Every finding on record at Great Lakes Rehabilitation Center

Based on observation, interview and record review, the facility failed to develop and implement meaningful interventions to prevent pressure ulcers for one resident (R30) and complete consistent wound documentation for one resident (R29) of two residents reviewed for pressure ulcers, resulting in the development of an unstageable pressure ulcer and inconsistent wound documentation. Findings include: Resident #29: On 1/13/2026 at 11:40 AM, an interview was conducted with Wound Nurse G regarding Resident #29's wound she admitted with. The nurse reported the resident was admitted from home with a Stage 2 coccyx wound and they are now monitoring the area. She explained the resident prefers being in her chair most of the day and refuses staff attempts to reposition her. Wound Nurse G was queried on the current interventions in place to prevent development of wounds and she stated she has a low air loss mattress. On 1/13/2026 at 12:00 PM, an interview was conducted with MDS (Minimum Data Set) Coordinator R, regarding Resident #29's wound. She stated the resident admitted with a pressure ulcer and it resolved and reopened in November 2025. Review was conducted of Resident #29's record and it revealed she admitted to the facility on [DATE] with diagnoses that included, Progressive Multiple Sclerosis, Bacteremia, Hyperlipidemia, Peripheral Vascular Disease and Quadriplegia. Further review was completed and it showed the following: Progress Notes: 6/30/2025 at 10:50: Resident was receiving bed bath when approached for wound treatment, denies pain, and is agreeable. Wound bed is 0.5cm x 1.0 with kerotic edges. Peri wound is red and blanchable. Will continue current treatment until assessed by NP (Nurse Practitioner) . Care Plan: (Resident #29) has an increased risk for skin impairment r/t (related to).known skin impairment – P2 sacrum, present on admit, 5/21/25 deterioration noted 9/11/25.air mattress applied to bed.monitor/document location, size and treatment of skin injury, report abnormalities. There were minimal interventions listed for prevention of skin alterations and there was nothing located regarding refusals to adhere to facility implemented interventions. 8/8/2025 at 12:03: Resident admitted from home on 5-21-25 with healing stage II pressure injury to coccyx/sacrum. Residents healing has been monitored and continues to improve. Currently, previously scabbed area has superficial skin loss and red. Measures approximately 1.0cm x 0.5cm with superficial skin loss. will continue current treatment until assessed by NP. Review was completed of Resident #29's Skin & Wound evaluation notes, it was found there was no consistent monitoring and assessment to include pictures, measurements, staging, further interventions, changes of treatment orders (if applicable) and description of wound. Skin & Wound Evaluations were completed on the following days: 5/21/25- Admission 6/3/25- readmission to facility 11/5/25 11/19/25 On 01/13/2026 at 1:14 PM, an interview was conducted with Wound Nurse G. She reported Resident #29 has a standard cushion in her chair and it would not be listed on her careplan or in an order. She expressed there is an order in the MAR (Medication Administration Record) for refusals to offload. The order stated, Encourage resident to lay down and offload throughout the day. Document refusals in nursing note. Nurse G was asked for clarity regarding the order as it was unclear how to interpret the responses indicated by nursing staff. Nurse G reported she would review the order and return with an answer. Upon her returning it was explained if the MAR indicated a No or N meant that the resident refused to lay down when approached by staff. Nurse G reported Resident #29 does not currently have a pressure ulcer and she assesses her skin monthly. She was further asked why the resident had two [NAME] orders, the orders are as follows: Cleanse sacral breakdown with Ph balances cleanser, dry, [NAME] thin layer of [NAME] every shift for breakdown. Entered on 11/17/2025 by Wound Nurse G Apply [NAME] to b/l (bilateral) buttock and sacrum- every shift for breakdown prevention and as needed for missing or soiled dressing. Order was entered on 8/25/205 by Wound Nurse G. Wound Nurse G reported she was not aware the resident had two orders for [NAME] (one for breakdown and the other for prevention) even though she was the nurse that entered both orders. On 1/14/2026 at 3:30 PM, Wound Nurse G explained Resident #29 should only have one order for [NAME]. One order was for breakdown and the other for prevention. Nurse G shared on 11/7/2025 the resident began to have maceration that was discovered during a skin assessment which is where the November 2025 [NAME] ordered originated from. Nurse G was asked to provide Resident #29's weekly wound notes from admission to when the wound first resolved and notes when it reopened. The nurse returned and expressed Resident #29 admitted with the wound and it resolved on 7/7/2025 and reopened on 8/8/2025. Nurse G provided a handwritten document with the following information: 5/21/25- admitted with 5/27/25- Hospital 6/3/25- readmitted with excoriation Nurse G off work from 6/13/25 to 6/15/25 6/30/25- Nurses note regarding wound 7/7/25- skin assessment showing wound closed Worked floor 6/2/25, 6/3/25, 6/4/25 and 6/23/25. Wound Nurse G stated she did not have weekly wound assessments of Resident #29's wound from admission to when it closed on 7/7/2025 because she was working the floor and not able to perform her job function as a wound nurse. Resident #29's coccyx wound was not being consistently monitored. Resident #30 R30 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include hypertension, fractures with routine healing, falls and chronic kidney disease. R30 was deemed capable of making her own decisions. On 01/12/2026 at 10:05AM, R30 was observed sitting in her wheelchair with a dressing on her left foot. R30 stated that someone was supposed to come down and change the dressing, but no one has done it yet. On 01/12/26 at 10:25AM, record review revealed that R30 developed a pressure ulcer on her left heel on 12/29/25 and it was facility acquired. On 01/14/2026 at 11:31AM, R30 was observed in her wheelchair. Licensed Practical Nurse (LPN) F was observed completing wound care on the left heel. LPN F was asked if R30 wears her protective PRAFO boot, LPN F stated that R30 refuses to wear her PRAFO boot quite often. This surveyor observed the pressure injury on the heel. LPN F was asked how the wound started. LPN F stated the left heel injury started as a blister and opened. LPN F offered R30 the PRAFO boot for her left heel R30 accepted and the boot was placed for protection. On 01/14/2026 at 11:47AM, an interview was conducted with wound care G. Wound care G was asked if the pressure ulcer on the left heel was present on admission. Wound care G stated, no, but the heels were boggy (soft, spongy feeling) on admission and R30 does not like to wear her PRAFO boot, and she lays in bed a lot. Wound care G stated one of the nurses did the skin assessment and they noted it as a skin tear and not a blister. When I looked at it, I spoke with the Nurse Practitioner (NP), we put the heel cup in place and R30 was still not elevating her feet. The NP saw her again, trimmed extra skin off the blister, the weekend went by and R30 was still not elevating her feet and the heel worsened. Wound care G was asked when the PRAFO boot was put in place for protection. Wound care G stated, we started the PRAFO boot on Monday 1/12/26. Wound care G was asked if R30 is in bed does staff elevate her heels. Wound care G stated, the staff try but she will refuse. On 01/14/2026 at 12:13PM, record review of care plans for R30 revealed a care plan for skin impairment in place. Focus R30 has an increased risk for skin impairment, initiated 12/23/25 and R30 has a known skin impairment Unstageable pressure wound, left heel, initiated 12/29/25 Interventions included: -Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Initiated 12/23/25 -Encourage good nutrition and hydration in order to promote healthier skin. Initiated 12/23/25. -Identify/document potential causative factors and eliminate/resolve where possible. Initiated 12/23/25 -Prafo boot to left heel at all times as tolerated. Initiated 01/12/26 -Use a draw sheet or lifting device to move resident. Initiated 12/23/25 -Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Initiated 12/23/25 The care plan for skin impairment does not have additional interventions for pressure prevention other than a PRAFO boot that was put in place on 1/12/26. On 01/14/2026 at 12:27PM, record review of the admission assessment and skin assessment revealed that R30's heels were boggy on admission. On 01/14/2026 at 12:36PM, record review of the Braden Scale for Predicting Pressure Sore, revealed a risk score of 14, indicating moderate risk for pressure ulcer. On 01/14/2026 at 1:45PM, an interview was conducted with the Director of Nursing (DON). The DON was asked where interventions for wound prevention would be in the electronic medical record. The DON stated, I would like to see the interventions be in the tasks, that way the aides can see them, ensure they are getting put in place and document that it was completed. On 01/14/2026 1:58PM, an interview was conducted with wound care G. Wound care G was asked if there should there have been more interventions for pressure ulcer prevention in place prior to the blister forming since R30's heel were already boggy. Wound care G stated there should have been skin prep (a product that protects the skin against irritation and damage caused by tapes, films and bodily fluids) in place and the standard of care is to elevate the heels. We do bi-weekly skin assessments as well. Wound care G was asked if they would care plan elevating the heels of a resident. Wound care G again stated, the standard of care is to elevate the heels off the bed, and we wouldn't put that in a care plan since it's a standard of care. Wound care G was asked if they thought the staff was elevating her heels or doing what they could to prevent the development of the pressure injury on the left heel. Wound care G stated, I feel like R30 does what she wants and she was not excited about the interventions we put in place. Wound care G was asked if they should have put the PRAFO boot(s) on prior to development of the pressure ulcer as an intervention to prevent breakdown. Wound care G stated, it would have been a good intervention to have in place, but it is not typically something we do on admission. If they would have had the PRAFO boots in the hospital, then I would've put them in place. Otherwise, we don't keep many of the PRAFO boots on hand, we happened to have one here so we could put it on her. On 01/14/2026 at 2:22PM, Certified Nursing Assistant (CNA) H was interviewed. CNA H was asked, If you are supposed to elevate a residents' heels where would you find that in the Electronic Medical Record (EMR). CNA H stated, I would find it in the EMR in the Kardex (which comes from the care plans) and in the room on a piece of paper in the closet. CNA H stated they are the staff member that prints out the Kardex from the EMR and places it in each resident's room on a weekly basis or as needed with a change. CNA H stated they highlight important interventions for the residents such as items for pressure prevention or the amount of assistance needed to transfer, as examples. Verified with CNA H that the Kardex did not indicate to elevate heels for R30. On 01/14/2026 at 3:41PM, an interview was conducted with LPN I. LPN I was asked what skin prep is. LPN I stated that it was a wipe they use on the skin of residents for putting on dressings. LPN I was asked if they needed a physician's order to use this product. LPN I stated, yes, there is typically an order in place to use the prep. LPN I was asked who can apply the skin prep. LPN I stated that nurses can apply it. On 01/14/26 at 3:55PM, record review of physician orders revealed that there was no order for skin prep. Record review also revealed no documentation for elevating the heels of R30. Review of the policy titled, Wound Management Program, revealed, Policy: To assure that residents who are admitted with, or acquire wounds receive treatment and services to promote healing, prevent complications and prevent new skin conditions from developing. Process (prevention): 3. Place initial interventions for residents at risk for development of skin breakdown in care plan.

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents who consume food from the kitchen.Findings include: On 01/12/2026 at 9:20am-9:40am during the initial kitchen tour with Certified Dietary Manager C observed chicken noodle soup inside refrigerator without datemarking. During this observation, CDM C was asked when the chicken noodle soup was prepared and stated she wasn't sure and removed the chicken noodle soup from the fridge. On 01/12/2026 at 9:20am-9:40am observed the mixer visibly soiled with a yellow residue. During this observation CDM C was asked how often the mixer is cleaned and stated it's cleaned after each use. On 01/12/2026 at 9:20am-9:40am observed the microwave visibly soiled on the interior ceiling. During this observation CDM C was asked how often the microwave is cleaned and stated it's cleaned after each meal. On 01/12/2026 at 9:20am-9:40am observed a chunky yellow residue on the interior walls of the ice machine. During this observation CDM C was asked how often the ice machine is cleaned and stated that maintenance is supposed to clean it monthly. On 01/12/2026 at noon-12:50pm during lunch observation observed [NAME] D put on gloves without washing hands and proceeded to prepare food in the kitchen. On 01/12/2026 at noon-12:50pm observed [NAME] D remove gloves and put new gloves on without washing hands and continued to prepare lunch in the kitchen. On 01/12/2026 at noon-12:50pm during interview with CDM C on handwashing procedures when using gloves, CDM C stated that hands should be washed after taking off gloves.According to the 2022 Food Code, 2-301.14 When to Wash, Food employees shall clean their hands and exposed portions of their arms.immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and.Before donning gloves to initiate a task that involves working with food.On 01/12/2026 at 1:12pm-1:30pm during interview with Maintenance E on the cleaning schedule for the ice machine, he stated that the ice machines are cleaned once a month, but there isn't a cleaning log for the ice machine. According to the 2022 Food Code, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, Equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations, nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the facility's policy on sanitization, All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions. Equipment used daily, ie microwave, stove, etc. is to be cleaned daily at end of shift.

Based on observation, interview and record review, the facility failed to implement an ongoing infection prevention and control program, resulting in a lack of precautions for one resident (Resident #61) with an eye infection and the absence of line listings, infection control audits and surveillance for multiple months. Findings include: On 01/13/2026 at 11:43 AM An interview was conducted with the Infection Control (IC) nurse B to set up a time to go over the infection control program. IC nurse B stated that she was behind on infection control tasks, she stated that she had some of the line listings for January 2026 completed, some of December 2025 completed and currently she is working on August 2025. IC nurse B stated that there is no line listing completed for September, October, November and part of December 2025. A time was set up for 1:30pm, 1/13/26 to go over the IC program. On 01/13/2026 at 1:16PM, the last 6 months of line listings were requested, the facility provided a partially completed December 2025 and January 2026. No line listings were provided for August, September, October or November 2025. On 01/13/2026 at 1:37PM, during the meeting to discuss the infection control program, IC nurse B confirmed that August, September, October and November 2025 are not completed for line listings. On 01/13/2026 at 1:39PM, IC nurse B was asked why they were so far behind on the infection control program. IC nurse B stated that were working a lot of hours on the floor providing direct care. IC nurse B stated, I believe I started working the floor in April 2025 until October 2025, a few times in November as well. Sometimes it was the whole week that I worked, it was 12hr shifts and it varied when I came in and left, but it was mostly on the midnight shift, we would work weekends as well. I filled in for admissions as well for a week and a half, then I cover for admissions when she is out of the building. On 01/13/2026 at 1:45PM, IC nurse B was asked if they had any outbreaks from August 2025 until today. IC nurse B stated, no, we have not had any outbreaks. IC nurse B was asked if they do any audits for hand hygiene, or anything related to infection control? IC nurse B stated, I initially delegated the audits for infection control to other staff, then I just started doing them myself. At one point I just stopped doing them completely and have not done any for 2025. We did our annual in-services, and we had two meetings that couldn't be completed due to someone being sick or me being sick and unable to perform my part. There were about 30 staff members that did not get the training on infection control or hand hygiene. IC nurse B was asked if they audit the kitchen or laundry? IC nurse B stated, I used to delegate the audits for both, then I did it myself, then I stopped doing it and have not completed an audit in 2025 for either of those departments. On 01/13/2026 at 1:55PM, IC nurse B was asked about R61 and having shingles in her left eye. IC nurse B stated that R61 has received all her antibiotics for her from [NAME] Eye; they never put any stop dates on it and that concerned me. They want the antibiotics going until she is completely healed. IC nurse B was asked why R61 was not on any precautions. IC nurse B stated, I initially put her in enhanced barrier precautions and then contact precautions. I really struggled with this one, she had no drainage or sores. I settled on putting her on enhanced barrier precautions. This surveyor and IC nurse B went to the room of R61 and verified that there were no precautions in place. A review of the electronic medical record revealed no orders or care plans for enhanced barrier precautions for R61. Review of the policy titled, infection Prevention and Control Committee, revealed,Duties of the Committee1. With the input of direct care staff, practitioners, the medical director, and the director of nursing services, assist in the development and implementation of written policies and procedures for the prevention and control of infectious or communicable diseases within the facility. 2.Assist in developing and implementing the written policies and procedures to identify and address infections within the facility. Review of the policy titled, Surveillance for Infections, revealed,Policy Statement The infection preventionist will conduct ongoing surveillance for healthcare-associated infections (HAI's0 and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions.Gathering Surveillance Data2. The surveillance should include a review of any or all of the following information to help identify possible indicators of infection;a. laboratory recordsb. skin care sheetsc. infection control rounds or interviewsd. verbal reports from staffe. infection documentation recordsf. temperature logsg. pharmacy recordsh. antibiotic reviewi. transfer log/summaries

Based on interview and record review the facility failed to maintain ongoing review and implementation of the antibiotic stewardship program, resulting in the lack of monitoring of residents receiving antibiotics. Findings include:On 01/13/2026 at 1:16PM, the last 6 months of line listings was requested, the facility provided December 2025 and January 2026. No line listings or infection maps were provided for August, September, October or November 2025. On 01/13/2026 at 1:37PM, Infection Control (IC)l nurse B confirmed that August, September, October and November 2025 are not completed for line listing. IC nurse B was asked how they know who is on antibiotics in the facility. IC nurse B stated, I keep track of it on paper currently but haven't gotten it put into a line listing. No maps of infections were observed. On 01/13/2026 at 2:06PM, IC nurse B was asked what the nurses do if they suspect infection. IC nurse B stated, they will put in a nurses note and they will contact me and see if they meet McGeer's criteria. If someone presents with one symptom of UTI, we will do a three-day monitoring, if on day two they meet criteria then we will send a UA. IC nurse B was asked if the physicians document risk vs benefit for antibiotic use. IC nurse B stated, yes, for the most part they are pretty good at it. But I do have to keep up on them at time. Review of the policy titled, Infection Prevention and Control Committee, revealed, RecordkeepingThe infection prevention and control committee will advise administration and management about ensuring that records are maintained to document the following:3. Findings made during surveillance of antibiotic usage patterns Review of the policy titled, Surveillance for Infections, revealed,Gathering Surveillance Data2. The surveillance should include a review of any or all of the following information to help identify possible indicators of infection;a. laboratory recordsb. skin care sheetsc. infection control rounds or interviewsd. verbal reports from staffe. infection documentation recordsf. temperature logsg. pharmacy recordsh. antibiotic reviewi. transfer log/summaries

Based on interview and record review, the facility failed to obtain informed consent for the initiation and dose changes of psychotropic medication for one resident (R4) of four residents reviewed for unnecessary medications. Findings include: Resident #4 (R4): R4 is [AGE] years old and most recently admitted to the facility on [DATE] with diagnoses that include anxiety disorder, dementia with other behavioral disturbance, adjustment disorder and depression. R4 has been deemed incapable of making her own decisions. On 01/14/2026 at 12:41PM, record review of the electronic medical record (EMR) revealed that R4 was receiving the following psychotropic medications: -Citalopram 20mg daily, order date of 8/19/25 for depression.-Lorazepam 0.5mg three times a day, order date of 8/18/25 for agitation.-Zoloft 50mg daily, order date of 10/4/25 for depression.-Seroquel 50mg twice a day, order date of 11/24/25 for behavioral disturbance. On 01/14/2026 at 2:31PM, an interview was conducted with Social Worker (SW) A SW A was asked when the last time was that she spoke to the durable power of attorney (DPOA) for R4. SW A stated, I spoke with the DPOA in October of 2025 for hospice questions and I spoke with the second contact just before Christmas. The DPOA was supposed to be at the care conference in November of 2025 but was unable to attend. SW A was asked how they attempt to contact the DPOA. SW A stated, I usually try to reach him by phone; I know nursing has been trying to reach out to him as well for admission documentation that needs to be signed. SW A was asked who is responsible for obtaining informed consent for psychotropic medications. SW A stated that psych services will reach out and gets the informed consent for meds and nursing does that as well. SW A stated, I have an updated consent for Seroquel that needs to be signed, but the DPOA has not been into the facility yet and I haven't been able to contact him. SW A was asked if they were aware the last signed informed consent for psychotropic medication was from 2023 and there have been dosage changes since then. SW A stated, yes, I am aware of that. The DPOA does not live locally anymore, and they have moved down state, they aren't as available as before. Do you get informed consent for anti-psychotic, anti-depressant or anxiolytics? Yes, but we just do the informed consent for anti-psychotic medications. On 01/14/2026 at 3:03PM, review of the policy titled, Psychotropic Medication Use revealed,Informed Consent or Refusal1. Prior to initiating the use of, increasing the dose of, or switching to a different antipsychotic medication, the staff and physician will review the following with the resident/representative prior to obtaining documented consent or refusal:a. non-pharmacological alternativesb. the indications and rationale for the recommendation.c. the potential risks and benefits (including possible side effects, adverse consequences, and black box warnings): andd. the resident's/representative right to accept for decline the treatment. -No evidence can be located in the EMR that indicates the DPOA is aware of medication initiation or dosage changes.

Based on interview and record review the facility failed to ensure accurate advanced directives for one resident (R30) of one resident reviewed for advanced directives, resulting in the resident being listed as a full code when their wishes were to be a Do not resuscitate (DNR). Findings include: R30 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include hypertension, fractures with routine healing, falls and chronic kidney disease. R30 was deemed capable of making her own decisions. On [DATE] at 10:00AM, record review of the electronic medical record (EMR) revealed that R30 had a signed physician's order for a full code, dated [DATE] at 15:40PM. A signed code status document that was scanned into the EMR revealed that R30 had elected to be a no for cardiopulmonary resuscitation (CPR) and no for mechanical ventilation, but yes to hospitalization. The form was signed and dated [DATE]. There is no care plan present for advanced directives.On [DATE] at 10:19AM, an interview was conducted with Social Worker (SW) A. SW A was asked who is responsible for completing the code status for residents? SW A stated, I do the care plans for code status, and the nurses do the orders and paperwork upon admission. S A was asked if R30 should she have an order for do not resuscitate (DNR) based on her signed code status in the EMR. SW A stated, yes, and she should have a matching care plan for that. Verified with the Social Services director that the physician order is for full code, there is no care plan present, and the signed code status is for a DNR with hospitalization only. SW A acknowledged this and stated they would correct it.

Based on interview and record review the facility to input stop dates for as needed psychotropic medications for two residents (Resident #16 and Resident #27). Findings include:Resident #16On 1/14/2026 at approximately 2:00 PM, a review was conducted of Resident #16's medical records and it indicated the resident admitted to the facility on [DATE] with diagnoses that included, Gastroenteritis and Colitis, Metabolic Encephalopathy, Dementia, Hypertension, Depression, Diabetes and Acute Kidney Failure. Further review of his records indicated the following:Physician Orders:Prochlorperazine (Antipsychotic medication) Maleate Oral Tablet 10 MG (milligram)Give 1 tablet by mouth every 6 hours as needed for nausea/vomiting. Ordered on 11/5/2025 without an end date.Care Plan:There was no mention of his usage of the antipsychotic medication in his careplan or any monitoring for adverse side effects.Pharmacy Review:12/2/25: Recommend discontinuing PRN (as needed) use of Prochlorperazine 10mg Q6H (every 6 hours) for this resident or reorder for a specific number of day. Handwritten on the form it stated, Hospice and signed by a facility practitioner on 12/8/25.On 1/14/26 at approximately 3:15 PM, Social Worker A was asked about the open-ended antipsychotic medication order. She reported she was not aware he was prescribed a current antipsychotic for nausea/vomiting or that the order was entered as needed and open ended. Resident #27On 1/13/2026 at 9:30 AM, a review was conducted of Resident #27's medical record and it indicated she admitted to the facility on [DATE] with diagnoses that included, Clavicle fracture, Acute Kidney Failure, Vascular Dementia, Hypertension, Psychotic Disturbance, Mood Disturbance and Anxiety. Resident #27 is not her own person and required the assistance of facility staff for her daily cares. Further review of her chart yielded the following:Physician Orders:Ativan (Antianxiety medications) Oral Tablet 0.5 mgGive 1 tablet by mouth every 6 hours as needed for anxiety and agitation. Ordered on 12/30/2025 with no end date. On 1/14/2026 at 12:20 PM, an interview was conducted with Social Worker A regarding Resident #27's prn Ativan order. She reported that the resident was crawling out of bed, eating her feces, screaming/yelling and many other behaviors. Since inception of the Ativan, it had appeared to be effective in decreasing her behaviors. Social Worker A stated she was aware the Ativan order did not have a stop date and emailed the DON (Director of Nursing) on Monday after she had completed an audit and found it. At the time of the discussion the order was still prn and open ended. Pharmacy Review:12/2/2026: Recommend discontinuing PRN use of Lorazepam 0.5mg Q6H for this resident or reorder for a specific number of day. The response stated to Continue PRN use of Lorazepam for __ days, as the benefit outweigh the wrists. Handwritten on the form it stated, Hospice and signed by a facility practitioner on 12/7/25.It can be noted for both residents that the pharmacy review indicated the inaccuracies of the medication order but due to the residents being on hospice the medications orders were not revised.Review was completed of facility policy entitled, Psychotropic Medication Use, revised 2/2025. The policy stated, psychotropic medications are not prescribed or administered on a PRN basis unless the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. the prescriber or attending physician believes it is appropriate to extend the prn order beyond 14 days.

