Every finding on record at Gogebic Medical Care Facility

Based on interview and record review, the facility failed to assess and implement person centered interventions associated with trauma for one Resident (#71) of three residents reviewed for trauma informed care.Findings include:Resident #71 (R71)Review of Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on [DATE], with diagnoses that included: depression. R71 scored 13 of 15 on the Brief Interview for Mental Status (BIMS) assessment reflective of intact cognition. Further review of the MDS Section D: Mood revealed R71 experienced the following:Little interest or pleasure in doing things and felt down, depressed, or hopeless.Trouble falling or staying asleep and felt tired or had little energy.Trouble concentrating on thingsFelt bad about herself or that she is a failureDuring an interview on [DATE] at 1:52 p.m., R71 reported, I am very depressed.my daughter died and she and I were very close.we did everything together. I don't feel like eating. I hope I am taking an antidepressant.I tried to commit suicide years ago but would not do that now as I don't think about that.I sometimes cry when I am by myself because I miss her so much.During an interview on [DATE] at 8:56 a.m., Social Services Designee (SSD) H stated, (R71) was raped when she was younger and I have not completed a trauma assessment. (R71) is also very depressed about her daughter dying. I have not completed a trauma assessment for (R71) regarding the death of her daughter.During an interview on [DATE] at 10:30 a.m., Certified Nurse Aide (CNA) I stated, (R71) talked about her daughters death and became very depressed.(R71) wont get out of bed for days.She used to not eat and there was a time for months she would not eat breakfast all she would do is sit in the dark in her room.(R71) also talked about what happened to her when she was raped and she got very depressed about that.I don't know what happens to her, but she cycles with her depression.During an interview on [DATE] at 10:41 a.m., R71 stated, When I was around [AGE] years old, I moved away to live with a girlfriend. While we were drinking alcohol and having a little party I went with one of the guys to get some more alcohol.He suddenly hit me over the head, beat me, and raped me. He beat me so much that I had a broken jaw, broken teeth, and I was bruised everywhere.I was so scared and for several months I thought I might be pregnant as I did not have a period.I started to drink a lot of alcohol to get through it. I became an alcoholic.I have been sober for over 40 years.I still have horrible nightmares about being raped and wake up scared and afraid.What had helped me thru the years was going to (Support Group Redacted). I talked about it and helped others . but I have not had the opportunity to help anyone since coming here. The other horrible nightmare I have is about my daughter's death.I miss her everyday and my heart hurts. There are days I don't want to get out of bed and sometimes I don't. I don't want to eat and just want to give up. I have those horrible nightmares about being raped and my daughter's death, but nothing really triggers them. When I wake up it all hits me again. It would help me to talk about it and to help other people at meetings like (Support Group Redacted) or other support groups.Review of Social Services notes dated [DATE], read in part .Resident [R71] feels depressed, resident then listed the personal losses that she has experienced.writer asked resident if a support group was started would she attend, resident said yes and that she had led support groups.and would be interested in helping. Writer will meet with resident Monday to plan. Review of Social Services notes dated since [DATE] did not reveal any support groups being offered or plans for resident to attend support groups.Further review of Social Services notes did not indicate a trauma assessment had been completed or any indication of resident having nightmares over the trauma from being raped or nightmares regarding the death of her daughter.Review of R71's care plan did not reveal any trauma assessment being completed or the recurrent nightmares R71 had been experiencing.Review of document titled Facility Assessment (FA) last revised 1/26, read in part .Part 2: Services and care we offer based on our residents' needs.mental health and behavior. Manage the medical conditions and medication related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety.care of individuals with depression, trauma.Review of policy titled Trauma-Informed Care (TIC) Policy and Procedure last revised 8/19, read in part . Trauma informed care is a principle based culture change process that acknowledges the pervasiveness of trauma a focuses on how trauma may affect an individual's life and response to behavioral health services.trauma is a wound.these traumatic events can create long lasting adverse effects on a residents physical, social, emotional, and spiritual well-being.adverse childhood experiences (ACE) contribute to trauma.(ACE's) include.abuse.substance use disorder, mental illness.when an elder faces a new trauma or stressor any changes involves loss and any loss needs to be grieved.During an interview on [DATE] at 12:34 p.m., the Nursing Home Administrator (NHA) acknowledged the concern regarding a lack of a trauma assessment/trauma informed care.Review of a document provided by the facility on [DATE] at 1:47 p.m., revealed an undated and untitled document, read in part .In the past I had a traumatic experience of being raped. Things that may upset me due to this experience is: Think about it sometimes makes me sick to my stomach. The document was unsigned by any staff member. The document did not indicate an assessment related to the trauma over the death of her daughter or the recurrent nightmares from being raped or the death of her daughter.

Based on observation, interview, and record review the facility failed to ensure appropriate hand hygiene during wound care for one Resident (#66) of three residents reviewed for pressure injuries. This deficient practice resulted in the potential for the transmission of infectious organisms and delayed wound healing.Findings include:Resident #66 (R66)Review of R66's Minimum Data Set (MDS) assessment, Section M: Skin Conditions, dated 3/20/26, revealed three unhealed Stage IV pressure injuries (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling). R66 scored 11 of 15 on the Brief Interview for Mental Status (BIMS) reflective of moderately impaired cognition.Review of R66's Physician Orders for Month of 04/2026, obtained from the facility on 5/6/26 at 10:20 a.m., revealed the following wound care treatment orders: Buttock wounds Including right glut (gluteal/buttock), left glut and sacral: :(brand name solution) 1/4 strength for 5 minutes to each wound with each dressing change. Apply (brand name dressing material) to all wound beds. Cut no more than 1 cm (centimeter) of overlap on Peri-Wound (surrounding wound tissue surface), The individual adhesive foam dressings. Change daily 7-3 (7:00 AM-3:00PM) shift first date: 01/22/26. Buttock wounds Including right glut (gluteal/buttock), left glut and sacral: : (brand name solution) 1/4 strength for 5 minutes to each wound with each dressing change. Apply (brand name dressing material) to all wound beds. Cut no more than 1 cm of overlap on Peri-Wound, The individual adhesive foam dressings. Change daily p.r.n. (as needed) if loose, soiled, or saturated first date: 01/21/2026.Observation of wound care/dressing changes for R66 was performed on 5/5/26 at 10:40 a.m., with Licensed Practical Nurse (LPN) B. The following infection control/hand hygiene breaches were observed during wound care dressing changes for three Stage IV pressure injuries (per R66's MDS assessment) on R66's sacrum, left gluteal and right gluteal.1. Left Gluteal Wound Observation on 5/5/26 at 10:40 a.m., of LPN B, who used a skin preparation wipe on the skin surrounding R66's left gluteal wound wearing clean gloves. LPN B touched the inside of the plastic garbage bag with now dirty gloves. LPN B picked up the (brand name dressing material) wound dressing with her contaminated gloves and applied the (brand name dressing material) directly onto the wound bed.2. Sacral Wound Observation on 5/5/2026 at 10:58 a.m., with donned gloves LPN B removed R66's dirty sacral wound dressing. With the same dirty gloves LPN B took clean 4x4 gauze pads out of a zippered storage bag, picked up the bottle of (brand name solution) and moistened the 4x4's with the (brand name solution) and applied the moistened 4x4's (with dirty gloves) to the sacral wound bed to soak for five minutes. Following appropriate hand hygiene and donning of clean gloves LPN B touched the inside of the plastic garbage bag with her gloves while cutting the (brand name dressing material). LPN B placed her dirty gloves into the clean dressing supply zippered storage bag to get a skin prep wipe. The skin prep wipe was used on the skin surrounding R66's sacral pressure injury, and using the same dirty gloves the (brand name dressing material) was placed on the wound bed and a 6x6 dressing applied.3. Right Gluteal Wound Observation on 5/5/26 at 11:36 a.m. with donned gloves LPN B removed the dirty dressing and placed it into the plastic garbage bag. Gloves were removed and new gloves donned, with no performance of hand hygiene, LPN B took clean 4x4 gauze pads out of the clean zippered storage bag with her, now considered dirty gloves, touched the inside of the plastic garbage bag with her gloves, applied (brand name solution) to the gauze and placed the gauze onto the wound bed (all with dirty gloves). With clean gloves now donned, skin prep was applied to the skin surrounding the right gluteal wound, including the scrotum. Slough was visible on the interior edges of the wound. With the same dirty gloves LPN B picked up the (brand name dressing material) and placed it into the wound bed. Exterior wound dressing was applied with the same contaminated gloves.During an interview on 5/5/26 at 11:36 a.m.Infection Preventionist (IP)/ Registered Nurse (RN) A agreed dirty gloves should have been removed and hand hygiene performed when dirty gloves were removed, after applying skin prep to the skin surrounding the wounds including the scrotum, gluteal area, and sacrum, and touching the plastic garbage bag during the wound care process. IP A acknowledge the discussed, above concerns were not consistent with hand hygiene infection control policies and procedures. During an interview on 5/6/26 at 8:35 a.m., when asked about failure to perform appropriate wound care hand hygiene for R66 the previous day, LPN B said she had thought about forgetting to perform hand hygiene with the removal of dirty gloves. When asked if LPN B understood concerns with potential contamination of the wound with the use of contaminated gloves LPN B acknowledged understanding and explained that the skin would be considered dirty with use of the skin prep wipe.Review of the Clean Dressing Change policy, last revised 9/2025, revealed the following, in part: . Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. 11. Wash hands and put on clean gloves. 12. Cleanse the wound as ordered taking care to not contaminate other skin surfaces or other surfaces of the wound . Pat dry with gauze.Review of the Hand Washing policy, last approved 10/2025, revealed the following, in part: Hand Washing Guidelines: Wash hands with soap and water or alcohol-based hand sanitizer (if hands are not visibly soiled) . before and after direct or indirect resident contact or contact with a contaminated object . before and after 'gloving'. During an interview on 5/6/26 at 10:31 a.m., when asked if gloves would be considered clean or dirty following use of a skin preparation wipe on the skin surrounding R66's pressure injuries, the Director of Nursing (DON) stated, Dirty. The DON acknowledged failure to perform hand hygiene following the removal of dirty gloves and prior to donning clean gloves and touching the interior of the garbage bag with clean gloves would not be acceptable infection control technique during wound care.

All times are in Eastern Daylight Time (EDT) unless otherwise noted. Based on interview and record review, the facility failed to replace a feeding tube in accordance with professional standards of practice for one Resident (#1) of two residents reviewed for enteral nutrition, which resulted in Immediate Jeopardy when Resident #1 subsequently suffered aspiration pneumonia requiring admission to the Intensive Care Unit (ICU) and ultimately resulted in Resident #1 being placed on comfort care measures. The Immediate Jeopardy (IJ) began on 1/11/25 when Registered Nurse (RN) J inserted a urinary catheter with 30 cc (cubic centimeter) balloon into the gastrostomy site of Resident #1 (R1) to use as a feeding tube. After the urinary catheter was placed, R1 experienced blood-tinged vomiting, an oxygen saturation (SPO2) level of 82%, and a decreased heart rate of 42 beats per minute. R1 was noted to be cool and clammy with a hardened abdomen. R1 was transferred to the hospital on 1/11/25 where x-ray examination confirmed the urinary catheter balloon was inflated in R1's esophagus. The Administrator (NHA) was notified of the Immediate Jeopardy on 2/27/25 at 4:00 PM. This surveyor confirmed by interview and record review that the immediacy was removed on 2/28/25 at 2:17 PM, however, noncompliance remained at the potential for more than minimal harm due to sustained compliance which has not been verified by the State Agency (SA). Findings include: According to the EMR, R1 was transferred to the Emergency Department (ED) on 1/11/25 and was admitted to the ICU with aspiration pneumonia (an infection that occurs after a large amount of food or liquid is breathed into the lungs) after RN J inserted a urinary catheter in his gastrostomy site. A radiology examination in the hospital on 1/12/25 at 12:38 AM CT revealed the balloon portion of the urinary catheter was inflated within R1's esophagus. R1 was placed on comfort measures and returned to the facility on [DATE]. A telehealth provider document dated 1/11/25 at 6:19 PM CT documented the provider was notified by RN J regarding R1 vomiting and coughing up copious amounts of white foam. RN J conveyed to the provider that R1 had a G-tube, and congestion was heard throughout R1's lung fields. RN J requested provider instruction regarding when to re-start R1's tube feeding. According to the documentation by the provider on 1/11/25 at 6:19 PM CT, the provider called RN J and was told by RN J that R1 had a Foley (urinary catheter held in place by a balloon) chronically. The provider documentation did not indicate RN J had informed the provider that a new Foley catheter had been inserted prior to R1 experiencing the symptoms of concern. The provider ordered Zofran (a medication to treat vomiting) and Duoneb (a combination medication to relax the airway and improve breathing). The provider ordered the tube feeding to be withheld for four hours and to obtain R1's vital signs every four hours for 24 hours. Telehealth provider documentation dated 1/11/25 at 9:30 PM CT documented RN J again contacted the provider to report R1 had blood-tinged emesis and was cool and clammy with a hardened abdomen. The provider documented in part: .This provider returned call to facility and talked to [RN J], and [RN J] states patient had pulled his G-tube out so replaced it and now noted that white milky pink type of fluid now patient is cool and clammy abdomen is hard. This provider inquired if an abdominal x-ray was done after replacing the feeding tube and [RN J] states they cannot do x-rays at the facility and will need to send patient out to ED [Emergency Department]. This provider discussed with [RN J] patient really needs to have x-ray done to make sure that the tube feedings in correct place and also since his oxygen saturation is 82% on room air please [sic] patient on oxygen and send patient to ED . The provider ordered R1 transferred to the ED via ambulance for vomiting and gastrostomy complication. The provider further documented, Patient presents with ongoing emesis and earlier had removed his G-tube and it was replaced by the nurse and now his abdomen hard: emesis secondary to G-tube malfunction. A Hospitalist note dated 1/12/25 documented, in part: .G tube replaced yesterday, and later he appeared to aspirate after vomiting. He was hypoxic on EMS arrival and in ER, required 6 L [oxygen] per NC [nasal cannula - a tube used to deliver oxygen]. He was later switch to oxymask [mask used to provide a broad range of oxygen concentrations] as he was breathing through his mouth . Reviewed pt hx [history] with SNF [Skilled Nursing Facility] nurse. Prior tube was noted to be leaking, so new tube was placed. He received approximately 50 ml of feeding and was noted to vomit and possibly aspirate . G tube was noted to be displaced, reviewed imaging with radiologist who reevaluated placement on CT [scan] and distal end of tube was in esophagus with balloon inflated in distal esophagus with tip facing superiorly [aimed towards the head]. Confirmed with x ray with gastrografin [contrast agent used for x-rays] via tube per radiology recommendation. Tube was initially withdrawn and reimaged. General surgery was consulted and replaced foley tube that was present with MIC-KEY tube [a low-profile gastrostomy feeding tube] . A hospital discharge summary dated 1/13/25 reiterated a foley catheter was placed in R1's gastrostomy site at the facility and R1 began vomiting and became short of breath with presumed aspiration after vomiting. The summary documented, in part: .Given the patients age and comorbidities, as well as acute illness with hypoxia and respiratory distress .discussion was held with the patent's brother who is [R1's] active POA (Power of Attorney) regarding plan and goals of care. [R1's brother's name redacted] opted to keep [R1]comfortable . [R1] has intermittently taken Ativan and morphine via IV to help with comfort and dyspnea which have been effective . A nurse's note entry on 1/12/25 at 2:44 PM CT documented a discussion between a facility nurse and a nurse from the hospital. The nurse's note documented R1 was expected to return to the facility on [DATE] and was being placed on comfort measures. R1 returned to the facility on comfort measures on 1/13/25 with a MIC-KEY in place. An untimed re-admission progress note dated 1/13/25 documented, in part: .Patient was readmitted to [name of facility redacted] 2nd floor Nurses station on 1/13/25 from [name of hospital redacted] at 4:05 PM [CT] via [name of ambulance transport redacted] following a 3-day stay related to aspiration pneumonia and complications of gastrostomy Tube. Rehabilitation Potential is poor related to monitoring of G-tube and pneumonitis [inflammation of the lungs] status . A nurse's note by RN J dated 1/16/25 at 8:54 PM CT documented as late entry for 1/11/25, read in part: . fluid coming from around g-tube site. Tube feeding was stopped. Existing tube was removed without difficulty . New g-tube/catheter was inserted .balloon inflated .Tube feeding was again restarted. Re-entered room to observe resident vomiting a white/pink opaque liquid .Telehealth was contacted . Returned to room, placement was verified via auscultation, Zofran was administered .Within 5 minutes, nursing assistant was calling for nurse, upon entering room, resident was vomiting same white/pink opaque liquid. Suctioning immediately started. SpO2 [oxygen saturation] at 82% RA [room air]. O2 [oxygen] applied via nasal cannula at 2 L [liters] and telehealth was contacted again, orders obtained to transfer resident to local ED to eval (evaluate) and imaging for proper g-tube placement . R1's EMR did not contain documentation by RN J on 1/11/25 of the circumstances surrounding the feeding tube concerns that resulted in R1 being transferred to the hospital on 1/11/25. Review of consecutive nurses' notes on 1/11/25 revealed an entry dated 1/11/25 at 5:09 PM CT documenting R1's feeding tube was flushed with 540 ml (milliliters) of water, 117.5 ml of liquid medications were provided through the feeding tube, and tube feeding was being administered at 55 ml per hour. The next nurse's note on 1/11/25 at 6:29 PM CT documented a PRN (as needed) medication was administered through the feeding tube. The following progress note at 8:10 PM CT documented Duoneb had been withheld. Subsequent nurses' note entries on 1/11/25 included R1's vital signs and notation R1 was transferred to the ED on 1/11/25 at 10:05 PM for hypoxia (low oxygen level), persistent emesis, low heart rate, and congestion throughout the lung fields. A nurse's note entered on 1/11/25 at 10:28 PM documented R1 had a pulse of 42 (beats per minute), a respiratory rate of 24 (breaths per minute), and an oxygen saturation of 82% on room air, for which supplemental oxygen at two liters per minute was administered. On 2/25/25 at 3:18 PM, R1 was observed lying in bed with labored, rapid respirations. R1 had audible rhonchi (gurgling sounds) with inhalation and expiration. A tube feeding pump was next to R1's bed without tube feeding connected. Review of R1's Electronic Medical Record (EMR) revealed admission to the facility 1/22/99 with a primary diagnosis of cerebral palsy. The EMR documented R1 was unable to consume foods or fluids orally and required enteral feeding for nutrition and hydration through a gastrostomy tube (G-tube, a tube placed through the abdominal wall into the stomach for delivery of food, fluid, and medications). A quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R1 was nonverbal and had short-term and long-term memory impairment. A Brief Interview for Mental Status (BIMS) could not be completed due to R1 never being understood. The MDS coded R1 as being dependent on staff for all activities of daily living. RN J was interviewed on 2/26/25 at 10:14 PM. RN J said R1 pulled his feeding tube out on 1/11/25 at approximately 4:30 PM CT so RN J replaced the tube with a 16 French foley catheter (catheter with diameter of 5.3 millimeters) with a 30-cc balloon. RN J said placement of the tube was verified through auscultation (listening with a stethoscope) using air injected from a piston syringe into the tube. When asked if residual was checked, RN J said it was but could not recall the amount of residual. RN J said after the tube was inserted, medications were administered and R1's tube feeding was started. RN J said about an hour after starting tube feeding, R1 was observed with a foam-like substance coming from the mouth. RN J alleged R1 was suctioned, the tube feeding was stopped, and the telehealth provider was notified. RN J said instruction was received by the provider to administer Zofran and Duoneb to R1, and to check placement of the tube after four hours and if all was good to restart the tube feeding. RN J said the Zofran was administered through the tube. RN J said about an hour after administering the medications, R1 commenced vomiting. The telehealth provider was contacted again, and orders were received to transfer R1 to the hospital ED. RN J said that on 1/13/25 or 1/14/25 the Director of Nursing (DON) asked about the situation and events with R1 on 1/11/25. RN J said the DON directed her to enter documentation about the event in R1's EMR. RN J acknowledged not documenting the situation on 1/11/25 with R1 until 1/16/25, five days after the events that lead to R1 being transferred and admitted to the hospital. RN J said there was no provision or offer of teaching or training in response to the event with R1 on 1/11/25. RN J was asked if training or competency evaluations on changing a feeding tube or inserting a urinary catheter in lieu of a gastrostomy tube had ever been conducted. RN J responded, No - we don't really have training, just online videos we watch unless there's something out of the ordinary like wound vacs. RN J acknowledged never receiving training or competency evaluations for changing a gastrostomy tube or inserting a urinary catheter as a feeding tube. The education and training records and the competency evaluations for RN J were reviewed on 2/26/25 and revealed no education or competencies for changing a gastrostomy tube or inserting a catheter to be used as a gastrostomy tube. Licensed Practical Nurse (LPN) K was interviewed on 2/27/25 at 8:15 AM. LPN K indicated they had [AGE] years of employment at the facility. LPN K said R1 had been in the facility since the 1990's and had used a catheter as a feeding tube for many years. LPN K said nurses had been changing R1's catheter for years. LPN K said another floor nurse showed LPN K how to change the catheter but confirmed never receiving training, or competency checks for inserting the catheter as a feeding tube. LPN K said R1 had a history of pulling the catheter causing it to become dislodged. LPN K stated a securement device had never been used to stabilize the catheter to keep R1 from causing the tube to become dislodged. LPN K said the facility did not have securement devices. LPN K said R1 had a MIC-KEY tube now and if the MIC-KEY comes out they will need to send R1 to the hospital because the nurses cannot change MIC-KEY tubes in the facility. Unit Manager/RN L was interviewed on 2/27/25 at 8:21 AM. RN L said the facility completed competency evaluations on nurses but the competencies did not include changing of gastrostomy tubes or inserting a catheter as a feeding tube. RN L denied receiving training or competency evaluations on changing of gastrostomy tubes or inserting a catheter as a feeding tube. RN L said securement devices were not used in the facility with G-tubes or with catheters used as feeding tubes. When asked about changing a MIC-KEY tube, RN L said, We don't change MIC-KEY tubes - that's done in the hospital. The education and training records and the competency evaluations for LPN K and RN L were reviewed on 2/27/25 and revealed no education or competencies for changing a feeding tube or inserting a catheter to be used as a gastrostomy tube. The Director of Nursing (DON) was interviewed on 2/27/25 at 11:42 AM. The DON said she was notified by a hospitalist about the catheter being identified in R1's esophagus with the balloon inflated. The DON said she reviewed the facility policies and determined the policy was followed because tube placement was verified according to the documentation. When asked to which documentation she was referring, the DON replied the nurse signed out verification of tube placement on the TAR (Treatment Administration Record). The DON said an investigation was not completed but acknowledged speaking to RN J after being called by a hospitalist the day R1 returned to the facility (on 1/13/25). The DON acknowledged instructing RN J to enter the documentation into R1's EMR. When asked if she had any concerns with the catheter found lodged in R1's esophagus with a 30 ml balloon inflated and subsequent blood-tinged emesis and hypoxia, the DON responded, I think the tube got in his esophagus when he aspirated. The DON confirmed R1 had not been assessed by a gastroenterologist to determine if a urinary catheter in lieu of a feeding tube was beneficial to R1. The DON confirmed R1's physician had no recent documentation for the reason a urinary catheter was used as a gastrostomy tube. The DON said if the physician had documented the risk versus benefit of using a urinary catheter in place of a gastrostomy tube it was years ago. No physician documentation was provided by the end of survey. When asked if any training or competency evaluation had been completed with RN J or the other nurses in the facility, the DON acknowledged no training or competency evaluations had been completed. The DON said nurse competencies should be completed yearly but the competencies did not include changing a feeding tube or inserting a catheter as a feeding tube. When asked why securement devices were not used with feeding tubes, including urinary catheters used as feeding tubes, to help secure the tubes in place and prevent dislodgment or migration of the tubes, the DON replied she did not know why securement devices weren't used. When asked if MIC-KEY tubes were replaced in the facility, the DON replied, We can. We have a policy. The DON did not provide a response when asked if nurses had been trained and competency evaluated on changing MIC-KEY tubes. R1's January 2025 TAR was reviewed and did not reveal documentation by RN J that catheter placement was verified on 1/11/25. The Facility Assessment (FA) dated 1/2025 documented tube feeding as one of the services and cares offered at the facility. The section of the FA for nurse education did not include changing feeding tubes or inserting urinary catheters for use as feeding tubes. R1's physician's orders with start dates after readmission on 1/13/25 were reviewed on 2/27/25. The orders were signed by R1's physician on 1/16/25 at 8:52 AM CT and contained an active order: Change G tube foley catheter 16 Fr with 30 cc balloon **MUST USE LATEX CATHETER** 1 X [time] month 2nd Sat [Saturday]. The physician's orders did not include an order for comfort care. The physician's orders did not include an order for a MIC-KEY tube. R1's care plan provided by the facility contained handwriting at the top of the first page that read; Readmit 1/13/25 reviewed no changes. The care plan did not include the use of the MIC-KEY or interventions to ensure placement of the tube or to direct staff what to do in the event the MIC-KEY was dislodged. A radiology technician from the facility's contracted provider of radiology services was interviewed on 2/28/25 at 9:06 AM. The technician confirmed the company he worked for provided mobile x-ray services for the facility. The technician said their services cover abdominal x-rays for verification of feeding tube placement. The technician said the facility was visited twice monthly or as needed at any time to provide x-ray services when needed and ordered by the physician. The DON was asked on 2/28/25 at 10:31 AM if the Medical Director was aware the nurses in the facility had not been trained and competency-evaluated on changing feeding tubes or the insertion of catheters in lieu of feeding tubes. The DON said the Medical Director was not aware. When asked about the expectations with care plans documenting interventions for the care and maintenance of feeding tubes, the DON said, There should be something in there. According to ASPEN (American Society for Parenteral and Enteral Nutrition) Safe Practices for Enteral Nutrition Therapy, Journal of Parenteral and Enteral Nutrition located at https://aspenjournals.onlinelibrary.[NAME].com/doi/10.1177/0148607116673053 and The National Library of Medicine, Chapter 17, 17.1. Enteral Tube Management found at www.ncbi.nlm.nih.gov/books/NBK593216/ Assessing Tube Placement: .Feedings or medications administered into an incorrectly placed enteral tube result in life-threatening aspiration pneumonia. The placement of an enteral tube is immediately verified after insertion by an X-ray to ensure it has not been inadvertently placed . After X-ray verification, the tube should be marked with adhesive tape and/or a permanent marker to indicate the point on the tube where the feeding tube enters the nares or penetrates the abdominal wall. This number on the tube at the entry point should be documented in the medical record and communicated during handoff reports. At the start of every shift, nurses evaluate if the incremental marking or external tube length has changed. If a change is observed, bedside tests such as visualization or pH testing of tube aspirate can help determine if the tube has become dislocated. If in doubt, a radiograph should be obtained to determine tube location Older methods of checking tube placement included observing aspirated GI contents or the administration of air with a syringe while auscultating (commonly referred to as the whoosh test). However, research has determined these methods are unreliable and should no longer be used to verify placement . The facility policy Tube Feeding dated as effective 3/2024 read, in part: Purpose: To ensure that staff providing care and services to the resident via a feeding tube are aware of, competent in and utilize facility protocols regarding feeding nutrition and care. Feeding tube care and services will be provided in accordance with resident needs and professional standards of practice . Prior to flushing the feeding tube, the administration of medication or providing tube feedings the nurse verifies the proper placement of the feeding tube by . a. Draw up 30 ml of air into a 60 ml syringe . c. Attach the syringe to the tube and inject the 30 ml of air into the feeding tube auscultating for placement . The policy did not include x-ray verification for placement after placing an enteral tube, the marking and documentation of the tube entry point, measuring of tube length, or bedside tests of aspirate if tubes are dislodged. The policy Care of Resident with Gastrostomy Tube dated as effective 3/2024 read, in part: .6. Secure tube with tape to prevent displacement of tube . The Immediate Jeopardy that began on 1/11/25 was removed on 2/28/25 when the facility took the following actions to remove the immediacy: 1. Affected Resident(s) / Other residents at risk: Resident R1 no longer has a foley catheter as a G-tube. The resident returned from the hospital with MIC-KEY low-profile tube in place. On February 27, 2025, the physician clarified that the orders to change the G-tube if plugged or compromised in any way is to be done at the hospital. The nurses are not to change the tube. 2. For current and new residents, On February 27, 2025 all residents receiving tube feeding were assessed for the presence of a G-tube. Only one was identified. [Resident reference redacted] On February 27, 2025 the physician clarified that the orders to change the G-tube if plugged or compromised in any way is to be done at the hospital. The nurses are not to change the tube. On February 28, 2025 the physician ordered Xray verification of the placement of current feeding tube to set a baseline for measuring. The facility's policies Gastric Tube Feeding and Policy and Procedure: Tube Feeding has been amended that the resident will be sent to the ED for replacement and measurements will be done to verify placement prior to medication administration, water flush, or start of formula. Also to notify the physician for any abnormalities including dislodging. The facility policy Insertion on indwelling catheter for gastric feeding has been removed. 3. All nursing staff working day shift have been educated on the policy changes and competency tested for measuring as of February 28, 2025.

