Every finding on record at Hillcrest Nursing and Rehabilitation Community

Based on observation, interview, and record review, the facility failed to follow professional standards of nursing practice for 5 of 12 residents (Resident #17, #1, #14, #23, and #29) reviewed for medication administration.Findings:Resident #17 (R17)Review of an admission Record revealed R17 was a [AGE] year-old female, admitted to the facility on [DATE].During an observation and interview on 12/04/2025 at 7:38 AM, Registered Nurse (RN) D administered 10 medications to R17 out of the 22 medications scheduled for the morning and exited the room. RN D did not report that he would be returning with additional medications for R17 or that there were any medications unavailable at that time.Review of R17 Medication Administration Record (MAR) on 12/04/2025 at 8:36 AM revealed that the 10 of 22 medications administered to R17 had not been documented as administered although RN D had completed that portion of the medication pass.During an interview on 12/04/2025 at 10:58 AM, RN D reported that the process was to get the medications prepared and click prep on the screen in the EMAR (electronic medication administration record) and once the medications are administered the finalize button is used to process/complete the medication pass. RN D reported that medications were to be signed out of the MAR immediately following the administration.During an interview on 12/04/2025 at 12:43 PM, RN D reported that following the initial medication administration, he returned to R17's room to administer the 12 additional medications and then documented in the EMAR. Confirming R17's medications were not documented as administered following the standard of practice of medication administration.Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, After administering a medication, immediately document which medication was given on a patient's MAR per agency policy to verify that it was given as ordered. Inaccurate documentation, such as failing to document giving a medication or documenting an incorrect dose, leads to errors in subsequent decisions about patient care. [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (pp. 643-644). Elsevier Health Sciences. Kindle Edition.Resident #1 (R1)Review of an admission Record revealed R1 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: diabetes.Review of R1's Order Summary dated 11/26/25 revealed, Humalog KwikPen Insulin (insulin lispro) insulin pen; 100 unit/mL; Amount to Administer: 12 units; subcutaneous Three Times A Day Hold for BS <120 (blood sugar less than 120). To be administered with breakfast, lunch, and dinner.Review of R1's November and December Medication Administration Record revealed:*On 11/28/25 R1's blood sugar was 115 and the lunchtime Humalog was administered.*On 11/29/25 R1's blood sugar was 73 and the lunchtime Humalog was administered.*On 12/1/25 R1's blood sugar was 102 and the breakfast Humalog was administered.*On 12/3/25 R1's blood sugar was 111 and the breakfast Humalog was administered.Review of R1's Electronic Medical Record revealed no documentation that the Humalog had been held or documentation to support the administration of the Humalog outside of parameters.Resident #14 (R14)Review of an admission Record revealed R14 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: diastolic congestive heart failure.Review of R14's Order Summary dated 11/17/2025 revealed, Midodrine tablet; 2.5 mg; amt: 1 tablet; oral Special Instructions: Take 1 tablet (2.5mg total) by mouth 3 (three) times a day before meals. Hold if SBP >140 (systolic blood pressure is greater than 140) Upon Rising, Mid-Day, Evening. Review of R14's November Medication Administration Record revealed:*On 11/23/25 R14's blood pressure was 157/79 and her morning midodrine was administered.*On 11/29/25 R14's blood pressure was 157/77 and her morning midodrine was administered.Review of R14's Electronic Medical Record revealed no documentation that the midodrine had been held or documentation to support the administration of the midodrine outside of parameters.Resident #23 (R23)Review of an admission Record revealed R23 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: diabetes.Review of R23's Order Summary dated 11/04/2025 revealed, Admelog SoloStar U-100 Insulin (insulin lispro) insulin pen; 100 unit/mL; Amount to Administer: 28 units; subcutaneous Three Times A Day Hold if BS <120. To be administered with breakfast, lunch, and dinner.Review of R23's November Medication Administration Record revealed:*On 11/5/25 R23's blood sugar was 90 and her dinner Admelog was administered.*On 11/7/25 R23's blood sugar was 119 and her lunch Admelog was administered.*On 11/13/25 R23's blood sugar was 93 and her breakfast Admelog was administered.*On 11/14/25 R23's blood sugar was 100 and her breakfast Admelog was administered.*On 11/17/25 R23's blood sugar was 107 and her breakfast Admelog was administered.*On 11/18/25 R23's blood sugar was 83 and her breakfast Admelog was administered.*On 11/19/25 R23's blood sugar was 91 and her breakfast Admelog was administered.Review of R23's Electronic Medical Record revealed no documentation that the Admelog had been held or documentation to support the administration of the Admelog outside of parameters.Resident #29 (R29)Review of an admission Record revealed R29 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: diabetes.Review of R29's Order Summary dated 11/18/2025 revealed, Insulin lispro insulin pen; 100 unit/mL; Amount to Administer: 6 units; subcutaneous Before Meals Hold for BS <120.Review of R29's November and December Medication Administration Record revealed:*On 11/24/25 R29's blood sugar was 111 and the breakfast lispro was administered.*On 11/30/25 R29's blood sugar was 112 and the breakfast lispro was administered.*On 11/30/25 R29's blood sugar was 109 and the lunch lispro was administered.*On 12/4/25 R29's blood sugar was 105 and the breakfast lispro was administered.Review of R29's Electronic Medical Record revealed no documentation that the lispro had been held or documentation to support the administration of the lispro outside of parameters.During an interview on 12/04/2025 at 2:06 PM, the Director of Nursing (DON) provided documentation showing a licensed nurse had been incorrectly documenting that medications had been held following the ordered parameters on multiple dates. She confirmed the medication errors and/or documentation errors listed above and reported that immediate education had been provided to the licensed nurses involved. DON reported that all licensed nurses would receive education on following ordered parameters and on complete and accurate documentation. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Responsibilities of medication administration include knowing medication therapeutics, assessing a patient before administration, calculating doses, administering medications using the seven rights, monitoring and evaluating medication effects, and assessing a patient's ability to self-administer medications.The seven rights of medication administration include the right medication, right dose, right patient, right route, right time, right documentation, and right indication. [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 705). Elsevier Health Sciences. Kindle Edition.

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 12/02/2025 at 10:05 AM, observed debris collected in the bottom of the ice scoop holder installed on the wall by the ice machine. According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.On 12/02/2025 at 10:21 AM, observed a water line at ceiling level, directly over dried good products on shelving in the dry storage room. During the walkthrough of facility with Maintenance Supervisor (MS) B, it was confirmed that the line was a water line and supplied the sprinkler system. According to the 2022 FDA Food Code section 3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor.On 12/02/2025 at 10:28 AM, in the refrigerator used to store residents' personal food, salsa was observed without a date and with mold growth on top of the food. Dietary Manager (DM) J stated that dietary staff was not responsible for dating the residents' food.According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROLOn 12/02/2025 at 10:28 AM, observed in refrigerator used to store residents' food, there was a large amount of water on the top shelf of the refrigerator.According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

Based on observation interview and record review, the facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility.Findings Include:On 12/02/2025 at 12:50PM, during an interview with Maintenance Supervisor (MS) B, regarding the water management plan, it was disclosed that room [ROOM NUMBER] has a non-operational shower (water lines) that is not being flushed. The water lines for the shower have been non-operational for over a year. At time of observation on 12/02/2025, the shower did not have a faucet handle and did not appear to be able to be turned on at the shower wall.Record review of the facility's water management document, Control Measures and Actions, under the Facility Control Measures section, it is noted that maintenance runs faucets and flushes toilets throughout the facility during monthly rounds.

Based on observation, interview and document review, the facility failed to ensure medications were administered in accordance with physician orders without errors for 1 of 3 residents (Resident #17) observed during the medication administration task. This resulted in a facility medication error rate of 8.33% (3 errors out of 36 opportunities).Findings include:Resident #17 (R17)Review of an admission Record revealed R17 was a [AGE] year-old female, admitted to the facility on [DATE].During an observation and interview on 12/04/2025 at 7:38 AM, Registered Nurse (RN) D administered 10 medications to R17 out of the 22 medications scheduled for the morning. RN D administered 1 tablet of Vitamin C, 1 capsule of Vitamin D3, and 1 capsule of potassium chloride. At the time RN D was preparing the potassium chloride he was asked if the order was for only 1 capsule of potassium chloride to which he responded yes, only 1.Following the medication administration observation a medication reconciliation was completed utilizing R17's Order Summary which revealed R17 was to receive:ascorbic acid (vitamin C) tablet; 250 mg; 4 tabletspotassium chloride capsule, extended release; 10 mEq; 2 tablets; andvitamin D3 (cholecalciferol (vitamin d3)) capsule; 25 mcg (1,000 unit); 2 capsules.During an interview on 12/04/2025 at 2:15 PM, the Director of Nursing (DON) was notified of the medication errors.Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, The seven rights of medication administration include the right medication, right dose, right patient, right route, right time, right documentation, and right indication. [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 705). Elsevier Health Sciences. Kindle Edition.

This citation refers to intake MI00151516. Based on observation, interview and record review, the facility failed to implement the hot liquid policy for 1 resident (R1) of 4 residents reviewed, resulting in second degree burn caused by a hot liquid spill. Findings include: A second-degree burn is deeper than the top layer of skin (through epidermis to the dermis) and causes a blister to form with pink, painful skin. The blister may break and leak clear fluid, there is risk of infection. Second-degree burns typically take 1 to 3 weeks to heal and can happen from contact with hot water, coffee, soup, hot surface, or hot grease Resident #1 (R1) Review of Face Sheet reflected R1 was admitted to the facility on [DATE] with pertinent diagnoses of Alzheimer's Disease, muscle weakness, Cognitive communication deficit, reduced mobility and Parkinson's disease. Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected R1 had a BIMS (Brief Interview for Mental Status) score of 02 indicating advanced cognitive impairment. R1 requires Supervision or touching assistance - Helper provides Verbal Cues or TOUCHING/STEADING assistance as resident completes the activity for eating. Review of R1's progress note dated 3/24/25 at 5:58 PM revealed, Resident spilled hot chocolate on upper chest and abdomen at dinner. Clothes immediately removed. Skin is red. Applied cool clothes. Will monitor for blisters/burns. Review of R1's progress note dated 3/24/25 at 7:41 PM revealed, Skin to upper right chest now peeling. Skin red and not subsiding. Obtained new orders from (Name of) PA (physician assistant)-antibiotic ointment cover with nonstick gauze. no tape TID (three times a day). Notified (Name of R1's) DIL (daughter-in-law) with update. I have been in contact with DON (Director of Nursing). And attempted to contact Administrator. Review of R1's progress note dated 3/25/25 at 4:30 AM revealed, Red areas on chest and abdomen remain red. Area on abdomen appear to have blisters developing, blisters fluid filled and intact. Resident also appears to have scratch mark on chest. Triple antibiotic ointment applied and covered with non-stick dressing with no tape applied. Resident has not c/o pain this shift. Review of R1's progress note dated 3/25/25 at 7:34 AM revealed, Observed chest and abdomen blistered areas, treatment per orders provided. This nurse asked resident if she was in any pain. Resident stated no and shook her head. Blisters are clean, dry and intact. No signs or symptoms of infection at this time. Will continue to monitor. Review of R1's progress note dated 3/25/25 at 9:42 AM revealed, Examination of anterior chest d/t hot liquid incident on 3/24/25. Mid chest with 5cm x 3cm superficial skin loss, no exudate, right breast with 3.5cm x 1.5cm fluid filled blister. Other areas on chest are light pink in color without skin loss. No pain expressed with light palpation to areas. Review of Physician Assistant Certified (PAC) F Progress Note dated 3/26/25 for R1 reflected the following skin assessment, Resident with an open area on the right medial breast measuring 4.2 x 3.4 x 0.1 cm, the wound base is 50% epithelial tissue and 50% granulation tissue, there is moderate serous drainage, no odor, wound edges are intact and attached, I did scrub the wound good and she showed no signs of pain with scrubbing. Resident with a serous filled bullous lesion to the right mid breast measuring 1.8 X 4.8 cm. resident with scattered areas of erythema to the mid and right upper abdomen, no blistering noted in these areas. During an interview on 3/28/25 at 3:00 PM, Certified Nursing Assistant (CNA) M stated, We tried getting her up for dinner on Monday, but she just refused. She wanted to stay in bed. So, she was in bed sitting straight up, she had a towel and a clothing protector on with her table in front of her. I got her hot chocolate for her it was hot (we got a new machine), so I did put a little cold water in it. I gave the cup to (Name of R1) and I waited as she took a couple of sips. She said she was good. I had just got out the door to the beverage cart when I heard her yell, and the cup hit the floor. I ran in stripped everything off her immediately, called to (Name of CNA I) to get a cool towel and grab the nurse. We got the towel on right away. During an interview on 3/28/25 at 3:18 PM, Certified Nurse's Aide (CNA) I revealed they had gotten a new coffee machine that was hot. CNA I stated that her and (Name of CNA M) were passing beverages and waiting on the tray. I was across the hall from (Name of R1's) room when I heard her yell out. (Name of CNA M beat me in the room and by the time I got in there she had (Name of R1's) clothing off, I grabbed a cool towel for her and then ran to grab (Name of RN B). CNA I revealed that the resident had been sitting up in bed and had double clothing protector on a towel plus her clothing protector. CNA I stated that she had only been working here a few weeks and was concerned that they had no lids for the hot beverages. Stated she thought that was odd because the other places she had worked had lids. During an interview on 3/27/25 at 11:13 AM, Registered Nurse (RN) B revealed I usually only work 1st shift but that day I did a double. Resident usually goes down to the dining room for assistance, but that night refused to go down for dinner. Resident was sitting upright in bed with the bedside table in front of her. The aides started passing the beverages while they were waiting for room trays. R1 spilled her hot chocolate somehow right down her neck and somehow missed her clothing, hand towel and clothing protector. I was helping another resident when the aides yelled and by the time I got to her room the aides had stripped her clothing off and had applied cool towels. At the time the skin was red on her upper chest and belly. At 7 pm noticed the upper right chest was starting to peel and antibiotic ointment and loose gauze were applied. By morning resident had a blister under her right breast along with scattered red areas. RN B stated she then notified the DON, residents' physician and family. RN B further revealed her care plan states she is supposed to be up at a table for meals and her hot chocolate did not have a lid on it. RN B stated (Name of R1) yelled out in pain when the initial burn happened, and she provided the resident with some Tylenol for pain, but she has denied any pain since. During an interview on 3/28/25 at 2:22 PM, R1's Daughter In Law (DIL) D stated when she was visiting (Name of R1) in the dining room at lunch time (about 2 weeks ago) she stated that (Name of R1) said the coffee was too hot to drink. I checked it and the coffee was too hot, and I had to ask an employee for ice. DIL D stated she was told by the employee the new coffee machine was holding the coffee hot. Feels her Mother-in-Law is not awake enough to drink (hot beverages) in her room by herself because she often is sleepy at meal times and has to be assisted. DIL D revealed the coffee/hot water use to be in white crafts and was usually served lukewarm which meant (Name of R1) could drink it right away. During an interview and record review on 3/27/25 at 12:09 PM, Dietary Manager (DM) C revealed they recently had gotten a new Coffee Machine and that as of 3/25/25 they had implemented a new temperature log form. DM C revealed they started the new form due to R1 receiving a burn and further revealed their previous forms did not have a space for hot liquids, but the current form does. Review of the daily Food Usage and Temperature Log from 3/20/25 - 3/23/25 reflected 3-meals are handwritten in and include food items and their temperatures. The daily log for 3/24/25 (the day R1 sustained a hot liquid burn) reflected information for breakfast and lunch, however, the dinner portion was not filled out. Milk and Juice temps were included on the logs, however hot beverage temps were not recorded. DM C reported during the interview that (Name of R1) is usually in the dining room for all meals and usually sits at the table with other residents that need assistance. DM C stated that for meals (Name of R1) has a divided plate and believes she needs a lid on her hot liquids usually hot chocolate. Review of Daily Temperature Log for Trayline a Sunday - Saturday form for Breakfast, Lunch and dinner reflected a space to document coffee/tea with a temperature of 155 written in and 165-180 crossed out. Temperature noted for coffee/tea from breakfast on 3/25/25 to lunch on 3/27/25 were between 148- 155 degrees. Review of DIETARY MANUAL for Management of Hot Food/Liquids Revised 1/25 reflects the following policy: It is the policy of this facility to manage resident consumption of hot liquids in order to prevent burns or resident injury. Review of the Procedure reflected facility failed to ensure the following areas were being followed: 1. A Hot Food/Liquid Assessment will be performed upon admission, quarterly, and with a resident significant change in condition by a facility clinical leader, and if needed in collaboration with Occupational Therapy. 2. Clinical Risk Review: Resident with a yes response in clinical section of the Hot Food/Liquid Assessment will have interventions selected to reduce risk of potential injury. 6. Residents identified as at risk will have selections listed on diet card in addition to an include Hot Spill Risk to alert staff during delivery of meal is at high risk for burn injury. 7. The individual resident care plan will reflect resident specific risk factors and appropriate interventions to assist in preventing burn injuries. 8. The dietary department will monitor hot food/beverage temperatures on the tray line on a daily basis to ensure appropriate temperatures are maintained. Review of R1's most current Hot Foods and Liquid Assessment (prior to her 3/24/25 burn) was completed on 2/25/23 (more than two years old) for a quarterly review. Further review of the assessment reflected Yes, the resident is considered to be a high-risk injury for hot food and liquids. Interventions included: Consume hot liquids/food while sitting at a table only. Clothing protector or cloth napkin over lap & chest. During an interview on 3/27/25 at 12:40 PM, with DON and DM C revealed the resident had refused to go down to the dining room the night she was burned. The DON further revealed (Name of R1) was wearing double protection (hand towel on top of her clothing then a clothing protector over the towel.) DON stated she believes the resident spilled the hot chocolate in such a way that it went right down her chest and burned more heavily on her right side. DON further stated they did not have a lid policy before on hot beverages, but she is changing that now. During the interview DON confirmed R1's last Hot Food/Liquid Assessment was on 2/25/23 and stated, No, they (the assessments) were not being done quarterly per policy.

Based on observation, interview, and record review, the facility failed to implement care planned interventions for the prevention of skin breakdown in 2 residents (Resident #20 and #16) out of 10 residents reviewed for comprehensive care plans. Findings: Resident #20 (R20) Review of an Admission Record revealed R20 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: stroke and contractures of the left and right hand. Review of a Minimum Data Set (MDS) assessment for R20, with a reference date of 9/8/24 revealed a Brief Interview for Mental Status (BIMS) score of 99, which indicated R20 was severely cognitively impaired. Review of R20's Rehab Order dated 5/12/22 revealed, Palm Protector schedule: Per therapy recommendation, to be worn after breakfast throughout the day, off at night and for hygiene. Review of R20's Order Summary dated 11/24/22 revealed, BUE (bilateral upper extremity) Palm Protector- ON upon rising, OFF at HS and for hygeiene (sic). Special Instructions: Wash hands with warm compress and then apply lotion prior to donning splints. Assess skin integrity with don/doffing- report concerns to PCP (primary care provider) Twice A Day. Upon Rising, (and) At Bedtime. Review of R20's Care Plan revealed, Problem: Resident is at risk for skin breakdown and/or injury r/t (related to) s/p (status post) CVA (cerebral vascular accident/stroke) with left side hemiparesis (paralysis) - requires assistance with repositioning to alleviate pressure .r/t bilateral hand contracture (fingers closing into palm) .r/t use of palm protector bilateral hands. Review of R20's Resident Profile/Care Plan revealed, 05/17/2022 BUE Palm Protector ON upon rising, OFF at HS (bedtime) and for hygiene. Nursing to monitor skin integrity upon application and removal and 01/11/2024 Turn TV on in am upon arising (per family request) Special Instructions: Family request to keep TV on during the day for stimulation. During an observation on 10/14/24 at 10:12 AM, R20 was in bed and did not have bilateral hand splints in place. Her television was not on. During an observation on 10/14/24 at 11:07 AM, R20 was in bed and did not have bilateral hand splints in place. Her television was not on. During an observation on 10/14/24 at 1:55 PM, R20 was up in a recliner and did not have bilateral hand splints in place. During an observation on 10/14/24 at 4:03 PM, R20 was up in a recliner and did not have bilateral hand splints in place. During an observation on 10/15/24 at 8:45 AM, R20 was in bed and did not have bilateral hand splints in place. During an interview on 10/15/24 at 8:52 AM, Registered Nurse (RN) E reported that R20 did not have hand splints in place because she hates them with a passion. During an observation on 10/15/24 at 12:48 PM, R20 was up in a recliner and did not have bilateral hand splints in place. During an observation on 10/16/24 at 8:12 AM, R20 was in bed and did not have bilateral hand splints in place. During an observation on 10/16/24 at 11:00 AM, R20 was in bed and did not have bilateral hand splints in place. Review of R20's Behavior Logs and Electronic Medical Record revealed only 1 entry of R20 removing splint. A note dated 06/19/24 revealed, Observed resident removing palm protectors-she did eventually remove both. An additional note dated 10/15/24 revealed This RN observed resident removing palm protector to right hand. She managed to remove w/o (without) difficulties. This writer did reapply. During an interview on 10/15/24 at 03:44 PM, Responsible Party (RP) G (power of attorney) reported that R20 was to wear splints in both of her hands but it's hit or miss and the splints were not always placed in her hands. RP G reported that the splint placement was to be part of her morning care and R20 needs to start the day with having them. RP G reported that she had informed the last couple DON's (Director of Nursing) that care planned interventions were not implemented and was told that they would ensure staff were aware of interventions that needed to be completed. RP G did not report that R20 would remove the hand splints or that she did not want to wear them. RP G confirmed refusal of hand splints was not part of her care plan. Resident #16 (R16) Review of an Admission Record revealed R16 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: Alzheimer's disease, weakness, and need for assistance with personal care. Review of a Minimum Data Set (MDS) assessment for R16, with a reference date of 9/8/24 revealed R16 was severely cognitively impaired. Review of R16's Progress Note dated 10/09/24 revealed, During bed bath with Hospice Aid reddened area noted to coccyx. This RN observed, area is blanchable not open. Measures 7.5cm cm x 3 cm . Review of R16's Progress Note dated 10/11/2024 revealed, .Area is reddened but it is blanchable. Continue to monitor and frequently reposition. Staff education provided. Review of R16's Resident Profile revealed 10/14/2024 provide frequent positional changes and ensure resident is off loading buttocks and 08/20/2024 Soft foam boots on at all times to relieve pressure points BL (bilateral) feet Hospice order. During an observation on 10/15/24 at 7:32 AM, R16 was assisted up to her Broda chair. She did not have foam boots in place. During an observation on 10/15/24 at 9:01 AM, R16 was up in her Broda chair in the dining room. She did not have foam boots in place. During an observation on 10/15/24 at 10:50 AM, R16 was up in her Broda chair in her room. She did not have foam boots in place. During an observation on 10/15/24 at 12:46 PM, R16 was up in her Broda chair in her room. She did not have foam boots in place. During an observation on 10/15/24 at 2:34 PM, R16 was in her bed. She did not have foam boots in place. During an observation on 10/16/24 at 8:10 AM, R16 was up in her Broda chair in the dining During an observation on 10/16/24 at 11:02 AM, R16 was up in her Broda chair in the dining room. She did not have foam boots in place. Review of R16's Behavior Logs and Electronic Medical Record revealed no documentation of behaviors or refusal to wear soft foam boots. During an interview on 10/16/24 at 2:10 PM, Director of Nursing (DON) reported that resident specific care planned interventions should be implemented and followed by the facility staff. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, A nursing care plan includes nursing diagnoses, goals and/ or expected outcomes, individualized nursing interventions, and a section for evaluation findings (see Chapter 20). The plan promotes continuity of care and better communication because it informs all health care providers about a patient's needs and interventions and reduces the risk for incomplete, incorrect, or inappropriate care measures .The plan gives all nurses a central document that outlines a patient's diagnoses/ problems, the plan of care for each diagnosis/ problem, and the outcomes for monitoring and evaluating patient progress. The plan of care communicates nursing care priorities to nurses and other health care providers. It also identifies and coordinates resources for delivering nursing care. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 249). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Care plans identify a plan of care based on a patient's appropriate nursing diagnoses, outcomes, and interventions individualized to the patient's unique needs. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 254). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Care planning is patient centered, taking into consideration the patient's most immediate needs and preferences . be vigilant in monitoring the patient and supervising assistive personnel in carrying out activities to prevent complications and potential injury. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 790). Elsevier Health Sciences. Kindle Edition.

Based on interview and record review, the facility failed to follow professional standards of nursing practice for comprehensive assessments and medication administration for 2 residents (Resident #25 and #30), out of 10 residents reviewed for the provision of nursing services. Findings: Resident #25 (R25) Review of an Admission Record revealed R25 was an [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: lymphedema, urine retention, heart failure, and kidney disease. Review of R25's Progress Note dated 09/25/2024 at 03:00 AM revealed, Resident with episode of confusion-states I think I am a little confused. B/P (blood pressure) 128/50, T (temperature)-98.9, P (pulse)-92, R (respirations)-19 SPO2 (oxygen level) 96%. Urine in Foley cath (catheter) clear dark yellow urine (dark urine is an abnormal finding). Resident also with increased anxiety. Currently sitting in w/c (wheelchair). Resident asked if he wanted to go the hospital and he responded no. Resident respiration even and non-labored. Asked if he wanted to go to the hospital and states no. Encouraged to sit in recliner chair. A comprehensive physical and neurological examination were not completed/documented (including a pain assessment and palpation of the abdomen). There was no documentation that the provider was notified of the change of R25's neurological status (increased confusion/altered mental status). Review of R25's Progress Note dated 09/25/2024 at 07:05 AM revealed, Just after shift change resident heard to be screaming from room. This RN (registered nurse) observed resident in panic state wanting this RN to stop his stationary chair from moving around the room .Increased confusion, and he is very weak. Unable to hold objects in hands w/o (without) dropping them .We called her and girlfriend had concerns with AMS (altered mental status) and immediately called residents daughter. Daughter did speak with resident and encouraged him to go to hospital. Obtained order to send. All paperwork sent with resident. VS (vital signs) (oxygen level) 90% RA (room air) 120 pulse 110/60 (blood pressure) 97.8 (temperature) 17 (respirations) . Approximately 4 hours from the initial documented change in condition. Review of R25's Vitals Report from 7/17/24-9/25/24 revealed no blood pressure assessments or pulse assessments were documented in the report. Review of R25's Hospital Records dated 9/25/24 revealed, .Pt (patient) was brought to the ER (emergency room ) today with concerns for fever and hallucinations. He was found to be hypotensive (low blood pressure) and tachycardic (elevated heart rate). Afebrile (no temperature) .Pt denies abdominal pain but does admit to poor appetite and 4-5 days of mid back pain. On exam, he does have RUQ (right upper quadrant abdomen) tenderness to deep palpation. Pt has been given 3 L (liters) of fluids in ER and BP (blood pressure) is improving. He remains tachycardic .Recommend continuation of resuscitation with IV fluids and antibiotics .Upon arrival to the emergency department, patient is afebrile. He is tachycardic with a heart rate in the 110s and hypotensive with a BP as low as 72/58 .Severe sepsis with acute renal failure without septic shock .As evidenced by tachycardia and leukocytosis . During an interview on 10/16/24 at 8:10 AM, Licensed Practical Nurse (LPN) D reported that when a resident is experiencing a change of condition/medical emergency a comprehensive assessment should be completed and documented in the resident's progress notes. Vital signs, physician notification, guardian/emergency contact notification, the comprehensive assessment, and transfer to hospital documentation should be recorded in the resident's Electronic Medical Record. During an interview on 10/16/24 at 2:10 PM, Director of Nursing (DON) reported that she was unable to find any additional vital sign assessments prior to R25's transfer to the hospital on 9/25/24. DON reported that she would have expected vital sign assessments leading up to R25's decline/discharge. DON reported that vital signs should be assessed monthly unless an identified change in condition. Request for documentation that the provider was notified of R25's change in condition as well as additional vitals signs and assessments was requested via email on 10/15/2024 4:43 PM and 10/16/2024 12:35 PM. No additional documentation was received prior to survey exit. Review of the facility policy Notification of Change dated 07/2017 revealed, The residents physician and responsible party must be notified when an event involving the resident occurs or when the resident experiences a change in condition, potential discharge, room transfer or death .INTERVENTIONS: The Licensed nurse will use professional judgment any time that in their opinion the resident requires immediate medical attention. ASSESSMENT: 1. When made aware of a change in condition of a resident the Licensed nurse will perform an assessment based on their professional judgement that may include: *Vital signs *Mental status * Major diagnosis .Monitor and reassess the residents status and response to interventions. The physician should develop a working diagnosis and guide nursing staff in what to look for, what to monitor, and when to re-contact the physician if the residents progress deviates from the anticipated or expected course. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, It is important to recognize early indicators of acute illness in older adults .A key principle of providing age-appropriate nursing care is timely detection of these cardinal signs of illness so that early treatment can begin. Mental status changes commonly occur as a result of disease and psychological issues. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 178). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Measurement of vital signs provides data to determine a patient's usual state of health (baseline data). Many factors such as the temperature of the environment, the patient's physical exertion, and the effects of illness cause vital signs to change, sometimes outside an acceptable range. An alteration in vital signs signals a change in physiological function. Assessment of vital signs provides data to identify nursing diagnoses, implement planned interventions, and evaluate outcomes of care . Vital signs are a part of the assessment database. You include them in a complete physical assessment (see Chapter 30), routinely per a health care provider's order, or obtain them individually to assess a patient's condition. Establishing a database of vital signs during a routine physical examination serves as a baseline for future assessments. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 467-468). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Document the following activities or findings at the time of occurrence: o Vital signs o Pain assessment o Administration of medications and treatments o Preparation for diagnostic tests or surgery, including preoperative checklist o Change in patient's status, treatment provided, and who was notified (e.g., health care provider, manager, patient's family) o Admission, transfer, discharge, or death of a patient o Patient's response to treatment or intervention. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (pp. 371-372). Elsevier Health Sciences. Kindle Edition. Resident #30 (R30) Review of an Admission Record revealed R30 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: chronic pain. Review of R30's Order Summary dated 6/1/24 revealed, pregabalin (Lyrica) capsule; 75 mg; amt: 1; oral twice a day (Upon rising and at bedtime). Review of R30's Controlled Substances Proof of Use reviewed on 10/14/24 at 11:40 AM revealed that R30's pregabalin was not signed out as administered the morning of 10/14/24. During an observation on 10/14/2024 at 2:10 PM, LPN F and LPN C were completing a narcotic count on the South Hall medication cart. During the count, LPN C identified that the amount of the controlled drug remaining did not match the number documented in the Controlled Substances Proof of Use form. LPN F reported she had not documented the administration of the medication earlier and signed it out at that time. During an interview on 10/16/24 at 7:53 AM, LPN D reported that the date, time, and nurse signature is documented at the time a controlled medication is removed from the medication cart in order to ensure the correct count of the medication. Review of the Controlled Substance Log on the South Hall medication cart revealed that a nurse removed medication on 10/10/24 and 10/11/24 and did not have a witness signature. During an interview on 10/16/24 at 2:10 PM, DON reported the licensed nurses were expected to follow the facility policy and professional standards of practice when receiving and administering controlled medications. Review of the facility policy Inventory Control of Controlled Substances last revised 8/1/24 revealed, .With respect to Schedule II controlled substances: 1.1 Facility should maintain separate individual controlled substance records on all Schedule II medications and any medication with a potential for abuse or diversion in the form of a declining inventory using the Controlled Substances Declining Inventory Record. These records should include: 1.1.1 Resident name, 1.1.2 Prescription number, 1.1.3 Medication name, strength, dosage form, dosage, 1.1.4 Total quantity received by facility, 1.1.5 Date and time of administration, 1.1.6 Quantity remaining, and 1.1.7 Name and signature of person administering the medication . Facility should ensure that the incoming and outgoing nurses count all Schedule II controlled substances and other medications with a risk of abuse or diversion at the change of each shift or at least once daily and document the results on a Controlled Substance Count Verification/Shift Count Sheet. Facility should: 1.3.1 Reconcile the total number of controlled medications on hand, add newly received medications to the inventory, and remove medications that are completed or discontinued from the inventory, pursuant to the Controlled Substance Verification/Shift Count Sheet; and 1.3.2 Reconcile the number of doses remaining in the package to the number of remaining doses recorded on the Controlled Substance Verification /Shift Count Sheet. 1.3.3 The facility should routinely reconcile the number of doses remaining in the package to the number of doses recorded on the Controlled Substance Verification/ Shift Count Sheet to the medication administration record .

