Every finding on record at Fraser Villa

Based on interview and record review, the facility failed to ensure one resident (R700) received the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices, related to pain management, out of five reviewed for pain medication management.Findings include:A review of the medical record revealed R700 admitted into the facility on 4/29/2026 with the following medical diagnoses, Fracture of neck of Left Femur and Presence of Left Artificial Hip Joint. A review of the most recent Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 15/15, indicating an intact cognition. R700 also required staff assistance with bed mobility and transfers. A review of an Intake called into the State Agency noted the following, (R700) had been waiting for [their] meds (medication) since around 1:30am and had not received it. Licensed Practical Nurse (LPN) A was the one who was supposed to give (R700) the meds. LPN A thought [they] were still on break and other staff covers [them] when [they] are on break. LE (Law Enforcement) had to help (R700) move around and get [their] meds.Further review of a R700's interview statement dated 5/15/2026 noted the following, Last night my leg was hurting, more than usual, it hurts everyday but not this bad. The man came and called the police for me.A review of the physician's orders noted R700's Tylenol was scheduled every four hours-2:00AM,6:00AM,10:00AM,2:00PM,6:00PM, and 10:00PM. A review of LPN A's statement dated 5/19/2026 noted they gave R700 Tylenol at 3:00 AM, but they forgot to sign out on the May 2026 Medication Administration Record (MAR) the medication until 5:00 AM that morning (5/15/26).Further review of the care plan noted the following goal, At risk for Pain left hip with a goal of 4 (10 being the highest and 1 being the lowest level of pain) R/T (Related To) weakness, s/p (status post) left hip hemiarthroplasty (left hip replacement). Status: Active.On 5/15/2026 during day shift (7:00 AM-7:00PM) a pain score of 7 was recorded and a leg Xray revealed R700s hip replacement was dislocated and R700 was sent to the hospital for treatment.Further review of pain assessments showed no recorded pain score for midnight shift (7:00PM-7:00AM) on 5/14/2026 into 5/15/2026. On 5/28/2026 at 12:49 PM, an interview was conducted with the Nursing Home Administrator (NHA). The NHA reported R700's call light was activated, and they believe it had been on for about an hour from approximately 3:20 AM-4:20 AM until the police came and found staff in what appeared to be sleeping positions, then LPN A came and gave R700 their pain medication. A request for a policy related to pain management was requested, and facility informed they did not have a policy related directly to pain management.

Based on interview and record review, the facility failed to document discharge information in the medical record for one resident (R136) out of one reviewed for discharge. Findings include:A review of the medical record revealed that R136 was admitted into the facility on 1/2/2026 with the following medical diagnoses, Muscle Weakness and Difficulty in Walking. A review of the most recent Minimum Data Set (MDS) revealed a Brief Interview for Mental status score of 12/15 indicating an impaired cognition. R136 also required staff assistance with bed mobility and transfer. Further review of the discharge MDS coded that R136 discharged from the facility AMA (Against Medical Advice) on 1/10/2026.Further review of the medical record revealed the following progress note, Effective Date/Time: 1/12/2026 10:30 AM.SW (Social Work) notified by nurse manager that patient left AMA (Against Medical Advice). SW spoke with patient's daughter, and she confirmed patient returned home. SW arranged home health care (HHC) through [HHC Agency] per family's request. Per nursing, patient was given all medications. Family recommended to follow up with PCP (Primary Care Physician) within one week.No other progress note related to R136 leaving AMA was noted in the medical record.On 3/18/2026 at 3:02 PM, an interview was conducted with the Director of Nursing (DON). The DON reported that they do not use AMA forms in the facility. The DON was asked if the education was provided to the resident regarding leaving AMA, as well as physician notification and what medications were sent with the resident and was education provided on when and how to take them. The DON reported they would look for more information regarding R136 leaving AMA.A review of a document titled, Resident/Family Education noted the following, Assessment Date: 1/10/2026.Topic, Information, Instruction.The resident understands the risks verse the benefits of leaving AMA. No signatures were observed on the form.On 3/19/2026 at 12:47 PM, an interview was conducted with Licensed Practical Nurse (LPN) A. LPN A reports they were the nurse when R136 requested to discharge from the facility. LPN A reported they notified the physician and education but just completed the resident/education form and did not put in a progress note.After a request for a facility policy, the facility stated they do not have one related to leaving the facility AMA.

Based on observation, interview, and record review, the facility failed to ensure proper insulin administration for one (R150) of three residents reviewed for insulin administration. Findings include:On 3/18/26 at 10:34 AM, Licensed Practical Nurse (LPN) B administered insulin via a pen device to R150. During the preparation process, LPN B did not perform a safety test (prime) on the pen after the needle was attached, a practice that removes any air bubbles, ensures the needle is working, and fills the needle prior to administration. As the process was occurring, LPN B showed the device to the surveyor stating, I do not need to prime the pen because the cartridge was used before, so there is no need to prime the needle.On 3/19/26 at 7:39 AM, LPN B prepared an insulin dose for administration for R150. LPN B did not prime the pen. On 3/19/26 at 1:59 PM, an interview with the Director of Nursing (DON) provided information for the pen in current use for R150, that did not specifically recommend priming the needle after the first use. This was not a package insert from the manufacturer. The DON further revealed the same manufacturer is not used at all times. The package insert does indicate that a safety test should be performed prior to administration.A review of the literature revealed that the recommended use for four manufacturers of equivalent insulin pens recommended priming the needle before each use to remove any excess air bubbles and to test the needle for patency. The following links provide patient inserts for using insulin pens: Semglee: Package Insert / Prescribing Information / [NAME]: LEVEMIR(R) (insulin detemir injection), for subcutaneous use: Insulin Glargine | BASAGLAR(R) (insulin glargine) injection | Lilly Insulins; Lantus(R) SoloStar(R) Insulin Pen | Lantus(R) (insulin glargine injection) 100 Units/mL.

This intake pertains to Intake: MI00149945. Based on interview and record review, the facility failed to supervise, prevent an elopement, and operationalize the policies and procedures for a missing resident for one resident, (R901) of three residents reviewed for elopement. Findings include: A review of information reported to the State Agency revealed the following, Resident was observed by the receptionist exiting the facility with appropriate outerwear and a suitcase and a bag at approximately 2:30 PM. Receptionist was not aware that [R901] was a resident residing in the rehab building . A review of R901's medical record revealed they were admitted into the facility on [DATE], with diagnoses that included, Hemiplegia following Cerebral Infarction affecting right dominant side, Aphasia, Dysphagia and Muscle Weakness. Further review revealed upon admission to the facility, the resident was assessed to be significantly cognitively impaired due to their Aphasia (inability to speak), and required the use of a front wheeled walker for gait instability. On 2/4/25 at 11:27 AM, Unit Manager A was interviewed regarding R901 eloping from the building on 1/28/25, and she explained at approximately, 4:15pm she was informed by R901's assigned nurse that they were going to administer medications to the resident, but had not seen them. Unit Manager A explained she began looking for the resident by calling to the therapy department, going to look in the beauty salon, and in the great room where activities are held, but could not locate the resident. Unit Manager A further explained then she contacted the resident's son via phone, and he advised the resident was with him. Unit Manger A acknowledged at that time, she was unaware the resident had left the building on their own. On 2/4/24 at 11:38 AM, Receptionist B was asked about R901's exit from the facility, and she explained she was speaking to a visitor while at the front desk, and saw someone who she thought was a family member walking toward the door wearing their coat, pulling a suitcase, with a purse on their shoulder. Receptionist B explained she unlocked the door allowing R901 to exit not realizing they were a resident of the facility. Receptionist B explained the procedure for allowing residents and guests in and out the facility requires them to sign in and out at the desk, but acknowledged this procedure was not completed on this date. On 2/4/25 at 11:48 AM, an interview was completed with Nurse C, assigned nurse to R901 on the afternoon shift. Nurse C explained she arrived for her shift at 3:00pm, was given shift report, and at that time, had not laid eyes on the resident. At approximately 4:00pm, Nurse C explained she began passing medications and upon arriving to administer medications to R901, noted they were not in their room. Nurse C explained she reported this information to Unit Manager A and from there, attempts to locate the resident in the therapy gym, beauty salon, and common area was completed. Nurse C explained Unit Manager A contacted the resident's son who indicated that he was with the resident. On 2/4/25 at 12:02 PM, Nurse E, assigned nurse for R901 on the day shift was asked about the resident eloping from the facility, and she confirmed she had last laid eyes on the resident between 1:10pm and 1:15pm, as she had provided the resident with pain medication, and wanted to ensure it had been effective. On 2/4/25 at 12:43 PM, Social Worker F was asked about R901, and communication she had with the resident's son regarding discharge. Social Worker F explained the resident and their son were not in agreement regarding discharge plans and upon the final determination after the elopment, the resident would not be returning to the facility. Social Worker F was asked if she was aware how the resident was able to get home from the facility, and explained the resident's son said the resident walked home. A review of R901's medical record revealed the resident lived approximately 1.7 miles away from the facility, which was approximately a 37-minute walk. On 2/4/25 at 1:15 PM, Certified Nursing Assistant (CNA) D was interviewed regarding R901 eloping from the facility, and she explained she started her shift at 3:00pm and at approximately 4:15pm she hadn't seen the resident, and informed the assigned nurse. CNA D explained oftentimes, residents are in therapy or getting their hair done around that time. On 2/4/25 at 1:28 PM, the Nursing Home Administrator (NHA) was asked about the incident involving R901, and explained she received a call from Unit Manager A about the resident, and she in turn contacted the resident's son who explained R901 had returned to their residence, and at that time was not physically with the resident, but indicated when they were, they would contact the NHA back. The NHA explained that a well-being check was completed by the local police department to ensure the resident's safety, and she was not aware of how the resident got home. On 2/4/25 at 1:37 PM, an interview was completed with Physical Therapy staff G who worked with R901, and was asked about the resident's ability to walk without their walker. Physical Therapy staff G explained the resident had demonstrated they could walk 200 feet with the walker, but had never been assessed to walk without the walker. On 2/4/25 at 2:08 PM, Unit Manager A was interviewed again regarding the date of the incident with R901, and explained upon learning R901 wasn't in their room at approximately 4:15pm, it took approximately 15-20 minutes to look for the resident, and the resident's son was eventually contacted at approximately 4:40pm. Unit Manager A confirmed a missing person code/communication had not been completed as it is common family members will take residents out without informing nursing staff. A review of the Facility Reported Incident folder was reviewed and documented the resident was last seen by facility staff at approxiamtely 2:30pm, and a well-being check to confirm the safety and whereabouts of the resident was completed at approximtely 5:55pm. Further review also revealed a full count of residents was not conducted following the elopement of the resident to ensure all residents had been accounted for. On 2/4/25 at 4:00 PM, the NHA was asked about the facility's outcome regarding R901 leaving the facility, and acknowledged the resident left the facility without signing out or without an appropriate discharge. A review of the facility's Elopement-Missing Resident policy revealed, 3. Should an employee become aware that a resident is missing from the community he/she should a) Determine if the resident in on an authorized leave or pass. If not; b) Shift Supervisor, Director of Nursing or designee assigns direct care staff to look for the resident by dividing teams assigned to look inside and outside the community by area, including, but not limited to, all locked/unlocked rooms, bathrooms, closets, stairwells, elevators, storage spaces, outbuildings, parking lots, and exterior campus. c) Notify the Nurse Manager/Director of Nursing and Administrator d) If the resident is not located in the buildings or on the grounds within 15 minutes, the following process is initiated: 1. The Shift Supervisor, Director of Nsg or designee Notifies: -Police Dept -Legal Guardian -Physician -Medical Director - Communication/code alert is made related to the missing resident with the proper code that staff has been educated on to alert staff on the search . A review of the facility's Signing out of Elders/Residents policy revealed the following .1. Each elder/resident leaving the premises must be signed out .

Based on observation, interview, and record review, the facility failed to ensure resident food items brought in from outside the facility were dated, and failed to maintain the resident refrigerators in a sanitary manner. This deficient practice had the potential to affect all residents that consume food in the facility. Findings include: On 1/13/25 between 9:15 AM-9:30 AM, the resident refrigerators were observed with Dining Services Director A. In the Candlewood Unit refrigerator, there was a pizza dated 12/23, a container of soup dated 1/3, an undated container of cinnamon rolls, a container with an unidentified food item dated 12/21-12/24, and an opened, undated bottle of ranch dressing. In the Meadow Lane refrigerator, there was an undated pizza slice, an undated container of salad, and the freezer was soiled with food spillage. In the Rehab 1 refrigerator, there was a container of chicken dated 1/9. In the Rehab 2 refrigerator, there was an undated jello salad, an undated container of cut fruit, and the freezer was soiled with a large pooled area of a brown substance. Dining Services Director A confirmed that all items should be dated and discarded after 3 days. Review of the facility's undated policy Resident Food From the Outside Community noted: All prepared/perishable food or beverages brought by resident, family or visitors for resident's use will be labeled with the resident's name and the date the item was stored.

Based on interview and record review, the facility failed to ensure the pharmacy medication regimen review was completed monthly for three (R45, R52, R60) out of seven residents reviewed for unnecessary medications. Findings include: R45 A review of R45's record revealed they were admitted to the facility on [DATE] with a diagnosis of peripheral vascular disease and depression. A review of R45's Brief Interview for Mental Status revealed a score of three, indicating cognitive impairment. Further review of R45's record revealed there was no medication regimen review (MRR) documented for February 2024. R52 A review of R52's record revealed that they were admitted to the facility on [DATE] with a diagnosis of dementia. A review of R52's Brief Interview for Mental Status revealed a score of seven, indicating cognitive impairment. Further review of R52's record revealed there was no MRR documented for July 2024 or October 2024. R60 A review of R60's record revealed they were admitted to the facility on [DATE] with a diagnosis of dementia and depression. A review of R60's Brief Interview for Mental Status revealed a score of nine, indicating cognitive impairment. Further review of R60s record revealed there was no MRR documented for July 2024 or October 2024. On 1/15/25 at 8:33 AM, The Director of Nursing (DON) explained that the pharmacy should do monthly medication reviews on all residents, then will make recommendations to be followed up on by the physician. The DON explained that the purpose of the reviews is to make sure there are no unnecessary medications or any interactions and to make sure certain medications are not negatively impacting the resident's organ function. On 1/15/25 at 9:43 AM, the DON confirmed that the above mentioned missing MRRS were not done. The DON provided an email communication from the pharmacist which revealed the following: audit revealed gaps in reviews completed. Below is a list of those gaps. (R45) February 2024, (R52) July 2024, October 2024, (R60) July 2024, October 2024. A review of the facility's policy titled Medication Regimen Review revealed the following: 1. The consultant pharmacist will conduct MRRs if required under a pharmacy consultant agreement and will make recommendations based on the information made available in the resident's health record. 2. The facility and consultant [pharmacist will follow guidance outlined in the CMS state operations manual Appendix PP and current practice guideline, for the appropriate provision of pharmaceutical care.