Based on observation, interview, and record review, the facility failed to provide treatment, services, and equipment to maintain and/or prevent avoidable reduction in Range of Motion (ROM) for one Resident (R76) of one resident reviewed for mobility. This deficient practice resulted in harm with incorrect application of a back brace and worsening of R76's L1 (spinal) compression fracture. Findings include: All times noted are Eastern Standard Time (EST) unless otherwise noted. During an interview on 2/25/25 at 3:34 p.m., when asked about any care concerns while residing in the facility, R76 stated, I was sent to a specialty (neurosurgery) appointment on Wednesday, 2/21/25 and they told me that my back has gotten worse because I have not been wearing the back brace correctly. I didn't know how to place the brace on . They (facility staff) should have known how to put the back brace on correctly. R76 said the therapist didn't know the back brace was applied incorrectly either. R76 stated, Now I may have to spend another three months in the nursing home because the brace was incorrectly applied. During an observation at this same time, R76 was wearing a black body brace, that surrounded her abdominal/back area as she reclined on the bed. Two black straps attached the front of the brace to the back over each shoulder. The top of the front body section appeared to be pushed up with no space present between R76's breasts and the top front of the brace. R76's Family Member (FM) E was present in the room at the time of the interview/observation, and confirmed the information provided by R76. Review of R76's Minimum Data Set (MDS) assessment, dated 1/27/25, revealed an admitted [DATE], with active diagnoses that included the following, in part: fractures and other multiple traumas, seizure disorder, anxiety, and collapsed vertebra. R76 scored 15 of 15 on the Brief Interview for Mental Status (BIMS), reflective of intact cognition. Review of R76's 1/16/25 hospital admission documentation revealed the following, in part: . recently diagnosed with L1 vertebral compression fracture in the emergency room . discharged home with pain control, who then re-presented to the ED (emergency department) with ongoing severe back pain on 1/16/25 and was admitted to the inpatient medical/surgical unit for intractable pain due to L1 vertebral compression fracture . Active Problems: . L1 Vertebral Compression Frx (fracture), Intractable Back pain. Recent fall . L1 vertebral compression fracture with retropulsion (fracture moves backwards into spinal canal), Neurosurgery was contacted when [R76] was evaluated here in the emergency room earlier. Recommended TLSO (thoracic-lumbar-sacral brace used to limit motion in the thoracic, lumbar and sacral regions of the spine) to be worn whenever [R76] was not lying down . should have on whenever [R76] was sitting up in bed, sitting in a chair, or up and ambulating . Review of R76's Physician Orders documented on the February 2025 MAR (Medication Administration Record)/TAR (Treatment Administration Record) between 2/1/25 and 2/26/25, revealed no physician order was present related to the use of R76's TLSO back brace. Review of a Neurosurgery Clinic Appointment: 2/21/2025 for Diagnosis: L1 Compression fracture, revealed the following report details completed by [Practitioner G]: Progress: Patient fracture has significantly worsened from 50% height loss to about 90% height loss, most likely due to brace not being placed or worn appropriately. Will need to continue to monitor for changes and/or worsening symptoms. Patient brace will need to continue for a minimum of 3 months from todays appt. (appointment). PLAN: Restrictions: No bending, twisting, pulling, no lifting > (greater than) 5 lbs. (pounds). Brace needs to be on at all times when head is greater than 30 degrees. Referral to Physical therapy gait, balance and mobility only . Reviewed with patient that if symptoms change, worsen, or new symptoms develop to call the clinic to be seen sooner. Patient also educated on red flag symptoms and if they develop patient should be seen through the ED and not wait for an appointment. During a telephone interview on 2/26/25 at 10:15 a.m., Medical Assistant (MA) H ,from the Neurosurgery Clinic appointment attended by R76 on 2/21/25, acknowledged being present during the appointment. MA H stated, .From what I recall the brace (TLSO back brace) was loose. I don't know if it was [R76] or the nursing staff (that applied the brace). It was not on as tight as it should have been. MA H said patients are usually instructed on how to apply the brace. R76 had not received the brace from the Neurosurgery Clinic, and MA H was unsure who had instructed R76 on how to put it on . MA H stated, Typically it is the responsibility (of the facility) to make sure that the brace was fitted properly. MA H said he would not have placed the responsibility of making sure the brace fit properly onto R76 as their back injury was recent. During a telephone interview on 2/26/25 at 2:03 p.m., Occupational Therapist (OT) B said R76 came to the facility with the back brace which was provided at the hospital. OT B stated, She has kind of a large abdominal area so it would ride right up on her . because of how [R76] was shaped it was hard to get it tight . when [R76 ] was sent to the Neurosurgery Clinic (on 2/21/25) they wanted it tightened more . (there are) pictures (taken at the Neurosurgery Clinic) in the closet to make sure it was tighter. During a repeat in-person interview on 3/4/25 at 12:00 p.m., when asked if OT B had provided education on R76's back brace to nursing staff and CNAs, OT B stated, No, I did not. When asked if any documentation of R76's refusal to all staff to assist with the back brace had been found OT B stated, I looked for the documentation, but I did not find it. OT B said they understood this Surveyors concerns related to the lack of education and assistance to R76 with a back brace provide to aid in healing the Resident's L1 compression fracture. During a second interview on 2/27/25 at 8:42 a.m., R76 was asked about staff assistance with the correct application of the TLSO back brace. R76 stated, When I first came to the facility, I put the (back) brace on. I thought it was on right. R76 stated she was not educated on use or application of the back brace in the hospital, nor did OT B (in the nursing home facility) come up and tell her how the brace should be used when [R76] arrived at the facility on 1/21/25. R76 stated, No, they were not helping me (with the back brace) before I went to [the Neurosurgery Clinic] . OT or PT (physical therapy) never came in and said I was wearing the brace incorrectly. During an interview on 2/27/25 at 8:45 a.m., when asked about the provision of assistance to R76 in putting on the back brace, Licensed Practical Nurse (LPN) M stated, We (nursing staff) were not instructed (how to apply/adjust the back brace). There was no education on how to apply it. R76's Family Member (FM)/Restorative Certified Nurse Aide (CNA) T, who went to the Neurosurgery appointment (on 2/21/25) with R76, provided pictures from the doctor on how to put the brace on. CNA T stated, R76 was not even provided education on the brace (when she received it at the hospital) . I was not instructed to assist [R76] with the brace or how to adjust the brace . During an interview on 2/27/25 at 8:50 a.m., when asked if they had provided assistant to R76 in application of the back brace , CNA U said she did not help the resident with any adjustment of the back brace prior to the appointment (between 1/21/25 and 2/21/25) at the Neurosurgery Clinic on 2/21/25. CNA U said no education had been provided to CNA staff, by the facility, regarding R76's back brace, and CNA U was unaware that any assistance with the brace was required for R76. Review of R76's Nurse Notes from admission 1/21/25 through 2/26/25, revealed the following documentation related to R76's back brace and level of assistance required: 1/21/25 - DRESSING . requires staff assist to don brace and fasten. RESIDENT NEEDS: assist with fasteners . 1/21/25 - UPPER BODY DRESS substantial/maximal assistance. 1/22/25 - UPPER BODY DRESS substantial/maximal assistance. 1/23/25 - UPPER BODY DRESS setup or clean-up assistance. 1/25/25 - DRESSING Requires one aide assist for dressing . RESIDENT NEEDS: requires staff assist for brace fastening. Evaluation: Dressing ability is unchanged. 1/26/25 - UPPER BODY DRESS partial/moderate assistance . 1/27/25 - UPPER BODY DRESS supervision or touching assistance. 2/8/25 - UPPER BODY DRESS substantial/maximal assistance assist with brace. 2/21/25 - PHYSICIAN VISIT (specialty clinic) .PT - gait, balance, mobility only. Restrictions: no bending, twisting, pushing, pulling, no lifting >75 # (75 pounds) . Brace on at all times when HOB>30 degrees . Review of the type-written physician instructions from the 2/21/25 Neurosurgery Clinic appointment clearly documented .no lifting > 5 lbs. Review of the ADL (Activities of Daily Living) policy, last approved 3/2024, revealed the following, in part; It is the policy of this facility to provide ADL cares to residents to ensure all ADL needs are met on a daily basis. 1. Each Resident's physical functioning will be assessed in accordance with the facility's assessment procedures . 3. The level of assistance needed for any ADL activity will be included on the Resident's plan of care . 8. The care plan interventions will be monitored on an ongoing basis for effectiveness and will be reviewed or revised as necessary . Residents that refuse ADL care, verbalize discomfort or concerns during care must be documented in the residents' medical record and reported to the nurse. Review of R76's Care Plans, received 2/26/25 at approximately 3:13 p.m., related to the TLSO back brace included the following: Title: Activities of Daily Living. Problem: Potential for ADL deficit, Potential for falls/injury. Potential for altered skin integrity, Potential for discomfort. Related to: Discomfort due to recent fall resulting in an L1 wedge compression fx (fracture) .decreased independent mobility, use of back brace . Other Areas of Concern: Potential for Altered Skin Integrity: . Monitor under back brace . The two mentions of R76's back brace were the only information related to the required back brace in all of R76's care plans. No instructions for use, assessment for correct usage, when the brace was to be worn, or level of assistance necessary for application of the back brace were present in R76's care plans. No physician order was present in R76's physician order summary. Review of R76's CNA closet sheet, retrieved on 2/27/25 at 8:42 a.m., revealed a listing of care instructions to the CNA's regarding the following care areas: alarms, ambulation, positioning, eating, transfers, devices (such as braces), toileting, briefs, and bathing. The Devices - Braces and Splints boxes were unchecked, indicating R76 did not have any brace or splint that was used. Review of the CNA Assignment Card, dated 2/3/25 at 11:28 a.m., provided no guidance in the level of assistance or proper application of R76's back brace. The exact references to R76's back brace (2 mentions) found in the care plans were also found on the CNA Assignment Card. No additional instructions regarding the back brace were present. During an interview on 2/27/25 at 10:41 a.m., a copy of the manufacturer's instructions for use for the TLSO back brace worn by Resident R76 since their 1/21/25 admission to the facility was requested. A copy of the manufacturer's instructions for the [Name Brand] TLSO back brace was provided electronically to this Surveyor on 2/27/25 at 12:15 p.m., downloaded from www.Manualslib.com manuals search engine via the internet. The DON acknowledged the manufacturer instructions for the back brace were retrieved electronically and had not been available for staff review and/or use prior to that day. Review of the [Name Brand] TLSO instructions, copyright 2018, revealed the following, in part; .Warnings: Carefully read use/care instructions and warnings prior to use. If increased pain, swelling, sensation changes, or any adverse reactions are experienced while using this product immediately consult your medical professional . The instructions included modifications for use including methods of trimming, heat forming, placement and proper application. During an interview on 2/27/25 at 11:21 a.m., Restorative Aide (CNA) T, also FM of R76 was asked about R76's back brace. CNA T said R76 came to the facility with the back brace from the acute care hospital, without instructions. CNA T stated, When she was in the ER, and she first broke her back . they put the brace on [R76]. I was there and they didn't tell us, they didn't tell her how to use the brace (back brace). Three days later [R76] could not get out of bed, and she was back in the hospital. They never showed her or me how to use the brace. Toward the end of January, she came to the facility. Nobody (in the facility) knew how to use the brace . To be honest I didn't know how to use it. When I went to [the Neurosurgery Clinic on 2/21/25], we were in with the doctor. and I asked about the purpose of this brace if it (was) loose. [Practitioner] G said it was not being worn right. I asked her to physically show me how this brace was supposed to be. I came back here, and I showed the nurse . If you would have seen [R76] with the brace it just looked loose. The more I kept looking at it, I asked what good is this if it is not supporting her back? [Practitioner G] told me and [R76] the brace was not being worn properly. I didn't know how to adjust the brace before we went to [the specialty clinic]. You would have thought the hospital would have shown me and [R76] and sent directions here. I don't work on the hall. I work in therapy. I don't think anybody knew what to do with the brace. I even showed therapy . We didn't come (to the facility) with any instructions. I feel bad that things got worse (deterioration of L1 compression fracture). There was no educational session (for facility staff) related to the back brace (before we went to the specialty clinic on 2/21/25). During an interview on 2/27/25 at 2:09 p.m., the Director of Nursing (DON) was asked to provide any documentation regarding training of staff as it pertained to R76's care and assistance with the back brace. Asked for all or any information that shows the facility was educated and prepared to care for and provide assistance to R76 with the back brace upon admission. During an comprehensive interview on 2/28/25 at 8:50 a.m., the DON was asked to review R76's Nurse Notes specific to admission on 1/21/25 where UPPER BODY DRESS showed substantial/maximal assist. The DON reviewed the Nurse Notes and said that information was part of supplemental section GG charting for R76's MDS assessment, specific to ADLS. The DON agreed R76 would have required maximal assistance with the TLSO back brace. After review of R76's Kardex (CNA care guide), the DON confirmed the back brace was not included on the Kardex. The DON acknowledged R76's back brace instructions/interventions were not present on the At a Glance form in the resident's closet, the CNA care plan in the resident's closet, R76's care plan, physician orders, or the TAR (treatment administration record). The DON agreed the back brace should have had a physician order that was placed on the TAR upon R76's admission. The DON also agreed there should have been more details related to use of the back brace in R76's care plans. The DON stated, I think we depended upon therapy a little too much . We were relying on therapy to provide us with that input. The DON also confirmed a Mitigating Risk form had been completed following the 2/21/25 specialty appointment, related to R76's improper usage of the back brace, although no documentation was found in the medical record of R76's refusal of assistance with the back brace, or failure to wear the brace properly. The Mitigating Risk form was received electronically on 2/26/25 at 3:12 p.m., unsigned and undated. The DON expressed understanding of this Surveyors concern with reliability of the Mitigating Risk form. The DON also acknowledged facility nursing staff, including CNAs did not receive education regarding the correct use of R76's back brace and were unaware of the level of assistance required for therapeutic use of the TLSO back brace in treatment of R76's L1 compression fracture.

