMALE WHO IS UNABLE TO WALK IN ROOM OR CORRIDOR AND IS TOTALLY DEPENDENT ON OTHERS FOR LOCOMOTION ON AND OFF UNIT. THIS MDS ALSO SAID RESIDENT #101 HAS FUNCTIONAL LIMITATIONS IN RANGE OF MOTION TO ONE SIDE OF HER BODY IN THE UPPER AND LOWER EXTREMITIES AND USES A WHEELCHAIR. RESIDENT #101'S MEDICAL RECORD CONTAINS A CARE PLAN WITH AN ONSET DATE OF 11/22/10 THAT SAID RESIDENT #101 IS AT RISK FOR FALLS RELATED TO IMPAIRED SAFETY AWARENESS. THIS CARE PLAN HAS A STATED GOAL THAT RESIDENT #101 WILL HAVE NO SERIOUS INJURY FROM FALLS THAT MAY OCCUR. THIS CARE PLAN IDENTIFIES ONE APPROACH, AMONGST OTHERS, AS ANTICIPATE RESIDENTS NEEDS AND DO FREQUENT CHECKS. RESIDENT #101'S MEDICAL RECORD CONTAINS A FALL RISK assessment dated [DATE] THAT SAID RESIDENT #101 HAS A TOTAL SCORE OF 12. ACCORDING TO THIS ASSESSMENT A SCORE OF 10 OR ABOVE REPRESENTS HIGH RISK FOR FALLING. THIS ASSESSMENT SAID RESIDENT #101 HAS INTERMITTENT CONFUSION, IS CHAIR BOUND, NOT ABLE TO STAND ON BOTH FEET WITHOUT HOLDING ONTO ANYTHING, NOT ABLE TO WALK STRAIGHT FORWARD, NOT ABLE TO WALK THROUGH DOORWAY, AND NOT ABLE TO MAKE A TURN. RESIDENT #101'S MEDICAL RECORD CONTAINS A PHYSICIAN ORDER [REDACTED]. RESIDENT #101'S MEDICAL RECORD CONTAINS A RESIDENT TRANSFER FORM DATED 01/26/11 THAT SAID RESIDENT #101 IS BEING TRANSFERRED TO AN OUTSIDE HOSPITAL TO RULE OUT FRACTURE TO LEFT LEG, RIGHT ARM, AND BILATERAL (BOTH) HIPS. THIS FORM ALSO SAID RESIDENT #101 HAS DISABILITY OF PARALYSIS. RESIDENT #101'S MEDICAL RECORD CONTAINED A RADIOLOGY REPORT FROM AN OUTSIDE HOSPITAL (PAGES 7-8 OF 9) DATED 01/26/11 AT 3:07 PM THAT SAID RESIDENT #101 HAS AN ACUTE OBLIQUE FRACTURE TO THE PROXIMAL LEFT HUMERAL METADIAPHYSIS (FRACTURE TO THE LEFT HUMERUS). RESIDENT #101'S FILE CONTAINED A 5 DAY FACILITY INVESTIGATION REPORT DATED 02/01/11 SIGNED BY DIRECTOR OF NURSING (DON) THAT SAID ON 01/26/11 SELECT RESIDENTS WERE SCHEDULED FOR A OFF GROUNDS FIELD TRIP TO A LOCAL RESTAURANT ACCOMPANIED BY 4 STAFF ON THE FACILITY BUS. THIS REPORT SAID RESIDENTS THAT UTILIZED A WHEELCHAIR WERE SECURED TO THE FLOOR BRACKETS IN THE REAR OF THE BUS. THIS REPORT SAID ON AROUND 9:15 AM RESIDENT #101 SLID FROM WHEELCHAIR WHEN THE BUS DRIVER SUDDENLY STOPPED DUE TO ANOTHER DRIVERS TRAFFIC ERROR. THIS REPORT SAID RESIDENT #101 COMPLAINED OF LEFT ARM PAIN AND RATED THIS PAIN AN 8 BASED ON THE WONG-BAKER SCALE (A SCORE OF 8 MEANS IT HURTS A WHOLE LOT), HAD CREPITUS (GRATING SOUND) UPON PALPATION, AND INABILITY TO PERFORM ACTIVE RANGE OF MOTION TO THE LEFT LEG WITHOUT PAIN. THIS REPORT SAID RESIDENT #101 WAS REadmitted to