Every finding on record at Glacier Hills

Based on observations, interview, and record review, the facility failed to: (1) effectively maintain 1 of 2 outdoor waste receptacles, (2) clean the concrete receptacle pads and adjacent grounds, and (3) effectively clean the outdoor waste grease receptacles and adjacent concrete receptacle pad surfaces effecting 35 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and pest attraction/harborage. Findings include: On 03/17/25 at 12:20 P.M., 1 of 2 outdoor waste receptacles were observed missing a drain plug. 1 of 2 outdoor waste receptacles were also observed with a severely bent mounting rod, allowing the receptacle lid to not close completely. The exterior surface of 1 of 2 outdoor waste receptacles were further observed bent inward. The damaged surface area measured approximately 24-inches-wide by 36-inches-long. The outdoor waste compactor assembly and adjacent ground surfaces were additionally observed soiled with accumulated and encrusted dirt and debris (dead leaves, used vinyl gloves, aluminum soda cans, etc.). 2 of 2 outdoor waste grease receptacles and adjacent ground surfaces were also observed soiled with accumulated and encrusted oil residue. Director of Dining Services N indicated he would contact maintenance for necessary repairs as soon as possible. Director of Dining Services N also indicated he would contact Environmental Services for necessary cleaning as soon as possible. On 03/18/25 at 03:30 P.M., Record review of the Policy/Procedure entitled: Regulated Waste Plan Overview dated (no date) revealed the following: It is the intent of the [NAME] Health Senior Communities (THSC) community to safeguard colleagues, the public, and the environment from exposure to the risk of injury, infection or disease from improperly disposed regulated wastes. The (THSC) community is considered to be a regulated waste generator. Colleagues of the (THSC) community comply with the OSHA (Occupational Safety and Health Administration), EPA (Environmental Protection Agency), and the Department of Transportation standards for handling, storage, and disposal of regulated waste. Record review of the Policy/Procedure entitled: Regulated Waste Plan Overview dated (no date) further revealed under Waste Disposal Guide: The type of waste determines the method of disposal. Reference the table below to identify the correct method of disposal. Infectious waste is bagged at the point of care using a leak proof bag that has been secured and then placed in the (THSC) community's biohazard disposal container which is lined with a red bag. Double bagging at the point of care is necessary when the initial bag is torn or moisture soaked through the outside of the bag. Sharps containers are disposed of when 3/4 full by first securing the top closed and then transporting and placing in the (THSC) community's biohazard disposal container. Regular trash is secured in lidded containers and disposed of in the (THSC) Community's outside refuse receptacle to avoid overflow.

Based on observation, interview, and record review the facility failed to ensure a call light was kept within resident reach for one resident (#12) out of twelve residents reviewed. Findings Included: Review of the medical record revealed R12 was admitted to the facility 11/14/2018 with diagnoses that included chronic obstructive pulmonary disease (COPD), hypertension, Hemiplegia (paralysis one side of the body) left side, multiple sclerosis, atrial fibrillation, bullous pemphigoid (skin condition causing large fluid-filled blisters), hyperlipemia (high fat content in blood), depression, dementia, pain, overactive constipation, neuromuscular dysfunction of bladder, anxiety disorder, osteoarthritis (tissue at end of bones wears down), and malnutrition. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/13/2025, revealed R12 had a Brief Interview of Mental Status (BIMS) of 12 (moderate cognitive impairment) out of 15. During observation and interview on 03/17/2025 at 11:20 a.m. R12 was observed lying down in bed. R12 explained that staff frequently did not place his call light within his reach, which would delay his request for services. R12 explained that he could not use his left hand and needed to have his call light placed on his abdomen so that he could push the buttons. On 03/18/2025 at 01:43 p.m. upon entering R12's room, R12 was observed lying down in bed. R12's call light was observed to be lying on a chair, on the left side of R12's bed. R12 explained that he was unable to reach his call light. During an interview on 03/18/2025 at 01:45 p.m. Clinical Care Coordinator (CCC) I explained that he was the Nursing Clinical Care Coordinator and was responsible for all the nursing units. CCC I explained that it was the facility expectation that all call lights were to be placed within the reach of the residents. During an interview on 03/18/2025 at 01:48 p.m. Assistant Director of Nursing (ADON) H explained that it was the facility expectation that all call lights were to be placed within the reach of the residents. On 03/18/2025 at 01:49 p.m. Assistant Director of Nursing (ADON) H and Clinical Care Coordinator (CCC) I entered R12's room. R12 was observed lying in bed. ADON H and CCC I confirmed that R12's call light was lying in a chair beside his bed. ADON H apologized to R12 and laid his call light across his abdomen.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 42 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage. Findings include: On 02/13/24 at 09:18 A.M., An initial tour of the food service was conducted with Executive Chef S. The following items were noted: Dry Storage Room: The individual white plastic disposable forks were observed unprotected. The inner plastic liner bag within the cardboard box container was also observed open, allowing potential contamination to enter the cavity opening. The 2017 FDA Model Food Code section 3-307.11 states: FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306. Chemical Storage Room: The return-air-exhaust ventilation grill was observed soiled with accumulated dust and dirt deposits. The 2017 FDA Model Food Code section 6-501.14 states: (A) Intake and exhaust air ducts shall be cleaned, and filters changed so they are not a source of contamination by dust, dirt, and other materials. (B) If vented to the outside, ventilation systems may not create a public health HAZARD or nuisance or unLAWful discharge. The plastic handheld scoop was observed resting within the white rice container. The handle was also observed resting directly on the stored bulk white rice. The 2017 FDA Model Food Code section 3-304.11 states: FOOD shall only contact surfaces of: (A) EQUIPMENT and UTENSILS that are cleaned as specified under Part 4-6 of this Code and SANITIZED as specified under Part 4-7 of this Code; (B) SINGLE-SERVICE and SINGLE-USE ARTICLES; or (C) LINENS, such as cloth napkins, as specified under S 3 304.13 that are laundered as specified under Part 4-8 of this Code. The mechanical dish machine final rinse pounds-per-square-inch (psi) gauge was observed to read 40 (psi) during the final rinse cycle. The (psi) gauge should read 5-30 pounds-per-square-inch during the final rinse cycle. The 2017 FDA Model Food Code section 4-501.113 states: The flow pressure of the fresh hot water SANITIZING rinse in a WAREWASHING machine, as measured in the water line immediately downstream or upstream from the fresh hot water SANITIZING rinse control value, shall be within the range specified on the machine manufacturer's data plate and may not be less than 35 kilopascals (5 pounds per square inch) or more than 200 kilopascals (30 pounds per square inch). On 02/13/24 at 10:30 A.M., An initial tour of the Care and Rehabilitation Center (CRC) Satellite Kitchen was conducted with Executive Chef S and Registered Dietician T. The following item was noted: Three frayed brooms were observed resting against the Ventless Cooking System (VSC) 2000 Unit. The three brooms were also observed with numerous bristles sporadically spaced and directed within each broom head. The 2017 FDA Model Food Code section 6-501.13 states: Dustless floor cleaning methods must be used so that food; equipment, utensils, and linens; and single-service and single-use articles are not contaminated. On 02/15/24 at 05:15 P.M., Record review of the Policy/Procedure entitled: Storage of Food and Supplies dated 12/15/2020 revealed under Dry Storage: (11) After removing single-serve items such as disposable plates or containers from the original case or carton, they must be stored inverted on clean surfaces to prevent contamination. Record review of the Policy/Procedure entitled: Storage of Food and Supplies dated 12/15/2020 further revealed under Paper Storage: (3) Cover all open cartons.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 42 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination. Findings include: On 02/14/24 at 08:25 A.M., An environmental tour of the facility Laundry Service was conducted with Environmental Services Supervisor W. The following items were noted: Clean Linen Room: The wall mounted oscillating fan was observed soiled with accumulated dust and dirt deposits. Soiled Laundry Room: The drywall surface was observed (etched, scored, particulate). The damaged drywall surface measured approximately 12-inches-wide by 20-feet-long. Environmental Services Supervisor W indicated she would contact maintenance for necessary repairs as soon as possible. On 02/14/24 at 12:35 P.M., A common area environmental tour was conducted with Facilities Manager X, Maintenance Team Leader Y, and Environmental Services Supervisor W. The following items were noted: Storage Room (2111): The laminate flooring transition strip was observed loose-to-mount. Facilities Manger X indicated he would have staff reinstall the transition strip as soon as possible. On 02/14/24 at 01:15 P.M., An environmental tour of sampled resident rooms was conducted with Facilities Manager X, Maintenance Team Leader Y, and Environmental Services Supervisor W. The following items were noted: 2207: The shower overhead light assembly was observed with dead insect carcasses, resting within the protective lens cover. The sink basin overhead light assembly was also observed with dead insect carcasses, resting within the protective lens cover. 2302: The restroom shower overhead light assembly was observed with dead insect carcasses, resting within the protective lens cover. 1 of 2 lower windowpanes were also observed fogged from excessive moisture exposure, within the double pane window. The damaged lower windowpane measured approximately 36-inches-high by 48-inches-long. Facilities Manager X stated: The window must have a bad seal. 2309: One 24-inch-wide by 48-inch-long acoustical ceiling tile was observed stained from previous moisture exposure. 2403: The shower overhead light assembly was observed with dead insect carcasses (10), resting within the protective lens cover. The drywall surface was also observed (etched, scored, particulate), directly behind the broda chair. The damaged drywall surface measured approximately 4-inches-wide by 4-inches-long. Facilities Manager X indicated he would have staff repair the damaged drywall surface as soon as possible. 2408: The shower overhead light assembly was observed non-functional. 2503: The shower overhead light assembly was observed with dead insect carcasses, resting within the protective lens cover. 2505: The shower overhead light assembly was observed with dead insect carcasses, resting within the protective lens cover. The restroom hand sink basin was also observed draining slowly. 2508: The shower overhead light assembly was observed with dead insect carcasses, resting within the protective lens cover. On 02/14/24 at 02:30 P.M., An interview was conducted with Facilities Manager X regarding the maintenance work order system. Facilities Manager X stated: We have the WorxHub software system. On 02/15/24 at 10:15 A.M., Record review of the WorxHub maintenance work orders for the last 45 days revealed no specific entries related to the aforementioned maintenance concerns. On 02/15/24 at 10:30 A.M., Record review of the Policy/Procedure entitled: Equipment Maintenance Program dated 1/2024 revealed under Policies: (1) Proper maintenance of the physical plant and all equipment in the Department is the responsibility of the Director in cooperation with the Maintenance Department and subject to policies set forth by the facility's administration. (2) The Director is directed or has knowledge of all routine, periodic, and critical maintenance work done to the physical plant or equipment in the department.

Based on observation, interview and record review, the facility failed to revise the Care Plan for one (Resident #17) of 13 reviewed for Care Plans, resulting in inaccurate Care Plans and the potential for unmet care needs. Findings include: Review of the medical record reflected Resident #17 (R17) admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included hemiplegia (paralysis on one side of the body), pain and unspecified dementia. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/14/23, reflected R17 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool), did not walk and required total assistance of one to two or more people for bed mobility, dressing, toilet use, personal hygiene and bathing. The same MDS was coded for upper extremity and lower extremity impairments on one side of the body. On 02/13/24 at 10:13 AM, R17 was observed lying in bed. His left hand was observed to be clenched into a fist, with his left wrist slightly bent inward, towards his body. R17 reported his left arm and left leg deficits were from a previous stroke. He reported having a left leg brace that staff did not put on him. R17 stated he was able to bend his left arm, when using his right arm to perform the movements of his left arm. R17's Care Plan reflected that he was to wear a left hand splint/carrot (splint) as tolerated, per order. Additionally, the Care Plan reflected R17 was to wear LNARD boots to both legs as tolerated, while in bed; a left ankle foot orthosis (AFO/brace) when out of bed, as tolerated; a brown brace to the left arm, as tolerated and a hip abductor brace, as tolerated. R17's Physician Orders did not reflect orders for orthotic devices or splints. During an interview on 02/14/24 at 3:11 PM, Director of Rehab E reported R17 did not have orthotic devices. She stated R17 did have a carrot splint for his hand that he allowed in the past but was no longer accepting. On 02/15/24 at 9:22 AM, R17 was agreeable to allowing Director of Nursing (DON) B check for orthotic devices in his room. R17's closet had two orthotics labeled as Softpro II ultrasmooth AFO boots and one left leg AFO. R17 reported he did not wear the orthotic devices because they hurt. During the observation, DON B reported he did not see any other orthotic devices in R17's room. During an interview on 02/15/24 at 9:27 AM, DON B reported Care Plans were modified through MDS, for quarterly assessments. He reported modifications were also made by the Assistant Director of Nursing (ADON) and the interdisciplinary team (IDT). The IDT met every morning, Monday through Friday, and went over things to include new admissions, discharges, falls, skin events and changes in condition. When reviewing the orthotic devices on R17's Care Plan, DON B reported the Care Plan may have needed some modifications. During an interview on 02/15/24 at 10:10 AM, ADON J reported she was not aware of R17 having orders for orthotic devices or that he should have been wearing any orthotics. She reported the Director of Therapy had multiple documents reflecting that R17 had refused any orthotic intervention.

Based on interview and record review the facility failed to ensure accuracy on a 5 day Minimum Data Set (MDS) assessment for one resident (resident #22) of one reviewed for Passar completion and discharge Minimum Data Set (MDS) assessment for one resident (resident #46) of 4 reviewed for discharge, resulting in the potential for unmet care needs. Findings include: Review of the clinical record reflected Resident 46 (R46) was an [AGE] year old male admitted to the facility on [DATE] with diagnosis that included right tibia fracture. Further record review reflected R46 had a planned transfer for inpatient rehab to the Veterans Affair (VA) on 12/05/23. There was no documentation in the clinical record that reflected R46 was hospitalized for an acute medical need/condition. Review of R46's discharge MDS dated [DATE] section A 0310 was coded 10 which indicated this was a planned discharge assessment and return was not anticipated. Section A 2105 was coded as a 4. Short-Term General Hospital (acute care hospital, IPPS) On 02/15/24 at 8:10 am during an interview with Social Worker D she reported R46 was transferred to the VA for rehab, not for an acute medical care condition. Social Worker D elaborated the VA offered different levels of care and reported R46 was transferred to the portion similar the their own skilled nursing facility. Interview with Registered Nurse (RN MDS Coordinator) G On 02/15/24 at 08:28 AM, R46's discharge MDS assessment was reviewed and determined question RN MDS Coordinator G agreed question A 2105 should have been coded as 5 Long term Care Hospital. RN MDS Coordinator G stated the facility Social Worker reported R46 was discharged to the VA and the assumption was made the acute care. Review of the MDS 3.0 Manual reflected in part for A2100: Ombudsman Budget Reconciliation Act (OBRA) Discharge Status Item Rationale Steps for Assessment 1. Review the medical record including the discharge plan and discharge orders for documentation of discharge location. Coding Instructions Select the 2-digit code that corresponds to the resident's discharge status. o Code 01, community (private home/apt., board/care, assisted living, group home): if discharge location is a private home, apartment, board and care, assisted living facility, or group home. o Code 02, another nursing home or swing bed: if discharge location is an institution (or a distinct part of an institution) that is primarily engaged in providing skilled nursing care and related services for residents who require medical or nursing care or rehabilitation services for injured, disabled, or sick persons. Includes swing beds. o Code 03, acute hospital: if discharge location is an institution that is engaged in providing, by or under the supervision of physicians for inpatients, diagnostic services, therapeutic services for medical diagnosis, and the treatment and care of injured, disabled, or sick persons. o Code 04, psychiatric hospital: if discharge location is an institution that is engaged in providing, by or under the supervision of a physician, psychiatric services for the diagnosis and treatment of mentally ill residents. o Code 05, inpatient rehabilitation facility: if discharge location is an institution that is engaged in providing, under the supervision of physicians, rehabilitation services for the rehabilitation of injured, disabled or sick persons. Includes IRFs that are units within acute care hospitals. 45135 Review of the medical record revealed Resident #22 (R22) was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included [NAME] Disease, Fibromyalgia, Anxiety, Major Depression, Dysphasia, Speech Disturbances, Difficulty Walking, Muscles Spasms, after care following joint repair, and pain. According to Resident #01 (R01)'s Minimum Data Set (MDS) dated [DATE], revealed R22 scored 12 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R22 requires assistance with all care due to upper extremities having contractures and use of an assisted device for walking with a walker or use of a wheelchair to be transferred. On 02/14/24 at 08:49 AM, an email was received by Regional Director of Operations C stating she did not see the information from the OBRA coordinator, that typically goes to social work, so she had sent Social Worker Director (SW) D an email to get that scanned into the record since she did end up staying beyond 30 days. During an interview on 02/14/24 at 10:09 AM, SW D stated the OBRA coordinator did not have the resident listed for this facility, so they didn't send it to them. During an interview on 02/15/24 at 08:20 AM, SW D stated when residents come from the hospital with the hospital Passar, admission department assigns the Passar to the que, after 25 days it goes to the SW, and she notifies OBRA. This did not take place. During an interview on 02/15/24 at 10:54 AM, Minimum Data Set Coordinator (MDS) G stated that under the admitted [DATE], section A1500, she was unable to find it. MDS G looked under admitted [DATE] and stated A1500 was 0. MDS G also stated R22 did not require a PASSAR to be completed. After further investigation, section A1500 should had been marked a 1. Yes- continue to A1510, Level 2 Preadmission Screening and Resident review (PASRR) Conditions.

Based on interview and record review, the facility failed to complete a timely quarterly Minimum Data Set (MDS) assessment for one (Resident #17) of 13 reviewed for MDS, resulting in the potential for unrecognized and unmet care needs. Findings include: Review of the medical record reflected Resident #17 (R17) admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included hemiplegia (paralysis on one side of the body), pain and unspecified dementia. The quarterly MDS, with an Assessment Reference Date (ARD) of 9/14/23, reflected R17 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool), did not walk and required total assistance of one to two or more people for bed mobility, dressing, toilet use, personal hygiene and bathing. R17's MDS history included an annual MDS, with an ARD of 4/4/23; a quarterly MDS, with an ARD of 6/29/23 and a quarterly MDS, with an ARD of 9/14/23. Additional MDS assessments included a discharge return anticipated MDS, with an ARD of 11/13/23; an entry record with an ARD of 11/14/23; a discharge return anticipated MDS, with an ARD of 12/29/23 and an entry record with an ARD of 1/3/24. During an interview on 02/14/24 at 4:03 PM, Registered Nurse/MDS Coordinator (RN) G reported R17 showed up on a missed assessments report due to his last quarterly MDS being 9/14/23. She reported R17 would have been due for a quarterly MDS within 92 days of his previous quarterly MDS for 9/14/23. According to the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2023, .The ARD of an assessment drives the due date of the next assessment. The next non- comprehensive assessment is due within 92 days after the ARD of the most recent OBRA assessment (ARD of previous OBRA assessment - Admission, Annual, Quarterly, Significant Change in Status, or Significant Correction assessment - + 92 calendar days) .The Quarterly assessment is an OBRA non-comprehensive assessment for a resident 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. As such, not all MDS items appear on the Quarterly assessment. The ARD (A2300) must be not more than 92 days after the ARD of the most recent OBRA assessment of any type .

Based on interview and record review, the facility failed to ensure Do-Not-Resuscitate (DNR) documents were completed in accordance with the Michigan Do-Not-Resuscitate Procedure Act for three (Resident #17, #149 and #350) of three reviewed for Advance Directives, resulting in the potential for code status wishes not being followed in an emergency situation. Findings include: Review of the MICHIGAN DO-NOT-RESUSCITATE PROCEDURE ACT, Act 193 of 1996 reflected, .An order executed under this section shall be on a form described in section 4. The order shall be dated and executed voluntarily and signed by each of the following persons: (a) The declarant, the declarant's patient advocate, or another person who, at the time of the signing, is in the presence of the declarant and acting pursuant to the directions of the declarant. (b) The declarant's attending physician. (c) Two witnesses [AGE] years of age or older, at least 1 of whom is not the declarant's spouse, parent, child, grandchild, sibling, or presumptive heir (3) The names of all signatories shall be printed or typed below the corresponding signatures. A witness shall not sign an order unless the declarant or the declarant's patient advocate appears to the witness to be of sound mind and under no duress, fraud, or undue influence . Further review of this Act reflected, .Sec. 4. A do-not-resuscitate order executed under section 3, 3a, or 3b must include, but is not limited to, the following language, and must be in substantially the following form: DO-NOT-RESUSCITATE ORDER This do-not-resuscitate order is issued by _______________________________________, attending physician for _________________________________________. (Type or print declarant's, ward's, or minor child's name) Use the appropriate consent section below: A. DECLARANT CONSENT I have discussed my health status with my physician named above. I request that in the event my heart and breathing should stop, no person shall attempt to resuscitate me. This order will remain in effect until it is revoked as provided by law. Being of sound mind, I voluntarily execute this order, and I understand its full import. _______________________________________ _______________ (Declarant's signature) (Date) _______________________________________ _______________ (Signature of person who signed for declarant, if applicable) (Date) _______________________________________ (Type or print full name) B. PATIENT ADVOCATE CONSENT I authorize that in the event the declarant's heart and breathing should stop, no person shall attempt to resuscitate the declarant. I understand the full import of this order and assume responsibility for its execution. This order will remain in effect until it is revoked as provided by law. _______________________________________ _______________ (Patient advocate's signature) (Date) _______________________________________ (Type or print patient advocate's name) . D. GUARDIAN CONSENT I authorize that in the event the ward's heart and breathing should stop, no person shall attempt to resuscitate the ward. I understand the full import of this order and assume responsibility for its execution. This order will remain in effect until it is revoked as provided by law. _______________________________________ _______________ (Guardian's signature) (Date) _______________________________________ (Type or print guardian's name) _______________________________________ _______________ (Physician's signature) (Date) _______________________________________ (Type or print physician's full name) ATTESTATION OF WITNESSES The individual who has executed this order appears to be of sound mind, and under no duress, fraud, or undue influence. Upon executing this order, the declarant has (has not)received an identification bracelet. ________________________________ ________________________________ (Witness signature) (Date) (Witness signature) (Date) ________________________________ ________________________________ (Type or print witness's name) (Type or print witness's name) THIS FORM WAS PREPARED PURSUANT TO, AND IS IN COMPLIANCE WITH, THE MICHIGAN DO-NOT-RESUSCITATE PROCEDURE ACT . (https://www.legislature.mi.gov/(S(izncxegpu4xl2mqzb3v3ru45))/documents/mcl/pdf/mcl-Act-193-of-1996.pdf) Resident #17 (R17): Review of the medical record reflected R17 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included hemiplegia (paralysis on one side of the body), pain and unspecified dementia. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], reflected R17 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R17's Treatment Preferences and Determination of Residents Wishes document reflected selection of, Code B - I want all my illnesses treated aggressively, including full hospitalization . This includes hospitalization for routine emergency treatment. However, I DO NOT want cardiopulmonary resuscitation (CPR). The document included a Presenter's Signature, the resident's signature and a physician's signatures, all dated for [DATE]. The document did not include the required witness signatures or the Michigan do-not-resuscitate procedure act language. During an interview on [DATE] at 1:37 PM, Director of Social Services (SS) D reported the presenter was the only witness used on the facility's DNR document. SS D stated it had not been the facility's practice to use the Michigan DNR form. 27306 Resident #149 (R149): Review of the medical record reflected R149 admitted to the facility on [DATE] and with diagnoses that included heart failure and melanoma. R149's Treatment Preferences and Determination of Residents Wishes document reflected selection of, Code D-Comfort measures only. No cardiopulmonary resuscitation (CPR). No artificial nutrition and hydration. The document included a Presenter's Signature, and the resident's signature dated [DATE], the physician signed the document on [DATE]. The document did not include the required witness signatures or the Michigan do-not-resuscitate procedure act language. 46955 Resident #350 (R350) Review of the medical record revealed that Resident #350 (R350) was admitted to the facility [DATE] with diagnoses including unspecified fall, pain, and multiple fractures. Review of the Minimum Data Set (MDS) with an Assessment Reference Date of [DATE] reflected that R350 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 15 (cognitively intact). In an observation and interview on [DATE] at 10:45 AM, R350 was observed lying in bed, on back, with oxygen noted to be in place at 2 liters per minute via nasal cannula. R350 stated that she had been admitted to the facility a couple weeks ago, for therapy, following a fall in her home setting. Review of R350's electronic medical record (EMR) on [DATE] at 2:29 PM included a physician order dated [DATE] which stated, Code B - hospitalization and no CPR [cardiopulmonary resuscitation] with further review of the EMR not noted to include a facility code status form. Review of a binder located within a cupboard at the second-floor nurses' station was noted to include a document titled Treatment Preferences and Determination of Residents Wishes signed and dated by R350 on [DATE]. Further review of the document was noted to include R350's initials reflecting selection of Code B - I want all my illnesses treated aggressively, including full hospitalization . This includes hospitalization for routine and emergency treatment. However, I DO NOT want cardiopulmonary resuscitation (CPR). The same document was noted to include a signature and corresponding date of [DATE] on both the line titled Presenter's Signature and Physician Signature. In an interview on [DATE] at 1:37 PM, Social Work Director (SWD) D stated that upon facility admission, the nursing department reviewed the facility's code status form titled Treatment Preferences and Determination of Residents Wishes with the resident, the admitting resident chose their desired code status, the form was forwarded to the physician for a signature and then reviewed by the social work department to ensure accuracy. SWD D stated that the form titled Treatment Preferences and Determination of Residents Wishes was the only form the facility utilized for code status determination, confirmed that the choice of hospitalization and no CPR would be considered a DNR (Do Not Resuscitate), that the presenter would be the sole witness and that a 2nd witness would not be indicated even with a DNR selection.

