Every finding on record at Holland Home - Raybrook Manor

This citation pertains to intake #2808946.Based on interview and record review, the facility failed to ensure residents received care in accordance with professional standards in 3 residents (Resident #101, #103 & #106) of 6 residents reviewed for quality of care, resulting in an immediate jeopardy for 1 resident (Resident #101) when, beginning on 2/28/26 at approximately 8:00 AM, Resident #101 had an acute change of condition and staff failed to accurately assess, monitor and notify the physician, resulting in Resident #101 being transported to the hospital on 3/1/26 (approximately 24 hours later) due to unresponsiveness, hypertensive (high blood pressure) and fever. Resident #101 was evaluated and diagnosed with an acute basal ganglia hemorrhagic (bleeding in brain) stroke, admitted to the hospital and died on 3/8/26. This deficient practice placed all residents at risk for serious harm, injury and/or death. The facility also failed to identify symptoms of a UTI (urinary tract infection) for Resident #103 resulting in harm when Resident #103 did not receive prompt treatment leading to death from severe sepsis and acute kidney failure. The facility failed to adequately monitor and assess Resident #106 after an acute change in condition was identified on 6/18/26.Findings include:The immediate jeopardy began on 2/28/26 and was identified on 6/17/26 due to the facility's failure to accurately assess and identify an acute change in condition for Resident #101 and notify the physician, resulting in a delay in medical treatment and death due to an acute hemorrhagic stroke. On 6/17/26 at 4:35 PM, the Director of Nursing (DON) B was verbally notified and the Nursing Home Administrator (NHA) A received written notification of the Immediate Jeopardy. The surveyor confirmed that the immediate Jeopardy was removed on 6/18/26 but noncompliance remains at the scope of isolated and severity of actual harm due to not all staff had received the education and sustained compliance has not been verified by the State Agency.Resident #101Review of an admission Record revealed Resident #101 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: hypertensive heart disease (heart condition caused by long-term high blood pressure).Review of Resident #101's Care Plan last revised 11/9/25 revealed, .I require assistance to maintain my self-care related to my cognitive deficits, poor safety insight with need for assistance with dressing, transfers, toileting, and ambulation.Interventions: Bed mobility (rolling from side to side in bed): supervision. Dressing: one person assistance, Eating: set up & supervision.Showers: one assist with bathing.Ambulate to/from the gym using 4 WW (wheeled walker).Review of Resident #101's Hospital Records revealed, History of Present Illness: .presents with altered mental status. Her family saw her on Friday (2/27/26) and they say she was in her normal state of health. On Saturday, they felt she was more tired than normal. They expressed concern to the staff and requested she be watched more closely. This morning the facility called as she was difficult to wake up. She has also been experiencing fevers since yesterday. Her blood pressure upon arrival to ED (emergency department was 230/88.CT (detailed x-ray) imaging showed acute basal ganglia hemorrhage (a life threatening type of stroke where a blood vessel ruptures inside the brain most commonly caused by high blood pressure) .Discussed level of disability she will likely have due to the IPH (Intraparenchymal hemorrhage is a type of stroke that involves bleeding directly into the functional tissue of the brain) and that she will likely have a new cognitive baseline. Also discussed increased morbidity and mortality with IPH.Hospital Course: .On the morning of 3/7 patient was noted to have posturing (stiffness and jerking of the body) after multiple episodes of vomiting overnight, tube feeds were held at that time and repeat head CT without contrast was obtained which showed new intraparenchymal hemorrhage with possible active bleed. She was transferred back to the ICU and neurosurgery was reengaged however there was no surgical intervention indicated at that time. After this event family wished to proceed with comfort and hospice measures and she was subsequently transferred out of the ICU to the general floor. Patient was pronounced expired at 0129 on 3/8/20/2026.Review of EMS report dated 3/1/26 revealed, .Call received: 9:28 AM.On scene: 9:47 AM.Mental status: Unresponsive. BP 190/101.Staff reports that (Resident #101) is A&Ox2 (a person is awake, but they only know who they are and where they are) at baseline and is ambulatory. (Resident #101) did not get out of bed for lunch yesterday and has been declining since.Review of the Resident #101's Transfer to Hospital Form completed by Registered Nurse (RN) E revealed, .Date of Transfer: 3/1/26 at 8:53 AM. Reason for transfer: Unresponsive.Usual Functional status before the acute change of condition: ambulates with assistive device.Usual mental status/Cognitive Function before the acute change of condition: Alert, disoriented, but can follow simple instructions.Review of Resident #101's Progress Note dated 3/1/26 at 9:07 AM written by RN E revealed, CNA notified nurse that resident was lethargic, minimally responsive, and unable to sit on side of the bed. Resident opened eyes when name called but did not respond, unable to take AM medications. BS (blood sugar) 117, BP (blood pressure) 197/77, 102 (heart rate), 20 (respirations), 91% (blood oxygen level) on RA (room air), 101.2 (temperature).Notified on call physician (name redacted). Send to ER (emergency room) for evaluation.Review of Resident #101's Progress Note dated 2/28/26 at 10:03 PM written by RN I revealed, I spoke to resident's daughter (Family Member (FM) L). She was very concerned about resident's increased fatigue and low blood sugar; she had many questions and concerns about her care. She requested that resident's care plan be updated because resident is no longer as independent as she used to be and she will need someone to toilet her and help her get out of bed to keep her from falling. I reassured (FM L) that resident does receive help and staff is present to help with her needs. I told her to call (Nurse Manager (NM) C) if she had additional concerns. It was noted that the physician was not notified.Review of Resident #101's Vital Signs Record revealed the last documented blood pressure, heart rate, respirations or O2 saturation documented was on 2/22/26.Review of Resident #101's Progress Note dated 2/28/26 at 9:39 PM written by RN I revealed, per previous nurse, resident has been sleeping and did not have lunch. During shift, (FM L) visited and called me in to resident's room; she was trying to get resident out of bed, but resident was not following commands. I checked VS (vital signs) which were stable, BS (blood sugar) 101. I gave resident orange juice and stayed with her and daughter. She slowly became more responsive, she said she was feeling tired and wanted to sleep. BS increased to 145. Denied pain or discomfort. (FM L) was very concerned about resident; she called other family members (FM K), and they visited for a while. (Resident #101) ate supper but continued to be very sleepy.Review of Resident #101's Progress Note dated 2/28/26 at 1:47 PM written by Licensed Practical Nurse (LPN) G revealed, Lethargic this shift; did not wake up for lunch; BS of 96 in AM, 136 before lunch; VS are WNL (within normal limits) for her; has been sleeping in bed with both eyes closed; did come down for breakfast; poor appetite; did drink 50% of Glucerna (supplement); drank orange juice and had doughnut with hard-boiled egg; went to sleep shortly after; negative for Covid-19; will continue to monitor; will pass on to oncoming shift. It was noted that the physician was not notified.In an interview on 6/16/26 at 1:46 PM, LPN G reported that during first shift on 2/28/26 Resident #101 was lethargic, not speaking, not eating well and would not get out of bed in the afternoon. LPN G reported that he had not worked with Resident #101 recently but normally the resident would walk to the dining room and fed herself. LPN G had received report from the previous shift that Resident #101 had not been feeling well. LPN G could not remember Resident #101's assessment and/or if the physician had been notified.In an interview on 6/16/26 at 4:21 PM, RN I reported that on 2/28/26 Family Member (FM) L reported that Resident #101 was not her usually self, was very tired, would not get out of bed and did not want to eat. RN I reported that she did a quick assessment and determined that Resident #101 was more tired than usual but RN I did not believe the resident's condition warranted contacting the physician. RN I reported that normally Resident #101 walked to the dining room for meals and fed herself, but that RN I had heard in report from the first shift nurse that Resident #101 was lethargic and did not get up for meals that day. RN I reported that she checked Resident #101's vital signs and they were normal and further explained that she only recorded vital sign results if they were abnormal.In an interview on 6/17/26 at 3:00 PM, RN D reported that she had worked third shift the night before Resident #101 was sent to the hospital. RN D reported that she had not been told about Resident #101 not feeling well and did not have any reason to go into the room that night. RN D reported that Resident #101 stayed in bed, sleeping all night and staff did not report any concerns.In an interview on 6/16/26 at 2:14 PM, RN E reported that she was told in report on 3/1/26 that Resident #101 was not doing well and needed assistance with care. RN E reported that she was notified by staff that Resident #101 was super weak, wouldn't talk, and wasn't able to stand. RN E reported that she assessed Resident #101 and the resident was not at her baseline; she was not responsive, had food in her mouth, and could only partially open her eyes. RN E reported that she checked Resident #101's vital signs and then sent the resident to the hospital.In an interview on 6/16/26 at 2:24 PM, Certified Nursing Assistant (CNA) N reported that staff had been talking about Resident #101 not acting like herself for a couple days; she was not smiling, not walking, not talking and the nurses did not take it seriously.In an interview on 6/17/26 at 2:33 PM, CNA F reported that he had worked with Resident #101 the day before she went to the hospital; she was slouched at the table, would not eat and slept all day. CNA F notified LPN G that Resident #101 did not seem like herself; normally the resident walked, talked, smiled and gave hugs. CNA F reported that he did not see anyone take vitals signs on Resident #101.In an interview on 6/17/26 at 2:22 PM, Restorative CNA (R-CNA) H reported that on 2/28/26 she did not even attempt to work with Resident #101 because staff had informed her that the resident had not gotten out of bed and had not eaten breakfast. R-CNA H reported that just a few days before that, Resident #101 was constantly walking and wanting to be up and around; it was unusual for the resident to be in bed during the day.In an interview on 6/17/26 at 11:30 AM, Nurse Manager (NM) C reported that she was not aware of any changes to Resident #101's health prior to the resident's hospitalization on 3/1/26; NM C had heard that Resident #101 had passed away but had not reviewed the hospitalization any further. NM C reported that Resident #101 had fallen in early February but last she knew, the resident was still walking around and at baseline. NM C reported that Resident #101 was taking a lot of medications for her heart and blood pressure and ideally would have been having her vital signs checked daily. NM C reported that the most recent vital signs documented prior to her hospitalization, were on 2/22/26; NM C noted that vital sign results should always be documented and not written as within normal limits. NM C reported that the Intradisciplinary Team reviewed Resident #101 on 2/24/26 and did not find any changes in her condition; documentation by staff did not reflect any changes to Resident #101 prior to 2/28/26. NM C reported that the nurse and/or CNA should have contacted the manager on call and the physician when they noticed Resident #101 change of condition on the morning of 2/28/26. In an interview on 6/17/26 at 3:21 PM, Primary Care Physician (PCP) J reported that the last he knew, Resident #101 was doing fine and was her normal self. PCP J reported that he was not notified when Residet #101 became lethargic, wouldn't eat, talk and/or walk on 2/28/26. PCP J reported that he would have expected staff to notify him to get further recommendations; adding that Resident #101's blood pressure would be an important assessment due to her history of heart problems.In an interview on 6/18/26 at 9:01 AM, FM K reported that on 2/28/26 FM L talked to a nurse and tried to relay her concerns about Resident #101's condition and the nurse did not take it seriously. Therefore, FM K called the facility later that evening and explained to RN I herself, that the family thought something was seriously wrong with Resident #101; FM K reported the nurse blew her off.On 6/18/26, this surveyor verified the facility completed the following to remove the Immediate Jeopardy:1) Resident #101 no longer resides at the facility.2) On June 17 and June 18 the Director of Nursing and the IDT reviewed current residents for any significant change identified. Physicians are to be notified, and orders received to be implemented for any changes of condition.3) A. Director of Nursing initiated an in-service on 6-18-2026 for licensed nurses and certified nurse aides. Licensed nurses call Nurse Manager and the On Call Physician for any resident demonstrating a change of condition including lethargy, increased fatigue, s/s of stroke, and changes to activities of daily living. Certified nurse aides to utilize the chain of command in reporting change of condition to licensed nurse, nurse manger, then director of nursing. This in-service will continue for each shift until all nurses and certified nurse aides are in-serviced. As of 6-18-2026, 26 of 128 licensed nurses and/or certified nurse aides have been educated. No staff will be allowed to work without having received education.B. On June 17 the Executive Director reviewed the Change of Condition policy. No changes were needed for the Change in Condition Policy.C. On 6-18-2026 interviews with nurses to determine that licensed nurses a) understand the Change of Condition policy and b) can list the symptoms of changes of condition requiring notification. These interviews will be conducted randomly at least 5X each week by the Director of Nursing or Designee until substantial compliance is achieved.D. The interdisciplinary team will continue to review resident changes of condition in morning meeting to determine if appropriate notifications and interventions were implemented for any significant changes in condition.The facility alleges the immediacy with the deficient practice has been removed on June 18, 2026. Although the immediate jeopardy was removed on 6/18/2026, the facility remained out of compliance with a scope of isolated and severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to all staff had not received the in-service education and sustained compliance had not yet been verified by the state agency. Resident #103Review of an admission Record revealed Resident #103 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: parkinson's (a brain disorder that causes problems with movement) and dementia (abnormal changes in the brain that causes loss of memory, language, problem solving, etc). Review of Resident #103's Hospital Records revealed, .Arrival Date/Time: 5/12/26 at 11:01AM. Hospital Course: .concerns for UTI/Sepsis. Brought in by EMS from his nursing home with concerns for decreased alertness and concern for sepsis. Nursing home staff were concerned that he was dealing with a urinary tract infection and was becoming less alert. On route, he went into ventricular tachycardia (fast abnormal heart rhythm) and was unresponsive but still had a pulse. WBC 25.1. Urine Culture: >=100,000 CFU/mL Enterococcus faecalis (an abnormal bacteria found in the urine). Hyperkalemia (condition where potassium level is too high in the blood), V-tach (ventricular tachycardia), Uremia (a life threatening condition where kidneys fail to filter waste from the body), Altered mental status, Pneumonia (an infection in the lungs) of right lower lobe (a part of the lung) due to infectious organism, Sepsis with acute organ dysfunction and septic shock (dangerously low blood pressure and widespread organ failure due to an infection), due to unspecified organism. date of death : 5/16/26.Review of Resident #103's Progress Note dated 5/12/26 at 3:25 PM written by RN E revealed, CNA notified nurse upon arrival that resident was vomiting and didn't look well. VS (vital signs) 155/70, 99.8 (temperature), 107 (heart rate), 26 (respirations), 87% (oxygen saturation in blood) on RA, BS 118. Resident clammy, applied 2L of oxygen via nasal cannula. Resident bladder scanned for >700 (milliliters). Cathed (catheterized: draining urine from bladder) for 800 ml. Urine dark amber, no odor. Resident denies frequency, urgency or dysuria. Resident no void throughout the night. Notified (on call provider) with ok to send to ER.Review of Resident #103's Transfer to the Hospital document revealed, .Date of Transfer: 5/12/26 at 9:44 AM.Reason for transfer: abnormal white blood cell count (high). HR (heart rate) 107, RR (respiratory rate) 26, Temp 99.8, O2 sat 87.Pain location: abdomen.Usual functional status before the acute change in condition: ambulates with human assistance.Usual mental status/cognitive function before the acute change in condition: Alert, disoriented, but can follow simple instructions.Review of Resident #103's Change of Condition Evaluation dated 5/12/26 at 9:34 AM revealed, .continued vomiting, low O2 (oxygen), increased pulse, urinary retention (not able to urinate).Review of Resident #103's relevant Progress Notes prior to hospitalization: 5/12/26 at 6:37 AM: No void this shift. Bladder scan for 733 ml. Unable to st (straight) cath (blockage). Waiting for doctor to call back.5/12/26 at 5:26 AM: Resident had a medium emesis this shift.5/12/26 at 5:24 AM: Unable to obtain CBC (complete blood count blood draw), resident moving around a lot, then said no. Incontinent this shift.5/12/26 at 1:40 AM: Continues on UTI monitoring. No complaints at this time. Fall vitals wnl (within normal limits). Right eye slightly dilated. Dr aware.5/11/26 at 11:06 PM: Received call from (MD Q), I went over resident's new symptoms of emesis, abnormal pupillary response, recent unwitnessed fall and elevated WBC count. Per provider continue monitoring, repeat vital signs q (every) shift, repeat CBC in the morning.5/11/26 at 10:56 PM: Shortly after speaking to on call provider, CNA notified me that resident had vomited. As we were sitting resident up to get him changed, he threw up a large amount of brownish liquid. BP 170/80, pulse 100, pulse ox 95% on room air, temperature 99.0. Pupils sluggish and right greater than left. I called on call again and reported new findings to (NP). She will notify provider and he will return call with further direction.5/11/26 at 10:14 PM: Elevated WBC of 17.1, paged on call provider and spoke to (NP). Resident does not have any clear symptoms of UTI but due to elevated WBC we'll need to place order for UA reflex culture. Continue monitoring resident and call again with any s/s (signs and symptoms) of infection.5/11/26 at 10:03 PM: Resident on UTI monitor for lethargy, decreased appetite, and suprapubic pain. VS WNL, no fever. Resident denies pain yet groans when he readjusts in bed. He also had an episode of emesis earlier today after receiving medications. No further episodes witnessed. He continues on fall charting after unwitnessed fall yesterday. CBC results still pending.5/11/26 at 6:57 PM: Resident started on UTI monitor. VSS (vital signs stable) Temperature 99.1, lethargic and c/o (complaint of) suprapubic pain when touched. Poor appetite. Urine dark yellow no c/o urgency, frequency or dysuria (painful urination) noted. CBC drawn, results pending.5/10/26 at 3:00 AM: Post Fall Evaluation. Fall was not witnessed. Fall occurred in the resident's room. Resident was attempting to self toilet at the time of fall.Resident was using incontinence supplies at time of fall.In an interview on 6/17/26 at 1:37 PM, MD Q reported that Resident #103 was on UTI monitoring prior to hospitalization, which consists of drawing blood, checking vital signs, pushing fluids, and looking for specific symptoms such as dysuria, frequent urination, urgent urination, and urine odor. MD Q reported that Resident #103's blood work clearly met the criteria for a UTI, he had abdominal pain, but he did not have any other criteria to indicate he needed treatment for a UTI. MD Q reported that the staff would need to closely watch behaviors for toileting and incontinence for a resident with dementia to determine if that would meet the UTI measure of frequent or urgent urination. MD Q reported that Resident #103's fall was unspecific and did not point to a UTI or head injury concern. MD Q reported that Resident #103's symptoms were not concerning enough to warrant further evaluation, until he was not able to void and was short of breath.In an interview on 6/16/26 at 2:09 PM, RN E reported that the day before Resident #103 was sent to the hospital he was lethargic, did not get up for lunch, had vomited in the afternoon, and was started on a UTI (urinary tract infection) watch. RN E reported that when she came in the next day she was told in report that Resident #103 had not urinated during the night and that his bladder scan showed urine in the bladder. RN E reported that the CNA's were doing morning rounds and reported that he was not doing well. RN E said that Resident #103's skin was pale, he was shaking and had vomited in bed. RN E reported that the in-house Nurse Practitioner (NP) assessed Resident #103 and sent him to the hospital.In an interview on 6/16/26 at 2:20 PM, CNA N reported that when she went in to check on Resident #103 during morning rounds on 5/12/26; he was breathing hard, sweaty and his face, neck and behind his head was covered in black emesis. CNA N notified RN E and started to clean Resident #103.In an interview on 6/17/26 on 3:10 PM, RN D reported that Resident #103 was very prideful; he always denied needing assistance and/or having pain. RN D reported that staff had to assess his pain in other physical ways because he did not ever complain. In an interview on 6/17/26 at 8:20 PM, CNA O reported that Resident #103 had black vomit on him and was having trouble breathing when they entered his room at approximately 7:30 AM on 5/12/26. CNA O said that the third shift CNA's did not mention any concerns about Resident #103 during report and CNA O was not aware that Resident #103 was being monitored for a UTI. CNA O had noticed for about a week that Resident #103 was more irritable, refusing care, got angry with staff; normally Resident #103 was very sweet and kind to staff. CNA O reported that Resident #103 was in the bathroom a lot and constantly removing his incontinence brief.In an interview on 6/17/26 at 9:28 AM, LPN P that on 5/12/26 very early in the morning (third shift) the CNA's had reported Resident #103 had not voided during the night. LPN P reported that she used the bladder scan and saw there was urine in the bladder, but she wasn't able to catheterize Resident #103 to drain the bladder. LPN P reported that she knew something was going on with Resident #103 but she would have to look at her documentation because it was too long ago. This surveyor read the documentation to LPN P and she replied that must be what happened then.In an interview on 6/17/26 at 12:10 PM, NM C reported that Resident #103 had an unwitnessed fall during the night on 5/10/26 which is a sign of UTI. NM C continued by saying that the next day Resident #103 had a low grade fever, vomiting, was lethargic and refusing to walk therefore, a UTI monitoring was ordered which included a blood draw. NM C reported that the WBC (white blood cell, which is an indicator for infection) was high. NM C reported that from the documentation, the nurse contacted the doctor a couple times to update about symptoms and Medical Director (MD) Q recommended to continue monitoring the resident and recheck blood work in the morning.In an interview on 6/17/26 at 2:37 PM, CNA F reported that Resident #103 frequently changed his own incontinence brief and took himself to the bathroom. CNA F reported that staff would have to monitor Resident #103 for appropriate incontinence hygiene and assist him to the bathroom due to his gait being unsteady. In an interview on 6/17/26 at 3:39 PM, PCP J reported that Resident #103's fall on 5/10/26, his low grade fever, complaints of superpubic (area of abdomen near bladder) pain, emesis (vomit), abnormal pupils (part of the eye that is assessed to ensure the nervous system is functioning properly) and WBC indicating infection are all indicative of a UTI. PCP J reported that and even when specific criteria for UTI is not met, treatment could still be started, and then documentation that the benefits of treating the resident outweighed the risks of not treating would be completed by the physician. PCP J was not the provider that was on-call and contacted regarding Resident #103's symptoms.In an interview on 6/18/26 at 2:18 PM, FM M reported that she was never contacted about Resident #103's fall on 5/10/26 and was not aware that he was being monitored or tested for a UTI, until 5/12/26 when NM C called to report they would be sending Resident #103 to the hospital because they thought he was septic (systemic life threatening condition due to infection) due to a UTI. FM M reported that she waited 90 minutes for Resident #103 at the hospital and when she called back, NM C reported that they were still doing the paperwork. FM M reported that Resident #103 went into cardiac arrest on the way to the hospital and never recovered; he passed away on 5/16/26. FM M reported that Resident #103 did not have a history of frequent UTI's and did not complain about anything, adding that the staff would have to be paying attention to other cues to identify a UTI.In an interview on 6/18/26 at 2:49 PM, NM C reported that it did not appear from documentation that Resident #103's responsible party FM M had been notified about the resident becoming ill, having emesis and getting his blood drawn.Resident #106Review of an admission Record revealed Resident #106 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: severe dementia.In an interview on 6/18/26 at 11:45 AM, RN E reported that she had just observed Resident #106 breathing hard and wheezing, so she notified the provider and family; the provider gave an order to send Resident #106 to the hospital for evaluation but the family would like her to stay in the facility and be treated first before going to the hospital. RN E reported that she had given Resident #106 a breathing treatment and the provider ordered lab work to be completed right away.Review of Resident #106's Progress Note dated 6/18/26 at 12:07 PM revealed, Resident in living area near TV, heard breathing noises. Observed resident who was tachypneic (rapid and shallow breathing). VS (vital signs) BP 186/74, 90 (heart rate), 36 (respirations), 92% (oxygen in blood) on RA (room air), temperature 98.2. Applied 2 L (liters) O2 (oxygen) via nasal cannula (tubing placed at base on nose) for comfort and administered Duoneb (a breathing treatment to open airway and reduce mucus) treatment via mask. Notified (NP) with N.O. (new order) to send to ER to eval.CBC (complete blood count lab order) and CMP (comprehensive blood test) stat (immediately) as well as STAT 2 view x-ray ordered. Son called back and stated that resident was sent out to a dermatologist appointment and it went really badly for her and doesn't think sending her out is the best option. (RN E) Stated we are able to do testing and treatment here while keeping her comfortable. Son stated he wanted to start with that and see what comes from the CXR (chest x-ray) and labs.Review of Resident #106's Progress Note dated 6/18/26 at 3:59 PM revealed, order note: .Azithromycin Tablet 250 mg. for infection.Review of Resident #106's Progress Note dated 6/18/26 at 7:01 PM revealed, CXR and lab results back. Labs WNL, CXR with pneumonia. (NP) notified. Resident 92% on RA. Son notified.It was noted that Resident #106 did not have any progress notes or vital signs recorded for approximately 24 hours, between 7:01 PM on 6/18/26 and 6:07 PM on 6/19/26.Review of Resident #106's Progress Note dated 6/19/26 at 6:07 PM revealed, Resident continues on (antibiotic) for PNA (pneumonia). No adverse side effects noted at this time. VSS. LS (lung sounds) diminished throughout. No crackles or wheezing heard. O2 sat 92% via RA. Resting in bed at this time.Review of Resident #106's Progress Note dated 6/20/26 at 1:54 PM revealed, Resident continues on oral antibiotics with no adverse effects noted. Resident remains afebrile with stable VS.It was noted that Resident #106 did not have any progress notes and or vital signs recorded for greater than 24 hours, between 1:54 PM on 6/20/26 to 7:08 PM on 6/21/26.Review of Resident #106's Progress Note dated 6/21/26 at 7:08 PM written by LPN G revealed, (Resident #106) during dinner started wheezing and blowing snot out of nose. Vitals taken that were as follows: BP 134/75, P (heart rate) 74, T (temperature) 97. RR 22, SpO2 74% RA; started to break out in sweats, put on O2 at 2L per PRN order, put in bed, called on-call (MD Q) with symptoms that ordered VS q (every) shift x 3 days, chest x-ray 2 views, and CBC with CMP for tomorrow. Called DPOA/Son to update on change of condition, stated to send her to hospital if needed, retook VS that were as follows: BP 128/72, P 71, T 97.2, RR 18, SpO2 91% 2L via nasal cannula, will continue to monitor and pass on to oncoming shift.Review of Resident #106's Progress Note dated 6/21/26 at 10:30 PM written by LPN G revealed, (Resident #106) was diaphoretic, cold to touch, lethargic, VS were as follows: BP 135/74, P 71, RR 24, BS 328, T 96 forehead, SpO2 74% 2L O2 via nasal cannula, called 911 for pick up, notified son earlier in night that she may be sent out and he said to send if she needs to be sent, notified on-call (MD Q) that she is being sent out D/T (due to) symptoms present, he stated to send out, notified manager on-call (NM R).Review of Resident #106's Vital Signs Record revealed results from 6/21/26 at 10:40 PM; 6/20/26 at 4:07 PM, 12:46 PM and 12:17 AM; and 6/19/26 at 4:05 PM. There were no results entered for 6/18/26.Review of Resident #106's Hospital Records revealed, .Arrival date/time: 6/21/26 at 11:32 PM.Discharge Summary note: .Sepsis (life threatening response to infection). On arrival she was found to be hypoxic (lack of oxygen to tissue and cells), hypertensive (high blood pressure), and severely hypothermic (low body temperature that can cause vital organs to fail), with unresponsiveness to voice and pain. Initial evaluation revealed leukocytosis (a sign the body is responding to an underlying infection), lactic acidosis (high acidity in the bloodstream due to inadequate oxygen), severe respiratory acidosis (lungs cannot remove carbon dioxide from your body causing body fluids to become too acidic), and acute kidney injury (sudden kidney failure). Chest x-ray. concerning for edema (fluid accumulation in the lungs) versus pneumonia (infection