Based on interview and record review, the facility failed to ensure a Level I Preadmission Screening (PAS)/Annual Resident Review (ARR) Mental Illness/Intellectual Disability/Related Conditions Identification was completed timely, accurately completed, and sent to the local community mental health (CMH) for a level II OBRA (Omnibus Budget Reconciliation Act of 1993) evaluation for two residents (R47 and R56) of three residents reviewed for PASARR's. Findings include: R47 A review of R47s medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included BI-Polar Disorder, Dementia, Mood Disorder and Major Depression. Further review of R47's Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 9/15 indicating a moderately impaired cognition. Further review of R47's medical record revealed an ARR completed on 10/10/23, seven months following the resident's admission to the facility. On 1/10/24 at 10:45 AM, all of R47's PASARRS were requested from the facility. The facility provided an exemption form signed, but undated by a physician, and there was no additional information regarding contact had been made between the facility and the local community mental health (CMH). R56 A review of R56's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included Alzheimer's Disease, Congestive Heart Failure, Dysphagia, and Anxiety. Further review of the medical record revealed that the resident was severely cognitively impaired. Further review of the medical records revealed that a PASARR was completed on 12/9/22 by the acute care setting that referred the resident to the facility. On 1/10/24 at 10:45 AM, all of R56's PASARRs were requested from the facility, however the only documentation received was the 12/9/22 PASAAR, and an exemption form signed and undated by a facility physician. On 1/10/24 at 1:53 PM, the Social Work Director was asked about the facility's procedure for the completion and submission of PASARRs to CMH, and was unable to provide an answer. The Social Work Director was asked for confirmation that the PASARRS had been sent to CMH, however, this information was not provided by the end of survey. On 1/11/24 at 12:55 PM, the Director of Nursing (DON) was asked about the concerns regarding the PASARRS, and indicated that she would look further into it, but explained that they should be completed. On 1/10/24 at 10:45 AM, a facility policy regarding PASARRs was requested however, the Nursing Home Administrator explained that the facility did not have a policy.

Based on interview and record review, the facility failed to develop hospice care plan for one resident (R97) of two residents reviewed for care plans. Findings include: R97 A review of the medical record revealed that R97 admitted into the facility on [DATE] with the following diagnoses, Adult Failure to Thrive and Malignant Neoplasm of Colon. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition. R97 also required assistance with bed mobility and transfers. A review of the progress notes revealed that R97 was admitted into the facility on hospice services. Further review of the medical record revealed that R97 did not have a facility developed care plan related to hospice care. On 1/11/2024 at 12:54 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that developing the hospice care plan is collaborative. The DON stated that there should have been a facility care plan related to hospice. A review of a facility policy titled, Care Planning Process noted the following, Purpose: To outline and maintain the community's procedure as it relates to identification of problems and interventions for care needs for the individual resident.

This citation pertains to MI 510. Based on interview and record review, the facility failed to consistently document resident intake per recommendation and follow up on weight loss prior to discharge for one sampled Resident (R430) of three reviewed for nutrition, resulting in inadequate nutritional and weight monitoring. Findings include: A review of intake MI 510 and per phone interview conducted on 6/17/21 at 4:15 PM with Confidential Witness B revealed allegations that R430 lost weight while in the facility, and that the facility failed to adequately monitor the resident's nutrition/hydration status. A review of R430's medical record and Minimum Data Set (MDS) assessments dated 4/19/21 and 5/11/21 revealed that the resident was admitted into the facility on [DATE] and discharged on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed that the MDS assessment dated [DATE] recorded the resident's weight as 91 pounds (lbs), and the MDS assessment dated [DATE] had the resident's weight listed as 80 lbs. The resident was assessed to be cognitively intact, eat independently with setup help, and required extensive to total assistance from staff for bed mobility, transfers, toileting, and bathing/hygiene. A review of R430's weights taken while residing in the facility revealed: 4/15/21 - 88.60 pounds (lbs) 4/16/21 - 89.40 4/19/21 - 91.00 4/21/21 - 90.00 4/23/21 - 89.00 4/28/21 - 89.50 4/30/21 - 89.30 5/3/21 - 87.00 5/7/21 - 84.30 5/10/21 - 80.10 A review of R430's Clinical Liaison Admission Assessment Date: 4/12/21 listed the resident's weight prior to coming to the facility as 47 kg (103.4 lbs). A review of R430's Comprehensive Nutritional Assessment, completed by Dietitian C and signed on 4/18/21 revealed: Height (in inches): 60 (5 feet), Weight (in lbs): 89.40, Ideal Body Weight (in lbs): 100, Usual Body Weight (in lbs): [blank] .Clinical Notes: Muscle Wasting Subcutaneous Fat Loss .Previous Weights: Previous Weights Unavailable . Will add ensure at lunch and dinner .Resident has dx (diagnosis) of CHF (Congestive Heart Failure) and on diuretic tx (treatment) so potential for s/s (signs/symptoms) of fluid imbalance/dehydration and it may anticipate some weight loss .Encourage adequate fluid intake to maintain hydration status .Resident has a [CONDITION(S)] .res (resident) is at risk for Malnutrition . Nutr Dx (Nutrition Diagnoses): 1. At risk for Malnutrition r/t (related to) advanced age and clinical condition AEB (as exhibited by) low BMI (body mass index) 17.4, muscle wasting, Subcutaneous Fat loss .dx of CHF. Intervention: .document FAR (Food Acceptance Record) .Physician to assess as indicated . Monitor & Eval (evaluate): 1. Energy and Fluid Intake- res will tolerate diet without difficulty and accept 75-100% of estimated nutrition needed via p.o. (oral) intake daily. 2. Weight- Maintain current body weight with no significant weight changes. On 6/22/21 at 1:34 PM, a request was made via email to the Nursing Home Administrator (NHA) that included the following: All . [R430's] food and liquid acceptance records. The facility provided a one page, paper copy of R430's food acceptance record (FAR). A review of R430's ADL Verification Worksheet, (Food Acceptance Record [FAR]) dated 4/12/21 through 5/11/21, revealed that the resident's intake (breakfast, lunch, and dinner) was not recorded until 4/17/21 and 4/18/21. On 4/19/21 and 4/20/21, dinner intake was not recorded. No meal intake information was recorded on 4/21/21 and 4/22/21, and only dinner intake was recorded on 4/23/21. No dinner intake was recorded on 4/24/21. No meal intake information was recorded from 4/25/21 through 4/29/21. No dinner intake was recorded on 4/30/21. No meal intake information was recorded from 5/1/21 through 5/3/21. Intake was recorded on 5/4/21, and no additional meal intake information for R430 was found on the facility-provided sheet for the remainder of the resident's stay (discharged [DATE]). A review of R430's progress notes revealed the following: 4/17/21 03:55 PM .Resident has a [CONDITION(S)] noted with several watery stools. Writer had to replace ostomy 3 times this shift from leakage . 4/25/2021 05:42 PM .Resident ostomy was changed x3 today .Ostomy bag replaced x3.[Written by Licensed Practical Nurse (LPN) E]. 5/08/2021 11:42 AM .This resident is incontinent. This resident has a [CONDITION(S)] that is very active .Resident c/o (complains of) feeling very tired . 5/10/2021 04:28 PM .Residents stoma beefy red. Resident noted with 2 large soft stools. Skin around ostomy is red and has some excoriation noted Incontinent of urine . 5/10/2021 10:39 PM .Elder has a [CONDITION(S)] .with appliance intact .also been noted with BM (bowel movement) from rectum. Incontinent of urine .[MEDICATION(S)] cream applied to reddened buttocks/coccyx . 5/11/2021 12:40 PM .resident discharged from facility via car .alert and able to make needs known, no distress or discomfort noted. all medications sent with resident to [facility name] .with approval from director of nursing, all transfer instructions discussed with family and resident. R430's progress notes did not include information regarding the changes in the resident's weight over the course of their stay at the facility. R430's medications included: [MEDICATION(S)] (diuretic aka, [MEDICATION(S)], a water pill) 20 mg (milligrams) once a day for fluid overload and [MEDICATION(S)] (generally used as an antacid, but can be used in kidney disease to maintain [MEDICATION(S)] levels in the body) 650 mg tablet once a day for fluid overload. A review of R430's care plan revealed: FLUID: Resident is at risk for dehydration related to diuretic therapy; fluid restriction STATUS: Active (Current) EFFECTIVE: 4/13/2021 - Present. A review of R430's orders revealed a fluid restriction had been ordered for R430 on 4/12/21 but discontinued on 4/13/21. On 6/23/21 at 8:44 AM, Dietitian C was interviewed regarding R430, and asked to review R430's medical record. When queried regarding knowledge of the resident's weight prior to entering the facility, Dietitian C reviewed R430's hospital records and indicated that a weight of approximately 103 lbs was noted. Dietitian C stated, Sometimes their scale and our scale are different. When queried regarding R430's initial weight being taken on 4/15/21 with the resident's admitted being 4/12/21, Dietitian C stated, Most of the time they do a weight right when they (resident) get here. We go by what we [assess]. When queried if that nutritional assessment signed on 4/18/21 was the only one completed for R430, Dietitian C confirmed that was the case. When queried regarding a hydration assessment for the resident, Dietitian C indicated that the comprehensive assessment covered both nutrition and hydration, and added, If there are any problems I put a note in with any intervention. We were checking weight and I thought [R430's] intake was good. When queried regarding a fluid restriction for R430, and where hydration intake is monitored, Dietitian C stated, When I did the assessment, the doctor discontinued the fluid restriction. The FAR monitors everything (food and liquid intake) .We check the FARs and through observations. When queried regarding assessments of the output of R430's ostomy, Dietitian C stated, We were looking at [R430] overall, how [they were] eating and drinking. When queried regarding the significant difference in R430's weight from admission compared to the one taken on 5/10/21 at 7:08 AM, Dietitian C stated, We do do a re-weight, I wanted one, I was waiting for that . When asked if a re-weigh was completed prior to R430 being discharged on [DATE], Dietitian C stated No. Dietitian C was then asked to review R430's chart to see if a physician was notified of the weight change, or if any nutritional interventions or assessments were discussed or implemented prior to the resident leaving the facility on 5/11/21. Dietitian C pulled up a Discharge visit note from a Nurse Practitioner (NP) on 5/9/21 that noted No significant weight change, and listed the resident's weight as 84.3 lbs. Dietitian C provided her discharge summary that stated, Intended wt loss (weight loss) since admission r/t dx of CHF and diuretic txt, and stated, I anticipated the weight loss due to the CHF and diuretics. When queried where in the record a physician/NP had noted any anticipated weight loss for R430, Dietitian C provided no further information upon looking in the record. Dietitian C stated, I think maybe the doctor didn't address weight loss because I was waiting for the re-weight. It would've been put in the log book or communicated to nursing. A physician's note dated 4/19/21 listed R430 as, At risk for malnutrition. Dietitian C was queried if she expected R430's intake to be documented on the FAR on each shift and responded, I wanted them to monitor intake every shift. When asked to look at the facility-provided paper-copy of R430's FAR, Dietitian C indicated that not every shift had intake documentation present and added, I was checking on [R430] frequently. R430's weight on 4/15/21 compared to 5/7/21 reflected a 4.85% loss, however, their weight from 4/15/21 compared to 5/10/21 reflected a 9.59% loss. This weight loss was not found to be addressed by a physician/NP prior to the resident's discharge from the facility on 5/11/21. Further review of R430's physician/provider notes revealed: 4/29/21 .still very weak and debilitated .has a [CONDITION(S)] and loose stools all the time so .drinks and try to drinks more fluids .due to [their] [CONDITION(S)] [they have] malnutrition and .is trying to get .supplementations but .appetite is not very good . 5/6/21 .Continue to monitor patient very closely .Continue dietitian monitor the patient's nutritional status . On 6/23/21 at 10:12 AM, the Director of Nursing (DON) and Dietitian C were interviewed. When queried regarding R430's fluid restriction being discontinued, the DON indicated the physician discontinued it because the resident did not have much [CONDITION(S)] while in the facility, and that fluid intake was planned to be encouraged. The DON also noted that the resident had a very active (with frequent output) [CONDITION(S)]. When queried regarding R430's FAR documentation, the DON indicated that it didn't appear as though intake was charted on every shift and added, [We] might have it documented on paper because sometimes the computers are down .not sure if I have it or not. The DON indicated she would provide it if it could be located. The DON/facility did not provide any further intake information for R430 prior to survey exit. When queried regarding the facility addressing the resident's weight loss prior to the resident leaving on 5/11/21, the DON and Dietitian C indicated that it was their facility policy to obtain a re-weigh within 48 hours, and [The resident] was gone before then. On 6/23/21 at 10:54 AM, LPN E, who had been assigned to care for R430 several times, was interviewed. LPN E indicated that R430 had a, Very active [CONDITION(S)], with soft, liquid-y stool .had to be emptied several times a shift for me .Fatigued from when [they] got here to when [they] left .Got up for every meal, never ate a whole lot. When queried as to where food/liquid intake for the resident was found, LPN E stated, That would be on the CNA (nurse aide) documentation (FAR documentation). When queried regarding the amount of fluid loss from the resident's [CONDITION(S)], LPN E stated, It was like [CONDITION(S)] drainage, very loose and liquid-y. When queried about the monitoring of fluid loss from the resident's [CONDITION(S)], LPN E indicated that if the physician or dietitian wanted intake/output, they would have ordered it, or it would be found in the nursing notes. A review of the facility's policy/procedure titled, Weight and Height Program, dated January 2017, revealed, 1. Resident will be weighed upon admission and at least monthly unless otherwise directed by IDT (interdisciplinary team) .3. The Dietitian or Interdisciplinary Team (IDT) will oversee the process. The IDT will determine if weights may need to be completed on a more regular basis, re-evaluated, and additional interventions put in place. The IDT will also meet and/or make suggestions to the resident/family in conjunction with the physician as necessary for care planning .The residents are weighed and height is taken within the first 24 hours of admission and documented on the resident weight record. (24 hours is the optimal timeframe, however, if not obtained in the first 24 hours attempt to receive in the first 72 hours) .A second weight is taken within the first 72 hours to ensure the accuracy of the initial weight recorded .Those residents determined nutritionally at risk may be weighted more often as determined by the IDT and/or physician .If a weight variance is noted per RAI manual: The resident is re-weighed within 48 hours. The results are documented on the resident weight record and the licensed nurse/dietitian follows up, as appropriate.