the facility on [DATE] WITH A [DIAGNOSES REDACTED]. DURING AN INTERVIEW WITH THE ADMINISTRATOR (ADM) ON 02/10/11 AT 11:50 AM, THE ADM SAID THE FACILITY UTILIZES THE Q ' STRAINT WHEELCHAIR AND OCCUPANT SECUREMENT SYSTEM TO SECURE RESIDENTS SAFELY IN SEATS AND WHEELCHAIRS DURING BUS TRANSPORT. THE ADM SAID ENVIRONMENTAL SUPERVISOR (ES) #3 IS IN CHARGE OF MAINTAINING THE FACILITY BUS. DURING AN INTERVIEW WITH ENVIRONMENTAL SUPERVISOR (ES) # 3 ON 02/10/11 AT 12:15 PM, ES #3 SAID ALL PASSENGERS ARE EXPECTED TO WEAR SEAT BELTS WHILE RIDING ON THE FACILITY BUS. ES #3 SAID THE FACILITY UTILIZES THE Q ' STRAINT WHEELCHAIR AND OCCUPANT SECUREMENT SYSTEM. ES #3 SAID Q ' STRAINT IS THE SEAT BELT AND WHEELCHAIR SECURING SYSTEM THE FACILITY USES ON IT'S BUS TO SECURE RESIDENTS SAFELY IN SEATS AND WHEELCHAIRS DURING TRANSPORT. THIS INTERVIEW WAS CONDUCTED SIMULTANEOUSLY DURING AN OBSERVATION OF THE FACILITY BUS AND Q'STRAINT WHEELCHAIR AND OCCUPANT SECUREMENT SYSTEM. ON 02/10/11 AT 12:45 PM, UNSUCCESSFUL ATTEMPTS WERE MADE TO INTERVIEW RESIDENT #101. AT THIS TIME, RESIDENT #101 WAS IN THE DINING AREA AND WAS OBSERVED WEARING SLING TO LEFT ARM AREA. ON 02/10/11 AT 1:05 PM THE SURVEYOR OBSERVED THE FACILITY TRAINING VIDEO FOR THE Q ' STRAINT WHEELCHAIR AND OCCUPANT SECUREMENT SYSTEM. THIS TRAINING VIDEO CLEARLY SHOWS THAT ALL RESIDENTS USING WHEELCHAIRS MUST HAVE THE WHEELCHAIR SECURED TO THE VEHICLE FLOOR VIA A SYSTEM OF STRAPS AND LATCHING RETRACTOR MECHANISMS AND, THEN, THE OCCUPANT IS SECURED TO THE WHEELCHAIR VIA LAP AND SHOULDER BELT SYSTEM. DURING AN INTERVIEW WITH THE ADMINISTRATOR (ADM) ON 02/10/11 AT 1:30 PM, THE ADM SAID DURING HER INVESTIGATION OF THE INCIDENT THAT OCCURRED ON 01/26/11, SHE FOUND THAT RESIDENT #101 WAS SEATED IN THE BACK OF THE BUS WITH WHEELCHAIR ANCHORED TO THE FLOOR OF THE BUS BUT THE LAP BELT AND SHOULDER BELT SYSTEM WAS NOT SECURED. THE ADM SAID RESIDENT #101 fell FROM WHEELCHAIR WHEN THE BUS DRIVER ABRUPTLY BRAKED TO AVOID AN ONCOMING VEHICLE. DURING AN INTERVIEW WITH BUS DRIVER (BD) #4 ON 02/10/11 AT 1:45 PM, BD #4 SAID, ON 01/26/11, RESIDENT #101 fell FROM WHEELCHAIR AFTER HE ABRUPTLY BRAKED TO AVOID AN ONCOMING VEHICLE THAT SUDDENLY TURNED IN FRONT OF THE BUS. BD #4 SAID RESIDENT #101 HAD WHEELCHAIR SECURED TO THE BUS FLOOR BUT RESIDENT #101 WAS NOT SECURED TO THE WHEELCHAIR. BD #4 SAID AT THE TIME OF THE INCIDENT RESIDENT #101 WAS NOT WEARING LAP BELT OR SHOULDER BELT. BD #4 SAID HE DOESN'T REMEMBER PLACING LAP AND SHOULDER BELT SYSTEM ON RESIDENT #101. BD #4 SAID HE DOES NOT KNOW WHY THE LAP BELT AND