Every finding on record at Harmony Village of Clawson

This citation pertains to intake #3075905 Based on interview and record review, the facility failed to ensure an accurate accounting of administration of controlled substances for three residents (R904, R905 and R906) of four residents reviewed for pharmacy services. Findings include: On 7/20/26 a concern submitted to the Stage Agency was reviewed which alleged there was an issue with controlled substance logs (CSL) and administration of controlled substances. On 7/20/26 at approximately 11:45 a.m., the Director of Nursing (DON) and the facility Administrator (abuse Coordinator) were interviewed pertaining to the allegation that a Nurse was signing another Nurses signature on the controlled substance log. The Administrator stated the allegation arose when the facility did an audit of controlled medications and identified that Nurse C had signed out some narcotic medications but did not document them as being administered on the Medication Administration Record (MAR). A facility wide audit was conducted in which all controlled medications were reconciled without any missing medications. All counts came up correct and no residents complained about missing medications. On 7/20/26 at approximately 12:45 p.m. during a conversation with Nurse Manager D (NM D), NM D reported they were the Nurse Manager that had completed the controlled substance investigation. On 6/25/26 Nurse C indicated that she thought another Nurse, (Nurse E) was signing their name on the controlled substance sheet. When Nurse C made the allegation to NM D, NM D reported they completed a review of the controlled substance administration and logs and could not identify any evidence of forged signatures but Nurse C had an issue with removing controlled substances from the lock box and documenting on the controlled substance log that the medications were administered however, they were not documenting the administration on the MAR. On 7/20/26 at approximately 1:00 p.m., a review of NM D's investigation was conducted with NM D and revealed the following: R904's CSL for June 2026 of oxycodone revealed Nurse C pulled the oxycodone on 6/25/26 at 1300 (1:00 p.m.) for administration. A review of R904's June 2026 MAR revealed no documentation that Nurse C had administered R904's oxycodone to them at that time. R905's CSL for June 2026 of oxycodone revealed the medication was pulled from the lock box for administration on 6/16/26 at (approximately) 0100 (1:00 a.m.), 6/16/26 at 1000 (10:00 a.m.), 6/16/26 at 1500 (3:00 p.m.) and 6/16/26 at 2100 (9:00 p.m.). A review of R905's June 2026 MAR revealed only one documented administration on 6/16/26 at 0530 (5:30 a.m.). R906's CSL for June 2026 of oxycodone revealed the medication was pulled from the lock box for administration on 6/23/26 at 8:00 a.m. and at 4:10 p.m. by Nurse C. A review of R906's June 2026 MAR revealed the only documentation of the oxycodone being administered was at 0215 (2:15 a.m.). Both of the 8:00 a.m. and 4:10 p.m. doses were not documented as being administered. An Employee Counseling Notice dated 6/25/26 for Nurse C revealed the following: After audit noted MAR and TAR (treatment administration record) did not have full signatures with time/date/signature signed out on MAR but signed out on book (CSL). [Nurse C] educated that all must match. [Nurse C] will ensure that PRN signature corresponds and accurate with MAR and narcotic signature page complete with time/date/signature. A Conclusion of the medication audit completed by NM D revealed the following: Conclusion of possible medication diversion after audit. Noted computer medical record and the controlled sheet did not have all dates signed out to reflect the times and dates on the controlled sheet proof of use record. Discussed with [Nurse C] who worked on 6/25/26 to ensure that both records reflect time given/pain level and time administered. [Nurse C] stated on 6/1 1 /26 after working before and after [Nurse E] I noticed my signature in the book. [Nurse C] further stated, After I work with her, I notice some signatures are not mine, so i have been signing [Nurse C] after my signature so I know it's me. [Nurse C] has a trend of not signing narcotics off in the narcotic book since her start date in May. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included.1. Random audits of narcotic administration records and Medication Administration Records (MARs) will be conducted to verify accuracy and consistency of documentation. 2. Any discrepancies identified during audits will be reviewed promptly and addressed through additional investigation, education, and corrective action as appropriate. 3. Education will be provided to all licensed nurses regarding narcotic documentation requirements, proper medication administration documentation, and the expectation that concerns involving possible forged signatures, documentation discrepancies, or suspected medication misappropriation be reported immediately to management. 4. Education will reinforce abuse reporting requirements and employee responsibility to immediately report concerns involving resident safety, medication administration, or documentation practices. 5. Management will continue to monitor resident pain management concerns through resident interviews, chart audits, and medication administration reviews. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on interview and record review, the facility failed to ensure Medicare liability notices were provided to the residents' court appointed legal representative responsible for finances for two (R15 and R16) of three residents reviewed for liability notices. Findings include:Review of the documentation provided by the facility revealed only three residents that were discharged from Medicare covered Part A services with benefit days remaining in the past 6 months and all remained in facility. Further review of the documentation revealed R15 and R16 both had legal guardians which were also in charge of financial decisions. R15:R15 was discharged from Medicare A benefits on 1/28/26. The documentation revealed R15 signed the Notice of Medicare Non-Coverage (NOMNC) form on 1/26/26 and also signed the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) form on 1/18/26. Further review of the clinical record revealed prior to and at the time the resident was cut from Medicare A coverage, they had a legal guardian in place. Additionally, the profile information identified this legal guardian was responsible for billing statement and primary contact - financial. Review of the clinical record revealed R15 was initially admitted into the facility on 8/30/24 and readmitted on [DATE] with diagnoses that included: cerebral infarction, paranoid schizophrenia, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, unspecified psychosis, and violent behavior. According to the Minimum Data Set (MDS) assessment dated [DATE] indicated R15 scored a 14/15 on the Brief Interview for Mental Status (BIMS) exam which indicated intact cognition (however they had continued legal guardianship with financial responsibilities implemented). Further review of the progress notes included an entry on 1/26/26 at 12:20 PM by MDS Nurse 'K' that read:[R15] has been receiving therapy and skilled care under Medicare A. At this time she is receiving skilled therapy and has no other skilled needs. Her last day of coverage will be 1/28/2026. Reviewed Notice of Medicare Non Coverage and Advanced Beneficiary Notice with [R15] at this time. [R15] states that she understands and is not interested in appealing at this time. Copy of NOMNC and ABN given to [R15]. R16:R16 was discharged from Medicare A benefits on 12/11/25. The documentation revealed R16 signed the NOMNC form on 12/9/25 and also signed the SNFABN form on 12/9/25. Further review of the clinical record revealed prior to and at the time the resident was cut from Medicare A coverage, they had a legal guardian in place. Additionally, the profile information identified this legal guardian was responsible for billing statement and primary contact - financial. Review of the clinical record revealed R16 was initially admitted into the facility on 7/22/25 and readmitted on [DATE] with diagnoses that included: Parkinson's disease without dyskinesia, without mention of fluctuations, acute metabolic acidosis, major depressive disorder recurrent, mild, mild cognitive impairment of uncertain or unknown etiology, cerebral infarction due to embolism of unspecified vertebral artery, dysthymic disorder, dementia in other diseases classified elsewhere moderate with mood disturbance, and vascular dementia. According to the MDS assessment dated [DATE], R16 had a BIMS scored of 15 which indicated intact cognition (however they had continued legal guardianship with financial responsibilities implemented). Further review of the progress notes included an entry on 12/9/25 at 11:20 AM by MDS Nurse 'K' that read:[R16] was recently hospitalized and returned to ECF (Extended Care Facility). She was evaluated by skilled therapy and found to have had functional deficits and need for therapy. Per therapy [R16] was reluctant to participate in therapy and had frequent refusals. [R16] has stabilized since hospital and has no other skilled needs at this time. Notice of Medicare Non Coverage and Advanced beneficiary notice issued to [R16] at this time. She verbalized understanding and signed Notices. copies of notices given to [R16] at this time. On 5/13/26 at 9:31 AM, the facility was requested via email to provide the NOMNC/SNFABN policy. On 5/13/26 at 10:15 AM an interview was conducted with MDS Nurse 'K'. When asked what their process was for providing the NOMNC and SNFABN notices, MDS Nurse 'K' reported they initiated the NOMNC and further reported whenever they had a resident that was alert and they had BIMS of 14 or 15 they would have them sign. When asked if there would be a different process if the resident had a legal guardian and if they would be notified, MDS Nurse 'K' reported if the resident had a high BIMS score, they would have them sign. On 5/13/26 at 11:30 AM, the Administrator reported there was no policy specific for the NOMNC/SNFABN process but acknowledged they were aware if the resident had a legal guardian, then the legal guardian should've been notified.

Based on observation, interview, and record review, the facility failed to ensure appropriate infection control practices when handling ready-to-eat food for one resident (R59) of seven residents reviewed for infection control. Findings include: On 5/11/26 at 12:22 PM, an observation of the lunch meal on the second floor was conducted. During the observation, Certified Nurse Aide (CNA) 'C' was observed providing one-to-one feeding assistance to R59. While providing assistance, CNA 'C' removed a dinner roll from a plastic snack bag with their bare hands and placed it on R59's plate. On 5/11/26 at 12:27 PM, CNA 'C' was observed to tear off a piece of the dinner roll and feed it to R59 with their bare hands. Continued observation of the meal revealed CNA 'C' repeatedly handling the dinner roll with their bare hands On 5/13/2026 10:57 AM, an interview was conducted with the facility's Infection Control Preventionist. They were asked about handling ready to eat foods with bare hands and indicated gloves should be worn. A review of the 2009 Michigan Modified Food Code effective October 2012 was conducted and read, .Preventing Contamination from Hands. (A) FOOD EMPLOYEES shall wash their hands as specified under S 2-301.12 .FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing EQUIPMENT .

This citation pertains to intake #'s 2688115 and 2682315.Based on observation, interview and record review, the facility failed to appropriately assess, supervise and ensure an environment was free of sexual abuse for two legally incapacitated residents with severely impaired cognition (R909 and R910) of ten residents reviewed for abuse, resulting in R909 and R910 being found unsupervised involved in a sexual encounter in R909's bed, both unclothed from the waist down, with R910 in between R909's legs with R909's legs up in the air. Applying the reasonable person concept standard, this deficient practice resulted in the increased likelihood of serious psychosocial harm, serious injury and/or death to occur. Findings include:The Immediate Jeopardy (IJ) began on 11/29/25 when the facility staff failed to ensure an environment free of sexual abuse. The IJ was identified on 12/23/25 and the Administrator was notified of the Immediate Jeopardy on 12/23/25 at approximately 4:42 PM. A plan of removal was requested at that time to remove the immediacy.The surveyor team confirmed by Observation, Interview and Record review that the Immediate Jeopardy was removed on 12/23/25 based on the facility's implementation of an acceptable plan of removal. The noncompliance remains at an isolated event with the potential for more than minimal harm that is not immediate jeopardy due to sustained compliance that has not been verified by the State Agency (SA).On 12/23/25 multiple complaints submitted to the State Agency were reviewed that alleged R909 and R910 were left unsupervised and subsequently had a sexual encounter with both resident being severely cognitively impaired.R909On 12/23/25 at approximately 9:59 a.m., R909 was observed in their room with non-purposeful ambulation. R909 was queried regarding the sexual encounter between them and R910 on 11/29/25. R909 was observed to be unable to follow any of the conversation and had responses with non-sensical statements, which were unrelated to the topic. R909 was then observed to go into their closet and start touching their clothing that was hanging up, staying they were working on it with other incoherent/non-sensical speech. On 12/26/25 at approximately 11:12 a.m., R909 was observed in their room, laying in their bed. R909 was queried if they knew who their legal guardian was and they responded by saying what is that R909 was unable to report what day of the week it was as well as the current year, time of day, who the president was or what they had to eat that morning or who their Nurse was. R909 appeared to continue to present with severe cognitive impairment and was unable to have a sensical conversation and stay on any specific topic. On 12/23/25 the medical record for R909 was reviewed and revealed the following: R909 was initially admitted to the facility on [DATE] and had diagnoses including Post Traumatic Stress Disorder, Dementia with other behavioral disturbance and Impulse Disorders. A review of R909's MDS (minimum data set) with an ARD (assessment reference date) of 9/17/25 revealed R909 needed assistance from facility staff with lower body dressing. R909's BIMS score (brief interview for mental status) was two, indicating severely impaired cognition. A facility document titled Physician Statement of Competency signed by a Psychologist and Physician on 1/19/22 revealed the following: [R909] has been evaluated and deemed incompetent to make medical and financial decisions for the following reason (s) .This person has a current diagnosis of mental illness or [dementia] (dementia circled) .My observations of the above-named person are as follows: Impaired memory and judgement .A legal court document titled Order Regarding Appointment of Guardian of Incapacitated Individual for R909 revealed the following: The court finds: 3. Upon the presentation of clear and convincing evidence, the individual named above [R909], by reason of [x] mental illness .[x] mental deficiency .[x]Physical illness or disability .is impaired to the extent of lacking sufficient understanding or capacity to make or communicate informed decisions and is an incapacitated individual. [x] 4. Upon the presentation of clear and convincing evidence, appointment of guardian is necessary as a means of providing continuing care and supervision of the individual. [x] 5. The individual is [x] totally without the capacity to care for himself/herself 8. The petition for guardian is granted A review of R909's care plan revealed the following: Focus-I have the potential to exhibit behavioral symptoms - including verbal outbursts, care resistance, intrusive behaviors, difficulty with boundaries, and attempts to invite male residents into my room related to cognitive impairment, dementia, psychosis with delusions and hallucinations, mood instability, and impaired judgment. I may become irritable, hyperverbal, confused, or impulsive, which can affect my ability to recognize social cues, maintain personal boundaries, and engage safely with others. These symptoms increase my risk for unsafe or inappropriate interactions and require supportive interventions, monitoring, and redirection to promote safety, dignity, and well-being for myself and those around me. Date Initiated: 10/29/2024. Revision on 11/29/25 .Interventions-Frequent staff checks to monitor my whereabouts, activities and to assess for needs. Date Initiated: 05/27/2025 .Observe for any attempts to lure or invite other residents, especially male residents, into private spaces; intervene immediately and redirect to safe, supervised areas. Date Initiated: 11/29/2025 .A Physician's evaluation for capacity of sexual consent/Intimacy dated 11/29/25 (completed after the sexual encounter had occurred) revealed the following: Assessment Details: Is the resident aware of who is initiating sexual contact? [Yes]. Does the resident believe that the other person is a spouse and, thus acquiesces out of a delusional belief? [No]. Or is he/she cognizant of the other's identity and intent? [Yes]. Resident's ability to avoid exploitation: Does the resident have the capacity to say no to any uninvited sexual contact? [Yes] Resident's awareness of potential risks: Does the resident realize that this relationship may be time limited (placement is temporary)? [No] (marked no). Can the resident describe how [he/she] will react when the relationship ends? [No] (marked no). Capacity for reasoning/consent to sexual relationships Does the resident have the capacity for the reasoning process inherent to sexual consent and Understanding of sexual options, consequences of sexual choices, and consistency with the resident's values and preferences? Capacity for reasoning/consent to sexual relationships Does the resident have the capacity for the reasoning process inherent to sexual consent and Understanding of sexual options, consequences of sexual choices, and consistency with the resident's values and preferences? a. Resident does have the capacity to consent to sexual relationship .A Nursing Incident progress note dated 11/29/25 at 17:31 revealed the following: .Report Type: Allegation of abuse. Description of what occurred: Patient observed with her legs up and male patient over top of her .Immediate intervention implemented: separation, assessment and reporting .An Incident report dated 11/29/25 at 12:40 AM., revealed the following: Incident Description Nursing Description: Patient observed with her legs up and male patient over top of her Immediate Action Taken Description: Patients separated, pain and skin assessment attempted and refused. Law enforcement called . Mental Status-Orientated to Place .Predisposing Physiological Factors: Confused .Impaired Memory .A Nursing progress note dated 12/1/2025 revealed the following: Writer met with daughter, Ombudsman and Administrator to go over patient recent incident and plan of care. Sexual capacity reviewed and explained, no concerns noted. The daughter is in agreement with the sexual capacity results and states understanding. Staff report patient continues to seek male attention periodically .A Nursing progress note dated 12/1/25 revealed the following: Writer visited resident in her room. Denies pain or discomfort. No s/s (signs/symptoms) of any acute distress. When writer asked resident how things have been going, she states just fine. Appears to have no recollection of previous events .A Social Service progress note dated 12/1/25 revealed the following: Wellness Visit: Writer met with resident in room to assess mood and behavior. Resident is in room resting in bed, watching TV, and calm. Resident sat up in bed and engaged writer in conversation when greeted. Resident exhibits some confusion and is not responding to inquiries coherently .A Psychiatry follow-up Evaluation by the Psychiatric Nurse Practitioner dated 12/1/25 that documented R909's cognitive status revealed the following: She is calm, cooperative, and in no apparent distress. She immediately engages with the writer, however her speech is mostly incoherent. At one point it appeared that she was joking about a dog barking then laughing. Her speech is pressured and as she continues her mood is elevated. Patient is not able to contribute in any meaningful way to this assessment due to impaired cognition, incoherent speech and disorganized thought process. Staff indicate that there was an incident on November 29 where the patient was observed lying in bed with her legs up in the air and male resident over the top of her. She has frequent behaviors of seeking male attention and inviting them into her room and then becoming agitated and combative when staff intervenes and attempts to separate her from the other patient. She has a significant history of aggression towards staff and other residents. It is also noted that she will intermittently refuse medications. Staff requested writer assess the patient for appropriateness of prescribing medication to decrease libido. Writer spoke to patient's daughter [Name of daughter] who is her legal guardian and requested that no medication changes be made at this time to continue behavioral interventions She is very often confused at baseline and does appear to be psychotic at times, making it difficult to fully assess due to her level of elevation and cognitive impairment Diagnosis: Dementia with associated psychotic and/or agitated behaviors Symptom(s): Other: Suspected delusions of talking to God, physical aggression, verbal aggression, multiple resident to resident altercations NEUROLOGIC- Cognitive impairment. PSYCHIATRIC- Increased agitation, Verbal aggression toward other residents, Accusatory behavior, Sexually inappropriate behavior with male residents .Psych History Social Psychiatric-Long-standing dementia with psychosis, paranoia, anxiety, PTSD (Post traumatic stress disorder), mood lability, and history of verbal/physical aggression toward staff and residents. Recent sexually disinhibited behaviors including incident on 11/29 involving a male resident; frequently seeks male attention and becomes agitated/combative when staff intervene. Intermittent medication refusal. Today calm and cooperative but incoherent, pressured/hyperverbal with elevated mood; disorganized thought process Ongoing risk for agitation, impulsivity, and sexually disinhibited behaviors; supervision and redirection remain indicated ORIENTATION- Oriented to person only, Current BIMS of 2 ATTENTION/CONCENTRATION- Impaired, JUDGMENT- Impaired, INSIGHT- Impaired, IMPULSE CONTROL- Impaired, SPEECH- Incoherent, Tangential, Hyperverbal, RATE- Pressured, Hyperverbal .THOUGHT PROCESS- Disorganized, Confused, Difficult to follow, FLIGHT OF IDEAS- Present, LOOSENING OF ASSOCIATIONS- Mild. THOUGHT CONTENT- Unable to contribute meaningfully to assessment due to impaired cognition .MEMORY/IMMEDIATE- Impaired. MEMORY/RECENT- Impaired, MEMORY/REMOTE- Impaired, FUND OF KNOWLEDGE- Impaired .BEHAVIOR- Seeking male attention, Becomes agitated and combative when staff intervenes, History of aggression towards staff and other residents, Intermittently refuses medications .Assessment and Plan .Patient continues to exhibit mood instability with significant agitation and combative behaviors. Recent incident on November 29 involved sexually inappropriate behavior with a male resident. She has frequent behaviors of seeking male attention and becoming agitated and combative when staff intervenes. Patient has a significant history of aggression towards staff and other residents .DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE, UNSPECIFIED SEVERITY, WITH OTHER BEHAVIORAL DISTURBANCE *Status: Uncomplicated, Chronicity Level: Chronic: Patient continues to present with significant cognitive impairment (BIMS score of 2) and behavioral disturbances related to her dementia. Today she was found in her room sitting in a chair looking out the window, calm and cooperative but with incoherent speech, joking about a dog barking then laughing. Her speech is pressured with elevated mood. Patient is not able to contribute in any meaningful way to assessment due to impaired cognition, incoherent speech, and disorganized thought process. Staff reported sexually inappropriate behavior with a male resident on November 29. Staff requested assessment for medication to decrease libido, but after discussion with daughter/legal guardian, decided to continue behavioral interventions without medication changes at this time. Nonpharmacological approaches include: maintaining consistent daily routine; providing calm and structured environment; implementing gentle redirection techniques; engaging in meaningful activities matched to cognitive abilities; ensuring adequate supervision especially with male residents; utilizing sensory interventions when agitated; and approaching with calm demeanor using simple, clear communication . PSYCHOTIC DISORDER WITH DELUSIONS DUE TO KNOWN PHYSIOLOGICAL CONDITION- Status: Uncomplicated, Chronicity Level: Chronic: Patient continues to demonstrate disorganized thought process with flight of ideas. Today she was observed to have incoherent, tangential speech with elevated mood. She continues on Seroquel 25 mg in the morning and 37.5 mg in the afternoon. Reduction of Seroquel is contraindicated at this time as it would likely result in worsening psychotic symptoms including increased paranoia, accusatory behavior toward staff and residents, heightened agitation, sleep disturbances, and potential for aggressive outbursts. Given her history of physical aggression and psychotic symptoms requiring hospitalization, maintaining her current antipsychotic regimen is essential for her safety and quality of life. No psychotropic changes made today. Nonpharmacological approaches include: avoiding confrontation about delusional beliefs; using validation therapy when appropriate; redirecting to pleasant topics when she becomes fixated on negative thoughts; minimizing environmental stimuli that may trigger paranoia; maintaining consistent caregivers when possible; and providing reality orientation in a gentle, non-confrontational manner R910On 12/23/25 the medical record for R910 was reviewed and revealed the following: R910 was initially admitted to the facility on [DATE] and had diagnoses including Dementia an Psychosis. A review of R910's MDS with an ARD of 9/20/25 revealed R910 needed supervision/touching assistance from facility staff for lower body dressing. R910's BIMS score was six indicating severely impaired cognition. A legal court document titled Lettes of Guardianship dated 5/6/21 was reviewed and revealed R910 had a legal guardian appointed to them by the probate court. An OBRA (Omnibus Reconciliation Act) level two evaluation signed/dated on 11/18/25 revealed the following: Cognitive Abilities: [R910] presented as alert and oriented x2-3 .His insight, judgement, thought process/content, memory and fund of knowledge fluctuated between fair and poor. He evidenced some mild impairment with his cognitive abilities. He can make his needs and wants known. [R910] has a guardian in place to assist with all his medical and financial decision-making The continued placement of [R910] in a skilled nursing facility is medically and psychologically necessary, primarily due to the convergence of severe cognitive impairment, complex medical needs, and significant safety risks that cannot be managed safely or effectively in a less restrictive environment. He suffers from profound and likely irreversible cognitive impairment, characterized by severe amnesia and confusion. He lacks insight into his need for care. The complexity of managing multiple chronic conditions, including hypertension (on specific holding parameters), hypothyroidism (with recent medication changes), and a history of acute issues (acute kidney failure, UTI), requires the availability of 24/7 skilled nursing care. He requires supervision and moderate assistance with ADLs, which demands dedicated, trained staff. [R910] requires long-term institutional care because his condition demands a highly structured, secure environment with continuous psychiatric, behavioral, and skilled nursing oversight to ensure his safety and the safety of others, which is the definition of continued nursing home necessity .A review of R910's care plan revealed the following: Focus-I have a history of Wernicke's encephalopathy, psychosis, alcohol use disorder, mild cognitive impairment, and mood instability, which may impact my judgment, participation in care, and interactions with others. I am oriented to person and place, able to express my needs, and supported by co-guardians for decision-making. I prefer to remain in bed much of the day and may decline showers, shaving, or haircuts. I have previously demonstrated verbal aggression, including swearing or making inappropriate or sexual comments or advances toward staff or peers, and may occasionally slam my door or make statements perceived as threatening. I am also at risk for elopement. These behaviors may fluctuate based on my cognitive status, mood, and response to psychotropic medications and may require staff to offer cues, redirection, and supportive approaches as needed. Date Initiated: 06/02/2025 .Interventions-1:1 Supervision - initiated 11/29/25. Date Initiated: 11/29/2025. Help me to avoid being alone with female residents. Notify management if I seem to be especially interested in another resident. Date Initiated: 11/29/2025 .A Nursing progress note dated 11/20/25 revealed the following: .Res (resident) continues to have poor impulse and safety control. Res has ongoing aggressive behavior and is difficult to redirect. When redirected he curses, uses vulgar language towards staff, and is exit seeking. [Psychiatric provider] agreeable and will send script to [pharmacy]. Res will be seen during next facility visit scheduled December 2, 2025.A behavior progress note dated 11/26/25 revealed the following: Please describe the behavior that was observed & was it distressing to the resident?: : Resident entered female resident's room An incident note dated 12/1/25 revealed the following: Report Type: Incident/Accident Description of what occurred:[R910] observed by staff laying on top of female res Immediate intervention implemented: Residents separated and [NAME]. (monitored) closely by [NAME] Nursing note dated 12/1/25 revealed the following: Writer visited with resident in his room. Denies pain and there are no s/s of any acute distress. Lying in bed, alert and cooperative. When asked about how things were going, if anything unusual happened, resident was unable to recall .A Psychiatry evaluation dated 12/2/25 completed by the Psychiatric Nurse Practitioner revealed the following: Last seen by behavioral care solutions midlevel provider on November 5, at which time Ativan was discontinued in favor of clonazepam. Staff requested medication review and patient assessment due to a recent incident between him and a female resident where he was found lying on top of her in bed. This is writer's first encounter with the resident who was found in his room lying in bed watching TV. He is alert and oriented to person with confusion noted and a current BIMS of 3 Previously, the patient had been hospitalized on [DATE] due to violent behavior, where he threw a phone at nursing staff and had been going in other resident's rooms and swearing at them. He has had multiple hospitalizations due to his level of physical aggression, including hitting nursing staff. He has a history of exit seeking behavior which has led to punching people in the past. He has very poor impulse and safety control that has led to violent behaviors threatening the safety of himself and other residents .Reason: Gradual dose reduction (GDR) of Zyprexa is contraindicated at this time due to patient's extensive history of significant physical aggression toward staff and other residents, which has previously required hospitalization. Reduction could lead to recurrence of psychotic symptoms, increased agitation, verbal aggression, sexually inappropriate behaviors, and violent behaviors that pose substantial risk to patient and others. The benefit of continued treatment with Zyprexa for behavior control and prevention of hospitalization outweighs the potential risks of metabolic effects, sedation, and fall risk .Review of Systems .NEUROLOGIC- BIMS = 3, oriented to person only .Social Psychiatric Longstanding severe behavioral dysregulation with physical and verbal aggression, exit-seeking, and sexually inappropriate behaviors; poor impulse and safety control with limited judgment and insight. Recent incident with female resident (found lying on top of her). BIMS 3 Risk Assessment Denies suicidal and homicidal ideation. Ongoing risk to self/others due to agitation, aggression, exit-seeking, intrusiveness, and sexually inappropriate behavior Mental Status Evaluation- .ORIENTATION- oriented to person only, not oriented to time, place, or situation. ATTENTION/CONCENTRATION- poor. JUDGMENT- poor. INSIGHT- poor. IMPULSE CONTROL- very poor. THOUGHT PROCESS- primarily confused. MEMORY- very poor, cannot remember episodes of agitation or upset, cannot remember behavior disturbances. FUND OF KNOWLEDGE- impaired .Patient continues to exhibit significant behavioral disturbances with documented episodes of aggression, exit seeking, and difficult redirection. Recently involved in an incident with a female resident where he was found lying on top of her in bed Alcohol dependence with alcohol-induced persisting dementia *Status: Uncomplicated, Chronicity Level: Chronic: Patient continues to have severe cognitive impairment with BIMS score of 3. He is only oriented to person. Patient has significantly impaired memory and cannot remember episodes of agitation after they occur An IDT (interdisciplinary team) review note dated 12/2/25 revealed the following: Nursing Mgt (management), MDS, SW (Social Work), Activity Director, Therapy Manager and medical providers present during At Risk meeting to discuss [R910]. Staff reported an incident involving a female resident. Capacity for sexual consent completed. Wellness checks ongoing. No s/s (signs/symptoms) of distress. Res at baseline and has no recollection of events. Res followed by psych (psychiatry) for behavior and medication management. Next visit scheduled 12/2/2025. PRN(as needed) Clonazepam ordered and effective for agitation. IDT will cont (continue) to [NAME] (monitor).On 12/23/25 a review of the facility investigation pertaining to the sexual encounter between R909 and R910 on 11/29/25 revealed the following: Abuse Investigation Summary Facility .Date of Event: 11/29/2025 Type of Allegation: Possible Sexual Abuse Resident Information Resident [R909] diagnosed with dementia and has a BIMS score of 2. [R909] requires supervision with ADL (activities of daily living) care. She has a legal guardian, her daughter. Staff report that she periodically seeks male attention as part of her baseline behavior, interventions include staff redirection. [R910] diagnosed with dementia and has a BIMS score of 3. [R910] requires 1 person assistance with ADL care. His legal guardian is a contracted guardian company. He has a known history of verbally sexually inappropriate behavior; however, staff' report that he has not exhibited this behavior in quite some time. Both residents reside on the same unit and frequently interact socially. Allegation Summary On 11/29/2025 at approximately 12:50 a.m., staff discovered Resident [R910] in Resident [R909]'s room. Staff observed both residents with their pants down, and Resident [R910] was positioned on top of Resident [R909]. When staff entered the room, both residents immediately began dressing .Immediate Actions Taken Residents were immediately separated. Staff were unable to safely redirect Resident [R910] out of the room; therefore, Resident [R909] was escorted to the nursing station for supervision. Resident [R910] was placed on one-to-one supervision for safety and continued monitoring. Administrator was notified at approx.(approximately) 12:50 am on 11/29/25 by the nurse. Physicians, legal guardians, and the ombudsman were notified. With the intent of ruling out abuse, police were called to the facility, arrived on site, and interviewed both residents. Pain and skin assessments were attempted on both residents; however, both refused On 11/29/2025, physicians completed a Capacity for Sexual Consent/Intimacy Evaluation on both residents. The evaluations determined that both residents have the cognitive capacity to consent to a sexual relationship. Capacity results were shared with both residents and their legal guardians along with counsel on safe sex practices. Staff were educated on the capacity results .care plans updated to reflect the determination that both residents were deemed cognitively able to consent to sex, their desire, and interventions to ensure privacy, safety and dignity. If either resident is likely to seek out other residents for non-exclusive sexual behavior, the facility's approach to limiting access to residents who are unable to consent includes providing staff education and increasing supervision as necessary. These measures help ensure resident safety while supporting appropriate monitoring and intervention. Conclusion Based on staff reports, resident interviews, police findings, physician capacity evaluations, lack of observable sexual activity, absence of injuries, and guardian/ombudsman review, the allegation of abuse is unsubstantiated On 12/23/25 at approximately 10:45 a.m., during a conversation with Social Worker C (SW C ), SW C was queried regarding the sexual capacity evaluation completed for R909 and R909's severely impaired cognitive status. They reported that due to R909's impaired cognition, they were unable to understand the risks, consequences and actions of any sexual encounters. SW C was queried if they believed that R909 was able to adequately process the emotions from the sexual encounter with R910, remember what had happened and who it had happened with, and they reported R909 could not. SW C was queried regarding the facility's determination that R909 had the ability to consent to sexual encounters/intimacy and if R909 would be a vulnerable resident when they could not recall or process any sexual encounters, and they reported that they understood the concern and they would have to review the determination again. SW C was queried regarding the risk section that was documented on the Physician's sexual capacity evaluation that indicated R909 was unable to understand the risks of sexual intimacy, and they reported they did not know how it was determined that R909 could consent to sexual encounters without understanding any of risks. On 12/23/25 at approximately 10:55 a.m., during a conversation with R909's legal guardian D (LG D), LG D was queried regarding the documented meeting with the facility staff and the ombudsman on 12/1/25. LG D was queried if they had provided consent for R909 to have sexual encounters with other residents in the facility and they indicated they did not. LG D reported the facility had informed them of the sexual capacity assessment and that they (the facility) could not stop the resident from having sexual encounters. LG D was queried if R909 had the ability to understand the risks, actions and potential consequences of sexual encounters and they indited they could not. LG D was queried if R909 had the ability to remember the encounters and they reported they did not. LG D was asked if R909 had the cognitive capacity to understand how to practice safe sexual practices including the risks of hurting themselves or contracting a sexually transmitted disease and they reported they did not. LG D reported they had provided consent for companionship with other residents such as in social settings but did not consent for R909 to have sexual encounters. On 12/23/25 at approximately 11:38 p.m., during a conversation with the local ombudsman H (LO H), LO H was queried if they had reviewed the capacity evaluation for cognition (indicating R909 had been declared mentally incapacitated) and the capacity evaluation for sexual consent for R909 during the meeting that they were present at with the facility staff and guardian, and they reported they had not reviewed either of the evaluations.On 12/23/25 at approximately 12:37 p.m., during a conversation with the facility Administrator (abuse coordinator), the Administrator was queried regarding the sexual encounter between R909 and R910. The Administrator reported that R909 was found in their room, in their bed, with R910 on top of them, in between R909's legs and both had all their pants removed and were unclothed from the waist down. The Administrator reported that once the residents were found by Nurse E they were separated immediately. The Administrator was queried regarding R909's sexual capacity assessment conclusion and how R909 was deemed having the capacity to consent to sexual encounters with other residents when they were severely cognitively impaired and not able to remember they had the encounter or who they had the encounter with as well as not having the mental capacity to understand the risks and consequences of sexual encounters and they reported that they understood the concern, but that the Physician had done the sexual capacity assessment. At that time, the Administrator was queried regarding the status of R909 having sexual encounters with residents in the facility and they indicated they were not encouraging it, but it was permitted by facility staff for both R909 and R910 to engage in sexual activity and the facility staff would not intervene. The Administrator was queried regarding the policy pertaining to sexual consent, that referenced the need for both the decision-making capacity evaluation and capacity for sexual consent evaluations to be done and that R909's decision making capacity evaluation dated 1/19/22 had documented R909 was mentally incapacitated to make informed decisions, and they indicated that they understood the discrepancy. On 12/23/25 at approximately 2:57 p.m., during a conversation with Nurse E, Nurse E was queried regarding finding R909 in bed with R910, unclothed from the waist down on 11/28/25. Nurse E reported they were on a split hall that day and could not supervise R910 but knew that they had been wanting to be with R909. Nurse E Stated that it was the midnight shift when it occurred, and that they came back up to the unit and looked for R910 in their room but did not find them in it and subsequently ran down to R909's room and found them both in bed with pants off with R910 in between R909's legs with R909's legs in the air. Nurse E reported they immediately separated both residents. Nurse E was queried if R909 was aware of the sexual encounter with R910 and what had occurred between them and they reported R909 had no recollection of what had occurred two minutes after the incident was discovered. Nurse E was queried if R909 had the capacity to understand risks/actions and consequences of having sexual encounters with other residents and they reported they did not. Nurse E further reported that R909 had severe dementia and did not know what they were doing or where they were. Nurse E was queried if R909 was a vulnerable target for sexual encounters and they reported that they were due to their dementia. On 12/2[TRUNCATED]

This citation pertains to incident: 2647112.Based on observation, interview and record reviews the facility failed to prevent a preventable fall for one (R901) of one resident reviewed for falls with injury, resulting in a preventable closed fracture of the distal end of the left femur and pain. Findings include:On 12/23/25 at 10:10 AM, R901 was observed laying in bed with a white sheet covering their head. The resident was unable to be awoken by verbal stimuli. A review of the medical record revealed R901 was initially admitted to the facility on [DATE] with diagnoses that included- dementia and required assistance from staff for all activities of daily living (ADLs).A review of a Facility's investigation documented the following in part, . On 9/28/2025, CNA (certified nursing assistant) staff turned Resident (R901 name) in bed toward her during care. Resident threw his left leg over and fell from the bed, landing on his left side. On 9/30/25, resident was again sent to the hospital for left leg pain and swelling. On 10/2/2025, facility was notified that the resident sustained a distal femur fracture. Facility investigation identified that the CNA misunderstood the difference between bed mobility and toileting assistance, contributing to the incident.A review of the progress notes revealed the following: An incident note dated 9/28/25 at 8:52 AM, documented in part . At approximately 0530 nursing assistant notified writer while rendering care resident had rolled off the bed on to the floor. When writer entered the room writer observed resident on the floor next to his bed laying on his left side. Writer and nursing assistant transferred resident back to bed. Skin tear to right elbow, left elbow, and skin tear to the left wrist, and redness at the scalp of head noted. Injuries were cleansed and treated as ordered. Order given to transfer resident to the hospital.A Nursing note dated 9/28/25 at 12:52 PM, documented in part . Resident returned to the hospital. The laceration sites are sealed with transparent dressings. He is dependent on assistance for bowel and bladder care.A Nursing note dated 9/28/25 at 5:05 PM, documented in part . Post Fall Note. Resident stated pain in his lower extremity bilaterally. Tylenol 500 mg (milligram) administered.A Nursing note dated 9/29/25 at 9:04 AM, documented in part . Noted right cheek bone in front of right ear abrasion and right toe abrasion lifted toenail. Informed. PA (physician assistant). Treatment order put in place.A change in condition note dated 9/30/25 at 12:49 PM, documented in part . Fall Resident. Does the resident/patient have pain? Yes. send to ER (emergency room) r/o (rule out) fracture left hip/knee/ankle.A PA note dated 10/2/25 at 8:41 PM, documented in part . readmit from (hospital name), noted to have leg selling/bruising, found to have L (left) distal femur fx (fracture). Seen by ortho, non operative management as non ambulatory, had recent fall. unable to stand and walk. multiple skin tears ext (exterior)/face. BLE (bilateral lower extremities) weakness with decreased movement. L femur fx/immobilizer. L knee with swelling/effusion. Mild tenderness.A review of a hospital After Visit Summary dated 10/2/25, documented in part . START taking. HYDROcodone-acetaminophen (NORCO). every 4 hours as needed for Moderate Pain (pain 4-6) or patient description for up to 3 days. Admitting Diagnosis: Closed Fracture of Distal End of Femur.A review of the October, November & December 2025 Medication Administration Records revealed the Norco pain medication was consistently being administered to the resident for pain. A review of a care plan titled I am long term care due to confusion and extensive assist with adls r/t (related to) Alzheimer's Dementia. Initiated 3/8/23, documented the following interventions: Bed Mobility- Extensive assist 2 staff (revised 6/9/25). Further review of the modifications of the care plan revealed R901 was noted as an extensive assist since admission in 2023. Toileting- Two caregivers at all times to complete incontinence care. I am an extensive/total assist with toileting (revised 6/9/25).Another intervention implemented on the care plan noted the following . Dependent with 1 staff, size medium white (initiated 6/9/25). revealing contradicting information. A review of R901's Kardex Report for 9/28/2025, documented in part . TOILETING- Two caregivers at all times to complete incontinence care. I am an extensive/total assist with toileting. BED MOBILITY- Extensive assist 2 staff. Further review of the Kardex noted multiple documentation of the resident to be extensive assistance for mostly all ADLs. On 12/23/25 at 11:04 AM, the Physical Therapy (PT) & Occupational Therapy (OT) assessments last completed before R901's fall on 9/28/25 was requested from Physical Therapist (PT) B and the facility's Administrator. A review of a PT Discharge Summary dated 6/10/2025-8/6/2025, documented in part . Bed Mobility. Baseline (6/10/2025)- Total Dependence w/o (without) attempts to initiate. Previous (6/24/25)- Total Dependence w/o (without) attempts to initiate. Discharge (8/6/2025)- Max (A)- (maximum assistance). Discharge Recommendations: 24 hour care.On 12/23/25 at 12:13 PM, CNA A (the CNA that provided care for R901 at the time of the fall) was interviewed and asked about the incident. CNA A explained they were changing the resident's brief by themselves when R901 rolled off the bed and onto the floor. When asked why they were by themselves when providing care to R901, CNA A stated they knew that the resident needed a two person care for bed mobility but not for toileting. Despite CNA A verbalizing that they were providing incontinence care in R901's bed, CNA A proceeded to provide care with a one person assist.A review of a ONE-ON-ONE IN-SERVICE provided noted in part . Kardex- The Kardex is where you will find all of the pertinent information about how to take care of the resident. The Kardex stems from the care plans which are reviewed and updated as needed with changes in patient needs and incidents.Further review of the facility's investigation revealed the Interdisciplinary team failed to identify the two interventions implemented at the same time for Toileting and the failure to ensure clear and precise interventions for assistance levels were implemented to ensure the residents safety and to prevent preventable accidents. Review of a facility policy titled Incident Reporting - Accidents and Supervision revised 8/24 documented in part . The resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents. This includes. Implementing interventions to reduce hazard(s) and risk(s). Monitoring effectiveness and modifying interventions when necessary. The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. the process of examining data to identify specific hazards and risks and to develop targeted interventions to reduce the potential for accidents. Interdisciplinary involvement is a critical component of this process. using specific interventions to try to reduce a resident's risks from hazards in the environment.On 12/23/25 at 12:50 PM, the Administrator was interviewed and asked about the fall and investigation into R901's fall. The Administrator stated they completed the investigation into R901's fall and identified that CNA A did not properly understand the toileting and bed mobility tasks. When showed the ADL care plan with two interventions implemented for toileting, despite an intervention for toileting and bed mobility to be documented as a two person assistance, the Administrator stated they had only identified the one person assistance intervention during their investigation. The Administrator stated they identified the cause of (CNA A) to have not used the proper assistance level needed. The Kardex for 9/28/25 was reviewed with the Administrator that also noted a two person assistance with toileting care and no response was provided. No further explanation or documentation was provided by the end of the survey.

This citation pertains to intake #'s 2636124 and 2638469.Based on observation, interview and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for five residents (R's 302, 303, 304, 305 and 306) of six residents reviewed for abuse. Findings include:On 10/14/25 the medical record for R302 was reviewed and revealed the following: R302 was initially admitted to the facility on [DATE] and had diagnoses including Dementia, bipolar disorder and Schizophrenia. A review of R302's MDS (minimum data set) with an ARD (assessment reference date) of 10/2/25 revealed R302 needed supervision from facility staff with most of their activities of daily living. A review of R302's careplan revealed the following: Focus-I have a history of demonstrating physical aggression towards others, staff and peers (Spitting, yelling, hitting). At times I pace and either swing my arms or make tight fist - both pose risk for injury. Date Initiated: 07/01/2025. A review of R302's progress notes pertaining to resident-to-resident altercations revealed the following: 10/9/2025-Incident Note-Writer was at medication cart and resident approached me. He seemed upset and I gave him some med pass. He accepted it and walked away towards the receptionist. Other resident was sitting in his wheelchair and [R302] was approaching him yelling out. Receptionist went to get in between residents. Resident in wheelchair backed up and while backing up his wheelchair, he extended his left leg. [R302] then kicked the other resident in the left shin. Resident's were immediately separated and assessed. Resident was placed on increased monitoring, 1:1. 10/9/2025-Nursing: Incident Note-Report Type: Allegation of abuse-Description of what occurred: Resident kicked another resident in the left shin. Immediate intervention implemented: Resident placed on 1:1. 10/03/2025-Type: Practitioner Progress Notes-seen for eval as he was hit on head by another resident. 10/3/2025-Nursing Progress Note-Nurse was notified by CNA (Certified Nurse Assistant) that a female resident called her into her room and stated the following: Resident from room [R302's room number] [R302] entered the female's room, touched her breast, and then put his hand down her brief. At that time, she told him No and then he turned around and went back into his room. The female resident then notified the CNA about the incident. Nurse was notified. Assured residents were separated. Administrator and DON (Director of Nursing) notified. [R302] put on one-on-one observation immediately. Resident unable to give a statement regarding the situation due to his medical dx (diagnosis). Police notified and investigated.Female resident stated that [R302] did not hurt her, she was just scared. Physician notified. 8/22/2025-Nursing: Incident Note-Report Type: Incident/Accident-Description of what occurred: Per receptionist she heard resident yell don't do that, stop. [R302] hit the other resident and I stepped in between them. [R302] turned around and walked away mumbling. Immediate intervention implemented: CNA stayed with resident, petition resident to ER (emergency room). 6/29/2025-Nursing: Incident Note-Report Type: Incident/Accident-Description of what occurred: Resident pacing in the hallways this morning and was reported by another resident that he had hit him. Immediate intervention implemented: Nurse stayed with resident Obtained vitals called doctor. R302 and R306 A review of the facility reported incident (FRI) revealed the following documentation pertaining to R302 kicking R306 on 10/9/25: Resident-to-Resident Altercation Investigation Report Date of Incident: October 9, 2025 Administrator: Resident #1: [R302] Resident #2: [R306] Type of Incident: Resident-to-Resident Physical Contact (Witnessed) Police Notification: [Police report number] Occurrence: On October 9, 2025, resident [R302] made physical contact with resident [R306]. Staff immediately intervened and separated the residents. A skin and pain assessment was completed on [R306], revealing a small bruise on his shin with pain rated 2/10. [R302] was placed on one-on-one supervision for the remainder of the day. The physician and legal guardian were notified. Immediate Actions Taken: Residents immediately separated following the incident. Skin and pain assessments completed on [R306]. Physician and legal guardian notified. One-on-one supervision initiated for [R302] for the remainder of the day. Three-day wellness checks completed on both residents.Interviews / Witness Statements: Witness (Nursing Staff): The nurse reported that [R306] had just finished receiving his medication and was walking down the hall when [R302] approached and began fussing. [R306] extended his leg defensively but did not make contact. [R302] then kicked [R306], striking him on the shin. Staff immediately intervened and separated the residents. Resident Statement [R306]: [R306] confirmed that [R302] kicked him on the leg. He rated his pain 2/10. Conclusion: After reviewing all interviews, documentation, and assessments, the facility determined that this incident meets the criteria for substantiated abuse. [R302] willful act of kicking another resident resulted in physical injury (bruise) and pain, as verified by staff witnesses and assessment. While [R302]'s cognitive impairment limits his understanding, the act itself was willful (not accidental) and resulted in harm, therefore substantiating the finding of resident-to-resident physical abuse. The facility's Abuse, Neglect, and Exploitation Policy was reviewed and followed. All required notifications, interventions, and follow-up actions were completed. A Pain assessment dated [DATE] for R306 revealed the following: .G. Pain Management. 1a. Describe treatment, any side effects and effectiveness: Received scheduled pain medications and ice to area. A progress note dated 10/9/25 for R306 revealed the following: Report Type: Allegation of abuse: Description of what occurred: Resident was kicked in the left shin by another resident. Immediate intervention implemented: Residents were separated and first aid administered to this re3sident <sic>. R302 and R304 A review of the FRI pertaining to an allegation that R302 pushed R304 on 8/22/25 revealed the following: Incident Summary: On Friday, August 22, 2025, at approximately 12:45pm the receptionist [receptionist F] reported to the administrator that resident [R302] pushed resident [R304] in the hallway. [receptionist F] immediately intervened, separating the two residents. Upon investigation it was determined that resident [R304] was ambulating in his wheelchair down the hallway as resident [R302] was approaching from the opposite direction. [R304] extended his foot outward, which [R302] perceived as an attempt to kick him. In response [R302] became upset and pushed him. Receptionist [receptionist F] promptly intervened to de-escalate the situation and ensured both residents were separated. A witness statement from Receptionist F dated 8/22/25 revealed the following: I was at the front desk and saw [R302] walking down the hallway. [R304] was in his wheelchair rolling down the hall. [R302] walked up on him and pushed him. I jumped up and ran to them and separated them. I told [R302] that he can't put his hands on another resident and he pointed to [R304] and [R302] was kicking his foot saying [R304] was trying to kick him. A progress note for R304 dated 8/22/25 revealed the following: Report Type: Allegation of abuse. Description of what occurred: Per receptionist, I heard yelling and went toward the yelling and as I arrived toward <sic> yelling near [room] 120 saw [R302] kick [R304] in the left hand. I immediately separated them. Immediate intervention implemented: pain assessment. On 10/14/25 at approximately 1:22 p.m., Receptionist F was queried regarding the altercations between R302 and R304 and R306. Receptionist F Sated that they were at the front desk and saw R304 come down the hall in their wheelchair. R302 walked up to R304 and pushed him with both of his hands. A 1:1 supervision was started with R302. Both residents were using profanity, and they informed the Nurse. Receptionist F was queried regarding R302 kicking R306 in the shin and they reported they witnessed that happen as well, and it was in the same hallway where the front desk was located and that R306 was walking down the hallway and R302 saw them and got mad and then kicked R306 in the leg. On 10/14/25 at approximately 2:46 p.m., the facility Administrator (abuse coordinator) was queried regarding the multiple physical abuse incidents involving R302. The Administrator reported that the incident on 8/22/25 involving R304 had been substantiated because it was witnessed by the Receptionist F. Stated R302 was separated from R304 immediately after the altercation and was provided a staff member for 1:1 supervision until they were transferred to the hospital. The Administrator was queried regarding the altercation between R302 and R304 and they indicated that they were still working on that investigation as it had occurred on 10/9 but that it was substantiated. The Administrator was queried about how they are trying to protect other residents from R302 and they indicated that they try to provide a 1:1 staff member for him when they notice him getting agitated and try to keep other residents away but that it is difficult because he is frequently impulsive. R302 and R303 Review of a facility provided investigation revealed, .On October 3, 2025, at approximately 3:00 PM, (R303) was observed striking (R302) during an altercation. Based on staff witness accounts, resident interviews, and assessment findings, the investigation confirmed that [R303] struck [R302]. Review of the clinical record revealed R303 was admitted into the facility on 3/10/25 with diagnoses that included: stroke with paralysis affecting right side, dementia and major depressive disorder. According to the MDS assessment dated [DATE], R303 had moderately impaired cognition. Review of R303's comprehensive care plan revealed a Focus created 10/8/25 that read, I have potential to demonstrate physical behaviors (hitting, slapping) r/t [related to] Dementia, Mental Illness. On 10/14/25 at 1:47 PM, Staff D, who served as the Health Information Coordinator, was interviewed and asked if she witnessed R303 strike R302. Staff D explained she had just walked out of an office when she saw R303 stand up and smack R302 on the back of the head. Staff D was asked if she had ever seen R303 hit anyone before. Staff D explained she had not, R303 will cuss out other people, but had never seen him hit anyone before and had also not known R303 could stand, she had always seen him in a wheelchair. On 10/14/25 at 1:52 PM, Unit Manager (UM) C was interviewed and asked about R303 hitting R302. UM C explained R302 was in her office to get a pop and he wanted some popcorn, so she was bending down to get the popcorn when she saw R303 stand up and hit R302 on the back of the head. was surprised, she did not know R303 could stand. R303 was not normally like that. On 10/14/25 at 2:03 PM, R303 was observed sitting in a wheelchair in his room. R303 was asked why he had hit R302. R303 explained the night before (10/2/25) R302 was all up on LPN (Licensed Practical Nurse) A like he wanted to hurt her. so he planned an assault, in the morning he put on his brace so he could stand up and waited until he had an opportunity and assaulted him. On 10/14/25 at approximately 3:05 PM, the Administrator was interviewed and asked about R303 hitting R302. The Administrator explained R303 was upset because he thought R302 was being mean to LPN A the night before and took it upon himself to correct R302. she had talked to him, and the police had talked to him and told him he could not take correction upon himself, he had to talk to the staff. R302 and R305 Review of a facility provided investigation revealed on 6/29/25 R305 was sitting in the hall in his wheelchair when R302 hit R305 in the stomach and on the knee. On 10/14/25 at 1:12 PM, R305 was observed sitting in a wheelchair in their room. R305 was asked about R302 hitting him on 6/29/25. R305 explained he was sitting in his wheelchair in the hall outside of his room, minding his own business, when R302 came and stood in front on him and got in his face. he tried to go around him, but he slapped his stomach and hit his right knee. he yelled and staff came then R302 walked away. R305 was asked if he had any interactions with R302 before this incident. R305 explained he had not. R305 was asked if he had any interactions with R302 since the incident on 6/29/25. R305 explained R302 wandered at night and would usually come into his room around 1:00 AM and just stand in his room. Review of the clinical record revealed R305 was admitted into the facility on 6/11/25 and readmitted [DATE] with diagnoses that included: acute and chronic respiratory failure, heart failure and paraplegia. According to the MDS assessment dated [DATE], R305 had intact cognition. On 10/14/25 at 1:41 PM, CNA E was interviewed by phone and asked about R302 hitting R305. CNA E explained it was early in the morning, R305 had just gotten up and was sitting in the hallway, she was coming out of the soiled linen room when R305 yelled that R302 had hit him. CNA E was asked if R302 wandered during the night. CNA E explained R302 did wander frequently at night. On 10/14/25 at approximately 3:05 PM, the Administrator was interviewed and asked about R302 hitting R305 on 6/29/25. The Administrator explained she was not the Administrator at that time, but the facility had petitioned R302 out to the hospital, but the hospital sent R302 right back to the facility. Review of a facility policy titled, Abuse, Neglect and Exploitation revised 6/2023 read in part, .'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . 'Willful' means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Prevention: . D. The facility will identify by ongoing assessment, care planning for appropriate interventions and monitoring of residents with needs and behaviors which might lead to conflict .