Based on interview and record review the facility failed to timely submit a Level 1 PASARR (Preadmission Screening and Resident Review) Screenings for one resident (Resident #31), resulting in Resident #31's PASARR not being completed within the annual timeframe or transmitted to OBRA (Omnibus Budget Reconciliation Act).Findings Include:On 1/13/2026 at 9:55 AM, a review was conducted of Resident #31's medical record and it revealed she was admitted to the facility on [DATE] with diagnoses that included, Hypotension, Bipolar Disorder, Adjustment Disorder with mixed Anxiety and Depressed mood and Major Depressive Disorder. Further review of Resident #31's records indicated the following:OBRA PASARR Correspondence:The last correspondence uploaded into the resident's chart was dated 6/25/2024 which indicated she did not meet criteria for a Level II evaluation by their local community mental health authority.A PASARR had not been submitted for Resident #31 in over a year. On 01/13/2026 at 4:34 PM, the facility provided a completed PASRR (DCH-3877) for Resident #31 that was signed as completed and submitted to OBRA on 9/19/2025. The response letter received from OBRA was dated 1/13/2026. On 01/13/2026 at 4:39 PM, an interview was conducted with Saginaw County OBRA Representative S, regarding Resident #31's response letter. She reported she recently reached out to the Administrator regarding their lack of submission of PASRR's. She believes they are creating the DCH 3877's in the system but did not press the submit button which transmits the document to OBRA. Representative S stated within the last year she has received less than 15 PASRR's from the facility. On 1/8/26 they did submit multiple PASRR's for review to her. On 01/14/2026 at 12:30 PM, Social Worker A stated since the change to electronic OBRA system she is no longer able to complete PASRR's. On 01/14/2026 at 1:15 PM, the Administrator was queried regarding the four-month gap in which the physician signed the PASRR's and correspondence was received from OBRA for Resident #31. The administrator explained since their past DON (Director of Nursing) resigned in the summer, they did not have access to the OBRA system until they found their Medical Director had access. In August/September 2025 they thought they had completed all facility PASRRs that were due/past due.Recently, they received a phone call from the OBRA representative who informed them they had not submitted any PASRRs. It was at this time they were informed it was two-step submission process, and they had only completed Step 1. All the PASRRs they completed in the fall were never submitted to OBRA but pending in their portal for transmission. The OBRA representative walked them through the full process so that they now have a good understanding of system and submission process. After the discussion they submitted all the pending PASRRs that were in the portal and have requested access for their current DON. There were 14 PASRR's the facility had pending to be transmitted. Review was conducted of the facility policy entitled, Coordination- Pre-admission Screening and Resident Review (PASRR) program, undated. The policy stated, .all residents admitted to the facility receive a Pre-admission Screening and Resident Review in accordance with State and Federal Regulations. Review was conducted of State of Michigan -OBRA -Specialized Nursing Home which stated, .In addition, persons residing in a nursing facility who are seriously mentally ill and/or have an intellectual / developmental disability are required to undergo a similar review annually or when there is a significant change in condition to determine whether they continue to require the services of a nursing facility or whether they require specialized mental health services. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included:1. a) Facility Medical Director and Facility Administrator completed PASRR screeningand submitted PASRR screening to OBRA for each resident impacted by thisdeficiencyb) Request for Director of Nursing access to OBRA system, originally initiated on8/12/2025, has been re-requested on 1/14/2026.2. a) Facility Medical Director and facility Administrator will complete PASRRscreenings and submit screenings to OBRA for all residents by screening due dateuntil Director of Nursing OBRA access has been granted.b) PSARR policy and procedure has been reviewed and updated to include a changein the policy in which the facility will have a second designee with OBRA access as aback up in the event the Director of Nursing or primary designee is unable tocomplete resident screening.3. a) Education by Community Mental Health was provided through email and viaphone regarding how to complete the two-step process to Administrator and SocialWorker. Administrator and Social Worker have educated Director of Nursing.4.a) Social Worker will keep a tracking log to ensure all PSARR screenings arecompleted and submitted in accordance with due date.b) PASRR tracking will be monitored monthly during QAPI. The Administrator will beresponsible for continued facility compliance.5. Date of Compliance: 1/12/2026The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on observation, interview and record review, the facility failed to follow care-planned interventions, update and/or revise the care-planned interventions and provide assistance for two residents (Resident #8, Resident #36) of two residents reviewed for accidents, resulting in unassisted Activities of Daily Living (ADL) care. Findings include. Resident #8 On [DATE], at 8:25 AM, Resident #8 was in their bathroom. They walked out of their bathroom to their bed. Their two-wheeled walker (2ww) was next to the foot of their bed on the left side. Resident #8 was asked if they were supposed to use the walker and Resident #8 offered that they use their wheelchair. Resident #8 stated they had lost their husband a long time ago and have been independent ever since. The call light was draped over the over bed table which was in the corner near the bathroom. Their wheelchair was at the foot of the bed approximately 10 feet away. On [DATE], at 8:52 AM, Resident #8 was observed in their wheelchair in the hallway outside of their room. On [DATE], at 11:45 AM, a record review of Resident #8's electronic medical record revealed an admission [DATE] with diagnoses that included fall on same level from slipping, tripping and stumbling, Dementia, Stroke and visual impairment. Resident had moderately impaired cognition. A review of the care plan Focus (the resident) has an ADL (activities of daily living) self-care performance deficit r/t: (related to) -Hx of mechanical fall -Hx of (L) Femural Neck Fx -Dementia -Fatigue -Limited Mobility -Limited ROM (range of motion) . Date Initiated: [DATE] Revision on: [DATE] Goal The resident will improve current level of function in ADL through the review date. Date Initiated: [DATE] Revision on: [DATE] Target Date: [DATE] Interventions/Tasks Ambulation: Resident requires extensive assist by 1 staff with 2ww/gait belt, proper footwear in room and to and from dinning room with wheelchair follow. Date Initiated: [DATE] . TOILET USE: The resident requires Limited X1 staff for toileting. Date Initiated: [DATE] Revision: [DATE] TRANSFER: The resident requires Limited X1 staff to move between surfaces as necessary with gait belt, two wheeled walker, and appropriate footwear Date Initiated: [DATE] Revision on: [DATE] A review of the care plan Focus (the resident) has an increased risk for fall r/t: hx of mechanical fall with (L) Femoral Neck Fx - Demenita -Forgets to use walker, does not use call light for assist . Does not use call light, self-transfers (observed ambulating in hall and in bathroom) Date Initiated: [DATE] Revision on: [DATE] Goal The resident will not sustain serious injury through the review date. Date Initiated: [DATE] Revision on: [DATE] Target Date: [DATE] Interventions/Tasks Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Date Initiated: [DATE] Ensure that The resident is wearing appropriate non skid, non slip footwear when ambulating or mobilizing in w/c. Date Initiated: [DATE] Revision on: [DATE] Follow facility fall protocol. Date Initiated: [DATE] Pt evaluate and treat as ordered or PRN Date Initiated: [DATE] The resident needs a safe environment (Such as: even floors free from spills and/or clutter, adequate, glare-free light, a working and reachable call light, the bed in low position at night; grab bars on walls near toilet, personal items within reach) Date Initiated: [DATE] Revision on: [DATE] A review of the Task:ADL-Walk in Room Look Back . WALK IN ROOM:SELF PEROFMARNACE - How resident walks between locations in his/her room . For the last 7 days the Not Applicable was check marked. According to the most recent comprehensive Minimum Data set Assessment, Resident #8 required setup or clean-up assistance (Helper sets up or clean up; resident completes activity. Helper assists only prior to or following the activity) for Walking 10 feet. For Chair/bed-to-chair transfer and Toilet transfer, the resident required Setup or clean-up assistance . On [DATE], at 4:30 PM, Resident #8 was in their room in their closet with the door closed. The light was on. Resident #8 exited the closet and sat in their wheelchair. The wheelchair was at the end of their bed and was facing towards the exit door. Resident #8 stood back up, walked back to their closet and shut off the closet light. Resident #8 walked back to their wheelchair and sat down. Their ambulation was slow with a slight sidestep to the left. Their walker was next to the left side of bed. Resident #8 was asked if they ever use the walker and Resident #8 offered not often as they tapped on the walker. The call light remained in the same position draped over the table in the corner. Resident #8 again stated they're independent, their husband died at age [AGE] and I've been on my own since then. Outside of the resident's room there were no visible staff. Moments later, Nurse F was in the hallway and was asked if Resident #8 required assistance for transfers and ambulation and Nurse F stated, oh, she's independent. On [DATE], at 10:51 AM, Resident #8 was lying in bed under a blanket. The wheelchair was at the foot of the bed. The call light was draped over the over bed table in the same position as the day prior. On [DATE], at 10:56 AM, CNA K was asked why Resident #8's wheelchair would be locked at the foot of the bed and CNA K offered, she put it there. She doesn't always use her call light, and we check on her but she doesn't always ask for help. Resident #36 On [DATE], at 8:28 AM, Resident #36 was in their bathroom. Their wheelchair was approximately 1 foot from the toilet. Resident #36 was standing up facing the wall that housed a handrail. Resident #8 was not holding onto the rail and was using both hands to pull down their robe that was folded up and stuck in their incontinent brief. Resident #36 was asked if they needed assistance and Resident #8 while giggling stated, I don't know. Resident #36 grabbed the rail and sat down in their wheelchair. Resident #36 was asked if they could reach the call light and Resident #36 offered, I can't reach it. The call light string was out of reach of the resident. The resident had slippers on. On [DATE], at 3:15 PM, a record review of Resident #36's electronic medical record revealed an admission on [DATE] with diagnoses that included Age related cognitive decline, altered mental status and Osteoporosis. According to most recent Minimum data set assessment, the resident had moderately impaired cognition. According to the most recent comprehensive assessment, the resident required Supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) assistance for both Chair/bed-to-chair transfer and Toilet transfer. A review of the care plan Focus (the resident) has increased risk for fall . Dependent on wheelchair for mobility Date Initiated: [DATE] Revision on: [DATE] Goal The resident will not sustain serious injury through the review date. Date Initiated: [DATE] Revision on: [DATE] Target Date: [DATE] Interventions/Tasks Anticipate and meet The resident's needs. Date Initiated: [DATE] Revision on: [DATE] . A review of the care plan Focus (the resident) has an ADL self-care performance r/t: Hx of (R) Total Shoulder Athroplasty ([DATE]) . Date Initiated: [DATE] Revision on: [DATE] Goal The resident will be assisted daily with ADL's by staff Date Initiated: [DATE] Revision on: [DATE] Target Date: [DATE] Interventions/Tasks . TOILET USE: The resident requires EXT x 1 assist for toileting. Date Initiated: [DATE] Revision on: [DATE] TRANSFER: The resident requires EXT x1 staff with gait belt and proper footwear to move between surfaces. Date Initiated: [DATE] Revision on: [DATE] . A review of the care plan Focus (the resident) has impaired cognitive function or impaired cognitive function or impaired though processes r/t -Neurological symptoms Last BIMS score of 8 on [DATE] Date Initiated: [DATE] Revision on: [DATE] . Interventions/Tasks Cue, reorient and supervise as needed. Date Initiated: [DATE] Revision on: [DATE] . On [DATE], at 10:34 AM, Resident #36 was in their bathroom sitting on the toilet. Resident #8 ripped off their disposable incontinent brief that was soiled with urine and bowel movement. Resident #36 offered, I do it myself when asked if they needed assistance. Resident #36 remained on the toilet. Resident #36 giggled when asked if they could activate the call light which was near their left shoulder on the wall. On [DATE], at 10:36 AM, Nurse Q was in the hallway and was alerted Resident #8 was on their toilet unassisted. Nurse Q was unable to find a gait belt in Resident #36's room. Moments later, CNA K entered the bathroom and offered, she refuses to use the gait belt. Nurse Q left out and reentered the bathroom with a gait belt. Nurse Q attempted to place the gait belt on Resident #36 who refused the gait belt. CNA K was asked if the resident uses the call light for help and CNA K she doesn't put the light on and the only time she does if she has a bm (bowel movement) and wants to be cleaned. CNA K was asked if the resident had therapy recently and CNA K offered, they pick her up every now and then. Nurse Q and CNA K was alerted the brief Resident #36 took off was soiled with BM. Nurse Q assisted the resident with perineal care. Resident #36 was assisted to a standing position. Resident #36 was asked if their bottom was sore as their buttocks and legs were reddened and Resident #36 offered, I get tired sitting here. During exit conference, the Administrator offered they couldn't do one on one with the residents and complained they couldn't restrain them as they questioned the concern of lack of supervision.

Based on observation, interview and record review, the facility failed to follow standards of practice for urinary catheters and follow care planned interventions for two (Resident #60, 62) of two residents reviewed for urinary catheters, resulting in urinary catheter bags on the floor, no physician orders for urinary catheters with the likelihood of urinary catheter associated infections. Findings include. On 1/12/2026, at 10:30 AM, Resident #60 was lying in bed. They had a urinary catheter hooked to the right side of their bed. There was no dignity bag. Their urine was clear yellow in color. On 1/13/2026, at 8:39 AM, Resident #60 was in their room in their wheelchair. Certified Nursing Assistant (CAN) maria adjusted the urinary catheter bag and tubing under the wheelchair with their gloved hands. There was no dignity bag covering the urinary drainage bag. On 1/13/2026, at 10:15 AM, a record review of Resident #60's electronic medical record revealed an admission on [DATE] with diagnoses that included chronic kidney disease, retention of urine and anxiety disorder. Resident #60 had intact cognition. A review of the Physician Orders revealed no order to care for the urinary catheter. A review of the Admit/Readmit Screener Date: 1/10/2026 revealed . Bladder . Catheter Type/Size . 16 fr (French) with 10 cc (cubic centimeters) balloon . On 1/13/2026, at 11:49 AM, Resident #60 was sitting in the dining room at a table. Their urinary drainage bag was touching the floor without a dignity bag. On 1/13/2026, at 11:50 AM, the Director of Nursing (DON) was asked if they saw Resident #60's drainage bag touching the floor and the DON stated, I sure do. On 1/13/2026, at 4:37 PM, Infection Control (IC) Nurse B was questioned if Resident #60 was going to continue the use of the urinary catheter and IC Nurse B offered, they would check. IC Nurse B was alerted Resident #60's catheter bag was on the floor in the dining room. Resident #62 On 1/13/2026, at 11:52 AM, Resident #62 was lying in their bed. Nurse F entered to prepare their antibiotic medication. CNA J and L assisted the resident from the wheelchair to their bed. The resident had a urinary catheter drainage bag hooked under their wheelchair with amber colored urine in the bag and tubing. The urinary catheter drainage bag was unhooked and dropped to the floor. Once the resident was in bed, CNA J picked up the drainage bag off the floor and lifted the drainage bag above the level of the resident's bladder. The urine in the drainage tube drained back towards the resident. CNA J handed the drainage bag to CNA L . Both CNA J and CNA L assisted the resident with care and once the catheter bag was hooked to the right side of the bed frame, the urine drained back through the tube into the drainage bag. On 1/13/2026, at 1:30 PM, a record review of Resident #62's electronic medical record revealed an admission on [DATE] with diagnoses that included Pneumonia, pressure ulcer and Multiple Sclerosis. Resident #62 had intact cognition. A review of the care plan Focus (the resident) has an indwelling 16 Fr foley catheter . Interventions/Tasks CATHETER: The resident has a 16 Fr Indwelling foley catheter. Position catheter bag and tubing below the level of the bladder . Date Initiated: 01/08/2026 . On 1/13/2026, at 4:37 PM, IC Nurse B was alerted of the observation of Resident #62's urinary drainage bag that was on the floor and then held above their bladder with urine observed flowing back toward the resident . On 1/14/2026, at 10:11 AM, The DON was alerted of the observation of Resident #62's urinary bag observation the day prior. A review of the facility provided policy Catheter Care, Urinary 2-2025 revealed . Be sure the catheter tubing and drainage bag are kept off the floor. Ensure catheter bag had a privacy/dignity covering . Position the drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder .

Based observation, interview and record review the facility to complete a comprehensive nutritional assessment and timely address weight loss for one resident (Resident #44) of one resident reviewed for nutrition.Findings Include:On 1/12/2025 at approximately 11:45 AM, Resident #44 was observed resting in bed. He stated he typically eats well at the facility but would like more food during meals.On 1/13/2025 at approximately 10:30 AM, a review was conducted of Resident #44's records and it indicated he admitted to the facility on [DATE] with diagnoses that included, Necrosis of left Femur, Acute and Chronic Respiratory Failure, Acute Embolism and Thrombosis and Osteoporosis. Further review of Resident #44's records indicated the following: Weights:12/17/2025 - 187.8 Lbs (pounds)10/3/2025 -199.3 Lbs 10/2/2025 - 201.2 Lbs 7/24/2025 -195.5 Lbs7/21/2025 -202.0 Lbs6/27/2025- 201.2 Lbs6/26/2025- 200.0 Lbs On 10/02/2025, the resident weighed 201.2 lbs. On 12/17/2025, Resident #44 weighed 187.8 lbs which is a -6.66% loss over two months.On 06/25/2025 (admission weight), the resident weighed 200 lbs. On 12/17/2025, Resident #44 weighed 187.8 lbs which is a -6.1% loss over six months. Progress Notes: 6/21/2025 at 11:27: Nutrition/Dietary Note: Met with (Resident #44) at bedside. He was in pain related to L (left) hip, stated not better since prior to surgery . He is on a regular diet with good intake at dinner last night. He is edentulous. Stated that he has dentures at home but rarely wears them, no trouble without them chewing. Ensure plus noted at bedside.There were no other notes related to Resident #44's weight loss that was indicated on 12/17/2025 nor were there any interventions placed to prevent further weight loss. Nutritional Assessments:6/21/2025- Mini Nutritional Assessment7/2/22025- Mini Nutritional Assessment10/22/2025- Mini Nutritional AssessmentThe mini nutritional assessment is a condensed tool that does not review totality of the resident as it relates to their nutrition. On 1/14/2026 at 8:45 AM, Resident #44 was observed in bed watching television. He was queried regarding his weight loss. He stated the facility has never weighed him and he was not worried about his weight currently. During the interview his breakfast was delivered and he stated he did not typically eat breakfast and would most likely not consume the meal. Further review was conducted of Resident #44's records and it indicated the following:Care Plan: .(Resident #44) has a nutritional problem or potential nutritional problem r/t (related to):Hx Idiopathic aseptic necrosis of left femur, aftercare following joint replacement surgery, dehydration, Gastrointestinal hemorrhage, anemia, Current Diet Order: Regular NAS Diet with thin liquids. (Diet changed 10/2-after re-admission from the hospital) .(Resident #44) will maintain adequate nutritional status as evidenced by no significant weight changes.RD to evaluate and make diet change recommendations PRN (as needed).On 1/14/2026 at 2:30 PM, an interview was conducted with Dietary Manager C regarding Resident #44s' weight loss. Manager C reported she requested a reweight in December 2025 after the weight of 187 was documented but it does not appear the reweight occurred. Manager C was queried if the weight loss was addressed and she stated she did not believe it was a true weight loss as his intake has not changed. She added he is a slower eater but some meals he receives double portions. As his record was reviewed there was no documentation in his chart of staff reapproaching for reweigh or any further clarity addressing the weight loss from last month.Manager C explained she completes the Mini Nutritional Assessments quarterly and the dietitian completes the comprehensive nutritional assessment on admission, annually and with change in condition. Manager C was unable to ascertain why Resident #44's full nutritional assessment was not completed upon admission. Review was conducted of the facility policy entitled, Nutritional Assessment, revised 2/2024. The policy stated, .as part of the comprehensive assessment, the nutritional assessment will be systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition.

Based on observation, interview and record review, the facility failed to administer medications per standards of practice for two residents (Resident #41, Resident #59) of eight residents reviewed during the medication administration task, resulting in a medication error rate of 6.67 percent with the likelihood of further medication errors. Findings include. On 1/13/2026, at 2:28 PM, During medication administration task with Nurse P, Nurse P prepared a Heparin injection for Resident #59. Nurse P drew up the Heparin medication into a 3 cc (cubic centimeter) syringe with a 1-inch needle and walked towards Resident #59's room. Nurse P was asked what medication and what route they were going to administer and Nurse P stated, Heparin IM (intramuscular) and then quickly stated no, sub q (subcutaneous). Outside Resident #59's room, Nurse P reached for Resident #59's door and was asked what size needle whas required for a sub q injection and were they sure of the physician's order. Nurse P clarified the order on Resident #59's electronic medical record and Nurse P again reached for the door. Nurse P was asked to stop and to find their nursing manager. Nurse P entered Nurse Manager B's office and asked for a sub q needle. Nurse Manager B was alerted of the observation with Nurse P. Nurse P held up the Heparin in the 3 cc syringe with the IM needle and asked Nurse Manager B for a sub q needle. Nurse P gathered a smaller sized syringe with the appropriate size needle and asked Nurse Manager B if they could use it and Nurse Manager B offered, yes. Nurse P drew up the Heparin into the correct syringe and administered the medication to Resident #59 with the correct size needle.On 1/13/2026, at 2:50 PM, a record review of Resident #59's electronic medical record revealed . Heparin Sodium (Porcine) Injection Solution 5000 UNIT/ML Inject 1 ml subcutaneously . On 1/14/2026, at 8:53 AM, During medication administration task, Nurse F gathered morning medications for Resident #41 to include Potassium chloride 30 milliequivalent which Nurse F crushed and administered to the resident orally. Nurse F offered that the resident was recently sent to the emergency room and that they were checking the resident for a change in condition. On 1/14/2026, at 12:48 PM, Nurse F was interviewed regarding the morning medication administration for Resident #41. Nurse F was alerted potassium should not have been crushed and Nurse F stated, Oh, because its extended release. Nurse F was asked if they had called the physician and alerted the physician of the crushed Potassium administration and Nurse F stated, NO, but they would. On 1/14/2026, at 2:00 PM, Medication administration task was completed with two significant medication errors out of a total of thirty medication administration observations which revealed a medication error rate of 6.67 percent. On 1/14/2026, at 2:52 PM, Pharmacist O was interviewed via telephone. Pharamcist O was asked if the order for Potassium chloride ER (extended release) was safe to crush and administer orally to Resident #41. Pharmacist O stated, No, it shouldn't be crushed and they could switch to liquid. A record review of the facility provided policy Administering Medications 2-2025 revealed Medications shall be administered in a safe and timely manner, and as prescribed . The individual administering medications must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication .

Based on observation, interview and record review, the facility failed to administer medications per standards of practice for two residents (Resident #41, Resident #59) of eight residents reviewed during the medication administration task, resulting in the likelihood of unwanted reactions such as hematoma, severe stomach pain and potentially dangerous, rapid increases in potassium levels in the blood. Findings include. On 1/13/2026, at 2:28 PM, During medication administration task with Nurse P, Nurse P prepared a Heparin injection for Resident #59. Nurse P drew up the Heparin medication into a 3 cc (cubic centimeter) syringe with a 1-inch needle and walked towards Resident #59's room. Nurse P was asked what medication and what route they were going to administer and Nurse P stated, Heparin IM (intramuscular) and then quickly stated no, sub q (subcutaneous). Outside Resident #59's room, Nurse P reached for Resident #59's door and was asked what size needle whas required for a sub q injection and were they sure of the physician's order. Nurse P clarified the order on Resident #59's electronic medical record and Nurse P again reached for the door. Nurse P was asked to stop and to find their nursing manager. Nurse P entered Nurse Manager B's office and asked for a sub q needle. Nurse Manager B was alerted of the observation with Nurse P. Nurse P held up the Heparin in the 3 cc syringe with the IM needle and asked Nurse Manager B for a sub q needle. Nurse P gathered a smaller sized syringe with the appropriate size needle and asked Nurse Manager B if they could use it and Nurse Manager B offered, yes. Nurse P drew up the Heparin into the correct syringe and administered the medication to Resident #59 with the correct size needle. On 1/13/2026, at 2:50 PM, a record review of Resident #59's electronic medical record revealed . Heparin Sodium (Porcine) Injection Solution 5000 UNIT/ML Inject 1 ml subcutaneously . On 1/14/2026, at 8:53 AM, During medication administration task, Nurse F gathered morning medications for Resident #41 to include Potassium chloride 30 milliequivalent which Nurse F crushed and administered to the resident orally. Nurse F offered that the resident was recently sent to the emergency room and that they were checking the resident for a change in condition. On 1/14/2026, at 12:48 PM, Nurse F was interviewed regarding the morning medication administration for Resident #41. Nurse F was alerted potassium should not have been crushed and Nurse F stated, Oh, because its extended release. Nurse F was asked if they had called the physician and alerted the physician of the crushed Potassium administration and Nurse F stated, NO, but they would. On 1/14/2026, at 2:52 PM, Pharmacist O was interviewed via telephone. Pharamcist O was asked if the order for Potassium chloride ER (extended release) was safe to crush and administer orally to Resident #41. Pharmacist O stated, No, it shouldn't be crushed and they could switch to liquid. A record review of the facility provided policy Administering Medications 2-2025 revealed Medications shall be administered in a safe and timely manner, and as prescribed . The individual administering medications must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication . According to the U.S. Food and Drug Administration, Do not administer Heparin Sodium Injection by intramuscular injection because of the risk of hematoma (a collection of clotted blood that has leaked from damage blodd vessels into surrounding tissues, organs, or body spaces) at the injection site.

Based on interview and record review the facility failed to administer an influenza vaccine for one resident (Resident #19) of five residents reviewed for immunizations. Findings include:R19 is [AGE] years old and admitted to the facility most recently on 03/25/2025 with diagnoses that include hypertension, dementia, acute kidney failure and muscle weakness. On 01/13/2026 at 2:31PM, record review of influenza, pneumococcal and COVID-19 immunization was conducted for five residents.R19 received an influenza vaccine on 01/30/2024. A scanned influenza immunization consent dated 01/07/2025 indicated that R19 consented to receiving the influenza vaccine. Record review of the EMR revealed that R19 had not received the influenza vaccine in 2025. On 01/13/2025 at 2:55PM, an interview was conducted with Infection Control (IC) nurse B. IC nurse B was asked if R19 had received an influenza vaccine in 2025. IC nurse was unsure if R19 had or not and said they would check. IC nurse B returned a few minutes later and stated that R19 had not received the vaccine and it was just missed. Review of the policy titled, Influenza Vaccine, revealed,Policy Interpretation and Implementation5. For those who receive the vaccine, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the resident's/employee's medical record.

This Citation pertains to Intake Numbers MI00150106 and MI00150127. Based on observation, interview and record review, the facility failed to prevent a fall with injury for one resident (Resident #301), of three residents reviewed, by not following the care plan which required 2 staff for all Activities of Daily Living (ADL) care. Only one staff member was attending to Resident #301 when she partially rolled out of bed and sustained a fracture of the left clavicle, several fractured ribs, extensive bruising, and back and rib pain, all of which resulted in an extended hospitalization . Findings include: Resident #301: Record review of Resident #301's hospital Emergency Department note, dated 2/3/2025 at 9:17 PM, noted acute left 5th through 10th rib fractures and medial left clavicle fractures. The Emergency Department noted that the resident was symptomatic with multiple rib fractures and a left clavicle fracture and had not achieved medical stability for a safe discharge from hospital . the current condition would worsen and an adverse event like worsening pain, pneumonia may occur . Observations and an interview were conducted on 2/14/2025 at 8:50 AM. Resident #301 in her room was lying in bed with a oxygen nasal cannula at 3 liters. Resident #301 was awake and able to answer questions. She stated that they dropped her from her bed. Resident stated that it was 2 days ago and later they took her to the hospital. The state surveyor observed a silver chrome bedside chair with black plastic arm rests in the corner of the room next to the head of the bed on the right side of bed, Also a right side bed fall mat and an air mattress were noted. A call light was within reach and the resident denied pain at that time. Record review of Resident #301's Minimum Data Set (MDS) assessment, dated 1/2/2025, revealed an elderly female with Brief Interview of Mental Status (BIMS) score of 12 out of 15. Medical diagnoses included: Medically complex conditions, anemia, hypertension, renal insufficiency, diabetes, hyponatremia, other fracture, cerebrovascular accident (CVA), hemiplegia/hemiparesis, malnutrition, depression and osteomyelitis of the left foot. Section GG: functional abilities: Dependent- helper does all of the effort. Resident does none of the effort to complete the activity. The assistance of 2 or more helpers is required for the resident to complete the activity for toileting hygiene, shower/bathe, upper body dressing, lower body dressing, rolling left and right, sit-to-laying, laying-to-sitting, and chair/bed-to-chair transfer. Record review of Resident #301's care plans, page 1- 27, revealed Activity of Daily Living (ADL) care plan related to self-care performance deficit secondary to cardiovascular accident (CVA) related to left hemiparesis, left hand contractures, left lower extremity contracture, left side neglect, osteomyelitis of left foot, surgical amputation of left great toe. The care plan noted limited mobility, limited range of motion (ROM), decreased mobility . Interventions: Bed Mobility, dated 11/10/2023: The resident requires extensive 2 staff to turn and reposition in bed. Dressing dated 11/10/2023: The resident requires extensive 2 staff to dress. Toilet Use dated 11/10/2023: The resident requires extensive 2 staff for bed pan/brief change. Record review of the facility 'Comprehensive Care Plan' policy. dated 2/2024. revealed a comprehensive, person- centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. (4.) Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: (g.) Receive the services and/or items included in the plan of care . An observation and interview was conducted on 2/14/2025 at 11:30 AM with Resident #301 and a family member at her bedside. Resident #301 stated again that she was dropped and flat on her back. Observation was made with the assistance of the family member of Resident #301. Resident #301 was dressed in a hospital gown. The observation revealed left upper shoulder/chest front view of a large bruising area of a green/yellow color, estimated to be the size of a basketball that went down the left side under the arm pit area. In an observation of the left hip area, visible through a brief, the surveyor noted a dark purple in color bruising estimated 3 inches wide by 6 inches in length. Resident #301 stated that she does get back pain and shoulder pain with hiccups and coughing on being moved. Sleeping at night hurts also. The state surveyor observed black bilateral soft boots on while in bed. Also observed a right upper arm PICC (Peripheral Inserted Central Catheter) line with dressing, dated 2/1/2025. A dressing was noted to the left lower arm, estimated 2 inch wide by 3 inch in length with a date of 2/13/2025. The family member stated that the resident spent 7 days in the hospital related to her fracture injuries and infection in her foot. Record review of the facility 'Falls-Clinical Protocol' policy, dated 1/2025, revealed: 'Following a Fall Event/Suspected Fall Event', an incident report and fall investigation will be completed after a fall or suspected fall . Post-fall interventions will be initiated by the nurse on duty, after the fall risk assessment has been completed to reduce the likelihood for reoccurrence of falls. The Director of Nursing/Fall Prevention Designee will review the fall event the next business day to initiate an analysis of contributive factors and determine if additional interventions should be implemented ' An interview on 2/14/2025 at 1:07 PM with Registered Nurse (RN) B revealed that he was working when Certified Nurse Assistant (CNA) I called the nurse into Resident #301's room to see a skin tear on the left lower arm by the hand. Then she mentioned that when she was getting Resident #301 ready for bed and giving a sponge bath she noticed bruising. She said for me to look at the bruising from her left upper shoulder area that was blur in color. RN B stated 'It (the bruising) went from the left upper chest to the right upper chest. Around that time CNA I mentioned that the resident said that she was dropped from the bed. She fell or was dropped. She (Resident #301) stated to her grandson that she was dropped or fell . I was in the room doing an assessment on Resident #301 and CNA I asked her about the bruising. I heard Resident #301 say that she was dropped from the bed. Resident #301 said it. I heard her say it. Resident #301 was having a lot of back pain. The left upper arm had small bruising on her elbow and a dark red color to arm. Resident #301 said she had severe back pain, left arm hurt and she hadn't ever complained of back pain before. I sent her to hospital around 8 PM that night (2/3/2025). CNA I had a couple of days off before this and saw the skin tear and asked if it was new. The skin tear was scabbed over with no dressing on it. I didn't know about the skin tear. It was not given in shift-to-shift report and not documented anywhere. Because of the severe back pain, new bruising, scabbed skin tear and she was on Eliquis blood thinner, I sent her to the hospital ER per protocol The black & blue bruising was new. She was on a blood thinner and had an unwitnessed fall/drop?' Interview and record review was conducted on 2/142025 at 2:18 PM with the Director of Nursing (DON) about Resident #301's injuries. The interview revealed that she started staff education yesterday on 2/13/2025 for a change in elevation related to the incident. The DON stated, 'Residents usually are lowered to the floor/ground. It was brought up last week about the change in elevation education. That is the only education that we have related to the incident. I put it out yesterday for the staff to sign the education. Certified Nurse Assistant (CNA) H reported to Licensed Practical Nurse (LPN) E and the LPN went in and looked at the Resident #301. LPN E then went to a second nurse, License Practical Nurse (LPN) G. LPN G went into the Resident #301's room and she asked the resident about a fall. CNA H explained that it was a roll out of bed. LPN G asked Resident #301 if she wanted to go to the hospital and she said no. CNA H stated that he was changing the resident while rolling her over on the bed. He turned to get the wipes and she rolled from the bed, but that he caught her. Resident #301 did not hit the floor. It happened on Sunday 2/2/2025 at around 8:56 PM. Then on 2/3/2025 at 8:01 PM, Registered Nurse (RN) B received a report form CNA I that there was bruising to the left side of the resident's chest. Also there was left hip bruising and a left lower arm skin tear without a dressing. Record review of Resident #301's medical record assessments and progress notes revealed there was no assessment or progress notes written on 2/2/2025, the evening of the incident. There was nothing written until 2/3/2025 when Resident #301 was sent to hospital. Record review of staff education forms revealed education for change in elevation. In an interview on 2/14/2025 at 4:46 PM, Certified Nurse Assistant (CNA) H, stated that he was changing Resident #301 and that she could only roll to one side. CNA H stated 'I rolled her up on the right side. I had to reach for the brief and wipes on the windowsill. I turned, saw her rolling and I had to catch her. No one was in there but me. I was in the room by myself. I caught her. No, she did not hit the floor. It was a hard catch. I notified the nurse (Licensed Practical Nurse E). They checked her out, got blood pressure and she was fine'. Record review of Resident #301's Kardex (resident care guide) on 2/14/2025 revealed that when toileting, the resident requires extensive 2 staff for a bed pan/brief change. In an interview on 2/17/2025 at 4:07 PM, Certified Nurse Assistant (CNA) C stated, 'I helped to transfer the resident (Resident #301) with a Hoyer lift machine to the bed. The process takes 2 people. I left the room after a successful transfer to the bed. No, I wasn't in the room when the incident happened. I heard about it later in the shift. She wasn't my resident to care for that night. No, he did not ask for help or for me to stay'.

