Every finding on record at Hazel I Findlay Country Manor

Based on observation, interview, and record review the facility failed to effectively clean and maintain food service equipment affecting 99 residents. On 09/10/2025 at 08:31 a.m. an initial tour of food services was conducted with Dietary Aide F and then Certified Dietary Manager (CDM) G. The following items were observed:Main Freezer had ice on the floor approximately 1 inch tall and the circumference of a silver dollar. Dietary Aide F explained that it may be coming from the cooler refrigeration fan.Dishwasher was observed to have lime scale on the outside of the machine and floor was visibly soiled around the dishwasher.Hand sink to the right of the entrance was visible soiled and the faucet was covered with lime scale.Hand sink across from the tray line was visible soiled and the faucet was covered with lime scale.The toaster on the tray line had visible breadcrumbs on all sides of the toaster.Soiled sink faucet had visible lime deposit.Oven racks appeared soiled with multiple lays of old burnt color. Those racks were in the oven at this time. Two old racks were observed discolored on top of the oven. Old grease and dust was observed on top of the oven. Dust and cobwebs were observed on the sprinkler system over the stove.Back lower vent hood above stove appeared to be covered with old grease. Lime and red colored deposit was observed in the dishwasher and lime was deposit was observed on the floor around the dishwasher. Five air vents in the ceiling of the kitchen were observed to be soiled with ceiling tiles around the vents to be observed soiled as well. On 09/15/2025 at 07:21 a.m. Tour of kitchen with Certified Dietary Manager (CDM) H the following items were observed:Main freezer ice was observed on the floor.Sinks still observed to have lime deposits.Five air vents in the ceiling of the kitchen were observed to be soiled with ceiling tiles around the vents be observed as well.All sinks and faucets observed on initial tour still were observed stained/soiled with lime deposit.Dishwashing machine was observed to still have lime and red substance on inside and outside of machine. Walk-in cooler had food observed on the floor.

Based on observation, interview, and record review the facility failed to investigate allegations of abuse for two residents (#6,#15) out of four residents reviewed for abuse. Findings Included: Resident #15 (R15) Review of the medical record revealed R15 was admitted to the facility 05/12/2025 with diagnoses that included Huntington’s Disease (inherited condition in which nerve cells in the brain break down over time), dry eye syndrome, bilateral myopia (near sightedness), bilateral astigmatism, dysphagia (difficulty swallowing), gastro-esophageal reflux, depression, and insomnia. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/19/2025, revealed R15 had a Brief Interview for Mental Status (BIMS) of 09 (moderate cognitive impairment) out of 15. During observation and interview on 09/10/2025 at 10:43 a.m. R15 was observed sitting in her electric wheelchair. R15 explained that a staff member was rude to her. R15 could not provide further details nor the name of the staff member. Review of facility grievance forms entitled “Solution Form-to document unresolved grievances or concerns” revealed document dated 07/13/2025 which stated, “(name of another resident) would go unplug (name of R15) fan. (name of resident) called her a stupid bitch and said she doesn’t deserve to have a family. She states she does not feel safe with her as a roommate and would like a new one”. The same document revealed in section of immediate actions “moved (name of roommate) into another room for the night, until long term solution is found, and I helped (R15) with this form”. Review of facility grievance forms entitled “Solution Form-to document unresolved grievance or concerns” revealed document dated 08/06/2025 “Resident stated (name of employee) was being rude to her in the dinning room resident was also crying. Resident didn’t explain to me how he was being rude”. The same document revealed in the section official follow up “verbal education given on customer service and approach. No emotional distress voiced toward (name of employee) as she was tearful about ex-boyfriend.” In an interview on 09/11/2025 at 10:28 a.m. Nursing Home Administrator (NHA) “A” explained that she was the facility abuse coordinator. NHA “A” explained that she had been notified of the allegation regarding R15 and another resident that had occurred on 07/13/25. NHA “A” also explained that she was aware of the allegation regarding R15 and an employee on 08/06/2025. NHA “A” explained that neither of these allegations were reported to the appropriate state agencies because it was her opinion that they did not meet CMS (Center for Medicaid/Medicare Services) guidance for allegation of abuse. NHA “A” explained that R15 was not upset or concerned about her safety and that R15 was tearful related to another reason not related to that events. NHA “A” was asked if she had an investigation file demonstrating that allegations were investigated. NHA “A” responded that she would provide files. Nursing Home Administrator (NHA) “A” provided a document entitled “non-reportable allegation”, dated 7/13/25, which revealed a section that stated “give a detailed description of incident (attach additional pages if necessary): Verbal altercation”. Then hand written on the above document “move immediately and no harm no distress”. No other documentation was provided regarding the allegation or investigation. Nursing Home Administrator (NHA) “A” provided a document entitled “non-reportable allegation”, dated 08/06/2025, which revealed a section that stated “give a detailed description of incident (attach additional pages if necessary): (R15) state staff are rude. They don’t stop and talk. Tearful d/t(related to) issue w/b.f. (with boyfriend). No other documentation was provided regarding the allegation or investigation. In an interview on 09/11/2025 at 12:12 p.m. Nursing Home Administrator (NHA) “A” explained that she did not have any further documents pertaining to the previous allegations list above. Resident #6 (R6): Per the facility face sheet R6 was admitted to the facility on [DATE]. R6 had stated during the screening process on 9/10/2025 that about two weeks ago she had waited two hours for her call light to be answered. R6 said the RCA (resident certified aid), who she could not recall the name of, entered her room and was disgusted with her, then turned her side to side jerking her side to side; then told her to stop yelling, but she could not because it was hurting her. Review of a SOLUTIONS FORM dated 8/12/25, revealed R6 had reported to her family member that last night she had waited two hours for assistance, and upon receiving that assistance the staff member, who was not identified, .came in and acted disgusted with me, turned me Jerked side to side, and said I am being too loud. Additionally, it was documented on the form that R6 stated she could not help moaning loud because it hurt. Continued review of the SOLUTIONS FORM revealed under, IMMEDIATE ACTIONS for SOLUTION (when concern is made--what did Work Family to resolve concern?) it was documented, Nursing assessment done-0 (zero) new inf (information)/ Resident (R6) stated staff skin assessment done--0 new inf/was in a hurry care plan for 2 w (with)/bed mobility V.S. (vital signs) done. The form was dated 8/12/2025 as the date the concern was resolved. The concern form did not have any documentation of any conversation with R6 in whether the solution was acceptable to R6. The form did not include any interview with R6. The form did not have any documentation that a thorough investigation was to immediately take place to R6 made the allegation of jerking her side to side against. Record review of a Non-Reportable Allegation form dated 8/12/2025, revealed at the top of the document, Use this form to report on the job accidents, injuries, medical situations, criminal activities, work related traffic incidents, etc. A report should be completed within 24 hours of the incident. The form revealed that the incident occurred in R6's room, and a detailed description was documented to say, Resident (R6) stated she waited 2 (hours) for her call light to be answered. & RCA (resident certified aid) came and acted disgusted w (with)/her-felt like it was a fast turn when providing care bed mobility to her and she (R6) yelled, and RCA said she was being loud. When asked to elaborate-She state RCA said others were sleeping and she (R6) said she couldn't help it. In an interview on 9/11/2025, Administrator A stated that herself along with Director of Nursing (DON) B spoke with R6 and as R6 if she felt the RCA was rough with her in which R6 reported to them no. Administer A said R6 reported she was painful, could not say who the staff member was, and was painful with light touch. Administrator A said her investigation was documented on the Non-Reportable Allegation form. Administrator A did not identify R6's concern as an allegation of abuse, because she spoke with R6 immediately and R6 said it was because of her pain and being painful when the RCA turned her. Administrator A said she came to the conclusion the incident was related to R6's pain and not an allegation of abuse. Administrator, who was identified as the Solutions coordinator or the abuse coordinator, did not interview other residents to identify any possible further allegations of abuse, did not interview other staff members, and did not thoroughly investigation R6's allegation of being yelled at and jerked side to side by a staff member.

Based on observation, interview, and record review the facility failed to implement its own written policies and procedures for Abuse and Neglect for two residents (#6, #15) of 4 residents reviewed. Resident #6 (R6): Per the facility face sheet R6 was admitted to the facility on [DATE]. R6 had stated during the screening process on 9/10/2025 that about two weeks ago she had waited two hours for her call light to be answered. R6 said the RCA (resident certified aid), who she could not recall the name of, entered her room and was disgusted with her, then turned her side to side jerking her side to side; then told her to stop yelling, but she could not because it was hurting her. Review of a SOLUTIONS FORM dated 8/12/25, revealed R6 had reported to her family member that last night she had waited two hours for assistance, and upon receiving that assistance the staff member, who was not identified, .came in and acted disgusted with me, turned me Jerked side to side, and said I am being too loud. Additionally, it was documented on the form that R6 stated she could not help moaning loud because it hurt. Continued review of the SOLUTIONS FORM revealed under, IMMEDIATE ACTIONS for SOLUTION (when concern is made--what did Work Family to resolve concern?) it was documented, Nursing assessment done-0 (zero) new inf (information)/ Resident (R6) stated staff skin assessment done--0 new inf/was in a hurry care plan for 2 w (with)/bed mobility V.S. (vital signs) done. The form was dated 8/12/2025 as the date the concern was resolved. The concern form did not have any documentation of any conversation with R6 in whether the solution was acceptable to R6. The form did not include any interview with R6. The form did not have any documentation that a thorough investigation was to immediately take place to R6 made the allegation of jerking her side to side against. Record review of a Non-Reportable Allegation form dated 8/12/2025, revealed at the top of the document, Use this form to report on the job accidents, injuries, medical situations, criminal activities, work related traffic incidents, etc. A report should be completed within 24 hours of the incident. The form revealed that the incident occurred in R6's room, and a detailed description was documented to say, Resident (R6) stated she waited 2 (hours) for her call light to be answered. & RCA (resident certified aid) came and acted disgusted w (with)/her-felt like it was a fast turn when providing care bed mobility to her and she (R6) yelled, and RCA said she was being loud. When asked to elaborate-She state RCA said others were sleeping and she (R6) said she couldn't help it. In an interview on 9/11/2025, Administrator A stated that herself along with Director of Nursing (DON) B spoke with R6 and as R6 if she felt the RCA was rough with her in which R6 reported to them no. Administer A said R6 reported she was painful, could not say who the staff member was, and was painful with light touch. Administrator A said her investigation was documented on the Non-Reportable Allegation form. Administrator A did not identify R6's concern as an allegation of abuse, because she spoke with R6 immediately and R6 said it was because of her pain and being painful when the RCA turned her. Administrator A said she came to the conclusion the incident was related to R6's pain and not an allegation of abuse and therefore did not report the allegation to the state agency. Administrator, who was identified as the Solutions coordinator or the abuse coordinator, did not interview other residents to identify any possible further allegations of abuse, did not interview other staff members, and did not thoroughly investigation R6's allegation of being yelled at and jerked side to side by a staff member. Review of the facility policy and procedure titled, Abuse, Neglect, and Exploitation Protocol dated May of 2005, revealed on page #4 V. Investigation of Alleged Abuse, Neglect and Exploitation, A. An investigation is warranted when suspicion of abuse, neglect of exploitation, or reports of abuse, neglect or exploitation occur. The above statement outlined in the facility policy revealed that an investigation was warranted for a suspicion however, it did not identify that an allegation, which is not the same as a suspicion, of abuse would warrant an immediate reporting to the state agency and the facility requirements to initiate an investigation. Further review of the policy and procedure revealed on page #5 under the same heading, B. Written procedures for investigations include ., d. Identifying and interviewing identified involved persons, including alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, e. Focus the investigation to determine if abuse, neglect, exploitation, and/or mistreatment had occurred, the extent, and cause, and f. Conduct a comprehensive investigation in accordance with standards of practice. Continued review of the facility policy revealed on page #5 under Reporting/Response A. The facility has written procedures that include A. Reporting alleged violations to the Administrator/Abuse Coordinator/designee, state agency .if needed within specific time frames. 1. Immediately (the Abuse Coordinator has 2 hours to report to the State Agency), after forming suspicion of abuse OR if the allegation involves abuse OR results in serious bodily injury. R6's allegation was not investigated by the facility and was not reported to the state agency per the facility's policy and procedure. Findings included: Resident #15 (R15): Review of the medical record revealed R15 was admitted to the facility 05/12/2025 with diagnoses that included Huntington’s Disease (inherited condition in which nerve cells in the brain break down over time), dry eye syndrome, bilateral myopia (near sightedness), bilateral astigmatism, dysphagia (difficulty swallowing), gastro-esophageal reflux, depression, and insomnia. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/19/2025, revealed R15 had a Brief Interview for Mental Status (BIMS) of 09 (moderate cognitive impairment) out of 15. During observation and interview on 09/10/2025 at 10:43 a.m. R15 was observed sitting in her electric wheelchair. R15 explained that a staff member was rude to her. R15 could not provide further details nor the name of the staff member. Review of facility grievance forms entitled “Solution Form-to document unresolved grievances or concerns” revealed document dated 07/13/2025 which stated, “(name of another resident) would go unplug (name of R15) fan. (name of resident) called her a stupid bitch and said she doesn’t deserve to have a family. She states she does not feel safe with her as a roommate and would like a new one”. The same document revealed in section of immediate actions “moved (name of roommate) into another room for the night, until long term solution is found, and I helped (R15) with this form”. Review of facility grievance forms entitled “Solution Form-to document unresolved grievance or concerns” revealed document dated 08/06/2025 “Resident stated (name of employee) was being rude to her in the dinning room resident was also crying. Resident didn’t explain to me how he was being rude”. The same document revealed in the section official follow up “verbal education given on customer service and approach. No emotional distress voiced toward (name of employee) as she was tearful about ex-boyfriend.” In an interview on 09/11/2025 at 10:28 a.m. Nursing Home Administrator (NHA) “A” explained that she was the facility abuse coordinator. NHA “A” explained that she had been notified of the allegation regarding R15 and another resident that had occurred on 07/13/25. NHA “A” also explained that she was aware of the allegation regarding R15 and an employee on 08/06/2025. NHA “A” explained that neither of these allegations were reported to the appropriate state agencies because it was her opinion that they did not meet CMS (Center for Medicaid/Medicare Services) guidance for allegation of abuse. NHA “A” explained that R15 was not upset or concerned about her safety and that R15 was tearful related to another reason not related to that events. NHA “A” was asked if she had an investigation file demonstrating that allegations were investigated. NHA “A” responded that she would provide files. Nursing Home Administrator (NHA) “A” provided a document entitled “non-reportable allegation”, dated 7/13/25, which revealed a section that stated “give a detailed description of incident (attach additional pages if necessary): Verbal altercation”. Then hand written on the above document “move immediately and no harm no distress”. No other documentation was provided regarding the allegation or investigation. Nursing Home Administrator (NHA) “A” provided a document entitled “non-reportable allegation”, dated 08/06/2025, which revealed a section that stated “give a detailed description of incident (attach additional pages if necessary): (R15) state staff are rude. They don’t stop and talk. Tearful d/t(related to) issue w/b.f. (with boyfriend). No other documentation was provided regarding the allegation or investigation. In an interview on 09/11/2025 at 12:12 p.m. Nursing Home Administrator (NHA) “A” explained that she did not have any further documents pertaining to the previous allegations list above.