Based on observation, interview, and record review, the facility failed to secure 1 of 2 medication carts (North Hall Medication Cart), resulting in the potential for misappropriation of resident medications. Findings include: During an observation on 10/14/24 at 01:45 PM, the North Hall Medication Cart was left unlocked (the lock was in a pulled out position and the red/orange dot- which would indicate the cart was unlocked- was clearly visible) and unattended in the hallway outside of a resident room. Registered Nurse (RN) B had been observed minutes before partially closing the top drawer of the medication cart, walking away from it, going down the hallway, and turning the corner towards the medication room/nurse's stations. The surveyor was able to pull open the top drawer (which was partially open) of the medication cart without any staff noticing. The medication cart was observed unattended for approximately five minutes and staff were observed walking by the medication cart during this time, but no one locked it. Residents and visitors were also observed in the hallway at the time of the observation. During an observation on 10/14/24 at 01:50 PM, RN B returned to her medication cart. As she was nearing the medication cart, she pulled out the medication cart keys with her right hand. When she approached the cart, she still had the keys in her right hand, but reached out with her left hand and opened the top drawer of the medication cart. She did not gesture towards the lock with the keys in her right hand (this would indicate she knew the medication cart was unlocked). She then grabbed something from the medication cart, locked it, and walked down the hallway to a resident's room. During an interview on 10/14/24 at 01:55 PM when RN B returned back to the medication cart from a resident's room, RN B was asked by the surveyor if her medication cart had been left unlocked not more than five to ten minutes ago. She stated she did not leave her medication cart unlocked and insisted it had not been left unlocked even after the surveyor stated they had seen it unlocked. RN B stated she always locks the medication cart when she walks away from it. She then proceeded to walk away from the surveyor. During an interview on 10/15/24 at 08:40 AM, Licensed Practical Nurse (LPN) C stated she always locks her medication cart when she walks away from it. She stated she does this to keep residents or staff members from stealing meds (medication) from it. During an interview on 10/16/24 09:00 AM, the Director of Nursing (DON) stated she would expect that the nurses lock their medication carts before they walk away from them and leave them unattended. A review of the facility's Storage and Expiration Dating of Medications and Biologicals policy, revised 8/1/24, revealed, 5. Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. A review of the facility's General Dose Preparation and Medication Administration policy and procedure, revised 1/1/22, revealed, 7. Facility should ensure that medication carts are always locked when out of sight or unattended.

Based on observation, interview, and record review, the facility failed to implement transmission-based precautions and utilize appropriate personal protective equipment for 1 resident (Resident #25) of 10 residents reviewed for transmission-based precautions, resulting in the potential for cross-contamination, disease exposure, and the development and spread of infection to a vulnerable population. Findings: Per the Centers for Disease Control and Prevention (CDC), .Isolate patients with possible C. diff immediately, even if you only suspect CDI (clostridium difficile infection) . https://www.cdc.gov/c-diff/hcp/clinical-overview/index.html (Article dated 3/5/24). Resident #25 (R25) Review of an Admission Record revealed R25 was an [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: lymphedema, urine retention, heart failure, and kidney disease. Review of R25's Order Summary dated 10/10/24 revealed, Collect stool sample DX (diagnosis) C diff/diarrhea . Confirming R25 was suspected to have C Diff and was subsequently tested for the infection. Review of R25's Laboratory Result dated 10/11/24 revealed, Negative for C. difficile toxin, however, may represent C difficile colonization. If suspicion for C difficile infection remains high and there is no other explanation for diarrhea, consider empiric treatment and/or consult Infections Diseases for guidance. The laboratory result was not reviewed/signed by the provider until 10/14/24 with an order to test again. Review of R25's Electronic Medical Record revealed no order for R25 to be placed in contact precautions pending the laboratory result for C Diff. Review of R25's Progress Note dated 10/14/2024 at 02:27 PM revealed, Results back from (name omitted) lab for C Difficile interpretation. (Physician assistant) notified and orders received to re-test for C. diff and consult with I&D (Infectious Diseases). Resident will remain in contact precautions until re-test results return as a precaution. Confirming R25 should have been in contact precautions while testing was in progress. Review of R25's Order Summary dated 10/14/24 at 2:09 PM revealed, General Contact Isolation re: positive VRE (vancomycin/antibiotic resistant bacteria) and suspected C-diff. Do not use hand sanitizer-must use soap and water. Use bleach sani-wipes and EPA registered disinfectants for C-diff. Confirming the delay in the implementation of transmission-based precautions/isolation. During an observation and interview on 10/14/24 at 10:11 AM, R25 did not have signage on his door indicating he was in contact precautions/isolation with the PPE required (personal protection equipment utilized when a resident is in transmission-based precautions). A therapy staff member was in his room completing his ordered services and R25 had a visitor in his room. The therapy staff member was not wearing PPE. R25 reported he was unable to complete his therapy at that time due to having diarrhea and the therapy staff member exited his room. R25 reported he had been having diarrhea since returning from the hospital on 10/1/24. During the interview, Certified Nursing Assistant (CNA) A entered the room to perform care on R25 and did not don PPE. During an interview on 10/16/24 at 08:21 AM, Director of Nursing (DON)/Infection Control Preventionist (DON) reported that facility staff were to place residents in isolation that had a suspected communicable infection, even if testing was ordered but not yet resulted. DON reported that R25 was being tested for C-diff and the contact isolation sign had been placed on the wrong resident's door. DON reported that she had given the sign to a staff member to put on R25's room door but had not ensured it was placed on the correct door. DON reported R25 had tested negative for C-diff, but the lab result had indicated R25 could be colonized (the bacteria is present but not causing symptoms) with C-diff. DON reported that the provider had ordered an additional stool sample to be collected. During an interview on 10/16/24 at 2:10 PM, DON reported R25 was to be in contact precautions/transmission-based precautions following the laboratory interpretation of his stool sample. DON reported that the laboratory result did not give a definitive result, and she would be reaching out to the local health department for guidance but in the meantime R25 would remain in contact precautions to prevent the potential spread of infection to other residents and staff.

Based on observations, interviews and record review, the failed to provide adequate supervision to prevent falls for 3 Residents (R1, R2, and R3) of 3 residents reviewed for falls, resulting in R1 falling and sustaining a hip fracture and the potential for R2 and R3 to sustain serious injuries. Findings included: R1 Review of R1 face sheet, no date, revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: cerebral infarction (stroke), vascular dementia, psychotic disturbance, mood disturbance, anxiety, need for assistance with personal care, muscle weakness, difficulty in walking, cognitive communication deficit, syncope (fainting) and collapse. Review of R1's Brief Interview of Mental Status (BIMS) dated, 1/30/24 revealed she scored 6/15 (severe cognitive deficit). Review of R1's incident and accident report dated 2/26/24 at 6:30 AM revealed, R1 had an unwitnessed fall that was discovered after shift change on 2/26/24 at 6:30 AM that resulted in a hip fracture. When R1 was found on the floor she did not have a brief on or proper footwear. The care plan was reviewed and revealed she required 1 assist and had decreased safety awareness that contributed to her fall. During a review of a facility interview dated 2/26/24, Certified Nurse Aide (CNA) C revealed CNA C was assigned to R1 prior to R1 being found on the floor. The report revealed CNA C had observed R1 moving around her room at night, she has had to put new briefs on R1 and cleaned up urine off R1's floor. CNA C reported R1 was naked in bed at 12:30 AM and at 4:00 AM, R1 was in bed. R1 was observed sitting in a wheelchair in front of the nurse's station on 3/11/24 at 8:32 AM. R1 was not able to answer any questions. R1 was sitting with 6 other residents. All residents were facing the nurses' station. No staff were in eye contact with the 7 residents or at the nurses' station. The residents were sleeping or just looking at the nurses' station. During an interview with Certified Nurse Aide (CNA) B on 3/11/24 at 8:38 AM, CNA B said she cared for R1 prior to her fall that resulted in a hip fracture. CNA B said R1 frequently self-transferred, and she would just try to do frequent checks on her when she was awake. CNA B said she did know she had to check on her when her door was closed. CNA B said she always leaves R1's door open when she puts her to bed and R1 frequently got herself out of bed and shut her door. CNA B said they do not have any staff designated to watch the dementia residents that wander or self-transfer. CNA B denied any documentation requirements for unsafe behaviors. During a telephone interview with the Director of Nursing (DON) and CNA C on 3/11/24 at 10:17 AM, CNA C confirmed that she provided care for R1 the night of 2/26/24 and she left at 6:00 AM. CNA C was not aware that R1 was on the floor when she left work. CNA C said R1 is generally awake at least half the night shift. She confirmed she assisted R1 at 12:30 AM when she was naked in bed, and she saw her in bed at 4:00 AM. CNA C did not observe R1 after 4:00 AM that night. CNA C said R1 self-transfers all the time and walks about unassisted at times. R1 was known to get out of bed and remove her wet brief. CNA C denied any knowledge of a toilet schedule for R1. R1 said they only have 2 CNA's and 1 nurse on the night shift for 36 residents. R1 said at least 5 of the residents including R1 are up during the night shift, and they are not safe left alone and 3 staff cannot supervise all the awake residents and provide for all the other care needs. CNA C said she has reported this concern to management on multiple occasions, but no one does anything. Review of R1's fall care plan dated 1/25/24 revealed, interventions that included: Assess for need of resident's participation in bowel and bladder program and provide assistance to toilet as needed. There was no indication of how staff were to provide supervision when R1 was awake. Review of R1's progress note dated 2/26/24 at 6:30 AM revealed, Res (resident) was observed shivering on the floor surrounded and saturated with urine (resident's hair, body/gown were all soaked). When asked what happened res (resident) states that she had to use the bathroom. When asked how long she had been there resident states all night. Review of R1's progress note dated 2/11/24 at 9:03 AM revealed, Res (resident) alert and pleasant with confusion at her baseline. Walks occasionally with walker, gait is unsteady. She uses the wc (wheelchair) for long distance Denies SOB (shortness of breath) no issues with respiratory distress reported or observed. Incont (incontinent) of B & B (bowel and bladder). She does have poor safety awareness and has been observed ambulating without assistance. During an interview with the DON and Corporate Nurse (CN) A on 3/11/24 at 11:17 AM, they confirmed that there were only 3 staff working on the night shift and they did not have a program in place to supervise the dementia residents that had unsafe behaviors (walking unassisted, wandering and self-transfers). They confirmed that the staff were not consistently documenting the unsafe behaviors. They were unable to locate any documentation on R1's wake/sleep cycle or toilet pattern. They reported that they were in process of developing a program and the program would be educated on and put in place today that would start tracking wake/sleep/toilet needs and have activities to assist in supervising the dementia residents when they were awake. R2 Review of R2's face sheet, no date, revealed she was an [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: cerebral infarction (stoke), fracture of left pubis (pelvic bone), unsteady on feet, need for assistance with personal care, and memory impairment. R2 was not her own responsible party. R2 was observed on 3/11/24 at 12:45 AM moving her wheelchair down the hall independently with no staff in eyesight of her. R2 was not able to answer questions. During an interview with CNA H on 3/11/24 at 12:47 PM, CNA H said she was assigned to R2 at this time. CNA H said R2 is not able to tell staff when she needs help and is known to self-transfer and fall. R2 was asked how the facility provides supervision for R2. CNA H said they do not have anyone assigned to provide supervision; she just tries to do frequent checks. Review of R2's ADL (Activities of Daily Living) care plan dated 10/31/23, revealed she required assist of 1 for toilet use and transfers. Review of R2's fall care plan dated 10/31/23 revealed she was at risk of falls related to impaired balance with transitions, lower extremity weakness, hypertension with use of antihypertensive medications with potential for fluctuations in blood pressure, diuretic medications use, glaucoma, peripheral vascular disease, osteoporosis, osteoarthritis, does not always comply with use of call light to alert staff of needs and will self-transfer/ambulate. There were no interventions listed to supervise R2 when she was awake. There was no indication of her sleep/wake cycle or toilet schedule. Review of the facility timeline for R2's falls between 2/6/24 and 11/25/23 revealed R2 had 3 unobserved falls (R2 was not being supervised at the time of these falls). Interventions placed did not include any interventions to supervise R2 when she was awake. R3 Review of R3's face sheet, no date, revealed she was an [AGE] year-old female admitted on [DATE] and had diagnoses that included: severe protein-calorie malnutrition, need for assistance with personal care, muscle weakness, difficulty in walking, cognitive communication deficit, dementia, and compression fracture of lumbar vertebra. She was not her own responsible party. Review of R3's ADL (Activities of Daily Living) care plan dated 12/20/23 revealed she required assistance of 1 person to walk to the bathroom with a walker, 1 assist for transfers, and 1 assist to move about in her wheelchair. Review of R3's fall care plan revealed she was at risk of falls related to dementia, impaired balance with transitions, weakness, incontinence and unaware of safety needs. There were no interventions related to how the facility planed to specifically supervise R3 when she was awake. Review of the facility timeline for falls for R3 revealed R3 had an unobserved fall on 12/31/23 at 4:30 PM. R3's husband had not visited that day and R3 was looking for her husband. On 3/11/24 at 12:51 PM, CNA B said R3 was currently assigned to her. CNA B said R3 will not walk with her walker or put her call light on. When R3's husband is not with her she tries to do frequent checks. R3 does not have any activities scheduled daily and no staff are assigned to watch her or other residents that self-transfer. CNA B was aware R3 was in her room and her husband was present today. R3 was observed in bed on 3/11/224 at 12:52 PM and her husband was holding her hand. R3's husband said R3 fell several times at home and denied the facility offering any structured programs to supervise his wife daily. R3's husband said he comes every day to walk with her, take her to the bathroom when needed, and tries to keep her awake so she will sleep at night. He said her children come on the weekend to give him a break. Her husband confirmed R3 cannot use her call light and will not alert staff when she needs to use the bathroom. R3 smiled at her husband as he talked about her. During an interview with the Nursing Home Administrator (NHA), Director of Nursing (DON) and Corporate Nurse (CN) A on 3/11/24 at 2:30 PM, the fall timelines for R2 and R3 were reviewed. They confirmed that the falls were not witnessed, both residents were known for unsafe transfers and walking, and the facility did not have structured activity plans for R1, R2 or R3. The DON just started and the NHA had started less than 2 months ago. CN A and the NHA said they just hired an activity aide that is starting this week and they had planned on providing more structured activities for the dementia residents. They were starting education today on monitoring residents wake/sleep and toilet schedules and implementing structured activities and supervision for residents with impaired safety.

Based on observations, interviews, and record review, the facility failed to develop and implement a meaningful activities program for 4 Residents (R1, R2, R3 and R4) of 4 residents sampled, resulting in residents sitting unsupervised and experiencing boredom without the option for diversional activities to decrease the risk of injury. Findings included: R4 Review of R4' face sheet (no date) revealed she was a [AGE] year-old female admitted on [DATE] and had diagnoses that included: dementia, glaucoma, need for assistance with personal care, repeated falls, and muscle weakness. R4 was not her own responsible party. During an observation on 4/17/24 at 1:37 PM, R4 sat in a wheelchair near the nurse's station. R4's feet were on footrests. R4 was not able to move her wheelchair or answer any questions. R4 grimaced as if she was in pain and rubbed her right leg. Staff moved about the unit. At times, staff were not in sight. There were no activities for the residents sitting near the nurse's station. Other residents in the area also appeared to be confused and had no activities provided. Review of R4's ADL (activities of daily living) care plan dated 1/17/24 revealed approach's that included: 4/15/24, for assistance of 1 person for walking with a 4 wheeled walker. 4/15/24 transfer assist of 1 person. 9/13/23, toileting assistance 1 person. 1/17/21, bed mobility independent. (no interventions were located for bed/chair alarms, 15-minute checks or 1:1, and nothing indicated for need of supervision for safety identified). Review of R4's fall care plan dated 1/17/21 revealed that R4 does not always alert staff to needs and requires one assist with transfer/ambulation related to history of falls with fractures. Approaches listed did not include interventions for supervision or diversional activities to increase supervision for increased safety. During an interview with Regional Clinical Nurse (RCN) A on 4/17/24 at 5:25 PM, she confirmed that R4's care plan did not include the 1:1, 15-minute checks, alarms for her safety, or the need for assistance with ambulation and transfers after a fall on 3/20/24. RCN A stated the team would evaluate R4 upon her return from a medical appointment but did not know what interventions they would implement. Upon survey exit, staff did not put any new interventions into place for R4's safety. RCN A said when R4 fell on [DATE] she should have been on 1:1 care and that they educated the nurse that changed R4 to 15-minute checks. (Upon survey exit, the facility did not provide documentation of this education). RCN A was not able to provide any information or documentation of an activities program when asked about activities and supervision for all the facility residents with cognitive impairments and poor safety awareness. The facility currently did not have an activity director or aide on staff. R1 Review of R1's face sheet (no date) revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: fracture of right femur, cerebral infarction (stroke), unsteady on feet, vascular dementia, need for assistance with personal care, difficulty in walking, and altered mental status. No indication of a guardian or durable power of attorney was located. Review of R1's Minimum Data Set (MDS) dated [DATE] revealed she had a Brief Interview of Mental Status (BIMS) score of 6/15 (severely cognitively impaired). During an observation on 4/17/24 at 8:30 AM, R1 was sitting in front of the nurse's station. Staff were not consistently in the area as all staff were busy providing care or doing other tasks. R1 could not recall what activities she liked, and she did not know where she would go if she wanted something fun to do. During an interview with Licensed Practical Nurse (LPN) C on 4/17/24 at 8:37 AM, he named the 4 residents sitting at the nurse's station and responded to questions of whether they were there for any reason by saying they took themselves there and they can move about the facility at will. LPN C said he was not aware of any activities available for the residents at this time but said sometimes staff do provide activities in the main dining area. LPN C was not aware of any safety concerns for R1 or the other 3 residents sitting at the nurses' station. Review of R1's ADL (activities of daily living) care plan dated 3/8/24 revealed, R4 has self-care deficits related to dementia, impaired balance, and right femur fracture. Approaches included: 3/27/24 check and change on or about every 2 hours d/t (due to) incontinence. 3/8/24 needs 1 assist for toileting/elimination, 1 assist for transfers and 1 assist for mobility with a walker, independent with wheelchair mobility. Review of R1's fall care plan dated 1/25/24 revealed she was at risk for falls related to impaired balance, not always aware of safety needs and multiple medical diagnoses. Approaches included: 3/26/24 while awake offer diversional activities - examples magazines, music fiddle objects and television. 3/22/24 reassess toileting needs. 3/1/24 round on resident on or about every hour to ensure nonskid footwear in place, assist with toileting needs if indicated and ensure brief on resident. 1/25/24 assess for residents' participation in bowel and bladder program. 4/17/24, R1 prefers independent activities in her room or to be in the public area; she does not want constant staff oversight. Provide diversional activities of choice such as baby doll, stress balls, snack, or drink. 4/17/24 offer R1 assistance with toileting on or about every 2 hours while awake to promote continence. During an interview with the facility care team for R1 on 4/17/24 at 2:45 PM, the facility Social Worker (SW) J said she met with R1 today and she prefers no supervision. SW J denied any offering of supervision or risk/benefits when asked if the facility offered supervision and risk/benefits or if they discussed them with R1 or her advocate/or guardian. SW J said R1's Brief Interview of Mental Status score was 6 and her physician had determined she was not competent, but the facility requested a second physician review for competency and a second physician has not completed that review yet. SW J had no idea when the second physician would address her competency and could not verify R1 understood the risks when she had the conversation. Regional Director of Operations B directed SW J to contact the second physician to evaluate R1's competency. Upon exit, the facility did not provide a risk benefit statement or any assurance that R1 could understand the risks related to lack of supervision. The facility did not provide any documentation that they changed R1's care plan to reflect supervision needed to ensure her safety. During an interview with the facility care team for R1 on 4/17/24 at 2:45 PM, they were unable to provide any information on how they were supervising R1 when she was awake. They had no documentation to indicate if staff were offering R1 diversional activities and no activity calendar was located for April 2024. R2 Review of R2's face sheet (no date), revealed she was an [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: cerebral infarction (stroke), fracture of left pubis (pelvic bone), unsteady on feet, and muscle weakness. She was not her own responsible party. During an observation on 4/17/24 at 8:30 AM, R2 sat in her wheelchair at the nurse's station. Staff were not always in the area as they were caring for other residents. No activities occurring at that time. R2 could not say what activities she liked or where the facility had activities. During an interview with Licensed Practical Nurse (LPN) C on 4/17/24 at 8:37 AM, he named the 4 residents sitting at the nurse's station and responded to questions of whether they were there for any reason by saying they took themselves there and they can move about the facility at will. LPN C said he was not aware of any activities available for the residents at this time but said sometimes staff do provide activities in the main dining area. LPN C was not aware of any safety concerns for R1 or the other 3 Residents sitting at the nurses' station. Review of R2's fall care plan dated 10/31/23 revealed, R2 is at risk for falls related to impaired balance, weakness and does not always comply with the use of call light to alert staff of needs and will self-transfer/ambulate. The care plan also listed multiple medical diagnoses as risk factors for her falls. Approaches included: 4/2/24, keep alarm box out of reach. 3/27/24, will attempt self-transfers, follow toileting routine as outlined and documented. 3/26/24 toilet before and after meals, upon rising and prior to bed. Also, toilet or check and change on or about 2 AM per bowel and bladder study. 3/22/24 occupy with meaningful distractions music, companion, diversional activity per resident preference, resident enjoys sitting in common area socializing with other residents and staff. 3/22/24 reassess toileting needs. 3/22/24 staff to round on resident on or about hourly when she is in her room related to resident's history of self-transferring. R3 Review of R3's face sheet (no date), revealed she was an [AGE] year-old female admitted on [DATE] and had diagnoses that included: severe protein-calorie malnutrition, need for assistance with personal care, muscle weakness, difficulty in walking, cognitive communication deficit, dementia, and compression fracture of lumbar vertebra. She was not her own responsible party. During an observation on 4/17/24 at 8:30 AM, R3 sat in her wheelchair at the nurse's station. Staff were not always in that area as they were attending to other residents. No activities occurring at that time. R3 could not say what activities she liked or where the facility had activities. During an interview with Licensed Practical Nurse (LPN) C on 4/17/24 at 8:37 AM, he named the 4 residents sitting at the nurse's station and responded to questions of whether they were there for any reason by saying they took themselves there and they can move about the facility at will. LPN C said he was not aware of any activities available for the residents at this time but said sometimes staff do provide activities in the main dining area. LPN C was not aware of any safety concerns for R1 or the other 3 Residents sitting at the nurses' station. Review of R3's ADL (activities of daily living) care plan dated 12/20/23 revealed she requires assistance with ADL's related to dementia, requires cues and assistance to complete ADL/mobility tasks, impaired balance and weakness, Approaches included: 3/22/24 resident is impulsive and will attempt to self-transfer, 12/20/23, toilet/elimination needs 1 assist. 12/20/23, mobility 1 assist to ambulate. 12/20/23, transfers 1 assist. During an interview with the Regional Director of Nursing (RDN) A on 4/17/24 at 2:45 PM, RDN A acknowledged R3's self-transferring and walking without assistance and said the facility trained the husband and that he is safe to assist at this time. RDN A could not say what supervision interventions were in place when R3's husband was not in the room. RDN could not provide any documentation of diversional activities attempted and there was no activity calendar for April. During an interview with the facility treatment team that included the Nursing Home Administrator (NHA), Interim Director of Nursing (IDON), Regional Clinical Nurse A and Regional Director of Operations (RDO) B on 4/17/24 at 2:45 PM., the facility could not provide current information on any activity program designed for their dementia residents that would allow diversional activities, quality of life, or supervision for the residents that wander and have unsafe behaviors. They acknowledged they were making attempts to provide some activities utilizing the Certified Nurse Aides (CNA) and Licensed Nurses. They currently had no activity staff employed. They did not have a calendar or any scheduled activities for the month of April. They were unable to provide documentation for R1, R2, R3 or R4 showing that the facility offered activities. They confirmed that all 4 residents lacked safety awareness and were unpredictable with when they would attempt to self-transfer. Facility staff offered all 4 residents the toilet or having a brief change every 2 hours and staff checked on them every 1 to 2 hours. They were still attempting to self-transfer or take themselves to the bathroom. The facility did not indicate when they would have diversional activities available on a routine basis to ensure dementia residents had supervision and/or assistance when needed to improve their quality of life.