Based on observation, interview and record review the facility failed to provide Physical and Occupational Therapy schedules upon request for three (Resident #25, 43, 151) out of three residents reviewed for accommodation of needs resulting in feelings of frustration. Findings Include: Resident #43 Review of the medical record revealed Resident #43 (R43) was admitted to the facility on [DATE] with diagnoses that included. A Social Work Progress Noted revealed R43 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). The medical record indicated that R43 was at the facility for a short term rehabilitation stay. In an observation and interview on 02/13/24 at 1:09 PM, R43 was seated in her reclining chair in her room with her feet elevated. R43 had a fiberglass cast on her left leg. A whiteboard was observed in R43's room which identified the care team assignment for the day, along with Physical and Occupational therapy times. R43 pointed out that the whiteboard does not get filled out and the therapy times written on the whiteboard are not consistent with the actual times that therapy occurs. R43 stated typically, therapy will stop in the morning and let her know that she will have Physical Therapy (PT) in the morning, however, PT doesn't return for her session until the afternoon timeframe. R43 also reported that therapy id not come on Sunday, so she inquired when they were coming, only to be told by a Certified Nursing Assistant that R43 was not on the therapy schedule for that day. R43 stated that she had requested a therapy schedule multiple times but has not received anything. R43 was in the process of handling legal matters for a recent tragedy which required scheduled Zoom calls and the uncertainty of therapy days and times left her feeling frustrated and anxious. In an interview on 02/14/24 at 02:42 PM, Director of Rehab- DOR E reported she tried to keep schedules consistent along with therapy times but due to staffing issues this was increasingly difficult. DOR E elaborated that more effort should be put into adhering to some type of schedule but due to call ins, Covid and various other issues consistency was difficult, DOR E stated her hope was that is therapy was canceled or going to be delayed or pushed back/running late she would expect the changes be communicated to residents but did not think that was happening. 27306 Resident #25 Review of the clinical record, including the Minimum Data Set, dated dated dated [DATE] reflected Resident 25 (R25) was admitted to the facility on [DATE], transferred to the hospital on 01/18 and returned to the facility on [DATE]. R25 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status. Further review of the electronic medical record reflected R25 was admitted for short term rehabilitation for a diagnosis of a fractured right humorous. On 02/13/24 at 12:28 PM, during an interview with R25 she reported feeling frustrated with the therapy department, R25 stated she had repeatedly asked for a schedule from therapy but had not received one. R25 reported concerns that on occasion she had missed visitors and at other times had missed therapy sessions due to the inability on how to plan her day due to lack of communication. R25 stated she felt as if her time was not valued or important and she was at their disposable. R25 elaborated she was ok with therapy choosing the times and days but would like to be informed so she could plan accordingly, reiterating she has friends and family that she would like to visit and was willing to plan accordingly around therapy but needed them to communicate a schedule they could adhere too. R25 followed up that statement with on the rare occasion she was given a time for therapy it was delayed or rescheduled all together. Resident #151 Review of the clinical record reflected Resident #151 (R151) was admitted to the facility on [DATE] with diagnosis of heart disease, and melanoma. Further record review reflected R151 was admitted for short term rehabilitation. During a bedside interview on 02/13/24 at 01:52 PM, R151 presented as alert and oriented x 3. Upon approach R151 reported he was angry because he was told that morning that Occupational Therapy (OT) was going to take place at 9:00 am and he has now waited nearly 5 hours. R151 stated he'd like to lay down but feels like he cant because someone from therapy should be here any minute. R151 stated he Has asked the therapy department for a schedule but has not been given one. During the interview with R151 an unidentified staff member entered R151's room and announced OT had been canceled for today and will be made up this coming Saturday. R151 then rolled his eyes and stated See that's what I mean! Resident pointed to a dry erase board in room and stated he thinks they (therapy) are supposed to write the times on there, the dry erase board also indicated the name of the nurse and name of the certified nursing assistant. Of note, the dry erase board had no therapy information, and was dated for the day before, 2/12/24 therefore the name of the nurse and the certified nursing assistant were not accurate. On 02/14/24 02:42 PM, during an Interview and record review with Director of Rehab- DOR E acknowledged that R25 had missed some therapy sessions on 1/10 due to R25 feeling ill but had also missed sessions on 2/6, 2/8 and again 2/13. DOR E reported she tried to keep schedules consistent along with therapy times but due to staffing issues this was increasingly difficult. DOR E elaborated that more effort should be put into adhering to some type of schedule but due to call ins, Covid and various other issues consistency was difficult, DOR E stated her hope was that is therapy was canceled or going to be delayed or pushed back/running late she would expect the changes be communicated to residents but did not think that was happening.

Based on observation, interview and record review, the facility failed to ensure a Preadmission/Annual Resident Review was completed after the 30-day exemption period and failed to notify the State Mental Health Authority for 1 of 1 resident (resident #22) reviewed for PAS/ARR, from a total sample of 13, resulting in the potential for unmet mental health treatment and services. Findings include: Review of the medical record revealed Resident #22 (R22) was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included [NAME] Disease, Fibromyalgia, Anxiety, Major Depression, Dysphasia, Speech Disturbances, Difficulty Walking, Muscles Spasms, after care following joint repair, and pain. According to Resident #01 (R01)'s Minimum Data Set (MDS) dated [DATE], revealed R22 scored 12 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R22 requires assistance with all care due to upper extremities having contractures and use of an assisted device for walking with a walker or use of a wheelchair to be transferred. On 02/14/24 at 08:49 AM, an email was received by Regional Director of Operations C stating she did not see the information from the OBRA coordinator, that typically goes to social work, so she had sent Social Worker Director (SW) D an email to get that scanned into the record since she did end up staying beyond 30 days. During an interview on 02/14/24 at 10:09 AM, SW D stated the OBRA coordinator did not have the resident listed for this facility, so they didn't send it to them. During an interview on 02/15/24 at 08:20 AM, SW D stated when residents come from the hospital with the hospital Passar, admission department assigns the Passar to the que, after 25 days it goes to the SW, and she notifies OBRA. This did not take place. During an interview on 02/15/24 at 10:54 AM, Minimum Data Set Coordinator (MDS) G stated that under the admitted [DATE], section A1500, she was unable to find it. MDS G looked under admitted [DATE] and stated A1500 was 0. MDS G also stated R22 did not require a Passar to be completed.

This citation pertains to intake MI00140950 Based on interview and record review, the facility failed to provide showers for one (Resident #48) of two reviewed for Activities of Daily Living (ADL) assistance, resulting in unmet care needs. Findings Include: Review of the medical record revealed Resident #48 (R48) was admitted to the facility on [DATE] with diagnoses that included chronic pain syndrome, lumbar spinal fusion, hypertension (high blood pressure), connective tissue disease, and anemia. A Social Work Progress Noted dated 10/24/23 revealed R48 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). The Resident Summary with a date of 10/19/23 revealed R48 required staff assistance of two people for Activities of Daily Living Care, including showers. In a telephone interview on 2/13/24 at 10:15 AM, R48 reported that she went multiple days without receiving a shower which made her feel gross. R48 stated that staff would tell her that they were busy when she requested her scheduled shower and that they would assist with her shower later, however, staff did not follow up with the request. R48 stated that she had brought the concern of not receiving showers to the staff's attention on multiple occasions. R48 stated that she had only refused one shower during her stay at the facility and that was near the end of her stay in November. Review of the same Resident Summary revealed R48 was scheduled to have showers on Monday's and Thursdays. Review of the Bath by Day report revealed that R48 did not receive a shower on her scheduled shower days of 10/19/23 and 10/23/23. There were no documented resident refusals on those same shower dates. In an interview on 2/15/24 at 11:15 AM, Assistant Director of Nursing (ADON) J stated that she was unable to locate any shower documentation or refusals for the two missed shower dates.

Based on observation, interview and record review, the facility failed to notify the resident and/or resident's representative of the facility's policy for bed hold for 2 (Resident #17 and #23) of 4 residents reviewed for hospital transfer, resulting in the potential for residents and/or representatives to be uninformed of the bed hold policy. Findings include: Resident #23 Review of the medical record reflected that Resident #23 (R23) was admitted to facility 3/17/2020 with diagnoses including hemiplegia following cerebral infarct, type 2 diabetes mellitus, peripheral vascular disease, major depressive disorder, and vascular dementia. Review of the Minimum Data Set (MDS) with an Assessment Reference Date of 1/30/24 reflected that R23 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 15 (cognitively intact). Review of the Discharge MDS dated [DATE] reflected that R23 had an unplanned discharge to an acute care hospital and that her return to the facility was anticipated. In an observation and interview on 2/13/24 at 12:08 PM, R23 was observed lying in bed, on back, dressed in a facility gown. R23 stated that she had an upset stomach that came and went, reported hospitalization s for kidney stones within the last few months, denied familiarity with the facility's bed hold policy and did not recall her nurse or anyone else at the facility reviewing or providing her with a bed hold policy at the time of her hospital transfer. Review of the Nursing Progress Note, within R23's medical record, dated 6/25/23 reflected that R23 was transferred to the hospital for increased facial drooping on the left side, c/o [complaints of] difficulty swallowing and dribbling water when drinking as well as pain on right sight [sic] since Saturday some time [sic]. No indication was noted within note or elsewhere in R23's record that the facility's bed hold policy was reviewed with or provided to her or her responsible party at the time of her 6/25/23 hospital transfer. In an interview on 2/14/24 at 12:55 PM, Regional Director of Operations (RDOO) C stated that with any hospital transfer, the facility's bed hold policy accompanied the resident in a transfer packet to the hospital, the transferring nurse signed a document that the bed hold policy was provided, and that the responsible party was contacted to notify of both the transfer and that the bed hold policy was in the transfer packet for their review. On 2/14/24 at 3:77 PM, electronic correspondence was sent to RDOO C with request for bed hold information pertaining to R23's 6/25/23 hospital transfer with return electronic correspondence received from RDOO C at 5:05 PM that indicated that the bed hold policy had been sent and that the document would be provided. In an interview on 2/15/23 at 10:31 AM, RDOO C stated that she was unable to provide evidence that the facility's bed hold policy was reviewed with or provided to R23 or her responsible party at the time of the 6/25/23 hospital transfer as a copy of the completed form had not been retained which was the facility's process. Review of the facility policy titled Bed Hold and Return to Facility dated August 2022 stated, Purpose: To ensure that the resident is informed of the State's bed hold duration and payment and their right to return to the facility from a hospitalization .Policy .A. Residents who are transferred to the hospital or go on a therapeutic leave are provided with written information about the State's bed hold protocols before the transfer .E. Residents and their representatives will be provided with bed hold and return information at admission and before a hospital transfer . 38383 Resident #17 (R17): Review of the medical record reflected R17 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included hemiplegia (paralysis on one side of the body), pain and unspecified dementia. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/14/23, reflected R17 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R17's MDS history reflected discharge return anticipated MDS assessments with ARDs of 5/21/23, 11/13/23 and 12/29/23. A Progress Note for 5/21/23 at 9:30 PM reflected R17 was found lethargic and difficult to arouse at 7:00 PM. The physician ordered for R17 to be sent to the emergency room for evaluation. R17's MDS history reflected he readmitted to the facility on [DATE]. R17's Progress Notes did not reflect the reason for discharge on 11/13/23. R17's MDS history reflected he returned to the facility on [DATE]. R17's Progress Notes did not reflect the reason for discharge on 12/29/23. A Progress Note for 12/30/23 at 9:15 AM reflected a call was placed to the emergency room to check on R17's status. The facility was informed that R17 was being admitted with a diagnosis of COVID-19. R17's MDS history reflected he returned to the facility on [DATE]. On 2/14/24, bed hold notices were requested, via email, for R17's hospitalization s for 5/2023, 11/2023 and 12/2023. The bed hold notices for 5/21/23 and 11/13/23 were not received prior to the exit of the survey on 2/15/24. During an interview with Regional Director of Operations (RDO) C, on 02/15/24 at 12:49 PM, R17's hospitalization s for 5/23/23, 11/13/23 and 12/29/23 were discussed. RDO C believed she had provided all the bed holds she could locate for R17, which was for 12/29/23. RDO C conveyed that staff had not been sending bed hold notices with their long-term care residents. An email from RDO C on 2/15/24 at 1:09 PM reflected R17 went out for a scheduled procedure on 11/13/24 that was planned as an outpatient. The facility only sent the information that was requested by urology, and a bed hold policy was not sent. The email further reflected that medical records was unable to locate a bed hold for 5/21/23.

Based on observation, interview, and record review, the facility failed to ensure that written notification required for facility-initiated transfers were provided to residents or resident representatives for 3 (Resident #17, #23 and #35) of 4 residents reviewed for hospitalization , resulting in the potential of residents and/or representatives being un-informed of the reason for transfer and their appeal rights. This had the potential to affect all 42 residents that resided in the facility. Findings include: Resident #23 (R23) Review of the medical record reflected that Resident #23 (R23) was admitted to facility 3/17/2020 with diagnoses including hemiplegia following cerebral infarct, type 2 diabetes mellitus, peripheral vascular disease, major depressive disorder, and vascular dementia. Review of the Minimum Data Set (MDS) with an Assessment Reference Date of 1/30/24 reflected that R23 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 15 (cognitively intact). Review of the Discharge MDS dated [DATE] reflected that R23 had an unplanned discharge to an acute care hospital and that her return to the facility was anticipated. In an observation and interview on 2/13/24 at 12:08 PM, R23 was observed lying in bed, on back, dressed in a facility gown. R23 stated that she had an upset stomach that came and went, reported hospitalization s for kidney stones within the last few months, denied familiarity with the facility's transfer notice and did not recall her nurse or anyone else at the facility reviewing or providing her with a written notice pertaining to the hospital transfer. Review of the Nursing Progress Note, within R23's medical record, dated 6/25/23 reflected that R23 was transferred to the hospital for increased facial drooping on the left side, c/o [complaints of] difficulty swallowing and dribbling water when drinking as well as pain on right sight [sic] since Saturday some time [sic]. No indication was noted within note or elsewhere in R23's record that a written notice of hospital transfer was provided to R23 at the time of her 6/25/23 hospital transfer. In an interview on 2/15/24 at 10:31 AM, Regional Director of Operations (RDOO) C confirmed that R23's 6/25/23 hospitalization was a facility-initiated hospital transfer but that no written notice pertaining to the hospital transfer had been provided to R23 or her family at the time of the transfer. Resident #35 (R35) Review of the medical record reflected that Resident #35 (R35) was admitted to facility 5/30/23 with diagnoses including Alzheimer's Disease and Gastrointestinal Hemorrhage. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/3/24 reflected that R35 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 00 (severe cognitive impairment). Review of the Discharge MDS dated [DATE] reflected that R35 had an unplanned discharge to an acute care hospital and that his return to the facility was anticipated. In an observation and interview on 2/13/24 at 3:10 PM, R35 was observed sitting in a high back reclining wheelchair, at bedside. R35 was alert, stated I'm doing all right when questioned but was unable to elaborate further. Review of the Nursing Change in Condition Clinical Note dated 10/25/23 and completed by Licensed Practical Nurse (LPN) P reflected that R35 was transferred to the hospital for rectal bleeding. No indication was noted within note or elsewhere in R35's record that a written notice of hospital transfer was provided to R35 or his responsible party at the time of his 10/25/23 hospital transfer. In an interview on 2/14/24 at 10:57 AM, LPN P stated that upon identifying a resident with a change in condition, would fully assess, obtain vital signs, notify physician, and if order received to transfer the resident to the hospital would write physician order to reflect transfer, call EMS (Emergency Medical Services) for transport, print pertinent paperwork and complete and send a Patient Transfer Form which included resident specific information such as vital signs, care needs, diet, and a brief summary of resident status. LPN P denied knowledge of any facility form pertaining to a written notice of hospital transfer that was reviewed and provided to a resident at the time of a hospital transfer as stated that the clinical Patient Transfer Form was the only transfer form that she had ever been aware of. LPN P stated familiarity with R35 as he resided on the unit that she primarily worked and confirmed that she had sent R35 to the hospital at one point due to low blood pressure and a suspected bleed. LPN P confirmed that she had not reviewed or provided a written notice of hospital transfer to R35 or his responsible party at the time of his 10/25/23 hospital transfer. In an interview on 2/14/24 at 12:15 PM, Registered Nurse/Assistant Director of Nursing/Infection Preventionist (RN/ADON/IP) J stated that with all hospital transfers the facility's Patient Transfer Form was completed which reflected the resident's contact information, vital signs, current status, and care needs. RN/ADON/IP J denied knowledge of any facility form pertaining to a written notice of hospital transfer that was reviewed with and provided to a resident and/or responsible party at the time of a hospital transfer confirming that the Patient Transfer Form was the only facility transfer form that she was aware of. In an interview on 2/14/24 at 12:55 PM, RDOO C confirmed that a Patient Transfer Form was completed and sent with all residents at the time of a hospital transfer but stated that to her knowledge the facility had no separate form pertaining to a written notice of hospital transfer that was reviewed with and provided to a resident or their responsible party. In a follow-up interview on 2/14/24 at 2:50 PM, RDOO C confirmed that the facility did not have a form pertaining to or separate policy that addressed a facility-initiated hospital transfer but that the facility's bed hold policy included a return to facility policy post hospitalization . Review of the facility policy titled Bed Hold and Return to Facility dated August 2022 stated, Purpose: To ensure that the resident is informed of the State's bed hold duration and payment and their right to return to the facility from a hospitalization .POLICY .E .Residents and their representative will be provided with bed hold and return information at admission and before a hospital transfer . 38383 Resident #17 (R17): Review of the medical record reflected R17 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included hemiplegia (paralysis on one side of the body), pain and unspecified dementia. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/14/23, reflected R17 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R17's MDS history reflected discharge return anticipated MDS assessments with ARDs of 5/21/23, 11/13/23 and 12/29/23. A Progress Note for 5/21/23 at 9:30 PM reflected R17 was found lethargic and difficult to arouse at 7:00 PM. The physician ordered for R17 to be sent to the emergency room for evaluation. R17's MDS history reflected he readmitted to the facility on [DATE]. R17's Progress Notes did not reflect the reason for discharge on 11/13/23. R17's MDS history reflected he returned to the facility on [DATE]. R17's Progress Notes did not reflect the reason for discharge on 12/29/23. A Progress Note for 12/30/23 at 9:15 AM reflected a call was placed to the emergency room to check on R17's status. The facility was informed that R17 was being admitted with a diagnosis of COVID-19. R17's MDS history reflected he returned to the facility on [DATE]. On 2/14/24, transfer/discharges notices were requested, via email, for R17's hospitalization s for 5/2023, 11/2023 and 12/2023. The notices were not received prior to the exit of the survey on 2/15/24. During an interview with Regional Director of Operations (RDO) C, on 02/15/24 at 12:49 PM, R17's hospitalization s for 5/21/23, 11/13/23 and 12/29/23 were discussed. RDO C reported the facility had not been providing written notices of transfer/discharge. An email from RDO C on 2/15/24 at 1:09 PM reflected R17 went out for a scheduled procedure on 11/13/24 that was planned as an outpatient. The facility only sent the information that was requested by urology.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 41 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination. Findings include: On 01/09/23 at 08:45 A.M., An environmental tour of the facility Laundry Service was conducted with Director of Environmental Services F. The following items were noted: Clean Linen Room: The wall fan was observed soiled with accumulated dust and dirt deposits. Soiled Linen Room: The drywall surfaces were observed (etched, scored, particulate), along both side wall surfaces. The damaged drywall surfaces measured approximately 28-feet-long by 12-inches-wide. On 01/10/23 at 08:45 A.M., A common area environmental tour was conducted with Nursing Home Administrator (NHA) A, Director of Maintenance G, and Director of Environmental Services F. The following items were noted: Staff Break Room (2120): The microwave oven interior surfaces were observed heavily soiled with accumulated and encrusted food residue. The return air exhaust ventilation grill was also observed soiled with accumulated dust and dirt deposits. Director of Environmental Services F indicated she would have staff thoroughly clean the microwave oven and return air exhaust ventilation grill as soon as possible. Clean Linen Room (2125): 4 of 6 overhead 48-inch-long fluorescent light bulbs were observed non-functional. Occupational Therapy/Physical Therapy: 4 of 4 sconce lights were observed non-functional. The return air exhaust ventilation grill was also observed soiled with accumulated dust and dirt deposits. Physical Therapist I stated: The sconce lights have been out for some time. Physical Therapist I further stated: It gets quite dark during the winter months. Support Closet (2116): The return air exhaust ventilation grill was observed soiled with accumulated dust and dirt deposits. Library (2110): 1 of 2 overhead light assemblies were observed non-functional. Restroom (2109): The overhead light assembly was observed non-functional. Dining Room (2124): The hand sink faucet actuator handle was observed loose-to-mount. The handle set screw was also observed missing, allowing the handle to separate from the valve stem assembly. On 01/10/23 at 09:25 A.M., An environmental tour of sampled resident rooms was conducted with Nursing Home Administrator (NHA) A, Director of Maintenance G, and Director of Environmental Services F. The following items were noted: 2209: The shower overhead light assembly was observed non-functional. 2304: The drywall surface was observed (etched, scored, particulate), adjacent to the adjustable Broda chair. The damaged drywall surface measured approximately 6-inches-wide by 18-inches-long. The overbed light assembly was also observed non-functional. The restroom return air exhaust ventilation grill was further observed soiled with accumulated dust and dirt deposits. 2310: The restroom shower light assembly was observed non-functional. 2409: The restroom hand sink was observed draining very slow. The taupe colored Broda chair was also observed with a small tare on the left-hand side, creating an infection control issue. The damaged vinyl surface measured approximately 2-inches-wide by 2-inches-long. On 01/10/23 at 11:01 A.M., An interview was conducted with Nursing Home Administrator (NHA) A regarding the facility maintenance work order system. Nursing Home Administrator (NHA) A stated: We have the WorxHub software system. On 01/10/23 at 11:03 A.M., An interview was conducted with Nursing Home Administrator (NHA) A regarding a specific Policy/Procedure for cleaning and maintaining the Long-Term Care Facility physical plant. Nursing Home Administrator (NHA) A indicated he would research the request. On 01/10/23 at 01:44 P.M., An interview was conducted with Director of Maintenance G regarding a specific Policy/Procedure for maintaining the Long-Term Care Facility physical plant. Director of Maintenance G stated: We really don't have a specific policy. Director of Maintenance G further stated: We use the WorxHub software system to document maintenance concerns. On 01/10/23 at 02:15 P.M., Record review of the WorxHub Work Orders for the last 60 days revealed no specific entries related to the aforementioned maintenance concerns. On 01/10/23 at 02:30 P.M., Record review of the Policy/Procedure entitled: Resident Room Cleaning Steps Daily dated (no date) revealed under High/Low Dust: High dust surfaces above shoulder height, including the tops of lights, doors, curtain tops, wall mounted TV sets, partitions, ventilation covers, etc. Do not reach over people, or dust surfaces above people.