This citation pertains to Intake Number(s): 1278772. Based on observation, interview and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident for two (R203 and R204) of four residents reviewed for abuse, resulting in R204 physically assaulting R203 (witnessed by R205 and R207) causing a scalp laceration that required three staples, a hematoma and swelling of the left eye, and expressions of fear of returning back to the facility from the hospital and R204 sustaining scratches to his nose, under right eye, and neck. Findings include:A review of a Facility Reported Incident (FRI) submitted to the State Agency (SA) revealed an allegation that (R203) was arguing with his roommate (R204) and hit him. No injuries noted. It was documented the incident occurred on 6/20/25 at 6:00 PM. On 7/8/25 and 7/9/25, an unannounced onsite investigation was conducted.A review of a Case Report completed by the local police department revealed they were called to the facility for aggravated/felonious assault. The following was documented in the Narrative section of the report: On the listed date and time (6/20/25 at 7:47 PM), (Officers' names) were dispatched to (facility address) (room number) for an assault and battery .the assault occurred at 5:50 PM .the patients were separated but one needed to be transported to the hospital for the injuries The nurses stated that two patients, lodged in the same room, got into a physical altercation. The nurses stated that they did not witness the assault .and advised officers that both suffer from dementia I met with the victim, later identified as (R203). (R203's) left side of his face was swollen and bloody. (R203's left eye was black, bruised, and swollen. (R203) had a fresh cut above his left eyebrow that was bleeding. There was a laceration on the top of (R203's) hairline. (R203's) left ear was bruised and the back of (R203's) neck was red. I took pictures of (R203's) injuries (R203) stated that him and the suspect, later identified as (R204), are not friends, but they share the same room together. (R203) advised me that he was laying down in his bed and (R204) jumped on him and started to hit him in the face. (R203) was unable to give me specific details about the assault due to his mental state (Officer name) met with (R204). (R204) stated that he was okay but was unable to give officers specific details about the assault due to mental state (Ambulance company) arrived on scene and transported (R203) to (hospital name) for his injuries .A review of R203's hospital records revealed the following:An ED (Emergency Department) Provider Note documented, .(R203) .presents to the emergency department due to assault .Physical exam shows scalp laceration, left periorbital edema (swelling around the eye) .Patient knew his name, location, however would intermittently answer questions inappropriately .Laceration was cleansed with sterile water and was repaired with staples .Patient states he does not feel safe going back to this facility, as he was assaulted by his roommate .Results from a CT (computed tomography) revealed, Preseptal hematoma (collection of blood that pools on the septum of the nose after trauma) of L (left) orbit (eye socket) without acute orbital fracture.On 7/9/25 at approximately 11:55 AM, R203 was observed in bed, in the dark, with the privacy curtain pulled around the bed. R203 was queried about any altercations with his previous roommate and R203 stated, My ear hurt worse than being here. I want to leave. R203 said he lived in Japan and did not speak English, despite speaking English at that time. R203 was not able to clearly answer questions about the alleged event. On 7/9/25 at 9:00 AM and 11:53 AM, R204 was observed sleeping. R204 did not respond when addressed.A review of R203's clinical record revealed R203 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: Multiple Sclerosis (MS). A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R203 had severely impaired cognition and no behaviors. A review of R203's progress notes revealed the following documentation:On 6/9/25, a Nursing Progress Note documented, approximately 10:30pm (R203) and roommate (R204) began arguing. Resident (R203) stated that roommate was sitting on his bed and that he wanted his sheets changed. CNA (Certified Nursing Assistant) reported that (R203) was agitated because (R204) is always walking around the room and going through his belongings. Words were exchanged and roommate was redirected back to his bed. Roommate (R204) was placed on a 1:1 (supervision), NP (Nurse Practitioner) on call notified, DON (Director of Nursing) notified, Administration notified.On 6/14/25, the following was documented in a Behavior Note, .Upon approaching the dining room. Resident observed throwing a cup towards another resident and yelling using profanity. A CNA was trying to intervene, and resident kicked the CNA in the stomach .What additional interventions were put in place to keep others safe? Residents should be monitored in the dining area at all times .On 6/20/25, the following was documented in a Nursing Progress Note written by Licensed Practical Nurse (LPN) 'C', Around (5:50 PM) writer was notified by nurse aid that two residents were fighting. When writer arrived at (room number) both residents were separated. (R204) was sitting in hallway and (R203) was lying in bed. Immediately assessed both residents and asked what happened. Both residents were arguing over (R203's) wheelchair. (R203) stated that (R204) touched his wheelchair which made him upset. After that both residents began to argue and then (R204) hit (R203) .(R203) had a scratch on left side of face, swelling in left side of face and small opening to top of scalp. Writer gave resident a shower, placed ice on side of face, and applied pressure to open area on head .physician notified. Physician ordered neuro checks and to apply ice to swollen area .It was documented in a Nursing Progress Note at 8:00 PM that Police and EMS (Emergency Medical Service) were called. A review of R204's clinical record revealed R204 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: epilepsy, schizoaffective disorder, and dementia without behavioral disturbances. A review of an MDS assessment revealed R204 had moderately impaired cognition and no behaviors. A review of a Nursing Progress Note dated 6/20/25 revealed the incident documented above in R203's progress notes and additionally noted, .(R204) stated that he was eating dinner and (R203) continued to move things on his tray. (R204) stated that (R203) kept calling him out his name. (R204) began <sic> angry and hit (R203) .(R204) had scratches on left side of nose, under right eye, under neck, and left hand is swollen .A review of an investigation completed by the facility revealed the following:A 5 Day Investigation Summary that documented interviews with residents and staff, including the following:CNA 'E' who was alerted by another resident that two residents were fighting (R203 and R204) so she yelled for a nurse and went to separate the residents. It was documented CNA 'E' saw (R204) standing near (R203's) bed and (R203) was in bed.LPN 'C' who was informed by the CNA of R203 and R204 fighting. LPN 'C' said the residents were separated when she arrived at the room. R203 was bleeding and she began her assessments and gave first aid. (A statement dated 6/20/25, handwritten and signed by LPN 'C' noted, the fight appeared to be over R203's wheelchair).R206, who resided across the hall from R203 and R204 said he was in the hallway and heard yelling and saw R203 cursing at R204, using very foul language. R203 was lying in bed but kept moving R204's curtain and touched R204's food. R204 got up and went to R203's side and hit him. R206 yelled for the nurse. The Incident Summary noted, On Friday, June 20, 2025, at approximately 6:30pm , (R205) reported to (CNA 'E') that two residents were fighting (R203 and R204). (CNA 'E') immediately went to the room and separated both residents. (LPN 'C') entered the room minutes later and stated she saw (R204) in the hallway in his wheelchair and (R203) was in his room lying in bed. (R203) was observed bleeding from a laceration on the top left side of his head near the scalp and first aid was initiated. (R205) stated that he did not witness the event, but (R206) did. (R206's) room is located directly across the hall from (R203 and R204) An investigation was initiated, during which (R206) interviewed. (R206) reported that (R203) had been argumentative and verbally aggressive toward his roommate (R204) throughout the day including cursing at him. Later in the evening, while both residents were in their rooms (R203) reportedly continued to provoke (R204) by pulling back the curtains and taunting him. (R203) then reached over and touched (R204's) food. In response, (R204) hit (R203) .During staff interviews no one reported overhearing (R203) cursing at (R203). (It should be noted that the other CNAs assigned to the 1st floor units were not interviewed as part of the investigation) During the physical altercation, (R203) sustained a black eye and a head laceration. He complained of pain and was transported to the hospital for further evaluation. Upon his return the next day, (R203) was treated with three staples for the head laceration. (R204) sustained a scratch on his face near the nose CONCLUSION .The Abuse Coordinator did validate that (R204) did strike (R203). However, it is important to note that both residents have cognitive impairment accompanied by diagnosis of Dementia. Due to the nature of their cognitive conditions, neither resident was able to accurately recall the incident during interviews (It should be noted that although R203 was unable to give details, the police report noted he did express that he was hit by R204 and R204 admitted to hitting R203 according to the nursing progress note). The altercation appeared to have been triggered by the behavioral symptoms associated with (R203's) medical condition. At the time of the incident, (R203) was diagnosed with a urinary tract infection (UTI), which is known to exacerbate behavioral disturbances in individuals with dementia .A review of R203 and R204's care plans revealed no interventions implemented after they had an argument on 6/9/25 as documented in their nursing progress notes after R203 was agitated about R204 coming to his side of the room. R203 did not have any additional interventions implemented on the care plan after he threw a cup at an unknown resident, was yelling and cursing, and hit a CNA in the stomach. On 7/9/25 at 12:20 PM, an interview was conducted with the Administrator in the presence of the DON. When queried about the incident between R203 and R204, the Administrator reported LPN 'C' called her and said there was a resident-to-resident incident between R203 and R204 and that R203 kicked R204's table and R204 hit R203. The Administrator explained she told her to assess the residents and make a room change. According to the Administrator, LPN 'C' did not report any injuries to her. The Administrator further reported the night nurse, LPN 'D' contacted her on when she started her shift to make sure she was aware of the incident and that R203 had a black eye and had a laceration. The Administrator said she was unaware of R203's injuries until LPN 'D' called her and she instructed her to contact the police. At that time, LPN 'D' was in the process of transferring R203 to the hospital because R203 complained of increased pain. When queried about any previous altercations between R203 and R204 (as documented in both residents' clinical records on 6/9/25), the Administrator reported the only incident she knew about was an argument and at that time told the staff to do 15-minute checks. When queried about the documented incident on 6/14/25 of when R203 attempted to throw a cup at a resident, yelled, used profanity, and punched a CNA in the stomach, the Administrator reported she did not know about that incident. The DON reported she knew about that incident, but R203 did not actually hit anyone with the cup. When queried about who the other resident was, the DON did not know. On 7/9/25 at 1:30 PM, an interview was conducted with LPN 'D' via the telephone. When queried about what occurred with R203 and R204 on 6/20/25, LPN 'D' reported she worked second shift (7:00 PM to 7:00 AM) and when she arrived for her shift LPN 'C' was still at the facility finishing up what she had to do for the incident. LPN 'D' said LPN 'C' said R204 struck R203 in the face. LPN 'D' reported R203 definitely was injured and had to be sent to the hospital because he was in pain. When queried about any previous behaviors or incidents between R203 and R204, LPN 'D' reported they argued back and forth a lot but never had a physical altercation.On 7/9/25 at 2:25 PM, an interview was conducted with LPN 'C' via the telephone. When queried about what occurred between R203 and R204 on 6/20/25, LPN 'C' reported she was passing medications when the CNA came to get her and said R203 and R204 were fighting. LPN 'C' went to the residents' room and upon assessment of R203, he was bleeding. LPN 'C' contacted the physician, and they said to do neurochecks and continue monitoring the resident. LPN 'C' reported she gave R203 a shower because he was bloody. R203's girlfriend came to the facility and was concerned about R203's eye. LPN 'C' said she first contacted the DON and reported everything, including the incident and a description of both residents' injuries and the DON instructed her to contact the Administrator. LPN 'C reported she told the Administrator everything she told the DON, including the injuries and what the physician's instructions were. The residents were already separated by the time LPN 'C' got to their room. LPN 'C' reported she was concerned when she learned R203 and R204 got in an argument over (R203's) wheelchair about a week prior to the incident and the current incident was supposedly over R203's wheelchair again. LPN 'C' said they should not have continued being in the same room together. LPN 'C' reported she did not observe R203 being verbally aggressive with R204 during her shift. (It should be noted that the nurse's station is down the hallway and around the corner from where R203 and R204 resided).On 7/9/25 at 2:48 PM, an interview was conducted with CNA 'E' via the telephone. When queried about the incident between R203 and R204 on 6/20/25, CNA 'E' said she was notified by R205 that the residents were fighting. CNA 'E' went to their room and saw (R203) grabbing (R204) so she separated the residents. CNA 'E' explained R203 was bleeding from the head. CNA 'E' did not witness the altercation but said based on the condition of the residents and seeing R203 grabbing R204, it was likely they had a physical fight. When queried about the residents' behavior toward each other throughout the shift, CNA 'E' reported they argued a bit and previously R203 was a little agitated because R204 took his wheelchair.A review of a facility policy titled, Abuse, Neglect and Exploitation, revised 2/2025, revealed, in part, the following, .The facility will implement policies and procedures to prevent and prohibit all types of abuse .that achieves .Identifying, correcting and intervening in situation in which abuse .is more likely to occur .The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might led to conflict .

This citation pertains to intake(s): MI00153082, MI00154080 & MI00154105.Based on observation, interview and record reviews the facility failed to conduct a thorough investigation into an injury of unknown origin for one (R202) of four residents reviewed for Abuse. Findings include:On 7/8/25 at 1:24 PM, R202 was observed sleeping in their bed. Three attempts were made to wake the resident with verbal stimuli, however all attempts were unsuccessful. A review of the medical record revealed R202 was initially admitted to the facility on [DATE] with diagnoses that included: dementia, history of unspecified adult abuse, and the need for assistance with personal care. R202 was noted to be under hospice services. Review of a progress note dated 4/30/25 at 12:36 PM, documented in part . Writer observed swelling to resident's right hand. NP (nurse practitioner) made aware and new orders were given.Review of a complaint submitted by the local Police Department documented the following in part . She (R202) had a large bruise on her hand and told staff that someone on staff had beat her up. (R202) will not reveal who this is. (R202 name) has dementia. Officers attempted to get (R202) to tell who had assaulted her and she said that she did not want to tell us who did it .Review of a 5 Day Investigation Summary submitted by the facility's Administrator documented in part . (R202) had a bruise on her right hand stating . that someone beat her up . (R202) is combative with care. According to staff reports she will grab things like curtains, bed frames, people etc. when she doesn't want to be changed . (R202) does have documented behaviors including combativeness with care and her care plan has been updated to include two-person assistance due to her combative behavior .Review of the progress note revealed the following:A Nursing: Incident Note dated 6/25/25 at 8:45 AM, documented . Nurse aide reported that resident had new skin concern, writer assessed resident and noted bruising swelling and pain to right back and front of hand at second third and fourth knuckle. Resident stating someone did it to her .A Nursing note dated 6/25/25 at 8:50 AM, documented in part . Nurse aide . notified writer that resident had a new injury to right hand, writer assessed resident and noted red and light purple discoloration and increased swelling to right hand at second third and fourth knuckle accompanied by increased pain set at 8. Resident stated someone grabbed her hand hard because they didn't like me. Resident stated her pain is at an 8 and was unable to make a fist .A Nurse Practitioner (NP) note dated 6/26/25 at 10:16 AM, documented in part . Because x-ray was unable to come to patient, facility transferred patient to hospital via EMS (emergency medical services) for hand x-ray .Review of a hospital After Visit Summary dated 6/26/25, documented in part . x-ray showed a displaced fracture in your right hand . Diagnosis Closed displaced fracture of distal phalanx of ring finger, unspecified laterality .A review of the facility's investigation file included the following:A statement by CNA A that documented the following I was (R202) Cena last night. The nurse went into the room with me to give her care. She wasn't combative, she let me change her. I just talked to her and was rubbing her arm so she would stay calm. I didn't see anything on her hand. She has <sic> no signs of Pain or discomfort .Review of a 5 Day Investigation Summary submitted by the Administrator documented in part . On Wednesday, June 25, 2025 . a bruise on resident's right hand and was informed by (R202 name) that someone bent her finger. (local police department name) were notified . It remains inconclusive how the injury specifically occurred .Review of a complaint submitted by the local police department documented in part . It was first reported on 6/25/2025. (Facility Administrator) reported that they had suspended (Certified Nursing Assistant - CNA A) after it was determined that she did not follow protocol by not being alone in the patient's (R202) room. It was reported that (R202) had a habit of grabbing things. She (Administrator) stated that staff are not supposed to pry patient's hands, due to the risk of injury. (Administrator) reported that (CNA A) pried (R202's) hand off . Officers were dispatched back to the facility where (R202) was transported for a fractured hand .CNA A is a night shift aide that was identified to be assigned to R202 for the night of 6/24/25 into the morning of 6/25/25. The injury to R202's right hand was identified by the morning aide on 6/25/25. A review of a care plan titled I have potential to demonstrate behaviors . I am combative with care, hitting staff, grabbing my bed frame so staff are unable to complete care with right hand . an intervention documented . Two staff to be present during care at all times . Initiated 5/7/25. On 7/8/25 at 12:29 PM, an attempt to conduct a telephone interview with CNA A was unsuccessful. CNA A's voicemail box was full, so a text message was sent regarding the investigation and a request was made for them to return the surveyor's call. A review of CNA A time card revealed no documentation of a suspension noted. On 7/8/25 at 3:50 PM, Licensed Practical Nurse (LPN) G (the midnight nurse assigned to R202 on 6/24/25 into the morning of 6/25/25- who worked alongside CNA A) was contacted via telephone and a message was left to return the surveyor's call. On 7/9/25 at 8:03 AM, LPN G returned the surveyor's call. When asked if they had assisted CNA A throughout the night of 6/24/25 into 6/25/25 with care provided by CNA A to R202, LPN G replied that (CNA A) had not asked them to assist at all throughout that night. LPN G stated CNA A did assist with (R202) on the morning of 6/25/25 while they (LPN G) completed the residents wound treatment. LPN G confirmed other than assisting them with the wound treatment, they had not assisted CNA A with R202 throughout that night.This conflicted with the statement submitted by CNA A during the facility's investigation. On 7/9/25 at 9:33 AM, CNA F (the dayshift CNA that identified the injury to R202 on 6/25/25) was interviewed via telephone. When asked about the identification of R202's right hand injury, CNA F stated they were setting their residents up for breakfast that morning. CNA F stated they walked into R202's room who was holding their right hand to their chest. CNA F stated they could visibly see that R202's hand was discolored and swollen. CNA F stated they asked R202 what happened and R202 replied that someone had bent her hand back. CNA F stated when the police came to the facility to talk to the resident they were present in the room. CNA F stated R202 told the police the same thing that R202 had told them. CNA F stated R202 told the police that a staff member had bent their hand back. When asked, CNA F stated no one followed back up with them for a statement until 7/2/25, a week after the allegation and identification of the injury. On 7/9/25 at 11:16 AM, the Administrator and Director of Nursing (DON) were interviewed together. When asked how they came to the conclusion of their investigation for R202 the Administrator stated that R202 was known to be combative with their care. They interviewed all of the staff that confirmed they had provided care with a second staff member, so they concluded the investigation to be inconclusive. The Administrator was then asked about the information they provided to the local police department regarding CNA A to have been suspended due to not following R202's plan of care and entering into the room to provide care without a second person present. The Administrator stated when they interviewed CNA A they stated they provided R202's care with LPN G that shift. When asked if they collaborated with LPN G to confirm that to be true, the Administrator stated LPN G informed them that CNA A assisted them with the resident while LPN G completed R202's wound treatment. The Administrator was again asked if they asked LPN G if they had assisted CNA A with R202 while CNA A provided care for the resident on that shift and the Administrator stated they did not. The review of the conflicting statement by CNA A, the statement by the local police department and LPN G interview was discussed and the Administrator was asked about CNA A to have supposedly been suspended, yet their time sheet did not reflect a suspension. The Administrator stated they attempted to call CNA A to inform them that they were suspended pending the investigation but they could not get ahold of them. The Administrator was asked why CNA A was being suspended if they allegedly provided care per the resident's plan of care as indicated by their investigation, and the Administrator did not have a response. The Administrator and DON was informed of the multiple attempts made to contact CNA A. The Administrator and DON was asked to contact CNA A and have them contact the surveyor for an interview. On 7/9/25 at 2:02 PM, a third attempt was made to contact CNA A and was again unsuccessful. On 7/9/25 at 4:01 PM, the Administrator and DON stated they were unsuccessful with getting in touch with CNA A. No further explanation or documentation was provided by the end of the survey.

Based on interview and record reviews the facility failed to ensure a Certified Nursing Assistant (CNA) maintained an active CNA certification while working at the facility, for one (CNA A) of three CNA certifications reviewed. Findings include: A review of CNA A's personnel file revealed a LAPSED status of their nursing assistant certification (nurse aide certification). The document revealed the certification expired on [DATE]. A review of CNA A timecard revealed the aide worked in the facility as a CNA with a lapsed certification on the following dates:[DATE]/[DATE]/[DATE]On [DATE] at 2:02 PM, an interview was attempted with CNA A but was unsuccessful.On [DATE] at 2:40 PM, the Administrator was interviewed and asked about CNA A's nursing aide certification to have been lapsed since [DATE], while still working in the facility as a CNA. The Administrator replied the facility did not have a Human Resource (HR) personnel in house but comes to the facility throughout the week. The Administrator stated the HR Personnel was in the building and they would follow up with the concern. On [DATE] at 3:00 PM, the Human Resource personnel (HR) B was interviewed and stated they are in the facility once a week. HR B stated they realized yesterday ([DATE]) when (CNA A personnel file was requested by the survey team) that CNA A nursing aide certification had lapsed and informed the Administrator. HR B stated the facility staff got in contact with CNA A and the CNA was able to get their certification fixed. At that time HR B was asked to finish the interview in the office of the Administrator. The Administrator was again asked about CNA A nursing aide certification to have lapsed while still working in the facility as an aide. The Administrator acknowledged the concern.No further explanation or documentation was provided by the end of the survey.

Based on interview and record review, the facility failed to protect the resident's right to be free from neglect for 11 residents (R#'s 37, 41, 43, 7, 19, 18, 33, 40, 36, 21, and R25) of 19 residents reviewed for abuse/neglect/mistreatment. Findings include: R19 On 3/18/25 the medical record for R19 was reviewed and revealed the following: R19 was initially admitted to the facility on [DATE] and had diagnoses including Dementia and Myocardial infarction. A progress note dated 2/25/25 revealed the following: Nursing Progress Note-Late Entry: Note Text: Medication was not administered at night-time on 2/25. Resident monitored for change in condition. No adverse reaction noted. Resident is stable Responsible party notified , Physician notified, Administrator notified , DON (Director of Nursing) notified . Immediate intervention implemented: Resident monitored for change in condition. A review of R19's February 2025 Medication Administration Record (MAR) revealed the following medications that documented as not administered on 2/25/25: Melatonin Oral Tablet 3 MG (milligram) (2100 dose), SEROquel Oral Tablet 50 MG (2000 dose), Apixaban Oral Tablet 2.5 MG (2100), Hydrocodone-Acetaminophen Tablet 5-325 MG (2000), Lorazepam Gel 0.5 mg 1 ML (milliliter) (2200). On 3/19/25 at approximately 3:57 p.m., during a conversation with the Director of Nursing (DON), the DON was queried regarding multiple medications not being administered for multiple residents residing on the first floor during the evening of 2/25/25. The DON reported that they had a Nurse (Nurse S) who was mandated to stay over their shift from 7:00 p.m. until 11 p.m. and Nurse S did not pass any medications to the residents on the first floor during that period of time. The DON reported they came in to provide relief shortly after 11:00 p.m. on 2/25/25 and started passing medications but could not pass the ones that had already been missed. The DON was queried why NurseS did not administer any medication and they reported that the Nurse informed them they were on the phone with pharmacy regarding a new admission. The DON indicated the Nurse was terminated as a result of the negligence and they did an investigation and implemented monitoring and notification to the Physician for each of the residents effected. The DON also reported they had provided in-service education to all Nursing staff regarding the importance of ensuring all medications are administered per Physician orders and that they were monitoring for continued compliance. At that time, a request a list of the resident effected by the practice was requested. On 3/20/25 at approximately 9:55 a.m., the DON provided the list of residents affected by Nurse S not administering medications on 2/2/5/25 and the termination documentation for Nurse S. On 3/20/25 the February 2025 Medication Administration Records for the additional effected residents were reviewed and revealed the following medications that were not administered on 2/25: R37: Atorvastatin Calcium Tablet 20 MG (2100 dose), LATANOPROST 0.005% EYE DROP (2100), DORZOLAMIDE-TIMOLOL EYE DROP (2200), metFORMIN HCl Oral Tablet 500 MG (2000). R41: Artificial Tears Solution 1 % (2100), Atorvastatin Calcium Oral Tablet 20 MG (2000), Montelukast Sodium Tablet 10 MG (2100), Senna Tablet 8.6 MG (2000), Eliquis Oral Tablet 5 MG (2100), dilTIAZem HCl Tablet 30 MG (2100). R43: Aricept Oral Tablet 5 MG (2100), Atorvastatin Calcium Oral Tablet 10 MG (2100). R7: Atorvastatin Calcium Oral Tablet 40 MG (2100), Ramelteon Tablet 8 MG (2100), Memantine HCl Oral Tablet 5 MG (2200). R18: Brimonidine Tartrate-Timolol Solution 0.2-0.5 % (2200), Dorzolamide HCl-Timolol Mal Solution 22.3-6.8 MG/ML (2100), prednisoLONE Acetate Suspension 1 % (2200). R33: Atorvastatin Calcium Oral Tablet 40 MG (2100), Flomax Oral Capsule 0.4 MG (2130), Latanoprost Ophthalmic Solution 0.005 % (2100), Docusate Sodium Capsule 100 MG (2100), Dorzolamide HCl-Timolol Mal Ophthalmic Solution 2- 0.5 % (2000) Keppra Oral Tablet 500 MG (2100), Senna Tablet 8.6 MG (2100), Vimpat Oral Tablet 200 MG (2000), Brimonidine Tartrate Ophthalmic Solution 0.2 % (2100), Refresh Liquigel Ophthalmic Gel 1 % (2100). R40: Senna Oral Tablet 8.6 MG (2100), Famotidine Oral Tablet 20 MG (2100), Gabapentin Capsule 100 MG (2000), Sodium Bicarbonate Oral Tablet 650 MG (2100), ZyPREXA Oral Tablet 5 MG (2100), diazePAM Oral Tablet 2 MG (2200), Valproic Acid Oral Solution 250 MG/5ML (2200). R36: Atorvastatin Calcium Oral Tablet 10 MG (2100), Melatonin Oral Tablet 5 MG (2100), Senna Tablet 8.6 MG (2100), traZODone HCl Oral Tablet 100 MG (2100), Bactrim DS Tablet 800-160 MG (2100), buPROPion HCl ER (SR) Oral Tablet Extended Release 12 Hour 150 MG (2200), Magnesium Oral Tablet 400 MG (2200), metFORMIN HCl Oral Tablet 500 MG (2200), Metoprolol Tartrate Oral Tablet (2200), Carbidopa-Levodopa Oral Tablet 25-100 MG (2200). R21: Lorazepam Gel 0.5 mg 1 ML (2000). R25: traZODone HCl Oral Tablet 150 MG (2000), lamoTRIgine Oral Tablet 200 MG (2100), levETIRAcetam Oral Tablet 500 MG (2100), guaiFENesin Oral Liquid 200 MG/5ML (2100), Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (2100) Morphine Sulfate Oral Solution 20 MG/5ML (2200). On 3/20/25 the facility investigation into the incident was reviewed and revealed the following: Description of Incident: During chart reviews it was noted that signatures in EMAR (electronic medication administration record) and EMAR documentation was not consistent with medication administration orders. Summary of Findings: Signature in EMAR and EMAR were not consistently signed when medications were ordered. Action is taken for residents involved: A review was completed for the Month of February to review omissions of signatures in EMAR documentation. Residents identified having significant medications involved were assessed to determine any concerns related to potential missed medications. Appropriate individuals were notified and resident monitoring initiated as appropriate A statement by the DON pertaining to the incident revealed the following: l [DON] at [Facility] Reviewed February MARS related to concern with medication administration. Those areas that were not signed as given were addressed with the appropriate staff. Physician was notified and resident were assessed for potential adverse effects . On 3/20/25 at approximately 2:40 p.m., during a conversation with the acting facility Administrator, the Administrator was queried regarding all the residents not being administered their medications on the evening of 2/25/25. The Administrator indicated they were not the Administrator at the time the neglect occurred but indicated they would have reported the incident to the State Agency. The case was reviewed with the Administrator and they were queried if in reviewing the case if they believed the incident was neglectful and they indicated they believed it was. A facility document titled Abuse Neglect and Exploitation was reviewed and revealed the following: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property Neglect means 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 . During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included 1. Nurses identified were provided with one on one education related to specific concerns. 2. A review of the Month of February EMAR (electronic medication administration record) was completed to identify any significant medications that may not have been provided per order. 3. Re-education of current licensed nurses on Medication Administration Documentation were provided. Nurses not receiving education by the date of compliance will receive the education on the next day of work. 4. DON/designee will review EMAR I x weekly x8 weeks to assure compliance. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on interview and record review, the facility failed to report an incident of neglect to the State Agency for 11 residents (R#'s 37, 41, 43, 7, 19, 18, 33, 40, 36, 21, and R25) of 19 residents reviewed for abuse/neglect/mistreatment. Findings include: [Cross Reference F-600] R19 On 3/18/25 the medical record for R19 was reviewed and revealed the following: R19 was initially admitted to the facility on [DATE] and had diagnoses including Dementia and Myocardial infarction. A progress note dated 2/25/25 revealed the following: Nursing Progress Note-Late Entry: Note Text: Medication was not administered at night-time on 2/25. Resident monitored for change in condition. No adverse reaction noted. Resident is stable Responsible party notified , Physician notified, Administrator notified , DON notified . Immediate intervention implemented: Resident monitored for change in condition. A review of R19's February 2025 Medication Administration Record (MAR) revealed the following medications that documented as not administered on 2/25/25: Melatonin Oral Tablet 3 MG (milligram) (2100 dose), SEROquel Oral Tablet 50 MG (2000 dose), Apixaban Oral Tablet 2.5 MG (2100), Hydrocodone-Acetaminophen Tablet 5-325 MG (2000), Lorazepam Gel 0.5 mg 1 ML (milliliter) (2200). On 3/19/25 at approximately 3:57 p.m., during a conversation with the Director of Nursing (DON), the DON was queried regarding multiple medications not being administered for multiple residents residing on the first floor during the evening of 2/25/25. The DON reported that they had a Nurse (Nurse S) who was mandated to stay over their shift from 7:00 p.m. until 11 p.m. and Nurse S did not pass any medications to the residents on the first floor during that period of time. The DON reported they came in to provide relief shortly after 11:00 p.m. on 2/25/25 and started passing medications but could not pass the ones that had already been missed. The DON was queried why NurseS did not administer any medication and they reported that the Nurse informed them they were on the phone with pharmacy regarding a new admission. The DON indicated the Nurse was terminated as a result of the negligence in failing to administer all the medications and they did an investigation and implemented monitoring and notification to the Physician for each of the residents affected. The DON also reported they had provided in-service education to all Nursing staff regarding the importance of ensuring all medications are administered per Physician orders and that they were monitoring for continued compliance. At that time, a request a list of the resident effected by the practice was requested. The DON was queried if they had identified neglect committed of behalf of Nurse S and they indicated they did not at that time and and the incident was not reported to the State Agency. On 3/20/25 at approximately 9:55 a.m., the DON provided the list of residents affected by Nurse S not administering medications on 2/2/5/25 that included (R#'s 37, 41, 43, 7, 19, 18, 33, 40, 36, 21, and R25) and the termination documentation for Nurse S. On 3/20/25 the facility investigation into the incident was reviewed and revealed the following: Description of Incident: During chart reviews it was noted that signatures in EMAR (electronic medication administration record) and EMAR documentation was not consistent with medication administration orders. Summary of Findings: Signature in EMAR and EMAR were not consistently signed when medications were ordered. Action is taken for residents involved: A review was completed for the Month of February to review omissions of signatures in EMAR documentation. Residents identified having significant medications involved were assessed to determine any concerns related to potential missed medications. Appropriate individuals were notified and resident monitoring initiated as appropriate On 3/20/25 at approximately 2:40 p.m., during a conversation with the acting facility Administrator, the Administrator was queried regarding all the residents not being administered their medications on the evening of 2/25/25. The Administrator indicated they were not the Administrator at the time the neglect occurred but indicated they would have reported the incident to the State Agency for review. The case was reviewed with the Administrator and they were queried if in reviewing the case if they believed the incident was neglectful and they indicated they believed it was. A facility document titled Abuse Neglect and Exploitation was reviewed and revealed the following: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property Reporting/Response A. The facility will implement the following: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury

Based on observation, interview and record review, the facility failed to ensure a resident was assessed for the safe self-administration of medication and to have medication kept at bedside for one (R8) of one resident reviewed for self-administration of medication. Findings include: On 3/18/25 at 10:53 AM, the door to R8's room was closed. Upon entry into the room, the resident was seated upright on the side of the bed holding a small clear plastic vial. A nebulizer machine (a small machine that turns liquid medicine into a mist that can be inhaled) was observed on a table next to the bed. When asked about the small vial, R8 stated that was for their breathing treatment. When asked if the nurse had given that to the resident for them to do themselves, R8 stated Yes, it's for me to do. Review of the clinical record revealed R8 was admitted into the facility on [DATE] with diagnoses that included: schizoaffective disorder, acute on chronic systolic heart failure, chronic obstructive pulmonary disease (COPD), asthma and dyspnea. According to the Minimum Data Set (MDS) assessment dated [DATE], R8 scored 13/15 on the Brief Interview for Mental Status (BIMS) exam which indicated they had intact cognition. Further review of the clinical record revealed there was no assessment, care plan, or physician order completed to indicate R8 was able to safely administer their own breathing treatment. Review of the care plans, orders and assessments revealed none for resident's ability to self-administer breathing treatment. The care plan for I have altered respiratory status/potential for difficulty with breathing r/t (related to) COPD, Asthma. - initiated 1/4/25, revised 1/6/25 included an intervention for Administer medication/puffers as ordered. Monitor for effectiveness and side effects. The physician orders included: Albuterol Sulfate HFA (Hydrofluoroalkane) Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Micrograms/Acutation) (Albuterol Sulfate) 1 puff inhale orally every 6 hours as needed for wheezing. This order started on 1/5/25. Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/SML (Milligrams per Symptom-monitored Loading Dose) 1 applicatorful inhale orally every 6 hours for copd. This order started on 3/4/25. Review of the Medication Administration Records for the above treatments revealed Nurse 'C' documented administration of the ipratropium-albuterol solution 0.5-2.5 (3) MG/ML on 3/18/24 at 12:00 PM and 6:00 PM. Nurse 'B' had documented administration at 12:00 AM and 6:00 AM. On 3/19/25 1:45 PM, an interview was conducted with the Director of Nursing (DON) who reported they had been in their role as of January 2025. When asked about the facility's process for self-administration, the DON reported there should be an assessment, physician order and care plan. The DON was informed of the observation for R8 on 3/18/25 and they reported they would have to follow-up. On 3/19/25 at 2:35 PM, an interview was conducted with Nurse 'C'. Nurse 'C' confirmed they were assigned to R8 yesterday and had taken over for Nurse 'B' who worked the evening prior as well as the evening of 3/18/25. When asked about R8's breathing treatment and their process for administration, Nurse 'C' reported they usually give it to the resident, stand outside the room and make sure it's done. When asked if they would give the nebulizer vial to the resident to do themselves, Nurse 'C' reported I would not personally give him anything like that. He's alert, but has confusion. Nurse 'B' was attempted to be interviewed by phone, but there was to return call. According to the facility's policy titled, Resident Self-Administration of Medication dated 2/2025: .A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely .No medication shall be left unattended without the residents' knowledge that it has been left there for them .The care plan must reflect resident self-administration and storage arrangements for such medications .

Based on observation, and interview the facility failed to offer a shower for one of one resident (R39) reviewed for accommodation of needs, resulting in R39's bathing preferences to be unrecognized. Findings include: On 3/18/25 at 10:30 AM, R39 was observed in their room and reported that she loved the facility, had no issues and the staff took great care of their needs, however R39 reported that they would like to take a shower. R39 expressed that the facility did administer bed baths but stated that it was nothing better than the actual water from the shower. R39 stated that the reason they were unable to shower was because their wheelchair did not fit into the shower room. A review of the record revealed that R39 was admitted to the facility on [DATE] with the diagnosis of schizoaffective disorder, bipolar, difficulty walking and morbid obesity. The Minimum Data Set (MDS) completed on 1/14/25 showed that R39's Brief Interview for Mental Status score (BIMs) of 15, which indicated high function cognitive ability. On 3/19/25 at 9:10 AM, the Director of Nursing (DON) was asked why couldn't R39 take a physical shower. The DON replied that the resident received bed baths so R39 did not miss being bathed. The DON was asked why couldn't R39 get a shower in the shower room or their bedroom and the DON replied that she would investigate why they did not receive showers. On 3/19/25 at 12:10 PM, R39 was asked that if staff were to offer them a shower would they take one, R39 replied, Yes. On 3/20/25 at 12:03 PM, the DON followed up on R39 getting showered and stated that they were working with therapy to find solutions to get R39 in the shower as their wheelchair did not fit through the doorframe. It should be noted that the resident was admitted to the facility in October of 2024. There was no additional information provided by the exit of survey.

Based on interview and record review, the facility failed to ensure an updated annual review of a Do-Not-Resuscitate (DNR) order with a legal guardian was in place for one (R32) of three residents reviewed for advance directives. Findings include: According to MCL 700.5314 [NAME] and duties of guardian, effective 2/3/14, amended 2/6/18, .(d) The power of a guardian to execute, reaffirm, and revoke a do-not-resuscitate order on behalf of a ward is subject to this subdivision. A guardian shall not execute a do-not-resuscitate order unless the guardian does all of the following: (i) Not more than 14 days before executing the do-not-resuscitate order, the guardian visits the ward and, if meaningful communication is possible, consults with the ward about executing the do-not-resuscitate order. (ii) The guardian consults directly with the ward's attending physician as to the specific medical indications that warrant the do-not-resuscitate order. (e) If a guardian executes a do-not-resuscitate order under subdivision (d), not less that annually after the do-not-resuscitate order is first executed, the guardian shall do all of the following: (i) Visit the ward and, if meaningful communication is possible, consult with the ward about reaffirming the do-not-resuscitate order. (ii) Consult directly with the ward's attending physician as to specific medical indications that may warrant reaffirming the do-not-resuscitate order . Review of the clinical record revealed R32 was admitted into the facility on [DATE] and readmitted [DATE] with diagnoses that included: major depressive disorder, schizoaffective disorder and bipolar disorder. According to the Minimum Data Set (MDS) assessment dated [DATE], R32 had moderately impaired cognition. The clinical record also indicated R32 had a legal guardian and was a DNR. Review of a Medical Treatment Decision Form for R32 revealed a signature in the box for DNR Do Not Resuscitate, signed by R32's guardian and dated 1/24/24. Review of R32's progress notes revealed no documentation of communication between R32's guardian and R32's physician regarding R32's continued DNR status. On 3/19/25 at 12:19 PM, Social Worker (SW) D was interviewed and asked why R32's DNR order had not been reaffirmed since it was over the annual time frame. SW D explained she was not aware a DNR order from a guardian required annual review. When asked about the lack of communication between R32's guardian and physician, SW D had no answer. Review of a facility policy titled, Residents' Rights Regarding Treatment and Advance Directives revised 2/2025 revealed it did not address the specific requirements for guardians to reaffirm annually or the communication between the guardian and physician.

Based on observation, interview and record review, the facility failed to protect residents personal privacy for two (R1 and R5) of two residents reviewed for privacy. Findings include: On 3/18/25 at 9:44 AM, R1 and R5, roommates, were observed sleeping in their beds. The privacy curtain between the beds was observed to only have the mesh top part attached to the ceiling track, the bottom, solid part, which provides privacy was gone. On 3/18/25 at 10:11 AM, R1 was observed sitting in their wheelchair in the room. R5 was observed sleeping in their bed. R1 was asked about the missing privacy curtain. R1 explained it had been removed to clean it. When asked how long it had not been there, R1 explained it had been off for a while. R1 was asked about privacy when getting dressed or changed. R1 explained staff would close the door to the hall. Review of the clinical record revealed R1 was admitted into the facility on [DATE] and readmitted [DATE] with diagnoses that included: heart disease, dementia and anxiety disorder. According to the Minimum Data Set (MDS) assessment dated [DATE], R1 had moderately impaired cognition and required the assistance of staff for activities of daily living (ADL's). Review of the clinical record revealed R5 was admitted into the facility on [DATE] and readmitted [DATE] with diagnoses that included: dementia, stroke and heart disease. According to the MDS assessment dated [DATE], R5 had severely impaired cognition and was dependent on staff for ADL's. On 3/19/25 at 10:53 AM, Housekeeper (HK) L was interviewed and asked who at the facility took down and/or put up privacy curtains. HK L explained sometimes Housekeeping did it, and sometimes Maintenance did it. HK L was asked if the whole curtain was taken down, or just the solid part unbuttoned from the mesh top. HK L explained they would unbutton the bottom part as the mesh top really didn't get dirty. When asked if he knew about the privacy curtain being removed in R1 and R5's room, HK L explained he had not removed it. On 3/19/25 at 1:47 PM, the Environmental Services Manager (ESM) was interviewed and asked about the privacy curtain in R1 and R5's room. The ESM explained he had not known the privacy curtain was missing, so when he was told about it, he put one up between the beds. The ESM was asked if he knew who had taken the privacy curtain down. The ESM explained he did not know, but it was usually Maintenance or one of the male Housekeepers. On 3/19/25 at 2:35 PM, the Housekeeping Supervisor (HKS) was interviewed and asked about the privacy curtain in R1 and R5's room. The HKS explained the facility did not have any extra privacy curtains, when one needed cleaning, they had to take it down, send it to laundry and then put it back up. When asked how long that took, the HKS explained it took an hour to wash and an hour to dry. The HKS was asked if she knew who took it down, or when it was taken down. The HKS explained she did not know. On 3/20/25 at 8:50 AM, Laundry Aide (LA) M was interviewed and asked about the process for laundering privacy curtains. LA M explained they washed all the towels and linens, then privacy curtains, then residents' clothing. LA M was asked approximately how long it usually took for the privacy curtains to be washed and dried. LA M explained it usually took about a half-a-day before they were done. When asked if there were any extra privacy curtains, LA M explained there were no extra curtains. On 3/20/25 at 9:36 AM, an interview was conducted with the acting Administrator, the Regional Director of Operations (RDO). The RDO was informed of the concern of the lack of a privacy curtain between R1 and R5's beds for an unknown amount of time. The RDO explained there were extra curtains, and one should have been put up immediately. The RDO was informed that Maintenance, Housekeeping and Laundry personnel were not aware there were extra curtains. The RDO explained he was not aware staff did not know about the extra curtains. The RDO was asked regardless if there were extra curtains or not, should not something be put up between the beds to maintain privacy during ADL care. The RDO agreed privacy should be maintained.

Based on observation, interview and record review, the facility failed to maintain a clean, comfortable, homelike environment for one (R44) of nine residents reviewed for environment. Findings include: On 3/18/25 at 10:00 AM, R44 was observed lying in bed sleeping. R44 was observed to have closely cut hair of uniform length. On 3/18/25 at 12:03 PM, R44 was again observed lying in bed sleeping. R44 was dressed, had a mechanical lift sling positioned under them. A bottle of shampoo/body wash was observed on the windowsill. The head of the bed was elevated and on the floor, under the head of the bed was a pile of hair, approximately four inches in diameter. Review of the clinical record revealed R44 was admitted into the facility on [DATE] and readmitted [DATE] with diagnoses that included: metabolic encephalopathy, vascular dementia and anxiety disorder. According to the Minimum Data Set (MDS) assessment dated [DATE], R44 had severely impaired cognition and required the assistance of staff for activities of daily living (ADL's). Review of R44's progress notes revealed a Discharge Note dated 3/18/25 at 7:20 PM that read in part, Resident was transferred to (local hospital) . On 3/19/25 at 10:40 AM, observation of R44's room and bed revealed the pile of hair was still under R44's bed. On 3/20/25 at 10:46 AM, the Housekeeping Supervisor (HKS) was interviewed and informed of the observation of a pile of hair under R44's bed even after being discharged from the facility. The HKS explained the expectation was that routine daily cleaning included sweeping the entire floor, including under the bed and behind furniture. Review of a 30 Day Look Back for R44's Shower/Bathing/Bed Bath task revealed documentation that R44 received a bed bath by Certified Nursing Assistant (CNA) P on 3/17/25. On 3/20/25 at 11:06 AM, CNA P was interviewed by phone and asked if they had cut R44's hair when they gave R44 a bed bath. CNA P explained they had not cut R44's hair. On 3/20/25 at 11:21 AM, a phone call was made to CNA Q, who had been assigned to R44 on 3/18/25 and a voice mail was left. No return call was made prior to the end of the survey. Review of a facility policy titled, Safe and Homelike Environment dated 1/11/21 read in part, .Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment .

Based on observations, interview, and record review the facility failed to transcribe medication orders correctly from the hospital resulting in one resident (R10) missing prescribed dosages of antibiotic medication (a medication used to treat infection). Findings include: On 3/18/25 at 10:10 AM, R10 was observed in bed. When R10 was asked how their stay at the facility was, the residents was not coherent. A review of R10's medical record revealed that the Brief Interview for Mental Status score (BIMS) completed on 3/3/25 was a 00, which indicated severe impaired cognition. A further review of the record showed that R10 was admitted to the facility initially on 7/15/2019 with the diagnosis of vascular dementia, history of falling and aphasia. Additional review of R10 record revealed that, they were admitted to the hospital on 2/15/25 for a fall and pain to the lower extremity and discharged from the hospital on 2/20/25 back to the facility. With in the discharge instruction paperwork R10 was to receive an antibiotic called Ciprofloxacin (Cipro) 500 milligrams (mg) every 12 hours for 5 days. In review of the medical administration record the antibiotic was not transcribed and there was no progress note to indicate that the physician had discontinued the treatment. On 3/20/25 at 10:45 AM, an interview with the facility's Infection Control Preventionist (ICP) was conducted, and they were asked why the Cipro was not ordered as the hospital intended for R10. The ICP, reported that they had just received the hospital paperwork on the 17th of February and noticed that the antibiotic was not ordered and intended to contact the physician to see what they would recommend since the medication was missed. The ICP was asked should the medication had been transcribed as ordered from the hospital. The ICP replied, It should have. On 3/20/25 at 12:03 PM, an interview with the Director of Nursing (DON) was conducted. The DON was asked should medications be transcribed as ordered from the hospital to a resident's medication administration record. The DON reported that medications should be transcribed as ordered and if for what ever reason a provider changed an order, the nurse who is verifying medications with the provider is to document that a change was made in a progress note. There was no additional information provided at the exit of survey.

Based on interview and record review, the facility failed to ensure a Change in Condition level one screening Form DCH (Department of Community Health/3877) was submitted to the local Community Mental Health Services Program (CMHSP) for a level two OBRA (Omnibus Budget Reconciliation Act) evaluation upon a change in the resident's condition for one (R61) of two residents reviewed for Preadmission Screening/Annual Resident Review (PASARR). Findings include: Review of the clinical record revealed R61 was admitted into the facility on [DATE] and readmitted on [DATE] with a new diagnosis of schizophrenia. According to the Minimum Data Set (MDS) assessment dated [DATE], R61 scored a 15/15 on the Brief Interview for Mental Status (BIMS) exam which indicated intact cognition. The schizophrenia diagnoses was not included in section I of the MDS assessment. Review of R61's physician orders included an order with a start date of 1/31/25 for Seroquel (an antipsychotic medication) oral tablet 50 MG (Milligrams) - give 1 tablet by mouth every 12 hours for schizophrenia. Further review of the most current level one (3877) form dated 3/26/24 revealed the section for screening criteria had an X marked next to question 1 which read, Yes The person has a current diagnoses of X Mental Illness or X Dementia (both were marked with an X'; question 2 which read, Yes The person has received treatment for X Mental Illness; question 3 which read, The person has routinely received one or more prescribed antipsychotic or antidepressant medications within the last 14 days.; and question 4 which read, There is presenting evidence of mental illness or dementia, including significant disturbances in thought, conduct, emotions, or judgement. Presenting evidence may include, but is not limited to, suicidal ideations, hallucinations, delusions, serious difficulty completing tasks, or serious difficulty interacting with others. The section to explain any Yes responses read, DX (Diagnosis): Psychotic disorder with delusions due to known physiological condition, unspecified mood [affective] disorder, Parkinson's disease with dyskinesia, Dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, receives Seroquel, Xanax, Depakote, mirtazapine, and escitalpram. There was no documentation that identified a change of condition 3877 form had been completed upon the addition of the new schizophrenia diagnosis upon readmission on 12/27/24. Review of R61's OBRA PASARR Correspondence letter dated 3/26/24 documented, .does not meet criteria for a serious mental illness, developmental disability, intellectual disability, or related condition under the PASARR provisions but may have a less than serious mental illness .This does not alter the nursing facility's requirement for completing the annual Level I (DCH-3877) or reporting significant changes to the CMHSP or their contract agency .[R61] has no apparent history of SPMI (Serious and Persistent Mental Illness), no Level II needed . On 3/19/25 at 1:24 PM, an interview was conducted with the Social Services Manager (Social Worker/SW 'D'). When asked about whether the facility had completed a change in condition and submission to the local community health regarding R61's new diagnosis of schizophrenia since their readmission on 12/27/24, SW 'D' reported they would have to find out. On 3/19/25 at 4:00 PM, SW 'D' provided a 3877 form dated 3/19/25 and reported they just submitted a change in condition 3877 form to OBRA today. When asked why this had not been identified until it was a concern during this survey, SW 'D' reported they were focused on other concerns. Review of the 3877 completed 3/19/25 had an X for Yes and Mental Illness for questions 1-4, and the section to Explain any YES read, New: Dx Schizophrenia-Seroquel Depression-Lexapro. According to the facility's policy titled, Resident Assessment - Coordination with PASARR Program dated 12/2023: .The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority .Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review .

Based on interview and record review the facility failed to ensure a Preadmission Screening/Annual Resident Review (PASARR) was submitted and completed by the local community mental health agency after the 30 day exemption period for one (R8) of two residents reviewed for PASARR screenings. Findings include: Review of the clinical record revealed R8 was admitted into the facility on [DATE] with diagnoses that included: schizoaffective disorder. According to the Minimum Data Set (MDS) assessment dated [DATE], R8 had intact cognition and had a psychiatric diagnosis of schizophrenia. Review of the initial 3877 form dated 1/3/25 revealed the screening section for questions 1-3 were marked with an X for Yes for mental illness. The section to explain any Yes read, .Patient qualified for exemption. diagnosed with schizophrenia. Patient is prescribed Seroquel. The 3878 form completed at the hospital identified on 1/3/25, R8 had a hospital exempted discharge (which meant the hospital anticipated R8 to be in the nursing facility no more than 30 days), therefore a level II evaluation had not been completed prior to admission into the facility. There was no further documentation in the clinical record that the facility identified and submitted a change in condition to the local community mental health for completion of a level II evaluation as of this review. Further review of the resident's admission social service assessment dated [DATE] documented, .Schizophrenia .PASRR review .Explain: Level 2 issued . (This was inaccurate as no Level 2 was completed.) On 3/19/25 at 2:55 PM, an interview was conducted with the Social Services Manager (Social Worker/SW 'D'). When asked about whether the facility had completed a revision and submission to the local community health regarding R8's diagnosis of schizophrenia and their stay beyond the initial hospital exemption of 30 days, SW 'D' reported they would have to find out. They were unable to explain why their assessment indicated a Level 2 had been issued. On 3/19/25 at 4:00 PM, SW 'D' followed up and reported there was no level II submitted and they just did that today. According to the facility's policy titled, Resident Assessment - Coordination with PASARR Program dated 12/2023: .If a resident who was not screened due to an exception above and the resident remains in the facility longer than 30 days: a. The facility must screen the individual using the State's Level I screening process and refer any resident who has or may have MD, ID or a related condition to the appropriate state designated authority for Level II PASARR evaluation and determination. b. The Level II resident review must be completed within 40 calendar days of admission .The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority .

Based on interview and record review, the facility failed to ensure diagnostic practices met professional standards for one (R61) of two residents reviewed for psychotropic medications when R61 received a new diagnosis of schizophrenia. Findings include: Review of the clinical record revealed R61 was admitted into the facility on [DATE] and readmitted on [DATE] with a new diagnosis of schizophrenia. According to the Minimum Data Set (MDS) assessment dated [DATE], R61 scored a 15/15 on the Brief Interview for Mental Status (BIMS) exam which indicated intact cognition. The schizophrenia diagnoses was not included in section I of the MDS assessment. Documentation also identified the resident had received antipsychotic, antianxiety, and antidepressant medication. Review of R61's physician orders included an order with a start date of 1/31/25 for Seroquel (an antipsychotic medication) oral tablet 50 MG (Milligrams) - give 1 tablet by mouth every 12 hours for schizophrenia. Review of the most recent psych provider consultation included a consult with Psychologist (PhD 'T') dated 1/13/25 which read, .When he arrived here, he had a diagnosis of Parkinson's disease. In June 2024 he went to an outpatient neurologist who stated he did not have Parkinson's disease and diagnosed vascular dementia. He was taken off of Sinemet at that time and it has not been restarted since. Last month, there was an episode where resident became physically aggressive toward staff. He was petitioned out to the hospital and admitted to the general medical unit but not the psych unit. He was seen by psychiatry and neurology at the hospital. No notes from psychiatry were available, but notes from neurology were. Hospital neurology carried over the diagnosis of Parkinson's but also said resident has schizophrenia, which I do not believe he has. Resident returned to this facility 12/29/24 and staff requested follow up today .Today resident was cooperative with encounter. His speech is very difficult to understand and interactions require great care and effort in listening, though his memory does appear decent. Resident indicated being upset about having to go to the hospital and he wants to put it all behind him. Said he is happy now and has no issues as long as he is not sent back to the hospital. Resident likes to sit in common areas and be in charge of others. He often thinks he is directing activities, likes to give advice to others, and tries to tell other residents what to do, though his behaviors appear to be well-meaning rather than aggressive .ASSESSMENT & PLAN .Plan: neurology recently stated that he did not have Parkinson's and that vascular origin was suspected based on history of bizarre behaviors combined with the young age at onset, I suspect possible fronto-temporal origin .Resident is continuing to display fluctuating ataxia with frequent falls as well as rapid fluctuations in speech ability. He likely has Parkinson's dementia or fronto-temporal dementia. I recommend he have another neurology consult to clarify this, as the type of dementia will help explain why he is having the symptoms he is having and help direct interventions. I suspect he is falling due to ataxia related to frontotemporal dementia, and that this diagnosis would also explain his emotional lability, fluctuating speech ability, and poor response to pharmacological interventions . Review of a neuro consultation dated 2/6/25 did not address or clarify the new diagnosis of schizophrenia and read, Pt (Patient) report no further falls, he feels stable. Stable in cognitive function. Still having Dyskinesia in BLEs (Bilateral Lower Extremities), Reviewed Labs, AST (Aspartate Aminotransferase) level elevated .Diagnosis Mild Dyskinesia, Moderate Cognitive Impairment, Confusion, Mood disturbance . Further review of the clinical record, including social services, attending physician/extender, and psych evaluations revealed there was no further clarification, including clinical rational or DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) criteria documented for the new diagnosis of schizophrenia. There was no further psych evaluation following the above consultation with PhD 'T' on 1/13/25. On 3/19/25 at 1:24 PM, an interview was conducted with the Social Services Manager (Social Worker/SW 'D'). When asked about the resident's new diagnoses of schizophrenia in December 2024, SW 'D' reported they were not aware of that. When asked about the psych consultations and whether there had been any follow-up since the most recent assessment available for review was from PhD 'T' on 1/13/25. SW 'D' reported they were now responsible for scanning those consultations into the medical record and would follow-up. On 3/19/25 at 2:55 PM, SW 'D' provided additional documentation of psych consultations which included the most recent one from PhD 'T' on 1/13/25. Additional consultations were from the Psych Physician Assistant (PA 'U') from 11/20/24 and 1/3/25. The consultation from 1/3/25 did not identify or further clarify the new diagnosis of schizophrenia. On 3/19/25 at 4:02 PM, an interview was conducted with the Director of Nursing (DON). They were informed of the concerns with R61's new diagnoses of schizophrenia and lack of further follow-up or clarification. The DON reported they would look into that further. There was no additional documentation or follow-up provided by the end of the survey. The facility was requested to provide a policy regarding professional standards in regard to practitioner's diagnostic practices. On 3/20/25 at 12:23 PM, the Regional Director of Operations (RDO 'A') acting as the interim Administrator reported they were not able to locate a policy for this concern.

This citation pertains to intake: MI00145934. Based on observation, interviews and record reviews the facility failed to implement interventions to prevent injury for one (R403) of three residents reviewed for an injury of unknown origin, resulting in pain and a right subtle nondisplaced medial malleolus (break of the tibia, at the inside of the lower leg) fracture. Findings include: Review of a Facility Reported Incident (FRI) submitted to the State Agency documented a bruise identified on R403's right ankle. An onsite investigation was conducted to investigate the injury of unknown origin. Review of a facility five day investigation summary report submitted to the SA, documented in part . On Thursday, July 18, 2024, at approximately 10:30 am, Cena (later identified as Certified Nursing Assistant - CNA N) reported a bruise on (R403's name) right ankle. Upon interview of (CNA N name), she states . went into (R403's name) room to do ROM (range of motion) and she started crying. (R403's name) was touching her right hip so when I went to turn to look at her hip I noticed the bruise on her ankle . Upon assessment of her environment in the room her wheelchair did not have foot pedals on it, which could have contributed to bruising to prevent her from dragging feet . Additionally, (R403's name) has an order to wear a Prafo boot daily . However, the Prafo boot was unable to be located and had not been worn prior to this event. The facility did order another Prafo boot on 7/22/24 . Staff will be re-educated to ensure foot pedals are on wheelchair to prevent her foot from dragging . On 8/12/24 at 11:39 AM, staff members were observed transferring R403 into their wheelchair via a hoyer lift. A gray leg boot was observed on the right lower leg and foot. Staff applied the wheelchairs right leg rest and placed R403's leg on the leg rest. An interview was attempted with R403, however unsuccessful due to the resident's cognitive level. Review of the medical record revealed R403 was initially admitted to the facility in 2008 and readmitted on [DATE], with diagnoses that included: dementia, spastic hemiplegia affecting right dominant side and nondisplaced fracture of medial malleolus of right tibia (7/26/24). Review of Nurse Practitioner (NP) note dated 7/18/24 at 9:58 AM, documented in part . CNA (certified nursing assistant- later identified as CNA N) reported bruising to the right foot/ankle this morning while she was doing ROM (range of motion) exercise. No reports found about recent injury or fall. There is also a non blanchable 1x1 diameter to right ankle. 1+ edema noted as well . Contusion of right foot . of right ankle, initial encounter . Unknown origin . ER (emergency room ) to do x-ray . Review of the hospital documentation noted the following: A Physician consultation dated 7/19/24 at 10:49 AM, documented in part . Per ED (emergency department), noticed a bruise over right ankle but no known falls per daughter . X-ray of right ankle demonstrates oblique lucency <sic> in the distal fibular diaphysis, concerning for possible age-indeterminate fracture . Pt is admitted . orthopedics consulted . Review of the progress notes revealed the resident was readmitted back to the facility on [DATE] with a . Right ankle broken below knee . boot on right foot upon arrival . Per a nursing note documented at 8:47 PM. A Nursing note dated 7/25/24 at 4:27 PM, documented in part . resident is being sent out to the hospital for MRI (Magnetic resonance imaging) due to redness with swelling with pain of an 8 on a grimace pain scale . PRN (as needed) medication and schedule pain medication was giving to resident, but pain did not subside. Right ankle is warm to touching <sic> with swelling . Review of the hospital documentation dated 7/25/24, documented an Ankle Fracture . Diagnosis Closed nondisplaced fracture of medial malleolus of right tibia, initial encounter . The resident was discharged back to the facility on the same day. Review of the care plans documented the following: . I require assist with adls (activities of daily living) due to confusion, and decreased mobility. I have limited physical mobility r/t (related to) contracture to right UE (upper extremity) flexion and right-side weakness from a prior stroke . Apply right pressure relief ankle foot orthosis (PRAFO) boot as tolerated with daily care . 10/11/2022 . Right Pressure relief ankle foot orthosis. PRAFO boot . 10/24/23 After the identified injury an intervention . Ensure my feet are up and not dragging on the ground when I am up in w/c (wheelchair) . 07/24/2024 On 8/12/24 at 2 PM, CNA N was interviewed and asked about 7/18/24 and them notifying the NP of R403's right foot. CNA N stated they were familiar with R403 and had been assigned to them multiple times. CNA N stated they went into the room with another CNA to perform range of motions with the resident. CNA N stated . (R403) was in so much pain, she grabbed my hand and hit her leg . CNA N again stated that R403 was in so much pain the day of 7/18/24, so they did not perform the range of motion exercises with them. They informed the staff of their observations. CNA N was asked if they ever seen or have observed a boot applied to R403's foot prior to the incident and CNA N stated No, the staff have never put a boot on R403 prior to the incident. When asked if they ensured the right leg foot rest were applied to the resident's wheelchair, CNA N stated No, either way she would drag it if we did (referring to the resident's right foot). The facility's education document provided by the Administrator was reviewed with CNA N. CNA N was asked why they had not attended the education on the Resident Devices/Foot Pedal and CNA N was not sure why they were not educated. Review of the Resident Devices/Foot Pedal in-service provided by the Administrator was compared to the facility's staff list, multiple staff were identified to have not been educated on the deficient practice. The Inservice date was completed on 7/26/24. This indicated the facility staff failed to follow proper protocol of applying leg rest to wheelchairs when applicable, failed to implement the resident specific interventions of the utilization of a right foot boot and failed to educate all staff on the deficient practice. On 8/12/24 the Administrator who also serves as the facility's Abuse Coordinator was interviewed and asked why the staff were not ensuring the wheelchair foot pedals and right foot boot interventions were not implemented as documented in the resident's care plans. The Administrator stated they were recently hired as the Administrator for the facility and during the investigation they found the resident's foot pedal was not applied to the wheelchair and they did not have a boot for the resident as documented in their care plan. The Administrator stated the staff was re-educated. The Administrator was asked why all staff had not been educated on the identified deficient practice and the Administrator stated they would look into it and follow back up. No further explanation or documentation was provided by the end of the survey.

This citation pertains to intake# MI00143166. Based on observation, interview and record review, the facility failed to protect the resident's right be free from sexual abuse by R702, resulting in R701 to have experienced humiliation, anxiety and feelings of being violated during and after unwanted sexual touching using the reasonable person concept. Findings include: A Facility Reported Incident (FRI) was reported to the State Agency (SA) on 3/17/24 that read in part, .A laundry aide was delivering linen and at 1025pm, he saw (R702) . sitting in his wheelchair in the doorway of his room with (R701) . standing next to him. Her pants and brief were pulled down and (R702) had his hand in between her legs . On 3/26/24 at 10:19 AM, R702 was observed lying in bed. R702 was asked if he had touched a female resident in her private areas. R702 asked, Why were her pants down? R702 was asked if he knew how her pants were removed. R702 explained he did not remember. R702 responded that he did not remember to all further questions asked. On 3/26/24 at 10:24 AM, R701 was observed sleeping in bed, the blankets were wrapped around her, cocoon like, and her head was covered. On 3/26/24 at 10:32 AM, R701 was observed lying in bed. When R701's name was called, R701 answered however, R701 was not able to answer any questions appropriately. Review of the clinical record revealed R701 was admitted into the facility on [DATE] and readmitted [DATE] with diagnoses that included: Alzheimer's disease, cognitive communication deficit and adult sexual abuse, suspected. According to the MDS assessment dated [DATE], R701 scored 3/15 on the Brief Interview for Mental Status (BIMS) exam, indicating severely impaired cognition. Review of R701's cognition care plan revised 3/19/24 read in part, .I am AOX1 (alert and orientated to self) able to voice a few words. I enjoy sitting and listening and watching what's going on. I am very passive . Review of R701's progress notes revealed a nursing note dated 3/17/24 at 10:25 PM by Licensed Practical Nurse (LPN) C that read in part, Resident was observed by laundry staff in walk way of room [ROOM NUMBER]-2 as stated by staff member, resident was observed with her pants and brief down, with male resident hand touching her genital area . Nurse immediately walked to room [ROOM NUMBER] and observed both residents in walk way of room [ROOM NUMBER]. Female resident had her pants down and brief pulled up, male resident was in front of her in wheelchair with both hand [sic] on lap . Review of the clinical record revealed R702 was admitted into the facility on [DATE] and readmitted [DATE] with diagnoses that included: heart disease, stroke and dementia. According to the Minimum Data Set (MDS) assessment dated [DATE], R702 scored 6/15 on the Brief Interview for Mental Status (BIMS) exam, indicating severely impaired cognition. Review of R702's cognition care plan revised 3/19/24 read in part, I am AOx2 (alert and orientated to self and place), able to voice my needs . I have had sexual behaviors in my room . I have a hx (history) of touching female peers inappropriately . Review of R702's progress notes revealed a nursing note dated 3/18/24 at 12:10 AM that read in part, Police transferred resident from facility for further questioning . Review of a police interview dated 3/18/24 at 12:11 AM read in part, .asked (R702) if he did anything to the other patient. (R702) raised his right hand and moved it in a [sic] up and down motion and said, 'I touched her peepee.' (R702) snickered when he said, 'I touched her pee pee.' . On 3/26/24 at 12:16 PM, Laundry Aide (LA) B was interviewed and asked what he observed on 3/17/24. LA B explained he was delivering laundry when he saw R701 standing in the doorway with her britches down and R702 had his hand between her legs and was rubbing on her . he said 'Hey, what's going on here?', moved R702 out of the way and yelled for the nurse. LA B was asked how R702's hand was positioned. LA B explained R702's hand was mostly flat, a little cupped, and rubbing directly on R701's genitalia, front to back repeatedly. LA B was asked how either resident reacted. LA B explained R701 was just standing there, but R702 said 'So' when he told him he was going to have to tell what happened. On 3/26/24 at 1:40 PM, Social Services Manager (SSM) D was interviewed and asked about R701. SSM D explained R701 would wander in the halls, that she is mostly an observer, she does not usually participate in activities, or interact with other residents, she just watches. When asked if R701 is known for taking her clothes off, SSM D explained she had never seen that behavior, or heard about it from staff. On 3/26/24 at 2:33 PM, Certified Nursing Assistant (CNA) F was interviewed via phone and asked about R701. CNA F explained R701 would wander around, sometimes go into other rooms. When asked if R701 would take her clothes off, CNA F explained R701 did not usually take her clothes off. CNA F was asked about R702. CNA F explained R702 sometimes goes into other residents rooms and gets into their stuff. On 3/26/24 at 2:57 PM, CNA G was interviewed by phone and asked about what happened on 3/17/24. CNA G explained she did not see anything that happened. CNA G was asked about R701. CNA G explained R701 will go into other resident's rooms, but it is usually to empty the garbage or something. When asked if R701 takes her clothes off, CNA G explained R701 does not take her clothes off. On 3/26/24 at 4:24 PM, R701's Power of Attorney (POA) was interviewed by phone and asked about the sexual incident on 3/17/24. The POA explained she was concerned the facility could not watch R701 appropriately . and was concerned how a male resident, who even though has dementia, had the wherewithal to pull down R701's pants and brief. The POA was asked if she had talked to R701 to see if she remembered anything. The POA explained R701 did not remember anything, but would have been humiliated by what had happened. On 3/27/24 at 10:39 AM, LPN C was interviewed via phone and asked about the incident on 3/17/24. LPN C explained she had not witnessed anything that happened. LPN C was asked about R702's normal demeanor. LPN C explained R702 was able to converse appropriately, and understood orders and directions. LPN C was asked about R701's normal demeanor. LPN C explained R701 was not able to converse appropriately, and usually was not able to follow directions. LPN C was asked if R701 routinely took her clothes off. LPN C explained R701 enjoyed dressing herself, and did not normally take her clothes off. On 3/27/24 at 11:41 AM, the Administrator was interviewed and informed all the staff interviewed said R701 did not normally take her clothes off. The Administrator agreed R702 most likely took R701's pants off. Review of a facility policy titled, Abuse, Neglect and Exploitation revised 6/2023 read in part, Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Sexual Abuse is non-consensual sexual contact of any type with a resident . Serious bodily injury also includes sexual intercourse with a resident who is incapable of declining to participate in the sexual act or lacks the ability to understand the nature of the sexual act .

This citation pertains to intake: MI00143015 & MI00143012. Based on observations, interviews, and record reviews, the facility failed to protect a vulnerable resident (R702) who lacks cognitive ability to consent to sexual activity, from a sexual incident initiated by R703 a cognitively intact resident for two of six residents reviewed for abuse, resulting in the failure of the facility to protect R702 and other vulnerable residents who resided in the facility on the day of the incident, the failure to conduct a thorough investigation, the failure to preserve potential criminal evidence and the failure to notify law enforcement of the incident, which resulted in an Immediate Jeopardy (IJ). The IJ was identified on 3/6/24 at 9:15 AM. The IJ began on 2/27/24. The Administrator was notified of the IJ on 3/6/24 at 11:59 AM and a plan of removal was requested to remove the immediacy. The IJ was removed on 3/6/24 based on the provider's implementation of removal and verified onsite on 3/7/24. Although the immediacy was removed the facility's deficient practice was not corrected and remained isolated with the potential for harm that is not immediate jeopardy. Findings include: Review of a complaint submitted to the State Agency (SA) documented in part . This morning, another patient, (R703 name and age) was found in (R702's name) bed with an erection. (R702 and R703 name) were both naked. It is unknown how long (R703 name) was in bed with (R702 name). There are concerns that (Facility name) did not respond appropriately to the incident as they did not call LE (law enforcement). (Facility name) sent (R702 name) to the ER (emergency room ) by way of EMS (emergency medical services). EMS called LE. (R703 name) is of sound mind. (R703 name) has been arrested for sexual assault . Review of a witness statement obtained from the local law enforcement department, written by Certified Nursing Assistant (CNA) A, documented the following . I was at the nursing station and notice (R702's room number) call light was on when I entered the room I witnessed (R703 name) in bed naked with (R702 name) with a fully erect penis. (R703 name) was on his back and (R702 name) being cuddled when I asked him what he was doing he began to dress himself. I was able to separate the two of them before getting the nurse he then went to his room and (R702 name) was taken downstairs to (room number). Review of a witness statement obtained from the local law enforcement department, written by Registered Nurse (RN) B, documented the following . Called to room (room number) by CNA (CNA A name). Upon entering room male resident was pulling up his white pull up with his blue jogging pants on floor. I immediated <sic> removed male resident to his room (room number and bed number). I transferred female resident to (room number and bed number). I questioned female resident who is confused and could only tell me hurt while pointing and grabbing at her lower abdomen. When questioning male resident as to why he was lying naked in bed (R702's room number) bed ,he stated she came down to my room and I walked her back to her room. Her brief fell down. I asked male resident why was he naked and he stated, I don't have to answer that. Review of a police report dated 2/27/24, documented in part . On 02/27/2024 at approximately 0537 hours . dispatched to (facility name) . on a report of a possible criminal sexual conduct . male resident was found fully nude in bed with a female resident, who is on hospice and suffers from severe dementia . I arrived on scene, and spoke with . (CNA A name) . observed a male resident (R703) . fully nude in bed next to victim . had an erect penis and was attempting to put his underwear back on . Due to (R702 name) severe dementia, she could not recall anything. Nursing staff stated that (R702 name) was walking around holding her lower abdominal area as if in pain . I went to (R703's room number) to speak with (R703 name), who was sitting in a wheelchair, watching television . (R703 name) stated that they were just lying in bed together. I asked him if he was nude at any point in time and he stated that he was not. I asked nursing staff where the bedding was that was on the bed in (R702's room), however they stated that they had washed it due to there being diarrhea on it . Due to the allegations made by the nursing staff and the witness who saw (R703's name) nude and with an erect penis, the decision was made to have (R702 name) transported to (hospital name) for an evaluation . (hospital name) staff attempted to take vitals from (R702's name), but she became increasingly agitated. The physician's assistant attempted to lift up (R702's name) gown to conduct an assessment on the abdominal area and (R702's name) quickly grabbed her gown and yanked it down. She yelled at staff and attempted to get up several times. The attending physician made the decision that (R702) may be more comfortable with (third party entity name) conducting the examination. (Third party entity name) was contacted by hospital staff. (Third party entity name) stated they would contact (facility name) to schedule a time to examine (R702 name) . warrant for attempted CSC (criminal sexual conduct) 3rd and aggravated indecent exposure . Review of the medical record revealed R702 was admitted to the facility on [DATE] with diagnoses that included: Alzheimer's, dementia and hospice care. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 00, which indicated severely impaired cognition and lacked the capacity to consent to sexual activity. R702 required staff assistance for all Activities of Daily Living (ADLs). Review of a legal guardianship document revealed R702 had a full guardian appointed by the court. Review of a Incident Note dated 2/27/24 at 6:59 AM, documented . Resident observed in bed naked with male resident. Resident c/o (complaints of) pain to lower abdomen. New order to transfer to ER. Resident transferred to (hospital name) for further evaluation. Notification: Resident/Family/Guardian/DPOA State who and when they were notified: Guardian notified . Administrator notified . MD (medical doctor) notified . Hospice nurse notified. Review of the hospital After Visit Summary dated 2/27/24, documented in part . Reason for Visit Sexual Assault . Review of R703's medical record revealed R703 was admitted to the facility on [DATE] with diagnoses that included convulsions. A MDS assessment dated [DATE], documented a BIMS score of 14, which indicated intact cognition and required minimal assistance for all ADLs. R703 was discharged from the facility at the time of the survey. Review of an Incident Note dated 2/27/24 at 7:52 AM, documented in part . Resident observed lying naked in a female resident bed . Resident removed . Administrator notified. MD notified. Family notified . Review of a Nursing Progress Note dated 2/27/24 at 8:01 AM, documented in part . Resident transferred to (city name) lockup via (city name) PD (police dept) . Administrator notified. On 3/5/24 at 3:38 PM, CNA A was interviewed and when asked stated they were at the nursing station the morning of 2/27/24 when they saw (R702's) call light on. CNA A stated they went down to the room and opened the door which is unusual that the door was shut because R702's room door is always open, and the door was open the last time CNA A had left R702's room. CNA A was uncertain of the time when they last visited R702's room, when asked. CNA A stated when they opened the door, they observed R703 in R702's bed naked. CNA A stated R702 had a gown on but their pull up brief was observed on top of the bedside table. CNA A stated R702 was laying on their side with the back and buttocks exposed and R703 was observed lying behind R702 on their back with their skin touching R702 skin as if you were cuddling with your significant other and R703 was observed to have an erection. CNA A stated R703's sweatpants and pull up brief was observed on the floor next to the bed. CNA A stated they left the room to get Registered Nurse (RN) B and when they returned to the room R703 was pulling up their pull up brief. CNA A was asked why they left R702 in the room with R703 and CNA A stated they were shocked and just left to get the nurse. CNA A stated despite R703 to utilize a wheelchair, R703 is still able to stand and walk short distances with an unsteady gait. CNA A stated they stayed in the room with RN B, watched R703 get dressed and go back into their own room. CNA A stated RN B then went to call the Administrator and they remained with R702 to clean the resident up and change their bedding because R702 had an episode of diarrhea. CNA A was asked why they disposed of R702's bed sheets, gown, brief and washed the resident before being assessed/examined by law enforcement and health professionals and CNA A stated the police asked them the same question that night and CNA A then stated they did not know they had to preserve those items, and their main concern was cleaning the resident. CNA A stated after they cleaned R702, R702 was escorted to the first floor and R703 remained on the second floor. CNA A was asked why R702 was placed on the first floor while R703 remained on the second floor with multiple other vulnerable residents, unsupervised and CNA A could not provide and answer. CNA A was then asked if they notified law enforcement of the incident and CNA A replied No. CNA A was asked if any of the Administration staff followed up with them to obtain their statement or asked them questions regarding the incident with R's 702 and 703 and CNA A stated the Administrator questioned them minutes before meeting the surveyor for this interview. CNA A was asked before today 3/6/24, had any administration staff followed up with them regarding this incident and CNA A replied No. On 3/6/24 at 4:04 PM, the Administrator was asked to provide the facility full investigation, including staff statements obtained for the incident involving R's 702 and 703, on 2/27/24. On 3/6/24 at 4:07 PM, R702 was observed eating off of a food tray found on the counter top in the second-floor community room. Another resident grabbed the tray from R702 and told R702 that they couldn't do that. A staff member arrived shortly after to intervene and took the cold food tray away. An interview was attempted with R702, however R702 was unable to answer any of the questions appropriately. R702 walked away and was observed wandering the unit hallways. On 3/5/24 at 4:22 PM, RN B was interviewed via telephone. When asked, RN B stated on 2/27/24 CNA A came running to the nurse's desk and told them that R703 was in the bed with R702. RN B stated they went to R702's room and they saw R703 sweatpants and pull up brief on the floor next to R702's bed. RN B stated R703 got dressed and they took R703 back to their room. RN B stated they then assessed R702 who was holding their stomach and saying they were in pain. RN B stated despite being a float nurse they were familiar with R702 and the resident holding their stomach and complaining of pain was something new. RN B was asked what R703's response was when they first saw R703 in R702's room and RN B stated R703 kept stating R702 brought them in their room and wanted R703 to be in their room. RN B was asked if they notified law enforcement regarding the incident and RN B stated No. RN B stated they informed the Administrator who directed the staff to do an assessment and document it, with no further directive given. RN B asked why R702 was placed on the first floor, leaving R703 on the second floor with multiple vulnerable residents and no implementation of increased monitoring/supervision and RN B replied they wanted to ensure the residents were separated, as they did not receive further directive from the Administrator on how to handle the situation. RN B stated they notified the Physician who directed RN B to send R702 out to the hospital for further evaluation. RN B was asked if any of the Administration staff followed up with them regarding this incident or obtained a statement from them and RN B stated No. RN B stated when they returned to the facility on [DATE] the Regional Clinical Director of Operations (RCDO) D asked RN B for a copy of their statement that RN B provided to law enforcement and RN B stated there was no additional follow up from the Administrator or Administration staff. Review of the facility census for 2/27/24 and medical records revealed multiple residents who wandered, had the diagnoses of dementia and/or Alzheimer's residing on the second floor of the facility, while R703 continued to reside on the second floor after the incident without adequate monitoring/supervision implemented. The facility staff failed to protect R702 and other vulnerable residents who resided on the second floor when R703 was allowed to remain on the second floor, after the incident with R702. Review of R703's medical record revealed no additional monitoring/supervision in place for R703 after the incident with 702, until law enforcement returned to the facility to arrest and escort R703 from the facility premises. The facility staff also failed to preserve the evidence needed for the investigation. Review of a facility policy titled Abuse, Neglect and Exploitation revised 6/23 documented in part .Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence) . Protection . The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after investigation. Examples include but are not limited to . Responding immediately to protect the alleged victim and integrity of the investigation . Further review of the hospital After Visit Summary dated 2/27/24, documented in part . Care after sexual assault . What should I do if I am sexually assaulted? - The first thing you should do is find a safe place away from the person who assaulted you . Do NOT try to clean up before you get medical care. Doing this can wash away proof of what happened. In particular: Do not change clothes, Do not take a shower or bath, Do not brush your teeth, Do not wash the inside of your vagina or rectum, If you can wait, try not to go to the bathroom or eat anything until after you have seen a doctor or nurse . Review of the investigation provided by the Administrator contained the incident report submitted to the State Agency (SA), which documented the Incident Summary as (R703 name) was found in a (R702 name) bed. Investigation ongoing. Further review of the investigation provided contained the facility's incident report, face sheets of both residents, progress notes, skin, and pain assessment for R702 and documentation of R702's transfer to the hospital. There were no other documents provided. On 3/6/24 at 8:44 AM, the Administrator (who also serves as the facility's Abuse Coordinator) was interviewed and asked when and by whom they were notified of the incident that occurred between R's 702 & 703, the Administrator replied they were notified by RN B on the day of the incident. The Administrator was asked what was reported to them and the Administrator replied that R703 was in R702 bed. The Administrator was asked what directive they gave the staff and the Administrator stated they instructed RN B to notify the doctor and let them know what occurred and to make sure the residents were separated and to monitor. The Administrator was asked what directive was implemented for monitoring and for which resident and the Administrator could not provide a reply. The Administrator was asked if it was their directive to move R702 the vulnerable resident to the first floor, and leave the perpetrator to remain on the second floor without additional monitoring or supervision implemented and the Administrator did not offer a response. The Administrator was asked about the safety of the other vulnerable residents that resided on the second floor with R703 to have remained on that floor without additional supervision/monitoring implemented and the Administrator did not provide a response. The Administrator was asked who completed the investigation for the incident and stated they were, and that the investigation was still ongoing. The Administrator was asked what they discovered during their investigation on 2/27/24 and the Administrator stated they did not come into the facility on [DATE] and started their investigation on 2/28/24 the next day. The Administrator was asked why at the very least did they not obtain statements from the witnesses that was on duty on the day that the incident occurred, the Administrator stated they had statements and would provide them. The Administrator was asked why the statements were not provided with the investigation documents initially as requested and the Administrator did not have a response. Shortly after the Administrator emailed copies of the two statements obtained by law enforcement as statements for the facility's investigation. At 11:34 AM, a second interview was conducted with the Administrator and the RCDO D in attendance. The Administrator was asked about their investigation into the incident and informed of the concern of a thorough investigation to not have been completed, including statements obtained by them from the witnessing staff. The Administrator was asked if their investigation into the incident identified any opportunity for improvement on how the facility staff handled the situation with R's 702 & 703, as directed by the facility's protocols and policy and the Administrator responded No, he (R703) was taken by the police, and she (R702) was taken to the hospital. Further review of the facility policy titled Abuse, Neglect and exploitation revised 6/23, documented in part . Investigation . An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or report of abuse, neglect or exploitation occur . Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations . Providing complete and thorough documentation of the investigation . The facility submitted a removal plan on 3/6/24, which documented the following: - Current residents with BIMS scores of 8 and above will be interviewed/assessed for potential sexual abuse. Current residents with BIMS scores of 7 and below will be assessed by a licensed nurse for an acute change in condition. Any concerns that arise will be addressed by the IDT immediately. - Resident 703 no longer resides in the facility. - Resident 702 received wellbeing checks by the facility Social Worker and her Hospice RN on the event date. Resident has shown no deviation from baseline. - The Abuse, Neglect & Exploitation Policy was reviewed by the Corporate Compliance Officer and deemed appropriate. - The abuse investigation procedure was reviewed by the Corporate Compliance Officer and deemed appropriate. - The Corporate Compliance Officer re-educated the facility Administrator on our Abuse, Neglect & Exploitation Policy, and the investigation procedure. - Beginning 3/6/24, all staff will be reeducated on the facility abuse policies, including abuse prevention and expected interventions. Education also includes preservation of potential crime scenes in the event of a sexual allegation. Any staff not educated on 3/6/24 will be educated prior to their next shift. As of 3/6/24 4:30p 62% of staff have received the education. - In the event of any future resident sexual abuse allegations, the perpetrating resident will immediately be placed on 1:1 supervision until additional safety interventions can be implemented. - The Medical Director was notified of this event on 03/06/2024.

This citation pertains to intake: MI00143015 & MI00143012 Based on observation, interviews, and record reviews the facility failed to prevent an incident of resident-to-resident sexual abuse with two (R's 702 and 703) of seven residents reviewed for abuse, resulting in the reasonable person to have experienced inappropriate, unwanted sexual contact and would have experienced humiliation, embarrassment, feelings of being violated, anxiety and helplessness after being the victim of resident-to-resident sexual abuse. Findings include: Review of a complaint submitted to the State Agency (SA) documented in part . This morning, another patient, (R703 name and age) was found in (R702's name) bed with an erection. (R702 and R703 name) were both naked. It is unknown how long (R703 name) was in bed with (R702 name). There are concerns that (Facility name) did not respond appropriately to the incident . (R703 name) has been arrested for sexual assault . Review of the medical record revealed R702 was admitted to the facility on [DATE] with diagnoses that included: Alzheimer's, dementia and hospice care. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 00, which indicated severely impaired cognition and lacked the capacity to consent to sexual activity. R702 required staff assistance for all Activities of Daily Living (ADLs). Review of a legal guardianship document revealed R702 had a full guardian appointed by the court. On 3/5/24 at 3:38 PM, CNA A (the aide assigned to R702 on the day/shift of the incident) was interviewed and when asked stated they were at the nursing station the morning of 2/27/24 when they saw (R702's) call light on. CNA A stated they went down to the room and opened the door which is unusual that the door was shut because R702's room door is always open, and they had just left the room not too long prior, and the door was open. CNA A stated when they opened the door, they observed R703 in R702's bed naked. CNA A stated R702 had a gown on but their pull up brief was observed on top of the bedside table. CNA A stated R702 was laying on their side with the back and buttocks exposed and R703 was observed lying behind R702 on their back with their skin touching R702 skin as if you were cuddling with your significant other and R703 was observed to have an erection. CNA A stated R703's sweatpants and pull up brief was observed on the floor next to the bed. CNA A stated they left the room to get Registered Nurse (RN) B and when they returned to the room R703 was pulling up their pull up brief. CNA A was asked why they left R702 in the room with R703 and CNA A stated they were shocked and just left to get the nurse. CNA A stated despite R703 to utilize a wheelchair, R703 is still able to stand and walk short distances with an unsteady gait. CNA A stated they stayed in the room with RN B, watched R703 get dressed and go back into their own room. CNA A stated RN B then goes to call the Administrator and they remained with R702 to clean the resident up and change their bedding because R702 had an episode of diarrhea. CNA A stated after they cleaned R702, R702 was escorted to the first floor and R703 remained on the second floor. On 3/5/24 at 4:22 PM, RN B was interviewed via telephone. When asked, RN B stated on 2/27/24 CNA A came running to the nurse's desk and told them that R703 was in the bed with R702. RN B stated they went to R702's room and they saw R703 sweatpants and pull up brief on the floor next to R702's bed. RN B stated R703 got dressed and they took R703 back to their room. RN B stated they then assessed R702 who was holding their stomach and saying they were in pain. RN B stated despite being a float nurse they were familiar with R702 and the resident holding their stomach and complaining of pain was something new. RN B was asked what R703's response was when they first saw R703 in R702's room and RN B stated R703 kept stating R702 brought them in their room and wanted R703 to be in their room. RN B stated they notified the Physician who directed RN B to send R702 out to the hospital for further evaluation. Review of a police report dated 2/27/24, documented in part . On 02/27/2024 at approximately 0537 hours . dispatched to (facility name) . on a report of a possible criminal sexual conduct . male resident was found fully nude in bed with a female resident, who is on hospice and suffers from severe dementia . I arrived on scene, and spoke with . (CNA A name) . observed a male resident (R703) . fully nude in bed next to victim . had an erect penis and was attempting to put his underwear back on . Due to (R702 name) severe dementia, she could not recall anything. Nursing staff stated that (R702 name) was walking around holding her lower abdominal area as if in pain . I went to (R703's room number) to speak with (R703 name), who was sitting in a wheelchair, watching television . (R703 name) stated that they were just lying in bed together. I asked him if he was nude at any point in time and he stated that he was not. I asked nursing staff where the bedding was that was on the bed in (R702's room), however they stated that they had washed it due to there being diarrhea on it . Due to the allegations made by the nursing staff and the witness who saw (R703's name) nude and with an erect penis, the decision was made to have (R702 name) transported to (hospital name) for an evaluation . (hospital name) staff attempted to take vitals from (R702's name), but she became increasingly agitated. The physician's assistant attempted to lift up (R702's name) gown to conduct an assessment on the abdominal area and (R702's name) quickly grabbed her gown and yanked it down. She yelled at staff and attempted to get up several times. The attending physician made the decision that (R702) may be more comfortable with (third party entity name) conducting the examination. (Third party entity name) was contacted by hospital staff. (Third party entity name) stated they would contact (facility name) to schedule a time to examine (R702 name) . warrant for attempted CSC (criminal sexual conduct) 3rd and aggravated indecent exposure . Review of the hospital After Visit Summary dated 2/27/24, documented in part . Reason for Visit Sexual Assault . Review of R703's medical record revealed R703 was admitted to the facility on [DATE] with diagnoses that included convulsions. A MDS assessment dated [DATE], documented a BIMS score of 14, which indicated intact cognition and required minimal assistance for all ADLs. R703 did not reside in the facility at the time of the survey. This indicated R703 could consent to sexual activity, however R702 could not. On 3/6/24 at 4:07 PM, R702 was observed eating off of a food tray found on the counter top in the second-floor community room. Another resident grabbed the tray from R702 and told R702 that they couldn't do that. A staff member arrived shortly after to intervene and take the cold food tray away. An interview was attempted with R702, however R702 was unable to answer any of the questions appropriately. R702 walked away and was observed wandering the unit hallways. Review of a facility policy titled Abuse, Neglect and Exploitation revised 6/23 documented in part, . It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect exploitation . Sexual Abuse is non-consensual sexual contact of any type with a resident . On 3/6/24 at 8:44 AM, the facility's Abuse Coordinator (who also serves as the facility's Administrator) was interviewed and asked when they were first notified of the incident that occurred on 2/27/24 with R's 702 and 703, and the Administrator stated the nurse that was on duty (RN B) had notified them the day of the incident. The Administrator was asked the findings of their investigation, and the Administrator stated the investigation is still ongoing. The Administrator was asked the immediate decision made to protect R702 after the incident with R703 and the Administrator stated the facility staff separated the residents and ultimately R702 went to the hospital and R703 was placed in police custody. No further explanation or documentation was provided by the end of the survey.

This citation pertains to intake: MI00143015 & MI00143012 Based on observations, interviews, and record reviews the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when the facility failed to ensure an allegation of sexual abuse was reported within the required time frame to the State Agency (SA) and reported the suspected crime to law enforcement, resulting in a delay in notification to the SA (when R703 was found naked with R702), the delay in notification to law enforcement and the inability for law enforcement and health officials to obtain and process evidence and resulting in the reasonable person to have felt fear, guilt, shame, anger, hurt, and anxiety as a victim of an unconsented sexual act. Findings include: Review of a complaint submitted to the State Agency (SA) documented in part . This morning, another patient, (R703 name and age) was found in (R702's name) bed with an erection. (R702 and R703 name) were both naked. It is unknown how long (R703 name) was in bed with (R702 name). There are concerns that (Facility name) did not respond appropriately to the incident as they did not call LE (law enforcement). (Facility name) sent (R702 name) to the ER (emergency room ) by way of EMS (emergency medical services). EMS called LE. (R703 name) is of sound mind. (R703 name) has been arrested for sexual assault . Review of the Incident report submitted to the SA documented the date and time of the sexual assault allegation to have occurred on 2/27/24 at 4:29 AM. The incident report documented the facility's Administrator, who also served as the facility abuse coordinator to have submitted the report to the SA on 2/27/24 at 5:03 PM. Further review of the incident report documented the following information submitted to the SA (R703's name) was found in (R702's name) bed. Investigation ongoing. The Administrator reported the allegation of sexual abuse to the SA, after the two-hour required time frame and omitted the detail of R703 and 702 to have been observed naked in R702's bed with R703 to have an erection. On 3/5/24 at approximately 1:30 PM, Sergeant (SGT) C (from the local law enforcement department) was interviewed and stated in part, . The facility did not notify us of the incident, EMS did at 5:37 AM, by the time we got there they threw away the bedding and clothes of the patient and had her (R702) cleaned up. On 3/5/24 at 3:38 PM, Certified Nursing Assistant (CNA) A (the aide assigned to R702 on the shift/date of the incident) was interviewed and when asked stated they were at the nursing station the morning of 2/27/24 when they saw (R702's) call light on. CNA A stated they went down to the room and opened the door which is unusual that the door was shut because R702's room door is always opened, and CNA A stated the last time they had left R702's room the door was open. CNA A stated when they opened the door, they observed R703 in R702's bed naked. CNA A stated R702 had a gown on but their pull up brief was observed on top of the bedside table. CNA A stated R702 was laying on their side with the back and buttocks exposed and R703 was observed lying behind R702 on their back with their skin touching R702 skin as if you were cuddling with your significant other and R703 was observed to have an erection. CNA A stated R703's sweatpants and pull up brief was observed on the floor next to the bed. CNA A stated they left the room to get Registered Nurse (RN) B and when they returned to the room R703 was pulling up their pull up brief. CNA A stated RN B then goes to call the Administrator and they (CNA A) remained with R702 to clean the resident up and change their bedding because R702 had an episode of diarrhea. CNA A was asked why they disposed of R702's bed sheets, gown, brief and washed the resident before being assessed by law enforcement and health professionals and CNA A stated the police asked them the same question that night and CNA A then stated they did not know they had to preserve those items, and their main concern was cleaning the resident. CNA A was then asked if they notified law enforcement of the incident and CNA A replied No. CNA A was asked if they were given the directive from the facility's Abuse Coordinator (Administrator) to call law enforcement and to keep the resident and bedding as is until law enforcement arrived and CNA A replied No and stated they did not speak with the Administrator, RN B spoke to the Administrator. On 3/5/24 at 4:22 PM, Registered Nurse (RN) B (the nurse assigned to R702 on the shift/date of the incident) was interviewed via telephone. When asked, RN B stated on 2/27/24 CNA A came running to the nurse's desk and told them that R703 was in the bed with R702. RN B stated they went to R702's room and they saw R703 sweatpants and pull up brief on the floor next to R702's bed. RN B stated R703 got dressed and they took R703 back to their room. RN B stated they then assessed R702 who was holding their stomach and saying they were in pain. RN B stated despite being a float nurse they were familiar with R702 and the resident holding their stomach and complaining of pain was something new. RN B was asked if they notified law enforcement regarding the incident and RN B stated No, when asked why they did not notify law enforcement, RN B replied they were trained to notify the Administrator for abuse allegations. RN B explained they were considered Float Pool staff and was not a regular scheduled employee for the facility. RN B stated they informed the Administrator who directed the staff to do an assessment and document it, with no further directive given. RN B was asked if the Administrator had given them directive to call law enforcement and preserve the resident and resident bedding as is until processed by law enforcement and RN B replied no. RN B stated minimal directive was given. RN B stated they notified the Physician who directed RN B to send R702 out to the hospital for further evaluation. The phone call to EMS to transfer R702 to the hospital for the evaluation of a sexual abuse allegation, prompted EMS to notify the local law enforcement of the sexual abuse allegation. Review of a facility policy titled Abuse, Neglect and Exploitation revised 6/23 documented in part .Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence) . The facility will implement the following . Reporting of all alleged violations to the Administrator, state agency . and to all other required agencies (e.g., law enforcement) within specified timeframes . Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse . On 3/6/23 at 8:44 AM, the Administrator was interviewed and asked when and whom they were notified by regarding the incident on 2/27/24 with R's 702 and 703 and the Administrator stated they were informed by (RN B name) and it was reported to them that day and shift of the incident. The Administrator was asked when they reported the incident to the SA and the Administrator stated they were unsure as they did not come into the facility on [DATE]. The Administrator was asked when an allegation of abuse is supposed to be reported to the SA and the Administrator replied uhhh two hours. The Administrator was asked if they gave the directive to the staff to call the police when the staff informed of the incident and the Administrator could not recall. The Administrator was asked if they had notified the local law enforcement of the incident and the Administrator stated they did not. The Administrator was asked why they omitted the details submitted to the SA of both residents to have been observed naked in R702's bed and R703 to have an erection and the Administrator stated the investigation is ongoing and they did not want to jump to conclusions. On 3/6/24 at 4:07 PM, R702 was observed eating off of a food tray found on the counter top in the second-floor community room. Another resident grabbed the tray from R702 and told R702 that they couldn't do that. A staff member arrived shortly after to intervene and took the cold food tray away. An interview was attempted with R702, however R702 was unable to answer any of the questions appropriately. R702 walked away and was observed wandering the unit hallways. No further explanation or documentation was provided by the end of the survey.

This Citation pertains to Intake#: MI00135254 Based on interviews and record reviews the facility failed to implement the physician order and provide the CPAP (Continuous Positive Airway Pressure machine-keeps the airway open by gently providing air through a mask while sleeping) machine during their entire length of stay for one of one Resident (R908) reviewed for respiratory care resulting in inadequate ventilation and respiratory distress requiring hospitalization . Findings include: R908 was admitted to facility on 2/9/23 for short-term skilled nursing and rehabilitation management after hospitalization . R908 was living the community prior to this hospitalization . R908's admitting diagnoses included pneumonia, sepsis, congestive heart failure (CHF), COPD (Chronic Obstructive Pulmonary Disease). R908 had a Brief Interview of Mental Status (BIMS) score of 14/15, indicative of intact cognition. A review of complaint filed to the State Agency revealed that the facility failed to provide the CPAP machine for R908 during their stay at the facility and was concerned about the quality of care. A review of the report received from local Police Department revealed that R908 called 911 on 2/21/23 at 8:47 AM. R908 reported to the officers that they were not receiving proper care at the facility and wanted to go to the hospital. R908 was transferred to the hospital via ambulance. Review of hospital discharge summary and orders read in part, O2 (oxygen) 2-3 liters/min via NC (Nasal Canula), CPAP at HS (hours of sleep) for OSA (Obstructive sleep Apnea) . A review admitting practitioner note from the hospital dated 1/26/23, revealed that R908 was admitted to hospital due acute on chronic hypoxic (decreased oxygen in blood) and hypercapnic (increased carbon-di-oxide in blood) respiratory failure. The note also revealed that R908 was dependent on oxygen and was using CPAP at home prior to hospitalization due to their history of multiple medical conditions. The physician and practitioner notes during the hospital stay revealed that R908 was depending on medications, supplemental oxygen therapy and their CPAP machine to maintain ventilation and respiration. R908 stayed in the hospital for 28 days, from 1/12/23 to 2/9/23. A review of nursing progress note dated 2/21/23 at 9:10AM, read in part, Writer in hallway, 3 police officers outside and in patient's room. Writer into room to see what situation was, 911 stated that resident had called and wanted to go out from the facility and go to (hospital name omitted) .MD (Medical Doctor) ordered to send per request. UM (Unit Manager) notified and DON notified and came in to see the situation . R908's Electronic Medical Record (EMR) review was completed. A review of facility admission physician orders summary dated 2/9/23, did not reveal any order for a CPAP. An admission physician note dated 2/9/23, read in part, admitted to (facility name omitted) from (hospital name omitted) where he was treated for shortness of breath CHF vs COPD . on 4 liters of home oxygen, OSA on CPAP. Further review of R908's EMR did not reveal any orders for CPAP from 2/9/23 to 2/14/23. An order dated 2/15/23, read auto set up, apply CPAP at QHS. Review of nursing progress notes from 2/15/23 to 2/21/23 revealed that R908 did not receive the CPAP as ordered. A nursing e-MAR (electronic Medication Administration Record) progress note dated 2/15/23, at 21:56 read, auto set pap, apply CPAP at QHS bedtime - awaiting delivery. Nursing e-MAR progress note dated 2/16/23, at 20:51 read, auto set pap, apply CPAP at QHS bedtime - N/A, note dated 2/19/23, at 22:59 read, auto set pap, apply CPAP at QHS bedtime - N/A, note dated 2/20/23, at 19:07 read, auto set pap, apply CPAP at QHS bedtime - N/A. A physician tele-visit noted dated 2/17/23 revealed that R908 was seen by the physician for abnormal labs. Physician progress read chief complaint: recent labs show lower hemoglobin with normal MCV -80 other abnormal labs below .Bicarbonate - 39. Assessment and Plan read .metabolic alkalosis (there is excess of bicarbonate in the body fluids) most likely due chronic hypercarbia from OSA . It must be noted that R908 had been at the facility for ten days and had not received the CPAP machine to maintain their ventilation. There is no documented evidence in R908's EMR that physician was notified that R908 has not been receiving their CPAP as ordered at this time. A physician visit note dated 2/20/23 at 12:26 read in part, Chief complaints/History of Present Illness: PULSE OX on routine testing was 88% on 5 Liters of oxygen. Does have a history of sleep apnea but has not been able to get his CPAP yet .hypoxia likely a reflection of hypoventilation/[NAME] (Obesity hypoventilation Syndrome) also OSA. Continue Current oxygen, which is baseline of 5L by NC, also needs the CPAP/or AUTOPAP has been ordered but still pending to be available . It must be noted that R908 had been at the facility for 12 days, waiting for their CPAP machine. A physician discharge progress note dated 2/21/23 at 9:10 read in part, complaining of SOB (shortness of breath) - was hypoxic requiring 5 liters of oxygen by NC .still waiting for CPAP, needed for his OSA .ASSESSMENT and PLAN: Shortness of breath- with underlying OSA/[NAME], hypoxia likely due to underlying problems .supportive positive pressure respiration like CPAP/BiPAP to maintain adequate ventilation. Not available at this time. Therefore, will transfer to (hospital name omitted) for further management). A review of EMR revealed that R908 did not receive CPAP machine that was needed to assist with their ventilation from 2/9/23 to 2/21/23. R908 had called 911and had requested to be transferred to the hospital with complaints of shortness of breath as noted in the physician discharge summary. A review of the equipment order confirmed that R908 did not receive a CPAP during their stay at the facility. An interview was completed with R908 via phone. During the interview R908 reported it happened few months ago and did remember all the specifics. R908 confirmed that they did not receive the CPAP machine during their stay at the facility and reported that they had spoken with staff members but they did not get one. They had to go out to the hospital because of their breathing and did not get the care they needed. An interview was completed with Director of Nursing (DON) on 7/13/23 at approximately 2:20 PM. During the interview the DON was queried if the facility was able to provide a CPAP for residents if they were ordered by the physician.The DON confirmed that they were able to provide the CPAP and they had a system in place to order the equipment. The DON was queried on why R908 did not receive the CPAP for thirteen days of stay at the facility. The DON agreed that the facility should have followed up and provided the CPAP as ordered.The DON reported that the facility should have everything in place before a resident comes into the facility to provide the care they needed and they were unsure of what had happened with R908's situation as they were in a different role during this time frame. The DON after verification with the central supplies staff member, reported that R908's CPAP was not ordered from the equipment vendor. A review of facility policy titled BiPAP-CPAP with most recent revision date of 6/23 read in part, BiPAP-CPAP or VPAP (auto-titrating) will be initiated following physician order. Non- invasive positive pressure ventilation is application of positive pressure via upper respiratory tract for the purpose of augmenting alveolar ventilation to improve oxygenation, decrease apneic episodes while sleeping, or treatment of hypercarbia.