Based on observation, interview, and record review the facility failed to follow professional practice of medication documentation for one resident (#58) of six residents reviewed during medication administration. Findings Included: Resident #58 (R58)Review of the medical record revealed R58 was admitted to the facility 03/13/2019 with diagnoses that included aortic valve stenosis, muscle weakness, dysphagia (difficulty swallowing), congestive heart disease (CHF), bilateral dry eye syndrome, cerebral infarction (stroke), type 2 diabetes, malignant neoplasm of skin (skin cancer), pain in left shoulder, depression, vascular dementia, gastro-esophageal reflux, right sided hemiparesis (muscle weakness or paralysis), atrial fibrillation, anemia (low red blood cells), fatty liver, obesity, hypertension, mood disorder, spinal stenosis (spinal narrowing), osteoarthritis (flexible tissue between bones wears down), rest less leg syndrome, hyperlipemia (high levels of fat in blood), and fibromyalgia (wide spread body pain and tiredness). During observation of medication administration on 09/11/2025 at 07:37 a.m. Licensed Practical Nurse (LPN) C was observed starting to prepare R58's medication to be administered. LPN C was observed placing the following medications in a medication cup: amlodipine 10mg (milligram)-1 tablet, aspirin 81mg- 1 tablet, duloxetine 30mg-1 capsule, iron 325mg-1 tablet, fish oil 1200 mg -1 capsule, lasix 40 mg-1 tablet, hydralazine hydrocholoride 25mg-1 tablet, loratadine 10mg-1 tablet, metoprolol tartrate 100mg-1 tablet, potassium 20 meq (milliequivalent)-1 tablet, ropinirole 0.5 mg-1 tablet, and Tylenol 325mg-1 tablet. At the conclusion of placing the above listed medication in a medication cup LPN C was observed documenting in R58's Medication Administration Record (MAR) that the medication had been given. On 09/11/2025 at 07:45 a.m. Licensed Practical Nurse (LPN) C was observed taking the medication cup into R58's room, who was observed sitting up in her wheelchair. R58 explained that she wanted to be taken to the bathroom and R58 expressed to LPN C that she would not take her medication until she was finished in the bathroom. LPN C was observed returning to the medication cart. LPN C was observed placing a label, that included R58's name, on the medication cup with the medication. LPN C was then observed placing that medication cup in the top drawer of the medication cart. On 09/11/2025 at 07:55 a.m. Licensed Practical Nurse (LPN) C was observed preparing and administrating another resident's medication, at which time LPN C did not lock the mediation cart and left it unattended. LPN C was observed returning to the medication cart on 09/11/2025 at 07:57 a.m. and locking the medication cart. On 09/11/2025 at 08:08 a.m. Licensed Practical Nurse (LPN) C was observed to be notified by R58 that she was ready to take her medication. LPN C was observed to remove the medication cup from the medication cart and proceeded to guide R58 to her room. LPN C was then observed administering R58's medication. Review of R58's Medication Admin Audit Report, dated 09/11/2025, revealed above medication was listed as being given on 09/11/2025 at 07:44 a.m. Review of policy Medication Administration Protocol policy, dated 5/2000 and last reviewed/revised 12/2024, revealed #15. Sign MAR after administered . During an interview on 09/11/2025 at 12:27 p.m. Director of Nursing (DON) B explained that it was her expectation, policy, and professional practice that nurses would document medication as given, in the residents Medication Administration Record (MAR), once the medication had been given to the resident.

Based on observation, interview, and record review the facility failed to report an allegation of abuse to the State Agency for two residents (#6,#15) of four residents reviewed for abuse. Findings Included: Resident #15 (R15) Review of the medical record revealed R15 was admitted to the facility 05/12/2025 with diagnoses that included Huntington’s Disease (inherited condition in which nerve cells in the brain break down over time), dry eye syndrome, bilateral myopia (near sightedness), bilateral astigmatism, dysphagia (difficulty swallowing), gastro-esophageal reflux, depression, and insomnia. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/19/2025, revealed R15 had a Brief Interview for Mental Status (BIMS) of 09 (moderate cognitive impairment) out of 15. During observation and interview on 09/10/2025 at 10:43 a.m. R15 was observed sitting in her electric wheelchair. R15 explained that a staff member was rude to her. R15 could not provide further details nor the name of the staff member. Review of facility grievance forms entitled “Solution Form-to document unresolved grievances or concerns” revealed document dated 07/13/2025 which stated, “(name of another resident) would go unplug (name of R15) fan. (name of resident) called her a stupid bitch and said she doesn’t deserve to have a family. She states she does not feel safe with her as a roommate and would like a new one”. The same document revealed in section of immediate actions “moved (name of roommate) into another room for the night, until long term solution is found, and I helped (R15) with this form”. Review of facility grievance forms entitled “Solution Form-to document unresolved grievance or concerns” revealed document dated 08/06/2025 “Resident stated (name of employee) was being rude to her in the dinning room resident was also crying. Resident didn’t explain to me how he was being rude”. The same document revealed in the section official follow up “verbal education given on customer service and approach. No emotional distress voiced toward (name of employee) as she was tearful about ex-boyfriend.” In an interview on 09/11/2025 at 10:28 a.m. Nursing Home Administrator (NHA) “A” explained that she was the facility abuse coordinator. NHA “A” explained that she had been notified of the allegation regarding R15 and another resident that had occurred on 07/13/25. NHA “A” also explained that she was aware of the allegation regarding R15 and an employee on 08/06/2025. NHA “A” explained that neither of these allegations were reported to the appropriate state agencies because it was her opinion that they did not meet CMS (Center for Medicaid/Medicare Services) guidance for allegation of abuse. NHA “A” explained that R15 was not upset or concerned about her safety and that R15 was tearful related to another reason not related to that events. NHA “A” was asked if she had an investigation file demonstrating that allegations were investigated. NHA “A” responded that she would provide files. Nursing Home Administrator (NHA) “A” provided a document entitled “non-reportable allegation”, dated 7/13/25, which revealed a section that stated “give a detailed description of incident (attach additional pages if necessary): Verbal altercation”. Then hand written on the above document “move immediately and no harm no distress”. No other documentation was provided regarding the allegation or investigation. Nursing Home Administrator (NHA) “A” provided a document entitled “non-reportable allegation”, dated 08/06/2025, which revealed a section that stated “give a detailed description of incident (attach additional pages if necessary): (R15) state staff are rude. They don’t stop and talk. Tearful d/t(related to) issue w/b.f. (with boyfriend). No other documentation was provided regarding the allegation or investigation. In an interview on 09/11/2025 at 12:12 p.m. Nursing Home Administrator (NHA) “A” explained that she did not have any further documents pertaining to the previous allegations list above. Resident #6 (R6): Per the facility face sheet R6 was admitted to the facility on [DATE]. R6 had stated during the screening process on 9/10/2025 that about two weeks ago she had waited two hours for her call light to be answered. R6 said the RCA (resident certified aid), who she could not recall the name of, entered her room and was disgusted with her, then turned her side to side jerking her side to side; then told her to stop yelling, but she could not because it was hurting her Review of a SOLUTIONS FORM dated 8/12/25, revealed R6 had reported to her family member that last night she had waited two hours for assistance, and upon receiving that assistance the staff member, who was not identified, .came in and acted disgusted with me, turned me Jerked side to side, and said I am being too loud. Additionally, it was documented on the form that R6 stated she could not help moaning loud because it hurt. Continued review of the SOLUTIONS FORM revealed under, IMMEDIATE ACTIONS for SOLUTION (when concern is made--what did Work Family to resolve concern?) it was documented, Nursing assessment done-0 (zero) new inf (information)/ Resident (R6) stated staff skin assessment done--0 new inf/was in a hurry care plan for 2 w (with)/bed mobility V.S. (vital signs) done. The form was dated 8/12/2025 as the date the concern was resolved. The concern form did not have any documentation of any conversation with R6 in whether the solution was acceptable to R6. The form did not include any interview with R6. The form did not have any documentation that a thorough investigation was to immediately take place to R6 made the allegation of jerking her side to side against. Record review of a Non-Reportable Allegation form dated 8/12/2025, revealed at the top of the document, Use this form to report on the job accidents, injuries, medical situations, criminal activities, work related traffic incidents, etc. A report should be completed within 24 hours of the incident. The form revealed that the incident occurred in R6's room, and a detailed description was documented to say, Resident (R6) stated she waited 2 (hours) for her call light to be answered. & RCA (resident certified aid) came and acted disgusted w (with)/her-felt like it was a fast turn when providing care bed mobility to her and she (R6) yelled, and RCA said she was being loud. When asked to elaborate-She state RCA said others were sleeping and she (R6) said she couldn't help it. In an interview on 9/11/2025, Administrator A stated that herself along with Director of Nursing (DON) B spoke with R6 and as R6 if she felt the RCA was rough with her in which R6 reported to them no. Administer A said R6 reported she was painful, could not say who the staff member was, and was painful with light touch. Administrator A said her investigation was documented on the Non-Reportable Allegation form. Administrator A did not identify R6's concern as an allegation of abuse, because she spoke with R6 immediately and R6 said it was because of her pain and being painful when the RCA turned her. Administrator A said she came to the conclusion the incident was related to R6's pain and not an allegation of abuse and therefore did not report the allegation to the state agency.

During Interview and record review facility failed to follow provider's orders for one (Resident #5) of 20 sampled causing unjust pain.Findings IncludeResident #5 (R5)Review of the medical record reflected that R5 was admitted to the facility on [DATE] and was re-admitted to the facility on [DATE]. Diagnoses of Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, muscle weakness, lack of coordination and difficulty walking.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/08/2025 revealed R5 had a Brief Interview of Mental Status (BIMS) of 09 (moderately impaired) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R5 had impaired mobility of both upper and lower extremities, set up and assist for meals, and dependent on all other care. During an interview on 09/10/2025 at 4:15 PM, R5's family member R stated R5 was taking a medication called Neurontin 100 milligram (mg) capsule for his neuropathy in his legs and feet, and it was stopped. R'5 family member R stated R5 had been on it a couple of weeks and it was really helping his neuropathy burning and pain. Family member R stated the facility stopped giving it to him without discussing it with her. Family member R stated once his neuropathy pain came back, it was identified that his neuropathy medication Neurontin 100 mg capsule had been stopped without reason. Family member R stated the facility staff would not have known of this error if R5 had not had his pain and burning returned to his legs and feet.During an interview on 09/15/2025 at 1:45 PM, House Supervisor S asked if writer was talking about Neurontin as she looked up his medications in R5's electronic medical record (EMR). House Supervisor S stated R5's provider ordered Neurontin 100 mg for 2 weeks to evaluate if it was beneficial for his nerve pain. House Supervisor S stated yes it was stopped after 2 weeks, provider was notified and reported it was beneficial and would like to continue it. Record review revealed the August Monthly Administration Record (MAR) for R5 was started on Neurontin 100mg 1 capsule at bedtime on August 26, August 27 and August 28th. August MAR then showed Neurontin 100mg capsule was given 2 times a day at 8:00 am and 8:00 pm on August 28, August 30 and August 31st. September MAR revealed R5 continued taking Neurontin 100 mg capsule 3 times a day at 8:00 am, 1:00 pm and 8:00 pm on September 1, September 2 and September 3, 2025, then stopped. There was a note on the September MAR for September 2, 2025, with the message Re-evaluate effectiveness of Neurontin and call provider with an update which was checked off as completed. During same interview with House Supervisor S stated she knew a form called Nursing Communication and Physician Response Form was sent to the provider on September 2, 2025, at 9:05 am, signed and dated September 3, 2025, when it was returned to the facility. The provider documented that he wanted to continue the Neurontin 100 mg capsules 3 times a day. This provider order was put in R5's EMR on September 9, 2025, and Neurontin 100 mg capsules 3 times a day started on September 10, 2025, not September 3, 2025, as ordered.During an interview on 09/15/2025 at 1:57 PM House Supervisor S stated she did not know how that order for Neurontin 100mg capsules 3 times a day was missed during that time frame of September 3, 2025, to September 10, 2025.

Based on observation, interview and record review, the facility failed to ensure that the drug regimens for 1 of 5 residents reviewed for antipsychotic drug (#34) use were free of medications used without adequate indications for use, without adequate monitoring, and without a resident-focused, risk-benefit statement completed, resulting in the risk for increased side effects from a potentially unnecessary medication. Findings include:Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R34 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included vascular dementia without behavioral disturbances, psychotic disturbance, mood disturbance, anxiety, urinary tract infection, and depression. The MDS reflected R34 had a BIM (assessment tool) score of 12 which indicated her ability to make daily decisions was moderately impaired. R34 Face Sheet reflected she had an activated Durable Power of Attorney(DPOA) for medical and financial care.Review of R34 Physican Orders and Medication Administration Record, dated 8/15/25 through current 9/15/25, reflected and order for SEROquel Oral Tablet 50 MG(Quetiapine Fumarate) Give 1 tablet by mouth in the evening for Agitation . The Medication Administration Record reflected R34 had received Seroquel 50mg every evening.Review of R34 Behavior Progress Note, dated 8/15/25 at 2:30 a.m., reflected, Resident attempted to walk out of the front door. She removed her wander guard that was found in her recliner chair and ripped the nurses station phone off the cord. It took two staff members to re-direct her from exiting. Resident is extremely agitated. She is demanding that the door be opened and her to be allowed to leave. She states that she is going to sue the facility and all the workers and have the place shut down. Resident is standing next to the exit door with a blanket and the phone in hand. Nurse attempted to comfort and console resident with no success. Redirection unsuccessful. Nurse called and notified administrator of events. [Named Physician] notified of current behaviors and attempts to elope and notified of previous statements of suicide ideations. [Named Physician] ordered Seroquel 50mg at HS[night], and stated to attempt to give ordered PRN Benadryl. Resident is being monitored closely by staff at this time. During an interview on 9/15/2025 at 1:50 PM, Social Worker (SW) I reported R34 had an activated DPOA and was not her own responsible party. SW I reported R34 admitted to the facility 8/12/25 and was not adjusting well at first and started to become agitated with attemps to elope on 8/14/25 evening into 8/15/25. SW I reported staff attempted to redirect R34 including calling family that were ineffective. SW I reported Physician ordered Seroquel 50mg every evening for agitation on 8/15/25 and reported not an expectable diagnosis for use. SW I reported R34 had not had any additional documented behaviors since 8/15/25. During a telephone interview on 9/15/25 at 2:34 p.m., Licensed Practical Nurse (LPN) T reported was nurse trainee for R34 on evening of 8/14/25 into 8/15/25 when R34 became very agitated and attempting to elope. LPN T reported she was unable to redirect R34 after several attempts and notified Nursing Home Administrator (NHA) A and Physician. LPN T reported Physician gave verbal order to start Seroquel 50mg every night and attempt to administer as needed order of Benadryl to calm down R34. LPN T reported R34 refused to take medications and Emergency Medical Services were in the facility at the time and were able to deescalate R34 on 8/15/25 until Nursing Home Administrator arrived in the morning. During an interview on 9/15/2025 at 3:09 PM, NHA A and Director of Nursing (DON) B, NHA A reported was notified by telephone of R34 behaviors and arrived at facility early that morning and R34 was very angry. NHA A reported was able to calm R34 down by reassuring her because she was overall concerned about the care of her daughter that was recently primary care giver for. DON A reported R34 had difficult time adjusting initially with facility admission and diagnosis but is currently doing very well. DON B reported R34 had not been prescribed antipsicotics prior to 8/15/25 and was unable to located justification for use and planned to attempt gradual dose reduction becuase she had not had any additional documented behaviors since 8/15/25.According to the guidelines outlined in the State Operations Manual for unnecessary medications, the risk/benefit statements must be a resident-focused review of symptoms and co-morbidities (diagnoses) compared to the possible risks of taking an antipsychotic medication for a resident diagnosed with dementia, psychosis and behaviors.According to the United States Black Box Warning, elderly patients with dementia-related psychosis treated with antipsychotics are at an increased risk of death compared to placebo. Most deaths appeared to be either cardiovascular (heart failure, sudden death) or infections (pneumonia, including that caused by aspiration). Anti-psychotics are not approved for the treatment of dementia-related psychosis. Neuroleptic malignant syndrome (life-threatening neurological disorder most often caused by an adverse reaction to antipsychotic drugs with symptoms of high fever, sweating, unstable blood pressure, stupor and muscular rigidity may develop any time during treatment) . Black box warning label for Seroquel reads. On a prescription for the antipsychotic medication Seroquel (quetiapine) from a national chain pharmacy, the following language appears: WARNING: This medicine is an antipsychotic. It may increase the risk of death when used to treat mental problems caused by dementia in elderly patients. Most of the deaths were linked to heart problems or infection. This medicine is not approved to treat mental problems caused by dementia .Thus, although the medication is used to treat psychosis, great care must be taken when the patient is elderly and psychotic symptoms are caused by conditions such as Alzheimer's and vascular dementia, among others. Psychosis and agitation in dementia is a situation that causes considerable distress to patients and families and may hasten institutionalization in some patients. Because there is a limited number of medications that can treat this condition in these circumstances, your loved one's doctor may still use one or more antipsychotic medications that carry this black box warning. In a situation like this, the doctor will consider whether the potential benefits of using the medication(s) are greater than the risks involved .