Based on observations, interviews, and record review, the facility failed to develop and implement a meaningful activities program for 4 Residents (R1, R2, R3 and R4) of 4 residents sampled, resulting in residents sitting unsupervised and experiencing boredom without the option for diversional activities to decrease the risk of injury. Findings included: R4 Review of R4' face sheet (no date) revealed she was a [AGE] year-old female admitted on [DATE] and had diagnoses that included: dementia, glaucoma, need for assistance with personal care, repeated falls, and muscle weakness. R4 was not her own responsible party. During an observation on 4/17/24 at 1:37 PM, R4 sat in a wheelchair near the nurse's station. R4's feet were on footrests. R4 was not able to move her wheelchair or answer any questions. R4 grimaced as if she was in pain and rubbed her right leg. Staff moved about the unit. At times, staff were not in sight. There were no activities for the residents sitting near the nurse's station. Other residents in the area also appeared to be confused and had no activities provided. Review of R4's ADL (activities of daily living) care plan dated 1/17/24 revealed approach's that included: 4/15/24, for assistance of 1 person for walking with a 4 wheeled walker. 4/15/24 transfer assist of 1 person. 9/13/23, toileting assistance 1 person. 1/17/21, bed mobility independent. (no interventions were located for bed/chair alarms, 15-minute checks or 1:1, and nothing indicated for need of supervision for safety identified). Review of R4's fall care plan dated 1/17/21 revealed that R4 does not always alert staff to needs and requires one assist with transfer/ambulation related to history of falls with fractures. Approaches listed did not include interventions for supervision or diversional activities to increase supervision for increased safety. During an interview with Regional Clinical Nurse (RCN) A on 4/17/24 at 5:25 PM, she confirmed that R4's care plan did not include the 1:1, 15-minute checks, alarms for her safety, or the need for assistance with ambulation and transfers after a fall on 3/20/24. RCN A stated the team would evaluate R4 upon her return from a medical appointment but did not know what interventions they would implement. Upon survey exit, staff did not put any new interventions into place for R4's safety. RCN A said when R4 fell on 4/6/24 she should have been on 1:1 care and that they educated the nurse that changed R4 to 15-minute checks. (Upon survey exit, the facility did not provide documentation of this education). RCN A was not able to provide any information or documentation of an activities program when asked about activities and supervision for all the facility residents with cognitive impairments and poor safety awareness. The facility currently did not have an activity director or aide on staff. R1 Review of R1's face sheet (no date) revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: fracture of right femur, cerebral infarction (stroke), unsteady on feet, vascular dementia, need for assistance with personal care, difficulty in walking, and altered mental status. No indication of a guardian or durable power of attorney was located. Review of R1's Minimum Data Set (MDS) dated [DATE] revealed she had a Brief Interview of Mental Status (BIMS) score of 6/15 (severely cognitively impaired). During an observation on 4/17/24 at 8:30 AM, R1 was sitting in front of the nurse's station. Staff were not consistently in the area as all staff were busy providing care or doing other tasks. R1 could not recall what activities she liked, and she did not know where she would go if she wanted something fun to do. During an interview with Licensed Practical Nurse (LPN) C on 4/17/24 at 8:37 AM, he named the 4 residents sitting at the nurse's station and responded to questions of whether they were there for any reason by saying they took themselves there and they can move about the facility at will. LPN C said he was not aware of any activities available for the residents at this time but said sometimes staff do provide activities in the main dining area. LPN C was not aware of any safety concerns for R1 or the other 3 residents sitting at the nurses' station. Review of R1's ADL (activities of daily living) care plan dated 3/8/24 revealed, R4 has self-care deficits related to dementia, impaired balance, and right femur fracture. Approaches included: 3/27/24 check and change on or about every 2 hours d/t (due to) incontinence. 3/8/24 needs 1 assist for toileting/elimination, 1 assist for transfers and 1 assist for mobility with a walker, independent with wheelchair mobility. Review of R1's fall care plan dated 1/25/24 revealed she was at risk for falls related to impaired balance, not always aware of safety needs and multiple medical diagnoses. Approaches included: 3/26/24 while awake offer diversional activities - examples magazines, music fiddle objects and television. 3/22/24 reassess toileting needs. 3/1/24 round on resident on or about every hour to ensure nonskid footwear in place, assist with toileting needs if indicated and ensure brief on resident. 1/25/24 assess for residents' participation in bowel and bladder program. 4/17/24, R1 prefers independent activities in her room or to be in the public area; she does not want constant staff oversight. Provide diversional activities of choice such as baby doll, stress balls, snack, or drink. 4/17/24 offer R1 assistance with toileting on or about every 2 hours while awake to promote continence. During an interview with the facility care team for R1 on 4/17/24 at 2:45 PM, the facility Social Worker (SW) J said she met with R1 today and she prefers no supervision. SW J denied any offering of supervision or risk/benefits when asked if the facility offered supervision and risk/benefits or if they discussed them with R1 or her advocate/or guardian. SW J said R1's Brief Interview of Mental Status score was 6 and her physician had determined she was not competent, but the facility requested a second physician review for competency and a second physician has not completed that review yet. SW J had no idea when the second physician would address her competency and could not verify R1 understood the risks when she had the conversation. Regional Director of Operations B directed SW J to contact the second physician to evaluate R1's competency. Upon exit, the facility did not provide a risk benefit statement or any assurance that R1 could understand the risks related to lack of supervision. The facility did not provide any documentation that they changed R1's care plan to reflect supervision needed to ensure her safety. During an interview with the facility care team for R1 on 4/17/24 at 2:45 PM, they were unable to provide any information on how they were supervising R1 when she was awake. They had no documentation to indicate if staff were offering R1 diversional activities and no activity calendar was located for April 2024. R2 Review of R2's face sheet (no date), revealed she was an [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: cerebral infarction (stroke), fracture of left pubis (pelvic bone), unsteady on feet, and muscle weakness. She was not her own responsible party. During an observation on 4/17/24 at 8:30 AM, R2 sat in her wheelchair at the nurse's station. Staff were not always in the area as they were caring for other residents. No activities occurring at that time. R2 could not say what activities she liked or where the facility had activities. During an interview with Licensed Practical Nurse (LPN) C on 4/17/24 at 8:37 AM, he named the 4 residents sitting at the nurse's station and responded to questions of whether they were there for any reason by saying they took themselves there and they can move about the facility at will. LPN C said he was not aware of any activities available for the residents at this time but said sometimes staff do provide activities in the main dining area. LPN C was not aware of any safety concerns for R1 or the other 3 Residents sitting at the nurses' station. Review of R2's fall care plan dated 10/31/23 revealed, R2 is at risk for falls related to impaired balance, weakness and does not always comply with the use of call light to alert staff of needs and will self-transfer/ambulate. The care plan also listed multiple medical diagnoses as risk factors for her falls. Approaches included: 4/2/24, keep alarm box out of reach. 3/27/24, will attempt self-transfers, follow toileting routine as outlined and documented. 3/26/24 toilet before and after meals, upon rising and prior to bed. Also, toilet or check and change on or about 2 AM per bowel and bladder study. 3/22/24 occupy with meaningful distractions music, companion, diversional activity per resident preference, resident enjoys sitting in common area socializing with other residents and staff. 3/22/24 reassess toileting needs. 3/22/24 staff to round on resident on or about hourly when she is in her room related to resident's history of self-transferring. R3 Review of R3's face sheet (no date), revealed she was an [AGE] year-old female admitted on [DATE] and had diagnoses that included: severe protein-calorie malnutrition, need for assistance with personal care, muscle weakness, difficulty in walking, cognitive communication deficit, dementia, and compression fracture of lumbar vertebra. She was not her own responsible party. During an observation on 4/17/24 at 8:30 AM, R3 sat in her wheelchair at the nurse's station. Staff were not always in that area as they were attending to other residents. No activities occurring at that time. R3 could not say what activities she liked or where the facility had activities. During an interview with Licensed Practical Nurse (LPN) C on 4/17/24 at 8:37 AM, he named the 4 residents sitting at the nurse's station and responded to questions of whether they were there for any reason by saying they took themselves there and they can move about the facility at will. LPN C said he was not aware of any activities available for the residents at this time but said sometimes staff do provide activities in the main dining area. LPN C was not aware of any safety concerns for R1 or the other 3 Residents sitting at the nurses' station. Review of R3's ADL (activities of daily living) care plan dated 12/20/23 revealed she requires assistance with ADL's related to dementia, requires cues and assistance to complete ADL/mobility tasks, impaired balance and weakness, Approaches included: 3/22/24 resident is impulsive and will attempt to self-transfer, 12/20/23, toilet/elimination needs 1 assist. 12/20/23, mobility 1 assist to ambulate. 12/20/23, transfers 1 assist. During an interview with the Regional Director of Nursing (RDN) A on 4/17/24 at 2:45 PM, RDN A acknowledged R3's self-transferring and walking without assistance and said the facility trained the husband and that he is safe to assist at this time. RDN A could not say what supervision interventions were in place when R3's husband was not in the room. RDN could not provide any documentation of diversional activities attempted and there was no activity calendar for April. During an interview with the facility treatment team that included the Nursing Home Administrator (NHA), Interim Director of Nursing (IDON), Regional Clinical Nurse A and Regional Director of Operations (RDO) B on 4/17/24 at 2:45 PM., the facility could not provide current information on any activity program designed for their dementia residents that would allow diversional activities, quality of life, or supervision for the residents that wander and have unsafe behaviors. They acknowledged they were making attempts to provide some activities utilizing the Certified Nurse Aides (CNA) and Licensed Nurses. They currently had no activity staff employed. They did not have a calendar or any scheduled activities for the month of April. They were unable to provide documentation for R1, R2, R3 or R4 showing that the facility offered activities. They confirmed that all 4 residents lacked safety awareness and were unpredictable with when they would attempt to self-transfer. Facility staff offered all 4 residents the toilet or having a brief change every 2 hours and staff checked on them every 1 to 2 hours. They were still attempting to self-transfer or take themselves to the bathroom. The facility did not indicate when they would have diversional activities available on a routine basis to ensure dementia residents had supervision and/or assistance when needed to improve their quality of life.

Based on observation, interview, and record review the facility failed to: 1. Date mark and discard potentially hazardous foods; 2. Properly cool potentially hazardous foods; 3. Ensure proper concentration of quaternary ammonium sanitizer; 4. Clean food and non-food contact surfaces to sight and tough; and 5. Ensure proper working order of the dish machine. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 55 residents who consume food from the kitchen. Findings Include: 1. During the initial tour of the kitchen, starting at 9:20 AM on 10/1/23, an interview with Cook I found that most foods are date marked for a seven-day discard, but foods made in house would usually be kept for three days. Observation of the two door True cooler found a package of hot dogs dated 9/25 to 10/5, and an open package of hard-boiled eggs with no date. During a tour of the dry storage refrigerator, at 10:50 AM on 10/1/23, the following items were found: yogurt with a best by date of 8/16/23, half and half with a best by date of 8/14/23, an uncovered cookie pudding with no date, and a taco wrapped in tin foil with no date. According to the 2017 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety . According to the 2017 FDA Food Code section 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3501.17(A) . 2. During the initial tour of the kitchen, at 9:25 AM on 10/1/23, observation of the True two door cooler found taco meat tightly wrapped in foil. An interview with Cook I found that the taco meat is for taco salad coming up. When asked how the item was cooled, Cook I stated she made it around 1:00 PM yesterday, the meat reached 180F when it was finished and over the next two hours it cooled to 155F where Cook I stated she covered it up and put it in the reach in cooler. Observation of the pan at this time found heavy accumulation of condensation inside the top cover. When asked if she knew the required time and temperature frequency for cooling, Cook I was unsure. According to the 2017 FDA Food Code section 3-501.14 Cooling. (A) Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 57 C (135 F) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less . According to the 2017 FDA Food Code section 3-501.15 Cooling Methods. (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S 3-501.14 by using one or more of the following methods based on the type of FOOD being cooled: .(2) Loosely covered, or uncovered if protected from overhead contamination as specified under Subparagraph 3-305.11(A)(2), during the cooling period to facilitate heat transfer from the surface of the FOOD. 3. During the initial tour of the kitchen, at 9:40 AM on 10/1/23, a sanitizer bucket containing quaternary ammonium was tested with Hydrion QT-40 test strips and found to be over 500 parts per million (ppm) when distributed from the pre dispense sanitizer system on the three-compartment sink. An interview with Cook I found the concentration is usually around 200-300 ppm. The pre dispense system was tested four times with the facilities test kit and found the concentration was over the 500 ppm (the max that registers on the test strip). Staff were unsure why the concentration was this high, the surveyor asked when the last time the unit was serviced, staff was unsure. According to the 2017 FDA Food Code section 7-204.11Sanitizers, Criteria. Chemical SANITIZERS, including chemical sanitizing solutions generated on-site, and other chemical antimicrobials applied to FOOD-CONTACT SURFACEs shall: (A)Meet the requirements specified in 40 CFR 180.940Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (Food-contact surface sanitizing solutions), or (B)Meet the requirements as specified in 40 CFR180.2020 Pesticide Chemicals Not Requiring a Tolerance or Exemption from Tolerance-Non-food determinations. 4. During a tour of the kitchen, at 9:40 AM on 10/1/23, it was observed that the ice scoop holder on the wall was found with a layer of stagnant water in the bottom of the holder with no holes for proper drainage. When asked how often the ice scoop gets cleaned, Cook I stated it gets cleaned once a week. During a tour of the kitchen, at 10:01 AM on 10/1/23, observation of the clean utensil drawers found three mechanical scoops with stuck on food debris, further review found one of the drawers contained excess food and crumb accumulation. When asked if the clean utensil drawers are on a cleaning list, Cook I stated yes. According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 5. During the initial tour of the dish machine area, at 10:16 AM on 10/1/23, it was observed that the dish machine required 155F for the wash cycle and 180F for the rinse water coming out of the manifold. A review of the High Temp Dish Machine Wash and Rinse Temperature Log dated September 2023, found 46 rinse temperatures recorded below the minimum requirement of 180F. According to the 2017 FDA Food Code section 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. (A) Except as specified in (B) of this section, in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90C (194F), or less than: .(2) For all other machines, 82C (180F).

Based on observations, interviews, and record review, the facility failed to ensure 1 Resident, (R12) had a legal representative to assist her in making medical decisions, resulting in R12 not having anyone to act in her best interest in making medical decisions. Findings included: Review of R12's face sheet, no date revealed she was a [AGE] year-old female admitted to the facility on [DATE] and diagnoses that included: cerebral infarction (stroke), aphasia (disorder that affects communication), hemiplegia (muscle impairment on one side of the body), and congestive heart failure. No legal decision maker was named. Review of R12's July 2023 Brief Interview of Mental Status (BIMS) score revealed she scored 9/15 (moderately impaired decision making). R12 was observed in the facility main dining room on 10/1/23 @ 11:52 AM. R12 was in a geriatric style wheelchair and was totally dependent on staff for mobility. R12 had her lunch in front of her and was unable to answer questions of if the food was good or what her food preferences were. When she was asked if she wanted food, she would nod her head, yes. At times she would feed herself with a spoon and accepted help when offered. R12's coordination was poor, and her movements were slow. R12 did not verbalize any words. Review of R12's care plan revealed she had a care plan, Psychosocial Well-Being. Resident has participated in Advanced Care Planning and has made wishes known if in the future they are no longer able to do so, dated 7/20/23. Approaches included: Resident has/has not appointed a proxy to make health care decisions when they are no longer able to make decision for themselves. Social Services. If ordered by the physician, honor resident's wishes for medication (s) and pain control, Resident does/does not wish to use hospice care to keep comfortable at the end of life. Licensed Nurse (LPN/RN), Social Services). Review of R12's progress note dated 8/30/23 at 12:25 PM revealed, (Name of Hospice Service), RN (Registered Nurse) visit completed. Pt (patient) sitting in a broda chair in dining room, staff feeding pt 1:1, pt ate about 30% of lunch, staff reported pt coughed several times while eating. LS (lung sounds) have rhonchi throughout. Pt hanging head during assessment. Trace edema in legs and feet b/l (bilateral) Face does not appear to be puffy like last week. Encourage rest as much as possible for comfort. There was no documented indication that R12 had a representative/responsible party notified of resident status and/or changes to care. Review of R12's progress note dated 9/13/23 at 12:17 PM revealed, SSD (Social Services Director) and pharmacist met today to discuss this resident's psychotropic medications. Resident continues on Remeron (antidepressant medication also used to stimulate appetite) recommending GDR (gradual dose reduction) at this time. Physician group to assess. There was no indication that R12 had a representative involved in this decision. During an interview with the Nursing Home Administrator on 10/2/23 at 12 :55 PM, the NHA said they do not currently have a facility Social Worker. The NHA confirmed R12 did not have a legal spokesperson and was no longer able to communicate her needs and wants daily. The NHA said the former facility Social Worker took paperwork to the courthouse for guardianship and informed the family. The NHA said the family did not follow through. A request was made for the documents and the follow up of when the family did not complete the forms. The NHA was not able to locate any documentation of attempts to obtain a legal responsible party for R12.

Based on observations, interview, and record review, the facility failed to provide ADL care per the current plan of care, and/or implement a plan of care for dining, for 2 Residents (R12 and R15), resulting in them not receiving routine showers and assistance required with eating. Findings include: Review of R12's face sheet, no date revealed she was a [AGE] year-old female admitted to the facility on [DATE] and diagnoses that included: cerebral infarction (stroke), aphasia (disorder that affects communication), hemiplegia (muscle impairment on one side of the body), and congestive heart failure. No legal decision maker was named. Review of R12's July 2023 Brief Interview of Mental Status (BIMS) score revealed she scored 9/15 (moderately impaired decision making). R12 was observed in the facility main dining room (MDR) on 10/1/23 at 11:52 AM. R12 was seated at a table with 2 other residents that required feeding assistance. There were 17 residents in the MDR at that time that required some assistance with set up and eating. During R12's time in the MDR for lunch there were between 1-3 staff assisting 17 residents. At times there was only one staff in the room. 2 different staff assisted R12 for about 5 minutes or less with eating. They only physically assisted her eat a few times each. They did cue her to eat. When she fed herself, she was slow and had poor coordination. When she was asked if she wanted food, she generally nodded her head yes. She never responded no. There were times she did not respond. After 45 minutes and less than 10 minutes of assistance R12 ate less than 25% of the food she was provided. Review of R12's weights revealed her last weight was done on 8/7/23 and she weighed 129.5 pounds. She was no longer having weights done because she was in hospice care. Review of R12's ADL (activities of daily living) care plan dated 7/26/22 revealed, an approach dated 8/23/23 for, Eating status: 1:1 feed. During an interview with the Dietary Manager (DM) H and the Director of Nursing (DON) on 10/3/23 at 10:45 AM, they were unable to find any daily food intake records and said they expected staff to document R12's daily food intake in the medical record. Observations that R12 was only receiving intermittent assistance during lunch on 10/1/23 was shared and they said they will look into it. Review of R12's ADL care plan dated 7/26/23 revealed R12's bathing/showering needs were not addressed. During an interview with Certified Nurse Aide (CNA) E on 10/2/23 at 11:25 AM, CNA E said she assisted the Residents with showers. CNA E was aware R12 was a hospice resident. CNA E said she had not been asked to assist with R12's showers and was not aware of what care hospice was providing. During an interview with the Director of Nursing (DON) on 10/2/23 at 11:30 AM, the DON was not able to locate any records that verified facility staff were providing showers for R12. The DON was able to locate some records from hospice indicating the hospice aide was doing some bed baths but R12 was refusing to have her hair washed. The DON was not able to find any documentation that the facility was following up on R12's refusals to have her hair washed. Review of the hospice company records that were faxed to the facility on [DATE] at 2:43 PM, revealed a hospice aide provided services for R12 on 9/19/23 and 9/22/23. The services provided were, partial bed bath, dressing, incontinence care and nail care. R12 was documented as refusing a shampoo on both dates. R15 Review of R15's face sheet, no date revealed she was an [AGE] year-old female admitted to the facility on [DATE] had diagnoses that included schizoaffective disorder, chronic respiratory failure, chronic kidney disease, difficulty in walking, and dementia with behavioral disturbances. R15 had a court appointed guardian. R15 was observed in bed on 10/1/23 at 9:26 AM. R15's hair appeared to be very greasy. R15 was in a hospital gown and had ice water and a carton of milk on her bedside table next to her. R15 was not able to say if she ate breakfast or if she needed any care. R15 was observed on 10/2/23 at 8:21 AM in bed receiving her medications. After R15 took her medications, the nurse set up R15's breakfast and handed her the milk carton with a straw and the nurse walked out of the room. R15 was observed in the facility main dining room (MDR) on 10/1/23 at 11:52 AM. R15's tray was set up and she attempted to feed herself independently with a spoon. She had poor coordination and was very slow. After 45 minutes staff did not offer her physical assistance and she had eaten less than 25 % of her food. She did not respond to questions on whether she was hungry or what food she liked. Review of R15's care plan, dated 12/21/20 revealed, Alteration in ADL's (activities of daily living) -self-care deficit r/t (related to) confusion - needs cues/assist to initiate and complete tasks, r/t anxiety, r/t impaired balance with transitions, r/t weakness. The approach dated 12/21/20 for eating revealed, Status of eating ability: set up and supervision, to be sitting up in w/c for all meals. Review of R15's weights revealed she weight 187.5 on 6/15/23 and 181.5 on 7/13/23 and 172.5 on 8/7/23. R15 was on hospice now and did not have any weights documented after 8/7/23. During an interview with the Dietary Manager (DM) H and the Director of Nursing (DON) on 10/3/23 at 10:45 AM, they were unable to find any daily food intake records and said they expected staff to document R15's daily food intake in the medical record. Observations that R15 was in bed daily at breakfast and not being assisted when food was present was shared with DM H and DON. They reported they would look into it. During an interview with Certified Nurse Aide (CNA) E on 10/2/23 at 11:25 AM, CNA E said she assisted residents with showers. CNA E said she did not assist R15 with any showers. CNA E was aware R15 was in hospice care but was not aware of what care hospice was providing. Review of R15's facility hospice book revealed a note for 9/22/23 at 5:30 PM, Care visit, Resident down eating supper upon arrival. Facility staff - CNA said she would do cares when she lays her down in a little while. There was no indication the facility staff did a bed bath or shower. Review of R15's facility hospice book revealed several handwritten notes from hospice staff. The last note in the book was dated 9/29/23 at 7:30 PM, signed by a hospice aide, Care visit - Resident was laying down in bed when I got here. Bed bath and hair wash was given. Review of R15's ADL care plan dated 12/21/23 did not address R15's bathing/showing needs. During an interview with the Director of Nursing (DON) on 10/2/23 at 11:30 AM, the DON was not able to locate any information verifying the facility staff were providing bed baths or showers for R15. The observation of R15's hair being greasy and dirty was shared along with the note that the hospice aide documented she did a bed bath and washed R15's hair on 9/29/23 at 7:30 PM. The DON was not aware of how the hospice aide was doing R15's hair. The DON said she would look into it.

Based on observation, interview, and record review, the facility failed to provide adequate supervision, implementation of meaningful intervention to prevent falls and ensure the fall care plan was followed for 1 Resident (R1), resulting in R1 sustaining multiple falls and the potential for serious injury. Findings include: Review of R1's face sheet, no date revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: Dementia with behavioral disturbance, muscle weakness, lack of coordination, difficulty in walking, and unsteadiness on feet. He was not his own responsible party. Review of the facility timeline of falls revealed R1 had 12 falls from June 4, 2023, to 9/30/23. Most falls were not witnessed, when they were witnessed, staff were too far away to assist in time to prevent the fall. Review of the root cause did not list lack of safety awareness or unsafe transfers. Review of the facility timeline of falls revealed R1's last fall on 9/30/23 at 11:17 AM, R1 was attempting to go to the bathroom and the alarm on the bathroom was not functioning. Review of R1's care plan revealed a care plan dated 9/20/16, Resident can no longer safely care for self at home and requires 24-hour care/supervision and family is unable to provide such. Approaches included: Staff to provide 24-hour care/supervision. Review of R1's ADL (activities of daily living) care plan dated, 4/29/16 revealed, self-care deficit r/t (related to) hydrocephalus s/p (status post) VP (shunt) placement, encephalopathy (brain disease) with impaired cognition/poor safety awareness/impulsivity, altered mental status, disorientation, glaucoma, HOH (hard of hearing) bilaterally, vitamin B deficiency, dysphagia, nystagmus (involuntary eye movements that may blur vision), restlessness/agitation, hx (history) of incontinence, cervical spondylosis, cervical disc degeneration, cervical disc disorder, glaucoma. Approaches did not include amount of assistance needed to use the bathroom or transfers. R1's fall care plan dated 5/9/16 revealed, Resident is at risk for falls and subsequent injury related to: hydrocephalus s/p (status post) VP (shut) placement, encephalopathy (brain disease) with impaired cognition/poor safety awareness/impulsivity, altered mental status, disorientation, glaucoma, HOH (hard of hearing) bilaterally, vitamin B deficiency, dysphagia, nystagmus (involuntary eye movements that may blur vision), restlessness/agitation, hx (history) of incontinence, cervical spondylosis, cervical disc degeneration, cervical disc disorder, glaucoma. Approaches included: Alarm to bathroom door dated 9/7/23, Resident is going to self-transfer, staff should anticipate needs with toileting, redirect when he is fidgety or restless by offering him coffee or snacks, helping him to bed when he is tired and when in bed place wheelchair with brakes locked near bed so when he does self-transfer he can reach for his chair and reduce risk of him falling. During an interview with the Director of Nursing (DON) on 10/3/23 at 8:38 AM, the facility falls timeline was reviewed. The timeline did not include root cause statement. The incident reports were not all complete with the root cause statements and the root cause statements that were listed did not include that R1 was impulsive and had unsafe transfers. The DON did not have documentation or evidence showing that the facility had done a sleep study or any kind of assessments for toileting patterns. The DON could not provide any information as to how staff were to anticipate R1's needs. Interventions included short term increased supervision and no rational for when 1:1 and 15 minutes checks were stopped without putting in place any direct supervision when R1 was awake.

Based on observations, interviews, and record review the facility failed to adequately assess and monitor 3 Residents (R12, R15 and R18) nutritional status and needs, resulting in R15 and R18 resident experiencing weight loss and the potential for R12 to have weight loss. Findings included: Review of R12's face sheet, no date revealed she was a [AGE] year-old female admitted to the facility on [DATE] and diagnoses that included: cerebral infarction (stroke), aphasia (disorder that affects communication), hemiplegia (muscle impairment on one side of the body), and congestive heart failure. No legal decision maker was named. Review of R12's July 2023 Brief Interview of Mental Status (BIMS) score revealed she scored 9/15 (moderately impaired decision making). R12 was observed in the facility main dining room (MDR) on 10/1/23 at 11:52 AM. R12 was seated at a table with 2 other residents that required feeding assistance. There were 17 residents in the MDR at that time that required some assistance with set up and eating. During R12's time in the MDR for lunch there were between 1-3 staff assisting 17 residents. At times there was only one staff in the room. 2 different staff assisted R12 for about 5 minutes or less with eating. They only physically assisted her eat a few times each. They did cue her to eat. When she fed herself, she was slow and had poor coordination. When she was asked if she wanted food, she generally nodded her head yes. She never responded no. There were times she did not respond. After 45 minutes and less than 10 minutes of assistance R12 ate less than 25% of the food she was provided. Review of R12's weights revealed she her last weight was done on 8/7/23 and she weighted 129.5 pounds. She was no longer having weights done because she was in hospice care. Review of R12's ADL (activities of daily living) care plan dated 7/26/22 revealed, an approach dated 8/23/23 for, Eating status: 1:1 feed. During an interview with the Dietary Manager (DM) H and the Director of Nursing (DON) on 10/3/23 at 10:45 AM, they were unable to find any daily food intake records and said they expected staff to document R12's daily food intake in the medical record. Observations that R12 was only receiving intermittent assistance during lunch on 10/1/23 was shared and they said they will look into it. R15 Review of R15's face sheet, no date revealed she was an [AGE] year-old female admitted to the facility on [DATE] had diagnoses that included schizoaffective disorder, chronic respiratory failure, chronic kidney disease, difficulty in walking, and dementia with behavioral disturbances. R15 had a court appointed guardian. R15 was observed in bed on 10/1/23 at 9:26 AM. R15 was in a hospital gown and had ice water and a carton of milk on her bedside table next to her. R15 was not able to say if she ate breakfast or if she needed any care. R15 was observed in the facility main dining room (MDR) on 10/1/23 at 11:52 AM. R15's tray was set up and she attempted to feed herself independently with a spoon. She had poor coordination and was very slow. After 45 minutes staff did not offer her physical assistance and she had eaten less than 25 % of her food. She did not respond to if she was hungry or what food she liked. R15 was observed on 10/2/23 at 8:21 AM in bed receiving her medications. After R15 took her medications, the nurse set up R15's breakfast and handed her the milk carton with a straw and then walked out of the room. Review of R15's care plan, dated 12/21/20 revealed, Alteration in ADL's (activities of daily living) -self care deficit r/t (related to) confusion - needs cues/assist to initiate and complete tasks, r/t anxiety, r/t impaired balance with transitions, r/t weakness. The approach dated 12/21/20 for eating revealed, Status of eating ability: set up and supervision, to be sitting up in w/c for all meals. Review of R15's weights revealed she weighed 187.5 on 6/15/23 and 181.5 on 7/13/23 and 172.5 on 8/7/23. R15 was on hospice now and did not have any weights documented after 8/7/23. During an interview with the Dietary Manager (DM) H and the Director of Nursing (DON) on 10/3/23 at 10:45 AM, they were unable to find any daily food intake records and said they expected staff to document R15's daily food intake in the medical record. Observations that R15 was in bed daily at breakfast and not being assisted when food was present was shared. They reported they would look into it. R18 Review of R18's face sheet, no date revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: dementia, weakness, wheelchair dependent, dysphagia (difficulty swallowing) and cognitive communication deficit. She had a court appointed guardian. R18 was observed in bed on 10/1/23 at 9:25 AM. R18 was asked about breakfast, and she said she had not eaten but would order breakfast soon. No food was observed in the room. R18 was observed in the facility main dining room (MDR) on 10/1/23 at 11:52 AM and was assisted for less than 5 minutes eating after having the tray in front of her for more than 45 minutes. R18 only ate a few bits of food. Review of R18 weight revealed she weighed 191 pounds on July 10, 2023, 183 pounds on 8/7/23 and 172 pounds on 9/7/23. Review of R18's nutritional progress note dated 9/11/23 revealed she lost 10 % of her weight in 180 days and 6 % in 30 days. Mighty shakes were added twice a day to help prevent further weight loss. The plan was to monitor weights, offer alternate food choices when she ate less than 75% of the food offered. There was no indication of any assessment for need of assistance with eating. Review of R18's ADL (activities of daily living) care plan dated 1/16/17 revealed she required set up assistance to eat. The intervention was also dated 1/6/17. During an interview with the Dietary Manager (DM) H and the Director of Nursing (DON) on 10/3/23 at 10:45 AM, they were unable to find any daily food intake records and said they expected staff to document R18's daily food intake in the medical record. Observations that R18 was being left in bed and reporting she still wanted to eat and not eating were shared. The DM H and DON were not able to verify the last time someone assessed R18's ability to feed herself, and they were not able to verify that an assessment was done. They were not sure what foods R18 ate best or liked. They said they would evaluate her nutritional likes and needs for assistance.