All times are in Eastern Daylight Time (EDT) unless otherwise noted. Based on interview and record review, the facility failed to offer and provide pneumococcal vaccinations to three Residents (#28, #44 & #1) of five residents reviewed for immunizations. This deficient practice resulted in R28 being hospitalized for pneumonia and subsequently expiring from pneumonia-associated complications. Findings include: Resident #28 (R28) R28 was admitted to the facility [DATE]. An annual Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 00 indicating R28 had severe cognitive impairment. R28's diagnoses included a primary medical condition of non-traumatic brain dysfunction. There were no pulmonary diagnoses, supplemental oxygen use, nor infections documented in the MDS. Section O documented the pneumococcal vaccination for R28 was up to date. A nurse's progress note in R28's Electronic Medical Record (EMR) dated [DATE] at 7:08 PM CT (Central Time) documented R28 had developed respiratory symptoms over the previous ,d+[DATE] hours. The symptoms included cough, congestion to both lungs, low oxygen saturation, and the need for supplemental oxygen use. R28 was transferred to the hospital Emergency Department (ED) on [DATE] and diagnosed with right upper lobe pneumonia. R28 was admitted to the hospital for treatment of the pneumonia. A hospitalist's discharge summary dated [DATE] documented, in part: . resides at [name of facility redacted] found unresponsive on ,d+[DATE] [2025] by nursing staff. Pt [patient] was hypoxic [low oxygen level] with SpO2 [oxygen saturation] 87% on RA [room air], and she had a temperature of 100.4 [degrees Fahrenheit]. ED findings with fever, altered mental status, and hypoxia. She was found to be dehydrated .CXR [chest x-ray] showed right upper lobe pneumonia . R28 returned to the facility on [DATE] but continued to experience a decline in respiratory status and overall health condition resulting in a significant change MDS assessment being completed on [DATE] for decline in Activities of Daily Living (ADL), use of supplemental oxygen, and weight loss. The significant change MDS documented the primary medical condition as debility, cardio-respiratory condition, with pneumonia and use of supplemental oxygen. A progress note in R28's medical record dated [DATE] at 1:56 PM CT documented the physician did not want to pursue a chest x-ray. The note read, in part: . resident is exhibiting end stage respiratory issues brought on by acute pneumonia . R28 was placed on comfort measures, was started on Morphine and oral medications were discontinued on [DATE]. R28 was documented as deceased on [DATE] at 7:25 PM CT. The Michigan Care Improvement Registry (MCIR - an official state of Michigan Immunization record) for R28 was reviewed on [DATE]. The MCIR documented the following instruction to the provider (facility): Assessment indicates that the vaccinations are overdue and should be administered today if not medically contraindicated. The MCIR listed the PCV20/PCV21 (pneumococcal vaccines) were overdue to be administered as of [DATE]. A pneumococcal vaccination consent form documented as updated on [DATE] was provided by the facility for R28 and was signed by R28's guardian on [DATE]. The consent form only covered consent for the pneumococcal vaccines PPSV23 and PCV13. The PCV20 and PCV21 vaccines were not included on the consent form. The PCV13 vaccine is no longer recommended by the Centers for Disease Control (CDC) for routine use among adults aged 65 and older as of [DATE] (www.cdc.gov/mmwr/volumes/68/wr/mm6846a5.htm). The PCV20 was recommended by the CDC starting [DATE], and would have been the vaccine available for administration when R28 became due for the pneumococcal vaccination on [DATE] (www.cdc.gov/mmwr/volumes/72/wr/mm7239a5.htm). The PCV21 was added as a vaccine option and recommendation by the CDC starting [DATE] (www.cdc.gov/mmwr/volumes/73/wr/mm7336a3.htm?s_cid=mm7336a3_w). There was no documentation found in the EMR or provided by the facility indicating the PCV20 or PCV21 vaccinations were ever offered to R28's guardian. The Infection Preventionist (IP) was interviewed on [DATE] at 3:40 PM. The IP said no additional consent forms for pneumonia vaccination could be found for R28. The IP said she was unable to locate documentation that R28 received the PCV20 or PCV21 vaccination or that R28's guardian was ever offered the PCV20 or PCV21 vaccination. Resident #44 (R44) R44 was admitted to the facility [DATE]. A quarterly MDS dated [DATE] documented R44's pneumococcal vaccinations were up to date. The MCIR was reviewed for R44 which documented R44 was overdue for pneumonia vaccination as of [DATE]. No documentation was found in R44's EMR indicating R44 or his resident representative was provided a consent form offering pneumococcal vaccination. No documentation was found or provided by the facility indicating R44 received the pneumococcal vaccinations as recommended. Resident #1 (R1): R1 was admitted to the facility [DATE]. A quarterly MDS dated [DATE] documented R1's pneumococcal vaccinations were up to date. The MCIR for R1 was reviewed for R1 which documented R1 was overdue for pneumonia vaccination as of [DATE]. No documentation was found in R1's EMR indicating R1 or his resident representative was provided a consent form offering the vaccination. No documentation was found or provided by the facility indicating R1 received the pneumococcal vaccination as recommended. The IP was interviewed on [DATE] at 5:05 PM. The IP confirmed there were no consents for pneumococcal vaccinations for the residents overdue or eligible for the vaccinations, including R44 and R1. The IP validated the consent form utilized by the facility was outdated and contained information for a vaccine that is currently unavailable and not recommended for use in adults. The IP confirmed the form did not include the recommended PCV20 and PCV21 vaccines. The IP confirmed the pneumococcal vaccinations were not administered as recommended, and appropriate consents had not been issued to residents or their representatives. The policy Influenza/Pneumococcal Vaccination Protocol dated as effective ,d+[DATE] read, in part: . All residents residing in the Facility are eligible to receive a pneumococcal vaccination if they meet the CDC recommended criteria . The standard recommended dose will be given after appropriate consent is received .

All times are in Eastern Daylight Time (EDT) unless otherwise noted. Based on interview and record review, the facility failed to ensure licensed nurses had the knowledge, competencies, and skill sets to replace the feeding tube of one Resident (#1) of one resident reviewed for nurse training and competency for feeding tube replacement. This deficient practice resulted in R1 being admitted to the ICU when the feeding tube was found to be lodged in R1's esophagus with the balloon inflated. Findings include: Resident #1 (R1) According to the EMR, R1 was transferred to the Emergency Department (ED) on 1/11/25 and was admitted to the ICU with aspiration pneumonia (an infection that occurs after a large amount of food or liquid is breathed into the lungs) after Registered Nurse (RN) J inserted a urinary catheter in his gastrostomy site. A radiology examination in the hospital on 1/12/25 at 12:38 AM CT revealed the balloon portion of the urinary catheter was inflated within R1's esophagus. R1 was placed on comfort measures and returned to the facility on [DATE]. Review of R1's Electronic Medical Record (EMR) revealed admission to the facility on [DATE]. The EMR documented R1 was unable to consume foods or fluids orally and required enteral feeding through a gastrostomy tube (G-tube, a tube placed through the abdominal wall into the stomach for delivery of food, fluid, and medications) for nutrition and hydration. Physician's orders for R1 included an order with a start date of 3/26/23 to change R1's feeding tube monthly using a 16 French urinary catheter (catheter with diameter of 5.3 millimeters). During an interview with Registered Nurse (RN) J on 2/26/25 at 10:14 PM, RN J said there was no teaching or training done in response to the event with R1 on 1/11/25. RN J was asked if training or competency evaluations on changing a feeding tube or inserting a urinary catheter in lieu of a gastrostomy tube had ever been conducted. RN J responded, No - we don't really have training, just online videos we watch unless there's something out of the ordinary like wound vacs. RN J acknowledged never receiving training or competency evaluations for changing a gastrostomy tube or inserting a urinary catheter as a feeding tube. Licensed Practical Nurse (LPN) K was interviewed on 2/27/25 at 8:15 AM. LPN K stated they had been employed at the facility for [AGE] years. LPN K said R1 had been in the facility since the 1990's and had used a catheter as a feeding tube for many years. LPN K said nurses had been changing the catheter for years. LPN K said another floor nurse showed LPN K how to change the catheter but admitted to never received training, or competency checks for inserting the catheter as a feeding tube. Unit Manager/RN L was interviewed on 2/27/25 at 8:21 AM. RN L said the facility completed competency evaluations on nurses, but the competencies did not include changing of gastrostomy tubes or inserting a catheter as a feeding tube. RN L denied receiving training, competency evaluations on changing of gastrostomy tubes, or training on inserting a catheter as a feeding tube. During an interview with LPN M on 2/27/25 at 8:27 AM, LPN M said she watched another floor nurse insert a urinary catheter as a feeding tube, but the nurse no longer worked at the facility. LPN M said no other training was provided but competency was evaluated upon hire over a year ago. The education, training records, and competency evaluations for RN J were reviewed on 2/26/25. The most recent date of hire for RN J was 1/3/24. There were no documented training, education, or competency evaluations for RN J for changing a feeding tube or inserting a catheter to be used as a feeding tube. The most recent competency evaluations for RN J were on 4/20/22 during a previous period of employment with the facility, but the competencies did not include changing a feeding tube or inserting a catheter as a feeding tube. The education, training records, and competency evaluations for LPN K were reviewed on 2/27/25. The date of hire for LPN K was 10/23/00. There were no documented training, education, or competency evaluations for LPN K for changing a feeding tube or inserting a catheter to be used as a feeding tube. The most recent competency evaluations for LPN K were on 4/19/22 but the competencies did not include changing a feeding tube or inserting a catheter as a feeding tube. The education, training records, and competency evaluations for RN L were reviewed on 2/27/25. The date of hire for RN L was 6/10/24. There were no documented training, education, or competency evaluations for RN L for changing a feeding tube or inserting a catheter to be used as a feeding tube. The most recent competency evaluations for RN L were on 5/13/23 but the competencies did not include changing a feeding tube or inserting a catheter as a feeding tube. The education, training records, and competency evaluations for LPN M were reviewed on 2/27/25. The date of hire for LPN M was 12/15/23. There was no documented training or education provided to LPN M for changing a feeding tube or inserting a catheter to be used as a feeding tube. There was no competency evaluations conducted for LPN M. The Director of Nursing (DON) was interviewed on 2/27/25 at 11:42 AM. When asked if any training or competency evaluation had been completed with RN J or the other nurses in the facility, the DON admitted no training or competency evaluations had been completed. The DON said nurse competencies should be completed yearly but the competencies did not include changing a feeding tube or inserting a catheter as a feeding tube. The Facility Assessment (FA) dated 1/2025 documented tube feeding as one of the services and cares offered at the facility. The section of the FA for nurse education did not include changing feeding tubes or inserting urinary catheters for use as feeding tubes.

All times are Eastern Standard Time (EST) unless otherwise noted. Based on interview and record review, the facility failed to complete a comprehensive facility assessment that included training required to meet the needs of the resident population, resulting in the potential for unidentified resources necessary to provide care and services to all 80 residents. Findings include. Review of the Facility Assessment (FA) last revised 1/2025, did not include training on resident rights, dementia care, behavioral health, ethics, and Quality Assurance Performance Improvement (QAPI). On 3/4/25 at 12:36 p.m., an interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) revealed competency/training did not include all the specific training required for the resident population within the facility assessment. The DON did not respond and the NHA acknowledged the facility needed to work on the facility assessment to include the required training for staff.

Based on observation, interview and record review, the facility failed to provide adequate supervision for one Resident (R42) of one resident reviewed unsafe wandering, resulting in R42 entering a second-floor stairwell unattended and the potential for falls and injury. Findings include: All times recorded in Eastern Standard Time (EST), unless otherwise noted. Review of the Minimum Data Set (MDS) assessment, dated 12/3/2024, revealed R42 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, osteoarthritis and macular degeneration. The MDS indicated R42 had severe cognitive impairment, was independent with wheelchair use and required supervision/touching assistance (helper provides verbal cures or touching/steadying assistance) for walking. During a telephone interview on 2/25/2025 at 3:36 p.m., Family Member (FM) O was asked if R42 had experienced any falls or unsafe wandering while residing in the facility. FM O reported she was alerted by facility staff of an incident when R42 entered a stairwell on the second floor unattended. FM O stated she was informed R42 was found on the second flight of stairs leading to the first floor entrance. FM O reported the event occurred within the past six months. FM O stated she was unsure how R42 was able to get into the stairwell without staff noticing. On 2/27/2025 at 12:05 p.m., R42 was observed seated in a wheelchair at a table in the Comfort Zone Unit dining area. Further observation revealed a position change alarm attached to the back of R42's wheelchair seat. The green activation light was observed lit up on the alarm, indicating the alarm was functioning. During an interview at the time of this observation, Certified Nursing Assistant (CNA) P reported R42 required standby assistance for walking and engaged in a walking activity with staff after meals. When asked if R42 exhibited exit seeking behavior, CNA P stated Oh, yeah. He has a wander guard [bracelet monitor that sounds an alarm when near doors equipped with sensors]. CNA P proceeded to point to a wander guard monitor bracelet attached to the wheelchair frame under R42's seat. When asked if R42 was wearing a wander guard bracelet on his body, CNA P confirmed R42 was not physically wearing a wander guard bracelet. CNA P confirmed R42 was able to walk independently but required supervision to ensure safety. Review of an incident report, provided by the Director of Nursing (DON) and dated 8/10/2024 at 2:56 p.m. Central Daylight Time (CDT), revealed the following: Date of Incident: 8/10/2024. Time of Incident: 11:20 [a.m. CDT]. Incident Type: Elopement attempt . Location: [NAME] emergency stairwell . resident was walking down the stairs . west fire exit door alarm sounded, resident's w/c [wheelchair] sensor pad [position change alarm] did not sound. Further review of the incident report revealed prior to being found in the stairwell, R42 was last observed by CNA Q seated in the Comfort Zone Unit dayroom at 10:00 a.m. CDT. According to the report, R42 was found by Licensed Practical Nurse (LPN) R in the west emergency stairwell at 11:20 p.m. CDT at which time R42 reported I need to get to the pharmacy before it closes. Review of R42's electronic medical record (EMR) revealed the following nursing note: 8/10/2024 [2:40 p.m. CDT] . Resident was observed walking down the stair well in the west hall exit. Wheelchair was on the [second] floor landing and resident was almost [two] flights down hanging onto both handrails . New sensor pad applied to [wheelchair]. During an interview on 2/27/2025 at 8:55 a.m., CNA Q recalled R42 being found in the west hall stairwell on 8/10/2024. CNA Q reported, prior to the incident, she last observed R42 seated in the Comfort Zone Unit dayroom. CNA Q stated she and another CNA left the dayroom to provide care to another resident and a third CNA assigned to the unit was off the unit on break. CNA Q reported she saw R42 walk by the door of the room she (CNA Q) was in and down the hall toward the unalarmed doors leading to the nurse's station and the west hall. CNA Q stated she was unaware R42 exited the unit and was found in the west emergency stairwell until staff brought R42 back to the Comfort Zone Unit dayroom around lunchtime. When asked if R42 was at risk for unsafe wandering, CNA Q stated R42 always hung out near the nurse's station and did at times state he was going home. During an interview on 2/28/25 at 9:41 a.m., the DON confirmed R42 exhibited exit seeking behaviors. The DON reported R42 resided on the second floor of the facility and often was found gazing out of windows looking for his car. The DON stated R42 was provided with a wander guard bracelet due to a history of R42 travelling unassisted to the ground floor (main entrance/exit floor) without staff knowledge. The DON agreed there was a risk of falls and injury related to R42 entering the stairwell without staff assistance but denied a risk of unsafe wandering due to the wander guard sensors placed at the main entrance/exit to the facility. The DON stated she was unaware the wander guard bracelet was attached to R42's wheelchair and not physically worn by R42, and acknowledged the wander guard sensors would not alarm if R42 physically walked out without the wheelchair. When asked how staff were made aware of residents at risk for unsafe wandering and elopement, the DON stated there was a binder listing residents names and photographs located at the first floor nurse's station, but not at the front desk or the second floor nurse's station, where R42 resided. The DON reported if R42 was observed to be near an exit door, staff should redirect the resident back to the Comfort Zone Unit. Review of R42's care plan revealed the following: 8/30/2022 . Potential for Elopement related to altered thought process. Manifested by . May inadvertently exit the unit, possibly with others . resident's whereabouts will be known at all times, assure that photo of resident is current and available to all staff . approach resident from the front slowly and calmly, gently guide back to a safe area, redirect conversation when resident speaks of going home, bring back into facility when found wandering outdoors unattended, assure wander guard is on resident' w/c . Review of the facility policy titled, Elopement - Wander Guard Transmitter, effective 3/2024, revealed the following: Residents that are assessed to be at risk for wandering or elopement shall have a wander guard transmitter applied to an extremity . Resident's care plan will be updated to include wander guard use and documented in [EMR] . Review of the facility policy titled, Elopement Procedure, effective 6/2024, revealed the following: Before admission, resident will be screened by the Nurse Manager/Social Services Designee to identify if they have a history of wandering. These identified residents shall have specific interventions to address wandering of [sic] elopement in their care plans. Depending on the severity of their condition and the availability of beds, residents assessed with risk for elopement may be transferred to the facility's special needs unit (Comfort Zone) for increased supervision and therapeutic activity.

This deficiency pertains to intake #MI00144437. All times are in Eastern Daylight Time unless otherwise noted. Based on interview and record review, the facility failed to utilize a process for accurate inventory and accounting of controlled substances for One Resident (R1) of three residents reviewed for controlled substances. Findings include: Resident #1 (R1) was on end of life, palliative care (comfort care focused on preventing and treating suffering). A Minimum Data Set (MDS) Assessment on 4/16/24 documented a score of 00 on the BIMS (Brief Interview for Mental Status), indicating R1 was severely cognitively impaired. R1 was prescribed Morphine Sulfate solution (a medication used to treat pain) 2-4 mg by injection every two hours as needed. According to a report filed with the State Agency, two vials of R1's Morphine were identified as missing from the medication cart on 4/30/24. The Nursing Home Administrator (NHA) was interviewed on 5/15/24 at 11:55 a.m. The NHA said she was notified by staff on 4/30/24 at 5:00 a.m. Central Standard Time (CST) about the missing medication. The NHA said a search of the facility was conducted on 4/30/24 but the missing vials of Morphine were not located. The NHA said continuous camera footage was reviewed and the last time the missing Morphine was observed being physically counted by nurses was on 4/24/24. The pharmacy delivery slip confirmed the delivery of twenty-five vials of Morphine Solution for R1 on 2/14/2024. The NHA asserted the floor nurses were the only individuals with keys and access to the medication carts. The NHA revealed the oncoming-shift nurses and off-going shift nurses were not counting controlled substances at shift change. The NHA said the nurses on the floor were counting the controlled substance inventory during their shift amongst themselves but were not validating the controlled substance inventory with the off-going nurse when the exchange of keys took place and the oncoming nurses assumed responsibility for the inventory from the previous shift's nurses. The NHA said the policy had been revised to include the verification of the controlled substance inventory was completed by the nurse coming on shift with the nurse going off shift. On 5/15/24 at 12:50 p.m., R1 was observed in her room lying in bed. R1 did not respond to questioning. On 5/15/24 at 2:05 p.m., The controlled substance inventory on the 200-unit east hall and the 200-unit west hall were validated with Licensed Practical Nurse (LPN) E. LPN E stated, We used to count the narcotics at some time during our shift but now we count with the nurse from the previous shift. It started sometime in May [2024]. LPN E was asked when the controlled substances were accounted for during the shifts prior to the new process. LPN E replied, it varied - there wasn't a set time. LPN C was interviewed on 5/15/24 at 2:55 p.m. LPN C said she and Registered Nurse (RN) H were the last nurses to verify the controlled substance inventory on 4/29/24 prior to the missing Morphine being identified on the next shift on 4/30/24. LPN C said she could not recall the time the medications were counted on 4/29/24. LPN C said on 4/29/24 she was sitting at the desk documenting on the declining inventory sheets while RN H visualized and inventoried the controlled substances in the medication cart. LPN C said RN H had the medication cart open and was counting the medications by herself while telling LPN C how many meds were there, and LPN C was writing the numbers RN H was telling her on the declining inventory sheet for each resident. LPN C said, I never even saw the medications in the cart. Phone calls were made to RN H on 5/15/24, and messages were left requesting a return call. RN H did not return the call as requested by the end of the survey. The facility's Consultant Pharmacist (RPh) was interviewed on 5/15/24 at 3:36 p.m. The RPh was asked if oncoming shift nurses are expected to verify the controlled substances inventory with the off-going shift nurses. The RPh replied, That goes without saying - it's a standard of practice. The RPh reiterated the nurse coming on-shift should be visually counting controlled substances with the nurse going off-shift to verify the accuracy of the number of controlled substances. The RPh produced an undated document labeled Control Substances with Facility. The document read, in part: . 8. Controlled substances are counted and agreed upon at shift change . The facility policy Controlled Substances dated 5/2024 read, in part: Purpose: The purpose of this policy is to assure [sic] safe and proper disposition of accounting for controlled substances .4. At the end of each shift, two nurses (outgoing nurse with oncoming nurse) together will count the amount of each controlled substance to ensure that [sic] it matches the amount of medication and number on the Certificate of Disposition form .