This citation has two Deficient Practice Statements (DPS). DPS #1. Based on observation, interview, and record review the facility failed to maintain tube feeding poles in a clean and sanitary manner affecting two Residents (R45 and R95) of three residents reviewed for tube feedings, resulting in the potential for the preventable spread of infections. Findings include: R95 On 06/21/21 at 10:10 AM, R95 was observed sleeping in bed and did not respond to knocking or greetings. A tube feeding was observed in progress. The tube feeding pole holding the tube feeding pump was noted to be soiled with a large quantity of dried-on tube feeding formula on the base of the pole. On 06/22/21 at 8:29 AM, R95 was again observed sleeping in bed. The base of the tube feeding pole continued to be soiled with dried-on tube feeding formula. On 06/22/21 at 2:31 PM, an interview was conducted with Nurse F regarding maintaining tube feeding poles in a clean and sanitary manner and stated, I believe that is the job of the housekeeper's, but I will have to check with my DON (Director of Nursing) to make sure. Record review of R95's Electronic Health Record (EHR) revealed R95 was admitted into the facility 09/16/2014 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set (MDS) assessment dated [DATE] revealed R95 had a severely impaired cognition and was totally dependent on staff for Activities of Daily Living (ADLs). R45 On 06/21/21 at 11:17 AM, an interview was conducted with R45 regarding the care at the facility. During the interview a tube feeding was observed in progress. The base of the tube feeding pole was soiled with a moderate amount of dried-on tube feeding formula. On 06/22/21 at 8:34 AM, R45 was observed sleeping in bed and the base of the tube feeding pole continued to be soiled with dried-on tube feeding formula. On 06/23/21 at 8:26 AM, R45 was again observed sleeping in bed and the base of the tube feeding pole was soiled with dried-on tube feeding formula. On 06/23/21 at 8:27 AM, an interview was conducted with Certified Nurses Aide (CNA I) regarding maintaining tube feeding poles in a clean and sanitary manner and stated, Housekeeping is supposed to clean them. On 06/23/21 at 8:35 AM, an interview was conducted with the Housekeeping Director (HDH) regarding maintaining tube feeding poles in a clean and sanitary manner and stated, I'll have it cleaned. That will have to be soaked off. On 06/23/21 at 8:39 AM, an interview was conducted with the DON regarding maintaining tube feeding poles in a clean and sanitary manner and stated, We tell housekeeping and nursing can clean them too. We change the poles monthly for a thorough scrubbing. Record review of R45's EHR revealed R45 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS assessment revealed R45 had a severely impaired cognition and was totally dependent on staff for ADLs. On 06/23/21 at 11:30 AM, the DON was asked for the facility's policy and procedure regarding the cleaning and sanitization of tube feeding poles and stated, We don't have one specific to tube feeding poles. DPS #2 Based on observation, interview, and record review the facility failed to perform hand hygiene to professional standards affecting one Resident (R358) of three residents observed for hand hygiene during a medication administration observation resulting in the likelihood of the preventable spread of infections. Findings include: On 06/22/21 at 7:52 AM, a medication administration observation was conducted with Nurse G on R385. Nurse G sanitized hands, reviewed the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse G then knocked on R385's door, informed the resident of the procedure and donned (applied) gloves. Nurse G placed the medication cup on R385's over-bed table, took R385's urinal to the bathroom to empty it, returned the urinal to R385's bedside stand and changed gloves. When R385 had taken the medications Nurse G discarded the medication cup, doffed (removed) gloves and washed their hands for 18 seconds. Nurse G was asked what should have been done before and after using gloves and stated, Wash hands. Record review of R385's EHR revealed R385 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent 5-day MDS had not been completed as of 06/23/2021. Progress notes revealed R385 was alert and could make needs known and needed assistance of one person for ADLs. On 06/23/21 at 11:30 AM, the DON was asked about the facility's policy and procedure regarding hand hygiene and stated, They should wash their hands for twenty seconds and before and after wearing gloves. Review of the facility's undated policy and procedure titled, Hand Hygiene revealed, Practice hand hygiene .Before: Putting on gloves .After: Removing gloves .HANDWASHING .3. Rub hand together for at least 20 seconds .

Based on observation, interview, and record review, the facility failed to maintain the ice machine in a sanitary manner, failed to ensure potentially hazardous food items were labeled, dated, and discarded when necessary, failed to use the correct sanitizer test strips for the 3 compartment sink, and failed to monitor the refrigerator temperature for the second floor resident refrigerator, resulting in the increased potential for cross contamination and foodborne illnesses. These deficient practices had the potential to affect all residents that consume food from the kitchen. Findings include: On 6/21/21 from 8:30 am-9:15 am, during an initial tour of the kitchen with Registered Dietitian (RD) O, the following items were observed: The filter for the ice machine was observed to be coated with a heavy layer of dust. In addition, the bottom edge of the interior ice chute, had a pink, slimy substance that could be observed when wiped with a paper towel. RD O stated that the ice machine was cleaned by an outside company on a quarterly basis. According to the 2013 FDA Food Code section 4-602.11 Equipment Food-Contact Surfaces and Utensils, (E) Except when dry cleaning methods are used as specified under § 4-603.11, surfaces of utensils and equipment contacting food that is not potentially hazardous (time/temperature control for safety food) shall be cleaned: (4) In equipment such as ice bins and beverage dispensing nozzles and enclosed components of equipment such as ice makers, cooking oil storage tanks and distribution lines, beverage and syrup dispensing lines or tubes, coffee bean grinders, and water vending equipment: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold. In the Norlake reach-in cooler, there was a tray of cottage cheese and fruit plates dated 6/16-6/18, an undated 3 quart container of cut honeydew melon, and an opened tub of sour cream dated 6/3-6/18. According to the 2013 FDA Food Code section 3-501.17: Ready-to-eat, potentially hazardous 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 41 degrees Fahrenheit or less for a maximum of 7 days. Refrigerated, ready-to- eat, potentially hazardous food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. Dietary Staff P was observed cleaning dishware in the 3 compartment sink. Dietary Staff P was asked to test the concentration of the sanitizer with a test strip. Dietary Staff P retrieved a DDBSA/Lactic acid test strip, and dipped it into the sanitizer bin. The strip did no change color, to indicate that the sanitizer was at the proper concentration. The sanitizer container hooked up to the chemical dispenser for the sanitizer bin, was observed to be quaternary [MEDICATION(S)]. When queried as to why the quaternary [MEDICATION(S)] sanitizer solution was not being tested with quaternary [MEDICATION(S)] test strips, Staff P stated, I was told we changed sanitizer and that these were the new test strips. RD P then stated she would get the correct sanitizer test strips from the dietary office. According to the 2013 FDA Food Code section 4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration, Concentration of the SANITIZING solution shall be accurately determined by using a test kit or other device. The resident refrigerator located on the second floor, was observed with no thermometer inside to monitor the temperature. In addition, there was no log for staff to record the temperature of the refrigerator daily. There was milk, orange juice, ensure and glucerna observed inside the refrigerator. When queried, RD O stated, This refrigerator wasn't being used for a while. We'll get a thermometer in there. According to the 2013 FDA Food Code section 3-501.16 Potentially Hazardous Food (Time/Temperature Control for Safety Food), Hot and Cold Holding, 1. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under (B) and in (C ) of this section, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) shall be maintained: .2. (2) At 5ºC (41ºF) or less.

Based on interview and record review, the facility failed to complete a quarterly assessment in a timely manner for four (R5, R6, R8, and R11) resident's Minimum Data Set (MDS) Assessment review, resulting in the potential for unmet resident care needs. Findings include: Quarterly MDS assessments not completed timely: R5 was admitted to the facility on [DATE]. Quarterly MDS assessment was due on 5/20/21 and was not completed until 6/22/21. R6 was admitted to the facility on [DATE]. Quarterly MDS assessment was due on 5/27/21 and was not completed until 6/22/21. R8 was admitted to the facility on [DATE]. Quarterly MDS assessment was due on 5/25/21 and was not completed until 6/22/21. R11 was admitted to the facility on [DATE]. Quarterly MDS assessment was due on 5/25/21 and was not completed until 6/22/21. On 6/23/21 at 10:44 AM, the MDS Nurse N was asked about the late assessments and if the facility had a policy related to the timeframe for completion. The MDS Nurse N acknowledged the assessments were late and explained that COVID-19 affected getting the assessments completed. The MDS Nurse N continued and explained that the facility uses the MDS manual for the timeframe. A review of the Long-Term Care Facility Resident Assessment Instrument User's Manual, version 3.0, stated, While the primary purpose as an assessment tool is used to identify resident care problems that are addressed in an individualized care plan .Quarterly Review Assessment is an Omnibus Budget Reconciliation Act of 1987 (OBRA) '87-required, non-comprehensive assessment that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored .

Based on observation, interview, and record review the facility failed to ensure that one sampled resident's (R57) catheter tubing was off of the floor and a privacy bag was covering their catheter urinary bag, of two residents reviewed for catheter care, resulting in the potential for infection and feelings of lack of dignity. Findings include: On 6/22/21 at 9:50 AM, an observation was made of R57 ambulating in the hall on their unit with the assistance of an unidentified physical therapy (PT) staff member. It was observed that R57's catheter tubing was dragging on the floor while they were ambulating. On 6/22/21 at 1:26 PM, an observation was made of R57 sitting in their wheelchair in the doorway of their room speaking with a different unidentified physical therapy staff member. It was observed that R57's catheter tubing was touching the floor. On 6/23/21 at 8:45 AM, an observation was made of R57 lying in bed and their urinary catheter bag being uncovered. R57 was queried about their urinary bag not being covered and indicated that it should be covered and was surprised that it was not covered. On 6/23/21 at 8:48 AM, Nurse A was queried regarding R57's catheter urinary bag and indicated that the urinary bag should be placed in a privacy bag. On 6/23/21 at 10:45 AM, the Director of Nursing (DON) was interviewed regarding catheter tubing touching the floor and their expectations involving covering of a resident's urinary catheter bag. The DON indicated that tubing should never be touching the floor and that a privacy bag should always be placed on a resident's urinary catheter bag. On 6/23/21 at 11:00 AM, a review of R57's electronic health record (EHR) revealed the following, R57 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R57's most recent Minimum Data Set assessment (MDS) dated [DATE] revealed that R57 had an intact cognition and required extensive one person assistance for all Activities of daily living (ADLs) other than eating. On 6/23/21 at 1:00 PM, a facility policy regarding catheter tubing and use of privacy bags was requested. The DON reported that the facility did not have a specific policy which addressed these issues.

This citation pertains to intake # 7. Based on observation, interview and record review, the facility failed to safely reposition R800 during care, resulting in a fall from the bed to the floor, a laceration to the right arm, and the possibility of serious injury. Findings include: On 10/14/2020 at 4:19 PM, the Complainant A was called and stated the following, I was told that my (R800) fell out of bed while the Aide was changing (their) brief. I cannot understand how (R800) rolled out of bed and hit the floor with someone there giving care and had another fall last week. This is ridiculous. On 10/15/2020 at 11:44 AM, R800 was observed in bed with their eyes closed. R800 was easily aroused and answered simple questions without difficulty. R800 was observed to have a laceration above their right eye, bruising above their right eye, and bruising underneath their right eye. R800 was queried about the injury to their right eye and R800 said, I fell out of bed last week and hit my face. I thought I was at home in my big bed. It really hurts. R800 was then asked if they recalled the fall in September when they received a laceration on their arm. R800 said, I know I fell out of bed, but I don't remember all the details. I fell out of bed two times here. A review of R800's electronic medical record noted the admission date of [DATE] with [DIAGNOSES REDACTED]. A review of the MDS (Minimum Data Set- standardized assessment of resident's functional capabilities and health needs) Functional Status G (dated 9/2/20 with the last evaluation of 9/14/20) noted R800 required extensive, two-person assistance with bed mobility, transfers, and personal hygiene. The MDS also noted R800 was total dependence with bathing. A review of R800's Brief Interview For Mental Status (BIMS) (screen used to assist with identifying a resident ' s current cognition) noted a score of 10 (Moderate impairment). A review of the Care Plan Intervention noted the following: Concave mattress, Effective: 9/17/20 .Complete fall risk assessment and modify care plan as needed, Effective 9/2/20 .Use assistive devices as described on resident summary for mobility and ADL (Activities of Daily Living) tasks, Effective 9/2/20. The Care Plan did not specify information/interventions regarding bed mobility, extensive assistance, or number of staff needed during care/brief changes. A review of R800's Clinical Notes dated 9/17/2020 at 9:40 PM noted the following: CNA (Certified Nursing Assistant B) was changing Resident and turned (R800) on (their) side and Resident continued to roll and fell out of bed. Resident has a skin tear on (their) right hand .resident able to follow commands. A review of the Follow up Summary Fall Event-Root Cause Analysis by Nurse Manager D dated 9/18/20 noted the following: Guest (R800) was being changed by staff. Staff and resident interviews show that resident was instructed to turn towards cena to complete brief change. Resident quickly rolled towards cena and (R800's) momentum caused (R800) to roll off the side of the bed. Cena (CNA B) attempted to stop (R800) from falling, (Cena B) was able to put (their) leg under (R800) to slow the impact of the fall and help to lower (R800) to the floor. Education provided to resident for when cena is helping (R800) to roll and be changed to allow cena to assist and help (R800) roll and to not push (R800) to roll on (R800) own for (R800) safety. A review of the Staff Interview Summary dated 9/17/20 noted the following statement from CNA B: I was with the resident, changing (their) brief. I instructed/helping to roll over towards me and cross (their) top leg over. When (R800) crossed the leg over, (R800 kept rolling and rolled off the bed. I tried to catch (R800) but (R800) rolled over too fast .I was at (R800's) bedside when (they) rolled off .I was trying to help (R800) and instruct (R800) but (R800) forced (their) repositioning and rolled out of bed. I tried to save but was not able to. Attempted to contact CNA B via phone call, however, a voice message was left. Per the Nursing Home Administrator, CNA B no longer works at the facility due to personal reasons. On 10/15/2020 at 2:23 PM, the NHA and Director of Nursing (DON) were interviewed regarding R800's fall out of bed during a brief change with CNA B. The DON stated, The CNA was assisting (R800) with care. The CNA (CNA B) asked (R800) to roll towards (CNA B). The CNA said that (R800) rolled so fast that (R800) fell on the floor .The CNA (CNA B) said (R800) was right in front of (them). (R800) was educated not to move so fast when the CNAs are helping. The DON and NHA were queried about the MDS indicating that R800 required extensive, two person assist with bed mobility, transfers, and personal hygiene. The DON stated, No. (R800) is only a one-person assist. That is not correct. The NHA stated, We follow POC (Plan of Care). The MDS is just an assessment. The MDS does not always know all of the details about the residents current situation. The NHA indicated that the MDS nurse would explain why the MDS noted two-person assist for R800. On 10/15/2020 at 2:59 PM The MDS Nurse C stated, Regarding bed mobility, the MDS means the resident may require one-person assist at times and two-person assist at other times. The two-person assist is mostly to prevent skin shearing when moving a resident in bed. A review of the Fall Management policy dated 12/2015 noted the follow: Purpose: To prevent and/or reduce the number of falls by providing an individualized, person-centered care approach with Communities managing fall risk through the process of assessment, planning, implementation, and evaluation .Residents who are at risk for falls will have an individualized care plan developed which identifies interventions to reduce fall risk. This can help the facility balance interventions to reduce the risk of an accident, while honoring the resident's autonomy.

Based on observation, interview, and record review, the facility failed to ensure the cleanliness of a shower curtain for one sampled resident (R281) of one reviewed for environment, resulting in resident dissatisfaction with their living environment. Findings include: On 8/12/19 at 11:30 AM, during the initial tour of the facility, R281 was met in their room and queried about any concerns they had regarding the facility. R281 stated, My shower curtain has mold on it, I've asked staff to change it twice and they have not done it. I'm not a fuss budget but I like things clean. On 8/12/19 at 11:38 AM, an observation of R281's shower curtain in their bathroom revealed a black colored substance on the bottom of the shower curtain. On 8/13/19 at 4:15 PM, R281 was met in their room and further queried about their shower curtain. R281 stated, They have not changed it yet, it's still dirty. It upsets me that the shower curtain is dirty. On 8/13/19 at 4:20 PM, an observation of R281's shower curtain was made and revealed that the shower curtain continued to have a black colored substance on the bottom of it. On 8/13/19 at 4:30 PM, Housekeeping Supervisor (HS) A was met in R281's room and queried about the frequency of shower curtains being cleaned or changed in resident rooms. HS A stated, There is no set schedule for them to be changed or cleaned, they should be changed or cleaned if they are dirty. HS A observed the bottom of R281's shower curtain in their bathroom and stated, Someone should have noticed it, I will clean it right now. On 8/14/19 at 9:00 AM, a review of R281's medical record indicated an admission to the facility on [DATE], with [DIAGNOSES REDACTED]. R281's most recent Minimum Data Set (MDS) Assessment, dated 8/9/19 indicated that R281 had a Moderately impaired cognition. On 8/14/19 at 9:30 AM, a facility policy titled Resident Room Occupied, Clean with no date, indicated the following, Policy/Purpose: To maintain a clean, attractive, and sanitary environment for patients visitors, and employees that reduces the possibility of cross infection and enhances the image of the facility.