Based on interview and record review, the facility failed to ensure all pharmacy recommendations were received and acted on for 2 residents (R11 and R26) reviewed for medication reviews. This deficient practice resulted in R11 and R26 having pharmacy recommendations that were not communicated to the facility and not acknowledged by the physician for suggested changes to be made. Findings include: R11 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R11 admitted to the facility on [DATE] with diagnosis of (but not limited to) congestive heart failure, high blood pressure, kidney failure and diabetes. Brief Interview for Mental Status (BIMS) reflected a score of 13 out of 15 which represented R11 was cognitively intact. R11 required extensive staff assistance of 1-2 with all activities of daily living. Record review of R11's monthly medication regime review reflected that the pharmacy reviewed the medications regime on 8/14/23 and indicated that recommendations were made. A records request was made for all pharmacy recommendations from 8/11/23 to current. The facility provided 2 documents dated 9/13/23 and 9/17/23. There was no recommendation provided for 8/14/23 made available for review. During an interview and record review on 10/3/23 at 1:55 PM, the Director of Nursing (DON) stated she was unaware of any recommendations made on 8/14/23 and the facility did not have a copy of them. The DON was able to obtain a copy of the 8/14/23 pharmacy recommendation report and provided it for review approximately 3:00 PM on 10/3/23. The report reflected, (Name of R11) receives three or more CNS (central nervous system) active medications which can cause an increased risk for falls and fractures: Lorazepam (antianxiety), Buspirone (antianxiety), Escitalopram (antidepressant), Aripiprazole (antipsychotic), Hydrocodone/Acetaminophen (narcotic pain reliever), bupropion (antidepressant). Recommendation: Please reevaluate this combination and reduce the dose of lorazepam to 0.5 mg in the morning and 1 mg at night, with the end goal of discontinuation . There were no signatures on the form and no evidence the recommendation was reviewed by the physician nor acted upon. R26 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R26 admitted to the facility on [DATE]/23 with diagnosis of (but not limited to) liver disease, kidney failure, high blood pressure, and abnormal posture. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which represented R26 was cognitively intact. R26 required extensive staff assistance of 1-2 with all activities of daily living. Record review of R26's monthly pharmacy medication reviews reflected that the pharmacy reviewed the medications on 4/4/23 and 6/6/23 and indicated that recommendations were made to the facility and physician. A records request was made for all pharmacy recommendations from 3/28/23 to current. There were no reviews provided for 4/4/23 or 6/6/23. On 10/3/23 at approximately 3:30 PM, the DON obtained a copy from the pharmacy and provided a copy of the 4/4/23 and 6/6/23 pharmacy recommendations for review. The recommendations were unsigned by the DON and the physician.

Based on observation, interview, and record review, the facility failed to provide collaborative hospice care for 2 Residents (R12 and R15), resulting in the potential for services and needs to be unmet. Findings included: Review of R12's face sheet, undated, revealed R12 was a [AGE] year-old female admitted to the facility on [DATE] and diagnoses that included: cerebral infarction (stroke), aphasia (disorder that affects communication), hemiplegia (muscle impairment on one side of the body), and congestive heart failure. No legal decision maker was named. Review of R12's July 2023 Brief Interview of Mental Status (BIMS) score revealed she scored 9/15 (moderately impaired decision making). During an interview with Certified Nurse Aide (CNA) E on 10/2/23 at 11:25 AM, CNA E revealed R12 had a notebook at the nurse's station that should contain information on R12's hospice schedule, what the services were and when hospice planned to provide the services. R12's book had a schedule for October 2023 in the front of the book that indicated the caregiver was scheduled to come every Tuesday and Friday during October at an unknown time. The licensed nurse was schedule to come on Thursdays. There were a few handwritten notes from the hospice social worker and Chaplin in the book. There was no indication what services the hospice caregiver had been providing or when the care was provided. CNA E said she assist other residents with showers in the facility but she does not assist R12 nor had she been approached by R12's hospice to assist with any showers. During an interview with the Director of Nursing (DON) on 10/2/23 at 11:30 AM, the DON revealed the information that showed when and what services the hospice caregiver had been providing for R12 was not in the hospice book. The DON said she would have to call hospice as they do not document in the facility record. The DON provided hospice records for R12 that had been faxed from the hospice company to the facility on [DATE] at 2:43 PM, that contained a total of 38 pages. The records were from the hospice electronic record, and you were not able to be filtered by the service being provided. The review revealed a hospice aide provided services for R12 on 9/19/23 and 9/22/23. The services provided were, partial bed bath, dressing, incontinence care and nail care. R12 was documented as refusing a shampoo on both dates. The DON was not able to find any facility documentation that they were aware of R12's refusal for a shampoo or documentation that the facility was providing a shower and shampooing of R12's hair. The DON was not able to locate any documentation showing the facility was meeting or collaborating with R12's care with hospice. R15 Review of R15's face sheet, undated, revealed she was an [AGE] year-old female admitted to the facility on [DATE] had diagnoses that included Schizoaffective disorder, chronic respiratory failure, chronic kidney disease, difficulty in walking, and dementia with behavioral disturbances. R15 had a court appointed guardian. R15 was observed in bed on 10/1/23 at 9:26 AM. R15's hair appeared to be very greasy. R15 was in a hospital gown and had ice water and a carton of milk on her bedside table next to her. R15 was not able to say if she ate breakfast or if she needed any care. During an interview with Certified Nurse Aide (CNA) E on 10/2/23 at 11:25 AM, she revealed R15 had a notebook at the nurse's station that should contain information on R15's hospice schedule and what services and when hospice planned to provide the services. R15's book did not contain any schedule or information on when R15's hospice aide was expected to arrive or what care they planned to provide. CNA E' said she assists the facility residents with showers but she had not been providing any showers for R15 and that hospice had not approached her to assist with showers. Review of R15's facility hospice book revealed several handwritten notes from hospice staff. The last note in the book was dated 9/29/23 at 7:30 PM, signed by a hospice aide, Care visit - Resident was laying down in bed when I got here. Bed bath and hair wash was given. No skin concerns. Bed linens changed. And trash emptied at the end of visit. There was no indication the facility staff assisted or were aware of the services provided. Review of R15's facility hospice book revealed a note for 9/22/23 at 5:30 PM, Care visit, Resident down eating supper upon arrival. Facility staff - CNA said she would do cares when she lays her down in a little while. She was content and eating. There was no indication that the hospice aide provided any care on that day. It appeared that the care the hospice aide was going to do was now going to be done by facility staff due to R15 eating at her normal scheduled time. Review of R15's care plan revealed a care plan for, Resident has DX (diagnosis) of Alzheimer Dementia and has elected to receive Hospice services, dated 6/19/23. Approaches included: Facility staff will assist hospice staff as needed during visits, Facility to continue to conduct routine duties including ADL's (activities of daily living), administration of medication (s), social services support, dietary management, and activities, ect. These approaches all indicated the hospice aide was involved in this service. There were no specific care areas identified for the hospice aide. There was no indication if R15 preferred a bed bath or a shower. There was no indication how often R15 preferred a bed bath or a shower. During an interview with the Director of Nursing (DON) on 10/2/23 at 11:30 AM, the facility hospice book was reviewed, and no schedule was located for when hospice staff were going to provide service for R15 this month. There were handwritten notes that indicated the hospice aide had been providing bed baths and washing R15's hair. The Surveyor reported that R15's hair appeared greasy and dirty. The Surveyor asked who was overseeing R15's hospice care and who was directing them on washing her hair. The DON said hospice staff are to communicate with the facility staff at the time of services. The DON was not able to locate any information that verified hospice staff and facilities staff communicate on the dates of service. There was no indication how the hospice staff were washing R15's hair. The DON was going to check with hospice to see when care was planned and how the staff were washing R15's hair.

This citation has two Deficient Practice Statements (DPS) DPS A This citation pertains to Intake MI00126689 Based on observation, interview and record review, the facility failed to plan and implement comprehensive medical care for a one Resident (R12), resulting in a decline in physical and mental well-being, pain, and the potential for all facility residents to not receive quality care. Findings: Review of the Electronic Medical Record (EMR) reflected R12 originally admitted to the facility 2/23/23 with diagnoses that included End Stage Renal Disease and Respiratory Failure. Review of the Minimum Data Set (MDS) dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 13 which indicated mild cognitive impairment. Section E of this MDS reflected R12 did not exhibit any behaviors or refusal of care. Section G reflected the Resident required extensive assist of two staff for bed mobility. The documentation of Section M of the MDS reflected R12 was at risk for pressure sores but did not present with any unhealed pressure sores or other skin impairment. On 5/4/23 at 10:38 AM an observation and interview were conducted with R12 in her room. R12 was observed to be in a low bed. The over-the-bed table was out of reach of the Resident as was the television remote control and a grabber device. An oxygen concentrator was running with a nasal cannula and tubing attached, but the oxygen tubing and cannula were draped over the oxygen concentrator out of reach of R12. R12 indicated she had wounds. Review of the EMR reflected R12 was readmitted to the facility from the hospital on 4/21/23. Review of the Re-admit skin assessment dated [DATE] at 4:00 PM was reviewed. The documentation identified pink on the sacrum/coccyx and excoriation of the groin and labia majora. The documentation did not reveal any open areas were identified. The documentation of the assessment did not reflect any immediate measures or Care Plan changes had been implemented to address the findings or the status of R12. The facility document titled Event Report with an Event Date of 4/24/23 at 3:34 PM was reviewed. The documentation reflected two open areas were noted by prior shift on 4/24/23. One area of skin identified was on the right coccyx that measured 1.01 x 1.02 (cm) and the second open area of skin noted was on the left anal area that measured 0.5 (cm). The documentation reflected the Medical Provider was informed and treatment orders obtained. The MDS dated [DATE] was reviewed. Section E of the MDS reflected R12 did not exhibit any behaviors or rejection of care like the documentation of 2/23/23. However, Section M of the MDS reflected R12 now had a Stage 2 pressure sore and Moisture Associated Skin Damage (MASD). Review of this same Event Report dated 4/24/23 reflected added documentation on 5/4/23 at 12:39 PM by the Director of Nursing (DON). The Event Report reflected a Root cause analysis which the DON attributed the Open area (singular) to the Resident being Recently hospitalized although R12 had returned without open areas of skin three days prior (4/21/23) to the Event. The Event Report did not reflect that impaired skin had been identified and documented on 4/21/23 or that no additional measures or monitoring had been implemented at that time. The DON's documentation reflected that the open area of skin resulted because R12 became increasingly incontinent and refuses to reposition at times due to pain. Open area obtained due to this. However, no documentation of refusals to reposition was found documented in the EMR prior to the afternoon of 4/24/23 since return from the hospital or that the DON had addressed the pain that allegedly caused an open area of skin to develop. The documentation by the DON reflected staff were continuing to educate (R12) with emphasis on importance of reposition although no documentation was found that R12 received this education. Review of the Care Plan for R12 reflected that Incontinence and Pain were last reviewed 2/23/23 and not following the recent re-admission from the hospital on 4/21/23. Past or present Care Plans did not reveal intervention had been formulated to address alleged refusals to reposition. Furthermore, no new Care Plan had been formulated for the treatment of two actual open areas identified 4/24/23. Additional EMR inaccuracies included the weekly Skin Body Assessments dated 4/27/23 at 2:08 PM and 5/4/23 at 4:12 PM. Both assessments reflected that No Areas of Skin Impairment were identified by the nurse although R12 was receiving treatment for wounds. Review of the EMR document titled Wound Management reflected a search screen of both healed and active wounds present or identified. The search criteria included, abrasions, skin tears, five types of ulcers, and other from 4/4/23 to 5/4/23 but the search results reflected no wounds that match your search criteria. Review of the EMR Progress Notes reflected documentation on 4/24/23 at 4:14 PM that R12 stated she just doesn't want to do it anymore because it hurts. The documentation reflected R12 the nurse offered Hospice or palliative care. When R12 returned from the hospital on 4/21/23 the facility identified concerns of a resident at risk but failed to formulate and implement measures to prevent or monitor a decline to include skin, incontinence, and pain. The facility also failed to accurately document the status of R12 through accurate skin assessments and wound history. The Risk Cause Analysis completed by the DON on 5/4/23 assigned identified concerns to the actions and disposition of R12. The Risk Cause Analysis failed to identify standard of care measures that were not implemented and that the system in place failed to ensure a compromised resident was afforded quality care to reach the highest well-being practicable. 37573 This citation pertains to intakes M100126209, M100131367, M100131531, M100131824 DPS B Based on observation, interview and record review, the facility failed to follow policies and procedures to meet the needs of the resident for answering call lights, follow physician orders, assess the resident, implement the care plan, and resolve grievances for 1(Resident #16) and all residents who attend Resident Council, resulting in a resident being left soiled for a long period of time causing skin break down and violating her rights to be treated with respect and dignity, and resolve call light concerns that can impede resident cares. Findings include: Resident #16 (R16) Review of a Face Sheet revealed R16 admitted to the facility on [DATE] with pertinent diagnoses of cerebral infarction (stroke), hemiplegia and hemiparesis (one sided weakness), and morbid obesity. Review of the Minimum Data Set (MDS) dated [DATE] for R16 revealed she is cognitively intact and requires extensive assistance of one staff for toileting and extensive assistance of 2 staff for transfers. She has limited range of motion on her upper and lower extremities on one side of her body. She is not on a toileting schedule and is always incontinent of bowel and bladder. Review of Resident Council Minutes dated 2/28/23 revealed: Old Business: expressed some shifts are better than others. They don't answer the call light when needed at times. New Business: Residents expressed the call light don't get answered when needed. Review of Resident Council Minutes dated 3/29/23 revealed: Old Business: No improvement with call lights being answered. Review of Resident Council Minutes dated 4/28/23 revealed: Old Business: we are still having problems with the call lights (3 Residents) expresses that the light stays going off often and is not pleased. During an observation on 5/4/23 at 10:32 AM, the call light was on in room [ROOM NUMBER] for R16. At 10:42 AM, Certified Nursing Assistant (CNA) S answered the call light and was overheard telling the resident who was sitting up in her recliner with a Physical Therapist (PT) standing next to, that her Aide was still on break and turned off the call light. The resident asked CNA S if she can at least get back in bed. The resident was assisted back to bed. In an interview on 5/4/23 at 10:45 AM, R16 was in bed and no staff were in her room. This surveyor asked the resident if her needs were met, and she said she needed to have her brief changed and has been waiting quite a while for care. At this time there were three nurses observed at the nurses' station and CNA S was observed in the hallway passing waters out to residents in their rooms. During an observation on 5/4/23 at 10:47 AM, two CNAs were observed coming back from break and walked down the hall past room [ROOM NUMBER] to another resident's room. The call light was on, and a staff member turned the call light off without meeting R16's needs. During an observation on 10/4/23 at 10:56 AM, the call light was back on in room [ROOM NUMBER] for R16 and Registered Nurse (RN) U was standing in the hallway near the nurses' station then walked past room [ROOM NUMBER] to the medication cart at the end of the hall. Two more call lights came on and CNA S continued to pass water. During an observation at 11:30 AM, R16 was in her room and CNA S was providing incontinence care for bowel and bladder for the resident. When the CNA left the room, the resident was laying flat on the bed crooked and reported she had been waiting for incontinence care since 10:00 AM that morning. R16 reported the staff kept telling her they needed a sit to stand to get her to bed and was glad that the therapist was there to help assist the resident back to bed. When asked if she had any skin breakdown, she reported that she had some redness and was sore and reported she had worn briefs that were too small for her but this day she is wearing the correct size. The resident reported she did not like the way it makes her feel to be left soiled for a lengthy period of time and having stool being in contact with her skin for so long makes it burn and irritated. Review of the Plan of Care (POC) charting in April 2023 for R16 revealed there are several days the resident was not documented as being toileted and several days the resident was provided incontinence care only once a day. Review of Physician Orders dated 2/22/22 for R16 revealed an order for weekly skin assessments on Tuesdays and to document findings under observations. Review of Physician Orders dated 4/19/23 for R16 revealed an order to apply barrier cream to the perineal area/buttocks every shift and with brief changes. Review of the Observations list documented in the electronic medical records revealed at the time of this survey, the last Skin Assessment was done on 4/18/23. Review of a Skin assessment dated [DATE] for R16 revealed she had a skin impairment on her left upper leg brief rub that is reddened, and the resident reported the area is sore but not opened. A treatment is in place. Review of a Care Plan for R16 revealed she has alterations in her activities of daily living (ADL) dated 10/25/19 and her brief is to be checked and changed every 2 hours and as needed. Review of the incontinence care plan dated 11/21/19 Resident will not exhibit skin breakdown, UTI (urinary tract infection), impaired social interaction or lowered self esteem secondary to incontinence. She is to wear extra-large briefs, be provided incontinence care after each incontinence episode, apply moisture barrier product to peri area, and report any signs of skin breakdown. In an interview on 5/5/23 at 10:39 AM, the Director of Nursing (DON) reported she expected call lights to be answered in a timely manner and no staff should say that is not my resident. The resident needs come first, and no staff should be sitting at the desk when call lights are on. The DON reported the needs of the resident should be met before turning the call light off. The DON is aware of the need for staffing education. Review of a policy titled Resident Rights last updated 9/2022 revealed: It is the policy of this facility to ensure residents have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside of this facility. c. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences, except when to do so would endanger the health or safety of the resident or other residents. Review of an Activities of Daily Living (ADLs)/Maintain Abilities policy dated 3/2023 revealed: It is the policy of the facility to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff, across all shifts and departments, understand the principles of quality of life, and honor and support these principles for each resident; and that the care and services provided are person centered, and honor and support each resident's preferences, choices, values and beliefs. Review of a policy titled Standards of Nursing Practices last reviewed 1/2022 revealed: Call Light Response: Staff will respond to residents' request for assistance by answering call lights within a reasonable amount of time. It is considered that a reasonable period to arrive to the residents' request for assistance is no longer than a 10-minute period of time. It is understood that response time may be delayed due to emergency events, unplanned urgent resident occurrences in which could cause a delay in responses.

Based on observation, interview, and record review, the facility failed to provide staffing levels to meet the needs of 4 resident's (Resident #1, Resident #21, Resident #26, and Resident #18), resulting in (a) Resident #1 laying in feces and urine for hours and not being repositioned, (b) Resident #21 being left in the same position in a wheelchair for multiple hours at a time and redeveloping a previously healed pressure area on the left buttock, (c) R26 being left soiled for extended periods of time and delays in staff availability to transfer R26 in or out of bed, and (d) Resident #18 sitting in a urine soaked brief and staff not responding to the residents needs for an extended period of time. All of which resulting in embarrassment, humiliation and the inability to meet their highest practicable well being. Findings: Review of a Resident Bed List Report dated 10/03/22, listed 23 of the 38 resident's in the facility required 2 person assist for transferring in and out of bed. Review of a facility Bed Board report dated 10/03/22 reflected 4 residents that required total assist from 1 staff person for all meals. The same report reflected that an additional 4 residents required set-up assistance from staff for meals and another 3 residents required cueing from staff for meals. Resident #1(R1) Review of a Face Sheet revealed R1 was a [AGE] year old female, last admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 10/03/22 at 10:30 AM, R1's Family Members (FM) R and S stated that the facility did not have enough staff and they are very upset because they were told that R1 had been left in feces smeared up her back for several hours on 10/02/22. During an interview on 10/03/22 at 10:50 AM, employee T confirmed that the facility has been very short staffed and verified that R1 had in fact been left sitting in fecal matter for several hours on 10/02/22. During an observation on 10/04/22 at 7:58 AM, R1 laid in bed positioned with 2 pillows under her right back and shoulder area, the head of the bed up 30 degrees, laying on her left side, covered with a blanket and in a hospital gown. During an observation on 10/04/22 at 8:46 AM, R1 laid in bed positioned with 2 pillows under her right back and shoulder area, laying on her left side, the head of the bed up 30 degrees, covered with a blanket and in a hospital gown. During an observation on 10/04/22 at 9:55 AM, R1 laid in bed positioned with 2 pillows under her right back and shoulder area, laying on her left side, the head of the bed up 30 degrees, covered with a blanket and in a hospital gown. R1's brief had not yet been checked nor changed by staff as of 7:58 AM. During an observation on 10/04/22 at 10:21 AM, R1 laid in bed positioned with 2 pillows under her right back and shoulder area, laying on her left side, the head of the bed up 30 degrees, covered with a blanket and in a hospital gown. R1's brief had not yet been checked nor changed by staff as of 7:58 AM. During an observation on 10/04/22 at 10:59 AM, R1 laid in bed positioned with 2 pillows under her right back and shoulder area, laying on her left side, the head of the bed up 30 degrees, covered with a blanket and in a hospital gown. R1's brief had not yet been checked nor changed by staff since prior to the first observation this morning at 07:58 AM. During an observation on 10/04/22 at 12:04 PM, R1 laid in bed positioned with 2 pillows under her right back and shoulder area, laying on her left side, the head of the bed up 30 degrees, covered with a blanket and in a hospital gown. R1's brief had not yet been checked nor changed by staff since prior to the first observation this morning at 07:58 AM. During an observation on 10/04/22 at 1:57 PM, staff entered R1's room to provide peri-care and change resident's brief. The brief was completely saturated in urine, the bed sheet was saturated with urine, and employee U indicated that R1 was a heavy wetter. Resident #21 Review of a Face Sheet revealed R21 was an [AGE] year old female, last admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R21 was dependent on staff for all activities of daily living, including repositioning whether lying or seated. During an observation on 10/03/22 at 9:34 AM, R1 sat in a wheelchair, eyes closed and leaning to the left. The hoyer strap was between R1 and the wheelchair. R1 had been taken to the dining room for lunch and then returned to the room and left seated in the wheelchair. During an observation on 10/03/22 at 1:40 PM, R1 sat in a wheelchair, eyes closed, the hoyer strap between R1 and the wheelchair, and leaning to the left. During an observation on 10/04/22 at 8:44 AM, R1 sat in a wheelchair in her room, eyes closed, leaning to the left, legs crossed at the ankles, right over left, and the hoyer strap between the resident and the wheelchair. During an observations on 10/04/22 at 10:20 AM and 10:57 AM, R1 sat in a wheelchair in her room, eyes closed, leaning to the left, legs crossed at the ankles, right over left, and the hoyer strap between the resident and the wheelchair. No fluids could be located in R1's room. During an observation on 10/04/22 at 12:08 PM, R1 sat in a wheelchair, in the dining room, ankles crossed, eyed closed, and leaning to the left while staff fed R1. During an observation on 10/04/22 at 1:03 PM, R1 sat in a wheelchair back in her room, eyes closed, leaning to the left, legs crossed at the ankles, right over left, and the hoyer strap between the resident and the wheelchair. During an interview on 10/04/22 at 1:20 PM, employee U entered R1's room to provide care. Employee U stated that staff have been instructed to not put resident's back to bed after meals and then back up again because there is not enough staff to get everyone in and out of bed. They said they can't do that here. During an observation on 10/05/22 at 9:25 AM, R1 returned to her room after breakfast, sat in a wheelchair, eyes closed, leaning to the left, and ankles crossed right over left. Review of an inter-disciplinary team note for R1, dated 09/29/22, reflected, in part, meeting to review open area noted on left medial buttock on 9/29/22. Area measures 2cm (centimeters) x .6 cm and was previously scabbed. A stage 2 pressure injury was identified on 07/27/22 and healed per wound PA (physician assistant) progress note on 09/21/22. Resident #26 (R26) Review of a facility Face Sheet reflected R26 admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) admission assessment dated [DATE] indicated R26 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15/15, required extensive assistance from two people for bed mobility, was totally dependent on two people for transfers and required extensive assistance from one person for dressing, toilet use and personal hygiene. Review of a Care Plan initiated on 8/24/2022 indicated R26 had an Alteration in ADL (Activities of Daily Living) related to non-weight bearing, related to [CONDITION(S)], related to pain, related to potential for communication deficit related to slurred speech related to SP (Suprapubic) catheter. The goal of the care plan was for R26 to remain clean and well groomed daily with R26's preferences honored to the extent possible. The care plan indicated R26 required the assistance for a full mechanical lift and the assistance of two people. During an interview on 10/03/22 at 2:05 PM, R26 reported that there isn't enough staff and said Nurse aides should be nurse aides. R26 said the aides will leave the unit and go help with kitchen and dining and then nothing gets done on the halls until 2:00 PM after lunch. According to R26, once you sit in a chair, you can expect to stay there for quite a while because there isn't enough help to complete transfers. R26 also alleged she sat in a soiled brief all weekend over the past weekend when only two people were working the unit where she lived. R26 reported that she thought that not having enough staff was a way for the facility to save money. During an observation on 10/03/22 at 2:19 PM, R26 activated her call light. Certified Nurse Aide (CNA) I went into R26's room and turned off light before meeting R26's request for assistance. CNA I was then observed getting a second person to assist with the Hoyer lift but then went into a room across the hall to assist another resident instead of R26. During an interview on 10/03/22 at 2:26 PM, The Nursing Home Administrator (NHA) was asked about R26's allegation of being left in a soiled brief for 3 days. The NHA said she just heard about the allegation today and did not have an incident report available yet and was starting an investigation. According to the NHA, staffing on the weekends was short. During a follow-up interview on 10/3/2022 at 2:35 PM, R26 said she finds herself waiting for second person (to assist with transfers) all the time. R26 said she often waits for two hours, Sometimes they come into the room and say that they can't take care of you, other people are more important and that makes you feel awful. Something has to be done. Resident #18 (R18) Review of a facility Face Sheet reflected R18 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment dated [DATE] reflected R18 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 13/15 and needed extensive assistance from one person for bed mobility, dressing and toilet use. R18 required extensive assistance from two people for transfers and was totally dependent on one person for personal hygiene. During an interview on 10/3/2022 at 11;18 AM, R18 reported Things are not going well and indicated it takes a long time for staff to come and assist her. R18's call light was observed on the floor and out of reach at this time. During a follow-up interview on 10/4/2022 at 11:06 AM, R18 was visibly uncomfortable, grimacing and shifting in bed. R18 said she had urinated, and it was very uncomfortable. R18 said staff do not come often enough to assist her. Resident Council Minutes Review of facility resident council meeting for the past 6 months revealed the following staffing concerns: April 2022 .no improvement in the call lights being answered timely .snacks are not being offered in the evening. May 2022 .call lights are not being answered promptly .snacks are not being offered in the evenings. June 2022 . no improvement in the call lights being answered in a timely manner .July 2022 call lights are not being answered promptly .condiments are not being offered at meals (ketchup, butter, mustard) .August 2022 .condiments are not being offered to resident's at meal times .September 2022 .snacks in the evening are not offered and given only if requested.

Based on interview and record review, the facility failed to prevent falls for 2 residents (Resident #1 and Resident #3) when care planned interventions were not implemented, resulting in the 1.) The potential for serious injury when Resident #3 was transferred incorrectly 2.) Cervical Spine (neck) fracture after Resident #1 fell from her bed onto the floor when care planned interventions were not in place. Findings: Review of a facility policy Fall Prevention and Management Policy revised 1/2022 reflected the purpose of the policy was to Assess resident risk for falls and implement interventions to reduce the incidence of falls and/or to mitigate the risk of injury related to falls. The policy included directives related to actions taken at the time of the fall and post fall event evaluation to include identification of contributing factors. Resident #1 (R1) Review of a facility Face Sheet reflected R1 admitted to the facility in 2018 with diagnoses that included dementia, depression, anxiety, [CONDITION(S)], [CONDITION(S)], a history of a stroke, diabetes and was receiving Hospice services. Review of a significant change Minimum Data Set (MDS) dated [DATE] reflected R1 had short- and long-term memory problems and had severely impaired cognitive skills for daily decision making, was totally dependent on two people for transfers and needed extensive assistance from one person for bed mobility, dressing, toilet use and personal hygiene. Review of a Care Plan initiated 1/7/2018 reflected R1 was At risk for falls and subsequent injury related to dementia and toxic [CONDITION(S)] with impaired cognition impacting on safety awareness, weakness/impaired balance, high blood pressure, [CONDITION(S)], history of falls, diabetes type 2 with [CONDITION(S)], limited mobility and receives antidepressant/diabetic/[CONDITION(S)] medications. The goal of the care plan was to prevent or reduce the occurrence of falls and subsequent injury related to falls. Approaches to reach the goal of the care plan included Body pillow to edge of bed to enhance resident ability to identify the edge of the bed initiated on 4/21/2020. Review of Progress Notes from 8/11/22 reflected that at approximately 3:15 PM, R1 was discovered on the floor in her room bleeding from a nickel sized bump and abrasion on her head after an apparent fall out of bed. According to the notes, R1 was sent to the hospital for evaluation. R1 returned from the hospital at approximately 8:30 PM, however the hospital did not call a report to the nurse indicating the hospital course of treatment. Review of a hospital After Visit Summary reflected that R1 was evaluated after a fall and was diagnosed with a Closed head injury, initial encounter and Closed nondisplaced fracture of posterior arch of first cervical vertebra, initial encounter. Review of a CT Cervical Spine wo (without) Contrast obtained on 8/11/22 at the hospital reflected R1 was found to have a nondisplaced fractures involving the left anterior and left posterior arches of C1 (first cervical vertebra). Review of a facility Event Report dated 8/11/22 reflected R1 had an unwitnessed fall out of bed. Physical assessment findings reflected R1 had moderate pain and a contusion and laceration to the top of her forehead with painful Range of Motion (ROM) to her right upper extremity. The report indicated that possible contributing factors to the fall included body pillow was against the wall instead of on the outside edge of bed. Evaluation Notes included in the event report reflected Fall event that occurred on 8/11/22 reviewed by IDT (interdisciplinary team). Information obtained for event report, nurse progress notes, staff interviews, POC (point of care) charting, and direct observations. (R1) received care from hospice aide that afternoon. Staff nurse observed (R1) resting in bed positioned supine with HOB (head of bed) slightly elevated at 1330 (1:30 PM). Hospice aide departed room at 1345 (1:45 PM). Facility CNA (Certified Nurse Aide) reported to nurse that (R1) was on the floor at 1515 (3:15 PM). (R1) was assessed for injury and then resident was assisted back to bed via Hoyer lift to further assess. Daughter/guardian notified, and she arrived at the facility shortly thereafter. (R1) was transferred to the ED (Emergency Department) for further evaluation. A CT (computed tomography) scan at the hospital identified a nondisplaced fracture of C1 vertebrae. Root-cause analysis determined fall to be related to an intervention being placed incorrectly. (R1) has care plan intervention to place body pillow on outside edge of bed. The body pillow was against the wall side of bed. Immediate intervention was to add an additional pillow to have one pillow outer edge of bed and another pillow against wall. Resident #3 Review of a Face Sheet reflected R3 admitted to the facility with diagnoses that included dementia, high blood pressure, a history of stroke, was dependent on a wheelchair, muscle weakness, abnormal posture, chronic pain, unsteadiness on feet and age-related [CONDITION(S)] without current pathological fracture. An MDS assessment dated [DATE] reflected R3 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 3/15 and needed extensive assistance from two people for transfers. Review of a Care Plan initiated on 1/16/2017 reflected R3 was At risk for falls and subsequent injury related to dementia with impaired cognition/variable forgetfulness, generalized weakness, high blood pressure, [CONDITION(S)], urinary frequency, incontinence, [CONDITION(S)] with fluctuating [CONDITION(S)], history of [CONDITION(S)] (stroke) x2 without residual effects, non-ambulatory, limited mobility, and receives high blood pressure medication, diuretic medication and is diagnosed with [CONDITION(S)]. The goal of the care plan was to prevent or reduce the occurrence of falls and subsequent injury related to falls. Interventions to reach the goal of the care plan included: Transfer Status: 2 assist stand and pivot. Review of a Progress Note dated 8/29/22 at 8:30 AM reflected Staff alerted this nurse that she was need in resident's room as she was sitting on the floor. When observed resident she was sitting on buttocks on floor facing her door in front of her WC (Wheelchair). BLE (Bilateral lower extremities) extended out in front of her. Right arm was resting on bed, left arm resting on WC. Gait belt was on in proper position, grippy socks were applied. Resident in good spirits asking for help to get up. ROM (Range of motion) on all extremities without noted pain. No outward turning of the legs. Resident assisted back into WC using gait belt and 2 staff assist. DON (Director of Nursing), son (name of son .said he would contact sister), and Administrator all informed. Staff educated on the importance of using care guides daily. During an interview on 8/31/22 at 1:42 PM, CNA I reported she was caring for R3 the morning of 8/29/22 when she fell . CNA I said she had gotten R3 ready for the day and needed help transferring her and went looking for her third shift partner but couldn't find her. CNA I asked CNA K where the other nurse aide was but did not specifically ask CNA K to assist with the transfer. CNA I decided to transfer the resident by herself. CNA I said she knew that R3 was a two person assist for transfers but that she usually did pretty well without a second person and felt pretty confident R3 could stand and pivot to the wheelchair. CNA I said she had R3 sit at the side of the bed, positioned her wheelchair diagonal to the bed, stood R3 up and that is when R3's feet slid out from under her. CNA I let R3 slide down her leg to the floor and at that same time CNA K walked into R3's room to see if she needed help.