Based on observation, interview, and record review the facility failed to ensure that all medication used in the facility was secured and stored in accordance with professional standards in one of three medication carts. Findings Included: Resident #58 (R58)Review of the medical record revealed R58 was admitted to the facility 03/13/2019 with diagnoses that included aortic valve stenosis, muscle weakness, dysphagia (difficulty swallowing), congestive heart disease (CHF), bilateral dry eye syndrome, cerebral infarction (stroke), type 2 diabetes, malignant neoplasm of skin (skin cancer), pain in left shoulder, depression, vascular dementia, gastro-esophageal reflux, right sided hemiparesis (muscle weakness or paralysis), atrial fibrillation, anemia (low red blood cells), fatty liver, obesity, hypertension, mood disorder, spinal stenosis (spinal narrowing), osteoarthritis (flexible tissue between bones wears down), rest less leg syndrome, hyperlipemia (high levels of fat in blood), and fibromyalgia (wide spread body pain and tiredness). During observation of medication administration on 09/11/2025 at 07:37 a.m. Licensed Practical Nurse (LPN) C was observed starting to prepare R58's medication to be administered. LPN C was observed placing the following medications in a medication cup: amlodipine 10mg (milligram)-1 tablet, aspirin 81mg- 1 tablet, duloxetine 30mg-1 capsule, iron 325mg-1 tablet, fish oil 1200 mg -1 capsule, lasix 40 mg-1 tablet, hydralazine hydrocholoride 25mg-1 tablet, loratadine 10mg-1 tablet, metoprolol tartrate 100mg-1 tablet, potassium 20 meq (milliequivalent)-1 tablet, ropinirole 0.5 mg-1 tablet, and Tylenol 325mg-1 tablet. At the conclusion of placing the above listed medication in a medication cup LPN C was observed documenting in R58's Medication Administration Record (MAR) that the medication had been given. On 09/11/2025 at 07:45 a.m. Licensed Practical Nurse (LPN) C was observed taking the medication cup into R58's room, who was observed sitting up in her wheelchair. R58 explained that she wanted to be taken to the bathroom and R58 expressed to LPN C that she would not take her medication until she was finished in the bathroom. LPN C was observed returning to the medication cart. LPN C was observed placing a label, that included R58's name, on the medication cup with the medication. LPN C was then observed placing that medication cup in the top drawer of the medication cart. On 09/11/2025 at 07:55 a.m. Licensed Practical Nurse (LPN) C was observed preparing and administrating another resident's medication, at which time LPN C did not lock the mediation cart and left it unattended. LPN C was observed returning to the medication cart on 09/11/2025 at 07:57 a.m. and locking the medication cart. On 09/11/2025 at 08:08 a.m. Licensed Practical Nurse (LPN) C was observed to be notified by R58 that she was ready to take her medication. LPN C was observed to remove the medication cup from the medication cart and proceeded to guide R58 to her room. LPN C was then observed administering R58's medication. During an interview on 09/11/2025 at 12:27 p.m. Director of Nursing (DON) B explained that it was professional practice that medication carts must be locked when not visible or being used by a licensed nurse. DON B also explained that it was her expectation that medication should not be placed in a medication cup and stored in the medication cart to be given to residents at a different time. DON B explained that it would be best practice to wait with the medication until the resident is ready to receive the medication or discard the medication at the time of delay or refusal.

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #6) of five reviewed was free of unnecessary medications. Findings include: Review of the medical record revealed Resident #6 (R6) admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included dementia, anxiety, and major depressive disorder. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/23/24 revealed R6 scored 11 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the Physician's Note dated 1/29/24 revealed We Discussed this the [sic] Seroquel [antipsychotic medication] is not helping with sleep. Her anxiety is on going especially at HS [bedtime]. We will try to use Hydroxyzine [antihistamine medication] 25 mg [milligrams] at bedtime see if this helps both her sleep and the anxiety. We will adjust dosing if needed. Review of the Physician's Order dated 1/29/24 revealed an order for hydroxyzine 25 mg at bedtime for anxiety. Review of the Pharmacist Recommendation to Prescriber dated 2/7/24 revealed This resident has an order for hydroxyzine (Atarax, Vistaril), a high risk medication due to strong, sedating anticholinergic properties (e.g. dry mouth, blurred vision, urinary retention, tachycardia, confusion, cognitive impairment, sedation and toxic psychosis). Recommendation: Please consider discontinuing this medication. The State Operations Manual Appendix PP-Guidance to Surveyors for Long Term Care Facilities warms that H-1 blocker antihistamines have strong anticholinergic properties and are not considered medications of choice in older individuals. The non-sedating antihistamines are generally preferred when treating non-life threatening allergic reactions in the elderly, when used at the lowest dose for the shortest duration possible. 2023 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Soc 2023 updated. AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatric Soc. 2023. 1-30 doi:10.1111/jgs.18372. The physician/prescriber response did not have agree, disagree, or other checked off. The written response revealed med dc'd [discontinued] on 2/9/24 and was signed by the physician on 2/18/24. Review of the Physician's Orders revealed hydroxyzine was not discontinued. R6 continued receiving hydroxyzine 25 mg at bedtime until 8/20/24. There was no documentation in the medical record that revealed why the medication was not discontinued per pharmacy recommendations. Review of the Health Status Note dated 8/20/24 revealed Per pharmacy recommendation: GDR [gradual dose reduction] is recommended for Paxil, Seroquel, and hydroxyzine. Dr agrees with GDR for hydroxyzine, dose changed to 12.5 mg x 2 weeks then d/c. Disagrees with GDR of Paxil and Seroquel. Review of the Physician's Order dated 8/20/24 revealed an order for hydroxyzine 12.5 mg at bedtime for sleep aid until 9/3/24. R6 did not have a care plan pertaining to trouble sleeping. On 08/28/24 at 10:19 AM, R6 was observed asleep in bed. On 08/28/24 at 10:32 AM, R6 was observed lying in bed, awake. R6 reported she felt tired and that she did not usually nap unless she was not feeling well. In an interview on 08/28/24 at 2:05 PM, Director of Nursing (DON) B was not able to explain why R6's pharmacy recommendation revealed the hydroxyzine was discontinued, but R6 continued to receive the same dose until the order was changed on 8/20/24. In an interview on 08/28/24 at 2:37 PM, House Supervisor (HS) D was not able to explain why R6's pharmacy recommendation revealed the hydroxyzine was discontinued, but R6 continued to receive the same dose until the order was changed on 8/20/24. On 08/28/24 at 3:09 PM, HS D reported the Health Status Note dated 8/20/24 regarding a gradual dose reduction was not in response to a pharmacy recommendation, but in response to an Interdisciplinary Team meeting.

Based on observation, interview and record review, the facility failed to ensure laboratory testing for psychotropic medication monitoring was completed according to Physician's Orders for one (Resident #22) of five reviewed. Findings include: Review of the medical record reflected Resident #22 (R22) admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included congestive heart failure, obsessive compulsive disorder and severe vascular dementia with psychotic disturbance. The Significant Change in Status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/24/24, reflected R22 scored 11 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 08/28/24 at 1:19 PM, R22 was observed lying in bed, awake. A Physician's Order, dated 6/30/23, reflected a Hemoglobin A1C (blood test that measures the average amount of sugar in the blood for the past few months) and Lipid Panel (blood test that measures the amount of cholesterol and fat in the blood) were to be drawn every six months. A Psychiatric visit note for 5/10/24 reflected recommendations to continue 5 milligrams of Zyprexa (antipsychotic medication) daily. A Hemoglobin A1C , Lipid Panel and Comprehensive Metabolic Panel were recommended every six months. R22's medical record reflected the last Hemoglobin A1C and Lipid Profile were drawn on 7/13/23. During an interview on 08/28/24 at 2:06 PM, Director of Nursing (DON) B reported the purpose of R22's laboratory monitoring was for antipsychotic medication use. DON B confirmed R22's most recent Hemoglobin A1C and Lipid Panel were drawn in July 2023.

Based on interview and record review the facility failed to accurately document in the medical record for one resident #64 (R64) out of 18 assessed for documentation from a total sample of 18 resulting in incomplete medical records. Findings include: Resident #64 (R64) Medical record revealed Resident #64 (R64) was admitted to the facility on [DATE] initially with diagnoses that included unspecified Dementia, unspecified severity without behavioral disturbance, mood disturbance and anxiety, moderate intellectual disability, unspecified symptoms and signs involving cognitive functions and awareness, major depression disorder, anxiety disorder. According to R64's Minimum Data Set (MDS) dated [DATE], revealed R64 scored 03 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. MDS section GG0120 Mobility Devices used by R64 was a walker. Independent with transfers and ambulation in her room. R64 needs set up assistant with meals and getting dressed. Record review revealed R64 had monthly medication regimen review (MRR) for the months of 08/07/24 with no recommendations, 07/03/24 with no recommendations, 06/03/24 with no recommendations, 05/02/24 with no recommendations, 04/04/24 with no recommendations, 03/03/24 with no recommendations, 02/07/24 with no recommendations, 01/07/24 with no recommendations, 12/06/24 with no recommendations, 11/03/24 with no recommendations, 10/09/24 with no recommendations and 09/12/23 with no recommendations. All monthly MRR's were check marked with the following statement .Based upon the information available at the time of the review and assuming the accuracy and completeness of such information, it is my professional judgement that at such time, the resident's medication regimen contained no new irregularities. For purposes of the foregoing statement, the term irregularity means an event or circumstance that is substantially inconsistent with customary, accepted clinical approaches to providing pharmaceutical products and services, or that could reasonably be expected to impede or interfere with the achievement of intended or reasonably expected outcomes . No recommendations from the pharmacy department. Record review revealed that the MRR for the month of 02/07/24 there was a recommendation found in the patient's medical record. The pharmacy did make recommendations to the prescriber. Recommended an increase in Donepezil from 5 milligrams (mg) per day to Donepezil 10mg per day with the rationale that Donepezil 10 mg may provide additional benefit in some individuals. This recommendation was discussed during the interdisciplinary team (IDT) meeting and recommended to follow the pharmacy recommendation to increase the Donepezil to 10mg daily. Record review revealed that the MRR for the month of 02/07/24 there was a recommendation found in the patient's medical record. The pharmacy did make recommendations to the prescriber. Recommendation to re-evaluate the need to continue Omeprazole 20 mg two times a day. Proton pump inhibitor (PPI) therapy beyond eight weeks needs justification per Beers criteria (a comprehensive guide for healthcare providers to identify potentially inappropriate medications for older adults). Long- term use is associated with hypomagnesemia (a low level of magnesium in the blood that can affect the neuromuscular system and heart), vitamin B12 deficiency, and increased incidence of Clostridiodes difficile (a bacterium that causes an infection of the colon in the longest part of the large intestine) During an interview on 08/28/24 at 12:45 PM, DON B stated she looked at all the areas in the medical record for recommendations. DON B also stated that some recommendations may not have been returned with physicians' signatures yet. DON B also stated the Assistant Director of Nursing (ADON) tracks those recommendations after they are returned to the facility with the provider's signature. DON B stated she would talk to the ADON and get back with this writer. During an interview on 08/28/24 at 03:05 PM, DON B stated she had a call out to the pharmacy and waiting for the returned call. DON B stated the pharmacist was the one who completed the monthly medication regimen review and documented there were no recommendations. DON B also stated the monthly medication regimen review form was completed incorrectly as some months there were recommendations made.

Based on observation, interview, and record review the facility failed to ensure appropriate treatment and services for contracture management for one resident (#34) of one resident reviewed resulting in the potential for worsening contractures and pain. Findings Included: Resident #34 (R34) Review of the medical record revealed R34 was admitted to the facility 07/07/2016 with diagnoses that included chronic obstructive pulmonary disease (COPD), metabolic encephalopathy (problem in brain caused by chemical imbalance), hypotension, contracture (shortening and hardening of muscle, tendons or other tissue leading to deformity and rigidity of joints), hypokalemia (low potassium), dysphagia (difficulty swallowing)oral pharyngeal phase, obstructive hydrocephalus (build of fluid in the brain cavity), stricture of ureter, osteoarthritis, anemia, hydronephrosis (abnormal enlargement of a kidney), neuralgia (pain along nerve) and neuritis (inflammation of a peripheral nerve), anxiety, obstructive and reflux uropathy (obstruction of urinary tract), peripheral vascular disease (PVD), osteoporosis (brittle bone), depression, bilateral macular degeneration (degenerative condition affecting the retina), mild intellectual disabilities, lumbago (pain in muscles and joints of lower back) with sciatica both sides, chronic pain, spinal stenosis (narrowing of spinal canal), Alzheimer's Disease, developmental disorder, gastro-esophageal reflux, urinary retention, and malignant neoplasm (cancer) of endometrium. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/26/2023, revealed R34 had a Brief Interview of Mental Status (BIMS) of 6 (severe cognitive impairment) out of 15. Section G0400-Functional Limitation in Range of Motions, MDS with same ARD, demonstrated that R34 had impaired upper and lower extremities to both sides. During observation and attempted interview 06/05/2023 at 11:10 a.m. R34 was observed lying in bed, her right wrist was curled inward toward her forearm and her left hand/wrist had a brace visible. R34's legs were not observed as they were covered with a sheet. R34 did not respond to verbal stimulation. During record review it was revealed that R34's plan of care stated, Current Functional Performance: . is currently in a Functional Maintenance Program to maintain her strength AEB (i.e. ass evidenced by) completing the interventions. R34's plan of care also revealed interventions that included, Gentle PROM (i.e. Passive Range of Motion)/stretching BUE (i.e. Bilateral Upper Extremities) 10 min or as tolerated. Further review of R34's medical record demonstrated clinical progress notes entitle Restorative Program Note for the dates of 05/09/2023, 04/25/2023, 04/03/2023, 03/28/2023, 3/10/2023, 03/07/2023, and 03/06/2023. No other documentation regarding the completion PROM was found in the medical record. In an interview on 06/06/2023 at 02:04 p.m. Activity Director F explained that the facility does have a restorative program but that it was referred to as Functional Maintenance Program and explained that she coordinated that program. She explained that R34 was on the program, as she had contractures bilaterally of her upper extremities. Activity Director F explained that R34 was to receive gentle PROM (i.e. Passive Range of Motion)/stretching BUE (i.e. Bilateral Upper Extremities) 10 min or as tolerated. Activity Director F explained that R34 was to receive PROM two times per week. She could not demonstrate the frequency in the medical record but demonstrated a document that included resident schedules, which included frequency of services, for those residents that were on the Functional Maintenance Program. Activity Director F explained that is was that and activity aide, that was assigned to the program, would perform the necessary activity as listed in the residents plan of care. Activity Director F explained that it was the expectation that documentation of completion or refusal of those specific task were document in the medical record. That documentation was entitled Restorative Program Note. Activity Director F verified that the only documentation was not completed twice per week since March 2023. She could not explain why R34 had not received PROM/stretching BUE 10 min or as tolerated twice per week since March 2023. In an interview on 06/06/2023 at 03:07 p.m. Director of Nursing (DON) B explained that it was the expectation that documentation be recorded for completion or refusal of the Functional Maintenance Program. DON B confirmed that R34 had not received the Functional Maintenance Program as listed in her plan of care. DON B could not explain why R34 had not received the Functional Maintenance Program twice each week.

Based on observation, interview, and record review, the facility failed to 1. Label an open eye drop bottle with a resident name and/or open date; and 2. Dispose of an expired insulin pen in 2 of 3 medication carts reviewed for medication labeling and storage, resulting in the potential for decreased medication efficacy and side effects. On [DATE] at 3:11 PM, North Hall Medication Cart was reviewed in the presence of Registered Nurse (RN) C. During the review, an open box of Artificial Tears Lubricant Eye Drops was noted to be labeled with Resident # 61's (R61's) last name with the open eye drop bottle inside the box not noted to be labeled with R61's name. Neither the opened eye drop box, nor the opened eye drop bottle was noted to be labeled with an open date. RN C confirmed absence of an open date on the eye drop box and absence of R61's name and an open date on the eye drop bottle. RN C proceeded to dispose of the opened eye drops and was observed to obtain a new box of Artificial Tears Lubricant Eye Drops and labeled both the box and bottle with R61's name and open date. Further review of the North Hall Medication Cart in presence of RN C revealed an open box of Brimonidine Tartrate Ophthalmic Solution 0.2%. Both the eye drop box and open eye drop bottle within the box contained a pharmacy label reflecting R18's name but neither the box nor bottle was noted to be labeled with an open date. RN C confirmed the absence of an open date on both the eye drop box and bottle, stated that I've got a brand new one here. I will be getting rid of the opened one, opened the new box and bottle of Brimonidine Tartrate Ophthalmic Solution 0.2% noted to contain a pharmacy label with R18's name, and was observed to label both the box and bottle with the open date. On [DATE] at 9:48 AM, East Hall Medication Cart was reviewed in the presence of Licensed Practical Nurse/House Supervisor (LPN/HS) D. During the review, a Novolin R FlexPen was noted with a pharmacy label reflecting R47's name and a handwritten open date of [DATE] and expiration date of [DATE]. The pen also contained a printed label with indication to Discard 28 days after opening. LPN/HS D confirmed that the insulin pen was expired and would be getting a new pen. Review of R47's medical record revealed an active order dated [DATE] for Novolin R FlexPen with twice daily administration based on blood sugar values. Review of the corresponding Medication Administration Record dated [DATE]-[DATE], reflected Novolin R FlexPen administration as follows: [DATE] at 6:00 AM 2 units, [DATE] at 8:00 PM 4 units, [DATE] at 8:00 PM 2 units, and [DATE] at 8 PM 2 units. In an interview on [DATE] at 10:14 AM, Director of Nursing (DON) B stated that when a facility stock eye drop (including Artificial Tears Lubricant Eye Drops) was opened, both the eye drop box and the bottle should be labeled with the specific residents name in case the bottle was separated from the box. DON B further stated that with prescription eye drops, would expect to see both the resident name and a handwritten date to reflect the date the eye drops were opened, on both the eye drop box and bottle, as different prescription eye drops had different expiration dates after opening. During the same interview, DON B stated that all insulin pens should be labeled with the resident's name, a date to indicate when the pen was opened, and should be disposed of by the expiration date for that specific insulin as different insulins were good for different durations of time after opening. Review of the document titled Medications with Shortened Expiration Dates provided by Facility Assistant E indicated, Novolin R Flexpen to have a 28 day Stability, In-Use, Room Temp (Temperature). Review of the facility policy titled Labeling of Medications and Biologicals with a reviewed/revised date of ,d+[DATE] stated, .Policy Explanation and Compliance Guidelines: 1. Medications and biologicals will be labeled in accordance with applicable federal and state requirements and current accepted pharmaceutical principles and practices .8. Labels for medications designed for multiple administrations (such as inhalers, eye drops), the label will identify the specific resident for whom it was intended).