This citation pertains to intake numbers: and Based on interview and record review, the facility failed to ensure that medications were given as ordered for two residents (Resident #701 and #702) of three residents sampled for medication review, [MEDICAL CONDITION] Embolism (PE/blood clot in the lung), and the potential for increased blood pressure and other undesired health effects. Findings include: Resident #701 A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #701 was readmitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #701 needed extensive assist with dressing and transfers and had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating a moderately impaired cognition. On 9/12/18 at 8:12 AM, an interview was completed with Family Member B. According to Family Member B, Resident #701 had not received their blood pressure medications during the week of (MONTH) 4th (2018). On 9/12/18 at 10:05 AM, an interview was completed with Resident #701 in regards to the missed blood pressure medications in July. Resident #701 stated, They didn't give me my blood pressure medication. Resident #701 was asked if they experienced any effects from not receiving the medication and stated, I do get headaches at times. A record review of the Progress Notes and Blood Pressure readings was completed and revealed the following: Notes-7/1/18 .upset this shift, states (Resident #701) should receive a red pill during med pass . Blood Pressures- 6/30/18 180/80 7/3/18 171/77 There were no readings documented on 7/1/18 and 7/2/18. Normal blood pressure is 110/70. Blood pressures over 140/90 are considered high. A record review of the Physician order [REDACTED]. Order-Catapril 50 milligrams (mg) every 8 hours (starting 6/20/18) [DIAGNOSES REDACTED].>MAR-Catapril 50 mg not administered on 7/1/18 for the 3:00 PM and 11:00 PM doses. On 9/12/18 at 2:06 PM, an interview was completed with the Director of Nursing (DON) regarding the missed blood pressure medication for Resident #701. The DON stated, Yes, we did miss the medication. It was not available and not in the back up. The DON was further queried in regards to the procedure if a blood pressure medication is not available. The DON stated, We have to follow up with the Doctor if a blood pressure medication is not available. On 9/12/18 at 2:43 PM, a protocol was provided by the DON in regards to missing blood pressure medications. The DON stated, We did not follow the protocol. I did educate the nurses. The protocol was not dated or titled but stated the following: 1. When charting 'Not Administered' in EMR (Electronic Medical Record), you must enter a note under 'Administration Notes'. 2. If not in (back up), you must call the Doctor for an order or substitute medication while waiting for the medication to be delivered. 3. Pharmacy must be contacted to inquire on when the medication will be sent to the facility. If needed, ask for the medication to be drop shipped ASAP (as soon as possible). On 9/12/18 at 2:45 PM, an interview was completed with Nurse C in regards to the missed blood pressure medication on 7/1/18 for Resident #701. Nurse C stated, It (the medication) was not available. I did not call the Doctor. They (the facility) gave me an education to make sure I call the Doctor when medication is not available. Resident #702 A record review of the MDS dated [DATE] revealed that Resident #702 had a BIMS score of 15 out of 15, indicating an intact cognition and needed extensive assist with transfers and dressing. The MDS also revealed that Resident #702 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. On 9/12/18 at 8:26 AM, an interview was completed with Confidential Witness A via phone. Confidential Witness A stated, (Resident #702) has two cardiac catherizations and needed a stent. They (the facility) had specific instructions from the hospital to be on a blood thinner ([MEDICATION NAME]). They wrote it in wrong, for one day only (instead of daily). (Resident #702) missed several days. I took them to the cardiologist on the 28th (August) and they agreed with me that (Resident #702) had a TIA ([MEDICAL CONDITION]/mini stroke). (Resident #702) started acting weird and I demanded they go to the hospital. (Resident #702) has a PE and a [MEDICAL CONDITION] in both their legs. The cardiologist was panicked. The facility told me they had a triple check system for this and would investigate this. A record review of the hospital discharge notes dated 8/23/18 revealed the following: Diagnoses: [REDACTED]. [MEDICATION NAME] 75 mg by mouth everyday. Newly added Discharge Goals: Patient takes medication as prescribed. Impression-s/p MI ([MEDICAL CONDITION] Infarction/[MEDICAL CONDITION]). A record review of the Progress Notes for Resident # 702 revealed the following: 9/1/18 Nursing- .Daughter stated (Resident #702) wasn't acting normal .speech was different .more confused, and that Tuesday while at their cardiology appointment the Doctor told them that they had a TIA [MEDICAL CONDITION].they had been that way for a few days .(Resident #702) alert with difficulty answering questions and following commands .Daughter requesting be transferred to the the hospital. Transferred at 9:30 PM. 9/10/18 Doctor- .T/f (hospital transfer sheet) Aspirin/[MEDICATION NAME]-only ASA (aspirin) given . A record review of Resident #702's MAR for August-September (YEAR) revealed an order for [REDACTED]. A record review of the Cardiology consult for 8/28/18 revealed the following: .Appears patient (Resident #702) may have had a TIA 3-4 days ago. Medications- .[MEDICATION NAME] 75 mg . Recommendations- .3. Continue present cardiac medications. A record review of Resident #702's 9/2/18-9/11/18 Hospital Stay Details revealed the following: Your [DIAGNOSES REDACTED]. Study Result Lower Extremity Bilateral Venous Duplex Report 9/4/18- .total occluding acute [MEDICAL CONDITION] (blood clot in left leg). A record review of the Incident Report for Resident #702 dated 9/1/18 revealed the following: Specific Event Type: Medication was omitted. Actual Severity Level: 1-Event has capacity to cause error. Describe the Event: [MEDICATION NAME] medication order written wrong. [MEDICATION NAME] written for 1 day instead of once daily. Date event was discovered: 9/1/18. On 9/12/18 at 1:25 PM, an interview was completed with the DON in regards to Resident #702's missed [MEDICATION NAME] order. The DON stated, It was a transcription error. I educated both nurses because we have a double check system. The nurse who puts in the order has another nurse check the orders that they are correct. They both missed it. Instead of writing once per day, they wrote for one day only. On 9/12/18 at 2:13 PM, an interview was completed with the Executive Director (ED) in regards to the missed [MEDICATION NAME] medication for Resident #702. The ED stated, We did discuss it. I am aware of what happened. We added another check in hopes if someone were to miss the medication on admission, we would be able to catch it sooner to prevent an error from happening. The Unit Managers have to check the orders. A record review of the Medication Administration Policy revised (MONTH) 2008 revealed the following: 3. Medications must be administered in a timely manner and in accordance with the attending physicians written/verbal orders. 14. Any explanatory note on the reverse side of the MAR must be entered when drugs are withheld, refused, or given other than scheduled times (Note: The Director of Nursing Services and Attending Physician should be notified when two (2) consecutive doses of medication are refused or withheld. During the survey the nurses responsible for double checking the medication orders were called but no return phone call was received by the end of the survey. The following policies were also requested but not received by the end of the survey process: Medication Transcription and Blood Pressure Medication Administration.

Based on observation, interview, and record review, the facility failed to ensure that cold food items were stored at the proper temperature, and failed to ensure quaternary ammonia test strips were up to date, resulting in the increased potential for foodborne illness and cross contamination. This deficient practice had the potential to affect 144 residents that receive food from the kitchen. Findings include: On 7/10/18 at 8:49 AM, during an initial tour of the kitchen with the Dietary Manager, the following items were observed: In the walk in cooler, there was a large, deep pan of gravy, dated 7/9. The internal temperature of the gravy was measured to be 45 degrees Fahrenheit. When asked if the facility keeps cooling logs, the DM stated, Usually we don't even keep leftovers, so we don't do cooling logs. According to the 2009 FDA Food Code, Section 3-501.14 Cooling, 1. (A) Cooked potentially hazardous food (time/temperature control for safety food) shall be cooled: (1) Within 2 hours from 57ºC (135ºF) to 21ºC (70°F); and (2) Within a total of 6 hours from 57ºC (135ºF) to 5ºC (41°F) or less. The QT test strips used for testing the sanitizer level in the 3 compartment sink and the sanitizer buckets, were observed inside a bucket with numerous other items, with no manufacturer's label attached to the container. There were 2 free floating QT test strip labels at the bottom of the bucket, one with an expiration date of 2014, and one with an expiration date of (YEAR). The DM stated, I didn't even know they had expiration dates. I have some new ones in my office. According to the 2009 FDA Food Code Section 4-501.116 Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device.

Based on observation, interview, and record review the facility failed to administer medicated eye drops per professional standards of practice for 1 ( # 358) resident that was not included in the total sample of 30 residents, resulting in the ineffective absorption of the medication. Findings include: On 7/11/18 at 9:40 a.m., a medication administration observation was conducted with Nurse D. Nurse D referred to the Medication Administration Record [REDACTED]. Nurse D then patted the resident's eyes with tissue. Later Nurse D was asked how long one should apply pressure to the eye after administering medicated eye drops and stated, Less than one minute. On 7/11/18 at 1:00 p.m., record review revealed that the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/12/18 at 10:30 a.m., The Director of Nursing (DON) was asked about the facility's policy and stated, They should hold the eye for one to two minutes. The DON was asked for the facility's policy and procedure for administering eye drops and provided an undated document titled OPHTHALMIC DROPS. Review of the document revealed in line 11. Gently press thumb over the inner canthus (corner) for 1 to 2 minutes after instilling drops while resident closes eyes gently. Prevents systemic absorption allows medicine to distribute over surface of eye.

This citation pertains to intake MI 190 Based on interview and record review, the facility failed to provide and document evidence of prompt resolution to a grievance identified by family for one (#356) of one sampled resident reviewed for choices, in a total sample of thirty, resulting in an unresolved grievance. Findings include: On 7/11/18 at 9:45 a.m., Resident #356's daughter reported during an interview that she was not informed of the findings of a complaint filed against a Certified Nursing Assistant (CNA L) regarding how her mother (#356) was treated while she was actively dying. The daughter stated, My mom was actively dying. She was in hospice. I just wanted her comfortable. I wanted to make sure that she was not wet (soiled with urine/stool) so I asked for CNA L to just check my mom's brief after her pain medication kicked in about 20 minutes. CNA L said, in a rude manner, 'If I check her then I am going to change her .' I did not want my mom moved unless she had to be. I requested the outcome of the investigation. The Administrator said legally that he could not tell me the outcome of the investigation. On 7/11/18 at 10:00 a.m., review of Resident #356's face sheet revealed an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #356's most recent quarterly Minimum Data Set (MDS) assessment, dated 3/2/18, indicated a severely impaired cognition and required extensive assistance with activities of daily living (ADLs). On 7/11/18 at 1:20 p.m., review of the facility's Grievance/Complaint Report form, with a completion dated of 5/1/18, revealed an incident that involved Resident #356 that occurred on 4/22/18. The Grievance/Complaint Report form revealed the following documentation: Dtr (daughter) reported an infraction with CNA (Certified Nursing Assistant L). Daughter asked for aide to check mother's brief to see if she needs changing. Aide proceeded to change brief instead of simply checking. When dtr objected, aide replied, 'If I'm going to check her, I'm going to change her.' Aide suggested dtr check. The dtr said she wasn't sure. Dtr reported aide saying, 'Then she's dry,' and left the room. The Grievance/Complaint Report form indicated the facility's follow-up regarding the complaint was assigned on 4/24/18 and the date to be resolved by was on 5/1/18. The grievance/complaint was indicated as being resolved per under the section of Resolution of Grievance/Complaint, on the form and indicated that the daughter was informed via telephone of the report. There was no date documented on when it took place. The form was signed as completed by the Administrator. On 7/11/18 at 2:50 p.m., the Administrator was interviewed regarding the lack of documentation for the follow up with the daughter's grievance/complaint. The Administrator stated, I spoke with the daughter. When asked why it was not documented on the Grievance/Complaint Report, the Administrator stated, I thought the Social Worker documented it. It was miscommunication. I did not formally do it right (completing the form). The CNA was suspended. On 7/11/18 at 3:15 p.m., The Social Worker (SW M) was interviewed regarding informing the daughter of the resolution regarding her complaint. SW M stated, I called the daughter. I followed up with her. Review of the resident's medical record, with SW M did not reveal any documentation of the daughter being informed of the resolution. SW M reported that she may have documented the conversation in her own personal file and reported that she would check. 7/11/18 at 3:29 p.m., Social Worker M was unable to locate documentation for the communication with the daughter regarding the resolution for the reported grievance. On 7/12/18 at 9:26 a.m., the Director of Nursing (DON) stated, I was aware of the incident. Human Resources (HR) and the Administrator did the investigation. We disciplined her (CNA L). We suspended her. HR informed us of the suspension. On 7/12/18 at 2:20 p.m., the facility's policy entitled Concern/Complaint/Grievance, dated (MONTH) 28, 2007, included the following documentation: Purpose: To provide a reporting process in which residents and family members can express a complaint and receive written follow-up action related to the complaint .It is expected that the community respond in a timely manner to the concern/complaint.

This citation pertains to intake MI 190 Based on interview and record review, the facility failed to honor resident's rights and ensure dignity and respect for one (#356) of one resident reviewed for choices, from a total sample of 30, when the facility failed to honor the request for incontinence care with the least amount of discomfort during the active phase of dying, resulting in possible increased discomfort and feelings of helplessness. Findings include: On 7/11/18 at 9:45 a.m., Resident #356's daughter stated during an interview, My mom was actively dying. She was in hospice. I just wanted her comfortable. I wanted to make sure that she was not wet (soiled with urine/stool) so I asked for Certified Nurse Assistant (CNA) L to just check my mom's brief after her pain medication kicked in about 20 minutes. CNA L said, in a rude manner, 'If I check her then I am going to change her .' I did not want my mom moved unless she had to be. I reported the incident to the nurse and other staff. On 7/11/18 at 10:00 a.m., review of the face sheet revealed that the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #356's most recent quarterly Minimum Data Set (MDS) assessment, dated 3/2/18, indicated a severely impaired cognition and required extensive assistance with activities of daily living (ADLs). On 7/11/18 at 1:20 p.m., review of the facility's Grievance/Complaint Report form, with a completion date of 5/1/18, revealed an incident that involved Resident #356 that occurred on 4/22/18. The Grievance/Complaint Report form revealed the following documentation: Dtr (daughter) reported an infraction with CNA (Certified Nursing Assistant L). Daughter asked for aide to check mother's brief to see if she needs changing. Aide proceeded to change brief instead of simply checking. When dtr objected, aide replied, 'If I'm going to check her, I'm going to change her.' Aide suggested dtr check. The dtr said she wasn't sure. Dtr reported aide saying, 'Then she's dry,' and left the room. The Grievance/Complaint Report form indicated the facility's follow-up regarding the complaint was assigned on 4/24/18 and the date to be resolved by was on 5/1/18. The grievance/complaint was indicated as being resolved under the section of Resolution of Grievance/Complaint, on the form and indicated that the daughter was informed via telephone on the report. There was no date documented on when it took place. The form was signed as completed by the Administrator. On 7/11/18 at 2:05 p.m., the facility's Pastor (Pastor I) was interviewed regarding the incident. Pastor I stated, I met with the daughter of Resident #356. I think I talked to someone. I think, if I remember, it had something to . I think her mom was sick. She was in the active stage of her disease process. There was something about wanting her mom's brief checked or changed. The CNA said, 'If I am going to check, I am going to change her.' I thought that was not acceptable. I talked to . can't remember. I know I talked to someone. I know we got a grievance or had that person spoken to or there would be re-training. What the CNA said was not appropriate. It was uncomfortable for the mom per the daughter. She just wanted her checked so that she would not be uncomfortable. I reported the incident. I may have filled out the initial incident report because she told me. I think it was just a tired aide. I think it was rudeness. I think she was totally oblivious as to what the daughter was going through watching her mother in that condition. She should have been more receptive or more aware of that. On 7/11/18 at 2:45 p.m., the Human Resources Director (Employee K) reported when interviewed, that CNA L was suspended for the incident. On 7/11/18 at 2:50 p.m., the Administrator was interviewed regarding the incident. The Administrator stated, I spoke with the daughter. The Administrator reported investigating the incident and reported the CNA was suspended for the incident. On 7/12/18 at 9:26 a.m., the Director of Nursing (DON) stated, I was aware of the incident. Human Resources (HR) and the Administrator did the investigation. We disciplined her (CNA L). We suspended her. HR informed us of the suspension. On 7/12/18 at 9:53 a.m., CNA L was called via telephone. There was no answer. A message was left on the answering machine.