Based on observations, interviews, and record reviews, the facility failed to effectively: (1) clean and maintain food service equipment, and (2) date mark all potentially hazardous ready-to-eat food products effecting 41 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and resident foodborne illness. Findings include: On [DATE] at 09:55 A.M., A tour of the food production kitchen was conducted with Director of Dining Services D and Clinical Nutrition Manager (Registered Dietician) E. The following items were noted: The Can Opener Assembly was observed soiled with accumulated and encrusted food residue, adjacent to the baking area. The FEW one-door reach-in refrigerator door gasket was observed soiled with accumulated dust and dirt deposits. The 2017 FDA Model Food Code section ,d+[DATE].11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. One gallon of unopened Prairie Farms Fat Free milk was observed within the dairy cooler with a manufacturer use-by-date that read [DATE]. The 2017 FDA Model Food Code section ,d+[DATE].17 states: (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S ,d+[DATE].12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. On [DATE] at 10:30 A.M., An interview was conducted with Director of Dining Services D regarding the fresh produce delivery schedule. Director of Dining Services D stated: Produce is received from our supplier (Contractual Name) on Monday, Wednesday, and Friday. The small Meat Cooler was observed with malodorous conditions. The external thermometer was also observed to read 36 degrees Fahrenheit. Director of Dining Services D stated: The fresh fish is creating the odor. Director of Dining Services D further stated: If you have different types of fresh fish, sometimes strong odors will be created. CRC: (Care and Rehabilitation Center) Floor 1 Satellite Kitchen: No soap was observed at the sole hand sink basin. Director of Dining Services D obtained a container of GoJo premium foam antibacterial hand wash (Fresh Fruit Scent) and placed the full container of foam soap at the hand sink basin. The 2017 FDA Model Food Code section ,d+[DATE].12 states: (A) Except as specified in (D) of this section, FOOD EMPLOYEES shall clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands or arms for at least 20 seconds, using a cleaning compound in a HANDWASHING SINK that is equipped as specified under S ,d+[DATE].12 and Subpart ,d+[DATE]. (B) FOOD EMPLOYEES shall use the following cleaning procedure in the order stated to clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands and arms: (1) Rinse under clean, running warm water; (2) Apply an amount of cleaning compound recommended by the cleaning compound manufacturer; (3) Rub together vigorously for at least 10 to 15 seconds while: (a) Paying particular attention to removing soil from underneath the fingernails during the cleaning procedure, and (b) Creating friction on the surfaces of the hands and arms or surrogate prosthetic devices for hands and arms, finger tips, and areas between the fingers; (4) Thoroughly rinse under clean, running warm water; and (5) Immediately follow the cleaning procedure with thorough drying using a method as specified under S ,d+[DATE].12. On [DATE] at 12:15 P.M., A tour of the food production kitchen was continued with Director of Dining Services D. The following items were noted: The Cookie Box was observed soiled with accumulated and encrusted food residue. Clear tape and tape residue was also observed on both the interior and exterior unit surfaces. The True heated one-door cabinet was observed with exterior soils. The interior door ledge was also observed soiled with accumulated food residue. The two Vulcan stacked convection oven(s) interior and exterior unit surfaces were observed soiled with accumulated and encrusted food residue. The [NAME] natural gas stove top, backsplash, and oven interior/exterior unit surfaces were observed soiled with accumulated and encrusted food residue. The Vulcan deep fat fryer was observed soiled with accumulated and encrusted food residue. Sesame Seeds were also observed around the unit perimeter and within the deep fat fryer basin. The frying oil was also observed extremely dark and opaque. The ventilation hood filters were observed soiled with accumulated and encrusted dirt and grease deposits. 6 of 6 ventilation hood light glass globe protective covers were also observed heavily soiled with accumulated and encrusted dirt and grease deposits. The Panasonic microwave oven interior surfaces were observed (etched, scored, particulate). The exterior surfaces were also observed soiled with accumulated and encrusted food residue. The [NAME] stand mixer was observed soiled with accumulated and encrusted food residue. The spindle guard assembly and backsplash were also observed soiled with food residue. The 2017 FDA Model Food Code section ,d+[DATE].11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 1 of 6 ventilation hood lights were observed non-functional. The two Vulcan stacked convection oven(s) were observed with 2 of 2 and 1 of 2 interior light bulbs non-functional respectively. The 2017 FDA Model Food Code section ,d+[DATE].11 states: The light intensity shall be: (A) At least 108 [NAME] (10 foot candles) at a distance of 75 cm (30 inches) above the floor, in walk-in refrigeration units and dry FOOD storage areas and in other areas and rooms during periods of cleaning; (B) At least 215 [NAME] (20 foot candles): (1) At a surface where FOOD is provided for CONSUMER self-service such as buffets and salad bars or where fresh produce or PACKAGED FOODS are sold or offered for consumption, (2) Inside EQUIPMENT such as reach-in and under-counter refrigerators; and (3) At a distance of 75 cm (30 inches) above the floor in areas used for handwashing, WAREWASHING, and EQUIPMENT and UTENSIL storage, and in toilet rooms; and (C) At least 540 [NAME] (50 foot candles) at a surface where a FOOD EMPLOYEE is working with FOOD or working with UTENSILS or EQUIPMENT such as knives, slicers, grinders, or saws where EMPLOYEE safety is a factor. Four 6-inch pans, two 16-inch pans, and two 20-inch stock pots were observed with accumulated and encrusted deposits. The pans and pots were also extremely caramelized and carbonized from exposure to natural gas flames over time. The 2017 FDA Model Food Code section ,d+[DATE].13 states: NonFOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues. The prep sink faucet assembly (hot water valve) was observed leaking water, adjacent to the Cleveland steamers. The 2017 FDA Model Food Code section ,d+[DATE].15 states: A PLUMBING SYSTEM shall be: (A) Repaired according to LAW; and (B) Maintained in good repair. The Delfield two-door reach-in cooler was observed with the external thermometer loose-to-mount. The 2017 FDA Model Food Code section ,d+[DATE].11 states: (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts ,d+[DATE] and ,d+[DATE]. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. (C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate FOOD when the container is opened. On [DATE] at 10:15 A.M, Record review of the Policy/Procedure entitled: Sanitation Standards Heavy Equipment dated (no date) revealed under Range Top: Keep free from grease and spills. Record review of the Policy/Procedure entitled: Sanitation Standards Heavy Equipment dated (no date) further revealed under Ovens: Clean daily. On [DATE] at 10:30 A.M., Record review of the Policy/Procedure entitled: Storage of Food and Supplies dated [DATE] revealed under Method/How To/Procedure: Cover, label, and date unused portions and open packages. Complete all sections on a (corporate name) date label or use an approved labeling system. Products are good through the close of business on the date noted on the label. Record review of the Policy/Procedure entitled: Storage of Food and Supplies dated [DATE] additionally revealed under Method/How To/Procedure: Date and rotate items; first in, first out (FIFO). Discard food past the use-by or expiration date. Record review of the Policy/Procedure entitled: Storage of Food and Supplies dated [DATE] further revealed under Refrigerated Foods: Unused portions of canned fruits and vegetables transferred to clean approved storage containers. Do not store in open cans. Remove any serving utensils and cover tightly. Label and date container. 27446 During a tour of a satellite kitchen (small kitchen that received food from the main kitchen), with Dining Room Supervisor (DS) W a standup refrigerator was opened and a jar of Mild Cherry Peppers was observed to have a sticker on the jar that indicated the jar was opened on [DATE], however no use by date was noted on the jar. A bag of sheep cheese was observed opened and placed into a zip lock freezer bag, however no manufactures expiration date was noted on either of the bags, and no opened or use by date was on either of the bags. An unopened block of cheese was also noted in the refrigerator, no manufacture expiration date was stamped onto the block of cheese, and mold was observed in a small area of the cheese, which DS W confirmed was mold. A 4.41 lb of olives in a jar was observed and had no opened or use by date on the jar. A 5 lb jar of olives was observed to have no open date, and no use by date. DS W was asked to provide the food temperature book that listed all food temperatures while on the steam table holding area. DS W said she did not take food temp, she just supervised. DS W was asked to provide the food temp log books. Review of the food temperature logs revealed that on [DATE]st, 2023 no food temperatures were documented for all three meals. On [DATE] only breakfast and lunch temperatures were documented, the on [DATE] only the dinner food was documented, on [DATE] only breakfast and dinner temperatures were documented, on ,d+[DATE] and [DATE] on the dinner meal had documented food temperatures documented, and on [DATE] only the breakfast meal was documented. Review of a facility policy and procedure titled Meal Temperatures. revealed .When food is transported to a remote serving location such as a household, neighborhood etc., final cook temperatures are taken and recorded in the kitchen; temperatures are taken and recorded again once transported to service location and prior to serving . In another cooler a gallon of unopened milk was observed to have expired on [DATE]. In an observation on [DATE], at 7:50 AM, with Registered Dietician (RD) E, and upon entering the walk in freezer a rotten smell was observed. Two tubs of prepared lettuce with a plastic covering was observed on a shelf, and had no date the lettuce was prepared or use by date. A twisty tie was observed to be wrapped around one bunch of herbs that were observed to be wilted.

Based on interview, and record review, the facility failed to notify the resident in writing prior to transfer to the hospital and send a copy of the notice to the ombudsman, in one of four residents reviewed for hospital transfer (Resident #89), resulting in the potential for unmet needs. Findings include: Resident #89 (R89) R89's Minimum Data Set (MDS) dated [DATE], indicated she was admitted to the facility on [DATE] from an acute hospital and discharged to an acute hospital on 11/09/22. Social Work J was interviewed on 1/11/23 at 9:51 AM and stated she did not notify the ombudsman of R89's transfer to the hospital in November 2022. Nursing Home Administrator A was interviewed on 1/11/23 at 10:15 AM and confirmed R39 did not receive a transfer notice when discharged to the hospital because it was planned.

Based on observation, interview and record review, the facility failed to ensure resident preferences were honored for 2 residents (Resident #4 and 31) of 2 reviewed for choices, resulting in feelings of frustration and loss of autonomy. Findings include: Resident #4 According to the clinical record including the Minimum Data Set (MDS) with an assessment reference date of 12/29/22, Resident # 4 (R4) was admitted to the facility on [DATE] for short term rehabilitation and had a diagnosis of cerebral infarction. Review of the MDS, section B reflected R4 had no long or short term memory impairment and was alert and oriented to season, room location, staff names, faces and that she was in a skilled nursing facility and was independent with decision making and that decisions were consistent/reasonable. Further review of the MDS reflected R4 had clear speech, had minimal hearing difficulties and had was able to make self understood and was able to understand others, under section F R4 reported choosing her bedtime was Very Important. During an interview with Resident # 4 (R4) on 01/08/23 09:18 AM, she reported being very frustrated with staff because the frequently woke her too early in the morning to administer medications. R4 stated she had voiced several times to several staff that she does not want to be woken up for breakfast, medications or therapy. R4 stated some staff continue to ignore her preferences and she does not wake up and start her day until well after 9:00 am, R4 elaborated that was the routine at home and did not want it changed/disrupted. R4 stated choosing her bedtime was just as important as choosing the time she started her day. During an interview with Certified Nursing Assistant (CNA) P she reported she routinely was assigned to R4 and described R4 as Not a morning person. CNA P stated R4 had made it clear she did not want to be woken up for care or breakfast, and does not do so per resident request. CNA P further stated she checks on R4 but knows not to wake her or attempt care until after 9:00 am, and that R4 had complained to CNA P that some Nurses will wake her up to administer medications and that she gets mad when that happens. On 01/11/23 08:15 AM, during an interview with Licensed Practical Nurse (LPN) Q reported she was aware that R4 liked to sleep in and that she tried to accommodated R4 as best as she could but would get a red dot on the computer if the medication requip was not administered by 9:00 a.m. i.e.; the medication was ordered at 8:00 am and there was a 1 hour window for it to be administered before it would be considered late. LPN Q elaborated that R4 tried to sleep through breakfast, and that she tries to work around R4, but this was a rehab facility and R4 should be up, eat breakfast and take her pills on time. On 01/11/23 at 08:42 AM, during an interview with LPN R she reported she was assigned to R4 on 01/09/23, review of the administration records for that day reflected R4 was administered her morning medications at 7:38 am. Further review reflected R4's medications were ordered Upon rising which LPN R stated she interpreted upon rising to mean at before 11:00 am. LPN R elaborated that R4 was not a morning person, when queried how she knew that, LPN R stated she knew that because when she wakes her up in the morning to administer medications, R4 was groggy and very grumpy. On 01/11/23 08:54 AM, during an interview with Assistant Director of Nursing (ADON) C discussed how levothyroxine had to be given on an empty stomach, ADON B acknowledged R4 had the right to refuse breakfast thus waking at after 9:00 and receiving thyroid medication at that time she would still have an empty stomach. When queried if R4's medication times and sleep preferences have been reviewed with the Physician in an attempt to meet R4's preferences, ADON C stated she would follow up. 30337 Resident #31 (R31) On 1/08/23 at 12:26 PM, R31 was observed sitting up in bed, wearing a hospital gown, and eating lunch. R31 explained many staff had come into her room that morning and disturbed her sleep. R31 stated she missed therapy at times during the week because of other activities and would have a make-up session on the weekend. R31stated the therapist woke her up that morning to tell her he would be back to get her for her therapy session at 1:00 PM. R31 stated she didn't understand why the therapist could not have informed her of her therapy schedule time after she got up for the day. R31 stated she was a night owl and preferred to sleep late in the morning. R31 added it seemed like the staff were on their own schedule, not her schedule. In review of R31's care plan, there was no information regarding her preferred time to start her day. Assistant Director of Nursing (ADON) C was interviewed on 1/10/23 at 9:11 AM and stated staff were aware R31 preferred to sleep late in the morning and stated her resident summary indicated she preferred to arise and retire upon her choosing. R31's resident summary dated 9/13/22 indicated Natural Sleep (preference, awake/bedtime): resident prefers to arise and retire upon her choosing; the same document did not include what her arise or retire times were. Physical Therapy Assistant (PTA) K was interviewed on 1/11/23 at 8:56 AM and stated she normally would schedule a therapy time with the resident directly, and if the proposed time did not work for the resident, she would try and accommodate them if possible. PTA K stated there was not a care plan or reference for resident preferred therapy times. ADON C was interviewed on 1/11/23 at 9:04 AM and stated she had discussed R31's preferences following the interview the day before; and stated R31 had requested that her garbage not be removed or any interruptions until after breakfast time. ADON C stated she updated R31's resident summary to reflect her preferences. R31's resident summary dated 1/10/23 indicated she preferred for garbage not to be changed, water not to be passed, and her communication board not to be updated until she was awake in the morning.

Based on interview and record review, the facility failed to provide the bed hold policy in one of four residents reviewed for hospitalization (Resident #89), resulting in the potential for unmet needs. Findings include: Resident #89 (R89) R89's Minimum Data Set (MDS) dated [DATE], indicated she was admitted to the facility on [DATE] from an acute hospital and discharged to an acute hospital on 11/09/22. On 1/10/23 at 8:20 AM Assistant Director of Nursing (ADON) C stated the bed hold policy was provided upon admission to the facility and not provided when she transferred to the hospital. Nursing Home Administrator A was interviewed on 1/11/23 at 10:15 AM and confirmed R39 did not receive a the bed hold policy when discharged to the hospital because it was planned.

Based on observation, interview, and record review, the facility failed to write a peripheral intravenous order and complete peripheral intravenous maintenance for 1 resident (Resident # 8) and failed to complete routine peripherally inserted central line dressing changes for 1 resident (Resident # 1) out of 4 residents reviewed for quality of care issues resulting in placement of an intravenous line without a physicians order and the potential for intravenous line dressing failure, dislodgement, and bloodstream infection. Findings include: Resident # 1 Resident # 1 (R1) admitted to facility 12/10/22 with diagnoses including infection and inflammatory reaction due to unspecified internal joint prosthesis and methicillin susceptible staphylococcus aureus infection. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/16/22 revealed that R1 had moderate difficulty hearing but was understood and understands with a Brief Interview for Mental Status (BIMS) score of 12 (mild cognitive impairment). Section G of MDS revealed that R1 required one-person extensive assist with bed mobility, transfer, dressing, toilet use, and personal hygiene. Section O of the same MDS indicated that R1 received IV medications. On 01/08/23 at 10:03 AM, R1 was observed laying in bed, on back, in facility gown. Peripherally Inserted Central Catheter (PICC) noted in left upper extremity covered with occlusive dressing dated 1/4/23. R1 confirmed receiving intravenous antibiotics through PICC line since facility admission. Review of R1's medical record complete with physician orders noted as follows: Order dated 12/11/22 with a 12/11/22 start date and a 12/18/22 discontinuation date stated, Write in (Describe Order in Notes) Every 1 week with a section titled Notes within same order noted to state, Change dressing to the PICC line today and every week. Last change looks like 12/4. Order dated 12/10/22 with a 12/14/22 start date stated, Dressing change every 7 days; PRN (as needed) with a section titled Notes within same order noted to state, Change transparent dressing every 7 days and PRN with sterile technique. Order dated 12/14/22 with a 12/14/22 start date stated, IV (intravenous)-PICC/Midline arm measurement Every 7 Days with a section titled Notes within same order noted to state, Measure mid upper arm circumference (10cm (centimeters) above the AC (antecubital)) in centimeters every 7 days and PRN. Order dated 12/14/22 with 12/14/22 start date stated, IV-PICC/Midline tail measurement Every 7 Days with a section titled Notes within same order noted to state, Measure external catheter tail in cm every 7 days and PRN. Review of R1's Treatment Administration Records complete with the following findings noted: December Treatment Administration Record (TAR) reflected 12/11/22 order to Change dressing to the PICC line today and every week. Last change looks like 12/4 with a = noted to be documented within the 12/11/22 administration box. The 12/18/22 administration box was noted to be shaded dark gray. December TAR also reflected 12/10/22 order with a 12/14/22 start date to Change transparent dressing every 7 days and PRN with sterile technique with a = noted to be documented within the 12/14/22 administration box. December TAR reflected 12/14/22 orders with 12/14/22 start dates for PICC/Midline arm measurements and PICC/Midline tail measurements with a = noted within the 12/14/22 and 12/28/22 administration boxes for each order. A Legend at the top of each TAR indicated that = meant Previously Scheduled. A complete Review of R1's Clinical Nursing Notes revealed no entry dated 12/11/22 or 12/28/22, nor did entries dated 12/14/22 and 12/18/22 include any documentation to indicate that a PICC line dressing change was complete on these dates. In an interview on 1/10/23 at 3:30 PM, Assistant Director of Nursing (ADON) C stated that the facility did not have a PICC line dressing change policy but stated that the facility followed the dressing change procedure outlined within the provided document titled Peripherally inserted central catheter (PICC) dressing change. Per ADON C, a PICC line dressing change should be complete every 7 days or PRN, not to exceed 7 days. ADON C also stated that each resident that had an order for a PICC line dressing change should also have orders for measurements of upper arm circumference and external PICC length and that these measurements should be complete weekly with the PICC line dressing change. During the same interview, ADON C reviewed R1's December TARS stating that the = (double dash) notation indicated previously scheduled but was unable to provide any further explanation as to what this meant stating that she would follow-up with additional information, when known. ADON C also stated that she did not know what the 12/18/22 dark gray shaded administration box indicated. In a follow-up interview on 1/11/23 at 8:04 AM, ADON C stated that a = documented within an administration box on the TAR meant that the order was placed past the time of the initial administration time for that date and therefore would not have triggered on the TAR for the nurse to complete. ADON C stated that although, per the physician order, the PICC line dressing was supposed to be changed on December 11th, it was not changed. ADON C stated that a dark gray shaded box on the administration record indicated that there was a note attached to the corresponding shaded date at the bottom of the TAR. Review of the Notes section corresponding with the 12/18/22 gray shaded administration box for the PICC line dressing change indicated Not Administered. ADON C confirmed that R1's PICC line dressing change went 17 days without being changed, from the 12/4/22 date indicated within the 12/11/22 order to the documented 12/21/22 change date. Review of the Peripherally inserted central catheter (PICC) dressing change procedure from the Academy of Medical-Surgical Nurses provided by ADON C indicated that, A transparent semipermeable dressing over a peripherally inserted central catheter (PICC) requires changing at least every 7 days .Implementation .Use a sterile tape or the incremental markings on the catheter to measure the external length of the catheter from hub to skin entry to make sure that the catheter hasn't migrated .Measure upper-arm circumference when clinically indicated to assess for the presence of edema and deep vein thrombosis. Take the measurement 10 cm (3.9 (inches)) above the antecubital fossa. 45135 Resident #8 (R8) Review of the medical record reflected R8 was originally admitted to the facility 10/10/2022 with diagnoses of Fracture of right femur and right hip, cancer of the bowel, colostomy and bone disease. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/08/2022, revealed R8 had a Brief Interview of Mental Status (BIMS) of 15 (cognition is fully intact) out of 15. During an interview on 01/08/23 at 10:09 AM R8 was observed to have an IV pole with pump, an empty intravenous (IV) bag of normal saline and tubing still connected in the pump chambers (mechanical section of the pump). In addition, the normal saline (salt water) bag did not have a name or date to reflect who the IV belonged to and when it was started. Further observation a peripheral intravenous (IV) line site on right shoulder of R8, taped in place, no date on plastic clear tape. R8 stated she thought it had been a couple of days since the dressing was changed and she had received any infusions. During an interview on 01/09/23 at 3:00 PM with Licensed Practical Nurse (LPN) M regarding R8's IV, LPN M stated she don't know how long the been hanging on the IV pole, because she not been here for 4 days, as she looked at the IV site dressing with no date or initials. LPN M also reported, it would pop up on my MAR if it was due on her shift. LPN M removed the IV bag from the pump and threw it away in the trash. Record review of nursing progress note on 01/10/23, revealed the IV was pulled from R8's right shoulder at 5:25 PM on 01/09/23 by LPN M. Record review on 01/09/23 of physician's orders dated from January 01, 2023, to 01/09/23 and did not reflect an order written for R8 to have IV insertion nor infusion of normal saline. During an interview on 01/09/23 at 3:45 PM with Assistant Director of Nursing (ADON) C stated she would go look for the physicians order for 01/04/23 to insert an IV and infusion normal saline and let me know. ADON C also stated dressing changes on a peripheral IV site is weekly, covered with a clear dressing to see the insertion site with initials of who changed it and date it was changed. On 10/10/23 at 1:27 PM, received an email from Nursing Home Administrator (NHA) A of a clinical note report that was dated for 01/09/23 at 6:43 PM, revealed on 01/10/23 at 8:43 AM a late entry clinical note was made for R8's order for her IV insertion and infusion. E-signed by Registered Nurse (RN) X on 10/10/23 at 8:43 AM reporting, on call doctor notified, ordered 1 liter of normal saline (NS) to run at 100 milliliters per hour, and to place a peripheral line. IV infusing and patient tolerating fluid for low blood pressure. Order update/ Change in condition, Begin date: 01/04/23 End date: 01/04/23. Continuous for 1 day. Electronically signed by RN X on 01/09/23 at 6:43 PM. Record review on 01/10/23 reflected the facility did not follow their policy on routine maintenance of a short peripheral IV catheter insertion site regular assessment of the site (at least every four hours). Dressing to include a transparent semipermeable dressing. The need for continued use of a short peripheral IV catheter should be reassessed daily. Catheter removal should occur as soon as the catheter is no longer included in the patients plan of care or the device hasn't been used for at least 24 hours.