This Citation pertains to Intake Number MI00150127. Based on observation, interview and record review, the facility failed give prompt treatment for several fractures related to a roll/fall out of bed for one resident (Resident #301). Findings include: Record review of the facility Abuse Prevention Program policy, dated 1/2025, defined 'Neglect' as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Resident #301: Record review of Resident #301's hospital Emergency Department note, dated 2/3/2025 at 9:17 PM, noted acute left 5th through 10th rib fractures and medial left clavicle fractures. The emergency department noted that the resident was symptomatic with multiple rib fractures and left clavicle fracture and has not achieved medical stability for safe discharge from hospital . the current condition would worsen and an adverse event like worsening pain, pneumonia may occur . Record review of Resident #301's progress notes, dated 1/31/2025, documented pain medication administered. The next progress note was dated through 2/2/2025 at 5:02 AM related to insulin administration. Record review of 2/3/2025 Progress note written by Registered Nurse B was strike out of documentation. A late entry progress note dated 2/3/2025 noted that the resident complained of back pain. Resident told CNA she was dropped, and writer went to speak with her and assess her . Record review of Resident #301's Minimum Data Set (MDS) assessment, dated 1/2/2025, revealed an elderly female with Brief Interview of Mental Status (BIMS) score of 12 out of 15. Medical Diagnosis included: Medically complex conditions, anemia, hypertension, renal insufficiency, diabetes, hyponatremia, other fracture, cerebrovascular accident (CVA), hemiplegia/hemiparesis, malnutrition, depression and osteomyelitis of left foot. Section GG: functional abilities: Dependent- helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity for toileting hygiene, shower/bathe, upper body dressing, lower body dressing, rolling left and right, sit to lying, lying to sitting, and chair/bed-to-chair transfer. Record review of Resident #301's care plans, page 1- 27, revealed Activity of Daily Living (ADL) care plan related to self-care performance deficit secondary to cardiovascular accident (CVA) related to left hemiparesis, left hand contractures, left lower extremity contracture, left side neglect, osteomyelitis of left foot, surgical amputation of left great toe. The care plan noted limited mobility, limited range of motion (ROM), decreased mobility . Interventions: Bed Mobility dated 11/10/2023: The resident requires extensive 2 staff to turn and reposition in bed. Dressing dated 11/10/2023: The resident requires extensive 2 staff to dress. Toilet Use dated 11/10/2023: The resident requires extensive 2 staff for bed pan/brief change. Record review of the facility 'Activity of Daily Living (ADL), Supporting' policy dated 1/2025 revealed residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. (2.) Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene, mobility, elimination . Definitions: Total Dependence- Full staff performance of an activity with no participation by resident for any aspect of the ADL activity Observation and interview was conducted on 2/14/2025 at 11:30 AM with Resident #301 and family member at bedside. Resident #301 stated again that she was dropped and flat on her back. Observation with assist of family member of Resident #301 dressed in a hospital gown revealed left upper should/chest front view of a large bruising area of a green/yellow color, estimated to be the size of a basketball that went down the left side under the arm pit area. Observation of the left hip area visible through a brief the surveyor noted a dark purple in color bruising estimated 3 inches wide by 6 inches in length. Resident #301 stated that she does get back pain and shoulder pain with hiccups and coughing or being moved. Sleeping at night hurts also. The state surveyor observed black bilateral soft boots on while in bed, observed a right upper arm PICC (Peripheral Inserted Central Catheter) line with dressing dated 2/1/2025. A dressing was noted to the left lower arm estimated 2 inch wide by 3 inch in length with date of 2/13/2025. The family member stated that the resident spent 7 days in the hospital related to her fracture injuries and infection in her foot. An interview on 2/14/2025 at 1:07 PM with Registered Nurse (RN) B revealed that he was working when Certified Nurse Assistant (CNA) I called the nurse into Resident #301's room to see a skin tear on the left lower arm by the hand and then she mentioned that when she was getting Resident #301 ready for bed and giving a sponge bath that she said for me to look at the bruising from her left upper shoulder area that was blur in color. RN B stated 'It (the bruising) went from left upper chest to right upper chest. Around that time CNA I mentioned that the resident said that she was dropped from the bed. She fell or was dropped; it was around that time. She (Resident) stated to her grandson that she was dropped or fell . I was in the room doing assessment on Resident #301 and CNA I asked her about the bruising, and I heard Resident #301 say that she was dropped from the bed. Resident #301 said it, I heard her say it. Resident #301 was having a lot of back pain. The left upper arm had small bruising on her elbow and dark red color to arm. Resident #301 said severe back pain, left arm hurt and she hadn't ever complained of back pain before. I sent her to hospital around 8 PM that night (2/3/2025). CNA I had a couple of days off before this and saw the skin tear and asked if it was new. The skin tear was scabbed over with no dressing on it. I didn't know about the skin tear it was not given in report shift to shift, and not documented anywhere. The severe back pain, new bruising, scabbed skin tear, she was on Eliquis blood thinner, and I sent her to the hospital ER per protocol the black & blue was new with a blood thinner and an unwitnessed fall/drop?' Record review of facility 'Charting and Documentation' policy dated July 2017 revealed all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medial, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. (2.) The following information is to be documented in the resident medical record: (a.) objective observations. (d.) Changes in the resident's condition. (e.) Events, incidents or accidents involving the resident . (8.) ADL (Activity of Daily Living) documentation shall be completed on each shift by Certified Nursing Assistants and will be monitored by nursing. An interview and record review on 2/14/2025 at 2:18 PM with the Director of Nursing (DON) about Resident #301's injuries revealed that she started staff education yesterday on 2/13/2025 for a change in elevation related to the incident. The DON stated, 'Residents Usually are lowered to the floor/ground. It was brought up last week about the change in elevation education. That's the only education that we have related to the incident. I put it out yesterday for the staff to sign the education. The Certified Nurse assistant (CNA) H reported to nurse Licensed Practical Nurse (LPN) E and the LPN went in and looked at the Resident #301 and then went to a second nurse, License Practical Nurse (LPN) G. LPN G went into the Resident #301's room and asked the resident about a fall. The CNA H explained that it was a roll out of bed. LPN G asked Resident #301 if she wanted to go to the hospital and she said no. CNA H stated that he was changing the resident while rolling her over from the bed he turned to get the wipes and she rolled from the bed, but that he caught her and she did not hit the floor. It happened on Sunday 2/2/2025 at around 8:56 PM. Then on 2/3/2025 at 8:01 PM Registered Nurse (RN) B received a report form CNA I that there was bruising to the left side of the resident's chest bruising and left hip bruising, left lower arm skin tear without a dressing. Record review of Resident #301's medical record with the DON of the resident assessments (skin, pain, and post injury of unknown origin) and progress notes from 2/1/2025 through 2/14/2025 revealed there was no assessment or progress notes written on 2/2/2025 the evening of the incident and not until on 2/3/2025 when the resident was sent to hospital. The state surveyor reached out to Licensed Practical Nurses (LPN) E and G who were on duty at the time that Resident #301's injury of unknown origin occurred, but they did not respond to the phone calls or voice messages left to return the phone call. Record review of facility investigation witness statements revealed: Certified Nurse Assistant (CNA) H written statement dated 2/5/2025 revealed the CNA went into Resident #301's room to change her. The CNA proceeded to change Resident #301 rolling her towards his body to change her and turned to get the brief and wipes that he placed in the window sill and, as he was turning to grab the items out of the windowsill, he saw the resident falling. CNA H noted he quickly grabbed resident with a swift force, but she unfortunately hit her shoulder and head on a chair. CNA H noted he placed the Resident #301 back into bed and went and got the nurse. They checked her (Resident #301) out, took her vitals and was seeing if she was OK. We checked on her through the night. She was sleeping and toward the ending of my shift me and the nurse went to go change her again. Record review of Resident #301's Medication Administration Record for the month of February 2025 revealed the medication Eliquis (anticoagulant/blood thinner) 2.5 mg give 1 tablet by mouth two times day for prophylaxis started on 3/20/2024 . Record review of 'Nursing 2017 Drug Handbook' Wolters Kluwer 2017, page 148- 149, revealed black box warning: Monitor patient for neurologic impairment (midline back pain, sensory or motor deficit, such as numbness or weakness in lower limbs, bowel or bladder dysfunction. Treat impairment urgently Record review of Resident #301's progress notes, dated 1/31/2025, documented pain medication administered. The next progress note was dated through 2/2/2025 at 5:02 AM related to insulin administration. Record review of 2/3/2025 Progress note written by Registered Nurse B was struck out of documentation. A late entry progress note dated 2/3/2025 noted that the resident complained of back pain. Resident told CNA she was dropped and writer went to speak with her and assess her . Record review of facility investigation witness statements revealed: Certified Nurse Assistant (CNA) H written statement dated 2/5/2025 revealed the CNA went into Resident #301's room to change her and put her into bed. The CNA put the resident into bed with a lift machine and placed her into bed. The CNA proceeded to change resident #301 rolling her towards his body to change her and turned to get the brief and wipes he placed in the windowsill and as he was turning to grab the items out of the windowsill he saw the resident falling. CNA H noted he quickly grabbed resident with a swift force, but she unfortunately hit her shoulder and head on a chair. CNA H noted he placed the Resident #301 back into bed and went and got the nurse. they checked her (Resident #301) out, took her vitals and was seeing if she was OK. We checked on her through the night. She was sleeping and toward the ending of my shift me and the nurse went to go change her again. Record review of Resident #301's Medication Administration Record for the month of February 2025 revealed the medication Eliquis (anticoagulant/blood thinner) 2.5 mg give 1 tablet by mouth two times day for prophylaxis started on 3/20/2024 . Record review of 'Nursing 2017 Drug Handbook' Wolters Kluwer 2017, page 148- 149, revealed black box warning: Monitor patient for neurologic impairment (midline back pain, sensory or motor deficit, such as numbness or weakness in lower limbs, bowel or bladder dysfunction. Treat impairment urgently

Based on observation and interview the facility failed to maintain sanitary conditions in the kitchen, resulting in an increased potential for cross contamination of food, foodborne illness and improper kitchen sanitization, potentially affecting all residents who consume meals from the kitchen. Findings Include: On [DATE] at 7:45 AM, initial tour was conducted in the kitchen in the presence of Dietary Manager F, the following expired/outdated items were found: Dry Storage Room: - ,d+[DATE]-gallon containers of [NAME] Vinegar with expiration date of [DATE] - Manager F stated the vinegar is good for a year after they receive it and the date received was [DATE]. Walk-in Cooler: - ,d+[DATE] pieces of pureed toast- expiration date [DATE] - 1 - Gallon size of brownies with no use by date - Premium Parmesan Cheese- opened [DATE] with no use by date - Manger F stated the cheese should have been discarded of after 14 days ([DATE]) Walk-in Freezer: - 1 bag of pecans- expired [DATE] - Gallon size bag of marinara sauce- expired [DATE] - Gallon size bag of turkey- cooked [DATE]- with no use by date - 30 lb box of sliced carrots- bag was not sealed and without open or use by date - Large plastic bag of mixed veggies without use by date - 2- pieces of cornbread found in the corner of the freezer - 1 -box of gluten free pizza cheese pizza without use by date - 1 box of gluten free waffles- expired [DATE] - ,d+[DATE] mini pie crusts- expired [DATE] - 2 -individually wrapped breakfast sandwich - without a use by date - 1 -bag of granulated peanuts- expired ,d+[DATE] - ,d+[DATE] bag hash browns- without use by date - 1-bag sliced almonds- expired [DATE] - 1 bag of walnuts- without expiration date - 1-gallon bag of frozen bananas- expired [DATE] - 1-gallon size bag of pork crumble- ex [DATE] - ,d+[DATE] turkey- expired [DATE] - 1 -gallon size of spaghetti sauce- expired ,d+[DATE] - Gallon size bag of sweet and sour sauce- without expiration date - 1-gallon size bag of Swedish meatballs- expired [DATE] Dietary Manager F stated all items should be labeled with an open and use by date and upon expiration be discarded of. On [DATE] at 7:50 AM, a follow up visit was conducted in the kitchen in the presence of Dietary Manager F. The manager reported the solution for their three-compartment sink is premixed through a mechanism installed by a contracted service provider. There were two red buckets utilized for sanitization and upon testing the strength of the solution both indicated 0 PPM (parts per million). Manager F reran the solution and rechecked it and it was barely at the 150 PPM mark, she stated she would contact the company for a service call. Manager F reported the sanitizing solution should be at 150 PPM. On [DATE] at 4:00 PM, Dietary Manager F reported the technician did locate a plug in the tubing where the chemicals mix, which was not allowing the correct amount of chemicals to mix. The technician was last at the facility on [DATE] but did not look at the mixing points for the three-compartment sink. It is unknown how long the plug has been present. Review was completed of Red Bucket PPM log, and it indicated the PPM on [DATE] (prior to checking it with Manager F) was 200 PPM. From [DATE] [DATE], the log showed the PPM as 200 daily. It is unknown how the solution strength was up to par and then not within limits shortly thereafter. Review was completed of the Service Report from [DATE] for the three-compartment sink. It stated, .reported sanitizer not working replaced metering tip and flushed unit is working fine . Review was completed of the policy entitled, Food Safety and Sanitation, reviewed ,d+[DATE]. The policy stated, .All leftovers are labeled, covered, and dated when stored. They are used within 72 hours (or discarded). Food with expiration dates are used prior to the date on the package . Review was completed of Sanitizer Test Procedures, it indicated the test for Quaternary Sanitizer should be at 150 PPM (at a minimum).

The facility failed to ensure comfortable room temperatures for two residents (Resident #24, Resident #110) from a census of 52 residents, resulting in Resident #110 becoming upset and disgruntled because he was too cold to eat and sleep. FACILITY Environment Resident #110: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #110 was admitted to the facility on [DATE] with diagnoses: Kidney disease, heart disease, pneumonia, COPD, and a history of falls with a fracture. The MDS assessment dated [DATE] revealed the resident had mild cognitive loss with a Brief Interview for Mental Status/BIMS score of ,d+[DATE] and needed some assistance with all care. On [DATE] at 10:53 AM, Resident #110 was observed lying in bed, watching TV. He was awake, alert and talkative. The resident pointed at the heat register in the room; it read 68 degrees Fahrenheit. Resident #110 said he was very cold. He was very upset. He said he kept telling people that he was too cold and they would tell him they would send someone. He said no one came to look at the heat register. He said the staff offered an extra blanket. Resident #110 stated, It's just cold. I'm cold. Three days in a row, I'm used to 72 degrees at home. I want to be comfortable. I can't eat or sleep. I don't want an extra blanket. I want them to do something about it. On [DATE] at 11:02 AM, Maintenance staff K entered Resident #110's room. He said he just received a work order that morning for the cold temperature in Resident #110's room. Maintenance staff K stated, You can hear the heat duct running; there's nothing blowing. He said the temperature was set at 79 degrees, but now it was reading 69 degrees. Maintenance staff K said there had been other resident rooms with the same issue. He said some of those residents had to be moved to another room, so the heating unit/heat register could be repaired. Certified Nursing Assistant L said she worked over the weekend and Resident #110 said he was too cold, so she put the work order in. On [DATE] at 10:25 AM, Operations Manager B was interviewed, and he said the resident's wall unit was not working and Maintenance staff K reset it on [DATE] and it was currently working. He said the facility had issues with other wall heating units in the residents' rooms and he said the would have to make a plan to replace them. 38471 Resident #24: During the initial tour on [DATE], Resident #24 shared she does not participate in many activities as she once did, because the common areas are cold. Even with a long sleeve shirt and sweatshirt on she is still cold in the common areas and hallways of the facility. Resident #24 stated many residents, and staff are bundled up when outside of their room given the cool temperatures in the facility. During Resident Council on [DATE] at 10:30 AM, all nine residents in attendance at the meeting expressed the common areas (theater, hallways, library and activity) are cold. They reported there is cool air blowing through the vents and they have to bundle up when coming out of their room as they anticipate being cold. Review was completed of Resident Council notes and the following was indicated in the notes from [DATE], .Facility is cold multiple residents . During the survey three facility staff members who requested their anonymity was maintained, stated residents have complained regarding it being cold in the hallways and common areas. They reported they typically wear jackets/fleeces throughout their shift and it's reasonable to believe that if they are cold so are the residents. The staff stated the residents have informed them they will not go to activities due to the cool temperatures. On [DATE] at 1:10 PM, the thermostat on 300 hall read 70.1 and it felt as if cool air was filtering from the vents on the ceiling. An infrared thermometer was utilized to measure temperatures in common areas and hallways the temperatures were as follows: Activity Area: 69.7 100 Hall: Thermostat: 73.5 Between room [ROOM NUMBER] and 103: 68.3 Outside room [ROOM NUMBER]: 71.2 Outside room [ROOM NUMBER]: 71.0 Outside room [ROOM NUMBER]: 69.7 200 Hall: Thermostat: 70.5 Outside room ,d+[DATE].7 Outside room ,d+[DATE].4 Outside room ,d+[DATE].3 Nurse Station-72.3 300 Hall: Between room [ROOM NUMBER] and 303: 71.4 Outside room [ROOM NUMBER]: 69.9 Outside room [ROOM NUMBER]: 70.3 Outside room [ROOM NUMBER]: 68.5 400 Hall: Nurse Station-68.8 Thermostat- 70.7 Outside room ,d+[DATE].0 Between Room: [DATE] Outside room [ROOM NUMBER] ,d+[DATE].5 Outside room ,d+[DATE].3 On [DATE] at 10:00 AM, an interview was conducted with Maintenance Director B regarding the resident complaints of the common areas being cold and the issues with heating/cooling units in residents' rooms. Director B explained they switched out a unit in a resident room and now they will have spare parts on hand in the event another unit malfunctions. The in-room units have a life expectancy of ,d+[DATE] years given how the residents run them continuously. He reported they maintain the facility at 71 -74 . Director B reported staff have complained the hallways are too warm as residents' room are close to 80 which push the hallway temperatures up. Director B was provided with concerns discussed from resident council, facility staff and initial tour on the coldness in the common areas and how they asked for it to be remedied without success. The Director explained there is a pinpoint size leak in the [NAME] line on the unit on the roof. There are six Fujitsu units on the roof, two outside units and units in the basement that work conjunctively to heat/ cool the common areas and hallways in the facility. The unit has been leaking Freon, which then causes the unit to continuously work and there is buildup on the copper tubing from it. They have to shut down the unit to defrost and contact an HVAC contractor to refill the Freon. They continuously go through this cycle as they do not know where the leak is. So, in the summer the building could be warmer and in winter cooler. Adding the Freon each time is a temporary fix to the main issue at hand and he stated it was recommended they mix an additive with the Freon and when the additive locates the leak it will mix and solder the pinpoint hole. But this solution has not yet to be presented and approved. Review was completed of facility's contracted HVAC work orders for [DATE]: [DATE]: Routine fall check. Due to current weather conditions, we are not finished. We are performing maintenance on HVAC. We found heat pumps units 1 and 6 low on refrigerant charge. Charged units and checked operation. Repaired 2 PTACH room units. Both units required blower repairs. I can forward the remaining repairs if there are any when the service is complete weather permitting. [DATE]: [DATE] @3:50 PM Maintenance Call ([NAME]) from facility stating some areas of facility are running cool, hall, library, movie theater. Also wants PTAC units in three rooms checked. Service call scheduled first available on Monday ,d+[DATE]. Rooms 113, 414, 314. Complete indoor blower rebuild. Note: parts availability for these units are ,d+[DATE] weeks out. Review was completed of the facility policy entitled, Maintenance of Building Temperatures/Provisions for Extreme Heat or Cold, reviewed ,d+[DATE]. The policy stated, .Required temperatures range- the building temperature in all resident areas at the facility will be maintained between seventy- one degrees Fahrenheit and eighty- one degrees Fahrenheit .Maintenance department staff are responsible for adjusting temperature thermostats and servicing heating and cooling units during the change of seasons .all reports of temperature problems must be reported to the Administrator or DON. In conjunction with maintenance staff, Administrator and nursing will assess and determine the extent and length of the problem and determine what types of action will need to be taken .

Based on interview and record review the facility 1) Failed to check blood sugars and administer insulin per physicians' orders for two residents (Resident #30, Resident #158) of two residents reviewed for timely medication administration and 2) Failed to ensure coordination and integration of hospice services for one resident (Resident #51) of one resident reviewed for hospice. Findings Include: Resident #30: During Resident Council on 11/19/2024 at 10:30 AM, Resident #30 shared many times her blood sugar is being checked after she had already completed breakfast. She continued the nurse typically has an excuse as to why it was not checked prior to meal service. On 11/19/2024 at approximately 2:00 PM, a review was conducted of Resident #30's medical record and it revealed she was admitted to the facility on [DATE] with diagnoses that include, Cellulitis, Peripheral Vascular Disease, Type 2 Diabetes Mellitus, Long term use of insulin and Heart Disease. Further review of Resident #30's records revealed the following: Physician Orders: Insulin Glargine 100 Unit/ML (milliliter)- inject 20 units subcutaneously one time a day for diabetes. Slated to be administer at 8:00 AM. Insulin Lispro Injection Solution 100 Unit/ML- inject subcutaneously with meals for diabetes Insulin Lispro Injection Solution 100 Unit/ML- inject as per sliding scale subcutaneously with meals for diabetes: If 0-124=x 125-150=2 151-200=4 201-250=6 251-300=8 301-350=10 351-400-12 401-9999= x Contact physician On 11/19/2024 at 2:00 PM, Dietary Manager F was asked what times meal service it completed on the halls and the order in which it is served. Manager F explained meals are at 8:00 AM, 12:30 PM and 5:00 PM. The dining room is served first, and halls are completed between 8:45 AM-9:00 AM, with 200 hall being served around 8:30 AM. On 11/19/2024 at 4:30 PM, Unit Manager G stated blood sugars should be checked prior to residents eating meals. Meal service begins in the dining room at 8:00 AM and then then hallways. Review was completed of the facility document that indicated the following mealtimes: Breakfast: 8:00 AM Lunch: 12:30 PM Dinner: 5:00 PM Review was completed of the times Resident #30's blood sugar was checked in relation to facility meal service times. It was found Resident #30's blood sugar was frequently checked well after meal service. The timeframes varied from 45 minutes to two hours after meal service. It can be noted 200 Hall receives their meals around 8:30 AM. The time frames are as follows: 11/17/2024 08:54 224.0 mg/dL 11/16/2024 08:47 216.0 mg/dL 11/15/2024 09:03 197.0 mg/dL 11/12/2024 10:14 200.0 mg/dL 11/12/2024 10:14 200.0 mg/dL 11/12/2024 10:14 200.0 mg/dL 11/10/2024 09:06 193.0 mg/dL 11/10/2024 09:06 193.0 mg/dL 11/10/2024 09:05 193.0 mg/dL 11/9/2024 09:04 157.0 mg/dL 11/9/2024 09:04 157.0 mg/dL 11/9/2024 09:03 157.0 mg/dL 11/8/2024 08:50 168.0 mg/dL 11/7/2024 08:41 189.0 mg/dL 11/7/2024 08:41 189.0 mg/dL 11/7/2024 08:41 189.0 mg/dL 11/6/2024 09:31 202.0 mg/dL 11/5/2024 18:03 217.0 mg/dL 11/5/2024 18:03 217.0 mg/dL 11/3/2024 17:46 227.0 mg/dL 11/3/2024 17:45 227.0 mg/dL 11/3/2024 09:32 220.0 mg/dL 11/3/2024 09:30 220.0 mg/dL 11/3/2024 09:30 220.0 mg/dL 10/31/2024 12:30 201.0 mg/dL 10/31/2024 11:06 208.0 mg/dL 10/31/2024 11:06 208.0 mg/dL 10/31/2024 08:40 208.0 mg/dL 10/31/2024 01:40 137.0 mg/dL 10/27/2024 09:04 185.0 mg/dL 10/27/2024 09:03 185.0 mg/dL 10/27/2024 09:03 185.0 mg/dL 10/26/2024 09:22 302.0 mg/dL 10/26/2024 09:22 302.0 mg/dL 10/26/2024 09:22 302.0 mg/dL 10/25/2024 09:01 235.0 mg/dL 10/25/2024 09:01 235.0 mg/dL 10/25/2024 09:00 235.0 mg/dL 10/20/2024 08:52 207.0 mg/dL 10/20/2024 08:51 207.0 mg/dL 10/20/2024 08:51 207.0 mg/dL 10/19/2024 08:46 244.0 mg/dL 10/13/2024 09:04 205.0 mg/dL 10/13/2024 09:04 205.0 mg/dL 10/13/2024 09:03 205.0 mg/dL 10/8/2024 09:17 181.0 mg/dL 10/8/2024 09:17 181.0 mg/dL 10/8/2024 09:16 181.0 mg/dL 10/7/2024 18:32 193.0 mg/dL 10/7/2024 18:32 193.0 mg/dL 10/5/2024 08:57 195.0 mg/dL 10/3/2024 18:16 297.0 mg/dL 10/3/2024 18:15 297.0 mg/dL Review was completed of Medication Audit Report from 10/1/2024 to 11/21/2024 and it revealed Resident #30 was administered her insulin well after her meal was completed which coincided with the untimely blood sugar checks. Both documents together show consistence in the resident receiving essential medications outside ordered timeframes. The document provides the following information: Insulin Lispro- injected per sliding scale subcutaneously with meals: 10/3/2024- administered at 18:16 10/5/2024- administered at 09:01 10/5/2024- administered at 18:31 10/7/2024- administered at 18:32 10/8/2024- administered at 09:16 10/13/2024- administered at 09:04 10/26/2024- administered at 09:22 10/27/2024- administered at 09:03 11/3/2024- administered at 09:30 11/5/2024: administered at 18:03 11/9/2024- administered at 09:04 11/10/2024- administered at 09:05 11/12/2024- administered at 10:14 11/15/2024- administered at 13:10 Insulin Lispro Injection- inject 10 unit subcutaneously with meals: 10/3/2024- administered at 18:15 10/7/2024- administered at 18:32 10/8/2024- administered at 09:17 10/13/2024- administered at 09:04 10/25/2024- administered at 09:01 10/26/2024- administered at 09:22 10/27/2024- administered at 09:03 10/31/2024- administered at 11:06 11/3/2024- administered at 09:30 11/5/2024- administered at 18:03 11/9/2024- administered at 09:04 11/10/2024- administered at 09:06 11/11/2024- administered at 09:20 On 11/21/24 at 01:38 PM, Resident #30 was having lunch her in her room, she reported the nurse that typically checks her blood sugar after she had consumed her meal, informed her if was because they (nurses) had to be in the dining room during meals. On 11/21/24 at 09:19 AM, Unit Manager G reviewed the Medication Audit Report, for Resident #30. The Unit Manager stated the nurses have not expressed their inability to check blood sugars and administer insulin timely. Morning medication pass is heavier and when reviewing the report, it was not isolated to one nurse, so she is not sure what the root cause is. Manager G understood the concern. Resident #158: On 11/20/2024 at approximately 3:15 PM, a review was completed of Resident #158's medical records and it revealed the resident was admitted to the facility on [DATE] with diagnoses that included Cellulitis, Metabolic Encephalopathy, Bipolar Disorder, Type 2 Diabetes and Schizoaffective Disorder. Further review yielded the following: Physician Orders: Insulin Lispro Injection Solution (Insulin Lispro) Inject per sliding scale- subcutaneously before meals for diabetes. Review was completed of the times Resident #158's blood sugar was checked in relation to facility meal service times. It was found Resident #158's blood sugar was frequently checked well after meal service. The timeframes varied from 45 minutes to two hours after meal services. 11/18/2024 12:53 150.0 mg/dL 11/16/2024 17:55 239.0 mg/dL 11/15/2024 17:54 134.0 mg/dL 11/12/2024 13:13 131.0 mg/dL 11/9/2024 17:56 195.0 mg/dL 11/8/2024 19:56 202.0 mg/dL 11/8/2024 13:12 89.0 mg/dL 11/20/2024 17:46 147.0 mg/dL 11/16/2024 17:55 239.0 mg/dL 11/16/2024 15:01 132.0 mg/dL 11/15/2024 17:54 134.0 mg/dL 11/11/2024 08:43 130.0 mg/dL 11/9/2024 17:56 195.0 mg/dL 11/8/2024 19:56 202.0 mg/dL 11/8/2024 13:12 89.0 mg/dL 11/7/2024 18:41 238.0 mg/dL Review was completed of Medication Audit Report from 11/8/2024 to 11/21/2024 and it revealed Resident #158 was administered his insulin well after her meal was completed and coincided with the untimely blood sugar checks. The document provides the following information: Insulin Lispro Injection Solution- Inject per sliding scale subcutaneously before meals: 11/8/2024- administered at 13:12 11/8/2024- administered at 19:56 11/12/2024- administered at 13:13 11/16/2024- administered at 15:01 (lunch administration) On 11/21/2024 at 9:10 AM, an interview was conducted with Unit Manager H regarding the late administration of Resident #158's insulin and checking blood sugars after meals were consumed. Manager H reviewed the Medication Audit Report and reported she was unsure as to why his insulin was being administered after meals. Progress notes were reviewed as well and there was no reasoning located in the charting. Review was completed of the policy entitled, Administering Medications, revised December 2012. The policy stated, .Medications should be administered in accordance with the orders, including any required time frame . 37666 Resident #51: Hospice and End of Life A record review of the Face sheet and Minimum Data Set/MDS indicated Resident #51 was admitted to the facility on [DATE] with diagnoses: Huntington's disease, history of falls, and depression. The MDS assessment dated [DATE] indicated the resident had severe cognitive loss with a Brief Interview for Mental Status/BIMS score of 0/15 and the resident needed some assistance with all care. On 11/18/2024 at 10:49 AM, Resident #51 was observed lying in bed, awake and alert. When asked questions he attempted to answer and stated, I don't know. A review of the Physician orders indicated Resident #51 was admitted to Hospice services on 10/9/2024. A record review of the electronic medical /EMR for Resident #51 indicated there was no Hospice notes or documentation related to resident care or visits with the resident. On 11/21/2024 at 1:26 PM, Unit Manager/UM Nurse G was interviewed about Resident #51 receiving Hospice services. She said the facility used several different Hospice services and some of the Hospice staff charted in the resident's EMR, but some used a separate paper chart in a binder at the nurse's desk. UM G looked around the nurse's desk and she said the resident did not have a Hospice book/chart at the desk. UM G also looked in the EMR and she said there was an order for Hospice, but nothing else. She said she would check further on it. On 11/21/2024 at 1:48 PM, UM H was interviewed about the Hospice documentation for Resident #51 and said there was no Hospice chart. UM H said she would call the Hospice service to see if they had any notes. On 11/21/2024 at 3:08 PM, the lack of Hospice service documentation of care for Resident #51 was reviewed with the Administrator and Assistant Administrator. They said they would look for documentation. On 11/21/2024 at 4:00 PM, UM H provided a stack of Hospice notes for Resident #51 dated from 10/8/2024 - 11/15/2024. She said they had been sent to the Social Worker's office and she was going to request that they were sent to the nursing department for placement into the resident's medical record in the future. A review of the facility contract with the Hospice service titled, . Hospice Services Agreement, dated March 11, 2022 provided, . Hospice shall communicate with the Resident, family members, Facility staff, and the attending physician to develop and update the content of the hospice plan of care .