THIS CITATION PERTAINS TO INTAKE #MI 153. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROPERLY POSITION AND PROVIDE TIMELY ORAL AND TRACHEAL SUCTIONING FOR 1 (#101) OF 6 RESIDENTS REVIEWED FOR EMERGENCY NURSING CARE FROM A TOTAL SAMPLE OF 9, RESULTING IN IMMEDIATE JEOPARDY FOR RESIDENT #101, WHO ASPIRATED FOOD AFTER BEING FED. RESIDENT #101 EXPERIENCED A PROLONGED PERIOD OF RESPIRATORY DISTRESS AND SUBSEQUENTLY died . FINDINGS INCLUDE: ACCORDING TO THE FACILITY'S ASPIRATIONS PRECAUTIONS POLICY, DATED [DATE], "...1. THE SPEECH-THERAPIST...WILL RECOMMEND SPECIFIC ASPIRATION PRECAUTIONS PER EACH INDIVIDUAL ELDER'S NEEDS..." ACCORDING TO THIS POLICY, STAFF WERE THEN TO "...FOLLOW THE ASPIRATION PRECAUTIONS AS RECOMMENDED BY THE PROFESSIONAL...WHO EVALUATED THE ELDER..." RESIDENT #101 ACCORDING TO THE FACE SHEET, DATED [DATE], RESIDENT #101 WAS A [AGE] year OLD FEMALE WHO WAS admitted to the facility on [DATE]. THE MINIMUM DATA SET (MDS) assessment dated , [DATE], INDICATED THAT RESIDENT #101 WAS UNABLE TO COMMUNICATE HER NEEDS AND REQUIRED THE EXTENSIVE PHYSICAL ASSISTANCE OF FACILITY STAFF WHEN EATING. SHE HAD SEVERAL [DIAGNOSES REDACTED]. ADDITIONAL [DIAGNOSES REDACTED]. ACCORDING TO THE SPEECH THERAPIST'S EVALUATION FOR DYSPHAGIA, DATED [DATE], RESIDENT #101 SUFFERED FROM OROPHARYNGEAL DYSPHAGIA AND REQUIRED A PUREED DIET WITH HONEY THICK LIQUIDS AND ASPIRATION PRECAUTIONS. ACCORDING TO THE EVALUATION, THE SPEECH THERAPIST DOCUMENTED THAT RESIDENT #101 HAD "...GOOD REHAB POTENTIAL...SHOULD MAKE SIGNIFICANT GAINS..." ACCORDING TO THE SPEECH THERAPY PROGRESS SUMMARY FORM, DATED [DATE], RESIDENT #101 WAS TO BE FED USING A "LOW [MEDICATION NAME]" (SMALL AMOUNT OF FOOD) SIZE, SLOW RATE OF INTAKE, AND SITTING "...UPRIGHT..." AT AN ANGLE OF "...90 DEGREES...." ACCORDING TO THE NURSE'S NOTE, DATED [DATE], RESIDENT #101 WAS BEING FED BY A CERTIFIED NURSE ASSISTANT (CNA) AND ASPIRATED FOOD. A SUCTION MACHINE WAS BROUGHT FROM THE DINING ROOM AND SET UP BUT A PIECE OF THE TUBING WAS MISSING AND THE SUCTIONING WAS NOT PROVIDED TO RESIDENT #101. ACCORDING TO THE NURSE'S NOTE, THE CNA WAS SENT FOR HELP, BECAUSE RESIDENT #101 WAS EXPERIENCING INCREASING DISTRESS AND COULD NOT BE LEFT ALONE. CNA #1 WAS INTERVIEWED ON [DATE] AT 2:45 P.M. DURING THE INTERVIEW, CNA #1 SAID THAT SHE WAS THE CNA WHO FED RESIDENT #101 HER EVENING MEAL ON [DATE]. ACCORDING TO CNA #1, RESIDENT #101 RESIDED ON THE SECOND FLOOR IN THE FACILITY ' S SANCTUARY UNIT AND, ON THAT EVENING, WAS FED IN HER ROOM WHILE LYING IN BED. THE RESIDENT RECEIVED A MEAL THAT CONSISTED OF PUREED FOODS WITH HONEY THICK LIQUIDS. CNA #1 FURTHER STATED THAT SHE (THE CNA) WAS SITTING NEXT TO THE BED ON RESIDENT #101'S LEFT SIDE AND RESIDENT #101'S DAUGHTER WAS IN THE ROOM SITTING ON RESIDENT #101'S RIGHT SIDE. RESIDENT #101 WAS POSITIONED IN BED, SITTING UP ABOUT A 45 DEGREE ANGLE FOR FEEDING. CNA #1 SAID RESIDENT #101 ATE MOST OF HER MEAL AND THEN STARTED COUGHING. CNA #1 SAID RESIDENT #101'S DAUGHTER THEN RAN OUT OF THE ROOM TO GET THE NURSE. RESIDENT #101'S DAUGHTER (FAMILY MEMBER #1) WAS INTERVIEWED ON [DATE] AT 3:15 P.M. RESIDENT #101'S DAUGHTER SAID THAT SHE WAS PRESENT DURING THE EVENING MEAL ON [DATE]. ACCORDING TO THE DAUGHTER, RESIDENT #101 WAS IN BED, SITTING UP AT ABOUT A 45 DEGREE ANGLE WHILE BEING FED BY THE CNA #1. THE DAUGHTER FURTHER STATED THAT WHEN SHE SAW HER MOTHER START COUGHING, SHE RAN OUT OF THE ROOM TO GET THE NURSE. RESIDENT #101'S DAUGHTER TOLD THE REGISTERED NURSE (RN #1) IN THE HALLWAY THAT HER MOTHER WAS CHOKING. RESIDENT #101'S DAUGHTER WENT ON TO SAY THAT RN #1 TURNED TO ANOTHER STAFF MEMBER AND ASKED THE OTHER STAFF MEMBER WHERE ON THE UNIT THE SUCTION MACHINE WAS KEPT. RESIDENT #101'S DAUGHTER SAID WHEN SHE REALIZED THAT RN #1 DID NOT KNOW WHERE THE FACILITY'S EMERGENCY EQUIPMENT WAS LOCATED, SHE (THE DAUGHTER, FAMILY MEMBER #1) WENT AND GOT THE SUCTION MACHINE FOR THE NURSING STAFF TO USE. ACCORDING TO FAMILY MEMBER #1, SHE (THE DAUGHTER) KNEW THAT THE SUCTION MACHINE WAS KEPT IN ONE CORNER OF THE DINING ROOM. RN #1, A UNIT MANAGER AT THE FACILITY, WAS INTERVIEWED ON [DATE] AT 12:55 P.M. ACCORDING TO RN #1, SHE (RN #1) WAS THE NURSE ASSIGNED TO THE SANCTUARY UNIT ON [DATE]. RN #1 SAID THAT ON [DATE] BETWEEN 6:30 P.M., AND 6:45 P.M., SHE WAS STANDING IN THE HALLWAY WHEN RESIDENT #101'S DAUGHTER CAME TO HER AND SAID THAT HER MOTHER WAS CHOKING. RN #1 SAID THAT RESIDENT #101'S DAUGHTER WENT AND GOT THE SUCTION MACHINE AND GAVE IT TO HER, AFTER SHE (THE DAUGHTER) REALIZED THAT SHE (RN #1) DID NOT KNOW WHERE THE SUCTION MACHINE WAS KEPT. RN #1 STATED THAT THE SANCTUARY UNIT WAS NOT HER USUAL ASSIGNMENT AND WHILE SHE AND RN #2 WERE THINKING OF THE LOCATION OF THE SUCTION MACHINE, THE RESIDENT'S DAUGHTER WENT AND GOT IT. RN #1 SAID THAT ONCE SHE HAD A SUCTION MACHINE, SHE (THE RN) ENTERED THE ROOM AND FOUND RESIDENT #101, IN BED, POSITIONED AT ABOUT A 45 DEGREE ANGLE. RN #1 SAID RESIDENT #101'S LIPS WERE TURNING BLUE; SHE (#101) WAS "BREATHING FAST," AND MAKING "GURGLING" SOUNDS. RN #1 SAID SHE THEN ATTEMPTED TO SET UP THE SUCTION MACHINE BUT REALIZED THAT THERE WAS A PIECE OF TUBING THAT WAS MISSING. WITHOUT THE TUBING, THE SUCTION MACHINE WAS UNUSABLE. ACCORDING TO RN #1, SHE SENT CNA #1, WHO HAD REMAINED IN THE ROOM WITH THE RESIDENT, FOR HELP. RN #1 SAID ONCE CNA #1 HAD LEFT THE ROOM, SHE (THE RN) PULLED RESIDENT #101 UP IN BED AND TURNED HER ON HER RIGHT SIDE. RN #1 THEN SAID, "...THERE WAS NOT A LOT I COULD DO WITHOUT SUCTION..." RN #2, ALSO A UNIT MANAGER AT THE FACILITY, WAS INTERVIEWED ON [DATE] AT 1:30 P.M. RN #2 SAID THAT ON [DATE] SHE WAS THE ASSIGNED NURSE ON THE CANDLEWOOD UNIT. RN #2 SAID THAT ON [DATE], SHORTLY AFTER SUPPER, SHE WAS IN THE SANCTUARY UNIT HALLWAY, TALKING WITH RN #1. RN #2 SAID THAT RESIDENT #101'S DAUGHTER CAME OUT OF THE ROOM SAID HER MOTHER HAD ASPIRATED AND NEEDED HELP. RN #2 WAS NOT USUALLY ASSIGNED TO THE SANCTUARY UNIT AND WHILE SHE AND RN #1 WERE THINKING OF THE LOCATION OF THE SUCTION MACHINE, THE RESIDENT'S DAUGHTER WENT AND GOT IT. RN #2 CONFIRMED THAT FAMILY MEMBER #1 RETRIEVED THE SUCTION MACHINE AND GAVE IT TO RN #1. RN #2 THEN STATED THAT SHE ACCOMPANIED RN #1 BACK INTO RESIDENT 101'S ROOM. RN #2 SAID THAT RESIDENT #101 WAS IN BED, POSITIONED AT ABOUT A 45 DEGREE ANGLE, AND MAKING "GURGLING" SOUNDS. THE GURGLING WAS AUDIBLE FROM THE DOORWAY. RN #2 DESCRIBED HOW RN #1 BEGAN TRYING TO SET UP THE SUCTION MACHINE. RN #2 SAID THAT THE SUCTION MACHINE WOULD NOT WORK BECAUSE A PIECE OF TUBING WAS MISSING. RN #2 SAID THAT SHE THEN WENT TO THE UNIT MEDICATION ROOM TO LOOK FOR THE TUBING, BUT COULD NOT FIND IT. WHEN INTERVIEWED, CNA #1 SAID THAT RN #1 TRIED TO SUCTION RESIDENT #101 BUT COULDN'T BECAUSE THERE WAS A PROBLEM WITH THE MACHINE. CNA #1 SAID THAT AT THE DIRECTION OF RN #1, SHE (THE CNA) WENT TO GET HELP. CNA #1 SAID SHE LEFT THE ROOM AND TOOK THE STAIRS TO THE PROMENADE UNIT, LOCATED ON THE FIRST FLOOR, WHERE SHE FOUND THE NURSE ASSIGNED TO THE PROMENADE UNIT, LICENSED PRACTICAL NURSE (LPN) #1. LPN #1 WAS INTERVIEWED ON [DATE] AT 2:50 P.M. LPN #1 SAID THAT ON [DATE], WHILE SHE WAS WORKING ON THE PROMENADE UNIT, CNA #1 CAME TO HER AND INFORMED HER (LPN #1) THAT THE SANCTUARY UNIT NURSE WAS UPSTAIRS HAVING TROUBLE SUCTIONING A RESIDENT. ACCORDING TO LPN #1, AT THE TIME, SHE (THE LPN) WAS PREPARING TO ADMINISTER MEDICATIONS TO A RESIDENT. LPN #1 SAID THAT AFTER SHE FINISHED PREPARING THE MEDICATIONS, SHE ADMINISTERED THEM TO A RESIDENT ON THE PROM UNIT, WHOSE IDENTITY SHE COULD NOT RECALL. LPN #1 SAID SHE THEN RETURNED TO THE MEDICATION CART, LOCKED IT, AND THEN USED THE ELEVATOR TO GET TO THE SANCTUARY UNIT ON THE SECOND FLOOR. LPN #1 SAID THAT WHEN SHE ENTERED RESIDENT #101'S ROOM, RESIDENT #101 WAS LYING IN BED, ON HER BACK, WITH THE HEAD OF THE BED UP AT ABOUT A 45 DEGREE ANGLE. LPN #1 DESCRIBED RESIDENT #101 AS BEING IN RESPIRATORY DISTRESS. ACCORDING TO LPN #1, HER (#101) EYES WERE "ROLLED UP," HER LIPS WERE BLUE, AND SHE WAS HAVING TROUBLE BREATHING. LPN #1 SAID THAT SHE COULD HEAR THE SOUND OF GURGLING FROM RESIDENT #101 FROM THE DOORWAY, WHEN SHE ENTERED THE ROOM. LPN #1 SAID THAT RN #1 WAS AT THE RESIDENT'S BEDSIDE, TRYING TO SUCTION THE RESIDENT, BUT THE SUCTION MACHINE WAS NOT WORKING. THE TUBING THAT ATTACHED THE CANISTER TO THE PUMP WAS MISSING. LPN #1 SAID THAT SHE THEN LEFT THE SANCTUARY UNIT AND WENT TO THE SUNNYDALE UNIT, ALSO LOCATED ON THE SECOND FLOOR OF THE FACILITY, NEXT TO THE SANCTUARY UNIT. LPN #1 STATED THAT WHEN SHE REACHED THE SUNNYDALE UNIT, SHE ASKED ONE OF THE SUNNYDALE UNIT'S CNAS TO HELP HER FIND THE UNIT SUCTION MACHINE. LPN #1 SAID THAT SHE AND THE CNA WENT TO THE DINING ROOM WHERE THE SUNNYDALE UNIT SUCTION MACHINE WAS USUALLY KEPT, BUT THE