This citation pertains to intake #2808946.Based on interview and record review the facility failed to notify the physician/designee and resident's responsible party in a timely manner of significant changes in condition for 2 residents (Resident #101 and #103) out of 6 residents reviewed, resulting in a delay in care for an acute basal ganglia hemorrhagic (bleeding in brain) stroke for Resident #101 when the physician was not notified immediately of an acute change in condition and delay in care for Resident #103 when his responsible party was not notified of a fall and an acute change in condition until the resident was being sent to the hospital 2 days later.Findings include:Resident #101Review of an admission Record revealed Resident #101 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: hypertensive heart disease (heart condition caused by long-term high blood pressure).Review of Resident #101's Progress Note dated 3/1/26 at 9:07 AM written by Registered Nurse (RN) E revealed, CNA notified nurse that resident was lethargic, minimally responsive, and unable to sit on side of the bed. Resident opened eyes when name called but did not respond, unable to take AM medications. BS (blood sugar) 117, BP (blood pressure) 197/77, 102 (heart rate), 20 (respirations), 91% (blood oxygen level) on RA (room air), 101.2 (temperature).Notified on call physician (name redacted). Send to ER (emergency room) for evaluation.Review of Resident #101's Progress Note dated 2/28/26 at 10:03 PM written by RN I revealed, I spoke to resident's daughter (Family Member (FM) L). She was very concerned about resident's increased fatigue and low blood sugar; she had many questions and concerns about her care. She requested that resident's care plan be updated because resident is no longer as independent as she used to be and she will need someone to toilet her and help her get out of bed to keep her from falling. I reassured (FM L) that resident does receive help and staff is present to help with her needs. I told her to call (Nurse Manager (NM) C) if she had additional concerns. It was noted that the physician was not notified.Review of Resident #101's Progress Note dated 2/28/26 at 9:39 PM written by RN I revealed, per previous nurse, resident has been sleeping and did not have lunch. During shift, (FM L) visited and called me in to resident's room; she was trying to get resident out of bed, but resident was not following commands. I checked VS (vital signs) which were stable, BS (blood sugar) 101. I gave resident orange juice and stayed with her and daughter. She slowly became more responsive, she said she was feeling tired and wanted to sleep. BS increased to 145. Denied pain or discomfort. (FM L) was very concerned about resident; she called other family members (FM K), and they visited for a while. (Resident #101) ate supper but continued to be very sleepy.Review of Resident #101's Progress Note dated 2/28/26 at 1:47 PM written by Licensed Practical Nurse (LPN) G revealed, Lethargic this shift; did not wake up for lunch; BS of 96 in AM, 136 before lunch; VS are WNL (within normal limits) for her; has been sleeping in bed with both eyes closed; did come down for breakfast; poor appetite; did drink 50% of Glucerna (supplement); drank orange juice and had doughnut with hard-boiled egg; went to sleep shortly after; negative for Covid-19; will continue to monitor; will pass on to oncoming shift. It was noted that the physician was not notified.In an interview on 6/16/26 at 1:46 PM, LPN G reported that during first shift on 2/28/26 Resident #101 was lethargic, not speaking, not eating well and would not get out of bed in the afternoon. LPN G reported that he had not worked with Resident #101 recently but normally the resident would walk to the dining room and fed herself. LPN G had received report from the previous shift that Resident #101 had not been feeling well. LPN G could not remember Resident #101's assessment and/or if the physician had been notified.In an interview on 6/16/26 at 4:21 PM, RN I reported that on 2/28/26 Family Member (FM) L reported that Resident #101 was not her usually self, was very tired, would not get out of bed and did not want to eat. RN I reported that she did a quick assessment and determined that Resident #101 was more tired than usual but RN I did not believe the resident's condition warranted contacting the physician. RN I reported that normally Resident #101 walked to the dining room for meals and fed herself, but that RN I had heard in report from the first shift nurse that Resident #101 was lethargic and did not get up for meals that day. RN I reported that she checked Resident #101's vital signs and they were normal and further explained that she only recorded vital sign results if they were abnormal.In an interview on 6/16/26 at 2:14 PM, RN E reported that she was told in report on 3/1/26 that Resident #101 was not doing well and needed assistance with care. RN E reported that she was notified by staff that Resident #101 was super weak, wouldn't talk, and wasn't able to stand. RN E reported that she assessed Resident #101 and the resident was not at her baseline; she was not responsive, had food in her mouth, and could only partially open her eyes. RN E reported that she checked Resident #101's vital signs and then sent the resident to the hospital.In an interview on 6/17/26 at 11:30 AM, Nurse Manager (NM) C reported that she was not aware of any changes to Resident #101's health prior to the resident's hospitalization on 3/1/26; NM C had heard that Resident #101 had passed away but had not reviewed the hospitalization any further. NM C reported that the nurse and/or CNA should have contacted the manager on call and the physician when they noticed Resident #101 change of condition on the morning of 2/28/26. In an interview on 6/17/26 at 3:21 PM, Primary Care Physician (PCP) J reported that the last he knew, Resident #101 was doing fine and was her normal self. PCP J reported that he was not notified when Residet #101 became lethargic, wouldn't eat, talk and/or walk on 2/28/26. PCP J reported that he would have expected staff to notify him to get further recommendations.In an interview on 6/18/26 at 9:01 AM, FM K reported that on 2/28/26 FM L talked to a nurse and tried to relay her concerns about Resident #101's condition and the nurse did not take it seriously. Therefore, FM K called the facility later that evening and explained to RN I herself, that the family thought something was seriously wrong with Resident #101; FM K reported the nurse blew her off.Resident #103Review of an admission Record revealed Resident #103 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: parkinson's (a brain disorder that causes problems with movement) and dementia (abnormal changes in the brain that causes loss of memory, language, problem solving, etc). Review of Resident #103's Progress Note dated 5/12/26 at 3:25 PM written by RN E revealed, CNA notified nurse upon arrival that resident was vomiting and didn't look well. VS (vital signs) 155/70, 99.8 (temperature), 107 (heart rate), 26 (respirations), 87% (oxygen saturation in blood) on RA, BS 118. Resident clammy, applied 2L of oxygen via nasal cannula. Resident bladder scanned for >700 (milliliters). Cathed (catheterized: draining urine from bladder) for 800 ml. Urine dark amber, no odor. Resident denies frequency, urgency or dysuria. Resident no void throughout the night. Notified (on call provider) with ok to send to ER.Review of Resident #103's relevant Progress Notes prior to hospitalization: 5/12/26 at 6:37 AM: No void this shift. Bladder scan for 733 ml. Unable to st (straight) cath (blockage). Waiting for doctor to call back.5/12/26 at 5:26 AM: Resident had a medium emesis this shift.5/12/26 at 5:24 AM: Unable to obtain CBC (complete blood count blood draw), resident moving around a lot, then said no. Incontinent this shift.5/12/26 at 1:40 AM: Continues on UTI monitoring. No complaints at this time. Fall vitals wnl (within normal limits). Right eye slightly dilated. Dr aware.5/11/26 at 11:06 PM: Received call from (Medical Director (MD) Q), I went over resident's new symptoms of emesis, abnormal pupillary response, recent unwitnessed fall and elevated WBC count. Per provider continue monitoring, repeat vital signs q (every) shift, repeat CBC in the morning.5/11/26 at 10:56 PM: Shortly after speaking to on call provider, CNA notified me that resident had vomited. As we were sitting resident up to get him changed, he threw up a large amount of brownish liquid. BP 170/80, pulse 100, pulse ox 95% on room air, temperature 99.0. Pupils sluggish and right greater than left. I called on call again and reported new findings to (NP). She will notify provider and he will return call with further direction.5/11/26 at 10:14 PM: Elevated WBC of 17.1, paged on call provider and spoke to (NP). Resident does not have any clear symptoms of UTI but due to elevated WBC we'll need to place order for UA reflex culture. Continue monitoring resident and call again with any s/s (signs and symptoms) of infection.5/11/26 at 10:03 PM: Resident on UTI monitor for lethargy, decreased appetite, and suprapubic pain. VS WNL, no fever. Resident denies pain yet groans when he readjusts in bed. He also had an episode of emesis earlier today after receiving medications. No further episodes witnessed. He continues on fall charting after unwitnessed fall yesterday. CBC results still pending.5/11/26 at 6:57 PM: Resident started on UTI monitor. VSS (vital signs stable) Temperature 99.1, lethargic and c/o (complaint of) suprapubic pain when touched. Poor appetite. Urine dark yellow no c/o urgency, frequency or dysuria (painful urination) noted. CBC drawn, results pending.5/10/26 at 3:00 AM: Post Fall Evaluation. Fall was not witnessed. Fall occurred in the resident's room. Resident was attempting to self toilet at the time of fall.Resident was using incontinence supplies at time of fall.In an interview on 6/16/26 at 2:09 PM, RN E reported that the day before Resident #103 was sent to the hospital he was lethargic, did not get up for lunch, had vomited in the afternoon, and was started on a UTI (urinary tract infection) watch. RN E reported that when she came in the next day she was told in report that Resident #103 had not urinated during the night and that his bladder scan showed urine in the bladder.In an interview on 6/17/26 at 9:28 AM, LPN P that on 5/12/26 very early in the morning (third shift) the CNA's had reported Resident #103 had not voided during the night. LPN P reported that she used the bladder scan and saw there was urine in the bladder, but she wasn't able to catheterize Resident #103 to drain the bladder. LPN P reported that she knew something was going on with Resident #103 but she would have to look at her documentation because it was too long ago. This surveyor read the documentation to LPN P and she replied that must be what happened then.In an interview on 6/17/26 at 12:10 PM, NM C reported that Resident #103 had an unwitnessed fall during the night on 5/10/26 which is a sign of UTI. NM C continued by saying that the next day Resident #103 had a low grade fever, vomiting, was lethargic and refusing to walk therefore, a UTI monitoring was ordered which included a blood draw. NM C reported that the WBC (white blood cell, which is an indicator for infection) was high. NM C reported that from the documentation, the nurse contacted the doctor a couple times to update about symptoms and Medical Director (MD) Q recommended to continue monitoring the resident and recheck blood work in the morning.In an interview on 6/18/26 at 2:18 PM, Family Member (FM) M reported that she was never contacted about Resident #103's fall on 5/10/26 and was not aware that he was being monitored or tested for a UTI, until 5/12/26 when NM C called to report they would be sending Resident #103 to the hospital because they thought he was septic (systemic life threatening condition due to infection) due to a UTI.In an interview on 6/18/26 at 2:49 PM, NM C reported that it did not appear from documentation that Resident #103's responsible party FM M had been notified about the resident becoming ill, having emesis and getting his blood drawn.Review of the facility policy Change in resident's condition dated March 2023 revealed, .The resident and/or resident representative and attending physician/designee are notified when the resident's condition, treatment, or status changes, in accordance with regulatory requirements. PROCEDURES: 1. Immediate and Prompt Notifications: a. The nurse/designee will immediately inform the resident, resident's physician and resident representative-consistent with his/her authority-when there is: .ii. a significant change in the resident's physical, mental, or psychosocial status that is a deterioration in the health, mental, or psychosocial status in either life-threatening conditions or clinical complication . c. The nurse/designee will notify the resident, resident's physician and the resident representative for non-immediate changes of condition. d. The nurse will document the notification and record any new orders in the resident's medical record .

Based on interview and record review, the facility failed to document vital signs during acute changes in condition for 2 residents (Resident #101 and #106) of 6 residents reviewed for complete and accurate medical record documentation, resulting in the potential for staff and providers mismanaging care for residents.Findings include: Resident #101Review of an admission Record revealed Resident #101 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: hypertensive heart disease (heart condition caused by long-term high blood pressure).Review of Resident #101's Progress Note dated 3/1/26 at 9:07 AM written by Registered Nurse (RN) E revealed, CNA notified nurse that resident was lethargic, minimally responsive, and unable to sit on side of the bed. Resident opened eyes when name called but did not respond, unable to take AM medications. BS (blood sugar) 117, BP (blood pressure) 197/77, 102 (heart rate), 20 (respirations), 91% (blood oxygen level) on RA (room air), 101.2 (temperature).Notified on call physician (name redacted). Send to ER (emergency room) for evaluation.Review of Resident #101's Progress Note dated 2/28/26 at 10:03 PM written by RN I revealed, I spoke to resident's daughter (Family Member (FM) L). She was very concerned about resident's increased fatigue and low blood sugar; she had many questions and concerns about her care. She requested that resident's care plan be updated because resident is no longer as independent as she used to be and she will need someone to toilet her and help her get out of bed to keep her from falling. I reassured (FM L) that resident does receive help and staff is present to help with her needs. I told her to call (Nurse Manager (NM) C) if she had additional concerns.Review of Resident #101's Vital Signs Record revealed the last documented blood pressure, heart rate, respirations or O2 saturation documented was on 2/22/26.Review of Resident #101's Progress Note dated 2/28/26 at 9:39 PM written by RN I revealed, per previous nurse, resident has been sleeping and did not have lunch. During shift, (FM L) visited and called me in to resident's room; she was trying to get resident out of bed, but resident was not following commands. I checked VS (vital signs) which were stable, BS (blood sugar) 101. I gave resident orange juice and stayed with her and daughter. She slowly became more responsive, she said she was feeling tired and wanted to sleep. BS increased to 145. Denied pain or discomfort. (FM L) was very concerned about resident; she called other family members (FM K), and they visited for a while. (Resident #101) ate supper but continued to be very sleepy.Review of Resident #101's Progress Note dated 2/28/26 at 1:47 PM written by Licensed Practical Nurse (LPN) G revealed, Lethargic this shift; did not wake up for lunch; BS of 96 in AM, 136 before lunch; VS are WNL (within normal limits) for her In an interview on 6/16/26 at 4:21 PM, RN I reported that on 2/28/26 Family Member (FM) L reported that Resident #101 was not her usually self, was very tired, would not get out of bed and did not want to eat. RN I reported that she did a quick assessment and determined that Resident #101 was more tired than usual but RN I did not believe the resident's condition warranted contacting the physician. RN I reported that she checked Resident #101's vital signs and they were normal and further explained that she only recorded vital sign results if they were abnormal.In an interview on 6/17/26 at 11:30 AM, Nurse Manager (NM) C reported that she was not aware of any changes to Resident #101's health prior to the resident's hospitalization on 3/1/26; NM C had heard that Resident #101 had passed away but had not reviewed the hospitalization any further. NM C reported that Resident #101 had fallen in early February but last she knew, the resident was still walking around and at baseline. NM C reported that Resident #101 was taking a lot of medications for her heart and blood pressure and ideally would have been having her vital signs checked daily. NM C reported that the most recent vital signs documented prior to her hospitalization, were on 2/22/26; NM C noted that vital sign results should always be documented and not written as within normal limits. NM C reported that the Intradisciplinary Team reviewed Resident #101 on 2/24/26 and did not find any changes in her condition; documentation by staff did not reflect any changes to Resident #101 prior to 2/28/26. NM C reported that the nurse and/or CNA should have contacted the manager on call and the physician when they noticed Resident #101 change of condition on the morning of 2/28/26. In an interview on 6/17/26 at 3:21 PM, Primary Care Physician (PCP) J reported that the last he knew, Resident #101 was doing fine and was her normal self. PCP J reported that he was not notified when Residet #101 became lethargic, wouldn't eat, talk and/or walk on 2/28/26. PCP J reported that he would have expected staff to notify him to get further recommendations; adding that Resident #101's blood pressure would be an important assessment due to her history of heart problems.Resident #106Review of an admission Record revealed Resident #106 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: severe dementia.Review of Resident #106's Progress Note dated 6/18/26 at 12:07 PM revealed, Resident in living area near TV, heard breathing noises. Observed resident who was tachypneic (rapid and shallow breathing). VS (vital signs) BP 186/74, 90 (heart rate), 36 (respirations), 92% (oxygen in blood) on RA (room air), temperature 98.2. Applied 2 L (liters) O2 (oxygen) via nasal cannula (tubing placed at base on nose) for comfort and administered Duoneb (a breathing treatment to open airway and reduce mucus) treatment via mask. Notified (NP) with N.O. (new order) to send to ER (emergency room) to eval.CBC (complete blood count lab order) and CMP (comprehensive blood test) stat (immediately) as well as STAT 2 view x-ray ordered. Son called back and stated that resident was sent out to a dermatologist appointment and it went really badly for her and doesn't think sending her out is the best option. (RN E) Stated we are able to do testing and treatment here while keeping her comfortable. Son stated he wanted to start with that and see what comes from the CXR (chest x-ray) and labs.Review of Resident #106's Progress Note dated 6/18/26 at 3:59 PM revealed, order note: .Azithromycin Tablet 250 mg. for infection.Review of Resident #106's Progress Note dated 6/18/26 at 7:01 PM revealed, CXR and lab results back. Labs WNL, CXR with pneumonia. (NP) notified. Resident 92% (level of oxygen in blood) on RA. Son notified.It was noted that Resident #106 did not have any progress notes or vital signs recorded for approximately 24 hours, between 7:01 PM on 6/18/26 and 6:07 PM on 6/19/26.Review of Resident #106's Progress Note dated 6/19/26 at 6:07 PM revealed, Resident continues on (antibiotic) for PNA (pneumonia). No adverse side effects noted at this time. VSS. LS (lung sounds) diminished throughout. No crackles or wheezing heard. O2 sat 92% via RA. Resting in bed at this time.Review of Resident #106's Progress Note dated 6/20/26 at 1:54 PM revealed, Resident continues on oral antibiotics with no adverse effects noted. Resident remains afebrile with stable VS.It was noted that Resident #106 did not have any progress notes and or vital signs recorded for greater than 24 hours, between 1:54 PM on 6/20/26 to 7:08 PM on 6/21/26.Review of Resident #106's Progress Note dated 6/21/26 at 7:08 PM written by LPN G revealed, (Resident #106) during dinner started wheezing and blowing snot out of nose. Vitals taken that were as follows: BP 134/75, P (heart rate) 74, T (temperature) 97. RR 22, SpO2 74% RA; started to break out in sweats, put on O2 at 2L per PRN order, put in bed, called on-call (MD Q) with symptoms that ordered VS q (every) shift x 3 days, chest x-ray 2 views, and CBC with CMP for tomorrow. Called DPOA/Son to update on change of condition, stated to send her to hospital if needed, retook VS that were as follows: BP 128/72, P 71, T 97.2, RR 18, SpO2 91% 2L via nasal cannula, will continue to monitor and pass on to oncoming shift.Review of Resident #106's Progress Note dated 6/21/26 at 10:30 PM written by LPN G revealed, (Resident #106) was diaphoretic, cold to touch, lethargic, VS were as follows: BP 135/74, P 71, RR 24, BS 328, T 96 forehead, SpO2 74% 2L O2 via nasal cannula, called 911 for pick up, notified son earlier in night that she may be sent out and he said to send if she needs to be sent, notified on-call (MD Q) that she is being sent out D/T (due to) symptoms present, he stated to send out, notified manager on-call (NM R).Review of Resident #106's Vital Signs Record revealed results from 6/21/26 at 10:40 PM; 6/20/26 at 4:07 PM, 12:46 PM and 12:17 AM; and 6/19/26 at 4:05 PM. There were no results entered for 6/18/26.In an interview on 6/23/26 at 9:40 AM, NM C reported that Resident #106 was positive for pneumonia and started oral antibiotics on 6/18/26; when a resident is on antibiotic it is expected that vitals signs are checked and record every shift and as needed. NM C reported that for Resident #106 staff would have been expected to also check lung sounds during the assessment of vital signs. Review of Resident #106's record with NM C and she concluded that vital signs and assessments were documented on 6/18/26 when the concern started, then once on 6/19/26 (nearly 24 hours later), three times on 6/20/26 (with the last time being at approximately 4:00 PM) and then no further assessments until 6/21/26 at approximately 7:00 PM (>24 hours later) when Resident #106 had another episode of shortness of breath.In an interview on 6/23/26 at 12:56 PM, MD Q reported that once a resident was place on an antibiotic, then vital signs should be checked every shift and as needed.