This citation pertains to intake MI 780. Past Non-Compliance was determined appropriate by the state agency for this citation. Plan outlined below. Based on observation, interview and record review, the facility failed to prevent misappropriation for 4 residents (Residents #16, #31, #42 and #178), reviewed for misappropriation. The deficient practice resulted in the misappropriation of controlled medications (narcotics) from Residents #16, #31, #42 and #178 when their medications were signed out but the nurse was never observed entering the rooms to administer the medications. Findings include: The facility provided the policy Abuse, Neglect and Exploitation dated 5/2005 with a last revised date of 2/12/21 for review. The policy reflected, Misappropriation of resident property means a deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of the resident's belongings or money without the resident's consent. On 7/13/22 at 1:40 PM and 1:45 PM, this surveyor called the last known phone number for Registered Nurse (RN) L regarding the investigation, but the number was no longer in service. RN L was not available to interview before the exit of this survey. The facility provided a copy of the police report case # 5 for review. The report reflected, VIDEO EVIDENCE: On file North Hall West #2: at approximately 4:32:50 a.m. It appears that (name of RN L) checks a pill out from the narcotics drawer, folds it up in a mask and sticks it deep down in the trash container next to the narcotics drawer. At 4:35:00 a.m. it appeasers (name of RN L) takes a pill out of a cup with her left hand throws the cup away with her right hand and puts the pill in her left pocket, keeping her hand in her left pocket until it appears that she places the pill in her mouth. On file east Hall South #5: at approximately 5:16:58 a.m. it appears (name of RN L) has checked a pill out of the narcotics drawer and attempts to place it in a little clear bag but the drops on the floor. (Name of RN L) then checks her clothing and gets down on the floor to look under the cart. She finds the pill under the cart, stands up and places it into the clear bag and puts it into her left pocket at 5:17 a.m. The facility provided a copy of a statement via a witnessed telephone interview dated 1/17/2022 at 10:30 am. The statement reflected that RN L was very tearful and at times difficult to understand. RN L explained that she was sorry for taking the pills and that she did it for her son who was going through withdrawals. She wanted to give him the pills so that she could get some peace. She stated that she just wanted to tell someone that she was sorry and explain it to somebody. During an interview on 7/13/22 at 1:50 PM, the DON (Director of Nursing) confirmed the facility and police investigation findings. RN L signed controlled medication out for Residents #16, #31, #42, and #178 and according to the video did not provide the medications to the resident to whom they belonged. The DON stated that the residents who were affected have memory impairment and were not able to verbalize or recognize the medications were not administered. The DON stated that RN L was subsequently terminated from the facility because of the misappropriation of narcotics. The facility provided the following timeline from the security camera footage starting on 1/5/22 at 6:30 PM until 1/6/22 at 7:00 AM of RN L's actions at the medication cart and in the hallways: 4:32 AM observed at the medication cart disposing of a medication 4:33 AM removed a pill from the narcotic drawer and puts it in a cup. 4:35 AM removes the pill from the cup and places it in her pants pocket. 4:41 AM removes a pill from the narcotic drawer directly into her hand and then placed it in her pants pocket 4:46 AM removes a pill from the top drawer of the medication cart and placed into her mouth. 5:16 AM removes a pill from the narcotic drawer, drops it on the floor, picked it up and placed it into a bag. The narcotic count down sheet reflected that RN L signed out narcotics for the following residents but was never observed on the video to enter the resident rooms to administer the medication during her shift: Resident #16- [MEDICATION(S)] 30 mg capsule for pain, signed out on 1/6/22 at 5:00 AM, not observed to enter room. Resident #31-[MEDICATION(S)] 0.5mg for anxiety, signed out on 1/6/22 at 6:00 AM, not observed to enter room. Resident #42-[MEDICATION(S)] oral concentrate 0.25 ml for pain, signed out on 1/6/22 at 5:00 AM, not observed to enter room. Resident #178-[MEDICATION(S)] 0.5mg tablet for anxiety, signed out 1/6/22 at 6:00 AM, not observed to enter room. On 7/13/22 the surveyor verified the following interventions were put into place and were effective to bring the facility into compliance: IMMEDIATE ACTIONS: The police were called, and the event reported; a facility reported incident (FRI). The nurse was removed from duties and sent for drug testing on 1/6/2022 (negative results). The identified resident was evaluated for pain or changes in functional status related to not receiving ordered medications. Facility physicians were notified. Developed a list of other residents cared for by the RN during the identified time frame to evaluate for pain or changes in functional status in the event of not receiving ordered medications. Verified the RN's license is in good standing and reviewed the human resource records. ROOT CAUSE of THE ISSUE: The root cause of this event is human action. The center's processes of routine record review including Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Element One: The resident(s) identified have been evaluated for indicators of unmanaged pain and indications of health condition changes. There have been no determinations of unmanaged pain or health condition changes related to medication regimen. The residents care plans were also reviewed and updated as needed. The identified resident(s) physicians and their responsible parties have been notified of the event. Element Two: Similar residents likely to be impacted by this identified area are those who have received care from the RN within the last two (2) weeks, who have cognitive impairments. A list of these residents has been developed and these residents are being reviewed for indications of unmanaged pain or health condition changes related to medication regimen. The residents care plans were also reviewed and updated as needed. If it is determined changes have occurred, the identified resident(s) physicians and their responsible parties will be notified. Alert and oriented residents receiving care from the RN during the last two (2) weeks were interviewed about care and services to identify medication administration concerns, care delivery issues and to gather feedback and suggestions as applicable. Reviewed risk factor for similar behaviors by licensed nurses: reviewed HR records for call ins, Element Three: The policies and procedures for administration, documentation and destruction of controlled substances were reviewed and determined to reflect current standards of practice. The policies and procedures for Abuse Prohibition Training and the Elder Justice Act were reviewed and determined to reflect current standards of practice. The licensed nurses have been re-educated on the Elder Justice Act with emphasis on misappropriation of resident property. The pharmacist reviewed the center's protocols for receiving, counting, administering, and destroying controlled substances to determine the facility's practices reflect the best standards of practices. The pharmacist conducted random medication administration passes to identify opportunities for process improvement. Element Four: Beginning the week of 1/10/2022, under direction of the QAPI Committee, audits of resident pain and controlled substance practices will be completed. A summary of findings will be reported to the QAPI Committee in January and February and the QAPI Committee will direct further action. The Administrator and Director of Nursing or designee are responsible for supervising ongoing compliance. The facility is in compliance with administration of controlled substances and medications as of 1/7/2022. During this survey, this surveyor reviewed documentation, conducted interviews, and made observations the preceding interventions were completed prior to the annual survey and no continuing issues related to this citation were noted. A determination of past non-compliance was approved by the state agency as of 1/7/22.

Based on interview and record review the facility failed to implement the grievance process for 1 resident (Resident #41) resulting in increased anxiety and frustration from a perceived lack of response to a formal complaint. Findings: Review of a policy Resident Centered Grievances last revised 10/20/2020 reflected The facility supports residents', family members' and staff members right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. The policy specified Prompt efforts to resolve' includes acknowledging a complaint/grievance and actively working toward a resolution . 2. The Grievance Officer oversees the grievance process and may assign designees or use assistance from other team members as needed; receives and tracks grievances to conclusion; coordinates necessary investigations; maintains confidentiality as needed; issues written or verbal grievance decisions to the resident and/or complainant; and coordinated with team members, state and federal agencies as necessary based on specific allegations . 4. A resident or a family member may voice grievances with respect to care and treatment which has been furnished or which has not been furnished, the behavior of staff and other residents, and other concerns. These may be written, or verbal reports and the team members will work to address concerns as they are brought up .8. Grievances may be voiced in several ways: A. Verbal or written complaint to a staff member or Grievance Officer. B. Written complaint to an outside party. C. Verbal complaint during resident or family council meetings. The policy indicated The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form, or assist the resident or family member to complete the form. i. Take prompt actions to reduce further potential grievances. ii. Report allegations involving neglect, abuse, injuries of unknown source, and/or misappropriation of resident property immediately to the administrator/abuse coordinator and follow procedures for those allegations. Resident #41 (R41) Review of an Admission Record reflected R41 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R41's wife was listed as his Power of Attorney/Responsible Party (POA). Review of a quarterly Minimum Data Set assessment dated [DATE] reflected R41 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 5/15 and was totally dependent on two people for transfers and toilet use. During an interview on 7/11/22 at 11:22 AM, POA G reported that a few weeks ago R41 had been left in feces for 45 minutes and had to eat dinner while sitting in feces before staff could change him. According to POA G, she was visiting with R41 at the time of the occurrence, and she reported the concern to the nurse on duty at the time of the incident who told her that one Certified Nurse Aide (CNA) was in the dining room assisting other residents to eat and the other CNA was on a break. POA G said the staff did not offer or complete a grievance form related to the incident which made her feel nervous about what kind of care R41 would get when she was not visiting. During an interview on 7/12/22 at 2:05 PM, Grievance and Solutions Officer (GSO) H reported she did not have any grievances on file for R41 in the last 4 months. GSO H said she was not aware of the complaint made by POA G related to R41 from a few weeks ago and explained that this was the first she was hearing about it. GSO H said that because of the nature of the allegation it is possible the Nursing Home Administrator (NHA) would know about it. During an interview on 7/12/22 at 2:22 PM, the NHA reported she was aware that POA G was concerned about R41 sitting in feces during a mealtime and first learned of the incident when POA G texted her cell phone asking how she would like eat dinner in a soiled brief. The NHA said she did not initiate the grievance process or file a facility report with the State Agency and instead called to the receptionist at the facility at the time of the occurrence (the NHA reported the text message was sent on June 23, 2022) to check on the situation. The NHA reported the receptionist on duty at the time of the report from GSO G was also a CENA and would have been able to help if needed. During an interview on 7/12/22 at 3:11 PM, the Director of Nursing (DON) reported she had not been aware of POA G's concern related to R41 being left in a feces soiled brief for 45 minutes and during a meal. During an interview on 7/12/22 at approximately 3:45 PM, CNA I reported she was on duty on 6/23/22 and recalled POA G being concerned R41 was sitting in a soiled brief during the dinner meal. According to CNA I, she came back from a break and directed her hall partner to go to the dining room to assist other residents with their meal. CNA I said POA G requested assistance for R41 and CNA I told her that as soon as meal trays were passed, she would find a helper to attend to R41 with her. CNA I said a receptionist, she did not know who she was, did come to the unit to ask what the matter was after POA G contacted the NHA and did not indicate the receptionist offered to assist with cares. During a follow-up interview on 7/13/22 at 8:28 AM, the NHA reported that there was an opportunity to do a better job related to the circumstances surrounding POA G's complaint pertaining to R41's care on 6/23/22.

This citation is related to intake # MI00- 2 Based on observation, interview and record review the facility failed to assess and monitor a skin alteration for 1 resident (Resident #42) resulting in the potential for avoidable worsening of the wound area. Findings: Review of a policy Skin Skan (sic) implemented 2/2/2022 reflected It is our policy to communicate changes in skin conditions to appropriate personnel as part of our systematic approach for pressure injury prevention/management and overall skin integrity. This policy establishes procedures for using the Skin Skan Tool to communicate skin abnormalities or changes. The procedure included directions for nurse aide staff to complete the tool and reported skin conditions or abnormalities noticed during bathing/showers and during morning and evening cares, to the floor nurse for assessment and treatment. The Skin Skan tool is also used as a form of communication to the unit managers or Assistant Director of Nursing (ADON) for weekly review. The policy specified that skin conditions to be reported include but are not limited to: redness, bruising, swelling, rashes, hives, blisters (clear or blood filled), skin tears, open areas, ulcers, [CONDITION(S)], check nails, soft heels, scratches, abnormal color, medication patches. Resident #42 (R42) Review of a quarterly Minimum Data Set assessment dated [DATE] reflected R42 admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment reflected R42 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status score of 7/15, needed extensive assistance from two people for bed mobility and eating and was totally dependent on two people for toilet use and dressing. Section H - Bladder and Bowel reflected R42 was always incontinent of bladder and bowels. Section M - Skin Conditions reflected R42 was at risk for pressure ulcers based on clinical assessment and did not indicate R42 had a pressure sore or other problems including open [CONDITION(S)], skin tears, [CONDITION(S)] or Moisture Associated Skin Damage (MASD). Review of the MDS Resident Matrix dated 7/11/22 did not reflect that R42 had a pressure ulcer or worsening pressure ulcer. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Order Note dated 7/4/22 at 1:51 PM reflected A & D ointment (a barrier ointment) discontinued to resident's coccyx and buttocks related to new order initiation for [MEDICATION(S)] (a sulfa antibiotic ointment used to stop the growth of bacteria that may infect an open wound) and [MEDICATION(S)] (absorbent foam dressing containing silver used to cover open wounds) to open area to coccyx, Resident's daughter (name) notified of new order. Further review of progress notes before and after the 7/4/22 entry did not reflect a nursing assessment, measurements or description of the open area to R42's coccyx. Sorting the progress notes by type reflected Skin/Wound Note had not been completed for R42 since 3/31/22. Review of R42's Treatment Administration Record (TAR) for the month of July 2022 reflected the order noted above had been completed daily beginning on 7/4/2022. The TAR also indicated the following order Skin check weekly and PRN (as needed) every day shift every Fri (Friday) and was documented as completed on 7/1/22 and again on 7/8/2022. No evidence a PRN skin check had been completed between 7/1/22 and 7/8/22. Review of R42's electronic medical record, under the Assessments tab reflected Skin Only Evaluation was marked as incomplete on 9/8/21, 9/15/21 and 10/01/21. No evidence a Skin Only Evaluation assessment had been initiated on R42 since 10/01/21. During an observation on 7/12/22 beginning at 10:05 AM, Registered Nurse (RN) B removed a [MEDICATION(S)] dressing from R42's coccyx revealing a small wound on the right buttock adjacent to the coccyx and described it as a slit but didn't think it was a pressure ulcer. The wound was not clearly visualized related to a whitish substance, likely [MEDICATION(S)], was over and around the area. RN B said she does not do wound measurements as these are completed weekly by the Assistant Director of Nursing (ADON). RN B did not clean the area or reapply [MEDICATION(S)] before recovering the wound with a fresh dressing and said she would document an assessment. During an interview on 7/13/22 at 10:04 AM the Director of Nursing (DON) and ADON K reported that the DON was the facility Wound Nurse and ADON K acted as the unit manager responsible for tracking pressure areas and taking weekly measurements of identified pressure sores. If a resident had a non-pressure skin alteration, the floor nurse was responsible for the weekly skin assessments which were documented only by exception (if there was an identified concern, an assessment would be documented), otherwise the floor nurse would simply indicate an assessment had been done on the TAR. According to the DON and ADON K, the nurse who identifies a skin concern will assess the area, document the assessment and a treatment is initiated. Neither the DON or ADON were aware of any open areas on R42's coccyx or new treatment orders initiated on 7/4/22 and had not been tracking the wound at all. At this time, any and all pertinent documentation pertaining to R42's skin was requested. The ADON denied there were any Skin Skan forms completed for R42 in the last few months. As of 7/13/22 at 4:00 PM, no supporting documentation pertaining to R42's wound were provided prior to the conclusion of the survey. During an observation on 7/13/22 at 10:45 AM, the ADON assisted the DON in completing the ordered dressing change and measuring the open area. The DON verbalized her assessment and reported the open area measured 1.5 centimeters (cm) by 0.50 cm, the wound bed was blanchable as well as the peri-wound skin. The DON described seeing evidence of maceration she thought was brought on by the treatment itself. The DON decided not to apply the [MEDICATION(S)] to the wound area and covered the area with [MEDICATION(S)] dressing until she could speak to the physician. Review of an article Everything You Need to Know About Macerated Skin updated on 9/16/2018 reflected Maceration occurs when skin is in contact with moisture for too long. Macerated skin looks lighter in color and wrinkly. It may feel soft, wet, or soggy to the touch. Skin maceration is often associated with improper wound care. In addition to the pain and discomfort it causes, maceration can also slow wound healing and make skin more vulnerable to infection. (Accessed from www.healthline.com/health/macerated-skin).