Based on observation, interview, and record review the facility failed to ensure that all drugs used in the facility were labeled and destroyed in accordance with professional standards in one of five medication carts resulting in the potential for residents to receive expired medication, decreased efficacy of medications, and improper disposal of pharmaceutical wasted. Findings Include: During observation of the 2200 Hall medication cart on 11/03/21 at 10:15 a.m. it was observed that the following medications did not have a date when opened placed on the container of the medication: [MEDICATION(S)] 90 micrograms (mcg) inhaler and [MEDICATION(S)] Injection pen. During observation of the 2300 Hall medication cart on 11/03/21 at 12:31 p.m. it was observed that the following opened medication had dates that were expired: Aspirin 325 milligrams (mg) tablets with an expiration date of 07/2021, Dietary Supplement Vitamin 40 mcg tablets with an expiration date of 10/2021, two bottles of [MEDICATION(S)] mg tablets with an expiration dates of 09/21, Aspirin 325 mg tablets with an expiration date of 05/21, [MEDICATION(S)] 5 mg tablets with an expiration date of 10/21. Once identified by Registered Nurse (RN) R that medications were expired it was observed that RN R dispensed of expired medications in the sharps disposal container, which was located on the side of the 2300 Hall medication cart. During interview on 11/03/21 at 12:55 p.m. with Director of Nursing (DON) B she was asked about the process of monitoring the medication administration carts for expired medication. DON B explained that the nursing management team conducts these audits on a weekly basis. DON B could not provide documentation showing results when requested. DON B was asked about the facility process for the destruction of medication that had expired. DON B explained that it was facility policy to place the expired medication in the sharps disposal containers. During record review on 11/03/21 of facility policy entitled Disposal/Destruction of Expired or Discontinued Medication it was observed that number one of the policy states: Facility staff should destroy and dispose of medications in accordance with facility policy and applicable law, and applicable environmental regulations. It was also observed that number four of the policy states: Facility should place all discontinued or outdated medications in a designated, secure location which is solely for discontinued medications or marked to identify the medications are discontinued and subject to destruction. During a telephone interview on 11/03/21 at 12:55 p.m. with Contracted Consultant Pharmacist Q she was asked regarding the observed destruction of expired medication by the facility. Pharmacist Q explained that this was not an acceptable practice as stated in facility policy entitled Disposal/Destruction of Expired or Discontinued Medication. Pharmacist Q explained that the sharps disposal containers would not be defined as secure solely for discontinued medication and would not be acceptable to professional standards. An observation on 11/02/21 at 08:44 AM, revealed Registered Nurse (RN) J was observed administering medications to Resident #12 (R12). R12 requested a stool softener. RN J then obtained [MEDICATION(S)] 100 milligrams (mg) from the medication cart. R12 refused the medication and asked for the red stool softener. RN J then disposed of the pill in the sharps container in R12's bathroom.

This citation pertains to Intake Number MI 261. Based on interview and record review, the facility is placed in Immediate Jeopardy (IJ) for its failure to immediately initiate emergency life-sustaining measures, including Cardio-Pulmonary Resuscitation (CPR), and its failure to summon Emergency Medical Services (EMS) for one resident (Resident #100) out of thirty-eight residents reviewed with Full Code designations. Resident #100, who was designated as a Full Code for life-saving measures, was found unresponsive and not breathing on [DATE] at 3:35 AM. CPR was not initiated nor was EMS called for over one hour. The facility also failed to ensure that nursing staff's CPR cards remained active and current for 21 of 30 nurses, to include the three LPN's E,F and K who were the nurses working in the facility on the night of [DATE], when Resident #100 expired. At the time of his death, there were no other CPR-certified nurse's on-site in the facility. These deficient practices place 38 residents, who are designated as being on Full Code status out of a facility census of 58 residents (at the time of the incident), at significant risk of not receiving competent, life-sustaining measures during an emergency, resulting in the likelihood of harm and/or death. Immediate Jeopardy: On [DATE] at approximately 3:35 AM, Certified Nursing Assistant (CNA) H found Resident #100 unresponsive and not breathing. CNA H summoned Licensed Practical Nurse (LPN) F. LPN F assessed Resident #100 and found him unresponsive and not breathing. LPN F summoned LPN E. LPN E assessed Resident #100 and determined that he was unresponsive and not breathing. LPN F and LPN E declared Resident #100 dead at 3:45 AM. LPN F verified on [DATE], at the beginning of her shift that night, that Resident #100 was designated as a Full Code. LPN F called 911 at 4:45 AM on [DATE] after calling and receiving orders from the on-call nurse manager. LPN F was instructed to initiate CPR on EMS arrived at the facility at 4:56 AM. EMS took over CPR at 5:02 AM and were informed that facility staff had initiated CPR six minutes earlier at 4:56 AM. EMS and facility staff performed CPR for approximately 15 minutes. EMS called Medical Control (physician's service) and received an order from a physician to terminate CPR at the scene and the time of death was declared and recorded at 5:20 AM. Immediate Jeopardy began on [DATE] at 3:45 AM. Immediate Jeopardy was identified on [DATE]. The Administrator was notified of the Immediate Jeopardy on [DATE] at 9:00 AM. The Immediate Jeopardy Abatement/Removal Plan was accepted on [DATE]. The IJ Removal Plan was verified on [DATE] with a Removal Date of [DATE]. Findings Include: On [DATE] at 10:55 AM, a phone interview was conducted with Paramedic D regarding the response to the facility on [DATE]. Paramedic D reported they were dispatched to the facility about 4:45 AM, and the notes that the dispatcher entered into the computer did not make sense to them. The Paramedic explained the notes stated Resident (#100) died an hour ago. Once the Paramedics arrived at the bedside of Resident #100, they witnessed two LPN's doing chest compressions on Resident #100. Paramedic D reported they completed their initial assessment and there were no signs of lividity or rigor (mortis). The Paramedics then took over performing CPR, administering medications, and following the Advanced Cardiac Life Support (ACLS) algorithm. Paramedic D reported the facility staff informed them they checked on Resident #100 about 2:15 AM, and the resident was talking and had no signs of distress. The staff went back to check on the resident at 3:45 AM and found him pulseless and not breathing. LPN E informed the Paramedics at his last place of employment, if there were 2 LPN's in the room, they could call the time of death. Paramedic D explained it appeared as the nurses found Resident #100 deceased and declared the time of death at 3:45 AM. Approximately one hour later, they reviewed his file and realized Resident #100 was a Full Code. The nurse caring for Resident #100 contacted the On-Call Supervisor and was directed to call 911 and initiate CPR. Paramedic D stated that from staff accounts, the nurses were performing CPR for about 6 minutes before the Paramedics arrived at the bedside. It was clarified, Resident #100 was assigned to LPN F's care and that LPN E was there to assist, as he was working the next unit over. He added, upon arrival, the nurses had the Automated External Defibrillator (AED) on Resident #100, but never delivered any shocks. Paramedic D explained when normally responding to a [MEDICAL CONDITION] they complete 30 minute of CPR efforts, follow the ACLS algorithm (administering medications) and other specific interventions. In this case, Resident #100 was in Asystole (No detectable heart rhythm ) the entire time they were working on him and were never able to establish a heart rhythm back. Because of this, Paramedic D contacted the Medical Control physician's service, who provided the order to terminate on scene and called the time of death at 5:20 AM. On [DATE] at 12:02 PM, a review was completed of Resident #100's medical records and it revealed that he was a [AGE] year-old male, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was his own responsible party and was able to make his own medical decisions. He required extensive assistance for bed mobility and dressing and was totally dependent for bathing and transferring. Further review revealed the following progress notes: [DATE] at 4:32 PM: - Patient arrived at facility at 1520 via stretcher. Patient is alert and oriented (A&O) to self, place, time, and situation. Transfers via Hoyer. Patient ,[DATE] pain on admission and ,[DATE] pain goal agreed upon . FULL CODE. [DATE] at 10:30 AM: - Patient arrived at facility at 1800 via stretcher and was accompanied by paramedics. Patient is A&O to self, place, time, situation. Transfers via Hoyer lift. Patient ,[DATE] pain on admission and ,[DATE] pain goal agreed upon. All orders reviewed and verified .FULL CODE. On [DATE] at 12:33 PM, an interview was conducted with Social Worker A regarding determining code status for facility residents. The Social Worker reported they complete Social Work assessments upon admission and hold Care Conferences with residents within 72 hours of admission. When residents are admitted , all their supporting documents are uploaded into their Electronic Medical Records (EMR). During Care Conferences they verify and/or determine residents' Advance Directives wishes and document them. Social Worker A explained that if a resident wishes to be on a Do Not Resuscitate (DNR) status, the supporting documents will be completed and uploaded into their medical records. When queried specifically about Resident #100, Social Worker A stated the plan was for him to return home after receiving rehabilitation at their facility. She continued that his wife was very involved in his care and when they held a Care Conference upon his admission, Resident #100 and his wife indicated he was a Full Code. Resident #100 was cognitively intact and able to make informed decisions about his care. On [DATE] at 1:36 PM, an interview was conducted with CNA J regarding the incident that occurred on [DATE]. CNA J reported her assignment that evening was on the opposite side of the floor. CNA J explained LPN F came over about 3 AM or 4 AM, to get LPN E and she believes they found Resident #100 unresponsive about 3:45 AM after CNA H discovered him and alerted LPN F. CNA J reported LPN F seemed shaken and LPN E was walking her through the protocol. CNA J stated it was her understanding they did not initiate CPR upon finding Resident #100 unresponsive. CNA J continued they contacted management after some time elapsed and then initiated CPR on Resident #100. On [DATE] at approximately 2:00 PM, an interview was conducted with Human Resource (HR) Director G to review employee HR files. Nurse F's HR filed was reviewed and the following disciplinary action was reviewed: - The disciplinary notice was dated [DATE], and indicated it was a Final Written. The document stated, Colleague failed to follow facility policy regarding code status of a resident. A resident was identified as a Full Code and colleague failed to start CPR on the resident. The is being escalated to a final warning due to the severity of the offense. During an on-site interview conducted on [DATE] at 2:09 PM, Licensed Practical Nurse (LPN) B indicated she was the nurse on-call during the night of [DATE] into the morning of [DATE]. LPN B verbalized she had received a phone call from LPN F in the middle of the night around 4 AM on [DATE]. LPN B said that LPN F called to inform her that someone had passed away. LPN B verbalized she expected it to be a Hospice resident and asked LPN F if she had followed protocol. LPN B verbalized LPN F initially did not reveal the name of the resident who had expired. LPN B asked LPN F if it was an expected death and LPN F stated, 'No'. LPN B asked what resident passed away and LPN F stated that it was Resident #100. LPN B said she started asking more questions of LPN F at that time, such as Code Status for Resident #100 and indicated LPN F verbalized that Resident #100 was deemed a Full Code Status. LPN B indicated she had asked several more questions and asked again if LPN F followed protocol and initiated CPR. LPN F verbalized No to initiating CPR on Resident #100. LPN B said, I freaked out. I started grilling her at that time. I got really excited. I asked her when the last time was, she had checked on him. LPN F verbalized it was around 1:30 AM, and he was doing OK. LPN B asked LPN F how she knew Resident #100 was a Full Code and indicated LPN F documented the Code Status on her report sheet at the beginning of the shift. LPN B stated that she told LPN F to record everything, call the physician, call 911, and to start CPR on Resident #100. LPN B verbalized that LPN F said she messed up and panicked, was very shaken up, and crying on the phone. LPN B said there were a few phone calls made between her and LPN F after the first call. LPN B indicated after she hung up with LPN F, she informed the Director of Nursing. LPN B verbalized that LPN F indicated she did not initiate CPR upon finding Resident #100 unresponsive around 3:45 AM. LPN B said that LPN F verbalized she sent Nursing Assistant H to the other side of the building to summon the other nurse LPN E, who was working on his residents, to come for additional help. LPN B indicated that LPN E had come to the room where Resident #100 resided and was informed it was approximately 4 AM. LPN B said she was informed that 2 LPN's F and E assessed Resident #100 for vital signs, observed none, and then pronounced him dead. LPN B was asked if 2 LPN's are allowed to pronounce deaths of residents in the facility. LPN B responded that, as far as she knew, the Facility's protocol indicated a Registered Nurse or a Physician had to pronounce death, but not LPN's. LPN B verbalized that during the several communications with LPN F, LPN F remained shook up and confused as to the next steps to complete. On [DATE] at 2:30 PM, an interview was conducted with the Director of Nursing (DON) regarding the circumstances surrounding the death of Resident #100 on [DATE]. The DON reported she was alerted around 4:30 AM-5:00 AM by LPN B that Resident #100 had died , and CPR was not started timely. LPN B informed the DON she was back and forth on the phone with LPN F and she provided direction to LPN F to start CPR. The DON reported when she received this call, she inquired about the resident's code status and it was reported the resident was a Full Code. The DON indicated she started an investigation and interviewed LPN F and the following was reported: LPN F stated about 3:30 AM, she ran into CNA H and LPN E as she was walking out of another resident's room. CNA H then alerted LPN F that she was needed in Resident #100's room (the CNA did not mention why a nurse was needed in the resident's room). CNA H and LPN F proceeded to Resident #100's room. LPN F stated the resident's face was discolored and his mouth was open. LPN F completed an assessment and indicated Resident #100 had no pulse or respirations. It was at this time she asked LPN E to assist and informed him the resident has died . LPN E was under the impression he was only there to verify the resident had expired. LPN E validated Resident #100 was without pulse and respirations. LPN E was not aware the resident was a Full Code and was never informed that CPR had not been initiated. The DON asked LPN F at what point she checked Resident #100's chart to verify code status. LPN 'F verbalized she checked at the beginning of her shift and wrote down the Code Status of all the residents she was assigned to care for. LPN F was aware Resident #100 was a Full Code but panicked, and acknowledged CPR should have been started initially when responding to Resident #100. LPN F was emotional while being interviewed and was not able to ascertain why she did not start CPR timely. The DON was interviewed about the two LPN's calling the time of death. The DON reported LPN's are not allowed to pronounce time of death; but clarified, LPN E thought he was only completing the secondary verification of expiration. Once LPN E left the room, LPN F contacted the physician, who questioned why she did not start CPR and instructed her to contact 911 and notify the family. The DON informed this writer that Resident #100 was initially assessed at 3:35 AM. CPR was started at 4:39 AM, and the resident was pronounced at 5:20 AM by the EMS physician. The DON was further queried if the facility was aware LPN F and E's CPR Certification cards were expired. DON stated LPN B informed her LPN E was in the process of completing his and LPN F's certification was renewed recently. LPN B was also designated as the Facility Educator. During a phone interview conducted on [DATE] at 3:00 PM, with Nursing Assistant H, who verbalized she was working Third shift on the night of [DATE], into [DATE], and that she was the aid assigned to Resident #100. Nursing Assistant H said she had last checked Resident #100 somewhere around 1:30 AM, and Resident #100 verbalized he was tired and had an appointment in the morning and wanted to get some rest. Nursing Assistant H said that she and LPN F had boosted Resident #100 up in bed and then left the room around 1:30 AM. Nursing Assistant H said around 2:45 AM, she went to do rounds and noticed around 3:35 AM, Resident #100 did not look right. I touched his wrist and he was cold, and I left to go find his nurse, LPN F. I couldn't find LPN F so I walked to the other side of the building and found the other nurse LPN E. I asked LPN E if he knew where LPN F was, and he said 'No'. I told LPN E that I needed his help, and we walked back to the other side of the building. On our way over as we came through the double doors. LPN F was walking in the hall. LPN E said, there is your nurse, now you know where she is. LPN E then went back to his assigned area. Nursing Assistant H was asked if she said to LPN E that she thought Resident #100 was not looking right and indicated No, I only said I needed help. I did not say what I needed. Nursing Assistant H said that she then informed LPN F that she needed help with Resident #100. Nursing Assistant H said when they walked into Resident #100's room and looked at Resident #100, LPN F told Nursing Assistant H to go get help and get LPN E again. Nursing Assistant H said she went back to the other side of the building and found LPN E and said the other nurse wanted him to come again. Nursing Assistant H and LPN E then went back to Resident #100's room. Nursing Assistant H verbalized she was familiar with death and that Resident #100 appeared to be dead. I had heard the two nurses talking and LPN F indicated she was supposed to have started CPR on Resident #100 but had not. The two nurses came in and called the death. I performed post-mortem care at that time and LPN F was making some calls. She called the funeral home, and I think his wife. The two nurses came back in and tried to do CPR after phone calls. I had done my final clean up on Resident #100 and LPN E had cut his shirt off after I cleaned him up. Nursing Assistant H verbalized it was the first time LPN F had to deal with the death of a resident and was very, very upset. She was a wreck. The nurses continued to work with Resident #100 and then EMT's came. I had exited the room to take care of my other residents who needed me. On [DATE],Cardio-Pulmonary Resuscitation (CPR) Cards were requested for the following Nurse's E, F, P, Q, N and O. LPN B reported Nurse O's CPR class was scheduled for [DATE]. Nurse E is in the process of renewing the certification, and Nurse N and Q's renewals are processing. Further review was completed of all nurse's CPR certifications working at the facility. It was noted that only nine facility nurses have active and current CPR Certifications, and 21 nurse's CPR Certification were expired ranging from a few months to over a year. The Administrator reported they do not have a policy related to who needs to be CPR certified, but they follow the regulation of having one CPR certified individual available 24 hours per day. It can be noted the CPR Certifications for the three LPN's F, E and K working the night of [DATE], when Resident #100 was found in cardiac and respiratory arrest, were expired. On [DATE] at 3:32 PM, an interview was conducted with LPN F regarding the death of Resident #100 on [DATE]. The LPN explained Resident #100 was alert and oriented and able to make his needs know. LPN F reported she worked earlier in the day and was not assigned to Resident #100 until 10 PM. Around 1:30 AM, LPN F and CNA H entered Resident #100's room to assist with pulling him back up in bed and changing his brief. They were speaking to the resident about his appointment in the morning and the need for him to get some rest. LPN F reported Resident #100 was able to utilize the call light if he required staff assistance but did not press his call light on again that evening. About 3:20 AM, CNA H was completing her rounds and observed Resident #100 unresponsive and not breathing. CNA H could not locate LPN F (who was in another resident's room providing care). CNA H went to summon LPN E and while on their way to Resident #100's room, they encountered LPN F coming of another resident's room. LPN F explained the CNA reported she needed her in Resident #100's room but did not indicate why nor was there any urgency in her voice to inform her it was an emergency. LPN F stated she and CNA H arrived back to Resident #100's room about 3:35 AM and was stunned at what she observed. LPN F reported the resident was discolored, his mouth was open, and did not appear to be breathing. LPN F admitted she panicked, as this was her first time dealing with an unresponsive resident. LPN 'F immediately sent CNA H to get LPN E. When LPN E arrived LPN F questioned him about the next steps to take and was informed by LPN E they needed to call time of death. LPN F stated at this time she was not thinking about the resident being a Full Code, although she knew he was, as she wrote it down at the beginning of her shift on her report sheet. LPN F verbalized that normally it is a Registered Nurse (RN) who would call the time of death but was under the impression if two LPN's were on shift, they can call time of death with the appropriate assessments. LPN F indicated there was not an RN in the facility working that night. LPN F and E both a verified there were no respirations. LPN E listened for an apical pulse (heart area) to no avail, and they called time of death about 3:45 AM. LPN F contacted the on-call manager LPN B about 3:56 AM, who informed her, she was supposed to initiate CPR when she first entered the room. LPN F explained it was not clarified if she needed to go back in Resident #100's room and initiate CPR. LPN F contacted the on-call physician who also expressed the nurses mistake of not performing CPR. After a few phone calls back and forth with management, she was instructed to begin CPR. LPN F began CPR on Resident #100 around 4:40 AM (over an hour after he was discovered unresponsive) and around this time 911 was contacted. LPN F enlisted the assistance of LPN E and they began chest compressions and breaths. They attached the AED but did not pick up a rhythm and no shocks delivered. LPN F reported the facility did not alert her that her CPR certification had expired and needed to be renewed. LPN F verbalized she had not been questioned about her certification until after this incident. At the time of Resident #100's death her CPR certification was expired. A telephone interview was conducted on [DATE] at 10:15 AM, with LPN E. LPN E was asked if he worked the night of [DATE] into [DATE], and verbalized he was on 3rd shift. LPN E asked if he was familiar with Resident #100 and indicated he had cared for him before, but not on the night in question. LPN E went on to say that he was preparing to pass his morning medications when Nursing Assistant H came to his side of the building inquiring if he knew where her nurse was LPN F. LPN E verbalized that LPN F was probably in a room. LPN E said that Nursing Assistant H indicated she needed help in Resident #100's room and could he come and help. LPN E verbalized that Nursing Assistant H did not verbalize it was an emergency and gave no indication that anything was wrong. Nursing Assistant H only verbalized she needed some help but was not specific as to the needs. LPN E said he locked his cart and he walked to the other side of the building with Nursing Assistant H and once they got to the other side of the building, LPN F was walking down the hall. LPN E said he verbalized There is your Nurse. LPN E indicated he turned around and went back to his assignment. LPN E indicated several minutes later, Nursing Assistant H came back and verbalized that LPN F needed his help. LPN E indicated again Nursing Assistant H did not indicate that there was an emergency situation. We walked over to Resident #100's room and walked in. LPN E said that LPN F's first words were He is dead. LPN E said it caught him off guard. I looked at Resident #100. I did not see any signs of life, and said, Oh yes, he is. I thought she wanted me over there to verify that death had occurred or help with pronouncing death. The time was approximately 3:45 AM, and LPN F did not know what to do or how to handle the situation. I listened to Apical Pulse (heart) for one minute, and felt for radial pulse, felt his Fistula, and looked for breathing. He was dusky looking. I asked LPN F what happened and she indicated that he was boosted up by her and the Aid around 2 hours ago and was talking and wanted to rest. This information was confirmed by Nursing Assistant H while in the room. I told LPN F to call the on-call Doctor at that time and management. She left the room to make phone calls. LPN F went to page the Doctor on-call and call the on-call nurse. I closed the door and went back to my side of the building. I heard LPN F with the on-call nurse on the phone and heard her say that Resident #100 was a Full Code. LPN F was checking the phone every few minutes waiting for the on-call doctor to return the call. I went to my assignment again. The on-call doctor returned the call at about 4:15 AM, or so, and was asking LPN F questions. The on-call doctor indicated that CPR should have been initiated, and gave direction to call the family, 911, and initiate CPR. Nursing Assistant H came back again and got me for 3rd time and said LPN F needs your help to do CPR. I hurried back to Resident #100's room and turned on the Emergency Light at that time. No other nurse came to help at that time, so I sent Nursing Assistant H to go get the other nurse downstairs to help with the Code. LPN F was still flustered and not handling the situation, so I started compressions. LPN F was using the Ambu bag to deliver breaths, and I told the other nurse who showed up to get the crash cart with the Automated External Device (AED) and placed it on the Resident after cutting his shirt off. The AED did not pick up any cardiac rhythm or indicated to deliver shocks. I sent the other nurse to direct the Paramedics/EMT's that were summoned as to where to go. We did several rounds of CPR until the EMT's took over, may be 10 minutes. We did not initiate CPR till about 4:45 AM. When the EMT's took over, they began asking LPN F questions about Resident #100's medical history. The EMT's must have worked on Resident #100 till about 5:20 AM, when they called their doctor who called the end of the code. The EMT's told us not to touch anything after they were finished because they were not sure if the police were going to show up and do an investigation. No Police were sent out, but the Fire Department came. They hooked Resident #100 up to an electronic machine that does compressions. Like I said it all stopped about 5:20 AM. LPN F was still shaken up. On [DATE] at 8:30 AM, further review was completed of Resident #100's progress notes, the following was documented: physician progress notes [REDACTED]. - Paged by nurse at (nursing facility) at 4:09 AM, pt found unresponsive without a pulse. Per the nurse it appeared pt had been down for an unknown length of time. Advised nurse to notify EMS, the appropriate authorities and family. [DATE] at 8:41 AM - Progress note completed by Nurse F: - At 0115 am-0130 am CNA asked writer to help pull patient up in bed. Writer entered patient room to help. CNA was talking to patient about having appointment this morning. Patient seem to be at his baseline at this time. He stated he was going to sleep tonight due to him having a early appointment . Around 0335 am CNA and other nurse was coming through double doors while writer was walking down hall. CNA stated she needed writer in (Resident #100 room).Writer immediately went into patient room. Writer saw patient face was discolored and mouth was open. Writer left room and started down hall to get the other nurse. Writer then asked CNA to go get other nurse and writer returned to patient room. The other nurse and I assessed patient. The patient did not have a pulse or respirations. The other nurse listened for apical heart rate for 1 minute. It was determined that patient had passed away. I paged the physician at this time, about 0345 am. While waiting for physician to return call, I notified the nurse manager on call of the patient passing . I updated the nurse manager at this time. I called EMS at approximately 0430 am, and then went to patient room. I started CPR at 0439 am. The other nurse and I were alternating CPR until EMS arrived at about 0450 am. The other nurse and I stayed with EMS. EMS called the hospital for Physician to end the code. The Physician at the hospital called the code and time of death at 0520 am. On [DATE] at 9:00 AM, review of the Prehospital Care Report Summary documented by the paramedics, who responded to facility on [DATE]. The following information was noted in the report: On [DATE] at 4:45 AM, EMS was dispatched to the facility for an emergent patient response. They arrived at the facility at 4:56 AM and made contact with Resident #100 at 5:01 AM. The narrative portion of the report stated the following: - .Dispatched to facility for an unwitnessed [MEDICAL CONDITION] .found patient (pt) lying supine in bed with (w) staff performing CPR and an Automated External Defibrillator (AED) placed. No shock wave delivered. Pt is confirmed by crew to be apneic and pulseless. There are no signs of lividity or rigor, and crew takes over resuscitation efforts with full Advanced Cardiac Life Support (ACLS) interventions at 0502. Per staff on scene pt was checked on at 0215 and found to be alert and talking with no complaints. Pt was checked on again at 0345 and found to be apneic and pulseless at this time. Staff on site, tells crew that because there were two LPN's in the room, they were able by protocol to call time of death and leave pt's side without performing any resuscitation efforts .At some point during the next hour, they discovered the pt was a full code, contacted their supervisor, and was told to contact EMS. During the time between pt discovery at 0345 and EMS contact at 0445, no interventions were done.Staff stated that they started CPR 6 minutes before crew took over at 0502, placing the start of CPR at 0456 .Full ACLS interventions were performed. Pt was placed on monitor and found to be in Asystole (no heart rhythm) which persisted throughout the entire arrest .Staff enlisted to perform compressions and ventilate the pt, with frequent coaching necessary .Medical control is contacted . and advised of situation. Medical control gives order for scene termination, with time of death at 0520. On [DATE] at 10:15 AM, review was completed of the facility's investigation regarding the circumstances surrounding Resident #100's death. The investigation included the following statements by the staff involved with Resident #100 on the night of [DATE] into [DATE]. Statement from CNA H - I cared for the resident on [DATE] into [DATE], 11:00 PM-7:00 AM. I checked on the resident at the start of my shift. Resident was awake in bed and resident was telling me how he needed to get to sleep because he has an appointment in the morning I checked on the resident again around 1:30 am, and he was again awake in bed. I asked the nurse to come and help me boost the resident in the bed .The resident had no concerns at this time and was going to try and get back to sleep. Around 330 am, I checked on him, the resident. The resident was lying in bed and appeared to be asleep. I gently touched the residents' arm, since I did not want to wake him, and he was cold. I tried to talk to the resident, and he did not respond. I immediately went and told the nurse. The nurse came down to the room right away and assessed the resident . Statement from LPN E - At around 3:30 AM, the CNA (CNA H) came to me, looking for the other nurse (LPN F). I told the CNA, I wasn't aware where the nurse was, but what could I help with. The CNA said she needed help in Resident #100's room. As we were walking to this resident's room, the other nurse (LPN F) came out of another room. I left the other nurse and CNA at this time and went back to my assignment. A few minutes later, the CNA came and got me and said the other nurse needed my help in Resident #100's room. I reported to this resident's room. The nurse told me the resident was dead. I checked for a pulse (radial and carotid) then listened for an apical for 1 minute. No pulse was identified. This was already confirmed by the other nurse .I was under the impression I was just verifying time of death. I reported back to my assignment at this time. After about 10 minutes, the other nurse (LPN F) told me she has notified the Physician, and the Nurse Manager was on the phone. I learned at this time that the resident was a Full Code. The other nurse was calling the Physician for further guidance. I reported back to my assignment and then at approxim (TRUNCATED)