MACHINE WAS NOT THERE. LPN #1 SAID THAT SHE THEN WENT TO THE CANDLEWOOD UNIT, THE NEXT UNIT OVER, ON THE SECOND FLOOR. LPN #1 STATED THAT AT THIS POINT, SHE BEGAN TO GET WORRIED ABOUT FINDING A SUCTION MACHINE. WHEN LPN #1 ARRIVED ON THE CANDLEWOOD UNIT, SHE WENT TO THE DINING ROOM AND FOUND A SUCTION MACHINE IN A GREY CANVAS BAG, OPENED THE BAG AND CHECKED THE UNIT FOR ALL THE PARTS, THEN THE TOOK THE SUCTION MACHINE IN THE CANVAS BAG TO RESIDENT #101'S ROOM ON THE SANCTUARY UNIT. LPN #1 SAID THAT WHEN SHE ARRIVED IN RESIDENT 101'S ROOM, SHE PLUGGED IN THE SUCTION MACHINE, CONNECTED ALL THE PARTS AND SUCTIONED RESIDENT #101'S ORAL CAVITY. LPN #1 SAID RESIDENT #101'S BREATHING WAS RAPID AND WHEN THE RESIDENT'S BLOOD OXYGEN LEVEL WAS tested , IT WAS FOUND TO BE 69% (NORMAL 90% TO 100%). WHEN ASKED TO DESCRIBE RESIDENT 101'S CONDITION, LPN #1 SAID THAT RESIDENT #101 HAD NOISY BREATHING AND DESCRIBED THE SOUNDS MADE BY THE RESIDENT AS BETWEEN GURGLING AND WHEEZING, "...BECAUSE (RESIDENT #101) HAD ASPIRATED..." RN #1 CONFIRMED THAT ONCE A USABLE SUCTION MACHINE WAS IN THE ROOM, LPN #1 STARTED SUCTIONING RESIDENT #101'S AIRWAY. RN #1 FURTHER STATED THAT LPN #1 SUCTIONED A LARGE AMOUNT OF LIQUEFIED FOOD FROM RESIDENT #101'S MOUTH AND THROAT. ACCORDING TO RN #1, IT WAS NOT UNREASONABLE THAT IT TOOK AROUND TEN MINUTES TO GET A WORKING SUCTION MACHINE INTO RESIDENT 101'S ROOM. RESIDENT #101'S DAUGHTER SAID THAT IT TOOK WELL OVER TEN MINUTES FROM THE TIME SHE WENT TO GET HELP FROM THE NURSES IN THE HALLWAY UNTIL THE TIME THAT A WORKING SUCTION MACHINE ARRIVED IN HER MOTHER ' S ROOM. RN #2 SAID THAT AFTER SHE WAS UNSUCCESSFUL IN HER ATTEMPT TO FIND THE TUBING (FOR THE SANCTUARY UNIT SUCTION MACHINE), SHE RETURNED TO RESIDENT #101'S ROOM. RN #2 FOUND LPN #1 IN THE ROOM SUCTIONING RESIDENT #101. RN #2 SAID THAT RESIDENT #101'S LIPS WERE BLUE AND THAT HER BREATHING WAS RAPID AND CONGESTED. RN #2 FURTHER STATED THAT SHE (RN #2) WAS CONCERNED ENOUGH THAT SHE THOUGHT RESIDENT #101 WOULD STOP BREATHING COMPLETELY AT ANY TIME. RN #2 SAID THAT RESIDENT #101'S EYES WERE OPEN, BUT THE RESIDENT WAS UNABLE TO COMMUNICATE VERBALLY, AND HAD A FRIGHTENED LOOK IN HER EYES. ACCORDING TO THE NURSE'S NOTES DATED [DATE], FACILITY STAFF CALLED 911 AND THE RESIDENT WAS "...SUCTIONED FOR COPIOUS AMOUNTS (OF) PUREED FOOD..." ACCORDING TO THE EMERGENCY MEDICAL SERVICES (EMS) REPORT, DATED [DATE] AT 6:57 P.M., EMS WAS CALLED BY THE FACILITY AND ALERTED TO THE NEED FOR SERVICE. ACCORDING TO THE EMS REPORT, EMERGENCY PERSONNEL ARRIVED AT 6:59 P.M., TO FIND THAT RESIDENT #101 WAS EXPERIENCING RAPID, LABORED BREATHING AND REQUIRED SUCTIONING ON ROUTE TO A LOCAL AREA HOSPITAL. ACCORDING TO THE LOCAL EMERGENCY DEPARTMENT PHYSICAL EXAMINATION, DATED [DATE], RESIDENT #101 WAS HAVING TROUBLE BREATHING, WAS SUCTIONED AND "...ALL SORTS OF FOOD PARTICLES CAME OUT..." RESIDENT #101 WAS admitted to the hospital with [REDACTED]. RESIDENT #101 SUBSEQUENTLY died on [DATE] AT 9:45 A.M. ON [DATE], AT 11:40 A.M., IN THE PRESENCE OF THE SURVEYOR, THE DIRECTOR OF NURSING (DON #1) RE-ENACTED THE SEQUENCE OF EVENTS INVOLVING RESIDENT #101, FIRST RE-TRACING THE STEPS THE RESIDENT ' S DAUGHTER, THEN CNA #1, AND THEN LPN #1. ALTHOUGH THIS RE-ENACTMENT DID NOT INCLUDE THE TIME LPN #1 SPENT PREPARING AND ADMINISTERING THE MEDICATIONS FOR THE SECOND RESIDENT, WALKING BACK TO THE MEDICATION CART AND LOCKING THE MEDICATION CART, DON #1 DID NOT ARRIVE BACK THE ROOM OCCUPIED BY RESIDENT #101 UNTIL 11:50 A.M., A 10-MINUTE TIME SPAN. ON [DATE] AT 11:50 A.M., DON #1 SAID IT WAS REASONABLE TO SURMISE THAT ACCORDING TO THE DESCRIPTION OF THE EVENTS PROVIDED BY FACILITY STAFF, BECAUSE OF THE FACILITY'S STRUCTURAL LAYOUT, AND THAT BECAUSE OF THE FACILITY'S FAILURE TO HAVE FUNCTIONING SUCTION UNITS AVAILABLE ON TWO OF THE NURSING UNITS, RESIDENT #101 WAS NOT PROVIDED WITH EMERGENCY CARE AND SUCTIONING FOR AT LEAST TEN MINUTES ON [DATE]. ADDITIONALLY, ACCORDING TO DON #1, THE FACILITY FAILED TO ENSURE THE SUCTION MACHINES WERE OPERATIONAL. ON [DATE], AT 9:35 A.M. AN IMMEDIATE JEOPARDY SITUATION WAS IDENTIFIED AT F-309. THE ADMINISTRATOR WAS INFORMED ON [DATE], AT 4:52 P.M. OF THE IMMEDIATE JEOPARDY THAT BEGAN ON [DATE] BETWEEN 6:30 P.M., AND 6:45 P.M., WHEN THE FACILITY STAFF FAILED TO ENSURE RESIDENT #101 WAS POSITIONED FOR A MEAL IN ACCORDANCE WITH THE PLAN OF CARE TO PREVENT ASPIRATION, WAS FED THAT MEAL, AND ASPIRATED FOOD; AFTER WHICH RESIDENT #101 WAS NOT PROVIDED WITH TIMELY ORAL AND TRACHEAL SUCTIONING AND EXPERIENCED A PROLONGED PERIOD OF RESPIRATORY DISTRESS. RESIDENT #101 SUBSEQUENTLY died . ON [DATE], THIS SURVEYOR CONFIRMED THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. ON [DATE] THE SURVEYOR VERIFIED THAT ON [DATE] THE INTERDISCIPLINARY TEAM (IDT) IDENTIFIED A TOTAL OF 37 RESIDENTS WITH DYSPHASIA/DIFFICULTY SWALLOWING, ALL WHO WERE RE-ASSESSED ON THAT DATE RELATED TO THE EATING OF THEIR MEALS WITH POSITIONING NEEDS AND THE AVAILABILITY OF WORKING SUCTION EQUIPMENT ACCESSIBLE TO THEIR LOCATION. 2. ON [DATE] THE SURVEYOR VERIFIED THAT ON [DATE], A COMPLETE CHECK OF ALL OF THE SUCTION EQUIPMENT IN THE FACILITY WAS COMPLETED TO MAKE SURE THAT ALL COMPONENTS OF EQUIPMENT ARE AVAILABLE AND READY FOR USE. 3. ON [DATE] THE SURVEYOR VERIFIED THAT ON [DATE] EACH SUCTION MACHINE WAS CHECKED AND DID HAVE ALL OF THE REQUIRED CONNECTIONS AND TUBING AND THAT THEY ALL WORKED. 4. ON [DATE] THE SURVEYOR VERIFIED THAT INSERVICES RELATED TO CLINICAL EMERGENCY EQUIPMENT AND PROCEDURES, SUCTIONING, SAFE EATING AND THE [MEDICATION NAME] MANEUVER WERE INITIATED FOR NURSING ASSOCIATES ON [DATE]. 5. ON [DATE] THE SURVEYOR VERIFIED THAT ON [DATE], THE EXECUTIVE DIRECTOR DEVELOPED A NEW POLICY ON CHECKING SUCTION EQUIPMENT IN THE FACILITY. 6. ON [DATE] THE SURVEYOR VERIFIED THAT ON [DATE] THE EXECUTIVE DIRECTOR CONTACTED THE SUCTION MACHINE VENDOR AND OBTAINED AN UPDATED PREVENTATIVE MAINTENANCE BASELINE OF EACH SUCTION MACHINE. 7. ON [DATE] THE SURVEYOR VERIFIED THAT ON [DATE] THE SUCTION MACHINE VENDOR, DELIVERED TWO ADDITIONAL SUCTION MACHINES AND COMPLETED THE PREVENTATIVE MAINTENANCE BASELINE CHECK ON EACH SUCTION MACHINE. 8. ON [DATE], THE SURVEYOR VERIFIED THAT ON [DATE], THE IDT DEVELOPED A POLICY FOR EMERGENCY SUCTION EQUIPMENT FOR LONG TERM CARE (LTC) AND REHAB AND WELLNESS. INSERVICING BEGAN ON [DATE]. ON [DATE], THE EMERGENCY SUCTION EQUIPMENT FOR LONG TERM CARE (LTC) AND REHAB AND WELLNESS POLICY WAS CHANGED TO INCREASE THE LEVEL OF MONITORING OF THE SUCTION EQUIPMENT TO ONCE EVERY SHIFT. INSERVICING ON THE REVISED POLICY BEGAN ON [DATE]. 9. ON [DATE], THE SURVEYOR VERIFIED THAT AS OF [DATE], 46 OF 48 NURSES HAD BEEN EDUCATED RELATIVE TO THE REVISED EMERGENCY SUCTION EQUIPMENT FOR LTC AND THE REHAB AND WELLNESS POLICY. 10. ON [DATE] THE SURVEYOR VERIFIED THAT ON [DATE], A NEW ADMINISTRATIVE GUIDELINE FOR IMPAIRED SWALLOWING SAFETY PRECAUTIONS WAS DEVELOPED. 11. ON [DATE] THE SURVEYOR VERIFIED THAT 92 NURSING PERSONNEL WERE IN SERVICED AS OF [DATE] AND 16 ADDITIONAL NURSING PERSONNEL WERE IN SERVICED AS OF [DATE] ON THE ADMINISTRATIVE GUIDELINE FOR IMPAIRED SWALLOWING SAFETY PRECAUTIONS. 12. ON [DATE], THE SURVEYOR VERIFIED THAT AN AUDIT WAS COMPLETED ON [DATE] THAT IDENTIFIED 13 OF THE 37 RESIDENTS WHO REQUIRED AN UPDATED SPEECH LANGUAGE THERAPY (SLP) SCREEN. THE SLP SCREENS BEGAN ON [DATE]. ON [DATE] THE SURVEYOR VERIFIED THAT 13 OF THESE 13 RESIDENTS HAD SLP SCREENS COMPLETED AS OF [DATE]. 13. ON [DATE] THE SURVEYOR VERIFIED THAT ON [DATE], THE IDT TEAM IDENTIFIED 3 RESIDENTS THAT SOMETIMES PREFER TO EAT IN THEIR ROOM WITH ASSISTANCE AND ARE AT HIGH RISK FOR ASPIRATION. 13. ON [DATE] THE SURVEYOR VERIFIED THAT ON [DATE] THREE SUCTION MACHINES WERE OBTAINED AND PLACED AT THE RESIDENTS' BEDSIDES. 14. ON [DATE] THE SURVEYOR VERIFIED THAT ON [DATE] ONE ADDITIONAL RESIDENT WAS IDENTIFIED TO BE AT HIGH RISK AND A SUCTION MACHINE WAS PLACED AT THAT RESIDENT'S BEDSIDE. 15. ON [DATE] THE SURVEYOR VERIFIED THAT BEGINNING [DATE] NURSING MANAGEMENT CONDUCTED WEEKLY AUDITS TO ASSURE COMPLIANCE. 16. ON [DATE] THE SURVEYOR VERIFIED THAT 16 SUCTION MACHINES WERE IN PLACE IN SEALED CONTAINERS AND AVAILABLE FOR EMERGENCY USE. 17. ON [DATE], THE SURVEYOR RANDOMLY CHOSE FOUR OF THE SIXTEEN SUCTION MACHINES AND VERIFIED THAT ALL COMPONENTS, NECESSARY FOR EACH MACHINE TO BE FUNCTIONAL, WERE PRESENT AND THAT EACH MACHINE OPERATED PROPERLY. WHILE THE IMMEDIATE JEOPARDY WAS REMOVED ON [DATE], THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF PATTERN AND A SEVERITY OF NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY BECAUSE NOT ALL STAFF HAS BEEN EDUCATED IN THE PERTINENT POLICIES AND BECAUSE THE FACILITY'S SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY. ( )