This citation pertains to intake # MI00- 2 Based on observation, interview and record review the facility failed to implement enhanced barrier precautions for residents with a indwelling medical device or history of [CONDITION(S)] ([CONDITION(S)]) infection or colonization for one resident (Resident #16) resulting in the potential for cross contamination and the transmission of multidrug-resistant organisms. Findings: Review of a policy Enhanced Barrier Precautions last revised 10/21/2021 reflected It is the policy of this facility to implement enhanced barrier precautions for preventing transmission of novel or targeted multidrug-resistant organisms . Enhanced Barrier Precautions refer to the use of gown and gloves for certain residents during specific high contact resident care activities that have been found to increase risk for transmission of multidrug-resistant organisms. The policy specified 2. Initiation of Enhanced Barrier Precautions-A. Nursing staff may place residents with certain conditions or devices on enhanced barrier precautions empirically while awaiting physician orders. B. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Wounds and/or indwelling medical devices (e.g., central line, urinary catheter, feeding tube, [CONDITION(S)]/ventilator) regardless of [CONDITION(S)] colonization status. ii. Infection or colonization with a novel or targeted [CONDITION(S)] when contact precautions do not apply. iii. Infection or colonization with other epidemiologically important MDROs .4. High-Contact resident care activities-a. dressing, b. bathing, c. transferring, d. providing hygiene, e. changing linens, f. changing briefs or assisting with toileting, g. device care or use: central line, urinary catheter, feeding tube, [CONDITION(S)]/ventilator, h. wound care: any skin opening requiring a dressing. Resident #16 (R16) Review of an Admission Record reflected R16 admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment dated [DATE] reflected R16 had short term memory impairments and demonstrated moderately impaired cognitive skills for daily decision making. R16 required extensive assistance from one person for personal hygiene, required two people for bed mobility and was totally dependent on two people for transfers, dressing, and toilet use. Section H - Bladder and Bowel reflected that R16 had an indwelling catheter (including suprapubic catheter and nephrostomy tube) and was always incontinent of bowels. During an observation on 7/11/22 at 10:39 AM a sign was on a hook outside R16's room that read STOP-Enhanced Barrier Precautions Everyone Must: Clean their hands, including before entering and when leaving room. Providers and Staff must also: Wear gloves and a gown for the following high-contact resident care activities. Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, [CONDITION(S)], wound care: any skin opening requiring a dressing. Do not use the same gown and gloves for the care of more than one person. During an observation beginning on 7/12/22 at 8:16 AM, Registered Nurse (RN) B organized her supplies, washed her hands and donned gloves before flushing R16's nephrostomy tube. RN B performed hand hygiene again, donning new gloves and performed suprapubic catheter care and replacing the dressing around the stoma. RN B again performed hand hygiene, donned new clean gloves and cleaned and replaced a dressing on R16's contracted right groin area. RN B did not don an isolation gown and reported that no enhanced barrier precautions were required for the procedures, did not know why they would be necessary and did not notice the sign outside the door or the personal protective equipment situated behind a privacy curtain in R16's room. During an interview on 7/12/22 at 8:31 AM, Infection Control Nurse (ICN) A reported that it isn't important that staff providing the care specified on the signage knew why the enhanced barrier precautions were in place, just that they follow the instructions on the sign.

This citation pertains to MI 747. Based on interview and record review, the facility failed to report an allegation of abuse timely for one (Resident #4) of three reviewed for abuse and/or neglect, resulting in an abuse allegation not being reported to the Nursing Home Administrator (NHA) or State Agency timely and the potential for further allegations of abuse not being reported timely. Findings include: Review of the medical record reflected that Resident #4 (R4) was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/24/21, reflected that R4 had short-term and long-term memory problems, did not walk and required extensive to total assistance for many activities of daily living. Review of a facility investigation reflected that on 6/13/21, around 12:30 PM to 1:30 PM, Certified Nurse Aide (CNA) G placed their gloved fingers in R4's mouth and stated, This brings back memories. CNA E and CNA F talked about it and thought it was weird but were busy on the hall. They did not discuss it again until around 6:30 PM, when they were talking to a CNA leader. The CNA leader told CNA E and CNA F it could be a reportable event and advised them to tell the nurse. According to the investigation, suspicion was formulated that the event could fall under reportable requirements at 6:30 PM. On 6/13/21, at 6:51 PM, the charge nurse reported the alleged event to the NHA. On 6/21/21 at 3:41 PM, CNA E described that around lunch time [on 6/13/21], CNA G was assisting them with R4's care. R4 was rolled towards CNA G, and R4 began hitting at CNA G and tried to bite CNA G. CNA E reported that when R4 tried to bite, CNA G put their gloved fingers in R4's mouth and said it brings back memories. Just before that, CNA F entered the room to say they were back from break. CNA E reported getting R4 cleaned up and leaving the room. CNA E stated they had asked CNA F if they saw it too. CNA E stated they briefly discussed it with CNA F but had to keep working due to so many call lights going off. CNA E reported they, along with CNA F, spoke to CNA K at 6:30 PM shift change, then to the charge nurse. CNA E stated they [along with CNA F] were trying to figure out how inappropriate it was and decided it should still be reported. During an interview on 6/22/21 at 11:22 AM, CNA F reported that while CNA G and CNA E were changing R4, CNA G stuck their gloved fingers in R4's mouth and said it brings back memories. CNA F reported CNA G said it in a weird way. CNA F reported they, along with CNA E, spoke to CNA K about it at shift change, then reported it to the nurse. CNA F reported the alleged event occurred around 1:00 PM, but they did not talk about it with CNA E until later and, we weren't really sure. CNA F stated they got swamped. CNA F stated they didn't think it was right and talked to CNA K, who also said it wasn't right and advised them to report it. CNA F stated they then reported to the charge nurse, Registered Nurse (RN) L. During an interview with NHA A and Staff Member (SM) D, on 6/22/21 at 4:11 PM, NHA A stated that at 6:51 PM [on 6/13/21], RN L told NHA A they got an allegation. According to NHA A, the staff said they thought it was weird and didn't know what to do about it. When CNA K was told of the alleged event at 6:30 PM, CNA K advised the staff to tell the charge nurse. The charge nurse then reported to NHA A. According to NHA A, the staff thought it was odd. NHA A reported they would expect when staff formulate the suspicion, they would inform us immediately. When asked if they felt there was a delay in reporting the alleged event, NHA A stated they did not. NHA A reported they believed the Elder Justice Act stated that once you formulate the suspicion, you have two hours. SM D said even though they [CNA E and CNA F] thought it was unusual, they didn't form the suspicion until talking to CNA K. According to the facility Abuse, Neglect and Exploitation Protocol, reviewed/revised on 2/12/21, .Reporting/Response .The facility has written procedures that include .Reporting alleged violations to the Administrator/Abuse Coordinator/designee, state agency, adult protective services and to all other required agencies, if needed, (e.g., law enforcement when applicable) within specified timeframes .Immediately (the Abuse Coordinator has 2 hours to report to the State Agency), after forming suspicion of abuse OR if the allegation involves abuse . According to the State Agency's system for reporting, the alleged event occurred on 6/13/21 at 6:30 PM, was discovered on 6/13/21 at 6:51 PM and was reported to the State Agency on 6/13/21 at 7:47 PM. Staff interviews and the facility's investigation revealed the alleged event occurred on 6/13/21, between 12:30 PM and 1:30 PM.

This Citation Pertains To Intake #MI 590 Based on interview and record review, the facility failed to follow Physician orders for 1 of 4 residents (R1) reviewed for quality of care, resulting in one on one supervision not being assigned as ordered by the physician and R1's subsequent death. Findings include: According to the clinical record Resident 1 (R1) was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was admitted for short term rehabilitation with the intent to return home with family. R1 expired at the facility on [DATE]. Review of the nursing progress notes Late entry from [DATE]. Resident A+OX1 (person) and follows commands without difficulty. Resident taking oxygen off intermittently and then having c/o (complaints of) SOB (Short of Breath) and [NAME] (Difficulty in Breathing). Oxygen placed back on making SOB and [NAME] dissipate. No c/o pain, N/V (nausea/vomiting), diarrhea, cough, numbness or tingling. LSCTA (lung sounds clear to auscultation). No s/sx of Covid. Participates in therapy. Skin warm , dry and intact. Cap refill > 3 sec (capillary refill greater than 3 seconds.) No [CONDITION(S)] noted. Pulses present including pedal. Nursing Progress notes dated [DATE] at 21:55 Resident A+OX1 (person) and follows commands without difficulty. Resident taking oxygen off consistently which was dropping his SPO2 (peripheral capillary oxygen saturation; the percentage of oxygenated hemoglobin in the blood) down to anywhere between ,d+[DATE]%. Notified Dr. (physician) and new order for 1:1 placed. No c/o pain, N/V, diarrhea, cough, numbness or tingling. LSCTA. No s/sx of covid. Not participating in therapy. Resident refusing pain gel. Skin warm, dry and intact. Cap refill > 3 sec No [CONDITION(S)] noted. Pulses present including pedal. Progress notes [DATE] at 02:42 Resident in bed, eyes open to sound. respirations even and unlabored. No signs of distress. Resident does have periods of confusion attempting to take oxygen off and get out of bed. When this happens oxygen, saturation drops dramatically. 1:1 order in place for resident safety with string alarm. No s/s of covid On [DATE] at 2:52 PM, during a phone interview, Registered Nurse ( RN) C reported she was assigned to R1 on ,d+[DATE], ,d+[DATE] and ,d+[DATE] and described R1 as, he continuously was taking his oxygen off and would sat very low, it was continuous, I was checking on him every 15, I had him for 2 or 3 days, he pretty much got really bad , I think it was Sunday and he would pull it off, I did an incident report, he had a PT person come in and they tried to to stand and walk him when I spoke with the tech they wanted me to get him up I took his spo2 it was very low, I got him a non-rebreather mask and got his 02 levels back up, that , I called the doctor and he ordered a 1:1 so he would keep his 02 in place. RN C said she was not scheduled the following day (,d+[DATE]) and was shocked to learn that R1's 1:1 had stopped and R1 expired. RN C further reported she has since resigned her position at the facility. On [DATE] at 4:40PM during a phone interview with Doctor (Dr.) G, who recalled the phone conversation with RN C, I told her to get him a 1:1 and if that can't be done send him to the hospital, he needed oxygen. Dr. G reported he had not discontinued the order and had not heard back from facility staff in relation to R1 until after R1 had expired. On [DATE] at 10:20 am, during an interview with Licensed Practical Nurse (LPN) D, he reported working a 12 hour shift on [DATE] and that Certified Nursing Assistant (CNA) F was R1's assigned 1:1 up until 2:30pm which was when her shift ended on [DATE], LPN D reported according to the schedule sheet there was nobody assigned to continue the 1:1 for R1 after 2:30pm. LPN D reported R1 was assigned the 1:1 because he kept trying to remove his oxygen. LPN D stated he did not receive an explanation from Management staff as to why the 1:1 for R1 was stopped abruptly, did not recall if there was a Physician order to discontinue the 1:1 and was provided no direction or new interventions (such as 15 minute checks) on [DATE]. LPN D stated he had last saw R1 around 3:00 or 4:00 PM on [DATE] when he administered him his medications. LPN D reported it wasn't until sometime after 5:00 pm that CNA E was in R1's room and yelled from the room, LPN D stated he immediately went to R1's room in response to CNA E's yelling and he observed , R1 in bed, legs were half way off the bed We were moving him up in bed and I saw that his face was purple. He was a DNR, and another nurse and I got our stethoscope, he was expired. It came out of left field, I didn't expect that. LPN D stated he was instructed by management several days after R1 expired, to write a progress note in R1's medical record that R1's nasal cannula was in place and 02 running at 4 liters. On [DATE] at 10:40 am, during an interview with CNA E, she reported she was assigned to R1 on [DATE], CNA E also stated R1 was assigned a 1:1 up until 2:30 PM and the 1:1 assignment was not replaced without reason. CNA E reported she was aware R1 was assigned the 1:1 because he was confused and kept removing his oxygen. CNA E stated after the 1:1 left she kept checking on R1 to ensure he was ok, and took her break about 4:00 or 4:30. CNA E reported when she went to deliver R1 his dinner tray at approximately 5:15 PM, she observed R1 in bed with his legs half way off the bed, CNA E stated R1's nasal cannula was not in his nose, CNA E further stated she put R1's nasal cannula back in R1's nose and started to shake him and yelled for the nurse, CNA E stated she worked at the facility for several years and had seen a lot over the course of those years, but this it was such a terrible day and seemed so unnecessary. On [DATE] at 11:25 am, during an interview with the CNA F she reported she was assigned to be the 1:1 for R1 on [DATE] and reported her shift ended at 2:30 PM that day, and that she had asked LPN D who was replacing her. He told me there was nobody assigned. CNA F stated she didn't understand why there was no replacement nor did she get an explanation. On [DATE] at 1:03pm, during an interview with Director of Nursing, (DON) B reported the interdisciplinary team (IDT) met the morning of [DATE] to discuss events from the weekend, it came up that R1 had a 1:1 ordered over the weekend. DON B stated, we reviewed his falls and decided he didn't need a 1:1, we kept the 1:1 until 2:30 (the end of CNA F shift) because he was on the transmission based precaution unit and at that point we couldn't reassign her anyway. When queried who was the one to decide R1 didn't need a 1:1 DON B did not respond. When queried if Dr G was a part of the IDT meeting on ,d+[DATE] DON B stated no. When queried if Dr. G was consulted or if an order was obtained about discontinuing the 1:1 DON B stated No. Review of R1's clinical record was done alongside DON B there was no documentation of a Care Plan in place to address R1's removal of oxygen, no Physician Order to discontinue the 1:1 and no evidence that any other interventions were implemented to ensure R1's safety related to oxygen use. Throughout the day of [DATE] confidential interviews of 8 members of the IDT participants from [DATE] were interviewed. Multiple members of the IDT meeting participants reported Administrator A stated she did not want to pay for 1:1 care. Some members from the IDT team expressed great concern for R1's safety if the 1:1 was removed. On [DATE] at 1:05 pm during an interview, Administrator A reported the facility did not currently do 1:1 supervision of residents. When queried about the discussion from the IDT meeting ,d+[DATE] and how it came about that R1 did not need a 1:1, Administrator A reported . I didn't think he needed a 1:1 . Administrator A reported she didn't know R1 was assigned the 1:1 to ensure his safety and keeping his oxygen in place. Administrator A offered no explanations as to why the care plan had zero interventions related to oxygen and R1's safety or why Dr. G was not contacted and consulted about the 1:1 order. When queried if there was an investigation into R1's death, Administrator A reported, No, its not suspicious. Administrator A stated she thought R1's oxygen was in place when he was found expired. Review of the Mayo Clinic website revealed Chronic obstructive pulmonary disease ([CONDITION(S)]) is a chronic [CONDITION(S)] lung disease that causes obstructed airflow from the lungs. Symptoms include breathing difficulty, cough, [MEDICATION(S)] (sputum) production and wheezing. Doctors often use these additional therapies for people with moderate or severe [CONDITION(S)]: Treatment options: Oxygen therapy. If there isn't enough oxygen in your blood, you may need supplemental oxygen. There are several devices that deliver oxygen to your lungs, including lightweight, portable units that you can take with you to run errands and get around town. Some people with [CONDITION(S)] use oxygen only during activities or while sleeping. Others use oxygen all the time. Oxygen therapy can improve quality of life and is the only [CONDITION(S)] therapy proved to extend life. Review of R1's death certificate revealed 36. PART 1 ENTER the chain of events-diseases, injuries or complications that directly caused the death. DO NOT enter terminal events such as [CONDITION(S)], respiratory arrest or ventricular fibrillation without showing etiology. Enter only one cause on line. The death certificate line titled Due to had [CONDITION(S)] written.