This citation has two deficient practices. Deficient Practice #1 Based on observation, interview, and record review, the facility failed to appropriately assess and monitor for a change in condition for one (R#6) of two residents reviewed for hospitalization , resulting in a resident being hospitalized and diagnosed with [REDACTED]. On 9/16/19 at approximately 11:15 AM, R#6 was observed in their room and was observed to be lying in bed. Review of the clinical record for R#6 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 00 out of 15 on a brief interview for mental status exam, which indicated the resident was severely cognitively impaired. Also per this assessment it was documented that R#6 was always incontinent of bowel. Review of nursing progress notes and a transfer form for R#6 for the time period of 7/17/19-7/20/19 revealed, in part, the following: -7/17/19 at 3:15PM: Resident took all scheduled meds in the am. resident is currently resting in bed, No complaint of pain, discomfort, or distress observed .Resident ate breakfast but drank his (nutritional supplement) 240 mls (milliliters). ate lunch and drank a (nutritional supplement) .currently resting in bed with frequent checks. -7/20/19 at 2:39PM: Resident took all scheduled meds in the am. resident is currently resting in bed, No complaint of pain, discomfort, or distress observed .Resident refused breakfast drank his (nutritional supplement) 240ml. refused lunch and drank a (nutritional supplement) . -7/20/19 at 11:32PM: It was reported to this nurse from previous shift, Resident has some abdominal distention observed some mold <sic> pain on rt (right) side. Resident had a med BM (bowel movement) on day shift. Nurse Logged in doc book to see resident. This writer went to assess resident noted resident has abdominal distention. Resident had Med. (medium) BM on shift noted to be a black stool. On-call was paged at approx. 8:30 no returned phone call within an hour. On-call supervisor was made aware. On-call supervisor was paged once more at approx. 9:50pm. No return call. Informed on-coming nurse of resident status. Oncoming nurse paged on-call once more. On-call NP (nurse practitioner) (Name Redacted) was informed of resident status was instructed to send resident out to have further evaluation .(ambulance company) arrived at 12:20am resident left with paramedic via stretcher at 12:33am. Review of a PATIENT TRANSFER FORM dated 7/20/19 revealed the primary [DIAGNOSES REDACTED]. Review of an ED Physician Note dated 7/21/19 at 2:03AM documented, in part, the following pertaining to R#6: .presenting from his extended care facility for concern for GI (gastrointestinal) bleed. They report they have noted abdominal distention over the last few days. They state that he has not seemed to be having abdominal pain. He has had 2-3 episodes of emesis, which they state has been nonbloody. He has had dark, tarry stools. There has been no bright red blood in his stools . Review of a CT (computed tomography) scan report from the hospital with a completed date of 7/21/19 at 4:09AM revealed, in part, the following: CT Abd (abdomen) and Pelvis w (with) Contrast .ABDOMEN .Evaluation the bowel is limited given the absence of contrast. Within the rectum there is a 13 x 7.5 x 9.0 cm (centimeter) stool ball. The colon proximal to this is mildly dilated. There are also colonic diverticula. No small bowel obstruction. The appendix is nondilated . Per the impression section of the report it was documented, .4. Large stool ball within the rectum with mildly dilated colon just proximally. Findings may relate to fecal impaction . Review of a hospital H & P (History and Physical) General Admission document for R#6 dated 7/21/19 at 8:40AM was noted to include abdominal distention, fecal impaction and Black stools/melena in the list of [DIAGNOSES REDACTED]. Review of a progress note for the resident dated 7/23/19 at 7:10PM documented, Resident returned to facility from ED (emergency department) LOA (leave of absence) A&O (alert and oriented)1, with no s/sx (signs/symptoms) of pain or discomfort. [DIAGNOSES REDACTED].> dissention resulting from constipation and fecal impaction . Review of a physician note for R#6 with a date of service of 7/24/19 was reviewed and revealed, in part, the following: Patient is a (age redacted)-year-old (gender redacted), long-term care resident at the facility, recently was sent to the hospital with abdominal distention and black stools, also had couple episodes of emesis. CT of the abdomen showed stool ball in the rectum with mild proximal colonic diliation. GI saw the patient and recommended attempting manual disimpaction and enemas. Patient had tap water enema and also milk of molasses enema (used to treat severe cases of constipation, especially if impaction develops). Hemoglobin (red blood cell count) did drop from 11 down to 8, GI did not feel an endoscopy was recommended as there is no active bleeding, even if had a recurrent small volume bleeding, because of patient's overall medical conditions did not feel endoscopy is appropriate at this time Plan: .Constipation: continue (Brand name [MEDICATION NAME] (a laxative medication)), (Brand name [MEDICATION NAME] Sodium (a stool softener medication), (Brand Name Polyethylene [MEDICATION NAME] (a laxative medication), PRN (as needed) ([MEDICATION NAME]), [MEDICATION NAME] (a laxative medication), monitor bowels closely. Discussed with nursing to notify if does not have a bowel <sic> movements at least every other day . Review of a bowel record for R#6 revealed the following documentation of bowel movements for the time period of 7/17/19-7/20/19: -7/17/19 at 2:00PM: formed medium bowel movement -7/19/19 at 6:32PM: formed small bowel movement -7/20/19 at 9:19PM: loose extra large bowel movement On 9/18/19 at 2:45PM, the facility's Director of Nursing (DON) was queried in regard to R#6. The DON was queried in regard to documentation in the provider notes which mentioned emesis, and acknowledged that they did not see charting related to emesis present in the resident's progress notes. The DON was queried in regard to the resident's hospitalization , and explained that she had been aware that the resident had went out but was not aware of the circumstances surrounding the event until the next day. Review of a facility policy titled Change in Resident's Condition dated (MONTH) 2008 revealed, in part, the following: .1. The nurse supervisor or charge nurse will notify the resident's attending physician or on-call physician when there has been .d) A significant change in condition; physical/emotional/mental .4. The nurse caregiver will record pertinent changes in the resident's medical record and whom was contacted related to these changes. Deficient Practice #2 Based on observation, interview and record review the facility failed to ensure protective sleeves were applied for one resident (R#47) of four residents reviewed for skin integrity, resulting in the increased potential for skin impairments/skin tears to occur. Findings include: On 9/16/19 at approximately 10:14 am., R#47 was observed in their room, up in their bed. R#47 was observed with red markings on both of their arms. No protective sleeves were observed to be applied to R#47's arms. On 9/17/19 at approximately 3:42 p.m., R#47 was observed in their room up in their bed. R#47 was observed with red markings up and down both of their arms. R#47 was observed without any protective sleeves on. R#47 was queried if they had anything in place to help cover their arms and they stated, They're supposed to give me stockings for my arms but they haven't in a while. I'm nervous about it because I have thin skin. R#47 was queried when the last time the facility had applied their stockings on their arms and they stated, I don't even remember when. It must be a few weeks ago. R#47 then stated, They're supposed to give me stockings for my legs too, but they haven't put them on in a while, they used too, but I care more about the ones for my arms. The hoyer lift is dangerous. On 9/18/19 at approximately 10:08 a.m., R#47 was observed in their room up in their bed. R#47 observed to be without any protective sleeves covering their arms. R#47 was queried if anyone has offered to place the sleeves on today and they stated Nobody has. On 9/18/19 at approximately 11:09 a.m., R#47 was observed in their room up in their bed. R#47 was observed without any protective sleeves on their arms. On 9/18/19 at approximately 12:18 p.m., R#47 was observed in the hallway, up in his wheelchair. R#47 was queried if anyone offered to put on their protective sleeves and they stated , Nobody did, but I asked CNA (Certified Nursing Assistant) EE to put them on me and she told me that the nurse would have to order them. On 9/18/19 at approximately 12:20 p.m., CNA EE and Nurse Manager C were queried if R#47 should have protective sleeves on their arms and Nurse Manager C stated, It's not in the resident summary (a summary of residents care directives for the direct care staff). I don't know why it wasn't in the resident summary if there is an order. We will have to put it on the summary. On 9/18/19 at approximately 12:41 p.m., the resident summary for R#47 was reviewed a second time with CNA EE. R#47's resident summary revealed a skin prevention intervention was added on 7/17/19 that indicated the following: Skin Care-Date modified 7/17/19 (turn/positioning, devices, preventative): Resident to wear geri-sleeves (protective coverings for arms to prevent skin tears) at all times as tolerated for protection. CNA EE was then queried if R#47 should have been given their sleeves to protect their arms and they stated, Yeah, I see that. He should have have them. I guess I missed that. We have have to get him some. On 9/16/19 the medical record for R#47 was reviewed and revealed the following: R#47 was initially admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of R#47's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 5/21/19 revealed R#47 needed extensive assistance from facility staff with most of their activities of daily living. R#47's BIMS score (brief interview of mental status) was 15 indicating intact cognition. A physician's orders [REDACTED]. Remove geri-sleeves BID (twice a day) to monitor skin integrity. A review of R#47's active care plan revealed the following: Problems-At risk for skin breakdown R/T (related to) decreased functional mobility, incontinence of bowel and bladder. Also has a history of Pemphigoid Bullae (an auto immune skin disease that may involve the formation of blisters) .Goal-Alterable risk factors for skin breakdown will be reduced and resident will be without skin breakdown within the boundaries of disease processes through next review .Interventions-Resident to wear geri-sleeves at all times as tolerated for protection . On 9/18/19 at approximately 2:15 p.m., during a conversation with the Director of Nursing (DON), the DON was queried if it was their expectation that their staff apply resident skin interventions to prevent skin tears and breakdown according to the care plan and resident summary and they indicated that it was. On 9/18/19 a policy on skin breakdown prevention was requested. A facility document titled Pressure Injury Management (revised 08/2016) was provided and reviewed but it did not address the use of Protective Sleeves (Geri-Sleeves).