Based on observation, interview, and record review the facility failed to ensure wheelchairs were kept clean and/or in good repair for 6 (Residents # 2, 52, 36, 6, 46, and 29) of 6 residents reviewed for environment resulting in dirty wheelchairs, wheelchairs with missing or broken parts, and the potential for injury. Findings include:Resident #2:Review of Resident #2's brief interview for mental status, dated 1/29/26, was scored 3 which reflected severely impaired cognition.During an observation and interview on 03/10/2026 at 11:27 AM, Resident #2 was seated in her wheelchair in the activity room. Her wheelchair was visibly soiled with an expansive dried-up splatter of brown/pink material. These stains/spills covered many parts of the wheelchair surface and were most prevalent on the right-hand side. Dried up spilled material was present on the wheelchair frame, seat, cushion, and front and back wheels. The 2 heavily soiled areas covering the surface on the wheelchair wheel that the hand would contact to move the wheelchair were approximately 6 inches long. Resident #2 was confused and unable to answer questions regarding the state of her wheelchair.During an observation on 03/11/2026 at 8:18 AM, Resident #2 was asleep with her wheelchair positioned near her bed. The wheelchair remained visibly soiled. In addition to the stains/spills observed on the right-hand side of the wheelchair previously, there were also more of the pink/brown stains/spills splattered on the left side of the wheelchair under the arm rest and front left tire.During an observation on 03/11/2026 at 12:35 PM, Resident #2 was seated upright in her wheelchair in the dining room for lunch. The stains/spills that were observed previously remained. Resident #2 was observed spilling food along her right-hand side on the wheelchair and on the floor. During an interview on 03/11/2026 at 4:01 PM, Director of Nursing (DON) B confirmed the facility's weekly wheelchair cleaning logs did not show that Resident #2's wheelchair was cleaned for the past 30 days.During an observation on 03/11/2026 at 4:12 PM, Resident #2 was in the activity room, and her wheelchair was still soiled with the stains/spills that were observed on 3/10/2026 and 3/11/2026.During an observation on 03/12/2026 at 8:15 AM, Resident #2 was in the dining room, seated in her wheelchair, and her wheelchair remained soiled as it had been on 3/10/2026 and 3/11/2026. Additionally, the front left inner wheel area was covered in a dried-up yellow material. Review of an email from DON B, dated 3/12/2026 at 7:16 AM, indicated Resident #2 was admitted on [DATE] and there was no documentation available to show when her wheelchair was last cleaned.Review of the facility's 4TH FLOOOR .WHEELCHAIR/WALKER CLEANING SCHEDULE 2026, dated 2/9/26 through 3/11/2026, revealed no documentation that Resident #2's wheelchair was cleaned.Resident #52: Review of Resident #52's brief interview for mental status, dated 2/24/26, was scored 2 which reflected severely impaired cognition.During an observation and interview on 03/10/2026 at 11:28 AM, Resident #52 was seated upright in his wheelchair in the activity room. His right wheelchair foot pedal strap (intended to provide foot support and to prevent slipping) was only attached to the outer side of the foot pedal. The strap was not attached to the inner part of the foot pedal (making the strap non-functional), was not secured, and was resting on the floor. There was no heel strap present on the left wheelchair foot pedal. Resident #52 was confused and unable to answer questions regarding the state of his wheelchair.During an observation on 03/12/2026 at 8:46 AM, Resident #52 was seated upright in his wheelchair in the hallway near the nurses' station with his feet on the foot pedals. The wheelchair's left foot pedal strap was still missing. The right foot pedal's strap was still broken and hung off the outer right side and was resting on the floor.Resident #36:Review of Resident #36's brief interview for mental status, dated 1/6/26, was scored 0 which reflected severely impaired cognition.During an observation and interview on 03/10/2026 at 12:52 PM, Resident #36 was seated upright in his high back wheelchair near the nurses' station. His wheelchair seat was soiled with brown and white debris/stains and chunks of unknown brown material that appeared to be old food. There was debris on the wheelchair frame. The wheelchair had an anti-tip bar (prevents the wheelchair from tipping backwards) on the left side, but the anti-tip bar on the right side was missing. Resident #36 was confused and unable to answer questions regarding the state of his wheelchair. During an observation on 03/10/2026 at 4:10 PM, Resident #36 was seated in his wheelchair in the activity room. Resident #36's wheelchair seat was still soiled as it had been on 3/10/26 at 12:52 PM. The right anti-tip bar was still missing.During an observation on 03/11/2026 at 8:29 AM, Resident #36 was seated upright in his wheelchair and was speaking nonsensically. His wheelchair remained soiled as it had been on 3/10/2026 and some yellow debris was also present. The anti-tip bar on the right side of the wheelchair was still missing. During an observation on 03/11/2026 at 12:25 PM, Resident #36 was seated in his wheelchair near the dining room. The anti-tip bar on the right side of the wheelchair was still missing, and the wheelchair seat remained soiled. During an observation on 03/11/2026 at 2:25 PM, Resident #36 was asleep in bed with his wheelchair near the bed with the back reclined. The wheelchair's seat fabric remained soiled with stains observed previously and there were various pieces of debris on the seat. The debris on the seat included an approximately 1-inch-long piece of material that looked like a green bean. The anti-tip bar on the right side was still missing.During an observation on 03/11/2026 at 3:57 PM, Resident #36 was in his wheelchair near the nurses' station. The anti-tip bar on the right side was still missing, and the back of the wheelchair was slightly reclined. The wheelchair seat remained soiled and there was some white and yellow debris on the wheelchair's framing. The approximately 1-inch-long piece of what appeared to be a green bean was still present.During an interview on 03/12/2026 at 1:03 PM, Nursing Home Administrator (NHA) A confirmed Resident #36's wheelchair anti-tipper bars were discontinued on 3/11/26 and that was when the work order was submitted for maintenance to remove the one remaining anti-tip bar. NHA A confirmed the wheelchair should have had both anti-tip bars in place for the period prior to their removal.During an interview on 03/11/2026 at 4:01 PM, DON B confirmed the facility's weekly wheelchair cleaning logs did not show that Resident #36's wheelchair was cleaned for the past 30 days. DON B confirmed each resident's wheelchair should be cleaned weekly.During an observation on 03/12/2026 at 9:01 AM, Resident #36 was seated in his wheelchair near the dining room. The wheelchair seat on each side of the resident was dirty and soiled with spills/stains.Review of Resident #36's Interdisciplinary Notes, dated 10/17/2023, stated, OT (Occupational Therapy) provided a new wheelchair with anti-tipper.Review of the facility's 4TH FLOOOR .WHEELCHAIR/WALKER CLEANING SCHEDULE 2026, dated Week of 1/19/26, indicated the last time Resident #36's wheelchair was cleaned was documented on 1/21 (1/21/26). Review of an email from DON B, dated 3/12/2026 at 7:16 AM, confirmed that Resident #36's .wheelchair was last cleaned on 1/21/2026 .Resident #6:Review of Resident #6's brief interview for mental status, dated 1/9/26, was scored 2 which reflected severely impaired cognition.During an observation and interview on 03/11/2026 at 4:26 PM, Resident #6 was seated in a wheelchair at a table next to the nurses' station. There was brown and pink material built up on the resident's right wheelchair frame on the areas of the wheel lock, metal frame, and front wheel. The wheelchair cushion Resident #6 was sitting on had some brown staining. Resident #6 was confused and unable to answer questions about the state of her wheelchair.During an observation on 03/12/2026 at 8:20 AM, Resident #6 was observed sitting in her wheelchair eating in the dining room. The right side of the wheelchair was still soiled as it had been on 3/11/26 at 4:26 PM. Resident #46: Review of Resident #46's brief interview for mental status, dated 3/5/26, was scored 6 which reflected severely impaired cognition.During an observation on 03/12/2026 at 8:26 AM, Resident #46 was seated in her wheelchair and eating breakfast in the dining room. Resident #46's left wheelchair anti-tip bar was in disrepair/misaligned as it was angled inwards towards the center line of the wheelchair (instead of being positioned straight back and down). The position of the left anti-tip bar made it so if the wheelchair was to tip backwards, the left anti-tip bar wouldn't have been able to contact the floor as intended.Resident #29:Review of Resident #29's brief interview for mental status, dated 1/15/26, was scored 3 which reflected severely impaired cognition.During an observation and interview on 03/12/2026 at 8:56 AM, Resident #29 was seated in her wheelchair outside the activity room in the hallway. Her wheelchair's right foot pedal was in disrepair as the heel strap wasn't secured as intended. The heel strap was not secured to the foot pedal and was resting on the floor. There was no heel strap on the wheelchair's left foot pedal.Review of the facility's Cleaning environment, resident equipment, and medical devices policy, revised 7/2025, indicated wheelchairs were to be cleaned Weekly. Applying the reasonable person concept, one would desire a clean wheelchair in good repair (having all pieces secured and in place as intended) to be maintained. The residents addressed above, due to impaired cognition, were unable to share their feelings on how the state of their wheelchair made them feel or impacted them.

This citation pertains to intake 2700015Based on interview and record review, the facility failed to protect the resident's right to be free from staff to resident verbal and threat of physical abuse in 1 (Resident #105) of 4 residents reviewed for abuse, resulting in Resident #105 being verbally abused by a staff member and the potential for a decline in mental and psychosocial well-being. Findings include: Resident #105 Review of an admission Record revealed Resident #105 was originally admitted to the facility on [DATE] with pertinent diagnoses which included unspecified dementia and major depressive disorder. Review of Resident #105's Care Plan revealed, I (Resident #105) have a diagnosis of senile dementia, depression, anxiety, and insomnia. Because of this I have a history of behaviors including touching others. I will rub others arms, legs, hands, and chest. This is not thought to be sexual in nature. I will also go into other's rooms, touch other belongings and food .kick at doors and attempt to repeatedly get into locked doors and will eat others food. Date initiated: 12/9/25. Interventions: Assess for contributing causes, such as, infection, electrolyte imbalance. Date Initiated: 12/19/2025. Behavior monitoring program to assist in determining cause and triggers. Date Initiated: 12/19/2025. Divert attention from stimulus and attempt to redirect me if I start to talk negatively about things. Date Initiated: 12/19/2025. Encourage verbalization of any fears or concerns I may have. Date Initiated: 12/19/2025 . Review of the Facility Reported Incident (FRI) dated 11/22/25 revealed, . Allegation: At approximately 6:00 PM on 11/22/25 Certified Nursing Assistant (CNA) F and W reported to Registered Nurse (RN) Y that they witnessed RN K potentially verbally abuse (Resident #105). CNA F and W reported that RN K had stated to Resident #105 that I'm going to kick your a** and When I quit or get fired, I'm going to kick your a**. This was in response to Resident #105 wandering and approaching the medication cart and another resident's room .Conclusion: Due to 4 eyewitness accounts corroborating the statement, I am going to kick your a** was made to Resident #105 by RN K; verbal abuse is substantiated . During an interview on 12/22/25 at 12:49 PM, CNA F reported he had observed Resident #105 trying to open RN K's medication cart and RN K told Resident #105 I am going to kick your as*, and When I quit or get fired, I'm going to kick your a**. CNA F reported the statements made by RN K were inappropriate and could be a form of abuse, so he reported RN K right away. During an interview on 12/23/25 at 9:50 AM, CNA W reported she observed Resident #105 attempting to get into RN K's medication cart and she stated to Resident #105, I am going to kick your a**. CNA W reported that a few minutes later she heard RN K tell Resident #105 that I cannot wait to quit, on my last day I am going to kick your a**. CNA W reported the statements made by RN K immediately. During an interview on 12/22/25 at 12:58 PM, Licensed Practical Nurse (LPN) P reported Resident #105 often wandered through the unit and often required redirection due to Resident #105's dementia diagnosis. LPN P reported she was given report from RN K the day she was suspended for the allegations of verbal abuse towards Resident #105. LPN P reported she did not witness the verbal abuse towards Resident #105, but that RN K told her that she was being investigated for allegations of verbal abuse. LPN P reported RN K told her that she would never actually do that; she was just joking around. This writer attempted to contact RN K on 12/22/25 at 12:59 PM. RN K did not return this writer's call at time of survey exit. During an interview on 12/22/25 at 11:28 AM, Nursing Home Administrator (NHA) A reported he had conducted the investigation for the allegations of verbal abuse from RN K towards Resident #105. NHA A confirmed that he had substantiated that Resident #105 was verbally abused by RN K. NHA A reported that RN K resigned during the investigation. Review of the facility's Abuse Policy last revised 9/2022 revealed, POLICY: Each resident has the right to be free from abuse and neglect. To provide a safe environment for residents, to promote respect, and to set standards of care, the facility will monitor for abuse and investigate all allegations of resident abuse . Definitions: . Verbal Abuse refers to any use of oral, written or gestured language that includes disparaging and/or derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability .

This citation pertains to intake 2693805 and 2707404.Based on interview, and record review, the facility failed to properly store and dispose of medications for 1 (Resident #103) of 7 residents reviewed for medication storage resulting in the potential compromise of medications and/or misappropriation of medications, accidental ingestion, medication errors, and decreased efficacy of medications. Findings include: Resident #103Review of an admission Record revealed Resident #103 was originally admitted to the facility on [DATE] with pertinent diagnoses which included Alzheimer's disease with late onset (disease characterized as progressive memory loss and cognitive decline) and type 2 diabetes (condition where body cannot use insulin correctly and sugar builds up in the blood.)Review of Resident #103's Emergency Medical Services (EMS) report dated 12/13/25 revealed, . Chief complaint: Unresponsive. Secondary complaint: Possible medication overdose . POSITION PT (patient) FOUND/INITIAL SCENE FINDINGS: upon EMS arrival pt was being held upright in a wheelchair . Facility staff reports that patient may have been given his medication as well as another patient's medication. Facility staff is unable to confirm for sure if a medication error occurred and facility staff is unable to say what medications the patient may have been administered. Pt was last seen normal at approximately 1800 (6:00 PM) tonight when his evening medications were administered . Review of the facility's Near Miss report dated 12/13/25 and documented by Nurse Manager (NM) L revealed, Incident Description: Suspected different medications given to Resident #105. Assigned nurse stated that the resident was not available for medications and left the medications in the med cup on top drawer of the med cart . Other info: There was another resident medication cup next to the resident's medication cup on top drawer of the med cart . In an interview on 12/23/25 at 8:29 AM, Nurse Manager I reported she had received a phone call from Licensed Practical Nurse (LPN) C on 12/13/25 that he had to send Resident #103 to the hospital because he was not responsive, and he was worried that he might have given Resident #103 the wrong medication. NM I reported that LPN C told her that he had prepped Resident #103's night medications and realized he was not in his room to take the medications, so he placed the medications in the top drawer of the medication cart and started passing medications to other residents. NM I reported LPN C reported he did not know if he gave Resident #103 the wrong medications, so she started an investigation to determine if Resident #103 was given the wrong medications. NM I reported that she was unable to confirm if LPN C had given Resident #103 the wrong medications. NM I reported that nurses should discard any medications that they are unable to administer, and that LPN C should have discarded Resident #103's pulled medications if he was unable to administer them. NM I reported pre setting medications and preparing more than one resident medications at a time is against the rights of medication administration. In an interview on 12/22/25 at 10:46 AM, LPN C reported that he was the nurse caring for Resident #103 when he had a change in condition and was sent to the hospital. LPN C reported that around 6:00 pm, He had pulled Resident #103's night medications, and he discovered that Resident #103 was not on the unit when he went to his room, so he was not able to administer Resident #103 his medications. LPN C reported he took the pulled medications for Resident #103 back to his medication cart and placed them in the top drawer of his cart, and he began to pull medications for a different resident. LPN C reported that he gave Resident #103 the medications he had pulled earlier when he returned to the unit, and shortly after that, Resident #103 became unresponsive and needed to be sent to the hospital. LPN C reported that he did tell Resident #103's family member and Nurse Manager I that he could have given the wrong medications to Resident #103. LPN C confirmed that he should have discarded Resident #103's medications, and that he knew that he was not supposed to pull medications for more than one resident at a time. LPN C reported that he was busy, overwhelmed, and trying to get ahead, and he knew he was not storing or passing medications correctly, and his likelihood for causing a medication error were increased due to this. During an interview on 12/22/25 at 1:50 PM, Director of Nursing (DON) B reported she had been made aware that LPN C reported that he could have given Resident #103 the wrong medications. DON B confirmed that the facility conducted an investigation into the potential medication error, but that they could not confirm if Resident #103 had been given the wrong medications. DON B confirmed that LPN C was not following the rights of medication administration and he should have discarded Resident #103's medication instead of storing them in the medication cart. Review of the facility's Medication Administration Policy last revised April 2024 revealed, POLICY: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the medication management system in the facility. The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions . Procedures: . Administration: 14. If medications are unable to be administered after preparation, the nurse will discard those medications and contact the pharmacy for replacement doses .

Based on observation, interview, and record review, the facility failed to 1.) implement documented intervention and provide adequate supervision to prevent a fall for 1 (Resident #8) resident and 2.) safely transport 2 (Resident #27 and #42) residents in their wheelchairs with foot pedals of 5 residents reviewed for accidents/hazards/falls, resulting in a fall with fracture and a significant change in health status (Resident #8) and the potential for falls for Resident #27 and #42. Findings include: Resident #8 Review of an Admission Record revealed Resident #8 was a female, with pertinent diagnoses which included: fracture of nasal bones (1/23/25), other fracture of third [NAME] (lumbar) vertebra (1/23/25). Review of an Minimum Data Set (MDS) dated [DATE] revealed Resident #8 had a BIMS score of 10/15 indicating mild cognitive impairement and required supervision when transfering to the toilet, was occassionally incontinent of urine, and had late onset Alzheimer's disase. Review of the Significant Change in Status Minimum Data Set (MDS) assessment for Resident #8, with a reference date of 1/27/25 (conducted after Resident #8's fall) revealed a Brief Interview for Mental Status (BIMS) score of 2, out of a total possible score of 15, which indicated Resident #8 was severely cognitively impaired. Review of Resident #8's Incident Report dated 12/27/24 revealed, Describe the Incident .What was the resident trying to DO? Transferred without staff assistance .Resident's Description: Resident stated I just needed to go to the bathroom .Root Cause: Resident uses items with wheels as walker Was Care plan reviewed: yes Care plan revisions: Remove items with wheels . Review of Resident #8's Care Plan for the period beginning 10/7/24 revealed the focus of (Resident #8) is at a risk for falls and injury related to impaired mobility, hx (history) of falls, opioids, incontinence & (and) is high risk for falls & OK if I fall & die but does not desire to spend any time out of room on unit with a start date of 7/18/23 with the entirety of care planned interventions which included Be sure call light is within reach and encourage to use it for assistance as needed. Respond promptly to all requests for assistance (start 7/18/23), Keep personal items within reach (start 7/18/23), Keep room and environment free of barriers and clutter (start 7/18/23), Offer toileting with AM/PM (day/evening) care, before and after meals and at (Resident #8's) request (start 7/18/23), Encourage resident to find the O2 (oxygen) line manually, as her vision is limited (start 7/21/23), Ambulate & transfer w/one moderate assist for upper body support using 4ww (4-wheeled walker) & GB (gait belt) (start 10/10/23), Red Dot: Remind visitors to let staff know when they leave if visiting a resident in a resident's room (start 10/10/23), Sign to call for assistance placed on walker (start 11/27/23), Assist to bathroom around 1:00 p.m. daily (start 1/19/24), Non-skin strips to floor in front of toilet (start 2/12/24), Dycem (anti-slip mat) added to recliner to prevent slipping out of chair (start 5/17/24), Anti-rollbacks placed on WC (wheelchair) (Start 7/8/24), Clip placed on call light so that call light can be clipped to front of resident clothing when in bed or recliner (start 7/24/24), Functional activity level is Green. Please refer to Activities Care Plan for non-pharmacological interventions (start 10/30/24). The care plan did not reflect the documented intervention of remove items with wheels. Review of Resident #8's Incident Report dated 1/23/25 at 12:00pm revealed, Describe the Incident: Describe the environment of the incident: Resident lying on face down in front of recliner, tray table pushed forward. Resident wearing blanket. How was staff alerted to the fall? Alarm notified staff, manager ran into resident's room. Where/what was resident doing prior to fall? Resident in recliner eating lunch. What was the resident trying to DO? Attempted to ambulate without assistive device .Resident's Description: Resident unable to describe at this time .If applicable, please describe any abnormalities: Bruising along forehead and down nose, residentalso (sic) bleeding from nose .Resident transferred to hospital: Yes .OTHERS INVOLVED Staff (Registered Nurse (RN) II) Staff (RN-MDS MM) Staff (Certified Nurse Aide (CNA) EE) Was Care plan reviewed: yes Care plan revisions: Resident to be placed in area of Higher Visibility at all times when awake and offer functional activity . Review of Resident #8's History & Physical from (hospital name omitted) dated 1/23/25 at 4:33 PM revealed, .(Resident #8) is a [AGE] year-old female .presented to the ER (emergency room ) after an unwitnessed GLF (ground level fall), with head injury but unclear if she had LOC (loss of consciousness). She was noted to have altered mental status, Baseline A&O (alert and oriented) x 2. On examination patient with obvious facial trauma with raccoon eyes, dried blood in both mouth and nose, no postnasal bloody drip .Imaging studies showed RLL (right lower lobe) atelectasis (collapsed lung) versus pneumonia. Also traumatic L1-3 (parts of the vertebra of the spine) transverse process (a bony projection on the side of the vertebrae) fractures, nasal bone fractures with deviation to right . Review of Resident #8's Physician Office Visit note dated 1/31/25 revealed, History and Physical Recent fall, nasal fracture and lumbar transverse process fractures, general weakness, status post hospitalization Subjective Patient is a very pleasant [AGE] year-old female with multiple medical problems .Patient recently did experience an unwitnessed fall. Due to injuries, she was transferred to the hospital for further evaluation .CT (computed tomography scan - a type of x-ray imaging) of spine did indicate displaced right L1-L3 transverse process fracture .CT maxillofacial (face, mouth, jaws, head, and neck) also showed .bilateral (both sides) nasal fractures with mild rightward displacement .Her DURABLE POWER OF ATTORNEY for healthcare was consulted, and she was admitted to hospice. She has now been discharged back to nursing facility under hospice care with goal of comfort care. Patient is now bed dependent, dependent on nursing staff for all of her ADLs (activities of daily living). She is unable to engage in any kind of conversation. She remains on oxygen . In an interview on 2/4/25 at 12:16 PM, RN-MDS MM reported when Resident #8 fell , she was sitting in her office and heard Resident #8's alarm activate. RN-MDS MM reported when she reached her office door, she heard a thud. RN-MDS MM reported when she got to Resident #8's room (which is located next to RN-MDS MM's office) Resident #8 was lying beside her recliner with her face on the floor on her right side with her right hand under her head and positioned on her right shoulder. RN-MDS MM reported Resident #8 was moaning and was trying to roll over. RN-MDS MM reported she asked an aide to get the nurse who then assessed the resident and got her up into her recliner chair. RN-MDS MM reported the nurse and the CNA took over from there. Review of the Urinary Incontinence care plan with a start date of 2/12/24 revealed Resident #8 was to be offererd toileting with morning/evening care and before and after meals. In an interview on 2/4/25 at 1:37 PM, CNA EE reported she had last seen Resident #8 approximately 20 minutes prior to her fall in her recliner chair when she delivered her lunch meal tray to her on her bedside table. CNA EE did not report having offered Resident #8 to go to the toilet prior to leaving the room after delivering her lunch. CNA EE reported Resident #8 was known to attempt to get up on her own. CNA EE reported at the time of Resident #8's fall, she was on the A hall delivering meal trays. CNA EE reported Resident #8 resided on the B Hall. CNA EE reported at the time of Resident #8's fall, the nurse assigned to B Hall was in the dining room assisting residents to eat. CNA EE reported neither the assigned CNAs nor the nurse were on B Hall at the time of Resident #8's fall and that RN-MDS MM had been in her office and heard Resident #8's alarm and responded. In an interview on 2/5/25 at 9:24 AM, RN II reported she had been in the dining room at the time of Resident #8's fall. RN II reported Resident #8 had been in her room and her lunch tray had just been delivered to her in her recliner chair. In an observation/interview on 2/5/25 at 9:30 AM, Registered Nurse Manager (RNM) DD was queried about Resident #8's 12/27/24 Incident Report with the root cause of Resident uses items with wheels as walker and the care plan revision to Remove items with wheels . RNM DD reported she had been on vacation at the time of the fall but that it was her understanding that Resident #8 had had her bedside table by her and had used that to basically get up and transport herself. At 2/5/25 at 9:40 AM, this surveyor accompanied RNM DD to Resident #8's room to observe her bedside table. The bedside table had wheels, without locks, and a foam lining around the tray portion of the bedside table. In a follow-up interview on 2/5/25 at 9:42 AM, RN-MDS MM reported she could not recall if Resident #8's tray table had wheels when she was found after her fall on 1/23/25 but that there was foam on the tray portion of the bedside table. In a follow-up interview on 2/5/25 at 10:10 AM, RNM DD reported Resident #8 preferred to eat in her room and would get mad when they encouraged her to come out of her room to eat. RNM DD reported because of Resident #8's history of falls, they had initiated an intervention to have her be in higher visibility areas, but that Resident #8 had been adamant about staying in her room. When queried about staff supervision at the time of Resident #8's fall, RNM DD reported CNA EE had been passing trays on the A Hall, the other CNA on duty on that hall had been in the dining room and RN II had been in the dining room, but that RN-MDS MM had been in her office which was next to Resident #8's room. 46999 Resident #27 Review of an Admission Record revealed Resident #27, was originally admitted to the facility on [DATE], with pertinent diagnoses which included: unspecified dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgement) and repeated falls. Review of a Minimum Data Set (MDS) assessment for Resident #27, with a reference date of 1/3/25, revealed the resident could not complete a Brief Interview for Mental Status and his decision making was severely impaired. Section GG revealed Resident #27 used a wheelchair for all mobility. Review of a Care Plan for Resident # 27, with a reference date of 5/2/23, revealed problem/goal/interventions of: Problem: I am at a risk for falls and injury related to impaired mobility .chronic pain .confusion. Goal: I will remain free of injury .Interventions: wheelchair for mobility. During an observation on 2/3/25 at 11:47am, Resident #27 was seated in a wheelchair with his legs extended in front of him, no foot pedals were attached to his chair. CNA CC stated put your feet up as she began to push the resident's wheelchair. Certified Nursing Assistant (CNA) CC pushed him from his room to his seat in the dining room. Resident #27, while holding his legs outward, was maneuvered through 2 steel doorways, and around a group of tables, before he and his wheelchair were placed at table by the windows in the dining room. The distance from Resident #27's room to the table in the dining room was 50'. In an interview on 02/05/25 at 09:42am, Registered Nurse (RN) II reported Resident #27 should have his foot pedals on his wheelchair when staff push him to maintain his safety. RN II reported Resident #27 did not consistently follow directions and did not recognize potentially dangerous situations. During an observation on 2/5/25 at 9:48am, Resident #27 was seated in his wheelchair outside his room, no foot pedals were in place as Licensed Practical Nurse (LPN) CCC pulled the resident's wheelchair backwards approximately 6' before turning the wheelchair around. LPN CCC then pushed Resident #27 into his room, at which time the resident planted his feet on the floor to stop the movement of his wheelchair, and pushed his wheelchair backwards, back into the hallway. During an observation on 2/5/25 at 9:52am, Resident #27 sat in his wheelchair, faced the door of the dining room, and fidgeted with the doorknob. No foot pedals were in place on his wheelchair. CNA J approached the resident, instructed him to lift his feet, as the resident lifted his feet, CNA J turned Resident #27's wheelchair around, and pushed him from the far dining room door to his room with no foot pedals in place. Resident #42 Review of an Admission Record revealed Resident #42, was originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgement) and localized edema (swelling caused by fluid buildup that causes a feeling of heaviness). Review of a Minimum Data Set (MDS) assessment for Resident #42, with a reference date of 1/24/25, revealed a Brief Interview for Mental Status (BIMS) score of 6/15 which indicated Resident #42 was severely cognitively impaired. Section GG revealed Resident #42 relied on a wheelchair for all mobility. Review of a Care Plan for Resident #42, with a reference date of 4/9/24, revealed a problem/goal/interventions of: (Resident #42) is at a risk for falls and injury related to impaired mobility, hx (sic)(history) of falls .depression. Goal: (Resident #42) will be remain free of injury secondary to falls. Interventions: .WC (wheelchair) for long distance. During an observation on 2/3/25 at 2:00pm, Resident #42 was seated in her wheelchair as CNA L pushed the resident from her room at the end of the hall, to the common area of the unit, a total distance of 75'. Resident #42's footrests were attached to her wheelchair, but the actual foot plates (platforms on which the user rests their feet) were folded up, perpendicular to the floor. Resident #42's feet hovered above the floor between the folded-up foot pedals as CNA L pushed her quickly down the hall. In an interview on 2/5/25 at 11:33am, Unit Manager (UM) T reported staff were expected to use foot pedals on resident wheelchairs any time they pushed a resident. UM T reported pushing a resident without proper foot pedals/proper use of foot plates was unsafe and could leave a resident at risk for falling from the chair or having other injuries. In an interview on 2/5/25 at 12:01pm, Director of Nursing (DON) B confirmed for safety purposes, staff should always use foot pedals on resident wheelchairs any time a resident is being pushed. Review of a Wheelchair Foot Pedal, Use of facility policy, with a reference date of 5/2023 revealed: Policy: To promote a safe environment, staff will use foot pedals when propelling residents in wheelchairs. Procedures: 1. Foot pedals must be used at all times when propelling a resident in a wheelchair, regardless of functional abilities. Review of Mosby's Textbook for Long-Term Care Nursing Assistants - E-Book by [NAME] A. [NAME], 6th Edition 2013 titled 'Wheelchair Safety revealed .Make sure the person's feet are on the footplates (foot pedals/rests) 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 1.) protect the residents right to privacy for 1 (Resident #50) of 1 resident reviewed for privacy when staff entered the resident's room without knocking or asking for permission, 2). maintain the confidentiality of the Protected Health Information (PHI) when the Electronic Medical Record (EMR) was left open and unattended in a common area of the facility, resulting in 1.) feelings of frustration and embarrassment (Resident #50) and 2.) potential for unauthorized access to unsecured resident protected health information. Findings include: Review of Nursing Home Resident Rights and Responsibilities, Leading Age Michigan, November 30, 2021, provided by the facility, revealed: This community is dedicated to meeting the highest standards of care and protecting the individual dignity of residents H. Privacy and Dignity: The resident has a right to personal privacy and confidentiality of his or her personal and medical records. During an observation on 2/4/25, at 9:02am, a laptop computer sat on top of a medication cart in the hallway outside room [ROOM NUMBER]. No staff were present in the hallway. The laptop screen was visible from passerby's and displayed the protected health information of an unidentified facility resident. The laptop remained unattended for 6 minutes as several individuals passed by. In an interview on 2/4/25, at 9:08am, Registered Nurse (RN) H reported she was responsible for the unsecured laptop on the medication cart outside room [ROOM NUMBER]. RN H reported the laptop was open with a resident's medical information displayed and should have been closed and locked before it was left unattended. RN H reported she had been busy and must have forgotten to close the laptop when she stepped away. In an interview on 2/5/25 at 11:59 AM, Director of Nursing (DON) B confirmed that an unattended laptop, with resident protected health information displayed in the hallway, was a breach of resident privacy and that staff were expected to ensure laptops were closed before leaving them unattended. 41982 Resident #50 Review of an Admission Record revealed Resident #50 was a female, with pertinent diagnoses which included: major depressive disorder and generalized anxiety disorder. Review of a Minimum Data Set (MDS) assessment for Resident #50 with a reference date of 12/5/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #50 was cognitively intact. In an interview on 2/3/25 at 12:31 PM, Resident #50 reported sometimes when she was in her room getting dressed, staff didn't always knock on the door prior to entering her room and had walked in on her while she was naked. Resident #50 described herself as a [NAME] when she was naked and didn't like people to see her. Resident #50 also reported over the past weekend, Licensed Practical Nurse (LPN) DDD had rushed in to give her insulin while she was on the toilet. Resident #50 reported LPN DDD did end up giving her the insulin while she was on the toilet, and she felt it was very disrespectful to her privacy. Resident #50 reported she had complained to the social worker in the past about staff not always knocking on the door prior to entering her room, and had a meeting scheduled with the social worker to covey her concern about the nurse giving her insulin while she was on the toilet. Attempts were made on 2/4/25 at 2:26 PM and 2/5/25 at 11:41 AM to contact LPN DDD to no avail. In an interview on 2/5/25 at 12:16 PM, Social Worker (SW) Z reported Resident #50 had complained to her in the past that staff were coming into her room without knocking and the facility had put a sign up at one time. SW Z reported was not sure if the sign was still up and that Resident #50 may have taken it down. SW Z reported she had spoken with Resident #50 the day before and that Resident #50 had complained that a nurse had gone into her room to offer her insulin while she was in the bathroom. SW Z reported she did not know that the nurse gave the insulin to Resident #50 but that she assured Resident #50 that they would speak to LPN DDD.