Based on observation, interview, and record review, the facility failed to promote the healing of pressure sores for 1 (#4) of 3 sampled residents reviewed for pressure sores, from a total sample of 10 residents, resulting in the worsening of pressure sores. Findings include: Review of Resident #4's medical record revealed a [AGE] year old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. His minimum data set ((MDS) dated [DATE] indicated he was severely cognitively impaired. Review of Resident #4's entire medical record could not locate an assessment of his for developing pressure sores (Braden Assessment). During an interview with the facility Director of Nursing (DON) "B", and Regional Utilization Director (RUD) "F" on 10/1/14 at 3:10 pm, DON "B" and RUD "F" stated there was no Braden Assessment in Resident 4's record and that one must not have been completed. Review of Resident #4's physician order's revealed an order dated 9/25/14 for a Braden scale to be done weekly for 4 weeks after admission. An physician's orders [REDACTED]. A physician's orders [REDACTED]. Review of Resident #4's "Initial Care Plan - 21 Day Care Plan", provided to the surveyor by DON "B", revealed he had been identified to be at risk for pressure sores with a goal to prevent/heal pressure sores and interventions listed to include bridge heels, monitor daily, protective boots, position every two hours on side. The problem and interventions were dated 9/24/14. Review of Certified Nurse Aide (CNA) care guide for Resident #4 revealed he was to have pressure relieving boots on when in bed. There were no other pressure sore interventions listed on Resident #4's CNA care guide. During an observation on 10/2/14 at 2:30 pm, the surveyor and DON "B" eDuring observations on 10/1/14 at 11:15 am, 11:50 am, 12:20 pm, and 1:20 pm, Resident #4 was observed to be sitting in his room in his wheelchair with his feet resting on the floor or on the foot pedals of his wheelchair with socks only on his feet. During observations on 10/2/14 at 11:00 am, 11:30 am, 12:15 pm, 1:00 pm, Resident #4 was observed sitting in his room in his wheelchair with his feet resting on the floor or the foot pedals of his wheelchair with socks only on his feet. ntered Resident #4's room and observed Resident #4 in bed with the bottom of both of Resident #4's feet resting firmly on the footboard of his bed. Resident #4 did not have his pressure reducing boots on and the boots were observed to be in a bedside chair at the end of his bed. DON "B" stated Resident #4 was supposed to have his heels floated, his pressure reducing boots on and absolutely was not supposed to have his feet against the footboard of the bed. During an observation of a dressing change of Resident #4's wounds with Licensed Practical Nurse (LPN) "H", on 10/2/14 at 12:15 pm, the surveyor asked Resident #4 if the wounds were painful and Resident #4 nodded yes. Review of facility "skin condition report for non-pressure sore skin conditions" for Resident #4, provided to the surveyor when the surveyor requested documentation on Resident #4's pressure sores, revealed one dated 9/24/14 with a location listed as right back ankle which measured 3 cm centimeters (cm) by 1.2 centimeter and on 9/26/14 measured 2.5 cm by 1 centimeter. During an observation on 10/2/14 at 2:30 pm, the surveyor observed DON "B" measure the right back ankle wound with a resulting measurement of 3.6 cm by 2 cm. Review of facility "skin condition report for non-pressure sore skin conditions" for Resident #4's right lateral heel listed measurements for the wound on 9/24/14 to be 4 cm by 1.6 cm and on 9/26/14 to be 3 cm by 2 cm. During an observation on on 10/2/14 at 2:30 pm, the surveyor observed DON "B" measure the right lateral heel wound with a resulting measurement of 3.2 cm by 2 cm. Review of facility "skin condition report for non-pressure sore skin conditions" for Resident #4's right lateral heel listed measurements for the wound on 9/26/14 to be 2.5 cm by 2.5 cm. During an observation on 10/2/14 at 2:30 pm, the surveyor observed DON "B" measure the right lateral heel wound with a resulting measurement of 3 cm by 2.5 cm. While DON "B" was obtaining measurements of Resident #4's wounds on 10/2/14 at 2:30 pm, Resident #4 sat partially up in his bed, had facial grimacing, and shook his hand at DON "B". DON "B" apologized to Resident #4, reassured him, stated she was almost done, and told the surveyor it was probably painful for Resident #4. The National Pressure Ulcer Advisory Panel (<http://www.npuap.org/resources/educational-and-clinical-resources/pressure-ulcer-prevention-points/>) reflected "Use devices that eliminate pressure on the heels. For short-term use with cooperative patients, place pillows under the calf to raise the heels off the bed. Place heel suspension boots for long-term use." #

This Citation pertains to intake numbers MI 802. Based on interview and record review, the facility failed to: 1.) thoroughly investigate and report to the State Agency three confirmed incidents of narcotic tampering and diversion in 3 of 7 sampled residents (#2, #4, and #1) reviewed for controlled substance diversion ([MEDICATION NAME] - opioid pain medication), from a total of 11 sampled residents, resulting in an Immediate Jeopardy when, on 3/13/14 three (3) bottles of [MEDICATION NAME] was discovered to have been tampered with, facility staffs did not test or remove the additional bottles of [MEDICATION NAME] from the medication carts that were to be administered, facility staffs did not determine if any of residents had been affected by the drug diversion, and no investigation was done to determine if there was continued diversion of controlled substances (bottle of various pills found in Resident #10's bed). This deficient practice placed all residents receiving [MEDICATION NAME], to have the potential for harm due to untreated or minimally treated pain due to drug diversion/tampering and/or serious harm or death due to receiving altered medications. Findings include: Review of the facility "Abuse and Neglect Procedure" revised 1/2014, revealed, "...investigate, document and report suspicions, allegations, and/or substantiated cases of resident abuse, neglect, mistreatment, misappropriation of property...to the state agencies...ensure that the facility Administrator reports to the appropriate State Agency...immediately or within 24 hours...Reporting is mandatory and is not contingent upon substantiation but rather is based on ANY allegation..." Resident #2 Review of the Resident Admission Record, undated, revealed Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses, Acute [MEDICAL CONDITIONS] Disorder, Idiopathic [MEDICAL CONDITION] Fibrosis (lung disease). Resident #2 had a Brief Interview of Memory Score (BIMS) of 13/15 according the Minimum Data Set (MDS), dated [DATE]. Review of a written statement from Registered Nurse (RN) "F", dated 3/13/14, revealed Resident #2's "[MEDICATION NAME] bottle was over by at least 5 ml (milliliters) ...The original opened bottle from 2/17(14) which should have had only 22 mls in it was full ...Also (Resident # 4's) [MEDICATION NAME] bottle was opened and had never been given. There is no reason to open a bottle unless we plan to give it (it measured 30 ml (full))." Resident #4 Review of the Resident Admission Record, undated, revealed Resident #4 was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #4 had a BIMS of moderately impaired. Resident #1 Review of the Resident Admission Record, undated, revealed Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses, Adult failure to thrive, pressure ulcer, shoulder pain and history of [MEDICAL CONDITION]. Resident #1 had a Brief Interview of Memory Score (BIMS) of 3/15 according the Minimum Data Set (MDA) dated 2/8/14. Review of a written statement dated 3/13/14 revealed Licensed Practical Nurse (LPN) "G" observed a bottle of [MEDICATION NAME] solution for (Resident #1) which was a different color and that the solution which had not been used had been opened. In an interview on 5/2/14 at 12:15 p.m., Regional Nurse Consultant (RNC) "B" stated that on 3/13/14 two staff nurses reported that there was a discrepancy in the amount of [MEDICATION NAME] in bottles as well as a bottle of [MEDICATION NAME] was a different color. RNC "B" stated, "We did have suspicion that the bottles were being tampered with". When asked if there was a policy and/or procedure put into place at that time to prevent further tampering and/or diversion, RNC "B" stated, "No, there was not". When asked if there was anything put into place to ensure the safety of the residents, RNC "B" stated, "we called the police". When asked what the facility did to ensure the safety of the residents during the police investigation, RNC "B" stated she called the facility's Pharmacy Consultant (PC), but did not receive any guidance on how to further protect the residents from medication tampering or diversion. RNC "B" was asked, if during the police investigation, and after contacting the PC, was a policy or procedure put into place to ensure the safety of the residents. The RNC stated, "No." Review of an untitled document dated 4/7/14 and signed by RNC " B " , revealed, " I received a phone (call) from (RN " I " ) ...she stated to me that she was the person who was diverting the [MEDICATION NAME] from the residents ...Police notified ...Pharmacy notified " . Review of the document failed to reveal that notification was made to the Facility ' s Medical Director or the Residents ' Physicians. In an interview on 5/2/14 at 10:15 a.m. when asked if the physician was notified of the medication tampering, Nursing Home Administrator (NHA) "C" answered, "no". Further, NHA "C" stated that on 3/13/14 the police did not take all of the [MEDICATION NAME] that was in the building, only took the bottles that belonged to Residents #1, #2, and #4. Review of police department "Reporting Officer Narrative" dated 3/13/14, revealed, "... (RN "F") noticed that the prescription bottle of [MEDICATION NAME] for one of her patients appeared to be too full because she had already given that patient part of a bottle. (RN "F") checked the other extra unopened bottle and found that the bottle had been opened and it shouldn't have been...she noticed that (the) bottles had been switched between the boxes they were in because the serial numbers didn't match. Each bottle and box have matching serial numbers. She also noticed that the bottles were off color and consistency as [MEDICATION NAME] has a bit more consistency then water and that the bottles appeared to be diluted... (LPN "G") who advised that she had her [MEDICATION NAME] sulfate also tampered with...one bottle should have never been open and that she found it opened and that the both bottles appeared diluted...Both (RN "F" and LPN "G") advised that this must have occurred sometime Wednesday 3-12-14..." Review of police department "Case Supplemental Report" dated 4/8/14, revealed, "(police officer) called (RN "I") and asked if she wanted to make a statement regarding the theft of [MEDICATION NAME](RN "I") explained to (police officer) that she had been to the Health Professionals Recovery Program on two different occasions...she previously worked at (a facility)...she resigned her position after being suspected of diverting narcotics from patients...(RN "I") said she then worked for a (prison) and was fired for diverting [MEDICATION NAME] (a controlled medication used for pain control)...(RN "I") said she then began working for (the facility)...in January 2014 and began to take [MEDICATION NAME] that she was suppose to be giving to the patients and taking it herself. (RN "I") said she would not take the [MEDICATION NAME] every day, but some of the days she worked she would remove the [MEDICATION NAME] from its container and replace it with either water of saline...(RN "I) said that she would give the diluted mixture to the patients..." Review of an e-mail from Pharmacy Consultant (PC) "E" to the current Nursing Home Administrator, NHA "C" dated 3/13/14, revealed that guidance on how to further protect the residents was supplied to the facility. PC "E" documented, "...I also attached a controlled drug policy from years past. It contains some information you may find useful. I would inform the nurses that they need to open all containers and verify that the contents have not been tampered with when receiving the medications and when doing shift change counts. Areas of concern are: [MEDICATION NAME]es, [MEDICATION NAME] vials, [MEDICATION NAME] solution, [MEDICATION NAME] sulfate solution, and oxyfast solution. For example, I have seen unopened boxes of [MEDICATION NAME] contain only four patches (should have 5), and found out the nurse glued the box shut after removing a patch. I have also had the ([MEDICATION NAME]) returned to the pharmacy without its tamper proof foil intact ...Please let me know what you find, and let me know if you have any questions or concerns that I could address". During the course of the survey, the facility failed to provide an updated policy and/or procedure pertaining to preventing further tampering and/or diversion from taking place. The facility also failed to provide evidence that the PC's areas of concerns were addressed, and that staff were educated on these areas of concerns. In an interview on 5/2/14 at 11:15 a.m. with the facility NHA (Administrator at the time of the drug tampering) the Surveyor ( ) asked the NHA what did he do to ensure residents in the facility were getting [MEDICATION NAME] (un-tampered) NHA stated he did not make any changes or instruct the staff to make changes. The NHA stated, "We will take that cite". During a telephone interview on 5-1-14 at 11:55 a.m., PC "E" reported he was aware of [MEDICATION NAME] tampering/diversion in the facility in March of 2013. The Surveyor asked the PC if there was any possible harm to residents receiving tampered [MEDICATION NAME] and the PC said Residents could get the wrong dose resulting in poor pain control, loss of consciousness and even death if the resident received a stronger dose than normal. The surveyor asked what would cause the [MEDICATION NAME] to change color and the PC said he was not sure, but did say that adding water or saline solution would not change the color of the [MEDICATION NAME]. Resident #10 Review of Nurse's Notes dated 04/21/2014 at 8:24 a.m., revealed, "While making res' (Resident #10)'s bed, (Certified Nursing Assistant) found pill bottle of various pills inside. Appropriate management staff notified, pills disposed of appropriately. Review of Resident #10's medical record failed to reveal that there was any type of investigation into the medications being found. In an interview on 5/9/14 at 1:53 p.m., Nursing Home Administrator (NHA) "C" stated, "There was no investigation" concerning the pills that were found in Resident #10's bed. On 5/8/14 the Administrator was notified of the Immediate Jeopardy that was identified on 5/2/14 and began on 3/13/14 when three (3) bottles of [MEDICATION NAME] was discovered to have been tampered with, facility staffs did not test or remove the additional bottles of [MEDICATION NAME] from the medication carts that were to be administered, facility staffs did not determine if any of residents had been affected by the drug diversion, and no investigation was done to determine if there was continued diversion of controlled substances (bottle of various pills found in Resident #10's bed). On 5/13/14, this Surveyor verified that the facility implemented the following to remove the Immediate Jeopardy: 1. On 5/9/13, the Director of Nursing and Regional Clinical Nurse reviewed all residents receiving a controlled substance for pain management to ensure that their pain medication was working adequately. All residents assessed were shown to have their pain controlled. 2. On 5/9/4, the Director of Nursing and Regional Clinical Nurse reviewed the Medication Administration Records along with the narcotic count sheets to ensure that the order was followed and the documentation was accurate along with the narcotic count sheet. 3. On 5/8/14, the controlled substances were inspected by the Administrator and Director of Nursing to ensure no tampering had occurred. 4. On 5/6/14, the Vice President of Clinical Compliance re-educated the Administrator and Director of Nursing on State & Federal Abuse Reporting Guidelines, time frame of immediate and no later than 24 hours. 5. On 5/8/14 and 5/9/14, the Director of Nursing and Regional Clinical Nurse educated all Licensed nurses the use and implementation of a monitoring tool that will require 2 Licensed Nurses to complete with each beginning and end of every shift. 6. On 5/9/14, the Regional Clinical Nurse provided the Director of Nursing with education and implementation of an additional monitoring tool. 7. Beginning 5/9/14, The Director of Nursing or Licensed Nurse Designee will complete a daily inspection of the Controlled Substances for 30 days of consistent compliance, then weekly for 2 months to ensure tampering control measures are in place and staff demonstrate knowledge of new and revised policy and protocols. 8. Beginning 5/9/14, The Consulting pharmacist will complete a monthly inspection of the controlled substances to ensure tampering is identified timely and verification that the narcotic count is correct. Results will be reviewed with the Director of Nursing following each visit. Findings from Director of Nursing reviews and Pharmacy visits will be presented to Quality Assurance and Performance Improvement committee monthly for next 3 months of consistent compliance. Although the Immediate Jeopardy was removed on 5/9/14, the facility remained out of compliance at a scope of pattern and severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due the fact that all facility staff had not yet been educated and sustained compliance had not yet been verified by the State Agency. ( )

This Citation pertains to intake numbers MI 802. Based on interview and record review, the facility failed to have safeguards and systems in place to control, account for and periodically reconcile controlled medications (Roxanol and Fentanyl) to effectively prevent the diversion/tampering of controlled medications, resulting in the Immediate Jeopardy when, beginning 3/13/14 three bottles of Roxanol appeared to be tampered and diluted. This deficient practice resulted in the potential for continued diversion and use of altered controlled substances and for inadequate pain control for the residents receiving controlled pain medication and/or serious harm or death due to receiving altered medications and inappropriate dosing. Findings include: Review of a written statement from Registered Nurse (RN) "F", dated 3/13/14, revealed Resident #2's "Roxanol bottle was over by at least 5 ml (milliliters) ...The original opened bottle from 2/17(14) which should have had only 22 mls in it was full ...Also (Resident # 4's) Roxanol bottle was opened and had never been given. There is no reason to open a bottle unless we plan to give it (it measured 30 ml (full)). Review of a written statement dated 3/13/14 revealed Licensed Practical Nurse (LPN) "G" observed a bottle of Roxanol solution for (Resident #1) which was a different color and that the solution which had not been used had been opened. Review of police department "Reporting Officer Narrative" dated 3/13/14, revealed, "... (RN "F") noticed that the prescription bottle of morphine for one of her patients appeared to be too full because she had already given that patient part of a bottle. (RN "F") checked the other extra unopened bottle and found that the bottle had been opened and it shouldn't have ben...she noticed that (the) bottles had been switched between the boxes they were in because the serial numbers didn't match. Each bottle and box have matching serial numbers. She also noticed that the bottles were off color and consistency as well...Roxanol has a bit more consistency then water and that the bottles appeared to be diluted... (LPN "G") who advised that she had her morphine sulfate also tampered with...one bottle should have never been open and that she found it opened and that the both bottles appeared diluted...Both (RN "F" and LPN "G") advised that this must have occurred sometime Wednesday 3-12-14..." Review of police department "Case Supplemental Report" dated 4/8/14, revealed, "(police officer) called (RN "I") and asked if she wanted to make a statement regarding the theft of Roxanol...(RN "I") explained to (police officer) that she had been to the Health Professionals Recovery Program on two different occasions...she previously worked at (a facility)...she resigned her position after being suspected of diverting narcotics from patients...(RN "I") said she then worked for a (prison) as was fired for diverting Dilaudid (a controlled medication used for pain control)... (RN "I") said she then began working for (the facility)...in January 2014 and began to take Roxanol that she was suppose to be giving to the patients and taking it herself. (RN "I") said she would not take the Roxanol every day, but some of the days she worked she would remove the Roxanol from its container and replace it with either water of saline...(RN "I) said that she would give the diluted mixture to the patients..." Review of an untitled document dated 4/7/14 and signed by Regional Nurse Consultant (RNC) "B", revealed, "I received a phone (call) from (RN " I " ) ...she stated to me that she was the person who was diverting the Roxanol from the residents ...Police notified ...Pharmacy notified". Review of the document failed to reveal that notification was made to the Facility's Medical Director or the Residents' Physicians. In an interview on 5/2/14 at 12:15 p.m., Regional Nurse Consultant (RNC) "B" stated that on 3/13/14 two staff nurses reported that there was a discrepancy in the amount of Roxanol in bottles as well as a bottle of Roxanol was a different color. RNC "B" stated, "We did have suspicion that the bottles were being tampered with". When asked if there was a policy and/or procedure put into place at that time to prevent further tampering and/or diversion, RNC "B" stated, "No, there was not". When asked if there was anything put into place to ensure the safety of the residents, RNC "B" stated, "we called the police". When asked what the facility did to ensure the safety of the residents during the police investigation, RNC "B" stated she called the facility's Pharmacy Consultant (PC), but did not receive any guidance on how to further protect the residents from medication tampering or diversion. RNC "B" was asked, if during the police investigation, and after contacting the PC, was a policy or procedure put into place to ensure the safety of the residents. The RNC stated, "No." Review of an e-mail from the PC "E" to the current Nursing Home Administrator, NHA "C" dated 3/13/14, revealed that guidance on how to further protect the residents was indeed supplied to the facility, "...I also attached a controlled drug policy from years past. It contains some information you may find useful. I would inform the nurses that they need to open all containers and verify that the contents have not been tampered with when receiving the medications and when doing shift change counts. Areas of concern are: Duragesic patches, Ativan vials, Ativan solution, morphine sulfate solution, and oxyfast solution. For example, I have seen unopened boxes of Duragesic contain only four patches (should have 5), and found out the nurse glued the box shut after removing a patch. I have also had the (Roxanol) returned to the pharmacy without its tamper proof foil intact ...Please let me know what you find, and let me know if you have any questions or concerns that I could address". The facility failed to provide an updated policy and/or procedure pertaining to preventing further tampering and/or diversion from taking place. The facility also failed to provide evidence that the PC's areas of concerns were addressed, and that staff were educated on these areas of concerns. During a telephone interview on 5-1-14 at 11:55 a.m. PC "E" said he was aware of Roxanol tampering/diversion in the facility in March of 2013. The Surveyor asked the PC if there was any possible harm to residents receiving tampered Roxanol and the PC said Residents could get the wrong dose resulting in poor pain control, loss of consciousness and even death if the resident received a stronger dose than normal. The surveyor asked what would cause the Roxanol to change color and the PC said he was not sure, but did say that adding water or saline solution would not change the color of the Roxanol. On 5/8/14 the Administrator was notified of the Immediate Jeopardy that was identified on 5/2/14 and began on 3/13/14 when beginning 3/13/14 three bottles of Roxanol appeared to be tampered and diluted. On 5/13/14, this Surveyor verified that the facility implemented the following to remove the Immediate Jeopardy: 1. On 5/9/13, the Director of Nursing and Regional Clinical Nurse reviewed all residents receiving a controlled substance for pain management to ensure that their pain medication was working adequately. All residents assessed were shown to have their pain controlled. 2. On 5/9/4, the Director of Nursing and Regional Clinical Nurse reviewed the Medication Administration Records along with the narcotic count sheets to ensure that the order was followed and the documentation was accurate along with the narcotic count sheet. 3. On 5/8/14, the controlled substances were inspected by the Administrator and Director of Nursing to ensure no tampering had occurred. 4. On 5/6/14, the Vice President of Clinical Compliance re-educated the Administrator and Director of Nursing on State & Federal Abuse Reporting Guidelines, time frame of immediate and no later than 24 hours. 5. On 5/8/14 and 5/9/14, the Director of Nursing and Regional Clinical Nurse educated all Licensed nurses the use and implementation of a monitoring tool that will require 2 Licensed Nurses to complete with each beginning and end of every shift. 6. On 5/9/14, the Regional Clinical Nurse provided the Director of Nursing with education and implementation of an additional monitoring tool. 7. Beginning 5/9/14, The Director of Nursing or Licensed Nurse Designee will complete a daily inspection of the Controlled Substances for 30 days of consistent compliance, then weekly for 2 months to ensure tampering control measures are in place and staff demonstrate knowledge of new and revised policy and protocols. 8. Beginning 5/9/14, The Consulting pharmacist will complete a monthly inspection of the controlled substances to ensure tampering is identified timely and verification that the narcotic count is correct. Results will be reviewed with the Director of Nursing following each visit. Findings from Director of Nursing reviews and Pharmacy visits will be presented to Quality Assurance and Performance Improvement committee monthly for next 3 months of consistent compliance. Although the Immediate Jeopardy was removed on 5/9/14, the facility remained out of compliance at a scope of pattern and severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due the fact that all facility staff had not yet been educated and sustained compliance had not yet been verified by the State Agency. ( )