Based on observation, interview and record review, the facility failed to adequately and accurately assess, monitor, and implement interventions for two (R#s 11 and 25) of four residents reviewed for pressure ulcers, resulting in the development of an unstageable pressure ulcer (full thickness skin and tissue loss with obscured wound bed), and the increased potential for delayed healing, and the development and/or deterioration of existing pressure sores. Findings include: Resident #25 On 9/16/19 at 2:35 PM, R#25 was observed asleep while seated in a wheelchair in the lounge area. There was a black padded covering to the wheelchair foot rest area to prevent the feet from slipping between the foot rests). R#25's feet were observed with regular black socks (non-grip socks) and there were no heel protectors or shoes worn. Both heels were observed to be pressed down, directly onto the foot cradle (resulting in direct pressure to the heel area). On 9/16/19 at 4:00 PM, review of the documentation provided by the facility identified R#25 as having a facility acquired unstageable pressure ulcer to the left heel. On 9/17/19 at 8:10 AM, Nurse A was asked about R#25's pressure ulcer and reported the Nurse Manager provides the wound care and deferred to Nurse Manager C. Nurse A further reported (name of R#25) is always immobile and stays in her chair (wheelchair) most of the day. On 9/17/19 at 8:13 AM, Nurse Manager C was asked about R#25's pressure ulcer and reported, It's on her left side, the left heel. It was from a tight shoe. At that time, when asked to observe the wound and the treatment, Nurse Manager C indicated it could be done at that time and proceeded to obtain the wound care items. At that time, R#25 was observed to be lying in bed asleep with heel protectors in place. During observation of the resident's wound, Nurse Manager C removed the heel protector from the left foot and there was no dressing or covering to the wound. Nurse Manager C confirmed the dark, eschar (dead or devitalized tissue that is hard or soft in textures; usually black, brown, or tan in color, and may appear scab-like) area to the back of the left heel and began to clean the area with skin prep, then placed the heel protector back on the resident's foot. When asked if there was any barrier/cover to the wound area, Nurse Manager C stated, No just do skin prep. It's not draining. When asked how often the heel protectors were washed, Nurse Manager C stated, That's a good question. If they look dirty, and I believe once a week. We supply them here so it's not like we don't have new, clean ones available. Review of the clinical record revealed R#25 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) assessment dated [DATE], R#25 had severely impaired cognition, had no mood or behavior concerns, required extensive assistance of one person for bed mobility, and was at risk of developing pressure ulcers/injuries but did not have any unhealed pressure ulcers/injuries at that time. Review of physician orders [REDACTED].>On 9/10/19, Skin-Prep Swab (1 swab) SWAB, NON-MEDICATED Topical 3 Times Daily Notes: Cleanse area on L (left) heel with NS (normal saline), pat dry, apply skin prep qshift dx: eschar. On 9/10/19, Wound-Care of area (describe location and exact treatment) 3 Times Daily Notes: Apply skin prep to L heel daily Q shift. D/C (discontinue) order once area is healed. Notify physician and unit manager if changes to area is observed and document. Dx: Unstageable area to L heel. Continued review of the physician orders [REDACTED]. Review of the Treatment Administration Records (TAR) for (MONTH) and (MONTH) 2019 revealed nursing documented R#25's skin assessments were completed on the 3:00 PM to 11:00 PM shift on 8/2, 8/6, 8/9, 8/13, 8/16, 8/20, 8/23, 8/27, 8/30, 9/3, 9/6, 9/10, 9/13, and 9/17, and each entry documented R#25 had No Skin Issue. Review of R#25's care plan for Alteration in skin integrity r/t (related to) unstageable pressure wound to L heel did not have a documented initiated and/or revised date. The only date was a Goal Date: 12/10/2019. Interventions included: Assess and document skin for color, moisture, texture, and turgor. Report abnormal findings Assess and manage risk for skin breakdown Complete head to toe skin assessment as ordered Contact family for new shoes to avoid further pressure to area Treatment as ordered. There were no identified interventions to offload pressure to the heels while the resident was up in the wheelchair. Review of R#25's care plan for At risk for skin breakdown R/T (related to): DECREASED MOBILITY, advanced dementia . did not have a documented initiated and/or revised date. The only date was a Goal Date: 10/12/2019. There were no current interventions for preventative measures such as offloading pressure to areas at risk for breakdown. Review of the discontinued interventions (there was no documented date of when these were discontinued) included: Use pillow/blankets/wedges to avoid contact between bony prominences . Float heels while in bed Review of the Wound Assessments documented by Nurse Manager C included: On 9/10/19, Unstageable pressure ulcer to L heel. cause: friction from shoe. Hard purplish black blister .Wound size Length (cm/centimeters) 1.00, Width (cm) 1.30, Depth (cm) 0 . On 9/17/19, unstageable pressure ulcer .Wound size Length (cm) 1.00, Width (cm) 1.00, Depth (cm) 0 . Review of the Braden Scale Risk Assessment (tool used to predict pressure ulcer risk) scores on 7/12/19 and 9/10/19 were both documented as 13 (moderate risk). Review of a podiatry consult dated 9/3/19 signed 9/13 documented, .(no) B (bilateral) pedal [MEDICAL CONDITION] . (There was no documentation regarding the resident's heel, only the toenails.) Review of the physician progress notes [REDACTED].>The most recent available documentation in the electronic clinical record from a physician and/or physician extender was on 8/23/19, authored by (Physician Assistant/PA N) which documented in part: .Chief Complaint/Nature of Presenting Problem: Patient with painful toenails per staff .Frail, elderly lady, not in any acute distress, up in wheelchair viewing television in activities area .Skin: Warm and dry, pink and moist no [MEDICAL CONDITION], bilateral feet with overgrown and hyperkeratotic nails .Alert and oriented to person only but follows with eyes, some resistance to examination but mostly co-operative .Spastic [MEDICAL CONDITION] of left dominant side Increased [MEDICATION NAME] and has new splint with some increased flexibility of hand . There was no further documentation that the physician or physician extender had evaluated the resident since the identification of the unstageable pressure ulcer on 9/10/19. Review of the interdisciplinary progress notes included: On 9/11/19 at 3:30 AM, Spoke to resident's son returning a call he received from the floor nurse on 9/10/19 regarding the eschar on L (left) heel. Son was aware and asked that the staff remove any shoe other than the slippers that the family recently purchased. He will be in for a visit on Thursday. On 9/10/19 at 10:34 AM, Upon assessing residents skin I noticed a 1x1.2cm (centimeter) area of eschar on L heel. Resident is nonverbal but did not show s/s (signs/symptoms) of pain when area was touched. Notified unit mgr (manager), left vm (voicemail) for son .Cleansed area and applied skin prep . On 9/17/19 at 1:45 PM, Nurse A and the Director of Nursing (DON) were asked to verify if the physician or physician extender had evaluated the resident and confirmed it last physician/extender visit was on 8/23/19. The DON was requested to provide documentation of what interventions were in place to prevent the development of a pressure ulcer. There was no further documentation provided by the end of the survey in regards to what interventions were in place prior to prevent this from occurring. On 9/18/19 at 2:20 PM, an interview was conducted with the DON. Upon review of the resident's biweekly skin assessments, when asked about the documentation of initials by staff that indicated that the assessment had been done, and the lack of identification of skin alteration even after it was identified on 9/10/19, the DON reported, There should be numbers, not initials. When asked to explain what that meant, the DON reported, If there was no area, would be coded as '00'. If new area, would be '1'. When asked if there was any other opportunity to identify changes in skin condition such as a shower, or daily care (including placing and removing socks), the DON stated, Her shower was regularly on the second shift and for whatever reason was done on the day shift and found (on 9/10/19). If new skin issues would open a voice, which would trigger on I/A (incident and accident report), and notify on-call manager of change in condition. The DON was informed of the observation of the resident's heels placed directly on the wheelchair foot rest cradle and the DON reported, the resident should have had grippy socks or heel protectors on. It was noted there was no documentation that the resident's pressure ulcer was unavoidable. Resident #11: On 9/16/19 at approximately 11:11 AM, R#11 was observed in bed. Fall mats were observed to both sides of the resident's bariatric bed, which was observed to have half side rails present on the bed. The resident was observed to have an alternating pressure mattress (an intervention utilized to prevent pressure ulcers), however the indicator lights on the pump controlling the mattress was not illuminated to indicate the pump was functional. On 9/16/19 at approximately 2:48 PM, the pump for the alternating pressure mattress continued to be non-functional. On 9/16/19 at approximately 3:17 PM, Licensed Practical Nurse Manager (LPNM) 'AA' observed the resident's pressure mattress was off, and turned it on. When queried as to when the mattress was normally on, LPNM 'AA' indicated normally it was on all the time. LPNM 'AA' was asked as to when she had last seen it on, and indicated at 1:15 PM. Review of the clinical record for R#11 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's MDS assessment dated [DATE] did not include an assessment of the resident's cognition. Review of a current plan of care for R#11 revealed the following: Skin breakdown: Resident has an open wound/impaired skin integrity to the left distal buttocks R/T (related to) MASD (moisture associated skin damage. Per an intervention included in the care plan, it was documented, Use pressure-reducing mattress and pads as necessary. Review of the facility's Pressure Ulcer Protocol policy dated Revised 3-16 documented, in part: .POLICY: Risk for pressure ulcer development will be assessed and preventive strategies will be implemented when needed .PURPOSE: To ensure consistent assessment, documentation, and care planning related to risk factors. To prevent occurrence of pressure ulcers when possible. To maximize conditions necessary for healing pressure ulcers .

Based on observation, interview, and record review, the facility failed to ensure a physician's order for the insertion of an indwelling urinary catheter, ensure appropriate procedures for the insertion of a urinary catheter, ensure accurate assessments of the urinary catheter were documented, ensure catheter care was provided as ordered and ensure the use of an indwelling urinary catheter anchor for one resident (R#200) of three residents reviewed for indwelling urinary catheters, resulting in the development of a urinary tract infection following the placement of a catheter that required antibiotic therapy, and the potential for worsening of urinary tract infections and [MEDICAL CONDITION] injury and or complications. On 9/16/19 at 10:23 AM, R#200 was observed in bed. R#200 was observed to have a catheter drainage tube leading to a collection bag hung on the right side of the bed. The drainage tube was observed to have cloudy, light yellow urine in the tube with yellowish white sediment and chunks in the drainage tube. An observation of the collection bag revealed cloudy/opaque yellow urine. At that time, R#200 was asked if she could be checked for an indwelling catheter anchor. R#200 consented and the catheter was observed to lead out from an incontinence brief down R#200's right upper leg and connect to the drainage tube. An indwelling urinary catheter anchor was not observed on her upper right leg to prevent the catheter from pulling. On 9/17/19 at 8:53 AM, R#200 was observed up in her wheelchair eating breakfast. R#200's urinary catheter drainage tube was observed to have cloudy/opaque yellow/orange urine with white sediment and appeared occluded by a white mass in the tubing. R#200's daughter was at the bedside. At that time, R#200 and her daughter were asked if she admitted to the facility with the catheter and R#200's daughter said, 'No, they put it in here. They were bladder scanning (a device that measures amount of urine in the bladder) her and she was greater than 250 (milliliters) so they put it in. A review of R#200's clinical record was conducted and revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. R#200's in progress Minimum Data Set (MDS) assessment dated [DATE] indicated R#200 had a Brief Interview for Mental Status (BIMS) score of 14/15, which indicated intact cognition. A review of R#200's care plans was conducted and revealed a care plan for a urinary catheter effective 9/13/19 that read, .Interventions monitor urine characteristics: color, odor, consistency, etc. Notify physician of abnormal findings and obtain orders as needed .Provide catheter care every shift and as needed .Secure tubing with leg strap/device and maintain collection bag below level of bladder . A review of R#200's orders was conducted and did not reveal an order for [REDACTED]. A review of a nursing note by Licensed Practical Nurse (LPN) 'Z' on 9/13/19 at 10:21 PM read, .PVR (post void residual) >500 mL (milliliters) 4 nurses tried to straight cath (catheter) patient and not able to straight cath. MD is notified. MD asked this writer to contact (Company Name) to put the Foley (indwelling urinary catheter) in. Foley is in place . A review of R#200's (MONTH) 2019 Treatment Administration Records (TAR) was conducted and revealed an order for [REDACTED]. A review of the TAR documentation included the following: An equal sign on the TAR for catheter care on 9/15/19 for the 11 PM to 7 AM shift. An equal sign on the TAR for catheter care on 9/16/19 for the 11 PM to 7 AM shift. A review of the nursing progress notes dated 9/14/19 at 11:01 AM, 9/14/19 at 4:05 PM, 9/15/19 at 11:22 AM and 9/16/19 at 2:08 PM (after the insertion of the catheter on 9/13/19) was conducted and each note written by Registered Nurse (RN) 'S' identically read the following: Patient admitted to facility for right THA (total hip athroplasty) Patient resident in bed A&Ox3, (alert and oriented to person, place, time) pleasant, able to make needs to know <sic>. VSS (vital signs stable) daughter at bedside, patient no c/o (complaints of) chest pain or SOB (shortness of breath during shift, patient denies pain at this time, patient Foley in place and draining with yellow urine . A review of a nursing progress note at 2:55 PM on 9/16/19 was conducted and read, WBC (white blood cells) increased today, MD aware 0.9%N.S (Normal Saline) 1L (liter) ordered, running at 80ml/hours patient needs to collect UA (urinalysis) and C/S (culture and sensitivity), endorsed to oncoming nurse, will continue to monitor. A review of a nursing note dated 9/16/19 at 10:06 PM by LPN 'Z' was conducted and read, .Foley is in place and draining yellow urine .Urine is sent to the lab for a UA and C&S . A review of the urine culture completed by the lab was reviewed on 9/17/19 and indicated that R#200 had large amounts of [MEDICATION NAME] cloacae complex and Esherichia coli bacteria (bacteria that can cause urinary tract infections requiring antibiotic therapy) in their urine. It was further noted that R#200 had been placed on antibiotic therapy for treatment of [REDACTED]. On 9/17/19 at approximately 10:20 AM, a discussion was held with the facility's Director of Nursing (DON) regarding R#200's catheter. First, the DON was queried about the documentation that indicated 4 nurses attempted to straight catheterize R#200. The DON said, That was wrong, we have a two attempt rule. If they can't get it after two attempts we call (company name) and they come out to do things like difficult catheters, IV accesses, or blood draws. The DON indicated she was not made aware of the situation. The DON was then asked to clarify what an equal sign on the TAR meant. The DON explained that she believed if an equal sign was generated on the TAR then that treatment had not been documented as having been completed. The DON was then asked about all the identical documentation that indicated R#200's catheter had been draining yellow urine, but had observed to be extremely cloudy with white chunky sediment on 9/16/19 at 10:23 AM and 9/17/19 at 8:53 AM, and the fact that on 9/16/19 the Doctor ordered a UA C&S test. The DON had no explanation for the documentation. Finally, the DON was queried if an indwelling urinary catheter should have an anchor to prevent pulling and the DON indicated it should. The DON further indicated she was going to look into R#200's catheter. A review of a facility provided document titled, Indwelling urinary catheter (Foley) care and Management was conducted and read, .Provide routine hygiene for meatal care .Make sure that the catheter is secured properly. Asses the securement device daily .Monitor intake and output, as ordered. Monitor for changes in urine output, including volume and color . The facility was asked if they had any additional information to provide regarding the concern; none was received by the end of the survey.

This citation pertains to intake #MI 301. Based on observation, interview and record review, the facility failed to ensure adequate supervision was provided while toileting for one resident (R#904) of three residents reviewed for accidents/hazards, resulting in R#904 falling and sustaining a C2 dens odontoid fracture (second vertebra towards the top of the neck). Findings include: On 6/4/19 at approximately 12:46 p.m., R#904 was observed in the dining room up in their chair. R#904 was observed dressed with a cervical collar around their neck. Due to cognitive impairment the resident was not able to participate in an interview. On 6/4/19 the medical record for R#904 was reviewed and revealed the following: R#904 was initially admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of R#904's MDS (Minimum Data Set) with an ARD (assessment reference date) of 3/28/19 revealed R#904 needed extensive assistance from facility staff with most of their activities of daily living including toileting. R#904's BIMS score (brief interview of mental status) was 10 which indicated moderately impaired cognition. A resident summary (a directive of care for the certified nursing assistants and nurses) created on 4/25/19 for R#904 revealed the following: Bathroom- Date Modified : 4/19/2019 .Bathroom (needs, supplies, toileting plan, equipment): .Dependent with toileting. Incontinent, toilet upon rising, before and after meals, upon retiring. A review of R#904's Careplans prior to 5/1/19 revealed the following: Problem: At risk for falls r/t (related to) hx (history) of pelvic fx's (fractures), clavicle fx, hip fx, and dementia aeb (as evidenced by) impaired mobility and unsteady gait Goal:Resident will have a decreased risk of serious injury r/t falls through next review .Interventions: resident encouraged not to use w/c (wheelchair) as a walker, resident encouraged to use call light for assist prior to transferring out of bed, resident will have bladder scans to check pvr (post-void residuals) to see if resident is having retention causing urgency, resident encouraged to use reacher to pick things up off the floor, therapy and nursing educated resident on use of reacher, when notifying it is time for dinner offer to assist at that time with transfer, encourage resident to use call light for assist, keep room clean and clutter free, nonslip foot wear, notify physicians of any complications, offer toileting upon rising, before and after meals upon retiring and prn (as needed), pt/ot (physical therapy/occupational therapy) referral as needed, remind/assist to wear glasses, CNA (certified nursing assistant) counseled on transfer per facility policy . Further review of R#904's careplan revealed the following: Problem: Impaired decision making related to cognitive impairment. Resident has some confusion and forgetfulness noted Goal: Optimal participation in daily decisions .Interventions: Use environmental cues pictures, calenders to stimulate memory and promote appropriate behavior, provide consistent physical environment and daily routine, ask resident yes/no questions and offer concrete choices Ex: would you like to wear the green sweater or red today . A clinical progress note dated 5/1/19 revealed the following: Resident left facility at 6:30 via stretcher alert with eyes open. A clinical progress note dated 5/2/19 revealed the following: Addendum to 5/1/19 note: On 5/1/19 at approx (approximately) 5:15 PM while walking up the hall I heard a loud noise from res room. Went into res room. Noted res lying on floor, on right side with head against the wall and 3 drawer storage bin. this nurse asked res what happened 'I was trying to get up off the toilet and I fell .' This nurse asked res if she hit her head and res said yes. Res was assessed this nurse. ROM (range of motion) to BUE (bilateral upper extremities) and BLE (bilateral lower extremities) where within normal limits. Res denied pain to BUE and BLE during ROM. When asked if she was in pain Res stated, 'I hit my head and it hurts.' This nurse and CNA (certified nursing assistant) got res off floor with hoyer lift. No apparent injuries noted. Neuro checks initiated. Res was then taken to the dining room where she c/o (complained of) head and neck pain. Tylenol given while waiting MD (medical doctor) return call. This nurse asked if res wants to lay down. Res said yes. CNA layed <sic> res down. Obtained order from MD to send to ER (emergency room ) for CT (Computerized [NAME]ography) of the head and neck. Call placed to (name of local ambulance company). A hospital radiology note with a result date of 5/1/19 revealed the following: Procedure: CT evaluations of the head and cervical spine were performed without intravenous contrast .Findings: .Cervical Spine: There is an acute fracture traversing through the dens. There is minimal anterior displacement by approximately 1 mm (millimeter) of the superior fracture fragments. Comminuted fracture lines extend inferiorly into the body of C2 with involved of the right superior acticular facet. Redemonstration of osseous fusion of C2 and C3. the complex fracture involves the cranial aspect of the right C3 [MEDICATION NAME] foramen. Stable multilevel [MEDICAL CONDITION] changes of the cervical spine. The spinal canal is patent unchanged grade 1 anterolisthesis of C3 over C4 and C6 over C7. There is a gas debris collection adjacent to the esophagus at the level of the [MEDICAL CONDITION] cartilage measure approximately 1.5 cm, this may represent an [MEDICAL CONDITION] diverticulum. A hospital geriatric medicine consult followup note with a date of service of 5/3/19 revealed the following: History of Present Illness: .Alzheimer's and dementia, [MEDICAL CONDITION], [MEDICATION NAME] degeneration who fell yesterday in the bathroom and sustained a C2 dens odonoid fracture. She was seen by Ortho and initially was cleared to go back to (name of nursing home) with a cervical collar and non-operative management . A nurse practitioner progress note with a date of service of 5/9/19 revealed the following: I am seeing (R#904) for follow-up of neck pain after ondontoid fracture with a past medical history of [REDACTED]. (R#904) was hospitalized from 5/1-5/3 for fall and was found to have an odontoid fracture with collar to be worn at all times . A facility document titled Current Summary Fall Event with a date of 6/4/19, signed by the Administrator and Director of Nursing (DON) on 5/2/19 that pertained to R#904's fall on 5/1/19 was reviewed and revealed the following: Details of the event: Specific Event Type: Toileting .Injury Incurred? Yes .Type of Fall: Accidental Fall .Actual Falls Severity Level 1-minor injury . Actual Severity Level: 5b-Event req'd (required) pt. transfers to other facility Brief Factual Description 'On 5/1/19 at approx (approximately) 5:15 PM while walking up the hall I heard a loud noise from res room. Went into res room. Noted res lying on floor, on right side with head against the wall and 3 drawer storage bin. this nurse asked res what happened 'I was trying to get up off the toilet and I fell .' This nurse asked res if she hit her head and res said yes. Res was assessed this nurse. ROM (range of motion) to BUE (bilateral upper extremities) and BLE (bilateral lower extremities) where within normal limits. Res denied pain to BUE and BLE during ROM. When asked if she was in pain Res stated, 'I hit my head and it hurts.' This nurse and CNA (certified nursing assistant) got res off floor with hoyer lift. No apparent injuries noted. Neuro checks initiated. Res was then taken to the dining room where she c/o (complained of) head and neck pain. Tylenol given while waiting MD (medical doctor) return call. This nurse asked if res wants to lay down. Res said yes. CNA layed <sic> res down. Obtained order from MD to send to ER (emergency room ) for CT (Computerized [NAME]ography) of the head and neck. Call placed to (name of local ambulance company).' .Preventative Measures and/or corrective actions taken: Reinforced with staff to stay with resident while toileting .Fall was: Alleged/unwitnessed .Person was: observed on floor .Transfer status: 1 assist .Contributing Factors-Actions by other(S)~~Action by patient/resident~~Toileting Related~~Unsupervised toileting .Follow-Up Actions: Details: Upon investigation nurse hear loud noise coming from resident's room upon entering nurse noted resident on floor of bathroom on right side. Resident stated that she was trying to get off the toilet and fell . Resident was sent to ER for further evaluation. Immediate intervention-staff educated on importance remaining within line of vision when toileting resident Action Plan Needed: 'Action plan needed.' On 6/4/19 a facility document titled One-on-One In-service Record for staff member A dated 5/2/19 was reviewed and revealed the following: . In-service topic/title: 1. Supervision of demented residents and fall risks. 2. Following at risk for injury care plan .Description of Procedure/Objectives/skill covered during in-service: Residents who are demented and/or a fall risk can not be left on toilet unattended. You must stay in the bathroom or within eye contact if resident requests privacy. On 6/4/19 at approximately 1:20 p.m., during a conversation with the Director of Nursing (DON), the DON was queried regarding the investigation of R#904's fall and the DON indicated that R#904 was not provided the appropriate level of supervision in the bathroom. The DON was queried if staff member A should have left R#904 alone on the toilet when R#904 was documented as being a fall risk and had cognitive impairments and the DON indicated that they shouldn't have and that they had to inservice staff member A on providing appropriate supervision in the bathroom for residents with dementia. The DON further indicated that they had to provide education to all the CNA's and nurses on providing appropriate supervision. On 6/4/19 at approximately 1:59 p.m., staff member A was queried regarding R#904's fall on 5/1/19. Staff member A indicated that they had helped R#904 get on the toilet in their bathroom and then left R#904's room and notified another nurse that R#904 was in the bathroom. Upon walking to R#904's room they heard a loud noise and went into the bathroom and found R#904 lying on the floor. Staff member A was queried if they had checked R#904's resident summary which documented that R#904 was dependent for toileting and they indicated that they hadn't. Staff member A was queried if they were aware that R#904 was an identified fall risk and they indicated that they didn't. Staff member A further indicated that the facility management had inserviced them, telling her that she should have been with R#904 in the bathroom and that R#904 had a history of [REDACTED]. On 6/4/19 a facility document titled Fall Risk Care Plans & Investigation (last revised 08/12) was reviewed and revealed the following: It is the policy of (name of facilty) to ensure the resident environment remains as free of accident hazards as is possible. That each resident receives adequate supervision and the least restrictive assistive devices to prevent accidents as is practicable, given the residents medical and cognitive social condition