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the dry storage area and ensure proper labeling and dating of foods in the resident refrigerator in 2 dining rooms resulting in the potential to spread food borne illness to all residents that consume food from the kitchen and residents that store food in the dining room refrigerators. Findings include: During a kitchen tour on 2/04/2025 at 9:24 AM, the following items were observed: The dry storage area: 64 fluid ounce of white vinegar in a plastic bottle on the shelf was dripping by the cap onto the side of the container onto the shelf. A box of grape juice concentrate on the shelf was dripping outside of the container onto the box of apple juice concentrate on the shelf below. During a tour of the resident refrigerators in the main dining rooms on 2/04/2025 at 10:24 AM, the following was observed: The 3rd floor resident refrigerator: A plastic bag had room [ROOM NUMBER] written on it and had the following food items in it without a label that indicated the open date and use by date: bag of open baby carrots, open bag of lettuce, a small styrofoam cup half full of sweet potatoes. The 4th floor resident refrigerator: Blueberries were in a small styrofoam cup which was not covered. During the kitchen tour on 2/4/2025 in the morning, Dining Services Manager (DSM) W stated that the items in the dry storage area should have been thrown out. He also indicated that the items in the resident refrigerators in the main dining rooms should have been labeled and dated or thrown out if there wasn't a label and date on it. DSM W said that the nursing staff should be labeling and dating resident food items when putting it in the refrigerator but it's the kitchen's responsibility ultimately. According to the 2022 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions. (A)PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean . 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 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 2022 FDA Food Code section 3-302.11 Packaged and Unpackaged Food -Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by . (4) Except as specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the FOOD in packages, covered containers, or wrappings . Review of the facility policy: Date Marking for Food Safety with a revision date of July 2019 revealed Procedures: Policy Explanation and Compliance Guidelines for Staffing: 2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. 3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. 4. The marking system shall consist of a color-coded label, the day/date of opening, and the day/date the item must be consumed or discarded. Review of the facility policy: Sanitation Inspection with a revision date of July 2019 revealed Policy: It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations. Procedures: Policy Explanation and Compliance Guidelines:1. All food service areas shall be kept clean, sanitary . 3. Inspections will be conducted but not limited to the following areas: a. Dry storage.

Based on interview and record review, the facility failed to maintain dignity and respond to a resident's call light in a timely manner in 1 (Resident #76) of 3 residents reviewed for dignity, resulting in feelings of frustration and the potential for overall decline in quality of life. Findings include: Resident #76 Review of an Admission Record revealed Resident #76 was a female, with pertinent diagnoses which included: anxiety disorder and depression. Review of a Minimum Data Set (MDS) assessment for Resident #76, with a reference date of 1/6/25 revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated Resident #76 was cognitively intact. Further review of said MDS revealed Resident #76 was dependent on staff for toilet transfer (the ability to get on and off a toilet or commode). Review of Resident #76's current Care Plan revealed a focus of I am experiencing occasional urinary incontinence w/ (with) need for assistance to reach toilet, manage incontinent product & (and) LE (lower extremity) weakness associated w/Sciatica (nerve pain in sciatic nerve that runs down one or both legs) with a start date of 1/9/25. In an interview on 2/3/25 at 11:49 AM, Resident #76 reported at times, it had taken up to about an hour for staff to respond to her call light. Resident #76 reported it was frustrating because she often had to use the bathroom, and she could hear staff out in the hallway talking amongst themselves. Review of Resident #76's Alarm History Report revealed the following findings: On 1/2/25, Resident #76's alarm was activated at 7:49:08 AM and completed at 8:20:39 AM, indicating a response time of approximately 31 minutes. On 1/5/25, Resident #76's alarm was activated at 3:38:23 AM and completed at 4:06:01 AM, indicating a response time of approximately 27 minutes. On 1/9/25, Resident #76's alarm was activated at 12:50:39 PM and completed at 1:37:13 PM, indicating a response time of approximately 46 minutes. On 1/12/25, Resident #76's alarm was activated at 10:16:52 AM and completed at 10:44:28 AM, indicating a response time of approximately 27 minutes. On 1/20/25, Resident #76's alarm was activated at 2:16:11 PM and completed at 3:00:39 PM, indicating a response time of approximately 44 minutes. On 1/22/25, Resident #76's alarm was activated at 12:47:56 PM and completed at 1:50:00 PM, indicating a response time of approximately 62 minutes. On 1/27/25, Resident #76's alarm was activated at 6:00:10 PM and completed at 6:51:31 PM, indicating a response time of approximately 51 minutes. In an interview on 2/5/25 at 12:07 PM, Registered Nurse (RN) GG reported the goal for call light response time was less than 10 minutes, but we hope for better. In an interview on 2/5/25 at 12:13 PM, Director of Nursing (DON) B reported call light wait time should be 5 minutes or less but no later than 10 minutes.

Based on interview and record review, the facility failed to resolve resident concerns for 1 (Resident #34) of 1 sampled resident reviewed for resolution of concerns resulting in feelings of frustration and a potential decline in psychosocial and mental well-being. Findings include: Resident #34 Review of Admission Record revealed Resident #34 was originally admitted to the facility on [DATE] with pertinent diagnosis which included functional urinary incontinence (a condition in which the bladder functions normally, but the individual is unable to reach the toilet in time due to physical or cognitive limitations.) Review of a Minimum Data Set (MDS) assessment for Resident #34, with a reference date of 12/6/24 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #34 was cognitively intact. Review of Resident #34's Care Plan revealed, Problem (Resident #34) had urinary incontinence related to decreased mobility, pain, requires staff to assist with transfers and toileting. Interventions: Change/peri care Q2H (every two hours) w (with) rounds during night. WAKE HER UP! . Start date 2/15/24 . During an interview on 2/3/25 at 11:24 AM, Resident #34 reported that she had concerns with the way that some of the staff at the facility treated and cared for her. Resident #34 reported staff would often not change her and she would have to lay in a wet brief for hours at a time. Resident #34 was tearful and reported that some of the staff made her feel bad about herself. Resident #34 stated I can't help it that I need help with these things, I wish I could do them by myself. Resident #34 reported that she had voiced her concerns to management before, and she had no idea if they had done anything about it. Resident #34 confirmed that she was still frequently being left wet and soiled overnight. On 2/4/2025 at 10:52 AM, This writer requested all concern/grievance forms for Resident #34. Nursing Home Administrator (NHA) A did not have any concern/grievance forms for Resident #34, but did upload a copy of an email that NHA A had sent to the facility's Interdisciplinary Team (IDT). Review of the email that NHA A sent to the facility's IDT team dated 11/20/24 revealed, Hello all : (Resident #34) family (Names redacted) had a meeting [NAME] President of Operations (VPO) K to discuss care concerns not resolved . (Resident #34) stating she has been left 50 times soiled in bed for 3 to 5 hours, usually on night shift, just happened last weekend . (Staff that do not do a good job) Licensed Practical Nurse (LPN) F and Former Certified Nursing Assistant (CNA) AAA . During an interview on 2/4/25 at 1:05 PM, NHA A reported that he was made aware of Resident #34's concerns via email from VPO K. NHA A reported that he had forwarded the concerns that were reported to the IDT team and he believed that they addressed Resident #34's concerns during Resident #34's care conference. NHA A reported that Social Worker (SW) Z and Unit Manager (UM) GG were responsible for following up and resolving the concerns Resident #34 had. During an interview on 2/4/25 at 1:57 PM, SW Z reported that she had been made aware of Resident #34's concerns in November 2024. SW Z reported that she thought that she had met with Resident #34, but she was not able to provide documentation of her meeting with Resident #34, or documentation that she had worked to resolve Resident #34's concerns. During an interview on 2/4/25 at 2:05 PM, UM GG reported that she was responsible for following up on Resident #34's concerns. UM GG was not able to provide any documentation or examples of what she had done to resolve Resident #34's concerns. UM GG was unaware that Resident #34 still had concerns with being left wet and soiled. UM GG confirmed that the facility had the ability to review cameras to confirm how often staff were entering into Resident #34's room, but that she had not reviewed the cameras. UM GG reported that she had not investigated Resident #34's allegations of being left wet and soiled for 3-4 hours at a time. UM GG was unable to report why she had not documented Resident #34's concerns on a grievance form. When queried by this writer about Resident #34's concerns with LPN F and Former CNA AAA, UM GG reported that she thought that LPN F and Resident #34 had personality conflicts. UM GG reported that Former CNA AAA no longer worked at the facility, and that she had received disciplinary action, but she could not recall if it was related to Resident #34's concerns. UM GG reported that she had not followed up with Resident #34 to ensure that her concerns had been resolved. Review of CNA AAA's employee file revealed that on 12/2/24, CNA AAA received a Coaching Conversation for Attempting to leave mid cares. When a resident told her to come back CNA AAA told her to talk more nicely because I am helping out of the kindness of my heart . During an interview on 2/5/25 at 11:59 AM, Director of Nursing (DON) B reported that she was not involved in following up on Resident #34's concerns, and that she thought that NHA A had addressed Resident #34's concerns. During a follow up interview on 2/5/25 at 12:11 pm NHA A reported that he had shared Resident #34's concerns with UM GG and asked that Resident #34's concerns be addressed with a care conference. NHA A confirmed that no documentation was present in the medical record regarding a care conference to address the issues. NHA A reported he also had no documentation regarding any staff education or disciplinary action. NHA A confirmed that the staff members listed in the grievance continue to work at the facility . NHA A stated I'm not seeing that any of this was addressed. This writer attempted to contact Former CNA AAA and VPO K during the survey. Former CNA AAA and VPO K were unable to be reached prior to survey exit. Review of the facility's Complaint-Grievance Policy dated 12/2018 revealed, POLICY Residents have the right to voice complaints and grievances to the facility or other agency (as identified in #3 below) without discrimination or reprisal and without fear of discrimination or reprisal. Complaints and grievances can address care and treatment that has or has not been provided; the behavior of staff and of other residents; and other concerns regarding their skilled nursing facility (SNF) stay. DEFINITIONS Voice grievances are not limited to a formal, written grievance process but may include a resident's verbalized complaint to facility staff. Prompt efforts .to resolve includes the facility's acknowledgement of complaint/grievances and active working toward resolution of that complaint/grievance. Procedures: .4. All staff members are responsible for taking immediate action to prevent further potential violations of any resident while an investigation is taking place a. communicating complaints and grievances, either verbal or written, to their supervisor, including immediate reporting of all alleged violations involving neglect, abuse, injuries of unknown source, and/or misappropriation of resident property. (A Registry of Complaint Form may be used for this purpose. See Complaint_Registry of form.)b.maintaining confidentiality of all information associated with the grievance, including the identity of resident for those grievances submitted anonymously . 6. The grievance official of each facility will be the executive director/designee who is responsible for: a. overseeing the grievance process b. receiving and tracking grievances through to their conclusions c. leading and completing any necessary investigations by the facility d. maintaining the confidentiality of all information associated with grievances e. providing a written report if requested by the complainant f. coordinating with state and federal agencies as necessary in light of specific requirements. 7. Follow-up investigation and documentation will be completed as directed by the executive director/designee including: a. completion of investigation b. written submission of the investigative report or status thereof to the complainant, if requested 8. Written decisions must include: a. the date the grievance was received b. a summary statement of the resident's grievance c. steps taken to investigate the grievance d. a summary of pertinent findings or conclusions e. a statement as to whether grievance was confirmed or not confirmed f. any corrective action taken g. the date the written decision was issued 9. If the complainant is not satisfied with the investigation or action taken, the executive director/designee will arrange a meeting with the complainant. 10. Written complaint records and documentation of investigation evidence will be maintained for three (3) years .

Based on interview and record review, the facility failed to report allegations of neglect to the State Agency in a timely manner for 1 (Resident #34) of 1 resident reviewed for neglect, resulting in the potential for continued violations involving neglect going undetected, unreported, or without thorough investigation. Findings include: Resident #34 Review of Admission Record revealed Resident #34 was originally admitted to the facility on [DATE] with pertinent diagnosis which included functional urinary incontinence (a condition in which the bladder functions normally, but the individual is unable to reach the toilet in time due to physical or cognitive limitations.) Review of a Minimum Data Set (MDS) assessment for Resident #34, with a reference date of 12/6/24 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #34 was cognitively intact. Review of Resident #34's Care Plan revealed, Problem (Resident #34) had urinary incontinence related to decreased mobility, pain, requires staff to assist with transfers and toileting. Interventions: Change/peri care Q2H (every two hours) w (with) rounds during night. WAKE HER UP! . Start date 2/15/24 . During an interview on 2/3/25 at 11:24 AM, Resident #34 reported that she had concerns with the way that some of the staff at the facility treated and cared for her. Resident #34 reported staff would often not change her and she would have to lay in a wet brief for hours at a time. Resident #34 was tearful and reported that some of the staff made her feel bad about herself. Resident #34 stated I can't help it that I need help with these things, I wish I could do them by myself. Resident #34 reported that she had voiced her concerns to management before, and she had no idea if they had done anything about it. Resident #34 confirmed that she was still frequently being left wet and soiled overnight. On 2/4/2025 at 10:52 AM, this writer requested all concern/grievance forms for Resident #34. Nursing Home Administrator (NHA) A did not have any concern/grievance forms for Resident #34, but did upload a copy of an email that NHA A had sent to the facility's Interdisciplinary Team (IDT). Review of the email that NHA A sent to the facility's IDT team dated 11/20/24 revealed, Hello all : (Resident #34) family (Names redacted) had a meeting with [NAME] President of Operations (VPO) K to discuss care concerns not resolved . (Resident #34) stating she has been left 50 times soiled in bed for 3 to 5 hours, usually on night shift, just happened last weekend . During an interview on 2/4/25 at 1:05 PM, NHA A reported that he did not report Resident #34's concern of being left wet and soiled for hours at a time to the State Agency. NHA A reported that he had thought that Resident #34's concerns were more care related, and not considered neglect, so he did not think that he needed to get involved with reporting and investigating the concerns. NHA A reported that he could have missed what Resident #34's concerns were, because the concerns had gone through several lines of communication before reaching him. On 2/05/25 at 10:24 AM, this writer attempted to contact VPO K. VPO K was not able to be reached prior to survey exit. In a follow up interview on 2/5/25 at 12:11 pm, NHA A reported he did not consider an allegation as potential neglect unless there was an injury, another type of negative outcome, or if the resident voiced a feeling of being neglected. NHA A reported no investigation was completed regarding the concerns Resident #34 voiced. Review of the facility's Abuse and Neglect Policy dated 9/2022, revealed, POLICY Each resident has the right to be free from abuse and neglect. To provide a safe environment for residents, to promote respect, and to set standards of care, .will monitor for abuse and investigate all allegations of resident abuse, neglect, mistreatment, exploitation, and misappropriation of property.Definitions: Neglect - failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress . 3. All alleged violations involving mistreatment, abuse, exploitation, neglect or misappropriation of property will be thoroughly investigated by the facility under the direction of the executive director / designee and in accordance with state law. 4.will adhere to State of Michigan reporting requirements as follows: a. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the executive director/designee and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures .

Based on observation, interview and record review, the facility failed to revise a person-centered care plan to reflect resident care needs for 1 (Resident #60) of 18 residents reviewed for care planning, resulting in an inaccurate reflection of resident care needs, and a potential for further injury and avoidable pain. Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, v1.16, Chapter 2: Assessments for the Resident Assessment Instrument (RAI), revealed .the resident ' s care plan must be reviewed after each assessment .and revised based on changing goals, preferences and needs of the resident and in response to current interventions .Residents' preferences and goals may change throughout their stay, so facilities should have ongoing discussions with the resident and resident representative, if applicable, so that changes can be reflected in the comprehensive care plan . Resident #60 Review of an Admission Record revealed Resident #60, was originally admitted to the facility on [DATE] with a pertinent diagnosis which included: dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgement). Review of a Minimum Data Set (MDS) assessment for Resident #60, with a reference date of 1/17/25 revealed a Brief Interview for Mental Status (BIMS) score of 2/15 which indicated Resident #60 was severely cognitively impaired. Review of a Care Plan for Resident # 60, with a reference date of 10/17/23, revealed a problem/goal/interventions of: Problem: Need for restorative nursing plan related to potential functional decline. Goal: Resident will maintain functional abilities; will actively participate in restorative program. Interventions: 3x week (3 times per week) ambulate with 4ww (4 wheeled walker, requiring use of both hands) x 80 feet, (exercise equipment name omitted) with BUE (both upper extremities) x 10min). During an observation on 2/3/25 at 9:48am, Resident #60 sat in a wheelchair, in the doorway of her room, a blue sling was noted on her right arm. In an interview on 2/3/25 at 11:27am Case Manager (CM) FFF reported Resident #60 had a recent right humerus (upper arm) fracture and should not exercise or bear weight on her right arm at this time. CM FFF reported the sling was to be used for comfort as the resident tolerated. In an interview on 2/3/25, at 2:45pm, Certified Nursing Assistant (CNA) CC reported she cared for Resident #60 on this date. CNA CC reporte the resident appeared apprehensive about doing anything that might cause pain in her right upper arm, and stated don't hurt me, don't hurt me during cares. CNA CC reported she was not sure if staff were supposed to provide any care that involved moving the resident's right arm, donning or doffing (putting on or taking off) Resident #60's sling. In an interview on 2/4/25 at 3:03pm, Unit Manager (UM) T reported Resident #60 suffered a right humerus fracture on 1/31/25 and per physician orders a sling was applied. UM T reported when a resident has an acute injury, and the physician orders an intervention, the floor nurse should update the care plan at that time. The care plan contained no guidance for staff regarding Resident #60's use of the sling or physical restrictions related to her fracture. UM T reported the Interdisciplinary Team (IDT) met to discuss Resident #60's needs due to her recent fracture and developed a plan for range of motion exercises, but the care plan was not updated. UM T reported it was her responsibility to update a resident's plan of care after the IDT met. UM T confirmed that the interventions listed in Resident #60's plan of care were no longer appropriate and could result in further injury and avoidable pain if they were carried out.