This citation pertains to intakes MI 655 and MI 787. Based on interview and record review, the facility failed to develop and implement an Abuse Policy and Procedure consistent with Federal Regulations for reporting of alleged violations for two (Resident #2 and #3) of three reviewed for abuse, resulting in 1) the facility's Abuse, Neglect and Exploitation policy not accurately reflecting the time frames for reporting of abuse allegations to the Nursing Home Administrator and State Agency; and 2) allegations of staff to resident abuse that were not reported to the Nursing Home Administrator immediately and not reported to the State Agency timely, with the potential for further abuse allegations not being reported timely. Findings include: According to the facility policy titled, Abuse, Neglect and Exploitation, last reviewed/revised 12/2020, .Reporting/Response . The facility has written procedures that include (see Appendix B): A. Reporting alleged violations to the Administrator/Abuse Coordinator/designee, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframe's: 1. Immediately, but not later than 2 hours after the allegation is made, if there is serious bodily injury, or 2. Not later than 24 hours if the allegation doesn't involve abuse and didn't result in serious bodily injury . According to the State Operations Manual reporting is outlined as, . In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: . (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported 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 not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures . Resident #2 (R2) Review of the medical record reflected that R2 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/24/2020 reflected R2 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R2 did not walk and required supervision to extensive assistance of one to two or more people for Activities of Daily Living (ADL's). Review of a State Agency Incident form reflected the Type of Alleged Incident: was Mistreatment. The document reflected that at approximately 9:54 PM on 11/27/2020, Registered Nurse (RN) L called Nursing Home Administrator (NHA) A to report that Certified Nurse Aide (CNA) K had information to share regarding CNA P and R2. The document reflected that CNA K reported being in R2's room around 7:00 PM [on 11/27/2020] and observed CNA P pull R2 by the ankles into the bathroom, while R2 was seated in their wheelchair. This was after CNA P allegedly said, She'll go to the bathroom when we get there. The State Agency Incident form reflected the incident was reported to the State Agency on 11/28/2020 at 5:34 PM. This was approximately 22.5 hours after the alleged event occurred. During a phone interview on 2/10/21 at 8:42 AM, CNA K stated it was their first time reporting [an allegation], so they didn't really know how to go about it. After a while, they made the decision to report and went to the nurse to ask how to report someone. CNA K stated they waited to report the allegation because they didn't want CNA P to know they reported. CNA K stated they believed if it was abuse or neglect, it had to be reported in the first 24 hours to the facility. During a phone interview on 2/11/21 at 11:33 AM, NHA A reported being made aware of the allegation around 10:00 PM [on 11/27/2020]. According to NHA A, the alleged event allegedly occurred around 6:30 PM [on 11/27/2020]. When queried if staff should have notified the NHA of the allegation sooner than they did, NHA A reported there was no serious bodily injury and no [MEDICATION(S)] effect on R2's psychosocial status. NHA A stated that in an ideal world, staff would call them or [Facility Assistant C] immediately. NHA A reported the beauty is staff did call as soon as the nurse was made aware [which was almost three hours after the alleged event occurred]. During the same phone interview, NHA A reported that was a busy time, and aides were doing after dinner cares. NHA A stated, when something horrible has happened in the building, staff have called immediately. According to NHA A, the regulation says the facility has up to 24 hours to get the report in. When queried about when they reported the allegation to the State Agency, NHA A stated they didn't think they would have done it at night. NHA A reported, you have to get some sleep when you know you have to do an investigation. According to NHA A, it [reporting the allegation to the State Agency] was within 24 hours of being notified, because that was the regulation, according to NHA A. When the Surveyor read that the State Agency Incident document reflected the report was made to the State Agency on 11/28/2020 at 5:34 PM, NHA A reported the next day sounded accurate. Resident #3 (R3) Review of the medical record reflected that R3 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The same MDS reflected R3 did not walk and required extensive to total assistance of one to two or more people for ADL's. Review of a State Agency Incident form reflected the Type of Alleged Incident: was Abuse. The document reflected that on 12/19/2020 at 4:31 PM, FA C received a call from Staff Member (SM) H about an event they alleged witnessing at the facility. SM H alleged they witnessed a CNA yelling and physically grabbing R3 about spilling a cup. Further review of the document reflected that in an interview on 12/19/2020 at 5:40 PM, SM H stated that between 1:30 PM and 2:00 PM, but closer to 2:00 PM, they heard the CNA screaming at R3 saying, You are spilling your drink all over. SM H reported the CNA then grabbed R3's wrist and arm of her wheelchair and shook it while continuing to yell at R3. SM H alleged the CNA then snatched the cup from R3's hand, then quickly threw it in the trash. SM H then said it was more like hollering than screaming. The State Agency Incident form reflected the incident was reported to the State Agency on 12/20/2020 at 8:20 AM, which was approximately 18 hours after the alleged event occurred. During an interview on 2/9/21 at 2:59 PM, SM H reported they knew they had to call [FA C] within a two hour time frame. During a phone interview on 2/11/21 at 2:58 PM, FA C was queried regarding the expectation for staff reporting allegations of abuse. FA C reported staff called whoever was on call for abuse and neglect and that all staff knew where to find that name. According to FA C, most staff were really good about calling. When queried about the time frame for reporting allegations of abuse, FA C reported her expectation was immediately. FA C reported SM H did not call her right away. When queried about the time frame for reporting allegations to the State Agency, FA C reported within two hours for serious injury and within 24 hours for everything else.

Based on interviews and record reviews, the facility failed to assess the condition and extent of injury for one (1) resident (Resident #1) of twenty-six (26) sampled residents reviewed for assessment and care, following a fall by Resident #101 on [DATE], which caused multiple fractures and severe pain. The facility further failed to notify the resident's physician or send Resident #101 to the hospital for over 24 hours subsequent to the fall. Resident #101 died on [DATE]. This deficient practice places one-hundred and twenty-six (126) residents, identified as being at risk for falls, at risk for serious harm, injury and/or death. Findings include: A licensed nurse shall, in a complete, accurate and timely manner, report and document nursing assessments or observations, the care provided by the nurse for the client, and the patient or to recognize changes in a patient's condition. Failure to recognize the significance of changes or to communicate them clearly and promptly to the attending practitioner could endanger the patient. (McMahon & Associates. Nursing Standards of Practice. HGExperts.com. Retrieved [DATE], from http://www.hgexperts.com/article. ) Nursing assessment is the deliberate and systematic collection of data of the residents' health and functional status and is the first step in Nursing Process. The data obtained in the assessment is communicated to other care givers and health professionals and is used to diagnose the problem and plan and implement care (Potter, P. A. & Perry, A. G. (2005) Fundamentals of Nursing (6th ed.). St. Louis: Mosby.). The facility's Resident Fall & Injury Policy, dated [DATE], revealed Completing Incident Reports Purpose: to investigate and prevent incident from reoccurring. Person observing incident illness or accident A. Report incident to Resident's nurse who will complete an incident Report (Exhibit C.) . Resident #101 was a [AGE] year-old female, who was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the facility Incident Report revealed that the report was dated [DATE], but that the incident was not reported until 2 days later on [DATE]. The document revealed that Resident #101 fell at approximately 6:50 PM, on [DATE], stating Resident was lowered to the floor in bathroom after resident went limp while ambulating to the toilet with nurse aide. The Incident Report was noted to have documentation that included Resident refuses tilting at times, periods of dizziness/[MEDICAL CONDITION] along with knees buckling at times. Staff was ambulating resident to the toilet, res. Went limp and was lowered to the floor in the bathroom. Resident sent to the hospital. According to the Incident Report resident was sent to the hospital on [DATE] and Physician was contacted on [DATE] at 6:30 PM. The hospital X-ray report, dated [DATE], at 10:58 PM, was reviewed. The report revealed, There is an acute spiral [MEDICAL CONDITION] femoral shaft with significant displacement. There is an acute fracture involving the distal femur with probable extension of the fracture into the distal articular surface of the knee. Resident #101's hospital radiology report, dated [DATE], revealed 1. Manubrial fracture appears acute . According to the nurse progress note (late entry-dated [DATE] at 8:18 AM) Late entry for [DATE] Aide came and got me and said that res was not acting her self and she thought she passed out. Went in to assesses her and she was slouched over in recliner and I said to her what is going on. She said there her leg was hurting. She was very pale in color and color and clammy Complaining of constant pain in lt. leg. Barley touched the leg and she was crying out. BP low ,[DATE] paged (physician) and he said to send her to the (local hospital) ER. According to nurse progress note dated late entry [DATE] at 12:15 PM, RCA notified this nurse that resident's daughter was requesting something for pain for this resident. This nurse gave scheduled Tylenol at this time. Resident had no prior C/O pain this shift. Daughter states that resident informed her that left leg had been painful all day. Upon palpation of left leg, Resident C/O tenderness in area to the RT of Lt knee area. No further C/O's from resident or daughter after Tylenol given. Will continue to monitor and notify physician if any further or and increase C/O pain. According to a noted dated [DATE] 19:25 late entry for [DATE] no time Resident with no C/O pain this afternoon . According to nurse progress note dated [DATE] at 00:24 AM, At beginning of shift res was crying out in pain and holding her right leg saying she was in pain all over. Gave res her scheduled Tylenol . In an interview on [DATE] at 4:00 PM, Family Member (FM) U reported that FM U had informed both LPN Q and the Unit Manager/ ADON D of Resident #101's increase and change of pain and requested an x-ray of Resident's leg to be done when visiting on the morning of [DATE] due to her increase in pain, and would not eat her lunch. FM U reported LPN Q had reported resident had C/O leg pain last night. FM U reported was then notified at 8:00 PM on [DATE] that Resident #101 had fainted and was being sent to the ER and no x-ray had been done all day and was not done at the time of resident's transfer to the ER. In an interview conducted on [DATE], at 10:30 AM, Certified Nurse Aide (CNA) K reported on the evening of [DATE] at approximately 7:30 PM, on the way in to the resident's bathroom, resident was a little off balance it was just a few steps there to get to the sink and we were almost there. Resident (#101) went to floor, and landed in sitting position with her legs folded under her. CNA K reported Resident #101 did not complain of any pain at that time. Not until we got her up. CNA K was asked who came to help get Resident #101 up off the floor? and stated, CNA L came to assist. CNA K was asked Did you notify the nurse at that time? and responded, The Nurse was not in the hall way and was she was not available. I stayed with Resident until CNA L came to help. CNA K was asked? Did any nurse come to assess her? Not until we had got her back up and finished her care. CNA K was asked, Did you request a nurse to assess and she responded, I went to nurses' station and thought Licensed Practical Nurse (LPN) F was at the nurses station and was later told it was Registered Nurse (RN) E and informed her that resident had fallen. CNA K was asked if she was not sure what nurse was informed that the resident had fallen and responded, No. CNA K stated, RN F stated, Did she hit her head? She ok? that was the end of it. CNA K was asked if either nurse assessed the resident and stated, I told them. CNA K reported during the rest of the shift during rounds resident had stated she was in pain. Each time rolled her she had pain. CNA K was asked, Did you inform the nurse? and stated, no they were busy. CNA K was asked, Are you aware of the facility policy to get a nurse before moving a resident when there is a fall before getting the resident up? and stated, Yes. It was a huge mistake on my part. On [DATE] at 11:35 AM, CNA L stated that she was responsible for the resident on [DATE] prior to her going to the hospital, had notified LPN F and RN H that resident had not eaten her supper, looked really pale had drool coming out of her mouth. CNA L reported LPN F assisted to return resident back to her bed from the recliner. Resident had a special gait belt, she (Resident #101) stood and we pivot her (Resident #101) but she wasn't standing very well. On [DATE] at 2:50 PM, LPN F reported she had worked a 4 hour shift on [DATE] and the 8 hour shift on [DATE] prior to resident going to the hospital. LPN F denied CNA K had reported the fall on [DATE]. Then later during the interview, LPN F reported either CNA K or L had reported Resident was moaning out on [DATE] at approximately 8:00 PM. LPN F went to Resident #!)!'s room and the resident was asked what was wrong. LPN F had her hand on Resident #101's leg and asked which one was hurting. Resident #101 was reported to have stated both of them. LPN F reported she had given Resident #101 her scheduled Tylenol with her other medications and instructed both CNA's to keep an eye on her and how Tylenol gets in her system. LPN F was asked did you ever look at her legs at that time and responded, No. LPN F reported she had worked the next night on [DATE] came in around 6:30 PM and started medication pass around 7:00 PM, and sent her (Resident #101) out to the hospital. LPN F stated, staff had reported Resident had passed out. Went to look at her. Resident was in her recliner chair. LPN F stated, staff reported, They were ready to walk her to the bathroom, but they were instructed to lay her in the bed and cleaned her up. (It is to be noted that it was previously reported by CNA L that LPN F assisted to transfer Resident #101 to bed from recliner with a pivot transfer.) Resident was reported as quite pale, looked like she had passed out ,[DATE] minutes, blood pressure was low around ,[DATE], oxygen was about ,[DATE] % around approximately 7:30 PM. LPN F reported she had paged the physician, called the family and sent resident to the hospital. On [DATE] at 3:35 PM, LPN Q, reported she had worked day shift on [DATE] and [DATE] until 2:00 PM and was responsible for Resident #101. LPN Q reported on [DATE] Resident #101 did not seem quite herself that day and was refusing medications during the day. LPN Q was asked if Resident reported any pain. LPN Q stated on [DATE] at 12:15 PM the CNA reported resident had pain. Cannot remember what aide it was. Gave her (Resident #101) Tylenol. LPN Q was asked if she had recalled having a conversation with Resident #101's daughter that day and what were the concerns? LPN Q responded, Said since she had fallen was having pain in her legs, was not under the impression she had fallen and it was not a fall. LPN Q stated, CNA M had stated, I am not sure how we should transfer because her legs went out on her. It did not catch my attention because I was busy and she has gone down so many times. I have filled out 50 charts on her. She went by the cart and did not really stop to ask the question. Apparently they were getting her up to the bathroom. LPN Q was asked to clarify that she assumed that because she (Resident #101) had slid to the floor prior, that is what happened this time? Yes. LPN Q was asked if she did went in and did any assessment on Resident #101's legs or take her socks off. LPN Q responded, No. LPN Q was asked, Did you evaluate Resident #101's transfer status? and responded, No. LPN Q was asked, Did she tell you specifically when her leg gave out on her? and responded, She said the night before. Did you do any follow up? No. LPN Q then stated, It was on a behavior chart the next day. I am still curious about that. They give the behavior notes to the social workers. Not sure why a behavior note was filled out for a fall. The aides fight it out. If she didn't like one aide she would do it and that is why they did a behavior log. LPN Q was asked what behavior would the resident do? and responded, She would buckle her legs. LPN Q was asked if Resident #101 was safe to transfer with one staff and stated, When I worked back there I don't care what the card says, I want you to transfer with 2 people when she goes to the bathroom. It happened mostly in the evenings after she had a BM she had a vasal (vagal) response and was fine in 10 minutes. (Vagal Response -during a bowel movement there is a rapid drop in heart rate and blood pressure, resulting in a decreased low of blood to the brain, resulting in [MEDICAL CONDITION]) LPN Q was asked if there was any evaluation of Resident #101 having recurrent Vagal response versus behaviors. There was no response to the question. LPN Q reported when talking to the daughter and looking at resident, The pain was the left leg, when I looked at it (pain) was on the right but I did not palpate. I got to the inner left leg and resident said. 'Oh that is tender there.' That is when I gave her the Tylenol. LPN Q was asked, At what time did the daughter ask about the X-ray? LPN Q responded, If she keeps complaining we need to call and get an x-ray and call the doctor. I left at 2:00 PM. LPN Q was asked, Was and X-ray done? and responded, No, I left she didn't ask again. LPN Q was asked if a resident, who is in pain and confused, has to ask for an x ray? LPN Q stated, I left at 2:00 PM. LPN Q was asked what happens when a resident with a (leg) fracture is transferred with a pivot transfer. LPN Q responded, It is going to be painful and make it worse. In an interview on [DATE] at 3:31 PM, CNA M reported she had worked at the facility for 2 years. She reported she was responsible for Resident #101 on [DATE] during the day shift. CNA M was asked how the resident was transferred and responded, We did a 2 man pivot on her. CNA M was asked was she complaining of any pain and responded, Moans and groans but no tears. CNA M was asked how resident was transferred and responded, One assist with ambulation with a padded gait belt per her card, if she was talking with me. If she wasn't talking to me I used a 2 person transfer. I like to do it because it protects me and I do not want anything to happen to the resident. CNA M stated, Resident #101 was not someone normally I worked with. CNA M was asked who assisted you with the transfer? and CNA M responded, CNA P assisted and we 'had' to have a third person assist. CNA M was asked who the third person was and responded, It was LPN R. In an interview on [DATE] at 2:55 PM, CNA P reported she had been a CNA for [AGE] years had worked at the facility for 3 months and had worked as CNA M's partner on the hall on [DATE] on the day shift and had provided care to Resident #101. CNA P reported during shift change / walking rounds that CNA K had reported Resident #101 was lowered to the floor by letting her slide down her leg, told me and CNA M both that so I assumed that she was checked out by the nurse and she was ok. There was no report on not to get her up, get VS or anything from the nurse. CNA P reported on the morning of [DATE] she had gone into the room, spoke to her (Resident #101) said, it is time to get up. She said, 'No it is not.' Got out stuff and gave bed bath. Girls told me she was complaining of pain. So, very gently rolled her. She was not conversing. She was not crying or anything. CNA P reported Resident #101 had a special gait belt for transfers. CNA P stated, Resident #101 would not put feet down, and bear weight, did a 2 person pivot and both had arm and gait belt and slid to chair. In an interview on [DATE] at 5:05 PM, Licensed Practical Nurse (LPN) R reported she was requested to assist as the third person for CNAs P and M on the day shift of [DATE] to assist Resident #101 to the bathroom as she was having difficulty standing. LPN R was asked if Resident was having pain at that time and stated Not that I recall. LPN R was asked to explain transfer process, and stated with resident sometimes it took 3 (staff), I believe 2 of us were lifting and 1 staff was cleaning and helping with her pants and grabbed the wheel chair. Her feet were on the floor. We did not have to carry her or anything. LPN R was asked if she did a pivot transfer and stated. We stood her up she would have had to turn. She had to turn the way the bathroom is set up. In an interview on [DATE] at 4:25 PM, LPN O reported her responsibility at the facility was education director and she had been present in the building on the morning of [DATE] at 4:30 AM. LPN O was asked if CNA K had mentioned a resident fall to her and stated, No. CNA K had ask me to take a peak at her, she was holding her leg funny and requested to take a look at her. LPN O was asked, Did you go look at it? No, I was busy with another resident for 15 minutes. Was there any reason you couldn't have checked on the resident? I had orientation, the CNAs were here. At 5:00 AM? There was no response from LPN O. Did you notify the nurse on the unit? I think I talked to the night nurse. LPN O was asked, You were aware she was holding her leg funny? and responded, Yes. In an interview on [DATE] at 10:00 AM, Unit Manager for Resident #101's unit and the Assistant Director of Nursing (ADON) D reported she was first aware Resident #101 had pain in her legs on [DATE] in the morning, and was refusing her medications. ADON D was asked if she had assessed Resident #101 or looked at her legs and responded, I did not physically go down there. I was told the nurse did. ADON D was asked if she recalled speaking to Resident #101's daughter about an X-ray request and responded, I had just started working here and do not recall. In an interview on [DATE] at 5:30 PM, Director of Nursing (DON) B was asked who followed up on the incident with the slide to the floor with Resident #101? Staff Y and myself spoke with CNA K and stated, We both asked her why she didn't report it to the nurse. DON B was asked if she had spoke with any of the nurses that were responsible for Resident #101 or had been aware of the assessment of pain of the resident, follow up on the incident report, resident lack of documentation in the clinical record that were late entries and stated, No I didn't talk to any of the nurses, I left a note by the time clock. I thought she had forgot to do an incident report, because CNA said she had notified her. When you were informed of the incident did you start an investigation at that point and start talking to the nurses? DON B responded No. Did you review the documentation in the resident's clinical record? I reviewed the notes and LPN F's were there on [DATE] (2 days later) and LPN Q's were late, but was not aware prior that they were late until then. A review of Resident #101's care plan indicated, Falls .periods of dizziness /[MEDICAL CONDITION] ., dated [DATE], revised [DATE], resident was a one assist with transfers and ambulation with padded gait belt and walker may require two assist PRN. In addition written in information that stated, the number 2 and One next to assist with transfer. Making it very unclear and confusing as to how many staff were to transfer the resident. There also was no update of the care plan with information, resulting from Resident #101's discharge from physical therapy on [DATE]. In an interview on [DATE] at 2:25 PM, Physical Therapy (PT) Manager I and PT J, reported had received a referral due to Resident #101's increased difficulty transferring and had made Resident #101 a 2-staff assist at that time. Resident was discharged from PT on [DATE] and made a 1-staff assist because she was doing well with transfers and ambulating back to prior level. PT J reported They (floor nursing staff) knew depending on who was working if she would cooperate (with transfer and ambulating). If she had some people she liked and she knew, then she worked better. PT Manager was asked if there was any communication between staff on resident buckling on staff and the need to keep resident a 2-person transfer and responded, While working with her she was working with the staff and it was not a concern at the time. PT Manager I was asked how long after discharge from PT had Resident fallen? PT I following review of her clinical records stated, I didn't realize it was only 2 days. Resident #101 died on [DATE] at 7:00 AM, while in hospice care at a different location. Immediate Jeopardy was identified at F-224 and F-323 on [DATE] due to the facility's failure assess the condition and extent of injury for Resident #101, following a fall on [DATE], which resulted in multiple fractures and severe pain and due to the facility's further failure to notify the resident's physician or send Resident #101 to the hospital for over 24 hours. Resident #101 subsequently died on [DATE]. This deficient practice places all facility residents, identified as being at risk for falls, at risk for serious harm, injury, and/or death. The Immediate Jeopardy was removed on [DATE] when observation, interview and record review confirmed that the facility had implemented the following: The resident was sent to the hospital on [DATE] and the resident ' s doctor was notified of the fall. Subsequently, the resident expired on [DATE] at 7:00 a.m. On [DATE] Certified Nursing Assistants (CNA) K and L were were suspended pending the completion of an investigation related to the circumstances giving rise to the immediate jeopardy. Beginning on [DATE], residents who have fallen or experienced an accident within the last 6 months were assessed to determine if they were appropriately assessed by a nurse for injuries and/or pain. As of [DATE] there were three residents who had experienced a fall. There were no other residents that were found to be affected by the same deficient practice. Beginning on [DATE], other residents in the facility who have the potential of being mistreated or neglected will be identified by use of Stop and Watch form as one way of communication between Certified Nurse Aides (CNA) and Nurses regarding condition changes. CNAs and Nurses were in-serviced on facility Neglect Policy starting on [DATE]. Beginning [DATE] nurses were in-serviced on completing a head to toe assessment and documentation at the time of the incident with a resident's condition change as reported by the nurse aide or by receipt of a Stop and Watch form (written communication of resident change in condition). Beginning [DATE] CNAs and Nurses have been educated on the new Stop and Watch form. The pain form assessment tool will be used to assess the pain of a resident following a fall. The physician will be notified after each fall and the incident will be documented and reported to the physician, interdisciplinary team, supervisor and resident decision maker. The fall policy was revised/changed on [DATE] for Pain Assessments. Reviewed falls since [DATE] (#25). Starting on [DATE] residents with a new fall were assessed for pain using the pain form assessment tool. As of [DATE], 23 residents' assessments were completed. All communication forms have been implemented as of [DATE]. The remainder of the staff will be educated during the early hours of their next scheduled shift until all staff have been completed. As of [DATE], an audit, following a fall or condition change, of the Stop and Watch form and an assessment documentation completion tool was developed to ensure compliance with this plan of correction. Tools will be reviewed by ADON and DON daily, weekly at staff meeting and quarterly at QA. Although the immediate jeopardy was removed on [DATE], the facility remained out of compliance at a scope of Isolated and a severity of Actual harm that is not immediate jeopardy, pending the facility's ability to achieve sustained compliance as verified by the State Agency ( )