Based on observation, interview and record review, the facility failed to ensure that food preferences were identified and followed for 2 residents (#8 and #109) of 2 residents reviewed for food or choices, resulting in both Resident #8 and #109 becoming upset, and discouraged that they did not receive the food that they had requested. Findings Include: Resident #109: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #109 was admitted to the facility on [DATE] with diagnoses: Cirrhosis of the Liver with ascites, vitamin/mineral deficiency, dehydration, history of falls, left hip pain, hypertension, COPD, depression, Panic disorder, GERD and arthritis. The MDS assessment dated [DATE] indicated Resident #109 had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 15/15 and needed some assistance with care. The MDS section K identified the resident was receiving a Therapeutic diet. On 11/19/2024 at 9:20 AM, Resident #109 was viewed sitting in a chair in his room. He said he had been at the facility for about 2 weeks, and he received 3 salads. The resident said it was difficult to get fresh fruit and salads, as he was trying to eat less processed foods. Resident #109 stated, I asked for a salad with every meal, like a side salad. I don't think they have salads every day here. I don't get milk unless I ask for it. The resident was asked if he had talked to anyone about not receiving the food he requested and he said he had spoken to several people from the kitchen. The resident showed his meal ticket on his breakfast tray. It listed his type of diet and fluids. There were no food preferences listed. On 11/20/2024 at 2:40 PM, the Certified Dietary Manager/CDM F was interviewed about Resident #109. She said she had spoken to him and he received a 4 week menu and alternative menu. The CDM said a side salad was an option on the alternative menu and included: lettuce, tomatoes, green pepper, cucumber, and onion. She said it was the only option for a salad and there was no chef salad. The CDM said Resident #109 could receive a salad and noted he had received several salads. The CDM said she would follow up with the resident, and flag his ticket to ensure he received a salad and fruit. During the interview with the CDM on 11/20/2024 at 2:45 PM, a dietary note dated 11/7/2024 was reviewed. It was created on 11/13/2024 and dated for 11/7/2024; a week after the resident was seen by the CDM. She said sometimes the notes were created late. Discussed with the CDM that Fruit was mentioned on the 11/7/2024 assessment but not addressed on the resident's food ticket. Salads were not mentioned on the notes/assessments, but the CDM said the resident had mentioned it to her and he had received them several times, although not consistently. On 11/21/2024 at 1:00 PM, Resident #109 was interviewed; his lunch tray was sitting on the bedside table. He said he talked to someone from the kitchen, and he said he didn't want a salad for breakfast but with lunch and supper It would be nice. He pointed at his meal tray and showed that he did not get a salad. In reviewing his lunch ticket, it did not identify any preferences or mention the resident would like fresh fruit and a salad. There was no fruit on the meal tray, but Resident #109 said he had some fruit the previous day and had an extra apple and orange in his room. On 11/21/2024 at 2:00 PM, during an interview with the CDM, it was pointed out that the resident did not receive a salad with his meal and his meal ticket did not identify food preferences. On 11/21/2024 at 2:45 PM, during an interview with the Administrator, Resident #109's food preferences were reviewed: the resident's meal ticket did not identify the resident's preferences, and he had been in the facility for 16 days. She said there were some challenges in the dietary department, and they were going to work on it. 38471 Resident #8: During Resident Council on 11/19/2024 at 10:30 AM, Resident #8 shared she requested grits from the kitchen for breakfast and received them consistently for 3-4 days and suddenly she stopped being served them. When she asked dietary staff about it, they stated she could not have them as she was the only resident that requested them. On 11/19/2024 at 2:00 PM, Dietary Manager F was queried regarding Resident #8's request to have grits daily for breakfast. She reported her cook informed her she was making it for the resident, but it was coming back to the kitchen, so they stopped preparing it for the resident. Manager F was asked to clarify if dietary spoke to Resident #8 regarding removing grits from her plate or if it was assumed she did not want them because it was not being eaten. On 11/20/2024 at 7:55 AM, a review was completed of Resident #8's records and it indicated she admitted to the facility on [DATE] with diagnoses that included, Acute Pancreatitis, Anxiety, Pulmonary Hypertension, Diverticulitis, Syncope and Collapse. Further review yielded the following: Care Plan: .Offer (Resident #8) food preferences. Offer subs of same nutritional value if resident dislikes main meal .Provide (Resident #8) wit as much control as possible in routines, food preferences etc. On 11/20/24 03:35 PM, Dietary Manager F followed up on Resident #8's grits preference. She expressed she found their cook made the decision to stop making Resident #8's grits every morning because it was too many breakfast items to prepare. Manager F explained they are going to use instant grits for Resident #8 Review was completed of the facility policy entitled, Resident Food Preferences, reviewed 2/2024. The policy stated, Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modification to diet will only be ordered with the resident's or representative consent . When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes .

This Citation pertains to Intake Number MI00139872. Based on interview and record review, the facility failed to ensure a timely transfer to acute care for evaluation after a fall with a head injury (swollen under left eye, indicating head injury) for one resident (Resident #101), who received a blood thinner (Xarelto 10 mg) and a low-dose aspirin (ASA 81 mg) daily, and who had a history of falls upon admission and of not using the call light, resulting in a slow brain bleed, hospitalization and death. Findings Include: Resident #101: Review of the Face Sheet, Fall Risk assessment dated [DATE], Physician orders dated 9/5/23, social service, nursing and physician notes dated 9/5/23 through 9/9/23, nursing admission assessment dated [DATE], care plans dated 9/5/23 and 9/6/23, and hospital notes dated 9/9/23, revealed resident #101 was admitted on [DATE], was [AGE] years-old, alert with some confusion, required staff assistance with Activities of Daily Living, had previous falls prior to admission and required frequent reminders to use the call light. The resident's diagnosis included, stenosis of spine, pain in left lower leg, difficulty walking, a history of blood clots and embolism, and had Atrial Fibrillation (was on blood thinner and Aspirin), and had other abnormality of red blood cells. The resident had previously been admitted to the facility with a known history of falls and not using her call light as instructed. Review of Resident #101's BIMS (brief mini mental assessment), dated 9/5/23 (admitted ), revealed she had a BIMS of 13 (alert with some cueing required). Review of the facility Code Status sheet dated 9/5/23, revealed Resident #101 requested to be transported to the hospital in case of an emergency or health condition requiring medical intervention. Review of the admission Fall Risk assessment dated [DATE], revealed the resident had a 6 total score, which indicated she was at moderate risk for a fall. The resident also had a history of falls prior to admission. Review of the facility Occupational Therapy Evaluation & Plan of Treatment dated 9/6/23, revealed the resident's functional cognition: Needed some help, and she had previous falls. Review of the resident's admission orders dated 9/5/23, revealed she received Xarelto 10 mg (blood thinner, medication has a high risk for internal bleeding and there is no approved antidote to stop bleeding, this is a dangerous medication), and ASA 81 mg (aspirin, platelet inhibitor, used for inflammation, pain, fever, chest pain, strokes, heart attacks and to prevent blood clots) daily, and Hydrocodone-Acetaminophen tab 5-325 (narcotic for pain) as needed every 4 hours. Both ASA 81 mg and Xarelto 10 mg, have a warning of internal bleeding and should be monitored closely. Review of the resident's electronic medication record dated 9/23, revealed he was given ASA 81 mg and Xarelto 10 mg on 9/5/23 (admission day), 9/6/23 (day of the fall), 9/7/23, 9/8/23 and on 9/9/23 (the day transferred to the hospital). Review of the facility nurse's notes dated 9/6/23, stated CNA (Nursing Assistant) alerted this writer that resident (Resident #101) had fallen in her bathroom. Resident observed laying on the floor on her belly, feet towards the door, head sideways facing the shower. Resident alert and oriented x 3 and her own person. Full head to toe assessment completed. Observed slight swelling above right eye (head injury observed by nurse), resident denied hitting her head. Doctor notified and son notified of fall. Predisposing Physiological Factors: Confused, Gait Imbalance. Review of the facility Incident Report dated 9/6/23, revealed at the time of her fall she was confused and had gait imbalance. The report stated, This nurse was passing morning meds. CNA alerted this writer that resident (Resident #101) had fallen in her bathroom. Resident laying on the floor on her belly feet towards the door head sideways facing the shower. Observed slight swelling above right eye, resident denied hitting her head. Doctor notified and son notified of fall. Documentation revealed Physician E was notified of the residents fall on 9/6/23 at 5:24 p.m. Review of facility nursing notes dated 9/7/23 through 9/8/23, had no documentation of additional assessment regarding the fall or of the resident answering questions or of talking (cognition status). Review of the facility neurological evaluation flow sheet dated 9/6/23 through 9/9/23, revealed no neurological concerns up to 9/9/23 (it was not filled out). This was the date the resident was found unresponsive and transferred to the hospital. Review of facility nursing notes dated 9/9/23, stated resident was found unresponsive in bed by her aide. Resident had no verbal or motor response. Eyes were open and would follow movement but not open of close on command. No s/s (signs/symptoms) of pain. Provider notified and resident sent to (Hospital) ER (emergency room ). No documentation of the primary physician returning the facility call was found by this surveyor, the Administrator or the Director of Nursing. Review of the resident's physician orders dated 9/5/23 through 9/9/23, revealed no physician order to be transferred to the hospital. Staff transferred the resident without an order. Review of the hospital discharge records dated 9/16/23, stated Traumatic subdural hematoma (brain bleed) with midline shift. Cerebral edema (brain swelling) leading to brain compression. Encephalopathy (swelling of brain), multifactorial including probable anoxic brain injury (lack of oxygen to brain). admitted with comfort measures only status. Review of the signed Certificate of Death, dated 12/6/23, revealed Resident #101 manner of death was accident, it was from a fall, and it was from complications of subdural hematoma (brain bleed). Review of the hospital Death Summary dated 9/9/23, stated Admission Diagnosis: unwitnessed fall while on anticoagulation for Afib & DVT leading to acute intracranial subdural hemorrhage (bleeding) causing mass effect leading to 13 mm left to right midline shift, Atrial Fibrillation on Xarelto (was also on Aspirin low dose), history of DVT (clots). Unwitnessed fall while on anticoagulation for Afib & DVT leading to acute intracranial subdural hemorrhages causing mass effect leading to 13 mm left to right midline shift and right temporal hematoma causing vasogenic edema. During an interview done on 12/7/23 at 11:30 a.m., Nurse B, she stated, I should have documented what (Nurse A) said to me; she told the doctor (Physician G) was told she (Resident #101) was on a blood thinner). Nurse B said she was told at shift change on 9/6/23, the resident fell and Nurse A said she had told (Physician G) she was on a blood thinner. Review of the medical record revealed no documentation of telling physician G that the resident was on a blood thinner, nor a phone call to the physician the resident was on a blood thinner after she fell . During a phone interview done on 12/6/23 at approximately 1:25 p.m., Nurse A informed this surveyor that she was unable to recall if she had told physician G or Nurse B that the resident was on a blood thinner and aspirin. Nurse A stated I thought I told him (PhysicianG) she was on a blood thinner, but I am not sure. I should have documented better. Review of facility nursing documentation dated 6/5/23 through 6/6/23, revealed no documentation of the resident being on a blood thinner or of informing the Physician G she was on a blood thinner. During a phone interview done on 12/7/23 at 12:30 p.m., Physician D (Medical Director) stated You have to refer to (Physician G). Physician D said he was not informed of the incident when the resident fell , and she was Physician G's resident. During a phone interview done on 12/12/23 at 10:00 a.m., Physician E stated They (staff) didn't tell me of a head injury; your right your completely right I should have documented. She didn't fall on her head, so I didn't send her to be evaluated at the ED (Emergency Department). Review of a handwritten interview done by the Administrator dated 9/22/23, stated Nurse, LPN A said she called (Physician E), he did not answer, per VM (voice mail) was full unable to leave message so she text him (on 9/6/23). Review of the facility Physician cell phone documentation dated 9/6/23 at 5:10 a.m., stated Resident (Resident #101) had a fall this morning. Vitals WNL (within normal limits). Neuro's initiated resident left eye is swollen from fall. Right knee abrasion. Physician E was informed by text message on 9/6/23 at 5:10 a.m., that Resident #101 had fallen and received a head injury from the fall. No physician reply was given to this text message (on 9/6/23). Review of the facility Falls-Clinical Protocol (un-dated) stated, The physician will identify medical conditions affecting fall risk and the risk for significant complications of falls. Review of the facility Anticoagulation Protocol dated 2/23, stated The physician will prescribe anticoagulation therapy appropriately and consistently with guidelines. The physician will identify individuals whose anticoagulant can be discontinued or reduced, and will document a rational for continuing anticoagulation over time, including the medication and current dosage. Review of the facility Attending Physician Responsibilities/Physician Services policy (un-dated), stated The attending physician shall be the primary practitioners responsible for providing medical services and coordinating the healthcare of each resident in the facility. The physician will respond in an appropriate time frame to emergency and routine notification by staff. The Banger Brain Trauma Indicator (BTI) blood test identifies a protein which is released with trauma to the head (TBI) or concussion. Signs of TBI's include changes in mood, memory, dizziness, fatigue, headaches, light sensitivity, and confusion. This blood test would be done in the hospital. If a patient was on a blood thinner, advanced age and had repeated falls, the chance of an brain bleed will be increased. https://myclevelandclinic.org

This Citation pertains to Intake Number MI 925. Based on interview and record review, the facility failed to 1) ensure consistent nursing documentation of pressure ulcers and 2) ensure that pressure ulcer preventive measures were in place for 1 resident (Resident #11) of 3 residents reviewed for pressure ulcers, resulting in an infected coccyx pressure ulcer, hospitalization debridement (surgical removal of dead tissue), delayed wound healing, and intravenous antibiotic usage with an extended hospital stay. Findings include: Resident #11: Review of the face Sheet, Minimum Data Set (resident assessment tool dated 10/19), nursing, social service and physician note's dated 10/18/19 through 12/30/19 and hospital records dated 10/18/19 and 12/30/19, revealed Resident #11 was a [AGE] year-old male, admitted to the facility on [DATE] for wound care and rehab services, who required assistance from staff with Activities of Daily Living (ADL's), positioning and encouragement to participate in own care and therapy. The residents [DIAGNOSES REDACTED]. The resident was admitted to the facility with one open area on his coccyx, a chronic pressure ulcer which the hospital had treated with antibiotics prior to admission to the facility (on 10/18/19). Review of the facility Nutrition care plan, dated 12/21/19, revealed the resident was at high risk r/t (related to) presence of stage 3 pressure ulcer and increased nutritional needs for healing. Review of the facility Skin Management care plan, dated 10/21/19, revealed the resident had a sacral ulcer and open area to right buttock and is at risk for further skin impairment r/t (related to) to fragile skin, impaired mobility. Staff were to assist with turning/repositioning while in bed every 2 hours. Document position, document if the resident refuses repositioning, document if resident positions self on back after being repositioned. Review of the Hospital record, dated 10/13/19 (prior to admission to facility), revealed the resident had an Infectious Disease consultation for the management of a Stage III infected wound over coccyx with [MEDICAL CONDITION] over the back; the resident received antibiotic management for his infected coccyx pressure ulcer prior to being admitted to the facility. No documentation was found regarding any other open areas or additional pressure ulcers upon discharge from the hospital and facility admission on 10/18/19. Review of the facility Admission Skin & Wound Evaluation, dated 10/18/19, revealed no documentation of open wounds was made regarding the ankle or the rib/back area. The evaluation stated Right buttock, Sacrum, small open area, skin prep applied, ulcer, cleaned with wound cleaner, pat dry, silver alginate applied, covered with foam dressing. The only pressure ulcer/wound documented upon admission to the facility was on the sacrum/coccyx area. Review of the Hospital record, dated 12/30/19 (date of transfer to hospital from the facility), stated The patient is a 65 y male presenting to the ED (Emergency Department) from (the facility) via MMR (ambulance) for a wound check. The patient's (Family Member #1) informs that the patient's wound has been worsening over the last three weeks. She informs of an additional wound to the right lateral back, the blood work showed elevated white blood cells at 17 yesterday (from the facility on 12/29/19, normal white blood cells (WBC)=3.4-11.0, indicates infection). Pt (patient) turned and wounds evaluated with (hospital physician). Stage III wound to coccyx noted with foam dressing covering site. Additional stage II wound noted to right lateral back also covered with foam dressing. Review of hospital labs, dated 12/30/19, revealed the resident's WBC lab was 13.10 (high, indicating an infection). Review of the hospital record, dated 12/30/19, stated he (the resident) was given 2,000 mg [MEDICATION NAME] IVPB (antibiotic per IV) and [MEDICATION NAME] (antibiotic), admit the patient for [MEDICAL CONDITION] and a decubitus. Diagnosis: [REDACTED]. Review of the hospital ED Physical Exam, dated 12/30/19, stated The patient has a large sacral ulcer. He has an additional ulcer to the right lateral back (rib area). The hospital Wound Care Exam, dated 12/31/19, stated Examination of the [MEDICATION NAME] area shows an ulceration of the right side of the [MEDICATION NAME] area posteriorly in the [MEDICATION NAME] area (right side back/rib area). This is an eschar (thick black layer of dead tissue over wound) with probable full-thickness ulceration. I would rate it as unstageable at this time. Over the coccyx there is a circular ulceration with necrosis (dead tissue) of the right side of the skin edge from 12:00 to approximately 5:00 position. I am able to palpate small pieces of coccygeal and sacral bone. The hospital Wound Nurse assessed two open ulcers with necrotic tissue on both. Review of the hospital Discharge documentation, dated 1/7/20 (after an 8 day stay at the hospital), stated Excisional debridement (surgical removal of dead tissue from coccyx wound) was performed at bed side on 1/1/20, Ulcer on right rib. Review of the facility Treatment Record (TAR), dated 12/19, revealed documentation of the resident's wound on 12/3/19, no documentation of the same wound on 12/7/19, documentation of the wound again on 12/14/19 and 12/17/19, then no documentation of the same wound on 12/21/19 and 12/24/19 and documentation again of the same wound on 12/28/19. During 12/19, there was inconsistent nursing documentation of wound treatment. It was documented as there and then it was not; again, it was there and then it was not. Review of the resident's facility Skin & Wound Evaluations, dated 12/12/19 through 12/23/19, revealed the ankle wound was identified on 12/12/19, as an in-house acquired pressure ulcer, and the back, rib area wound was identified on 12/23/19, as an in-house acquired pressure ulcer. At the facility the resident acquired a right back/rib area pressure ulcer, right ankle pressure ulcer and worsening/infected coccyx pressure ulcer. Review of the progress note's (resident assessment data), dated 1/27/19, stated Skin: Skin color is WNL (within normal limit). Mucous membranes are moist. Skin warm/dry to touch. Normal skin turgor. No documentation was found regarding the resident's pressure ulcers on his back/rib area, right ankle or coccyx area. Review of the facility Skin Assessment, dated 10/18/19, stated Stage 3 to RT (right) mid back (the right mid back, right rib area). Review of the facility Skin Assessments, dated 10/19/19 through 11/5/19 (that is all that was made available to this surveyor), revealed the only documentation of an opened area (the pressure ulcer on the residents back/rib area) was documented on 10/18/19. An interview and record review with the Administrator, Director of Nursing (DON) and Nurse Manager C, on 1/22/20 at 2:00 p.m., revealed inconsistent nursing documentation found upon review of the Electronic Medical Record (EMR). Nursing staff did not consistently document resident non-compliance with positioning nor education given regarding the need for skin preventive measures including frequent turning. No facility care plan was found regarding the resident being non-compliant with pressure ulcer preventive measures (including turning). During an interview on 1/22/20 at 2:50 p.m., the DON stated I think their (facility nursing staff) documentation is absolutely terrible. We have in serviced on it, they do it and then it goes by the wayside. Review of the nursing meeting notes, dated 1/20/20, revealed During your skin assessment you must take off the dressing and in your charting, you need to describe what the wound looks like. Make sure all skin assessments are getting done, even if a resident still continues to refuses skin assessment there needs to be a nurses note added describing why you did not do the assessment and what the resident stated. Make sure you are looking at every residents' heels and coccyx and bony prominence's and documenting what they look like. Monitoring wounds when doing a dressing change, if you notice it is getting worse or better advise wound nurse so treatment can be changed accordingly. Review of the facility Pressure Ulcers/Skin Breakdown policy, dated 2014, revealed The nursing staff and Wound Nurse will assess and document an individual's significant risk factors for developing pressure sores. The staff/Wound Nurse will examine the skin of a new admission for ulcerations or alterations in skin. The Nurse/Wound Nurse will help the staff review and modify the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions.

Based on observation, interview and record review, the facility failed to implement interventions, assess and monitor a facility-acquired pressure ulcer to the heel, and failed to assess, monitor and implement treatments per physician's order for multiple wounds to the legs for one Resident (Resident #1) of two residents reviewed for skin integrity, resulting in Resident #1 developing an unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of tissue damage with the pressure ulcer cannot be confirmed due to eschar (dry dark/dead skin)) to the left heel, wounds to the right leg to be left untreated, pain and the potential for infection, delayed wound healing and overall deterioration in health status. Findings include: A review of Resident #1's medical record revealed an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set assessment, dated 3/20/19, revealed the Resident had moderately impaired cognition and needed extensive assistance of two (plus) person physical assist with bed mobility, transfers, dressing, toilet use and personal hygiene. The MDS indicated the Resident was at risk for developing pressure ulcers/injuries and had no unhealed pressure ulcers/injuries. A review of Resident #1's medical record of progress notes revealed: -Date 5/16/19 at 11:57, (Hospice Agency) routine skilled nursing visit . Intact blister left calf. Ruptured blisters x(times)2 right inner lower leg, x 1 front left lower leg, x2 small inner left lower leg . Left heel new unstageable wound (started out as a blister). Now with dark edges and white/yellow center. Skin prep applied and heel floated on pillow . Pain relieved with wound care completion ., author Hospice Nurse E. -Date 5/28/19 at 12:24 PM, (Hospice Agency) routine skilled nursing visit . Patient did begin to get agitated with skin assessment and care. Does not like to have legs moved around at all. Right leg has 2 nickel sized blisters on inner leg. 1 large blister approximately 2x(by)4 cm (centimeters). Ruptured blister 4.5 x 3.5 cm above large closed blister. Back of left lower leg ruptured blister. Front of left lower leg with scab where previous blister present. Redness to bilateral lower legs surrounding blisters. Left heel 4 x 3.5 cm unstageable wound. Maceration around edges. Removed sock and shoe, elevated leg on pillow. Left hand with skin tear covered with [MEDICATION NAME]. Coordinated care with facility nurse (name). Reported left heel ulcer maceration around edges. Recommend elevation on pillow and leaving sock and shoe off. Recommend facility wound care nurse to see patient and place new orders for left heel wound ., author Hospice Nurse E. -Date 6/4/19 at 9:57 AM, (Hospice Agency) routine skilled nursing visit completed . Reports mild pain in bilateral legs, reported to facility nurse . Reported pain, requested medication. Reported worsening lower leg blisters. Right leg 5 x(by)4 cm (centimeters) ruptured blister, 3/4 covered with yellow skin, 1/4 open, pink, 2 scabs inner right leg, 2.5 x 8 cm inner leg blister, irregular, partially open, Dime size closed blister front right ankle. Left leg scab on shin, 1 x 1.25 cm outer lower leg closed blister, 4 x 5 cm inner/back of leg, irregular shape, pink with yellow slough, 3.5 x 2.5 cm left heel unstageable pressure ulcer, author Hospice Nurse E. A review of Resident #1's Medication Administration Record (MAR) for (MONTH) 2019, revealed: -an order for [REDACTED]. Give 2 tablet by mouth every 6 hours as needed for pain/fever. -an order for [REDACTED]. Give 0.25 ml by mouth every 4 hours as needed for pain/sob (shortness of breath). -There was no [MEDICATION NAME] or [MEDICATION NAME] documented as given from (MONTH) 1, 2019 to (MONTH) 13, 2019. A review of Resident #1's Treatment Administration Record (TAR) for (MONTH) 2019, revealed: -An order to Cleanse RLE (right lower extremity), (ankle area) with wound cleanser, pat dry, apply moistened [MEDICATION NAME] AG (a dressing with silver to treat wounds) mesh to scabs/open area, secure with kerlix, change daily and PRN (as needed), off at hs (night), scheduled to be completed at 0600 (6:00 AM) and included instructions that stated, Document on wound appearance q (every) shift, with a start date on 5/21/19. -The above dressing was documented as completed on 6/2/19. The dressing was documented as refused on 6/5 and 6/11/19, documented as other, see nurses note on 6/3 and 6/4/19. There was no documentation that the dressing had been completed or refused on 6/1, 6/6, 6/7, 6/8, 6/9, 6/10, 6/12, and 6/13. -an order for [REDACTED]. -The skin prep to bilateral heels twice a day was not documented, in the month of June, as completed at 5:00 AM on 6/1, 6/6, 6/8, 6/9, 6/10, 6/12, and 6/13 and not documented as completed or refused at 8:00 PM on 6/5, 6/8, 6/11, and 6/12. A review of Resident #1's care plan revealed the following: -Focus, (Resident #1) is at risk for alteration in skin integrity r/t (related to) Bullos Pemphigoid, incontinence and decreased mobility, date initiated on 3/15/17 and a revision on 5/15/19. -Goal, Minimize risk of skin failure through next review, date initiated on 8/15/18 and revision on 8/15/18. -Interventions revealed the following: -Apply barrier cream with peri-care for incontinence -Assist (Resident) to change position frequently, utilizing pillows and support cushions for comfort, safety, and to alter position pressure points -Keep nails short and clean to reduce risk of scratching or picking at skin -Keep skin lubricated; apply lotion w(with)/AM and HS (night) Care -[MEDICATION NAME] ordered daily, reduce inflammation -Pressure relieving cushion when in chair -Pressure relieving mattress on bed -Treatment as order to bilateral lower extremity -Weekly skin assessment to be completed and documented. Record any open areas, size, appearance, drainage, & intervention. Ensure that Nurse Manager/Wound Nurse/MD (doctor) are aware. A review of Resident #1's medical record of Skin Assessments for 6/2019 revealed documented skin assessments on 6/10, 6/6, and 6/3. Copies of the Skin Assessments were requested but were not provided prior to the exit of the survey. A review of Resident #1's medical record of the progress notes regarding wound care and assessment of the Resident's legs, by facility nursing staff included: -6/5/19 at 6:38 AM, author Nurse G, revealed, Cleanse RLE, (ankle area) with wound cleanser, pat dry, apply moistened [MEDICATION NAME] AG mesh to scabs/open area, secure with kerlix, change daily and PRN, off at hs in the morning related to [DIAGNOSES REDACTED] Document on wound appearance q shift resident refused, legs open to air elevated on pillow. -6/4/19 at 6:39 AM, author Nurse I, revealed, Cleanse RLE, (ankle area) with wound cleanser, pat dry, apply moistened [MEDICATION NAME] AG mesh to scabs/open area, secure with kerlix, change daily and PRN, off at hs in the morning related to [DIAGNOSES REDACTED] Document on wound appearance q shift resident did not want BLE wrapped at this time. -6/3/19 at 6:53 AM, author Nurse G, revealed, Cleanse RLE, (ankle area) with wound cleanser, pat dry, apply moistened [MEDICATION NAME] AG mesh to scabs/open area, secure with kerlix, change daily and PRN, off at hs in the morning related to [DIAGNOSES REDACTED] Document on wound appearance q shift resident resting in room with legs elevated, open to air. -5/31/19 at 2:30 PM, author Nurse I, revealed, Cleanse RLE, (ankle area) with wound cleanser, pat dry, apply moistened [MEDICATION NAME] AG mesh to scabs/open area, secure with kerlix, change daily and PRN, off at hs in the morning related to [DIAGNOSES REDACTED] Document on wound appearance q shift resident did not allow this nurse to wrap legs, she yelled out stating Don't, stop, this nurse attempted mult. (multiple) times with resident continuing to yell out On 6/13/19 at 9:30 AM, an observation was made of Resident #1 sitting in a wheelchair in the Resident's room. The Resident had on a robe and had her legs elevated up and straight out with a pillow under her legs. The Resident's lower legs were exposed without a dressing on. The right ankle area had a reddened area that was moist looking and had some scabs and a water filled blister to the top of the shin area. The left leg had a wound just above the ankle area that was scabbed over and dried. The right foot/ankle area had the foot pedal of the wheelchair indenting the skin on the outer aspect of the area between the ankle and heel area. The Resident had slipper/shoes on both feet. Multiple blisters and scabbed areas were on the Resident's bilateral legs. The Resident had a rolled towel between her lower legs. The CNA (Certified Nursing Assistant) A was contacted and repositioned the Resident's legs to prevent the indentation of the foot pedal on the Resident's ankle area. When the rolled towel was removed, there was a small amount of bloody drainage and yellow serous drainage from the left leg that had an open area on the inside of the left leg above the ankle area. There was a small amount of yellow serous drainage from the right leg. The CNA replaced a towel between the lower legs. When queried regarding dressings to the Resident's legs, the CNA indicated the Resident did not have dressings on unless the Resident was out of the room. The Resident was uncomfortable with the repositioning of her legs and did not want her legs to be examined with the nurse when queried. The CNA was queried regarding dressings on the Resident's leg and indicated the legs have been without a dressing while she is in her room and stated, She needs a dressing if she comes out of her room but she has been in her room. I'm not sure why she doesn't come out. She can't come out without her legs wrapped. On 6/13/19 at 11:48 AM, an interview with Confidential Person C was conducted on the phone regarding Resident #1's bilateral leg wounds. The Confidential Person indicated they had visited the Resident and stated, Sometimes (the Resident) had bandages and sometimes not. The Confidential Person indicated the dressing was to be changed daily and stated, A fresh bandage in the morning and off at night to leave it open to air. On (MONTH) 25th she (the Resident) had the same dressing on for a couple days. They had not changed it for three days, the dressing said (MONTH) 22nd and it was the 25th. The Nurse (Nurse D) told her supervisor about it. It (the dressing) was stuck to her legs and she had to soak it to get it off. When queried regarding the wound to the left heel, the Confidential Person stated, The heel wound was large, huge, and indicated the day was (MONTH) 25, 2019. When queried if the wound to the left heel was a blister or open, the Confidential Person was unsure. On 6/13/19 at 11:57 AM, an interview was conducted with Nurse D regarding Resident #1's wounds to the legs. When queried regarding the dressing for the right leg, the Nurse indicated the dressing was to be done at 6:00 AM and that the Resident refuses. When queried why the Resident refuses, the Nurse stated, I don't know. They go in and she doesn't want to be touched. I have tried, sometimes she lets us and sometimes she doesn't. I don't think she has any open areas at this time. When queried why the Resident does not have a dressing on at this time, the Nurse stated, I don't want to fight with her because they are all closed. On 6/13/19 at 12:02 PM, an observation was made with Nurse D of Resident #1 in a wheelchair in the dining area. The Resident had their legs elevated on a pillow with the foot rest elevated. Light drainage was observed on the pillowcase underneath the Residents legs. No dressing was on the right leg. When queried regarding the wounds and drainage, the Nurse stated, I have not gotten to it (assessment of the wounds) yet. The Nurse reviewed the Resident's TAR and when queried when the last dressing had been completed in the month of May, the Nurse indicated the last dressing was on the 2nd. When queried if any PRN dressing had been completed, the Nurse stated, No. When queried regarding the facility policy on documenting refusals, the Nurse indicated that the treatment record is marked with a 2 (refused) or 9 (see nurses note) and put a note in the progress notes and stated, We are suppose to attempt 3 times when they refuse. When queried regarding documenting the attempts, the Nurse stated, Yes, we should document them. I haven't. When queried regarding the assessments every shift, the Nurse stated, I assess and measured the wounds with the Hospice Nurse, but indicated assessment of the wounds were not documented every shift. When queried regarding the dressing on Resident #1's leg on 5/25/19, the Nurse stated, (Visitor) was in there, and they were concerned. The dressing was dated on the 22nd and it was the 25th. They could see the date on the dressing and they asked me about it. I cleansed the legs and did the skin treatment . When I opened up the dressing, it was stuck to her legs and then the heel was moist, mushy and draining. Before that the heel was dry, it had a flat blistered area that we were treating with skin prep. It smelled, it didn't (smell) after I cleaned it or I would have gotten a culture. The Nurse indicated she had discussed the issue with the Wound Care Nurse (I) and the Assistant Director of Nursing F. On 6/13/19 at 12:30 PM, an interview with Hospice Nurse [NAME] was conducted regarding Resident #1's wounds to the lower bilateral legs. When queried regarding the wound to the left heel, the Hospice Nurse indicated the area to the left heel was a pressure ulcer that started as a blister. The Hospice Nurse stated, There was a wound care nurse that was making recommendations. They should be doing daily wound care for (the Resident). They should be doing measurements. The Hospice Nurse stated, There is miss communication with the CNA's and Nurses. The slipper shouldn't be on the left foot. There is brown eschar (dead tissue) to that area. The slipper was on today. I took it off today and left her legs elevated on a pillow. When queried regarding staff not leaving the slipper off, the Hospice Nurse indicated she did not know why it was on and stated, I didn't think that should be an order to leave her slippers off. It should not ever have a slipper on that left foot. That hard middle is surrounded by macerated edges. When queried regarding Resident #1 having pain, the Hospice Nurse stated, She didn't complain of pain today, but she was having pain last week in her legs. The Hospice Nurse was queried regarding the Resident's pain and stated, She gets upset with dressing changes. When I do measurements and pull the dressing off, she is very uncomfortable during that. When queried if the Resident received pain medication, the Hospice Nurse was unsure but indicated the Resident had pain medication ordered. When queried regarding any open wounds, the Hospice Nurse stated, There is a ruptured blister on the right inner ankle that is open, pink and brown with scab on the edge. She has multiple closed blisters and scabs on that leg. The Hospice Nurse indicated the left lower leg had an long open pink area on the back of the ankle, moist with serous drainage and stated, It started as a couple blisters and then opened and connected. When queried regarding the Resident's left heel, the Hospice Nurse stated, It's a pressure ulcer that started as a blister. On 6/13/19 at 3:30 PM, an interview was conducted with Assistant Director of Nursing (ADON) F regarding Resident #1's wound to the left heel. When queried regarding the dressing on 5/25/19 the ADON stated, The dressing hadn't been changed. It was dated for the 22nd. It was still a daily (dressing change). It was a 6 AM dressing change. The nurse (Nurse D0 had to soak it to get the dressing off. When queried why the TAR was documented that the dressing had been changed on the 23rd the ADON indicated the nurse (Nurse H) didn't know how to chart the Resident refused and stated, They need to put a progress note of why they (the Resident) refused it. The ADON indicated that for refusals they need to re-approach and after three days of refusals we need to figure something else. When queried if the wound on the left heel was a pressure wound, the ADON stated, Yes, unstageable. When queried regarding a care plan for the facility acquired pressure ulcer to the Resident's left heel, the ADON reviewed the care plan and stated, This is the only skin care plan (Alteration in Skin Integrity). There should be an actual wound care plan. When queried what a wound care plan would include, the ADON listed, Treatments, interventions, hospice coordination of care, refusals and interventions, interventions for what we are doing to prevent skin breakdown, supplements, turn and reposition. She doesn't have the right care plan, an actual skin impairment one. When queried why the care plan was not in place, the ADON indicated she was unsure and that the Wound Care Nurse would do the care plan and stated, Our Wound Care Nurse typically follows wounds, if they come in with or acquire here and any surgical wounds. When queried regarding the Resident having pain and if there were any refusals for pain medication, the ADON, after a review of the medical record indicated pain medication was not given. When queried regarding interventions to premedicate prior to dressing changes, the ADON stated, That would be addressed on the wound care plan. When queried regarding facility policy for documenting refusals the ADON stated, (Documenting) the refusals, why and what they did as an intervention. A review of the order for documenting on the wound appearance every shift on the treatment order for the dressing change to the right leg, was conducted with the ADON. A review of the skin assessments completed on 6/10/19, 6/6/19 and 6/3/19 that did not indicate a complete assessment of the wounds, the ADON was queried if that was an assessment of the wounds and stated, No. When queried what would be in an assessment of the wounds, the ADON stated, What it looks like, any drainage, measurements weekly. When queried if assessments were completed every shift as the order indicated, the ADON indicated the assessments should be done every shift. When queried regarding drainage from the lower leg wounds, the ADON indicated that if there was drainage, a treatment should be in place. If scabbed over and dried then keep them open to air. When queried regarding the Resident being out of the room the ADON stated, If a draining wound, they should be covered in or out of the room. If she is refusing to have a dressing put on, re-approach or be creative with interventions. An observation was made with the ADON of Resident #1 lying in bed. The Residents legs were covered with the blanket and upon uncovering, the pillowcase had serous and light pink drainage from the lower legs. The ADON stated, I will have them take care of that. On 6/13/19 at 4:32 PM, an interview was conducted with the Director of Nursing (DON) regarding Resident #1's wound to the left heel with a review of the Resident's care plan. When queried if the Resident had a pressure wound, the DON stated, Yes, to the left heel, but was uncertain of when the wound originated. When queried regarding dressing changes the DON stated, We don't want any infection if they are weeping (draining). If they are weepy then they have to be wrapped. If in the room, open to air, if out of the room and weeping they need a dressing. When queried regarding the Resident refusing, the DON stated, She has refused because of pain. The DON indicated the Nurse could give her pain medication before the dressing change and for refusals to document on the MAR and type in a note in the progress notes. The DON indicated the staff are to re-approach and offer Tylenol or a narcotic and to document the refusals and any interventions. When queried if it was documented, the DON stated, If they didn't put it on the progress note or on there (MAR), I don't know what they did with them. When queried regarding a care plan for the facility acquired pressure ulcer to the Resident's left heel, the DON stated, We should have one for risk of skin alteration and one for skin breakdown. It's a standard of care. The DON explained that the facility has a wound care plan that the Wound Care Nurse would put into the Residents chart. When queried why a wound care plan was not initiated for the pressure ulcer to the heel, the DON stated, I haven't gone back to check to see if it was done. When queried regarding care planned interventions for refusals of dressing changes, the DON stated, If she is resistive to care, it would be listed in her ADL (Activities of Daily Living) care plan and it is not. On 6/13/19 at 5:10 PM a phone call was made to Nurse G regarding Resident #1's wound assessments, dressing changes, Resident refusals for wound care and the lack of intervention of pain medication prior to dressing changes. There was no answer and a message was unable to be left. No return phone call was received prior to the exit of the survey. On 6/13/19 at 5:13 PM, a phone call was made to Nurse H regarding Resident #1's wound assessments, dressing changes, Resident refusals for wound care, a dressing documented as completed that had not been changed and the lack of pain medication administered prior to dressing changes. There was no answer and a message was left. No return phone call was received prior to the exit of the survey. On 6/13/19 at 5:18 PM, an interview was conducted with Wound Care Nurse (WCN) I regarding Resident #1's pressure wound to the left heel. When queried regarding when the wound originated, the WCN stated, I am not certain off hand. It was a blister, they (blisters) come and go. It must have popped and turned into what it is now. Last time I seen it, it was a blister. When queried when they had last seen the Resident, the WCN stated, Last week or a week prior. When queried what the left heel wound was now, the WCN stated, Yellow and black tissue and a little granulation tissue. A picture of Resident #1's left heel wound, that had been put into the electronic medical record, was reviewed and the wound appeared to have blackened tissue on the Resident's heel. When queried if any pictures were taken prior to the one today, the WCN indicated she had not assessed the wound prior to today and stated, It was just a blister, last week or a week before. I don't know why no one let me know. The WCN indicated they had taken the picture today and in the process of measurements and that measurements had not been done by the WCN prior to today. When queried regarding a care plan, the WCN stated, I was going to do her wound care plan today after her assessment. When queried if other nurses can put in wound care plans, the WCN stated, Yes and notify me. A review of the facility policy entitled, Pain-Clinical Protocol, dated 9/2018, revealed, Assessment and Recognition. 2. The licensed nurse will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain . 4. The licensed nurse staff will identify any situations or interventions where an increase in the resident's pain may be anticipated; for example, wound care, ambulation, or repositioning . A review of the facility policy entitled, Charting and Documentation, dated 3/2018, revealed, . Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate . 7. Documentation of procedures and treatments will include care-specific details, including: a. The date and time the procedure/treatment was provided . c. The assessment data and/or any unusual findings obtained during the procedure/treatment; d. How the resident tolerated the procedure/treatment; e. Whether the resident refused the procedure/treatment . A review of the facility policy entitled, Wound Management Program, dated 3/2018, revealed, Purpose: To eliminate, modify or minimize factors that place residents at risk for skin breakdown. Policy: To assure that residents who are admitted with, or acquire, wounds receive treatment and services to promote healing, prevent complications and prevent new skin conditions from developing. Process (Prevention): Unless otherwise specified, the Charge Nurse is responsible for the following: . 5. Complete skin observation tool according to schedule. Report any abnormal findings to the physician and Certified Dietary manager or registered dietician. Initiate treatment according to physician guidance . 7. Monitor any acute illness or change in condition. Update Care Plan to reflect new risks and interventions. Process: management of pressure ulcers/non pressure wounds. The following process is completed by the designated nurse, unless otherwise specified. 1. If pressure ulcer identified: Develop an individualized plan of care/Kardex . 3. Complete the following daily (Charge Nurse). Verify that resident specific Care Plan interventions are in place (pressure relieving devices, turning/positioning). Inspect dressing to assure it is intact. Inspect skin surrounding ulcer. Inspect any pressure ulcer that does not require a dressing .