Based on interview and record review the facility failed to act on an identified change of condition for one (R86) of one resident reviewed for a closed record death in the facility, resulting in the resident to have a change of condition and the physician not being notified, and no transfer to the hospital for a higher level of care. Findings include: Review of the medical record revealed R86 was initially admitted to the facility on [DATE], with a readmitted [DATE] and diagnoses that included: systolic congestive heart failure, dysphagia, weakness and cellulitis of the left toe. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of six, which indicated severely impaired cognition and required staff assistance for all Activities of Daily Living (ADLs). Further review of the medical record revealed a Medical Treatment Decision Form dated 5/12/22, which documented the wishes of R86's representative, . In the event that your heart and breathing should stop, we will provide emergency treatment based on your decision . DNR (Do Not Resuscitate) . Other Treatment Options . These treatment options may be utilized to maintain comfort and quality of life, treat acute conditions, or describe what kind of care you want if you have an illness that you are unlikely to recover from . YES- hospitalization . Pain Management . Antibiotic Treatment . Oxygen Therapy . the form was signed by the resident representative, two witnesses and the physician. Review of the progress notes documented the following: On 1/22/2023 at 11:40 PM, a Nursing note documented in part . resident lethargic at this time and not able to take medication . On 1/23/2023 at 00:00 a Nursing note documented in part . Resident appears to be lethargic at this time, with 02 (oxygen) sat (saturation) 82% via NC (nasal cannula) at 4 lpm (liters per minute). In and out of sleep, respirations shallow. Review of a physician oxygen order with a start date of 5/23/22, documented in part . Oxygen as needed with sterile water, 2 L (liters) NC (nasal cannula), as needed for SPO2<92% . This note was documented by Registered Nurse (RN) B. Review of the medication record revealed no documentation of the nurse to have increased the resident's oxygen to maintain a safe oxygen level (92% or over), no documentation of the physician to have been informed of the resident's change in condition and no documentation of the resident to have been sent to the hospital following their change of condition. A Nursing note dated 1/23/23 at 7:30 AM, documented by RN B noted in part . 01:00 BP (blood pressure) 98/60, T (temp) 97.3 RR (respirations) 16, 02 (oxygen saturation level) 82 % @ (at) 4L (liters) via NC, resident not verbally responding at this time or making eye contact; shallow breathing noted. 02:30 RR 16: no changes in patient status at this time. 04:00 RR 14; no other changes in patient status at this time. Resident not verbally responding at this time or making eye contact, showing no signs or symptoms of pain or discomfort. 05:30 RR 14; no changes in patient status at this time. 06:45 CNA (Certified Nursing Assistant) called RN (Registered Nurse) into room due to patient status at this time. RN noted no vital signs detected at this time; absent pulse, no rise and fall of chest. Time of death called at 06:45am. Physician, resident's son, and unit manager notified . This indicated the resident change of condition was identified at 1:00 AM, and the facility staff failed to conduct follow-up monitoring of the resident's pulse oxygenation levels after having identified it as being abnormal, the facility staff failed to initiate treatment to improve R86's oxygen level, the facility staff failed to notify the physician of the change of condition and failed to send the resident out to the hospital for further care. This change of condition was first identified at 1:00 and left untreated for five hours and 45 minutes later when the resident was found with no vital signs and time of death was called. Review of a facility policy titled Change in Condition revised 07/20 documented in part, . It is the policy of this facility to inform . attending physician . of a change in the resident's condition . The facility will inform the resident; consult with the resident's physician . A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications . The facility staff failed to follow the facility's policy. On 3/16/23 at 2:46 PM, RN B was interviewed and asked to review their notes in the medical record on R86 as noted above. After reading their notes RN B was asked why no further assessments of R86's pulse ox levels were obtained, why their oxygen was not increased to maintain a level of 92%, why the physician was not notified of the change in condition and why the resident was not sent out to the hospital. RN B stated R86 was a DNR (do not resuscitate), which was acknowledged however it was pointed out to RN B that R86's advance directive documented the wishes of R86 to receive hospitalization . Pain Management . Antibiotic Treatment . Oxygen Therapy . if necessary. RN B stated they could not remember exactly back to that moment on why they did not increase the resident's oxygen, notify the physician or send the resident out to the hospital. RN B stated they could not remember the details of the incident. On 3/16/23 at 2:56 PM, the Director of Nursing (DON) was interviewed and asked to read nursing notes documented by RN B as noted above. Once completed, the DON was asked what should have been done for R86 and the DON replied that the nurse should have increased the oxygen and called the physician. The DON stated if the interventions did not work in bring the resident's oxygen level back up then the resident would have been sent out to the hospital. The DON was then asked why the facility failed to complete all of the interventions and notify the physician of R86's change of condition and the DON stated they would look more into it and follow back up. At 3:54 PM, the DON returned and stated the nurse saw that R86 was an DNR, however failed to look at the resident wishes documented on the advance directive. When asked what a DNR had to do with treating a resident in respiratory distress, notifying the physician and sending the resident out for further treatment, the DON did not have a response. No further explanation or documentation was provided by the end of survey.

Based on observation, interview, and record review, the facility failed to administer the ordered amount of enteral tube feeding (liquid nourishment administered directly into the stomach through a feeding tube) and hydration (water) per physician order for (R9) of one resident reviewed for tube feeding, resulting in dehydration, weight loss, hospitalization , and psychosocial distress utilizing the reasonable person concept. Findings include: R9 was originally admitted to the facility on [DATE] and recently readmitted after hospitalization on [DATE] with primary diagnoses that includes Alzheimer's disease, anxiety disorder, pressure ulcer of the left heel, difficulty swallowing, diabetes mellitus, and respiratory failure. Based on the MDS (Minimum Data Set) assessment dated [DATE], R9 needs extensive assistance for repositioning in bed and totally dependent on staff assistance for transfers. Unable to complete resident interview with R9 to complete BIMS (Brief Interview of Mental Status) as they were non-verbal. Staff interview indicates severe cognitive impairment. R9's admitted d 11/23/22 was 156.3 lbs. and weight dated 3/7/23 (weight completed twice) was 129 lbs. On 3/14/23 at approximately, 9:50 AM, an initial observation of R9 was completed. During initial observation R9 was observed in bed with eyes closed. R9 had dry lips and sunken cheeks and did not respond when called his name. R9's head of bed was up at approximately 30 degrees. R9 was nonverbal and coughed during the observation. R9 had a wet cough. An unopened bottle of Glucerna 1.5 CAL (liquid nourishment) and a bag of water were hanging on the stand next to the bed. The label in the bottle had R9's name, dated for 3/14/23, start time 9:00 AM, with rate at 85 ml/hr. The water bag was dated for 3/14/23 and start time was marked as 9:00 AM. R9's tube feeding was not on during this observation. On 3/14/23 at approximately, 11:20 AM, R9 was observed leaving the facility in via ambulance. At approximately, 12:30 PM, staff member H was queried regarding R9. Staff member H reported that they were sent out to hospital due to clogged PEG (Percutaneous Endoscopic Gastrostomy tube - a tube directly placed on stomach to provide nutrition and hydration) tube. R9's hospitalization was later confirmed by the staff member L. On 3/14/23 two subsequent observations were completed at approximately 2 PM and 3 PM, and R9 was not in their room. R9 was out of the facility, had not returned from the hospital. On 3/15/23, three observations were made at approximately 8:15 AM, 9:15 AM, and 9:45 AM. R9 was in their bed with eyes closed. R9 was not getting any nutrition through the PEG tube during these three observations. The tube feed stand next to the bed did not have any tube feeding bottle during all three observations. R9's abdominal binder was laying in a chair next to the bed. Review of R9's EMR (Electronic Medical Record) revealed the following orders: NPO (nothing through mouth) diet effective 1/31/23; enteral feed order-flush with 30 ml (milliliters) H2O (water) before/after meds, before initiating feeding or when there is an interruption of feeding to maintain tube patency effective 1/31/23; ONE TIME A DAY Glucerna 1.5 1360 ml (milliliter) @ 85 ml/hr. x 16 hrs. up 4 PM down 8 AM or UNTIL FORMULA INFUSED effective 1/31/23; and three times a day Bolus flush 200 ml H2O for hydration. Order also read, ensure that binder is in place to secure PEG tube in place except for showers/bed bath every shift. R9 also had new physician orders for Albuterol (2.5 ml/3 ml) 3 ml nebulizer treatments four times/day for shortness of breath and secretions, Pulmicort inhaler 0.25 mg/2 ml once every 12 hours for secretions, Tussin-DM oral syrup 30 ml via PEG tube four times a day for cough and secretions. These medications were ordered on 3/13/23. R9's care plan review revealed a focus area and goal as follows: I am unable to meet nutritional needs by mouth as evidenced by: NPO status. I receive my fluids via PEG tube. I will maintain adequate nutritional and hydration status as evidenced by stable weight, no s/s of malnutrition or dehydration . Further review of R9's EMR revealed the following: A progress note dated 3/14/23 completed by the practitoner at 10:55 AM read, .seen for eval PEG clogged overnight, unable to be clogged by staff and myself will transfer to hospital for exchange as unsuccessful with removing old for exchange. chest congestion, immobility. Nursing progress note did not indicate the amount of nutrition and water R9 received via PEG tube prior to the clogging that happened overnight per practitioner note. A review of R9's tube feeding administration record completed by staff member H revealed that R9 had not received his nutrition via tube feeding as ordered indicated by code 9. No other additional information was found on R9's EMR during the initial record review on 3/14/23 at approximately 15:00. A progress note dated 3/14/23 at 15:30, completed by staff member H (assigned to care for R9 from 7 AM - 7 PM shift) read, R9 transferred out to ---hospital per doctors orders for clogging of PEG tube, no s/s (signs and symptoms) of distress upon transfer, family member notified of transfer. Staff member's progress note clearly indicated that on 3/14/23 at 15:30 PM, R9 was out at the hospital during this time. A progress note the same day, dated 3/14/23, completed at 19:03 by staff member H read, Resident returned to facility via ambulance, no s/s any distress, peg tube working well, currently lying bed, VS stable, 138/62 74 16 97.6 98%, call light within reach, safety and comfort measures met, will continue to monitor. A review of R9's tube feeding administration record completed by staff member H revealed that R9 did not receive their 200 ml of bolus flush on 3/14/23 at 12:00 and 15:00 as ordered as R9 was at the hospital, indicated by a code 6. The administration record also revealed that R9 did not receive their tube feeding on 3/14/23 after returning from hospital, from a clogged PEG tube. The administration record signed by staff member H indicated that R9 was hospitalized by a code 6. No additional documentation on R9's EMR indicated that R9 received their nutrition and hydration upon return from hospital. Three observations were completed on 3/15/23 at approximately 8:15 AM, 9:15 AM, and 9:45 AM. During these observations R9 was not getting their feeding as recommended by the dietician and ordered by the physician. A nutrition at risk note dated 3/14/23, completed at 8:26 AM, revealed that R9 had 15% weight loss in 30 days and nutritional needs of R9 are increased due to low BMI (Body Mass Index). R9 also had a pressure ulcer on left heel. R9 was receiving daily treatments to their left heel pressure ulcer. A progress note dated 3/14/23 completed by the Director of Nursing (DON) at 21:33 read, R9 has wt (weight). loss 19 lbs. (pounds) in 30 days. --- (practitioner) phoned and made aware of plan of care. Writer also text message family member 'M' requested phone conference, received response, scheduled for 3/15 at 9:30 AM. An interview was completed with family member M on 3/14/23 at approximately, 7:05 PM. During the interview family member M indicated that they were at the facility most of the days. Family member M reported that they visited during late afternoons. Family member reported that they were at the facility on 3/13/23 late afternoon when R9's PEG tube was clogged. Family member H reported that R9 did not receive his nutrition and water. Family member was unsure if R9 received any of their medications that afternoon when the tube was clogged. On 3/15/23 at approximately, 10:50 AM, an interview was completed with staff member L. Staff member was queried on discharge documents from 3/14/23 hospital emergency visit. Staff member L reported that there was no change in R9's orders and provided a copy of the discharge instructions from the hospital. Staff member reported that R9 returned late from the hospital on 3/14/23. Staff member was queried on the amount of tube feeding and duration. Staff member L reported that the staff were administering the tube feeding as ordered by the physician and R9's tube feeding ran until the ordered amount was completed. An interview was completed on 3/15/23, at approximately 10:40 AM, with staff member H. Staff member H was assigned to care for R9 on 3/14/23 (from 7 AM to 7 PM). Staff member was queried about R9 returning from hospital late on 3/14/23 and their tube feeding status. Staff member was made aware that multiple observations in the AM were made on 3/15/23 when R9 was not receiving their nutrition. Staff member H reported that they disconnected the tube feeding around 8:30 AM. An interview with Staff member K was completed on 3/15/23 at approximately 11:00 AM. Staff member K identified themselves as a corporate support staff member covering the facility. Staff member K was queried on R9's status and tube feeding orders. Staff member K reviewed the EMR and reported that R9 had a significant weight loss and needed that nutrition as ordered, 1360 ml at 85 ml/hr. x 16 hrs., started at 4 PM and ran until it is fully administered. Staff member K reported that staff should have started after R9 returned from the hospital. A review of the tube administration record with staff member K for 3/14/23 revealed R9 was hospitalized . Staff member K reported that tube feeding should be running for 16 hours or until the ordered dose was administered and did not provide any further explanation. A record review revealed a late entry progress for 3/14/23, completed on 3/15/23 at 16:48, by staff member Q. Staff member Q was not assigned to R9, based on record review of staff schedules provided by the facility. Staff member Q's late entry note read, Resident arrived at 15:30 to the facility, PEG tube hung at 1600. PEG tube functioning well, meds given per doctors' orders, no s/s of distress, will continue to monitor. An interview was completed with the staff member Q on 3/16/23 at approximately, 7:10 AM regarding the facility staffing. During the interview staff member Q had indicated they worked 12 hours from 7 PM to 7 AM. The staffing schedule provided by the facility did not have staff member Q on schedule to work for 3/14/23. Record review confirmed that staff member Q was not assigned to care for R9 on 3/14/23. This late entry note was completed after the concern regarding R9's tube feeding administration was brought up to the attention of facility's nursing administration. An interview was completed with the DON on 3/15/23, at approximately 11:20 AM. The DON was queried on the orders, administration note for tube feeding, the nutrition administration duration of 16 hours and R9's late afternoon arrival from hospital on 3/14/23. The DON reported that R9 returned from hospital sometime before 7 PM on 3/14/23. This Surveyor notified the DON of the multiple observations made on 3/15/23 AM when R9 was not receiving their tube feeding. The DON agreed that if tube feeding was started after R9 returned from hospital, it should have been running in the AM during surveyor observations. The DON reported that they will follow up with the staff, calculate the missed dose and administer the missed dose to R9. R9 also did not receive their ordered dose of nutrition and hydration on 3/13/23 due to a clogged PEG tube. An interview was completed with the staff member CC on 3/16/23, at approximately 12 PM, regarding R9's significant weight loss and most recent MDS assessment with a locked date of 3/10/23. Staff member CC reported that R9's significant weight loss was not coded in this MDS assessment as the weight loss was out the assessment reference date range.

This citation pertains to intake #s: MI 607, MI 619, and MI 365. Based on observation, interview and record review, the facility failed to ensure resident to resident abuse did not occur for five (R705, R706, R707, R710 and R711) residents of seven residents reviewed for abuse, resulting in R706 having their fingers bent back painfully by R705; R707 having their arm squeezed and scratched by R705; and R710 being hit several times in the head with subsequent black eye. Findings include: According to the facility's policy titled, Abuse, Neglect and Exploitation dated 12/20, .Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish .Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking . R705 & R706 Review of an investigation report submitted to the State Agency on 1/29/22 alleged there was a resident-to-resident incident that resulted in harm. Review of the facility's investigation from an event on 1/29/22 revealed, .(R706) stated that (R705) walked into her room and started to mess with her roommate's things. (R706) stated that she asked her politely to leave. (R706) stated that (R705) started to mock her. (R706) wheeled over closer to her and started yelling at her to get out of my room. (R706) stated that (R705) got on her knees and was mocking her and then grabbed her fingers and bent them back. (Certified Nursing Assistant/CNA 'R') and (Activity Staff 'S') her <sic> (R706) yelling get out of my room from down the hall. They both arrived at (R706's) room at the same time and helped (R705) off the ground and escorted her out of the room then reported the incident to the nurse (Nurse 'T') . Review of R705's clinical record revealed the resident was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS) assessment dated [DATE], R705 had severe cognitive impairment, required supervision with setup help only for walking in room/corridor and locomotion on and off the unit, and did not use an assistive device for mobility. Review of R706's clinical record revealed the resident was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS assessment dated [DATE], R706 had intact cognition, and required extensive physical assistance of one person for bed mobility, transfer, dressing, toilet use, personal hygiene, and bathing, had no functional limitations in range of motion and used no assistive device for mobility. Review of R705 care plans included, I have potential to demonstrate physical behaviors (hitting, kicking, resistive to care, slapping, repetitive movements) r/t (related to) Dementia, History of harm to others. This was initiated on 12/23/21. On 4/4/22 at 12:00 PM, R705 was observed in their room eating lunch. Staff 'X' was observed seated in a chair next to the resident's bed and reported they were assigned as a one to one for the resident. When asked the frequency of R705's need for a one-to-one staff, Staff 'X' reported it was 24/7 due to R705 constantly going into other resident rooms. R705 was unable to communicate details about the incident on 1/29/22 due to significant cognitive impairment. On 4/5/22 at 9:09 AM, an interview was conducted with R706. When asked about the incident with R705, the resident reported R705 entered their room and started going through the roommate's things. R706 asked her to leave, but R705 started teasing/mocking and so R706 started to yell at R705 to get out. R706 reported R705 went down on their knees on the floor and continued mocking them. R706 said R705 then grabbed their fingers and bent them back, which was very painful. R705 & R707 Review of the facility's investigation from an event on 1/25/22 revealed, .(R707) stated that he was sitting in his wheelchair in room when (R705) walked into his room. (R707) stated that he told her to get out and she grabbed his arm, squeezed, and dug her nails in. (R705) is unable to recall the incident due to her BIMS (Brief Interview for Mental Status exam) of 1 .ACTION TAKEN (R707) was moved to the first floor and has been doing well. No other issued <sic> or concerns. He did not want to press charges .There were no witnesses involved . (Activity Director) While making rounds on the 2nd floor, residents in room (R707's room) waived his hand for her to come in. When (Activity Director) entered the room, he showed her his arm. When (Activity Director) asked (R707) what happened, he started wheeling outside in the hall and over to (R705's) room, pointed at her then pointed at his arm .(R707) stated that he was sitting in his wheelchair in room when (R705) walked into his room. (R707) stated that he told her to get out and she grabbed his arm, squeezed, and dug her nails in . Review of the clinical record revealed R707 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS assessment dated [DATE], R707 had unclear speech but was usually understood and usually understands others, had severe cognitive impairment, required supervision with setup help only for bed mobility, required limited assistance of one person for transfer, dressing, toilet use, personal hygiene, had impairment on one side for both upper and lower extremities, and used a wheelchair for mobility. Review of R707's care plans revealed a care plan initiated 11/1/19 which read, At times my peers will wander in my room, I prefer not to have a stop sign. On 4/4/22 at 11:45 AM, R707 was observed seated in a wheelchair next to their bed. R707 was asked about the incident on 1/25/22 and was unable to communicate details about the incident, due to R707's cognitive impairment. On 4/5/22 at 9:45 AM, an interview was conducted with the Administrator (also the facility's Abuse Coordinator) reported they began working at the facility around 2/15/22. When asked about the above incidents for R705, R706 and R707, the Administrator reported they were not able to offer any further explanation as these incidents occurred prior to their arrival at the facility. When asked if there was any further documentation of what had been implemented following the above incidents to prevent further potential abuse, the Administrator reported they would look to see if there was any other documentation. There was no additional documentation provided by the end of the survey. On 4/6/22 at 1:30 PM, an interview was conducted with Social Worker (SW 'Q'). When asked about the resident-to-resident incidents involving R705 with R706 and R707, SW 'Q' reported, My biggest thing was she needed a sitter from day one, but we just didn't have the staff. SW 'Q' further reported R705's dementia has advanced and had behaviors of wandering in more alert residents' rooms in which they reacted and R705 reacted back. SW 'Q' also reported they were in the process of trying to have the resident transferred to another facility that specializes in dementia care and Velcro stop signs were placed in the rooms that might be the biggest problem. When asked about the one-to-one sitter, SW 'Q' reported that was recently implemented for another unrelated resident to resident incident. R710 and 711 A review of a complaint received by the State Agency alleged there was a resident-to-resident altercation where R711 hit R710 several times in the head. On 4/4/22 at 12:30 PM, R710 was observed in their bed. R710's right cheek around their eye was observed to have a yellowish healing bruise discoloration. At that time, an interview was conducted with R710 regarding the resident-to-resident altercation with R711, their former roommate. R710 said their bed was very close to R711's bed with the privacy curtain pulled in between the two beds. R710 said R711, used his fist to smack him in the head several times. R710 was asked if they knew what provoked R711 to hit him and said he thought it was because he was snoring. R710 continued to describe the incident saying it was, unprovoked and he was fearful because of his physical impairments and his inability to get out of bed and get away from R711. R710 described the strikes as violent and said, I wish I could have gotten up and beat the (expletive) out of him. On 4/4/22 at 12:30 PM an interview was conducted with R711 regarding the altercation with R710. R711 said R710 was, not too friendly and said one night he hit him through the privacy curtain. R711 was asked what provoked him to hit R710. R711 said R710 was snoring with his mouth open, and because of the snoring, he was not able to get any sleep. R711 was asked if they previously had any issues with R710 and said R710's snoring frequently kept him awake. R711 also verbalized frustration with R710 staying up late at night the light on and, messing around with his book. R711 was asked if they had reported any issues with R710 to anyone in the facility and said they informed the facility's Social Worker. R711 was then asked what happened after they informed the Social Worker, and R711 said they were told there were no available rooms. On 4/5/22 at 11:05 AM, a review of the facility's investigation file for the resident-to-resident altercation between R710 and R711 was conducted. The file included a summary of the incident that read, On 3/16/22 .Unit Manager (name) was made aware that the resident (R710) in (room #) had reported a concern to the staff nurse (name) during lunch that his roommate (R711) had hit him in the head with a closed fist multiple times .resident was assessed, there was some discoloration noted to the right side of his head and eye .When (R711) was asked why did he strike (R710) and he stated 'he snores too loud and it's annoying'. (R711) also stated 'that he can't sleep with all that noise, and he sleeps with his mouth open, and fumbles with a book all night long' (R711) admitted that yes, he argues with (R710) and yes, struck (R710) on the shoulder a couple of times .Based on the investigation the facility concluded that this was an isolated incident involving two residents. (R711) was frustrated with (R710) loud snoring and noise making throughout the night and didn't know how to address it other than to strike out at the resident. On 4/5/22 at 2:10 PM, an interview was conducted with the facility's Social Worker, Social Worker 'Q' regarding the altercation between R710 and R711. Social Worker 'Q' said after they learned of the incident they assessed the residents, consulted psychiatric services, informed the families, and had been following up with R710 and R711. Social Worker 'Q' said R711 had no impulse control, and when he became frustrated with R710's snoring, he hit him. Social Worker 'Q' was asked how they determined R711 had no impulse control and explained that even though R711 appeared upset about hitting R710, he would not describe why he hit R710, but just kept repeating R710 wouldn't stop snoring. Social Worker 'Q' said, He (R711) just didn't know how else to deal with it. Social Worker 'Q' was asked if R711 had ever brought any concerns to their attention about rooming with R710 and said they did not. On 4/5/22 at 2:25 PM, a follow-up interview was conducted with R711. R711 asked again about the incident with his former roommate, R710. R711 again admitted to hitting R710 because of his snoring, and again described his frustration with R710 being up late at night with the light on, reading his book. R711 was asked again if they had ever let anyone from the facility know and maintained they had told the Social Worker. A review of R710's clinical record revealed they admitted to the facility on [DATE]. R710's Minimum Data Set (MDS) assessment dated [DATE] documented R710 had moderate cognitive impairment. A review of R711's clinical record revealed they admitted to the facility on [DATE]. R711's MDS assessment dated [DATE] documented R711 had moderate cognitive impairment. A review of R711's care plans was conducted and did not include any care planning for behaviors, prior to, or after striking R710. A review of R711's certified nursing aide (CNA) tasks was also conducted and did not include a task to monitor for any type of behaviors. A review of R711's Psychiatric Services Note dated 3/17/22 (the day after the incident between R710 and R711) was conducted and read, .Complaint: Psychological evaluation of mood, cognition, and behaviors/dementia/delusions/agitation/aggressiveness .He described interaction with former roommate who the resident punched when roommate was snoring .He reports having trouble staying asleep for about a couple days a week .Review of System .Thought Process: + Intact .Orientation: + Oriented to Time, Place and Person .Judgement & Insight: + judgement fair, + insight fair .Disposition .The patient will be seen for further evaluation of cognition, mood and behavior to assist with further intervention planning and to generate additional recommendations for managing the above-noted problem behaviors only as needed . On 4/6/22 at approximately 11:30 AM, an interview was conducted with the facility's Administrator/Abuse Coordinator regarding the incident between R710 and R711. The Administrator indicated they investigated the concern and discussed it in the facility's Quality Assurance meeting. They were asked if R711's care plan had been updated, what the facility had put into place to prevent future occurrences of resident-to-resident altercations involving R711, or if they assessed any other residents for their satisfaction with their roommate situations, as none of this was evidenced in the facility provided investigation file. The Administrator said they would follow-up with the facility's Social Worker and report back, however; no additional information was received by the end of the survey.

This citation pertains to intake MI 111. Based on interview and record review the facility failed to perform thorough skin assessments, consult the wound care physician, and implement treatments and interventions to prevent the development and worsening of pressure ulcers for one resident (R701) of two residents reviewed for pressure ulcers resulting in the development of two unstageable pressure ulcers (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar), a stage III pressure ulcer (full-thickness loss of skin, in which fat tissue is visible in the ulcer and granulation tissue and rolled edges are often present), and a stage II pressure ulcer (partial-thickness loss of skin with exposed dermis) that required surgical intervention. Findings include: A review of a facility provided policy titled, Skin and Pressure Injury Risk Assessment and Prevention last revised 7/2021 was conducted and read, .1. A skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter .4. Documentation of skin assessment: a. Document observations (e.g., skin conditions .) b. Document type of wound c. Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain) .9. Residents determined as at risk for developing pressure injuries will have interventions documented in plan of care .10. Interventions for Prevention and to Promote Healing a. after completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan .c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present .d. Evidence-based treatments in accordance with current standards of practice will be provided for all resident who have a pressure injury present . On 4/4/22 at 11:20 AM, a review of R701's closed clinical record was conducted and revealed an admitted [DATE] with a discharge to the hospital on 1/9/22. R701's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R701's most recent Minimum Data Set (MDS) assessment dated [DATE] indicated R701 had intact cognition, was non-ambulatory, and required extensive assistance from one staff member for most activities of daily living. A review of the MDS assessment, Section M- Skin Conditions was conducted and revealed R701 had been coded for having a stage II pressure ulcer upon admission to the facility. Continued review of R701's clinical record revealed an admission assessment dated [DATE] performed by Nurse 'F' indicated the resident had a Pressure type injury on their right buttock, Bruising to their left buttock, and a Blister on their right buttock. It was noted the electronic assessment form was left blank for measurements of the wounds as well as staging of pressure ulcers. It was further noted, there were no other documented skin or wound assessments in R701's record. A review of Nurse 'F's Admission Summary note documented 12/30/21 at 2:38 PM, was conducted and did not indicate R701 admitted with any alterations in skin integrity. R701's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R701's care plan was reviewed and included an incomplete care plan initiated by Nurse 'F' on 12/20/21 that read, .Focus: I have a Pressure Injury, Stage: (left blank); Location: (left blank). This wound was present on admission/developed in the facility .Interventions/Tasks: Assess for pain, promote comfort per my plan . A review of R701's Certified Nursing Aide (CNA) Kardex (care guide) and CNA tasks was conducted and did not include any interventions such as: pressure offloading, turning, and repositioning, or the use of specialized mattresses or cushions for the worsening or development of pressure ulcers. A review of Physician Assistant (PA) 'A's' progress notes for R701 dated 1/3/22 was reviewed and did not indicate any alterations with skin integrity. A review of Doctor 'B''s progress notes for R701 dated 1/5/22 was reviewed and read, .Skin: Patient has chronic lower extremity [CONDITION(S)] . The note did not indicate any other alterations with skin integrity. A review of R701's medical records from their stay at the hospital from 1/9/22 to 2/1/22 was conducted and revealed the following: A history and physical note from the hospital physician dated 1/9/22 that read, .6. Per RN, skin assessment suggests wounds and formal consult placed for wound care . A Surgical Wound Care Service Progress Note dated 1/10/22 that read, .Reason for Consultation/Indication: coccyx and left buttock wound .History of Present Illness .Patient being seen today .for evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .Focal examination of wounds: .Wound: Coccyx-Patient has a very concerning full thickness wound located near the coccyx region that has 100% moist dark necrotic tissue with edges still attached .I anticipate this wound will open soon. Today wound measures 3.5cm x 3cm x UTD (unable to determine) .Surrounding peri-wound region has [CONDITION(S)] and induration that is firm and swollen .Wound: Left Medial buttock-Full thickness wound noted measures 4cm x 2.5cm x UTD with 100% firm pale necrotic tissue with wound edges beginning to separate .Wound Left distal buttock-Partial thickness wound is located to distal region and measures 2cm x 2cm x 0.1cm with moist epithelial tissue .Wound: Left plantar heel-full thickness wound noted measuring 1.5cm x 2.5cm x 0.3cm with pale pink wound base with poor granulation and moderate serous drainage . A Surgical Wound Care Service Note dated 1/12/22 that read, .Focal examination of wounds .Wound: Coccyx and mid-left buttock pressure injury sites have evolved and merged and now one larger wound that measures 9cm x 7cm x UTD. The entire wound is full thickness and black/necrotic . A General Surgery Note dated 1/14/22 for a procedure conducted on 1/13/22 that read, .Under clean conditions and with topical anesthesia .The central portion of the ulcer in the gluteal cleft was elevated with forceps. A scalpel was used to enter the eschar and necrotic tissue was excised sharply, down to and including the level of subcutaneous tissue. A moderate amount of foul smelling, brown drainage was encountered at the central portion of the wound. The wound remains unstageable at this time . An Infectious Disease Consultation note dated 1/15/22 that read, .Impression: infected coccygeal <sic> wound stage 3-4. Chronic non-healing wound to left heel . A Surgical Wound Care Service Follow-up note dated 1/17/22 that read, .Focal Examination of wound/s: Wound Location: Sacrum with 15 by 10 cm wound within this region .open deep wound with undermining .greatest undermining of 4.5 cm .wound base: Black necrotic .Odor: Strong foul odor .Wound Location: Left heel Unable to determine depth of injury secondary to non-blanching darkened region . A Surgical Wound Care Service Progress Noted dated 1/18/22 that read, .Recommendations/Plan for Wound Care .Patient will need OR (operating room) debridement of sacral wound due to extensive necrotic tissue and drainage-likely will need extension of wound to include bilateral buttocks . An Operating Room Note from General Surgery dated 1/20/22 that read, .Postoperative Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] .Description of Findings: .sacral ulcer stage IV with necrosis of sacral bone .ulcer tracked into bilateral buttocks, worse on right side with necrotic tissue and purulence . On 4/5/22 at 9:35 AM, an interview was conducted with the facility's Director of Nursing (DON) regarding new admissions. The DON explained that new admits have a head-to-toe skin assessment done and it should be documented in the resident's record. When asked if nurses should describe the nature of any skin impairments, they indicated they may not feel comfortable staging pressure ulcers, but they should be documenting what the skin impairments look like and said they should be measured. The DON was then asked if the admitting nurse should receive any orders for any treatments or pressure ulcer prevention interventions and said the nurse should let the physician know, get orders, and consult the facility's Wound Care Consultant. At that time, R701's assessment of Pressure Bruising and Blister documented by Nurse 'F' on 12/30/21 was shared with the DON and it was reported there should have been better documentation of the wound descriptions and the Bruising on the buttock was most likely a deep tissue injury (Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration. The wound may evolve rapidly to reveal the actual extent of tissue injury). On 4/5/22 at 1:05 PM, an interview with PA 'A' was conducted regarding R701. PA 'A' did not remember much about R701 and said the admitting nurse is responsible for placing the wound care consult for any resident who admits with wounds. On 4/5/22 at 1:45 PM, an interview was conducted with Dr. 'B' regarding R701. Dr. 'B' also did not remember much about the resident but said that when a resident admits with wounds, the nurse can initiate treatment and they are responsible for placing the wound care consult.

This citation pertains to intake: MI 658. Based on interview and record review the facility failed to implement interventions to prevent falls for a high risk resident one (R902) of four residents reviewed for Activities of Daily Living (ADLs) for dependent residents, resulting in a fracture of the distal end of the right clavicle. Findings include: Review of a complaint submitted to the State Agency (SA) on 1/13/22 documented concerns of the facility staff to have failed to assist the resident (R902) with a transfer and obtained a broken clavicle. Review of a hospital preadmission packet provided to the facility contained a Hospice Visit Note Report dated 8/29/2021 that documented in part, . He (R902) came to the ED (Emergency Department) . due to increased weakness and 3 falls in 2 days, the last fall he was unable to get up off the floor due to weakness . Review of the medical record revealed R902 was admitted to the facility on [DATE] with diagnoses that included: [CONDITION(S)], palliative care, muscle weakness and repeated falls. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13 indicating intact cognition and requiring staff assistance for all Activities of Daily Living (ADLs). Review of an admission fall risk assessment dated [DATE] at 6 PM, documented At Risk for Falls but failed to check off the care plan section on this assessment. Review of the resident care plans revealed the facility staff failed to implement a care plan and interventions to inform all staff of the resident's high-risk status and to prevent further falls. Review of a facility policy titled Fall Reduction Policy revised 8/21 documented in part, . Our residents have the right to be free from falls, or to sustain no or minimal injury from falls . The nurse will initiate interventions on the resident's baseline care plan, in accordance with the resident's identified risks . Interventions will monitor for effectiveness . Review of a 10/28/21 Nursing note dated 10/28/21 at 6:46 AM, documented in part . Resident was awake and laying in his bed upon writers arrival to shift . at (3:30 am) resident was found lying on the floor in his room next to his bed. Body audit done and vitals and neuro checks initiated. Staff returned resident to the bed. Resident was anxious stating he couldn't breathe. O2 was in the 70's (oxygen saturation levels, normal is greater than 92). Administered oxygen via canister and residents O2 rose to 95% . Resident has multiple skin tears, lacerations and bruising throughout his body. Physician informed . Review of a hospice note dated 10/28/21 at 9:58 AM documented in part, . Resident had an unwitnessed fall at (3:30 am). Skin tears to right arm and right knee. Resident c/o (complaints of) pain in b/l (bilateral) hips. Hospice Nurse assessed resident and ordered an x-ray of b/l hips . Review of a radiology report dated 10/28/21 at 12:43 PM, documented in part . IMPRESSION RIGHT SHOULDER: Fracture of the distal end of the right clavicle . Review of a Physician noted dated 10/28/21 at 3:43 PM, documented in part . see for R (right) arm pain post fall . sustained skin tears on R arm seen by hospice this AM with imaging + (positive) for R . fx (fracture) or distal clavicle . d/w (discussed with) his father gave option of ER (emergency room ) visit discussing with him usual treatment of sling for comfort, he declined and wants to maintain comfort with sling inhouse . has [MEDICATION(S)] available as needed . On 1/25/22 at 10:56 AM, the Director of Nursing (DON) was interviewed and asked why there was no fall risk care plan implemented to prevent falls for R902 (who had a history of falls and was identified as a fall risk) until after 10/28/21 when the resident fell and obtained a fractured clavicle. The DON stated they were not employed with the facility at that time but would look into it. At 2:20 PM the DON returned and stated they could not find any care plans for falls until 10/28/21 and was unable to provide any further explanation or documentation. No further information or documentation was received by the end of survey.

This citation pertains to Intake(s): MI 582 and MI 835. Based on observation, interview, and record review the facility failed to timely identify, monitor, and treat a pressure wound for two (R's 801 and 812) of three residents reviewed for pressure ulcers, resulting in a facility acquired unstageable pressure ulcer to the right heel of R801 and a facility acquired Stage 4 pressure ulcer to the Coccyx of R812. Findings include: R801 Review of complaint submitted to the State Agency dated 6/14/21 revealed, .Complainant states at the hospital it was also discovered the resident had a bed sore on the heel . Review of a hospital wound care note dated 5/9/21 revealed R801 was admitted to the hospital with a Pressure injury - right heel that was unstageable and present upon admission. Further review of this note revealed the pressure injury measured 4 centimeters x 4 centimeters and was described as black eschar with red, yellow, draining edges. A review of the clinical record revealed the following: R801 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12 indicating moderately impaired cognition and required extensive staff assistance of one person for bed mobility and all Activities of Daily Living (ADLs). Further review of the MDS revealed R801 had no pressure ulcers but was at risk for the development of pressure ulcer. A Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] at 4:27 PM documented a score of 16.0, which categorized the resident as being At Risk for the development of pressure sores. An I have potential for pressure ulcer development r/t decrease mobility . care plan dated 1/23/21 revealed an intervention of, Complete a full body check weekly and document. A Head to Toe Skin Check dated 3/24/21 at 11:13 AM, documented in part .Right heel- redness .Bilateral heels are reddened and blanchable . The next documented sign assessment for the resident is on 5/5/21. Six weeks after the original Head to Toe Skin Check was completed. Review of Resident #801's medical chart, to include the care plan, failed to reveal any interventions to address the Right heel- redness .Bilateral heels are reddened and blanchable . A Weekly Skin Sweep dated 5/5/21 at 10:36 PM, failed to document and skin issues to R801's heels. A Weekly Skin Sweep dated 5/8/21 at 6:55 PM, failed to document and skin issues to R801's heels. On 5/8/21 at 7:14 PM, there is documentation that indicated R801 was transferred to the hospital due to a fall. The facility failed to monitor, identify the decline of, and treat the right heel wound which was identified upon admission to the hospital. On 6/23/21 at 4:54 PM, the Administrator and Director of Nursing (DON) was queried regarding the lack of weekly skin assessments and why the right heel pressure wound was not identified by staff and reported to the physician for treatment and adequate monitoring. The administrator and DON stated they would follow up. On 6/24/21 at 8:27 AM, the Administrator, with the DON present, stated the staff that was assigned to the resident before sending them to the hospital denied any abnormal skin findings on the resident. No further explanation or documentation regarding the right heel wound was provided by the end of the survey. R812 A review of the clinical record revealed R812 was admitted into the facility on [DATE] with a readmitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment dated [DATE] revealed a BIMS of 5 indicating severely impaired cognition. Further review of the MDS revealed R812 required extensive assistance of one person for ADLs to include bed mobility, had no pressure ulcers, but was at risk for the development of pressure ulcers. Review of a Head to Toe Skin Check dated 3/21/21 revealed that R812 had no skin issues identified on the assessment. The next skin assessment was completed on 4/17/21 (almost four weeks since the last skin assessment was completed). Review of this Weekly Skin Sweep assessment revealed, . Open Area . Coccyx- open area 1 cm L x 0.5 cm W edges white and base of wound pink, surrounding skin pink . Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply to coccyx topically every shift for excoriation. Review of a Wound consultation note dated 4/27/21 revealed, . I was asked to see this patient for my opinion on how to manage the patient's wounds . Initial Consult: 4/27/21 . Wound #1 Coccyx is a Stage 4 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 0.7cm length x 0.4cm width x 0.3cm depth, with an area of 0.28 sq (square) cm and a volume of 0.084 cubic cm. Tendon is exposed. No tunneling has been noted. No undermining has been noted . 50% tendon visible . Wound Orders . Rub [MEDICATION(S)] dressing between hands to warm up dressing. Then apply skin prep to peri wound then allow to dry to get tacky then apply the [MEDICATION(S)] dressing . Review of a I have potential for pressure ulcer development . care plan initiated 8/18/21 revealed the following interventions: Complete a full body check weekly and document . Follow the facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] On 6/24/21 at 8:27 am, The Director of Nursing was queried regarding the facility's wound program and stated in part, . The wound doctor comes weekly and weekly head to toe assessments are required for all residents . On 6/25/21 at 2:14 pm, an observation was made with Wound Physician (WP) M to observe the current status of the resident's wound. WP M stated it was currently a pressure Stage 2, measuring at 0.6 x 0.5 x 0.2 cm. The resident was assisted by staff, revealing a pea size opening to their Coccyx area. WP M clarified that they started covering the wound care at the facility at the end of May 2021 and since that time the resident's wound was a stage 2. When asked how the wound could be classified as a stage 2 when previously classified as a stage 4, WP M stated the previous wound doctor classified it as a stage 4, however when they took over the resident's care it was a stage 2. On 6/25/21 at 2:57 pm, the Administrator and DON was queried regarding the missed skin assessments, identification of worsening of the wound, and delay in treatment to the resident coccyx area and both stated they would look into it. No further explanation or documentation was provided by the end of survey. A facility policy titled Skin Management (Revised July 2017) documented in part . Residents receive care to aid in the prevention or worsening of wounds and/or pressure ulcers. Individuals at risk for skin compromise are identified, assessed, and provided treatment to promote healing . Ongoing monitoring and evaluation are provided for optimal resident outcomes . If a new pressure ulcer is identified . the wound is , assessed and documented on the Weekly Pressure Ulcer Record . The licensed nurse will document daily monitoring of pressure ulcers on the Treatment Administration Record . A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A Weekly Skin Check will be completed in the resident's record using the Head-to-Toe Skin Check . a new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . the nurse will initiate treatments, interventions, Care Plan, and the appropriate skin documentation records in a timely manner according to Practice Guidelines .

This citation pertains to Intake(s): MI 582, MI 835 and MI 721. Based on observation, interview and record review, the facility failed to consistently conduct root cause analysis of falls, consistently update care plan(s) with new and or modified interventions to prevent further falls, ensure required eating assistance was provided, ensure wheelchairs remained locked and residents were transferred timely to the emergency room for three (801, 814 and 809) of three residents reviewed for falls/accidents, resulting in a C1 and C2 fractures (neck region), lacerations of the frontal scalp, bridge of nose and upper lip all requiring sutures and multiple skin tears (R801), a 4-part intertrochanteric fracture of the right femur requiring surgery (R814) and a subcapital hip fracture causing pain and requiring hospitalization and surgery (R809). Findings include: A complaint submitted to the State Agency noted concerns that the resident broke their neck from a fall at the facility. A review of the clinical record revealed the following: R801 R801 was admitted into the facility on [DATE] with a readmitted [DATE] with diagnoses that included: dementia, muscle weakness, kidney failure, difficulty walking and altered mental status. A Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12 indicating moderately impaired cognition and required staff assistance for all Activities of Daily Living (ADLs). On 6/23/21 at 8:44 am, a request to the Administrator for all Incident and Accident reports documented for (falls only) within the last two years was requested for R801. A second request was made to the Administrator on 6/23/21 at 1:50 pm. The Administrator did not provide these documents by the end of the survey. A Nursing Progress Note dated 5/8/21 at 7:14 pm, documented in part Writer observed resident lying on the floor next to bed with a puddle of blood surrounding her head. Resident's nurse was in the room assessing resident and applying pressure to head with a towel. Writer called EMS (Emergency Medical Services) to have resident transported to hospital per doctor's order . This note was documented by Licensed Practical Nurse (LPN) A. On 6/23/21 at 8:19 am, a telephone interview was conducted with LPN A. When queried regarding the events that led to R801 being observed on the floor on 5/8/21, LPN A stated in part . I remember the incident, (LPN C) was her nurse . I saw (R801) on the floor and blood was around her. She told me she fell out the bed, this is right during dinner. She was eating dinner. She (her assigned nurse) went and checked on her 30 mins prior .The Aide (Certified Nursing Assistant- CNA B) was walking by and saw her on the floor . On 6/23/21 at 8:32 am, a telephone interview was conducted with LPN C (the assigned nurse to R801 on 5/8/21). When queried regarding the fall, LPN C stated in part, I really don't remember it too much . LPN C could not recall what CNA found the resident on the floor or if the resident required staff assistance during meals. On 6/23/21 at 10:58 am, CNA B (the CNA assigned to R801 on 5/8/21) was queried regarding the 5/8/21 fall with R801 and stated in part . Me and (another CNA name redacted) was in another resident room cleaning her up. When I came out the room (R801's roommate) light was on and that's when I see her (R801). She was laying on the floor, face down and blood was on the floor . I immediately went to get the nurse . She (R801) did not say what happened. At one point she was walking on her own. She started declining and having falls. She just wasn't able to do it anymore . When queried whether staff was present to help assist the resident while they were eating dinner, CNA B stated in part, . No, she would eat. We would just monitor her . We walk up and down the hallway monitoring . The resident was required to have extensive assistance x 1 for eating on the day of their fall, not supervision assistance. Review of a CNA Kardex for R801 documented in part, . Eating/Nutrition EATING- I require Extensive assistance x 1. The above interviews revealed there was no staff present to assist with R801's dinner the evening of the fall. On 6/23/21 at 11:35 am, R801's roommate was queried regarding the fall on 5/8/21 and stated in part, . She is such particular. A good housewife. That particular day, she had a tray with food on it and it slid off the bed. She bent over to pick up the food and she lost her balance and hit the floor. It was pretty hard. I was hoping that she made it but was told that she passed away two days later . I called for help to the young ladies . the food tray crashed but I couldn't help her . Review of R801 care plan titled I have an ADL self-care performance deficit r/t (related to) Dementia, Impaired balance I am on hospice services further decline anticipated (Revision date of 4/30/21) documented in part . EATING: I require Extensive assistance x 1 (revision 3/2/21) . Another revision was completed on 5/10/21 (two days after the resident left the facility and was transferred to the hospital) which documented in part EATING: I require Supervision assistance x 1 . The 5/20/21 revision was completed by MDS Nurse D. On 6/23/21 at 3:46 PM, an interview was conducted with MDS Nurse D. MDS Nurse D was asked why they changed the resident's assistance level for eating two days after R801 was discharged from the facility, MDS Nurse D stated they (IDT) had a discussion on 5/10/21 and anticipated the resident to come back to the facility. MDS Nurse D requested to obtain their notes from meeting. At 3:57 PM, MDS Nurse D returned with no further documentation, however explained that the facility anticipated the resident to return. When asked if the resident fell while trying to obtain their dinner tray from the floor, why would it be a good idea for the facility to lessen her assistance level to supervision two days after being transferred to the hospital rather than increase the assistance level required or ensured the resident had the required assistance level (extensive assistance x 1) that was documented in the resident's care plan and CNA Kardex, MDS Nurse D did not respond. MDS Nurse D was then asked why was an IDT meeting held for a discharged resident and MDS Nurse D had no further explanation or response. A 5/8/21 ED (Emergency Department) Provider Note documented in part, . ED Course and Medical Decision Making . Head CT (cat scan) shows heterogeneous left frontal lobe mass containing mild hyperdensity could be from hemorrhage . patient also has fractures of C1 and C2 as seen on c-spine CT . Fall (at ECF- Extended Care Facility, unwitnessed), Arm Injury (Left upper), Leg Injury (skin tears on bilateral shins), and Head Injury (laceration to forehead) .Laceration repair . Forehead, Length (cm): 3, Depth (mm): 2 . Number of sutures: 7 . Nasal bridge, Length (cm): 0.5, Depth (mm): 1 . Number of sutures: 1 . Face, above upper lip, Length (cm): 1, Depth (mm): 1 . Number of sutures: 1 . On 6/23/21 at 4:54 pm, a request was made to the Administrator and Director of Nursing (DON) to provide all documentation pertaining to the resident fall history (third request), fall notes, IDT meeting notes and the history of fall interventions implemented, and none was provided by the end of survey. R814 A review into the clinical record revealed the following: R814 was admitted into the facility on [DATE] with a readmitted [DATE] with diagnoses that included: dementia, Alzheimer, muscle wasting and atrophy, muscle weakness, lack of coordination, cognitive communication deficit and acute kidney failure. A MDS assessment dated [DATE] documented a BIMS of 7 indicating severely impaired cognition and required staff assistance with all ADLs. A review of the progress notes, Interdisciplinary Post Fall Review notes, Post-fall/Fall Risk Assessment and Nursing notes documented on a paper chart was reviewed to identify all of the most recent falls for R814, which revealed the following: A Interdisciplinary Post Fall Review dated 8/6/20 at 4:32 pm, documented the following in part . Date and Time of Fall: 8/5/2020, 11:30 . Resident had a fall from wheelchair while attempting to self-ambulate unassisted . Intervention Recommendations . Summary of the Interdisciplinary Team- Staff educated husband to come to front door first when trying to have room visit, to allow staff to go into room and open window for resident instead of him coming to room and resident attempt to open window herself . Care Plan Revision . An Interdisciplinary Post Fall Review dated 8/5/20 at 4:59 pm, documented the following in part . Date and Time of Fall 8/5/2020 1600 (4pm) . observed on floor in room, husband at window. Husband stated she got up out of w/c (wheelchair) to go to the window . educated husband to come to facility door prior to going to resident room, so that the resident can be moved towards window for visit . Care Plan Revision . The care plan also documented and intervention to ensure appropriate fitting footwear with antiskid surface when ambulating or mobilizing in w/c . Initiation date of 8/6/20. A Nursing Progress Note dated 8/31/20 at 6:06 pm, documented in part . Writer spoke with resident Husband to do f/u (follow up) r/t (related to) Skin Tear to back of Left Knee . Husband is aware of Fall and reports his wife did tell him . Further review of the clinical record revealed no other documentation of this fall. There was no documented IDT meeting or modification of interventions regarding this fall. An Interdisciplinary Post Fall Review dated 12/22/20 at 7:47 pm and 2/1/10 at 5:30 am, documented an unwitnessed fall, that was discussed by the IDT and modifications of interventions were implemented on the resident's care plan. An Interdisciplinary Post Fall Review dated 2/25/21 at 8:00 pm, documented in part, . Unwitnessed fall . Abrasion to back of skull . Writer was in the hallway when a loud sound was heard and when writer enter the room, resident was sitting on the floor next to her nightstand and back toward the wall and knee bend. She was screaming I fell . She was assess (sic) by nurse and unit manager, she has an abrasion on the occipital lobe, it was cleanse and pressure was applied to stop bleeding . IDT meet to review I&A (Incident and Accident), Resident fell resulting in injury to back of skull. Resident needs assistance with transfers, has a cognition deficit and she forget to get help. Resident will attempt to transfer w/o assistance and unsuccessful . skull xray (sic) ordered . The clinical chart was reviewed and revealed no results of a skull x-ray. On 6/25/21 at 10:00 am, the results of the x-ray of the skull was requested from the Administrator and at 1:04 pm, the Administrator and DON stated they called the radiology company who confirmed that an x-ray of the skull was not completed for R814. A repeat intervention for PT (Physical Therapy) evaluation was documented for the 2/25/21 fall, which was initially documented as an intervention for the 2/1/21 fall as well. This revealed to be an ineffective intervention, as the resident was already supposed to be receiving PT services for the 2/1/21 fall. A progress noted dated 3/24/21 at 7:30 am, documented in part . The resident appears to have fallen while attempting to ambulate unassisted . was found sitting on the floor next to the head of her bed . Review of the clinical record revealed no meeting held by the IDT to discuss the fall or new/modified interventions implemented to prevent further falls. A paper chart (provided by the Administrator) dated 4/5/21 at 4:00 pm, documented in part . Resident was observed on the floor in her room. Fall was unwitnessed . Further review of the clinical record revealed no meeting held by the IDT to discuss the fall or new/modified interventions implemented to prevent further falls. A paper chart (provided by the Administrator) dated 4/13/21 at 11 pm, documented in part . Patient observed sitting on the floor . Patient was assisted back in bed . will continue to reorientate patient to use call light . Further review of the clinical record revealed no meeting held by the IDT to discuss the fall or new/modified interventions implemented to prevent further falls. A Post-fall/Fall Risk assessment dated [DATE] at 11:45 am, documented in part . Resident was observed sitting on the floor, next to bed in her room . Intervention . Proper fitting shoes put on . This intervention is a repeat intervention from 8/6/20. A progress note dated 5/19/21 at 7:00 pm, documented in part . Falls . Resident not utilizing call light for assistance. Resident ambulating without assistance . Further review of the clinical record revealed no meeting/discussion held by the IDT to discuss the fall; however, the care plan was revised and a new intervention to Move dresser closer to bed and Toilet me before dinner was implemented on 5/19/21. A Nursing Progress Note dated 6/4/21 at 9:41 pm, documented in part . Resident observed sitting on floor between the bed and wheelchair. Resident is unable to state what happened. Wheelchair observed in the unlock position . Further review of the clinical record revealed no meeting held by the IDT to discuss the fall or new/modified interventions implemented to prevent further falls. A Nursing Progress Note dated 6/17/21 at 6:45 pm, documented a Late Entry note that documented in part . Resident was observed on the floor in her room. Resident was unable to provide details of what occurred . Assisted resident to bed w/(with) staff assistance . Further review of the clinical record revealed the resident complained of pain in the middle of the night and was transferred to the hospital. A hospital Emergency Department Radiology report dated 6/18/21 at 1:17 pm, revealed in part . 4-part intertrochanteric fracture of the right proximal femur . An Operative Note dated 6/19/21 at 9:33 am, documented in part . Preoperative Diagnosis: Right Intertrochanteric Fracture .Procedure . Right - Right Hip Intramedullary Nail . A review of the clinical record on 6/25/21 revealed no meeting held by the IDT to discuss the fall or new/modified interventions implemented regarding the fall that resulted in the resident to have a fractured hip and requiring surgery. R814 was readmitted back into the facility on [DATE]. An observation of the resident was attempted on 6/25/21 at 10:13 am, however the facility Social Worker stated the resident was transferred back out to the hospital earlier that morning. On 6/25/21 at 2:57 pm, A review of the resident falls, IDT follow up and interventions was conducted with the Administrator and DON. The Administrator and DON was queried regarding the facility fall system in place to easily identify the resident falls, lack of consistent IDT meetings and implemented interventions for the resident falls. The Administrator and DON stated they would look into it and return. At that time a request was made to the Administrator and DON to provide all documentation regarding the resident falls, IDT follow up and care plan revision. No further documentation and/or explanation was provided by the end of survey. R809 It was reported to the State Agency (SA) that R809 fell and sustained a subcapital (hip) fracture on the right side. A review of the incident summary reported to the SA documented, in part: . R809 had a fall from bed to the wheelchair at approximately 1AM on 12/12/20 and that the resident was barely understood due to a language barrier. Nurse R heard a sound and went into the resident's room and saw the resident lying on the floor next to the bed. The resident describe <sic>during interview that she fell while trying to transfer to wheelchair. R809 stated the wheelchair moved while she was transferring .R809 received an x-ray and with results of subcapital hip fracture on right side. She was transferred to (name redacted) hospital. R809 had surgery and returned to the facility .staff has been reminded to ensure the wheelchair is locked after transfers . On 6/25/21 at approximately 12:50 PM, R809 was observed lying in bed. The resident was alert, but not able to answer many questions asked. R809's roommate reported that the resident was very quiet and rarely got out of bed. A review of R809's clinical record documented the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: type II diabetes, dementia, anxiety disorder, muscle weakness and reduced mobility. A review of the resident Minimum Data Set (MDS) dated [DATE] indicated the resident had a Brief Interview for Mental Status score of 1/15 (cognitively impaired) and required limited one person assistance for transfers. Continued review of the MDS (dated 3/23/21) documented the resident required extensive one person assistance for transfers. A review of R809's Care Plan for falls documented, in part: I am a fall risk r/t (related to) right side [CONDITION(S)], impaired gait (date initiated 6/14/16) .Interventions Anti roll back (date initiated 12/14/2020), Encourage use of call light (6/14/16), Remind staff to ensure W/C is lock when transfers are completed (12/12/20) . A review of R809's progress notes document, in part the following: 12/12/20 (SBAR Summary) 7:12 AM: .writer was at the nursing station when writer heard a sound and . saw resident lying on floor. when assessed, there was no visible injury noted . 12/12/20 (Nursing Progress Note) 7:13AM: Writer was at the nursing station when heard a sound and went walking into the hallway and saw resident lying on the floor. resident wheelchair was next to her resident must have wanted to go to the bathroom and tried to get into her wheelchair and it must have move <sic>, because when she was assessed back to her chair, she pointed and said bathroom . 12/12/20 (Nursing Progress Note) 1:15 PM: A STAT X-ray was ordered for bilateral with 2 views due to resident had a fall on night shift. Resident is yelling in pain and is having incont. (incontinent) issue when she is cont. (continent) .Claim # (number redacted). 12/13/20 (Nursing Progress Note) 6:35 AM: Awaiting X-Ray at this time . 12/14/20 (Nursing Progress Note) 9:01 PM: IDT (interdisciplinary team) meet to discuss resident unwitnessed fall on 12/12/20. Resident attempted to self-transfer from bed to chair and w/c moved. Xray ordered for right hip pain, results currently not in (electronic record) from (name redacted) X-ray company. Pain medication given. Post fall intervention is staff to ensure resident wheelchair is locked after a transfer has been completed and the order for anti-rollbacks to be applied to the wheelchair. Writer will follow up on x-ray results and monitor resident pain . 12/14/20 (Nursing Progress Note) 1:17 PM Writer received x-ray results that appears resident has a right hip fracture from fall on 12/12/20. Writer spoke to doctor and was ordered to send resident to (name redacted) hospital . Hospital records were reviewed and documented, in part, the following: .admitted /Time: 12/14/20 - 02:42PM . oriented x1 (person) .only able to follow one step commands .evidence of memory deficit .Gait unsteady with support .Internal Medicine (creation time 12/15/20) . Patient .who present with fall with hip pain. Seen in ER (emergency room ), R(right) femoral neck fx (fracture) Pain with movement .Surgery at 12/16/2020 (6:11 AM) . On 6/25/21 at approximately 1:30 PM an interview was conducted with Physical Therapist S. PT S was queried as to R809's fall and transfer status. PT S indicated that R809 was not able to transfer without a one person assist. When queried as to the fall that occurred on 12/12/20, PT S indicated that following a transfer and when a wheelchair is stable it should be locked. When queried as to when Anti-Rollback devices should be placed on a resident's wheelchair, PT S reported the device is used to help prevent falls for residents who are confused and will forget to set the lock the wheelchair themselves. On 6/25/21 at approximately 1:54 PM an attempt to contact Nurse R via phone was made. No return contact was made prior to the end of the survey. On 6/25/21 at approximately 2:59 PM an interview was conducted with Unit Manager (UM) Nurse Q. When queried about R809's fall, Nurse Q reported that she was not the nurse assigned to the resident the night she fell , but recalled the resident pointing to her hip and jestering that she had slipped when self-transferring. When queried if she recalled whether the W/C was locked, Nurse Q reported that it was not, but indicated that it should have been. When asked why R809 waited almost two days before being transferred to the hospital, UM indicated that the facility was waiting on X-ray results and at that time of the incident there was a delay due to COVID-19.