THIS CITATION PERTAINS TO INTAKE #MI 153. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE APPROPRIATE SAFETY INTERVENTIONS AND SUPERVISION TO PREVENT ACCIDENTS IN 2 (#101 AND #102) OF 9 RESIDENTS REVIEWED FOR FALLS, FROM A TOTAL SAMPLE OF 9, RESULTING IN RESIDENT #101'S LEFT FEMUR FRACTURE (BROKEN HIP) RESIDENT #102 ' S BROKEN THORACIC VERTEBRAE (BACK BONE), REPEAT FALLS, ASSOCIATED DISCOMFORT, THE POTENTIAL FOR FUTURE FALLS WITH INJURY, AS WELL AS UNDUE EMOTIONAL DISTRESS. FINDINGS INCLUDE: RESIDENT #101 ACCORDING TO THE FACE SHEET DATED 12/23/2011, RESIDENT #101 WAS A [AGE] year OLD FEMALE WHO WAS admitted to the facility on [DATE]. THE MINIMUM DATA SET (MDS) assessment dated [DATE], INDICATED THAT RESIDENT #101 WAS UNABLE TO COMMUNICATE HER NEEDS AND REQUIRED THE EXTENSIVE PHYSICAL ASSISTANCE OF TWO STAFF MEMBERS FOR ALL TRANSFERS AND TOILETING (INCLUDING CLEANING AFTER ELIMINATION). RESIDENT #101 HAD [DIAGNOSES REDACTED]. ACCORDING TO THE FALL RISK assessment dated [DATE], RESIDENT #101 WAS ASSESSED BY THE FACILITY AS BEING HIGH RISK FOR FALLS. ACCORDING TO THE INTERDISCIPLINARY PLAN OF CARE, DATED 8/16/2010, RESIDENT #101 REQUIRED THE USE OF A "...(MECHANICAL) LIFT FOR TRANSFERS..." WITH THE ASSISTANCE OF TWO STAFF MEMBERS. ACCORDING TO THE NURSE'S NOTES, DATED 12/19/2011 AT 4:30 P.M., THE NURSE WAS CALLED INTO THE ROOM AND THE CERTIFIED NURSE ASSISTANT (CNA) "...STATED (RESIDENT #101) ROLLED OUT OF BED WHEN SHE (CNA) WAS TURNING HER..." ACCORDING TO THE UNPLANNED OCCURRENCE REPORT DATED 12/19/2011, RESIDENT #101 WAS BEING TURNED BY CNA #2 AND ROLLED ONTO THE FLOOR. THE UNPLANNED OCCURRENCE REPORT SAID THAT RESIDENT #101 ROLLED FROM THE BED WHEN CNA #2 TURNED RESIDENT #101 TO APPLY THE LIFT SLING FOR TRANSFER FROM THE BED. ACCORDING TO THE HAND WRITTEN STAFF INTERVIEW SUMMARY SIGNED BY CNA #2 AND DATED 12/20/2011, RESIDENT #101 fell WHEN CNA #2 REACHED FOR THE LIFT SLING. AFTER BEING EXAMINED BY HER PHYSICIAN, RESIDENT #101 WAS SENT TO A LOCAL HOSPITAL emergency roiagnom on [DATE]. X-RAYS WERE OBTAINED IN THE emergency room . ACCORDING TO THE RADIOLOGY REPORT DATED 12/20/2011, RESIDENT #101 SUFFERED FROM AN ANGULATED INTERTROCHANTERIC FRACTURE OF THE PROXIMAL LEFT FEMUR (BROKEN LEFT HIP). CNA #2 WAS INTERVIEWED ON 1/12/2012 AT 2:00 P.M. CNA #2 SAID THAT ON 12/19/2011, AT AROUND 4:30 P.M., RESIDENT #101 HAD A BOWEL MOVEMENT. CNA #2, WHO WAS THE CNA ASSIGNED TO RESIDENT #101 ON THAT DAY, SAID SHE WENT INTO THE RESIDENT'S ROOM ALONE TO CLEAN HER UP AND THEN TRANSFER HER INTO A WHEELCHAIR. CNA #2 SAID THAT RESIDENT #101 REQUIRED THE ASSISTANCE OF 2 PEOPLE FOR TRANSFERS, BUT THAT THE FACILITY NURSING STAFF ROUTINELY PROVIDED TOILETING CARE SUCH AS CLEANING AFTER ELIMINATION USING ONLY ONE STAFF MEMBER. DURING THE INTERVIEW, CNA #2 BECAME VISIBLY ANXIOUS, AND REPEATED THAT IT WAS ALL RIGHT THAT SHE WAS ALONE WHEN PROVIDING CARE FOR RESIDENT #101, BECAUSE SHE WAS CLEANING UP A BOWEL MOVEMENT. CNA #2 SAID RESIDENT #101 WAS COUGHING A LOT THAT DAY. CNA #2 SAID THE COUGHING WAS SO STRONG THAT THE RESIDENT'S ARMS AND LEGS WERE MAKING INVOLUNTARILY JERKING MOTIONS. CNA #2 WENT ON TO SAY THAT THERE WERE NO SIDE RAILS ON THE BED; HOWEVER, THERE WAS A SMALL MOBILITY ASSIST BAR THAT WAS ON THE SIDE OF THE BED AT A LEVEL ABOVE RESIDENT #101'S HEAD. ACCORDING TO CNA #2, RESIDENT #101 WAS "...NOT A VERY LARGE WOMAN, HOWEVER SHE WAS NOT TINY..." CNA #2 SAID THAT IF RESIDENT #101 WAS IN THE CENTER OF THE BED, RESIDENT #101 COULD BE ROLLED ON HER SIDE AND THEN ONTO HER BELLY WITHOUT BEING TOO CLOSE TO THE EDGE OF THE BED. CNA #2 DESCRIBED HOW SHE TOOK CARE OF RESIDENT #101 ON 12/19/2011. CNA #2 STATED THAT SHE STOOD ON THE LEFT SIDE OF THE BED AND BEGAN TO TURN RESIDENT #101 ON HER RIGHT SIDE, FACING AWAY FROM CNA #2. CNA #2 SAID THAT RESIDENT #101'S LEFT LEG WAS CROSSED OVER HER RIGHT LEG AND THAT SHE (RESIDENT #101) WAS CLOSE TO THE EDGE OF THE BED. CNA #2 SAID THAT RESIDENT #101 WAS CLOSE TO THE EDGE OF THE BED BUT SHE (CNA #2) WAS "...NOT SURE HOW CLOSE... " CNA #2 SAID THAT AS SHE TURNED RESIDENT #101 ON HER SIDE SHE (#101) BEGAN TO AGAIN COUGH STRONGLY. CNA #2 SAID THAT ALTHOUGH RESIDENT #101 AGAIN DISPLAYED THE INVOLUNTARY JERKING MOTIONS THAT ACCOMPANIED HER COUGHING, SHE (CNA #2) CONTINUED TO CARE FOR RESIDENT #101 WITHOUT ASSISTANCE. CNA #2 SAID THAT SHE THEN TURNED TOWARDS THE FOOT OF THE BED TO GET RESIDENT #101 A BRIEF. ACCORDING TO CNA #2, AS SHE TURNED AWAY FROM RESIDENT #101, SHE HEARD RESIDENT #101 COUGH AND SAW HER JERKING MOTIONS. CNA #2 SAID THAT THEN, "...OUT OF THE CORNER OF MY EYE I SAW HER START TO FALL..." CNA #2 SAID THAT AS RESIDENT #101'S LEGS BEGAN TO COME OFF THE BED, SHE (CNA #2) TURNED BACK AND TRIED TO CATCH HER, BUT COULDN'T REACH HER IN TIME. CNA #2 SAID SHE RAN AROUND THE BED, SAW HER ON THE FLOOR AND CALLED FOR THE NURSE. CNA #2 SAID RESIDENT #101 WAS NOT WEARING A BRIEF WHEN SHE fell . THE FALL OCCURRED BEFORE SHE (CNA #2) WAS ABLE TO PUT THE BRIEF ON RESIDENT #101. IN AN INTERVIEW ON 1/13/2012 AT 2:33 P.M., LICENSED PRACTICAL NURSE (LPN) #2 SAID THAT ON 12/19/2011 AT AROUND 4:30 P.M., SHE WAS CALLED TO RESIDENT #101'S ROOM BY CNA #2. LPN #2 SAID SHE ENTERED THE ROOM TO FIND RESIDENT #101 ON THE FLOOR NEXT TO THE BED. LPN #2 SAID CNA #2 TOLD HER RESIDENT #101 WAS ROLLED OUT OF BED. LPN #2 SAID RESIDENT #101 WAS WEARING A "...DUSTER ROBE..." WITH SNAPS DOWN THE FRONT AND THE SNAPS WERE CLOSED. LPN #2 SAID RESIDENT #101'S PHYSICIAN CAME INTO THE ROOM AND ASSESSED RESIDENT #101 WHILE SHE WAS ON THE FLOOR. LPN #2 SAID THAT THE PHYSICIAN LIFTED RESIDENT #101'S LEGS AND PERFORMED RANGE OF MOTION EVALUATION ON ALL FOUR OF RESIDENT #101'S EXTREMITIES. LPN #2 SAID RESIDENT #101 "...DID HAVE A BRIEF ON BECAUSE WE DID NOT HAVE TO COVER HER WHEN THE LEGS WERE LIFTED..." LPN #2 SAID RESIDENT #101 COULD NOT MOVE HER SELF IN THE BED AND COULD NOT INDEPENDENTLY MOVE HER LEGS. LPN #2 SAID THAT CNA #2 TOLD HER RESIDENT #101 fell AS SHE ROLLED RESIDENT #101 ON HER SIDE TO PLACE HER ON THE TRANSFER SLING. DURING AN INTERVIEW ON 1/13/2012 AT 2:47 P.M., CLINICAL CARE COORDINATOR (CCC) #1 SAID SHE LED THE INVESTIGATION FOR RESIDENT #101'S FALL. CCC #1 SAID THAT THE INVESTIGATION DETERMINED THAT CNA #2 HAD TURNED RESIDENT #101 AWAY FROM HER (CNA #2) BY HOLDING THE CLOTH INCONTINENCE PAD, PULLING IT UP AND PUSHING RESIDENT #101'S BODY AWAY FROM HER (CNA #2). CCC #1 WENT ON TO SAY THAT RESIDENT #101 HAD NO ABILITY TO HOLD HERSELF UP OR TO STOP THE FALL. CCC #1 SAID IT WAS NOT VERY SAFE TO ROLL A RESIDENT WITH NO MUSCULAR CONTROL AWAY FROM THE CAREGIVER WHEN IN A BED WITH NO BARRIERS (SIDE RAILS) ON THE OPPOSITE SIDE AND WHEN THE CARE GIVER IS ALONE. CCC #1 SAID THAT THERE SHOULD HAVE BEEN TWO STAFF MEMBERS PRESENT AND THAT IF SHE (CCC #1) DID HAVE TO ROLL A RESIDENT IN THE BED ALONE, SHE WOULD HAVE TURNED RESIDENT #101 TOWARDS HER OWN BODY, BECAUSE "...IT WOULD BE SAFER..." CCC #1 SAID THAT WHEN SHE ARRIVED IN RESIDENT #101'S ROOM ON 12/19/2011, RESIDENT #101 WAS ON THE FLOOR WITH A BRIEF ON. THERE WAS A TRANSFER SLING ON THE RESIDENT'S BED. CCC #1 SAID THAT ACCORDING TO HER INVESTIGATION, RESIDENT #101 WOULD NOT HAVE FALLEN IF SHE HAD NOT BEEN SO CLOSE TO THE EDGE OF THE BED AND IF CNA #2 HAD NOT BEEN CARING FOR RESIDENT #101 BY HERSELF. CCC #1 SAID THAT ACCORDING TO FACILITY POLICY, WHEN THERE WAS A MECHANICAL LIFT IN USE, THE FACILITY REQUIRES THE ASSISTANCE OF TWO PERSONS. CCC #1 SAID THERE WAS NO REASON TO PUT RESIDENT #101 IN A SLING EXCEPT AS PART OF A TRANSFER. CCC #1 SAID RESIDENT #101 fell WHILE PUTTING HER IN THE SLING. CCC #1 SAID THERE WAS A 2 PERSON REQUIREMENT FOR RESIDENT #101'S TRANSFERS AND THERE WAS ONLY ONE PERSON THERE. CCC #1 SAID NO ONE WAS SUPERVISING RESIDENT #101 WHEN CNA #2 TURNED AWAY TO GET THE SLING. ACCORDING TO CCC #1, CNA #2 RECEIVED ADDITIONAL TRAINING ON MECHANICAL LIFT TRANSFER TECHNIQUES. CCC #1 WAS ASKED TO PROVIDE THE FACILITY'S POLICY RELATED TO THE LIFT, BUT AT THE TIME OF THE EXIT INTERVIEW, THE POLICY HAD NOT BEEN PROVIDED. ACCORDING TO THE LIFT OPERATING INSTRUCTIONS DATED 1/9/2006, THE "...LIFT WAS DESIGNED TO BE OPERATED SAFELY BY ONE PERSON. HOWEVER WITH SOME PATIENTS IT IS BEST TO USE TWO PEOPLE..." ( ) RESIDENT #102 ACCORDING TO THE FACE SHEET DATED 12/19/2011, RESIDENT #102 WAS AN [AGE] year OLD FEMALE WHO WAS admitted to the facility on [DATE]. THE MINIMUM (MDS) data set [DATE], INDICATED THAT ALTHOUGH RESIDENT #102 WAS ABLE TO COMMUNICATE HER NEEDS VERBALLY, SHE HAD IMPAIRED COGNITION. RESIDENT #102 REQUIRED THE EXTENSIVE PHYSICAL ASSISTANCE OF STAFF ALL ACTIVITIES OF DAILY LIVING. RESIDENT #102 HAD [DIAGNOSES REDACTED]. OBSERVATION OF RESIDENT #102, ON 1/19/2012, AT 1:30 P.M., REVEALED THAT THE RESIDENT WAS CONFUSED. ALTHOUGH THE RESIDENT KNEW SHE HAD BEEN WEARING A BRACE, SHE DID NOT REMEMBER WHY. FALL INTERVENTIONS WERE OBSERVED IN PLACE. THE CARE PLAN DATED 12/19/2011, IDENTIFIED FALLS AS AN AREA OF CONCERN AND IMPLEMENTED SEVERAL INTERVENTIONS INCLUDING ASSISTANCE WITH ACTIVITIES OF DAILY LIVING, A LOW BED, BED AND WHEELCHAIR ALARMS AND ENROLLMENT INTO THE RED STAR FALLS PREVENTION PROGRAM. ACCORDING TO THE PHYSICAL THERAPY EVALUATION DATED 12/22/2011, RESIDENT #102 CAME TO THE FACILITY FROM ANOTHER LONG TERM CARE FACILITY, WHERE ASSISTANCE WAS REQUIRED FOR ALL ACTIVITIES OF DAILY LIVING. ACCORDING TO THE PHYSICAL THERAPIST'S ASSESSMENT, RESIDENT #102 REQUIRED THE MODERATE ASSISTANCE OF STAFF FOR BED MOBILITY AND ALL TRANSFERS. ACCORDING TO THE PHYSICAL THERAPIST'S ASSESSMENT RESIDENT #102 REQUIRED THE MAXIMUM ASSISTANCE OF STAFF FOR WALKING. ACCORDING TO "INTRODUCTION TO PHYSICAL THERAPY FOR PHYSICAL THERAPIST ASSISTANTS," BY OLGA DREEBEN, PUBLISHED BY JONES & BARTLETT PUBLISHERS, 2006, MODERATE ASSISTANCE REQUIRES THE STAFF TO "CONSISTENTLY PROVIDE ASSISTANCE TO THE RESIDENT IN THE FORM OF ASSISTANCE WITH BALANCE, MOVING EXTREMITIES OR ASSISTIVE DEVICES, PROVIDE ASSISTANCE WITH APPROXIMATELY 50 % OF THE TOTAL WORK INCLUDING WEIGHT BEARING, AND GUARD THE RESIDENT FROM PROBABLE ACCIDENTS." MAXIMUM ASSISTANCE REQUIRES THE STAFF TO "CONSISTENTLY PROVIDE ASSISTANCE TO THE RESIDENT IN THE FORM OF ASSISTANCE WITH BALANCE, MOVING EXTREMITIES OR ASSISTIVE DEVICES, PROVIDE ASSISTANCE WITH APPROXIMATELY 75 % OF THE TOTAL WORK INCLUDING WEIGHT BEARING, AND GUARD THE RESIDENT FROM PROBABLE ACCIDENTS." ACCORDING TO THE NURSE'S NOTED 12/21/2011, RESIDENT #101 REQUIRED EXTENSIVE ASSISTANCE BY TWO STAFF MEMBERS WITH TRANSFERS. ACCORDING TO THE PHYSICIAN ORDER [REDACTED]. A REVIEW OF RESIDENT #102'S CLINICAL RECORD AND INCIDENT REPORTS REVEALED 4 INDIVIDUAL FALLS FOR RESIDENT #102 FROM 12/23/2011 TO 1/15/2012. ACCORDING TO THE NURSE'S NOTES DATED 12/23/2011 AT 3:25 P.M., THE FACILITY FAILED TO PROVIDE ASSISTANCE WITH TRANSFERS AND RESIDENT #102 ATTEMPTED TO SELF TRANSFER FROM THE WHEELCHAIR TO THE BED AND fell . RESIDENT #102 WAS FOUND ON THE FLOOR SITTING ON HER BUTTOCKS. ACCORDING TO THE UNPLANNED OCCURRENCE REPORT DATED 12/23/2011 RESIDENT #102 WAS ASSESSED AND NO INJURIES WERE FOUND. PREVENTATIVE MEASURES AND/OR CORRECTIVE ACTION TAKEN INCLUDED RE-EDUCATED ABOUT THE USE OF THE CALL LIGHT SYSTEM, A MEASURE ALREADY IN PLACE. NO EVIDENCE COULD BE FOUND IN THE RESIDENT'S CHART TO INDICATE ANY CHANGES IN SUPERVISION OR INTERVENTIONS TO PREVENT ACCIDENTS FOR RESIDENT #102. ACCORDING TO THE NURSE'S NOTES DATED 12/30/2011 AT 5:30 P.M., RESIDENT #102 WAS REACHING FOR A LID ON FLOOR, fell , BUMPED FOREHEAD AND DEVELOPED NASAL BLEEDING. RESIDENT #102 SENT TO A LOCAL AREA HOSPITAL FOR TREATMENT. ACCORDING TO EMERGENCY DEPARTMENT RECORDS DATED 12/31/2011 RESIDENT #101 SUFFERED FROM A T3 (THORACIC VERTEBRAE #3) FRACTURE (BROKEN BACK BONE) AND WAS RETURNED TO THE FACILITY WITH A BRACE. ACCORDING TO THE UNPLANNED OCCURRENCE REPORT DATED 12/30/2011, PREVENTATIVE MEASURES AND/OR CORRECTIVE ACTION TAKEN INCLUDED TO REMIND RESIDENT #101 TO CALL FOR ASSISTANCE. NO EVIDENCE COULD BE FOUND IN THE RESIDENT'S CHART TO INDICATE ANY CHANGES IN SUPERVISION OR INTERVENTIONS TO PREVENT ACCIDENTS FOR RESIDENT #102. ACCORDING TO THE POST FALL assessment dated [DATE], RESIDENT #102 NEEDED "...A 1 ON 1 BECAUSE SHE SAYS SHE WON'T TRY AND GET UP, BUT SHE WILL. 95% SURE SHE WILL..." NO EVIDENCE COULD BE FOUND IN THE RESIDENT'S CHART TO INDICATE ANY CHANGES IN SUPERVISION TO PREVENT ACCIDENTS FOR RESIDENT #102. ACCORDING TO THE NURSE'S NOTES DATED 1/6/2012, RESIDENT #102 WAS OBSERVED ATTEMPTING TO SELF TRANSFER OUT OF BED. NO EVIDENCE COULD BE FOUND IN THE RESIDENT'S CHART TO INDICATE ANY CHANGES IN SUPERVISION OR INTERVENTIONS TO PREVENT ACCIDENTS FOR RESIDENT #102. ACCORDING TO THE NURSE'S NOTES DATED 1/11/2011 AT 8:00 A.M., THE FACILITY FAILED TO PROVIDE ASSISTANCE WITH TRANSFERS AND RESIDENT #102 WAS FOUND LYING ON THE FLOOR NEXT TO THE BED WITH NO INJURIES. ACCORDING TO THE UNPLANNED OCCURRENCE REPORT DATED 1/11/2012 AT 8:00 A.M., RESIDENT #102 TRANSFERRED WITHOUT STAFF ASSISTANCE FROM HER BED AND WAS FOUND ON THE FLOOR NEXT TO THE BED ON HER BACK BY CNA #3, WITH NO OBVIOUS INJURY. THIS REPORT, COMPLETED BY LPN #3, DOCUMENTED THAT CNA #3 RESPONDED TO THE SOUND MADE BY RESIDENT #102'S ALARM. PREVENTATIVE MEASURES AND/OR CORRECTIVE ACTION TAKEN INCLUDED THAT RESIDENT #102 WAS "...ENCOURAGED TO USE CALL LIGHT..." NO EVIDENCE COULD BE FOUND IN THE RESIDENT'S CHART TO INDICATE ANY CHANGES IN SUPERVISION OR INTERVENTIONS TO PREVENT ACCIDENTS FOR RESIDENT #102. IN AN INTERVIEW ON 1/19/2012 AT 11:18 A.M., CNA #3 REVIEWED THE UNPLANNED OCCURRENCE REPORT, DATED 1/11/2012. CNA #3 SAID THAT THE FACTS AS DOCUMENTED ON THE REPORT WERE NOT TRUE, AS SHE (CNA #3) WAS WALKING BY RESIDENT #102'S ROOM ON 1/11/2012 AND SAW RESIDENT #102 ON THE FLOOR. CNA #3 SAID THAT THE SAFETY ALARM WAS NOT IN USE. CNA #3 SAID SHE WAS THE FIRST PERSON IN THE ROOM AND CALLED FOR THE LPN. AS SHE (CNA #3) RECALLED, NO ALARM WAS SOUNDING AT THE TIME. WHEN LPN #3 WAS INTERVIEWED ON 1/19/12, AT 12 NOON, SHE WAS NOT ABLE TO EXPLAIN THE DISCREPANCY IN THE DOCUMENTATION. ACCORDING TO THE NURSE'S NOTES DATED 1/15/2012 AT 12:30 A.M., THE FACILITY FAILED TO PROVIDE ASSISTANCE WITH TRANSFERS AND RESIDENT #102 WAS FOUND ON THE FLOOR NEXT TO THE BED ON HER KNEES WITH NO INJURIES. ACCORDING TO THE POST FALL assessment dated [DATE] RESIDENT #102 WAS GETTING OUT OF BED UNASSISTED BY STAFF TO GET DRESSED. ACCORDING TO THE UNPLANNED OCCURRENCE REPORT DATED 1/15/2012 AT 12:30 A.M., RESIDENT #102 WAS FOUND ON THE FLOOR NEXT TO THE BED ON HER KNEES WITH NO OBVIOUS INJURY. PREVENTATIVE MEASURES AND/OR CORRECTIVE ACTION THAT WERE TAKEN INCLUDED HAVING NURSING STAFF CHECK ON RESIDENT #102 EVERY 15 MINUTES WHILE THE RESIDENT WAS IN BED. IN AN INTERVIEW ON 1/19/2012 AT 1:09 P.M., CNA #5 SAID THAT ON 1/15/2011, STAFF WERE CHECKING ON RESIDENT #102 FREQUENTLY. CNA #5 SAID THAT TWICE RESIDENT #102 WAS FOUND WITH HER LEGS HANGING OUT OF THE BED, ONCE BY ANOTHER CNA AND ONCE BY CNA #5. CNA #5 SAID THAT BOTH TIMES RESIDENT #102 WAS REPOSITIONED, BUT THAT THERE WERE NO CHANGES IN SUPERVISION OR INTERVENTIONS TO PREVENT ACCIDENTS FOR RESIDENT #102. CNA #5 SAID THAT AROUND 12:30 A.M., SHE (CNA #5) HEARD RESIDENT #102'S ALARM SOUNDING AND SHE (CNA #5) RESPONDED. CNA #5 SAID RESIDENT #102 WAS FOUND ON THE FLOOR ON HER KNEES. CNA #5 SAID RESIDENT #102 WAS ON THE FLOOR ON THE LEFT SIDE OF THE BED AND fell on TO THE CONCRETE FLOOR. CNA #5 SAID THAT AT THE TIME RESIDENT #102 DID NOT HAVE A FLOOR MAT PAD ON THE LEFT SIDE OF THE BED, BUT DID ON THE RIGHT SIDE OF THE BED. CNA #5 COULD NOT EXPLAIN WHY ONLY ONE FLOOR MAT WAS IN USE ON 1/15/2012, OR HOW STAFF WERE TO PREDICT ON WHICH SIDE OF THE BED RESIDENT #102 WOULD FALL. ON 1/18/2012 AT 1:35 P.M., THE DIRECTOR OF NURSING (DON) #1 AND THE CLINICAL CARE COORDINATOR (CCC) #1 WERE GIVEN THE OPPORTUNITY TO REVIEW RESIDENT #102'S CLINICAL RECORD AND OCCURRENCE REPORTS. DON #1 SAID THAT RESIDENT #102 fell REPETEDLY BECAUSE SHE LACKED SAFETY AWARENESS AND WAS TRANSFERRING WITHOUT THE ASSISTANCE OF FACILITY STAFF. ( )