Based on observation, interview and record review the facility failed to supervise residents to prevent an accident and a fall for 2 of 6 residents (R#50 and R#54) reviewed for falls and accidents, resulting in a burn for Resident 50 and a head injury for Resident 54. Findings include: Resident 50's Nutrition Care Plan dated 3/7/16 reflected she was an 83 (at the time this was written) old female, who had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Cognitive Loss/Dementia care plan dated 3/11/16 Resident 50 had short and long term memory deficits with impaired decision making ability and poor safety awareness related to [DIAGNOSES REDACTED]. The Vascular care plan indicated to protect Resident 50 from injury/trauma, however it did not say how that should be done. The nurse aide's care guide called Kardex dated 6/13/16 reflected when eating supervision was needed. Resident 50's Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected Resident 50 was totally dependent to eat, and had a Brief Interview for Mental Status score of 2 out of a possible 15 reflecting severe cognitive impairment. Resident 50's Quarterly MDS dated [DATE] reflected she needed limited assistance while eating. On 11/16/16 at about 2:20 PM in Administrator's A's office we watched the video of Resident 50 going into the dining room, sitting at table, baby doll placed on table, Nurse Aide H placed hot soup in front of Resident 50, Resident 50's blanket was also on the table then the video skipped a section (Administrator A called it stuttering due to motion) and Resident 50 was seen propelling herself down the hall one way, then came back into the dining room and picked her blanket off of the floor, then left the dining room again and propelled herself down the hall the other way to a nurse at the medication cart. When Administrator A was asked to replay that part again so Resident 50 could be seen when the soup spilled on her lap. Administrator A replayed the video tape again and the tape skipped in the same exact spot. On 11/16/16 at between 2:20 PM and 2:40 PM, during a interview with Administrator A it was explained that the most recent quarterly MDS dated [DATE] reflected Resident 50 was totally dependent to eat, Administrator A reviewed the MDS dated [DATE] and called MDS Nurse C. MDS Nurse C also reviewed the Quarterly MDS dated [DATE] and stated that code was an error and that she would submit a correction to MDS. In a separate incident where Resident 50 was not being supervised, nurses notes dated 10/3/16 at 1900 (7 PM) Reported that resident was observed with cleaning bottle up to lips an cleaning solution spilled on clothes at approximately 1:00 PM . Nurses notes on 10/3/16 and 10/4/16 reflected Resident 50 was monitored for signs of ingestion. Nurses notes dated 10/15/16 at 5:45 PM reflected Resident 50 was in dining room for supper Resident spilled soup on her lap. According to Administrator A's timeline Resident 50 entered dining room on 10/15/16 at 5:25:02 PM and soup appeared to be spilled at 5:25:27 PM. At 5:33:45 Resident 50 continues down hall from nurses' station and at that time Resident 50 refused to have her legs inspected. At 6:30 PM Nurse inspected Resident 50's legs as much as Resident 50 would allow and noted some pinkness on the resident's legs. That on 10/16/16 the 6 AM night shift nurse reported to oncoming Registered Nurse F that bilateral blisters were found on resident's thighs. Nurses' notes dated 10/15/16 at 9:00 PM reflected Resident (50) has blisters on b/l (bilateral) inner thighs from soup spilled on lap @ dinner. TAO applied & ABD pad placed in between. Resident (50) states 'it hurts' TAO effective resident slept all night. Nurses' notes dated 10/16/16 8:00 AM reflected assessed bil inner thighs 1 X 3 blister on R (right) thigh has 1 X 4 inch approx. blister . According to the Incident Report dated 10/15/16, Resident 50 had blisters on both inner thighs. The recommended steps to prevent recurrence was to change placement of resident in dining room to a feeder table for more supervision. Change diet to finger food instead of soup. Director of Nursing Bsigned the incident report on 10/18/16 and added Staff educated, resident move to a restorative table. This same incident report dated 10/15/16 reflected there were several nurse aides in the dining room and yet this was an unobserved occurrence. What was seen on the video tape of that event was nurse aides passing food to residents already seated in the dining room, there were no staffed who witnessed the burn and resident interviews regarding what happened had not been provided. The facility failed to follow their policies on Hot Liquids and Foods revised 4/2015 (this part was partially cut off, but date was confirmed by Administrator A on 11/15/16 between 11:00 AM and 1:00 PM). This policy reflected The facility will provide supervision to residents who receive hot food and beverages in an attempt to prevent hot liquid/food spills which may result in burns. Supervise the area . The Serving Meals policy dated 6/2007 reflected Residents requiring assist will be served last. As these residents receive their tray the CNA (certified nurse aide) will stop serving and assist them as needed. Director of Nursing B gave an inservice 10/2016 to all nursing staff on neglect for failure to supervise residents during meals. On 11/15/16 at between 2:30 PM and 4:30 PM, Resident 50 was observed attempting to exit the facility through a locked door on the Home for the Aged side of the building far from view and supervision of the nursing home side. ( ) According Resident 54's face sheet undated, Resident 54 was an [AGE] year old female readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 54's Quarterly Minimum Data Set ((MDS) dated [DATE] reflected she had severe cognitive impairment and was totally dependent for all Activities of Daily Living. Resident 54's care conference summary notes dated 8/2/16 reflected she had advanced dementia, was severely impaired, had impaired vision, verbalized simple statements, totally incontinent, cooperative and used a mechanical lift. The accident/incident report dated 8/2/16 reflected observed resident (54) on floor with head on Hoyer leg. Bleeding noted vs (vital signs) taken, Dr. notified, family contacted. Sent to (Name of Hospital) ER (emergency room ) for eval and treat. The interdisciplinary post-fall assessment dated [DATE] reflected Resident 54 was observed with head on Hoyer lift leg. Res. (Resident 54) was up in Hoyer sling, started leaning and slid out of sling. While transferring res., staff did not have second person for transfer. Nurse Aide I's typewritten statement reflected Resident 54 was up in sling, as resident (54) was in air, transferring from chair to bed, resident begin (sic) to slid (sic) out of sling, and fell . CNA (Nurse Aide I) did state she left the room for no more than 2 minutes to toilet another resident, when she came back out from toileting other resident, (Nurse Aide G) was waving her down and asking her to come in and help her. On 11/17/16 at 10:10 AM, during an interview with Nurse Aide G, she stated she was the nurse aide that was assigned to Resident 54 that day. Nurse Aide G explained that Resident 54 was sitting in a sling in her wheelchair and she was not aware that the sling was not in place properly beneath Resident 54 before hooking her to the mechanical lift. Nurse Aide G explained the Nurse Aide from the previous shift did not place the sling underneath her properly. According to the accident/incident report dated 8/2/16 the time of the incident took place at 1:45 PM, and Nurse Aide G stated she was a day shift nurse aide. As Resident 54 was being lifted, she began to lean, she tried to stop her from leaning but could not and Resident 54 fell hitting her head on the mechanical lift. Nurse Aide I had left the room to attend to another resident while Resident 54 was in mid air of a mechanical lift transfer. Nurse Aide G said Nurse Aide I did not have an emergency, she simply wanted to complete her tasks. Nurses' notes dated 8/2/16 reflected Resident 54 Returned from (Name of Hospital) ER via (medical transportation) . observed 4 staples R (right) side upper head, applied ice pack . Nurses notes dated 8/9/16 reflected to remove Resident 54's staples to head on 8/12/16. There was a doctor's order dated 8/9/16 to Remove staples to res. head on 8/12/16 with a [DIAGNOSES REDACTED]. According to the fall care plan dated 5/6/16 Resident 54 was to be transferred with a mechanical lift and a 2 person assist. ( )

This citation pertains to MI 015 and MI 917. Based on observation, interview, and record review, the facility failed to successfully operationalize a wireless call system resulting in the inability for all 50 residents residing in the facility to receive timely responses, if any, when they directly communicated their needs for nursing assistance, to include any emergent needs such as chest pain, choking, respiratory distress, or falls or communicate their needs for nursing assistance requiring pain control. The Immediate Jeopardy was identified at F-463 on 5/18/16 at 11:30 am. Immediate Jeopardy began on 5/18/16 at 11:30 am, when it was identified that only one staff member out of all facility staff assigned to the 55-bed skilled nursing facility had a pager on their person for the wireless call system to receive calls placed by the residents who were in need of nursing assistance. A staff person who does not wear the pager needed to receive notification of a resident's needs, is not aware of that need. The wireless call system pagers are the only way for all residents in the facility to communicate their need for assistance, as there are no lights that illuminate outside of the resident's room to also alert staff of resident's needs. The pagers are the only way to alert staff of resident's needs or requiring assistance. It was identified that the facility's Administrator had been aware that the staff was not utilizing the pagers 6 to 8 weeks ago. It was further identified that the facility did not have a policy and procedure in place, a manufacturer's user guide or a manual for the utilization of the wireless call light system, which per the Administrator, was installed 1 to 2 years prior. There was also no policy and procedure to identify which staff members were to have the nurse call system pager on while on duty. The Resident Council meeting minutes of November 2015, December 2015, and April 2016, and the confidential group meeting, held on May 16, 2016 at 2:00 PM, all identified concerns regarding the delay of call light response times. A formal written complaint regarding delay in call light response times was received to the State Agency prior to the initiation of the Annual Survey on 5/16/16. During the course of the Annual Survey, concerns regarding call light response times were received from individual residents and family members. The Immediate Jeopardy was due to the facility's failure to operationalize the wireless nurse call system. This deficient practice has the potential to cause a non-response or a delay in responses to residents, who are in need of assistance, or asking for assistance. This non-response or delay has the potential to result in delay of treatment for [REDACTED]. The Nursing Home Administrator was notified of the Immediate Jeopardy situation on 5/18/16 at 4:00 PM. Findings include: During Environmental rounds of the facility, on 5/18/16 at 9:00 AM, accompanied by Maintenance, AE it was observed that staff were not responding to call lights when turned on, during call light functioning checks, in a timely manner, or at all. Staff AE was demonstrating in the facility's shower room that all three emergency call lights were functioning during rounds. Staff AE activated 3 of the call lights in the shower room at 10:00 am, and said to this Surveyor, I will close the door and see who comes first to check the call lights. At 10:06 am, Staff Member, Nursing Assistant, Staff M , who was identified by Staff AE, entered the shower room, looked around and then started to exit. This Surveyor asked staff M if she was there to answer the 3 call lights that had been activated, and Staff M said, No, I am looking for the Hoyer lift (mechanical lift used to transfer residents). Staff M then exited the shower room without responding to the call lights that were activated. This Surveyor and Staff AE continued to wait for staff to respond to the call lights activated. At 10:15 am, This Surveyor and Staff AE approached the nurse station and observed 5 pagers laying on the desk at the nurse station vibrating. There was no audible sound other than a buzzing going off with the 5 pagers lying on the desk. Staff were observed to be walking past the nurse station, and occasionally stopping to check the monitor board, located at the nurse station, which tells what room had pushed the call system, the time it was activated, and how long it had been activated, then walking by without responding to the activated call lights. Nursing Assistant, Staff E approached the nursing station at 10:16 am, looked at the monitor board. This Surveyor asked Staff E if she had her pager on her person. Staff E said, No, Staff E was asked why not, and replied to this Surveyor I don't know, it is either lost or gone. The Director of Nursing, Staff B, was present at the nurse station at the time Staff E was asked if she had her pager on and heard the response from Staff E. Staff B was asked at that time, how many nursing assistants were assigned that day to care for 50 residents. Staff B said there were 6 nursing assistants, and 2 nurses, and picked up 5 pagers that were on the desk and showed the nursing assistant the pagers. This Surveyor then asked Nursing Assistant, Staff I who was walking past the Nurse Station at 10:20 am, if she had her pager on her person. Staff I said, No. Staff I was asked how she responds to call lights activated if she is not carrying the pager. Staff I said, I just come and look at the board. Staff I was asked what happens if she is in another resident room providing care when the call system is activated. Staff I said, They have to wait until I am done, and I just look at the board. At 10:22 am, Nursing Assistant, Staff H was approached and asked if she had her pager on her. Staff H said No. Staff H was asked how she responded to call lights activated by residents. She replied, I just look at the board at the nurse station. At 10:25 am, Nursing Assistant, Staff R was asked if she had her pager on her person. Staff R said, No. At 10:27 am, Nursing Assistant, Staff F was asked if she had her pager on her. She said, No, I took it off to use the bathroom , and was observed to pick up a pager lying on the nurse station desk. At 10:30 am, Licensed Practical Nurse, Staff Q was observed standing in from of the medication cart and was asked if she had her pager on her person. Staff Q said, No, it is in the medication cart, locked up. Staff Q was asked how she responded to call lights activated by the residents. She said, I look at the board. Staff Q was asked what happens when she is in a resident's room and some needs emergency assistance. Staff Q said, I don't have a good answer for that. Staff Q was asked if she was responsible to ensure that her nursing staff had their pagers on their person while on duty. Staff Q said, I don't know, I am new here, and have only been here a month or so Licensed Practical Nurse, Staff O was observed to be sitting at the nurse station at 10:33 am, and was asked at that time if she had her pager on her person. Staff O said, No, it is in the medication cart. Staff O was asked if she was responsible for ensuring the nursing assistants had their pagers on them while on duty. She said, I don't know, I guess so, myself and the other nurse. Staff O was asked if she checked to see if her staff had them on their person that day. She said, No. Staff O was asked how she responds to call lights activated while in another room, away from the monitoring board. Staff O said, They have to wait until I come out of the room and go look at the board. Staff O was asked what if there was an emergency, like a fall or respiratory distress, or choking, and how would she know someone needed help. Staff O said, That is a good point, the nursing assistants look at the board. At 10:36 am, Nursing Assistant, Staff D was asked if she had her pager on her person. Staff D said, Yes I do, and pulled her pager out of her pocket. At 10:45 am, Restorative Nursing Assistant, Staff M was asked if she helped answer call lights. Staff M said that she did. Staff M was asked if she had a pager on her person. Staff M said, No. Staff M was asked how she knew what call lights to respond to. Staff M said, I walk up to the nurse station and look at the board. Staff M was asked why she did not have a pager. Staff M said, I use to, but we have changed things here and I don' t carry one now. Staff M was asked what happens when she is in a room helping provide care. Staff M said, They have to wait until I am finished or someone else looks at the board. It was identified at 10:46 AM, that out of 9 staff members on duty 5/18/16, that only one staff member was carrying a pager on her person to care for 50 residents, which was the only way for the residents to communicate their need for assistance to the staff on duty by the wireless nursing call system. An interview was conducted with the Administrator, Staff A on 5/18/16 at 11:00 am, related to the wireless call system. The Administrator said the call system was installed by the previous Administrator one or two years previous, and explain how it works. He said the resident pushes the call button in their room and it sends a message to the monitoring board at the nurse station, and pages at least 8 pagers. He also said he had to check them out 6 to 8 weeks previously when he came in the facility on a Saturday and re-program them to ensure they were functioning as he had some concerns with the pagers. He said he was not able to audit call light response time because he did not have the capabilities to do auditing of reports, and was not auditing call light response time. He said his expectation was that the staff should be carrying them on their person while on duty. The Administrator said that he did not have an owners manual for the system, and that they were not progressive pagers. He also said that floor staff received education upon orientation to the system. The Administrator was asked to see his facility's policy and procedure related to the call system and he verbalized that he did not have one that addressed who carries the pagers, and he also verbalized there was no operational manual or user guide, that he had only a portal page on a website. The Administrator was asked if was aware there were call light issues. He verbalized that some complaints were generated by the residents in some of the council meetings, and while out on the units talking to some residents. He did say that the Director of Nursing had a mandatory meeting 2 weeks ago to address call lights, pagers, and the DON had done an outline on what was presented to the staff. He verbalized that the nursing assistants and nurses are supposed to be carrying the pagers on their persons. Review was done on 5/18/16 at 1:00 PM, of the Facility's Policy and Procedure titled 'Answering the Call Light' , dated 2001, Revised 2010, which per the Administrator was the content given to the staff 2 weeks prior by the DON. Under General Guidelines, #8, documented Answer resident's call as soon as possible.The Policy did not address who was to carry the pagers, or who was responsible to ensure staff had them on their persons while on duty. The Administrator was notified of the immediate jeopardy at 4:00 PM on 5/18/16. The immediate jeopardy was removed on 5/19/16 at 1:00 PM, when this Surveyor confirmed, by observation, interview, and record review, that the following had been completed: 1. Beginning on 5/18/16, staff were being educated on the call light policy. 2. Audits were being conducted by the Director of Nursing beginning on 5/18/16, to ensure caregivers had pagers on them while on duty, for all shifts, and to monitor staff compliance 2 times daily for four weeks, then 1 time daily for four weeks, then 2 times per week for four weeks, then 1 time per week for four months. 3. The facility drafted a new call light policy on 5/18/16, regarding usage of call light system. 4. This Surveyor verified on 5/19/16 at 8:00 AM, that the assigned care givers had pagers on their persons and were responding to request for staff assistance from residents. Although the Immediate Jeopardy was removed on 5/19/16, the facility remained out of compliance with a scope of isolated and severity of No actual harm with potential for more that minimal harm that is not immediate jeopardy, pending verification by the State Agency (SA) of the facility's ability to demonstrate sustained compliance. Observations on 5/16/16 at 6:30 AM during the entrance tour of the resident care area revealed there to be three vibrating black pagers noted on the nursing station counter top next to the call light monitor. In an interview on 5/16/16 at 7:10 AM with Certified Nurse Assistant AD stated as the CNA and state surveyor observed the three black pagers to still be laying on the nursing station counter top that those were extra pagers and that the CNA's just checked the nursing station monitor for call lights. Record review of facility 'Resident Rights' policy dated 6/2015, revealed the facility protects and promotes the rights of each resident. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services Record review of facility 'Resident Council' policy dated 5/23/13 revealed that the purpose of the council shall be to relay any issues of concern, to recommend changes in policy and relay any new ideas or suggestions to the facility administration Record review of Resident Council Meeting minutes for the months of November 2015 revealed nursing concerns of residents not always knowing who their assigned Certified Nurse Assistant (CNA) was, that call light response was not always timely in being answered, and that residents had concerns about timeliness asking for pain medications. Record review of the December 2015 Resident Council Meeting notes revealed residents had concerns of nurses not being timely when asking for medication and call lights being answered are delayed and no coverage for when staff when they are on break. January 2016 Resident Council Meeting notes revealed residents had concerns of nurses are not being timely when asking for medications and residents were not sure who the assigned Certified Nurse Assistant (CNA) was. February 2016 Resident Council Meeting notes revealed residents had concerns of nurses are not being timely when asking for medications. April 2016 Resident Council Meeting notes revealed call lights response can be slow at times, especially on the weekends. During the confidential Resident Council Meeting held in the main dining room on 5/16/16 at 2:00 PM revealed that six out of nine residents ' verbalized concerns/complaints of facility call light response time to be slow and that the some of the residents had waited from 30 minutes to 1 hour for the assistance to use the toilet. In resident individual interviews done on 5/18/16 and 5/19/16 of alert residents identified that 6 of 10 resident who wished to remain anonymous, revealed that they had experienced extended wait times for call lights of 20 to 30 minutes on all shifts. #