This citation has two deficient practices. Deficient Practice #1 Resident #68 Based on observation, interview and record review, the facility failed to adequately monitor and appropriately transfer in safe manner two residents (#42 and #68) that were identified and assessed as being a high risk for falls out of seven residents reviewed for transfers and falls resulting in fractures that required surgery. Findings Include: Resident #68 On 8/6/18 at 9:40 a.m., R#68 was observed in the dining/activity common area reclined in a geri-chair with her head down. When asked questions, R#68 did not respond. At that same time, R#68's family was observed in the same room engaged in a meeting with the hospice nurse. 8/6/18 at 10:54 a.m., during an interview, when asked about R#68's care at the facility, R#68's Family Member 'T' stated, R#68 had a broken wrist from a fall in (MONTH) of last year. There were three falls that interventions were kind of late. They were behind the curve on that. Family Member 'T' further stated, In late December, R#68 stood up and fell . Broke her hip and had a three-day hospital stay, and they put a pin in her hip. After that, in January, one month later, R#68 fell and broke the same left hip right below the recent broken hip. They had to take out the pin and put in a longer one. Family Member 'T' then stated, Since the series of falls, she (R#68) has had a lot of ups and down . She recently went into hospice care last month. There are a ton of emails that I sent to the Memory Care Manager 'U' about mom's falls and things they could have done to prevent her falls. On 8/6/18 at 2:35 p.m., a review of the clinical record revealed R#68 was originally admitted into the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the discharge Minimum Data Set (MDS) assessment dated [DATE], revealed R#68's cognition was moderately impaired - decisions poor, cues/supervision required. The MDS revealed R#68 had one fall with no injury and one fall with a major injury. The facility's fall care plan revealed the following: Effective 5/2/1016 - Problems: Potential for injury associated with falls R/T (related to) [MEDICAL CONDITION], dementia, impaired mobility, hx (history of fx (fractures), hx of falls. Goal DATE: 10/27/2018 - Goals: Residents risks for injury related to falls will be minimized through next review. Interventions: Encourage resident to ask for assistance before transfer. Offer position changes if resident appears restless . Resident to use geri-chair when fatigued instead of standard w/c (wheelchair) when out of bed . Monitor ability to use call light. If unable to use, assess need for additional fall risk reduction interventions and implement as needed. Further review of R#68's fall history revealed a total of 24 Incidents/Accidents (I/As) related to falls and skin altercations from 6/29/17 through 8/1/18. A review of multiple fall assessments revealed R#68 had a score of 75 before the fall that occurred on 12/9/17, and a score of 90 before the falls with fractures on 12/17/17 and 1/19/18. The facility's assessment tool Morse Fall Scale and Tug Mobility Test indicated falls. (equal to or greater than 51 is high risk). On 8/7/18 at 3:45 p.m., during an interview and record review of R#68's I/As along with Unit Manager 'K', the following falls indicated inadequate monitoring and improper transfers: 7/6/17 at 7:00 p.m. - resident attempted to stand up and walk. Intervention: Staff member (CNA 'X') was present. CNA 'X' was given disciplinary action for sitting behind resident not supervising (doing a word find puzzle) . 11/24/17 at 6:45 p.m. - Resident was in 2800 Hall D/R (dining room), she was trying to get out of wheelchair and fell to floor, landing on left side. Son aware, on call aware. Pain at left elbow, x-rays ordered. Intervention: Keep in area where resident can be watched . 12/9/17 at 5:00 p.m. - writer was standing at med cart when a staff member yelled out that resident had fallen. Writer ran to dining room on 2800 hall and observed resident on the floor sitting upright with legs stretched out in front of her at her table. Writer asked resident what she was trying to . Resident stated, 'I don't know what happened. Resident denied pain, no injuries noted. Resident was transferred back to wheelchair 2 assist. Neuro checks initiated and were within normal limits. Son was notified at 5:15 p.m. Dr. N . was notified at 5:20 p.m. Intervention: Frequent checking of resident to maintain safety. 12/17/17 at 10:25 p.m. - resident attempted to self-transfer out of bed. Injury: Fractured Left Hip - Intervention: Resident encouraged to wear gripper socks while in bed. Nursing staff educated to document refusal of gripper socks while in bed. Wheelchair to be kept within reach of bedside as resident often self-transfers out of bed without calling for assist. Disciplinary Notice LPN (Licensed Practical Nurse) LPN 'Y' - Employee's Statement 12/19/17: Wasn't aware to call on call (Manager). Disciplinary Notice Certified Nurse Assistant (CNA) 'Z'. Counseling: Resolution of problem or action taken - CNA 'Z' will follow (Name of Facility) policy to use a Hoyer lift post fall unless resident can completely unassisted transfer themselves off the floor. Failure to comply with (Name of Facility) policy and procedure will result in further disciplinary action up to and including termination. Further review of the facility's investigation revealed the following statements: On 12/17/17 - CNA 'Z' stated, .When I looked into (Name) R#68's room I saw her hand by the door and heard a thump and she had fallen on the floor on her left side in the middle of the room facing the opposite wall of the beds with her head towards the closet. I ran into the room and then left to call for the nurse to come in the room. Another CNA 'AA' came to assist along with the nurse ('Y') came into the room . CNA 'AA' and I got her (R#68) up with 2 person assist into the w/c and then I transferred her onto the bed without gait belt because I didn't want to add more stress onto her by using the gait belt. While she was being assessed again back in the bed she had complaints of left hip pain . On 12/17/17 - CNA 'AA' stated, Around 10:15pm I was discussing job duties for the shift when another CNA ('Z') notified me that resident (R#68's -Name) had fallen in her room. I told the nurse (LPN 'Y') and she came into the room to assess the resident. After the nurse finished assessing (R#68 - Name) I came into the room to help with the transfer from the floor to the wheelchair per direction from the nurse. Myself and CNA 'Z' 2 person transferred her into the wheelchair without gait belt . 1/19/18 at 7:25 p.m. - Resident attempted to walk in hallway. Injury: Fracture of Left Femur. Intervention: One-on-One CNA with log for behavior management . Resident was transported out to the hospital . On 8/7/18 at 10:25 a.m., R#68 was observed in a high back wheelchair in the common dining/activity area with her head down. On 8/8/18 at 8:35 a.m., R#68 was in a high back wheelchair leaning forward attempting to get out of the chair. At that time, CNA 'V' was in the area and re-directed R#68 to sit back in the wheelchair. When asked if R#68 could get up out of the wheelchair, CNA 'V' stated, I really don't know, this is my first time being with her. I usually work the afternoon shift. On 8/8/18 at 1:50 p.m., during an interview, when asked if R#68 should be sitting in a wheelchair and a geri-chair, Unit Manager 'K' stated, Resident is in geri-chair when she is fatigue. She uses both. On 8/8/18 at 4:10 p.m., an interview was conducted with the Director of Nursing (DON). When queried about R#68's multiple falls with and without injuries and the improper transfers after the falls, the DON stated, Anytime someone has a fall, the nurse should assess prior to moving the resident off the floor. Once they determine it is safe to move the resident off the floor, it should be done with a Hoyer lift. The nurse and CNA did not use the Hoyer lift. They were educated not only during orientation but was recently reeducated during a routine in-service on falls. A review of the facility's policy titled Falls Management revised on (MONTH) (YEAR) documented the following: 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 (APIE) . However, this policy did not address proper transfers post falls. Deficient Practice #2 Resident #42 On 8/6/18 at approximately 12:24 p.m., R#42 was observed in their room lying in their bed. Staff member W was observed transferring R#42 from their bed to their chair using a mechanical lift. Staff member W was observed to be performing the lift transfer without any other assistance from any other facility staff members. On 8/7/18 at approximately 12:51 p.m., R#42 was observed in their room up in their chair. R#42 was queried how many nursing aides usually assist them in transferring when they use the mechanical lift and R#42 stated, they mostly use one but they have used two. R#42 was queried how many aides are supposed to assist them when transferring them and they stated, I've heard it's supposed to be two but I don't know. On 8/7/18 at approximately 2:45 p.m., staff member K was queried if facility staff should be using the mechanical lift with one staff person to transfer R#42. Staff member K stated some residents are one person transfer with (brand name of mechanical lift) and some are two person transfer. The amount of people used for the transfer is indicated on the resident summary (a directive of care for the nursing assistants). Staff member K was informed of the observation on 8/6/18 of R#42 being transferred in the mechanical lift with one person and stated, We will have to see what the resident summary says. Staff member K was shown R#42's resident summary which indicated 2 PERSON MAX W/ (brand name of mechanical lift) Staff member K stated, They should have been transferred with 2 people. There will have to be some education. Staff member K was queried what the danger of having one staff member perform the transfer for R#42 versus two staff and they stated, their is an increased risk of falling. On 8/8/18 at approximately 8:23 a.m., the medical record for R#42 was reviewed and revealed the following: R#42 was last admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. R#42's MDS (minimum data set) with an ARD (assessment reference date) of 6/1/18 revealed R#42 needed extensive assistance from two facility staff with bed mobility, transfers, toileting and personal hygiene. R#42's BIMS score (brief interview of mental status) was 13 indicating intact cognition. A review of the current resident summary for R#42 revealed R#42 was a 2 person Max assist with the mechanical Lift. Mobility Specialized devices for R#42 was indicated as (brand name of mechanical lift). A review of R#42's active careplan with a target goal date of 8/29/18 revealed the following: Problems-Potential for injury associated with falls r/t (related to) decreased mobility,[MEDICAL CONDITION](stroke) .Goal-Residents risks for injury related to falls will be minimized through next review .Interventions-Provide supervision/assistance when transferring, ambulation, and toileting as described on the resident summary. On 8/8/18 at approximately 3:13 p.m., during a conversation with the Director of Nursing (DON), the DON was queried if all staff should be transferring residents according to their resident summary and they indicated that they should be. On 8/8/18 at approximately 3:35 p.m., a facility document titled Minimal lift program with a date of 7-10 was reviewed and revealed the following: It is the policy of (Name of Nursing Facility) that all patient transfers/lifting is done safely and appropriately to protect the employee and patient from injury. All patient lifting, shifting or transferring will be done with Mechanical Lifting Equipment when appropriate. Failure to follow the guidelines established by this policy will result in disciplinary action being taken An injury to a health care professional from patient transfer/lifting activities directly affects the quality of life for our staff members and patients. Therefore, it is crucial that healthcare professionals practice safe lifting, transporting and proper body mechanics at all times. Mechanical Patient Lifts are a key component in this effort . Deficient Practice #2 Based on observation, interview and record review the facility failed to ensure one resident (R#42) was provided appropriate supervision while eating of eight residents reviewed for accidents/hazards resulting in the potential for aspiration or choking. Findings include: On 08/07/18 at approximately 12:50 p.m., R#42 was observed in their room up in their chair. R#42 was observed eating their cottage cheese (a mechanical soft food) from their lunch tray. R#42's cottage cheese was observed to not be pureed. R#42 was observed to be eating their cottage cheese without any facility staff providing 1:1 supervision. R#42 was queried if facility staff were supposed to be providing 1:1 supervision while they ate certain foods and they stated, sometimes they do, sometimes they don't. I don't understand it. On 8/8/18 at approximately 12:54 p.m., staff member K was queried if R#42 needed 1:1 supervision from staff while eating non pureed foods and they stated, they need 1:1 supervision while they're eating when they eats foods that are not pureed. Staff member K was informed of the observation on 8/7/18 of R#42 eating cottage cheese in their room without 1:1 supervision and they indicated that R#42 should have been provided 1:1 supervision while they were eating the cottage cheese. Staff member K was queried why R#42 needed 1:1 supervision while they ate cottage cheese and they stated, there is a chance of aspiration. On 8/8/18 at approximately 2:24 p.m., the medical record for R#42 was reviewed again and revealed the following: R#42 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. R#42's MDS (minimum data set) with an ARD (assessment reference date) of 6/1/18 revealed R#42 needed extensive assistance from two facility staff with bed mobility, transfers, toileting and personal hygiene and required limited assistance from one staff member with eating. R#42's BIMS score (brief interview of mental status) was 13 indicating intact cognition. A review of the resident summary for R#42 (a summary of the care provided to a resident that the nursing assistants use for care direction) revealed R#42 had the following direction for eating: puree with nectar thick liquids, resident may have cottage cheese, pancakes, scrambled eggs, mac+cheese, pasta, fruited yogurt, fish, soft fruit, oatmeal, soft pastries/desserts with 1:1 supervision for all intake and to eat meals in dining room. A dietary progress note dated 7/24/18 revealed the following: Discussed resident with hospice nurse. Reports resident and family have been requesting diet upgrade from Puree, NTL (nectar thick liquids). Hospice nurse educated resident and family on high risk associated with diet upgrade. Per hospice, in addition to Puree, NTL diet, resident may have cottage cheese, pancakes, scrambled eggs, mac+cheese, pasta, fruited yogurt, fish, soft fruit, oatmeal, soft pastries/desserts with 1:1 supervision for all intake and to eat meals in dining room. Meal ticket updated. Will continue to monitor & f/u (follow up) PRN (as needed). A physician's orders [REDACTED]. A review of R#42's current careplan with a goal date of 8/29/18 revealed the following: Problem-Self Care Deficit associated with need for assistance with adl's (activities of daily living) r/t (related to) decreased mobility,[MEDICAL CONDITION](stroke) . Goal-Resident will be neat, clean, well-groomed, without odor or oral infection with assistance as needed through next review .Interventions-Assist with meals as needed Provide assistance as described on the resident summary to complete ADL tasks. Allow resident to complete as much as possible for self and then complete task to standard On 8/8/18 at approximately 4:40 p.m., staff member M was queried regarding R#42's physician order [REDACTED]. On 8/8/18 at approximately 3:38 p.m., a facility document titled Feeding Assistance of a Resident/Elder dated May, 2008 was reviewed and revealed the following: Purpose: To provide a process to assist an elder in feeding as needed or care planned 1. Identify the elder and call them by name. Assure that the dietary care on the tray lists that elder's correct name and diet. (Check the care plan for other special instructions)

This citation pertains to intake #MI 377. It was alleged staff failed to provide adequate and appropriate care to treat and prevent pressure sores. Based on observation, interview and record review, the facility failed to implement timely preventative measures once skin breakdown was identified, and failed to implement adequate preventative interventions to prevent additional skin breakdown for one (#704) of three sampled Residents reviewed for pressure ulcers in a total sample of six, resulting in the development of an avoidable stage three pressure ulcer (full thickness skin loss) to the Resident's left elbow, and the potential for further skin breakdown. Findings include: On 2/3/16 at 2:00 p.m., Nurse Manager E was asked about Resident #704's pressure ulcer and stated, It was reported last week, an area on the elbow. We (facility) implemented interventions and now has padded armrests and elbow protectors. She's (Resident #704) a leaner and tends to rest on those (elbows). She has a history of breakdown there (elbow). On 2/4/16 at 1:50 p.m., Nurse Manager E was asked about when the preventative implementations (padded armrests and elbow protectors) had been implemented and stated, I added the padded armrest when the skin opened up on the left elbow. Prior to that she had a history of [REDACTED]. I also just added bilateral elbow protectors in addition to padded elbow rests. When asked why preventative interventions had not been in place prior to 2/3/16, given Resident #704's history of skin breakdown and knowledge of Resident's positioning which puts direct pressure onto the elbows, Nurse Manager E stated, She's a leaner and at risk. No further explanation was offered. On 2/3/16 at 2:00 p.m., Resident #704 was observed seated in a wheelchair with padded armrests in a group activity which was held in the lounge area next to the nursing station. There were no visible elbow protectors observed at this time. Resident #704's elbows were observed to be positioned so that both of the elbows were pressed directly onto the padded armrests. On 2/4/16 at 8:00 a.m., and 1:05 p.m., Resident #704 was observed seated in a wheelchair with no elbow protectors in place. At each observation, Resident #704's elbows were observed to be positioned so that both of the elbows were pressed directly onto the padded armrests. Review of the current physician orders [REDACTED].>1/27/16 Cleanse open area left elbow with NS (normal saline) apply skin prep to surrounding area. Apply allevyn change q (every) 3 days 2/3/16 Resident to wear bilat elbow protectors, remove for skin checks and hygiene (7 days after the skin breakdown was first identified). Review of Resident #704's skin assessments identified an area of breakdown on 1/27/16 which documented, 1/27/16 3:26 pm Partial thickness wound .(no size noted). Red nonblanchable. The skin assessment dated [DATE] documented, Stage 3 pressure ulcer to left elbow. L (length) 2.0 cm W (width) 2.0 cm, wound edge pink, tissue type - slough (yellow of white tissue that is soft, stringy, or mucinous in texture). On 2/4/16 at 1:20 p.m., an observation of Resident #704's wound care treatment was conducted with Nurse Manager E who reported, It was a stage three and now it's visualized at a stage one. Measurements are 1.3 cm by 0.5 cm. See the right elbow has a healed cicatrix (scar area from previous skin breakdown). At that time, Nurse Manager E was asked about the lack of elbow protectors and stated, I don't see them sitting out. I'm not sure why there are no elbow protectors in place. I'll see if they're getting cleaned. Nurse Manager E searched the room and located one elbow protector on top of the dresser. Nurse Manager E further reported, I think they (nursing assistants) took off when getting dressed and forgot to put on. I'm putting on right now. When asked if Resident #704 had a history of [REDACTED]. I'm not aware of her refusing. Nurse Manager E proceeded to ask Resident #704 to lift the left arm so she could put the elbow protector in place. At that time, Resident #704 lifted her left arm without hesitation and allowed the Nurse Manager to put the elbow protector in place over her sweater. On 2/4/16 at 1:40 p.m., an interview was conducted with Certified Nursing Assistant (CNA L) in the presence of Nurse Manager E. At that time, CNA L confirmed she was assigned to Resident #704 and reported that she was not normally assigned to Resident #704. When asked about the lack of elbow protectors, CNA L stated, When I tried to put on this morning, she refused. They don't normally work for her. When asked if Resident #704 had been reapproached since then, CNA L stated, Yeah but she still refused. When asked if the continued refusals had been documented as such, CNA L stated, No I'm about to put it in now (electronic documentation system). At that time, Nurse Manager E reported, I'll add a non-compliance care plan now. That (refusal) should be documented at each time it occurred. Further review of the clinical record revealed Resident #704 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] documented Resident #704 was severely cognitively impaired, and was at risk for skin breakdown but did not have any open areas. Review of the Pressure Ulcer/Skin impairment care plan initiated 6/16/15, identified the following interventions: Avoid Prolonged Sitting, and Positioning Device pillows. This care plan was not updated with the current interventions to address the left elbow pressure ulcer until 2/3/16 (7 days after the skin breakdown was first identified) which read, impaired skin integrity - pressure ulcer left elbow with interventions that included allevyn to left elbow; elbow protectors; and padded arm rest for w/c (wheelchair). Review of the interdisciplinary progress notes included: An entry from Nurse N documented, 1/27/16 3:28 pm Resident noted while walking to BR (bathroom) 6:30 a.m. to have open area to left elbow with scattered yellow tissue; surrounding skin red, nonblanchable . An entry from Nurse Practitioner M documented, 1/30/16 1:11 pm .elbow pressure ulcer .Nursing reports stage III pressure ulcer of elbow .Shouts out when touched. Pt is unable to verbalize .left elbow with area of apr (approximately) 2 x 3 cm yellow slough with no surrounding [DIAGNOSES REDACTED] . Review of a wound consult dated 7/8/15 documented, .the wound is lateral on the right elbow. The wound began at the nursing facility .Impression: Right elbow traumatic wound - resolved. There were no other wound consults available for review. Review of the facility's Pressure Ulcer Protocol dated 8/2015 included: .Pressure Ulcer Prevention .Assess for the presence of risk factors and initiate individualized interventions as appropriate .Stage III Definition: Full thickness tissue loss .Manage Tissue Loads: Support surface .Prevent friction with .elbow protectors .wheelchair arm cushions .Interdisciplinary Skin Management Responsibility .Nursing .Ensures preventative measures are implemented . ( )

This citation pertain to intake number MI 486 Based on interview, and record review, the facility failed to ensure that a resident who required a two person assist to perform safe transfers was positioned and transferred appropriately by mechanical lift for one (#201) of three sampled residents reviewed for falls from a total sample of 3, resulting in the resident falling and sustaining severe pain and left hip fracture. Findings include: On 3/27/15 at 8:30 A.M., an attempt to contact the complainant was made. On 3/27/15 at 3:30 P.M. the complainant was interview by phone. The complainant identified that the resident (#201) was not available for interview stating she (#201) was "currently in the hospital for an unrelated incident. She (#201) sustained a hip fracture, left. That evening the nurse called me about the fall, (#201) said she heard the pop or break when it happened. I had her (#201) sent to the hospital. She (#201) was in the wheelchair and they were putting the sling on her, during the adjustment of getting the sling under her bottom when she fell out the wheelchair. She was scared and had fear from past fall (at home) with fracture. She was non-ambulatory and could tell she was sliding off the wheelchair and told the staff . They (staff) did not stop. She (#201) refused to return to the facility do to the incident and increased anxiety from with transfer and falling." On 3/27/15 at 10:00 A.M. Resident #201's closed clinical record was reviewed. The resident's current admission was dated 9/30/14. [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) resident assessment and care screening dated 10/7/14 described the resident with independent cognitive and decision-making skills. Resident #201 required extensive two person physical assistance from staff for transfers, mobility and other activity of daily living need. A plan of care for falls, dated 9/30/14 identified that the resident was at high risk for falls due to problems with mobility and gait. Care plan approaches included: To keep environment free from obstruction, promote proper use of hand rails-hand grips-side rails, nonslip footwear, call light within reach, wheelchair wheels locked and etc. On 3/27/15 at 10:00 A.M., the Incident Report dated 10/18/14 at 5:30 P.M. was reviewed. It identified that the "CNA (certified nurse aide) informed (nurse) that patient (#201) slid off of her wheelchair when they were trying to put the (mechanical lift) sling under her to transfer from wheelchair to bed. The CNA stated they lowered the patient to the floor. The patient stated she heard a distinct pop in her hip bone. Patient in extreme pain. The physician and family were notified. Initially a stat x-ray examination was ordered, but family requested patient to be sent to the hospital. The physician was made aware." The nurse assessed and noted patient slid off of the wheelchair cushion while transferring from wheelchair to bed with two person assist and use of mechanical lift. Patient stated that her hip was injured. On assessment the nurse did not see bruising, swelling or skin tears. A review of interdisciplinary notes dated 10/19/15 at 10:48 A.M., noted that "the (family) called to find out next steps after fall that had resulted in a fractured hip." On 3/27/15 at 11:00 A.M., the Assistant Director of Nursing(ADON), employee "A" was interviewed. The ADON stated, "The incident was a lowering onto the floor, not a fall. Staff was interviewed and we did not find anything inappropriate occurred. We felt all processes were appropriate just an unfortunate incident. The resident is heavier on top and slipped off the wheelchair during positioning of the sling." The ADON was not sure how the staff were standing during the transfer (both sides or one in front and one behind wheelchair). The resident was transferred to the hospital and did not return. The facility was made aware by family that the resident had a hip fracture. On 3/27/15 at 12 noon the In-service Director, employee "B" was interviewed. Employee "B" stated, "We have had several meetings on fall prevention, in-service training and actually use aides during demonstration of lifts. The employee was questioned about the procedure that occurs prior to a mechanical lift from wheelchair to bed. She stated, "While sitting in the wheelchair they (staff) would first tuck the sling behind the resident lifting for placement under the buttocks, then they would lift each upper thigh to position tucking with clip between the legs to attack to the (mechanical lift). On 3/27/15 at 1:40 P.M. physical therapy assistant (PTA), employee "C" was interviewed. Employee "C" stated, "All transfers were total assist. The CNA's would always use the (mechanical lift). The resident was fearful and resistant to let go due to fear of falling... She was being seen five times weekly with overall improvement with sitting balance, increased participation with decreased pain. I was shocked to hear that she had fallen." On 3/27/15 at 2:30 P.M. an attempt was made to contact CNA #1, employee "E" by phone with no answer. A written statement provided for the facility was reviewed. It stated, "Myself and (CNA #2) went to assist resident (#201) who asked to be put to bed, while placing the (mechanical lift) sling under her she began to slide forward...the cushion in the wheelchair began to move with her. We eased her to the floor. We were unable to prevent her from sliding from the wheelchair...(#201) complained of pain. RN gave her pain medication and did the necessary facility protocol." On 3/27/15 at 3:00 P.M. CNA #2, employee "F" was interviewed by phone. She stated, "I was assisting with the transfer. It was something about the postioning. Resident (#201) slid down and I had to lower her to the floor. She did not fall...was in own wheelchair with cushion that slid forward while putting sling in place. I could not bear the weight...I was on right side and (CNA #1) was on the other side, we were putting the sling down the back (of wheelchair) but the seat was small and her body slid forward." The CNA went on to state, "Improper cushion (silky) and short wheelchair seat for a bigger lady. It was hard to grab and position back up. She (#201) slid down and landed (top heavy) seating on her leg (folded under). I hated it happened, but there was nothing I could do. She (#201) was in pain." The personal records for CNA #1 and CNA #2 were review with the Human Resource Director, employee "E". It was identified that both employees were properly registered with background checks in place. There were no disciplinary actions in place or additional education noted as a result of this incident. The facility was asked to provide a policy for falls and transfers. The policy titled "Fall Management Program" (dated revised 3/14) was reviewed. Policy: To insure all resident's at fall risk are triggered upon admission or during on-going assessment's to prevent fall/injuries..."Transfers/Lift/Equipment" 3. Proper use of body mechanic. ( )