Based on observation, interview, and record review, the facility failed to ensure special eating utensils were provided during meal times in 2 of 2 residents (Resident #55 & #30) reviewed for adaptive equipment, resulting in impaired ability to eat independently and the potential for weight loss. Findings include: Review of the policy/procedure Meal Delivery, revised November 2010, revealed .A defined meal delivery service is followed to ensure delivery of appropriate diet, a dignified dining atmosphere and necessary assistance to promote nutritional health .Nursing staff delivers the food trays to each resident and .Ensures that food items served match meal ticket .Assists with meal set-up .Assists resident as needed with eating, according to his or her Plan of Care .The (Registered Dietitian) or designee arranges and includes in the resident's Plan of Care specific variables to meal delivery to ensure that individualized dietary needs, meal services preferences, and special requests are provided . Resident #55 Review of a Profile Face Sheet revealed Resident #55 was a male, with pertinent diagnoses which included arthritis, depression, and dementia. Review of a current Care Plan for Resident #55 revealed the problem .I am at risk for alteration in nutrition and hydration status r/t (related to) multiple medical problems . with approaches which include .Diet: General, thin liquids .Built up silverware / cup w/ (with) lid for hot liquids . with a start date of 4/28/22. Review of a Quarterly Nutrition Assessment for Resident #55, dated 1/24/25, revealed .Adaptive equipment: cup w/ (with) lid for hot liquids and gray built up utensils .Feeds self w/ meal setup at lunch but staff do provide more assistance w/ dinner . Review of a Quarterly Nursing Note for Resident #55, dated 1/24/25, revealed .He needs set up and adaptive equipment for meals, spouse will assist at times when visiting . Review of a Quarterly Care Conference Note for Resident #55, dated 1/30/25, revealed .(Resident #55) has been eating well. (Registered Dietitian) ordered new built-up silverware for him .Plastic throwaway (utensils) have been put in place r/t an outbreak (of illness) on the floor. Wife voiced she does not like the plastic silverware but does help feed him as best she can . In an observation and interview on 2/3/25 at 12:51 PM, Resident #55 was noted in his recliner in his room with Family Member BBB sitting in a chair beside him. Observed Resident #55's lunch tray on the table nearby, which had been served in a foam container with disposable cutlery. Family Member BBB reported all food items are currently being served with disposable containers and cutlery due to an illness outbreak on the unit. Family Member BBB reported the dietary department has not been sending Resident #55's built-up silverware with his meals. In an observation on 2/4/25 at 11:57 AM, Resident #55 was noted in his recliner in his room. Noted Resident #55's lunch tray had just been delivered. Observed all food items were served in disposable containers, with only disposable plastic utensils provided. No built up utensils were provided to Resident #55 for his lunch meal. In an interview on 2/4/25 at 12:04 PM, Dietitian EEE reported due to the gastrointestinal illness outbreak within the facility, all residents are provided with disposable utensils only. Dietitian EEE reported no special eating utensils/adaptive equipment for meals are being provided at this time. In an observation on 2/5/25 at 8:19 AM, Resident #55 was noted in his recliner in his room. Noted no staff or family present in room at this time. Observed Resident #55's breakfast meal had been served in a foam container with disposable plastic utensils. No built up utensils were provided to Resident #55 for his breakfast meal. In an interview on 2/5/25 at 8:44 AM, Director of Nursing (DON) B reported the purpose of the disposable containers/utensils for meals was to minimize the risk for transmission of gastrointestinal illness. DON B reported residents should still receive special eating utensils/adaptive equipment as ordered or indicated in the care plan. 47659 Resident #30 Review of Admission Record revealed Resident #30 was originally admitted to the facility on [DATE] with pertinent diagnoses which included dysphagia (difficulty swallowing foods) and parkisons disease. Review of a Minimum Data Set (MDS) assessment for Resident #30, with a reference date of 11/15/24 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #30 was cognitively intact. Review of Resident #30's Care Plan revealed, Nutritional Status. (Resident #30) is at risk for alteration in nutrition/hydration status r/t (related to) multiple problems including Parkinson . Interventions: Diet: mech(mechanical) soft gluten and lactose free diet with nectar thick liquids. Cut up food. Supervision, recommended to eat in dining room or high traffic areas. No gravy on my foods. Suction divided plate, red foam on silverware . start date 6/20/24 . During an observation on 2/3/25 at 12:17 PM, Resident #30 was sitting in his wheelchair with his tray table in front of him eating lunch. Resident #30 was struggling to eat as food slipped off of his silverware before he could get the food to his mouth multiple times. Resident #30 also struggled to put more spoonfuls of food in his mouth. It was noted that Resident #30 did not have red foam (adaptive equipment) on his silverware. During an observation on 2/4/25 at 11:58 AM, Resident #30 was sitting in his wheelchair with his tray table in front of him eating lunch. It was noted that Resident #30 did not have red foam on his silverware. During an interview on 2/4/25 at 2:21 PM, Resident #30 reported that the facility had not been providing him with the red foam for on his silverware over the past week. Resident #30 confirmed that the red foam on his silverware made it easier for him to feed himself, and he had been struggling to eat without it. During an interview on 2/4/25 at 2:31 PM, Registered Nurse (RN) H reported that she had delivered Resident #30's lunch tray, and he did not have his red foam on his silverware. During an interview on 2/4/25 at 1:30 PM, Speech Language Pathologist (SLP) QQ reported that Resident #30 should always have the red foam on his, as it was what worked best for Resident #30 to assist him with eating. During an observation on 2/5/25 at 8:35 AM, was sitting in his wheelchair with his tray table in front of him eating breakfast. It was noted that Resident #30 did not have the red foam on his silverware. Resident #30 was struggling to use a spoon to eat cereal and was spilling food off of his spoon frequently.

Based on observation, interview and record review, the facility failed to successfully implement the use of personal protective equipment (PPE) and hand hygiene practices in resident rooms that were under transmission-based precautions (TBP), resulting in a potential for cross contamination and the spread of infectious diseases. This deficient practice has the potential to impact all residents of the facility. Findings include: Review of a facility policy Categories of Transmission Based Precautions(TBP) with a reference date of 7/2024, revealed: Policy: Transmission-based precautions .are used for residents who are known or suspected to have communicable diseases .C. Implement Contact Precautions for residents known or suspected to be infected with microorganisms .don (put on) gloves, gown prior to entering the room .remove and discard gloves and gown before leaving room; perform hand hygiene(if microorganism is known or suspected to be .norovirus, perform hand hygiene with soap and water only). During an observation on 2/3/25 at 11:04am, Unit Manager (UM) T placed a sign on the door frame of room [ROOM NUMBER] that stated: , VISITORS: PLEASE REPORT TO A NURSE BEFORE ENTERING THE ROOM Gloves - Wear gloves when entering the room. Remove gloves and discard before leaving the room. Gown - Wear a gown when you anticipate that your clothing will have substantial contact with resident or environmental surfaces, or when you are unable to contain the infective material. Handwashing- Wash hands before and after each resident encounter. These precautions are in addition to Standard Precautions which are always to be used. UM T also pulled a PPE cart closer to the door of room [ROOM NUMBER] at this time. During an observation on 2/3/25 at 11:02am, Certified Nursing Assistant (CNA) L entered room [ROOM NUMBER] without donning (putting on) a gown or gloves. CNA L placed her bare hands on a lift device the resident had used during toileting and brought the device to the hallway for disinfecting. In an interview on 2/3/25 at 11:15am, UM T reported she found the contact precautions sign for room [ROOM NUMBER] on the floor. UM T reported the resident in room [ROOM NUMBER] was placed in contact precautions for suspected norovirus on 2/1/25. UM T reported staff relied on the signs to tell them what precautions to use when providing cares to residents, but the signs were not staying affixed to the door frames. In an interview on 2/3/25 at 11:21am, CNA L confirmed she did not know the resident in room [ROOM NUMBER] was on contact precautions when she entered the room without the proper PPE. CNA L confirmed there was no sign on the doorframe of room [ROOM NUMBER] when she entered, and that UM T found the sign on the floor. In an interview on 2/3/25 at 11:41am, Licensed Practical Nurse (LPN) XX reported staff share information about resident's who are on precautions with oncoming staff based on the report sheet. LPN XX reported the report sheet for 2/3/25 did not indicate room [ROOM NUMBER] was under contact precautions. During an observation on 2/3/25 at 2:14pm, CNA HH entered room [ROOM NUMBER] using only a surgical mask for PPE. CNA HH assisted the resident of 440 to the restroom. CNA HH exited the restroom and transferred the resident back to his recliner at 2:21pm. At that time, CNA L walked to the doorway of room [ROOM NUMBER] and told CNA HH she needed to use a gown and gloves when caring for the resident of that room. In an interview on 2/3/25 at 3:01pm, CNA HH reported she did not know the resident of room [ROOM NUMBER] was in contact isolation precautions until she was told by CNA L. CNA HH reported she started her shift early on this date and did not receive report from the off going staff. When further queried, CNA HH reported she did not notice the small isolation sign on the door frame of room [ROOM NUMBER] and was confused because the PPE cart was next to his door. CNA HH reported several more residents had been placed in isolation precautions for suspected norovirus since the last time she worked, and she was shocked at how many residents had symptoms. CNA HH reported the facility had not provided any recent education about PPE use and hand hygiene during the facility's norovirus outbreak, but she knew from personal experience that it was necessary to use soap and water to cleanse her hands after caring for a resident with norovirus. In an interview on 2/3/25 at 2:45pm, CNA CC reported the facility had not provided any recent training regarding proper PPE use and hand hygiene when caring for residents with norovirus. When further queried regarding what method of hand hygiene was necessary after caring for a resident with suspected norovirus, CNA CC reported using hand sanitizer was sufficient if the staff member's hands were not visibly soiled. 41982 During an observation on 2/3/25 at 11:49 AM, it was noted that room [ROOM NUMBER] had a Contact Precautions (a set of practices used to prevent the spread of infectious diseases through direct or indirect contact) sign posted on the door. There was no Personal Protective Equipment (PPE) noted outside the door. Review of the posted sign on the door outside room [ROOM NUMBER] revealed, During an observation and interview on 2/3/25 at 12:05 PM, Certified Nurse Aide (CNA) X entered room [ROOM NUMBER] to deliver a meal tray. CNA X was wearing a surgical mask but did not don (put on) gloves nor a gown prior to entering the room. From the hallway, this surveyor overhead CNA X speaking to one of the residents in the room asking the resident if they were sick to which the resident reported that they were. CNA X looked outside the room for PPE and then exited the room. This surveyor queried CNA X if the resident was on Contact Precautions to which CNA X reported she had not seen PPE outside her room, but now saw from the sign that Contact Precautions were in place. When queried as to whether CNA X should have donned gloves and a gown prior to entering the room, CNA X reported she had only gone in the room to deliver a tray and then deferred to Licensed Practical Nurse (LPN) LL. In an interview on 2/3/25 at 12:15 PM, LPN LL was queried as to whether CNA X should have donned gloves and a gown prior to entering a room with Contact Precautions, LPN LL simply stated, I always wear a gown. In an interview on 2/3/25 at 12:28 PM, Registered Nurse (RN) GG reported when delivering a meal tray in a room where Contact Precautions were in place, the expectation was that a surgical mask, gloves, and gown were worn. In an interview on 2/4/25 at 12:02 PM, LPN F reported staff should be gowning up and wearing gloves when delivering a tray to a room with Contact Precautions. In an interview on 2/5/25 at 8:57 AM, Director of Nursing (DON) B reported when staff delivered a tray to a resident in Contact Precautions, staff needed to wear PPE which included a surgical mask, a gown, and gloves. 48637 During an interview on 2/05/2025 at 9:02 AM, Infection Preventionist (IP) N stated that when a resident was on Transmission Based Precautions (TBP), which included contact precautions (set of practices used to prevent the spread of infectious diseases through direct or indirect contact), Personal Protective Equipment (PPE) such as a gown and gloves should be worn by staff when going into the room whether it was to provide care, to deliver meal trays or just to talk to the resident. IP N said if a resident has gastrointestinal issues and was vomiting then staff should wear a mask too. She reported that with TBP rooms, PPE should be put on prior to entering the room and should be taken off prior to exiting the resident room. IP N stated that when staff was in a TBP room, they needed to wash their hands with soap and water before they exited the room. If staff was in a room that wasn't under TBP, IP N said hand sanitizer was acceptable to use unless the hands were visibly soiled and then soap and water must be used.

This citation pertains to intake #MI00142031 Based on interviews and record review, the facility failed to protect the resident's right to be free from verbal, physical and psychosocial abuse by staff, resulting in abuse and the potential of psychosocial harm. Findings include: Review of an Admission Record revealed Resident #80 was a female with pertinent diagnoses which included Alzheimer's disease, visual hallucinations, and dementia moderate with agitation, anxiety. Resident #80 spoke English as a second language. Review of the facility's incident findings report received on 12/24/23 at 9:32 PM, revealed, .Incident Summary: (Certified Nursing Assistant (CNA) F), C N A went to C Hall on the 4th floor after hearing a commotion to assist. (CNA F) reports that (CNA M), C N A, was yelling at (Resident #80), resident. (CNA F) stated that (CNA M) was yelling close to (Resident #80)'s face stating, you are not my only resident, why are you acting this way, I have no time for this. (CNA F) observed (CNA M) grab onto (Resident #80)'s scarf. (CNA F) intervened and removed (Resident #80) from the immediate area. (CNA F) stated she though (CNA Z), C N A observed the occurrence. (CNA M) gave a statement saying that she did say these things to (Resident #80) but did not yell and did not grab her scarf. (CNA M) placed on administrative leave and escorted out of the building. Investigation initiated. (Licensed Practical Nurse (LPN) S), charge nurse, completing skin check . Review of Progress Note dated 12/24/23, revealed, .CNA reports that she witnessed another CNA grab the resident by her scarf and yelled in the residents face, also an LPN reports that she was yelled at by the CNA as well. Initial intervention: resident was removed from CNA's care. Upon skin assessment, LPN and CNA noted 2 small purple bruises on right arm above elbow, and one small purple bruise on left arm above elbow. NP notified, family notified, (Administrator) notified, CNA escorted out of the building . In an interview on 1/15/24 at 11:39 AM, CNA F reported she heard a commotion down that hallway with lot of yelling and disagreement between CNA M and another private duty aide. CNA F reported she had been on break, and she had observed CNA M had Resident #80 by her religious scarf, screaming that she couldn't take care of her all the time, whipped her around in the wheelchair, with Resident #80 about to fall out. CNA F reported she had her by her scarf, pulled tight underneath her chin, screaming in her face - inches from her face. CNA F reported she took Resident #80 and the other resident all the way down the hallway by me. CNA F reported the situation escalated after that and how she had been behaving as she should not be on the floor working with residents. CNA F reported she bawled her eyes out as she had never witnessed that before, worked in long term care for a long time. CNA F reported when Resident #80 was shaking and speaking in her Pakistan language which happened when she was upset. CNA F reported CNA M could have come to any of them and say she needed help or assistance, or she might have needed to get off the floor for a break. In an interview on 1/25/24 at 2:18 PM, CNA Z reported she was standing on the C hall and observed CNA M yelling at the resident, shaking her with both hands on her upper arms, held down, and not able to defend herself. CNA Z reported she intervened, told CMA M to stop and attempted to get in between the two. CNA Z shared that she felt she was not able to protect her fast enough. CNA Z reported Resident #80 couldn't speak for herself, she spoke another language, she was getting agitated and has dementia, it was not just a behavior. CNA Z reported that was not how you would handle a resident with dementia with those types of behaviors, she did not deserve to be verbally, physically, and mentally abused. In an interview on 1/26/24 at 8:48 AM, Licensed Practical Nurse (LPN) S reported she had finished receiving report and a CNA F reported to me they had observed CNA M grabbed and yelled at Resident #80. LPN S reported she contacted the Administrator and informed him of the situation. By this time, CNA F had removed the resident from the area, and she was currently safe. LPN S reported she assessed the resident and completed a skin assessment. LPN S reported the Administrator informed her the accused CNA would need to leave the building. LPN S reported M was escorted out of the building but trying to get her to leave was a task .I was going to call the police .she was irate, kept saying it was her (LPN HH) fault for not helping her . LPN S reported she had to redirect her and told her she had to leave but she stayed yelling and venting and then she finally left. LPN S indicated she was unsure of the event happening because the CNA had a repore with Resident #80 and she adamant denial of events. LPN S reported she completed an assessment and skin assessment for Resident #80. During the skin assessment, LPN S reported she observed there were two small bruises on one arm and the other one had a small bruise, just across from under the deltoid (shoulders) on each side. LPN S reported Resident #80 mostly spoke another language and was alert to self only, so it was hard to determine the psychosocial affects it had on her. LPN S reported Resident #80 was placed in bed where she fell asleep after her assessment. In an interview on 1/26/24 at 9:55 AM, Certified Nursing Assistant (CNA) M reported it was Christmas Eve approximately 7:00 PM. CNA M reported she was on a one to one with Resident #80 and another aide was one to one with another resident. CNA M reported there were call lights on her assigned hallway, but she was unable to attend to them due to being one to one with Resident #80. CNA M reported the nurse on duty, LPN HH did not offer to watch the residents so the two CNAs could answer the call lights and CNA M reported she and LPN HH exchanged loud words because of the multiple call lights and the nurse not assisting the CNAs by supervising the two residents so they could answer the call lights. CNA M did report Resident #80 was seated in her wheelchair at the nurse's station with her chair pulled up to the desk. CNA M reported she had the wheelchair wheels locked as she would propel herself backwards and the resident had slid out/down the front of her chairs. CNA M reported she would pull her out from the desk and readjust her and place her back at the desk. CNA M reported she had gone to break and came back to the allegations of her abusing Resident #80. When this writer interviewed CNA M when asked about the allegation against her she denied the allegations. In an interview on 1/26/24 at 3:13 PM, This writer attempted to speak with Licensed Practical Nurse (LPN) HH in regard to the concern of abuse for Resident #80 and LPN HH stated to, get lost. Review of the written statement for LPN HH revealed, .I was working B cart on 12/24/23 3-11 .During my med pass I walked down to C nurses' station. I was ask by staff if we had an extra CNA to send down to C unit .I said that we had nobody extra but what did they need help with? .(CNA M) CNA yelled that she can't watch (Resident #80) and take care of other resident's needs .I delivered meds to my resident in RM 429, then went back (sic) to C Nurses station. (CNA M) continued to repeat that (Resident #80) is too much she can't get anything done .I offered 2 times to take (Resident #80) so that (CNA M) could take a break or tend to other residents on the 3rd try I told (CNA M) I felt she should leave the floor and take a break I would watch (Resident #80) .(CNA M) just got louder and ignored me .I went and got (LPN S) the nurse so she could address . Review of the facility's investigation dated 1/3/24 at 2:05 PM, revealed, .Investigation Summary Allegation: On 12-24-2023 at approximately 7:15 PM, (CNA F), C N A, heard yelling on the C Hall of the 4th floor and proceeded to provide assistance. (CNA F) observed (CNA M), C N A, yelling at (Resident #80), standing in front of her close to her face. (CNA F) gave a statement indicating (CNA M) was yelling in a disrespectful tone and volume you are not the only resident I have, why do you have to act like this, no time to deal with this. (CNA F) did not hear profanity, name calling or threats. (CNA F) did observe (CNA M) grab the resident's scarf around her head and shoulders. (CNA F) intervened and moved (Resident #80) to another unit and provided activities and notified the charge nurse (LPN S), LPN. (CNA F) had not witnessed (CNA M) be aggressive or yell at a resident previously. Other staff witness statements: (CNA Z), C N A, was the hall partner for (CNA M) on 12-24-2023 and was present for this occurrence. (CNA Z) gave a statement that she witnessed (CNA M) getting in the face of (Resident #80) and grab her scarf and stated in a raised voice, stop acting like that. (CNA Z) did not hear profanity, name calling or threats but described the tone as aggressive. (CNA Z) had not observed (CNA M) be aggressive or yell at a resident previously and considered her good with residents with dementia. (LPN HH), LPN, did not witness the occurrence, but did hear (CNA M) yelling and be disruptive and offered to give her a break to collect herself. (LPN HH) notified (LPN S), the charge nurse for A Hall, that (CNA M) had been disruptive. (LPN HH) had not witnessed (CNA M) be aggressive or yell previously at a resident. (LPN S), LPN, did not witness the occurrence as she was meeting with another nurse at this time, but did observe (CNA M) being disruptive with her peers. (CNA M) was given a break off the floor and (LPN S) contacted the Executive Director to report an allegation of verbal abuse. (LPN S) had not observed (CNA M) previously be aggressive or yell at a resident. (LPN J), LPN, was on duty on A Hall and did not witness the occurrence. (LPN J) had not witnessed (CNA M) be aggressive or yell at a resident previously. The Unit Managers, (Nurse Manager Q), RN and (Nurse Manager, I), RN, had no previous reports or observations of (CNA M) being aggressive with or yelling at residents. (LPN S) stated (CNA M) normally does well with residents with dementia and displayed insight on burn out prevention during a recent discussion in huddle meeting. None of the employees interviewed observed (CNA M) strike (Resident #80) or grab her body. Statement of the alleged employee: (CNA M) denies yelling at (Resident #80) or grabbing her scarf or causing any injury to her or striking her in any way. (CNA M) does admit she readjusted (Resident #80)'s scarf and warned (Resident #80) to stop as she was propelling backwards into a wall. (CNA M) did ask (Resident #80) in a respectful manner after (Resident #80) yelled out, if God would want her to behave that way? (CNA M) denies ever being aggressive with a resident. (CNA M) indicated that (CNA Z) was present in the area when this allegedly occurred and that a statement should be obtained from her. Resident and family statements: (Resident #80) is not interviewable and could not provide a statement. (Family Member R#80), DPOA for (Resident #80), was surprised to hear of the allegation as she had gotten to know (CNA M). (Family Member R380) had not witnessed (CNA M) yell or be aggressive or disrespectful to (Resident #80). (Family Member R#80) did state in retrospect that she noticed a correlation with (Resident #80) to be more likely to experience agitation and restlessness when (CNA M) cared for her. (Two residents), residents on the assignment, did not experience or witness yelling by (CNA M). Review of CCTV video surveillance (no audio): (Administrator), Executive Director, reviewed the video surveillance on the 4th floor for any corroboration of the allegation. At approximately 7:14 PM (CNA M) is observed in front of (Resident #80) with her face lowered and then making physical contact with the scarf with her right hand. Review of personnel file: The personnel file did not indicate any previous discipline or action plans for (CNA M). The file displays documentation of orientation in code of conduct, resident rights, and prevention of resident abuse. There was documentation of pertinent in-services including Dementia Journey on 2-15-2023, Positive Approach to Care on 2-27-2023, Dementia and the New Admit on 8-17-2023 and Abuse Neglect Prevention and Reporting on 10-11-2023. Action Taken (CNA F) and (LPN HH) intervened to protect the resident and separate (CNA M). A statement was taken and (CNA M) was placed on administrative leave and escorted by (LPN S) charge nurse from the building. A skin check was completed by (LPN S) , LPN, and two new small purple bruises on each arm above the elbow were discovered. The last weekly skin check was completed on 12-22-2023 by (Registered Nurse (RN) U), LPN, and no areas of concern were observed. (Social Worker MM),LLBSW, has met with and assessed (Resident #80) and has not observed changes in behaviors or routine with no memory and . Conclusion: there were two corroborating independent interviews ((CNA F), C N A and (CNA Z), C N A) with staff observing yelling and a grab of the resident's scarf with video surveillance corroborating these statements. In the CMS SOM Appendix PP on page 75, an example of mental/ verbal abuse is yelling or hovering over a resident with the intent to intimidate. The allegation of mental/ verbal abuse is substantiated. (CNA M) was discharged from employment on 12-26-2023, while on unpaid administrative leave, for violations of conduct for verbal abuse of a resident and being disruptive in a resident care area . In an interview on 01/26/24 at 02:15 PM, Certified Nursing Assistant (CNA) AA reported the staff had a green card with the information on abuse that was the size of their badges. CNA AA reported they would remove the resident from the situation to ensure their safety, find someone to tell such as the charge nurse, and make the call within two hours to the Nursing home administrator. The number was on the green card for the staff. In an interview on 01/26/24 at 02:22 PM, Certified Nursing Assistant (CNA) E reported they would intervene and take over the situation, inform the nurse, and the Director of Nursing (DON). CNA E reported the staff had green cards, which were given to them by the facility, with information on them for what to do in cases of abuse. In an interview on 01/26/24 at 02:27 PM, Social Worker (SW) MM reported she would ensure the resident was safe, call the Director of Nursing, and the police, if necessary, if she observed a resident being abused by another resident or staff member. In an interview on 01/26/24 at 02:30 PM, Winter CNA reported she received education on abuse and neglect prior to coming to the floor for CNA shadowing. In an interview on 01/26/24 02:44 PM, Nurse Manager, RN I reported first thing the staff member and the resident would be immediately separated, resident would be taken to a safe area, and report to the Administrator and DON immediately. The resident would be assessed for injuries, incident report completed, witness statements would be taken as well as other staff assigned on the hallway. Review of employee file showed the staff member, CNA M on 12/26/23 was terminated from employment. In an interview on 1/26/24 at 4:38 PM, Admininstrator reported he was the abuse coordinator and addressed the abuse concerns. Administrator reported he observed the video recording which did not have volume and he had observed CNA M in Resident #80's personal space, standing over her, flipped her scarf, and it was all disrespectful and intimidating. Administrator reported all the training in the world could not prevent poor judgment. Administrator reported staff receive training at hire, yearly, and usually there were other trainings for abuse as well as the green cards the facility provided to the staff. Review of policy, Abuse and Neglect - Guidelines and Responsibilities revised September 2022, revealed, .Each resident has the right to be free from abuse and neglect.

Based on interview and record review, the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASARR) evaluation was completed for 1 (Resident #63) of 1 residents reviewed for PASARR Screening, resulting in the potential for unmet mental health and psychiatric care needs. Findings include: Resident #63 Review of Resident #63 Minimum Data Set (MDS) dated [DATE] revealed Resident #63, was originally admitted to the facility on [DATE] with pertinent diagnoses which included anxiety, depression, manic depression and post traumatic stress disorder. Review of Resident #63's Preadmission Screening (PAS) Annual Resident Review (ARR) Level I Screening dated 9/18/23 indicated the following: Resident #63 was listed as hospital exempted discharge Questions 1-3 in section II were marked Yes: 1. Resident #63 had a current diagnosis of mental illness. 2. Resident #63 had received treatment for mental illness. 3. Resident #63 had routinely received one or more prescribed antipsychotic or antidepressant medications within the last 14 days. The instructions at the bottom of the page indicated that if any answers to items 1-6 in Section II were marked YES to send one copy to the local Community Mental Health Services program (CMHSP), with a copy of form DCH-3878 if an exemption is requested . Review of Resident #63's Preadmission Screening (PAS) Annual Resident Review (ARR) Level II Screening dated 9/18/23 revealed, Instructions: Must be completed, signed, and dated by a nurse practitioner, physician's assistant, or physician. The patient being screened shall require a comprehensive LEVEL II evaluation UNLESS any of the exemption criteria below is met and certified by a physician's assistant, nurse practitioner, or physician. Indicate which exemption applies . Hospital Exempt Discharge: Yes, I certify that the patient under consideration: 1. Is being admitted after a hospital stay, AND 2. requires nursing facility services for the condition for which he/she received hospital care 3. is likely to require less than 30 days of nursing services . During an interview on 1/25/24 at 2:18 PM, Social Worker (SW) LL reported that Resident #63 did not have any additional II PASARR's completed since 9/19/2023. SW LL reported that the facility should have completed a Level II PASARR as Resident # 63 had remained in the facility longer than 30 days, but this was missed.