All times are in Eastern Standard Time (EST) unless otherwise specified. Based on interview and record review, the facility failed to ensure three alert and oriented residents (R12, R65, & R233) were afforded the opportunity to sign and determine their preferred code status out of four residents reviewed for advanced directives. This deficient practice resulted in the potential for residents to be unable to exercise medical related decisions regarding their care. Findings include: Resident #233 (R233) R233) was admitted to the facility on [DATE]. A Brief Interview for Mental Status (BIMS) examination was completed on [DATE] and identified R233 as cognitively intact, scoring 15 of 15 possible points. A Minimum Data Set (MDS) Assessment completed on [DATE] identified R233 as having no difficulties with comprehension of verbal content and no difficulties with the ability to understand others. There were no behavioral symptoms or mood concerns documented or identified in the Resident Assessment. R233's medical record did not reflect psychiatric history or concerns with R233's ability to understand and execute an advanced directive. R233 was not deemed incompetent to make her own decisions. R233's admission paperwork included a 5-page discharge summary document that contained post-hospitalization discharge information and instructions. The document was dated [DATE] and read, Code Status at Discharge: DNR (do not resuscitate). R233's medical record contained an Advanced Directive (AD) designating R233's daughter as power of attorney (POA) for health care. The AD was dated [DATE] and was signed by R233. The AD contained the signatures of 2 witnesses attesting to have personally witnessing R233 signing the AD. Section 3 of the AD outlined R233's choices and wishes if she were to become incapacitated. R233 indicated in Part 3.2, .this is my choice about CPR if my heart or breathing stops. I do not want CPR. Let me die a natural death. A facility code status document dated [DATE] was in R233's medical record. The form said, (R233) is a full code as there is no other legally executed document to indicate an Advance Directive designating any other code desire. The form was signed by the Nursing Home Administrator (NHA). The form did not contain R233's signature. There were no other signatures on the form. The NHA was interviewed on [DATE] at 11:12 a.m. The NHA said verbal conversations are held with alert and oriented residents when they are admitted to the facility regarding their choices for code status. When asked regarding documentation that R233 elected to be a full code instead of the signed DNR status documented in the POA paperwork, the NHA confirmed R233 had not signed any documentation at the facility regarding a choice in code status. When the discrepancy between the hospital paperwork and Advance Directive versus the facility code status form were pointed out to the NHA, the NHA responded the facility was reviewing the Advanced Directive process to make sure residents sign code status documents showing their preference for code status. Resident #65 (R65) R65 was admitted to the facility on [DATE]. A BIMS examination was completed on [DATE] and identified R65 as cognitively intact, scoring 15 of 15 on the examination. A MDS was completed on [DATE] and identified R65 as having clear comprehension. The MDS coded R65 as having no difficulties with comprehension of verbal content, and no difficulties with the ability to understand others. There were no behavioral symptoms or mood concerns documented or identified in the resident's assessment. R65's medical record did not reflect psychiatric history or concerns with R65's ability to understand and execute an advanced directive. R65 was not deemed incompetent to make his own decisions. R65's most-recent physician visit was dated [DATE]. R65's physician documented R65's cognition summary score was 15 (cognitively intact) and described R65 as alert and awake, oriented. R65's medical record contained an AD designating R65's brother as POA for health care. The document was dated [DATE] and was signed by R65. The AD contained the signatures of two witnesses. The AD included R65's wishes if he was to become incapacitated. The AD read in part, .I do not fear death itself as much as the indignities of deterioration, dependence, and hopeless pain. I request my agent to refuse or discontinue any medical treatment which will only prolong the process of my dying . I expressly authorize my health care agent to make decisions to withhold or withdraw medical treatment which would allow me to die, and I acknowledge such decisions could or would allow my death. The facility code status document in R65's medical record was dated [DATE]. The form read, (R65) is a full code as there is no other legally executed document to indicate an Advance Directive designating any other code desire. The form was signed by the previous NHA. The form did not contain R65's signature. There were no other signatures on the form. The NHA was interviewed on [DATE] at 2:43 p.m. The NHA confirmed the facility code status form conflicted with the information contained in R65's AD. The NHA confirmed the facility did not have any signed documentation from R65 that he elected to reverse his code status decision from what was in the AD. The NHA confirmed there was no signed facility documentation from R65 regarding his code status choice. Resident #12 (R12) R12 was admitted to the facility on [DATE]. A BIMS examination was completed on [DATE] and identified R12 as cognitively intact, scoring 14 of 15 points. The most recent MDS dated [DATE] coded R12 as having no difficulties with comprehension of verbal content, and no difficulties with the ability to understand others. There were no behavioral symptoms or mood concerns documented or identified in the Resident Assessment. R12's medical record includes a consultation visit on [DATE] from a provider of psychological services for a diagnosis of depression. The consultation report documented R12's judgement and insight were intact with organized thought processes. The report reflected R12's immediate, recent, and remote memory were grossly intact (normal and working as expected). A document was in R12's medical record designating a power of attorney for health care. The document was signed by R12 and dated [DATE]. The document reflected R12 appointing her spouse as patient advocate. The section of the document authorizing the patient advocate's power regarding life-sustaining treatment decisions was blank. The signature line in this section read sign your name if you wish to give your patient advocate this authority. The signature line is blank and unsigned by R12. The section of the document indicating R12's wishes for the patient advocates authority for decision-making on R12's behalf is blank. The document contained a stamp on the first page that read Inactive DPOA. The facility code status document in R12's medical record was dated [DATE]. The form was a do-not-resuscitate (DNR) order. The form read activated patient advocate making decisions and was signed by R12's spouse. The form did not contain R12's signature indicating R12 elected to be a DNR status. The second page of the DNR form reflected discussion and review and contained R12's spouse again signing on [DATE] that R12 was to be a DNR code status. Staff A was interviewed on [DATE] at 11:55 a.m. Staff A confirmed she was the facility social services representative. Staff A confirmed R12 had not signed DNR code status. When asked if the spouse of a resident would be allowed to consent to a DNR status if the resident had a 14 of 15 BIMS, Staff A responded, No! After reviewing the documentation showing R12's paperwork was inactive, Staff A said the code status options would be reviewed with (R12) today and R12 would be afforded the option to elect and sign for R12's preferred code status designation. The facility policy 'Advanced Directives' dated as revised ,d+[DATE] read in part: A resident code is a written advance directive giving health care providers instructions concerning emergency actions to be taken regarding the resident's evacuation and resuscitation. The code must be signed, in advance, by a competent resident.

Based on observation, interview and record review, the facility failed to ensure appropriate hand hygiene during feeding assistance for four Residents (#13, #44, #62 and #75) of 12 residents observed during meal service. This deficient practice resulted in the potential for cross-contamination of food and eating utensils with infectious organisms. Findings include: An observation of the lunch meal service in the first-floor day room, on 3/22/2023 at 1:30 p.m., revealed Resident #62 eating bites of spaghetti with a fork, unassisted. Certified Nurse Aide (CNA) U was observed approaching Resident #62 and using Resident #62's used fork, began cutting up the Resident's food and handed the fork back to Resident #62 to finish eating. CNA Y then approached Resident #13 and using the fork Resident #13 was eating from, began cutting up the Resident's food and then handed the fork back to Resident #13. It was noted, prior to CNA U assisting Resident #13, the Resident was observed eating bites of meatballs with her hands and alternately using her fork. After assisting Resident #13, CNA U approached Resident #44 and picking up the Resident's fork, cut up the Residents' food and handed the fork back to Resident #44. CNA U then walked across the room and sat next to Resident #75 and proceeded to feed the Resident by using the Resident's fork with her soiled hands to place bites of food into the Resident's mouth. It was noted during the observation, CNA U did not perform hand hygiene after touching any of the observed Residents used forks, prior to moving on to assist the other Residents to cut up their foods or before feeding Resident #75. During an interview immediately following the observation, CNA U confirmed she did not perform hand hygiene after touching the Resident's soiled forks and cutting up their food, and before assisting Resident #75 with eating. CNA U reported she was aware of the need to perform hand hygiene after touching Resident's used forks. CNA U stated but sometimes we get too busy. During an interview on 3/23/2023 at 11:07, the facility Infection Preventionist, Registered Nurse (RN) F confirmed staff should be performing hand hygiene after touching soiled eating utensils and prior to assisting other Residents. RN F acknowledged there is a risk of cross-contamination with bacteria and viruses when staff touch the used eating utensils and do not perform hand hygiene prior to completing other tasks including feeding assistance. A review of the facility policy titled Hand Washing, last approved 2/2023, revealed the following: Wash hands with soap and water or alcohol-based hand sanitizer (if hands are not visible soiled) before coming on duty, before and after direct or indirect resident contact or contact with a contaminated object .

Based on observation, interview, and record review, the facility failed to ensure controlled medications were reconciled for two medication carts of four medication carts reviewed. This deficient practice had the potential for drug diversion and or missing controlled substances. Findings include: On 3/22/23 at 8:30 AM, observation of the second floor South medication cart found missing double signatures in the narcotic count binder at the nurses station. 17 total narcotic count sheets within the binder were reviewed and had missing signatures on 3/15/23, 3/16/23 and 3/17/23 for the 7 PM to 7 AM shifts, where two nurses are required to sign after verifying the counts are correct. On 3/22/23 at 8:45 AM, Licensed Practical Nurse (LPN) X was interviewed. LPN X was asked if there should be missing signatures in the areas of the narcotic count sheets that were blank. LPN X, stated, No. Two signatures are needed on all the sheets, one by the oncoming nurse and the other by the outgoing nurse. There should never be any blanks on the sheets. On 3/22/23 at 9:15 AM, a second observation of the second floor West medication cart was found missing double signatures in the narcotic count binder at the nurses station. 20 total narcotic count sheets within the binder were reviewed and had missing signatures on 3/15/23, 3/16/23 and 3/17/23 for the 7 PM to 7 AM shifts, where two nurses were required to sign after verifying the counts were correct. One narcotic count sheet within the binder had two missing signatures on 3/14/23 and 3/18/23 for the 7 PM to 7 AM shift. On 3/22/23 at 9:30 AM, LPN X was asked if he would be able to identify which nurses were responsible for the missing narcotic count signatures. LPN X replied, Yes. Give me a few minutes and I should be able to find out. LPN X stated that on 3/14/23, 3/15/23, and 3/16/23 would have been Registered Nurse (RN) Y, and on 3/17/23 and 3/18/23 would have been LPN Z. On 3/23/23 at 1:45 PM, an interview was conducted with the Director of Nursing (DON). The DON was asked if the narcotic count sheets required two nurses to sign for verification of counts and confirmed that the narcotic count sheets should not have any missing signatures and two nurses are required to sign all the sheets in the controlled medication binders at the time of every change in nurse to nurse shift. The policy Controlled Substances, dated 02/2022, read in part, .Procedure .4. At the end of each shift, two nurses together will count the amount of each controlled substance to ensure that it matches the amount of medication and number on the Certificate of Disposition form .

(All times are recorded in Eastern Daylight Time.) This citation pertains to intake #MI00135070. Based interview and record review, the facility failed to ensure appropriate assessment and follow-up was completed related to a medical change in condition for one Resident (#78) out of twenty-one residents reviewed for quality of care. This deficient practice resulted in delayed care and a decline in status. Findings include: The facility Summary of Investigation, undated, confirmed a written allegation on 1/22/23, and read, in part, Registered Nurse (RN) AA was allegedly reported to the state board of nursing, after Resident #78 suffering a non stemi (partial blockage of one of the coronary arteries, causing reduced blood flow of oxygen-rich blood to the heart muscle), CHF [congestive heart failure], and effusions (an abnormal collection of fluid in hollow spaces or between tissues of the body such as the lungs) .Through this investigative process, the facility could not verify any abuse or neglect transpired . The facility Investigation, revealed Resident #78 was transferred to the local hospital on 1/17/23. Resident #78 returned to the facility on [DATE] with a diagnosis of chest pain and pneumonia (respiratory infection). On 1/20/23 shortly before midnight, Resident #78 was noted to have audible wheezing (high pitched lung sound) and rhonchi (low pitched lung sound like a snore or gurgle), a temperature of 100.3 degrees Fahrenheit and oxygen saturation of 82 percent by RN CC. On 1/21/23 at approximately 3:30 AM, RN CC was relieved by RN AA of her shift duty. RN AA indicated she was informed of Resident #78 and her change in condition by RN CC. On 1/21/23 at approximately 6:45 AM, RN BB arrived for her shift and Certified Nurse Aide (CNA) DD pulled RN BB into Resident #78's room to have her evaluated, as CNA DD felt Resident #78 had declined. CNA DD told RN BB that she asked RN AA to contact the doctor and family, but RN AA had not contacted the doctor or family. On 1/21/23 at approximately 7:00 AM, Licensed Practical Nurse (LPN) Z came on shift and received report from RN AA. RN AA reported to LPN Z that Resident #78 had a decline in status, oxygen saturation had dropped, and supplemental oxygen had been initiated. At 7:13 AM, LPN Z was directed by RN BB to contact the family representative of Resident #78. Resident #78's family representative requested Resident #78 be sent to the local hospital for evaluation. The medical director was contacted by RN BB and verbal orders were received for Resident #78 to be transferred to the local hospital for evaluation. Resident #78 left the facility via ambulance at approximately 8:30 AM. On 1/21/23 Resident #78 later returned to the facility on comfort measures with medical diagnoses of non-ST [stemi] elevation MI [myocardial infarction], congestive heart failure, pneumonia, and hypoxia (low oxygen levels in the blood). On 3/21/23 at approximately 2:30 PM, an interview was conducted with RN BB. RN BB stated, Arrived early that day, came in around 6:30 AM and CNA DD was crying and sobbing. CNA DD asked me to go check on Resident #78 related to reported agonal (gasping for air) breathing. CNA DD reported to her that she [CNA DD] had expressed concerns to RN AA and did not get a response. RN BB stated, I asked RN AA if she had called the doctor or the family and she replied no, and that day shift could deal with it. RN BB stated, I initiated the transfer along with LPN Z who I was training and had her sent out and notified the family who wanted her sent out. On 3/23/23 at 9:50 AM, an interview was conducted with LPN EE. LPN EE was asked when a resident is sent out for evaluation to the hospital and returns with a diagnoses of chest pain and pneumonia would there be anything nursing would be tasked or triggered to do. LPN EE responded, Yes. Nursing should complete a respiratory assessment, every shift, until the pneumonia has been resolved and monitor for signs and symptoms of antibiotic use. For instance, if the medication is working or if the resident is not improving. LPN EE was then asked if a resident had a standing order for oxygen and it was initiated what is the nurse responsible to do for a follow-up. LPN EE replied, The nurse has to send a change of condition to the physician and let them know the situation of why the oxygen was applied to see if they want further orders and then the physician gives the order to continue the use of the oxygen with monitoring of conditions related to respiratory therapy. On 3/23/23 at 11:05 AM, an interview was conducted with RN CC. RN CC confirmed her part of the investigative summary of the incident involving Resident #78's change of condition. RN CC confirmed that she did not send a fax to the physician related to the initiation of oxygen to Resident #78 and did not communicate the change in condition at the time it occurred. RN CC stated, When RN AA come on shift to relieve me I asked her if she would call and notify the physician and she [RN AA] said she would and she would send Resident #78 out to the local hospital. RN CC was asked why she left the responsibility with RN AA and replied, I do not know. I figured that she would call. Resident #78's Face Sheet, revealed an original admission to the facility on [DATE], with medical diagnoses of dementia, chronic kidney disease, and tachycardia (increased heart rate). Resident #78's Care Plan, revealed, .Activities of daily living .Alert MD [Doctor of Medicine] for changes. Date initiated: 1/10/23 .Related to: disease process. Nurses - assess change in level of consciousness, assess electrolyte status .Note changes and notify MD .Date initiated 1/7/23 . Resident #78's care plan lacked any new problem, approach, or goal related to her new diagnoses of pneumonia or chest pain. Review of Resident #78's After Visit Summary, from the local hospital, dated 1/17/23, read in part, .Today's Visit .Reason for visit - chest pain. Diagnoses - chest pain and pneumonia . Review of Resident #78's, Emergency Department (ED) Provider Notes, dated 1/22/23, read in part, .spoke with her daughter .They do want all other measures done at this time .She has coarse breath sounds .ED Course: 1039: Patient has bibasilar (both lungs) pneumonia. She also has an elevated troponin 826 consistent with non ST elevation MI .She also has an elevated BNP [B-Type Natriuretic Peptide] (a blood test that measures for congestive heart failure) .1148: At this time patient and the daughter have decided that they would just like to keep her comfortable .They request that she be discharged back to the nursing home. Patient will be a DNR [do not resuscitate] comfort care. Review of Resident #78's nurses notes, dated 1/17/23 through 1/23/23, revealed on 1/17/23 at 12:47 AM, she presented with left side radiating chest pain. Nursing note lacked any vital signs, initiation of treatment, or nursing assessment completed. On 1/17/23 at 4:49 AM, a transfer note by nursing. Nursing notes lacked a return note of Resident #78's condition post ED evaluation. On 1/20/23 lack a nursing note regarding Resident #78 had a change in condition or interventions. On 1/21/23 at 12:05 PM a late transfer out nursing note was made after the local ED communicated the condition of Resident #78 (Resident #78 was transferred out to the local hospital three to four hours after the note was made). On 1/21/23 at 7:10 PM a return note from nursing after Resident #78 returned at 2:30 PM (five hours later). Review of Resident #78's vital signs, dated 1/17/23 through 1/23/23, revealed a lack of vital signs pulse, blood pressure, and temperature before, during, or after the transfer on 1/17/23. Lacked a full set of vital signs on 1/18/23. On 1/20/23 the electronic medical record (EMR) lacked a full set of vital signs. On 1/21/23 after the return of Resident #78 lacked a full set of vital signs. Review of Resident #78's assessments, dated 1/17/23 through 1/23/23, revealed a lack of any nursing assessments, including a respiratory assessment. No lung sounds had been documented per standards of practice regarding the diagnosis of pneumonia first indicated on 1/17/23 after she returned to the facility from the local hospital. Review of Resident #78's communications to the physician, dated 1/17/23 through 1/23/23, revealed a lack of communication for change in condition and the initiation of oxygen therapy by nursing staff. Review of Resident #78's physician orders, dated 1/2023 an date printed 3/23/23, revealed no orders for oxygen therapy. On 3/23/23 at approximately 1:20 PM, and interview was conducted with the Nursing Home Administrator (NHA). The NHA was asked if there were any written witness statements regarding the investigation of Resident #78. The NHA stated, We did do interviews with staff involved and scratched down some notes to try and figure out what transpired. The NHA was asked if she knew if RN CC contacted the physician. The NHA replied, I would have to look at my notes. The NHA was asked if she interviewed all staff that working during the time of the incident. The NHA replied, No. We only asked that staff that was involved that we were aware of. The NHA was requested to provide these scratch notes and by the time of the survey exit no hand scratch interview notes were obtained or presented to this Surveyor. On 3/23/23 at approximately 1:30 PM, an interview was conducted with the Director of Nursing (DON). The DON confirmed that there was poor documentation from nursing regarding Resident #78. The DON stated, The nurses need to do a better job with documentation and communication. The DON was asked if her nursing staff did accurate assessments, vital sign monitoring, and documentation of interventions. The DON responded, No. Not recorded. The DON was asked if she knew why CNA DD had concerns for Resident #78 when day shift RN BB came on to shift. The DON replied, I am unsure of the urgency to RN BB to transfer Resident #78. The DON was asked if she knew why RN CC did not notify the physician of the change in condition for Resident #78 when she had called the physician for a different resident regarding a change in condition. The DON replied, I do not know. She had him on the phone and she could have notified the physician at that time but did not. The policy Standing Orders, dated 5/2022, revealed, A. Prior to administering any of the following standing orders, nursing personnel shall be cognizant of the following: 1. Condition of the resident .3. Oxygen: Oxygen may be administered in an emergency situation. It must be started by licensed personal at 2 liters per nasal cannula (device used to deliver oxygen through the nose) per minute until another dosage is ordered by the physician. The physician should be called ASAP [as soon as possible]. The policy Oxygen Order Requirements, dated 9/2022, revealed, 1. Diagnosis/medical condition appropriate for the need of oxygen. 2. Required liter flow. An order for Oxygen PRN [as needed] or Oxygen as Needed does not meet this requirement. 3. Hours used per day. For intermittent use, indicated activity or time of day .4. Duration of need .5. Delivery system to be used . The policy Management of Acute Change of Condition, dated 9/2022, revealed, 1. Upon admission all residents will be assessed to establish a base from which change of condition can be measured. 2. Major risk factors shall be identified with a problem statement and addressed in the resident care plan. 3. Condition changes shall be noted by the charge nurse in the 24-hour report and followed up with: Notification to family and physician, communication to staff at shift change, changes to care plans as needed, .documentation of assessment, implementation and planning in notes each shift while unstable or symptomatic and at least daily while stable and asymptomatic, appropriate interventions .6. The decision to transfer to the hospital for treatment shall be based on the information provided to the physician and family by the nursing staff, therefore assessment must be detailed and accurate.