SHOULDER BELT WAS NOT SECURED ON RESIDENT #101. DURING AN INTERVIEW WITH ACTIVITY STAFF (ACT) #7 ON 02/10/11 AT 2:20 PM, ACT #7 SAID SHE WAS SITTING IN FRONT OF RESIDENT #101 WHEN BD #4 ABRUPTLY BRAKED TO AVOID AN ONCOMING VEHICLE CAUSING RESIDENT #101 TO FALL FROM WHEELCHAIR. ACT #7 SAID SHE DID NOT SEE RESIDENT #101 FALL FROM WHEELCHAIR BUT SAW HER SITTING ON FLOOR OF THE BUS WITH HER HEAD AGAINST THE WHEELCHAIR SEAT AFTER BD #4 ABRUPTLY BRAKED THE BUS. ACT #7 SAID RESIDENT #101 HAD WHEELCHAIR SECURED TO THE BUS FLOOR BUT RESIDENT #101 WAS NOT SECURED TO THE WHEELCHAIR. ACT #7 SAID AT THE TIME OF THE INCIDENT RESIDENT #101 WAS NOT WEARING LAP BELT OR SHOULDER BELT. ACT #7 SAID SHE DID NOT PLACE LAP AND SHOULDER BELT SYSTEM ON RESIDENT #101. ACT #7 SAID SHE DOES NOT KNOW WHY THE LAP BELT AND SHOULDER BELT WAS NOT SECURED ON RESIDENT #101. DURING AN INTERVIEW WITH ACTIVITY STAFF (ACT) #6 ON 02/11/11 AT 11:00 AM, ACT #6 SAID SHE WAS SITTING BEHIND BD #4 WHEN BD #4 ABRUPTLY BRAKED TO AVOID AN ONCOMING VEHICLE CAUSING RESIDENT #101 TO FALL FROM WHEELCHAIR. ACT #6 SAID SHE DID NOT SEE RESIDENT #101 FALL FROM WHEELCHAIR BUT SAW HER SITTING ON FLOOR OF THE BUS WITH HER HEAD AGAINST THE WHEELCHAIR SEAT AFTER BD #4 ABRUPTLY BRAKED THE BUS. ACT #6 SAID RESIDENT #101 HAD WHEELCHAIR SECURED TO THE BUS FLOOR BUT RESIDENT #101 WAS NOT SECURED TO THE WHEELCHAIR. ACT #6 SAID AT THE TIME OF THE INCIDENT RESIDENT #101 WAS NOT WEARING LAP BELT OR SHOULDER BELT. ACT #6 SAID SHE DID NOT PLACE LAP AND SHOULDER BELT SYSTEM ON RESIDENT #101. ACT #6 SAID SHE DOES NOT KNOW WHY THE LAP BELT AND SHOULDER BELT WAS NOT SECURED ON RESIDENT #101. ATTEMPTS TO INTERVIEW CERTIFIED NURSE AIDE (CNA) #5 ON 02/11/11 AT 11:20 AM WERE UNSUCCESSFUL. THE FACILITY PROVIDED A TRAINING MANUAL FOR THE Q ' STRAINT WHEELCHAIR AND OCCUPANT SECUREMENT SYSTEM ENTITLED "THE QRTMAX WORK BOOK FOR TRAINEES". THIS TRAINING MANUAL SAID, WITHIN THE SECTION ENTITLED SECURING THE OCCUPANT ON PAGES 12-14, BEGIN BY THREADING THE LAP BELT AROUND THE PASSENGER AND THROUGH THE OPENING BETWEEN THE SEAT BACK AND BOTTOM OR BETWEEN THE SEAT BACK AND ARM RESTS, AND THE LAP BELT MUST BEAR ON THE BONY STRUCTURE OF THE BODY AND WORN AS LOW AS POSSIBLE ACROSS THE FRONT OF THE PELVIS, AND AFTER THE TWO SECTIONS OF THE LAP BELT HAVE BEEN PROPERLY THREADED AROUND THE PASSENGER, ATTACH THE ENDS TO THE PIN CONNECTORS ON TOP OF THE TWO REAR RETRACTORS, AND NOW BRING THE SHOULDER BELT OVER THE CENTER OF THE SHOULDER OF THE PASSENGER AND ATTACH THE LOOSE END TO THE PIN CONNECTOR ON TOP OF THE TWO REAR RETRACTORS.