REFER TO INTAKE # MI 519 BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE AND APPROPRIATE ASSISTANCE TO MAINTAIN SAFETY AND PREVENT A FALL FOR ONE RESIDENT (#103) OF 3 SAMPLED RESIDENTS RESULTING IN FRACTURE OF THE LEFT ELBOW AND HIP CONTUSION. FINDINGS INCLUDE: RESIDENT #103 WAS admitted to the facility on [DATE] FOR A COMPREHENSIVE REHABILITATION PROGRAM WITH A GOAL TO RETURN HOME. RESIDENT #103'S HISTORY AND PHYSICAL DATED 3/26/11, REVEALED THAT RESIDENT #103 HAD A RIGHT HIP ORIF (OPEN REDUCTION WITH INTERNAL FIXATION) SECONDARY TO FRACTURE AFTER A FALL AT HOME. RESIDENT #103 WAS ALERT AND ORIENTED. HOWEVER, DUE TO THE RECENT HIP FRACTURE, HE WAS ASSESSED ON 3/25/11, AND WAS DETERMINED TO BEAT "HIGH RISK" FOR FALLS. PHYSICAL/OCCUPATIONAL THERAPY REASSESSMENT ON 3/31/11, INDICATED THAT HE REQUIRED ONE PERSON CONTACT GUARD ASSISTANCE ON AMBULATION USING AN ASSISTIVE DEVICE (WALKER). RESIDENT #103 WAS PLACED INTO THE "RED STAR" FALL PREVENTION PROGRAM. ACCORDING TO RESIDENT #103'S "RED STAR" CAREPLAN DATED 3/25/11, INTERVENTIONS INCLUDED: (1) RED STAR PLACED OUTSIDE OF ROOM DOOR, (2) RED STAR PLACED ON WHEELCHAIR, (3) LOW BED, (4) BED ALARM AND (5) WHEELCHAIR ALARM. ACCORDING TO THE FACILITY' S INVESTIGATIVE REPORT DATED 4/21/11, ON 4/20/11 AT 2:00 AM, RESIDENT #103 AMBULATED UNASSISTED TO THE BATHROOM AND fell . THE FACILITY'S POST FALL INVESTIGATION DATED 4/20/11 REVEALED THAT THERE WAS NO RED STAR SIGN AT THE DOOR, OR WHEEL CHAIR AND THERE WAS NO CHAIR ALARM OR BED ALARM IN PLACE. NO SAFETY CHECKS FOR ALARMS HAD BEEN COMPLETED EVERY SHIFT SINCE 3/25/11, WHEN THE RED STAR PROGRAM WAS ORDERED. THE P0ST FALL assessment dated [DATE], REVEALED THAT RESIDENT#103 WAS NOT WEARING ANY FOOTWEAR, DID NOT USE HIS WALKER, AND DID NOT USE HIS CALL LIGHT ON 4/20/11 AT 2:00 AM, RESIDENT #103 AMBULATED TO THE BATHROOM WITHOUT ASSISTANCE AND fell . RESIDENT #103 SUSTAINED A LEFT ELBOW FRACTURE. XRAY OF THE LEFT ELBOW DONE ON 4/20/11, REVEALED TRANSVERSE FRACTURE OF THE PROXIMAL OLECRANON WITH NO SIGNIFICANT DISPLACEMENT. RESIDENT # 103 WAS INTERVIEWED ON 5/12/11 AT 11:00 AM. HE RECALLED THAT NIGHT THAT HIS URINAL WAS FULL AND HE CALLED FOR HELP. HE WAITED FOR A LONG TIME BUT NOBODY CAME. HE DECIDED TO THE BATHROOM WITHOUT WAITING FOR ASSISTANCE BECAUSE HE COULD NOT "HOLD IT" ANY LONGER. WHILE STANDING IN THE BATHROOM, RESIDENT #103 FURTHER DESCRIBED SEEING SPOTS AND LOST HIS BALANCE. THERE WAS NOTHING TO GRAB ON TO. HE fell AND LANDED ON HIS LEFT SIDE. INTERVIEW WITH NURSE #6 WAS CONDUCTED ON 5/12/11 AT 2:45 PM. NURSE #6 STATED THAT RESIDENT #103 WENT TO THE BATHROOM WITHOUT ASKING FOR HELP AND DID NOT USE HIS WALKER. "HE PRESSED THE BATHROOM CALL LIGHT AFTER HE fell . AND THAT'S HOW WE RESPONDED. HE DID NOT HAVE BED OR TAB ALARM AT THAT TIME." DURING AN INTERVIEW WITH THE DON (DIRECTOR OF NURSING) ON 5/13/11 AT 10:20 AM, SHE STATED THAT THE STAFF FAILED TO FOLLOW THE DOCTOR'S "RED STAR" ORDER AND DID NOT IMPLEMENT THE "RED STAR" CARE PLAN. RESIDENT #103 DID NOT HAVE THE ALARMS IN PLACE. "AFTER THE FALL WE ADDED AS ONE OF THE CORRECTIVE ACTIONS ON 4/20/11, THAT STAFF WILL ANSWER CALL LIGHT PROMPTLY AND EMPTY URINAL." ON 5/12/11 AT 11:15 PM, THE DON (DIRECTOR OF NURSING) AND SURVEYOR WERE IN RESIDENT #102'S ROOM TO OBSERVED THE STAFF RESPONSE TIME TO CALL LIGHT. THE DON ACTIVATED THE CALL LIGHT. RESIDENT #102 WAS ALSO PRESENT IN THE ROOM. THE SURVEYOR AND DON WAITED FOR 15 MINUTES, BUT NO STAFF CAME IN THE ROOM TO OFFER ASSISTANCE. WHEN THE SURVEYOR AND DON FURTHER INVESTIGATED, THE STAFF (NURSE AIDE #4, NURSE #3 AND CCC#5) WHO WERE RESPONSIBLE FOR 10 RESIDENTS IN THE UNIT, WERE FOUND NOT CARRYING THEIR PAGERS. NURSE #3 AFTER 8 MINUTES OF SEARCHING, FOUND 2 PAGERS THAT WERE TURNED OFF IN ONE OF THE DRAWERS AT THE NURSES' WORKING AREA. NURSE #3 ON 5/12/11 AT 11:38 AM, DENIED KNOWLEDGE OF HOW LONG BOTH PAGERS WERE TURNED OFF IN THE DRAWER. THE DON admitted THAT THE 3 STAFF (NURSE AIDE #4, NURSE #3 AND CCC #5) DID NOT RESPOND TO THE CALL LIGHT AND DID NOT FOLLOW THE FACILITY'S PROCEDURE. THEY WERE NOT CARRYING THEIR PAGERS. ( )