Based on interviews and record reviews, the facility failed to ensure the safety and prevent a fall with injury for one sampled resident (Resident #101) of 26 residents reviewed for falls and post-fall care, by not ensuring that clearly identified interventions were in place. Resident #101 experienced a fall on [DATE], which caused multiple fractures and severe pain. The facility further failed to notify the resident's physician or send Resident #101 to the hospital for over 24 hours subsequent to the fall. Resident #101 died on [DATE]. This deficient practice places 126 residents, identified as being at risk for falls, at risk for serious harm, injury and/or death. Findings include: According to The Fundamentals of Nursing (Potter and Perry, 6 th Edition, 2005), Nursing interventions are prioritized to provide safe and efficient care .The client's mobility problem is an obvious priority because of its influence on skin integrity and risks for falls. The nurse plans individualized interventions based on the severity of risk factors and the client's developmental stage, level of health, lifestyle, and culture .nursing interventions are directed toward maintaining the client's safety in all types of settings. Nursing measures for providing a safe environment include health promotion, developmental interventions, and environmental interventions .To promote an individual's health, it is necessary for the individual to be in a safe environment to practice a life style that minimizes risk of injury. According to Geriatric Nursing Protocols for Best Practice, Second Edition. (2003) Springer Series on Geriatric Nursing, The majority of all falls that occur in the acute care setting involve individuals over the age of 65 .The increased risk of falling in older adults may be due to a number of age-related changes, such as altered visual acuity, decreased reaction time, decreased balance and muscle strength .Nurses in the acute care setting have the most contact with patients and are in key positions to evaluate these individuals and implement interventions to decrease falls .A prior history of falls is frequently cited in the literature as a risk factor contributing to falls. Once an older adult has fallen, there is a significant increased risk that he or she will fall again under similar circumstances .a major concern with a fall is the subsequent fear of falling that can occur. Fear of falling has been cited as one of the most serious and debilitating psychological consequences of a fall .The intention of a fall prevention program in acute care is not only to prevent falls, but also to provide patients with nursing care that focuses on improving and maintaining the functional ability of older patients. Per the Falls/Fall Risk Process Guidelines (MDCH, 2001) residents who have fallen are at risk for delayed consequences which may occur within several days after the fall; occasionally they can occur several weeks later. Resident #101 was a [AGE] year-old female, who was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the facility Incident Report was dated [DATE], but that the incident was not reported until 2 days later on [DATE]. The document revealed that Resident #101 fell at approximately 6:50 PM, on [DATE], stating, Resident was lowered to the floor in bathroom after resident went limp while ambulating to the toilet with nurse aide. The Incident Report was noted to have documentation that included Resident refuses tilting at times, periods of dizziness/syncope along with knees buckling at times. Staff was ambulating resident to the toilet, res. Went limp and was lowered to the floor in the bathroom. Resident sent to the hospital. According to the Incident Report resident was sent to the hospital on [DATE] and Physician was contacted on [DATE] at 6:30 PM. The hospital X-ray report dated [DATE], at 10:58 PM, was reviewed. The report revealed, There is an acute spiral fracture of the distal femoral shaft with significant displacement. There is an acute fracture involving the distal femur with probable extension of the fracture into the distal articular surface of the knee. Resident #101's The hospital radiology report dated [DATE], 1. Manubrial fracture appears acute . According to the nurse progress note (late entry dated [DATE] at 8:18 AM) Late entry for [DATE] Aide came and got me and said that res was not acting her self and she thought she passed out. Went in to assesses her and she was slouched over in recliner and I said to her what is going on. She said there her leg was hurting. She was very pale in color and color and clammy Complaining of constant pain in lt. leg. Barley touched the leg and she was crying out. BP low ,[DATE] paged (physician) and he said to send her to the (local hospital) ER. According to nurse progress note dated late entry [DATE] at 12:15 PM, RCA notified this nurse that resident's daughter was requesting something for pain for this resident. This nurse gave scheduled Tylenol at this time. Resident had no prior C/O pain this shift. Daughter states that resident informed her that left leg had been painful all day. Upon palpation of left leg, Resident C/O tenderness in area to the RT of Lt knee area. No further C/O's from resident or daughter after Tylenol given. Will continue to monitor and notify physician if any further or and increase C/O pain. According to a noted dated [DATE] 19:25 late entry for [DATE] no time Resident with no C/O pain this afternoon . According to nurse progress note dated [DATE] at 00:24 AM, At beginning of shift res was crying out in pain and holding her right leg saying she was in pain all over. Gave res her scheduled Tylenol . In an interview on [DATE] at 4:00 PM, Family Member (FM) U reported had informed both LPN Q and the Unit Manager/ ADON D of Resident #101's increase and change of pain and requested an x-ray to be done when visiting on the morning of [DATE] due to her increase in pain, and would not eat her lunch. FM U reported LPN Q had reported resident had C/O leg pain last night. FM U reported was then notified at 8:00 PM on [DATE] that Resident #101 had fainted and was being sent to the ER and no x-ray had been done all day. In an interview conducted on [DATE], at 10:30 AM, CNAK reported on the evening of [DATE] at approximately 7:30 PM, on the way in to the resident's bathroom, resident was a little off balance it was just a few steps there to get to the sink and we were almost there. Resident went to floor, and landed in sitting position with her legs folded under her. CNA K reported Resident #101 did not complain of any pain at that time. Not until we got her up. CNA K was asked who came to help you get Resident #101 up off the floor? and stated, CNA L came to assist. CNA K was asked Did you notify the nurse at that time? and responded, The Nurse was not in the hall way and was she was not available. I stayed with Resident until CNA L came to help. CNA K was asked? Did any nurse come to assess her? Not until we had got her back up and finished her care. CNA K was asked, Did you requested a nurse to assess and responded, I went to nurses station and thought Licensed Practical Nurse (LPN) F was at the nurses station and was later told it was Registered Nurse (RN) E and informed her that resident had fallen. CNA K was asked so you were not sure what nurse you informed that the resident had fallen and responded, No. CNA K stated, RN F stated, Did she hit her head? She ok? that was the end of it. CNA K was asked if either nurse assessed the resident and stated, I told them. CNA K Reported during the rest of the shift during rounds resident had stated she was in pain. Each time rolled her she had pain. CNA K was asked, Did you inform the nurse? and stated, no they were busy. CNA K was asked, Are you aware of the facility policy to get a nurse before moving a resident when there is a fall before getting the resident up? and stated, Yes. It was a huge mistake on my part. On [DATE] at 11:35 AM, CNA L she was responsible for resident on [DATE] prior to her going to the hospital, had notified LPN F and RN H that resident had not eaten her supper, looked really pale had drool coming out of her mouth. CNA L reported LPN F assisted to return resident back to her bed from the recliner. Resident had a special gait belt, she stood and pivot her but she wasn't standing very well. During the survey it was reported by an anonymous staff, a unit manager that had left the facility in August had been instructing staff not to report to their nurse and not complete incident reports in the event a resident was lowered to the floor. The facility had been aware of this and had not instructed the staff on the facility policy. The staff person did not want to be identified for fear of being terminated. On [DATE] at 2:50 PM, LPN F reported she had worked a 4 hour shift on [DATE] and and the 8 hour shift on [DATE] prior to resident going to the hospital, denied CNA K had reported the fall on [DATE]. Then later during the interview, reported either CNA K or L had reported Resident was moaning out on [DATE] at approximately 8:00 PM, Resident was asked what was wrong, had her hand on her leg, asked which leg was hurting and resident was reported to have stated both of them. LPN F reported she had given her scheduled Tylenol with her other medications, instructed both CNA's to keep an eye on her and how Tylenol gets in her system. LPN F was asked did you ever look at her legs at that time and responded, No. LPN F reported she had worked the next night on [DATE] came in around 6:30 PM and started medication pass around 7:00 PM. and sent her out to the hospital. The staff had reported Resident had passed out. Went to look at her. Resident was in her recliner chair. LPN F stated, staff reported they were ready to walk her to the bathroom but they were instructed to lay her in the bed and cleaned her up. Resident was reported as quite pale, looked like she had passed out ,[DATE] minutes around reported time of 7:30 PM, blood pressure was low around ,[DATE], oxygen was about ,[DATE] %. LPN F reported she had paged the physician, called the family and sent resident to the hospital. LPN F stated, CNA K had said something about (It is to be noted that it was previously reported by CNA L that LPN F assisted to transfer resident to bed from recliner to the bed with a pivot transfer.) On [DATE] at 3:35 PM, LPN Q, reported she had worked day shift on [DATE] and [DATE] until 2:00 PM and was responsible for Resident #101. LPN Q reported on [DATE] Resident #101 did not seem quite herself that day and was refusing medications during the day. LPN Q was asked if Resident reported any pain and stated on [DATE] at 12:15 PM the CNA reported resident had pain. can not remember what aide it was , gave her Tylenol. LPN Q was asked if she had recalled having a conversation with the daughter that day and what were the concerns? and responded, Said since she had fallen was having pain in her legs, was not under the impression she had fallen and it was not a fall. LPN Q stated, CNA M had stated I am not sure how we should transfer because her legs went out on he. It did not catch my attention because I was busy and she has gone down so many time. I have filled out 50 charts on her. She went by the cart and did not really stop to ask the question. so to clarify, You assumed that because she had slid to the floor prior that is what happened this time? Yes. Did you go in and do any assessment. No. Did she tell you specifically when her leg gave out on her? she said the night before. Did you do any follow up? no. When talking to the daughter the pain was the left leg, when I looked it was on the right but did not palpate. I got to the inner left leg and Resident said. Oh that is tender there. That is when I gave her the Tylenol. At what time did the daughter ask about the x-ray? LPN Q responded. If she keeps complaining we need to call and get an x-ray and call the doctor. I left a 2:00 PM. LPN W was asked, Was and x-ray done? and responded, No, I left she didn't ask again. LPN Q was asked what happens when a resident is transferred with a pivot transfer with a fracture? It is going to be painful and make it worse. On [DATE] at 3:31 PM, CNA M reported she had worked at the facility for 2 years. Reported she was responsible for Resident #101 on [DATE] during the day shift. CNA M was asked how resident was transferred and responded, We did a 2 man pivot on her. CNA M was asked was she complaining of any pain and responded, Moans and groans but no tears. CNA M was asked how resident was transferred and responded, One assist with ambulation with a padded gait belt per her card, if she was talking with me, if she wasn't talking to me. So, I used to 2 person transfer. I like to do it because it protects me and I do not want anything to happen to the resident. Resident was not someone normally I worked with. CNA M was asked who assisted you with the transfer? and CNA M responded, CNA P assisted and we had to have a third person assist. CNA M was asked who the third person was and responded, It was LPN O. On [DATE] at 2:55 PM, CNA P reported she had been a CNA for [AGE] years had worked at the facility for 3 months and had worked as CNA M's partner on the hall on [DATE] on the day shift and had provided care to Resident #101. CNA P reported during shift change during walking rounds that CNA K had reported Resident #101 was lowered to the floor by letting her slide down her leg. told me and CNA M both that so I assumed that she was checked out by the nurse and she was ok. There was no report on not to get her up, get VS or anything from the nurse. I spoke to her (Resident) said it is time to get up. She said, 'No it is not.' Got out stuff and gave bed bath. Girls told me she was complaining of pain. So, very gently rolled her. She was not conversing. She was not crying or anything. Has a special gait belt, would not put feet down, and bear weight, did a 2 person pivot and both had arm and gait belt and slid to chair. On [DATE] at 5:05 PM, RN R reported she was requested to assist as the third person for CNAs P and M on the day shift of [DATE] to assist Resident #101 to the Bathroom as she was having difficulty standing. RN R was asked if Resident was having pain at that time and stated Not that I recall. RN R was asked to explain transfer process, and stated with resident sometimes it took 3 (staff), I believe 2 of us were lifting and 1 was cleaning and helping with her pd person grabbed the wheel chair. Her feet were on the floor. We did not have to carry her or anything. RN R Was asked if she did a pivot transfer and stated. We stood her up she would have had to turn. She had to turn the way the bathroom is set up. On [DATE] at 4:25 PM, LPN O reported her responsibility at the facility was education director and had been present in the building on the morning of [DATE]. LPN O was asked if CNA K had mentioned a resident fall to her and stated, No. CNA K had ask me to take a peak at her, she was holding her leg funny and requested to take a look at her. LPN O was asked, Did you go look at it? No, I was busy with another resident for 15 minutes. Was there any reason you couldn't have checked on the resident? I had orientation, the CNAs were here. Did you notify the nurse on the unit? I think I talked to the night nurse. LPN O was asked, You were aware she was holding her leg funny? and responded, Yes. On [DATE] at 10:00 AM, Assistant Director of Nursing (ADON) D reported she was first aware resident had pain in her legs on [DATE] in the morning, was refusing her medications. Unit Manager for the unit Resident #101 was residing. ADON D was asked if she had assessed Resident #101 or looked at her legs and responded, I did not physically go down there. I was told the nurse did. ADON D was asked if she recalled speaking to the daughter and responded, I had just started working here and do not recall. On [DATE] at 5:30 PM, Director of Nursing (DON) B was asked who followed up on the incident with the slide to the floor with Resident #101? Staff Y and myself spoke with CNA K and asked her why she didn't report it to the nurse. DON B was asked if she had spoke with any of the nurses about follow up on the incident report, assessment of pain of the resident, documentation in the clinical resident, that was late entries and stated, No I didn't talk to any of the nurses, I left a note by the time clock. I thought she had forgot to do an incident report, because CNA said she had notified her. When you were informed of the incident did you start an investigation at that point and start talking to the nurses? DON B responded No. Did you review the documentation in the resident's clinical record? I reviewed the notes and LPN FS there on [DATE] (2 days later) and LPN Q's were late, but were not aware prior they were late. According to Resident #101's care plan Falls .periods of dizziness /syncope ., dated [DATE], revised [DATE], resident was a one assist with transfers and ambulation with padded gait belt and walker may require two assist PRN. In addition written in information that stated, the number 2 and One next to assist with transfer. Making it very unclear and confusing as to how many staff were to transfer the resident. There also was no up date of the care plan with information, resulting from Resident #101's discharge from physical therapy on [DATE]. On [DATE] at 2:25 PM, Physical Therapy (PT) Manager I and PT J, reported had received a referral due to Resident #101's increased difficulty transferring and had made Resident #101 a 2 staff assist at that time. Resident was discharged from PT on [DATE] and made a 1 assist because she was doing well with transfers and ambulating was back to prior level. PT J reported They (Floor nursing staff) knew depending on who was working if she would cooperate ( with transfer and ambulating). If she had some people she liked and she knew, then she worked better. PT Manager was asked if there was any communication between staff on resident buckling on staff and the need to keep resident a 2 person transfer and responded, While working with her she was working with the staff and it was not a concern at the time. PT Manager I was asked how long after discharge from PT Resident had fallen? PT I following review of her clinical records stated, I didn't realize it was only 2 days. On [DATE] at 4:20 PM, Orthopedic Surgeon G reported Resident #101's injuries were not a result of a spontaneous twist injury, but of typically a bend of some sort and a pop would have been heard at that time. Probably at the time of the fall. Orthopedic Surgeon G was asked if Resident #101 was transferred with using pivot transfers following this injury would it have caused her extreme pain and responded, Oh, yes. According to the facility Resident Fall & Injury Policy, dated [DATE] revealed Completing Incident Reports Purpose: to investigate and prevent incident from reoccurring. Person observing incident illness or accident A. A. Report incident to Resident's nurse who will complete an incident Report (Exhibit C.) B. Give exact circumstances surrounding the incident. Location, time and names of witnesses and all other information must be included. C. If incident was not observed but physical effects are evident, state not observed on the form 5 Recent change in resident's condition? What are the circumstances for recent change in resident's condition? .F. 3. Implements a Fall Prevention Protocol Intervention. Educates staff and updates care plan. G. Will Call responsible party on all falls and on skin tears, bruises. J. Calls physician only when there has been an injury otherwise fax report. Must call physician for all questionable head injuries. Such as any head injury, pain, limited ROM (range of motion), etc. Call physician if resident is exhibit a change in condition or suspect adverse effect from a new or changed medication. K. Initiate neuro assessment sheet if suspected head injury or hitting head. L. Incident report is reviewed by ADON and continued investigating on cause of incident. Initiates further interventions if necessary. Documents any further findings then forwards to DON. M. Charting to be done for 72 hours after falls in progress notes on computer system. N. Incident Report will be reviewed by the attending Physician for further comments or follow-up. According to the facility Resident Fall & Injury Policy, dated [DATE] revealed Completing Incident Reports Purpose: to investigate and prevent incident from reoccurring. Person observing incident illness or accident A. A. Report incident to Resident's nurse who will complete an incident Report and pain assessment (Exhibit C and Exhibit G) (was added to include a pain assessment). D. If gait is unsteady, Is it due to? F. Pain (was added). I. Reviews and completes Incident Reports (i.e description of injury, description of treatment, neuro checks, date, time & name of family notified, physicians or recurrence/additional comments) and pain assessment. (was added) According to the Facility Stop and Watch, policy dated [DATE], is a 1. Written communication tool from nurse aide to nurse when resident has a change of condition. 2 The nurse will complete a head to toe assessment to determine the source of condition change 3 The nurse will document the findings, notify the physician, interdisciplinary team, supervisor and resident decision maker. 4 After the assessment and notifications have been completed, the Stop and Watch form is to be given to the ADON or DON. 5. The ADON/DON will audit the documentation for completion. According to the Facility's Documentation Principles and Guidelines, revised on ,[DATE] stated, 13. Promptly document a change in the resident's condition and the actions taken based on that change. (See attached guidelines for acute change of condition (exhibit B - tables 10,13, 14). Attached table 10 Pain The following may indicate an ACOC (acute change of condition) and should be asses further: Pain worsening in severity, intensity, or duration, and /or occurring in a new location. New onset of pain associated with trauma. New onset of pain greater than 4 on a 10 point scale. -Falls The following may indicate an ACOC and should be asses further: Repeated falls on the same day. Recurrent falls over several days to weeks. New onset of falls not attributable to a readily identifiable cause. A fall with consequent change in neurological status, or findings suggesting a possible injury. Resident #101's Facility Resident Care Guide was unable to be reviewed. On [DATE] a copy of the information was requested and was informed by the DON that the family had removed the information from the room at the time resident's belongings were removed. On [DATE] Family Member (FM)U was contacted and asked if a copy of the Resident Care guide was available and responded, It was not in the room at the time her items were removed, but I will double check. On [DATE] at 10:48 AM, FM U reported the Resident Care guide was not in Resident #101's personal belongings. A copy of Resident #101's behavior log was requested from Director of Nursing B on [DATE] as it was reported the fall was recorded on the behavior log. at the time of exit a copy of the behavior log was not provided. Resident #101 was reported to have expired on [DATE] at 7:00 AM. Immediate Jeopardy was identified at F-224 and F-323 on [DATE] due to the facility's failure assess the condition and extent of injury for Resident #101, following a fall on [DATE], which resulted in multiple fractures and severe pain and due to the facility's further failure to notify the resident's physician or send Resident #101 to the hospital for over 24 hours. Resident #101 subsequently died on [DATE]. This deficient practice places all facility residents, identified as being at risk for falls, at risk for serious harm, injury, and/or death. The Immediate Jeopardy was removed on [DATE] when observation, interview and record review confirmed that the facility had implemented the following: The resident was sent to the hospital on [DATE] and the resident ' s doctor was notified of the fall. Subsequently, the resident expired on [DATE] at 7:00 a.m. On [DATE] Certified Nursing Assistants (CNA) K and L were were suspended pending the completion of an investigation related to the circumstances giving rise to the immediate jeopardy. Beginning on [DATE], residents who have fallen or experienced an accident within the last 6 months were assessed to determine if they were appropriately assessed by a nurse for injuries and/or pain. As of [DATE] there were three residents who had experienced a fall. There were no other residents that were found to be affected by the same deficient practice. Residents who have had a recent fall (25) since [DATE] will be reviewed by means of incident reports. Care plans will be updated beginning [DATE]. Residents' care plans have been reviewed and interventions updated for residents who have fallen since [DATE], and for residents who are at high risk for falls. (Education started on [DATE] and is continuing until nursing staff are educated, care plan reviews started [DATE] and will be ongoing). Beginning [DATE] a review of residents with a history of falls was started to assess for appropriate transfer status by Therapy and Nursing per evaluation. Beginning [DATE], residents who have had a fall or accident over the last 6 months are being assessed to determine if the appropriate interventions were in place and used at the time of the incident. Residents who meet this criteria in the previous 6 months have started to be assessed in relation to any patterns that can be established relative to ongoing risks as of [DATE]. Current review does not indicate that any of 126 residents were inappropriately transferred. Total reviews of 117 have been completed. Other residents who could be affected include any resident who had an injury of unknown origin that meets the definition of injury of unknown source as defined in the abuse policy. CNAs, Nurses and Therapy staff were in-serviced on changes in the facility fall policy and on action to take when a resident falls or is lowered to the floor. As of [DATE], 118 CNAs and Nurses out of 136 have been completed and 7 out of 11 therapy staff. Beginning [DATE] nurses were in-serviced on completing a head to toe assessment and documentation at the time of the incident with a resident's condition change as reported by the nurse aide or by receipt of a Stop and Watch form (written communication of resident change in condition). CNAs, Nurses and Therapy staff were in-serviced on changes in the facility fall policy and on action to take when a resident falls or is lowered to the floor. As of [DATE], 118 CNAs and Nurses out of 136 have been completed and 7 out of 11 therapy staff. Beginning [DATE] CNAs and Nurses have been educated on the new Stop and Watch form. The pain form assessment tool will be used to assess the pain of a resident following a fall. The physician will be notified after each fall and the incident will be documented and reported to the physician, interdisciplinary team, supervisor and resident decision maker. The fall policy was revised/changed on [DATE] for Pain Assessments. Reviewed falls since [DATE] (#25). Starting on [DATE] residents with a new fall were assessed for pain using the pain form assessment tool. As of [DATE], 23 residents' assessments were completed. Beginning [DATE] staff will communicate that all fall or change of condition care plan revisions are correct (Nurse to Therapy to Nurse) to reflect resident needs. Education started by [DATE] and is continuing until nursing staff are educated by the early hours of their next scheduled shift. Care plan reviews started [DATE] and will be ongoing. On [DATE] an auditing tool had been developed to assure compliance with this plan of correction and all fall incidents will be reviewed by ADON daily and overseen by DON daily, discussions in staff meeting weekly and quarterly at QA. Although the immediate jeopardy was removed on [DATE], the facility remained out of compliance at a scope of Isolated and a severity of Actual harm that is not immediate jeopardy, pending the facility's ability to achieve sustained compliance as verified by the State Agency. ( )