This citation pertains to Intake Numbers: MI 238 and MI 835 Based on interview, and record review, the facility failed to ensure a physicians' order was implemented for pain medication for two (R803 and R815) of three residents reviewed for pain management, resulting in R803 experiencing severe pain with emotional distress and R815 experiencing intolerable and unmanaged pain. Findings include: R803 On 6/23/21 at 10:50 AM, R803 was observed seated in a wheelchair in his room. An interview was conducted at that time. When queried about any concerns he had with the care he received in the facility, R803 reported there were big issues with getting his pain medication. R803 further reported that there was one week where he had to wait until the next shift for his pain medication. R803 stated, I had to ask for it, but I was supposed to receive it at 6 AM, 12 PM, 6 PM, 12 AM. R803 reported one day he went 18 hours without pain medication. When queried about what medication he was talking about, R803 reported it was Tylenol #4 (acetaminophen-[MEDICATION(S)] #4, a narcotic medication used to treat pain). R803 further stated, One time they told me they didn't have my medication! How does that even happen? When queried about whether he experienced an increase in his pain level when he did not get the medication, R803 stated, It was so bad. I wanted to scream and pull out my hair, I was in so much pain. R803's clinical record was reviewed and revealed the following: R803 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) assessment dated [DATE] documented R803 had intact cognition. A Physicians' Order with a start date of 3/20/21 documented, Acetaminophen-[MEDICATION(S)] #4 Tablet 300-60 MG (milligram) (a schedule II-controlled substance) Give 2 tablet by mouth every 6 hours as needed for Spinal Stenosis. A previous order started on 1/29/21 and discontinued on 3/20/21 was for one tablet of Acetaminophen-[MEDICATION(S)] #4 every six hours as needed. A review of R803's progress notes revealed the following: A Nursing Progress Note dated 3/31/21 at 6:28 AM written by Licensed Practical Nurse (LPN) G documented, Spoke to .pharmacy about reordering Tylenol #4 (Acetaminophen-[MEDICATION(S)] #4), she said insurance will not pay for more until Thursday April 1st. They allow for 6 tablets/24hrs and the order is for 2 tablets q 6hrs which is over allowable amount by insurance. Placed in Dr book and Dayshift nurse will be made aware. No pain medication available. There was no documentation that the physician was called, only logged to be seen. A Nursing Progress Note dated 3/31/21 at 6:38 PM (approximately 12 and a half hours since R803 received the last tablet (half of the prescribed dose of Tylenol #4) documented, .Tylenol 4 is on the way. DON (Director of Nursing) is aware and will make a call to the pharmacy in regard to insurance matter, Admin (Administrator) is aware new order for extra strength Tylenol 500mg 2 tab PRN (as needed) Q6 hours has been added for break through pain . A Provider Note dated 3/31/21 at 7:01 PM documented the physician saw the patient using telehealth services. The physician documented, .severe pain and is not able to get his downward <sic> for which pharmacy has not yet sent-also having jerking movements of his head and arms-gets [CONDITION(S)] tremors and upset and emotional .continued current medications until (R803's) Tylenol with [MEDICATION(S)] (Acetaminophen-[MEDICATION(S)] #4) as <sic> received patient may get Tylenol plain extra strength or [MEDICATION(S)]-to be notified if C2 forms will be needed for [MEDICATION(S)]-also contacted the pharmacy to have the prescription of Tylenol No. 4 delivered ASAP (as soon as possible) . A Nursing Progress Note dated 3/31/21 at 7:02 PM (approximately 13 hours after R803 received the last tablet of Tylenol #4) documented, Pain med have arrived, and 2 tabs have been given while MD was on [video call] witnessing him taking them. There was no documentation in R803's clinical record that indicated R803's Acetaminophen-[MEDICATION(S)] #4 had been reordered prior to receiving only half a dose (one tablet versus the physician ordered two tablets) on 3/31/21 at 5:49AM. R803 received the next dose approximately 14 hours later at 7:09 PM, as documented on the MAR. Review of a Concern Form for R803 dated 3/31/21 revealed R803's family member filed a concern that revealed the following:, Writer received call from resident daughter stating that her father has not received his pain medication and is in pain .Writer spoke with (R803) who repeated same story . Review of a One on One Inservice Record form dated 4/8/21 revealed LPN G received inservice education for the following: Nurse educated on the pain management policy in relation to ensuring resident receives pain medication and ordering pain medications . On 6/24/21 at 2:15 PM, the Director of Nursing (DON) and the Administrator were interviewed. The DON and Administrator were queried about whether they were aware of any issues related to pain medications. The Administrator reported she was aware of issues. The Administrator reported that when the facility switched ownership on 4/1/21, the previous owners discontinued orders with the pharmacy which resulted in the insurance information that was previously on file to also be deleted. The Administrator stated, None of the insurance information saved and the pharmacy was not able to fill the medications without an authorization, then they would only send so many, and then it would need to be preauthorized and approved again. When queried about whether the facility ensured the information would transfer over upon change in ownership, the Administrator did not offer a response.When queried about R803 and the issues with the resident running out of Acetaminophen-[MEDICATION(S)] #4 on 3/31/21, the Administrator reported she investigated his concern and found out it was due to the change in ownership and insurance issues. When queried about the inservice education provided to LPN G, the Administrator reported the nurse should have called the physician instead of placing the resident on the log to be seen to address the resident's pain. The Administrator further reported the medication should have been reorders prior to it running out. R815 A complaint was submitted to the State Agency that alleged R815's pain was not being managed effectively. R815's clinical record was reviewed and revealed the following: R815 was admitted into the facility on [DATE], was readmitted on [DATE], and discharged to the hospital on 6/21/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A MDS assessment dated [DATE] documented R815 had intact cognition, required limited assistance with transfers and bed mobility, and received scheduled and as needed pain medications. A review of R815's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] HCl Tablet 5 MG Give 1 tablet by mouth every 8 hours for Pain Management (Started on 2/2/21, held on 5/23/21, and discontinued on 5/30/21) [MEDICATION(S)]-Acetaminophen ([MEDICATION(S)]) Tablet 5-325 MG Give 1 tablet by mouth every 4 hours as needed for Pain Management (Started on 1/20/21 and discontinued on 5/30/21) A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .pain intolerable-patient with metastatic lung cancer metastasis apparently to bone skin in other places currently on [MEDICATION(S)] and [MEDICATION(S)] not holding her pain .Assessment and plan metastatic mass on back/ chest wall-with increasing pain -likely from lung cancer -as <sic> [MEDICATION(S)] ([MEDICATION(S)]) sublingual (administered under the tongue) when necessary . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .severe pain uncontrolled with oral medications . Assessment and plan .severe generalized pain/metastatic lung cancer to bones and subcutis tissues .this is not controlled despite multiple narcotic pain medications including [MEDICATION(S)] and [MEDICATION(S)] and [MEDICATION(S)] . Further review of R815's clinical record revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/24/21 at 3:40 PM, the Director of Nursing (DON) was interviewed and asked to clarify why the order for [MEDICATION(S)] as recommended by the physician on 5/19/21 was not implemented for R815. The DON reported she would look into it. On 6/25/21 at 10:40 AM, the DON followed up regarding the lack of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON reported R815 was supposed to sign onto hospice but changed her mind and reported that might have been why the [MEDICATION(S)] did not get ordered. At that time R815's clinical record was reviewed with the DON, and it was revealed that hospice was not discussed until after a hospitalization that occurred from 5/21/21 through 6/4/21. The DON reported she was not sure why the [MEDICATION(S)] was never ordered, and the physician would have to answer that. The physician who wrote the note was not available for interview prior to the end of the survey. A facility policy titled, Pain Management (undated and without the facility's name) documented, .any resident report of inadequate pain control or identified with a new onset of pain .will have a pain evaluation .Following the pain evaluation notify the physician if indicated and implement new orders as received .

This citation pertains to Intake #MI 104 Based on interview and record review, the Facility failed to ensure Resident #704 was transported to outpatient [MEDICAL TREATMENT] per their physician ordered schedule/plan of care and ensure ongoing communication between the [MEDICAL TREATMENT] center and the facility was completed for one (R#704) out of two reviewed for [MEDICAL TREATMENT] services, resulting in R#704 missing [MEDICAL TREATMENT] services on at least two occasions, an emergency transfer via EMS to the hospital, [MEDICAL CONDITION] (elevated potassium level that can lead to [MEDICAL CONDITION]), and emergent [MEDICAL TREATMENT] provided at the Hospital. Findings include: A complaint was filled with the State Agency that alleged that facility staff failed to ensure R#704 received their [MEDICAL TREATMENT] resulting in hospitalization . The complainant reported that the Facility failed to provide a hoyer lift strap on [DATE] resulting in R#704 missing a [MEDICAL TREATMENT] treatment and failed to resend R#704 to the [MEDICAL TREATMENT] center on the next scheduled day ([DATE] or [DATE]) and that they reported their concern to the physician and was later informed that R#704 was sent to the Hospital due to a change in condition. The complainant reported that the resident expired in the Hospital on [DATE]. A survey was conducted on [DATE]-[DATE]. A review of R#704's clinical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R#704's Minimum Data Set (MDS) indicated that the resident had a Brief Interview for Mental Status Score (BIMS) of 10 (moderately impaired cognition) and required two-person assist for transfers. R#704's care plan documented the following: I have an ADL (activities of daily living) self-care performance deficit .Interventions . I require (extensive assistance) by (1) staff to move between surfaces with Hoyer lift .I need [MEDICAL TREATMENT] .Tu/TR/SAT (Tuesday, Thursday and Saturday) @ (Name Redacted) P/U (pick-up) 10 AM . Interventions [MEDICAL TREATMENT] Communication Record is sent to the [MEDICAL TREATMENT] center with each appointment, and return form is ensured after appointment is completed . An order dated [DATE] documented, Must be sitting on Hoyer Sling When Going to [MEDICAL TREATMENT] . A nurse note dated [DATE] (10:47) and authored by Nurse C documented, in part, resident loa (leave of absence) to [MEDICAL TREATMENT] . A nurse note dated [DATE] (14:15) and authored by Nurse D documented, in part, the following: Resident was awaiting Transportation to [MEDICAL TREATMENT] unit, upon investigation I was informed the w/c (wheelchair) transportation companies are no longer transporting residents from this facility to and from (name redacted) [MEDICAL TREATMENT] units .Dr. (name redacted) notified and suggested sending her to hospital for [MEDICAL TREATMENT] .spoke with (name redacted) daughter .she does not want R#704 going to hospital today . A provider note authored by Nurse Practitioner (NP) B dated [DATE] (14:57)documented, in part, the following: Chief complaints . pt. (patient) daughter noticed pt. mental status appeared alerted via phone, will assess for infectious process vs missing HD (Hemo-[MEDICAL TREATMENT]), as pt has missed 2 HD appointments d/t transportation A SBAR (situation, background, assessment and recommendation) note dated [DATE] (19:05) and authored by Nurse D documented, in part, the following, .O2 (oxygen level) 60% .Appearance of resident is: The resident has missed her [MEDICAL TREATMENT] appointments and I think the toxins and excess fluid was building causing her breathing to be unmanageable. Causing tachypnea (rapid breathing) .Ambulance called .Resident transferred out of facility . A review of R#704's Hospital records documented, in part, the following: A facility Transfer/Discharge Report dated [DATE], .Chief complaint . R (respiratory) ,[DATE], T(temp) 97.6, O2 (60) . miscellaneous information .she hasn't had [MEDICAL TREATMENT] since [DATE]. Continued Hospital records documented, in part, .PT presents to (name redacted) Hospital for SOB (shortness of breath) .Pt states I was fine and suddenly I could barely breathe .While in ED (emergency department), pt found to be hypoxic . she received [MEDICAL TREATMENT] (in hospital) and had 2L removed during [MEDICAL TREATMENT] .her [MEDICAL CONDITION] improved and her oxygen requirements improved . Hospital lab work indicated .Abnormal Result . Potassium 9.4 (Ref range 3.5 -5.2) . Glucose .743 . Orders placed . Emergent [MEDICAL TREATMENT] treatment . On [DATE] at approximate 11:00 AM, [MEDICAL TREATMENT] Nurse E from (name redacted) [MEDICAL TREATMENT] center was interviewed via phone. [MEDICAL TREATMENT] Nurse E reported that according to the Center's records the last [MEDICAL TREATMENT] treatment provided by the center was on [DATE]. Nurse E was asked if R#704 needed the Facility to provide a sling used for transfer to the [MEDICAL TREATMENT] chair and reported that they did and indicated that there had been times when the Facility did not always provide the sling and that [MEDICAL TREATMENT] would be rescheduled for either later in the day or the next day so as to avoid a long delay in treatment. A review of documentation provided by the (name redacted) [MEDICAL TREATMENT] Center documented that R#704's last treatment was on [DATE] and that the resident had missed treatments scheduled on [DATE] and [DATE] due to transportation issues. An attempt to contact Nurse C via phone was made on [DATE] and a voice message was left. No return call was made by the end of the survey. A phone call was made to NP B and a voice message was left on [DATE]. No return call was made by the end of the survey. On [DATE] an interview was conducted with Nurse D regarding R#704. When queried as to why R#704 did not receive [MEDICAL TREATMENT] treatment on [DATE] and [DATE], Nurse D replied that they were told that the transportation company used to take R#704 to [MEDICAL TREATMENT] was no longer providing services due to COVID-19. Nurse D was not sure when the failure to provide services started, but knew it was not available on [DATE]. When queried as to whether R#704 could have been sent via ambulance to [MEDICAL TREATMENT], Nurse D indicated that it was not an option. Nurse D stated they wanted to send R#704 to the hospital earlier, but family member did not want the resident going to the Hospital due to COVID-19. R#704 was noted as Full Code and no evidence was found in the clinical record that R#704 would have denied Hospital treatment or that the family member was legally able to make treatment decisions. An interview with the Administrator was conducted on [DATE] at approximately 10:20 AM. When queried as to why R#704 missed two [MEDICAL TREATMENT] appointments ([DATE] and [DATE]) and was sent to the hospital via EMS on [DATE], the Administrator reported that the contracted transportation service (name redacted) shut down its services due to COVID-19. When asked for the exact day, time and documented record as to date of shutdown, the Administrator reported that she did not have any documentation, but remembered that the Service representative (name redacted) came to the Facility and reported that they were not going to provide services. A phone call was made to the transportation service representative who indicated that services were stopped due to COVID-19 but could not provide an exact date or documentation. When queried as to whether the Facility had a back-up transportation service it could have used or utilized EMS, the Administrator reported that it did have a second transportation service contract, but it was also was not providing services and reported that she made arrangements with (name redacted) transportation and has been using that service currently. When asked if the reason R#704 did not receive [MEDICAL TREATMENT] services on [DATE] was due to a facility failure to provide a sling to get R#704 out of the wheelchair, the Administrator indicated that she did not believe R#704 required the sling and was not sure why the [MEDICAL TREATMENT] appointment was missed. A request was made for all [MEDICAL TREATMENT] communication forms for R#704 from admission ([DATE]) through [DATE]. The Facility was able to provide records for the following dates: [DATE], [DATE] (with recommendation/follow-up from [MEDICAL TREATMENT] center: please bring sling under pt. Pt. rescheduled for tomorrow 11 am [DATE]., [DATE] and two additional forms that were not dated or completed. A second request for [MEDICAL TREATMENT] communication forms was made. No further forms were provided by the end of the survey. A review of the Facility's policy titled, [MEDICAL TREATMENT], Care of Residents (Revised [DATE]) documented, in part, the following: The facility provides residents with safe, accurate, and appropriate care, assessments and interventions consistent with the Comprehensive Care Plan and the resident's goals and preferences .Admission and General Care: Review and ensure orders upon admission are received for follow-up [MEDICAL TREATMENT] center appointments .A [MEDICAL TREATMENT] Communication Record is initiated and sent to the [MEDICAL TREATMENT] center for each appointment. Ensure it is received upon return . A review of the Facility Policy titled, Referral to Outside Agencies (Revised Date [DATE] )documented, in part, the following: The facility ensures that residents receive treatment and care from outside agencies .FUNDAMENTAL INFORMATION .Referrals are made for the following outside agencies/services .[MEDICAL TREATMENT] services . Procedure: .6. If services are not provided at the facility, the facility arranges transportation to and from the outside agency .Appointments and transportation arrangements are communicated to direct staff .8. Information/forms required for the resident's appointment are prepared by social services and nursing. The packet includes: .[MEDICAL TREATMENT] Communication Form .

This citation pertains to Intake Number MI 570 Based on observation, interview, and record review, the facility failed to assess a resident for safety with handling hot liquids, and ensure assistance with feeding to [MEDICAL CONDITION] one (R#701) of three residents reviewed for monitoring during meals, resulting in redness, blisters, [MEDICAL CONDITION] required a visit to the emergency room (ER). Findings Include: A facility reported incident (FRI) was filed with the State Agency (SA) on 2/24/2020 that reported the resident spilled hot soup on her lap while not being monitored. On 3/11/20 at 12:35 p.m., R#701 was in her room being assisted by Restorative Certified Nursing Assistant (RCNA) 'A' with transfer from bed to wheelchair for her lunch meal. When asked about the incident on 2/13/20, R#701 stated, I was holding my soup in one hand and the cup in the other. My table-mate reached over to brush off some soup that had wasted on my top. R#701 further stated, That was too much for me to do myself, because I am slow at doing things. R#701 was asked if any of the staff asked to assist her with her lunch meal that day, R#701 stated, No because I hardly ever have soup . We told them we like soup in the wintertime and they just started giving it to us . R#701 was asked if she used special utensils to eat and stated, No, I use the regular stuff they have. It's just as good as any. When queried if she was wearing a clothing protector, R#701 stated, No, we didn't have any clothing protectors. When asked if staff usually assist her with eating her meals, R#701 stated, No one helps me normally. When asked if there was staff in the dining room at the time of the incident, R#701 stated, I'm not sure if staff was in the dining room at the time. When asked where the soup spilled, R#701 stated, The soup spilled out of the bowl into my lap. When asked if the soup was too hot, R#701 stated, No, I like it hot and I like my coffee hot. My table-mate (R#702) said 'It is finally good to get some hot soup.' R#701 further stated, I tried to brush it (soup) off, but I'm just so slow. It was all down the front. I didn't let anyone know that I needed help until we got back in here (room). The aide (CNA 'B') wanted to change my brief. They always do that before they lay me down. It was real red there. She (CNA 'B') got the nurse (Licensed Practical Nurse - LPN 'C') and they decided to take me to (Name) Hospital 'D'. They said something about a second degree . On 3/11/20 at 12:45 p.m., R#702 was observed in the first-floor dining room sitting at the table with R#701. When asked if she knew about the incident that happened with R#701, R#702 stated, (Name) R#701 said, 'I spilled my soup', I was trying to wipe it off of her. When asked if R#701 was wearing a clothing protector, R#702 stated, I don't remember, but usually she is, but I don't remember that day. R#702 was asked if she ever needed help with eating her meals. R#702 stated, No, I feed myself, but I help her (pointing at R#701). On 3/11/20 at approximately 12:50 p.m., while R#701 and R#702 were observed in the first-floor dining room sitting at the table engaged in conversation with RCNA 'A', the lunch meal was served that included broccoli soup. When asked if R#701 was usually assisted with her meals, RCNA 'A' stated, We have a list of residents that need assistance. When asked if R#701's name was on the list for assistance, RCNA 'A' stated, I think they are going to add her. Further review of the facility's I/A (Incident/Accident) dated 2/13/2020 02:05 PM - revealed the following: . (Name Redacted) 'R#701' . Was Harmed: Yes . Cognitive Status: Independent. BIMS Score: 15 . Type of Injury/Harm: Physical . Ambulatory Status at Time of Incident: Total Dependence . Diagnosis: [REDACTED]. Were there any witnesses? Yes. Name: (Name) R#702 . Date/Time Incident Discovered: 2/05/2020 02:05 PM. Date/Time Incident Occurred: 2/05/2020 02:05 PM. Facility Investigator: (Name) Administrator. Incident Summary: Resident stated that she spill (sic) her soup and upon assessment resident has reddened area with blisters on bilateral thighs . Submitted by: (Named Redacted) Administrator. Submitted Date/Time: 2/14/2020 12:23 PM. A review of the clinical record revealed R#701 was originally admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R#701 had a Brief Interview for Mental Status (BIMS) exam score of 15 which indicated intact cognition and required extensive to total care assistance with one to two-person physical assist with activities of daily living (ADLs). R#701 required limited assistance with one-person physical assist with eating. The facility's care plans revealed the following: Focus: I have potential alteration in nutrition, Mechanically altered diet, r/t (related to) [MEDICAL CONDITION], difficulty with self feeding at times. I need feeding assistance at times/set up assistance . Date Initiated: 04/19/2018. Revision on: 11/27/2019. Goal: . Skin to remain intact as feasible. Date initiated: 08/12/2015. Revision on: 02/13/2020. Interventions: I do need help with feeding myself at meals and snacks- please assist me. Please encourage me to slow my rate of intake, take smaller bites and alternate between liquids and solids if you notice increased oral residue. Dated Initiated: 04/01/2019. Revision on: 07//25/2019. Focus: I have difficulty navigating eating utensils to my mouth. Date Initiated: 07/15/2019. Goal: I will get assistance with eating all meals. Date Initiated: 07/15/2019. Revision on: 02/16/2020. Interventions: I will receive assistance with all meals as I allow. I like my independence please re approach as needed. Date Initiated: 07/15/2019. Revision on: 02/16/2020. The SBAR (Situation, Background, assessment, Recommendation) Communication Form and Progress Note dated 2/13/20 15:28 (3:28pm) revealed the following: . Assessment (RN - Registered Nurse) or Appearance (LPN) . LPN . Resident stated she had spilled soup in lap during lunchtime. Observed resident in bed with bilateral reddened areas at inner thigh Left leg measures 9 x 8 cm (centimeters) and Right Leg measures 7.8 cm x 5.5 cm both with multiple closed blisters noted. After interviewing resident, she stated that she inadvertently drifted asleep while eating and knocked soup onto lap. Transfer to the (Name) hospital 'D' .Specify other new orders ([MEDICATION NAME] Cr (Cream) 1% to bilateral thighs Q (every) 12 hrs. Further review of R#701's meal ticket provided by the facility revealed R#701 received the following meal: REGULAR - THURSDAY . LUNCH 2/13/2020, GROUND BREADED CHICKEN PATTY* - 3/8, 1 CUP MAYONNAISE (OZ)-2 OZ, CAPRI VEGETABLE BLEND-1/2 CUP, POTATO WEDGES-1/2 CUP . CORNBREAD-1 SQUARE, . SOUP OF THE DAY-8 OZ . It was not documented on the meal ticket whether R#701 should be assisted with hot liquids (soup). A review of the facility's Service Line Checklist for 2/13/20 revealed the temperature for chicken soup during the lunch meal was 164 degrees Fahrenheit (DF). Further review of the service line checklist revealed temperatures for hot foods are greater than or equal to 135 DF. there was no signature or initial of whomever completed the list. R#701's feeding assessment for hot liquids (before the incident on 2/13/20) was requested, but not provided before the end of the survey. However, the facility submitted an Occupational Therapy (OT) Addendum dated 2/18/2020 04:19 PM that read as follows: Date of Note: 2/18/2020 . Summary. Note: Discussion on this day re: recommendation for use of AE (as evidence) during self-feeding tasks, specifically with consumption of soup in order to increase safety and independence in self-feeding tasks. Pt (patient) agreeable to trial of weighted mug with mug lid in order to promote safety and reduce risk for spillage; AE order placed on this day. Pt demonstrates ability to participate in self-feeding task with min (minimum) assist/CGA (Contact Guard Assist) and increased time for completion of self-feeding tasks due to disease process ([MEDICAL CONDITION]). Pt with AROM (Active Range of Motion) WFL (Within Functional Limits) and addressing deficits in BUE (Bilateral Upper Extremities) strength, including grip strength, at this time with skilled OT services. Electronically signed by OTR/L 'E'. On 3/11/20 at 1:52 p.m., during an interview, when asked about the process for tempting foods before they are served to the residents, Dietary Manager 'F' stated, For our hot foods, we take the temperatures as they are produced out of the stove and oven. We make sure they hit their safe zones. We put the food on the steam table. Right before we start serving, we tempt them again while they are on the steam table. We make sure they are at holding temperature of 135 degrees Fahrenheit or higher. We record them and then we begin serving. On 3/11/20 at 3:31 p.m., an interview was conducted with CNA 'B' about the incident with R#701 on 2/13/20. When asked if she was assigned to R#701 on 2/13/20 during the day shift, CNA 'B' stated. Yes, I was. When asked if R#701 require assistance with feeding at mealtimes, CNA 'B' stated, Sometimes when she need it. It's limited assistance with one-person physical assist. CNA 'B' was asked what that meant and stated, Sometimes she (R#701) need help, but we still sit there and watch her. CNA 'B' was queried further, if anyone was sitting with R#701 on the day she spilled the hot soup, CNA 'B' stated, I really couldn't tell you because I was the hall person that day, so I was in the hallway. CNA 'B' was asked if anyone else assisted R#701 with her lunch meal on 2/13/20. CNA 'B' stated, I can't answer that because I wasn't in the dining room at all. When I got through picking up my trays, I laid her down. She told me that she wasted her soup . When I laid her down and changed her pants and her brief. CNA 'B' was asked to describe what she saw. CNA 'B' stated, I seen redness from where the soup had wasted on her. I ran and got my nurse (LPN 'C') and reported it to her. She reported it to the Administrator. On 3/11/20 at 3:51 p.m., a call was placed to LPN 'C'. There was no answer and the greeting recorded message was that the Person did not have a voice mail set up. On 3/11/20 at 4:00 p.m., the Administrator was made aware of LPN 'C's greeting message and later stated that LPN 'C' was on vacation and not available . On 3/11/20 at 4:56 p.m., during an interview with LPN/Unit Manager 'G', when queried if R#701 was supposed to be assisted with feeding during meals, LPN 'G' stated, If I had to guess, she is assist, but she is pretty independent. when asked if it was documented at any time that R#701 refused to be assisted with her meals, LPN 'G' stated, I'm not aware of that. On 3/11/20 at 5:25 p.m., The Director of Nursing (DON) was interviewed and stated, In reviewing her (R#701's) information, it was my understanding that she was limited assist with assistance as needed. The DON was asked if the MDS coded R#701 as one-person physical assist, should R#701 have had a staff member assisting with her lunch meal. on 2/13/20, the DON stated, Yes. The DON was asked if the resident refused assistance with her meals if it was documented in a progress note or the care plan, the DON stated, that I would have to check. No further information was provided before the end of the survey. On 3/11/20 at 6:15 p.m., an interview was conducted with the Administrator and DON. When asked what the expectation of the facility was if R#701 had limited assistance with one-person physical assist for eating, the Administrator stated, The expectation is that she has the assistance that is needed or the care plan be updated at that time. A review of the facility's policy titled Meal Service revised March 2012 revealed the following: Guidelines . Resident Supervision: A licensed nurse will be available during all meals to assist, if necessary. For residents who eat in their room, supervision levels vary according to the resident's ability to safely consume food . Feeding Assistance: Staff assisting residents with eating should sit at the resident's level. Clothing protectors are used when necessary to protect the resident's clothing. Offer fluids throughout the meal to aid in eating/swallowing . The policy did not address the assistance with hot food or liquids.

Based on observation, interview, and record review, the facility failed to prevent the development of a pressure ulcer, implement interventions and treatments in a timely manner, provide treatments according to physician orders, and communicate missed treatments to the physician and/or consulting wound practitioner for one (R#74) of two residents reviewed for pressure ulcers, resulting in the development of an avoidable stage 3 pressure ulcer (full thickness loss of skin) that worsened to a stage 4 pressure ulcer (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) that became infected and required surgical debridement, and has not healed. Findings include: On 1/13/20 at 1:55 PM, R#74 was observed lying in bed. When asked if she had any wounds, R#74 stated, I have something right here (R#74 pointed to her right hip/thigh area). I have had it forever and it won't go away! I wish I could see a real doctor about it to see what is really going on.they just keep measuring it and it's not getting better or going away. On 1/13/20 at 4:50 PM, an observation of the dressing to R#74's right hip and the wound underneath was conducted with Nurse R. An outer dressing to R#74's right hip was dated 1/9/20, which was confirmed by Nurse R. Upon removal of the outer dressing, three layers of gauze and a strip of dressing that was packed inside of the wound were observed to be entirely soiled with brown drainage and a slight odor was noted. R#74's right hip was observed with two open areas separated by a strip of healthy skin. The depth of the wounds were not visible. When queried about the wound treatment order, Nurse R was unsure and reported he would look in the electronic record to confirm the order and would change the dressing. R#74's clinical record was reviewed and revealed the following: R#74 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented R#74 had moderately impaired cognition, rejected care at times, and was a two person extensive physical assist for bed mobility and transfers. The MDS assessment documented R#74 was always incontinent of urine and stool and had one stage 4 pressure ulcer that was not present on admission into the facility. A significant change MDS dated [DATE] documented R#74 was a one person physical assist for bed mobility and transfer status did not occur during the assessment look back period. It was documented R#74 had a stage IV pressure ulcer that was not present on admission into the facility. A significant change MDS assessment dated [DATE] documented R#74 had a stage III pressure ulcer that was not present on admission into the facility, no behaviors including rejection of care, and was totally dependent on staff for transfers and bed mobility. Physician orders [REDACTED]. 1. Cleanse right hip with NS (normal saline), pack wound lightly with (packing strip) gauze every day shift for wound care. 2. Cleanse right hip with NS, pack wound lightly with (packing strip) gauze every 12 hours as needed for wound care. A (MONTH) 2020 Treatment Administration Record (TAR) revealed no documentation of R#74's wound treatment being completed on 1/11/20, 1/12/20, and 1/13/20, as evidenced by no initials by a nurse to indicate the treatment was completed. Nurse R's initials were documented on 1/10/20 to indicate the treatment was completed. However, it was noted during the observation of R#74 that the treatment dressing was dated 1/9/20. On 1/13/20 at 5:00 P.M., Nurse D reported Nurse Q (a nurse who was working on 2 South with Nurse R on the day shift) ended her shift around 3:30 P.M. or 4:00 PM and was no longer in the building. On 1/14/20 at 7:30 [NAME]M., R#74's (MONTH) 2020 TAR was reviewed and documented Nurse Q's initials to indicate the wound treatment was completed by that nurse on 1/13/20. Nurse Q's initials were not documented on the TAR as of 1/13/19 at 4:30 P.M. On 1/14/20 at 11:36 AM, Nurse Q was interviewed. Nurse Q reported she was the first floor unit manager, but worked on the 2 South unit on 1/13/20. Nurse Q reported the 2 South unit had 32 residents and Nurse R was assigned to the 2 South unit along with her. Nurse Q was asked if she completed the wound treatment to R#74's right hip on 1/13/20. Nurse Q stated, I did not. When queried about why she did not complete the wound care, Nurse Q stated, I was not familiar with her wound. It was my first time up there. I didn't get a chance to do it before I left. Nurse Q was queried about why she did not get a chance to complete R#74's wound treatment. Nurse Q stated, There was confusion in the morning about who was going to be working up there (second floor). I came up there at 8 AM. I just didn't get it done. I was supposed to work from 7-3:30 and got off at 4:15 (PM). (Nurse R) was supposed to go back and do everything that was open (not completed). R#74's TAR was reviewed with Nurse Q at that time. Nurse Q confirmed that the initials documented under the wound treatment on 1/13/20 were in fact her initials, but stated, I did not do her wound care and I did not sign off that I did it. On 1/14/20 at 1:47 PM, an interview with the Director of Nursing (DON) was conducted. The DON reported she had been working in the facility as the DON for approximately one month. The DON reported that the facility did not utilize a wound treatment nurse and that a contracted wound care practitioner came to the facility on e time per week. When queried about the facility's protocol for assessment of residents with pressure ulcers, the DON reported that the nurse assigned to the resident conducted skin assessments on a weekly basis and the contracted wound care practitioner (accompanied by a facility nurse) assessed pressure ulcers weekly. When asked about who determined the type of wound/pressure ulcer, the DON stated, Perhaps the attending physician and/or the Nurse Practitioner. The DON reported that the assigned nurse was responsible for providing the physician ordered wound treatments. When queried about her knowledge and history of R#74's pressure ulcer, the DON reported she would have to look into it. The DON acknowledged that R#74 had the only facility acquired pressure ulcer in the facility. When asked if she was aware of any missed treatments for R#74's pressure ulcer, the DON reported she was not aware. When queried about what her expectations would be if a treatment was missed or a nurse was unable to complete it, the DON reported she would expect to be notified. The DON reported she was not notified of any missed treatments to R#74's pressure ulcer to the right hip and stated, Taking that into consideration and based on the presentation, the physician should be notified to prevent any infection or worsening of the pressure ulcer. At that time, the (MONTH) 2020 TAR for R#74 was reviewed with the DON. The DON did not have an explanation of why Nurse R signed off the treatment as completed on 1/10/20 (dressing was dated 1/9/20 on 1/13/20) or how Nurse Q's initials were documented for the completed treatment on 1/13/20 when she was no longer in the building. The DON was asked about when the pressure ulcer to R#74's right hip was first identified, what interventions were in place prior to the development of the pressure ulcer, what interventions were put in place after the development of the pressure ulcer, and what caused the pressure ulcer. The DON reported she would look into it. In addition, a report of the actual treatment administration times was requested. On 1/14/20 at 2:35 PM, Nurse K was observed providing treatment to R#74's pressure ulcer. The dressing was observed to have Nurse R's initials and was dated 1/13/20. Nurse K inserted a long cotton swab into the wound which was observed to have significant depth. There was no (packing strip) gauze packed in the open area. Nurse K reported she was familiar with R#74 and last provided wound treatment about two weeks prior. When queried about the appearance of the pressure ulcer, Nurse K stated, It has gotten significantly deeper than last time I saw her. I put the cotton swab inside to see if there was anything inside of the wound. R#74 was observed to be calm and cooperative and was agreeable to wound care. On 1/14/20 at approximately 4:00 P.M., the DON stated, I see we have a documentation problem. However, it looks like the wound is healing. The resident also refuses care. On 1/15/19 at approximately 11:30 [NAME]M., the DON was further interviewed. When queried about how it was determined R#74's pressure ulcer was healing as mentioned on 1/14/20, the DON stated, The information I was given was conflicting. I'm still waiting on more information. The DON reported she has not seen R#74's pressure ulcer. When asked what was in place prior to the development of the pressure ulcer and what interventions were implemented afterwards, the DON did not offer a response. Consults from the contracted wound care company were provided at that time and reviewed and the DON reported the first consult was conducted on 5/2/19. On 1/15/20 at 1:39 PM, MDS Director, Nurse O was interviewed per the DON's request. Nurse O was asked when the pressure ulcer was first identified on R#74's right hip. Nurse O reviewed the wound consults and stated, It looks like it changed from a stage 3 to a stage 4 on 6/6/19. When queried about how R#74 got the pressure ulcer, Nurse O stated, I don't know how she got it. I'm just trying to help. R#74's clinical record was further reviewed and revealed the following: Progress notes revealed no Nursing Notes between 3/29/19 and 5/3/19. A progress note dated 5/20/19 documented, IDT (Interdisciplinary Team) at risk team meeting: RD (Registered Dietician, DON, Administrator, Unit manager, MDS, rehab, risk maanger <sic>. Resident with recurrent pressure ulcer to the R (right) hip. Wound care following, treatment orders in place. (Brand name protein supplement) 30mL (milliliter) to be initiated. A progress note dated 6/6/19 documented, resident seen by wound care today, new order for (an antibiotic) 250mg (milligrams) Q (every) 6 hours x 10 days, continue (brand name for antiseptic solution to treat infected wounds) BID (two time a day) x 7 days. A progress note dated 6/13/19 documented, resident was seen by wound care today, wound appears to be improving . A progress note dated 6/14/19 documented by the MDS Director, Nurse O noted, Significant change pending due to worsening of wound. A Care Conference Note dated 9/24/19 documented, .She is being followed by wound care for a wound on her right hip. It is close to being healed . A progress note written by Nurse K on 1/14/20 documented, Writer spoke with (physician) this evening to update on treatment to L (left) hip and the missed days of treatment being performed . A progress note written by Nurse K on 1/15/20 documented, Writer spoke with wound MD here at facility today. Writer updated wound MD on the missing days of treatments and the improper treatment being done (no packing gauze wound). Wounds <sic> noted that the wound would heal faster if the treatment were to be done correctly and daily. Writer informed MD that if any new orders needed to be written or updated to please update writer for fast administration once she saw the wound. Consults completed by the contracted wound care team were reviewed and revealed the following: The first consult was completed on 5/2/19 and it documented, .Location: R hip .Context: Pressure .Right Hip is a Stage 3 Pressure Injury Pressure Ulcer .measurements are 2cm (centimeters) length x 2cm width x 0.5cm depth .There is a moderate amount of sero-sanguineous drainage noted .Wound bed has Yellow Base [MEDICATION NAME] .Diagnosis: [REDACTED].TREATMENT RECOMMENDATIONS (a [MEDICATION NAME] agent) + (wound dressing) QD AND PRN .PRESSURE REDUCTION MATTRESS .LOW AIR LOSS MATTRESS OR LOW AIR LOSS BED .FREQUENTLY REPOSITION .Cover wound with secondary dressing . A consult dated 6/6/19 (over one month after the first consultation) documented, .Right Hip is a Stage 4 Pressure Injury Pressure Ulcer .measurements are 2.5cm length x 3.5cm width x 2cm depth .There is a large amount of purulent (containing pus) drainage noted .Wound bed has Yellow Necrotic Base epithetlialization, Two wounds with a communicating bridge granulation .Procedures: Wound #1 (Pressure Ulcer) is located on the right hip. A Surgical debridement .was performed by (Name of wound NP). Adipose (fat) was removed along with devitalized tissue: necrotic/eschar .Post Debridement Measurements: 2.5cm length x 3.5cm width x 7cm depth .necrotic tissue is sharply debrided, underlying tissue is pink base with minimal necrotic tissue, undermining (destruction of tissue or ulceration extending under the skin edges so that the pressure ulcer is larger at the base than at the skin surface) at 6:00 of 2.5cm .TREATMENT RECOMMENDATIONS (antiseptic solution to treat infected wounds)1/4 STRENGTH BID AND PRN X 7 DAYS .(Brand name of antibiotic) 250mg PO (by mouth) Q6 hours x 10 days . There was no documented consult provided between 5/2/19 and 6/6/19. A consult dated 8/28/19 documented R#74 had a Stage 4 pressure ulcer that measured 1cm length x 1cm width x 5cm depth with undermining noted at 1:00 and ending at 12:00 with a maximum distance of 3cm . with a large amount of serosanguineous drainage and two wounds with a communicating bridge granulation. Treatment was changed to (absorbant dressing) daily and PRN lightly packed. There were no wound consults provided between 6/6/19 and 8/28/19. A consult dated 10/2/19 documented a Stage 4 pressure ulcer that measured 1cm x 1cm x 4.7cm and Tunneling (passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound has been noted at 6:00 with a maximum distance of 3.7cm. There is a large amount of serosanguineous drainage . A consult dated 10/9/19 documented increased tunneling distance of 4cm and no other changes to the pressure ulcer. The treatment remained the same. On 10/16/19, the pressure ulcer measured the same as the previous assessment and had a decreased tunneling distance of 3.5cm and moderate amount of serous drainage. The treatment remained the same. On 11/6/19, the depth of the stage 4 pressure ulcer increased to 5cm and the tunneling distance increased to 5cm. On 11/13/19, the tunneling distance of the pressure ulcer increased to 5.7cm. On 11/20/19, the depth of the pressure ulcer increased to 5.3 cm and the tunneling distance increased to 6.2cm. The treatment was changed to (packing strip) gauze lightly packed once a day and as needed. On 12/18/19 and 12/23/19 it was documented R#74 refused services of the wound care team. On 1/8/20 the consult documented a measurement of 1cm length x 1 cm width x 4.3cm depth with tunneling at 6:00 with a maximum distance of 6.7cm with moderate serosanguineous drainage. Two wounds with a communicating bridge granulation remained. The treatment remained the same as 11/20/19. On 1/15/20, it was documented R#74 refused services and the wound was unable to be evaluated. Head-to-Toe Skin Checks for R#74 were reviewed and revealed the following: A Skin Check dated 5/2/19 documented an existing stage 2 (partial thickness loss of skin with exposed dermis) pressure ulcer to the right hip. (A consult by the contracted wound care practitioner documented R#74 had a stage 3 pressure ulcer on that same day.) A Skin Check dated 5/9/19 documented R#74's skin was intact. A Skin Check dated 5/16/19 documented R#74 had a stage 2 pressure ulcer to the right hip. A Skin Check dated 5/23/19 documented R#74 had a stage 2 pressure ulcer to the right thigh side with redness around site and drainage. A Skin Check dated 5/30/19 documented R#74 had an existing pressure ulcer on side of right thigh, redness around site and drainage that is yellowish in color. A Skin Check dated 6/26/19 documented R#74 had a stage 4 pressure injury to the right hip. There was no documentation of any changes in R#74's skin prior to 5/2/19. Physician order [REDACTED].#74 and revealed the following: An order to apply ([MEDICATION NAME] agent) and (wound dressing) to the coccyx after cleansed with wound cleaner QD and PRN in the evening for pressure ulcer . This began on 4/29/19 and was discontinued on 5/20/19. (There was no documentation of a coccyx wound in R#74's clinical record) There was no order documented on the TAR for treatment to R#74's right hip until 5/31/19, at which time the treatment order was changed to (antiseptic solution) 0.25% to right hip two times a day for 14 days. (R#74 was seen by the wound care practitioner on 5/2/19 who recommended ([MEDICATION NAME] agent) and (wound dressing) to the right hip). R#74's (MONTH) 2019 TAR revealed two orders for (antiseptic solution) 0.25% twice a day, pack with kerlix and apply dressing for 7 days starting 6/7/19 and 6/13/19. Treatment was not completed on 6/12/19 and 6/16/19 as evidenced by no nurse's initials to indicate it was done. After 6/20/19, there was no order for treatment to R#74's right hip pressure ulcer documented on the (MONTH) 2019 TAR. A (MONTH) 2019 TAR revealed no order for treatment to R#74's pressure ulcer until 7/4/19, at which time, the following was ordered: CLEANSE RIGHT HIP WOUND WITH NS. APPLY (absorbant dressing)(LIGHTLY PACK) every night shift . The TAR revealed no treatment was provided on 7/13/19, 7/14/19, 7/22/19, 7/27/19, 7/28/19, and 7/30/19. An (MONTH) 2019 TAR revealed no treatment was provided to R#74's right hip pressure ulcer on 8/5/19, 8/7/19, 8/10/19, 8/11/19, 8/12/19, 8/24/19, and 8/27/19. On 8/7/19, there was an order for [REDACTED].>A (MONTH) 2019 TAR revealed no treatment was provided to R#74's right hip pressure ulcer on 9/2/19, 9/4/19, 9/7/19, 9/14/19, 9/21/19, 9/22/19, and 9/24/19. An (MONTH) 2019 TAR revealed no treatment was provided to R#74's right hip pressure ulcer on 10/7/19 and 10/20/19. A (MONTH) 2019 TAR revealed no treatment was provided to R#74's right hip pressure ulcer on 11/2/19, 11/3/19, 11/8/19, 11/10/19, 11/13/19, and 11/30/19. A (MONTH) 2019 TAR revealed no treatment was provided to R#74's right hip pressure ulcer on 12/14/19, 12/15/19, and 12/19/19. On 12/20/19, the treatment order was changed to Cleanse right hip with NS, pack wound lightly with (packing strip) gauze every day shift . Care Plans were reviewed for R#74 and revealed the following: A care plan initiated on 5/20/19 documented, I have a stage 4 pressure injury to my right hip r/t (related to) fragile skin, immobility . An intervention for a low air loss mattress was initiated on 5/21/19. On 7/25/19 an intervention for staff to assist with turning and repositioning was initiated. There were no new interventions after 7/25/19 despite multiple missed treatments and R#74's non-healing wound. A care plan initiated on 11/12/17 and revised on 3/8/19 documented, .resistive to ADL care at times r/t my hx (history) . There was no documentation on the dates of the missed pressure ulcer treatments that R#74 refused any wound care. There was no care plan that documented R#74 refused wound care. A facility policy titled, Skin Management (revision date: (MONTH) (YEAR)) documented, .Residents receive care to aid in the prevention or worsening of wounds and/or pressure ulcers. Individuals at risk for skin compromise are identified, assessed and provided treatment to promote healing, prevent infection, and prevent new ulcers from developing. Ongoing monitoring and evaluation are provided for optimal resident outcomes . No additional information was provided prior to the end of the survey.