This citation pertains to intake MI 545, MI 545. Based on interview, and record review, the facility failed to follow up with physician's orders 1 of 3 sampled residents (#101), reviewed for injuries, from a total sample of 3 residents, resulting in a delay in treatment for [REDACTED]. Findings include: Review of Resident #101's medical record revealed a [AGE] year old male who was admitted to the facility on [DATE] and re-admitted to the facility on [DATE] and passed away on 11/10/13. The [DIAGNOSES REDACTED]. His minimum data set ((MDS) dated [DATE] indicated he required limited physical assistance of one person for transfers, ambulation, and dressing. Review of Resident #101's falls care plan dated 11/14/12 indicated he was at risk for falls and subsequent injury related to ...limited mobility, debility, balance/coordination issues, jerking movements at times... Review of Resident #101's activity of daily living care plan dated 3/16/11 revealed he had a self care deficit related to impaired cognitive status with [DIAGNOSES REDACTED].. Review of nurse's note for Resident #101 dated 10/31/13 at 5:04 am revealed Resident #101 had been awake most of the night with tremors, very weak, could not stand up due to legs being very wobbly. A facility incident report for Resident #101, dated 11/1/13 at 7:00 am indicated Resident #101 complained of discomfort in his right foot with movement and stated he hit it in his wheelchair "yesterday post lunch". The incident report indicated Nurse Practitioner #5 was notified at 8:40 am on 11/1/13 and the section titled, "Additional comments and/or steps taken to prevent recurrence:" indicated to put foot pedals on wheelchair PRN (as needed), when being assisted, when legs weak. The facility incident report section "Person preparing report" is signed by LPN #6 on 11/1/13, signed by the facility Director of Nursing (undated), signed by the facility Medical Director on 11/2/13, and signed by the facility Administrator on 11/2/13. In an interview on 12/2/13 at 10:50 am, CNA (certified nurse aide) #8 stated on 10/31/13 Resident #101 was self propelling his wheelchair in the hall on his way back from lunch, from the dining room to his room. CNA #8 stated as she walked past Resident #101 he asked her (CNA #8) to help him and stated he couldn't push himself. CNA #8 stated she told Resident #101 yes he could, but he insisted he couldn't over and over, so she (CNA #8) just "helped him out" and told him to pick up his feet. CNA #8 stated there were no foot pedals on Resident#101's wheelchair. CNA #8 pushed him almost to the next corner by the nurse's station when Resident #101 dropped his feet to the ground and yelled, "ow my foot", so CNA #8 stated she stopped. CNA #8 stated LPN #6 came around the corner and Resident #101 was holding his right foot saying, "ow my foot". CNA #8 stated LPN #6 told her (CNA #8) she wasn't supposed to be pushing Resident #101 without foot pedals and CNA #8 stated she knew that. CNA #8 stated she then took Resident #101 the rest of the way to his room by pulling him from the front of his wheelchair and put him to bed. CNA #8 stated the next morning she worked first shift and first thing she went in and saw Resident #101's foot was swollen and bruised. CNA #8 stated she was immediately concerned about the incident the day before when he said, "ow my foot" while she was pushing him, because it was the same foot. CNA #8 stated LPN #6 told her with the "situation yesterday, she needed to write a statement, so she did..on a facility form. CNA #8 stated she was given a "Teachable Moment" for pushing Resident #101 without foot pedals. CNA #8 stated a "Teachable Moment" is sort of an education and discipline. CNA #8 stated she gave her written statement to LPN #8 and after she signed the "Teachable Moment" she returned that to LPN #8. In an interview on 12/2/13 at at 10:25 am, LPN #6 stated she was at the nurse's station on the afternoon of 10/31/13 when she heard Resident #101 yell out and it caught her attention. LPN #6 stated when she stood up she observed Resident #101 in his wheelchair and CNA #8 standing behind him with her hands up. LPN #6 stated she asked Resident #101 if he was okay and Resident #101 mumbled he was going back to his room to lay down. LPN #6 stated she couldn't be sure if she saw Resident #101 again until the next morning. LPN #6 stated the day, 11/1/13 around 7:00 she was standing at her medication cart just down the hall from Resident #101's doorway when she heard Resident #101 yelling, "ow, ow, ow". LPN #6 stated she entered Resident #101's room and saw him grabbing his right foot, flailing and yelling, "my foot, my foot". LPN #6 stated Resident #101's right foot was bright red and swollen on the top of his foot, and at that time CNA #10 entered the room, assisted Resident #101 with the urinal and helped elevate his foot on a pillow. LPN #6 stated Resident #101 was yelling stuff about his wheelchair the day before. LPN #6 stated at that point she started filling out an incident report and passing out witness statements and CNA #8 stated to her (LPN #6) "I hope I didn't hurt his foot yesterday with the wheelchair". LPN #6 stated she gave CNA #8 a witness statement form and told her to fill it out, and also had CNA #10 fill out a witness statement form. LPN #6 stated she also filled out a witness statement form along with the incident report, then called Resident #101's Nurse Practitioner, obtained an order for [REDACTED].#2) at the nurse's station that morning. In an interview on 12/3/13 at 12:40 pm, CNA #7 stated on 10/31/13 during first shift she was assigned to Resident #101. CNA #7 stated after lunch CNA #8 reported to her that Resident #101 was having a hard time keeping his feet up while being pushed in his wheelchair and when she (CNA #8) had been pushing Resident #101 back from the dining room his feet were up but they came down and one got caught under the wheel. CNA #7 stated CNA #8 was like "Oh my God", and warned that Resident #101 was having a hard time keeping his feet up, so when she (CNA #7) pushed him to be careful. In an interview on 12/4/13 at 8:30 am, CNA #10 stated on the morning of 11/1/13 she entered Resident #101's room to get him up and noticed his foot was swollen. CNA #10 stated Resident #101 also complained of pain in his foot, so she got the nurse (LPN #6), who said she would get an Xray and then they put Resident #101's foot up on a pillow. CNA #10 stated she filled out a written witness statement and put it on the desk for LPN #6. CNA #10 stated Resident #101 did complain of pain when he used his foot that day, 11/1/13. Nurse's note for Resident #101 dated 11/1/13 at 9:16 am, signed by LPN #6, indicated Resident #101 sat independently at edge of bed and was heard yelling "ow", complained of discomfort to right ankle. The note indicated Resident #101 had redness, [MEDICAL CONDITION], and decreased range of motion at the right ankle with notification of the nurse practitioner and message to Resident #101's sister. The note also indicated Resident #101 was using urinal well, safety device was in place, and he fed himself his morning meal well. Nurse's notes for Resident #101 dated 11/1/13 as a late entry, signed on 11/7/13 at 4:48 pm by LPN #6, indicated LPN #6 was in the hallway and heard Resident #101 yell "ow" in his room. The note indicated LPN #6 entered Resident #101's room to observe him pushing himself to an upright sitting position in his bed, bilateral feet on the floor. The note indicated Resident #101 yelled, "my foot, ow, ow" and his right foot from the toes to ankle was light red and non-[MEDICAL CONDITION] was present. No bruising was noted, but decreased range of motion. CNA heard him yelling out and entered Resident #101's room, Resident #101 was assisted to bed with his leg elevated with no further complaints of discomfort. Nurse's note for Resident #101 dated 11/1/13 at 8:11 am, as a late entry, signed on 11/7/13 at 4:59 pm, indicated an order was faxed for a stat Xray. A physician order for [REDACTED]. Nurse's note for Resident #101 dated 11/1/13 at 10:00 am, as a late entry, signed on 11/7/13 at 3:05 pm, indicated Resident #101 was resting without complaints or signs or symptoms of pain or discomfort. In an interview on 12/4/13 at 8:45 am, CNA #11 stated she provided regular care for Resident #101, and did help other CNA's provide care for Resident #101 on 11/1/13 after the Xray was ordered, because he became a two person assist with transfers. The surveyor asked CNA #11 if Resident #101 complained of pain in his foot or leg when he transferred out of bed and CNA #11 stated, "Oh yeah". In an interview on 12/4/13 at 9:30 am, RN (Registered Nurse) #4 stated she worked as a nurse with Resident #101 on second shift on 10/31/13 and she did not recall Resident #101 getting out of bed on second shift at all. RN #4 stated she assisted Resident #101 with the urinal and he stayed in bed. In an interview on 12/4/13 at 9:50 am, CNA #12 stated she worked second shift on 10/31/13 with Resident #101. CNA #12 stated Resident #101 was in a lot of pain in his foot that night and did not get out of bed. CNA #12 stated she remembered her son came and went trick or treating, and when she (CNA #12) worked the next night, Resident #101 was still in a lot of pain. Radiology report for Resident #101 dated 11/1/13 (no time) 11/1/13 indicated "stat chest and right ankle and foot Xray" impression to include oblique vertical, slightly displaced recent fracture is seen in the distal shift of the fibula above the level of the ankle (An oblique fracture is a break in a bone that runs diagonally to the bone shaft). Review of written statement by management staff at radiology service used by the facility, dated 12/4/13, revealed an order was received by the radiology service company on 11/1/13 at 9:22 am for an ankle and foot x-ray on Resident #101. The statement indicated the usual phone call from the facility to confirm the radiology service received the stat (immediate) order, was not made, but a phone call was received from the facility at 1:15 pm, and the radiology tech was made aware at 1:35. The statement indicated the radiology tech arrived at the facility and performed the x-rays at 4:04 pm with the exams uploaded on the "server" at 5:00 pm. The statement indicated the x-ray report was confirmed with the facility nurse at 7:08 pm. Nurse's note for Resident #101 dated 11/1/13 at 10:29 pm indicated Xray results received for right ankle show fracture in distal fibula area above the ankle, with results called to physician and order received to send Resident #101 to the emergency room . A physician order for [REDACTED]. Nurse's note for Resident #101 dated 11/2/13 at 2:40 am indicated the ambulance was at the facility to transport Resident #101 to the hospital for evaluation. An ambulance run sheet for Resident #101 dated 11/1/13 indicated Resident #101 left the facility by ambulance en route to the hospital at 11:39 pm. #

This citation pertains to intake MI 545, MI 545. Based on observation, interview and record review, the facility failed to provide assistive devices to ensure safe transportation for 1 (#101) of 3 sampled residents and 1 ("A") nonsampled resident, who were reviewed for safety, from a total sample of 3 residents, resulting in Resident #101 sustaining a fractured right ankle, pain, decreased mobility and level of independence, and the potential for serious injury for nonsampled Resident "A". Findings include: Review of Resident #101's medical record revealed a [AGE] year old male who was admitted to the facility on [DATE] and re-admitted to the facility on [DATE] and passed away on 11/10/2013. The [DIAGNOSES REDACTED]. His minimum data set ((MDS) dated [DATE] indicated he required limited physical assistance of one person for transfers, ambulation, and dressing. Review of Resident #101's falls care plan dated 11/14/12 indicated he was at risk for falls and subsequent injury related to ...limited mobility, debility, balance/coordination issues, jerking movements at times...with interventions listed to include pressure alarms to bed and wheelchair. Review of Resident #101's activity of daily living care plan dated 3/16/11 revealed he had a self care deficit related to impaired cognitive status with [DIAGNOSES REDACTED].. A facility incident report for Resident #101 dated 10/26/13 at 1:30 pm, revealed Resident # 101 was "on the floor, face down, in blood, moving full body erratically and rolling back and forth moaning". The incident report indicated Resident #101 was taken to the hospital. Review of hospital emergency room physician note for Resident #101 dated 10/26/13 at 2:24 pm, revealed Resident #101 was found by nursing staff at the facility and taken to the emergency room by ambulance with a 2 centimeter laceration on his right lateral eyebrow area. The physician note stated Resident #101 "only complained to me of a bit of a sore area on his right forehead." Under the section titled, "Review of systems", the physician note indicated Resident #101 had no other pain complaints. Impression listed was 1. Assessment for fall, 2. 2 centimeter eyebrow laceration, 3. History of [DIAGNOSES REDACTED] (condition characterized by altered brain function and structure). In an interview on 12/3/13 at 10:15 am, LPN (Licensed Practical Nurse) #6 stated she was present when Resident #101 was found on the floor and sent to the hospital 10/26/13. LPN #6 stated she was a regular nurse for Resident #101 on the day shift. The surveyor asked LPN #6 if Resident #101 had shown any signs of distress with his right leg, foot or ankle from 10/26/13 until 10/31/13 and LPN #6 stated "absolutely not". LPN #6 stated between the time Resident #101 returned from the hospital on [DATE] and 10/31/13 Resident #101 had no complaints of foot or ankle pain on the right or left side, and no complaints of having difficulty walking or signs/symptoms of pain or the inability to walk or bear weight on his right foot. Review of nurse's note for Resident #101 dated 10/27/13 at 9:21 am revealed Resident #101 self propelled his wheelchair down to his meal, and care was done with 1 person assisting. Review of nurse's note for Resident #101 dated 10/28/13 at 8:45 pm revealed Resident #101 had no complaints of pain and was up with assistance. Review of nurse's note for Resident#101 dated 10/30/13 at 5:31 pm revealed Resident #101 had no complaints of pain or discomfort. Review of nurse's note for Resident #101 dated 10/31/13 at 5:04 am revealed Resident #101 had been awake most of the night with tremors, very weak, could not stand up due to legs being very wobbly. A facility incident report for Resident #101, dated 11/1/13 at 7:00 am indicated Resident #101 complained of discomfort in his right foot with movement and stated he hit it in his wheelchair "yesterday post lunch". The incident report indicated Nurse Practitioner #5 was notified at 8:40 am on 11/1/13 and the section titled, "Additional comments and/or steps taken to prevent recurrence:" indicated to put foot pedals on wheelchair PRN (as needed), when being assisted, when legs weak. The facility incident report section "Person preparing report" is signed by LPN #6 on 11/1/13, signed by the facility Director of Nursing (undated), signed by the facility Medical Director on 11/2/13, and signed by the facility Administrator on 11/2/13. In an interview on 12/2/13 at 10:50 am, CNA (certified nurse aide) #8 stated on 10/31/13 Resident #101 was self propelling his wheelchair in the hall on his way back from lunch, from the dining room to his room. CNA #8 stated as she walked past Resident #101 he asked her (CNA #8) to help him and stated he couldn't push himself. CNA #8 stated she told Resident #101 yes he could, but he insisted he couldn't over and over, so she (CNA #8) just "helped him out" and told him to pick up his feet. CNA #8 stated there were no foot pedals on Resident#101's wheelchair. CNA #8 pushed him almost to the next corner by the nurse's station when Resident #101 dropped his feet to the ground and yelled, "ow my foot", so CNA #8 stated she stopped. CNA #8 stated LPN #6 came around the corner and Resident #101 was holding his right foot saying, "ow my foot". CNA #8 stated LPN #6 told her (CNA #8) she wasn't supposed to be pushing Resident #101 without foot pedals and CNA #8 stated she knew that. CNA #8 stated she then took Resident #101 the rest of the way to his room by pulling him from the front of his wheelchair and put him to bed. CNA #8 stated the next morning she worked first shift and first thing she went in and saw Resident #101's foot was swollen and bruised. CNA #8 stated she was immediately concerned about the incident the day before when he said, "ow my foot" while she was pushing him, because it was the same foot. CNA #8 stated LPN #6 told her with the situation yesterday, she needed to write a statement, so she did on a facility form. CNA #8 stated she was given a "Teachable Moment" for pushing Resident #101 without foot pedals. CNA #8 stated a "Teachable Moment" is sort of an education and discipline. CNA #8 stated she gave her written statement to LPN #8 and after she signed the "Teachable Moment" she returned that to LPN #8. In an interview on 12/2/13 at at 10:25 am, LPN #6 stated she was at the nurse's station on the afternoon of 10/31/13 when she heard Resident #101 yell out and it caught her attention. LPN #6 stated when she stood up she observed Resident #101 in his wheelchair and CNA #8 standing behind him with her hands up. LPN #6 stated she asked Resident #101 if he was okay and Resident #101 mumbled he was going back to his room to lay down. LPN #6 stated she couldn't be sure if she saw Resident #101 again until the next morning. LPN #6 stated the day, 11/1/13 around 7:00 she was standing at her medication cart just down the hall from Resident #101's doorway when she heard Resident #101 yelling, "ow, ow, ow". LPN #6 stated she entered Resident #101's room and saw him grabbing his right foot, flailing and yelling, "my foot, my foot". LPN #6 stated Resident #101's right foot was bright red and swollen on the top of his foot, and at that time CNA #10 entered the room, assisted Resident #101 with the urinal and helped elevate his foot on a pillow. LPN #6 stated Resident #101 was yelling stuff about his wheelchair the day before. LPN #6 stated at that point she started filling out an incident report and passing out witness statements and CNA #8 stated to her (LPN #6) "I hope I didn't hurt his foot yesterday with the wheelchair". LPN #6 stated she gave CNA #8 a witness statement form and told her to fill it out, and also had CNA #10 fill out a witness statement form. LPN #6 stated she also filled out a witness statement form along with the incident report, then called Resident #101's Nurse Practitioner, obtained an order for [REDACTED]. LPN #6 stated she handed all of the written statements and the incident reports to the facility Director of Nursing (DON #2) at the nurse's station that morning. In an interview on 12/3/13 at 12:40 pm, CNA #7 stated on 10/31/13 during first shift she was assigned to Resident #101. CNA #7 stated after lunch CNA #8 reported to her that Resident #101 was having a hard time keeping his feet up while being pushed in his wheelchair and when she (CNA #8) had been pushing Resident #101 back from the dining room his feet were up but they came down and one got caught under the wheel. CNA #7 stated CNA #8 was like "Oh my God", and warned that Resident #101 was having a hard time keeping his feet up, so when she (CNA #7) pushed him to be careful. In an interview on 12/4/13 at 8:30 am, CNA #10 stated on the morning of 11/1/13 she entered Resident #101's room to get him up and noticed his foot was swollen. CNA #10 stated Resident #101 also complained of pain in his foot, so she got the nurse (LPN #6), who said she would get an Xray and then they put Resident #101's foot up on a pillow. CNA #10 stated she filled out a written witness statement and put it on the desk for LPN #6. CNA #10 stated Resident #101 did complain of pain when he used his foot that day, 11/1/13. Nurse's note for Resident #101 dated 11/1/13 at 9:16 am, signed by LPN #6, indicated Resident #101 sat independently at edge of bed and was heard yelling "ow", complained of discomfort to right ankle. The note indicated Resident #101 had redness, edema, and decreased range of motion at the right ankle with notification of the nurse practitioner and message to Resident #101's sister. The note also indicated Resident #101 was using urinal well, safety device was in place, and he fed himself his morning meal well. Nurse's notes for Resident #101 dated 11/1/13 as a late entry, signed on 11/7/13 at 4:48 pm by LPN #6, indicated LPN #6 was in the hallway and heard Resident #101 yell "ow" in his room. The note indicated LPN #6 entered Resident #101's room to observe him pushing himself to an upright sitting position in his bed, bilateral feet on the floor. The note indicated Resident #101 yelled, "my foot, ow, ow" and his right foot from the toes to ankle was light red and non-pitting edema was present. No bruising was noted, but decreased range of motion. CNA heard him yelling out and entered Resident #101's room, Resident #101 was assisted to bed with his leg elevated with no further complaints of discomfort. Nurse's note for Resident #101 dated 11/1/13 at 8:11 am, as a late entry, signed on 11/7/13 at 4:59 pm, indicated an order was faxed for a stat Xray. A physician order [REDACTED].#6, indicated an order for [REDACTED]. Nurse's note for Resident #101 dated 11/1/13 at 10:00 am, as a late entry, signed on 11/7/13 at 3:05 pm, indicated Resident #101 was resting without complaints or signs or symptoms of pain or discomfort. In an interview on 12/4/13 at 8:45 am, CNA #11 stated she provided regular care for Resident #101 and he had not complained of pain to his foot or ankle or showed signs of trouble with transfers from 10/26/13 until 10/31/13 to her knowledge. CNA #11 stated she did help other CNA's provide care for Resident #101 on 11/1/13 after the Xray was ordered because he became a two person assist with transfers. The surveyor asked CNA #11 if Resident #101 complained of pain in his foot or leg when he transferred out of bed and CNA #11 stated, "Oh yeah". In an interview on 12/4/13 at 9:30 am, RN (Registered Nurse) #4 stated she worked as a nurse with Resident #101 on second shift on 10/31/13 and she did not recall Resident #101 getting out of bed on second shift at all. RN #4 stated she assisted Resident #101 with the urinal and he stayed in bed. In an interview on 12/4/13 at 9:50 am, CNA #12 stated she worked second shift on 10/31/13 with Resident #101. CNA #12 stated Resident #101 was in a lot of pain in his foot that night and did not get out of bed. CNA #12 stated she remembered her son came and went trick or treating, and when she (CNA #12) worked the next night, Resident #101 was still in a lot of pain. Radiology report for Resident #101 dated 11/1/13 (no time) 11/1/13 indicated "stat chest and right ankle and foot Xray" impression to include oblique vertical, slightly displaced recent fracture is seen in the distal shift of the fibula above the level of the ankle (An oblique fracture is a break in a bone that runs diagonally to the bone shaft). Nurse's note for Resident #101 dated 11/1/13 at 10:29 pm indicated Xray results received for right ankle show fracture in distal fibula area above the ankle, with results called to physician and order received to send Resident #101 to the emergency room . A physician order [REDACTED].#14, indicated an order to send Resident #101 to the emergency room for evaluation of a right fibula (bone in the lower leg) fracture. Nurse's note for Resident #101 dated 11/2/13 at 2:40 am indicated at 11:30 pm, the ambulance was at the facility to transport Resident #101 to the hospital for evaluation. Review of medication adminintration record for Resident #101 revealed Tylenol (pain medication) 650 milligrams was given on 11/1/13 at 8:00 am for complaints of right ankle pain. Tylenol 650 milligrams was also given to Resident #101 on 11/6/13 at 1:45 pm for complaints of right lower extremity pain and on 11/6/13 at 6:00 pm for general pain. Tylenol 650 milligrams was also administered to Resident #101 on 11/9/13 for "grimacing and moaning". During an observation on 12/3/13 at 12:05 pm, in the hall near the North nurse's station, the surveyor observed CNA #8 pushing non-sampled Resident "A" in the hall in her wheelchair with no footpedals on the wheelchair while Resident "A" held her feet up. LPN #6 was observed sitting at the North nurse's station and asked CNA #8 where Resident "A"'s footpedals were. CNA #8 stated she didn't know, but would go get them. Occupational therapy note dated 11/6/13 indicated Resident #101 required 2 person maximum assistance with toilet transfers, required a 3 person assist to pull up his pants, and was non-weight bearing on right lower extremity. Review of the facility, "Wheelchair and Stretcher Safety" policy and procedure (undated) provided to the surveyor by DON #2 on 12/3/13, revealed staff are to; "..position the person's feet on the footplates, make sure the person's feet are on the footplates before moving the chair. The person's feet must not touch or drag on the floor when the chair is moving. #

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION FOR ONE OF EIGHT RESIDENTS (#9) REVIEWED FOR BEHAVIORS, OUT OF A TOTAL SAMPLE OF THIRTEEN RESIDENTS, RESULTING IN RESIDENT #9, WHO WAS COGNITIVELY IMPAIRED, ELOPING ON 3/11/12 TO A STORE ADJACENT TO A BUSY FIVE-LANE HIGHWAY, PLACING HER IN IMMEDIATE JEOPARDY TO HER HEALTH AND SAFETY. THE IMMEDIATE JEOPARDY BEGAN AT OR BEFORE 12:30 P.M. ON 3/11/12 AND CONTINUED UNTIL FACILITY STAFF MET THE RESIDENT AT THE STORE WHERE SHE HAD ELOPED TO, AT A TIME NOT SPECIFIED IN THE RECORD, BUT AT OR BEFORE 1:30 P.M. ON 3/11/12, AFTER THE FACILITY RECEIVED A TELEPHONE CALL FROM THE RESIDENT'S FAMILY ALERTING THEM THAT THE RESIDENT HAD ELOPED. THE IMMEDIATE JEOPARDY WAS REMOVED WITH THE FACILITY'S "ABATEMENT PLAN" THAT IDENTIFIED THE "IMMEDIATE INTERVENTIONS IMPLEMENTED ON 3/11/2012 TO PREVENT A REOCCURRENCE". FINDINGS INCLUDE: ACCORDING TO ELECTRONIC PROGRESS NOTES DATED 3/11/12 AT 1:30 PM AND ENTERED BY REGISTERED NURSE "K", RESIDENT #9 "...WALKED ACROSS THE STREET TO (NAME OF STORE) AT AROUND 12:30 PM. SHE USED THE PHONE AT (NAME OF STORE) AND CALLED HER EX-HUSBAND TO PICK HER UP. HER DAUGHTER WAS THERE (I.E., AT THE EX-HUSBAND'S HOME) AND OVERHEARD THE CONVERSATION AND CALLED OUR FACILITY. I (RN "K") RAN OVER TO THE (NAME OF STORE) AND ATTEMPTED TO BRING THE RESIDENT BACK TO THE FACILITY. SHE STATED SHE WAS NOT GOING BACK. HER DAUGHTER, THE GUARDIAN, ARRIVED AND ALSO TRIED TO CONVINCE HER TO GO BACK, BUT SHE WAS RESISTANT. THE DAUGHTER GAVE PERMISSION TO ALLOW THE RESIDENT TO VISIT (NAME OF RELATIVE), WHO IS THE RESIDENT'S DAUGHTER VIA (DAUGHTERS NAME) HUSBAND. THE RESIDENT WAS SIGNED OUT AND BROUGHT TO THE DAUGHTERS HOUSE." THE NOTES DID NOT SPECIFY HOW LONG RESIDENT #9 HAD BEEN ABSENT FROM THE FACILITY BEFORE THE FACILITY WAS MADE AWARE OF HER ABSENCE. THERE WERE NO OTHER NOTES ENTERED FOR THAT DATE; THE NOTE BEFORE THE 3/11/12, 1:30 PM NOTE WAS ENTERED ON 3/10/12 AT 1:46 PM AND THE NOTE AFTER THE 3/11/12, 1:30 PM NOTE WAS ENTERED ON 3/12/12 AT 1:08 AM. ACCORDING TO HANDWRITTEN NOTES OF AN INTERVIEW WITH RESIDENT #9'S DAUGHTER, DOCUMENTED BY THE FACILITY ADMINISTRATOR AND DATED 3/11/12 AT 12:30 (NO INDICATION OF AM OR PM), RESIDENT #9 "PROBABLY GOT THE CODE (TO EXIT THE FACILITY) FROM (NAME OF EX-HUSBAND)." ACCORDING TO THE NOTES, RESIDENT #9'S DAUGHTER SAID THAT RESIDENT #9 HAD DONE A SIMILAR THING AT ANOTHER FACILITY. BASED ON REVIEW OF THE "INCIDENT ACCIDENT REPORT" DATED 3/11/12 AT 12:30 PM, THE DESCRIPTION OF THE EVENTS BY DIRECTOR OF NURSING "L" REFLECTED, "DAUGHTER (NAME) CALLED TODAY TO SAY RESIDENT (#9) AT (NAME OF STORE). RESIDENT (#9) REFUSING TO COME BACK. DAUGHTER DPOA (NAME) SIGNED RESIDENT OUT TO HER DAUGHTER'S (NAME) HOUSE. RETURNED AROUND 5 PM." THE INCIDENT REPORT IDENTIFIED THE TIME OF THE INCIDENT AS 12:30 PM, BUT THE REPORT DID NOT SPECIFY HOW MUCH TIME HAD ELAPSED BETWEEN THE RESIDENT'S LAST KNOWN APPEARANCE AT THE FACILITY AND STAFF'S ARRIVAL AT THE STORE WHERE THE RESIDENT HAD ELOPED TO. ACCORDING TO THE ADMISSION FACE SHEET DATED 4/20/10, RESIDENT #9 WAS A [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE QUARTERLY MDS (MINIMUM DATA SET) assessment dated [DATE] REFLECTED RESIDENT #9'S BRIEF INTERVIEW FOR MENTAL STATUS (BIMS) SCORE WAS ASSESSED AS "4" OUT OF A POSSIBLE "15". THIS SCORE REFLECTED THAT RESIDENT #9'S MENTAL STATUS WAS SEVERELY IMPAIRED. THIS MDS ALSO REFLECTED THAT RESIDENT #9 RECEIVED SUPERVISION FOR WALKING IN THE FACILITY. RESIDENT #9 WAS NOTED TO BE "NOT STEADY, BUT ABLE TO STABILIZE WITHOUT HUMAN ASSISTANCE WHILE MOVING FROM A SEATED TO STANDING POSITION AND SURFACE TO SURFACE TRANSFER (TRANSFER BETWEEN BED AND CHAIR OR WHEELCHAIR)." THE MDS REFLECTED THAT RESIDENT #9 PARTICIPATED IN THE ASSESSMENT. THE MDS ALSO REFLECTED IN THE DISCHARGE PLAN FOR RESIDENT #9 THAT "DISCHARGE TO THE COMMUNITY (WAS) DETERMINED TO BE NOT FEASIBLE." DURING A REVIEW OF FACILITY DOCUMENTS TITLED, "(NAME OF FACILITY) ELOPEMENT RISK ASSESSMENT" FOR DATES 10/14/11 AND 1/7/12, THE STAFF MEMBER COMPLETING THE FORM (LICENSED SOCIAL WORKER "M") HAD RESPONDED IN THE AFFIRMATIVE TO THE FOLLOWING QUESTIONS REGARDING RESIDENT #9'S ELOPEMENT RISK: "1. DOES THE RESIDENT HAVE THE ABILITY TO MOVE INSIDE AND OUTSIDE THE FACILITY INDEPENDENTLY (INCLUDING IN A WHEELCHAIR OR OTHER ASSISTIVE DEVICE)...2) DOES THE RESIDENT HAVE A HISTORY OF WANDERING/ELOPEMENT...3) DOES THE RESIDENT VERBALIZE THE DESIRE TO LEAVE THE FACILITY OR RETURN HOME..." (SOCIAL WORKER "M" HAD INDICATED A NEGATIVE RESPONSE TO QUESTIONS 4 AND 5 AND HAD ENTERED NO RESPONSE TO QUESTION 6.) ACCORDING TO THE FORM, IF THE ANSWER TO ANY OF THE QUESTIONS #2 THROUGH #6 WERE ANSWERED IN THE AFFIRMATIVE, THE INTERDISCIPLINARY TEAM (IDT) WAS REQUIRED TO IMPLEMENT THE ELOPEMENT PROTOCOL AS DESCRIBED IN CHAPTER 2 OF THE FACILITY'S CARE STANDARDS MANUAL. ACCORDING TO THE FACILITY'S "CARE STANDARDS", CHAPTER 2.1, REVISED 6/10, THE GOAL OF THE "ELOPEMENT PREVENTION AND MANAGEMENT PROGRAM" WAS STATED AS FOLLOWS: "IT IS THE POLICY OF THIS FACILITY THAT PERSONNEL WHO HAVE RESIDENTS UNDER THEIR CARE ARE RESPONSIBLE FOR KNOWING THE LOCATION OF THOSE RESIDENTS (MINIMUM HOURLY) ..." A REVIEW OF A DOCUMENT TITLED "15 MINUTE CHECKS" FOR MARCH 2012 REFLECTED RESIDENT #9'S LOCATION WITHIN THE FACILITY AT 15 MINUTE INTERVALS DOCUMENTED ON A GRID. THE LIST OF LOCATIONS INCLUDED THE FOLLOWING: (R) ROOM, (B) BED, (D) DINING ROOM, (L) LOUNGE, (Y) COURTYARD, (H) HALL AND (O) OTHER. THE LETTER "B" WAS WRITTEN ON THE GRID FOR THE TIMES OF 12:00 PM, 12:15 PM AND 12:30 PM, ON 3/11/12, TO INDICATE THAT RESIDENT #9 WAS IN BED AT THOSE TIMES. THE ADMINISTRATOR'S HAND-WRITTEN NOTES DATED 3/11/12 IDENTIFIED THE CNA (CERTIFIED NURSING ASSISTANT) WHO HAD DOCUMENTED RESIDENT #9'S LOCATIONS ON THE GRID FOR THOSE TIMES AS CNA "O". THE DOCUMENTATION ENTERED ONTO THE GRID BY CNA "O" WAS NOT CONSISTENT WITH THE OTHER RECORDS REVIEWED. ACCORDING TO THE PROGRESS NOTES, INCIDENT AND ACCIDENT REPORT, AND THE ADMINISTRATOR'S HAND-WRITTEN NOTES, RESIDENT #9 HAD NOT BEEN IN HER BED AT THE FACILITY AT 12:30 PM ON 3/11/12, AS DOCUMENTED ON THE GRID BY CNA "O"; RESIDENT #9 WAS, BY THAT TIME, AT THE STORE ACROSS THE STREET FROM THE FACILITY. DURING OBSERVATIONS MADE FROM A CAR, ON 9/21/12 AT APPROXIMATELY 5:25 PM, THE FACILITY WAS NOTED TO BE SITUATED IN A RESIDENTIAL AREA . THE STORE THAT RESIDENT #9 HAD WALKED TO WAS OBSERVED TO BE LOCATED ADJACENT TO A BUSY FIVE-LANE HIGHWAY. THE STORE WAS MORE THAN TWO BLOCKS FROM THE FACILITY. THE ROAD THAT RESIDENT #9 HAD CROSSED TO GET FROM THE FACILITY TO THE STORE WAS OBSERVED TO BE A TWO-LANE ROAD. THE STORE WAS LOCATED IN A TWO-STORE PLAZA THAT HAD A LARGE BUSY PARKING LOT IN FRONT OF IT. DURING AN INTERVIEW IN THE CONFERENCE ROOM ON 9/21/12 AT APPROXIMATELY 11:15 AM, THE ADMINISTRATOR RESPONDED TO QUESTIONS REGARDING HOW RESIDENT #9 HAD MANAGED TO EXIT THE FACILITY UNDETECTED BY STAFF. THE ADMINISTRATOR STATED THAT RESIDENT #9 "KNEW THE CODE FROM THE HUSBAND AND HAD A PLAN WITH THE HUSBAND." DURING AN INTERVIEW ON 9/21/12 AT APPROXIMATELY 11:20 AM, LPN (LICENSED PRACTICAL NURSE) "C" STATED THAT RESIDENT #9 WAS "ABSOLUTELY NOT" ABLE OR APPROPRIATE TO GO OUTSIDE UNACCOMPANIED BY STAFF. LPN "C" DESCRIBED RESIDENT #9'S BEHAVIORS AS CARE AND MEDICATION REFUSALS, ACCUSATORY STATEMENTS, AND PARANOID BEHAVIORS. DURING AN INTERVIEW ON 9/21/12 AT APPROXIMATELY 11:27 AM, CNA "D" DESCRIBED RESIDENT #9 AS, "VERY FORGETFUL IN A MATTER OF MOMENTS. SHE (RESIDENT #9) IS NOT SAFE BY HERSELF OUT OF DOORS." DURING A TELEPHONE INTERVIEW ON 9/21/12 AT APPROXIMATELY 1:25 PM, RESIDENT #9'S DAUGHTER DESCRIBED RESIDENT #9 AS "VERY CONVINCING. SHE COULD TALK SOMEONE INTO A RIDE OR CALLING A CAB." THE DAUGHTER EXPLAINED THAT RESIDENT #9'S EX-HUSBAND HAD ALZHEIMER'S DEMENTIA AND FURTHER STATED, "SHE (RESIDENT #9) COULD CONVINCE HIM TO LET HER GO WITH HIM...(BUT) SHE IS NOT ABLE TO BE ON HER OWN. SHE HAS A HISTORY OF OVER [AGE] years OF NOT BEING ABLE TO BE ON HER OWN WITHOUT FAMILY OR HELP." RESIDENT #9'S DAUGHTER SAID THERE HAD BEEN AN INCIDENT ABOUT SEVEN YEARS AGO WHEN RESIDENT #9 GOT ON A BUS BY HERSELF, THE BUS COMPANY CALLED, AND IT HAD TAKEN ABOUT TWO HOURS TO FIND RESIDENT #9, WHO HAD, BY THEN, GOTTEN OFF THE BUS. BASED ON REVIEW OF A FACILITY DOCUMENT TITLED "ABATEMENT PLAN: OVERALL CORRECTIVE ACTION TAKEN AT (NAME OF FACILITY) TO PREVENT A REOCCURRENCE", THE IMMEDIATE INTERVENTIONS IMPLEMENTED BY THE FACILITY ON 3/11/12 TO PREVENT REOCCURRENCE OF ELOPEMENT INCIDENTS INCLUDED THE FOLLOWING: 1) ALL 44 OF 44 RESIDENTS WERE ASSESSED FOR ELOPEMENT AND 6 CONTINUE TO BE AT RISK FOR ELOPEMENT. ELOPEMENT RISK WAS ACCURATELY REFLECTIVE. 2) UPDATED CARE PLANS TO REFLECT ELOPEMENT PRECAUTIONS. 3) ALL DOOR ALARMS WERE CHECKED FOR PROPER FUNCTIONING. 4) EDUCATION BEGINS * IN REGARDS TO: A) ELOPEMENT POLICY AND PROCEDURE TO INCLUDE RESPONSE TO ALARMS, IMMEDIATE ALERT OF RESIDENT MISSING WITHIN THE FACILITY, TAKING THE SEARCH OUTSIDE. (THERE WAS NO "B" OR "C" INDICATED ON THE "ABATEMENT PLAN") D) SAFETY CHECKS AND DOCUMENTATION E) RESIDENT MONITORING AND SUPERVISION OF THOSE RESIDENTS AT RISK OF ELOPEMENT F) DOORS CHECK DAILY FOR PROPER LOCKING AND FUNCTIONING * STAFF WORKING WERE IMMEDIATELY INSERVICED REGARDING THE ELOPEMENT PROCEDURE. 5) THE DOOR CODES WERE IMMEDIATELY CHANGED. 6) SIGNAGE WAS PLACED ON THE EXIT DOORS ALERTING VISITOR TO BE AWARE TO NOT LET RESIDENTS FOLLOW THEM OUT OF THE FACILITY. RESIDENT #9 WAS OBSERVED IN HER ROOM ON 9/21/12 AT APPROXIMATELY 11:33 AM. RESIDENT #9 WAS OBSERVED STANDING AND INTERACTING PLEASANTLY WITH ANOTHER RESIDENT SEATED IN A WHEELCHAIR. AFTER THE CONVERSATION BETWEEN THE TWO RESIDENTS WAS FINISHED, THIS SURVEYOR INTRODUCED HERSELF TO RESIDENT #9 AND REQUESTED TO TALK WITH HER. RESIDENT #9 REFUSED THE REQUEST. NO CONTINUING NON-COMPLIANCE WITH THIS REGULATORY REQUIREMENT WAS NOTED DURING THE SURVEY OF 9/21/12. ( )