Based on observation, interview and record review, the facility failed to maintain the integrity of a medication label, to ensure appropriate medication adminstration, for one Resident (#34), and failed to ensure the secure and separate storage of all medications, potentially effecting all 102 Residents. This deficient practice resulted in the potential for drug diversion and the wrong dose to be given and decreased efficacy of treatment for [REDACTED]. Findings include: (All times are recorded in Eastern Standard Time.) During a review of the storage of medications in central supply on [DATE] at 10:10 a.m., various over the counter medications such as pain relievers, anti-heartburn, anti-diarrheals, anti-fever medications, vitamins and minerals, and anti-stomach upset medications were observed stored on open shelves in the room. Staff D was present and said the supply room was accessible to others after hours, including janitors. There was a video camera on the ceiling behind the medication shelves. There was a refrigerator in the room with a dirty bottom shelf and dried various foodstuffs on the shelves lining the door. The refrigerator contained various vaccinations, containers of coffee, Staff D's lunch, as confirmed by Staff D, and other food condiments in the door of the refrigerator. When asked if it was appropriate to store the food stuffs in the same refrigerator as the vaccines, Staff D stated, I don't know. Staff D confirmed there was no process to account for each of the shelved medications and that more was ordered only when the supply was visually low. During an interview on [DATE] at 10:51 a.m., the Director of Central Supply/ Staff E confirmed the camera footage in the supply room was not routinely monitored, and that other staff had access to the room after hours. Staff E confirmed the foodstuffs should not be in the same refrigerator as the vaccines. Staff E also agreed there was potential for staff to enter the supply room and remove a bottle of pain medication for personal use, without discovery. On [DATE] at 11:09 a.m., the first floor south hall medication cart was reviewed with Registered Nurse (RN) F. RN F confirmed a plastic bag of bottled prescribed medications in the bottom compartment of the cart, was for Resident #34, who acquired medications through a different approved source. One of the bottles contained [MEDICATION NAME], a diabetes medication, with a defaced label. The dosage of the pills was unable to be seen by this Surveyor or RN F. The expiration date was barely readable, but was noted to be [DATE]. RN F confirmed she could not make out the dosage of the pills and confirmed the expiration date. RN F also confirmed the pills should not be given, but that Resident #34 was given the pills in the defaced bottle. RN F said ensuring the five rights (safety checks required prior to any medication administration: right resident, right medication, right route, right dose, right time), prior to medication administration was not possible with the defaced label. During an interview on [DATE] at 11:27 a.m., the Director of Nursing (DON) had Resident #34's bottle of [MEDICATION NAME] on her desk and confirmed the label was defaced. The DON could not discern the dosage of the pills, and confirmed the bottle was expired. The policy Medication Storage, dated [DATE], was absent any information regarding the security of medication storage, medication labels, and the separation of medications from food storage.

Based on observation, interview and record review, the facility failed to appropriately reconcile controlled substances, and account for all controlled medications, potentially effecting all second floor Residents. This deficient practice resulted in the potential for drug diversion. Findings include: (All times are recorded in Eastern Standard Time.) On 3/04/20 at 8:05 a.m., Licensed Practical Nurse (LPN) C and LPN B were observed counting/reconciling the controlled substances in a second floor medication cart. LPN C did not look at the medication cards in the cart, but rather wrote numbers in a book that LPN B called out, as she flipped through the cards in the medication cart. When asked how she knew first hand that the numbers LPN B called out were actually the accurate number of pills in the card, LPN C said she didn't. Registered Nurse (RN) A was nearby and was asked if she reconciled the controlled substances in the medication cart she was responsible for, and responded she did not. RN A said LPN C and LPN B reconciled both carts then she would take responsibility for her cart, without actually determining first hand that the controlled substances she was responsible for were accurate. All three nurses confirmed they could not verify an accurate controlled substance count, using the manner in which the reconciliation was observed. During an interview on 3/04/20 at 8:31 a.m., the Director of Nursing (DON) and LPN C were present. LPN C said she took over the medication cart on the second floor, from a different nurse at 1:00 p.m., without counting or reconciling the controlled substances in that cart. The DON agreed that controlled substances could not accurately and definitively be accounted for in that manner. The DON stated, I would want to know myself that my med(ication) cart was accurate. I understand. Both nurses confirmed accurate reconciliation of controlled substances needed to happen. The policy Controlled Substances, dated 11/12/15, revealed, .The purpose of this policy is to assure safe and proper disposition of accounting for controlled substances .two nurses together will count the amount of each narcotic in the narcotic cabinet to ensure it matches the amount of drug and number on the Certificate of Disposition form. Medications to be counted for verification include all Scheduled II medications .all controlled medications .

Based on observation, interview and record review, the facility failed to provide adequate behavioral health services following worsening behaviors, to achieve the highest practicable physical, mental, and psychosocial well-being for one Resident (Resident #703) of three residents reviewed for behavioral health services. This deficient practice has the potential for psychosocial distress, increased aggression, and worsening behaviors. Findings include: According to the Minimum Data Set (MDS) quarterly assessment, reference date 2/12/19, Resident #703 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Resident #703 needed two-person assistance for bed mobility, transfers, and toilet use, and one-person assistance for dressing and eating. The Brief Interview of Mental Status (BIMS) revealed a score of 5, indicating severe cognitive impairment. A facility reported incident (FRI #MI 001) to the State Agency (S.A.), received on 4/25/19, revealed (Resident #703) was observed hitting (Resident #703's) arms and hands on (Resident #703's) bedrails while (Certified Nurse Aide, CNA I) was assisting (Resident #703's) roommate with breakfast. (Resident #703's) right hand started to swell and there was a small bruise to the pinky area. An x-ray was taken and the impression revealed a [MEDICAL CONDITION] of the fifth metacarpal .These injuries were self-inflicted and occurred when (Resident #703) was slapping (Resident #703's) arms/hands on (Resident #703's) padded side rails .(Resident #703's) self-injuring behavior/attempt to communicate was witnessed by a CNA (CNA I) .This CNA redirected (Resident #703), who then punched and continued to strike the padded rail at intervals despite frequent redirection. The facility incident report, dated 4/25/19 at 10:30 a.m., revealed the type of occurrence as a bruise and possible cause, Resident often bangs on his siderails. The facility investigation report, dated 4/29/19 and signed by the Director of Nursing (DON) revealed, On 4/25/19 at 10:30 a.m. it was reported to (Registered Nurse, RN H) that (Resident #703) .had bruising and swelling on the dorsal surface of (Resident #703's) right hand, and bruising on left elbow .At 8:45 a.m. (Certified nurse aide, CNA I) was assisting (Resident #703's) roommate to eat breakfast .(CNA I) witnessed (Resident #703) striking both arms/hands on (Resident #703's) padded quarter rails. As this was occurring, (CNA I) asked (Resident #703) to stop the activity. (CNA I) then witnessed (Resident #703) punch the padded side rail. (CNA I) continued to redirect (Resident #703), and (Resident #703) would stop, but then (Resident #703) would again start to hit (Resident #703's) arms and hands on the rails . There is no mention of CNA I obtaining assistance or alerting a nurse or manager of this incident. Review of Resident #703's nursing aide progress notes, from April, 2019, revealed the following: 4/03/19: Behavior record: Screaming, disruptive sounds .Outcome: unchanged. 4/05/19: Behavior record: Throwing/Smearing Food/Waste, screaming disruptive sounds .Outcome: unchanged. 4/07/29: Behavior record: Screaming, Disruptive Sounds, swearing, hitting the heating register. Outcome: Improved temporarily. 4/08/19: Behavior record: Screaming, Disruptive Sounds Outcome: unchanged. 4/09/19: Behavior record: Screaming, Disruptive Sounds, repetive swearing, hitting the bedrail. Outcome: unchanged. 4/14/19: Behavior record: Throwing, Smearing Waste/Food. Outcome: improved each time a little while. 4/15/19: Behavior record: Resistive to Cares, swearing, hitting staff. Outcome: improved each time a little while. 4/16/19: Behavior record: Screaming, disruptive sounds, repetitive hit staff (confidential staff person) in the face when he was cleaning floor mats, yelling hitting bedrails .Outcome: unchanged. 4/22/19: Behavior record: Screaming Disruptive Sounds, yelling the same phrases he does everyday, hitting the siderail. Outcome: unchanged. 4/25/19: Behavior record: hitting the bedrails 'cause (Resident #703) wants (Resident #703's) shoes on in bed to keep (Resident #703's) feet warm .hitting on rails to move to a different room. Outcome: Unchanged, still hits on rails when calling out for something, remind him to just use call light but he doesn't understand. 4/26/19: Behavior record: Screaming, disruptive sounds, swearing, repetitive hitting bedrails before they were removed . 4/27/19: Behavior record: Screaming, disruptive sounds, swearing, hitting staff with broken hand, yelling. Outcome: Unchanged, Worsened. 4/29/19: Behavior record: Hitting, scratching self, swearing, hitting staff, and hitting arms of wheelchair with broken hand .Outcome: Unchanged 5/01/19: Behavior record: Swearing, hitting, punching .Outcome: Unchanged. 5/02/19: Behavior record: Screaming, Disruptive Sounds, hitting and swearing, demanding .Outcome: Unchanged. Review of Resident #703's nursing progress notes, from April, 2019, revealed the following: 4/05/19: Behavior: Resident was swearing, hitting the bed rail, threw glass of pop, hit writer in hand. 4/30/19: Behavior: Resident was yelling and swearing since the start of the shift. (Resident #703) was hitting CNA .continues to yell out and swear. Review of Resident #703's recent Care Plans, provided by the NHA, dated 12/03/18 and 2/22/19, revealed one social services intervention, dated 3/22/19, Involve brother (confidential family name) in (Resident #703's) care. The Care Plan did not include specific updated behavioral interventions pertaining to Resident #703's recent aggression, and increased recurrent episodes of excessive agitation, frequently with reported attempts to communicate his needs. A care plan revision, dated 1/24/19, ADL (activities of daily living) section, revealed a hand-written entry, dated 1/24/19, Be aware that resident (Resident #703) has the potential to strike out unpredictably. During an interview on 5/01/19 at 2:50 p.m., RN H was asked if Resident #703 had a history of [REDACTED].#703's) bed. RN H responded, (Resident #703) has a habit of flailing (Resident #703's) arms, hitting the bedrail, throwing cups; (Resident #703) has been for a couple months, when (Resident #703's) ammonia levels rise. It is definitely not new. It's a part of who (Resident #703) is. I have seen (Resident #703) .(Resident #703) is spastic. (Resident #703) doesn't really use the call light; (Resident #703) yells out 'nurse, nurse.' During an interview on 5/01/19 at 3:00 p.m., CNA I was asked if CNA I reported the incident on 4/25/19 with Resident #703 to any staff or to the charge nurse. CNA I confirmed CNA I did not report the event to the any other staff or to the charge nurse or a manager. CNA I further added, I kinda let it be, 'cause it didn't seem like it bothered (Resident #703) when (Resident #703) did it, (Resident #703) didn't say 'ow' or anything like that .(Resident #703) did not seem to be injured . During an interview on 5/01/19 at 3:15 p.m., CNA J was asked if CNA J had observed Resident #703 hitting the quarter/side rails on his bed prior to this incident. CNA J responded, .(Resident #703) doesn't use (the) call light; (Resident #703) hits the bedrail; we enforced it with sheepskin, then it was tubing underneath the sheepskin, I could still feel it .(Resident #703) is always hitting the bedrail when (Resident #703) wants pain meds . During an interview on 5/01/19 at 5:40 p.m. with the Nursing Home Administrator, NHA, this Surveyor requested additional social services notes, as no entries were by found by this Surveyor beyond 1/23/19, with the DON also present. The NHA confirmed there were not additional progress notes in the Electronic Medical Record (EMR); the NHA provided one additional entry, a care conference note by the Social Services Director, RN M, dated 3/20/19: Medication reviewed, yes, and psyche related Diagnoses: [REDACTED]. (Psychological services) recommended changing the [MEDICATION NAME] to BID date of last decrease in medication 4/5/2018, decrease not effective, increase in physically agitated behavior There were no non-pharmacological interventions noted. There was no other social services documentation found in the EMR to show ongoing care coordination for behavioral health. During an interview on 5/02/19 at 9:00 a.m., RN M, was asked about any additional documentation of social services behavioral documentation, monitoring, or interventions. RN M responded, 'There should have been another one (social services progress note) in here for around (MONTH) (2019). I will look at my team conference note here too. I do a team conference note quarterly, this one is dated 3/20/19. RN M acknowledged there were no other social services notes, interventions, educations, or evidence of social services monitoring for Resident #703 beyond 3/20/19. During an interview on 5/02/19 at 10:05 a. m.,The DON was asked if she was aware of Resident #703 hitting the bed/side rails prior to 4/25/19. The DON responded, I maybe heard of that one time before but it was inconsistent, nothing serious, striking out at the staff. I don't think it was happening on a regular basis. I was talking to CNA I, and CNA I shared when you talked to (Resident #703), (Resident #703) would stop; it wasn't a daily thing. Review of (Resident #703's) therapy screen, dated 4/2/619, found no therapy services were added after this incident. At that time, there was no recommendation for therapy to improve Resident #703's functional communication in order for Resident 703 to communicate any needs. The policy, Abuse Prevention Policy and Procedure, updated (MONTH) 8, (YEAR), revealed, Behavior Management .The facility is responsible for assessing behaviors and needs and developing plans of care designated to protect residents from harm. During an interview with the NHA on 5/02/19 at 12:08 p.m., the NHA was asked if there was any additional documentation found pertaining to social services or recent, updated behavioral interventions for Resident #703. The NHA and social services staff did not provide any additional documents by the time of exit from the facility on 5/02/19.

Based on observation, interview, and record review, the facility failed to perform a significant change in condition MDS (Minimum Data Set) Assessment for one (Resident #700) of two residents reviewed for significant change in condition. This deficient practice resulted in the potential for inappropriate care and unmet care needs. Findings include: According to the Minimum Data Set (MDS) quarterly assessment, reference date 4/02/19, Resident #700 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Resident #700 was independent with transfers, toilet use, and walking in his room and in the corridor. During an observation on 4/30/19 at 4:00 p.m., Resident #700 was observed slowly propelling his manual wheelchair in the day (dining) room and in the facility corridor. Review of Resident #700's incident report, dated 4/07/19, revealed Resident #700 had a fall on 4/07/19 in the facility while ambulating with his quad cane due to a loss of balance. Review of Resident #700's facility fall investigation report, dated, 4/11/19, revealed Resident #700 was diagnosed with [REDACTED]. Review of Resident #700's Care Plan, revised 4/08/19, revealed: A (assist) with gait belt (a handwritten entry), for toileting, ambulation, and transferring. The Director of Nursing confirmed some of the Care Plan updates are handwritten. Review of Resident #700's progress notes, dated 4/23/19, 4/27/19, and 4/30/19, all revealed: .Transfering: Requires one aide assist with transfer .Walk in Room: Requires one aide assist to walk in room .Toilet use: Requires one aide assist for toilet use . Review of Resident #700's physical therapy progress note (most recent), dated 4/22/19, Current Level revealed Resident #700 scored 3 (partial/mod (moderate) assist for transfers (chair to bed, toilet), and gait A-Attempted, Not Completed. The Physical Therapy Plan of Care, dated 4/10/19, Prior Level revealed Resident #700 scored 6 (Independent) for transfers and gait walking 50' with turns and walking 150' with wide based quad cane . A recent physical therapy progress note, dated 4/23/19, revealed, patient refuses to ambulate .patient stands for 5 minutes but detours ambulation . During an interview with the Director of Rehabilitation, Occupational therapist, OT [NAME] on 5/01/19 at 10:54 a.m., OT [NAME] was asked about Resident #700's current level of assistance with transfers, ambulation, and toileting. OT [NAME] responded, .Level of assist is one person assist, he is a min (minimal) assist (assistance) .transfers, he is a min assist .toileting, he is a one assist . During an interview on 5/01/19 at 10:20 a.m., the MDS coordinator, RN (Registered Nurse) D was asked about why a significant change MDS was not completed after Resident #700's recent fall and clavicle fracture, and reported functional decline in three ADL (activities of daily living) physical care areas. RN D responded, .We are watching him to improve with those therapies, he is participating with PT .we watch and see if they (the residents) are making improvements, then we would initiate a sig (significant) change .I have been off (absent from work) for two weeks .with PT and OT we are hoping he returns to baseline .When someone (a resident) has a decline or a change in a couple areas; we watch them (the resident) for about two weeks . During an interview on 5/01/19 at 10:37 a.m. the DON (Director of Nursing) was asked about why a significant change MDS assessment was not completed for Resident #700, after his recent fall and clavicle fracture, and reported functional decline in three ADL physical care areas. The DON responded, .When the resident is involved in therapy, we hope to see if they have an improvement there .Usually we go a couple weeks .we usually like to do it (the significant change MDS assessment) around the two week period, however if we were seeing improvement at that time we would not . During an observation on 5/01/19 at 11:25 a.m. Resident #700 was observed ambulating with Physical Therapist Assistant, (PTA) G in the facility corridor. PTA G was holding Resident #700 closely with a gait belt. Resident #700 was ambulating with a front wheeled walker. During an interview on 5/01/19 at 11:55 a.m., PTA G was asked to clarify the level of assistance Resident #700 needed today during ambulation. PTA G responded, Today (Resident #700) was contact guard assist .transfers, there probably min (minimum assist), to get out of a chair, to sit to stand .(Resident #700) used a quad cane before the incident. The policy, Comprehensive Assessment and Care Planning with (Electronic Medical Record), revised 10/10/17, revealed, Frequency: Assessments must be conducted: b. Promptly after a significant change in the resident's physical or mental condition.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent an avoidable fall with harm for one Resident (#1), of three residents reviewed for falls. This deficient practice resulted in Resident #1's humeral neck and greater tuberosity (shoulder) fractures, increased pain, and decreased mobility and function of the right arm. Findings include: Review of the Minimum Data Set (MDS) assessment, dated 11/6/2018 revealed Resident #1 was independent in bed mobility, transfers, walking in room and corridor, required extensive one-person physical assist with dressing, personal hygiene, and bathing, was always continent of bowel and bladder, and had no functional limitations to upper or lower extremities. Resident #1 scored a 2/15 on the Brief Interview for Mental Status (BIMS) reflective of severe cognitive impairment. Review of Resident #1's 1/29/2019 (post-fall) MDS assessment revealed Resident #1 now required extensive, two-person assistance with bed mobility and transfers, dressing, toilet use, and personal hygiene, was totally dependent upon staff for bathing, had an upper extremity impairment on one side to range of motion (ROM) and was occasionally incontinent of bowel and bladder. Review of an Unusual Occurrence Witness Form, completed by Certified Nurse Aide (CNA) A for Resident #1's 1/23/19 fall revealed the following, in part: .One shoe on, untied, one shoe off. Her laces were under her shoe. I went towards her to take the shoe off, so she had only grippy socks on and she fell . Review of the facility Investigation Fall with Right Upper Extremity Fracture, (Resident #1), 01/23/19, dated 1/29/19 by the Director of Nursing (DON) revealed Resident #1 fell on the evening of 1/23/19, first complained of pain on the evening of 1/24/19, complained of pain and observed with right upper arm bruising on the morning of 1/25/19, and received x-rays on 1/25/19 that showed .Acute humeral neck and greater tuberosity fractures, with mild displacement. In comparison to prior study (11/02/2018), findings are new . Review of Resident #1's ADL care plan, revealed the following, in part: Need for supervision at all times for ADLs, does not recognize limitations .DRESSING: limited assist. Review of Resident #1's 1/25/19 Emergency Department (ED) After Visit Summary revealed the following instructions: Keep shoulder immobilizer on at all times. Your able to use ([MEDICATION NAME]) as needed for pain relief. Ice may be of some relief . Observation on 2/12/19 at 10:10 a.m. with the Nursing Home Administrator (NHA), DON, and Information Technology (IT) Staff G, of the 1/23/19 surveillance video of the 2nd floor Comfort Zone hallway showed Resident #1 ambulating independently with grippy socks on both feet, and a shoe on the right foot. The video did not clearly show which foot the shoe was on, but with closer inspection both this Surveyor and the NHA agreed it was on the right foot. CNA A was observed kneeling in front of Resident #1 and appeared to lift Resident #1's right foot to remove the untied shoe. Resident #1 immediately fell to the floor. During an interview at this same time, the DON stated, (Resident #1) fell when (CNA A) was trying to lift her foot to remove the shoe. Review of a 1/24/19 Staff Development Form revealed education of CNA A and included the following: (CNA A) was assisting (Resident #1) with her shoes. This resident lost their balance and fell . (CNA A) stated she should have gotten a chair for the Resident to sit in while fixing her shoes. On 2/12/19 at 10:20 a.m. Resident #1 was observed lying in bed with an immobilizer on her right arm and wrapped around her chest to stabilize the right arm/shoulder. Resident #1 said her arm was injured in a fall, but responses were inconsistent with further questions regarding the fall. On 2/12/19 at 10:25 a.m. Registered Nurse (RN)/Head Nurse D was asked about Resident #1's pain. RN D stated, She has pain with movement .I have passed meds (medications) everyday from the time she had the fracture (following 1/23/19 fall) until yesterday .She takes ([MEDICATION NAME]) and a ([MEDICATION NAME]) and that seems to keep the pain under control . Review of a facility FAX to MD, dated 1/29/2019, regarding Resident #1 revealed the following: .Resident (#1) with increased (sic) in pain. She has a fracture in right humerus in surgical neck. She cries when you move her. Resident is allergic to [MEDICATION NAME] and related. 2) Can we please have an order for [REDACTED]. Review of Resident #1's Electronic Medication Administration Records 12/12/18 through 2/12/19, and a PRN pain medication report, received from the DON on 2/12/19 at 1:50 p.m. revealed Resident #1 had PRN pain scores and documentation of [MEDICATION NAME] administration beginning 1/24/19 at 22:46 (10:46 p.m.) through 1/31/19 and prescribed and administered [MEDICATION NAME] and [MEDICATION NAME] initiated on 1/29/19 for pain which continued through the date of this survey 2/12/19. Interviews were conducted on 2/12/19 at 10:30 a.m., 10:46 a.m., 10:55 a.m., 11:05 a.m., and 11:10 a.m. with CNAs E, I, J, K, and L respectively. When asked about CNA training and practice regarding dressing assistance, specifically the position a resident is placed in with putting on and taking off shoes, all CNAs agreed a resident would be sitting or lying, and never standing with shoe placement or removal. Review of a Physician Assistant (PA) 1/24/19 progress note (following the 1/23/19 fall) revealed the following documentation. REVIEW OF SYSTEMS: No recent falls or trauma .SUBJECTIVE: Patient seen today in normal nursing home rounds .MUSCULOSKELETAL/EXTREMITIES: no pedal [MEDICAL CONDITION]. No cyanosis .Visit Diagnoses: [REDACTED].#1 for potential injury from the fall on the previous night. Review of a 1/26/19 18:28 (6:28 p.m.) nursing progress note, completed by RN C revealed the following entry: On 1-24-19 assessed resident (#1) after fall checked all extremities, hip alignment, performed range of motion, resident showing no s/s of pain resident verbalized I have no pain no bruising or redness noted. Review of the facility Fall Prevention and Management Procedure, updated 8/8/2017, read in part: Policy .Each resident receives adequate supervision and assistive devices to prevent accidents including: 1. Identifying hazards and risks, 2. Evaluating and analyzing hazards and risks, 3. Implementing interventions to reduce hazards and risks .All staff are involved in observing and identifying potential hazards in the environment and evaluating the risk of an avoidable resident accident . On 2/12/19 at 12:55 p.m. the DON reviewed the above PA progress note with this Surveyor and was asked if Resident #1 was assessed for any injuries post-fall during the 1/24/19 PA visit. The DON agreed the PA progress note did not document a post-fall assessment for Resident #1. The DON also reviewed nursing progress notes for post-fall assessment documentation from RN C, on duty at the time of Resident #1's 1/23/19 fall. The DON acknowledged RN C had not documented post-fall assessment following the fall on 1/23/19 until 1/26/19. RN C's progress note entry on 1/26/19 documented post-fall assessment being completed on 1/24/19, not the day of the fall (1/23/19). When asked what CNA A should have done to ensure safety when removing Resident #1's shoe the DON stated, I as the DON would have liked (CNA A) to get a chair or a staff member. On 2/12/19 at 1:30 p.m. CNA A was asked about Resident #1's fall. CNA A stated, .it was my fault that she (Resident #1) fell . I went to take her shoe off, and I should have gotten a chair first .When I took the shoe off she lost her balance, and I was not able to catch her when she fell .I think she fell on her right arm .I know it was my fault .They (facility administration) did go over it with me and I know what I need to do in the future.