This citation pertains to intake MI 391. Based on observation, interview and record review, the facility failed to prevent the elopement and ensure the safety of one resident (Resident #101), out of 7 residents reviewed for elopement from a total sample of 7, resulting in Resident #1, who was [AGE] years old and severely cognitively impaired, being discovered alone and unsupervised after Licensed Practical Nurse (LPN) Charge Nurse "E" saw the resident outside a facility window, walking on the grass toward a public park and the facility employee parking lot, in immediate jeopardy to her health and safety and at high risk for injury, serious harm or death. The immediate jeopardy began on on 9/21/14 at 10:14 a.m., when Resident #101 walked out of the facility's WanderGuard (registered trademark) alarmed exit door #8, unsupervised and alone. She walked down a 4-inch sloped sidewalk, which led directly to the front parking lot and a busy side street. Resident #101 then walked around the back of the building, toward the employee parking lot, another busy street, and a public park, at which time LPN Staff Member "E" (Charge Nurse) observed the resident through the break room window. Review of the facility video tape, dated 9/21/14, revealed Resident #101 (who had been fitted upon admission to the facility with an alarm bracelet that activated all exit door wander alarms) leaving the facility through exit door #8 at 10:14:40 (seconds) a.m. and Certified Nursing Assistant (CNA) Staff Member "B" shutting off the alarm on door #8 at 10:16:15 a.m., without going outside to look for a resident. Resident #101 was subsequently discovered and led back into the facility by Restorative CNA "C", Charge Nurse LPN "E" and CNA "F" through the employee entrance door on the other side of the building at 10:17:38 a.m. Staff were not aware Resident #101 had eloped or that she was outside alone and unsupervised. In an interview on 9/30/14 at 10:15 a.m. the facility Director of Nursing (DON) "A" said that Staff Member CNA "B" should have gone out exit door #8, when the alarm was activated, and looked to see if a resident had eloped. The Immediate Jeopardy was identified on 9/30/14 at approximately 4:00 pm. The Administrator and DON "A" were notified of the immediate jeopardy on 10/1/14 at 4:35 p.m. Due to the facility's failure to prevent the elopement of Resident #101 and ensure that all staff followed the elopement procedure, all 7 sample residents (#'s101, 102, 103, 104, 105, 106 and 107) of the 14 residents who were assessed by the facility as being at risk for elopement (in the facility census of 46 residents) were placed at increased risk for physical harm, injury and/or death. Findings Include: Review of the Face Sheet, Minimum Data Set (MDS) assessment tool dated 9/22/14; physician orders [REDACTED].#101 was a [AGE] year old female, alert with confusion, who required supervision due to decreased safety awareness and exit seeking behaviors, and self-ambulated and required staff assistance with her Activities of Daily Living (ADL). The resident's [DIAGNOSES REDACTED]. Review of the Social Service notes, dated 9/23/14, revealed Resident #101 had a Brief Interview for Mental Status (BIMS) score of "4", indicating severe cognitive deficits. A review of the resident's fall care plan, dated 9/15/14, revealed she had poor safety awareness. Review of the interdisciplinary notes, dated 9/24/14, revealed the resident had been assessed on 9/15/14 to be at "high" risk for elopement and was fitted with a WanderGuard bracelet. Review of the Hospital History and Physical dated 8/26/14 (prior to the resident's admission to the facility) stated, "This [AGE] year old female with history of Alzheimer dementia has been developing increasing confusion and agitation. The patient is forgetful. She keeps talking as though her husband was next to her bed. She herself is sitting in a bedside armchair. She repeatedly asked her husband questions." Review of Resident #101's Admission Nursing Evaluation, dated 9/15/14 at 10:35 a.m., revealed the facility had assessed Resident #101 as a "12" for fall risk (high risk for falls). Review of the MDS, dated [DATE], revealed Resident #101 was assessed by the facility as requiring "supervision" and as needing one person physical assist with ambulation, both on and off the unit. Review of the CAA (Care Area Assessments, part of the MDS resident assessment tool) dated 9/22/14 stated, "Resident makes statements about looking for him (her husband) and 'wanting to get home.' She is ambulatory. On 9/17/14 resident had a room move to move her away from exit door." Review of the facility interdisciplinary notes, dated 9/16/14, stated: "Resident admitted to facility 9/15/14, she is oriented at times to person, place and time, but easily switches to just person. She wanders, has a (alarmed bracelet) in place." Review of the interdisciplinary notes, dated 2/14/14, stated: "Resident has short term memory deficits, she often becomes anxious, makes statements regarding looking for her husband and makes statements about going home. She is also ambulatory and elopement risk." Review of the Resident Elopement Assessment Form (dated 9/15/14 and 9/22/14) revealed, on 9/15/14, Resident #101 was assessed and coded by the facility as a number "10" (at risk for wandering). Review of Resident #101's Fall, Elopement Risk and Behavioral care plans (all dated 9/21/14, prior to her elopement on 9/21/14), revealed the resident was at risk for falls and elopement. The facility had fitted her with an alarmed bracelet, which activated wander alarmed exit doors if she was near an alarmed door, opened an alarmed exit door, or went out a door. Staff were to redirect her when she was exhibiting exiting seeking behaviors and offer her divisional activities, monitor her whereabouts, and respond to exit alarms immediately. Review of facility nurses notes dated 9/21/14 at 2:00 a.m. (entered on the day the resident eloped, prior to her elopement) stated Resident #101 was "Severely agitated when redirected from other rooms, resident was more agitated, told nursing staff to 'go to ---- ', M.D. (physician) on-call notified, no new orders, nursing supervisor contacted, staff alternating sitting outside of room, will monitor." Observation of the facility exit door #8 was done on 9/30/14 at 9:10 a.m., accompanied by Staff Member "J" (Director of Maintenance). Door #8 was observed to alarm when opened by this surveyor. Continued observation on 9/30/14 at 9:15 a.m. revealed the condition of the route taken by Resident #101 (on 9/21/14), when Resident #101 exited door #8 and walked down the 4 inch sloped sidewalk alongside the building. The sidewalk led directly into the front main parking lot and then, in one direction, to a side road or, in the other direction, to the busy front main road. When Resident #101 went around the back of the building, the area was not fenced in, and it connected with a large neighborhood, a public park, the employee parking lot and, around to the front of the building, to the busy front main road. The resident would potentially have crossed over uneven and broken pavement, uneven sidewalks and grass, and decorative rocks surrounding the outside of the facility. Staff Member "J" (Director of Maintenance) and this surveyor measured the distance from exit door #8 to the break room window (where Resident #101 had been observed by staff) to be a total of "315" feet she had walked outside, alone and unsupervised. Observation of Resident #101 was done on 9/30/14 (at 9:00 a.m.) and on 10/1/14 (at 12:00 p.m. and 2:20 p.m.) on the long hall in the facility, at which times she was walking around the facility at a fast pace accompanied by a staff member, showing signs of being anxious and very distracted. The resident was unable to be interviewed due to her decreased cognitive ability, anxious behaviors and being very distracted. She would not stop walking. She said she was trying to go "somewhere." Review of the mental health notes dated 9/22/14 (the day after Resident #101 had eloped from the facility) stated, "[AGE] year old female who is new to facility, was seen today for evaluation. Pt. (patient) presents with high anxiety & delusional thinking. Pt. has associated s/s (signs and symptoms) of tearfulness, suspiciousness of others, wandering, exit seeking, paranoia, depression, attempt to socially isolate herself, poor insight and worry." Per interview done on 9/30/14 at 2:48 p.m., Staff Member "E" (Charge Nurse, LPN) stated, "I was in the break room (on 9/21/14) and I looked outside and she (Resident #101) was walking on the grass near the sidewalk alone, she was trying to find her home, she asked me where her house was. Prior to her elopement, she (the resident) wandered and wanted to know what door she can go out. I didn't hear any alarm." (Staff Member "E" was in the break room when the door #8 alarm was activated). Staff Member "E" said she and Staff Members "C" (Housekeeper) and "F" (CNA) went outside, and walked the resident back into the facility, where staff were not aware the resident was even gone. An interview was done on 9/30/14 at 9:35 a.m., with Staff Member "B" (Nursing Assistant/CNA). Staff member "B" (CNA) stated, "I was in (another resident's room), when I came out of the resident's room I heard the door #8 alarm. I went to the door and looked out. I didn't go outside. I shut the alarm off because I saw them (Staff Members "C" Restorative CNA, "E" Charge Nurse LPN, and "F" CNA) bring her (Resident #101) down the hall." A second interview was done in the Administrator's office on 9/30/14 at 11:40 a.m. with Staff Member "B" (CNA). During this interview, staff member "B" (CNA) was shown the video tape (dated 9/21/14) of the resident eloping, and her (CNA "B") shutting off the door #8 alarm. The video tape showed down the entire short hall (where staff brought the resident back into the facility), and there was no recording of the resident being brought back by Staff Members "C" (Restorative CNA), "E" (Charge Nurse, LPN) or "F" (CNA) until 10:17:38 sec. and staff member "B" (CNA) had shut the alarm off at "10:14:40 sec." Staff Member "B" (CNA) was asked again by this surveyor if she had shut the door #8 alarm off prior to seeing the resident being brought back in the facility by staff after she had eloped, and Staff Member "B" (CNA) stated, "Yes, I shut the alarm off. No I didn't see her (the resident) coming down the hall. No I didn't go outside. I was not taught to go outside (by the facility). I guess I should of looked outside." Staff Member "B" had first said (when interviewed on 9/30/14 at 9:35 a.m.) that she had shut the door alarm off because she saw the resident being brought back in the facility. Then, after viewing the facility video (dated 9/21/14) on 9/30/14 at 11:40 a.m., Staff Member "B" said she turned the door alarm off and did not see the resident coming down the hall with staff. She also said she did not look outside the door when it alarmed. Review of Staff Member "B's" (CNA) facility orientation education (dated 7/16/12), resident safety inservices (dated 3/13/14, 3/14/14 and 3/21/14) and elopement/missing person drill (dated 7/28/14) revealed she had been educated on facility elopement policy and procedures prior to Resident #101's elopement on 9/21/14. Review of Staff Member "B's" (CNA) personnel file revealed documentation of corrective action forms regarding quality of care and resident safety dated 8/19/14, 8/13/14, 4/25/14 and 3/11/13. During interviews done with the Administrator on 9/30/14 (at 9:45 a.m.) and on 10/1/14 (at 9:50 a.m. and 10:45 a.m.) regarding the door #8 alarm system, the Administrator revealed door #8 was next to the dining room, and if a resident with an alarmed bracelet was in the dining room's far right corner near the location of door #8, the door's alarm would be activated by the resident's alarmed bracelet. Facility staff would then have to go to door #8, check in the dining room, and check inside the building and outside the building every time door #8 was activated. The Administrator revealed she had called the alarm company on 9/24/14 to check the alarm system, and to make sure it had been working correctly on 9/21/14 when Resident #101 had eloped. Review of the alarm company service record, dated 9/24/14, revealed the alarm system was working. The service notes stated, "After testing the door alarms on the (alarm) system, I found that the doors are working properly." An interview was done on 10/1/14 at 10:03 a.m., with Staff Member "K" (CNA). Staff Member "K" (CNA) revealed she was in another resident's room when the door #8 alarm was activated on 9/21/14. She said she did not go to door #8 or check inside and outside for residents. An interview was done on 10/1/14 at 10:08 a.m., with Staff Member "L" (CNA). Staff Member "L" (CNA) revealed she was in the middle of care with another resident on 9/21/14, when the door #8 alarm was activated, and she did not go check for residents who may have eloped. Staff Member "L" (CNA) stated, "we are supposed to go check it out. If the door alarms, you have to do a head count, check outside and check all residents." An interview was done on 10/1/4 at 10:25 a.m., with Registered Nurse (RN) Staff Member "Q" (Charge Nurse). Staff member "Q" (Charge Nurse) stated, "I was doing a treatment (on another resident, on 9/21/14 when the door #8 alarm was activated); I knew someone is going to get it. You are supposed to go to the door (when an alarm is activated), look inside and outside." An interview was done on 10/1/14 at 3:15 p.m., with Staff Member "O" (CNA). Staff Member "O" (CNA) stated, "I heard the (wander) alarm (on 9/21/14 when the resident eloped); I was in the shower room with a resident." When asked by this surveyor what staff had been taught to do when they heard an exit door alarm had been activated, Staff Member "O" (CNA) stated, "go check the area and outside." An interview was done on 10/1/14 at 10:55 a.m., with Staff Member "G" (Inservice Nurse, RN). Staff member "G" (Inservice Nurse) stated, "I told all employees prior to her (Resident #101's) elopement (on 9/21/14); they should look all over and outside (when any exit door alarm was activated)." An interview was done on 10/1/4 at 11:35 a.m., with Staff Member "I" (Director of Housekeeping). Staff Member "I" stated, "I run the elopement drills and we go over staff looking inside (the facility), outside, under the beds, in the closets, everywhere." Review of the facility Wander Guards policy (dated 3/25/14) stated, "To ensure Resident safety, using the least restrictive means available. Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior." The immediate jeopardy was abated on 9/30/14 based on confirmation, during observation and interviews conducted on 10/2/14 at 4:00 p.m., that the facility had implemented the following to remove the immediate jeopardy: 1. On 9/21/14 at 10:17 a.m., Resident #101 was brought back into the facility by staff after she eloped, and a full assessment was done by the nurse with no injuries. 2. On 9/21/14 at 10:18 a.m., all residents were visualized and accounted for, and all 8 exit door alarms were checked by staff and found to be working properly. 3. On 9/21/14 at 10:30 a.m., Resident #101's primary physician, responsible party and the on-call nursing supervisor were notified of the elopement per facility policy. 4. On 9/21/14 at 10:40 a.m., the on-call nursing supervisor notified the Director of Maintenance of the elopement. 5. On 9/21/14 at 10:51 a.m., the Director of Maintenance arrived at the facility and all exit doors were tested for functionality and found to be working properly. 6. On 9/22/14 at 8:30 a.m., the Administrator tested all exit doors for functionality and they were all found to be working properly. 7. On 9/22/14 at 9:15 a.m., the Management team reviewed Resident #101's elopement and clinical record, and her care plan was up-dated. Social Service made referral to have Psychiatric Group evaluate the resident. 8. On 9/22/14 at 11:45 a.m., the Director of Housekeeping initiated mandatory elopement drills for all staff. 9. On 9/22/14 management inserviced staff on door alarms, elopement procedure, resident safety checks and the facility safety system. The in services continued until 9/29/14 at 2:00 p.m. 10. On 9/22/14 at 12:00 p.m., Social Services assessed all residents for elopement risk, up-dated the Code Silver Book and reviewed and up-dated all resident elopement risk care plans. 11. On 9/22/14 at 1:00 p.m., Psychiatric Group Practitioner assessed Resident #101 with recommendations regarding medication changes made along with continue one-on-one staff monitoring for safety. 12. On 9/24/14 and 9/25/14, Resident #101's primary physician assessed her with orders received. 13. On 9/24/14, the Interdisciplinary Team (IDT) reviewed and up-dated Resident #101's clinical record, plan of care and behavior logs. The IDT reviewed all other 14 residents assessed to be at risk for elopement with alarmed bracelets clinical records and plan of care. 14. On 9/30/14 at 5:00 p.m., the Administrator implemented a Door Alarm/Wander alarm policy and initiated all staff mandatory inservicing for all employees, so that staff knew they were not to turn off a (wander alarm) until all residents were safe and accounted for. Inservicing was completed on 10/1/14, and 98 out of a total of 101 employees were inserviced. The remaining 4 employees were expected to be inserviced by management prior to their next scheduled shift. 15. Weekly elopement drills will be done, starting 10/13/14 for 3 months, and will then be reviewed in QI meeting (quality insurance/assurance) for further direction. The Administrator will be responsible for on-going compliance. Although the immediate jeopardy was removed on 9/30/14, the facility remained out of compliance at a scope and severity of isolated potential for more than minimum harm to Resident #101, due to all staff having not yet been in serviced and the facility's ability to sustain compliance pending verification by the State Agency. It was confirmed by this surveyor on 10/2/14 (at 4:00 p.m.), that 13 facility residents with alarm bracelets (one resident with an alarm bracelet had been transferred to the hospital) had been tested , and the alarm bracelets were in working condition. Staff had been educated on the elopement policy and procedure with elopement drills conducted. Observation of the facility exit door #8 was done on 9/30/14 at 9:10 a.m., while accompanied by Staff Member "J" (Director of Maintenance) and was confirmed to be in proper functioning condition. All other alarmed facility doors (7 in total) were confirmed to be in proper working condition on 10/1/14 between the times of 9:20 a.m. and 9:40 a.m.. Observation was made on 9/30/14 (at 9:00 a.m.) of Resident #101; she was with staff at all times (one-on-one) and had an alarm bracelet on her left wrist that was in proper function condition. Observations were made on 9/30/14 (at 9:00 a.m., 1:30 p.m., 1:35 p.m., 1:40 p.m., 1:43 p.m., 1:45 p.m. and 2:00 p.m.) of all 7 sampled residents (#'s101, 102, 103, 104, 105, 106 and 107)) assessed to be at risk for elopement and fitted with wander protection bracelets. All were confirmed to have alarm bracelets on and they were in proper functioning condition. ( )

This citation pertains to intake MI 770. Based on observation, interview and record review, the facility failed to (1) provide adequate supervision to prevent a fall and (2) ensure alarmed safety devices were in place and functioning properly for 1 (Resident #4) out of 5 sampled residents reviewed for falls from a total sample of 11 residents, with cognitive impairment and a history of falls, resulting in Resident #4 sustaining 2 fractures of the wrist, an acute head injury, pain, hospitalization and surgery. Findings Include: Review of the Face Sheet, Minimum Data Set (MDS, assessment tool) dated 1/18/14, Nurse's notes dated 8/18/13 through 2/22/14 and hospital records dated 1/9/14 and 2/22/14 through 2/24/14, revealed Resident #4 was an [AGE] year old female admitted to the facility on [DATE], alert and oriented to self with confusion, required assistance with Activities of Daily Living (ADL) and transfers, had decreased safety awareness and was at high risk for falls. The resident's [DIAGNOSES REDACTED]. The resident fell at the facility on 2/22/14, acquiring 2 fractures of her left wrist which required hospitalization and surgical repair. Review of facility Social Service notes dated 8/13/13, stated "BIMS (cognitive ability test) completed in which she (Resident #4) scored a 5, indicating severe cognitive impairment." Review of the Fall assessment dated [DATE], revealed documentation that the resident was scored by the facility as a "15" (high risk) for falls. Review of the resident's clinical record and facility unusual occurrence reports (July 2013 through January 2014) revealed she had fallen previously at the facility on 7/30/13 (at 3:50 p.m.), 8/18/13 (at 6:50 p.m.) and on 1/13/14 (at 10:30 p.m.). Review of Resident #4's facility Fall and ADL care plans (dated 12/18/13, prior to her fall on 2/22/14) and Plan of Care Kardex (dated 1/14 and 2/14), revealed she had "alarmed floor mats" along with wheelchair and bed alarms in place as fall preventive interventions, with no direction for staff to close her door completely when she was sleeping. Review of the facility Accident/Incident report (dated 2/22/14) and staff's written statements (dated 2/22/14) and staff interviews, revealed the resident was found in her room at 7:15 a.m., on the floor of her room, with swelling in her left hand and left temple area following an unwitnessed fall. The resident was put to bed on 2/22/14 at approximately 7:00 a.m., after staying up all night with her door completely closed. The resident's bed alarm was sounding and was faintly heard by staff through the closed door, but her alarmed floor mat was not put on the by staff (in accordance with her Plan of Care Kardex). By the time staff located the sounding alarm, she was found on the floor across the room from her bed, near her dresser where her snacks were kept. Staff believed the resident was trying to get to snacks located on the other side of her room, on her dresser, when she fell . Review of the nurse's note's dated 2/22/14 at 8:30 p.m., stated "Resident found on floor about 7:15 a.m., in room, bed alarm was ringing, left wrist was very puffy and looked out of place, resident c/o (complained) severe pain and guarding wrist and arm (left), left side of temple was a hematoma (bruise)." Review of physician orders [REDACTED]." Review of the hospital records dated 2/22/14 at 9:41 a.m. and 11:27 a.m., stated "[AGE] year-old female presents to the emergency department Saturday morning (on 2/22/14) by EMS (Emergency Medical Services), she apparently had a crown fall (fall involving hitting the head) injuring her left forearm that caused deformity to her wrist, she does have evidence of bruising and swelling above her left eyebrow as well and is complaining of a frontal headache. She tells nursing staff the pain as a 7 on a scale of 0-10. Wrist (left) is painful, pain increased with any movement of arm and fingers, admitting because of the history of fall with head injury to the trauma service. Diagnosis: [REDACTED]." Review oaf the hospital x-ray dated 2/22/14 at 9:38 a.m. and per physician consult dated 2/23/14 at 7:31 p.m., the resident had "displaced, intra articular distal radius and ulnar styloid (bones in the wrist area) fractures (of her left wrist), recommend surgery to better align bones, as well as to decrease pain. Plan closed reduction and pinning, with fiberglass casting, cast and pins for 6 weeks, then remove." Review of the hospital operation report dated 2/23/14 at 8:28 p.m., revealed the resident had a closed reduction and pinning with a fiberglass cast applied to her left wrist. Observation of the resident was done on 2/25/14 at 10:30 a.m., at the facility, while the resident was sitting in her wheelchair in the assisted living hallway with staff pushing her. The resident was alert to name with confusion. When asked if she had any pain, she said "yes" and gestured that the pain was in her left wrist area. The resident was not observed propelling her self, as she did prior to her fall on 2/22/14; staff were pushing her wheelchair. Review of the hospital records dated 2/22/14 at 11:27 a.m., confirmed prior to the resident's fall on 2/22/14, she propelled herself in her wheelchair using both hands. An interview was done on 2/24/14 at 3:15 p.m., with Staff member "C", nurse. Staff member "C" revealed she was charting at the nurses' station (on the morning of 2/22/14 at 7:15 a.m.), when she heard an alarm ring. She said the alarm was "faint" and when she found it was coming from the resident's room, she (the resident) was already on the floor. Staff member "C" said the resident's door was closed when she fell and stated, "I don't think the door closed is a good idea." Review of staff member "C's" written statement, dated 2/22/14, also revealed documentation that the resident's alarm was "faint" sounding. Staff member "C" revealed CNA's had a daily assignment sheet for each shift, and this sheet included the task of doing safety checks on all assigned residents at the beginning of each shift when giving report to the on-coming CNA. Staff member "C" said the safety check would include making sure all residents' alarms were on and in working condition. Staff member "C" confirmed CNA's were to document they had completed all resident duties, including the safety checks, by initialing the resident's Plan of Care Kardex each shift. Review of Resident #4's Plan of Care Kardex dated 2/22/14, on "days" (1st shift, when the resident was found on the floor) revealed no documentation of staff initials. Review of the facility's Fall Prevention policy (un-dated), obtained by this surveyor from the CNA's information book at the nurses' station on 2/24/14, stated "Alarms will be checked every shift by CNA's for placement and function." An interview was done on 2/24/14 at 1:20 p.m., with staff member "A", nurse. Staff member "A" stated "she (staff member "C") said she couldn't tell where the alarm was coming from, so there was a delay in the time they found her (due to the resident's door being completely closed on 2/22/14)." An interview was done on 2/24/14 at 3:30 p.m., with staff member "B" (Nursing Assistant/CNA). Staff member "B" stated "we are supposed to go room-to-room with the on-coming CNA and give report, we didn't because I was running behind." Staff member "B" said she and the on-coming CNA (staff member "G") did not check the resident's alarms for proper placement and functioning at shift change on 2/22/14, prior to the resident's fall. Staff member "B" said she had put the resident to bed just before she punched out (approximately 7:00 a.m.) because she had been up all night and stated "I put the black floor mat down. I didn't see her gray one, the alarmed floor mat in the room, so I didn't put it down. I told (staff member "G") before I left that I had put her (the resident) in bed with her door closed." Staff member "B" confirmed it was not on the resident's Plan of Care to close her door, but stated "everyone closes her door." Observation of the Resident #4's room was done by this surveyor and staff member "B" during the interview (on 2/24/14). A black mat was observed in the bathroom along with an alarmed gray mat, sitting on the floor behind the door. An interview was done on 2/24/14 at 9:45 a.m., with staff member "G". Staff member "G" said he did not do rounds at the start of his shift on 2/22/14 with staff member "B" on Resident #4, or check to ensure her alarms were on and functioning properly. Staff member "G" said staff member "B" had put the resident to bed prior to her fall and confirmed the door of her room was closed. Staff member "G" stated, "I have seen her door closed, but not all the way, her door was closed all the way (on 2/22/14), she was put in bed, the black mat was down on the floor on the left side of her bed and the gray mat was in the bathroom, I did not put her to bed. We (CNA's) were told all doors will be kept open on Saturday afternoon approximately 11:00 a.m. to 11:30 a.m. (by management after the resident's fall on 2/22/14), there was no inservice on falls after her fall." An interview was done on 2/24/14 at 11:05 a.m., with staff member "H", nurse. Staff member "H" stated, I don't agree with having her door closed, we just sent her out (to the hospital) for having seizures. She does not know how to use the bell (to ring for staff assistance), she does not know how to call for help, she can't process that." A phone interview was done on 2/15/14 at 3:38 p.m., with the resident's responsible party #1. Responsible party #1 said the facility needs to find a way to keep the resident safe and stated, "I am concerned about her falls, they (the facility) should check on her more." Review of the facility Motion, Magnet and Bed Alarms policies (all un-dated) revealed safety alarms were to be placed on residents (per Care Plans and /or Plan of Care) and stated "Purpose: To give staff an advanced warning that a high fall risk resident may be in danger of a fall. Policy: Respond to the residents need for assistance in a timely manner in order to prevent a fall."