Based on observation, interview, and record review the facility failed to ensure residents received care in accordance with professional standards of nursing practice for 2 residents (Resident #9 and #5) of 6 residents reviewed for standard of care when nursing staff failed to sign out narcotic medications after dispensing and administering the medications resulting in inaccurate documentation and the potential for health complications and mismanagement of narcotic medications. Findings include: Resident # 9 Review of an Admission Record revealed Resident #9, was originally admitted to the facility on [DATE] with pertinent diagnoses which included low back pain. Review of Resident #9's Orders revealed, Order: Oxycodone (narcotic pain medication) 5 mg by mouth 4 times as day for pain. Order start date 1/16/24. During an observation on 1/25/24 at 11:31 AM, Registered Nurse (RN) G reviewed Resident #9's medication orders and removed 1 Oxycodone 5 mg tablet from Resident #9's blister pack and placed the medication into a cup with two other non-narcotic medications. It was noted that RN G did not verify the count of the medication in the blister pack with the count on the narcotic count sheet. RN G then placed the medication in a spoonful of pudding, locked her medication cart and computer, and walked to the location that Resident #9 was sitting at. RN G assisted Resident #9 in taking her medication, and then returned to the medication cart and marked the medication as administered in the electronic health record (EHR). RN G then moved on to review medication orders for the Resident #5. It was noted that RN G did not sign out the oxycodone on the narcotic count sheet after she dispensed or administered the oxycodone. Resident #5 Review of an Admission Record revealed Resident #5, was originally admitted to the facility on [DATE] with pertinent diagnoses which included chronic pain. Review of Resident #5's Orders revealed, Order: Methadone ( narcotic pain medication) 10 mg tablet (generic) type MPN-Pain Management - 5 mg Oral By Mouth Four Times a Day for Pain. 5 mg PO (by mouth) QID (4 times daily). During an observation on 1/25/24 at 11:31 AM, Registered Nurse (RN) G reviewed Resident #5's medication orders and removed 1 Methadone tablet from the blister pack and placed the medication into a cup. It was noted that RN G did not verify the count of the medication in the blister pack with the count on the narcotic count sheet. RN G prepared two other non-narcotic medications and placed the medications in the same cup. RN G locked her medication cart and computer and went to the location that Resident #5 was at to administer the medication. RN G assisted Resident #5 in taking the medication, and then returned to the medication cart and marked the medication as administered in the electronic health record (EHR). RN G then moved on to review medication orders for the another resident. It was noted that RN G did not sign out the oxycodone on the narcotic count sheet after she dispensed or administered the oxycodone. During an interview on 1/25/24 at 11:40 AM, RN G reported that nurses were required to verify that the count of medication in the blister pack with the recorded count on the narcotic count sheet for any narcotic medication after they administer the medication. RN G reported that she had forgotten to check the count of the narcotic medications and write down the count on the narcotic count sheet. During an interview on 1/26/24 at 2:49 PM, RN Unit Manger (RN-UM) SS reported that nurses were required to verify the count of all narcotic medications and write down the count immediately after they dispense the narcotics from the blister packs to ensure the count matched the narcotic count sheet. RN-UM SS reported that nurses were expected to write down the narcotic count sheet prior to administering the medication to a resident, and not after.

Based on observation, interview, and record review, the facility failed to properly label, date, and store medications in 3 out of 3 medication carts reviewed for medication storage and labeling resulting in the potential for decreased efficacy of medications and the exacerbation of medical conditions. Findings include: Review of the facility's Storage of Medication policy last revised on ,d+[DATE], revealed, Policy: Medications and biologicals are stored safely, securely, and properly, following manufacture's recommendations or those of the supplier. Procedure: .2. All medications dispensed by the pharmacy will be stored in the container with the pharmacy label. 3. Medication containers that have soiled, illegible, worn, makeshift, incomplete, damaged, or missing labels will be returned to the pharmacy . 9. Process all discontinued, outdated, or deteriorated drugs or biological's per contracted pharmacy policy and procedure . During an observation on [DATE] at 7:48 AM, inspection of the medication cart for rooms ,d+[DATE] revealed an unopened bottle of the prescription for Travatan (prescription eye medication used to treat glaucoma) eye drops. The expiration date on the eye drops was [DATE]. The eye drops did not have a label on them to indicate which resident the eye drops were for. It was also noted that the cart contained one opened Ipratroprium bromide (medication used to treat chronic obstructive pulmonary disease and asthma) inhaler which did not have a label to indicate which resident the inhaler was for. During an interview on [DATE] at 7:48 AM, Registered Nurse (RN) TT reported that all prescription medications in the cart should have a label to indicate which resident the medication is for, and that this was missed with the eye drops and inhaler, and she was not able to identify which resident the medications belonged to. During an observation on [DATE] at 8:34 AM, inspection of the medication cart for rooms ,d+[DATE] revealed one opened medication bottle which contained liquid Nyastatin (Medication used to treat fungal infections). The medication bottle was labeled with a resident name and an dispense date of [DATE], but there was not an expiration date noted on the bottle. During an interview on [DATE] at 8:34 AM, RN UU reported that the resident that the Nyastatin medication was prescribed for was no longer taking the medication, and it should have been disposed of. During an observation on [DATE] at 11:26 AM, inspection of the medication cart for room ,d+[DATE] revealed one open bottle of Guaifenesin (medication used to treat coughs) cough syrup with the dispense date of ,d+[DATE], but no expiration date was noted on the medication. It was also noted that the cart had one Novolog (medication used to treat diabetes) insulin pen and one Glargine (medication used to treat diabetes) insulin pen which both were missing a label to identify which resident the medications were for. During an interview on [DATE] at 11:26 AM, RN G reported that she did not know when the Guaifenesin cough syrup was expired or when the medication should be disposed of. RN G reported that she had opened both the Novolog and Glargine pens on [DATE], but she had missed ensuring that the pens had a resident label on them. During an interview on [DATE] at 2:49 PM, RN Unit Manager TT reported that the facility expectation was for all prescription medications to include an open date, expiration date, and a label that identifies which resident the medication is for and that all medications should be discarded once the resident is no longer taking the medication.

Based on interview and record review, the facility failed to track and offer the pneumococcal vaccine for 3 (Resident #38, #47, and #57) of 5 residents reviewed for immunizations, resulting in a delay in the residents being given the opportunity to receive or decline the pneumococcal vaccination. Findings include: According to the Centers for Disease Control and Prevention (CDC) PCV20 Vaccination for Adults [AGE] years and Older dated 02/09/23, revealed, .Routine vaccination: Adults [AGE] years or older who have- Previously received both PCV13 and PPSV23, AND PPSV23 was received at age [AGE] years or older: Based on shared clinical decision-making, 1 dose of PCV20 at least 5 years after the last pneumococcal vaccine dose . www.cdc.gov/vaccines/hcp/admin/downloads/job-aid-SCDM-PCV20-508.pdf Resident #38: Review of an Admission Record revealed Resident #38 was a male with pertinent diagnoses which included dementia, anemia, seizure disorder, Parkinson's, pressure ulcer left and right buttocks, muscle weakness, and pemphigus (blister disorder). Review of Pneumococcal Vaccine Informed Consent dated 5/3/22, revealed, .Type of Pneumococcal Vaccine: PCV13 .PPSV23 .Permission: Refused .Had both previously .signed on 5/3/22 . Note: No additional consent was completed for the PCV20. Resident #47: Review of an Admission Record revealed Resident # 47was a female with pertinent diagnoses which included dementia, anemia, DVT (blood clot in a deep vein, usually in the legs), thyroid, osteoporosis (condition in which bones become weak and brittle), anxiety, depression, visual impairment, edema, and pain in left and right legs. Review of Pneumococcal Vaccine Informed Consent dated 1/18/23, revealed, .Type of Pneumococcal Vaccine: PCV13 .PPSV23 .Permission: Refused .Previously received .signed on 1/18/23 . Note: No additional consent was completed for PCV20. Resident #57: Review of an Admission Record revealed Resident #57 was a female with pertinent diagnoses which included dementia, progressive supranuclear palsy (uncommon brain disorder that causes serious problems with walking, balance, and eye movements), pain in right knee, and ulcerative colitis (chronic inflammatory bowel disease that causes inflammation in the digestive tract). Review of Pneumococcal Vaccine Informed Consent dated 10/25/23, revealed, .Type of Pneumococcal Vaccine: PCV13 on 1/24/2017 .PPSV23 on 10/7/1999 .PCV15 .PCV20 .Permission: Refused .Had series .signed on 10/25/23 . Note: The PCV 15 or PCV 20 was not offered and declined, those boxed were left blank with no previous vaccination noted for PCV15 or PCV20. No additional consent was provided for the completion of the vaccines, or no declinations were provided. No signature was completed or a notation of contact by phone with the medical responsible party. Review of Immunization Report dated 7/1/23 to 1/25/24 for Influenza, PPSV23, PCV13, PCV15, and PCV20, revealed, .PPSV23: 1 .PCV13: 0 .PCV15: 0 .PCV20: 7 . In an interview on 01/26/24 at 10:40 AM, This writer and the IFP PP reviewed the immunization records for Residents #38, #47, and #57 in their medical records and it was determined they did not receive either the PCV15 or the PCV20 based on their pneumococcal immunization completion dates and timelines designated for the PCV15 or PCV20 immunizations to be provided following the completion of the pneumococcal immunizations. Infection Preventionist (IFP) PP reviewed the CDC (Centers for Disease Control and Prevention) website and reported the change for the pneumonia immunization implementation began on 9/21/23 per her review of the website and the residents should have been offered the additional immunization. Review of policy, Immunizations of Residents revised in July 2023, revealed, .All residents are offered immunizations and vaccinations that aid in preventing infectious diseases unless medically contraindicated, refused by resident/authorized representative, or otherwise ordered by the resident's attending physician or the facility's medical director .4. Pneumococcal Vaccinations - PCV20 and PCV15: a. For adults [AGE] years or older who have not previously received any pneumococcal vaccine: i) Give 1 dose of PCV15 or PCV20 .a) If PCV15 is used, this should be followed by a dose of PPSV23 at least one year later. The minimum interval is 8 weeks and can be considered in adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid lea. (sic) .b) If PCV20 is used, a dose of PPSV23 is NOT indicated .b. For adults [AGE] years or older who have only received a PPSV23: i) Give 1 dose of PCV15 or PCV20 .a)The PCV15 or PCV20 dose should be administered at least one year after the most recent PPSV23 vaccination. b)Regardless of whether PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended. c. For adults [AGE] years or older who have only received PCV13: i) Give PPSV23 as previously recommended a) For adults who have received PCV13 but have not completed their recommended pneumococcal vaccine series with PPSV23, one dose of PCV20 may be used if PPSV23 is not available. If PCV20 is used, their pneumococcal vaccinations are complete .7. Immunization Record - ongoing use of: b. Pneumococcal Vaccination -follow the directions as listed previously. Education and consent must be obtained with each vaccination. Thus, a new consent form must be obtained prior to any administration of the vaccine .

This citation pertains to intake MI 022. Based on observation, interview, and record review the facility failed to ensure a gait belt was used during ambulation for 1 (Resident #6) of 4 residents reviewed for falls resulting in pain, hospitalization , and a subdural hematoma (bleed that occurs within your skull but outside the brain tissue) for Resident #6. Findings include: During an observation and interview on 8/10/22 at 9:30 AM, Resident #6 reported she fell last month, she hit her head, went to the hospital, and she had stitches in the right side of her head. Resident #6 stated the stitches came out a few days ago and reported it was painful when she fell . Resident #6 was observed seated upright in her recliner chair in her room watching television. There was an approximately 3-4-inch-long scar on the top right side of her head with the hair around the area short as if it were shaved recently. During an interview on 8/10/22 at 11:15 AM, Director of Nursing B confirmed Resident #6's scar on her head was a result from the 7/11/22 fall. During an interview on 8/11/22 at 8:13 AM, Certified Nurse Aide (CNA) C reported when she was walking with and through Resident #6's room Resident #6 stepped on the edge of her own pants and fell . CNA C reported it all happened so quickly and she did not have time to grab her, and Resident #6 landed into the wall, hit the back of her head, and when she fell to the floor one of the photograph frames fell off the wall and hit Resident #6 in the head. CNA C reported she immediately went to get help. CNA C reported she thought she had used a gait belt but stated, she probably wasn't wearing one (gait belt) regarding responding staff's reports indicated she didn't have a gait belt on when she was found on the floor and observed by two other staff members with no gait belt on. CNA C confirmed Resident #6 was supposed to have a gait belt on when ambulating in her room as they had been at the time of the fall. CNA C stated, No I did not take a gait belt off the resident when she was on the floor after she fell . CNA C confirmed there was no blood, but stated, Only her head had pain, but didn't recall a pain scale rating. CNA C reported Resident #6 went to the hospital after the fall. Review of Resident #6's care plan, dated 7/11/22, stated, One assist w/(with) GB (gait belt) & walker in room. WC (wheelchair) for distances outside room. Review of Resident #6's Incident report, dated 7/12/12, stated, Was Harmed: Yes .Type of Injury/Harm: Pain .Serious Bodily Injury .Incident Summary: Certified Nurse Aide (CNA) C was completing a 1 assist with (Resident #6) for changing at approximately 7:15 P.M. on 7-11-2022 .Resident tripped on pants and fell making contact with head. CNA C claims she was using a gait belt but responding nurse (Licensed Practical Nurse (LPN) D) did not observe this in her statement. (Resident #6) currently in ICU (intensive care unit) with subdoral (subdural) hematoma at (Hospital Name) hospital .Investigation Summary/Actions Taken: (Resident #6) has a history of [CONDITION(S)] (stroke) and chronic back pain and was care planned to ambulate in room with walker and gait belt with 1 assist (one staff member) .(Resident #6) had made contact with her head and the wall and a picture hanging on the wall also fell and made contact with her head .Upon entering (LPN D) observed there was no gait belt on the resident and that the gait belt needed to be put on (Resident #6) to get her up. Another CNA (Certified Nurse Aide), (CNA E), was in the room to assist getting the resident up and observed the gait belt being put on (Resident #6) and not on the resident during the fall. After the fall, the resident complained of dizziness and neurochecks (after fall assessment tool) indicated resident had difficulty grasping hands, pupils were sluggish and resident displayed difficulty following instructions. Physician gave order for resident to be evaluated at emergency department and was transferred at approximately 2120 (9:20 PM). (Hospital Name) verified that the resident was admitted to intensive care unit with subdural hematoma. Action Taken .Review of the documents on the morning of 7-12-2022 indicated there was a discrepancy in the use of the gait belt during ambulation in the resident room .The responding nurse supervisor (LPN D) and CNA (CNA E) do not support the use of a gait belt as this had to be put on to transfer the resident after the nurse's fall assessment. Conclusion .there is evidence that CNA C used poor judgement and did not have a gait belt on during ambulation in the room with the walker, as designated for this resident in the care guide .Submitted Date/Time: 7/12/2022 12:21 PM. Review of Resident #6's incident/accident report, dated, 7/11/22, stated, Location .Res (resident) Room .Describe the Incident: .Head was against the same wall with heater. Her chin was touching her chest and body stretched out in front of her. How was staff alerted to the fall? staff was assisting her .please describe any abnormalities: C/o (complain of) that her head hurt and her right side of her back was red and bruising .pain level: 6 (out of 10) .Injury Type (1): .Bruise/Contusion .Did resident go to hospital? Y .Is injury life threatening: yes .Does Resident receive anticoagulants: yes . Review of the Discipline Record for Certified Nurse Aide (CNA) C, dated 7/18/22, stated, .failure to use a gait belt during a transfer, failure to use due caution during ambulation of a resident .On July 15, 2022 an investigation concluded that CNA C did not use a gait belt during ambulation of a resident (Resident #6) to the bathroom which was stated on the care guide and is standard policy .Due to the care guide not being followed and the significant injury sustained, this work rule violation warrants termination of employment. Review of Licensed Practical Nurse (LPN) D's interview statement for Resident #6's 7/11/22 fall, dated 7/13/22, stated, Upon entering (Resident #6's room) with CENA (certified nurse aide). Resident (Resident #6) was observed laying on floor with head resting on the wall. After initial assessment of Resident I asked (CNA C) where her gait belt was. As she frantically looked around the room I pointed to her left leg where it was folded up in her pants pocket. She pulled it out and we applied it to Resident's waist .When I stated to (CNA C) You didn't have the gait belt on the Resident when she fell . (CNA C) replied, Yes I did I said when we walked in the room there wasn't a gait belt around the Resident's waist we just put it on together. I also said to (CNA C) that if you would have had it on you could of guided her fall and lowered her to the floor. (CNA C) became quiet and put her head down to finish the fall report. Review of Certified Nurse Aide (CNA) E's interview statement for Resident #6's 7/11/22 fall, undated, stated, The aide (CNA C) came to get me after the accident to help get the resident up. When I walked into the room myself, (Licensed Practical Nurse D), and (CNA C) put the gait belt on the resident and got her off the floor . Review of Resident #6's progress note, dated 7/11/22, stated, CNA (certified nurse aide C) notified this nurse (Licensed Practical Nurse D) that resident had a fall at approximately 19:15 (7:15 PM). When entering the room resident was observed with head against the wall and body stretched out in front of her. Resident stated that her head hurt and her back hurt .CNA (CNA C) notified this nurse at approximately 2025 (8:25 PM) that elder (Resident #6) had emesis (vomit) x1 (once). Pupils sluggish, unable to follow direction, stated that she felt dizzy and that she couldn't grasp this nurses hands or move her BLE (bilateral lower extremities; her legs). Resident appears flushed in her face .Resident was transported via stretcher with (Company Name) ambulance and left approximately 2120 (9:20 PM). Review of Resident #6's emergency department's records, dated 7/11/22, stated, [AGE] year old female (Resident #6) presents with high pre-test suspicion for TBI (traumatic brain injury) [CONDITION(S)]. She is anticoagulated. Had a fall several hours prior to arrival. Hit her head. Sometime later, staff (at facility) noticed diminished levels of arousal .GCS (Glasgow Coma Scale) of 13 (mild head injury score). Patient went to CT (a test/imaging) and has sizable right-side subdural hemorrhage .ED (emergency department) Disposition: hospitalized .Patient (Resident #6) ultimately admitted to surgical intensive care unit for further care for her subdural hemorrhage .Imaging: CT Head without IV Contrast Final Result 1. Large acute right subdural hemorrhage with a maximum thickness of approximately 2.5 cm (centimeters) .Per EMS (emergency medical system) report, this (fall) happened approximately 2 hours prior to arrival to the emergency department .Craniotomy evacuation hematoma (generally done to treat or prevent increased pressure inside the skull, and/or to remove collected blood that is irritating the brain.) Review of Resident #6's progress note, dated 7/22/22, stated, (Resident #6) .admitted here on 07/22/2022 from (Hospital Name) via ambulance, related to diagnosis of Right sided (sided) craniotomy .Skin findings: 10cm (centimeter) incision to left (writer likely meant right side) side of head . Review of Resident #6's progress note, dated 7/22/22, stated, Resident admitted following right sided craniotomy .Resident c/o (complain of) HA (headache) and Tylenol administered with relief .Sutures to right side of head . Review of Resident #6's progress note, dated 7/23/22, stated, Res (resident) admitted s/p (status post; after) R (right) sided craniotomy post (after) fall .Sutures in place to head . Review of Resident #6's progress note, dated 7/24/22, stated, .Recent right craniotomy secondary to subdural hemorrhage . Review of Resident #6's Kardex (Resident information card to direct staff on resident care needs), dated 7/11/22, stated, One assist w/(with) GB (gait belt) & walker in room. WC (wheelchair) for distances outside room. Review of Resident #6's activity of daily living care plan, dated 7/26/22, stated, (Resident #6) has self-care deficit related to history of fall .Resident was admitted for skilled therapy / rehab (rehabilitation) after falling and obtaining a subdural hematoma (a type of bleed inside your head). Resident #6's fall care plan, dated 7/26/22, stated, (Resident #6) is a HIGH risk for falls with severe injury related to impaired mobility, cognition, Hx (history) of frequent falls & prior SDH's (subdural hematomas), anticoagulant use, SDH (subdural hematoma), CLBP (chronic low back pain) & poor safety awareness. Resident #6's coagulation care plan, dated 8/5/22, stated, Potential for altered health maintenance r/t (related to) anticoagulation therapy and increased risk for bruising, bleeding and serious injury. Review of Resident #6's admission report indicated Resident #6 left the facility following the fall on 7/11/22 and returned 7/22/22. Review of Resident #6's diagnoses, dated 8/1/22, stated [NAME] (traumatic) subr hem (subdural hematoma) w/o loss of consciousness and weakness. Review of fall policy, revised 6/2020, stated, The Falls Program will identify residents who are at risk for falls in order to protect residents from injury and to promote resident safety. Review of the facility's Gait Belt Use education form, undated, stated, Gait belts provide a secure and safe hand hold for caregivers while transferring residents .Transfer that ALWAYS require a gait belt: .One Assist-1A .Do not begin resident cares without your gait belt and without reading the care guide. Review of the one-person assist transfer policy, revised 11/2020, stated, Residents who are able to bear weight and assist with turning/pivoting with instruction and/or cueing will be transferred in a safe manner .Apply gait belt by placing the belt around the waist of the resident over clothing .Adjust belt so it is snug (you should be able to slip two fingertips of one hand under the belt.