THIS CITATION HAS MULTIPLE DEFICIENT PRACTICES. DEFICIENT PRACTICE #1: BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE TIMELY PRESSURE RELIEF INTERVENTIONS TO PRESERVE SKIN INTEGRITY FOR ONE (#900) OF TWO SAMPLED RESIDENTS REVIEWED FOR WOUNDS FROM A TOTAL OF 24, RESULTING IN THE DEVELOPMENT OF AN FACILITY ACQUIRED PRESSURE SORE. FINDINGS INCLUDE: ON 6/5/12 AT 2 PM, RESIDENT #900'S SKIN WAS OBSERVED WITH NURSE UNIT MANAGER 'F.' THE RESIDENT WAS ALERT, BUT CONFUSED AND APHASIC (UNABLE TO SPEAK). THE RESIDENT'S LOWER EXTREMITIES WERE SLIGHTLY [MEDICAL CONDITION] AND A DRESSING WAS PRESENT ON THE RIGHT FOOT. THE DRESSING WAS REMOVED TO REVEAL A 4 CENTIMETER (CM) X 3.5 CM PRESSURE SORE ON THE HEEL. HALF OF THE SORE WAS COVERED WITH ESCHAR (DEAD, BLACK, LEATHERY TISSUE), WHICH REPRESENTED FULL THICKNESS TISSUE LOSS. IMMEDIATELY FOLLOWING THE SKIN OBSERVATION, RESIDENT #900'S CLINICAL RECORD WAS REVIEWED WITH NURSE 'F.' THE RESIDENT WAS admitted on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM (MDS) data set [DATE] NOTED THAT THE RESIDENT HAD SEVERE COGNITIVE IMPAIRMENT, REQUIRED EXTENSIVE ASSISTANCE FOR TRANSFERS AND BED MOBILITY, AND HAD NO PRESSURE SORES. BRADEN (PRESSURE SORE RISK) SCALES DATED 5/3, 5/8, 5/15, AND 5/29/12 NOTED THAT THE RESIDENT HAD A SCORE OF 16 (LOW RISK FOR DEVELOPMENT OF PRESSURE SORES). A SCORE OF 14 OR LESS INDICATED HIGH RISK. REVIEW OF THE MAY 2012 TREATMENT RECORD NOTED THAT THE RESIDENT WAS TO RECEIVE A WEEKLY BODY AUDIT EVERY TUESDAY. THERE WAS NO AUDIT NOTED ON TUESDAY, 5/8/12. A BODY AUDIT ON TUESDAY, 5/15/12, NOTED RESIDENT #900 HAD NO SKIN ISSUES. REVIEW OF A physician's orders [REDACTED]." "[MEDICATION NAME] (WATER PILL), ONE BY MOUTH EVERY MONDAY-WEDNESDAY-FRIDAY, [MEDICAL CONDITION]." PER THE WEBSITE "MAYOCLINIC.COM" ACCESSED ON 6/11/12, COMPLICATIONS OF [MEDICAL CONDITION] INCLUDE: "INCREASED RISK OF SKIN ULCERS." THE MEDICATION RECORD NOTED THAT [MEDICATION NAME] WAS NOT GIVEN TO RESIDENT #900 ON MONDAY 5/14/12 AND WEDNESDAY 5/16/12 BECAUSE IT WAS "NOT AVAILABLE." THE RESIDENT DID NOT BEGIN RECEIVING [MEDICATION NAME] UNTIL FRIDAY 5/18/12. A 24-HOUR FLOWSHEET (NURSES NOTE) DATED 5/18/12, NOTED THAT THE RESIDENT HAD NO PRESSURE SORES. ON 5/19/12 AT 11:45 AM, THERE WAS A physician's orders [REDACTED]. NURSE 'K' NOTED IN THE 24-HOUR FLOWSHEET ON 5/19/12 AT 12:33 PM, THAT THE RESIDENT DID NOT HAVE PRESSURE SORES. THERE WAS NO MENTION WHY THE DRESSING WAS ORDERED FOR THE RIGHT HEEL. ON 5/20/12 AT 2:14 PM, NURSE 'K' NOTED THAT THERE WERE NO PRESSURE SORES. ON 5/21/12 AND 5/22/12, THE 24-HOUR FLOWSHEETS DID NOT MENTION PRESSURE SORES. ON TUESDAY, 5/22/12, THE BODY AUDIT NOTED NO SKIN ISSUES. RESIDENT #900'S CARE PLAN DATED 5/3/12 FOR "PRESSURE ULCERS" NOTED: "POTENTIAL ALTERATION IN SKIN INTEGRITY RELATED TO IMPAIRED MOBILITY....RESIDENT WILL MAINTAIN INTACT SKIN FREE OF REDNESS, BLISTERS, DISCOLORATION...." THERE WERE NO DOCUMENTED INTERVENTIONS RELATED TO THE HEELS AND THE [MEDICAL CONDITION]. ON 5/21/12, AN ORDER WAS WRITTEN: "WEAR FOAM BOOTS WHILE IN BED." THE FOAM BOOTS, PROTECTIVE RIGHT HEEL DRESSING, AND LEG ELEVATION FOR [MEDICAL CONDITION] WERE NOT CARE-PLANNED. ON 5/23/12 AT 1:15 PM, NURSE 'L' NOTED ON THE 24-HOUR FLOWSHEET: "ASKED TO EVALUATE RESIDENT (#900) FOR BLISTER ON RIGHT HEEL. OBSERVED RIGHT HEEL AND NOTED A 5 CM X 4 CM DARK PURPLE CIRCULAR AREA" AND THAT THE HEEL WAS "SOFT." WHEN QUERIED ABOUT THIS NOTE, NURSE 'F' STATED THAT SHE DID NOT BECOME AWARE OF THE PRESSURE SORE ON RESIDENT #900'S HEEL UNTIL THE RESIDENT'S DAUGHTER BROUGHT IT TO HER ATTENTION ON 5/23/12 AND ASKED HER TO LOOK AT IT. NURSE 'F' THEN CONSULTED ANOTHER NURSE (NURSE 'L') ABOUT CARE OF THE SORE. NURSE 'F' DEFERRED TO THE RESIDENT'S DAUGHTER FOR FURTHER EXPLANATION. ON 6/5/12 AT 2:30 PM, THE RESIDENT'S DAUGHTER STATED THAT ON 5/19/12, NURSE 'K' TOLD HER THAT THE RESIDENT HAD A BLISTER ON THE RIGHT HEEL AND PUT A PROTECTIVE DRESSING ON IT, AND THAT ON 5/23/12, THE DAUGHTER ASKED NURSE 'F' (THE UNIT MANAGER) TO LOOK AT THE HEEL. WHEN QUERIED ABOUT THE LACK OF NURSES NOTES REGARDING THE PRESSURE SORE FROM 5/19-5/22/12, NURSE 'F' STATED THAT IT SHOULD HAVE BEEN REPORTED AND NOTES SHOULD HAVE BEEN WRITTEN BY NURSE 'K.' WHEN QUERIED ON 6/6/12 AT 10:30 AM, NURSE 'K' SAID, "I SHOULD HAVE NOTED IT" AND "IT SHOULD HAVE BEEN REPORTED TO THE WEEKEND MANAGER." SHE SAID, "I THOUGHT IT WAS A BLISTER BUT (NURSE 'L') THOUGHT IT WAS A DEEP TISSUE INJURY (PURPLE INTACT SKIN OR BLOOD FILLED BLISTER DUE TO DAMAGE OF UNDERLYING SOFT TISSUE FROM PRESSURE)." THE FOLLOWING CHANGES IN CARE, DATED 5/23/12, WERE WRITTEN FOR RESIDENT #900: CLEAN THE RIGHT HEEL, APPLY AN AEROSOL WOUND TREATMENT, LOOSELY COVER WITH A DRY DRESSING, AND WRAP WITH GAUZE; PERFORM DAILY SKIN AUDITS; TURN AND REPOSITION EVERY TWO HOURS; FOAM BOOTS TO BE WORN WHEN IN BED. ON 5/23/12, NURSE 'F' ADDED AN INTERVENTION TO THE RESIDENT'S PRESSURE ULCER CARE PLAN: "SUSPEND HEELS WHILE IN BED OR IN CHAIR." THE CARE PLAN STILL READ "POTENTIAL" ALTERATION IN SKIN INTEGRITY AFTER THE SORE WAS FOUND. WHEN QUERIED ABOUT THE CHANGE IN ORDERS, NURSE 'F' STATED THAT THE PRESSURE SORE REQUIRED MORE THAN THE PROTECTIVE DRESSING INITIALLY APPLIED. SHE WAS UNABLE TO EXPLAIN WHY THE RESIDENT'S CARE PLAN WAS NOT APPROPRIATELY UPDATED TO MENTION THAT A PRESSURE SORE HAD ACTUALLY DEVELOPED AND WHY THERE WERE NO DOCUMENTED PRESSURE RELIEF INTERVENTIONS FOR THE HEELS ON THE CARE PLAN UNTIL 5/23/12. THE RESIDENT'S MAY 2012 TREATMENT RECORD NOTED THAT THE FOAM BOOTS WERE WORN DAILY, BUT THE TREATMENT RECORD FOR JUNE 2012 NOTED THAT THE RESIDENT REFUSED TO WEAR THE BOOTS FROM 6/1-6/5/12. THERE WAS NO DOCUMENTED REASON WHY. WHEN QUERIED ABOUT ALTERNATIVE INTERVENTIONS, SUCH AS HEEL PADS OR LIFT CUSHIONS, SINCE THE BOOTS WERE REFUSED, NURSE 'E' SAID, "I JUST FOUND OUT THAT SHE HAD BEEN REFUSING THE BOOTS" AND STATED THAT SHE WOULD WRITE an order for [REDACTED]. ACCORDING TO THE FACILITY'S "PRESSURE ULCER PROTOCOL" DATED 10/2009: -"RISK OF PRESSURE ULCER DEVELOPMENT WILL BE ASSESSED AND PREVENTATIVE STRATEGIES WILL BE IMPLEMENTED WHEN NEEDED. PRESSURE ULCER OCCURRENCE WILL BE PREVENTED WHEN POSSIBLE AND APPROPRIATE PLANS OF CARE DEVELOPED WHEN ULCERS OCCUR." -ANY BRADEN SCORE "LESS THAN 19 (NOT 14 AS PREVIOUSLY NOTED), INDICATES A RISK FOR PRESSURE ULCER DEVELOPMENT." -MANAGE OFF-LOADING OF TISSUE THROUGH SUCH PREVENTATIVE DEVICES AS FOOT ELEVATORS AND FOAM BOOTS. ( ) DEFICIENT PRACTICE #2: THE FACILITY FAILED TO MAINTAIN PROPER HAND HYGIENE DURING THE treatment of [REDACTED]. FINDINGS INCLUDE: ON 6/6/12 AT 9:50 A.M., A PRESSURE ULCER WOUND TREATMENT WAS RENDERED TO RESIDENT #903 BY NURSE "I." NURSE "I" WAS OBSERVED PERFORMING THE TREATMENT TO THE RESIDENT'S SACRAL AREA. WHILE WEARING A PAIR OF GLOVES, NURSE "I" REMOVED THE OLD DRESSING WITH SEROSANGUINOUS DRAINAGE. A PRESSURE ULCER WITH A WHITE CENTER AND SURROUNDING PINK TISSUE WAS NOTED. NURSE "I" THEN OBSERVED SOME FECAL MATTER NEAR THE RECTUM AND BEGAN TO CLEAN THE FECAL MATTER WHILE STILL WEARING THE FIRST PAIR OF GLOVES. NURSE "I" THEN REMOVED THE FIRST PAIR OF GLOVES AFTER CLEANING THE FECAL MATTER AND PROCEEDED TO PUT ON A NEW PAIR OF GLOVES WITHOUT FIRST WASHING HER HANDS. NURSE "I" THEN PRECEDED TO COMPLETE THE TREATMENT TO THE SACRAL PRESSURE ULCER. ON 6/6/12 AT 10:25 A.M., NURSE "I" WAS QUERIED WHY SHE PRECEDED WITH THE TREATMENT TO THE SACRAL PRESSURE ULCER WITHOUT FIRST WASHING HER HANDS AFTER CLEANING FECES FROM RESIDENT #903'S RECTAL AREA. NURSE "I" STATED, "I KNOW I SHOULD HAVE WASHED MY HANDS AFTER CLEANING HER (RESIDENT #903). I THOUGHT ABOUT IT AFTERWARDS." REVIEW OF RESIDENT #903'S FACE SHEET REVEALED AN ADMISSION INto the facility on [DATE] AND A RE-ADMISSION ON 5/15/12 WITH [DIAGNOSES REDACTED]. THE MOST RECENT QUARTERLY MINIMUM DATA SET (MDS), dated [DATE] INDICATED A MODERATELY IMPAIRED COGNITION AND REQUIRED EXTENSIVE TO TOTAL ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING (ADL'S). THE MDS ALSO INDICATED SHE HAD A PRESSURE ULCER (UNABLE TO DETERMINE) TO THE SACRAL AREA. REVIEW OF THE FACILITY'S FORM TITLED, "WEEKLY PRESSURE ULCER REPORT," DATED 5/28/12, RESIDENT #903'S SACRAL/COCCYX PRESSURE ULCER MEASURED 3 X 1 CENTIMETER (CM) X 1.2 CM X 0.3 CM. APPEARANCE WAS PINK WITH YELLOW SLOUGH. THE SACRAL/COCCYX PRESSURE ULCER STAGED AS UNSTAGEABLE. ON 6/8/12 AT 12:30 P.M., THE DIRECTOR OF NURSES (DON) WAS INFORMED OF THE OBSERVATION. THE DON STATED, "WE JUST HAD AN IN-SERVICE ON PRESSURE ULCER TREATMENT AND HANDWASHING." THERE WAS NO FURTHER EXPLANATION PROVIDED. ON 6/8/12 AT 3 P.M., THE FACILITY'S POLICY FOR HANDWASHING WAS REQUESTED. A FACILITY'S POLICY TITLED, "ANTISEPTIC HAND CLEANSER," DATED 11/11/09, WAS GIVEN. THE POLICY STATED UNDER #5; "WASH HANDS AFTER GROSS SOILING AND WHENEVER IN DOUBT." ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO IMPLEMENT APPROPRIATE CORRECTIVE ACTIONS AFTER EACH FALL FOR ONE (#912) OF EIGHT SAMPLED RESIDENTS REVIEWED FOR FALLS, OUT OF A TOTAL OF 24 SAMPLED RESIDENTS, RESULTING IN MULTIPLE FALLS AND A HIP FRACTURE. FINDINGS INCLUDE: ON 6/5/12 AT 9:15AM, OBSERVED RESIDENT #912 LAYING IN A LOW POSITION BED SLEEPING. A FALL MATT WAS PALCED ON THE FLOOR NEXT TO THE BED. ON 6/5/12 AT 11:30 AM., REVIEW OF RESIDENT #912'S FACE SHEET INDICATED HE WAS ORIGINALLY admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. ON 6/4/12 RESIDENT #912 WAS readmitted INTO THE FACILITY AFTER A RIGHT FEMUR NECK FRACTURE. THE MINIMUM DATA SET (MDS) dated ON 9/5/11 AND 5/17/12 NOTED THAT RESIDENT# 912 HAD SEVERE COGNITIVE IMPAIRMENT, WAS NON AMBULATORY, HAD UNSTEADY GAIT, AND REQUIRED EXTENSIVE ASSISTANCE FOR TRANSFERS, AMBULATION, AND ACTIVITIES OF DAILY LIVING. REVIEW OF A FALLS QUARTERLY assessment dated [DATE], INDICATED RESIDENT #912'S SCORE WAS 14. A SCORE OF 10 OR ABOVE INDICATED A HIGH RISK FOR FALLS. IT FURTHER REVEALED THAT THE RESIDENT HAD A BALANCE PROBLEM WHILE STANDING AND WALKING AND HAD DECREASED MUSCULAR COORDINATION. RESIDENT #912 WAS DISORIENTED TIMES 3 AT ALL TIMES AND WAS CHAIR BOUND. RESIDENT #912'S CARE PLAN TITLED "HIGH RISK FOR FALLS", UPDATED ON 5/17/12, INCLUDED THE FOLLOWING INTERVENTIONS ON 12/4/11: BED/WHEELCHAIR WHEELS LOCKED, ASSESS CAUSE, PATTERN OF PREVIOUS FALLS AND ACT UPON RESOLVABLE FACTORS, PROVIDE ASSISTANCE AS NEEDED WITH TRANSFERS, ON 12/6/11: BED ALARM/CHAIR ALARM. ON 6/6/12 AT 10:15 AM., RESIDENT #912'S ACCIDENT AND INCIDENT REPORTS WERE REVIEWED AND REVEALED THE FOLLOWING: 1. ON 9/28/11 AT 8 PM, "WHILE GIVING MEDS TO ROOMMATE FOUND RESIDENT KNEELING ON THE FLOOR MATTRESS. NO INJURY NOTED." IMMEDIATE ACTION TAKEN TO PREVENT FURTHER INCIDENTS: "ARROW UP (UP) IN THE HALLWAY FOR CONSTANT MONITORING." 2. ON 10/3/11 AT 9:30 AM, "HEAR ALARM (CHAIR) SOUNDING AND WAS NOTIFY BY THE CLEANING STAFF, RESIDENT ON THE FLOOR LYING ON THE RIGHT SIDE." resident sustained [REDACTED]." IMMEDIATE ACTION TAKEN TO PREVENT FURTHER INCIDENTS: "INSTRUCTED STAFF NOT TO LEAVE RESIDENT IN COMMON AREA-TV BY HIMSELF. NEED MONITORING BY STAFF AT ALL TIMES." 3. ON 11/28/11 AT 9:00 AM, "HEARD CHAIR ALARM SOUNDING AND WHEN STAFF CHECK ON RESIDENT FOUND RESIDENT ON THE FLOOR LYING ON THE RIGHT SIDE. NO INJURY NOTED." IMMEDIATE ACTION TAKEN TO PREVENT FURTHER INCIDENTS: "INSTRUCTED STAFF TO MONITOR RESIDENT WHEREABOUTS IF PROPELLING SELF AND TO NOT TO BE AT TV ROOM BY HIMSELF." 4. ON 5/18/12 AT 6:45 AM, "WRITER HEARD CHAIR ALARM GOING OFF AND CERTIFIED NURSING ASSISTANT (CENA) RAN TO PATIENT SIDE AS WRITER TURNED CORNER A SLAM WAS HEARD OF THE WALKER AND A YELL OUT FROM THE PT (PATIENT) WRITER OBSERVED PATIENT ON BOTH KNEES HOLDING ON TO WALKER. CENA WAS STANDING DIRECTLY IN FRONT OF PATIENT. NO INJURY NOTED. IMMEDIATE ACTION TAKEN TO PREVENT FURTHER INCIDENTS: "BED ALARM/CHAIR ALARM (BA/CA)." 5. ON 5/26/12 AT 2:00 AM, "(CERTIFIED NURSING ASSISTANT) CNA FOUND RESIDENT CRAWLING OUT OF BED WITH KNEES ON THE FLOOR MAT." NO INJURY NOTED. IMMEDIATE ACTION TAKEN TO PREVENT FURTHER INCIDENTS: LEFT BLANK. 6. ON 5/29/12, AT 12:05 AM, "RESIDENT OBSERVED SITTING ON FLOOR BESIDE LANDING STRIP... ALARM WAS SOUNDING." NO INJURY NOTED. IMMEDIATE ACTION TAKEN TO PREVENT FURTHER INCIDENTS: "RESIDENT SITTING UP ON COMMON AREAS FOR STAFF SUPERVISION." 7. ON 6/3/12, STATED "RESIDENT WAS AMBULATING FROM LIBRARY TO DINING ROOM, LOST BALANCE AND fell TO THE FLOOR. HE fell on TO HIS RIGHT HIP." INJURY NOTED: "FRACTURE." COMPLIANT WITH PRESCRIBED ASSISTIVE DEVICES? MARKED "NO" EXPLAIN: "AMBULATED WITHOUT WHEELCHAIR. IMMEDIATE ACTION TAKEN TO PREVENT FURTHER INCIDENTS: "EDUCATED RESIDENT REGARDING IMPORTANCE OF USE OF (WHEELCHAIR) WC (DUE TO) D/T WEAKNESS AND INSTABILITY OF RESIDENT." ON 6/6/12 AT 10:15 AM RESIDENT #912'S CLINICAL RECORDS WERE REVIEWED WITH MANAGER "G." A CLINICAL PROGRESS NOTE DATED 6/3/12 AT 2:38 PM REVEALED " AT 2 PM ON 6/3/12 RESIDENT ATTEMPTED TO AMBULATE BY HIMSELF FROM THE LIBRARY TO THE DINING ROOM. HE LOST HIS BALANCE AND fell TO THE FLOOR. HE fell on HIS RIGHT HIP...THE ALARM WAS ON BUT WAS NOT SOUNDING." THE DOCTOR WAS CONTACTED AND GAVE ORDERS TO SEND TO THE EMERGENCY DEPARTMENT. A REVIEW OF RESIDENT #912'S emergency room DOCUMENT "DISCHARGE SUMMARY", DATED 6/4/12 AT 2:13 PM, REVEALED THAT RESIDENT #912 HAD "MILDLY IMPACTED, APEX SUPERIOR ANGULATED RIGHT FEMORAL NECK FRACTURE WITH MILD SUPERIOR DISPLACEMENT OF THE DISTAL FRAGMENT." NURSE MANAGER "G" WAS QUERIED ABOUT THE WHEEL CHAIR ALARM NOT SOUNDING, NURSE MANAGER "G" STATED "THE CNA'S ARE SUPPOSED TO CHECK THE ALARMS DAILY." SHE STATED NO LOGS WERE KEPT TO MONITOR THE FUNCTIONING OF SAFETY DEVICES. SHE WAS UNABLE EXPLAIN WHY THE ALARM WAS NOT SOUNDING. UNIT MANGER "G" FURTHER STATED THE LIBRARY WAS NOT MONITORED BY THE STAFF. WHEN QUERIED ABOUT WHY RESIDENT #912 WAS LEFT ALONE IN THE LIBRARY, UNIT MANGER "G" STATED "HE JUST PROPELLED HIMSELF." PER REVIEW, THE FACILITY POLICY TITLED "FALL MANAGEMENT PROGRAM," DATED 11/11/09, DID NOT MENTION SUPERVISION OF RESIDENTS THAT ARE AT HIGH RISK FOR FALLS. ( / )