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO UPDATE AND IMPLEMENT CARE INTERVENTIONS TO PREVENT A PRESSURE SORE FROM DEVELOPING FOR ONE OF TWO RESIDENTS (#2) REVIEWED WITH PRESSURE SORES OUT OF A TOTAL SAMPLE OF TWELVE RESIDENTS, RESULTING IN THE RESIDENT DEVELOPING AN AVOIDABLE AND PAINFUL STAGE IV PRESSURE SORE. FINDINGS INCLUDE: ACCORDING TO THE FACE SHEET DATED 8-19-13 AND RE-ADMISSION MINIMUM DATA SET ((MDS) dated [DATE], RESIDENT #2 WAS AN [AGE] year OLD FEMALE admitted to the facility on [DATE] AND RE-admitted on [DATE] WITH [DIAGNOSES REDACTED]. ON 9-3-13 AT ABOUT 10:15 A.M. DURING THE INITIAL TOUR OF THE FACILITY WITH LPN (LICENSED PRACTICAL NURSE) "AT", RESIDENT #2 WAS IDENTIFIED AS HAVING A FACILITY ACQUIRED PRESSURE SORE ON THE LEFT ISCHIUM (LOWER POSTERIOR PORTION OF HER HIP BONE). REVIEW OF RESIDENT #2'S ADMISSION NURSING EVALUATION DATED 9-17-12 REVEALED A COCCYX (TAILBONE) AREA THAT WAS RED, HOWEVER, NO PRESSURE SORE WAS DOCUMENTED ON THE LEFT ISCHIAL AREA. HOWEVER, REVIEW OF THE WOUND/SKIN CARE MANAGEMENT DOCUMENTATION FORM FOR "LEFT ISCHIUM" DATED 11-30-12 STATED: "STAGE II (ULCER) 3 X (BY) 3.5 CM (CENTIMETERS). FURTHER REVIEW ON THE LEFT ISCHIUM WOUND/SKIN CARE FORMS REVEALED ON 1-21-13: "UNSTAGEABLE DUE TO SLOUGH (DEAD TISSUE COVERING THE WOUND)." ON 1-30-13 THE WOUND/SKIN CARE MANAGEMENT DOCUMENTATION FORM FOR THE LEFT ISCHIUM STATED: "UNSTAGEABLE, 1.8 CM X 1.5 CM, DEPTH, 1 CM". ON 3-1-13: "UNSTAGEABLE 1.5 CM DIAMETER - 1.5 CM DEPTH." THE WOUND/SKIN HEALING RECORD DATED 6-12-13 STATED: "STAGE III, 1 CM X 1.5 CM" PAIN DOCUMENTED AS "OW THAT HURTS." ON 6-17-13, RESIDENT #2 WAS DOCUMENTED AS SAYING, "THAT HURTS" ON THE WOUND /SKIN HEALING RECORD FOR THE LEFT ISCHIUM. THE WOUND/SKIN HEALING RECORD FOR THE LEFT ISCHIUM DATED 7-1-13 REVEALED STAGE III MEASUREMENTS AS FOLLOWS: "2 CM X 2 CM", DEPTH "1.8 CM", RESIDENT #2 "STATES OW, THAT HURTS" DURING PACKING OF WOUND. ACCORDING TO CLINICAL PRACTICE GUIDELINE, UNITED STATES DEPARTMENT OF HEALTH AND HUMAN SERVICES, 1994, PRESSURE ULCER TREATMENT, THE FOLLOWING DEFINITIONS APPLY: STAGE II=PARTIAL THICKNESS SKIN LOSS INVOLVING EPIDERMIS, DERMIS OR BOTH; STAGE III=FULL THICKNESS SKIN LOSS INVOLVING DAMAGE TO OR NECROSIS OF SUBCUTANEOUS TISSUE THAT MAY EXTEND DOWN TO, BUT NOT THROUGH, UNDERLYING FASCIA (MUSCLE TISSUE); STAGE IV=FULL THICKNESS SKIN LOSS WITH EXTENSIVE DESTRUCTION, TISSUE NECROSIS, OR DAMAGE TO MUSCLE, BONE, OR SUPPORTING STRUCTURES. ON 9-3-13 AT 2:52 P.M. WOUND CARE WAS OBSERVED IN RESIDENT #2'S ROOM WITH REGISTERED NURSE (RN) "CR", THE DON AND AIDE "DD" PRESENT. RESIDENT #2'S LEFT ISCHIUM PRESSURE SORE WAS OBSERVED TO BE REDDISH PINK IN COLOR. THE WOUND WAS MEASURED WITH A LENGTH OF 2.4 CM, X A WIDTH OF 2.0 CM, AND A DEPTH OF 3.0 CM. WOUND CARE physician progress notes [REDACTED]." physician progress notes [REDACTED]..STAGE IV L (LEFT) ISCHIAL ULCER." RESIDENT #2'S "BRADEN RISK ASSESSMENT SCALE" (AN INDICATOR OF SKIN BREAKDOWN RISK) DATED 9-17-12 (ON ADMISSION) REVEALED A "TOTAL SCORE =10 (WITH 18 OR LESS INDICATING HIGH RISK OF DEVELOPING A PRESSURE SORE). RESIDENT #2'S SKIN CARE PLAN DATED 10-01-12 IDENTIFIED: "RESIDENT IS AT RISK FOR SKIN BREAKDOWN RELATED TO DECREASED MOBILITY." CARE APPROACHES WERE IDENTIFIED AS "TURN AND REPOSITION Q (EVERY) 2 HOURS AND PRN (AS NECESSARY)" AND "ASSIST RESIDENT WITH BED MOBILITY PRN (AS NEEDED)." RESIDENT #2'S ADMISSION MINIMUM DATA SET ((MDS) dated [DATE] IDENTIFIED RESIDENT #2 AS A LEVEL "3" (EXTENSIVE ASSISTANCE FOR BED MOBILITY WITH ONE PERSON PHYSICAL ASSIST), MEANING THE RESIDENT NEEDED ASSISTANCE TO TURN IN BED. THE SKIN CARE PLAN WITH A START DATE OF 10-1-12 STATED: "OPEN AREA ON ISCHIUM" DATED FOR 12-13-12. HOWEVER, THE ISCHIUM WOUND HAD FIRST BEEN DOCUMENTED BY THE FACILITY APPROXIMATELY TWO WEEKS EARLIER ON 11-30-12. NO NEW INTERVENTIONS OR APPROACHES WERE DATED 12-13-12 AS ADDED. A NEW CARE PLAN TITLED "PRESSURE ULCER" DATED 3-19-13 STATED: "ACTUAL ALTERATION IN SKIN INTEGRITY AEB (AS EVIDENCED BY) STAGE III PRESSURE ULCER ON ISCHIUM." REVIEW OF RESIDENT #2'S SKIN CARE PLAN DATED 10-1-12 AND HER PRESSURE ULCER CARE PLAN DATED 3-19-13 REVEALED THAT NO NEW PROTECTIVE OR PREVENTATIVE INTERVENTIONS/ADDITIONS WERE ENTERED EXCEPT FOR: "KEEP SKIN AS LUBRICATED AS POSSIBLE, APPLY LOTION PRN" (WITH A START DATE OF 3-19-13) AND "DIETARY TO EVALUATE FOR NEED FOR SUPPLEMENTS TO PROMOTE WOUND HEALING" (WITH A START DATE OF 6-5-13, APPROXIMATELY 6 MONTHS AFTER THE LEFT ISCHIAL WOUND DEVELOPED). ADDITIONALLY, THE PRESSURE ULCER CARE PLAN DATED 3-19-13 FAILED TO CARRY OVER FROM THE SKIN CARE PLAN DATED 10-1-12, TO TURN AND REPOSITION THE RESIDENT EVERY 2 HOURS AND PRN, AND ASSIST THE RESIDENT WITH BED MOBILITY PRN. RESIDENT #2'S "PAIN ASSESSMENT" DATED 7-25-13 STATED: "DX (DIAGNOSIS) RELATED TO PAIN: LEFT ISCHIUM, STAGE III...INTENSITY OF PAIN: 5 (EXCRUCIATING)...IT REALLY HURTS VERBALIZES DURING WOUND CARE." RESIDENT #2'S "PAIN" CARE PLAN DATED 3-19-13 STATED: "RESIDENT AT RISK FOR PAIN R/T (RELATED TO) STG (STAGE) III PRESSURE ULCER, DEMENTIA & ARTHRITIS." ON 9-4-13 AT 2:30 P.M. AN INTERVIEW WAS HELD WITH THE DON RELATED TO RESIDENT #2'S PRESSURE ULCER. THE DON CONFIRMED THAT THE DOCUMENTATION FOR THE PRESSURE ULCER ON THE RESIDENT'S LEFT ISCHIUM BEGAN ON 11-30-12 AS A STAGE II. THE DON WAS THEN ASKED TO EXPLAIN HOW RESIDENT #2'S LEFT ISCHIAL PRESSURE ULCER DETERIORATION TO A STAGE IV WOUND WAS UNAVOIDABLE. THE DON RESPONDED BY SAYING THAT THE RESIDENT HAD A LOT OF COMORBIDITIES WHEN SHE WAS admitted . THEN, THE DON STATED THAT THE RESIDENT HAD A PRESSURE REDUCING MATTRESS WHEN SHE WAS admitted , BUT THE PRESSURE REDUCING MATTRESS WAS CHANGED TO A LOW AIR LOSS MATTRESS AFTER THE PRESSURE ULCER HAD ALREADY DEVELOPED. THE DON WAS UNSURE OF THE SPECIFIC DATE THAT THE CHANGE WAS MADE. REVIEW OF RESIDENT #2'S PHYSICIAN ORDERS [REDACTED]. AIR LOSS BED WAS NOT ADDED UNTIL 7-2-13. THE INDICATION FOR USE WAS DOCUMENTED AS: "STG (STAGE) III WOUND." ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE FLUIDS TO 1 OF 12 RESIDENTS (#1) REVIEWED FOR HYDRATION NEEDS IN A TOTAL SAMPLE OF 12 RESIDENTS, RESULTING IN THE RESIDENT DEVELOPING SERIOUS AND POTENTIALLY AVOIDABLE DEHYDRATION AND BEING PLACED AT INCREASED RISK FOR RECURRENCE; THE RESIDENT WAS TRANSFERRED TO AN ACUTE CARE HOSPITAL WITH ACUTE KIDNEY INJURY SECONDARY TO DEHYDRATION. FINDINGS INCLUDE: ACCORDING TO THE RESIDENT ADMISSION RECORD WITH A CURRENT admission date of [DATE], RESIDENT #1 WAS AN [AGE] year-old FEMALE WITH [DIAGNOSES REDACTED]. THE ACCUMULATIVE [DIAGNOSES REDACTED]. THE MINIMUM DATA SET RESIDENT ASSESSMENT (MDS), dated [DATE], REFLECTED THAT RESIDENT #1 WAS TOTALLY DEPENDENT ON THE STAFF FOR ALL ACTIVITIES OF DAILY LIVING INCLUDING EATING AND DRINKING. THE MDS, dated [DATE], INDICATED THAT RESIDENT #1 WAS ON A MECHANICALLY ALTERED DIET THAT REQUIRED A CHANGE IN TEXTURE OF THE FOOD OR LIQUIDS. ON 7/10/2013 AT 6:35 AM, THE NURSING NOTES REFLECTED THAT RESIDENT #1 WAS SENT TO A HOSPITAL emergency room FOR EVALUATION AND TREATMENT. ACCORDING TO THE HOSPITAL DISCHARGE SUMMARY WITH AN admitted [DATE], RESIDENT #1 HAD BEEN admitted IN "POOR" CONDITION WITH [DIAGNOSES REDACTED]. HER CREATININE ON ARRIVAL WAS 1.1, PRE-RENAL (NOTE, ACCORDING TO MEDLINE PLUS, A SERVICE OF THE US NATIONAL LIBRARY OF MEDICINE, THIS MEANS THAT THE KIDNEY INJURY IS A RESULT OF A LACK OF BLOOD FLOW TO THE ORGAN AND CAN USUALLY BE REVERSED WHEN THE PROBLEM IS CORRECTED), SECONDARY TO DEHYDRATION", URINARY TRACT INFECTION, [MEDICAL CONDITION], ACUTE [MEDICAL CONDITION] "SODIUM ON ARRIVAL 156", ACUTE DEHYDRATION, AND POORLY CONTROLLED DIABETES MELLITUS, TYPE TWO. ACCORDING TO THE UNDATED RESIDENT ADMISSION RECORD, RESIDENT #1 WAS REadmitted to the facility on [DATE]. ACCORDING TO THE MOST RECENT "NUTRITION RISK ASSESSMENT" IN THE RESIDENT'S FACILITY MEDICAL RECORD, DATED 2/5/2013, RESIDENT #1 WAS ON A REGULAR PUREED DIET AND ATE ALL MEALS IN THE SKILLED DINING ROOM AT A "FEEDER/CUE" TABLE. THE "NUTRITION RISK ASSESSMENT" REFLECTED THAT RESIDENT #1 WAS PROVIDED 1500 TO 1800 CUBIC CENTIMETERS OF FLUIDS DAILY WITH HER DIET AND CONSUMED 50-75 % OF ALL MEALS AND FLUIDS. THE "NUTRITION RISK ASSESSMENT", DATED 2/5/2013, LISTED THE OVERALL RISK CATEGORY FOR RESIDENT #1 AS "HIGH RISK". THE NUTRITION CARE PLAN, WITH AN ONSET DATE OF 8/17/2012, INDICATED THAT RESIDENT #1 HAD THE POTENTIAL FOR "ALTERATION IN NUTRITION/HYDRATION" BECAUSE OF A THERAPEUTIC-MECHANICALLY ALTERED DIET. THE GOALS INCLUDED "RESIDENT WILL TOLERATE A PUREE DIET D/T (DUE TO) HAVING NO TEETH AND WILL MAINTAIN A STABLE WEIGHT". THE CARE PLAN APPROACHES INCLUDED: "ENCOURAGE FLUIDS; MONITOR RESIDENT FOR S/S (SIGNS AND SYMPTOMS) DEHYDRATION (POOR SKIN TURGOR, DRY MOUTH); TOTAL FEED AT ALL MEALS TO MAINTAIN STABLE WEIGHT THRUGH (SIC) NEXT REVIEW; STAFF TO ENCOURAGE AND FEED FOR OPTIMAL INTAKE WITH ALL MEALS; PRUNE JUICE WITH BREAKFAST ...S.F. H SHAKE (SUGAR FREE HEALTH SHAKE) TID (THREE TIMES A DAY) WITH ALL MEALS; SNACK OFFERED AT 10 - 2 - HS (BED TIME); AND B F (UNKNOWN/UNIDENTIFIED ABBREVIATION) DRINK OFFERED TID (THREE TIMES A DAY) WITH MEALS". THE MOST RECENT REVIEW DATE OF THE CARE PLAN WAS 5/2013. DURING AN INTERVIEW WITH STAFF "II", AN AIDE, AT THE NURSES STATION ON 9/4/2013 AT 2:30 PM, STAFF "II" STATED THAT RESIDENT #1 RECEIVED A HEALTH SHAKE FOR A SNACK AT 10:00 AM AND 2:00 PM DELIVERED BY THE DIETARY DEPARTMENT. A LIST OF SNACKS OFFERED BY THE DIETARY DEPARTMENT WAS REQUESTED. AN UNDATED LIST TITLED "DAILY SNACKS 10/2/HS (BED TIME)" WAS PROVIDED. THERE WERE THREE RESIDENTS ON THE LIST. RESIDENT #1 WAS NOT ON THE LIST. DURING AN INTERVIEW WITH STAFF "AZ", A LICENSED PRACTICAL NURSE, AT THE NURSES STATION ON 9/5/2013 AT 11:00 AM, STAFF "AZ" STATED THAT AT 10:00 AM THE ACTIVITY AIDES TAKE THE SNACK CART AROUND AND OFFER RESIDENTS SNACKS AND FLUIDS. DURING AN INTERVIEW WITH STAFF "D", THE ACTIVITY DIRECTOR, AT THE NURSES STATION ON 9/5/2013 AT 11:10 AM, STAFF "D" STATED THAT THE ACTIVITY AIDES TAKE THE SNACK CART AROUND TO RESIDENT ROOMS AT 10:00 AM AND AT 2:00 PM TO OFFER SNACKS AND FLUIDS TO THE RESIDENTS AND THAT THE DIETARY DEPARTMENT DELIVERED SNACKS AND FLUIDS AT BED TIME. STAFF "D" WAS ASKED WHO HAD DELIVERED THE SNACKS THIS MORNING. STAFF "D" STATED THAT NO ONE HAD DELIVERED SNACKS AND FLUIDS THIS MORNING AS THE ACTIVITY AIDE HAD BEEN OUT OF THE BUILDING. STAFF "D" WAS ASKED FOR THE DOCUMENTATION FOR SNACKS AND FLUIDS OFFERED TO RESIDENTS. THE DOCUMENTATION FOR THE SNACKS AND FLUIDS PROVIDED IN THE MORNING, AFTERNOON, AND EVENING FOR RESIDENT #1 FOR THE MONTH OF JUNE 2013 REFLECTED THAT A "FLUID" (NO AMOUNT WAS SPECIFIED) WAS PROVIDED IN THE MORNING ON 6/1/2013 AND 6/8/2013. RESIDENT #1 WAS IN "BED" IN THE AFTERNOON OF 6/10/2013. RESIDENT #1 WAS GIVEN A SNACK AND FLUID IN THE MORNING OF 6/12/2013 AND WAS ASLEEP IN THE AFTERNOON OF THE SAME DAY. RESIDENT #1 WAS PROVIDED A FLUID IN THE MORNING ON 6/17/2013, A FLUID AND A SNACK IN THE MORNING OF 6/18/2013 AND 6/20/2013. RESIDENT #1 WAS PROVIDED A FLUID IN THE MORNING OF 6/21/2013, AND 6/25/2013. THERE WAS NO ADDITIONAL DOCUMENTATION TO RECORD AN OFFERING OF A SNACK OR FLUID AT ANY OTHER TIME OR DATE. THE PAGES WERE EITHER MISSING OR THE COLUMNS FOR ADDITIONAL OFFERINGS WERE BLANK. THUS, THE DOCUMENTATION REFLECTED THAT RESIDENT #1 RECEIVED OR WAS OFFERED A SNACK OR FLUID ONLY NINE OF THE NINETY SCHEDULED/CARE PLANNED TIMES IN THE MONTH OF JUNE 2013. THE DOCUMENTATION FOR THE SNACKS AND FLUIDS PROVIDED IN THE MORNING, AFTERNOON, AND EVENING FOR RESIDENT #1 FOR JULY 2013 WAS REVIEWED. THERE WERE NO RECORDS FOR JULY 1 AND 2, 2013. THE DOCUMENTATION REFLECTED THAT RESIDENT #1 WAS AT AN ACTIVITY IN THE AFTERNOON OF 7/3/2013 AND THE MORNING OF 7/4/2013. IT DID NOT REFLECT IF SHE WAS OFFERED A SNACK OR FLUID AT THE ACTIVITY. THERE WAS NO DOCUMENTATION PROVIDED FOR JULY 5, 6, OR 7/ 2013. THE DOCUMENTATION RECORDED FOR 7/8/2013 STATED THAT RESIDENT #1 WAS "ILL" AT BEDTIME AND WAS BLANK FOR MORNING AND AFTERNOON. THE DOCUMENTATION WAS BLANK FOR RESIDENT #1 FOR 7/9/2013. ACCORDING TO THE NURSING NOTES, RESIDENT #1 WAS SENT TO THE hospital on [DATE] AT 6:35 AM. THE FOOD ACCEPTANCE RECORD WAS REVIEWED FOR RESIDENT #1 FOR THE MONTHS OF JUNE AND JULY 2013. THE RECORDINGS FOR BREAKFAST WERE BLANK ON JUNE 6, 8, AND 9, AND FOR EVERY DAY FROM THE 16TH THROUGH THE 30TH. THE RECORDINGS FOR LUNCH WERE BLANK ON JUNE 2, 3, 4, 5, 7, 8, 9, 10, AND EVERY DAY FROM THE 15TH THROUGH THE 25TH, ZEROS WERE RECORDED ON THE 26TH, AND THE 27TH THROUGH THE 30TH WERE BLANK. THE RECORDINGS FOR DINNER WERE BLANK ON JUNE 2, 3, 4, AND WERE BLANK FROM THE 6TH THROUGH THE 30TH. THERE WAS NO RECORDED FOOD INTAKE FOR BREAKFAST FOR THE MONTH OF JULY. THE RECORDINGS FOR LUNCH IN JULY WERE BLANK ON THE 1ST AND 2ND, AND THE 5TH THROUGH THE 30TH. THE RECORDINGS FOR DINNER WERE BLANK FROM THE 6TH THROUGH THE 30TH. DURING AN INTERVIEW WITH THE DIETARY SUPERVISOR, STAFF "AF" ON 9/6/2013 AT 12:50 PM IN HIS OFFICE, HE STATED THAT FOOD ACCEPTANCE WAS TO BE RECORDED FOR ALL RESIDENTS WHO WERE DEPENDENT ON THE STAFF TO BE FED. STAFF "AF" WAS ASKED FOR A POLICY ON WHEN FOOD ACCEPTANCE RECORDS WERE TO BE COMPLETED FOR RESIDENTS AND STATED "WE DON'T HAVE ONE". ACCORDING TO THE NURSING NOTES FOR 7/8/2013 AT 5:30 PM, RESIDENT #1 HAD A BLOOD SUGAR READING OF "HI" (GREATER THAN 600), "RAPID BREATHING AT 30/ MIN", A HEART RATE OF 96 PER MINUTE, BLOOD PRESSURE OF 150/100 (AVERAGE READING IS 120/80). THE PHYSICIAN WAS CONTACTED AND ORDERED LAB TESTS OF HER BLOOD. THE NOTES ALSO STATED THAT RESIDENT #1 HAD "SKIN TURGER (SIC) TENTING > 3" SECONDS. ACCORDING TO RESIDENT #1'S CARE PLAN, AS NOTED ABOVE, THIS WAS ONE OF THE SIGNS TO MONITOR FOR DEHYDRATION. THE NOTE READ "FLUIDS TO BE ENCOURAGED". THERE WAS NO INDICATION THAT THE NURSING STAFF MONITORED RESIDENT #1'S FLUID INTAKE TO ASSURE ADEQUATE HYDRATION AS EVIDENCED BY THE DOCUMENTATION ON THE FOOD ACCEPTANCE RECORDS, THE RECORD OF SNACKS AND FLUIDS OFFERED AS NOTED ABOVE, AND THE NURSING NOTES FOR 7/8/2013 THROUGH 7/10/2013. ON 7/10/2013 AT 6:35 AM, THE NURSING NOTES REFLECTED THAT RESIDENT #1 WAS SENT TO A HOSPITAL emergency room FOR EVALUATION AND TREATMENT. ACCORDING TO THE HOSPITAL DISCHARGE SUMMARY WITH AN admitted [DATE], RESIDENT #1 HAD BEEN admitted IN "POOR" CONDITION WITH [DIAGNOSES REDACTED]. HER CREATININE ON ARRIVAL WAS 1.1, PRE-RENAL (NOTE, ACCORDING TO MEDLINE PLUS, A SERVICE OF THE US NATIONAL LIBRARY OF MEDICINE, THIS MEANS THAT THE KIDNEY INJURY IS A RESULT OF A LACK OF BLOOD FLOW TO THE ORGAN AND CAN USUALLY BE REVERSED WHEN THE PROBLEM IS CORRECTED), SECONDARY TO DEHYDRATION", URINARY TRACT INFECTION, [MEDICAL CONDITION], ACUTE [MEDICAL CONDITION] "SODIUM ON ARRIVAL 156", ACUTE DEHYDRATION, AND POORLY CONTROLLED DIABETES MELLITUS, TYPE TWO. ACCORDING TO THE UNDATED RESIDENT ADMISSION RECORD, RESIDENT #1 WAS REadmitted to the facility on [DATE]. ACCORDING TO THE PHYSICIAN'S ADMISSION ORDER SHEET, DATED 7/12/2013, RESIDENT #1 WAS TO RECEIVE A PUREE DIET WITH NECTAR THICK LIQUIDS. ACCORDING TO THE HOSPITAL DISCHARGE SUMMARY, SIGNED BY THE PHYSICIAN ON 7/12/2013, RESIDENT #1 HAD BEEN GIVEN A SWALLOW EVALUATION AT THE HOSPITAL AND IT HAD BEEN RECOMMENDED THAT SHE TAKE ONLY NECTAR THICK LIQUIDS. THE MINIMUM DATA SET RESIDENT ASSESSMENT ((MDS) dated [DATE] WAS NOT CHECKED FOR "DEHYDRATED" ON SECTION J "HEALTH CONDITIONS". THE NUTRITIONAL APPROACHES ON THE MDS dated [DATE] INCLUDED A MECHANICALLY ALTERED DIET. THE MDS dated [DATE] ALSO INDICATED THAT RESIDENT #1 WAS TOTALLY DEPENDENT ON STAFF FOR ALL ACTIVITIES OF DAILY LIVING INCLUDING EATING AND DRINKING. THE CARE AREA ASSESSMENT (CAA) SUMMARY, DATED 7/24/2013, REFLECTED THAT THE CARE AREA OF "DEHYDRATION/FLUID MAINTENANCE" HAD BEEN TRIGGERED FOR ADDITIONAL REVIEW. THE CAA SUMMARY REPORT FOR THE DEHYDRATION/FLUID MAINTENANCE INSTRUCTED THAT AS AN ANALYSIS OF FINDINGS, DOCUMENT THE DESCRIPTION OF THE PROBLEM, CAUSES AND CONTRIBUTING FACTORS, AND RISK FACTORS RELATED TO THE CARE AREA. THE FACILITY STAFF DOCUMENTED, "[AGE] year OLD FEMALE IS ON A REG. (REGULAR) PUREE DIET WITH NECTOR (SIC) THICKEN LIQUIDS AND EATS ALL MEALS IN THE SKILLED DINING ROOM AT A FEEDER TAKE (SIC) WERE (SIC) SHE IS FEED (SIC) ALL HER MEALS. NO SIGNIFICANT WEIGHT CHANGE IN 1-3 OR 6 MONTHS". THERE WAS NO DOCUMENTATION OR ASSESSMENT RELATED TO THE RECENT hospitalization AND RECENT [DIAGNOSES REDACTED]. THE LAST REVIEW DATE ON THE CARE PLAN THAT ADDRESSED THE POTENTIAL FOR ALTERATION IN NUTRITION/HYDRATION RELATED TO A THERAPEUTIC-MECHANICALLY ALTERED DIET WAS 5/13/2013. A HOSPICE NURSE HAD SIGNED AT THE BOTTOM ON 8/6/2013 WITHOUT INDICATING WHAT THE SIGNATURE PERTAINED TO AND NO ADDITIONAL ENTRIES WERE RECORDED ON THE CARE PLAN PROBLEM, GOALS, OR APPROACHES BY THE HOSPICE NURSE. THE LAST "NUTRITION RISK ASSESSMENT" IN THE MEDICAL RECORD WAS DATED 2/5/2013. ON 9/4/2013 AT 9:10 AM IN THE CONFERENCE ROOM, THE DIETARY SUPERVISOR, STAFF "AF" WAS ASKED WHY ANOTHER ASSESSMENT HAD NOT BEEN PERFORMED. HIS RESPONSE WAS, "I COULD HAVE MISSED HER, I WILL CHECK." A PROGRESS NOTE BY THE REGISTERED DIETICIAN, DATED 8/2/2013, WAS REVIEWED. THE PROGRESS NOTE DID NOT ADDRESS THE PHYSICIAN [DIAGNOSES REDACTED]. AN "INTAKE/OUTPUT RECORD" FOR RESIDENT #1 LISTED THE FOLLOWING: 7/12/2013- INTAKE 360 CUBIC CENTIMETERS (CCS) FOR SECOND SHIFT AND URINE X 2. THERE WERE NO ENTRIES FOR 3RD OR 1ST SHIFTS. 7/13/2013-INTAKE 550 CCS ON SECOND SHIFT AND URINE X 3. THERE WERE NO ENTRIES FOR 3RD OR 1ST SHIFTS. THERE WERE NO ENTRIES FOR 7/14/2013. 7/15/2013-INTAKE 600 CCS ON SECOND SHIFT AND URINE X3. THERE WERE NO ENTRIES FOR 3RD OR 1ST SHIFTS. 7/16/2013-THERE WERE NO ENTRIES. 7/17/2013-INTAKE 240 CCS ON SECOND SHIFT AND URINE X3. THERE WERE NO ENTRIES FOR 3RD OR 1ST SHIFTS. 7/18/2013-INTAKE 740 CCS ON SECOND SHIFT AND URINE X3. THERE WERE NO ENTRIES FOR 3RD OR 1ST SHIFTS. 7/22/2013-INTAKE 720 CCS ON SECOND SHIFT AND URINE X3. THERE WERE NO ENTRIES FOR 3RD OR 1ST SHIFTS. DURING AN INTERVIEW WITH LICENSED PRACTICAL NURSE "AT", WHO IDENTIFIED HERSELF AS THE UNIT MANAGER, ON 9/6/2013 AT 12:05 PM IN THE HALL OUTSIDE OF HER OFFICE, SHE STATED THAT FOR SEVEN DAYS AFTER ADMISSION INTAKE AND OUTPUT ARE RECORDED FOR ALL RESIDENTS. WHEN ASKED, SHE STATED THAT THERE WAS NO POLICY, THAT THE FORM CAME IN THE ADMISSION PACKET AND IT WAS A NURSING PROTOCOL. SHE DID NOT KNOW WHY THE INTAKE AND OUTPUT RECORD FOR RESIDENT #1 WAS INCOMPLETE. DURING AN INTERVIEW WITH LICENSED PRACTICAL NURSE (LPN) "AQ" ON 9/6/2013 AT 12:15 PM IN THE HALL OUTSIDE THE DINING ROOM, SHE STATED THAT INTAKE AND OUTPUT WAS RECORDED FOR ALL NEW ADMISSIONS FOR SEVEN DAYS. LPN "AQ" FURTHER STATED THAT THE RESULTS WERE REPORTED TO THE PHYSICIAN WHO THEN MADE A DECISION WHETHER OR NOT TO CONTINUE MONITORING A RESIDENT'S FLUID INTAKE. DURING AN INTERVIEW WITH LPN "AR" AT THE NURSES STATION ON 9/6/2013 AT 12:20 PM, SHE CONFIRMED THAT INTAKE AND OUTPUT WAS RECORDED FOR ALL RESIDENTS FOR SEVEN DAYS AFTER ADMISSION. DURING AN INTERVIEW WITH STAFF "EE", AN AIDE, AT THE NURSES STATION ON 9/4/2013 AT 2:30 PM, SHE STATED THAT RESIDENT #1 HAD TAKEN A "SMALL" ORANGE JUICE AND CHOCOLATE MILK FOR BREAKFAST. AIDE "EE" STATED THAT RESIDENT #1 HAD TAKEN FOUR OUNCES EACH OF A MILK SHAKE AND JUICE AND "SOME" OF HER WATER FOR LUNCH. ON 9/5/2013 AT 8:30 AM, RESIDENT #1 WAS OBSERVED IN THE DINING ROOM BEING FED HER BREAKFAST BY AIDE "JJ". AT 9:10 AM, RESIDENT #1 WAS OBSERVED IN HER CHAIR IN HER ROOM. STAFF AIDE "JJ" ENTERED THE RESIDENT ROOM TO DELIVER FRESH WATER FOR RESIDENT #1. AIDE "JJ" REPORTED THAT AT BREAKFAST RESIDENT #1 HAD DRUNK HALF OF HER ORANGE JUICE (TWO OUNCES), A "LITTLE" MILK, HALF OF HER PRUNE JUICE (TWO OUNCES), AND TWO OR THREE SIPS OF WATER. AIDE "JJ" THEN LEFT THE ROOM WITHOUT OFFERING RESIDENT #1 A DRINK OF THE FRESH WATER. THE FOOD ACCEPTANCE RECORD FOR RESIDENT #1 WAS FOR JULY 7 THROUGH JULY 31, 2013 WAS BLANK. THE ENTIRE AUGUST 2013 FOOD ACCEPTANCE RECORD WAS BLANK FOR RESIDENT #1. THE FOOD ACCEPTANCE RECORD FOR SEPTEMBER WAS REQUESTED. ON 9/6/2013 AT 1:15 PM IN THE CONFERENCE ROOM, LPN "AT" STATED THAT THERE WERE NO SEPTEMBER FOOD ACCEPTANCE RECORDS FOR ANY RESIDENT. DURING AN INTERVIEW WITH THE DIETARY SUPERVISOR "AF" ON 9/6/2013 AT 1:30 PM IN THE CONFERENCE ROOM, HE STATED THAT THERE WAS NO POLICY ON WHEN RESIDENTS WERE TO HAVE FOOD INTAKE RECORDED. STAFF "AF" STATED THAT THE DIETARY DEPARTMENT HAD BEEN RECORDING FOOD ACCEPTANCE, BUT IT WAS DISCUSSED AND DECIDED THAT THE NURSING ASSISTANTS WOULD START RECORDING THE FOOD ACCEPTANCE. STAFF "AF" CONTINUED SAYING, "THEY DIDN'T FOLLOW THROUGH" AND IT HAD NOT BEEN DONE. SINCE RESIDENT #1 HAD BEEN diagnosed with [REDACTED]. ( )

This citation pertains to intake number MI 133. Based on interviews and record review, 1 of 4 sampled residents (#101) reviewed for medication errors, from a total of 4 residents reviewed for medication errors, experienced a significant medication error when facility staff failed to administer an anti-[MEDICAL CONDITION] medication ([MEDICATION NAME]), twice daily, for a period of 38 days, resulting in Resident #101 experiencing [DIAGNOSES REDACTED] (medical emergency characterized by continuous [MEDICAL CONDITION]), treatment in a local hospital emergency department, and subsequent hospitalization . Findings include: The face sheet revealed Resident #101 was an [AGE] year old man who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Transfer Orders accompanying Resident #101 from the hospital to the facility, dated 2/14/2013 at 1:23 PM, specified Resident #101 was to receive [MEDICATION NAME] 150 milligrams, twice daily. The Physician orders [REDACTED].#101 was to receive [MEDICATION NAME] 150 milligrams, twice daily. According to the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the MAR's for March 2013 and April 2013 revealed Resident #101 received [MEDICATION NAME] 150 milligrams once daily in the AM; the afternoon dose was not administered from 3/1/2013 through 4/7/2013 (a period of 38 days). According to the [MEDICAL CONDITION] Care Plan (undated), Resident #101 was identified with "potential for [MEDICAL CONDITION] activity, injury related to [MEDICAL CONDITION] disorder" and was to receive "administration of medications as ordered." Review of the Medication and Treatment Incident Report dated 4/9/2013 (untimed), revealed an "electronic MAR printed 3/1/2013 was incorrect; dosage was typed correctly, but only timed for 8 AM. 8 PM dose was omitted and not printed on MAR for 3/2013 or 4/2013." During an interview on 8/21/2013 at 9:30 AM, Assistant Director of Nursing (ADON) #5 said a comparison of Resident #101's MAR's (dated February 2013, March 2013, and April 2013) and the computerized pharmacy data sheet performed on 4/8/2013 as part of discharge planning review, revealed an error in administration of [MEDICATION NAME] that had existed for a period of 38 days; the Resident was reported to have received [MEDICATION NAME] 150 milligrams once daily, not twice daily as ordered, for a period of 38 days. The ADON said she notified the Resident's attending physician (witness #3), and received an order on 4/8/2013 at 11:30 AM (one hour prior to the Resident's discharge from the facility) to continue [MEDICATION NAME] 150 milligrams daily. During a phone interview on 8/21/2013 at 10:40 AM, Resident #101's attending physician said he had been notified by phone on 4/8/2013 by ADON #5 that [MEDICATION NAME] 150 milligrams had not been administered twice daily as he had ordered, for "a period of time. I wasn't sure how I should monitor this, so I kept him (Resident #101) on the lowered dose (150 milligrams daily); he'd been on it for a long time. The original order (dated 2/15/2013) had been for [MEDICATION NAME] 150 milligrams twice daily; this was based on prior therapeutic response, no [MEDICAL CONDITION], so we continued the same management." According to the Emergency Department Provider Notes dated 4/9/2013 (untimed), "He (Resident #101) has a history of [MEDICAL CONDITION] disorder however this has been stable for quite some time . . . found out also that he has not been receiving his [MEDICATION NAME] which he has been stable on for years." The Transfer Summary of the hospital treating Resident #101, dated 4/11/2013 (untimed), revealed the Resident was diagnosed with [REDACTED]." The summary specified the Resident was discharged from the hospital "on his current medication also with his original [MEDICATION NAME] dose at 150 mg BID." During an interview on 8/21/2013 at 9:05 AM, Nursing Home Administrator #1 said, "We didn't even know we had a med error for a long time. For March (2013) the pharmacy sent a form that had only an area to sign off on the med ([MEDICATION NAME]) once daily in the morning, not twice daily."