This citation pertains to intake #MI 071 Based on observation, interview, and record review, the Facility failed to prevent staff to Resident physical abuse (Residents restrained for staff convenience), for 2 of 5 sampled Residents (#102 and #103), resulting in Resident #102 sustaining serious bruising on entire chest and rib area due to being tied to a wheelchair with a gait belt. Findings include: Resident #102 Licensed Practical Nurse (LPN "F"), in a second phone interview on 7/28/11 at 11:50 AM, said she remembered on Sunday 7/10/11 (not sure of the time), instructing Certified Nurse Assistant (CNA "E") to put a gait belt on Resident #102 and restrain her so she could not get out of her wheelchair. LPN "F" said she didn't think she put the gait belt on herself, but said she was having difficulty recalling the incident. LPN "F" said she did not know how long the restraint was left on Resident #102. LPN "F" said she started work on 7/10/11 at 6:00 AM and left at 6:00 PM. LPN "F" said she did not notify the Physician, the Director of Nursing, the Administrator, or document the use of a restraint for Resident #102. LPN "F" said, "everyone was so stressed out and couldn't get anything done!" Review of the closed, clinical record face sheet revealed Resident #102 was a [AGE] year old woman admitted to the facility on [DATE]. Review of her Minimum Data Set ((MDS) dated [DATE] revealed her [DIAGNOSES REDACTED]. According to the discharge summary, Resident #102 was discharged on [DATE] to a Hospice house. Review of her fall prevention risk assessment dated [DATE] revealed a score of 15 (15 or above indicated high risk). Review of the Facility's "Statement Form" dated as signed on 7/15/11 by Registered Nurse (RN "G") was written, "I came into work Sunday July 10, 2011 at 6:00 PM and (LPN "K") told me (LPN "F") had put belts on (Resident #102 and #103), but they could get out of them. I went to check on these Residents first thing and saw gait belts on both of them fastened on the back and they were snug. I immediately took them off the Residents and when I saw the DON Monday 7/11/11, I informed her of the above. (LPN "F") had left prior to her arrival and given the med. (medication) keys to (LPN "K") and the med. count was off also." LPN "K" had also written that she checked for bruises and Resident #102 and Resident #103 had no bruising at that time. On 7/28/11 at 11:05 AM, during an interview, RN "G" said on 7/10/11 at 6:00 PM she came to work at the Facility and was told by LPN "K" that Resident #102 and Resident #103 were restrained. RN "G" went to check on both Residents and saw both Resident #102 and Resident #103 restrained with a gait belt. The buckle was in the back of the wheelchair and neither Resident was able to remove the belts and RN "G" said they were "snug and near the breast area". RN "G" said she removed the belts immediately and checked and did not see any bruising at that time. RN "G" said she reported it to the DON but not until the next day. RN "G" said, "in retrospect I should have called immediately". RN "G" said she did not do an incident report. Review of the Facility's "Statement Form" dated as signed on 7/15/11 by RN "N" was written regarding the incident of physical abuse on 7/10/11, "when I was leaving work I looked over at (Resident #102), who was restrained in a wheelchair with a gait belt. I called the DON to ask her if Resident was supposed to be restrained. DON stated she would call the Facility to speak to the nurse in charge of Resident." "On 7/11/11 a CNA asked me if she could put a gait belt on the Resident to keep her in the chair. I told the CNA no and explained to that CNA that is not appropriate. This CNA told me (LPN "F"), told us we could put gait belt on the Resident." On 7/28/11 at 2:50 PM, in a phone interview with RN "N" who was on a medical leave from the Facility, RN "N" said on Sunday 7/10/11 she saw Resident #102, across from the nurse's station restrained to her wheelchair with a gait belt. RN "N" said it was approximately 2:00 PM and she was leaving her shift for the day. RN "N" said she immediately notified the DON using the phone at the nurse's station and spoke to her directly. The DON told her she would call back later and talk to LPN "F" about it. Review of the Facility's "Statement Form" dated as signed on 7/15/11 by CNA "E",was written, "On Sunday July 10, 2011 I witnessed (LPN "F"), put a gait belt around (Resident #102) with the intentions of restraining her to the chair. (Resident #102) has bruising on her ribs and under her breasts, which I believe was caused from the gait belt. (Resident #102) was given a shower by myself on Friday 7/7/11 and the bruising was not there at that time. The gait belt was used to keep the Resident in her chair." On 7/27/11 at 11:15 AM, in an interview, CNA "E" said LPN "F" asked for his gait belt and then took it and said she was going to use it to hold Resident #102 in the chair. CNA "E" said he gave her the gait belt and LPN "F" put the belt around Resident #102's rib cage area and buckled her into the chair so she could not stand up. The restraint was put on Resident #102 at approximately 11:00 AM and was still on at 2:00 PM. CNA "E" said he did not remove the restraint and he left at about 2:00 PM. CNA "E" said Resident #102 had bruises from the same area where the gait belt was applied. The bruises remained on her until she was sent out to a Hospice Home. On 7/27/11 at 2:00 PM, in an interview, LPN "C" said Resident #102 had a low cut blouse on and she noticed the bruises on her chest. When she took her blouse off on 7/13/11, the day she noticed the bruises, she said they were very, dark purple on both breasts and extended to both sides of her toward her back. The bruise was the size of a gait belt and consistent in size around her front and side. When she questioned the CNA's, CNA "E" told her it was from LPN "F" restraining Resident #102 with the gait belt. LPN "C" said she reported it to her DON that day. LPN "C" said she completed a skin assessment sheet on 7/13/11 for Resident #102 but was not able to locate the sheet in Resident #102's closed record. On 7/28/11 at 8:59 AM, during an interview, the Administrator said he found an incident report and a skin assessment sheet dated 7/13/11 regarding the bruises on Resident #102 and a file with a few notes. The corner of the file had written, "7/10/11 RESTRAINED" and Resident #102's name written next to it. Review of the Facility's skin assessment sheet dated 7/13/11 and signed by LPN "C" revealed Resident #102 had bruising under breasts extending to sides. The color of the bruise was purple. The length was 55 centimeters and the width was 2 to 5 centimeters. She had facial bruises and weeping leg wounds covered with dressings bilaterally. Resident #103 Review of the clinical record face sheet revealed Resident #103 was a [AGE] year old woman admitted to the facility on [DATE]. Review of the MDS dated [DATE] revealed [DIAGNOSES REDACTED]. On 7/28/11 at 11:30 AM CNA "H" said she saw Resident #102 and Resident #103 with gait belts on them used as restraints. It was between 12:30 PM and 2:00 PM on 7/10/11. CNA "H" said she did not report the use of restraint because she was working on a different hall and wasn't sure if it was through a Doctor's order. CNA "H" said no one asked her any questions about it and no one asked her to write a statement. On 7/28/11 at 2:10 PM, in an interview, LPN "K" said she knew LPN "F" put a restraint on Resident #102 and Resident #103 and questioned LPN "F" about it who told her she was trying to keep the Residents from getting up and falling. It was about 6:30 PM or 7:00 PM but did not recall the date. LPN "K" said the gait belt was around the Residents and fastened in the back. LPN "K" said she did not report the use of restraint for staff convenience. On 7/28/11 at 2:00 PM, CNA "M" said she worked on Sunday 7/10/11 from 2:00 PM until 10:00 PM and was assigned to Resident #102 and Resident #103. CNA "M" said LPN "F" had her put the gait belts on Resident #102 and Resident #103 to use as restraints to keep them from getting out of their chairs. "The restraints were already on when I got there", CNA "M" said. CNA "M" said she questioned LPN "F" and told her it was a restraint and they were not supposed to restrain the Residents and LPN "F" said, "I don't care". "Then I saw Resident #102's bruises a couple days later and they were all across her chest area. They were dark purple." An observation, on 7/27/11 at 9:21 AM revealed Resident #103 lying in bed, on her back. There were no apparent bruises on her face, arms, hands, chest, abdomen, back and shoulder area. An interview, at the time of the observation, when asked how she was treated by the Facility staff, Resident #103 closed her eyes, shook her head negatively and said, "I don't know". Resident #103 said she had fallen a couple of times while at the Facility. Resident #103 said she did not know any of the nursing staff's names and appeared to want to rest and not continue the interview. The bed next to Resident #103 belonged to Resident #102, according to CNA "A, in an interview on 7/27/11 at 9:28 AM. Review of the Facility's policy titled, "Physical Restraint Overview" and dated as revised 1/08. Under 4.1 Overview 1. (last sentence) was written, "ALL RESIDENTS MUST BE ASSESSED AS NEEDING A RESTRAINT FIRST". Under revision dated 6/08 12. Emergency situations: a) was written, "restrains may not be used for staff convenience". Under definition of Physical Restraint was written, "Any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the resident cannot remove easily which restricts freedom of movement or normal access to the resident's own body." #

This citation pertains to intake #MI 819 and MI 071 Based on interview and record review the Facility failed to report staff to Resident physical abuse for 2 of 5 sampled Residents (Residents #102 and #103 restrained to wheelchairs for staff convenience) and Visitor to Resident physical abuse for 1 of 5 sampled Residents (Resident #105 slapped across the face ), resulting in a delay in the investigation and prevention of possible further abuse for not reporting to Administration immediately and not reporting to State authority. Findings include: Resident #102 Review of the closed, clinical record face sheet revealed Resident #102 was a [AGE] year old woman admitted to the facility on [DATE]. Review of her Minimum Data Set ((MDS) dated [DATE] revealed her [DIAGNOSES REDACTED]. According to the discharge summary, Resident #102 was discharged on [DATE] to a Hospice house. Review of her fall prevention risk assessment dated [DATE] revealed a score of 15 (15 or above indicated high risk). On 7/27/11 at 2:00 PM, in an interview, LPN "C" said Resident #102 had a low cut blouse on and she noticed the bruises on her chest. When she took her blouse off on 7/13/11, the day she noticed the bruises, she said they were very, dark purple on both breasts and extended to both sides of her toward her back. The bruise was the size of a gait belt and consistent in size around her front and side. When she questioned the CNA's, CNA "E" told her it was from LPN "F" restraining Resident #102 with the gait belt. LPN "C" said she reported it to her DON that day and completed an incident report and a skin assessment sheet on 7/13/11. The Interim Director of Nursing (IDON), in an interview on 7/27/11 at 3:15 PM, said she was informed by the current Administrator that Licensed Practical Nurse (LPN "F") had allegedly restrained Resident #102 with a gait belt. IDON said she did not investigate or report the allegation of abuse to the State authorities. The Administrator, in an interview on 7/27/11 at 3:20 PM, said he was informed of an allegation of abuse from the previous DON on 7/15/11. The allegation the Administrator said he was informed about was that LPN "F" used a gait belt to restrain Resident #102 and Registered Nurse (RN "G") took it off. When asked why he did not report the allegation of abuse to State authorities, the Administrator said, "I called my boss. They called clinical nursing who instructed him not to report the incident because the Nurses intention was to prevent the Resident from falling." The Administrator had no incident report or completed investigation when requested on 7/27/11. On 7/28/11 at 8:59 AM, during an interview, the Administrator said he found an incident report and a skin assessment sheet dated 7/13/11 regarding the bruises on Resident #102 and a file with a few notes. The corner of the file had written, "7/10/11 RESTRAINED" and Resident #102's name written next to it. Resident #103 Review of the clinical record face sheet revealed Resident #103 was a [AGE] year old woman admitted to the facility on [DATE]. Review of the MDS dated [DATE] revealed [DIAGNOSES REDACTED]. On 7/28/11 at 11:30 AM CNA "H" said she saw Resident #102 and Resident #103 with gait belts on them used as restraints between 12:30 PM and 2:00 PM on 7/10/11. CNA "H" said she did not report the use of restraint because she was working on a different hall and wasn't sure if it was through a Doctor's order. CNA "H" said no one asked her any questions about it and no one asked her to write a statement. On 7/28/11 at 2:10 PM, in an interview, LPN "K" said she knew LPN "F" put a restraint on Resident #102 and Resident #103 and questioned LPN "F" about it who told her they were to keep the Residents from trying to get up and fall. It was about 6:30 PM or 7:00 PM but did not recall the date. LPN "K" said the gait belt was around both Residents #102 and #103 and fastened in the back. LPN "K" said she did not report the use of restraint for staff convenience to anyone. An observation, on 7/27/11 at 9:21 AM revealed Resident #103 lying in bed, on her back. There were no apparent bruises on her face, arms, hands, chest, abdomen, back and shoulder area. An interview, at the time of the observation, when asked how she was treated by the Facility staff Resident #103 closed her eyes, shook her head negatively and said, "I don't know". Resident #103 said she had fallen a couple of times while at the Facility. Resident #103 said she did not know any of the nursing staff's names and appeared to want to rest and not continue the interview. Resident #105 Review of the clinical record face sheet revealed Resident #105 was a [AGE] year old woman admitted to the facility on [DATE]. Review of the MDS dated [DATE] revealed [DIAGNOSES REDACTED]. Review of the Facility's investigation report regarding Resident #105 and titled, "Visitor to Resident" revealed the date and time of incident was 7/3/11 at 12:00 PM, in the dining room. According to the Facility's investigation summary the alleged abuse was not reported to Administration immediately. It was reported on 7/4/11 at 4:00 PM. The abuse was witnessed by another Visitor "2" and a Resident (not on the sample) who said they saw the Visitor "1" slapped Resident #105 across the face when she didn't respond to her. Visitor "1" was removed from the dining room and brought to the nurse's station and then taken out of the building. The Police were notified as was Adult Protective Services. There was no apparent injury on Resident #105, who, when interviewed by staff, could not recall the incident. Review of the Statement form for witness (Visitor "2") of the incident on 7/3/11 at 12:00 PM involving Resident #105 which was dated 7/5/11 and signed by the Facility Social Worker, revealed Visitor "2" said Visitor "1" came into the dining room, sat down at Resident #105's table, swore at her and then she saw her lean over and slap Resident #105. Visitor "2" said she saw Resident #105 put her hand to her face and say "ouch, that hurts". Visitor "2" said Visitor "1", then got up and left. Visitor "2" said she told CNA "M" what happened. Review of the Summary statement dated 7/5/11 and signed by the previous Director of Nursing (DON), revealed that both Nurses who worked on 7/3/11 at 12:00 PM were disciplined as a result of their failure to notify the DON or the Administrator of the abuse. Review of the Facility's Employee Memorandum form dated 7/6/11, and signed by LPN "C" was disciplined for her failure to report to DON or Administrator that she was informed that Visitor "1" was verbally abusive to Resident #105 and that Visitor "1" was upsetting Residents in the Facility with her loud, disorderly manner. Review of the Facility's Employee Memorandum form dated 7/6/11, and signed by LPN "O" was disciplined for her failure to report to DON or Administrator that she had heard the word "asshole" used in the dining room and did nothing about it and also that she did not report verbal and physical abuse of Resident #105 immediately to the DON or the Administrator. #

Complaint Intake Number: MI 553 Based on interview and record review the Facility failed to report an incident of elopement of approximately 30-minutes during blizzard conditions for 1 of 9 residents in the sample (#101) resulting in an Immediate Jeopardy due to not reporting to the State Agency the potential for serious and possibly life threatening harm to Resident #101 from the elopement and for all other residents who may potentially experience a reportable event. Findings include: Per the Incident Report dated 2/20/11 Resident #101 eloped from the Facility and was "found outside of facility." In an interview on 4/25/11 at 10:30 a.m. during the Entrance Conference the Director of Nursing and the Administrator admitted they did not report the elopement of Resident #101 on 2/20/11 to the State Agency. In an interview on 4/25/11 at 3:40 p.m. Licensed Practical Nurse (LPN) #18 said Resident #101 was missing for approximately 30 minutes on 2/20/11 and was found walking in the blizzard on a busy street. LPN #18 identified the location where she found Resident #101 and assisted him into a car for return to the Facility. On 4/26/11 at 8:15 a.m. this Surveyor measured the distance from the spot identified by LPN #18 to the Facility (using the State issued automobile odometer) as 0.7 miles. In an interview on 4/25/11 at 1:35 p.m. Nurse Aide #14 said on 2/20/11 Resident #101 was returned to the Facility wearing canvas shoes, pajama pants and a sweater. Nurse Aide #14 said Resident #101 was covered with snow and had snow in his beard; Resident #101's clothing was wet and his shoes were so wet they "squished" when he walked. Per the Hospital emergency room Physician Note dated 1/13/11 Resident #101 was a [AGE] year-old male who was diagnosed with [REDACTED]. On 4/27/11 at 4:02 p.m. the Administrator was notified of the Immediate Jeopardy that began on 2/20/11 as a result of failure to report the elopement of Resident #101 to the State Agency as required by law which placed Resident #101 and other residents at risk of elopement at high risk for serious harm, injury and/or death. On 5/2/11 at 11:30 a.m. the Surveyor confirmed that the facility staff completed the following to remove Immediate Jeopardy: 1. Resident #101 was discharged to another Facility on 3/1/11. 2. On 4/28/11 the Facility reviewed the incident and accidents reports for reportable events and determined their decisions to not report these incidents were correct. 3. On 4/28/11 8 of 13 licensed nurses received inservice training regarding reportable events and the remaining 5 nurses were notified via registered mail to report for training before commencing their next scheduled assignment; as of 4/30/11 the remaining 5 nurses had completed the inservice training. 4. On 4/27/11 the Facility reviewed the policies and procedures governing reportable events and determined they were appropriate, however, additional education on reportable events and examples given were included in the inservicing. 5. On 4/28/11 a plan to monitor the incident reports weekly for reportable events was developed in which the Administrator and Director of Nursing will review all incidents weekly to determine if an incident was reportable. Although the Immediate Jeopardy was removed on 4/28/11, the Facility remained out of compliance at a scope and severity of isolated with no actual harm but the potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance had not been verified by the State Agency. ( & )