Based on interview and record review, the facility failed to provide written notice of transfer and/or discharge to residents/resident representatives from (MONTH) (YEAR) through (MONTH) (YEAR). This deficient practice resulted in the potential for residents being uninformed of their rights and/or unnecessary transfer/discharge. Findings include: Review of the (MONTH) (YEAR) Monthly Report of Emergency Transfers Past 6-Month Period (July through (MONTH) (YEAR)), provided by the facility, revealed resident transfer/discharge documentation was provided to the Ombudsman, but no evidence of written notification to the resident/resident representative was provided by the facility. On 1/17/19 at 12:50 p.m. the Nursing Home Administrator (NHA) was asked to review facility transfer/discharge information provided upon resident transfer/discharge. A discharge packet, including the Resident Discharge and Transfers Internal Standard Operating Procedures, Updated 10/07/16, was reviewed with the NHA. The NHA, after review of the procedures, confirmed no language was present within the document regarding written notification of transfer to the Ombudsman and resident/resident representative. The NHA acknowledged the 10/7/16 transfer procedures were used with previously documented transfers/discharges. During an interview on 1/17/19 at 12:50 p.m., the DON was asked if the facility had been providing written notification to residents transferred from the facility. The DON stated, No, we (facility) have not (provided written notice of transfers). We have been doing half of it (notifying the Ombudsman) but not the other half (written notification to resident/resident representative).

Based on interview and record review, the facility failed to report allegations of resident to resident abuse for four Residents (#47, #62, #85, & #98) of 20 residents reviewed for abuse. This deficient practice resulted in the potential for continued abuse for facility residents, and unreported allegations of potential abuse to the State Agency. Findings include: Review of two separate Incident Reports for Resident #85 and Resident #98, revealed the following identical information, in part: Type of Occurrence: Resident to Resident, 11/29/2018 .Time of Occurrence: 16:20 (4:20 p.m. Central Standard Time (CST)) . Actions: Altercation was intervened, residents were separated and kept away from each other rest of shift . Review of Unusual Occurrence Witness Forms regarding the 11/29/2018 Resident to Resident altercation between Resident #85 and Resident #98, completed by Certified Nurse Aide (CNA) J, read, in part: Asked both residents if they had hit each other and they said yes. Dining Assistant/Staff K also completed an Unusual Occurrence form documenting witness of physical contact between Residents #85 and #98. Staff K noted, When I entered the hall both residents were hitting at each other . Review of the facility Abuse Program Policy and Procedure, (MONTH) 8, (YEAR), read, in part: .Allegations of abuse or neglect will be reported to resident representative of official agencies according to State/Federal law .By statute, the Administrator and the Director of Nursing are legally required to report allegation of abuse .to the Bureau of Health Systems .Physical Abuse: Is not limited to hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment .Communication of How to Report Incidents: .Immediately (no later than 2 hours) after allegation is made, if the events that cause the allegation involve abuse . On 1/16/19 at 3:41 p.m. the Director of Nursing (DON) was asked if the above altercation between Resident #85 and Resident #98 was reported to the State Agency. The DON stated, No, it wasn't. Review of the investigative file entitled Alleged Resident to Resident Incident Between (Resident #47) and (Resident #62) revealed in part: On 03/21/18, (Resident #47) stated (Resident #62) hit me. The file revealed Resident #62 walked in the room and confirmed she had hit Resident #47, and both Residents (roommates) were interviewed and assessed for injury. Both (Resident #47 and Resident #62) . verbalized that each one had been struck by the other one. On 01/16/19 at approximately 5:15PM (4:15 p.m. Central Standard Time) , the Nursing Home Administrator (NHA) discussed this incident and the facility procedure. The NHA stated this incident (Resident to Resident altercation between Resident #47 and Resident #62) had not been reported.

Based on interview and record review, the facility failed to monitor International normalized ratio for anticoagulant monitoring (INR) levels during use of [MEDICATION NAME], a medication to prevent blood from clotting, for one Resident (#800) of three residents reviewed for medication monitoring from a total sample of four residents. This deficient practice resulted in an abnormally high medication (anticoagulant) level causing excessive bleeding, which may have contributed to death. The facility self-identified the deficient practice for F329 with lack of adequate monitoring for medications. A plan of correction was implemented on [DATE] and the facility had demonstrated substantial compliance with F329 at the time of the survey ending [DATE], so no citation was written. Findings include: An investigation was conducted at the facility from [DATE]-[DATE] to review allegations concerning lack of INR blood tests to determine anticoagulant status for Resident #800. A closed record review was completed for Resident #800, as the resident no longer resided within the facility. According to the Minimum Data Set ((MDS) dated [DATE], Resident #800 was admitted to the facility from a local hospital on [DATE] with multiple diagnoses, including [MEDICAL CONDITION] and [MEDICAL CONDITION] (abnormal fluttering of the top chambers of the heart). Discharging hospital record 'Continuity of Care Document' for Resident #800 signed by Doctor F and dated [DATE] read, .(Resident #800) was started on anticoagulation with [MEDICATION NAME] ([MEDICATION NAME]). INR (laboratory blood test to determine correct [MEDICATION NAME] dose) has been staying in therapeutic range during the hospital stay .[MEDICATION NAME] 4 mg (milligrams), take 1 tablet by mouth at bedtime, start date [DATE] Recommended getting (PT/)([MEDICATION NAME] time)INR (levels) on [DATE], and discussing with PCP (primary care provider) for further recommendations . This document was given to this Surveyor by the facility on [DATE], and was part of Resident #800 electronic medical record. Review of Resident #800's Medication Administration Record [REDACTED]. The resident was transferred to the admitting hospital on [DATE]. During an interview on [DATE] at 2:15 p.m., Registered Nurse (RN) A stated, There are no PT/INR results for (Resident #800) (in the facility medical record) .The hospital called us to let us know (Resident #800) [MEDICATION NAME] levels were high .the orders for [MEDICATION NAME] (testing) were missed on the admission orders [REDACTED] Per facility 'Transfer and Referral Record' dated [DATE], Resident #800 was transferred to the Emergency Department per ambulance. Emergency Department notes dated [DATE] indicated Resident #800 had a PT of 97.6 (normal range 11.9 to 14.3 seconds) and an INR (greater than)>12.6 (normal range 2 to 3.5). Hospital Physician notes dated [DATE] indicated Resident #800 required 4 units of fresh frozen plasma and vasopressors (medication to maintain blood pressure) as a result of these laboratory results. Based on review of facility faxed communication to Physician G on [DATE], the facility and attending Physician G was made aware that Resident #800 was bleeding into her stool as her stool was highly positive for blood. During an interview on [DATE] at 10:45 a.m., the Administrator stated, They (referring hospital) did not mention when the [MEDICATION NAME] was initiated and the need for follow up (lab testing for medication dosing). When asked what the Continuity of Care Document is used for, the Administrator stated, It is just scanned (into the resident electronic medical record) when we get it . That same day at 11:05 a.m. Physician G stated, .There was no PT/INR ordered (for Resident #800) .nurse navigator and facility admissions nurse overlooked the need (for anticoagulant testing) and I did too .when the positive guaiac (test to identify blood in the stool) came back positive, we should have held [MEDICATION NAME] . The hospital Discharge Summary dated [DATE] indicate Resident #800 died on [DATE] with a primary [DIAGNOSES REDACTED]. A death certificate was unavailable for review. The facility was notified by the admitting hospital on [DATE] regarding high [MEDICATION NAME] levels for Resident #800. The facility provided education to staff regarding medication monitoring on [DATE] and identified all residents within the facility receiving [MEDICATION NAME], as reviewed by this Surveyor on [DATE]. These residents were reviewed by facility and INR level monitoring was verified on [DATE], as reviewed by this Surveyor on [DATE]. Documentation showed the facility had carried out monitoring of PT/INR levels for all residents receiving anticoagulant therapy as part of a quality assurance program for 30 days, ending [DATE] with continued intermittant monitoring. The facility self-identified the deficient practice, implemented corrective actions, and substantial compliance was maintained for 6 weeks before the survey dated [DATE].