This citation pertains to MI 478. Based on interview and record review the facility failed to ensure that residents without pressure sores did not develop pressure sores in 3 (#103, #108, #110) of 10 sampled residents, from a total sample of 10 residents, resulting in all three residents developing stage II pressure sores while at the facility. Findings include: Record review of the facility Pressure Ulcer Treatment Policy and Procedure revised date 11/2/11 revealed that staff shall provide care to residents to prevent the development of pressure ulcers. According to the National Pressure Ulcer Advisory Panel, pressure ulcer stages defined stage II as partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. An interview on 12/15/11 at 11:00 AM with the Registered Nurse (RN) skin/wound care nurse #4 revealed that she was not aware of any resident skin care assessment sheets prior to 12/14/11. On 12/14/11 RN #4 stated did skin sweeps/assessments on the facility residents and that she found residents to have open areas of pressure ulcers. RN #4 stated that sampled residents #103, #108, #110 did have recently developed pressure ulcers. An interview on 12/20/11 at 9:25 AM with the director of nursing (DON) #1 was asked about the pressure ulcer/skin program and stated that there was no functioning program. DON #1 reported that stage II pressure ulcers were discovered by a facility wide skin sweep that was done on 12/14/11, and that no skin assessments were being done regularly for facility residents. DON #1 stated that the skin sweeps done facility wide were to establish a baseline of pressure ulcers in the facility. An interview on 12/20/11 at 2:30 PM with the RN #3 reported that Resident #110 was found to have 3 new pressure sores. RN #3 reviewed Resident #110's medical record with the state surveyor and was aware that Resident #110 was admitted on [DATE] with no pressure sores. RN #3 stated that no one documented blanching of Resident #110's skin (red area to right buttocks) for staging as a pressure ulcer. RN #3 stated that the pressure sores were noted on 12/14/11 as already opened areas and staged at level II. Resident #103 Record review of the minimum data set ((MDS) dated [DATE] revealed Resident #103 was a [AGE] year old female with a brief interview of mental status (BIM's) score of 00/15 (severely impaired). Resident #103 was assessed as being totally dependent on staff for transfers and locomotion on the unit. Resident #103 was assessed to have functional limitations bilaterally to lower extremities and to have frequent urinary incontinence. The MDS Skin assessment noted a surgical wound post [MEDICAL CONDITION] repair. Record review of Resident #103's physician monthly orders dated 12/1/11 through 12/31/11 revealed under the treatment section: left hip incision wound: cleanse with normal saline, pat dry, apply Vaseline gauze, and cover with ABD pad every shift. Bilateral Heels: Apply skin prep. There were no orders for treatment of [REDACTED]. Record review of a handwritten order dated 12/2/11 at 2:00 PM for Resident #103 revealed [MEDICATION NAME] to coccyx after cleansing area with normal saline every 72 hours and PRN-[DIAGNOSES REDACTED]. Record review of the skin care plan dated 10/26/11 revealed Resident #103 was at risk for infection related to impaired skin integrity do to surgical wound. Interventions included care of the surgical wound, care of heels, skin assessment weekly with shower. There were no noted updated interventions for the stage II pressure ulcers noted. Resident #108 Record review of Resident #108's minimum data set ((MDS) dated [DATE] revealed an [AGE] year old male with a brief interview of mental status (BIM's) score of 3/15 (severely impaired). Resident #108 was assessed as needing extensive assistance for transfers and was totally dependent for locomotion on the unit. Resident #108 was assessed to have functional limitations bilaterally to lower extremities. The MDS skin assessment noted Resident #108 as being at risk for pressure ulcers, but did not list Resident #108 as having current pressure ulcers. Record review of Resident #108's physician monthly orders dated 12/1/11 through 12/31/11 revealed under the treatment section: Please shower resident at least twice weekly. Right elbow: cleanse skin tear with normal saline, apply steri strips, and monitor every shift until healed. There were no orders for treatment of [REDACTED]. Record review of a handwritten order by RN #4 dated 12/1/11 (un-timed) for Resident #108 revealed [MEDICATION NAME] every 72 hours and PRN (as needed) until healed. The order did not give a location as to where the treatment was to be used, or a [DIAGNOSES REDACTED]. Record review of Resident #108's skin care plan dated 10/17/11 revealed Resident #108 was at risk for skin break down do to decreased mobility, confusion, a history of combative behaviors, and depression. Interventions did not include updated interventions for the stage II pressure ulcers and treatment identified on 12/1/11. Resident #110 Record review of the minimum data set ((MDS) dated [DATE] revealed Resident #110 was a [AGE] year old male with a brief interview of mental status (BIM's) score of 5/15 (severely impaired). Resident #110 was assessed as needing extensive assistance for transfers and locomotion on the unit. Resident #110 was assessed to have functional limitations bilaterally to both upper and lower extremities. The MDS skin assessment noted Resident #110 was at risk for pressure ulcers, but did not list the resident as having any pressure ulcers. Record review of Resident #110's admission assessment 11/23/11 at 10:30 AM noted skin condition of Resident #110 was warm and dry and that there was redness to the right buttock area. The was not a note as to if the red area was blanchable (to become pale) or non blanchable and no measurement of the red area was noted. Record review of the nurse notes from 11/23/11 through 12/14/11 revealed that Resident #110's right buttocks reddened area had no documented assessment. Review of the daily skilled nurse's notes dated 11/24/11 and 12/13/11, for skin assessment, did note Resident #110 had a facial rash, but nothing pertaining to the right buttocks red area noted on admission. Record review of the nurse notes dated 12/14/11 (un-timed) revealed that the nurse reported that Resident #110 had 3 open areas on his bottom. A second nurse note dated 12/14/11 (un-timed) revealed that while doing skin assessment it was discovered Resident #110 had 3 open areas stage II pressure ulcers measuring 2 centimeters (cm) X 1.5 cm buttocks, 4 cm X 1.5 cm coccyx, 1 cm X 0.5 cm buttocks. Record review of Resident #110's facility performed skin sweep form dated 12/14/11 revealed a diagram of a human with circular areas which noted stage II pressure ulcers to the bilateral right and left, and midline areas of the buttocks. Record review of the skin care plan dated 5/5/09 (no revised dates noted) revealed Resident #110 was at risk for altered skin integrity due to bowel and bladder incontinence, required assist with transfers, and increased risk for diabetic wounds. Interventions did not include updated interventions for the stage II pressure ulcers and treatment identified on 12/14/11. #

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT 1 OF 7 RESIDENTS (#1) REVIEWED FOR FALLS FROM A TOTAL SAMPLE OF 11, RECEIVED APPROPRIATE SUPERVISION AND DEVICES TO PREVENT ACCIDENTS RESULTING IN A FALL WITH A FRACTURED HIP. FINDINGS INCLUDE: ACCORDING TO THE ADMISSION FACE SHEET DATED 9/1/11 AND THE NOVEMBER 2011 physician's orders [REDACTED]. A FACILITY REPORTED INCIDENT FORM DATED 10/22/11 INDICATED THAT ON 10/21/11 RESIDENT #1 WAS FOUND ON THE FLOOR IN HER BEDROOM "ON HER BACK BY HER CHAIR". THE RESIDENT HAD COMPLAINED OF HIP PAIN AND WAS SENT TO THE HOSPITAL AND treated for [REDACTED]. HER BED." THE FALLS CARE PLAN FOR RESIDENT #1 DATED 9/1/11 HAD "BED ALARM ON IN BED " AND "BED AND CHAIR ALARMS" ON THE CARE PLAN WITH THE FIRST CROSSED OUT AND THE "BED" PART OF THE SECOND CROSSED OUT. NEITHER CHANGE WAS DATED SO IT WAS IMPOSSIBLE TO TELL WHEN THE BED ALARM HAD BEEN DISCONTINUED. THERE WAS NO ENTRY FOR A "TWEETER" ALARM ON THE CARE PLAN. THE CARE PLAN ALSO STATED "KEEP BED AT LOWEST LEVEL AT ALL TIMES". "WHILE RESIDENT IN IT" HAD BEEN HANDWRITTEN IN BUT NOT DATED AS TO WHEN THAT INTERVENTION WAS ADDED. A REVIEW OF THE "DISCIPLINARY FORM" FOR THE STAFF PERSON WHO HAD BEEN CARING FOR RESIDENT #1 JUST PRIOR TO THE FALL STATED "LEFT RESIDENT'S BED IN HIGH POSITION RATHER THAN THE LOWEST POSITION. FLOOR MAT WAS PLACED ON FLOOR ON WRONG SIDE, MAKING IT VERY SLIPPERY." AN INTERVIEW WITH THE FACILITY ADMINISTRATOR ON 11/22/11 AT 8:45 AM CONFIRMED THAT THE STAFF MEMBER INVOLVED WAS TERMINATED. ACCORDING TO THE "PT (PHYSICAL THERAPY) EVALUATION & PLAN OF TREATMENT" DATED 10/27/11 THE "CURRENT REFERRAL - REASON FOR REFERRAL" PT (PATIENT) SUSTAINED A FALL WITH LT (LEFT) HIP FX (FRACTURE) ON 10-21-11 AND THA (TOTAL HIP ARTHROPLASTY) PERFORMED ON 10-21-11. PT IS NON AMBULATORY AND HAS DECREASED FUNCTIONAL INDEPENDENCE". PRIOR TO THE FALL, RESIDENT #1 HAD BEEN USING A WHEELCHAIR (PER FALL CARE PLAN DATED 9/1/11). AS OF 11/2/11, THE FALL CARE PLAN WAS REVISED TO INCLUDE THE USE OF A "GERI-CHAIR (WITH) TRAY TABLE AT ALL TIMES WHEN UP" MAKING FOR A MORE RESTRICTED ENVIRONMENT. THIS WAS CONFIRMED WHEN THE RESIDENT WAS OBSERVED AT BREAKFAST ON 11/22/11 AT ABOUT 8:00AM, IN THE DINING ROOM, IN HER GERI CHAIR WITH A TRAY TABLE IN PLACE, BEING FED BY AN AIDE. ( )

THIS CITATION PERTAINS TO MI 342. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO SUPERVISE 1 (RESIDENT #200) OF 5 SAMPLED RESIDENT'S OUT OF A TOTAL SAMPLE OF 5 WHO WAS SEVERELY COGNITIVELY IMPAIRED, NON-AMBULATORY, HAD DECREASED SAFETY AWARENESS AND A HISTORY OF FALLS WHO WAS LEFT IN HIS ROOM IN HIS WHEELCHAIR AND FOUND ON THE FLOOR, RESULTING IN A FALL WITH THREE FRACTURES, PAIN AND hospitalization . FINDINGS INCLUDE: REVIEW OF THE FACE SHEET, MINIMUM DATA SET (RESIDENT ASSESSMENT TOOL) DATED 3/12/11, SOCIAL SERVICE NOTES DATED 3/3/11 THROUGH 4/28/11, MINI-MENTAL EXAMINATION DATED 12/08, PHYSICIAN ORDERS [REDACTED].# 200 WAS admitted to the facility on [DATE], REQUIRING EXTENSIVE ASSIST FOR TRANSFERS USING A MECHANICAL LEFT AND WAS NON-AMBULATORY. THE RESIDENT NEEDED ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING (ADL'S) AND WAS AT HIGH RISK FOR FALLS DUE TO DECREASED COGNITION AND HAVING A HISTORY OF FALLS. THE RESIDENTS [DIAGNOSES REDACTED]. ON 5/28/11, THE RESIDENT fell AT THE FACILITY RECEIVING THREE FRACTURES TO HIS LEFT LOWER LEG AND UPPER FOOT/ANKLE AREA. HE WAS TRANSFERRED TO THE HOSPITAL AND DID NOT RETURN TO THE FACILITY. THE SURVEYOR WAS UNABLE TO OBSERVE RESIDENT # 200; HE WAS NOT LIVING AT THE FACILITY AT THE TIME OF THE INVESTIGATION (6/23/11 THROUGH 7/6/11). REVIEW OF THE CLOSED CLINICAL RECORD, RESIDENT # 200 HAD SEVEN PREVIOUS FALLS AT THE FACILITY PRIOR TO HIS FALL ON 5/28/11. REVIEW OF RESIDENT # 200'S FACILITY FALL RISK ASSESSMENTS DATED 5/26/09, 6/1/09, 6/8/09, 6/23/10, 7/12/10, 8/9/10, 8/10/10, 8/14/10, 8/19/10 AND 9/16/10, STATED HE WAS AT "HIGH RISK FOR FALLS". REVIEW OF RESIDENT # 200'S FALL CARE PLAN DATED 7/10, STATED "HIGH RISK FOR FALLS RELATED TO IMPAIRED MOBILITY, RESIDENT IS NON-AMBULATORY, IMPAIRED COGNITIVE STATUS WITH DECREASED SAFETY AWARENESS, HX (HISTORY) OF FALLS. NOT TO BE LEFT ALONE IN ROOM IN W/C (WHEELCHAIR)". REVIEW OF THE CNA (NURSING ASSISTANT) CARE GUIDE/KARDEX DATED 11/07, STATED "DO NOT LEAVE ALONE IN ROOM IN W/C". REVIEW OF SOCIAL SERVICE PROGRESS NOTE DATED 3/3/11, STATED "RESIDENT (RESIDENT # 200) HAS HX (HISTORY) OF ALZHEIMER'S DEMENTIA AND AGITATED DEPRESSION. HE IS A SOCIAL GENTLEMAN, TYPICALLY PLEASANT. PT (PATIENT) IS OBVIOUS WHEN HE IS QUIET OR NOT NICE TO PEOPLE THAT SOMETHING IS WRONG WITH HIM". REVIEW OF THE FACILITY UNUSUAL OCCURRENCE REPORT DATED 5/28/11 AT 1:50 P.M. AND FACILITY INVESTIGATION DATED 6/2/11, REVEALED A CNA TOOK RESIDENT # 200 TO HIS ROOM TO TOILET HIM. THE CNA LEFT THE RESIDENT ALONE IN HIS ROOM, SITTING IN HIS WHEELCHAIR AND WENT TO FIND ASSISTANCE BECAUSE HE WAS A TWO PERSON TRANSFER. ANOTHER STAFF MEMBER HEARD THE RESIDENTS CHAIR ALARM GOING OFF, WENT INTO HIS ROOM TO FIND HIM FACE DOWN ON THE FLOOR. REVIEW OF THE HOSPITAL HISTORY AND PHYSICAL DATED 5/28/11, REVEALED AN X-RAY (DATED 5/28/11) THAT SHOWED RESIDENT # 200 HAD A CLOSED LEFT TIBIA (LOWER LEG BONE) AND FIBULA (LOWER LEG BONE) FRACTURES AND A FRACTURE OF THE NAVICULAR BONE (TOP OF THE FOOT/ANKLE BONE). REVIEW OF THE FACILITY PHYSICIAN ORDER [REDACTED].M., STATED "TRANSFERRED TO (HOSPITAL) ER (emergency room ) VIA MMR (MOBILE MEDICAL RESCUE)". REVIEW OF THE FACILITY TRANSFER AND REFERRAL RECORD DATED 5/28/11 STATED "RESIDENT (RESIDENT # 200) HAD A FALL, UN-WITNESSED HAD A BRUISE L (LEFT) SHIN AND RESIDENT C/O (COMPLAINED) PAIN AND ALSO HAD MEDIUM EMESIS (VOMITED)". REVIEW OF THE HOSPITAL EMERGENCY DEPARTMENT NOTES DATED 5/28/11, STATED "ACCORDING TO (RESIDENT # 200'S FAMILY MEMBER) SHE GOT A PHONE CALL FROM THE (FACILITY) AT 4:00 P.M. SHE WAS TOLD THAT (RESIDENT # 200) HAD FALLEN AT 2:00 P.M. IN THE AFTERNOON. HE WAS IN HIS WHEELCHAIR UNSUPERVISED IN HIS ROOM. INITIALLY THEY (THE FACILITY) STATED THAT THERE WAS NO INJURY BUT WHEN THEY WERE GETTING HIM READY FOR DINNER THEY NOTICED THAT HIS LEFT LEG WAS BOTHERING HIM AND SENT HIM INTO THE EMERGENCY DEPARTMENT. HIS (FAMILY MEMBER) STATES THAT HE SHOULD NOT BE UNACCOMPANIED IN HIS WHEELCHAIR BECAUSE HE DOES END UP FALLING FROM IT. HE CAN ONLY BE IN HIS RECLINER IN HIS ROOM UNACCOMPANIED. THE PATIENT IS DEMENTED AND CAN GIVE VERY LITTLE HISTORY. UPON QUESTIONING AND PHYSICAL EXAM HE FINALLY STATES THAT HIS LEG IS HURTING HIM". REVIEW OF UNUSUAL OCCURRENCE STAFF (HOUSEKEEPER #1) STATEMENT DATED 5/28/11 AT 12:40 P.M., STATED IN "DINING ROOM WAITING TO CLEAN AND YOU HEARD (RESIDENT # 200) SAYING, "I NEED TO GO TO BATHROOM", AIDE (CNA #3, ON 5/28/11 ASSIGNED TO RESIDENT # 200'S UNIT) CAME IN AND (HOUSEKEEPER #1) TOLD AIDE (THE RESIDENT) NEEDED BATHROOM, SHE (CNA #3) LEFT HIM IN DINING (THE DINING ROOM), SHE WAS TAKING RESIDENT'S TO ROOM'S, CAME BACK, HE (THE RESIDENT) TOLD HE HAD TO GO BATHROOM, SHE (CNA #3) TOOK HIM (TO HIS ROOM)". AN INTERVIEW WAS DONE ON 6/28/11 AT 10:35 A.M., WITH HOUSEKEEPER #1. HOUSEKEEPER #1 STATED "HE (RESIDENT # 200) WAS SAYING REAL LOUD "I HAVE TO GO TO THE BATHROOM". HE WAS YELLING, HE WAS NOT TRYING TO GET UP. OTHER RESIDENT'S AND MYSELF WERE IN THE DINING ROOM AT THE TIME. I LOOKED DOWN THE HALL; I DID NOT SEE ANYBODY, SO WHEN THE YOUNG LADY (CNA #3) CAME BACK I TOLD HER HE HAD TO GO TO THE BATHROOM. THERE WAS ABOUT 6 RESIDENT'S LEFT IN THE DINING ROOM (UNSUPERVISED), I CAN'T CLEAN WHEN THEY'RE IN THERE " . AN INTERVIEW WAS DONE ON 6/28/11 AT 12:55 P.M., WITH CNA #3 (ON 5/28/11, ASSIGNED TO RESIDENT # 200'S UNIT). CNA #3 STATED "I STARTED AT 1:15 P.M. (ON 5/28/11). THE ONLY ONE I REMEMBER IN THE DINING ROOM WAS (HOUSEKEEPER #1). HE (RESIDENT # 200) WANTED TO GO TO THE BATHROOM AND HE WAS YELLING HE HAS TO GO TO THE BATHROOM. I TOLD HIM I WOULD TAKE HIM TO THE BATHROOM. I PULLED THE CORD LIGHT IN THE BATHROOM (THE RESIDENTS ROOM BATHROOM), I KNEW HE USED A LIFT (A MECHANICAL LIFT) AND WAS A 2 PERSON ASSIST. I DID NOT LOOK AT THE RESIDENT INFORMATION SHEET (THE CNA CARE GUIDE/KARDEX IN THE RESIDENTS ROOM). I WAITED MAYBE 3 MINUTES; THERE WAS NO STAFF IN THERE, SO I WENT DOWN THE HALL, ALL THE WAY TOWARD THE END. I COULD NOT FIND ANYONE WHO WAS FREE. I HEARD CODE GREEN (A PAGE INDICATING A RESIDENT FALL) BY THAT TIME, HE HAD fell . I WAS LOOKING FOR HELP FOR ABOUT 2 MINUTES " . REVIEW OF THE UNUSUAL OCCURRENCE STAFF (LPN CHARGE NURSE #1, ON 5/28/11 ASSIGNED TO RESIDENT # 200'S HALL) STATEMENT DATED 5/28/11 AT 1:50 P.M. STATED "OTHER NURSE CALLED ME TO RESIDENTS (RESIDENT # 200) ROOM, RESIDENT PRONE (FACE DOWN) ON FLOOR IN FRONT OF W/C. SWELLING NOTED ON LEFT SHIN, INDENTATION NOTED BELOW SWELLING ON SHIN, ANKLE JOINT " LOOSE " NO SWELLING OR REDNESS NOTED. RESIDENT WAS LEFT ALONE IN ROOM IN W/C, RESIDENTS BRIEF WAS SOILED WHEN FOUND ON FLOOR". REVIEW OF THE NURSES NOTES DATED 5/28/11 (NO TIME DOCUMENTED), STATED "RESIDENT (RESIDENT # 200) FOUND ON FLOOR OF ROOM IN (1:50 P.M.) FRONT OF W/C BY AIDE WHO HEARD ALARM GO OFF. resident sustained [REDACTED]. RESIDENT WAS GIVEN VICODIN 5/500 MG (PAIN MEDICATION). ALERT NO COMPLAINTS OF PAIN UNLESS L LEG IS MANIPULATED. 4:15 (P.M.) AIDE REPORTED WHEN PUTTING ON RESIDENTS SOCKS, ANKLE WAS "LOOSE". RESIDENT VOMITED". A PHONE INTERVIEW WAS DONE ON 6/28/11 (AT 9:55 A.M.) AND ON 7/6/11 (AT 3:15 P.M.), WITH RESIDENT # 200'S FAMILY MEMBER. THE FAMILY MEMBER STATED "THEY (THE FACILITY) NOTIFIED ME (OF THE RESIDENTS FALL) AT 4:45 P.M. (ON 5/28/11); THEY SAID THEY DIDN'T KNOW HOW IT HAPPENED. THEY GAVE HIM PAIN MEDS (VICODIN) AND LAID HIM BACK DOWN". REVIEW OF UNUSUAL OCCURRENCE STAFF (CNA #1, ASSIGNED ON 5/28/11 TO RESIDENT # 200'S UNIT) DATED 5/28/11 AT 1:50 P.M., STATED "RESIDENT (RESIDENT # 200) DISCOVERED ON FLOOR OF ROOM IN FRONT OF WHEELCHAIR AFTER HEARING ALARM GOING OFF. LEFT SHIN SWOLLEN, INDENTATION LOWER THEN LEFT SHIN". AN INTERVIEW WAS DONE ON 6/28/11 AT 2:05 P.M., WITH CNA #1. CNA #1 STATED "I WAS GETTING THE LIFT FOR MY RESIDENT AND I HEARD HIS (RESIDENT # 200) ALARM GOING OFF. HE WAS FULL OF BM, HE KEPT SAYING "MY HEAD HURTS, MY HEAD HURTS". THERE IS TIMES WHEN NO ONE IS IN THE DINING ROOM". AN INTERVIEW WAS DONE ON 6/28/11 AT 12:40 P.M., WITH CNA #2 (ON 5/28/11, ASSIGNED TO RESIDENT # 200'S UNIT). CNA #2 STATED "MY NURSE PULLED ME OUT THAT DAY (ON 5/28/11, OUT OF THE DINING ROOM AT THE NOON MEAL) TO LAY (ANOTHER RESIDENT) DOWN. THERE WAS TIMES WHEN NO ONE WAS IN THE DINING ROOM (ON 5/28/11). WE (THE CNA'S) CAN ONLY DO ONE THING AT A TIME". AN INTERVIEW WAS DONE ON 6/28/11 AT 10:15 A.M., WITH RN CHARGE NURSE #1 (ON 5/28/11, ASSIGNED TO THE UNIT RESIDENT #200 WAS ON). RN CHARGE NURSE #1 STATED "I TOLD (LPN CHARGE NURSE #1) TO CALL CODE GREEN (A FACILITY PAGE INDICATING A RESIDENT FALL). WE ASSESSED THE RESIDENT (RESIDENT #200), HE VOMITED LATER. HIS LEFT LEG LOOKED DENTED IN, BELOW HIS KNEE TOWARDS HIS FOOT ON TOP. I ASKED (LPN CHARGE NURSE #1) IF THIS WAS HIS NORMAL AND SHE SAID SHE DID NOT KNOW AND WHEN WE MOVED HIS LEFT LEG IT HURT HIM". AN INTERVIEW WAS DONE ON 6/28/11 AT 10:55 A.M., WITH LPN CHARGE NURSE #2 (ON 5/28/11, ASSIGNED TO THE NON-SKILLED UNIT). NURSE #2 STATED "WHEN I HEARD CODE GREEN, I WENT TO THE SKILLED SIDE (THE UNIT RESIDENT #200 WAS ON). (LPN CHARGE NURSE #1) AND TWO CNA'S WERE IN THE ROOM. THE RESIDENT WAS FACE DOWN; FACING THE LEFT AND HIS WHEELCHAIR WAS BEHIND HIM. HIS LEFT LEG WAS FOLDED (UNDER THE RESIDENT) AND HIS RIGHT LEG WAS STRAIGHT. THE LEFT SHIN, WHEN WE TOUCHED IT HE WAS SCREAMING OUT. WHEN I CAME BACK IN THE ROOM (AT 4:30 P.M.), HIS LEFT LEG LOOKED INDENTED TOWARDS THE FOOT. I FELT IT AND IT FELT WARM TO TOUCH AND (LPN CHARGE NURSE #1) SAID HE HAD JUST VOMITED". AN INTERVIEW WAS DONE ON 6/28/11 AT 12:20 P.M., WITH REHAB CNA #1. REHAB CNA #1 STATED "THE KITCHEN (KITCHEN STAFF) LEAVES AT 1:15 P.M., SO STAFF (THE KITCHEN STAFF) CAN'T BE IN THE DINING ROOM AT THAT TIME. I SAW NO ONE IN THERE THAT DAY (ON 5/28/11 AT 1:15 P.M.), YOUR ONLY ONE PERSON AND WHEN YOU HAVE SEVERAL THINGS TO DO, YOU CAN'T". AN INTERVIEW WAS DONE ON 6/28/11 AT 11:50 A.M., WITH CNA #4 (ON 6/28/11, ASSIGNED TO THE UNIT RESIDENT #200 WAS ON). CNA #4 STATED "WE (THE CNA'S) TAKE THE RESIDENT'S BACK TO THEIR ROOM'S OR IN THE HALLWAY (AFTER MEALS) AND THEN WE GO BACK IN AND CLEAN THE DINING ROOM. THERE SHOULD BE SOMEONE IN THERE (IN THE DINING ROOM) ALL THE TIME". AN INTERVIEW WAS DONE ON 6/28/11 AT 1:25 P.M., WITH THE RESTORATIVE MANAGER. THE RESTORATIVE MANAGER STATED "A STAFF MEMBER IS TO BE IN THE DINING ROOM (AT MEAL TIMES) AT ALL TIMES". AN INTERVIEW WAS DONE ON 6/28/11 AT 12:55 P.M., WITH CNA #5 (ON 6/28/11, ASSIGNED TO THE HALL THE RESIDENT WAS ON). CNA #5 STATED "TODAY (A NON-SAMPLED RESIDENT) WAS WALKING AROUND ABOUT 12:45 P.M. (IN THE DINING ROOM AFTER AT THE NOON MEAL). SHE GOT UP AND HER ALARM WAS GOING OFF AND NO ONE WAS IN THE DINING ROOM, NO STAFF. THERE WERE ABOUT 12 RESIDENT'S IN THE DINING ROOM, BUT NO AIDES. THERE SHOULD ALWAYS BE STAFF IN THERE (THE DINING ROOM) AT MEAL TIMES". REVIEW OF THE RESIDENT INFORMATION SHEET (CNA KARDEX/RESIDENT CARE GUIDE) POLICY DATED 5/18/10, STATED "UPON COMPLETION THE KARDEX IS HUNG BEHIND THE BATHROOM DOOR FOR EACH PARTICULAR RESIDENT. BEFORE PROVIDING CARE IT IS THE RESPONSIBILITIES OF THE NURSING ASSISTANT TO CHECK THE KARDEX FOR THE KINDS OF CARE THEY ARE EXPECTED TO PROVIDE. CARE PROVIDED SHOULD ALWAYS MATCH WHAT IS ASSIGNED ON THE KARDEX". REVIEW OF THE FALL MANAGEMENT PROGRAM DATED 5/11, STATED "IT IS THE POLICY OF (THE FACILITY) TO IDENTIFY AND TREAT THE FALL RISK POTENTIAL OF EACH INDIVIDUAL RESIDENT BY IMPLEMENTATION OF ITS FALL MANAGEMENT PROGRAM, THEREBY MAINTAINING RESIDENT SAFETY TO THE GREATEST PRACTICABLE". REVIEW OF THE FACILITY FALL PREVENTION POLICY AND PROCEDURE DATED 5/11, STATED "IT IS THE POLICY (THE FACILITY) HOME TO IDENTIFY AND TREAT THE FALL RISK POTENTIAL OF EACH INDIVIDUAL RESIDENT BY IMPLEMENTATION OF ITS FALL PREVENTION PROGRAM, THEREBY MAINTAINING RESIDENT SAFETY TO THE GREATEST PRACTICABLE EXTENT". REVIEW OF RESIDENT # 200'S CLOSED CLINICAL RECORD, HOSPITAL RECORDS, FACILITY UNUSUAL OCCURRENCE REPORTS AND THROUGH STAFF INTERVIEWS, IT WAS REVEALED ON 5/28/11 AT 1:50 P.M., A CNA LEFT THE RESIDENT ALONE IN HIS WHEELCHAIR IN HIS ROOM TO GET ASSISTANCE TO TOILET HIM. THE UNSUPERVISED RESIDENT GOT UP, fell AND RECEIVED THREE FRACTURES. THE RESIDENTS CARE PLAN AND CNA CARE GUIDE/KARDEX SAID NOT TO LEAVE HIM ALONE IN HIS WHEELCHAIR IN HIS ROOM DUE TO HIS HISTORY OF FALLS AND BEING SEVERELY COGNITIVELY IMPAIRED. THE CNA admitted SHE DID NOT LOOK AT THE RESIDENTS CARE GUIDE/KARDEX FOR CARE INSTRUCTIONS WHEN SHE TOOK HIM TO HIS ROOM TO TOILET HIM. REVIEW OF THE CNA'S FACILITY ORIENTATION DOCUMENTATION REVEALED SHE HAD BEEN EDUCATED ON RESIDENT SAFETY DURING HER ORIENTATION. ( )