Complaint Intake Number: MI 553 Based on observation, interview, and record review the Facility: 1) failed to ensure standards of practice for the assessment and treatment of [REDACTED].#101) in the sample of 9 resulting in an Immediate Jeopardy when Resident #101 who was found on 2/20/11 at 1:45 p.m. walking along a busy street 0.7 mile from the Facility, in blizzard conditions, with no coat, boots, or gloves which placed him at high risk of serious harm from frostbite and unidentified and untreated hypothermia and placed 4 additional residents identified as an elopement risk at high risk for serious harm; and 2) failed to follow standards of practice for documentation of medication orders in 2 of 9 sampled residents (#107 & #108) resulting in an increased risk for harm due to the potential for serious medication errors. Findings include: Assessment and treatment for [REDACTED]. "Hypothermia is defined as core, or internal body temperature of less than 95 degree Fahrenheit. Any person who is at risk for hypothermia and is suspected to have sustained a cold exposure should be brought to the hospital's emergency department...The temperature may be measured rectally, by a tube placed in the esophagus, or by an instrument inserted in an ear canal. Self Care at Home-Remove all wet clothes and move the person inside. The victim should be given warm fluids if he or she is able to drink...cover the person's body with blankets and aluminum coated foils and place the victim in a sleeping bag..." Following incorrect procedures can "cause the brain to dilate the blood vessels in the arms and legs from their highly narrowed state. This action can bring cold blood that was previously trapped in the arms and legs back to the core of the body and actually lower its temperature." (emedicinehealth.com/hypothermia). Resident #101 As evidenced by the following interviews on 2/20/11 Resident #101 was at risk of hypothermia and frostbite due to being outdoors for approximately 30 minutes in blizzard conditions while wearing canvas shoes, jogging pants, sweater and stocking cap (no coat or gloves). When Resident #101 was returned to the facility on [DATE] after he was found 0.7 miles from the Facility, he was wet and snow covered. Resident #101 exhibited symptoms of hypothermia-such as not shivering, pale skin and confusion-and was not adequately assessed. He did not receive core temperature rewarming care such as warm liquids. Per the Incident Report dated 2/20/11 Resident #101 eloped from the Facility and was found outside. In a telephone interview on 4/28/11 at 3:25 p.m. Med Tech #37 who was employed at the Assisted Living next door to this Facility stated on 2/20/11 she was driving on a busy street when she saw standing on the corner of an intersection of two 5-lane streets "this man covered with snow (who she later learned was Resident #101). He was walking in the snow. There was snow. I seen his face and shirt covered with snow." Med Tech #37 said she assumed Resident #101 had fallen because of the amount of snow on his beard and sweater. In an interview on 4/26/11 at 11:00 a.m. Med Tech #19 (an employee of the Assisted Living Center section of the Facility) said on 2/20/11 she drove her car to pick up Resident #101. Med Tech #19 said, "It was the day of that horrible blizzard...it was a blizzard. It was blowing snow everywhere." Med Tech #19 described the driving visibility conditions as, "Awful! I could have hit him." Med Tech #19 said, "We saw him at the bridge. I pulled over and put the hazard lights on..." Med Tech #19 said she did not "clearly remember" what clothing Resident #101 was wearing but "he wasn't dressed anywhere near appropriate for the conditions." Med Tech #19 stated Resident #101 was "pale faced" and was "not shivering. He was very zoned out. He didn't appear to comprehend his surroundings." In an interview on 4/25/11 at 3:40 p.m. Licensed Practical Nurse (LPN) #18 said on 2/20/11 at approximately 2:10 p.m. she and Med Tech #19 drove to a bridge that spanned a river and found Resident #101 was wearing canvas shoes, sweat pants, a sweat shirt and a stocking cap. LPN #18 said she got out of the car and "hollered" to Resident #101 but "he didn't hear me because it was so windy. I got within 5 feet of him" before he heard her and stopped walking. LPN #18 said she recalled there was accumulation of snow on the ground. LPN #18 said Resident #101's clothing was "wet from snow" and "one side had more snow than the other side" due to the blowing snow. LPN #18 said Resident #101 was "pale". In an interview on 4/25/11 at 1:35 p.m. Nurse Aide #14 said on 2/20/11 he saw Resident #101 upon his return to the Facility at approximately 2:15 p.m. Nurse Aide #14 said Resident #101 was wearing pajama pants, green sweater and tennis shoes. Nurse Aide #14 said when Resident #101 "walked in he was wearing the same clothes. He had no jacket. He had a knitted hat. His shoes were soaking wet-they squished when he walked. His pants were wet from the knees down. His hands and face were red. He had a small trimmed beard that looked wet. His shoulders and shoulder blades were wet." In an interview on 4/26/11 at 1:40 p.m. Nurse Aide #20 said she saw Resident #101 upon his return to the facility on [DATE] and described him as "completely soaked in snow." In an interview on 4/26/11 at 2:06 p.m. Nurse Aide #22 said on 2/20/11 she saw Resident #101 on his return. Nurse Aide #22 said Resident #101 had, "... was snow all over him. He had thin shoes on and no socks. He said he was cold. I asked him and he said, 'yes.' There was snow in his beard. There was snow on him everywhere." Per the weight records Resident #101 was 6'2" tall and weighed 150 pounds. Per the undated face sheet Resident #101 was [AGE] years-old. Per www.wunderground.com/weatherstation/WXDailyHistory the temperatures for the city in question on 2/20/11 from 1:45 p.m.-2:15 p.m. the temperatures ranged from 29.3-29.5 degrees Fahrenheit, with Wind Speeds of 1.6-4.5 mph and wind gusts of 6-9.8 mph and 99% humidity. Per the Nurses' Notes dated 2/20/11 at 2:19 p.m. LPN #17 wrote, "Assisted by staff into the facility. Alert, mental status unchanged. I asked where he was going and he laughed and stated he was going to his mother's house. Assisted to his room, body assessment performed, no changes and skin intact. Denies pain. Neuro assessment performed and WNL (within normal limits) for residents as were vital signs. ROM (range of motion) same as before..." In an interview on 4/25/11 at 2:47 p.m. LPN #17 said she was not sure of the time that Resident #101 returned to the facility on [DATE] but knew the "report said it was 2:15 p.m." LPN #17 said she saw Resident #101 enter the Facility with LPN #19 wearing a stocking cap, sweatshirt and no coat. LPN #17 said Resident #101 was wearing tennis shoes and "looked cold" but was "not shivering." LPN#17 said, "I don't remember his clothing looking wet." LPN #17 said she took Resident #101 to his room and "I took his clothes off and looked at him." LPN #17 said she took a tympanic temperature within minutes of removing the wet clothes and verified that the temperature of "98.9" written on the Incident Report dated 2/20/11 was the temperature she obtained. LPN #17 said she "changed his clothes into dry clothes and got him into bed with blankets." Upon further questioning LPN #17 insisted she dressed Resident #101 in clean dry street clothes after she "checked his whole body" and then put him to bed. LPN #17 said she "didn't specifically recall" any of the findings of her assessment of Resident #101's body. LPN #17 said she did not give Resident #101 a hot drink. In an interview on 4/26/11 at 2:20 p.m. Nurse Aide #24 said on 2/20/11 she was at the Nurses' Station when Resident #101 entered the Facility with LPN #18. Nurse Aide #24 said Resident #101's pants and shirt were "wet." Nurse Aide #24 said LPN #18 instructed her to take Resident #101 to his room and she followed the instructions. Nurse Aide #24 said, "It was just me and him." Nurse Aide #24 said Resident #101 went into the bathroom in his room and removed his wet clothing handing them out to her as she stood in his bedroom with the bathroom door partially closed. Nurse Aide #24 said she put the wet clothing in a bag. Nurse Aide #24 said Resident #101 told her his "brief wasn't wet but I made him change it anyway. I handed him (clean and dry) shirt and pants and I watched him pull up his brief. He was in the bathroom. He took off his socks. They were wet." Nurse Aide #24 said her observations of Resident #101's skin were made through the partially opened bathroom door and she did not perform any close examination. Nurse Aide #24 said after Resident #101 was dressed they both walked out of his room and wandered the corridors. Nurse Aide #24 denied Resident #101 was given any blankets and denied that he was put to bed. Nurse Aide #24 stated LPN #17 did not enter Resident #101's room during the entire time of the clothing change and did not perform any assessment on Resident #101 that shift. Nurse Aide #24 said she was assigned one-to-one supervision of Resident #101 from the time he returned to the Facility until the end of her shift (per her time card dated 2/20/11 she punched out at 10:10 p.m.) and she never left his side. Nurse Aide #24 said she did not give Resident #101 anything to eat or drink until the evening meal on 2/20/11. In an interview on 4/26/11 at 4:40 p.m. Nurse Aide #32 said on 2/20/11 she witnessed Nurse Aide #24 walk with Resident #101 from the Nurses' Station to his room immediately upon his return to the Facility. Nurse Aide #32 said Resident #101's "nose was pink and he was laughing. He said he was going home." Nurse Aide #32 said she was aware that Nurse Aide #24 was assigned the duty of one-to-one supervision of Resident #101 for the remainder of their shift. Nurse Aide #32 said she saw Nurse Aide #24 standing in Resident #101's bedroom outside of a partially closed bathroom door. Nurse Aide #32 said Nurse Aide #24, "stood by the bathroom door. It was cracked open and then she shut the door. He (Resident #101) asked for something. (Nurse Aide #24) wasn't in the bathroom with him." Nurse Aide #32 said she saw Nurse Aide #24 open the bathroom door slightly and hand something into the bathroom to Resident #101. Nurse Aide #32 said she did not see any nurse in Resident #101's room after he returned to the Facility. Nurse Aide #32 said moments later she saw Resident #101 dressed in dry street clothes and Nurse Aide #24 exit his room and then Resident #101 wandered with Nurse Aide #24 about the Facility. Nurse Aide #32 said she did not see Resident #101 eat or drink anything until supper on 2/20/11. On 4/28/11 at 12:42 p.m. a second interview was conducted with LPN #17. At first LPN #17 insisted she took Resident #101 to his room immediately upon his return to the facility on [DATE] with LPN #19. But after she was informed that Nurse Aide #24 said she took Resident #101 to his room and Nurse Aide #32 said she saw Nurse Aide #24 take Resident #24 to his room, LPN #17 revised her statement saying she went to Resident #101's room "about 5 minutes later." LPN #17 insisted that she took Resident #101's vital signs while he was still wearing the wet clothing. LPN #17 stated she obtained the vital signs while Resident #101 was in his room but she could not recall if he was sitting, lying, or standing or whether he was in the bedroom or in his bathroom. LPN #17 insisted she performed a head-to-toe assessment and a neurological exam including assessment of hand grips but did not recall where this assessment took place-saying it was probably in Resident #101's room as the was "not enough room in the bathroom." LPN #17 then stated she didn't recall "who took off what" and did not recall "who took off his shoes and socks" and did not recall who dressed Resident #101 in dry clothing. Again she insisted she put Resident #101 into his bed and covered him with blankets. When she was told that Nurse Aides #24 and #32 stated Resident #101 did not get into bed but in fact was walking in the corridor immediately after getting his clothing changed, LPN #24 said she did not remember "for sure" about the bed covers. From that point on in the second interview LPN #24 answered all questions with, "I don't remember." Per the Incident Report dated 2/20/11, LPN #17 notified the Nurse Practitioner via telephone at 3:05 p.m. about Resident #101's elopement. In a telephone interview on 4/27/11 at 3:22 p.m. the Nurse Practitioner stated she did not recall the details of Resident #101's elopement but she was accustomed to being "read the Incident Report" when she received a page while on call. This Surveyor read the Incident Report dated 2/20/11 to the Nurse Practitioner as follows: "Resident eloped. Happy Feet Drill initiated and resident found outside of facility. A&O (alert and oriented) to self and family confused (sic). Temperature 98.9, Pules 78, Respirations 20, Blood Pressure 132/80. Time of incident 1:53 p.m." The Nurse Practitioner stated she believed the information just read to her was what she was told on 2/20/11 at 3:05 p.m. The Nurse Practitioner stated if she had been made aware that Resident #101 was outside for possibly 30 minutes in the blizzard without a coat, gloves or boots she would have sent him to the emergency room for evaluation and treatment of [REDACTED].#101 had gone outdoors and was returned within seconds to minutes without injury. Per the transfer sheet Resident #101 was admitted to this Facility on 1/31/11 from a psychiatric facility and his [DIAGNOSES REDACTED].#101's skin on his feet was impaired. Per the Nutrition/Hydration Care Plan dated 2/7/11 Resident #101 had continual loose stools related to a history of [MEDICAL CONDITION] bypass surgery. Per the Nurses' Notes dated 2/20/11 at 9:14 a.m. Resident #101 was independent with ambulation and "able to make some needs be known." Per the Nurses' Notes dated 2/25/11 discharge planning to a facility with a locked unit was being done. Per the Nurses' Notes dated 3/1/11 Resident #101 was discharged to another facility. On 4/27/11 at 4:02 p.m. the Facility was notified of the Immediate Jeopardy that began on 2/20/11 as a result of failure to provide adequate and appropriate assessment and treatment for [REDACTED].#101 and the risk of serious harm to the 5 other residents who were identified as elopement risks. On 5/2/11 at 11:30 a.m. the Surveyor confirmed that the facility staff completed the following to remove Immediate Jeopardy: 1. Resident #101 was discharged from the facility on 3/1/11. 2. On 4/28/11 the Facility reviewed the incident reports for the prior 3 months and determined the physical assessment and treatment of [REDACTED]. 3. On 4/28/11 8 of 13 licensed nurses received inservice training on physical assessments and assessments for hypothermia, frostbite and hyperthermia and on documentation of assessments. The 5 remaining nurses were contacted by registered mail and informed they must receive the inservice training prior to reporting for duty for their next assigned shift. By 4/30/11 the remaining 5 nurses had completed the inservice training. 4. On 4/28/11 the Facility added assessment for hypothermia, frostbite, hyperthermia, physical assessment and documentation requirements to the Orientation checklist. 5. On 4/28/11 the Facility developed a monitoring tool and plan to review all Incident and Accident reports and Nurses' Notes related to an incident weekly for four weeks and quarterly thereafter. Although the Immediate Jeopardy was removed on 4/28/11, the Facility remained out of compliance at a scope and severity of isolated with no actual harm but the potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance had not been verified by the State Agency. ( & ) Resident #107 According to the "Fundamentals of Nursing" by Potter, P.A and Perry A.G. in (6th Edition, 2005). St. Louis, Mosby. "The (Medical) Record should be the most current and accurate source of information about a (Resident's) Health Care Status." In "Legal and Ethical Issues in Nursing." by G. Guido (2001), it states that "documentation must show continuity of care, interventions that were uses, and patient responses to the therapies implemented." (P 171) Review of the Telephone Order dated 4/24/11 revealed Resident #107 was placed at serious risk for a medication error due to the order lacking a medication concentration and an failure to indicate it was intended for a one-time use of the medication. Resident #107's Physician's Telephone Order dated 4/24/11 at 11:30 a.m. read "8 units Additional [MEDICATION NAME] Plus 7 units (normal dose) for a total of 15 units, indication BS elevated 493/523" signed by RN # 28. The order as written prescribed an insulin used to treat Diabetes (high blood sugars) - "indication was for an elevated blood sugar of 493/523", a high level. No physician co-signed the order, as of 4/26/11. The original order Physician's telephone order was located in the Physician's to be Signed Book, in the nurses' station. In a telephone interview on 4/27/11 at 3:09 p.m. Registered Nurse (RN) #28 admitted she took Resident #107's Physician's Telephone Order dated 4/24/11 was and said the order was a "STAT" (immediate-one time dose) "extra dose of [MEDICATION NAME]." Review of Nurses' Notes for Resident #107 dated 4/24/11 revealed, "Resident with an elevated blood sugar 493 and 523 on recheck. (The attending physician) notified and states to give 8 units of [MEDICATION NAME] in addition to usual dose of 7 units for a total of 15 units." Review of Resident #107's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"8 units extra [MEDICATION NAME], BS 495/523, x 1" indicating the medication to be given only once, a one time dose of the extra insulin. Review of the face sheet of the medical record revealed that Resident #107 was a [AGE] year-old female who was admitted to the facility on [DATE]. Review of the physician progress notes [REDACTED]. Review of the MDS (Minimum Data Set) dated 4/14/11 revealed Resident #107 [DIAGNOSES REDACTED]. The Nurses' Notes dated 4/20/11 disclosed Resident #107 was alert with forgetfulness and confusion. Resident #107 was observed on 4/26/11 at 4:12 p.m. seated on the edge of her bed in her room. After the surveyor introduced self, Resident #107 began crying and stated she wanted to go home and that she was having a bad day. ( & ) Resident #108 Review of the Telephone Order dated 4/21/11 revealed Resident #108 was placed at risk of potentially serious medication error due to incorrect spelling of the prescribed medication and incorrect use of medical abbreviations. The errors were not brought to the attention of the Physician who wrote the order by the Nurse who noted the order. Resident #108's Physician's Telephone Order dated 4/21/11 stated, "Melaton (sic) 3 mg, (followed by undecipherable letters or numbers) qh." The order as written was an herbal product used to treat [MEDICAL CONDITION]-"[MEDICATION NAME]," to be given every hour-the abbreviation for "every" is the letter "q" and the abbreviation for "hour" is the letter "h" (Love Smith, Genevieve, Davis, Phyllis E., & Tannis Dennerll, Jean (1988) Medical Terminology A Programmed Text (5th ed.). New York: John Wiley & Sons, Inc.). In an interview on 4/27/11 at 11:41 a.m. Licensed Practical Nurse (LPN) #17 admitted that she noted Resident #108's Physician's Telephone Order dated 4/21/11 as evidenced by her signature on the document. When asked to define the order, LPN #17 said, "[MEDICATION NAME] 3mg 1 PO q HS" meaning one 3 milligram tablet of the herbal product [MEDICATION NAME] was prescribed to be given per os (by mouth) every hour of sleep (bedtime) (ibid). There was no documented evidence found in the physician's orders [REDACTED].#108's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]." Nurse #17 exceeded the scope of nursing practice by transcribing a corrected physician's orders [REDACTED]. If a physician's orders [REDACTED]. A. & Perry, A. G. (2005) Fundamentals of Nursing (6th ed.). St. Louis: Mosby). Review of the (undated) face sheet of the medical record revealed that Resident #108 was a [AGE] year-old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per the Nurses' Notes dated 4/25/2011 Resident #108 was alert and oriented to self and place. Resident #108 was observed on 4/25/11 at 3:35 p.m. seated in a chair in his room. He rose and seated himself on his bed offering the chair to the Surveyor. Resident #108 stated he had surgery and anticipated a "long recuperation" prior to possible discharge as he "lives alone." ( & )

Complaint Intake Number: MI 553 Based on observation, interview, and record review the Facility failed to provide adequate and appropriate supervision to prevent the elopement in 1 of 5 residents identified as an elopement risk (#101) in the sample of 9, resulting in Immediate Jeopardy for Resident #101 who was found walking along a busy street 0.7 mile from the Facility in blizzard conditions while not wearing a coat, boots or gloves which placed him at high risk of serious harm, injury, and/or death and placed 5 additional wandering residents at risk of elopement and serious harm, injury, and/or death. Findings include: Per the Incident Report dated 2/20/11 Resident #101 eloped from the Facility and was found outside. In an interview on 4/25/11 at 12:52 p.m. Nurse Aide #13 said on 2/20/11 she was assigned to provide one-to-one supervision for Resident #101 however she left him unattended while she went to the restroom. Upon her return-which she estimated was at 1:50 p.m.-she could not find Resident #101. When last seen Resident #101 was wearing a sweater, jogging pants, shoes and socks. Resident #101 had a history of [REDACTED]. Per the Hospital emergency room Physician's note dated 1/13/11 Resident #101 had wandered from his Adult Foster Care home and was discovered wearing only an incontinence brief at a gas station. Resident #101 had a [DIAGNOSES REDACTED]. Per the Hospital Transfer Sheet dated 1/31/11 Resident #101 had been admitted to a psychiatric unit on 1/13/11. Per the Admission Elopement Risk assessment dated [DATE] Resident #101 was identified as an elopement risk. Per the Care Plan dated 2/1/11 Resident #101 was placed on 15-minute checks to prevent elopement. Per the Nurses' Notes dated 2/16/11 Resident #101 attempted an unauthorized exit from the Facility. Per the Nurses' Notes dated 2/17/11 Resident #101 made more than one attempt to exit from the Facility. Per the Nurses' Notes dated 2/18/11 Resident #101 made another attempt to exit the Facility and was thus placed on one-to-one supervision. In a telephone interview on 4/28/11 at 3:25 p.m. Med Tech #37 who was employed at the Assisted Living next door to this Facility stated on 2/20/11 she was driving on a busy street when she saw "this man covered with snow. He was walking in the snow. He looked familiar" thus she telephoned the Assisted Living and then discovered that Resident #101 from the nursing home section of the facility was missing and staff members from both sections of the Facility were looking for him. Med Tech #37 said, "There was snow. He was walking in the snow. I seen his face and shirt covered with snow." Med Tech #37 said she assumed Resident #101 had fallen because of the amount of snow on his beard and sweater. In an interview on 4/26/11 at 11:00 a.m. Med Tech #19 (an employee of the Assisted Living Center section of the Facility) said on 2/20/11 she answered the phone call from Med Tech #37 and she and Licensed Practical Nurse (LPN) #18 drove to pick up Resident #101. Med Tech #19 said, "It was the day of that horrible blizzard...it was a blizzard. It was blowing snow everywhere." Med Tech #19 described the driving visibility conditions as, "Awful! I could have hit him." Med Tech #19 said, "We saw him at the bridge. I pulled over and put the hazard lights on..." Med Tech #19 said she did not "clearly remember" what clothing Resident #101 was wearing but "he wasn't dressed anywhere near appropriate for the conditions." Med Tech #19 stated Resident #101 was "pale faced" and was "not shivering. He was very zoned out. He didn't appear to comprehend his surroundings." In an interview on 4/25/11 at 3:40 p.m. LPN #18 said on 2/20/11 at approximately 2:10 p.m. she and Med Tech #19 drove to the place Med Tech #37 said she saw Resident #101. LPN #18 said they found Resident #101 walking along the side of a divided roadway in the snow further down and across the street than where he was last seen by Med Tech #37. LPN #18 said Resident #101 was walking onto a bridge that spanned a river. LPN #18 said Resident #101 was wearing canvas shoes, sweat pants, a sweat shirt and a stocking cap. LPN #18 said she got out of the car and "hollered" to Resident #101 but "he didn't hear me because it was so windy. I got within 5 feet of him" before he heard her and stopped walking. LPN #18 said she recalled there was accumulation of snow on the ground. LPN #18 said Resident #101's clothing was "wet from snow" and "one side had more snow than the other side" due to the blowing snow. LPN #18 said Resident #101 was "pale". In an interview on 4/25/11 at 1:35 p.m. Nurse Aide #14 said on 2/20/11 he helped look for Resident #101. Nurse Aide #14 said he saw Resident #101 upon his return to the Facility at approximately 2:15 p.m. Nurse Aide #14 said Resident #101 was wearing pajama pants, green sweater and tennis shoes at "5 to 6" that morning. Nurse Aide #14 said when Resident #101 "walked in he was wearing the same clothes. He had no jacket. He had a knitted hat. His shoes were soaking wet-they squished when he walked. His pants were wet from the knees down. His hands and face were red. He had a small trimmed beard that looked wet. His shoulders and shoulder blades were wet." In an interview on 4/26/11 at 1:40 p.m. Nurse Aide #20 said when she arrived on duty for the 2:00 p.m.-10:00 p.m. shift on 2/20/11 she was informed that Resident #101 was known to be missing for 10-15 minutes prior to her arrival. Per Nurse Aide #20's time card she punched in on 2/20/11 at 1:56 p.m. Nurse Aide #20 said she saw Resident #101 upon his return to the facility on [DATE] and described him as "completely soaked in snow." In an interview on 4/26/11 at 1:55 p.m. Nurse Aide #21 said on 2/20/11 Resident #101 had not returned to the Facility before she punched out and went home. Per the time card Nurse Aide #21 punched out on 2/20/11 at 2:05 p.m. In an interview on 4/26/11 at 2:06 p.m. Nurse Aide #22 said on 2/20/11 she assisted in the search for Resident #101 and she saw him on his return. Nurse Aide #22 said Resident #101, "Looked cold. There was snow all over him. He had thin shoes on and no socks. He said he was cold. I asked him and he said, 'yes.' There was snow in his beard. There was snow on him everywhere." In an interview on 4/26/11 at 2:20 p.m. Nurse Aide #24 said on 2/20/11 she assisted Resident #101 to his room and provided clean clothes for him to change into after he returned from being found walking in the snow alongside a busy street. Nurse Aide #24 said Resident #101's clothing was "wet." Nurse Aide #24 said Resident #101 was wearing socks which were wet. On 4/26/11 at 8:15 a.m. this Surveyor drove the route taken by Resident #101 on 2/20/11 per the information obtained in the interviews with Nurse Aide #14 (4/25/11 at 1:35 p.m.), Med Tech #37 (4/28/11 at 3:25 p.m.), Med Tech #19 (4/26/11 at 11:00 a.m.) and LPN #18 (4/25/11 at 3:40 p.m.). The route began at the end of the sidewalk that was identified by Nurse Aide #14 as where on 2/20/11 he saw the footprints from Converse tennis shoes exiting from a door in the Assisted Living section of the Facility. The route followed a southwesterly direction down Street "A", turned left at Street "B" (the first intersection), continued past the intersection of Streets "B" and "C "(the spot identified by Med Tech #37 as where she saw Resident #101 standing on 2/20/11) and continued down Street "B" to the bridge in the south bound lanes identified by Med Tech # 19 and LPN #18 as the spot where they intercepted Resident #101 on 2/20/11. The distance was 0.7 miles. There was a sidewalk along Street "A" (the two-lane street that angled from the northeast to the southwest from the Assisted Living Facility's sidewalk) to the intersection with Street "B"(a 5-lane street which angled from the northwest to the southeast). The intersection of Streets "A" and "B" had a red-yellow-green traffic signal and had cross walks equipped with "walk/wait" pedestrian crossing signals. There was no sidewalk along either side of Street "B" (a 5-lane northwest/southeast street). Med Tech #37 reported she saw Resident #101 standing on the northwest corner of an intersection of Streets "B" and "C." Street "C" was 5-lanes wide at the intersection. The intersection of Streets "B" and "C" was equipped with a red-yellow-green traffic signal, but had no walk/wait signal light at any of the crosswalks. Street "B" widened on the south side of the intersection to 6 lanes. When he was found by Med Tech #19 and LPN #18 Resident #101 had crossed the Street "C" (without a walk/wait pedestrian crossing signal) and had continued walking south along the edge of the then 6-lane Street "B" (there was no sidewalk) and continued along Street "B" which bifurcated into 2-lanes in either direction which were separated by a park with large ponds of water. The bridge where Resident #101 was stopped spanned a river adjacent to a coal-fired power plant. Per www.wunderground.com/weatherstation/WXDailyHistory the temperatures for the city in question on 2/20/11 from 1:45 p.m.-2:15 p.m. ranged from 29.3-29.5 degrees Fahrenheit, with Wind Speeds of 1.6-4.5 mph and wind gusts of 6-9.8 mph and 99% humidity. On 4/27/11 at 4:02 p.m. the Facility was notified of the Immediate Jeopardy that began on 2/20/11 as a result of failure to provide adequate and appropriate supervision to prevent elopement for Resident #101 resulting in the high risk of serious harm, injury or death for Resident #101 and the risk of serious harm, injury, and/or death for the 5 additional residents who were identified as elopement risks. On 5/2/11 at 11:30 a.m. the Surveyor confirmed that the facility staff completed the following to remove Immediate Jeopardy: 1. Resident #101 was discharged to a facility with a locked unit on 3/1/11. 2. On 4/28/11 40 of 40 resident elopement risks assessments were reviewed and found accurate. The elopement risk care plans for the 5 Residents who had already been deemed at risk of elopement were reviewed and deemed adequate. 3. On 4/28/11 the Elopement Risk policy and procedures were reviewed by the Facility and deemed appropriate. 4. On 2/21/11 the Maintenance Staff assessed the delay time on the 5 alarmed exit doors and adjusted the time from 30 seconds to 15-18 seconds on the door between the nursing home and the assisted living residence and determined the other 4 alarmed door delay time of 10-15 seconds was adequate. 5. On 4/28/11 the Elopement Book was reviewed by the Facility and determined appropriate. 6. On 4/28/11 the Elopement Drill program was reviewed by the Facility and determined appropriate. 7. On 4/27/11 an Elopement drill was conducted and a plan was put in place for monthly elopement drills. 8. On 4/28/11 43 of 66 employees received inservice education regarding the policy and procedures for one-to-one supervision and the procedures to follow in the event of an elopement (a program called "Happy Feet.") The remaining 23 employees were notified by telephone or by registered mail that attendance of these inservice training sessions was required before they reported for their next assignment. As of 5/2/11, 20 of the 23 remaining employees had completed the inservice training. 9. The Director of Nursing was identified as the individual responsible to ensure the remaining 3 employees received the inservice training on one-to-one supervision and "Happy Feet" before they began their next scheduled assignment. 10. On 4/28/11 the Orientation Checklist was reviewed to ensure it included training for one-to-one supervision and the "Happy Feet" elopement procedures. 11. On 4/28/11 a preventive maintenance program was developed whereby the Maintenance Director checked functionality of the alarms on the 5 alarmed exit doors five days a week and recorded the findings on a log with abnormalities reported to the Administrator. 12. On 4/28/11 a monitoring tool and program was developed whereby the Director of Nursing will interview 5 employees chosen at random each week for an understanding of one-to-one supervision and the "Happy Feet" elopement procedures. Interviews will be conducted weekly for one month then quarterly thereafter. Although the Immediate Jeopardy was removed on 4/28/11, the Facility remained out of compliance at a scope and severity of isolated with no actual harm but the potential for more than minimal harm that is not Immediate Jeopardy due to not all staff in-service training was completed, and sustained compliance had not been verified by the State Agency. ( & )

Complaint Intake Number: MI 553 Based on observation, interview, and record review the Facility failed to ensure staff members were competent to perform one-to-one supervision and missing person procedures, and failed to ensure nurses were competent to assess and treat possible hypothermia for 1 of 5 residents who were identified as at risk of elopement (#101) in the sample of 9 resulting in actual harm-elopement-with the potential for serious harm due to exposure to blizzard conditions. Findings include: One-To-One: In an interview on 4/25/11 at 12:52 p.m. Nurse Aide #13 stated she was assigned to provide one-to-one supervision for Resident #101 on 2/20/11 however she failed to fulfill her duty when she left him unattended in the dining room while she went to the restroom. Nurse Aide #13 stated when she returned Resident #101 was not where she left him and she began looking for him. Nurse Aide #13 admitted she did not immediately report Resident #101 missing to her supervisor but attempted to find him by searching in an unsystematic manner. Nurse Aide #13 said she did not remember ever receiving training on the elopement procedures however review of her orientation checklist dated 12/29/10 revealed elopement procedures were included in her orientation. Per interviews with Licensed Practical Nurse (LPN) #18 (4/25/11 at 3:40 p.m.) and Med Tech #19 (4/26/11 at 11:00 a.m.) Resident #101 was found on 2/20/11 at approximately 2:15 p.m. walking alongside a busy street in blizzard conditions 0.7 miles from the Facility. Elopement Missing Resident Procedure: Resident #101 was found by happenstance as evidenced by an interview with Med Tech #37 (4/28/11 at 3:25 p.m.) who said as she was driving to work on 2/20/11 she noticed a man standing at the intersection of two 5-lane streets in blizzard conditions without benefit of a coat. The man appeared familiar to her thus she telephoned the Assisted Living where she worked and asked if anyone was missing. Per interviews with LPN #18 (4/25/11 at 3:40 p.m.) and Med Tech #19 (4/26/11 at 11:00 a.m.) Resident #101 was retrieved 0.7 miles from the Facility on 2/20/11 while walking on a busy street in blizzard conditions while wearing canvas shoes, jogging pants, sweater and stocking cap. The Facility's Policy and Procedure for Elopement Prevention and Management Program-Missing Resident Procedure (revised 1/08) instructed staff in the event of a missing resident conduct an "directed search" throughout the entire facility and "initiate a coordinated organized search of the facility grounds" while simultaneously maintaining "adequate staff on each unit to attend to residents' needs during the search." The time cards and schedules for 2/20/11 first and second shift were obtained and all staff who were present in the Facility on the first and second shifts on 2/20/11 were interviewed. In the following interviews it was learned that, none of the staff members who were on duty at the time Resident #101 was known missing on 2/20/11, stayed on each unit to attend to residents' needs while the search for Resident #101 was conducted and the search was not effectively "directed" resulting in duplication of effort in some areas which thus decreased the number of persons available to extend the search. The search was not coordinated to ensure an ever widening circle from the inside of the Facility through the community was conducted. LPN #17 (4/25/11 at 2:47 p.m. & 4/28/11 at 12:42 p.m.) LPN #18 (4/25/11 at 3:40 p.m.) LPN #23 (4/26/11 at 2:09 p.m.) LPN #25 (4/26/11 at 3:00 p.m.) Nurse Aide #13 (4/25/11 at 12:52 p.m.) Nurse Aide #14 (4/25/11 at 1:35 p.m.) Nurse Aide #20 (4/26/11 at 1:40 p.m.) Nurse Aide #21 (4/26/11 at 1:55 p.m.) Nurse Aide #22 (4/26/11 at 2:06 p.m.) Nurse Aide #24 (4/26/11 at 2:12 p.m.) Nurse Aide #26 (4/26/11 at 3:05 p.m.) Nurse Aide #32 (4/26/11 at 4:40 p.m.) Housekeeping Assistant #34 (4/28/11 at 11:00 a.m.) Housekeeping Assistant #33 (4/28/11 at 10:30 a.m.) Dietary Staff #16 (4/25/11 at 2:29 p.m.) Med Tech #19 (4/26/11 at 11:00 a.m.) Med Tech #37 (4/28/11 at 3:25 p.m.). The staff members stated they searched the following areas: Resident #101's room: Nurse Aide #13, Nurse Aide #14, Nurse Aide #21, Nurse Aide #22, Nurse Aide #26 South Hall (Resident #101's unit): Nurse Aide #13, Nurse Aide #14, Nurse Aide #22, Nurse Aide #26 North hall: LPN #18 Residents' dining room: Nurse Aide #13, Nurse Aide #14, Nurse Aide #21, Nurse Aide #22, LPN #19 Activity room (door opens onto the corridor connecting the nursing home with the Assisted Living Center): Nurse Aide #22 Through the locked door of the therapy room (door opens onto the corridor connecting the nursing home with the Assisted Living Center) but did not enter: Nurse Aide #22 Staff break room and bathroom: Nurse Aide #22 Connecting hall from nursing home to assisted living center: Nurse Aide #22, LPN #19, LPN #18 Nurses' station: LPN #17 (and "down and around from the desk") Resident rooms in the Assisted Living Center: Med Tech #19 Through the hall (but not into residents' rooms) on the first floor of the Assisted Living Center: Nurse Aide #20 Outside perimeter of the Facility (including the attached Assisted Living Center): Housekeeping Assistant #33 Back parking lot: Nurse Aide #20 Grocery store across the street: Nurse Aide #14 Other stores across the street Nurse Aide #14, Nurse Aide #32 Did not participate in the search even though on duty: Dietary Staff #16, LPN #23, Nurse Aide #24, LPN #25, Housekeeping Assistant #34. In an interview on at 2:09 p.m. LPN #23 stated on 2/20/11 she heard the page "Happy Feet" (the code paged when a resident was missing and a search needed to begin) but she did not know what it meant. LPN #23 said after she heard the page "Happy Feet" she continued performing her duties in the treatment room and did not join in the search for Resident #101 who was missing. LPN #23 said later she, "asked one of the aides, 'What is she saying-Happy Feet?'" In an interview on 4/26/11 at 1:55 p.m. Nurse Aide #21 stated she was unaware until after 2/20/11 that she was supposed to stay on duty until a missing resident was found or she was released from duty by her supervisor. Nurse Aide #21 said although Resident #101 had not been found she went home at the end of her shift on 2/20/11. Per the time card Nurse Aide #21 punched out at 2:05 p.m. on 2/20/11. Knowledge of Hypothermia-assessment and treatment: In an interview on 4/25/11 at 2:47 p.m. LPN #17 admitted she did not know the stages of hypothermia and did not know the importance of rewarming the core by administration of warm liquids or any other means. LPN #17 admitted she did not administer warm liquids to Resident #101 upon his return from an elopement of approximately 30 minutes outdoors in blizzard conditions while inadequately dressed for the weather conditions. LPN #17 admitted she was responsible for Resident #101's care on the day shift on 2/20/11 and she admitted she was the nurse who received him upon his return from the elopement episode. In an interview on 4/26/11 at 3:00 p.m. LPN #25 stated she was responsible for Resident #101 on the second shift which began at 2:00 p.m. on 2/20/11. LPN #25 stated she was aware that Resident #101 had been found walking on a busy street 0.7 miles from the Facility in blizzard conditions and was missing for an unknown period of time. LPN #25 stated she did not perform any type of physical assessment on Resident #101 during her shift on 2/20/11 as "first shift did it." LPN #25 stated the stages of hypothermia were "cold, sleepy, then feel warm" and the treatment was "keep them warm. Put warm packs in the groin and on the neck. Warm towels in hot water and then put them into plastic bags and wrap the bag in a dry towel and put it in the groin." LPN #25 denied any knowledge of warming from the core and giving warm fluids or of the dangers of driving the cold into the core by dilating blood vessels in the extremities by application of external heat such as the "warm packs to the groin." ( & )