This citation pertains to Intake: MI 345 Based on interview and record review, the facility failed to provide adequate supervision and implement appropriate care planned interventions to prevent a fall in 1 of 5 residents (Resident #102) reviewed for falls, resulting in a fall with laceration injury to the resident's head and Findings include: Review of Incident Summary dated 8/19/2021, revealed, .Resident had a fall during either a repositioning in bed or transfer out of bed in her room on 8-18-2021 at approximately 9:10pm. (Unit Manager G) discovered possible root cause, during post-fall review, may have been a one person transfer by the (CNA C), when the care guide indicates transfers with two assist. Investigation initiated and employee placed on administrative leave. Resident returned to facility after treatment in the emergency department for a laceration to the head. Physician and family had been notified at the time of the fall occurrence . Review of Investigation Summary/Actions Taken dated 8/24/21 revealed, .Investigation Summary: (CNA C) was assisting (Resident #102) with (Resident #102's) night-time routine. At approximately 9:10 p.m. (CNA C) was assisting Mrs. Buiten who was sitting in her wheelchair next to the bed. (CNA C) placed a gait belt on (Resident #102) and began a transfer to the bed as (Resident #102) had been cooperative during night-time routine. During the transfer (Resident #102) has a misstep as her knee buckled. (CNA C) lost her grip on the gait belt and she attempted to lower (Resident #102) to the floor. During this transfer (Resident #102) made physical contact with her head with the corner of the dresser. At this time (CNA C) called out to the charge nurse, (LPN E), who immediately assessed (Resident #102), provided first-aid for a bleeding scalp injury and provided pain medication. (LPN E) completed a range of motion assessment. An physician order was obtained to send to Emergency Department for treatment of the scalp injury. (Resident #102) is care planned to transfer with two assist and a gait belt, wheelchair for all transportation needs. (CNA C) documents she was aware of the two person transfer status and initiated the transfer rather than waiting for the other (CNA D) to assist as (CNA D) was with another resident. There were five CNA ' s and two nurses on duty at the time of this occurrence for forty residents for a staff/ resident ratio of 1:8 for CNA ' s, 1:6 for all staff. (Resident #102) has been observed functioning at her baseline since the fall with no changes in behavior or routine according to the interdisciplinary team . Action Taken: First aid was administered by the charge nurse and order was received to treat the scalp injury through the Emergency Department. The DPOA and physician were notified of the occurrence. (CNA C) was placed on administrative leave and her statement was taken. (CNA C) is taking responsibility for using poor judgement and transferring with 1 assist rather than 2 and was clear in her written statements she was aware (Resident #102) needs a two person transfer for safety. Education on following the care guide and transferring with two persons when designated has been provided. Conclusion: (CNA C) did not follow (Facility Name) policy with this transfer and will receive a final warning and a suspension without pay during the administrative leave. (CNA C) is being transitioned to an assisted living assignment and will not be eligible to be considered for a skilled nursing assignment for six months . Review of Process Improvement Analysis dated for 4/6/21 and signed by CNA C on 4/7/21, revealed, .Description of Concerns/Issues: * Not following the Care Guide, * This allowed a fall .What are the possible root causes of the concern? * Staff not reading and following the care guide .What Strategies are needed to improve the Process: * Get a new care guide at beginning of each shift .*Read the care guide .* Follow the care guide . Review of Discipline Record dated for 6/1/21 and signed by CNA C on 6/2/21, revealed, .Statement of Violation: Misconduct *#33 Neglect of duties, Careless Workmanship, or failure to meet work performance standards .Investigation Results: *Providing cares and not following care guide .*Resulting in a lower to the floor .Employees Comments during discussion: I apologize for my actions I should have used the gait belt In an interview on 9/8/21 at 2:01 PM, Certified Nursing Assistant (CNA) C stated, .I was bringing her (in her wheelchair) and pushed her over by the bed, locked the wheels, and then I had to get her into the bed .I put the gait belt on her .I was standing right in front of her and like with my hand on her gait belt and on her .She was doing great .She was having a good day and she was letting me help her .And everything was going great and she was doing it and her feet got twisted and she tripped over her foot .She was facing the night stand and I tried to stop it .She hit the front of her head .I was more in a panic at this point and went to get help .I quickly went into the hallway and called for help .She had to be sent out to the hospital . Review of a Face Sheet revealed Resident #102 was originally admitted to the facility on [DATE], with pertinent diagnoses which included Alzheimer's disease, dementia, history of falls, repeated falls, muscle weakness, unsteadiness on feet, and [CONDITION(S)] ([CONDITION(S)] joint disease). Review of Care Plan Resident #102, revised on 5/10/21, revealed the focus, .I have a history of multiple falls r/t (related to) to Alzheimer's dementia, [CONDITION(S)], generalized weakness . with the intervention .2 Assist and Gait belt with transfers . Review of Care Guide for Resident #102 dated 8/19/21 revealed, .Ambulate & Trans: Transfers with two assist and Gait belt. W/C (wheelchair) for all transportation needs .Falls Program: Transfers with two assist . Review of Gait Belt Use reviewed and signed off by CNA C on 1/19/2021, revealed, .Gait belts provide a secure and safe hand hold for caregivers while transferring residents .Gait belt use by the care giver during resident transfer is a standard practice .Transfers that ALWAYS require a gait belt: One Assist-1A, Contact Guard Assist-CGA, Stand by Assist-SBA, Two Assist-2A .Do not begin resident cares without your gait belt and without reading the care guide . In an interview on 9/8/21 at 3:48 PM, Certified Nursing Aide (CNA) D stated, .The thing is we had enough staff on that day .We had just finished getting another resident in the bed .I had to use the restroom and I hadn't even closed the door and CNA C was yelling for help that (Resident #102) had a fall .When I entered the room, there was blood everywhere, (Resident #102) had hit her head on the nightstand next to her bed .I told her (CNA C) I would stay with her to go get the nurse .(Resident #102) had been laying on her forehead and on her side with her head up by her dresser .When we rolled her on to her side and the nurse began to assess the back of her head and there was blood all over .When we moved (Resident #102) was screaming out in pain .Indicating her right side was hurting her .I held the gauze to the back of her head and just held her hand and tried to keep her calm until the Fire Department got there .It happened so quickly .(Resident #102) since coming back here, she is very hesitant with having us assist her with rolling and she is afraid for us to do anything for her .Prior to her fall, she could tell you yes or no but since this happened she is non-verbal .I just don't understand why (CNA C) didn't speak up and say she needed help .We all knew that she was a two person assist and (Resident #102) couldn't pivot anymore and she as declining .She couldn't use her feet or legs .And at times she could be combative so you would want to have someone with you to transfer her .Her nightstand was next to her bed .it has been moved now .The wheelchair was next to the bed facing the nightstand .She had to get a lot of staples .She has like a U shaped scar on her head . In an interview on 9/8/21 at 1:05 PM, Licensed Practical Nurse (LPN) E stated, .I was being called for assistance and went I went into the room, (Resident #102) was on the floor and there was blood underneath her head .I asked (CNA C) what happened and she said the fell when she transferred her .She was trying to get her from her wheelchair to her bed and her legs gave out and she fell over to the side and hit the floor .(Resident #102) didn't want you to touch her at all .She was laying on her right side and next to the bed right in front of the dresser table .I saw blood under her head .So we turned her on to her back and checking her legs and to me one looked shorted than the other .She would scream out in pain I touched her legs and when I got a chance to look at the back of her head she had a huge laceration to the back of her head and it was gushing blood .She had to go out to the hospital .I called 911, doctor, DPOA, and hospice nurse .After she left to the hospital I had asked the CNA how she was for transfer and she said that she is a two person .I asked her who helped her and CNA C stated she transferred her herself and I was upset .as she was not supposed to do that and I told her to make sure on her CNA summary report to make sure that you put that you transferred her by yourself . In an interview on 9/8/21 at 4:07 PM, Director of Nursing (DON) B reported the expectation would be the nursing staff would review the care guide for the resident they are assisting and follow the care guide for transfer status. If a resident was a two person assist, two staff members should be used to transfer the resident. If the staff go in to transfer a resident and discover that the resident was unable to transfer as a two person assist, they can always use the hoyer or the sara (sit to stand).

This pertains to intake MI 245. Based on observation, interview, and record review, the facility failed to prevent an elopement and ensure safety in 1 of 4 residents (Resident #101) reviewed for safety/supervision, resulting in an Immediate Jeopardy when on 9/9/19 at approximately 6:06 P.M., Resident #101 (with a know elopement risk) triggered the wanderguard alarm and exited the unit, unbeknownst to facility staff, and was found at approximately 6:18 P.M. outside of the facility by a facility staff member that had exited the facility for the day. The resident was returned to the facility via wheelchair by staff at approximately 6:29 P.M. This deficient practice placed 4 residents, identified as at risk for elopement, at risk for serious harm, injury, and/or death. Findings include: Review of a facility policy Missing Persons last revised (MONTH) 2014 revealed, Resident will be assessed for elopement potential. Assessment criteria will include but not be limited to history of confusion, history of wandering and/or elopement, verbalization of wanting to leave, and ability to move without assistance. Staff will perform an organized search for a resident who cannot be located and will request the assistance from outside sources as necessary. 1). The following actions will be taken to prevent residents from eloping. a). the social worker/designee will: i). assess residents for elopement potential at the time of admission, quarterly, and or with a change in condition. ii). Obtain current picture of each resident at the time of admission and post it with the medication administration record. Additionally each facility will maintain a process for identifying at risk individuals in a manner that insures the residence right to privacy, dignity, and respect. iii). Develop a plan of care to prevent or reduce wondering and elopement, including appropriate interventions in the residence care guide. iv). Initiate frequent monitoring checks based upon the individual residents needs and behavior .2). The decision to discontinue frequent monitoring checks will be made by the interdisciplinary team and based upon assessment criteria that include but are not limited to recent behaviors, presence of agitation and/or confusion, and attempts to leave unit .4). The security system will also be inspected on a monthly basis by facility services .5). When a resident is missing and or believed to have left the facility unsupervised, a search will be initiated immediately in accordance with the emergency response: missing resident. Review of a facility policy Resident Alarms dated 12/2017 revealed, Wander/elopement alarms includes devices such as bracelets or building/unit exit sensors worn/attached to the resident that alert the staff when the resident nears or exits an area or building. This includes devices that are attached to the resident's assistive devices (e.g., walker, wheelchair, cane) or other belongings .The use of alarms does not eliminate need for adequate supervision of the resident. Review of a Face Sheet revealed Resident #101 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 8/28/19 revealed a Brief Interview for Mental Status (BIMS) score of 18, out of a total possible score of 15, which indicated Resident #101 was cognitively moderately impaired. Review of the Functional Status revealed that Resident #101 required limited assistance of 1 person and her walker for walking on in the facility. Review of the Behaviors indicated Resident #101 had no wandering behavior. Review of the Restraints indicated that Resident #101 used a wander/elopement alarm daily. Review of Resident #101's Physician order [REDACTED].M., revealed, Monitor wanderguard for placement and function every shift. Review of Resident #101's Care Plan indicated, Behavior Problem: I have a [DIAGNOSES REDACTED]. Because of this I have a tendency to wander the halls and look for exits. I have been known to attempt to get off the floor via the elevator. Goal: I will have fewer than 5 attempts at getting off the unit, as my disease process allows, through the next review period. Interventions: If I am wandering near exits or going through others' rooms please attempt to redirect me by offering a snack, showing me where my room is or attending an activity. Start: 07/03/19 Please document any wandering in my EMR. Start: 07/03/19 . I have wanderguard in place. Staff to check q shift. It was started on 9/9/19. Start: 07/03/19. I prefer to have wanderguard attached to my walker not my wrist. Start: 07/03/19. Review of Resident #101's assessment document Risk of Elopement/Wandering Review dated 9/10/19 revealed, Resident is at risk for elopement/wandering .(physician orders [REDACTED]. Dementia diagnosis. Did elope from facility. Care plans updated, 15 minute checks in place, education provided to staff, wanderguard re-initiated. Review of Resident #101's assessment document Risk of Elopement/Wandering Review dated 8/30/19 revealed, Resident is at risk for elopement and wandering as evidenced by: sitting by elevator trying to convince people to open. Additional comments: Wanderguard in place. Able to ambulate. Some wander cx (concern). Interventions in place and appropriate. Review of Wandering and Elopement Risk Binder revealed, a photo of Resident #101 along with 4 other residents. Review of Behavior Note dated 9/4/19 16:18 (4:18 P.M.) revealed, (Resident #101) complained she was sick and she needed to go home, was very insistent that she needed help to get out of here. unable to redirect her conversations she became more agitated. [MEDICATION NAME] given at 16:40 (4:40 P.M.). Review of Resident #101's Interdisciplinary Team Note dated 9/4/19 at 13:21 (3:21 P.M.) revealed, .dc'd (discontinued) wanderguard d/t (due to) no concerns of elopement. Review of Progress Note dated 7/3/19 indicated, Social Worker SW G added the wanderguard related to Resident #101's episodes of confusion. Review of Progress Note dated 7/2/19 at 17:12 (5:42 P.M.) indicated, Resident #101 attempted to get on the elevator with staff. Review of Resident #101's Treatment Administration Record (TAR) for (MONTH) 2019, indicated orders for monitoring placement and function of the wanderguard every shift (11-7 [NAME]M., 7-3 P.M. and 3-11 P.M.) with the order started on 7/5/19 and ending on 9/4/9. The record indicated the wanderguard was monitored from 9/1/19 11-7 [NAME]M. shift until 9/4/2019 11-7 [NAME]M. shift, with no records indicating that the wanderguard was monitored from 9/4/19 7-3 P.M. shift through 9/9/19 7-3 P.M. shift. The record indicated on 9/9/19 orders to re-start the wanderguard monitoring for placement and function every shift with no end date indicated. The record indicated the wanderguard was monitored from 9/9/19 3-11 P.M. shift through 9/25/19 (present time). Review of Resident #101's Treatment Administration Record (TAR) for (MONTH) 2019, revealed no record that the wanderguard bracelet was monitored for placement or function from 9/4/19 7-3 P.M. shift through 9/9/19 7-3 P.M. shift, indicating that there were 15 missed opportunities to monitor the wanderguard. During an interview on 9/25/19 at 8:59 [NAME]M., DON B reported that Resident #101's records indicated that the wanderguard bracelet was started on 7/3/19 and discontinued on 9/4/19, but it in fact remained in place without an order or being monitored from 9/4/19-9/9/19. DON B reported that on 9/9/19 after Resident #101's elopement, the wanderguard order was re-started and a treatment order to monitor the wanderguard placement and functioning every shift. Review of Resident #101's Incident Report dated 9/9/19 revealed, The following is a timeline the depicts the sequence of event that resulted in an elopement when (Resident #101) left the skilled nursing unit and went outside to the sidewalk for three minutes on 9-9-2019 .1807 (6:07 P.M.) (Resident #101) enters the East elevator on the 4th floor skilled nursing unit as a visitor exits (confirmed by video footage) 1809 (6:09 P.M.) Resident exits the elevator on 1st floor (confirmed by video footage) 1815 (6:15 P.M.) Resident exits the A Wing lobby exit to the southeast parking lot (confirmed by video footage) 1818 (6:18 P.M.) Social Worker (SW) G, exits (facility) through chapel and observes resident walking on sidewalk using walker; (SW G) supervises resident and calls 4th floor nursing unit 1829 (6:29 P.M.) Resident is escorted back into building by wheelchair by (Registered Nurse F). Comments: Wanderguard bracelet noted to resident's walker. Wanderguard functioning. Wanderguard ordered and added to the eTar (electronic treatment administration record) as it had been discontinued on 9/4/19. It is suspected wanderguard alarm was thought to had been activated per another resident and staff deactivated the wanderguard alarm. Review of Video Footage depicting the Elopement of Resident #101 on 9/9/19 revealed, a camera recording footage of the 4th floor A Hall closest to the exit elevator indicating at 6:05 P.M. Resident #101 was walking with her walker in the hall towards the 4th floor elevator, where the wanderguard alarm was located. She is observed to stop at the elevator door at 6:06 P.M. while a visitor is observed exiting the elevator, and is then immediately observed to walk onto the elevator. CNA I was observed exiting another residents room with a meal tray at 6:08 P.M. and then entering another room with no acknowledgement of wanderguard alarm observed. CNA I was again observed exiting a residents room at 6:11 P.M. with no acknowledgement of the wanderguard alarm observed. At the same time, CNA J observed exiting a residents room, with no acknowledgement of the wanderguard alarm. CNA J was then observed at 6:12 P.M. to walk down to the alarm (indicating that she was turning it off). No observation of CNA J making an effort to locate the 4 residents on the 4th floor that are at risk for elopement, prior to or after turning the alarm off. The next video revealed, a camera recording footage of the 1st floor lobby which shows the elevator and an unlocked exit. Resident #101 observed to exit the elevator at 6:09 P.M., where she walks around in the lobby and then sits down in a chair, until she is observed to exit the facility through the door at 6:15 P.M. The last video revealed, a camera recording footage of the exit hall located near the Chapel on the 1st floor. At 6:28 P.M. RN F observed with a wheelchair to exit the building and then enter with Resident #101 at 6:29 P.M. This video footage indicated that Resident #101 was with out supervision between 6:06 P.M. and 6:29 P.M. (approximately 23 minutes). This surveyor was informed that there was no video available that would reveal Resident #101's whereabouts or supervision status between the time she exited the building at 6:15 P.M. and when she returned with RN F at 6:29 P.M. Review of Alarm History Report from 9/9/19 during the elopement revealed, a wanderguard alarm was recorded active at 6:05 P.M., received to facility phones at 6:05 P.M., and then manually deactivated at 6:12 P.M. These details confirmed what was observed on the video footage. During an interview on 9/24/19 at 10:38 [NAME]M., SW G reported that on 9/9/19 at approximately 6:18 P.M. she exited the facility for the day through the Chapel doors towards the staff parking lot, and noticed Resident #101 standing at the end of the walk way that lead to the parking lot. SW G reported that she was familiar with Resident #101 and knew that she was at risk for wandering and elopement. SW G reported that she called RN F and informed her that Resident #101 was outside. SW G reported that she stayed with Resident #101 until RN F arrived at approximately 6:29 P.M. During an interview on 9/24/19 at 4:27 P.M., RN F reported that she was the nurse assigned to Resident #101 on 9/9/19 during her elopement. RN F reported that she remembers hearing the wanderguard alarm sound, but did not respond because she was busy and assumed that it was the result of a resident that frequently triggered the alarm. RN F could not recall if she had her facility phone with her that day or if she had received an alert notification of the wanderguard alarm. RN F reported that the wanderguard alarm is not loud or distinguishable between other alarms in the facility and cannot be heard unless you are in close proximity to it. RN F reported that she did not ensure the safety and location of Resident #101 or the other 3 residents that have wanderguard bracelets in place. RN F reported that she last saw Resident #101 at about 6:00 P.M. when she administered her medication and then first became aware of Resident #101's elopement when SW G called her to report that Resident #101 was outside at about 6:15 P.M. During an interview on 9/24/19 at 1:07 P.M., CNA J reported that she was working on 9/9/19 during the time that Resident #101 eloped. CNA J reported that she was on the hall assisting other residents with their meals and remembered hearing the wanderguard alarm when she walked out of a room and into the hall. CNA J reported that she responded to the alarm by entering the code to turn it off. CNA J reported that she turned the wanderguard alarm off and did not determine the location of Resident #101 or the other 3 residents with wanderguard bracelets in place. CNA J reported seeing a resident wandering in the hall earlier that evening and figured that it was her that triggered the wanderguard alarm. CNA J could not remember if Resident #101 had a wanderguard bracelet in place at the time of her elopement. CNA J reported that she was not aware of the 4 residents that were at risk for elopement/wandering and that she did not know that she was supposed to ensure the safety and location of Resident #101 or the 3 other residents with wanderguard bracelets when a wanderguard alarm was triggered, until being educated after Resident #101's elopement on 9/9/19. During an interview on 9/24/19 at 4:41 P.M., CNA I reported that she was working on A Hall during the time that Resident #101 eloped on 9/9/19. CNA I could not recall if she had been carrying her facility phone or if she had received the alert notification on her phone. CNA I reported that she was assisting another resident with dinner in their room on A Hall, and remembers first hearing the wanderguard alarm when she came out into the hall. CNA I reported that she did not respond to the alarm because she was busy, did not see any residents in the hall, and assumed that someone had just forgotten to turn the alarm off. CNA I reported that she figured it was the resident that triggers the alarm all the time and never considered that Resident #101 could have triggered the alarm. CNA I reported that she did not ensure the safety and location of Resident #101 or the 3 other residents with wanderguard bracelets when she heard the wanderguard alarm. During an interview on 9/25/19 at 9:23 [NAME]M., CNA K reported that Resident #101 was part of her assigned group of residents on A Hall on 9/9/19. CNA K reported that during Resident #101's elopement, she was assigned to the dining room (between A Hall and C Hall) to assist residents with their dinner. CNA K reported that the wanderguard alarm cannot be heard from the dining room and she could not recall if she had a facility phone with her on 9/9/19, but there have been issues recently with charging the phones or the phones not working, so she may not have had one that evening. CNA K indicated that if she had a facility phone, she should have heard the alarm, but still she would not have left the dining room to respond to it. CNA K reported that the CNA's assigned to A Hall during meal times are responsible for responding to the wanderguard alarm. CNA K reported that the wanderguard alarm goes off a lot and if there is no resident near it, then it gets turned off, assuming that it was probably the same resident that usually sets it off and that they have likely moved on. During an interview on 9/24/19 at 9:40 [NAME]M., Registered Nurse (RN) [NAME] reported that when a resident wearing a wanderguard bracelet is near the exit, an alarm sounds and we receive an alert notification on our facility phone. RN [NAME] reported that the nursing staff all carry a facility phone. During an observation and interview on 9/24/19 at 12:02 P.M., Network Administrator (NA) P explained, the wanderguard exciters on both walls of the hallway on the 4th floor approximately 20 feet from the exit elevator. These exciters are intended to send a signal which forms an invisible line across the hallway, and triggers the wanderguard alarm to sound when a wanderguard bracelet enters into its close proximity. The wanderguard alarm controller unit that emits the sound was observed inside of a closet next to the exciters. Nursing Home Administrator (NHA) A explained that when the wanderguard alarm is triggered the facility phones should also receive an alert notification of 911 Door 4th. During an observation and interview on 9/24/19 at 9:50 [NAME]M., RN [NAME] triggered the wanderguard alarm to sound by using Resident #101's wanderguard bracelet and getting close to the wanderguard exciters near the 4th floor exit elevator. The alarm controller unit was heard by this surveyor to emit a buzzing sound. The volume of this buzzing sound did not disrupt conversation, standing approximately 4 feet away. RN [NAME] and Certified Nursing Assistant (CNA) H were both present with their facility phones in hand. When the alarm did not send an alert notification immediately to either facility phone, RN [NAME] triggered the wanderguard alarm for the second time at 9:50 [NAME]M. The facility phones were observed to receive the alert notification 911 Door 4th at 9:54 [NAME]M. (approximately 4 minutes after the alarm had been triggered the first time) and then again at 9:56 [NAME]M. (approximately 6 minutes after the alarm had been triggered the second time). At this time RN [NAME] reported that she would notify management about the delay in alert notification to their facility phones. During an observation on 9/24/19 at 9:57 [NAME]M., Director of Nursing (DON) B triggered the wanderguard alarm to sound by using Resident #101's wanderguard bracelet. When the facility phone that she was holding did not receive the alert notification immediately, DON B triggered the wanderguard alarm again at 9:58 [NAME]M. The facility phone was then observed to receive the alert notification 911 Door 4th at 10:03 [NAME]M. (approximately 6 minutes after the alarm was triggered) and again at 10:04 [NAME]M. (approximately 6 minutes after the alarm was triggered the second time). DON B reported that she would be contacting the IT department about the delay in alert notification to the facility phones. During an interview on 9/24/19 at 10:53 [NAME]M., NHA A reported that the Alarm History Report was showing delays from the time that the wanderguard alarm goes off and when the notification is received to the facility phones. NHA A reported that (name of company) which is the company that manages the wanderguard alarm system is looking into the issue that caused the delay in the notifications being sent to the facility phones. During an interview on 9/24/19 at 11:05 [NAME]M., NHA A reported that a staff member would be supervising the exit to ensure that no elopements occur, until he has confirmed that the issue of the delay in the notifications sent to the facility phones has been resolved. During an interview on 9/24/19 at 11:12 [NAME]M., NHA A revealed an Alarm History Report which included wanderguard alarm details from today 9/24/19 at 7:23 [NAME]M. through 9/24/19 at 11:02 [NAME]M. This report indicated that there had been 4 logged occurrences today (9/24/19) at 9:50 [NAME]M., 9:50 [NAME]M., 9:57 [NAME]M. and 9:58 [NAME]M., that a delay occurred between when the wanderguard alarm was activated and when the alert notification was sent to the facility phones. The report included 5 wanderguard alarm entries prior to these times and 12 entries after these times, that all indicated that the facility phones were sent an alert notification immediately when the wanderguard alarm was triggered. These findings confirmed observations made by this surveyor. During an interview on 9/24/19 at 1:26 P.M., NHA A and NA P reported an update from (name of wanderguard IT company) regarding the delay in the wanderguard alarm alert notifications being sent to facility phones, 23 minutes of corruption on the data base system had been identified as the issue and they are currently working on repairs. Review of an email from (name of wanderguard IT company) addressed to NA P dated 9/24/19 at 2:18 P.M. revealed, The issue that made the problem occur was an disk corruption that apparently happened 1 year ago according to the garbage in the alarm history logs .We eliminated a problem and now we have to see if that was what caused the delay in alerts going to the (facility phones). During and observation and interview on 9/25/19 at 10:15 [NAME]M., Licensed Practical Nurse (LPN) N observed walking briskly from C Hall to A Hall and observed to deactivate the wanderguard alarm on A Hall. This surveyor was standing at the nurses station between A Hall and C Hall and did not hear the wanderguard alarm sounding. LPN N reported that she had responded to the wanderguard alarm because she had received the alert notification 911 Door 4th on her facility phone. LPN N reported that the actual wanderguard alarm is only audible from A Hall. LPN N reported that she checks her phone frequently, because the phone often times will shut off without notice. LPN N reported that there are times when she does not have a facility phone due to the phones being repaired. During an interview on 9/25/19 at 10:01 [NAME]M., CNA L located on C Hall stated, The wanderguard alarm is way down there by the elevator .so No I cannot hear it unless I get it on my phone. During an interview on 9/25/19 at 10:09 [NAME]M. Housekeeper (HK) M reported that she regularly works on A Hall. HK M reported that if she hears the wanderguard alarm, she would respond by making sure that there are no residents by the door and then deactivate the alarm. On 9/24/19, Nursing Home Administrator A was notified of an Immediate Jeopardy that began on 9/9/19 when Resident #101, who was identified as an elopement risk, eloped from the facility unbeknownst to facility staff. On 9/26/19, this surveyor verified the facility completed the following to remove the Immediate Jeopardy. 1) Resident was observed and supervised at 9-9-2019 at 6:18 pm and returned to the unit at 9-9-2019 at 6:29 pm. Resident #101 was returned to the unit with no visible signs of injury or complaints of pain. 2) The wander guard was originally placed on the resident walker on 7-5-2019. Resident had wander guard on the resident's walker which she had during the elopement. Resident was immediately placed on 15 minute checks on 9-9-2019 at 6:35 pm. The wander guard bracelet was tested to be functional. Physician and responsible party notified by the Nurse Supervisor. 3) On 9-9-2019 the Director of Nursing completed a head count and ensured all residents were present on 4th floor on the second shift at approximately 7:00 pm. 4) On 9-10-2019 the Director of Nursing completed skin check on Resident # 101 with no indication of injury. 5) Video footage of incident was reviewed by the Executive Director on 9-9-2019. 6) On 9-11-2019 a different resident room was offered by the Social Worker to Resident #101's durable power of attorney (DPOA) which was out of line of sight of the elevator; DPOA declined a room move for the resident. 7) On 9-9-2019 there were three other residents using wander guard bracelets who were assessed to be an elopement risk. 8) On 9-9-2019 during the evening shift all wander guard bracelets are testing as functional verified by the Director of Nursing with the wander guard testing device. 9) Placement and function of wander guard bracelets has been added to the treatment administration record to be completed every shift by the charge nurse on 9-10-2019. 10) Elopement assessments have been completed on the three residents with wander guards on 9-10-2019 by the Social Worker. 11) On 9/13/19, elopement assessment began on all skilled nursing residents by 9-18-2019 (6 on 9-13-2019; 2 on 9-16-19; 45 on 9-17-19 and 34 on 9-18-2019) by the interdisciplinary team and will be completed quarterly thereafter. 12) The Elopement Policy was reviewed by the Executive Director on 9-9-2019. No recommendations for changes to the policy were made. 13) Staring 9-9-2019 with second shift, nursing, facility services, recreational therapy and dietary staff were trained on elopement risk and responding to an elopement alarm/ phone alert by the Director of Nursing or designee. On 9-9-2019 - 15 employees were trained, on 9-10-2019 - 60 employees were inserviced, on 9-11-2019 - 61 employees were inserviced on 9-12-2019 - 6 employees were inserviced. No skilled nursing staff have worked since the elopement without being inserviced. 14) On 9-10-2019 signage on the inside of the visitor and employee elevator and a removable magnetic barrier on the outside of the visitor and employee elevator entrance on the 4th floor was enhanced by the Executive Director, to warn visitors of potential resident elopements and to not allow a resident to enter the elevator. 15) The elopement books were updated by Social Worker to ensure resident information was correct and current on 9-10-2019. 16) Audits to determine if staff know who has a wander guard to be checked during an alarm, where the wander risk binders are, and how nurses are checking the function of the wander guard bracelet were conducted for 51 employees from 9-17-2019 to 9-24-2019, by the Director of Nursing and designees. Elopement drills completed by the Executive Director on 9-17-2019 with 16 participants on 4th floor nursing at 2:30 pm during shift change and 9-18-2019 with 19 participants on 3rd floor at 2:30 pm during shift change. 17) On 9-24-2019 at 9:50 am discovered a 5 minute delay in wander guard notification to the call light phones. A staff observer was immediately placed to ensure there was no elopement until the problem could be diagnosed . The vendor completed a diagnostic remotely and corrected the root cause of the delay on 9-24-2019 at approximately 2:18 pm. 18) The Executive Director ran a wander guard call light report on 9-24-2019 from 9-9-2019 6:12 am through 9-24-2019 up until 9:50 am and no delayed notifications were observed. 19) The Executive Director will run a daily report starting 9-24-2019 to ensure wander guard call light system is being notified immediately and that the delay issue is resolved until substantial compliance is achieved and then the report will be weekly thereafter. 20) Continuing on 9/24/19, there are a sufficient quantity of phones on the skilled nursing floors for each nurse and nurse aide. Employees are required to carry their phone as part of their uniform and to exchange their phone for a charged phone if the assigned phone for their group is not charged. 21) On 9-25-2019 facility services and information services are evaluating and installing additional speakers on the units to make the wander guard alarm more audible. On 9-25-2019, the elevator vendor is providing a quote to install a safe mode for the visitor elevator when the wander guard is activated and the elevator is on the 4th floor. Although the immediate jeopardy was removed on 9/24/19, the facility remained out of compliance at a scope of isolated and severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to not all facility staff had received education and the State Agency had not yet verified sustained compliance.