This citation pertains to MI 669 and MI 699. Based on observation, interview, and record review, the facility failed to respect a resident's request of no male care givers in 1 of 6 residents (#1) reviewed for dignity in a total sample of 24 residents resulting in resident #1 experiencing emotional distress. Findings include: Review of the face sheet dated 7/18/13 reflected Resident #1 was an [AGE] year old female admitted to the facility on [DATE]. Review of the physician's monthly order for December 2013 reflected Resident #1's [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] reflected Resident #1 had a BIMS (Brief Interview for Mental Status) score of 15 indicating no cognitive impairments. The MDS reflected Resident #1 required extensive assistance with transfers, dressing, hygiene, and bathing. Review of an Activities of Daily Living (ADL's) care plan initiated on 12/19/12 reflected no male care givers per resident request. Review of resident council meeting minutes dated 7/11/13 reflected Resident #1 stated she had male caregivers and requested female caregivers only. Review of a nurse's note dated 11/19/13 reflected Resident #1 complained of not sleeping well and Licensed Practical Nurse (LPN) "J" noted Resident #1 slept until 4:00 am. The note reflected Resident #1 complained of her pubic hair needing to be shaved because it was itching. The note reflected cream was applied to this area and Resident #1 went back to sleep within 15 minutes. In an interview on 12/4/13 at 9:30 am and review of witness statement by Resident #1 dated 11/21/13, Resident #1 reported she was woken from her sleep to a male staff member with his hand down her brief and asked him what he was doing. Resident #1 reported he responded that he was checking her to see if she was wet and told her that he had to check her every 2 hours to see if she was wet. Resident #1 reported she did not know the staff had to check her every 2 hours and thought maybe it was a new rule. Resident #1 reported the staff member came back into her room about an hour and half later and woke her up, asking if she was itchy. Resident #1 reported she didn't know why he was asking her if she was itching but she told him no. Resident #1 reported he left the room but came back approximately 30 minutes later to check her again and she told him at that time she was itchy. Resident #1 reported he left the room and came back with some cream to put on her peri-area. Resident #1 reported when he did this he was rough and really rubbing around her peri-area. Resident #1 reported he then tried to rub it around her vaginal opening and that he started to push his fingers in, like he was trying to get the cream inside of her. Resident #1 reported she said "ouch!" and then he promptly left the room. Resident #1 reported she was fearful that he would work with her again. In an observation on 12/4/13 at 9:30 am, Resident #1 was crying as she was explaining the events that occurred on 11/20/13. Review of a written statement by Certified Nursing Assistant (CNA) "K" (undated) reflected "On the morning of Wednesday during my Tuesday night shift (11/19/13) a resident (Resident #1) had at one point complained to me of vaginal itching. I had reported this to my nurse (LPN "J") as soon as the resident complained. My nurse then proceeded to give me some cream in a plastic cup and instructed me to apply it topically to the skin surface of the problem area. I re-entered the resident's room and found the resident to be still awake. I informed the resident that the nurse had given me some cream for her problem and that I was to apply it. The resident gave me permission to apply the cream and did so over the span of roughly five to ten seconds. I applied the cream to the skin at the perineal area using a gloved hand. I applied the cream holding my hand as a mitt, as one would apply lotion. When I finished, I asked the resident if she felt relief, and she told me that she had. She also mentioned that she had never had this problem when she was able to shave herself. During that time, I refastened her brief and cover her with blankets. I asked if she was comfortable and left after receiving an answer in the affirmative. After I left I gave a full report to my nurse." In a phone interview on 12/5/13 at 12:54 pm, LPN "J" reported on 11/20/13 between 2:00 am and 4:00 am, CNA "K" told her Resident #1 complained of her pubic hair itching and wanted some cream or lotion. LPN "J" reported she dispensed regular lotion in a small plastic medication cup and gave it to CNA "K" to give to Resident #1. LPN "J" reported she did not assess Resident #1 and could not remember the name of the lotion she gave to CNA "K". LPN "J" reported she was aware of Resident 1's request of no male care givers. Review of the Treatment Administration Record (TAR) for the month of November 2013 reflected Resident #1's treatments reflected no treatments were ordered for Resident #1's pubic hair itching. Review of a Corrective Action Record dated 11/27/13 reflected LPN "J" directed a male CNA to give treatment to a resident resulting in harm. The record reflected "Giving treatments is a nurse's responsibility and the resident's care card stated no male caregivers." The facility confirmed that CNA "K" was suspended during the investigation and then CNA "K" resigned. ( )