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ADEQUATELY SUPERVISE AND/OR PROVIDE APPROPRIATE ASSISTIVE DEVICES TO PREVENT AN ACCIDENT FOR ONE RESIDENT (#1) OF THREE SAMPLED RESIDENTS, FROM A TOTAL FACILITY POPULATION OF 108 RESIDENTS, RESULTING IN HARM TO RESIDENT #1 WHEN SHE SUSTAINED A FALL WITH FRACTURE TO HER RIGHT ANKLE. FINDINGS INCLUDE: AN ABBREVIATED SURVEY WAS CONDUCTED ON 5/21/12. DURING THIS SURVEY, THE MEDICAL RECORDS OF RESIDENT #1 WAS REVIEWED. HER FACE SHEET SHOWED SHE IS A [AGE] year OLD WOMAN ORIGINALLY admitted to the facility on [DATE] AND REadmitted on [DATE]. HER [DIAGNOSES REDACTED]. HER MOST RECENT MINIMUM DATA SET (MDS) ASSESSMENT, PRIOR TO HER FALLS ON 4/22/12 AND 4/23/12, WAS DATED 1/31/12. THIS MDS REVEALED RESIDENT #1 HAD ONLY MINIMAL COGNITIVE IMPAIRMENT, SCORING A 13 OUT OF 15 ON HER BRIEF INTERVIEW FOR MENTAL STATUS. HER FUNCTIONAL STATUS INDICATED SHE NEEDED LIMITED PHYSICAL ASSISTANCE OF ONE PERSON FOR TRANSFERS AND WALKING. HER BALANCE WAS NOT STEADY; SHE WAS ABLE TO STABILIZE ONLY WITH HUMAN ASSISTANCE. HER USUAL MOBILITY DEVICES WERE A WALKER AND A WHEELCHAIR. A FALL RISK ASSESSMENT WAS COMPLETED ON 1/26/12. RESIDENT #1 SCORED AN 11, PLACING HER AT HIGH RISK FOR FALLS. A CARE PLAN FOR POTENTIAL FOR INJURY INITIATED ON 9/10/09, WITH THE GOAL BEING "RESIDENT WILL HAVE NO INJURY, RESIDENT WILL HAVE NO FALLS" WAS UPDATED ON 4/5/12 TO INCLUDE THE INTERVENTION "PRESSURE PAD (ALARM) TO BED AND CHAIR." THE CNA (CERTIFIED NURSE AIDE) ASSIGNMENT CARD INITIATED 3/18/09 AND UPDATED ON 2/2/12, INCLUDED THE INTERVENTIONS: 1) STANDBY ASSIST FOR TRANSFERS AND, 2) AMBULATION WITH ASSIST OF ONE PERSON AND A WALKER. THIS CNA ASSIGNMENT CARD WAS UPDATED ON 4/5/12 TO INCLUDE THE INTERVENTION PRESSURE PAD TO BED AND WHEELCHAIR. THE FACILITY INVESTIGATION REVEALED AT 4:45 P.M. ON 4/22/12, RESIDENT #1 HAD BEEN LYING IN HER BED. CNA "A" RESPONDED TO RESIDENT #1'S ALARM SOUNDING, FOUND RESIDENT #1 SITTING ON HER FLOOR MAT, THEN FALLING BACKWARD. A COMPUTERIZED NURSE PROGRESS NOTE, ENTERED BY REGISTERED NURSE (RN) "F" AND DATED 4/22/12 AT 9:33 P.M., SHOWED RESIDENT #1 WAS IMMEDIATELY ASSESSED AND THERE WERE NO APPARENT INJURIES. THIS ENTRY ADDED IN PART, "RESIDENT PLACED IN CONSTANT VISUAL SUPERVISION OF STAFF... MAGNETIC ALARM APPLIED TO BED AND W/C (WHEELCHAIR) AGAIN STARTING THIS SHIFT... MONITORING 1:1 (ONE STAFF FOR ONE RESIDENT) AT THIS TIME DUE TO RESIDENT'S CONFUSION." AN ATTEMPT TO INTERVIEW CNA "A" BY TELEPHONE ON 5/21/12 AT 1:20 P.M. CENTRAL DAYLIGHT TIME (CDT) WAS UNSUCCESSFUL, AS THERE WAS NO ANSWER. RN "F" WAS INTERVIEWED BY TELEPHONE ON 5/21/12 AT 1:48 P.M. CDT. SHE STATED, "(RESIDENT #1) HAD BEEN UP IN HER CHAIR. I WAS DOING MED PASS. THEY MUST HAVE PUT HER BACK IN BED. THE AIDES CAME AND TOLD ME SHE HAD FALLEN OUT OF BED. SHE HAD AN ALARM ON; IT WAS SOUNDING. I PUT HER BACK ON SENSOR ALARMS AFTER SHE fell . I TOLD STAFF SHE WAS TO BE ON 1:1, CONSTANT SUPERVISION. A 1:1 SUPERVISION MEANS CONSTANT SUPERVISION, SOMEBODY SITTING NEXT TO HER. NOBODY WAS TO TAKE THEIR EYES OFF OF HER." CNA "C" WAS INTERVIEWED BY TELEPHONE ON 5/21/12 AT 1:35 P.M. CDT. SHE STATED, "WE WERE 1:1 WITH (RESIDENT #1) THAT NIGHT. TO ME, 1:1 MEANS TO SIT WITH HER, NEVER TAKE YOUR EYES OFF HER, NEVER LEAVE HER SIDE. IT'S CRUCIAL THAT YOU'RE RIGHT NEXT TO HER; SHE'S QUICK." ON 4/22/12, THE CNA ASSIGNMENT CARD WAS UPDATED TO INCLUDE, "MAGNETIC ALARM TO BED AGAIN" AND THE CARE PLAN UPDATED TO READ, "MAGNETIC TO BED & CHAIR ALONG WITH PRESSURE PAD, LOW BED & FLOORMATS." RN "F" ENTERED INTO THE COMPUTER AT 7:23 P.M., "AFTER THAT (FIRST)FALL, RESIDENT WAS PUT IN BRODA CHAIR NEXT TO NURSES STATION FOR CONSTANT SUPERVISION. THEN WAS WITNESSED FALLING OUT OF CHAIR (SECOND FALL) BY LPN (LICENSED PRACTICAL NURSE) AT APPROX. 1805 (6:05 P.M.) BUT HE COULD NOT MAKE IT TO HER IN TIME... AGAIN NO NOTED INJURIES." RN "F" ENTERED AT 8:47 P.M., FOR THIS SECOND INCIDENT/FALL, "POSSIBLE CAUSE OF INCIDENT: RESIDENT'S DIAGNOSIS'S (SIC), WITH INCREASED CONFUSION, IRRITABILITY AND ANXIOUSNESS HAVE INCREASED IN THE PAST COUPLE WEEKS. ALONG WITH RESIDENT HAVING AGGRESSIVE BEHAVIORS." LPN "B" WAS INTERVIEWED BY TELEPHONE ON 5/21/12 AT 1:22 P.M. CDT. HE STATED, "I WAS SITTING AT THE NURSES STATION DESK. (RESIDENT #1) WAS SITTING IN FRONT OF ME ON THE OTHER SIDE OF THE DESK. I WAS CHARTING AND KEEPING AN EYE ON HER. I COULD SEE HER OUT OF THE CORNER OF MY EYE AND AS SOON AS I SAW HER MOVING, I LOOKED UP. SHE WAS LEANING FORWARD. THEN I GOT UP TO ASSIST HER. I STARTED TO RUN AROUND THE DESK BUT IT WAS TOO LATE. SHE fell OUT OF THE CHAIR." THE FIRST FLOOR NURSING STATION WAS OBSERVED DURING THE INVESTIGATION ON 5/21/12, AND IT WAS NOTED THAT A HALF-WALL, SURROUNDING THE STATION, IS APPROXIMATELY 3-1/2 FEET TALL. IN ADDITION, THERE WAS A HALF-WALL OF THE SAME HEIGHT PERPENDICULAR TO AND ATTACHED TO THE END OF THIS PERIMETER, WHICH WAS APPROXIMATELY 3-4 FEET IN LENGTH. A PERSON SITTING AT A COMPUTER AT THE DESK INSIDE THIS HALF-WALL, COULD, BY LIFTING THEIR HEAD, SEE A PERSON SITTING IN A CHAIR ON THE OTHER SIDE OF THE WALL, BUT WOULD HAVE TO WALK AROUND THE PERPENDICULAR WALL TO REACH THE OTHER PERSON. ON 4/23/12, RN "G" MADE THE FOLLOWING ENTRIES INTO RESIDENT #1'S CHARTING: AT 4:50 A.M., "RESIDENT UP HOLLERING AT BEGINNING OF SHIFT... ASSISTED TO HALLWAY AND STAYED WITH STAFF FOR 1:1. (RESIDENT #1) DID KICK AND SLAP STAFF DURING THAT TIME." AT 5:21 A.M., "CALLED TO ROOM BY STAFF AT 0500 (5:00 A.M.) TO INSPECT RESIDENT'S RIGHT ANKLE... AT THIS TIME RIGHT ANKLE IS BRUISED, SWOLLEN AND TENDER... RESIDENT DID NOT COMPLAIN OF PAIN TO RIGHT ANKLE OR FOOT DURING THE NIGHT OR DURING TRANSFER. DURING THE EARLY NIGHT SHE REFUSED TO HAVE ANY COVERING ON HER LOWER EXTREMITIES. WAS 1:1 WITH THIS RN AND WAS KICKING ME WITH BOTH FEET. DID NOT SHOW SIGNS OF PAIN AT THAT TIME." FOLLOWING DISCOVERY OF THE RESIDENT'S BRUISED AND SWOLLEN RIGHT ANKLE AFTER THE SECOND FALL, RESIDENT #1'S PHYSICIAN WAS NOTIFIED AND AN ORDER WAS GIVEN TO HAVE AN X-RAY TAKEN LATER THAT DAY. ON 4/23/12, RN "H" ENTERED AN INCIDENT SHOWING A THIRD FALL FOR RESIDENT #1. THE REPORT BY RN "H" REVEALED LATER THAT SAME MORNING AT 10:40 A.M., RESIDENT #1 "SLID OUT OF CHAIR." NO INJURY WAS NOTED. CNAS ASSIGNED TO RESIDENT #1 WERE IDENTIFIED (CNA "D" AND CNA "E"). CNA "D" WAS INTERVIEWED ON 5/21/12 AT 2:00 P.M. CDT. SHE STATED, "WHEN (RESIDENT #1) GETS AGITATED, SHE THROWS HERSELF. SHE HAD DONE IT TWO TIMES EARLIER THAT MORNING AND I STOPPED HER. THERE WERE THREE OF US... WE PUT HER ON HER BEDSIDE COMMODE, THEN BACK INTO HER WHEELCHAIR. WE PUT THE ALARMS ON AND TWO OF US LEFT THE ROOM. THE THIRD PERSON, WHO WAS ON 1:1 TURNED HER BACK TO EMPTY THE COMMODE BUCKET. THE ALARM WENT OFF; (RESIDENT #1) HAD FALLEN AGAIN. THERE'S NO POLICY REGARDING 1:1 -- IT'S JUST AN UNDERSTANDING THAT 1:1 MEANS YOU NEVER LEAVE THAT PERSON -- DON'T LET THEM OUT OF YOUR SIGHT -- MAKE SURE YOU'RE CLOSE ENOUGH TO REACH THEM. IS (RESIDENT #1) QUICK? OH, YEAH!! (CNA "E") WAS ASSIGNED 1:1." CNA "E" WAS INTERVIEWED ON 5/21/12 AT 2:25 P.M. CDT. SHE STATED, "I WAS DOING 1:1 WITH HER. WE HAD PUT HER ON THE COMMODE, THEN BACK IN HER WHEELCHAIR. THE OTHER TWO AIDES WERE ON THEIR WAY OUT OF THE ROOM. I TOOK THE COMMODE BUCKET INTO THE BATHROOM TO RINSE IT OUT. I HEARD (RESIDENT #1) CALL FOR HELP. THERE WAS NO ALARM SOUNDING. SHE WAS ALREADY ON THE FLOOR. I WAS IN THE BATHROOM, NOT EVEN TWO MINUTES. IT WAS A MISCOMMUNICATION AS TO WHO PUT THE ALARM BACK ON, OR SHOULD HAVE PUT THE ALARM BACK ON. IT WAS NOT ALARMING. (THE DIRECTOR OF NURSING) TOLD ME AFTER (RESIDENT #1) fell , 'AT NO POINT IN TIME DO YOU LET HER LEAVE YOUR SIGHT.' I THOUGHT THERE WAS STILL SOMEBODY IN THE ROOM WITH HER. (RESIDENT #1) IS VERY QUICK." RN "H" WROTE, IN PART, "RES. HAS 1:1 PRESENT, SHE IS NOT TO TAKE HER EYES OFF RES. DURING 1:1... HAS PRESSURE ALARM TO BED AND CHAIR, SENSOR ALARM TO BED, LOW BED WITH FLOOR MATS, MAGNETIC ALARM TO CHAIR." RN "H" UPDATED RESIDENT #1'S CARE PLANS AND CNA ASSIGNMENT CARDS ON 4/23/12 TO INCLUDE, "PROVIDE 1:1 AT ALL TIMES," AND "SENSOR ALARM TO BED." DURING AN INTERVIEW WITH THE DIRECTOR OF NURSING (DON) ON 5/21/12 AT 4:30 PM CDT, SHE STATED, "(RESIDENT #1) WENT TO THE HOSPITAL FOR AN X-RAY OF HER RIGHT ANKLE ON 4/23/12. SHE LEFT THE FACILITY AT 12:46 PM AND RETURNED AT 6:30 PM." AN X-RAY REPORT OF RESIDENT #1'S RIGHT ANKLE, DATED 4/23/12, READ IN PART, "THERE WAS AN AVULSION FRAGMENT OFF THE DORSAL SUPERIOR ASPECT OF THE TALUS. THIS APPEARS ACUTE IN NATURE. THE OSSEOUS STRUCTURES WERE DEMINERALIZED." RESIDENT #1'S MEDICATION ADMINISTRATION SHEET SHOWED THE PAIN MEDICATION VICODIN WAS ORDERED FOR HER ON 4/23/12. ALTHOUGH A PHYSICAL THERAPY (PT) PROGRESS NOTE DATED 4/24/12, SHOWED THE INTENTION TO DISCHARGE RESIDENT #1 FROM THERAPY AS OF 4/27/12, PT CONTINUED TO TREAT RESIDENT #1 FOLLOWING HER [DIAGNOSES REDACTED]. RESIDENT #1 WAS OBSERVED TO BE IN THE THERAPY ROOM ON 5/21/12 AT 11:00 A.M. CDT. AN INTERVIEW WITH RESIDENT #1 ON 5/21/12 AT 11:15 A.M. CDT WAS UNRELIABLE. WHEN ASKED ABOUT HER FALL, SHE STATED, "I WAS COMING DOWN THE STAIRS." WHEN ASKED IF SHE WAS HAVING PAIN, SHE STATED, "MY LEFT FOOT HURTS SOMETIMES. YES, THE PAIN MEDICATION HELPS." ALTHOUGH IT COULD NOT BE DETERMINED EXACTLY WHEN OR HOW RESIDENT #1 FRACTURED HER RIGHT ANKLE BEFORE IT WAS X-RAYED ON 4/23/12, IT WAS DETERMINED THAT THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION TO RESIDENT #1 AFTER HER FIRST AND SECOND FALLS ON 4/22/12 AND FAILED TO IMPLEMENT THE USE OF A WHEELCHAIR ALARM BEFORE HER THIRD FALL ON 4/23/12, RESULTING IN RESIDENT #1 SUSTAINING THREE FALLS IN TWO DAYS RESULTING IN A FRACTURE TO HER RIGHT ANKLE. ( )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE ONE RESIDENT (#1) OUT OF FOUR RESIDENTS REVIEWED FOR APPLICATION OF HOT PACKS/WARM MOIST COMPRESSES, FROM A TOTAL RESIDENT POPULATION OF 98 RECEIVED ADEQUATE SUPERVISION AND ASSISTANCE DEVICES TO PREVENT AN ACCIDENT. SPECIFICALLY, THE FACILITY FAILED TO PROVIDE THE CORRECT HEAT APPLICATION TO RELIEVE RESIDENT #1'S PAIN AND FAILED TO SUPERVISE HIM WHILE THE HEAT APPLICATION WAS IN USE, RESULTING IN RESIDENT #1 SUSTAINING TWO BURNS TO HIS POSTERIOR NECK AND PLACING HIM IN IMMEDIATE JEOPARDY TO HIS HEALTH AND SAFETY. FINDINGS INCLUDE: THE IMMEDIATE JEOPARDY WAS IDENTIFIED AT 1:35 P.M. ON 10/12/11. THE IMMEDIATE JEOPARDY BEGAN ON 10/6/11 AT APPROXIMATELY 7:15 P.M. WHEN, ACCORDING TO A FACILITY REPORTED INCIDENT (FRI) DATED 10/07/11, A HOMEMADE CORN PACK WAS HEATED IN THE MICROWAVE AND PLACED ON RESIDENT #1'S POSTERIOR NECK IN AN EFFORT TO RELIEVE HIS NECK PAIN. ON 10/12/11 AT 4:45 P.M., THE ADMINISTRATOR WAS INFORMED VIA TELEPHONE AND FACSIMILE NOTIFICATION THAT THE FINDINGS CONSTITUTED IMMEDIATE JEOPARDY. THE IMMEDIATE JEOPARDY WAS REMOVED WHILE THE SURVEYOR WAS ONSITE AT THE FACILITY ON 10/12/11 AT 2:00 P.M. WHEN THIS SURVEYOR CONFIRMED, THROUGH OBSERVATION AND INTERVIEWS WITH THE DIRECTOR OF NURSING (DON) AND CERTIFIED NURSE AIDE (CNA) "A", THE CORN PACK HAD BEEN REMOVED FROM THE FACILITY. IN ADDITION, THE DON HAD AMENDED THE FACILITY'S POLICIES AND PROCEDURES TITLED, "APPLICATION OF WARM MOIST COMPRESS" AND "HOT PACK APPLICATION PROCEDURE" TO INCLUDE THE PARAGRAPH, "ELECTRIC HEATING PADS, ELECTRIC BLANKETS, RICE, CORN, CHEMICAL, OR OTHER NATURAL HEATING PADS ARE NOT PERMITTED AS A SOURCE OF SUPPLEMENTAL HEAT." THE WARM MOIST COMPRESS POLICY AND PROCEDURE ALSO INCLUDED, AT THE END OF THIS PARAGRAPH, "MICROWAVE SHALL NEVER BE USED TO HEAT ANY TYPE OF COMPRESSES." ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, THE FACILITY DEFICIENT PRACTICE WAS NOT CORRECTED AS THE FACILITY HAD NOT YET EDUCATED STAFF ON THE CORRECT USE OF HOT PACKS AND WARM MOIST COMPRESSES FOR RESIDENT USE PER FACILITY POLICIES AND PROCEDURES. THE FACILITY REMAINS AT AN ISOLATED DEFICIENCY FOR MORE THAN MINIMAL HARM PENDING THE FACILITY'S ABILITY TO: 1. DEMONSTRATE THEIR ABILITY TO USE THE APPROPRIATE ASSISTIVE DEVICES PER PHYSICIAN ORDERS [REDACTED]. 2. DEMONSTRATE THEIR ABILITY TO SAFELY FOLLOW FACILITY POLICY AND PROCEDURE WHEN UTILIZING WARM COMPRESSES/ HOT PACKS. 3. DEMONSTRATE THEIR ABILITY TO PROVIDE ADEQUATE SUPERVISION TO RESIDENTS WHO ARE RECEIVING TREATMENT WITH WARM COMPRESSES/HOT PACKS. 4. VERIFICATION OF THE INITIATION AND MONITORING OF THE FACILITY'S QUALITY ASSURANCE MEASURES BY THE STATE AGENCY. UPON ARRIVAL AT THE FACILITY AND DURING AN INTERVIEW WITH THE DON ON 10/11/11 AT 12:30 P.M. CENTRAL DAYLIGHT TIME (CDT), SHE STATED, "WE JUST FINISHED THE 5-DAY INVESTIGATION REPORT TODAY." A COPY OF THIS FACILITY INVESTIGATION WAS RECEIVED. THE DON ALSO STATED, AT 1:10 P.M. CDT, "THESE WERE THE POLICIES THAT WERE IN EFFECT ON THAT DAY (10/6/11). I UPDATED THEM TODAY TO INCLUDE 'NO MICROWAVING OF WARM COMPRESSES.'" SHE PROVIDED COPIES OF THE FACILITY'S POLICIES AND PROCEDURES FOR "APPLICATION OF WARM MOIST COMPRESS" AND "HOT PACK APPLICATION PROCEDURE", BOTH UPDATED 10/11/11 TO INCLUDE A PARAGRAPH AT THE BOTTOM WHICH READ, "*NOTE: ELECTRIC HEATING PADS, ELECTRIC BLANKETS, RICE, CORN, CHEMICAL, OR OTHER NATURAL HEATING PADS ARE NOT PERMITTED AS A SOURCE OF SUPPLEMENTAL HEAT." THE WARM MOIST COMPRESS POLICY AND PROCEDURE ALSO INCLUDED, AT THE END OF THIS PARAGRAPH, "MICROWAVE SHALL NEVER BE USED TO HEAT ANY TYPE OF COMPRESSES." REVIEW OF THE FACILITY REPORTED INCIDENT (FRI) FIVE DAY REPORT DATED 10/11/11, SHOWED ON 10/6/11, RESIDENT #1 REQUESTED TO USE AN ELECTRIC HEATING PAD FOR HIS CHRONIC NECK PAIN. HE BECAME UPSET WHEN TOLD THAT HE COULD NOT USE AN ELECTRIC HEATING PAD AND STATED IF SOMETHING WASN'T DONE HE WAS "GOING TO LEAVE THE FACILITY TONIGHT". A PHYSICIAN ORDER [REDACTED].#1 TO HAVE MOIST WARM PACKS TO HIS POSTERIOR NECK AS NEEDED. ACCORDING TO THE FRI FIVE DAY REPORT DATED 10/11/11, THIS INFORMATION WAS PASSED ON TO THE ONCOMING AFTERNOON SHIFT STAFF. THE NURSING STAFF HAD BEEN INFORMED ONLY RESTORATIVE NURSE AIDES CAN APPLY HOT PACKS FROM THE HYDROCOLLATOR, BASED ON THEIR KNOWLEDGE AND TRAINING. AT THE TIME OF THE INCIDENT, NO STAFF ON THE AFTERNOON SHIFT WAS TRAINED TO USE THIS DEVICE. THE DAY SHIFT RN "D", THE AFTERNOON SHIFT RN "N", AND THE AFTERNOON SHIFT CERTIFIED NURSE AIDES (CNAS) DISCUSSED WHAT TO DO. CNA "A" STATED SHE HAD A HOME-MADE HOT PACK MADE FROM CORN THAT SHE HERSELF USED FREQUENTLY AND HAD IT THERE AT THE FACILITY. STAFF FELT IT WOULD BE WORTH TRYING. ACCORDING TO THE FRI FIVE DAY REPORT DATED 10/11/11, WHEN RESIDENT #1 REQUESTED A HOT PACK LATER ON THE AFTERNOON SHIFT, CNA "A" HEATED THE CORN PACK IN THE MICROWAVE, INITIALLY FOR 30 SECONDS, THEN FOR AN ADDITIONAL 30 SECONDS UNTIL IT FELT WARM, HAD RN "N" FEEL IT, THEN PLACED IT BEHIND RESIDENT #1'S NECK. LATER THAT EVENING, RESIDENT #1 REQUESTED THE CORN PACK BE RE-WARMED, SO CNA "B" PLACED IT IN THE MICROWAVE FOR ONE MINUTE. AFTER SHE ASSISTED RESIDENT #1 WITH HIS EVENING CARES, WHICH TOOK ABOUT 20 MINUTES, SHE HELPED HIM INTO BED AND PLACED THE CORN PACK BEHIND HIS NECK. AT THE END OF THE SHIFT AT APPROXIMATELY 10:45 P.M., A THIRD CNA "T" ASSISTED RESIDENT #1 TO THE BATHROOM AND NOTICED A RED AREA AT THE BACK OF HIS NECK. RESIDENT #1 DENIED PAIN AT THE SITE. RN "N" THEN ASSESSED THE REDNESS, THOUGHT IT MIGHT BE RED FROM THE PRESSURE OF THE CORN PACK, NOT A BURN, AND PASSED THE INFORMATION TO THE ONCOMING NURSE. CNA "T" WROTE IN HER WITNESS STATEMENT, "(THE RN "N") HAD ME APPLY A COLD WASHCLOTH." RESIDENT #1'S PHYSICIAN ASSESSED HIM THE FOLLOWING MORNING, FELT THAT THE AREA WAS POSSIBLY A BURN AND ORDERED TREATMENT. REVIEW OF RESIDENT #1'S MEDICAL FILE REVEALED, ON HIS FACE SHEET, THAT HE IS AN [AGE] year OLD MAN ORIGINALLY admitted to the facility on [DATE], THEN REadmitted on [DATE] FROM AN ACUTE CARE HOSPITAL WITH [DIAGNOSES REDACTED]. THE FACE SHEET ALSO SHOWED RESIDENT #1 WAS COMPETENT AND RESPONSIBLE FOR HIS OWN HEALTH CARE. HIS MOST RECENT MINIMUM DATA SET (MDS) PRIOR TO THE 10/6/11 INCIDENT, DATED 8/18/11, SHOWED HE SCORED 14 OUT OF A POSSIBLE 15 POINTS ON HIS BRIEF INTERVIEW FOR MENTAL STATUS (BIMS) AND HE WAS ABLE TO MAKE HIMSELF UNDERSTOOD AND HAD CLEAR COMPREHENSION IN HIS ABILITY TO UNDERSTAND OTHERS. REVIEW OF HIS MEDICATION ADMINISTRATION SHEET FOR THE MONTH OF OCTOBER 2011 SHOWED HE HAD ORDERS FOR AND RECEIVED, IN ADDITION TO OTHER MEDICATIONS, PAIN MEDICATIONS IN THE FORM OF A TOPICAL DURAGESIC PATCH 25 MICROGRAMS/HOUR EVERY 72 HOURS AND PERCOCET 5/325 MILLIGRAMS BY MOUTH EVERY FOUR HOURS AS NEEDED. REVIEW OF NURSING PROGRESS NOTES IN RESIDENT #1'S MEDICAL RECORD SHOWED THAT ON 10/6/11 AT 11:33 A.M., A FAX WAS SENT TO RESIDENT #1'S PHYSICIAN THAT READ, "RESIDENT STRONGLY REQUESTING TO HAVE MOIST WARM PACKS TO THE POSTERIOR NECK PRN (AS NEEDED). OKAY FOR SAME?" A COPY OF THE FAX WAS OBTAINED AND SHOWED THE PHYSICIAN RESPONDED BY SAYING, "OK." AT 9:12 P.M., AN ENTRY READ, "MD ORDER RECEIVED: OKAY FOR WARM MOIST PACKS TO POSTERIOR NECK AT NIGHT." IN HER WITNESS STATEMENT, THE AFTERNOON SHIFT RN "N" CONFIRMED THE DAY SHIFT RN "D" HAD INFORMED HER OF THE NEW ORDER FOR WARM PACKS TO BE APPLIED TO RESIDENT'S NECK. A CONVERSATION ENSUED BETWEEN HERSELF, THE DAY SHIFT RN "D", AND THE AFTERNOON SHIFT CNAS REGARDING WHAT TO USE, AS RESTORATIVE THERAPY, WHO PROVIDED WARM PACKS, HAD ALREADY LEFT FOR THE DAY. THE AFTERNOON SHIFT RN "N" WROTE, "(RN "D") MENTIONED POSSIBLY WETTING A TOWEL AND WARMING IT IN THE MICROWAVE. I GAVE (CNA "A") THE GO AHEAD THAT WE COULD TRY THE HOMEMADE DEVICE (CORN PACK) OR THE TOWEL." CNA "A" WROTE IN HER WITNESS STATEMENT, "WE WERE TOLD BY ( RN "D")TO JUST HEAT A WET TOWEL IN THE MICROWAVE. I THEN REMEMBERED THAT I HAVE A HOMEMADE HEATING PAD MADE WITH CORN AND THEN WRAPPED IN FLEECE. I MENTIONED IT IN REPORT AND EVERYONE SEEMED OK WITH USING IT ON (RESIDENT #1)." DURING AN INTERVIEW WITH CNA "A" ON 10/11/11 AT 2:50 P.M. CDT, SHE STATED, "AT AROUND 7:15 P.M., (RESIDENT #1) WAS REQUESTING THE HEATING PAD. SO I PUT THE CORN PACK IN THE MICROWAVE FOR 30 SECONDS. WHEN I FELT IT, IT WAS STILL COLD, SO I PUT IT IN THE MICROWAVE FOR ANOTHER 30 SECONDS. IT WAS WARM, BUT NOT HOT. I HAD THE NURSE (RN "N") CHECK IT BEFORE I PUT IT UNDER (RESIDENT #1'S) NECK; SHE SAID IT WAS OKAY. HE WASN'T MY RESIDENT SO I DIDN'T SEE HIM ANYMORE THAT NIGHT; HE WAS (CNA "B")'S RESIDENT. I'VE BROUGHT THE CORN PACK HOME." CNA "B" WROTE IN HER WITNESS STATEMENT, "I WAS GOING TO GET (RESIDENT #1) READY FOR BED. I NOTICED HE HAD THE BAG (CORN PACK). HE SAID IT WASN'T WARM ANYMORE SO I ASKED HIM IF HE WANTED IT HEATED AGAIN. HE SAID 'YES' SO I WENT DOWN AND HEATED IT IN THE MICROWAVE FOR 1 MINUTE. I HAD ASKED (CNA "T") HOW LONG TO PUT IT IN THE MICROWAVE FOR, BECAUSE SHE WAS THE ONE WHO MADE IT FOR (CNA "A")." DURING AN INTERVIEW WITH CNA "B" ON 10/11/11 AT 3:00 P.M. CDT, SHE STATED, "AT AROUND 9:00 P.M., HE (RESIDENT #1) WANTED THE CORN PACK RE-HEATED. I PUT IT IN THE MICROWAVE FOR ONE MINUTE. BUT THEN HE WAS IN THE BATHROOM AND BY THE TIME HE FINISHED IN THERE AND I GOT HIM READY FOR BED, AT LEAST 20 MINUTES HAD GONE BY BEFORE I PUT THE CORN PACK UNDER HIS NECK. NO, I DIDN'T LOOK AT THE BACK OF HIS NECK BEFORE PLACING IT THERE." A NURSING PROGRESS NOTE IN RESIDENT #1'S MEDICAL RECORD, ENTERED BY RN "N" ON 10/7/11 AT 9:09 P.M. (AS A LATE ENTRY FOR 10/6/11) READ, IN PART, "DISCUSSION WAS HAD ON WHAT TO USE FOR HIS WARM PACK... (CNA "A") SUGGESTED THAT IN HER LOCKER SHE HAD A FABRIC THING FILLED WITH CORN THAT SHE WOULD HEAT IN THE MICROWAVE UNTIL WARM AND THAT IT WORKED REALLY WELL FOR WHEN SHE WAS HAVING NECK/BACK TROUBLES. ( RN "D") SUGGESTED THAT WE COULD USE A TOWEL AND MICROWAVE SAME...THIS WRITER SUGGESTED THAT WE COULD TRY THE CORN FABRIC THING UNTIL MORNING WHEN PT (PHYSICAL THERAPY) COULD GET A WARM PACK AVAILABLE. THIS WRITER IS ALSO HONEST AND DID NOT KNOW THE POLICY REGARDING WARM MOIST COMPRESSES. ASSUMED IT WAS TAKEN CARE OF BY RESTORATIVE AIDES. AT END OF SHIFT AT APPROX. (10:45 P.M.), (CNA "T") CAME AND GOT THIS WRITER AND INFORMED THAT SHE THOUGHT RESIDENT'S NECK/BACK OF HEAD WAS BURNT FROM THE FABRIC CORN THING. WE OBSERVED RESIDENT'S NECK/BACK OF HEAD AND AREA WAS RED. THIS WRITER WAS UNSURE WHETHER IT WAS ACTUALLY BURNT OR RED FROM PRESSURE TO AREA FROM LYING ON SAME. RESIDENT DENIED ANY PAIN/DISCOMFORT." A COMPUTERIZED INCIDENT REPORT, DATED 10/7/11 AT 2:18 P.M., DESCRIBED THE BURNS TO RESIDENT #1'S POSTERIOR NECK AS FOLLOWS: LEFT POSTERIOR NECK-5CM (CENTIMETERS) X 2.5CM AND RIGHT POSTERIOR NECK 1CM X 1CM. LEFT POSTERIOR NECK AREA WITH REDNESS...NO BLISTERING OR DRAINAGE. RIGHT POSTERIOR NECK AREA WITH PINKISH REDNESS...NO BLISTERING OR DRAINAGE." A PROGRESS NOTE IN RESIDENT #1'S MEDICAL RECORD DATED 10/7/11 AT 11:06 A.M. READ, "PHYSICIAN VISIT: (RESIDENT #1'S PHYSICIAN "C") EXAMINED CLIENT 10/7/11 REVIEWED PHYSICIAN ORDERS [REDACTED]." THE PHYSICIAN DICTATION FOR THIS VISIT WAS NOT YET AVAILABLE SO THE DON CONTACTED PHYSICIAN "C" BY PHONE AND HAD HIM SPEAK WITH THIS SURVEYOR. DURING THIS PHONE INTERVIEW ON 10/11/11 AT 3:25 P.M. CDT, PHYSICIAN "C" STATED, "I SAW (RESIDENT #1) ON FRIDAY (10/7/11). WE DON'T LIKE TO USE THOSE (MICROWAVABLE HEAT PACKS); THEY HAVE HOT SPOTS THAT YOU CAN'T FEEL BY JUST TOUCHING THE OUTSIDE SURFACE. I ASSESSED (RESIDENT #1) AND SAW A FIVE CENTIMETER RED AREA WITH MILD INDURATION ON THE BACK OF HIS NECK; THE CENTER OF THIS AREA HAD A VERY SUPERFICIAL SECOND DEGREE BURN WITH BLISTERING AND PEELING. THERE WAS NO EXUDATE. MY ASSUMPTION IS THAT THERE WAS A HOT SPOT IN THE CORN BAG. WE QUESTIONED IF PHYSICAL THERAPY WAS THE CAUSE BUT IT WAS MORE LIKELY FROM THE BAG." COPIES OF NURSING PROGRESS NOTES AND A FAXED ORDER FROM THE PHYSICIAN REVEALED THE WARM MOIST PACKS WERE DISCONTINUED FOR RESIDENT #1 ON 10/7/11. A PROGRESS NOTE, DATED 10/8/11 AT 11:07 A.M., ENTERED AS A 48-HOUR FOLLOW UP TO THE INCIDENT REGARDING BURNS ON POSTERIOR NECK, READ, "INTERVENTION TO PREVENT RE-OCCURRENCE: STAFF MUST FOLLOW ORDERS AND NOT MAKE SUBSTITUTIONS." REVIEW OF A PROGRESS NOTE, DATED 10/10/11 AT 9:29 A.M., REVEALED A FAX WAS SENT TO PHYSICIAN "C" THAT READ, "BURN TO POSTERIOR NECK COMPLETELY RESOLVED WITH NO SCARRING, PEELING, OR REDNESS NOTED. OKAY TO DISCONTINUE BACITRACIN AND TELFA DRESSING CHANGES?" THE FAXED RESPONSE FROM THE PHYSICIAN, DATED 10/10/11 READ, "D/C (DISCONTINUE) BURN CARE." A PROGRESS NOTE ENTERED AS A 72 HOUR FOLLOW UP, DATED 10/10/11 AT 1:06 P.M. READ, "BURN UNABLE TO FIND ANY SIGN OF BURNED TISSUE BUT RES (RESIDENT #1) DOES STILL VOCALIZE SORENESS AT AREA OF SKIN THAT PREVIOUSLY HAD A RED MARK." DURING AN INTERVIEW WITH RESIDENT #1 ON 10/11/11 AT 2:00 P.M. CDT, HE STATED, "I USED TO USE AN ELECTRIC HEATING PAD. I USED IT ONCE SINCE I CAME HERE, BUT THEY SAID I COULDN'T USE IT HERE SO I PUT IT AWAY. I HAVE BEEN GETTING PAIN MEDS TWICE A DAY--THEY TOOK THE EDGE OFF, BUT DIDN'T GET RID OF THE PAIN COMPLETELY. I DON'T WANT TO BE TAKING PILLS ALL THE TIME. SO AFTER I PUT THE ELECTRIC HEATING PAD AWAY, I ASKED THEM IF THEY WOULD GET ME SOME OTHER KIND OF PAD. I HADN'T SLEPT WELL FOR TWO NIGHTS BECAUSE OF THE PAIN. SO WHEN THEY PUT THAT COMPRESS BEHIND MY NECK, I MUST HAVE fell ASLEEP. NO, THEY ONLY PUT IT BEHIND MY NECK ONCE. I DIDN'T NOTICE ANYTHING AT FIRST, BUT A DAY OR SO LATER, MY SKIN REALLY BURNED." RESIDENT #1'S POSTERIOR NECK WAS OBSERVED AT THIS TIME WITH A NURSE PRESENT AND NO EVIDENCE OF A BURN WAS NOTED. OBSERVATION OF RESIDENT #1'S ROOM SHOWED THE CORN PACK NOWHERE IN SIGHT. REVIEW OF THE FACILITY'S POLICY AND PROCEDURE, "APPLICATION OF WARM MOIST COMPRESS," READ, IN PART, AS FOLLOWS: "SUPPLIES & EQUIPMENT: COMPRESS OR WASH CLOTH, SANDWICH BAG OR PLASTIC WRAP, GLOVES IF NECESSARY. PROCEDURE: 1) OBTAIN A physician's orders [REDACTED]. WRING THE COMPRESS OR PACK, REMOVING AS MUCH WATER AS POSSIBLE... 8) ASSESS THE CONDITION OF THE RESIDENT'S SKIN AT LEAST EVERY 10 MINUTES... 12) DOCUMENT THE TREATMENT IN THE RESIDENT'S CHART." NO DOCUMENTATION COULD BE FOUND IN RESIDENT #1'S MEDICAL FILE TO SHOW HIS SKIN HAD BEEN ASSESSED WHILE THE CORN PACK WAS ON HIS POSTERIOR NECK. DURING AN INTERVIEW WITH THE DON ON 10/12/11 AT 9:50 A.M. CDT, SHE STATED, "THEIR (STAFF) INTENTIONS WERE GOOD; THEY WERE TRYING TO HELP HIM. BUT AT THE SAME TIME, WHAT WERE THEY THINKING?! IF THEY DIDN'T KNOW WHAT TO USE, THEY SHOULD HAVE CALLED ME--THEY'VE CALLED ME FOR SMALLER THINGS THAN THAT BEFORE." SHE ADDED, "I TOLD THE AIDE (CNA "A"), 'BRING IT (CORN PACK) HOME RIGHT NOW AND I DON'T EVER WANT TO SEE IT HERE AGAIN.' WE'LL BE HAVING A STAFF INSERVICE ON THE APPLICATION OF WARM MOIST COMPRESSES." IT WAS DETERMINED THE FACILITY: 1) FAILED TO USE THE APPROPRIATE ASSISTIVE DEVICE AS ORDERED BY THE PHYSICIAN; 2) FAILED TO FOLLOW THE FACILITY'S POLICY AND PROCEDURE FOR THE "APPLICATION OF WARM MOIST COMPRESS" BY USING A MICROWAVE TO HEAT A CORN PACK INSTEAD OF USING A COMPRESS OR WASH CLOTH HEATED IN TAP WATER; AND 3) FAILED TO ASSESS THE CONDITION OF THE RESIDENT'S SKIN AT LEAST EVERY TEN MINUTES WHILE THE COMPRESS WAS IN PLACE PER FACILITY POLICY AND PROCEDURE. THESE FAILURES RESULTED IN RESIDENT #1 SUSTAINING BURNS TO HIS POSTERIOR NECK. ( )