This citation pertains to intake #MI 8 Based on interview and record review, the facility failed to ensure a resident's choice and physician order [REDACTED].#713) who had a DNR (Do Not Resuscitate) Code order of three residents reviewed for code status, resulting in an Immediate Jeopardy (IJ) when staff performed CPR to R#713 who had a documented DNR code status causing the likelihood for serious injury and/or harm. Findings Include: The IJ started on [DATE] at approximately 7:59 a.m. The IJ was identified on [DATE] at approximately 3:30 p.m. The Administrator was notified of the IJ verbally and electronically on [DATE] at 4:40 p.m. The immediacy was removed on [DATE] at approximately 12:30 p.m., based on the facility's implementation of an acceptable plan of removal as verified on-site by the survey team. Although the immediacy was removed, the facility remained out of compliance at the scope of isolated/potential for more than minimal harm that is not immediate jeapardy. According to [NAME]D.[NAME]M. (Accreditation HealthCare Commission), Inc. (,[DATE]), A do-not-resuscitate order, or DNR order, is a medical order written by a doctor. It instructs health care providers not to do cardiopulmonary resuscitation (CPR) if a patient's breathing stops or if the patient's heart stops beating. On [DATE] the medical record for R#713 was reviewed and revealed the following: R#713 was initially admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. R#713's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of [DATE] revealed R#713 had moderate cognitive impairment, required extensive assistance with bathing, and was incontinent of bowel and bladder. A nursing note dated [DATE] at 8:45 AM, revealed the following: Writer made aware at 0748 (AM) by Resident Care Specialist Resident was not responsive during rounds. Writer immediately went to assess Resident. Resident was noted to have no pulse no active vital signs she was not arousable to name or touch. CPR was initiated and EMS (Emergency Medical Services) was called. Team began CPR, EMS arrived and order for DNR was validated . A care conference note dated [DATE] at 10:49 AM, revealed the following: IDT (Interdisciplinary team) held care conference with resident's son and DPOA (durable power of attorney) (R#713's son). (R#713's son) provided DPOA documentation. Medication review and care plan provided and discussed in full detail. Resident will remain a DNR . (R#713's son) expressed interest in comfort care once resident completes therapy. She is total care with ADLs (Activities of Daily Living). Per assigned RCS (resident care specialist) she is an overall decline with ADLs since readmission . A physician's orders [REDACTED]. A paper DNR document in R#713's physical record signed by R#713's son (durable power of attorney) and dated for [DATE] revealed the following: Do Not Resuscitate Declaration .I request that in the event my heart and breathing should stop, no person shall attempt to resuscitate me .This order is in effective until it is revoked by me .Being of sound mind, I voluntarily execute this order and I understand its full import . An EMS Pre-hospital Care Report Summary for R#713 dated [DATE] revealed the following: Crew (number of local EMS team) called priority one to a CPR pt. (patient) EMS arrives on scene to a nursing facility. (Local Police Department) is on scene and has made pt contact. EMS ATF (arrived to find) an (R#713 demographics) lying pusine <sic> in bed in her room. PT is unresponsive. PT is apneic (no breathing) and pulseless. Staff members are currently doing CPR. BVM (bag valve mask) that staff is using is not fully opened and is not providing proper ventilations. PT was last seen normal at 0650 (AM). Staff states they began CPR at 0750 (AM). Staff has not placed an AED (automated external defibrillator) onto pt, stating that 'There is not an AED in the building.' PT is placed on EMS monitor. Asystole (no heartbeat) is seen. When asked about PT code status multiple staff members state pt is a full code. CPR with proper ventilations provided by EMS is continued. Before access and an airway are attempted, a staff member states pt is a DNR and provides proper paperwork to prove this. CPR is held (Name of local hospital) is contacted. (Name of Doctor at hospital) advised to follow DNR paperwork and provides time of death of 0812 (AM). Efforts are ceased. Information given to (Local Police). EMS clears scene. A police report dated [DATE] pertaining to R#713's death on [DATE] revealed the following, Officers were dispatched to (location of facility) on an unresponsive female in (R#713's room). Officers arrived and found (R#713) in bed unresponsive. (Nursing facility) personnel were give <sic> (R#713) CPR .Paramedics arrived on scene and I asked a nurse if there was a DNR order on the patient. Nurse (Nurse I) advised me that she would check. (Nurse I) advised that there was a valid DNR order and it was confirmed by the Paramedics. CPR was stopped on (R#713). On [DATE] at approximatley 3:40 p.m., Unit Manager (UM) H was queried regrding the provision of CPR to R#713. UM H indicated that CNA U informed them that R#713 was unresponsive. UM H indicated that the two nurses at the nurses station (Nurses F and I) shouted out that R#713 was a full code. UM H stated, I was the first on the scene and started chest compressions. UM H was queried if anyone had stopped and verified if R#713 was a full code and she reported that they didn't until EMS arrived. UM H stated, I just took their words for it that she a full code. EMS told us to stop performeing the code when they got their and verified that she was a DNR. UM H indicated the nurses in the room did chest compressions on R#713 for apporoximatley ,[DATE] minutes until EMS arrived and told them to stop. On [DATE] at 3:00 PM, a telephone interview with LPN 'F' (R#713's assigned nurse on [DATE]) was conducted regarding R#713 and the incident that occurred on [DATE]. LPN 'F' explained they were getting report from the off going nurse, LPN 'I' when the assigned CNA informed them that R#713, .Didn't look good, like she needed CPR or something LPN 'F' stated, (LPN 'I') told me (R#713) was a full code, so I ran and got the crash cart. LPN 'F' was asked if they initiated CPR and indicated they did not. When asked who started CPR, LPN 'F' said that Unit Manager 'H' started CPR while she was bringing the crash cart down to the room. LPN 'F' was asked if she checked R#713's code status and stated, No, I reversed a step. I took the other nurse at her word, she (Nurse 'I') told me she was a full code. When further queried how they found out that R#713 was a DNR and when CPR was stopped, LPN 'F' said, When EMS got there they wanted us to re-check the code status, when they verified (R#713) was a DNR, CPR stopped. LPN 'F' was queried who else was present during the code and they indicated that Unit Manager 'H' and Registered Nurse (RN) 'G' were present at the time of the code. On [DATE] at 3:18 PM, a telephone interview with RN 'G' was conducted. RN 'G' was queried if they were present and involved with R#713's code. RN 'G' indicated they were. RN 'G' was asked to describe the incident and stated, I heard the announcement for the code and ran upstairs to help. RN 'G' continued to explain they actively performed CPR on R#713 and stated, I did three or four sets of CPR, 30 compressions, then I switched out. RN 'G' was asked who they switched out with and said they did not remember. RN 'G' explained that the police and EMS arrived, and the police asked for some papers. When asked what papers the police requested, RN 'G' stated, I made a copy of the code status and the MAR (medication administration record), packaged it and gave it to the police. RN 'G' was asked what R#713's code status was on the paper provided to the police and indicated that R#713's code status was DNR. When asked if CPR was still being performed when the papers were provided to the police, RN 'G' stated, I'm not sure. RN 'G' was then queried if they were interviewed by the Director of Nursing (DON) or Administrator; or if they wrote and or signed a statement after the incident and stated, Yeah, (Administrator) interviewed me the day after. I don't remember if I signed a statement. RN 'G' was then asked if the facility did any in-service or education after the incident and indicated they did, and they signed off on an in-service attendance record. On [DATE] at 3:28 p.m., during an interview with the Administrator and Director of Clinical Services, when asked about how staff determined a resident's code status before performing CPR, both stated, Staff are reminded to check (name of electronic system) for code status prior to initiating a code. On [DATE] at 2:48 p.m., an interview was conducted with the Administrator and Director of Clinical Services regarding R#713's code status on [DATE], and the staff's ability to perform their duties under intense situations. The Administrator and Director of Clinical Services stated, They (staff) are all educated upon hire, receive a 1:1 (one-on-one) discussion, and receive a pamphlet . The Director of Clinical Services further stated, Nurses are taught to follow policy and nursing standard of practice . When asked what the expectation of the staff was during R#713's treatment on [DATE], the Director of Clinical stated, Nurses should have checked for code status . The Director of Clinical Services further stated, If the resident is a DNR, when confirmed, you keep them comfortable and let the family know, and we call hospice if the resident is a hospice patient . On [DATE] at approximately 2:30 PM, a review of a facility provided document titled, ONE ON ONE INSERVICE RECORD signed by LPN 'F' was reviewed. The document read, .DATE: [DATE] DEPARTMENT: Nursing TITLE: Nurse INSERVICE DESCRIPTION: Code Status Identification. Use of (electronic medical record name) and e-MAR (electronic medication administration record) for Identification of code status . The facility provided the following plan to remove the immediacy and it was verified onsite on [DATE] by the survey team: The facility has identified that one licensed personnel provided life sustaining nursing services including: CPR, against the advanced directive of resident 713. The licensed nurse failed to validate the chart for the advanced directive prior to initiating life sustaining services, due to the emotional response to the situation. Upon response from Emergency Medical Services resident 713's advanced directives were validated by the facility and life sustaining services were discontinued. On [DATE] The District Director of Clinical Services provided education for all licensed nurses on shift at the time of the cardiac event regarding the facility Medical Management Policy, physician's orders [REDACTED].The licensed nurse that failed to Initiate the Cardiac Event correctly was provided a 1:1 counseling/education, as well as addressed her emotional response to the event with the facility Employee Assistance Program that offers shoreterm counseling that assists with work related stress, anxiety and unresolved grief. The facility will instruct the licensed nurse to engage the Employee Assistance Program prior to return to shift.Notified the Family, physician, and Medical Director of the event and the facility response on [DATE]. Element 2: Due to the identified deficient practice of the facility failing to follow advanced directives, physician orders, and resident plan of care potentially affecting all residents with an advanced directive in the facility. On [DATE], The facility validated all resident's advanced directives for accuracy that reside in the facility, including physician orders [REDACTED]. On [DATE], The facility validated that the resident advanced directives matched not only the electronic medical record but their hard record as well. On [DATE], licensed nurses were trained on identifying advanced directive status on the Electronic Medication Administration Record [REDACTED]. On [DATE], A Code Blue Drill was conducted and completed correctly on [DATE] that was supervised by the District Director of Clinical Services Element 3: The facility will ensure licensed personnel are following advanced directives, physician orders, and resident plans of care, upon a cardiac event that has the potential for the licensed nurse to initiate life sustaining services. On [DATE] all licensed nurses Cardio [MEDICAL CONDITION] Resuscitation certificates were validated and are all active and in good standing. On [DATE] the facility conducted a Code Blue Event drill to validate accuracy to the policy and procedures of the facility, and will continue with a 1 drill per week for 6 weeks or until the QAPI committee has deemed the facility compliant.Weel<ly the facility will conduct an audit off all residents' that reside in the facility, their advanced directives and their accuracy.

This citation pertains to intake #MI 3 Based on interview and record review, the facility failed to ensure timely administration of intravenous (IV) fluids for one resident (R#701), of three residents reviewed for medication administration, resulting in a transfer to the emergency room . Findings include: A complaint was reported with the State Agency that alleged R#701 was not appropriately administered IV fluids to treat dehydration and had to be transferred to the hospital. On 11/18/19 a review of R#701's closed record was conducted. During the review, it was discovered that R#701 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R#701's most recent Minimum Data Set assessment dated [DATE] indicated R#701 had severe cognitive impairment, was non-ambulatory and required extensive to total assistance of one to two staff members for all activities of daily living. A review of R#701's laboratory reports was conducted and revealed the following: Labs drawn on 7/17/19 Sodium- 146 (Normal 136-145), elevated levels can indicate dehydration Blood Urea Nitrogen (BUN) - 30 (Normal 7-25), elevated levels can indicate dehydration BUN/Creatinine Ratio - 60 (Normal 8-25), elevated levels can indicate dehydration Labs drawn on 7/24/19 Sodium - 167 BUN- 27 BUN/Creatinine Ratio - 39.13 A review of a progress note dated 7/19/19 from Dr. 'X' was conducted and did not indicate acknowledgment of the irregular lab values on 7/17/19. A review of a progress note dated 7/23/19 from Physician's Assistant (PA) 'W' was conducted and read, Note Text: seen of <sic> poor oral intake and fall from chair .started on IVF (intravenous fluids) labs today pending. labs from 7/17 .na (Sodium) 146, bun 30 . A review of a progress note dated 7/24/19 from Unit Manager 'H' was reviewed and read, stat bmp (basic metabolic panel, lab values) .ordered, 7/23/19 labs were not able to be obtained per lab tech documentation . A review of R#701's physician's orders [REDACTED]./22/19 at 4:52 PM that read, D5 0.45 normal saline (an IV fluid with [MEDICATION NAME] (sugar) and half the concentration of normal saline) 75cc/hr (infusion rate of 75 milliliters per hour) for 48hrs every shift for fluids for 2 days . It was noted the MAR had the fluids scheduled for administration on 7/22/19 at 11 PM and 7/23/19 at 7AM and 3 PM. The MAR was blank for the administration on 7/22/19 at 11 PM, and 7/23/19 at 3 PM, and an '8' was coded for the 7/23/19 7 AM dose by Licensed Practical Nurse (LPN) 'C'. It was noted that an '8' coded on the MAR indicated the medication was held and a progress note was present that explained why the medication was not given. A review of the progress notes did not reveal an associated note around the time (7 AM on 7/23/19) LPN 'C' held the IV fluid medication. It was further noted on the MAR the first documented administration of the IV fluids was signed off on 7/23/19, at 11 PM by LPN 'F'. A review of the nursing progress notes for R#701 was conducted and revealed no nursing progress notes for 7/22/19 that mentioned the insertion of an IV or the initiation/administration of IV fluids. The notes on 7/23/19 revealed the following: A note by LPN 'C' on 7/23/19 at 4:33 PM that read, D5 0.45 normal saline 75cc/hr for 48hrs every shift for fluids for 2 Days NP (Nurse Practitioner) re-ordered for fluids to be started for pt (patient) at bedtime and continue for 48 hrs. A note by LPN 'C' on 7/23/19 at 5:56 PM that read, Pt (patient) iv had to be reinserted by ADON (Assistant Director of Nursing, no longer employed at the facility) due to iv not being placed correctly before . A review of Nursing Daily Skilled Charting assessments was conducted and it was noted an assessment was not completed on 7/22/19, and the assessment on 7/23/19 at 6:59 AM, completed by LPN 'B' read, .C. Skilled Services Provided 1. Receiving Intravenous Medications/Fluids .2. Were new orders received in the last 24 hours? ., each question was noted to have a check mark for No. Continued review of the record included a Nursing Note dated 8/2/19 that indicated R#701 was transferred to the hospital on [DATE]. The note read, Late Entry: 07/24/19 At approx. (approximately) 4:00pm, resident appeared lethargic, skin pale in color, shallow breathing .Orders given to send resident to (Hospital Name) . On 11/18/19 at approximately 11:30 AM, an interview with the facility's Director of Nursing (DON) was conducted regarding orders for IV insertion and documentation of medication administration. The DON explained that there should be an order written [REDACTED]. On 11/18/19 at 1:15 PM, an interview with the facility's District Director of Clinical Services was conducted regarding R#701's initial IV placement on 7/22/19 when the fluids were first ordered, the IV replacement referenced in LPN 'C's note on 7/23/19, and administration of the IV fluids. During the interview, the Director of Clinical Services was queried who inserted the IV on 7/22/19, when was it inserted, and when were the fluids started. They indicated they believed the ADON (no longer employed by the facility) started the IV but did not know when. When queried if there should have been an order for [REDACTED].), they explained there should have been orders for the IV insertions and whoever inserted them should have documented it on a treatment record or in a note. The Director of Clinical Services was then asked about why the medication had been ordered on [DATE] at 4:52 PM, but the first documented administration was on 7/23/19 at 11 PM, and they had no explanation. The Director of Clinical Services further indicated that improvements throughout the facility needed to be made with regards to documentation. On 11/19/19 at 8:10 AM, records from the hospital that R#701 had been transferred to on 7/24/19 were obtained. A review of those records revealed the following: .Date of Service 07/24/19 1829 (6:29 PM) .Chief Complaint: Patient presents with Altered Mental Status, Shortness of breath .HPI (History of Present Illness) The patient is a (age, gender redacted) .who presents with altered mental status and shortness of breath. Per EMS (Emergency Medical Services) the patient was found on the floor of his room .EMS reports that the patient was thought to be dehydrated .Labs significant for .sodium >160 .[MEDICAL CONDITION] (elevated sodium level) likely 2/2 (secondary, or due to) dehydration, patient's son states that he has not been eating and drinking well . A review of a facility provided policy titled, Medication Administration revised (MONTH) 2008 was conducted and read, Resident Medications are administered in an accurate, safe, timely, and sanitary manner . A request for a policy on IV medication administration was requested, however; was not received by the end of the survey. The facility was asked if they had any additional information to provide regarding the concern; none was received by the end of the survey.

This citation refers to Intake #MI 558. Based on interview and record review, the facility failed to determine the root cause of falls and implement interventions to prevent further falls for one (#805) of three residents reviewed for falls, resulting in two emergency hospital transfers for a head injury with a brain bleed and a [MEDICAL CONDITION] requiring sutures. Findings include: A complaint was submitted to the State Agency that alleged R#805 had multiple hospital transfers within the past six months that resulted in injuries to her brain, a fractured leg, and stitches to the face. During a phone conversation on 6/3/19 at 8:53 A.M., the complainant reported R#805 sustained multiple falls at the facility that required transfers to the hospital, stitches to the head and face, a brain bleed, and a fractured leg. The complainant reported R#805 had dementia, does not walk, and there was a concern with the number and severity of injuries in the recent months. An onsite investigation into the above complaint was conducted on 6/3/19. R#805's clinical record was reviewed and revealed the following: R#805 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Minimum Data Set (MDS) assessments dated 1/13/19 and 4/11/19 documented R#805 had severely impaired cognition. The 1/13/19 MDS assessment indicated R#805 required extensive one person physical assistance for transfers, was able to propel in a wheelchair with supervision only, and had one fall with no injury. The 4/11/19 MDS assessment documented R#805 required extensive two person physical assistance for transfers, was able to propel in a wheelchair with supervision only, and had no falls during the assessment period. Progress notes revealed the following: On 2/20/19, a Nursing Note written by Nurse C documented, resident observe on the floor at the bedside. laceration noted above right eye, skin tear to right hand .bleeding controlled. first aid provided. MD present to eval, order to transfer to (hospital abbreviation) . On 2/20/19 a second Nursing Note written by Nurse C documented, writer returned phone call to r/p (responsible party) to clarify concerns regarding today's fall. resident was observed on the floor at the bedside by nursing laceration noted above right eye, skin tear to right hand. dr. present to eval. new order to transfer resident to (hospital name abbreviation) for further evaluation. resident has a dx/o ([DIAGNOSES REDACTED]. On 2/25/19, a progress note documented, IDT at risk meeting: DON (Director of Nursing), Adm (Administrator), Unit managers, SW (Social Worker), RD (Registered Dietician) present 2/20 fall un witnessed at bedside, laceration above R eye, R hand skin tear. Interventions .resident participate in activities. Sent out to hospital. An Admission Note dated 2/26/19 documented, Resident .readmitted [DATE] from (hospital name) at approx. 5:00 pm on stretcher via ambulance. Primary [DIAGNOSES REDACTED]. A Nursing Note dated 5/3/19, written by Nurse D documented, Resident was witnessed falling out of wheelchair, resident received laceration on forehead. Bleeding occurred .Doctor notified of injury and transfer . A Nursing Note dated 5/6/19 documented, IDT at risk team: RD, rehab, infection control, unit manager, risk manager. Resident slid from her wheelchair in the dining room. Staff education meal tray set and ensure resident is positioned at table appropriately. Offer to lay down after lunch meal service. A care plan created on 5/29/19 (eight days after R#805 was discharged from the facility) and revised on 5/30/19 documented, I am at high risk for falls related to decreased safety awareness, impaired cognition. 5/3/19 with injury. Interventions initiated on 5/29/19 (after R#805 was discharged from the facility on 5/21/19) documented the following interventions: .Bed in lowest position .Dycem in w/c .Encourage me to participate in activities .ensure my meal tray's are setup, and make sure I'm positioned properly at the table .offer me to lay down after lunch . All above interventions were documented as initiated on 5/29/19 after R#805 was discharged from the facility. On 6/3/19 at 10:30 A.M., all Incident and accident reports and any investigations since (MONTH) 2019 were requested from the Administrator. On 6/3/19 at 1:30 P.M., Incident/Accident Reports (I&A) were reviewed for R#802 since (MONTH) 2019. When provided by the Assistant Director of Nursing (ADON) it was explained that any investigation would be attached to the I&A. The following was revealed: An I&A dated 2/20/19 at 12:23 P.M. completed by Nurse C documented R#805 was observed on the floor at the bedside with a laceration above the right eye and a skin tear to the right hand. The I&A noted R#805 was sent to the hospital. There was no attached investigation. An I&A dated 5/3/19 at 11:15 A.M. completed by Nurse D documented, Cut across forehead. A handwritten signed statement written by Nurse D dated 5/6/19 documented, Resident ambulating in wheelchair. Leaned forward and fell out of chair. Resident received laceration on forehead. There was no documented investigation into the fall. On 6/3/19 at 1:45 P.M., Nurse C (Unit Manager) was interviewed. When queried about the process for unwitnessed falls, Nurse C stated, Assess the resident, call the doctor and family, follow through with the orders, contact the DON or nurse on call, do a post fall assessment, neurochecks, and whoever finds the resident does the I&A. When queried about when R#805's I&A on 2/20/19, Nurse C stated, The CNA (Certified Nursing Assistant) called me to the room and she was on the floor. We put her in bed. Nurse C reported the fall was not witnessed and the resident was unable to explain what happened. When asked how unwitnessed falls were investigated, Nurse C stated, We try to determine what happened right then or with the IDT, update the care plan or put in an at risk note. We all collaborate to determine the cause. Nurse C did not know how R#805 ended up on the floor on 2/20/19. On 6/3/19 at 2:00 P.M., Nurse D was interviewed. When queried about the fall sustained by R#805 on 5/3/19, Nurse D stated, (R#805) was rolling toward the window and slid forward out of the wheelchair, hit her forehead and started bleeding. Nurse D was asked when the incident occurred and stated, I think it was right after breakfast (The I&A documented it occurred at 11:15 A.M.). Nurse D further stated, (R#805) just flew forward, she moves in the wheelchair with her feet and just slid forward. Nurse D reported he witnessed the fall when he was walking through the dining room and did not recall if any other staff members were present at that time. On 6/3/19 at 2:35 P.M., the ADON (identified as the person to interview in place of the DON, as the DON was not available during the survey) was interviewed. When queried about the facility's protocol when a resident sustained [REDACTED]. It really depends on the resident. We look at everything. The incident on 2/20/19 when R#805 was observed on the floor next to the bed was discussed and the I&A reviewed with the ADON at that time. When queried about how R#805 ended up on the floor, who found her, what she was doing prior to the fall, and how the cause of the incident was determined, the ADON stated, I can't tell you how she fell . There's a nursing note and a care plan. The ADON was queried about R#805's fall in the dining room on 5/3/19 and the I&A and clinical record was reviewed. The ADON stated, I couldn't tell you what happened. (Nurse C) was over falls at that time. On 6/3/19 at approximately 3:00 P.M., the Administrator was interviewed about the above falls sustained by R#805 and stated, I am not clinical so I cannot say. There was no evidence that either fall was investigated to determine the root cause and the care plan did not document any interventions after the falls until after R#805 was discharged from the facility. Hospital records for R#805 from the 5/3/19 hospital transfer documented received a laceration repair that required 10 sutures to her forehead. A facility policy titled, Falls Management dated (MONTH) (YEAR) was reviewed and documented, .Initiate the interdisciplinary post fall review .The IDT reviews all resident falls within 24-72 hours at the IDT meeting to evaluate circumstances and probable cause for the fall .The IDT designee will discuss recommended significant changes to the care plan to minimize repeat falls .The care plan will be reviewed and/or revised as indicated . No additional information was provided prior to the end of the survey.

This citation has two deficient practices. Deficient Practice #1 Based on observation, interview, and record review, the facility failed to administer medications (pain medications, [MEDICAL CONDITION] medications, diabetic medications, anticoagulant medications, antibiotics, antipsychotic medications, blood pressure medications, medications to treat dementia, and muscle relaxants) in accordance with physician's orders [REDACTED].#'s 1, 6, 7, 20, 21, 25, 39, 45, 49, 52, 60, 65, 68, 81, & 86) out of 26 residents reviewed and three of ten residents who attended a confidential group meeting and failed to ensure duplicate medication orders were clarified for three resident (#'s 39, 6, & 65), resulting in an immediate jeopardy when residents experienced elevated blood sugar levels, increased pain and the likelihood for [MEDICAL CONDITION], blood clots, elevated blood pressure, impaired mood and cognition, worsening infection, and muscle spasms and adverse effects from duplicate medication therapy. This deficient practice placed all 94 facility residents who receive care and services per physician's orders [REDACTED]. The IJ was identified on 10/23/18 at 2:00 PM. The IJ began on 8/13/18. The administrator was notified on 10/23/28 at 3:07 PM and a plan of removal was requested to remove the immediacy. The IJ was removed on 10/24/18 based on the provider's implementation of the plan of removal and verified onsite 10/24/18. Although the immediacy was removed the facility's deficient practice was not corrected and remained a pattern with the potential for harm that is not immediate jeopardy. Resident #81: On 10/22/18 at 4:11PM Resident #81 was observed in their room, and an interview was conducted with the resident at this time. When queried in regard to their stay at the facility, the resident responded, in part, that the facility had forgot to give the resident their insulin. R#81 reported that the facility had run out of insulin and explained that they had to go without their shot. On 10/23/18 approximately 10:45AM R#81 was observed in their room and sat up to the edge of the bed upon approach. R#81 was queried in regard to their previous statement of having missed their insulin, and R#81 explained that for one day they had not received insulin. R#81 stated, I didn't get no insulin that day. R#81 further explained that the facility had said the pharmacy was supposed to bring it (the medication) and they didn't bring it. Per R#81 their family member had told them they should receive it because they had paid for it. R#81 was queried regarding their blood sugar and responded, It went up to 500 and something. When queried as to how the resident felt, R#81 responded, Like s***. I felt really bad. When queried as to how specifically R#81 had felt, R#81 responded, When it goes up like that it makes me feel real bad I can't function . Resident #81 further explained, They didn't give me anything till the next morning then it was late in the morning before they gave it to me. Per R#81 they had requested the medication. R#81 explained, the shakes I got got worse .it took a day or two to get it under control again. Resident continued to explain she had been active that day, and explained, I come in first thing I did was want my shot The resident then explained that the facility had informed the resident that there was good news and bad news, and the bad news was that they didn't have the insulin in. Per R#81 the resident had asked the facility if they were going to the hospital, and the facility responded no and had explained to the resident that as soon as it (the medication) came in they would bring it to the resident. R#81 reported, I went to sleep before it came in I can't miss my shots like that. R#81 then explained that they had been in more control than they had been at the facility, stating I may be late getting my shot, but I never missed it. The resident was then queried in regard to her insulin orders and responded that she took 230 units of insulin 500 in the morning, and 100 units of the insulin 500 at night. Review of current physician orders [REDACTED]. -Order date 9/18/18: Insulin Regular Human (Conc) Solution Inject 230 unit subcutaneously in the morning for diabetes mellitus -Order date 9/20/18: Insulin Regular Human (Conc) Solution Pen-Injector 500 UNIT/ML Inject 100 unit subcutaneously in the evening for DM (diabetes mellitus) -Order date 9/18/18: Insulin Regular Human (Conc) Solution Inject per sliding scale: If 0-80= -20 Subtract 20 from morning 230 unit dosage; 81-100 = 0; 101-150 = 10; 151-200 = 20; 201-250 = 30; 251-300 = 40; 301-350 = 50; 351-400 = 60, subcutaneously two times a day for diabetes mellitus GREATER THAN 400 GIVE 70 UNITS SUBCUTANEOUSLY. Further review of the resident's MAR it was revealed the resident's scheduled insulin was to be administered at 8:00AM and 6:00 PM and was to receive sliding scale insulin at 8:00AM and 8:00PM. On 10/24/18 at 8:54 AM Registered Nurse (RN) 'D' was observed to enter R#81's room. At this time, R#81 was observed to be in their room with their breakfast tray present. RN D' then explained that the resident had their breakfast and they (the nurse) would come back. On 10/24/18 at 9:30 AM R#81 was queried as to whether their blood sugar had been checked and was queried whether they had received their insulin, and the resident confirmed that neither had been done at that point. Review of R#81's blood sugar documentation for the date of 10/24/18 documented the following: -10/24/18 at 11:11AM: 380 mg/dl (milligrams per deciliter) Review of R#81's MAR for 10/24/18 revealed the resident's Insulin Regular Human (Conc) Solution 230 units to be administered in the morning and the resident's Insulin Regular Human (Conc) Solution to be injected per sliding scale (both scheduled at 8:00AM) had been documented as having been administered to R#81. Per documentation, 60 units of sliding scale insulin had been administered for a blood sugar of 380. Review of the Location of Administration Report 10/1/2018 thru 10/31/2018 revealed Insulin Regular Human (Conc) Solution due to be administered on 10/24/18 at 8:00AM had been documented as administered to R#81 by RN 'D' on 10/24/18 at 10:42AM and 11:11AM. Review of R#81's blood sugars revealed, in part, the following blood sugars documented for the resident on 9/27/18: -9/27/18 at 9:59AM: 350 mg/dl -9/27/18 at 2:22PM: 218 mg/dl -9/27/18 at 8:54PM: 536 mg/dl Review of R#81's MAR for 9/27/18 documented the following: Administration of the resident's 8:00AM dose of Insulin Regular Human (Conc) Solution 230 units had been documented with a code of 8 (indicating other/see progress notes) by LPN 'K'. Documentation of the resident's sliding scale insulin due to be administered at 8:00AM revealed a code of 8 had been documented for the medication dosage while also indicating that 50 units of insulin had been administered (while blood sugar had been documented as 350mg/dl) by LPN 'K'. Documentation of the resident's Insulin Regular Human (Conc) Solution Pen-Injector 500 units/ml 100 units due to be administered at 6:00PM documented the medication had been administered by LPN 'K'. Documentation of the resident's sliding scale insulin due to be administered at 8:00PM documented a code of 2, indicating Away from facility without meds. Documentation of the resident's blood sugar at this time was 536mg/dl. Review of the resident's Location of Administration Report 9/1/2018 thru 9/30/2018 documented the following for the date of 9/27/18: Insulin Regular Human (Conc) Solution Pen-Injector 500 UNIT/ML scheduled on 9/27/18 at 6:00PM was documented as administered to the resident on 9/27/18 at 8:19PM by LPN 'K'. No other documentation was present on the report for the date of 9/27/18. On 10/23/18 at 11:22AM an attempt was made to contact LPN 'K' and a voicemail message was left for LPN 'K' at this time. On 10/23/18 at 12:40PM LPN 'K' was queried via telephone in regards to R#81's insulin and as to whether she was aware of the resident not having had insulin available. LPN K' denied knowledge of resident having missed doses of the medication, and voiced the resident always had the medication. Per LPN 'K' R#81 had expressed they had run out of insulin before they had been transferred to a different floor of the facility. LPN 'K' was queried as to when a code of 8 would be used in the clinical record and responded I don't know. Continued review of R#81's clinical record documented, in part, the following: Per a nursing note dated 8/20/2018 at 10:00PM it was documented: resident found sitting on side of her bed looking distressed. she stated not feeling well and that she had just thrown up, AEB (as evidenced by) vomit seen on bed sheets. blood sugar found to be 501 at this time. Doctor (Name Redacted) called. 1 time order taken to give 100 units [MEDICATION NAME] R at this time Review of the resident's MAR for (MONTH) (YEAR) revealed the following order, dated 8/20/18 at 10:00PM for R#81: [MEDICATION NAME] R U-500 (CONCENTRATED) Solution (Insulin Regular Human (Conc)) Inject 100 unit subcutaneously one time only for IDDM until 08/20/2018 23:59 (11:59PM) LOOD GLUCOSE 501ONE TIME ORDER FOR BLOOD GLUCOSE OF 501. Review of the resident's MAR pertaining to the above order documented the resident had received the medication at 6:01AM on 8/21/18. This information was also reflected on the Location of Administration Report 8/1/2018 thru 8/31/2018. Review of Orders-Administration Note progress notes dated 8/18/2018 at 6:27 PM revealed the following: [MEDICATION NAME] R U-500 KwikPen Solution Pen-injector 500 UNIT/ML Inject as per sliding scale: if 0 - 80 = -20; 81 - 100 = 0; 101 - 150 = 10; 151 - 200 = 20; 201 - 250 = 30; 251 - 300 = 40; 301 - 350 = 50; 351 - 400 = 60 GREATER THAN 400 70 UNITS , subcutaneously two times a day for DM pharmacy to send stat [MEDICATION NAME] R U-500 (CONCENTRATED) Solution 500 UNIT/ML Inject 100 unit subcutaneously in the evening for dm USE WITH CAUTION CONCENTRATED DOSE to dose with TB SYRINGE pharmacy to send stat Review of a plan of care for R#81 dated 9/11/15 and revised on 9/30/18 revealed the following: I have Diabetes Mellitus I receive insulin. Per an intervention dated 5/2/16 included in the plan of care it was documented, Diabetes medication as ordered by doctor. Observe/document for side effects and effectiveness. Review of the clinical record for R#81 revealed the resident was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of R#81's minimum data set (MDS) assessment dated [DATE] documented the resident scored 15 out 15 on a BIMS assessment, which indicated R#81 was cognitively intact. Resident #45: On 10/24/18 at 6:10 PM review of the clinical record for R#45 revealed the resident was admitted into the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Per review of the resident's MDS assessment dated [DATE] it was revealed the resident scored 01 out of 15 on a brief interview for mental status (BIMS) exam, which indicated the resident was severely cognitively impaired. Review of physician orders [REDACTED]. Start date: 5/5/17: (Brand Name Rivastigmine) Patch 24 Hour 9.5 MG/24HR (milligram per 24 hour) (Rivastigmine-a medication used for dementia) Apply 1 patch [MEDICATION NAME] in the morning for psych D/C (discontinue) old order when this patch arrives. and remove per schedule. Start date: 4/11/18: Levetiracetam 100MG/ML (milligram/milliliter) SOLN (solution) Give 5 ml by mouth every 12 hours for [MEDICAL CONDITION]. Review of Orders-Administration Note progress notes for R#45 for the months of (MONTH) (YEAR) and (MONTH) (YEAR) revealed, in part, the following: Per notes dated 10/14/18 at 6:39AM and 10/5/18 at 5:59AM it was documented the resident's Rivastigmine patch was unavailable. Review of a note dated 9/29/18 at 5:22AM documented, (Brand Name Rivastigmine) Patch 24 Hour 9.5MG/24HR Apply 1 patch [MEDICATION NAME] in the morning for psych D/C old order when this patch arrives. and remove per schedule. No additional documentation was included in R#45's progress note. Per review of an Orders-Administration Note dated 9/5/18 at 9:07PM the following was documented: LEVETIRACETAM 100 MG/ML SOLN Give 5 ml by mouth every 12 hours for [MEDICAL CONDITION]. unavailable. Review of a note dated 9/4/18 at 10:06PM documented the following: LEVETIRACETAM 100MG/ML SOLN Give 5 ml by mouth every 12 hours for [MEDICAL CONDITION]. not given. Review of documentation on R#45's MAR for (MONTH) (YEAR) revealed that a code of 8 had been marked pertaining to application of the resident's Rivastigmine Patch (due at 6:00AM) for the dates of 10/5/18 and 10/14/18. Review of the resident's (MONTH) (YEAR) MAR revealed a code of 8 had been documented on 9/29/18 pertaining to the 6:00AM application of the resident's Rivastigmine patch. R#45's (MONTH) (YEAR) MAR also revealed the resident's Levetiracetam 5ml dosage had been marked with a code of 8 for the 10:00PM dose of the medication due on 9/4/18 and 9/5/18. Review of a plan of care for R#45 dated 8/30/15 and revised on 8/30/18 documented the following: I have impaired cognitive function or impaired thought process r/t (related to) Dementia. Review of an intervention dated 6/25/17 per the plan of care documented the following: Administer medications as ordered . Resident #68: On 10/24/18 at 1:33 PM the clinical record for R#68 was reviewed and revealed the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Per review of R#68's quarterly MDS assessment dated [DATE] the resident scored 3 out of 15 on a BIMS assessment, which indicated the resident was severely cognitively impaired. Review of a physician order [REDACTED]. Review of an Orders-Administration Note dated 8/24/2018 at 1:55PM revealed the medication had been documented as having been on order. Review of the resident's MAR for (MONTH) (YEAR) documented the code of 8 had been documented for the resident's 2:00PM dose of Valproate Sodium due on 8/24/18. Review of a physician order [REDACTED].(gastrostomy tube) one time a day for [MEDICAL CONDITION] WITH DELUSIONS. Review of an Orders-Administration Note for the resident dated 8/30/2018 at 9:14AM revealed the medication was documented as being on order. Review of an Orders-Administration Note dated 9/16/2018 at 9:41AM revealed the following: (Brand Name Quetipine [MEDICATION NAME]) Tablet 25 MG Give 1 tablet via [DEVICE] one time a day for [MEDICAL CONDITION] WITH DELUSIONS on order Review of documentation on the resident's MARs for (MONTH) (YEAR) and (MONTH) (YEAR) for the above medication revealed the code of 8 had been documented for the medication dosages due on 8/30/18 at 9:00AM and the dosage due on 9/16/18 at 9:00AM. Review of R#68's MAR for (MONTH) (YEAR) revealed the resident had been ordered (Brand Name Quetipine [MEDICATION NAME]) 50 MG Give 1 tablet via [DEVICE] one time a day for [MEDICAL CONDITION] WITH DELUSIONS DUE TO KNOWN PHYSIOLOGICAL. It was documented this physician order [REDACTED]. Review of an Orders-Administration Note for R#68 dated 9/15/2018 at 1:06PM revealed the above medication had been on order. Review of the resident's MAR pertaining to the above medication revealed a code of 8 had been documented for the 2:00PM dosage of medication due on 9/15/18. Review of R#68's (MONTH) (YEAR) and (MONTH) (YEAR) MAR revealed the resident had been ordered (Brand Name Quetipine [MEDICATION NAME]) 50 MG to be administered via [DEVICE] at bedtime for [MEDICAL CONDITION] WITH DELUSIONS, active from 5/18/18 and discontinued on 10/8/18. Review of Orders-Administration Note progress notes for R#68 for (MONTH) (YEAR) and (MONTH) (YEAR) pertaining to administration of the above medication revealed the following: Per notes dated 8/28/2018 at 11:14PM, 9/19/2018 11:12PM, and 9/20/2018 11:25PM (Brand Name Quetipine [MEDICATION NAME]) 50 MG had been documented as not available. Review of R#68's MARs for (MONTH) (YEAR) and (MONTH) (YEAR) revealed a code of 8 had been documented pertaining to medication dosages due at 10:00PM on 8/24/18,9/19/18, and 9/20/18. Review of a plan of care for R#68 dated 5/23/17 and revised on 9/27/18 revealed the following: I require administration of psychoactive medication. The plan of care specified R#68's use of antidepressant, antianxiety, and antipsychotic medications. Review of an intervention per the plan of care revealed the following: current meds as ordered. Review of an additional plan of care for the resident dated 7/17/18 and revised on 9/30/18 identified R#68 as being at risk for [MEDICAL CONDITION]. Per a care plan intervention dated 7/17/18 the following was documented: Give medications as ordered . Resident #65 On 10/22/18 at 9:20 A.M., R#65 was observed lying in bed. R#65 was observed to be non-verbal, was exhibiting facial grimacing, flailing arms and legs, and moaning. R#65 appeared extremely thin and skeletal with contractures to both hands. R#65's clinical record was reviewed and revealed the following: R#65 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A MDS assessment dated [DATE] documented R#65 had severely impaired cognition, was totally dependent on staff for transfers and all ADLs (activities of daily living), received nutrition via a Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube surgically inserted into the stomach to provide nutrition), and received hospice care (physical, emotional, and spiritual care for terminally ill individuals and their families with a focus on comfort and pain relief). physician's orders [REDACTED]. [MEDICATION NAME] Suspension 1MG/ML Give 1 ML via PE[DEVICE] two times a day for spasms (originally ordered 7/25/18 and discontinued on 9/11/18, ordered 9/11/18 and discontinued 10/9/18, and with a current order date of 10/9/18). Two identical orders for (Brand name for [MEDICATION NAME] HCl - a medication used to treat depression) 20 MG 1 tablet via PE[DEVICE] at bedtime were ordered (one was ordered on [DATE] and discontinued on 9/11/18, reordered on [DATE] and discontinued on 10/9/18, and then reordered on [DATE]). A second identical order was started on 8/10/18. Between 8/10/18 and 10/23/18, R#65 had two identical orders for [MEDICATION NAME] HCl at the same dosage and administration time. [MEDICATION NAME] Patch (a narcotic [MEDICATION NAME] used to treat severe pain) 72 Hour 25 MCG (microgram)/HR Apply 1 patch [MEDICATION NAME] every 72 hours for pain and remove per schedule (ordered and started on 12/5/17). A review of R#65's progress notes and MARs from (MONTH) (YEAR) through (MONTH) (YEAR) revealed the following: Orders - Administration Notes for (MONTH) (YEAR) revealed on 8/1/18, 8/5/18, 8/6/18, 8/7/18, 8/9/18, 8/10/18, 8/11/18, 8/13/18, 8/15/18, 8/16/18, 8/18/18, 8/19/18, 8/20/18, 8/21/18, 8/23/18, 8/24/18, 8/28/18, and 8/30/18 [MEDICATION NAME] Suspension was not given, indicated by notes that documented, on order or n/a(not available). There were no progress notes that documented the physician, hospice, or Director of Nursing was notified of R#65 not receiving the medication. The MAR for (MONTH) (YEAR) documented the [MEDICATION NAME] was not administered (indicated by an 8 to see progress notes) to R#65 on 8/1/18, 8/2/18, 8/4/18, 8/5/18 (5:00 P.M. dose), 8/6/18, 8/7/18, 8/8/18, 8/13/18 (5:00 P.M. dose), 8/15/18 (5:00 P.M. dose), 8/16/18 (9:00 A.M. dose), 8/18/18 (9:00 A.M. dose), 8/19/18, 8/20/18, 8/21/18 (9:00 A.M. dose), 8/23/18, 8/24/18, 8/28/18 (5:00 P.M. dose), and 8/30/18. Progress notes documented [MEDICATION NAME] HCl 20 MG 1 tablet via PE[DEVICE] at Bedtime was not given on 8/3/18 (n/a was documented for the 8/2/18 night shift 9:00 P.M. dose), 8/9/18 (logged for md if he wants to continue the meds not given was documented). The MAR documented [MEDICATION NAME] HCl was not given on the above dates, indicated by 8. The progress notes for 8/3/18 at 8:27 A.M. documented R#65's [MEDICATION NAME] Patch was n/a held pharmacy notified. The MAR documented the old [MEDICATION NAME] was removed on 8/3/18 at 8:27 A.M. and a new patch was applied at 8:29 A.M. A progress note for 8/24/18 documented R#65's [MEDICATION NAME] Patch was n/a hospice nurse notified. The MAR documented, the old patch was not removed (indicated by an 8 on the MAR) and a new patch was applied at 8:46 A.M. Orders-Administration Notes for 9/2/18 and 9/3/18 documented (brand name for [MEDICATION NAME]-aceteminophen 5-325 MG) was not available and [MEDICATION NAME] sulfate was given on 9/3/18 for face grimace of pain. The (MONTH) (YEAR) MAR documented [MEDICATION NAME]-[MEDICATION NAME] was not given on 9/2/18 (6:00 A.M., 2:00 P.M., and 10:00 P.M. dose) or 9/3/18 (10:00 P.M. dose). [MEDICATION NAME] HCl 20 MG was not given per the MAR on 9/3/18 (no nurse's signature on both orders) and 9/22/18 and 9/27/18 (on one order). All other doses of [MEDICATION NAME] HCl were signed out as given for both duplicate orders. A progress note dated 9/22/18 documented duplicated order and on 9/27/18 documented duplicated, not given. There were no progress notes that documented the physician was notified to clarify the duplicate order. An Order-Medication Administration note dated 10/8/18 documented [MEDICATION NAME] HCl was unavailable. Notes written on 10/19/18 and 10/22/18 documented [MEDICATION NAME] HCl was duplicated. The MAR for (MONTH) (YEAR) documented two identical orders for [MEDICATION NAME] HCl to be given at the same time (10:00 P.M.) and at the same dose (20 MG) which would equal 40 MG if given together. On 10/8/18 (both orders), 10/19/18 (one order) and 10/22/18 (one order) an 8 was documented on the MAR which indicated the medication was not given and to see the progress note. All other doses of [MEDICATION NAME] HCl were signed out as given for the duplicate orders. A progress note written by Nurse P on 10/20/18 at 6:29 A.M. documented a [MEDICATION NAME] Patch was removed from R#65. A progress note written by Nurse P on 10/23/18 at 5:47 A.M. documented R#65's [MEDICATION NAME] Patch was unavailable and at 5:50 A.M. the old patch was removed. The MAR documented the old patch was not removed on 10/20/18 and a new patch was applied on 10/20/18 to R#65's left arm. On 10/23/18 it was documented on the MAR that the old patch was not removed, and a new patch was not applied. An observation of R#65's [MEDICATION NAME] Patch was made with Nurse N on 10/23/18 at approximately 9:30 A.M. A [MEDICATION NAME] was observed on R#65's left shoulder dated 10/20/18 6:30 AM with initials (Nurse P). Resident was clenching face and grimacing as if in pain. Nurse N reported that the midnight nurse reported that R#65 did not have any [MEDICATION NAME] Patches left and that the nurse who worked before the midnight nurse talked to pharmacy. When queried about the process for ensuring residents' medications were available, Nurse N stated, We should order when we are seeing it is getting low, so it doesn't run out. I didn't even know (R#65's) was due this morning until you asked me about it. Nurse N was unable to locate the Controlled Substance Proof of Use (C2) form and stated, When a resident is out the C2 sheet is placed inside of the binder but it's not there. An interview was conducted with the ADON on 10/23/18 at 11:33 AM. When queried about R#65 running out of [MEDICATION NAME] Patches, the ADON stated, The C2 sheet was filed because he was out. On 10/8/18 (13 days prior) pharmacy requested a new C2 from the physician. The physician is supposed to sign it and then it gets sent back to pharmacy. The ADON reported that the physician did not sign the new order and nurses should document when they contacted pharmacy, hospice or the physician. When queried about whether or not unavailable medications should be pulled from back up if available, the ADON reported they should. Documentation of all medications removed from the back up emergency supply for the past three months was requested at that time. No documentation was received prior to the end of the survey. Further review of R#65's clinical record revealed the following care plans: A care plan initiated on 5/9/16 and revised on 9/18/18 documented, I have potential for pain with emotional distress R/T (related to) [MEDICAL CONDITION]'s disease. Interventions included: .Administer pain medication as ordered . A care plan initiated on 7/8/17 and revised on 10/20/18 documented, I receive antidepressant medication r/t Depression. Interventions included: .Administer ANTIDEPRESSANT medications as ordered by physician . Resident #39 On 10/22/18 at approximately 9:00 A.M., R#39 was observed sitting up in bed, eating breakfast. R#39 did not respond when spoken to. R#39's roommate reported R#39 was deaf. On 10/23/18 at 4:25 P.M., it was discovered that R#39 was able to communicate verbal responses to written communication. R#39's clinical record was reviewed and revealed the following: R#39 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A MDS dated [DATE] documented R#39 had moderately impaired cognition, severely impaired hearing, no behaviors including rejection of care, and required extensive physical assistance with activities of daily living, transfers, and bed mobility. physician's orders [REDACTED]. Carbamezepine Tablet 200 MG Give 1 tablet by mouth every 8 hours for [MEDICAL CONDITION] was ordered on [DATE] and discontinued on 10/9/18. Carbamezepine Tablet 200 mg give 10 ml (milliliters) by mouth every 8 hours for [MEDICAL CONDITION] was ordered and started on 10/9/18. Two identical orders for potassium chloride Packet give 40 mEq by mouth two times a day for low potassium were ordered and started on 8/17/18 and discontinued on 10/11/18 (which would equal 80 mEq if both were given). A review of R#39's progress notes and MARs from (MONTH) (YEAR) through (MONTH) (YEAR) revealed the following: On 8/19/18 an Orders - Medications Administration note written by Nurse I documented, Potassium Chloride Packet Give 40 mEq by mouth two times a day for low potassium .duplicate order. On 8/24/18 a note written by Nurse I documented, Potassium Chloride Packet Give 40 mEq by mouth two times a day for low potassium duplicate order must verify. On 8/28/18 a note written by Nurse P documented, Potassium Chloride Packet .for low potassium on order, not given. R#39's MAR for (MONTH) (YEAR) revealed the following: R#39 did not receive potassium chloride 40 mEq by mouth two times a day scheduled at 9:30 A.M. and 5:30 P.M. ordered and started on 8/17/18 (indicated by an 8 entered on the MAR which is the code for Other/See Progress Note) on 8/18/18 at 9:30 A.M., and 8/28/18 at 5:30 P.M. A second identical order for Potassium Chloride (due to be administered at the same dosage and time as above and started on the same date) was not given on 8/24/18 at 5:30 P.M. and 8/28/18 at 5:30 P.M. (8 was documented on the MAR). All other doses of Potassium Chloride were signed out as given for both duplicate orders. R#39 did not receive [MEDICATION NAME] Tablet 200 MG give 1 tablet by mouth every 8 hours for [MEDICAL CONDITION] on 8/20/18 (2:00 P.M.), 8/27/18 (2:00 P.M.) and 8/30/18 (10:00 P.M.). The MAR was left blank on those dates and times. There were no progress notes that documented the medication was given or a reason it was not. On 9/4/18 a note written by Nurse R documented, [MEDICATION NAME] Tablet 200 MG (milligrams) Give 1 tablet by mouth every 8 hours for [MEDICAL CONDITION] on reorder. On 9/5/18, a note written by Nurse P documented, Potassium Chloride Packet .two times a day for low potassium duplicated, not given . On 9/10/18, two notes written by Nurse I at 10:08 A.M. documented, Potassium Chloride .n/a . On 9/12/18, a note written by Nurse P documented, Potassium Chloride .duplicated times, not given . On 9/28/18, a note written by Nurse P documented, [MEDICATION NAME] .for [MEDICAL CONDITION] .on order. R#39's MAR for (MONTH) (YEAR) revealed the following: Potassium chloride 40 mEq two times a day was not given on 9/10/18 (9:30 A.M. both orders., 9/19/18 (5:30 P.M. on one order), and 9/5/18 (5:30 P.M. on one order.) 8 was documented on the MAR for those dates and times. All other doses of potassium chloride were documented as given for the duplicate orders. Carbamezepine 200 MG every 8 hours was not given on 9/3/18 (10:00 P.M., no nurse's signature) 9/4/18 (6:00 A.M. indicated by an 8), 9/22/18 (10:00 P.M., no nurse's signature), and 9/27/18 (6:00 A.M., an 8 was documented). There was no progress note for 9/3/18 that documented the dose was given or a reason it was not. On 10/1/18, a note written by Nurse L documented, [MEDICATION NAME] .on order . On 10/9/18, a note written by Nurse P documented, [MEDICATION NAME] .on order . R#39's MAR for (MONTH) (YEAR) revealed R#39 did not receive a 2:00 P.M. dose of [MEDICATION NAME] on 10/1/18 (R#39 received the 6:00 A.M. and 10:00 P.M. dose indicated by the nurse's signature and a check mark on the MAR). There were no progress notes documenting the duplicated order for Potassium Chloride was clarified with the physician, that the physician was notified when medications were documented as unavailable, or that medications documented as on order were reordered from the pharmacy. On 10/23/18 at 4:47 P.M. an interview with Nurse P was conducted via the telephone. Nurse P was queried about R#65's [MEDICATION NAME] Patch on 10/20/18. Nurse P reported she did not remove the 10/20/18 [MEDICATION NAME]. Nurse P stated, I went into do PEG Tube care and then (R#65's) roommate asked for catheter care. Then two ladies came in, maybe from therapy and dietary. I spoke with them. Then I forgot to remove it. When asked why she documented it was removed on the MAR, Nurse P stated, I clicked it off before I went into the room. I should have removed it first. Nurse P further stated, I put the last [MEDICATION NAME] on R#65 on 10/20, took the box out of the drawer, took the pink slip (C2) and zeroed it out, signed and filed it so that it could be faxed over. I didn't even know he needed one today. When queried about what to do when a duplicate order was discovered, Nurse P stated, If it's for the same time and same dose, I just give one dose. When asked about the duplicate orders for R#35 and R#65, Nurse P reported she did not clarify with the physician and stated, When it first happened I told the nurse manager and was told to just put it as a duplicate. Resident #49 On 10/22/18 at approximately 8:50 A.M., 12:32 P.M., and 2:56 P.M., R#49 was observed sleeping. On

This citation refers to Intake Number(s): MI 277 Based on observation, interview, and record review, the facility failed to ensure a signaling wander alert device was in place on the resident's person for one (#905) of eight residents reviewed for elopement, resulting in an Immediate Jeopardy (IJ) when resident #905 who had severely impaired cognition, a physician's orders [REDACTED]. This had the likelihood to result in serious injury, harm, and/or death. Findings include: The IJ was identified on 7/23/18 at 4:04 P.M. The IJ started on 6/29/18. The Administrator was notified on 7/23/18 at 4:23 P.M. and a plan of removal was requested to remove the immediacy. On 7/23/18 at 9:00 A.M. an anonymous complaint submitted to the State Agency was reviewed and documented an allegation that a resident (R#905) eloped from the facility. An Incident/Accident Report submitted with the complaint dated 6/24/18 at 1:00 A.M. documented the Exact location of incident/accident as Parking Lot. The Incident/Injury Type documented Elopement. The Findings documented, Resident was spotted out the window in the parking lot in her wheelchair. Staff immediately called to assist in bringing the resident back inside. Resident had been seen in the hallway less than 5 minutes before this event . Action documented, Staff training and replaced (brand name for signaling wander alert device - a device worn by a resident that will prevent the door from opening or alarm if a resident were to exit the door while it was open). The I&A was completed by Nurse M. On 7/23/18 at 10:40 A.M., I&A reports were requested from the Administrator for R#905 for the months of (MONTH) through (MONTH) (YEAR). The Administrator reported he started working in the facility in (MONTH) (YEAR). On 7/23/18 at 1:30 P.M., I&As were reviewed for R#905. There were no I&As related to elopement. On 7/23/18 at 1:45 P.M., the Administrator was interviewed. When queried about any residents who eloped from the facility in the past three months, the Administrator stated, We haven't had any elopement. I'm not aware of any resident leaving unsupervised from the building. We have had attempts. Our (brand name for signaling wander alert device) work. We haven't had any actual elopements. On 7/23/18 at 2:35 P.M., R#905's clinical record was reviewed and revealed the following: R#905 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]., and [MEDICAL CONDITION]. A Minimum Data Set (MDS) assessment dated [DATE] documented R#905 had severely impaired cognition, no wandering behaviors, and was able to independently ambulate in a wheelchair with supervision. A progress note dated 5/10/18 at 6:47 P.M. written by Nurse N documented, .agitated at this time, packing her bags, sitting by the door stating she is going home .(signaling wander alert device) in place . A progress note dated 5/13/18 at 4:15 P.M. written by Nurse N documented, .attempting to leave facility, (signaling wander alert device) in place and functioning . A progress note dated 6/24/18 at 1:00 A.M. written by Nurse M documented, Staff member looked out the window and saw this resident in the back parking lot (in her wheelchair). Additional staff immediately called to assist in bringing the resident back inside the building .(signaling wander alert device) was not in place, found in shower room after this event .DON (Director of Nursing), Administrator .notified . A progress note dated 6/24/18 at 9:07 A.M. written by Nurse M documented, Current (signaling wander alert device) band is loose; needed to use two bands around ankle; this RN tightened by tying in place, but needed access to the office where the bands are stored. On 7/23/18 at 3:43 P.M., Nurse M was contacted via telephone for an interview. There was no answer and a message was left. Nurse M was unavailable for interview prior to the end of the survey. On 7/23/18 at 3:46 P.M., Nurse N was contacted via telephone for an interview. There was no answer and a message was left. Nurse N was unavailable for interview prior to the end of the survey. On 7/24/18 at 9:30 A.M., Elopement Risk Assessments for R#905 were reviewed and revealed the following assessments: A quarterly assessment dated [DATE] documented R#905 was at risk for elopement, An assessment dated [DATE] documented R#905 was not at risk for elopement (on 5/10/18 and 5/13/18 R#905 verbalized wanting to leave the building and attempted to leave the building). A care plan initiated 7/18/18 (24 days after R#905 eloped from the facility) documented, (R#905) is an elopement risk .Check placement and function and expiration date of safety monitoring device every shift . A care plan initiated 9/13/17 and revised on 7/23/18 documented R#905 was an elopement risk and wanders in w/c (wheelchair) w/o (without) purpose. (R#905) is assessed to be at risk for elopement. She does present with exit seeking behaviors and is not always easily redirected . On 7/23/18 at 4:55 P.M., the facility's policy titled, Elopement Management dated (MONTH) (YEAR) was reviewed and it documented the following: .If a signaling device is determined to be an appropriate safety device, the facility is to: .Check placement and function of the signaling device routinely .The signaling device will be replaced if it is missing or fails to function On 7/23/18 at 5:00 P.M., the facility's policy titled Resident Elopement dated (MONTH) 2012 was reviewed and it documented the following: .Personnel must report and investigate all reports of missing residents .It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the Director of Nursing and the Administrator and to document the occurrence .Upon return of the resident to he facility, the Director of Nursing and the Administrator should: .Examine the resident for injuries (Director of Nursing) .Complete and file an Incident/Accident Report .Make appropriate notations in the resident's medical record (Director of Nursing) .Investigate how the resident how the resident eloped .Update the resident's care plan with interventions . The Facility submitted the following acceptable plan including supporting documentation to remove the immediacy on 7/23/18: Resident #905 never left the facility/door/foyer/ramp on the day/note in question on 6/24/18. It is unclear why the wander guard wasn't attached. She was seen, however, attempting to leave the facility through the front entrance and, furthermore, was seen by a member of staff through the top window. The entrance is visible from that window. She was immediately brought back in to the facility, by staff, and wander guard was reattached. Resident's vitals were taken and were normal. As a precaution, resident was moved to the second floor of the facility to allow for more supervision and a more difficult opportunity for her to attempt to leave the facility. 1. Resident 905 is safe and in room (room number redacted) with wander-guard attached. Resident Care plan has been reviewed and deemed appropriate for risk of elopement. The resident's care plan has been updated to include exit-seeking behavior. The last assessment/care plan was completed on 6/24/18. Social Services note dated 7/12/18 shows contact was made to the family/representative explaining the move to the second floor. Resident representative agrees that this may be a good precaution as it is inferred that the resident may be removing her wander guard. 2. All residents at risk for elopement have been assessed for having their wander guards attached. 3. All facility doors have been tested and are working in proper order. 4. The nurse, in question, was in-serviced on note taking incidents versus completing an incident/accident and to whom was notified. 5. A recent inservice of all staff on elopement was completed on 6/28/18.