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION/ASSISTIVE DEVICES TO PREVENT ACCIDENTS FOR ONE (#1) OF SEVEN SAMPLED RESIDENTS REVIEWED FOR FALLS. THIS FACILITY DEFICIENT PRACTICE CONTRIBUTED TO AN UNWITNESSED RESIDENT FALL RESULTING IN A FRACTURED PELVIS. FINDINGS INCLUDE: ON 5/24/11 AT 8 A.M., AN INVESTIGATION WAS INITIATED AT THE FACILITY REGARDING A FACILITY REPORTED INCIDENT (FRI) OF AN UNWITNESSED FALL INVOLVING RESIDENT #1 WHICH OCCURRED ON 4/21/11. A REVIEW OF AN INCIDENT REPORT FROM THIS FALL REVEALED THAT ON 4/21/11 AT APPROXIMATELY 6:35 P.M., RESIDENT #1 WAS FOUND SEATED ON THE FLOOR OF HER ROOM NEXT TO HER DOOR BY LICENSED PRACTICAL NURSE (LPN) "B". THE PROBABLE CAUSE NOTED FOR THE FALL WAS DETERMINED TO BE "SELF-AMBULATING IN ROOM WITH NO ASSISTANCE". THE INCIDENT REPORT FURTHER REVEALED, "NO APPARENT INJURY, MOVES ALL EXTREMITIES. NO COMPLAINTS OF PAIN DURING INITIAL ASSESSMENT BUT LATER RESIDENT (#1) DID COMPLAIN OF PAIN TO THE RIGHT POSTERIOR THIGH. INITIALLY RESIDENT (#1) ABLE TO MOVE ALL EXTREMITIES WITH NO COMPLAINTS OF PAIN. UPON R.N. (REGISTERED NURSE) ASSESSMENT, FINDINGS INDICATED NO INTERNAL OR EXTERNAL ROTATION AND NO SHORTENING OF EITHER EXTREMITY. APPROX. (APPROXIMATELY) 1 1/2 HOURS LATER RESIDENT WITH COMPLAINTS OF PAIN TO RIGHT POSTERIOR THIGH." ON 5/24/11 AT 10 A.M., A REVIEW OF NURSING PROGRESS NOTES FROM 4/21/11 AND 4/22/11 REVEALED THAT ON 4/21/11 AT APPROXIMATELY 8 P.M., RESIDENT #1 WAS NOTED TO BE COMPLAINING OF SEVERE PAIN IN HER RIGHT POSTERIOR THIGH. SHE WAS TRANSFERRED TO A LOCAL HOSPITAL FOR EMERGENCY EVALUATION AND X-RAY. RESIDENT #1 RETURNED FROM THE HOSPITAL AT 11:15 P.M. ON 4/21/11 WITH A [DIAGNOSES REDACTED]. ACCORDING TO NURSING NOTES FROM 4/21/11 AND 4/22/11, FOLLOWING HER RETURN TO THE FACILITY, RESIDENT #1 WAS NOTED TO HAVE INCREASED ANXIETY AND BEGAN REGISTERING LOW OXYGEN SATURATION LEVELS. ON 4/22/11 AT APPROXIMATELY 8:22 A.M., RESIDENT #1 WAS RETURNED TO THE LOCAL HOSPITAL FOR AN ASSESSMENT OF A POSSIBLE PULMONARY EMBOLISM RELATED TO HER EARLIER FALL. RESIDENT #1 RETURNED TO THE NURSING FACILITY AT APPROXIMATELY 1 P.M. WITH A [DIAGNOSES REDACTED]. AN INTERVIEW WAS CONDUCTED WITH THE DIRECTOR OF NURSING (DON) ON 5/24/11 AT APPROXIMATELY 11 A.M. THE DON INDICATED THAT RESIDENT #1 HAD NO PRIOR FALLS AT THE FACILITY SINCE HER ADMISSION ON 5/27/10. PER THE DON, FALL PREVENTION SAFETY MEASURES HAD BEEN PUT IN PLACE AT ADMISSION AS RESIDENT #1 HAD FALLEN AT HOME PRIOR TO HER ADMISSION, SUFFERING A LEFT HIP FRACTURE.. THESE MEASURES HAD REMAINED IN PLACE AND INCLUDED THE USE OF ALARMS ON HER BED AND WHEELCHAIR. ON 5/24/11 AT APPROXIMATELY 12 NOON, A REVIEW OF THE CURRENT "AT A GLANCE" CARE GUIDE FOR RESIDENT #1 REVEALED THAT RESIDENT #1 WAS TO HAVE BOTH MAGNETIC AND PRESSURE PAD ALARMS APPLIED TO HER BED AND HER WHEELCHAIR WHEN IN USE. ON 5/24/11 AT APPROXIMATELY 1 P.M., A REVIEW OF THE FACILITY'S INVESTIGATIVE SUMMARY OF RESIDENT #1'S FALL OF 4/21/11, REVEALED THAT CERTIFIED NURSE AIDE (CNA) "A" HAD ASSISTED RESIDENT #1 TO THE BATHROOM AT AROUND 6:30 P.M. THE EVENING OF HER FALL AND HAD RETURNED HER TO HER WHEELCHAIR. CNA "A" HAD REPORTEDLY SET RESIDENT #1 UP TO BRUSH HER TEETH AND INSTRUCTED HER TO USE HER CALL LIGHT TO LET HER KNOW WHEN SHE WAS DONE. CNA "A" INDICATED THAT SHE FORGOT TO PLACE ALARMS ON RESIDENT #1'S WHEELCHAIR PRIOR TO LEAVING RESIDENT #1. CNA "A" CONFIRMED THAT SHE HAD FORGOT TO ALARM THE WHEELCHAIR OF RESIDENT #1 IN AN INTERVIEW WITH HER ON 5/24/11 AT 3:30 P.M. RESIDENT #1 SUSTAINED HER FALL SHORTLY AFTER BEING LEFT BY CNA "A" ON THE EVENING OF 4/21/11. AN INTERVIEW WAS CONDUCTED WITH RESIDENT #1 ON 5/24/11 AT APPROXIMATELY 2 P.M. RESIDENT #1 WAS ASKED ABOUT HER RECENT FALL AND SHE RESPONDED THAT SHE HAD FALLEN WHEN GOING DOWN TO THE BASEMENT TO GET POTATOES. ALTHOUGH THIS INFORMATION MAY HAVE BEEN RELATED TO A FALL PRIOR TO ENTERING THE FACILITY, RESIDENT #1 COULD PROVIDE NO INFORMATION SPECIFIC TO HER RECENT FALL. AN INTERVIEW WAS CONDUCTED WITH RESIDENT #2, WHO HAD BEEN THE ROOMMATE OF RESIDENT #1 AT THE TIME OF THE FALL. RESIDENT #2 COULD PROVIDE NO ADDITIONAL INFORMATION. RESIDENT #1 ENTERED THE FACILITY ON 5/27/10. RESIDENT #1 HAD CARE PLAN INTERVENTIONS TO PREVENT FALLS IDENTIFIED AS PRESSURE AND MAGNETIC ALARMS ON HER BED AND WHEELCHAIR WHEN IN USE. WHEELCHAIR ALARMS WERE NOT PLACED ON HER CHAIR ON 4/21/11 AT 6:30 P.M. RESIDENT # 1 EXPERIENCED AN UNWITNESSED FALL AT THAT TIME, RESULTING IN A FRACTURE OF HER PELVIS. ( )

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION FOR ONE RESIDENT (#2) WHICH RESULTED IN HARM FROM A TOTAL SAMPLE OF 5 RESIDENTS REVIEWED WITH HISTORY OF FALLS. THIS FAILURE RESULTED IN RESIDENT #2 FALLING AND FRACTURING THE LEFT FEMORAL NECK OF HER HIP, REQUIRING hospitalization AND SURGERY. FINDINGS INCLUDE: RESIDENT #2 IS AN [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH HISTORY OF PERSONAL FALLS, MALAISE AND FATIGUE, SYNCOPE AND COLLAPSE, DIZZINESS AND GIDDINESS, CIRCULATORY DISEASE, ATRIAL FIBRILLATION, CORONARY ARTERIOSCLEROSIS AND LOWER EXTREMITY WEAKNESS. RESIDENT #2 HAD A FALL ON 8/29/10 AT THE FACILITY RESULTING IN A NON-PLACED FRACTURE OF THE GREATER TROCHANTER OF THE RIGHT HIP, BUT SHE DID NOT REQUIRE SURGERY. RESIDENT #2'S CARE PLAN TITLED, "ACTIVITIES OF DAILY LIVING", DATED 8/6/10, LISTED APPROACHES WHICH INCLUDED: "PRESSURE ALARM IN W/C (WHEELCHAIR) AND BED, MAGNETIC ALARM IN BED AND WHEELCHAIR AND SENSOR ALARM TO FOOT OF BED." A FACILITY REPORTED INCIDENT, DATED 9/6/10, REVEALED RESIDENT #2 HAD A FALL ON 9/5/10 WHICH RESULTED IN A "FRACTURE TO THE LEFT HIP". ACCORDING TO THE REPORT, THE RESIDENT WAS IN HER BED AND ATTEMPTED TO GET UP INDEPENDENTLY. THE FACILITY'S INVESTIGATION INTO THE FALL REVEALED RESIDENT #2 APPARENTLY REMOVED HER MAGNETIC ALARM. THE INVESTIGATION ALSO REVEALED HER PRESSURE PAD WAS, "ON BUT DID NOT SOUND IMMEDIATELY... (AND) HER SENSORY ALARM WAS NOT ON". RESIDENT #2 WAS admitted TO THE hospital on [DATE] AND HAD SURGERY TO THE LEFT HIP ON 9/6/10. SHE WAS REadmitted to the facility on [DATE]. DURING AN INTERVIEW ON 10/19/10 AT 2:05 P.M. CENTRAL STANDARD TIME (CST) WITH THE DIRECTOR OF NURSING (DON), THE ASSISTANT DON "K", CHARGE NURSE "J", AND THE ADMINISTRATOR, IT WAS STATED THAT CERTIFIED NURSE AIDE (CNA) "E" DID NOT APPLY THE RESIDENT'S SENSORY ALARM, AND THE PRESSURE ALARM HAD LOOSE BATTERIES WHICH CAUSED IT NOT TO ALARM. DURING AN INTERVIEW ON 10/19/10 AT 2:30 P.M. CST WITH CERTIFIED NURSE AIDE (CNA) "E", SHE STATED, "I DIDN'T KNOW SHE (RESIDENT #2) HAD A SENSORY ALARM.... I DIDN'T SEE IT (THE SENSORY ALARM) AND IT NEVER WAS PUT ON." DURING AN INTERVIEW ON 10/19/10 AT 1:15 P.M. CST WITH THE DON, SHE STATED, "THE ALARMS, IF WORKING PROPERLY AND PROMPTLY... MAY HAVE ALERTED STAFF THERE WAS A PROBLEM... THEY MAY HAVE RESPONDED TIMELY TO PREVENT THE FALL OR ASSISTED WITH THE FALL TO THE GROUND, POSSIBLY PREVENTING THE FRACTURED HIP." FOLLOWING RESIDENT #2'S RETURN TO THE FACILITY, SHE SHOWED A DECLINE IN FUNCTION AS EVIDENCED BY A "FAX TO MD (MEDICAL DOCTOR)" DATED 10/9/10. THE FAX READ, "PLEASE ADVISE... FAST COGNITIVE DECLINE SINCE HER HIP SURGERY... NO OTHER ISSUES LEADING INTO CURRENT EPISODE (DECLINE IN COGNITION)." ( )