This citation refers to Intake Number(s): MI 763 and MI 841. Based on observation, interview, and record review, the facility failed to honor a competent resident's request not to receive ADL care who had a history of [REDACTED].#801) of three residents reviewed for resident rights, from a total sample of three, resulting in the resident becoming combative and acquiring a broken wrist requiring hospitalization , increase in pain, and decreased ability to use the dominant hand. Findings include: A complaint reported to the State Agency was reviewed and documented an allegation by Resident #801 that a staff member physically bent the resident's arm back and fractured the arm resulting in hospitalization . A facility reported incident pertaining to the same allegation was reported to the State Agency and reviewed on 12/8/17 at 7:45 A.M. On 12/8/17 at 8:55 A.M., Resident #801's clinical record was reviewed and revealed the following: Resident #801 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented Resident #801 had moderately impaired cognition (as evidenced by a Brief Interview for Mental Status - BIMS score of 11), physical and verbal behaviors, and required extensive physical assistance from one staff member for transfers, dressing, eating, hygiene, and toilet use. The MDS documented Resident #801 required extensive assistance from two staff members for transfers. A Significant Change MDS dated [DATE] documented Resident #801 had moderately impaired cognition (BIMS = 11), had no behaviors, and required extensive assistance from two staff members for bed mobility and dressing (a decline from the previous MDS assessment) . Progress Notes were reviewed and revealed the following documentation: On 11/12/17 at 8:08 P.M., Nurse H documented, .Result of X-ray to right wrist with acute distal radial fracture (wrist) .send patient to the ER .warm and slightly swollen . On 11/12/17 at 9:08 P.M., a SBAR (a tool used to communicate to members of a medical team) documented by Nurse I noted, .STAT wrist X-ray conclusion: Acute distal radial fracture .writer attempted to obtain blood pressure on right wrist and resident refused stating, 'Please just leave me alone, I've been suffering for weeks.' Resident also refused to eat using her right dominant hand and subsequently asked the restorative aide (RA C) for a right wrist x-ray . A note written on 11/13/17 documented, .Returned from hospital .cast on right arm . On 12/8/17 at 9:45 A.M., Resident #801 was observed eating breakfast in bed. A cast with an elastic bandage was observed on the resident's right arm. Resident #801 was asked what happened and the resident stated, There's an overactive nurse or aide. She grabbed on to my arm and pulled until it snapped. It was on November 11th in the evening. Resident #801 reported that she had a fractured wrist and was unable to use her right arm and hand. Resident #801 reported that she had left sided paralysis. Resident #801 stated, I just want this off of me (the cast). I'm stuck with it for 6-8 weeks and not allowed to use my arm. On 12/8/17 at 11:55 A.M., Certified Nursing Assistant (CNA) B (the CNA assigned to Resident #801 on 11/11/17 on the afternoon shift according to the facility provided daily assignment sheets) was interviewed via the telephone. CNA B indicated that she was currently suspended from employment pending the results of an investigation. When queried about what happened between CNA B and Resident #801 on 11/11/17, CNA B stated, (Resident #801) was combative as usual. She is always combative with me. She has put her hands on me before. I have my routine that I do with my residents to make sure they all get changed. (Resident #801) doesn't like to be bothered but I try to change all my people two to three times a day. I did my first change (brief) after dinner. I came in and did the same routine, explained what I was going to do and put (resident #801's) gown up. She pulled it back down. I said 'I have to change you' and Resident #801 didn't say anything so I pulled the gown back up. Resident #801 said 'Don't touch my gown. I don't want it on my face.' I told her I had to lift it to get to the brief. (Resident #801) said I could change her so I pulled up the gown and she pulled it down again. At this time I treated like she was refusing care and I told Nurse H. Nurse H went in to talk to Resident #801 and the resident agreed to let me change her. Nurse H had CNA G come in with me. Resident #801 let me change her at that time . CNA B further stated, At 10:30 P.M., I was doing my last rounds for the shift and got to Resident #801 around 10:40 P.M. I came in and did my same routine, explained what I was going to do, closed the curtain, but did not close the door because of a situation I had with Resident #801 a few months ago when she was combative with me and hit me in my mouth when she was mad about me taking her gown off. Ever since then she is combative a lot with me, calling me names. I let the nurses know when this happens and they tell me to document it and that behavior like that is expected from residents with dementia and that there was nothing they could do to protect us from residents .On 11/11/17, I came in, explained what I was going to do. I had everything set up, opened up the brief, wiped her front and then asked her to turn toward the wall. Resident #801 just laid there though. I started talking to her roommate and then reapproached Resident #801 and asked to turn toward the wall. She didn't' talk or move so I turned her and as soon as I turned her she started swinging her arms, calling me stupid. I was supporting her on her side and trying to hurry up and wipe her and tuck the brief in, but she reached back and grabbed my hand that was supporting her and dug her nails into my wrist and then latched on to my hair and wouldn't let go. She was gritting her teeth like she was trying to hurt me. I kept saying 'let go of my hair' but she wouldn't let go. I took my opposite hand and finally got her loose. I didn't know Resident #801 was injured until that Monday (11/13/17). Interviews were attempted via telephone with Nurse H and Nurse I. Messages were left. No return calls were received. Resident #801's clinical record was further reviewed on 12/8/17 and it revealed the following: Hospital records documented on a continuing patient care report dated 11/13/17, .Physically harmed .By whom: Employee at (facility name) where she is living . ED (emergency Department) notes dated 11/12/17 documented, .Alert and oriented x 4 .Pt transferred from (facility name) for right nondisplaced radial fracture. Pt (patient) states aide at facility was rough during ADL (activities of daily living) assistance and yanked pt's arm .Pt states she has been unable to feed herself due to wrist injury on only functional arm . Care plans for Resident #801 documented the following: A care plan initiated on 11/16/17 documented, I have increased pain in the right arm and decreased strength in bilateral LE (lower extremities) and sitting balance due to recent fracture . A care plan initiated on 11/27/17 documented, I have increased pain in the Right arm and decreased strength and ROM (range of motion) of the Right shoulder. I require assist for completion of my ADLs including self feeding . A care plan initiated on 11/12/17 (the day resident went out to the hospital) and revised on 11/15/17 documented, (Resident #801) is resistive to care r/t (related to) physically aggressive behavior when staff is providing care. Fighting, kicking, spitting, hitting staff, clawing nails into staff, gritting teeth, facial grimacing, swearing at staff . A care plan dated 11/15/17 documented, (Resident #801) has an alteration in musculoskeletal status r/t [MEDICAL CONDITION] . A care plan dated 11/27/17 documented, .Cast care right wrist . Assessments were reviewed at that time and revealed the following: A Pain Evaluation dated 11/15/17 documented, .[DIAGNOSES REDACTED]. The pain evaluation documented Resident #801 experienced pain, almost constantly, and that pain limited day-to-day activities. The worst pain/hurting gets was documented as 8 (very severe pain). physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. Between 11/15/17 and 12/5/17, Resident #801 received 21 doses of narcotic pain medication and experienced pain levels documented from 2 to 9 in severity (1 indicating the least pain possible and 10 indicating the worst pain possible). A progress note written by the Activities Director documented Resident #801 was unable to participate in completing word search puzzles as usual due to the wrist fracture. An Incident/Accident Report dated 11/12/17 completed by Nurse H documented, .Resident aggression .Pt stated 'I grabbed her hair because she's very rude and attempted to pull out my brief . On 12/8/17 at 3:30 P.M., the Administrator (who also acted as the full time social worker) was interviewed about the incident with Resident #801 that led to a fractured wrist. The Administrator reported Resident #801 never said anything to any staff member about anyone hurting her and the facility found out from the hospital. The Administrator reported that CNA B stated, Resident #801 had combative and aggressive behaviors toward her and as far as I understand she went and got the nurse and reapproached her later on. When asked if staff should continue with care if a resident was refusing or resistant, the Administrator reported they should stop, let the nurse know, and reattempt later. The Administrator was asked if Resident #801 was her own responsible party and the Administrator indicated that she made her own decisions. The facility's policy titled Refusal of Treatment dated April 2005 was reviewed on 12/8/17 at 4:45 P.M. and it documented the following: The facility honors a competent resident's request not to receive medical treatment as prescribed by his or her physician, as well as care routines outlined on the resident's assessment and plan of care .

This Citation Refers to Intake Number MI 073 Based on observation, interview and record review, the Facility failed to ensure safety alarms were properly functioning for a resident that was admitted to the Facility with a history of exit seeking behavior and provide supervision to prevent an elopement from the Facility, resulting in an Immediate Jeopardy (IJ) for one cognitively impaired Resident, (#701) of four sampled residents reviewed for elopement risks from a total of six resulting in the potential for serious harm or death to the Resident who exited the building unaccompanied and without the Facility's knowledge. The Administrator was notified of the Immediate Jeopardy on 9/20/17 at 11:58 a.m A plan to remove the immediacy was requested. The immediacy was removed on 9/20/17 at approximately 2:50 p.m. based on the Facility's implementation of an acceptable plan of removal as verified on-site by the surveyor. Although the immediacy was removed the Facility's deficient practice was not corrected and remained isolated with actual harm that is not immediate jeopardy. Findings Include: On 9/20/17 at 8:30 a.m., an interview and record review was conducted pertaining to a Facility Reported Incident (FRI) reported to the State agency on 9/2/2017. The Verification of Investigation document dated 9/2/17 was reviewed with the Administrator and documented, in part, the following: Resident #701 (name redacted) .presented to the Facility (name redacted) on August 21, 2017 .for rehabilitation and long term care. Resident #701 is ambulatory and alert and oriented x1. He has a BIMS (brief interview for mental status) score of 4. His [DIAGNOSES REDACTED]. On September 1, 2017 at at approximately 6:25 p.m., staff (name redacted A) reported that while driving north on (name redacted) street, approximately a block away from the Facility, she noticed a male walking on the side walk that looked like a resident of the facility .staff A reported that after parking her vehicle, she approached the male and recognized him as Resident #701 Resident #701 stated, I am looking for my wife.Resident #701 agreed to walk back to the facility .Upon reentering the facility, Staff A escorted the resident back to the floor where he was assessed by a nurse . When queried about the incident, the Administrator reported that the Facility was not able to determine how the Resident eloped from the Facility. The Administrator reported that the Resident was wearing a safety monitoring alarm device and resided on the second floor of the building. The Administrator reported that prior to the elopement on 9/1/17, Resident #701 was not considered an elopement risk. When queried as to why the Resident was wearing a safety monitoring device if he was not considered at risk for elopement, the Administrator reported that she was not sure and no order for the alarm was made prior to the elopement on 9/1/17 and his initial elopement risk assessment did not place him at risk. On 9/20/17 at 9:05 a.m., Resident #701 was observed in his room. The Resident was alert and reported that he was able to walk without assistance, but was confused as to time and date questions. The Resident was not able to recall exiting the Facility. On 9/20/17 at 9:30 a.m., an interview and reenactment of the event was conducted with Occupational Therapist Staff A regarding Resident #701. Staff A reported that on 9/1/17 at approximately 5:45 p.m., she exited out of the building and entered her vehicle that was in the parking lot. After beginning a phone call, Staff A then exited the Facility parking lot, making a left turn onto a four lane road heading North. Approximately two blocks down the road, Staff A reported that she noticed a man walking on the sidewalk on the North/East side of the street. The Resident had already crossed one side street and began to cross to a second. Staff A turned off the main road and parked her vehicle in a parking lot. She exited her vehicle and approached Resident #701 and escorted him back to the Facility entering through the door adjacent to the back parking lot. At the time of entry, Staff A reported she viewed an alarm on the Resident's right ankle and the alarm sounded as they entered the building. Staff A escorted the Resident to Nurse C on the second floor. Staff A reported that Nurse C did not know the Resident had left the building. On 9/20/17 at 10:00 a.m., a review of the Resident's clinical record was conducted and revealed that the Resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident Minimum Data Set ((MDS) dated [DATE] documented the Resident had a BIMS score of four (severely cognitively impaired) and required extensive one person assistance for ambulation. Further review of the Resident's record's care plans documented, in part, the following: Focus (initiated 8/21/17/Revision date 9/7/17): Resident is an elopement risk r/t (related to) adjustment to nursing home. Disoriented to place, Impaired safety awareness. Resident wanders aimlessly. (Name Redacted) is assessed to be at risk for elopement, Elopement risk assessment score of 18, HX (history) of wandering per family. Interventions: · Check placement and function and expiration date of safety monitoring device every shift. Date initiated: 8/21/17 · Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, Resident prefers (SPECIFY) Date initiated: 8/21/17 On 9/20/17 at 12:10 p.m., further review of the Facility's investigation pertaining to Resident #701 was conducted. A Verification of Investigation (dated 9/2/17) documented, in part, the following: Staff Name (RCS (resident care specialist/certified nursing assistant (CNA) B) Date of Finding: 9/2/17 Administrator spoke with RCS B regarding the above incident, RCS B reported that resident was walking aggressively in circles on the unit today and getting into peoples faces. RCS B reported that the resident came to her and asked where is my wife? you make me sick! RCS B reported that she was in a room providing care to residents and did not see resident exit the building but was told by nurse (C) to keep an eye on him. On 9/20/17 at 12:25 p.m., a phone interview was conducted with CNA B regarding her statement made on 9/2/17 pertaining to Resident #701's elopement from the Facility. CNA B stated, The statement I made was correct. He was very agitated that day. The family had visited earlier and he just kept walking in circles. I know he had an alarm on. When queried as to whether she knew if the Resident was an elopement risk, CNA B reported that she was not sure and stated, I am not really sure how he got out of the building, but I do know that he does not look like a typical resident. When queried as to whether CNA B had reported the Resident's agitated behavior to anyone, CNA B stated, No. When queried as to how staff is aware if a Resident is an elopement risk, CNA B stated, We have an elopement book at the Nurses station. Continued review of the Facility investigation documentation was conducted. A Verification on Investigation form dated 9/2/17, documented, in part, the following: Staff Name: RCS/CNA D Administrator spoke with RCS D regarding the above incident. RCS D reported that she saw resident earlier in the day walking around on the 2nd floor in circles. RCS D reported that while walking on the unit, resident hit her in the arm, asked her what are you looking at? I'm sick of looking at you! and had a mean look on his face. RCS reported asking resident if he wanted to lay down and he stated, no, and kept walking. At approximately 6:00 p.m., RCS D reported that resident was observed sitting in the dining room. RCS D reported that she was providing care to another resident and was informed by nurse C that the above resident had got out of the building. On 9/20/17 at 12:40 p.m., a phone message was left with RCS D. No return call was made prior to the end of the survey. On 9/20/17 at 1:30 p.m., an interview was conducted with Nurse C. Nurse C reported that she was not aware that Resident #701 was an elopement risk and stated, The Resident did like to walk. I know his family had been in earlier that day. When queried if she was made aware of his agitated behavior, Nurse C stated, No, the CNAs did not report anything to me. When further queried as to whether she was aware of the Resident's elopement, Nurse C stated, I was not aware that he left the building. I was in the dining room helping other residents. I did know that he had an alarm on him. Staff A brought him to me and told me she found him walking outside. I did an assessment, he appeared fine with no injuries. The physician and family were notified. I contacted the Administrator and left the building. On 9/20/17 at 2:30 p.m., an interview was conducted with the Maintenance Director Staff E regarding the Facility's alarm system and Resident's wearing safety alarms. Staff E stated, The alarms are supposed to sound and lock the door if a Resident wearing an alarm attempts to exit the building. I do not know what happened with Resident #701. We do know he had a wander guard alarm because he came back in with one and Staff A said it sounded. Staff E provided manufactures documentation pertaining to the (name redacted )wandering alarm system (WAS) used by the Facility. The Functions section revealed, The system is two systems for the price of one. It can operate as a WAS system which is unlocked for normal traffic flow and will lock only when a monitored wandering resident approaches the door. It is also able to perform a variety of perimeter alarm and access control functions by becoming a locked door during the hours of your choice and alarming if an unauthorized entry or exit has occurred when interfaced to the WAS lock, the WAS locks the door when a resident wearing a transmitter approaches the door. Then quietly unlocks when resident leaves the area. On 9/20/17 at 2:45 p.m. a review of the Facility's policy titled Resident Elopement (revision date June 2007) documented, in part, the following: Policy: The facility will provide a safe environment and prevent measures for elopement . Procedure: Wander/Elopement Alarm Activation: if an employee hears a door alarm, he or she should (a.) immediately go to the site of the alarm . The Facility submitted the following acceptable plan (signed by the Administrator) including supporting documentation to remove the immediacy on 9/20/2017: Corrective Action: 1:1 supervision immediately initiated by facility for affected resident until resident elopement status reassessed and safety device fully initiated. The care plan and care kardex have been reviewed and updated as necessary. The resident profile was placed in facility elopement books. The completion of this intervention was September 2, 2017. Identification of Others: The interdisciplinary Team including the Nursing Home Administrator(NHA) and facility charge nurses reviewed current facility residents on September 2, 2017 to ensure that they have an accurate and current elopement risk assessment. Care plans for residents identified as at risk were updated and individualized to reflect elopement risk assessment and any required interventions. This was completed on September 2, 2017. The facility Interdisciplinary Team including the NHA and facility charge nurses reviewed all current resident who utilize a (name redacted herein after referred to as wander alarm system chip (WASC) to ensure proper orders are in place to visually check placement of the WASC every shift and check functionality of device via electronic machine once a day and to change out device prior to expiration on WASC. Any resident choosing not to wear the WASC has personalized interventions to minimize risk of elopement. This was completed September 2, 2017. The NHA made rounds with the facility Maintenance Assistant on September 2, 2017 of all facility alarmed exits to ensure the WAS was functioning appropriately. All alarms were functioning properly. The elopement book at each nurse station was audited on September 2, 2017 to ensure accuracy of records based on current residents identified at risk. These books will continue to be updated with any change of condition regarding assessed elopement risk including verbalization of desire to leave the facility, information communicated via 24 hour report and acute change in condition. The Director of Nursing (DON) and designees provided education to all facility staff beginning on September 1, 2017 on elopement policy, including, but not limited to, providing appropriate supervision and adequate interventions to minimize elopement risk, appropriate placement of wandering resident system and back-up-systems in the case the wandering resident system is not functioning. No employee was permitted to work until education was completed. Elopement drills were conducted daily on various shifts for three days to insure appropriate response an knowledge of policy. A copy of the elopement management policy was added to each elopement book for reference. New admissions to the facility will be evaluated for elopement risk upon admission. Based on the risk score the facility will following its established elopement policy to ensure appropriate supervision and adequate intervention are in place and individualized to minimize the risk of elopement. Post admission resident will be reassessed quarterly, annually, with significant condition change and/or elopement attempt/event to re-determine elopement risk. The DON or Designee will complete an audit to check resident Treatment Administration Records (TARS) 5 times/week to ensure nursing staff are following physicians orders for WASC placement and functionality. The Maintenance Director or Designee will check all facility exits Monday-Friday to ensure wandering resident system is functioning appropriately. Saturday, Sunday and Holiday checks will be done by the first floor south charge nurse. The first floor south charge nurse will be educated by the Maintenance Director regarding checking the facility alarmed exits with the hand held transmitter (number redacted) to ensure the system is functioning properly. The education will be completed prior to the charge nurse's scheduled coverage. If the wandering system is found to not be functioning properly the facility alarmed doors will be supervised by a staff member via line of sight until it is functional. Facility elopement drills will continue to be conducted by the Maintenance director at a minimum of biannually. Final Submission at 1:00 p.m. 9/20/17. The facility alleges compliance as of this date and time.

This citation deficient practice refers to intake MI 191 Based on interview and record review the facility failed to prevent a resident (#902) from sustaining an injury from a fall for one sampled resident of two residents reviewed for accidents of total sample of 4 residents. This deficient practice resulted in the resident being hospitalized as well as the resident sustaining a left nasal bone fracture and left rib fracture. A review of the clinical record on 7/12/17 at 10:30 AM, was conducted and revealed that Resident #902 was originally admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #902 became Hospice on 1/9/15. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #902 scored 5 out of 15 on the BIMS (brief interview of mental status) which indicated severely impaired cognitively. Resident #902 required one person assistance from staff for all activities of daily living. The MDS further documented for Walking: Not steady only able to stabilize with staff assistance. A review of Resident #902's Fall Risk assessment dated [DATE] was conducted on 7/12/17 at 12:30 PM. The Fall Risk Assessment was scored a 13 which indicated that Resident #902 was a High Risk for falls. A review of the facility's Incident/Accident Report (I/A)completed by Nurse 'B' which was dated 5/15/17 and timed 7:15 AM was performed on 7/12/17 at 2:00 PM and revealed impart the following: Findings: Observed on dining room floor faced down with blanket in between legs. Resident was kicking, punching and spitting at staff while providing care. Cognitive state prior to incident/accident- Normal. Equipment involved- Yes. If Yes, type of equipment- Hoya lift. Physician and daughter notified. Steri strip applied. Was incident/accident witnessed? Yes. Name, title of witness (es) RCS (resident care staff). Further review of the I/A reports for Resident #902 revealed that the resident had a previous fall on 3/19/17 at 9:30 PM and the I/A documented: Findings: PT. (patient) was observed on the hallway floor in front of room . 2 North in a dorsal position with head halfway to the floor. An interview with Nurse 'B' was conducted on 7/12/17 at 2:55 PM. When queried regarding I/A dated 5/15/17 and Resident #902's fall, Nurse 'B' indicated that RCS 'A' witnessed the fall and stated: It was the beginning of my shift on May 15th. We were in the middle of counting narcotics. RCS 'A' came and got me. RCS 'A' said Resident #902 fell at 2 North dining entrance and had blanket between legs. Resident #902 was bleeding in the nose area. I was trying to get her up. We were trying to do steri strips. I ordered stat X ray for nose then called Resident #902's daughter to help calm her down. I was the one that sent her to the hospital for X rays. She was combative and would not let us do X rays here. Wanted to rule out skull fracture. An interview with RCS 'A' was conducted on 7/12/17 at 3:15 PM. When queried regarding incident on 5/15/17 and Resident #902's fall, RCS 'A' stated: We were at the desk getting assignments when Resident #902 was coming down the hall and around by the nurse's station with blanket in hand. Resident #902 walked and tripped at the 2 North dining room door. She fell face down. I ran over to her. The Nurse (referring to Nurse 'B') came to check vital signs and we were trying to determine where the blood came from. Resident #902 had a cut on her nose. RCS 'A' further explained that Resident #902 picked up things and stated: She (referring to Resident #902) always had something in her hands. She had a blanket on her bed and she would pull it off. The nurses tried to get her up and as we were getting her up she was combative. They (referring to the nurse) called for X rays, but I don't know if they were done. I just witnessed the fall. The RCS 'A' indicated that on 5/15/17 the resident ambulated by herself from her room which was located on 2 South with the blanket in her hand to the 2 North side dining area and then fell at the dining area entrance with the blanket located between her legs. A review of Resident #902's care plan date initiated: 7/11/2016 and Revised on: 5/15/2017 was conducted on 7/12/17 at 4:00 PM. The care plan documented: Focus- is at risk for falls r/t (related to) Unaware of safety needs, Confusion, Poor communication/comprehension, Wandering, Incontinence. Interventions: Anticipate and meet the resident's needs. Cue, reorient and supervise as needed. Falling Star Program. Follow facility fall protocol. Goal- Resident whereabouts will be known by others and she will remain in safe environment. A telephone interview was conducted with the Hospice Regional Director 'E' on 7/13/17 at 10:25 AM. When queried regarding Resident #902, the Hospice Regional Director indicated that the hospice nurse coordinator note of 5/15/17 documented: Resident #902 was admitted into the hospital due to injury sustained from fall at facility. Resident #902's daughter stated that the resident had broken nose and broken rib. Resident #902 had been admitted to the hospital due to injury and pain management. On 7/13/17 at 12:00 PM, a review of Resident #902's hospital X ray results dated 5/15/17 were conducted. The X ray results documented: Head CT and CT Scan Maxillofacial without contrast: Provided History: Trauma. Findings: There is a hairline fracture of the left nasal bone with adjacent soft tissue swelling. RIBS UNILATERAL LEFT WITH PA (posterior anterior) CHEST. HISTORY: Trauma, pain. FINDINGS: There is nondisplaced fracture of the left eighth rib with some peripheral callus formation. An interview was conducted with the Administrator and Director of Nursing (DON) on 7/13/17 at 1:10 PM. When queried regarding Resident #902's fall and observed to be bleeding in nasal area by RCS 'A' as well as Nurse 'B' on 5/15/17, the Administrator stated: I am not going to say she had an injury here (referring to the facility) because she was combative with staff and the ambulance drivers. When queried further regarding Resident #902's history of falls and care plan which documented that the Resident was on the facility's falling star program, the Administrator indicated that RCS 'A' witnessed the fall and that staff would have followed the care plan. The DON stated: Because of the fact that she (referring to Resident #902) walked and wandered, the RCS would walk with her. When queried further regarding if staff walked with Resident #902 on 5/15/17, the DON stated: No, I don't know. I would be just speculating. A review of the facility's policy and procedure titled Fall Management Revision Date: August 2012 was conducted on 7/13/17 at 1:30 PM and documented: Practice Guidelines-3. All residents will be assessed for risk quarterly, annually, and for significant change using the Fall Risk Assessment. 7. The IDT (interdisciplinary team) modifies and implements a Care Plan and treatment approach to minimize repeat falls. Falling Star Program- 1. The Falling Star is a visual identifier/reminder program for staff to recognize and to be aware of residents determined to be at risk. 2. Visual identifiers will assist the facility staff to identify those residents that are at risk for falls and to respond accordingly when the resident demonstrates a behavior that may be associated with an impending fall. Placement on the Falling Star Program- Residents identified at risk.

This citation refers to Intake Number M#I 180 Based on observation, interview and record review, the Facility failed to ensure corrective safety measures (bed and wheelchair sensor alarm devices) were working for two Residents (#701 & 702) of three residents reviewed for falls/injuries, from a total sample of three, resulting in Resident #701 falling and sustaining a femoral neck fracture requiring surgery and over a week long stay in the Hospital and the potential for Resident #702 to fall and sustain an injury. Findings include: The Facility reported to the State Agency that Resident #701 had sustained a fall in the hallway on 3/4/17 resulting in a fracture. Resident #701 On 3/29/17 at 12:15 p.m., Resident #701 was observed sitting in a high back wheel chair in the hallway outside of his room. The Resident had an fall alarm attached to the back of the chair. A family member was standing with the Resident. When queried about the fall, Resident #701 was not able to answer questions asked. The Resident's family member stated, He had a bad fall. He broke his hip and was in the Hospital and had surgery. He is doing pretty well. We were contacted and informed of the fall, I really can't say what happened. I am not sure how he walked all the way out in the hallway, but that's what we were told. I know he has an alarm attached to his wheelchair and one to his bed. I don't know if it was working or not that night. On 3/29/17 at 12:23 p.m., Resident #701's clinical record was reviewed and revealed the following: Resident #701 was originally admitted into the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 2/01/17 documented that Resident #701 had severely impaired cognition and required total extensive two person assist for transfers and bed mobility. A Fall Assessment document dated 2/8/17 documented that the Resident was High Risk for falls. A Care Plan for Activities of Daily Living (ADL) dated 10/30/2016 documented the following: Focus: Resident has ADL self-care performance difficulty: Transfer: The Resident requires Mechanical Lift with 2 Staff assistance for transfers. Care Plan Focus: Resident is High Risk for fall r/t Alzheimer's, cognition, mood and unsteady gait disturbances (Actual fall on 5/3/16, 9/17/16 (fall), 11/7/16, (fall) 11/21/16, 11/28/16, 12/1/16, 12/4/16 (fall), 12/7/16 (fall).) Interventions: · 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 11/01/16) · Close curtain only when doing care (date initiated 12/7/16) · Educate the resident to participate in activities that promote exercises, physical activity for strengthening and improved mobility as tolerated. (date initiated 11/1/15) · Ensure the resident is wearing appropriate footwear. (date initiated 11/1/15) · Falling Star Program (date initiated 11/01/15) · Follow fall protocol (date initiated 11/01/15) · Grippy socks during bed time (date initiated 12/7/16) · Monitor resident's position frequently when in bed. Be sure he is not near the edge(date initiated 11/9/16). · The Resident uses chair/bed alarms. Ensure the devices are in place as needed.(date initiated 11/1/15) · Anticipate and meet the resident's needs (date initiated 3/14/17) · Bed in lowest position. (date initiated 3/14/17) Review of the Investigation and Accident Reports for the dates noted above were reviewed and contained no documentation pertaining to the chair/bed alarms. On 3/29/17 at review of the Resident's Incident and Accident Report was conducted and documented the following: Time: 2:05 a.m. Date: 3/4/17 Resident was witnessed falling by RCS (term represents (CNA) Certified Nursing Assistant) on the floor and hit left side of hip and head to side wall Cognitive State: Confused Location: Hallway Further Investigation documents were reviewed and documented interviews with Facility Staff. working the night Resident #701 fell and sustained an injury. No documentation was provided pertaining to sensor alarm function. On 3/29/17 at 12:52 p.m., a phone interview was conducted with Nurse B. Nurse B was queried as to the Resident #701's fall on 3/4/17. Nurse B stated, I remember when he fell . I was trying to correct a computer error and did not witness the Resident or the fall. When queried as to whether she heard the Resident's bed alarm sound, Nurse B stated, No. On 3/29/17 at 1:03 p.m., a phone interview was conducted with CNA D with respect to Resident #701's fall on 3/4/17. CNA D stated, I worked that night. I was not assigned to the Resident. I rarely work with him. I don't know much about him. CNA A was assigned to him, but she was on break in the break room. I was down the hall and saw him walking. I tried to get to him, but he fell before I could get to him. CNA D was queried as to whether she heard a bed alarm prior to the Resident's fall. CNA D stated, No, I did not hear it go off. When further queried as to whether she would have been able to hear it, from the location she was working, she replied, Yes. On 3/29/17 at 1:35 p.m., a phone call and voice message was made to CNA A. No return call was made by the end of the Survey. On 3/29/17 at 1:45 p.m., an interview was conducted with Rehabilitation Manager Staff E regarding Resident #701's ability to ambulate. Staff E stated, I don't believe I have any documents that would document how far, if at all, the Resident can walk. Resident #702 On 3/29/17 at 1:20 p.m., Resident #702 was observed wheeling herself on the first floor hallway near an exit door. No staff were noted in the hallway. The Resident had a fall alarm attached to the back of the Resi wheelchair. No light appeared to be blinking on the alarm. The Resident was observed bending over in the wheelchair to pick up two empty milk container lying on the floor. At 1:25 a.m., Staff E was observed assisting, Resident #702 pick up the milk containers. When queried as to whether Resident 702's alarm was functioning, Staff E stated, It definitely is not working. It is disconnected. I will re-connect it and take her into the physical therapy room and assist her. On 3/29/17 at a review of Resident #702's clinical record was conducted and revealed that the Resident was originally admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Resident's MDS dated [DATE] documented that the Resident had a Brief Interview for Mental Status (BIMS) score of six (cognitively impaired) and required extensive one person assist for transfers and locomotion. A Fall assessment dated [DATE] indicated that Resident was a High Risk. Review of the Fall Care Plan dated 2/8/17 documented the following, Sensor Alarm to bed and wheelchair maintain QS (as much as needed) for placement and function. On 3/29/17 at 3:20 p.m., an interview was conducted with the Administrator and Director of Nursing (DON) regarding Resident #701's fall with injury on 3/4/17 and Resident #702's Fall Sensor Alarm. The DON stated that she was not employed by the Facility at the time of the Fall pertaining to Resident #701, but was familiar with the investigation and the Facility's Fall Policy. The Administrator was queried as to the investigation pertaining to Resident #701's fall. The Administrator stated, The Resident has a history of getting up on his own. He does not use his call light. He is very impulsive and has poor judgement. When queried as the Facility's Policy pertaining to fall sensor alarms. The Administrator stated, The alarms are ordered and care-planned. They don't always prevent falls, but they are used to alert staff that the Resident is getting up. When further queried as to whether there was any documentation that would indicate that Resident #701's Sensoer Bed Alarm was working the night of the fall or at anytime leading up to the fall, the Administrator stated, I don't think we have that documentation. We are working on the alarms going forward after the fall. The Administrator and DON were queried as Resident #702's wheelchair alarm. The DON stated, I'm not sure why it was not working. We have been checking all our Residents to assure their alarms are working. On 3/29/17 at 3:20 p.m., a review of the Facility Policy titled Fall Management (revision date August 2012) was conducted and revealed, in part, the following: Each resident is assisted in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assist devices and/or functional programs as appropriate to minimize the risk for falls. The IDT (interdisciplinary team) evaluates each resident's fall risks. A Plan of Care is developed and implemented based on this evaluation, with ongoing review.

Based on observation, interview and record review, the facility failed to provide adequate supervision and implementation of fall safety interventions for two (# 901 and #909) of 13 sampled residents reviewed for accidents from a total of 22 and one (#99) supplemental sampled resident, resulting in falls, lacerations, bruises, abrasions, fractures, a pneumothorax and emergency hospitalization s. Findings include: Resident #909: On 7/28/15 at 10:20 AM, during a tour with nurse unit manager 'B', resident #909 was observed reclined in a wheelchair in the dining room with a fall safety alarm attached. The alarm control box was not flashing to indicate that it was functioning. Nurse 'B' inspected the box and pressed on the alarm sensor (motion detector) pad on the wheelchair seat. The alarm did not sound and nurse 'B' was unable to figure out why. The resident had six steri-strips on her face near the corner of the right eye. On 7/31/15 at 9:40 AM, resident #909's clinical record and Incident/Accident (I/A) Reports were reviewed with the Administrator. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was receiving Hospice services. Minimum data sets ((MDS) dated [DATE], 1/16/15, 2/17/15, and 5/4/15 noted that the resident had severe cognitive impairment and required extensive assistance for transfers, bed mobility, and ambulation. The 5/4/15 MDS noted that the resident had sustained a minor and a major injury from falls. Fall Risk Evaluations for resident #909 dated 10/10/14, 1/8/15, 2/4/15, and 4/24/15 noted that the resident was at high risk. The resident's 'At Risk for Falls' care plan dated 10/2014 noted interventions that included, bed/chair alarms. The resident was prescribed bed and chair alarms and monitor every shift for placement and function. Incidents/Accidents occurred on the following dates involving resident #909: 1. On 10/22/14 per I/A report-Found on the floor next to the bed-no noted injury; corrective action taken-monitor every hour and move resident to a room closer to the nursing station; no mention that an alarm sounded to alert staff of attempts to self transfer. 2. On 11/11/14 (no documented I/A report or nursing note)-An order noted: Ice to left side of head. Cleanse area with normal saline .Steri-strips until healed. When queried, the Administrator said she did not know what happened to the resident. 3. On 1/15/15 per I/A report-While in the bathroom being assisted by a nurse aide, the resident fell on the floor-laceration to the nose and bleeding from nose hitting the bathroom door; action taken-transport to hospital for evaluation. Per review of hospital records dated 1/15/15-1/16/15: The resident was going to the bathroom with help of an aide and While the aide was turning to grab some supplies in the bathroom the resident fell . The resident hit her face on a counter top; New anterior pneumothorax (collapsed lung) present likely secondary to recent trauma clinical rib fractures. CAT Scans on 1/15/15 revealed: Nondisplaced fracture of the nasal bone tip is of indeterminate age and Mild T1 (first thoracic vertebrae) compression new since chest CAT Scan (on) 11/11/14; Abrasion over bridge of nose, small laceration over right forehead, right medial canthus ecchymosis (bruise in inner corner of the eye); A chest X-ray dated 1/16/15 noted: Several left inferior lateral subacute rib fractures. The resident was transported back to the facility on [DATE]. Per admission nursing notes: The resident had yellow/green bruising around both eyes. The Administrator did not offer a response as to whether there was a link between the CAT Scan on 11/11/14 and the injury sustained on 11/11/14 that did not have an I/A report. 4. On 2/5/15 per I/A report-on fall mat besides bed-no noted injury; action taken-none noted; no mention of an alarm sounding. 5. On 4/13/15 per I/A report-on floor between nightstand and bed-complaining of pain to right shoulder, possible fracture; no mention that the alarm sounded; action taken-called ambulance, concave mattress (a raised edge around perimeter to prevent rolling out). The resident was transported to the hospital. Per the Resident Transfer Form: Right shoulder, holding shoulder saying it hurts. Resident #909 returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. A concave mattress and thicker floor mats were requested per the notes. A portable fracture follow-up X-ray report dated 4/21/15 noted: There is a fracture involving humeral neck with mild lateral displacement. 6. On 4/23/15 per I/A report-found lying on right side with alarm sounding, had rolled out of bed onto floor mat; action taken-change mattress to concave mattress. A right shoulder X-ray was done on 4/25/15 due to pain shoulder humerus region which showed no change from the 4/21/15 X-ray. When asked, the Administrator did not respond why the concave mattress was not already in place before the fall. 7. On 5/27/15 at 3 PM per a Neurological Record (no documented I/A report or nursing note)-neurological checks had begun (indicating a head injury). Per nursing notes dated 5/28/15: No complaint of pain or signs/symptoms of injury as a result of previous fall. When asked, the Administrator said that she did not know what happened to the resident. 8. On 6/29/15 per I/A report-head was hanging out of bed touching the mat-no noted injury; action taken-Hospice to bring a concave mattress. The Administrator did not respond why the mattress was not already in place. 9. On 7/10/15 per a Hospice nursing note (no documented I/A report or facility nursing note)- Per staff patient fell this AM from bed to floor. Patient does have some abrasion on chest some bumps along ridge of skull with bruises ; no mention of a concave mattress, floor mats, alarm sounding, or if the bed was in its' lowest position at the time. Per a physician progress notes [REDACTED]. A Communication Form/Progress note dated 7/10/15 noted: Resident on the floor next to bed with scrapes to mid chest area and small bump to left side of head scrapes cleansed with normal saline and a dressing was applied. An order dated 7/20/15 noted: Change batteries to alarms every 30 days and as needed prophylactically. 10. When asked why resident #909 had steri-strips by the right eye, the Administrator said that she did not know what happened and would have to ask staff. There was no documented I/A report or nursing note regarding the wound. On 7/31/15 at 3 PM, the Director of Nursing (DON) provided a Communication Form/Progress Note dated 7/26/15. The form documented: scratch above right eye informed by (nurse aide) that resident had a scratch above her right eye when she (the aide) went to get her up. The physician prescribed a daily band-aid to the area, however steri-strips were applied. (Steri-strips are not changed daily like band-aids and are used to close wounds by bringing the skin edges together, indicating that the wound was more than a scratch.) When queried, the DON said that she did not know why steri-strips were applied. Resident #901: On 7/29/15 at 12 Noon, resident #901 was observed sitting in a wheelchair in the dining room with his family representative (Rep) present. The resident was alert, non-verbal, and appeared tall in stature. The Rep said that about eight weeks ago, while a nurse aide had the resident lying on his side changing his incontinence brief, the resident rolled out of the bed onto the floor and broke his nose. The Rep said that the resident's eyes became black. The Rep pointed out a small visible lump on the resident's forehead that the Rep said was a remnant of the incident. The Rep said, He is a big guy. The bed was too small, so they got him a bigger bed. At 3:40 PM, the resident was observed asleep in the center of the wider bed with a perimeter around the mattress. On 7/31/15 at 1:50 PM, resident #901's clinical record and I/A reports were reviewed with the Administrator. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] and 6/25/15 noted that the resident had severe cognitive impairment, was non-ambulatory, had limited motion to all extremities, incontinent of bowel/bladder, and required extensive two-person assistance for transfers, bed mobility, toileting, and hygiene. The resident was 6 feet 4 inches tall and weighed 200 pounds per the MDS. Fall Risk Evaluations dated 10/8/14, 12/30/14, 3/9/15, and 6/16/15 noted that the resident was at high risk. An AT Risk for Falls care plan dated 1/12/15 noted interventions that included: Resident to be PRN (as needed) assisted with activities of daily living with 2 person assist. Incidents occurred on the following dates for resident #901: 1. On 11/28/14 per I/A report-resident lying on floor on right side on floor mat with redness and swelling to left temple; action taken-wedge beneath legs. When asked how the immobile resident ended up on the floor mat and how he injured the left side of the head, but was lying on the right side, the Administrator said that she did not know. There was no documented investigation or nursing note. The Administrator was asked about the purpose of a wedge under the legs as an intervention and how it could protect the resident versus safety measures identified, such as a low bed or concave mattress. She said that the resident's Rep suggested it. She did not respond when asked about the staff 's interventions and suggestions. 2. On 4/24/15 per I/A report-Resident was being changed and when being turned resident kept rolling and could not be stopped, sustained pain, skin tear, bruise/hematoma, bleeding to forehead; was being assisted by one-person (nurse aide 'J'); action taken-larger mattress with side mattress; transported to the hospital. The Resident (hospital) Transfer Form noted: The resident was on 6 milligrams of Coumadin (blood thinner), fell out of bed on his face and had a laceration to the nose. Per review of hospital records, resident #901 had a laceration and hematoma to the nose. There was no available X-ray of the nose. When asked if the resident's nose was fractured, the Administrator said, I'm not sure. An X-ray result was requested, but not provided by the end of the survey. Resident #901 returned to the facility on [DATE]. On 4/25/15, per nursing notes, the resident was placed on a larger (bariatric) bed and had a large raised area to forehead. There was an order dated 4/25/15: routine X-ray to bilateral knees (pain, swelling) rule out fracture. Per a nursing note dated 4/26/15: Continue to note blue/purple bruising bilateral eyes and a bump mid forehead with red/purple bruising and bilateral knee X-rays obtained. The X-ray results (negative for fracture) were not obtained until 4/27/15 per nursing notes. When asked why the resident received a bigger bed after the fall and if he was on the edge of the bed when he fell , the Administrator said, The aide could not stop the fall. He was a one-person assist. The Administrator did not respond when told that he was coded on the MDS as requiring two-persons. An intervention was added to the fall care plan dated 4/27/15: Utilize 2 staff assist PRN for toileting needs/positioning/transfers. At 3:20 PM, aide 'J', who was alone with the resident when he fell on [DATE], was asked how the fall happened. She said that she was changing his brief and turned him toward her. She said, Even when you turn him, his legs would go over the side because of his (leg) contractures. He is a big man. When I rolled him toward me, he continued to roll out. We got him a bigger bed. He wasn't a two-person (assist) at that time, but we then made him one. Resident #99: On 7/29/15 at 10:40 AM, resident #99 was observed to be alert and sitting in the hallway alone by the nursing station in a wheelchair with a fall safety alarm attached. The resident appeared anxious and confused. The alarm control box was not flashing to indicate that it was functional. Nurse unit manager 'B' was asked to observe the alarm. She looked at the box and said, I don't think it is supposed to flash. When asked to look more closely at the control switch, nurse 'B' saw that the switch was set in the off position. When she turned the alarm on, the box beeped and began to flash appropriately. When asked why the alarm was turned off, nurse 'B' said, I don't know what to say. At 11 AM, a review of resident #99 's clinical record revealed that the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] noted that the resident had severe cognitive impairment, was non-ambulatory, and required extensive assistance for transfers. Fall Risk Evaluations dated 10/21/14 and 1/12/15 noted that the resident was at high risk. An 'At Risk for Falls' care plan dated 10/27/14 noted interventions that included: Chair/bed alarms, monitor function and placement every shift, change batteries every 30 days. Nursing notes dated 6/25/15 documented that the resident had a fall that day. On 7/29/15 at 2 PM, when informed that the resident's alarm was turned off and asked why, the Administrator did not respond. On 7/31/15 at 3 PM, the facility's Fall Management policy dated 8/2012 was reviewed and noted the following: -When a fall occurs, the staff must modify and implement care plan and treatment approaches to minimize repeat falls and the nurse aide assignment sheets and kardexes (care guides used by nurse aides) must be updated. -The facility is responsible for implementing individualized interventions related to/for each resident's fall risks. ( )

Based on observation, interview and record review the facility failed to implement individualized interventions to prevent the development of pressure ulcers for three sampled resident's (#'s 504, 506 and 512) of five residents reviewed for pressure ulcers from a total sample of 23, resulting in three facility acquired pressure ulcers. Findings include: During the initial tour of the " One South Nursing Unit" with Unit Manager (A) on [DATE] at 9 a.m., Resident #504 was observed lying in bed. During the tour, Unit manager (A) reported, Resident #504 had unstageable pressure ulcers/sore on the bilateral heels (Unstageable Pressure Ulcer -Full thickness tissue loss in which the base of the wound is covered by slough and or eschar (dead tissue usually black or brown). Unit Manager (A) further explained Resident # 504 ' s pressure sores had been recently acquired in the facility as a result of being left in bed all weekend. On [DATE] at 9:25 a.m., a dressing change and wound care observation was conducted for Resident #504 with Nurse (B). It was observed that resident #504 had pressure sores on the left and right heel. Nurse (A) described the pressures ulcers as unstageable with hard black caps (eschar tissue/dead tissue). The pressure ulcer on the left heel measured 6.0 cm (centimeters) and the pressure ulcer on the right heel measured 5.0 cm x 4.5 cm. Nurse (B) also reported Resident #504 ' s pressure ulcers were facility acquired as a result of being left in bed all weekend without pressure relief devices in place to alleviate pressure on Resident #504 ' s heels. On [DATE] at 1:30 p.m., record review for resident #504 was initiated and revealed the following: A " Weekly Pressure Ulcer " record dated, [DATE], revealed, a " ...new DTI ... (deep tissue injury/pressure ulcer) ... " was identified to resident ... " #504 ' s right heel. " ... reddened and non-blanchable ... " that measured, " ...5.0 x 4.5 cm ... " and a, " ...new DTI to resident ' s #504 ' s left heel that measured, " ...4.8 x 5.0 cm ... " The DTI was described as discolored, non-blanchable and painful to touch for Resident #504. An Ultra sound report for resident #504, dated [DATE], revealed " ...no evidence of [MEDICAL CONDITION] in bilateral lower extremities ... " A physician ' s wound care progress note dated [DATE], revealed Resident #504 had " ...Vesicle-Bulla (Deep Blister also known as Pressure Ulcer) to the right and left heels. The pressure ulcer on the right heel had been measured at 4.5 cm x 5.0 cm and the left heel had been measured at 6.5 cm x 4.5 cm. A physician ' s wound care progress note dated [DATE], revealed by [DATE], the pressure ulcer on Resident #504 ' s right heel had increased in size and measured 5.0 cm x 4.0 and the pressure ulcer on the left heel showed little progress with a measurement 6.0 x 4.0 cm. Further review of resident #504 ' s clinical record initiated on [DATE], at 10:00 a.m., revealed Resident #504 entered the facility without pressure ulcers on the heels, was at risk for the development of pressures ulcers, and the facility failed to develop and implement specific and individualized interventions to alleviate pressure on Resident #504 ' s heels to help prevent new pressure ulcers. The Nursing Admission assessment dated [DATE], revealed resident #504 was admitted into the facility without any pressures ulcers. The Admission Minimum (MDS) data set [DATE] and the Care Area Assessment (CAA) dated [DATE], revealed Resident #504 had no pressure ulcers but was at risk for the development of pressure ulcers related to immobility, altered mental status and incontinence. The CAA revealed resident #504 required extensive assistance with bed mobility. The most recent Braden Scale (a scale to determine risk for skin breakdown) dated, [DATE], and the quarterly Minimum Data Set, dated dated dated , [DATE], revealed Resident #504 had no pressure ulcers during that assessment period, but remained at risk. Further review of the "Care Plan- Pressure Ulcers Potential," for Resident # 504 revealed Resident #504 was risk at for the development of pressures sores related to " ...moisture /incontinence, deceased activity, impaired mobility, friction and shear problem ... " However, there were no specific and individualized interventions in place in the plan of care to prevent or alleviate pressure on Resident #504 ' s heels when the resident was in bed. On [DATE], at 10:00 a.m., an interview and record review was conducted with the Director of Nursing (DON) regarding the facility acquired unstageable pressure ulcers on Resident #504 heels. The DON was unable to explain why the facility failed to develop and implement specific and individualized interventions to alleviate pressure to Resident #504's heels to help prevent the development of new pressures ulcers. According to the face sheet record dated [DATE], resident #504 was admitted into the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set, dated dated dated , [DATE], revealed Resident #504 was severely cognitively impaired, and required extensive assist with bed mobility and transfers. ( ) On [DATE] at 2:30 p.m., resident #506 was observed up in the wheelchair in the room. A pressure relieving boot was noted on the left foot. On [DATE] at 3:00 p.m., record review revealed that the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set Assessment ((MDS) dated [DATE] indicated the resident's cognition was intact and required extensive assistance from staff for bed mobility. A Braden Scale (a scale to determine a resident's risk for skin breakdown) dated [DATE], documented that the resident was a "14" (moderate risk for skin breakdown). The initial "Pressure Ulcer" plan of care dated [DATE] indicated that the resident was a potential for skin break down with approaches of; pressure reduction devices to bed and wheelchair, turn and reposition while in bed frequently to comfort and pressure reduction, weekly body checks and monitor lab values. The admission nursing skin assessment dated [DATE] documented one plus [MEDICAL CONDITION] (small amount of swelling) to the left heel, but no skin breakdown. There was no documentation to float the resident's heels on the "Resident care Cardex Worksheet" ( a guide for the Certified Nurse Assistant's-CNA's for resident care needs). On [DATE] at 3:15 p.m., a physician's orders [REDACTED]." On [DATE] at 11:00 a.m., Unit Manager "A" was queried regarding the facility acquired pressure ulcer on the left heel of resident #506. She was asked that if a resident that required extensive assistance with bed mobility, had a [MEDICAL CONDITION] and was experiencing swelling on the affected side would be at risk for skin breakdown, she stated, "Yes, and that person should have they're heels floated to off load any pressure." When asked if resident #506 had his heels floated upon admission she stated, "Well since he got a deep tissue injury on his left heel, I'm assuming their (the direct care staff) weren't floating them. They obviously weren't floating his heels and he should have had a special low loss air mattress from the start." On [DATE] at 9:30 a.m., during a wound care observation with Staff Nurse "D", observation was made of the left heel. The heel had a black cap encapsulating it measuring 3.5 centimeters (cm) by 4.0 cm. On [DATE] at 1:30 p.m., Staff Nurse "D", who was the nurse who routinely worked with resident #506, was queried as to if the resident had his heels floated when he was first admitted into the facility and stated, "I can't remember if I saw his heels floated or not." On [DATE] at 9:15 a.m., (CNA) "E", who was the CNA who routinely worked with resident #506, was queried as to if the resident had his heels floated when he was first admitted and stated, "He wouldn't do anything at first. He was kind of tired and wouldn't move. In the morning when I came in his heels would be down in the mattress. He wouldn't move them." On [DATE] at 1:20 p.m., the DON was queried regarding the pressure ulcer for resident #506 and said that the facility had recognized that they have had an increase in facility acquired wounds. She said that they are trying to identify residents at risk for pressure ulcers and put interventions into place before the wound develops. "But with (resident #506), floating the heels would have been an intervention I would have expected because he was at high risk." On [DATE] at 9:30 A.M., Certified Nursing Assistant (CNA) "K" was queried regarding Resident #512's ability to move in bed without help, and stated, "She needs help on that." On [DATE] at 9:30 A.M., wound care for Resident #512 by Unit Manager (UM), Registered Nurse "I" was observed. The resident was lying in bed with eyes closed, mouth open with oxygen administered by nasal cannula. The resident did not assist with repositioning, and did not appear to move independently. UM "I" stated, "she's been dependent for eating (needed to be fed) but she's had a recent decline. She stopped eating, and didn't want to get out of bed. Her labs (laboratory results of blood tests)were off and her Blood Urea Nitrogen (BUN - a marker of kidney function) went up so we gave her intravenous (IV) fluids. She developed that pressure sore so quickly." Resident #512 was observed to have a dark blue/black circular discolored area at the back of the left heel, measuring 2.5 centimeters (cm) by 2.5 cm. When queried, UM "I" described the area on Resident #512's left heel as a "Deep Tissue Injury (DTI - pressure related damage to underlying tissues)." Two superficial wounds over Resident #512's coccyx were observed, measuring 1.5 cm by 0.1 cm with a pale pink base and 0.5 cm by 0.1 cm with yellow slough (moist dead tissue). UM "I" stated, "Those are new, her skin is starting to get fragile." On [DATE] at 10:00 A.M., Resident #512's clinical record was reviewed with UM "I" and revealed the following: A face sheet documented that Resident #512 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set assessment ((MDS) dated [DATE], documented that Resident #512 had severely impaired cognition, impaired ability to communicate and understand, needed extensive physical assistance for movement in bed, transfers to the wheelchair hygiene and toileting, did not walk, and was dependent on staff for eating and for mobility around the unit, and was incontinent of bowel and bladder. A Braden Scale assessment dated [DATE] documented that Resident #512 was at mild risk for developing pressure sores on that date, with a score of 15. The Braden scale documented that Resident #512 did not have the following risk factors at the time of the assessment: "bedfast (confined to bed)", "very limited mobility (unable to make frequent or significant changes independently)", "Nutrition; very poor" or "probably inadequate". A Nursing Care Plan for Resident #512 entitled, "pressure Ulcers", dated [DATE] (last updated on [DATE]), contained instructions (interventions) to, "reposition in chair frequently for comfort and pressure reduction", and "Turn and reposition while in bed frequently for comfort and pressure reduction." There were no documented interventions to reduce pressure on the resident's heels in bed. A Nursing Care Plan for Resident #512 entitled "Activities of Daily Living", dated [DATE], noted, "mobility limits", "cognitive limits", and "extensive assistance". "Related factors on the care plan were documented as, "Immobility" and "Dementia." A Resident Care Cardex Worksheet (CNA care guide) for Resident #512, dated [DATE], documented that Resident #512 required extensive assistance for mobility and was "at risk for pressure ulcers". A "SBAR Communication Form" (used by facility to notify physician of a change in condition) for Resident #512, dated [DATE] documented, "lethargy, shaking". A physician's orders [REDACTED]." when queried about this, UM "I" stated, "She wasn't eating or drinking so we were worried about dehydration." A physician's orders [REDACTED].M." When asked at this time whether a resident's risk of developing a pressure sore would increase if they became lethargic, were not eating or drinking, had possible dehydration, and became bedfast , UM "I" stated, "yes." When asked whether a resident who needed extensive physical assistance from staff for mobility in bed should have interventions to off load pressure from the heels, UM "I" stated, "yes." A "SBAR Communication Form" for Resident #512, dated [DATE] documented, "left heel wound dark purple 2.5 cm by 2.5 cm" and, "Things that make the condition or symptom worse are "not floating heels". When queried about this, UM "I" stated, "She declined suddenly. Before ([DATE]) she was up in her chair for most of the day. She had a Urinary Tract Infection [MEDICAL CONDITION]. She stopped eating and didn't want to get out of bed." UM "I" was requested to provide documentation that Resident #512's heels were elevated when in bed prior to development of the left heel area, but this was not provided prior to survey exit. An "Evaluation Request Form" for Resident #512, dated [DATE] noted the "problem" as an "Unable To Determine (UTD - unable to determine how deep the pressure ulcer is)" on the left heel." On [DATE] at 10:20 A.M. the Director of Nursing (DON) was interviewed and stated, "A Resident who needed extensive assistance for bed mobility should have interventions to elevate the heels when in bed. I've always told staff if somebody is in the bed for more than eight hours, offload (elevate) the heels. We've realized that this is an issue." On [DATE] at 1:30 P.M., The Wound Care Consultant Physician's Nurse Practitioner (NP) "H", was interviewed and stated, "If needing extensive assistance for bed mobility, the heels should be elevated in bed even if the Braden is not high risk. If someone has a decline and becomes bedridden for even for one to two days, they should off load heels." On [DATE] at 2:00 p.m., review of the facility's "Skin Management" policy with a revision date of [DATE], documented; "Residents who are a risk or with wounds and/or pressure ulcers and those at risk for skin compromise are identified, assessed and provided appropriate treatment to encourage healing and/or integrity. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes." ( , , )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO MONITOR THE RESIDENT'S MULTIPLE UNINTENDED REMOVALS OF A [MEDICAL CONDITION] AND FAILED TO REINSERT A DISLODGED [MEDICAL CONDITION] THAT HAD BEEN OUT FOR AT LEAST 35 MINUTES FOR ONE (#308) OF ONE SAMPLED RESIDENT REVIEWED WITH A [DIAGNOSES REDACTED]. THE IJ WAS IDENTIFIED ON 8/17/12 AT 8 AM. THE ADMINISTRATOR WAS NOTIFIED OF THE IJ ON 8/17/12 AT 2:25 PM. A PLAN OF CORRECTION WAS REQUESTED TO REMOVE THE IJ. THE IJ WAS REMOVED ON 8/17/12 BASED ON THE FACILITY'S IMPLEMENTATION OF CORRECTIVE ACTIONS ON 8/17/12, AS VERIFIED ONSITE BY THE SURVEY TEAM. ALTHOUGH THE IJ WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE WAS NOT CORRECTED AND REMAINED AS ISOLATED, NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY. FINDINGS INCLUDE: ON 8/15/12 AT 9:35 AM, RESIDENT #308 WAS OBSERVED IN THE PRESENCE OF NURSE 'F' IN BED WITH A [MEDICAL CONDITION] FEEDING TUBE AND A [MEDICAL CONDITION] IN PLACE. THERE WAS NO EMERGENCY [MEDICAL CONDITION] OBSERVED IN THE ROOM. WHEN QUERIED, NURSE 'F' STATED THAT THE [MEDICAL CONDITION] WAS USUALLY KEPT ABOVE THE RESIDENT'S BED IN A WALL BRACKET. RESIDENT #308 WAS OBSERVED WEARING A MITT RESTRAINT OVER THE RIGHT HAND. THE MITT RESTRAINT PROVIDED THICK PADDING IN THE PALM OF THE HAND TO PREVENT THE FINGERS FROM BENDING ENOUGH TO GRASP ITEMS. THE MITT WAS THEN COVERED WITH A SOCK USED AS A PROTECTIVE SLEEVE TO PREVENT THE MITT FROM COMING OFF AND TO PREVENT THE PADDING FROM SHIFTING AWAY FROM THE PALM. NURSE 'F' STATED THAT THE RESIDENT HAD THE MITT RESTRAINT BECAUSE HE HAD A TENDENCY "TO PULL" AT [MEDICAL CONDITIONS] FEEDING TUBES. ON 8/16/12 AT 9 AM, RESIDENT #308 WAS OBSERVED IN BED WITH THE HAND MITT AND PROTECTIVE SOCK ON THE RIGHT HAND, AND [MEDICAL CONDITION] IN PLACE. THE RESIDENT WAS ALERT, NON-VERBAL, AGITATED, AND AGGRESSIVE. HE WAS UNABLE TO MOVE EXTREMITIES ON THE LEFT SIDE. THE RESIDENT WAS THRASHING THE RIGHT LEG AND ARM, AND REPEATEDLY RAISING THE RIGHT LEG WITH FORCE, HIGH ABOVE THE BED AND THEN SLAMMING IT DOWN ON THE MATTRESS. ON SEVERAL OCCASIONS, THE RESIDENT SUDDENLY RAISED HIS RIGHT FOOT AND KICKED AIDE 'H' IN THE BACK AND ON THE HEAD AS THE AIDE WAS PROVIDING CARE. ON 8/17/12 AT 8:45 AM, RESIDENT #308 WAS ALERT, AGGRESSIVE, AND AGITATED IN BED WITH THE HAND MITT ON. THERE WAS NO SOCK OR SLEEVE OVER THE MITT. THE PADDING FOR THE PALM AREA OF THE MITT HAD SHIFTED OUT OF PLACE ALLOWING THE RESIDENT TO USE HIS FINGERS FOR GRASPING. THE RESIDENT'[MEDICAL CONDITION], WHICH WAS A DOUBLE LUMEN TUBE (AN INNER CANNULA (TUBE) LOCKED INSIDE AN OUTER CANNULA), WAS OBSERVED OUT AND IT WAS LAYING ON TOP OF A CHEST OF DRAWERS, NEXT TO THE TELEVISION, ACROSS THE ROOM FROM THE RESIDENT, WITH THE TIES STILL ATTACHED USED TO SECURE THE TUBE IN PLACE. THE RESIDENT HAD A GAPING HOLE IN HIS THROAT AT THE [MEDICAL CONDITION] SITE AND RATTLING RESPIRATIONS COULD BE HEARD FROM A BUILD-UP OF MUCOUS THAT COULD BE SEEN JUST INSIDE OF THE OPENING. THE ASSISTANT DIRECTOR OF NURSING (ADON) OBSERVED RESIDENT #308'S [MEDICAL CONDITION] RESTING ON TOP OF THE CHEST OF DRAWERS. THE ADON STATED, "HE (RESIDENT) REMOVES THE TUBE." WHEN ASKED HOW THE TUBE ENDED UP ON TOP OF THE CHEST, THE ADON LEFT THE ROOM WITHOUT THE TUBE RE-INSERTED AND STATED, "I WILL FIND OUT." THE ADON RETURNED AND STATED, "THE AIDE ('H') SAID THAT HE (RESIDENT) PULLED IT (TRACH TUBE) OUT AND THREW IT ON THE FLOOR, SO SHE PICKED IT UP AND PUT IT THERE (ON THE CHEST) AND TOLD THE NURSE ('G'). THE ADON IMMEDIATELY SUMMONED NURSE 'G,' WHO WAS STILL IN THE BUILDING FROM THE PREVIOUS MIDNIGHT SHIFT IN WHICH SHE WAS RESIDENT #308'S ASSIGNED NURSE. THE ADON LEFT THE AREA TO GET AIDE 'H.' WHEN QUERIED REGARDING WHY THE RESIDENT'[MEDICAL CONDITION] WAS NOT RE-INSERTED AFTER BEING TOLD IT WAS OUT BY AIDE 'H,' NURSE 'G' STATED, "I DIDN'T KNOW IT WAS OUT. I DID NOT HEAR HER SAY IT WAS OUT." AIDE 'H' WAS QUERIED REGARDING [MEDICAL CONDITION] BEING OUT, IN THE PRESENCE OF NURSE 'G' AND THE ADON AND REPORTED SHE ENTERED RESIDENT #308'S ROOM "AROUND 8 (AM)," SAW [MEDICAL CONDITION] ON THE FLOOR, AND TOLD NURSE 'G.' NURSE 'G' REPEATED, "I DIDN'T HEAR YOU TELL ME THAT." THE ADON WAS UNABLE TO EXPLAIN WHY THE RESIDENT'[MEDICAL CONDITION] WAS STILL OUT AND LAYING ON THE CHEST WITH NO ONE ATTEMPTING TO RE-INSERT IT. NURSE 'G' SAID UPON FURTHER INTERVIEW STTATED, "I SAW HER (AIDE 'H') COME OUT OF THE ROOM AND ASKED HER IF HE (RESIDENT #308) PULLED OUT HIS TUBE AGAIN. I DIDN'T HEAR HER RESPONSE, SO I ASSUMED IT WAS OKAY." NURSE 'G' REPORTED THAT THE RESIDENT HAD PULLED OUT [MEDICAL CONDITION] THREE TIMES DURING THE MIDNIGHT SHIFT, WHICH SHE REPLACED TWICE AND REPLACED IT THE THIRD TIME WITH THE ASSISTANCE OF DAY SHIFT NURSE 'F'. NO ONE WAS SEEN GOING INTO RESIDENT 308'S ROOM TO RE-INSERT THE RESIDENT'[MEDICAL CONDITION] UNTIL 9:20 AM, WHEN NURSE 'F' AND NURSE 'G' WERE OBSERVED RE-INSERTING THE TUBE, 35 MINUTES AFTER THE TUBE WAS FIRST OBSERVED OUT (AT 8:45 AM). WHEN QUERIED, DAY SHIFT NURSE 'F' STATED, "WHEN I CAME ON THIS MORNING A LITTLE AFTER 7 (AM), ME AND (NURSE 'G') PUT IT (TRACH TUBE) BACK IN, BUT HE KEPT PULLING IT OUT. IT HAPPENED ABOUT FOUR TIMES WHILE I WAS STANDING HERE." RESIDENT #308 WAS THEN OBSERVED PULLING AT [MEDICAL CONDITION]. NURSE 'F' STATED, "SEE, THERE HE GOES AGAIN." THERE WAS NO SOCK OR SLEEVE OVER THE MITT THAT HAD SHIFTED OUT OF PLACE. WHEN ASKED WHY THERE WAS NO SOCK TO SECURE THE MITT, NURSE 'F' STATED, "I WAS TOLD BY THE DIRECTOR OF NURSING (DON) NOT TO USE A SOCK BECAUSE IT WAS INAPPROPRIATE," SO THE SOCK WAS REMOVED AND NOT REPLACED WITH AN APPROPRIATE SLEEVE. THE RESIDENT WAS STILL AGITATED AND ACTIVE. AT 9:45 AM, NURSE 'F' AND AIDE 'H' WERE OBSERVED IN THE HALLWAY PASSING BACK AND FORTH BY RESIDENT #308'S ROOM, ATTENDING TO OTHER RESIDENTS. UPON RE-ENTRY INTO RESIDENT #308'S ROOM, THE RESIDENT'[MEDICAL CONDITION] WAS OBSERVED OUT AND LAYING ON THE FLOOR SAFETY MAT WITH NO STAFF PRESENT. THE RESIDENT WAS ALERT, AGITATED, BANGING HIS RIGHT LEG ON THE MATTRESS, AND HAD RATTLING MUCOUS AT THE THROAT AREA. THE HAND MITT WAS ON WITH NO PROTECTIVE SLEEVE AND THE PALM PADDING WAS OUT OF PLACE. THERE WAS NO [MEDICAL CONDITION] AT THE BEDSIDE FOR REPLACEMENT. THE NURSES STATION WAS IMMEDIATELY APPROACHED IN SEARCH OF ASSISTANCE. THE ADON WAS SEATED AT THE DESK. THE ADON ENTERED RESIDENT #308'S ROOM AND OBSERVED THE TUBE LAYING ON THE MAT. WHEN QUERIED ABOUT THE RESIDENT BEING LEFT UNATTENDED, IN A STATE OF AGITATION, WITH NO SLEEVE ON THE HAND MITT, AND NO [MEDICAL CONDITION], THE ADON STATED, "I'M GOING TO GIVE HIM A PRN (AS NEEDED) [MEDICATION NAME] (FOR ANXIETY/AGITATION) RIGHT NOW" AND LEFT THE ROOM WITHOUT THE TUBE RE-INSERTED. A REVIEW OF THE RESIDENT'S MEDICATION ADMINISTRATION RECORDS (MARS) REVEALED THAT THERE WAS NO ORDER FOR PRN [MEDICATION NAME]. AT 11:15 AM, AIDE 'H' WAS QUERIED REGARDING DETAILS OF RESIDENT #308'[MEDICAL CONDITION] BEING OBSERVED DISLODGED AT 8:45 AM. THE AIDE STATED, "I WENT INTO THE ROOM AND SAW THE TUBE ON THE FLOOR, SO I PICKED IT UP. HE (RESIDENT) HAD SHREDDED HIS DIAPER (INCONTINENT BRIEF), SO I LEFT AND GOT SUPPLIES, WENT BACK IN AND CLEANED HIM UP, AND ANSWERED A (CALL) LIGHT. I SAW (NURSE 'G') OUTSIDE THE ROOM AND TOLD HER THAT THE TUBE WAS OUT (ABOUT 8 AM)." WHEN ASKED WHY SHE GOT SUPPLIES, PROVIDED CARE, AND ANSWERED A CALL LIGHT BEFORE TELLING THE NURSE ABOUT THE TUBE BEING OUT, AIDE 'H' THEN SAID, "NO, I TOLD THE NURSE FIRST (BEFORE PROVIDING CARE) AND THEN I CLEANED HIM (RESIDENT) UP. I THOUGHT SHE (NURSE 'G') WAS COMING RIGHT BACK." WHEN ASKED WHY SHE PROCEEDED WITH CARE WHILE [MEDICAL CONDITION] WAS OUT, AIDE 'H' SAID, "I SUPPOSED I SHOULD HAVE WAITED." AIDE 'H' REPORTED THAT NURSE 'G' DID HEAR HER SAY (AT 8 AM) THAT THE RESIDENT'S TUBE WAS OUT BECAUSE THE NURSE SAID "OKAY" WHEN INFORMED. WHEN QUERIED ON 8/17/12 AT 11:30 AM ABOUT RESIDENT #308 NOT HAVING THE SOCK OVER THE MITT TO SECURE IT, THE DON SAID, "I TOLD (NURSE 'G') A SOCK WAS INAPPROPRIATE." THE DON WAS UNABLE TO STATE WHY THE SOCK WAS REMOVED AND NOT REPLACED WITH A SLEEVE OR SOME OTHER PROTECTIVE DEVICE. AT 11:45 AM, RESIDENT #308'S Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. THE MARS NOTED THAT THE RESIDENT WAS SUPPOSED TO HAVE HIS PULSE OXYMETRY (OXYGEN) LEVEL CHECKED EVERY SHIFT. THERE WAS NO PULSE OX DOCUMENTED BY NURSE 'G' DURING THE MIDNIGHT SHIFT OR BY NURSE 'F' ON THE DAY SHIFT ON 8/17/12 DURING THE NUMEROUS TIMES THAT [MEDICAL CONDITION] WAS OUT THAT MORNING. WHEN QUERIED, NURSE 'F' STATED, "IT WAS NOT CHECKED" AND WAS UNABLE TO EXPLAIN WHY. THE RESIDENT WAS OBSERVED IN BED WITH [MEDICAL CONDITION] AND THE HAND MITT IN PLACE, WHICH WAS AT THAT TIME, SECURED WITH A STRETCH, MESH COVERING. A REVIEW OF RESIDENT #308'S CLINICAL RECORD REVEALED: THE RESIDENT WAS admitted on [DATE] WITH [DIAGNOSES REDACTED]. THE MDS NOTED THAT THE RESIDENT HAD SEVERE COGNITIVE IMPAIRMENT AND WAS TOTALLY DEPENDENT FOR ALL ACTIVITIES OF DAILY LIVING. RESIDENT #308'S physician's orders [REDACTED]. [MEDICATION NAME] DAILY FOR DEMENTIA. [MEDICATION NAME] 1 MILLIGRAM (MG) EVERY SIX HOURS FOR ANXIETY/AGITATION. [MEDICATION NAME] 25 MG TWICE A DAY AND 50 MG AT NIGHT (ANTIPSYCHOTIC). PULSE OX LEVELS EVERY SHIFT AND RECORD RESULTS. RIGHT HAND MITT TO BE WORN AROUND THE CLOCK TO PREVENT REMOVAL [MEDICAL CONDITION] FEEDING TUBES. THE CARE PLANS FOR RESIDENT #308 NOTED THE FOLLOWING: 1. "RESPIRATORY RISK" CARE PLAN DATED 5/16/12 RELATED TO [MEDICAL CONDITIONS], AND HISTORY OF [MEDICAL CONDITION]. INTERVENTIONS INCLUDED-"APPROPRIATE EQUIPMENT AT BEDSIDE FOR EMERGENCY USE" AND "PULSE OXIMETRY AS INDICATED." 2. "RESTRAINT" CARE PLANS DATED 11/11/11 AND 5/16/12 FOR RIGHT HAND MITT DUE TO "ATTEMPTS TO REMOVE TRACH-HAD REMOVED IN THE PAST." INTERVENTIONS INCLUDED-"MONITOR BEHAVIOR/RESPONSE TO RESTRAINT." 3. "BEHAVIORAL SYMPTOMS" AND "DEPRESSION/ANXIETY/SAD MOOD" CARE PLANS DATED 11/11/11 AND 5/16/12 DUE TO "REPETITIVE PHYSICAL MOVEMENTS," "HITTING, KICKING AT TIMES," AND "RESISTS CARE." INTERVENTIONS INCLUDED-"REVIEW DRUG REGIME...." 4. "PSYCHOACTIVE MEDICATION" CARE PLANS DATED 11/11/11 AND 5/16/12 RELATED TO [MEDICAL CONDITION], DEMENTIA WITH BEHAVIORS, KICKING, HITTING, RESTLESSNESS, CALLING OUT, AGITATION, REMOVAL [MEDICAL CONDITION] FEEDING TUBE. INTERVENTIONS INCLUDED-"OBSERVE FOR MEDICATION EFFECTIVENESS....GLOVE (MITT) ON RIGHT HAND FOR PROTECTION AGAINST REMOVING [MEDICAL CONDITION] FEEDING TUBE." ON 8/21/12 AT 10:45 AM AND 12:45 PM, RESIDENT #308'S PCP AND MEDICAL DIRECTOR, WERE INTERVIEWED RESPECTIVELY BY PHONE. WHEN QUERIED REGARDING THE RESIDENT'S AGITATION AND REPEATEDLY PULLING OUT [MEDICAL CONDITION], THE PCP DID NOT RESPOND. THE MEDICAL DIRECTOR SAID, "I FOUND OUT LAST WEEK" ABOUT THE RESIDENT REMOVING [MEDICAL CONDITION]. ON 8/21/12, THE FACILITY'S POLICIES AND PROCEDURES WERE REVIEWED. AT 1 PM, THE ADMINISTRATOR STATED THAT THE FACILITY HAD REVISED ITS' POLICIES RELATED TO [MEDICAL CONDITION], HOWEVER, THERE WAS NO AVAILABLE FACILITY POLICY. THE STAFF DEVELOPMENT COORDINATOR AND THE DON HAD BEEN QUERIED EARLIER AT 10:30 AM AND AT 11:50 AM, REGARDING THE FACILITY'S POLICY [MEDICAL CONDITION]. THE FACILITY USED A NURSING TEXTBOOK (LIPPINCOTT 5TH EDITION) PRESENTED BY THE STAFF DEVELOPMENT COORDINATOR AS ITS POLICY WHICH NOTED: -TRACH CARE ENSURES AIRWAY PATENCY BY KEEPING THE TUBE FREE OF MUCUS BUILDUP, TO PREVENT INFECTION, TO MAINTAIN MUCOUS MEMBRANES AND SKIN INTEGRITY, AND TO PROVIDE PSYCHOLOGICAL SUPPORT. -SUPPLIES, INCLUDING [MEDICAL CONDITION], MUST BE "IN FULL VIEW IN THE RESIDENT'S ROOM AT ALL TIMES FOR EASY ACCESS IN CASE OF EMERGENCY." CONSIDER TAPING/MOUNTING AN [MEDICAL CONDITION] ABOVE THE HEAD OF THE BED IN CASE OF EMERGENCY. -"DON'T REMOVE THE [MEDICAL CONDITION] ENTIRELY BECAUSE THIS MAY ALLOW THE AIRWAY TO CLOSE COMPLETELY....REFRAIN FROM CHANGING....THE OUTER CANNULA OF A DOUBLE CANNULA TUBE BECAUSE OF THE RISK OF TRACHEAL COMPLICATIONS. THE DOCTOR USUALLY CHANGES THE CANNULA." COMPLICATIONS INCLUDE "BLOOD VESSEL EROSION AND HEMORRHAGE." THE IJ WAS REMOVED ON 8/17/12 WHEN THE FOLLOWING PLAN OF CORRECTION WAS SUBMITTED: THE RESIDENT IDENTIFIED DURING THE SURVEY AS REMOVING THE INNER CANNULA FROM [MEDICAL CONDITION] SUFFERED NO RESPIRATORY DISTRESS AS A RESULT OF DELAYED ACTION BY THE NURSE. AT APPROXIMATELY 8:45 AM THE CHARGE NURSE WAS NOTIFIED AND RE-INSERTED THE RESIDENT ' S INNER CANNULA WITHOUT DIFFICULTY. RESPIRATORY ASSESSMENT WAS COMPLETED AT THAT TIME AND SHOWED NO RESPIRATORY DISTRESS. THE LUNGS CLEAR TO AUSCULTATION, WITH MILD SECRETIONS REQUIRING SUCTIONING, AND AN OXYGEN SATURATION LEVEL OF 92 %. THE RESIDENT HAS A ROUTINE ORDER FOR [MEDICATION NAME] 6 AM AND 12 PM, AND RECEIVED THE 6 AM DOSE PER SCHEDULE. LICENSED STAFF WAS PLACED 1:1 WITH THE RESIDENT BEGINNING AT 9:30 AM THROUGHOUT THE BALANCE OF THE DAY SHIFT ON 8.17.12, UNTIL IT WAS OBSERVED THAT AGITATION HAD RESOLVED. ON 8.17.12 AT APPROXIMATELY 3:30PM 1:1 WAS REMOVED FROM THE RESIDENT, AS HE WAS SHOWING NO SIGN OF AGITATION OR RESPIRATORY DISTRESS. BEGINNING AT 3:30PM ON 8.17.12 AND ONGOING THE RESIDENT WAS PLACED ON 15 MINUTE CHECKS FOR CONTINUED MONITORING FOR SIGNS OF AGITATION. ON 8.17.12 THE RESIDENT WAS RE-EVALUATED BY SENIOR WELLNESS GROUP AND AN ORDER WAS OBTAINED FOR [MEDICATION NAME] 0.5MG EVERY 3 HOURS AS NEEDED FOR AGITATION. MAY GIVE AFTER SCHEDULED DOSE IF NEEDED, FOR 2 WEEKS AND THEN RE-EVALUATE. THE RESIDENT ' S ATTENDING PHYSICIAN WAS CONTACTED ON 8.17.12 AND COMPLETED A RESPIRATORY EVALUATION. THE RESIDENT ' S PLAN OF CARE AND CARE CARDEX HAS BEEN REVIEWED AND REVISED TO REFLECT THE CHANGES. [MEDICAL CONDITION] KITS AND NEEDED SUPPLIES HAVE BEEN PUT IN THE RESIDENT ' S ROOM WITH THE EXISTING EMERGENCY [MEDICAL CONDITION] KIT AND AMBU BAG AT THE RESIDENT ' S BEDSIDE. NO OTHER RESIDENTS RESIDE IN THE CENTER HAVE TRACHEOSTOMIES AT THIS TIME. THE FACILITY POLICY REGARDING [MEDICAL CONDITION] CARE HAS BEEN REVIEWED BY THE INTERDISCIPLINARY TEAM AND DEEMED TO BE APPROPRIATE FOR THE FACILITY ' S USE. THE NURSE WHO FAILED TO RESPOND HAS BEEN SUSPENDED PENDING FURTHER INVESTIGATION. THE RESIDENT CARE SPECIALIST IDENTIFIED AS PROVIDING CARE TO THE RESIDENT DURING THIS INCIDENT HAS BEEN RE-EDUCATED REGARDING CESSATION OF CARE AND IMMEDIATE NOTIFICATION IN THE EVENT THAT A RESIDENT ' S INNER CANNULA BECOMES DISLODGED. SHE HAS ALSO RECEIVED EDUCATION REGARDING HER RESPONSIBILITY TO CONTACT THE DIRECTOR OF NURSING OR ANOTHER NURSE SUPERVISOR IF A NURSE DOES NOT RESPOND TO HER REQUEST FOR ASSISTANCE. ON 8.17.12 THE DIRECTOR OF NURSES OR DESIGNEE WILL EDUCATE ALL STAFF REGARDING IMMEDIATE NOTIFICATION TO LICENSED NURSE PERSONNEL WHEN [MEDICAL CONDITION] RESIDENTS ARE OBSERVED WITH RESPIRATORY CONCERNS, INCLUDING REMOVAL AND OR DISLODGED INNER CANNULA. NURSES WERE REMINDED OF THEIR RESPONSIBILITY TO RESPOND TO SUCH EVENTS IMMEDIATELY AND ARE TO REPORT TO A SUPERVISOR IF A RESPONSE IS NOT INITIATED IMMEDIATELY. EDUCATION WILL CONTINUE UNTIL ALL STAFF HAS BEEN EDUCATED. STAFF THAT HAS NOT RECEIVED EDUCATION WILL NOT BE ALLOWED TO RESUME WORK RESPONSIBILITIES UNTIL SUCH EDUCATION HAS BEEN COMPLETED ON 8.17.12 AN AD HOC SUBCOMMITTEE OF THE QUALITY ASSURANCE AND ASSESSMENT COMMITTEE MET TO DISCUSS AND APPROVE THIS PLAN. A TELECONFERENCE WAS HELD WITH THE MEDICAL DIRECTOR ON 8.17.12 AT APPROXIMATELY 3:45 PM TO DISCUSS DETAILS OF THE ABOVE PLAN. THE PLAN WAS DISCUSSED IN ITS ENTIRETY AND APPROVED BY THE MEDICAL DIRECTOR ON 8.17.12 THE COMMITTEE WILL MEET ON A WEEKLY BASIS FOR ONE MONTH AND MONTHLY THEREAFTER. FINDING FROM THE RESULTS OF AUDITS AND OVERSIGHT WILL BE REPORTED TO COMMITTEE ON A MONTHLY BASIS. THE COMMITTEE WILL MAKE RECOMMENDATIONS FOR POLICY CHANGES OR FURTHER EDUCATION WHERE NECESSARY. ( ) ( ) ( ) ( ) ( )

THIS CITATION WAS THREE DEFICIENT PRACTICES DEFICIENT PRACTICE #1 BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ONE TO ONE SUPERVISION FOR A RESTLESS AND AGITATED RESIDENT FOR ONE (#313) OF 14 SAMPLED RESIDENTS REVIEWED FOR ACCIDENTS OUT OF A TOTAL SAMPLE OF 25, RESULTING IN A FALL WITH FRACTURE. FINDINGS INCLUDE: ON 8/15/12 AT 8:50 A.M., DURING AN INITIAL TOUR OF THE FACILITY, RESIDENT #313 WAS OBSERVED SITTING IN A WHEELCHAIR NEAR THE NURSES STATION. A LAP TRAY RESTRAINT WAS ATTACHED TO THE WHEELCHAIR. THE RESIDENT DID NOT RESPOND TO QUESTIONS. ON 8/16/12 A REVIEW OF INCIDENT AND ACCIDENT (I/A) REPORTS FOR RESIDENT #313 REVEALED THAT THE RESIDENT HAD FALLS ON 12/13/11, 1/30/12, 4/9/12, AND 5/22/12 WITH NO INJURIES OR MINOR BRUISING. A FALL ON 6/11/12 RESULTED IN A FRACTURED RIGHT HIP FROM AN UNWITNESSED FALL. REVIEW OF A NURSES NOTES DATED 6/11/12 AT 12 AM-"RESIDENT RESTLESS, TRYING TO GET OUT OF BED SEVERAL TIMES....TRIES TO STAND, BED ALARM HAS SOUNDED...." 3 AM-RESIDENT UP IN WHEELCHAIR AT NURSES DESK FOR SAFETY." PER WRITTEN INVESTIGATION DATED 6/12/12 DOCUMENTED BY THE ASSISTANT DIRECTOR OF NURSING (ADON): "RESIDENT FOUND LYING ON THE FLOOR ON HER RIGHT SIDE BEHIND THE NURSES DESK...." ANALYSIS-"(RESIDENT) HAD BEEN RESTLESS AND STAFF HEARD HER BED ALARM RINGING AROUND 4:30 (AM). (NURSE AIDE 'R')....HAD TAKEN (RESIDENT) BEHIND NURSES DESK WHERE THE NURSE (NURSE 'Q') WAS WORKING. THE WHEELCHAIR BRAKES WERE LOCKED....THE NURSE ('Q') LEFT THE DESK TO PROVIDE CARE FOR ANOTHER RESIDENT....WHEN THE NURSE ('Q') WAS RETURNING TO THE DESK, SHE AND THE (AIDE 'R') HEARD A NOISE AND THE WHEELCHAIR ALARM RINGING....THEY WENT IMMEDIATELY AND FOUND (THE RESIDENT) LYING ON HER SIDE....(THE RESIDENT) IS ALERT BUT VERY CONFUSED. SHE BECOMES ANXIOUS....SHE HAS POOR SAFETY AWARENESS AND IMPULSIVE BEHAVIOR. THE STAFF FOUND THE WHEELCHAIR PUSHED ABOUT 12 INCHES AWAY FROM THE DESK, BRAKES STILL LOCKED AND IN AN UPRIGHT POSITION WITH THE ALARM RINGING. RESIDENT WAS LYING BESIDE THE CHAIR." REVIEW OF A WRITTEN INTERVIEW DATED 6/11/12 WITH NURSE 'Q' DOCUMENTED: "....I WAS THERE QUITE AWHILE WITH (THE RESIDENT), TOOK THE (MEDICATION) CART, AND WENT AROUND THE CORNER. (NURSE 'Q' WAS ASKED) DID IT OCCUR TO YOU TO TAKE (THE RESIDENT) WITH YOU? (ANSWER)-IT DID BUT (THE RESIDENT) SEEMED TO BE OK. I'M DOING (ANOTHER RESIDENT'S) TUBE FEEDING AND SHE (THE RESIDENT) CAN'T BE THERE. HAVING HER PARKED AT NURSES DESK, WHEELS LOCKED, SHE SHOULD HAVE BEEN SAFE. SHE NEEDS A TRAY TABLE (RESTRAINT)....THE ONLY THING THAT WILL KEEP HER SAFE IS A TRAY TABLE. IT IS IMPOSSIBLE TO DO 1 TO 1 (SUPERVISION) THROUGHOUT THE NIGHT. I HAVE TO DO TRACH CARE AND TUBE FEEDINGS. THE (RESIDENT) REQUIRES A LOT OF CARE. I DIDN'T HAVE TIME TO CHECK CARE PLANS OR ANYTHING ELSE." REVIEW OF A WRITTEN INTERVIEW DATED 6/11/12 WITH AIDE 'R' DOCUMENTED: "DURING THE NIGHT (THE RESIDENT) HAD BEEN TRYING TO GET UP. WE HAD BEEN PUTTING HER BACK TO BED. AROUND 4:30 AM....HER ALARM WAS RINGING....I WENT AHEAD WASHED HER, GOT HER DRESSED, AND TOOK HER TO THE NURSES STATION AT 5 AM. NURSE ('Q') WAS SITTING AT THE DESK. I LEFT THE DESK BECAUSE I WAS PASSING MY ICE WATER. I CAME OUT OF A ROOM NEAR THE END OF THE HALL AND WAS WALKING TOWARD THE NURSES STATION. AT THE SAME TIME, THE NURSE ('Q') WAS PUSHING HER CART DOWN THE HALL. I BELIEVE SHE HAD STARTED PASSING HER MEDS." AIDE 'R' AND NURSE 'Q' HEARD A NOISE, CAME TO THE DESK, AND FOUND THE RESIDENT ON THE FLOOR. RESIDENT #313 COMPLAINED OF "RIGHT HIP PAIN" FOLLOWING THE FALL. REVIEW OF AN X-RAY REPORT OF THE RIGHT HIP DATED 6/11/12 REVEALED: "ACUTE NONDISPLACED INTERTROCHANTERIC FEMORAL FRACTURE." PER REVIEW OF THE CLINICAL RECORD FOR RESIDENT #313: THE RESIDENT WAS ORIGINALLY admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. DISORDER PER THE ADMISSION FACE SHEET. THE RESIDENT WAS readmitted FOLLOWING hospitalized from [DATE] THRU 6/15/12 FOR THE HIP FRACTURE. THE MINIMUM DATA SET ((MDS) dated [DATE] DOCUMENTED THAT THE RESIDENT REQUIRED EXTENSIVE ASSISTANCE WITH BED MOBILITY AND TRANSFERS FROM WHEELCHAIR, BED, AND CHAIR, THAT SHE WALKED IN THE CORRIDOR ONLY ONCE OR TWICE, AND HAD MODERATELY IMPAIRED COGNITION. A REVIEW OF FALL RISK ASSESSMENTS FOR RESIDENT #313 DATED 11/15/11, 2/7/12, AND 5/3/12 NOTED THAT THE RESIDENT WAS AT HIGH RISK FOR FALLS WITH SCORES OF 12-14. A SCORE OF 10 OR MORE=HIGH RISK. REVIEW OF RESIDENT #313'S "POTENTIAL FOR INJURY" AND "RISK FOR FALLS" CARE PLANS, DATED 5/3/11 THROUGH THE LAST UPDATE ON 5/22/12 PRIOR TO THE HIP FRACTURE, INCLUDED: -IF RESIDENT BECOMES AGITATED PROVIDE ONE TO ONE CARE. RESIDENT NOT TO BE LEFT ALONE IN SHOWER ROOM. 15 MINUTE CHECKS. FREQUENT TOILETING. ON 8/16/12 AT 3:30 P.M., THE DIRECTOR OF NURSES (DON) WAS INTERVIEWED REGARDING RESIDENT #313'S FALL. WHEN QUERIED AS TO WHY THE RESIDENT WAS LEFT WITHOUT SUPERVISION BEHIND THE NURSES STATION, THE DON STATED, "THEY SAID (RESIDENT #313) WAS CALM, BUT YOU CAN'T LEAVE HER LIKE THAT. THEY TOLD ME (THE RESIDENT) WAS IN THE WHEELCHAIR, AND THE NEXT TIME THEY SAW (THE RESIDENT) SHE WAS ON THE FLOOR. THAT WAS NOT APPROPRIATE FOR (THE RESIDENT) TO BE LEFT ALONE." ON 8/17/12 AT 1:08 P.M., THE ADON WAS INTERVIEWED REGARDING RESIDENT #313'S FALL. WHEN QUERIED, THE ADON STATED, "THE CARE PLAN SAYS NOT TO LEAVE (THE RESIDENT) ALONE WHEN AGITATED, BUT I ASKED THE NURSE, WHY DIDN'T YOU TAKE HER WITH YOU AND JUST PARK HER OUTSIDE THE DOOR OF THE RESIDENT'S ROOM YOU WERE GOING TO? YOU COULD HAVE KEPT AN EYE ON HER THAT WAY. SHE WOULD HAVE BEEN RIGHT THERE WITH YOU." THE DON AND ADON WERE UNABLE TO RESPOND WHY STAFF FAILED TO DO SO. NURSE 'Q' AND NURSE AIDE 'R', WERE UNAVAILABLE FOR COMMENT. ( ) DEFICIENT PRACTICE #2 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE ONE (#312) OF 14 RESIDENTS REVIEWED FOR FALLS OUT OF A TOTAL SAMPLE OF 25 WAS ASSISTED DURING TRANSFERS TO THE CHAIR WITH THE CORRECT NUMBER OF STAFF, RESULTING IN A FALL AND A SPRAINED ANKLE. FINDINGS INCLUDE: ON 8/16/12 AT 3:10 P.M., RESIDENT #312 WAS INTERVIEWED IN THE ROOM. RESIDENT # 312 WAS SITTING IN A WHEELCHAIR, AND WAS ALERT BUT WAS UNABLE TO REMEMBER ANY FALLS WHILE IN THE FACILITY. RESIDENT #312 WAS OBESE, AND HAD A LEFT LEG BELOW THE KNEE AMPUTATION (BKA). RESIDENT #312 WAS NOT WEARING A PROSTHESIS (ARTIFICIAL LEG) BUT PROPELLED THE WHEELCHAIR WITH THE RIGHT FOOT. WHEN ASKED HOW MUCH HELP WAS NEEDED TO TRANSFER BETWEEN BED AND WHEELCHAIR, RESIDENT #312 STATED, "IT'S ONE OF THE TALLER AIDES. THEY DO IT BY THEMSELVES. WITH THE LITTLE GIRLS, IT TAKES TWO OF THEM TO TRANSFER ME." ON 8/17/12 AT 9:25 A.M., REVIEW OF RESIDENT #312'S CLINICAL RECORD WITH THE DIRECTOR OF NURSING AND UNIT MANAGER, NURSE "A" REVEALED THE FOLLOWING DOCUMENTS: A FACE SHEET DOCUMENTED ADMISSION INto the facility on [DATE] WITH READMISSION AFTER hospitalization , ON 2/17/12. [DIAGNOSES REDACTED]. THE MOST RECENT MINIMUM DATA SET ASSESSMENT ((MDS) dated [DATE], REVEALED RESIDENT #312 HAD INTACT COGNITION, AND NEEDED EXTENSIVE ASSISTANCE OF ONE STAFF FOR TRANSFERS TO THE WHEELCHAIR AND BED MOBILITY. THE MDS ALSO DOCUMENTED THAT RESIDENT #312 HAD POOR BALANCE, NEEDING HUMAN ASSISTANCE TO REMAIN STEADY. AN ANNUAL MDS dated [DATE] ALSO DOCUMENTED THAT RESIDENT #312 HAD UNSTEADY BALANCE AND NEEDED EXTENSIVE ASSISTANCE OF ONE STAFF FOR TRANSFERS TO THE WHEELCHAIR, TOILETING AND BED MOBILITY, AND DID NOT WALK. REVIEW OF AN INCIDENT AND ACCIDENT REPORT DATED 1/3/12, REVEALED THAT RESIDENT #312 HAD FALLEN WHILE ASSISTED BY A CERTIFIED NURSING ASSISTANT IN THE SHOWER ROOM. THE REPORT DOCUMENTED THAT RESIDENT #312 HAD BECOME WEAK DURING TRANSFER FROM THE SHOWER CHAIR AND HAD SLID TO THE FLOOR. THE DON REPORTED THAT POST FALL CORRECTIVE MEASURES INCLUDED A REFERRAL TO SKILLED PHYSICAL THERAPY (PT). REVIEW OF A THERAPY PROGRESS REPORT FOR RESIDENT #312, DATED 1/26/12 TO 2/2/12 REVEALED THE FOLLOWING NOTATION, "SIT TO STAND AND BED TO WHEELCHAIR MAXIMUM TO MODERATE ASSISTANCE." REVIEW OF A NURSING CARE PLAN FOR FALLS DATED 2/5/12 REVEALED THE FOLLOWING PROBLEM FOR RESIDENT #312, "AT RISK FOR FALLS RELATED TO RECENT FALL, HISTORY OF FALLS, BALANCE PROBLEM, ARTHRITIS, LEFT HEMINEUROPATHY (LEFT SIDED NERVE DAMAGE).' INTERVENTIONS INCLUDED "TWO STAFF DURING SHOWERS. TWO PERSON TRANSFERS WITH FAMILY." REVIEW OF A FACILITY INCIDENT/ACCIDENT REPORT DATED 2/8/12 REVEALED THE FOLLOWING UNWITNESSED INJURY FOR RESIDENT #312: "RIGHT ANKLE SWOLLEN AND DISCOLORED, BRUISING NOTED. RESIDENT STATED, "I MIGHT HAVE TWISTED IT GETTING OUT OF BED. IT HURTS." X-RAY WAS NEGATIVE FOR FRACTURE. THE DON AND UM "A", WERE QUERIED ABOUT THIS, AND REPORTED THAT THE RESIDENT STATED SHE TWISTED HER ANKLE DURING A TRANSFER. REVIEW OF AN INCIDENT AND ACCIDENT REPORT DATED 2/27/12 REVEALED THAT RESIDENT #312 fell DURING A STAFF ASSISTED TRANSFER FROM THE WHEELCHAIR TO THE SHOWER CHAIR AT 7:45 A.M. THE REPORT NOTED THAT A CNA, "WAS ASSISTING RESIDENT TO PULLING BAR FOR TRANSFER FROM WHEELCHAIR TO SHOWER CHAIR. RESIDENT UNABLE TO STAND. LOWERED RESIDENT TO FLOOR." WHEN ASKED WHY ONE STAFF WAS TRANSFERRING RESIDENT #312 IN THE SHOWER WHEN THE CARE PLAN DOCUMENTED TWO STAFF WERE NECESSARY, THE DON STATED THE MDS NURSE HAD DONE THE FALLS CARE PLAN AND NURSING WAS NOT AWARE OF IT. IT WAS UNCLEAR WHY NURSING DID NOT REFER TO THE RESIDENT'S NURSING CARE PLAN FOR GUIDANCE WITH CARE. THE DON WAS QUERIED WHY THE RESIDENT REPORTED, AND THE MDS, AND THE CNA CARE TRACKER DOCUMENTED THAT RESIDENT #312 USUALLY REQUIRED ONE STAFF ASSISTANCE FOR TRANSFER. THE DON STATED, "ABSOLUTELY NOT. (RESIDENT#312) MUST ALWAYS HAVE TWO STAFF TO TRANSFER. I DON'T CARE HOW BIG OR HOW SMALL THEY ARE." ON 8/17/12 AT 10:15 A.M., THE MDS NURSE "C" WAS INTERVIEWED AND REPORTED THE FALL CARE PLAN WAS UPDATED AFTER RESIDENT #312 HAD A FALL DURING A STAFF ASSISTED TRANSFER. MDS NURSE "C" STATED THAT THE INTERVENTION FOR TWO STAFF TO ASSIST WITH TRANSFERS IN THE SHOWER WAS ADDED AS A POST FALL INTERVENTION DUE TO THE FALL ON 1/3/12. REVIEW OF THE FACILITY POLICY TITLED "FALL MANAGEMENT" DATED 2/2010 REVEALED, "IF A FALL OCCURS, THE INTERDISCIPLINARY TEAM CONDUCTS AN EVALUATION TO ENSURE APPROPRIATE MEASURES ARE IN PLACE TO MINIMIZE THE RISK OF FUTURE FALLS." ( ) DEFICIENT PRACTICE #3 BASED ON OBSERVATION AND INTERVIEW THE FACILITY FAILED TO MONITOR THE USE OF POWER STRIPS IN FOUR OF 59 ROOMS (#'S 127, 246, 244, AND 237). THIS HAD THE POTENTIAL TO AFFECT THREE OF 25 SAMPLED RESIDENTS (#'S 302, 306 AND 313), AND FIVE SUPPLEMENTAL SAMPLED RESIDENTS (#'S 37, 38, 110, 111 AND 112), AND RESULTED IN THE POTENTIAL FOR LOSS OF POWER TO ESSENTIAL MEDICAL EQUIPMENT AND HARM TO RESIDENTS. FINDINGS INCLUDE: ON 8/15/12 AT 9:50 A.M., DURING AN INITIAL TOUR OF THE FACILITY, THE FOLLOWING OBSERVATIONS WERE MADE: ROOM 127: THERE WAS A POWER STRIP PROVIDING ELECTRICITY TO THE RESIDENT'S BED AND AIR MATTRESS FOR BED #1. THERE WAS A POWER STRIP PROVIDING ELECTRICAL CURRENT TO THE OXYGEN CONCENTRATOR FOR THE RESIDENT IN BED #2. ROOM 246: THERE WERE POWER STRIPS PROVIDING ELECTRICAL CURRENT TO THE OXYGEN CONCENTRATOR AND THE BED FOR THE RESIDENT IN BED #1, AND A POWER STRIP SUPPLIED ELECTRICAL CURRENT TO THE BED FOR THE RESIDENT IN BED #2. ROOM 237: THERE WAS A POWER STRIP PROVIDING ELECTRICITY TO THE BED AND AIR MATTRESS FOR THE RESIDENT IN BED #1, AND A POWER STRIP SUPPLIED THE ELECTRICAL CURRENT TO THE OXYGEN CONCENTRATOR AND AIR MATTRESS FOR THE RESIDENT IN BED #2. ROOM 244: THERE WAS A POWER STRIP PROVIDING ELECTRICITY TO THE RESIDENT'S BED AND AIR MATTRESS IN BED #1, AND A POWER STRIP SUPPLIED THE ELECTRICAL CURRENT TO THE BED FOR THE RESIDENT IN BED #2. DURING AN INTERVIEW ON 6/17/12 AT 8:35 A.M., THE MAINTENANCE DIRECTOR STATED, "I CAN'T EXPLAIN WHY THE AIR MATTRESSES, BED, OR OXYGEN CONCENTRATORS WOULD BE PLUGGED INTO A POWER STRIP. THEY SHOULD BE PLUGGED DIRECTLY INTO THE EMERGENCY WALL OUTLET." UPON REQUEST, THERE WAS NO AVAILABLE FACILITY POLICY REGARDING USE OF POWER STRIPS. ( )