This citation refers to intake MI 677. Based on observation, interview, and record review, the facility failed to prevent neglect of 1 of 1 sampled resident (Resident #146) reviewed for neglect from a total sample of 21 resident, resulting in a fall with a femur fracture and death 9 days later from the femur fracture. Findings include: Review of a Detailed Summary revealed Resident #146 was an [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #146, with a reference date of 1/26/18, revealed a Brief Interview for Mental Status (BIMS) staff assessment Resident #146 has short and long term memory problems and was severely cognitively impaired for daily decision making skills. Review of the Incident Report 7/17/18 at 1:56 p.m., reflected Resident (#146) was in the process of being transferred with a Sara lift (mechanical lift) and he was lowered to the floor by the Certified Nursing Assistant (CNA). Date of alleged incident 7/17/18. Time of alleged incident: 6:00 a.m Location: In resident's room Is the alleged perpetrator known? yes CNA (I) .What allegedly occurred or was said? CNA (I) assisted Resident (#146) with morning cares. CNA (I) then attempted to assist resident out of bed into wheelchair (w/c) using the Sara lift. There was not another staff member present during the transfer. During the transfer, the resident would no longer hold onto the Sara lift and it was unsafe to continue the transfer. CNA (I) then assisted resident to the floor from the Sara lift. Charge nurse Licensed Practical Nurse (LPN) AA was notified by CNA (I) and performed a head to toe assessment. CNA X then arrived on scene to assist. LPN AA then came to nurse manager's office and asked for assistance. Nurse manager Registered Nurse (RN) U arrived on scene in resident's room and observed resident on the floor, on his back with his head resting on a pillow. Right leg straight out flat on floor, and left knee bent with foot on floor. Nurse manager RN U did note that resident was guarding left knee. Resident did complain left leg pain with range of motion (ROM). No internal or external rotation noted to either leg. Resident wanted off the floor and RN U , and CNA (I) assisted resident off the floor using a Hoyer lift (mechanical lift) and green sling. Resident did have a slight moan with lifting off the floor. Resident wanted to sit in wheelchair. No further complaints of pain when resident was in w/c CNA (I) did state that she transferred Resident (#146) using the Sara lift and his green sling without another staff member present. Nurse manager explained that all lift transfers are a two person assisted, and asked CNA (I) if she understood that? CNA (I) replied, Yes. CNA (I) reported He was grabbing at the straps to the Sara lift, and let go of the lift. He was not close enough to the wheelchair or bed to sit him down. I then lowered the Sara lift to the lowest level and grabbed onto Resident (#146) and removed him from the clips and brought him down to the floor using my knee as a guidance. He then laid on the floor, I moved the Sara lift out of the way. Placed a pillow under his head and called my charge nurse. Review of the Investigation Summary dated 7/20/18 at 4:19 p.m., reflected A statement was taken from CNA (I) and she clocked out. At approximately 3:15 p.m. Director of Nursing (DON B) was notified that the mobile X-ray show a displace distal [MEDICAL CONDITION] femur and knee. Resident (#146) was sent out the the emergency room for CT scan by the physician to further diagnose. The emergency room confirmed the distal, non-displaced femur fracture but did not observe or confirm a knee fracture. CNA (I) stated that she did initiate the transfer with the sit to stand lift and when she observed the transfer was not being completed safely, due to Resident (#146) grabbing at the straps of the lift then letting go of the lift, she assisted in lowering the resident to the floor . Review of the Safety Precaution When Using a Mechanical Lift: Sara Lift revealed, Verified whether resident is a 1 or 2 person assist in the patient care plan. Signed by Certified Nursing Assistant I 5/3/2018. Attempted to contact CNA I 08/23/18 at 10:46 a.m. call was not returned prior to investigation ending. Review of the Actives of Daily Living Care Plan dated 6/26/17, reflected, When getting me up with the Sara lift, please use green sling and 2 assist. During an interview on 08/23/18 at 11:07 a.m., CNA X reported that she called CNA I to help her transfer another resident and she said I can't I have an emergency (Resident #146) is on the floor between the Hoyer lift and the W/C. CNA X stated, I called the nurse, and went to (Resident #146's) room just as LPN (AA) was also getting there. CNA X reported that Resident #146 was laying on the floor on his back with his head up by CNA I with something holding head up, he was complaining about his leg (thought it was left leg). LPN AA was checking him out. During an interview on 08/23/18 at 11:10 a.m., RN U reported that on 7/17/18 at 6:00, LPN AA came to get her stating Resident #146 was on the floor he had been transferred with a one person and a Sara lift and she needed me to come to his room and help her assess the resident. RN U reported we assessed range of motion (ROM), he was guarding left leg when he was laying on his back (holding on to the left knee with his hands, demonstrated). RN U reported Resident # 146 was laying on his back when she entered the room, and wanted to get back in his wheelchair after the assessment so they (CNA I and RN U) used the Hoyer lift to transfer him into his wheelchair. RN U reported that CNA I was asked to come into her office, asked her what happened, she reported that she assisted with morning cares, then proceeded to transfer with the Sara lift transfer, said there was no one to help her, she stated that he was letting go of the bars and messing with the straps so she lowered him to the floor, CNA I had the care guide available and it did state 2 person transfer with the Sara lift and green sling (which he had on), RN U reported that CNA I stated that she was not close enough to wheelchair or bed when he was messing with the strap so she lowered the Sara lift as far as she could then disconnected the straps and used her knee and the strap to lower him to the floor. The Sara lift was in the lowest position. she did not yell for assistance, CNA I stated she was always taught to allow the resident to fall as natural as possible, she stated once she got him to the floor she placed a pillow under his head, moved the Sara lift, and called the charge nurse. Review of the Emergency/Urgent Cart Records dated 7/17/18 at 6:02 p.m., reflected concerns for a left femur fracture from a fall from a lift earlier today at facility, per family he normally was alert, wheelchair bound due to stenosis in lower back. Surgical history: left knee replacement. Musculoskeletal: examination of left leg was not performed secondary to known fracture, sensation intact to bilateral lower extremities, moves upper extremities. Neurological: eyes closed, grunting in pain .Discharge Instructions: Femoral shaft fracture. Review of the Radiology Report dated 7/17/18 at 1:51 p.m., reflected Knee exam 3Views AP LAT Oblique, left Conclusion: acute nondisplaced distal femoral metaphyseal fracture. Review of the CT Scan dated 7/17/18 at 7:33 p.m., reflected Impression Oblique fracture is seen along the lateral distal femur extending towards the femoral arthroplasty component. The arthroplasty component limits characterization at the level of the knee joint. No additional fracture or dislocation is seen. Review of the Medical Examiners Report dated 7/26/18 at 3:37 p.m., reflected Investigator Narrative: This [AGE] year-old white, male descendent had a history of [REDACTED]. On (MONTH) 17, (YEAR), during a transfer he fell from his lift and fractured his left femur. He declined since that time and was pronounced dead on (MONTH) 26, (YEAR) at 1530 (3:30 pm) hours .I discussed the case with .Medical Doctor (MD) II who deemed the cause of death to be medical complications [REDACTED]. The manner of death was accident. Suspected cause of death. Fall Trauma. Observations were made during the annual survey of mechanical transfers of sampled residents, there were no concerns found with sampled residents.

Based on observation, interview, and record review, the facility failed to provide the necessary interventions, monitor and assess for skin breakdown in resident identified as at risk for skin breakdown causing a delay in treatment of [REDACTED].#25) reviewed for pressure ulcers, out of a total sample of 21 residents, resulting in pain, infection, and a full thickness pressure ulcer. Findings include: Review of a face sheet revealed Resident #25 was a [AGE] year old female who originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #25 with a reference date of 6/8/18 revealed a Brief Interview of Mental Status (BIMS) score of 15 out of a total possible score of 15 which revealed Resident #25 was cognitively intact. Review of section G: Functional Status revealed Resident #25 required extensive assistance with 1 staff person for dressing and personal hygiene and required extensive assistance with 2 staff persons for bathing. Review of section M: Skin Conditions revealed no pressure ulcer present during the assessment look back period. Review of the current Skin care plan for Resident #25 revealed, I am at risk for impaired skin r/t my physical and cognitive deficits. I have bent left great toe, bilateral contracted knee . It is my preference that my skin remain intact thru my next review. I expect that my skin will be assessed daily with am and PM cares. I want any changes in my skin such as redness or open areas reported . Dated 10/10/17. Review of the current ADL functional/Rehab Potential care plan for Resident #25 revealed, I have a self-care deficit r/t my impaired mobility, OA ([MEDICAL CONDITION]), general weakness, inability to reposition myself unassisted. I will be free of immobility complications as evidenced by; no new contractures, skin breakdown . Dated 8/21/18. Review of a Braden scale assessment for Resident #25 dated 6/8/18 revealed a score of 15, which indicated she was at high risk for pressure ulcer development. Review of the electronic treatment administration record (eTAR) revealed start date 10/20/17: monitor left great toe every shift. Nurse initials were present for each shift from 8/1/18 to 8/3/18 with no comments or notes on any entry. Review of a Skin Assessment note dated 8/4/18 revealed, Skin is warm dry and intact, no areas of concern. n/a Review of a Progress Note dated 8/2/18 from (outside entity providing care) revealed, Clinic nurse reports patient has foul discharge from the left foot near the base of the great toe. Patient denies any pain or other concerns; states it only hurts when the great toe is manipulated. Great toe with near 90-degree deviation from bunion and 1st toe overlaps 2nd toe which has been present for many years according to the patient .Assessment/Plan: Open wound of left foot, initial encounter .open wound of left great toe area to be treated as follows: . daily dressing change of absorbent gauze between the 1st and second toes of left foot until drainage has ceased. Cleanse area prior to applying new absorbent gauze .Instructions: Return in about 4 days (around 8/6/18 ) for left toe infection. Review of a Progress Note dated 8/2/18 from (Outside entity providing care) revealed, (Resident #25) seen in clinic for follow up on left foot swelling. Left great toe is red, swollen and painful. Creamy white odorous drainage in between left great toe and 2nd toe. Soaked for 15 minutes in tea tree soap and water. White macerated tissue present . Cleansed with saf clens. Applied gauze in between toes. Sent home with bottle of saf clens and gauze from dressing changes. Review of an interdisciplinary (ID) note dated 8/2/18 revealed, On 8/2/18 Open wound found near base of Left great toe with foul drainage. New order for Bactrim DS 800mg-160mg 1 tab PO BID x 10 days. Review of an Infection entry revealed Date of onset: 8/2/18 .A red, swollen area with drainage and warm to the touch observed near the base of the left great toe. Suspected bacterial paronychia (nail infection). New physician order [REDACTED]. 8/7/18: New physician order [REDACTED]. Culture report indicates three species . In an interview on 8/22/18 at 9:57 AM, Licensed Practical Nurse (LPN) EE reported that Resident # 25 had been on Bactrim since 8/3/18 for [MEDICAL CONDITION] between her toes, and then she was put on [MEDICATION NAME] after a culture was obtained. LPN EE reported that the area is open and might be a pressure ulcer because of the way Resident #25's toes are, but that she doesn't think anyone is calling the wound a pressure ulcer. In an interview on 8/23/18 at 9:20 AM Registered nurse (RN) GG reported that Resident # 25 is a (outside entity providing care) program participant. This program oversees all the medical care the resident receives. RN GG stated, (Outside entity) is slow to get us information, and everything must be triaged over there to the head nurse and physician. Our doctor doesn't round on her. Our hands are kind of tied . Our nurses see skin once a week. Bed baths are only upon need or request. (Resident # 25) has had an infection in the same location months ago. RN GG reported that no additional monitoring of her feet or preventative interventions were put in place, and stated, but, given that her toes are tightly overlapped and prone to issues, we can definitely implement something. Review of Progress Notes from (Outside entity providing care) dated 8/8/18 revealed, Patient seen for follow up to issuance of Bactrim DS on 8/2/18 for left foot [MEDICAL CONDITION] which was located at the base of the great toe; appearance of a port from which purulent foul exudate was seeping from and a small patch of macerated skin between the 1st and 2nd toes was present; note advanced hallux valgus with 1st toe overriding the 2nd toe . In an observation on 8/23/18 at 10:35 AM, Licensed Practical Nurse (LPN) T and Registered Nurse (RN) GG washed hands and donned gloves. LPN T set up clean supplies. RN GG asked Resident #25 what hurts? Resident # 25 stated, the whole thing is sore. RN GG unwrapped the old dressing. LPN T cleansed the wound and then washed her hands and applied new gloves. An open area was present between the left great toe and 2nd toe. The great toe completely overlapped the second toe at a 90-degree angle. The wound was circular, approximately dime sized, with unknown depth and a yellow-ish white, wet wound bed. LPN T placed the new dressing while Resident #25 gripped the arm of her wheelchair tightly. Resident #25 closed her eyes tightly, lips pursed, face turned red and shook. RN GG asked Resident # 25 to give a pain scale and she responded, at least a 10. In an interview on 8/23/18 at 9:52 AM LPN T stated, without having measured the wound, my best description is that the surrounding tissue was pink, the middle had a yellow white base with no odor. I'd say it was dime size or a bit smaller with about 2-3 mm of depth. This was the first time I've seen the wound. I think we just call over the description to (Outside entity). LPN T reported that she didn't know if the wound had improved or worsened. She had not seen measurements. LPN T stated, In between weekly skin assessments, certified nurse aides (CNAs) can clean between toes and report to us things they see in their skin. In an interview on 8/23/18 at 10:45 AM, CNA II stated, when we do morning care to assist with hygiene, we start with mouth care, face, underarms, chest, back, peri-care, lotion upper and lower extremities, hair care, shaving, nail care if needed. If it's appropriate we lotion feet - if there are contractures, I try to use wash clothes, or q tips to gently clean and keep them dry. We are not allowed to pry contracted body parts. I let the nurse know if it gets gunky and gross, any odor or residue that comes off on the wash cloth is my key to let the nurse know. It's a very distinct odor. In an interview on 8/23/18 at 10:49 AM CNA D stated, In the mornings I usually help wash their face, do oral care, arm pits, back, peri-care, of course, upper legs. We don't typically wash feet, but I put on new socks, brush hair. I do try to keep contracted areas dry with a wash cloth. On shower days we look at the skin and fill out the paper if we see anything. But the nurse is supposed to come it to look at all areas. And if they can't get there during the shower, they do it at another time- sometimes they get busy. For (Resident #25's toes), that's a tough one. I would try to get between toes very gently to clean, but I would not move any fingers or toes like hers, so I probably couldn't get eyes on those areas. But if I got residue or blood or noticed new pain I would tell the nurse. In an interview on review of a Bath/Shower Skin Observation Report on 8/23/18 at 9:30 AM revealed no abnormal areas on 7/28/18, and on 8/4/18. RN GG stated, I'm not sure why nothing would be documented, clearly there's a system breakdown here. Review of physician's orders [REDACTED]. Cleanse area prior to applying new absorbent gauze. ordered on [DATE] and discontinued on 8/13/18. Wound orders: Cleanse wound between 1st and 2nd toes on L foot with saf clens, apply [MEDICATION NAME] Blue ready to wound bed, and secure with conforming gauze and paper tape. Dressing change to be completed daily. Ordered 8/13/18, ongoing. Review of Wound documentation dated 8/13/18 from (outside entity providing care) revealed, Wound- Non-Pressure Ulcer. Non-staged wound description: Full thickness. Wound Bed: White. Peri-wound assessment: maceration. Drainage amount/description: None. Wound length: 0.6 cm. Wound Width: 0.5 cm. Depth: 0.3 cm. Margins: Defined edges. Review of Wound documentation dated 8/16/18 from Care (outside entity providing care) revealed, Wound- Non-Pressure Ulcer. Non-staged wound description: Full Thickness. Wound Bed: White; Red, Pink. Peri-wound assessment Blanchable. Drainage Amount/description: Moderate serosanguinous. Wound Length: 0.7 cm. Wound Width: 0.7 cm. Depth: 0.3 cm. margins: Defined edges. In an interview on 08/23/18 at 1:54 PM Director of Nursing (DON) B stated, I saw the wound initially, but I haven't seen it since. It was red, kind of scaly, didn't really have any drainage. It was not open. I remember, because I wanted to see if it was pressure, but it looked more like [MEDICAL CONDITION]. (Outside entity providing care) saw it after that. I knew she had something going on because RN GG had mentioned it in stand up. The nurse managers get report from the nurses. I know that to have the nurses initial in the eTAR when monitoring that toe is vague. It doesn't say what they saw. And unless every nurse carefully moves her toes apart, you wouldn't see the area. And that area is of course prone to issues. That toe rests on the 2nd toe and can create friction and pressure. And it can be difficult to clean. Our nurses do weekly skin assessments but that leaves six to seven days in between. (outside entity providing care) is supposed to leave us a note after every visit. But everything is delayed. We even had to call to get that documentation for you today. I didn't know that it had increased in size. Based on the description, it sounds like a pressure ulcer. Review of a Skin Care Program policy revised (MONTH) (YEAR) revealed, .C. Ongoing Assessment- Nurses. 1. The nurse will perform weekly assessments unless a significant change in condition or individual resident needs necessitate greater frequency. In an interview on 8/23/18 at 2:56 PM, DON B reported that the first order to treat the wound was on 8/7/18. DON B confirmed that the first wound treatment order was put in place 5 days after the first documentation of the wound. DON B stated, There is no documentation of who from our staff first saw it or what it looked like.

Based on observation, interview, and record review, the facility failed provide supervision and implement new resident appropriate interventions to prevent a fall for one resident (Resident #8), out of 7 residents reviewed for falls, from a total sample of 20 residents, resulting in a fall with a fracture. Findings include: According to a facility face sheet dated 9/12/17 at 2:53 p.m., Resident #8 was an [AGE] year old male admitted into the facility on [DATE] with the Diagnoses: [REDACTED]., such as tremors, slow movement and stiffness, abnormalities of gait and mobility and weakness. http://www.parkinson.org/sites/default/files/Parkinsonism.pdf). According to an comprehensive Minimum Data Set assessment dated [DATE], Resident #8 was staff assessed for mental status as a 2 indicating his cognition was moderately impaired. According to a fall risk assessment for Resident #8 dated 9/5/17 at 11:09 p.m. a score of 16 was reflected indicating high risk for falls. A request was made on 9/13/15 at 10:45 a.m. to UM C for a fall risk assessment prior to 10/10/17. UM C wrote on the request, out of 1 year timeline and was not received by exit conference on 9/14/17 at 3:20 p.m. Review of a timeline for Resident #8's falls compiled by Unit Manager (UM) Cand incident/accident reports for falls for Resident #8 reflected that he had 4 falls from 10/10/16 to 9/5/17. According to a facility document titled, Incident dated 1/27/17 at 8:00 a.m., Resident #8 was in BR (bathroom) and had used toilet on way of BR resident tripped (considered a fall) hitting the side of his left hand. The MDS (Minimum Data Set) defines a fall as, unintentionally coming to rest on the ground, floor, or other lower level but not as a result of an overwhelming external force (e.g., resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for staff intervention, is considered a fall. Review of a timeline for Resident #8's falls compiled by Unit Manager (UM) Cand incident/accident reports for falls for Resident #8 reflected, Intervention (to prevent another fall) offer resident to use toilet approximately every 2 hours. PT (physical therapy) to assess for safety with independent toileting. During an interview on 9/14/17 at 9:00 a.m. with UM C, UM C revealed that CNA (Certified Nurses Aide) do rounds every two hours and offer toileting as a normal routine. The intervention to offer toileting every two hours was already in place and did not prevent this fall. UM C stated Resident #8 won't use a call light and that he is not supposed to transfer himself, ambulate alone or be left alone in the bathroom. UM C confirmed Resident #8 is very impulsive. The intervention to have a physical therapy evaluation would not prevent Resident #8 immediately from having a fall. Review of an x-ray of Resident #8's left hand report dated 1/29/17 at 3:23 p.m. reflected, There is a fracture involving fifth metacarpal shaft without displacement. There is associated soft tissue swelling. During an observation and interview on 9/14/17 at 11:47 a.m., Resident #8 was observed to be standing in his room doorway, unaccompanied. Licensed Practical Nurse (LPN) LL was observed to see him from the hall and rush quickly to him as she stated, Lets get you into your chair. LPN LL confirmed Resident #8 is known to get up by himself. According to Geriatric Nursing Protocols for Best Practice, Second Edition. (2003) Springer Series on Geriatric Nursing, The majority of all falls that occur in the acute care setting involve individuals over the age of 65 .The increased risk of falling in older adults may be due to a number of age-related changes, such as altered visual acuity, decreased reaction time, decreased balance and muscle strength .Nurses in the acute care setting have the most contact with patients and are in key positions to evaluate these individuals and implement interventions to decrease falls .A prior history of falls is frequently cited in the literature as a risk factor contributing to falls. Once an older adult has fallen, there is a significant increased risk that he or she will fall again under similar circumstances .a major concern with a fall is the subsequent fear of falling that can occur. Fear of falling has been cited as one of the most serious and debilitating psychological consequences of a fall .The intention of a fall prevention program in acute care is not only to prevent falls, but also to provide patients with nursing care that focuses on improving and maintaining the functional ability of older patients.

This citation contains multiple deficient practice statements (A and B). A. Based on observation, interview and record review, the facility failed to identify a potential safety hazard, and develop a safe system for the use of a microwave when heating liquids to ensure safe serving temperatures and provide immediate medical attention to reduce the extent of an injury in 1 of 6 residents (Resident #1) from a total of 6 residents reviewed for burns, resulting in Resident #1 sustaining a second degree burn that measured 8 cm x 5 cm to the right thigh when he was provided hot liquid from the microwave and spilled it. These deficient practices placed all residents at the facility at risk for serious harm, injury, and/or death. The immediate jeopardy began at approximately 5:45 PM on 1/2/15 when, according to the Accident/Incident Report, Resident #1 spilled hot water on his right thigh which resulted in an open blister (2nd degree burn) that measured 8 cm x 5 cm (approximately the size of a saucer). The immediate jeopardy was identified on 1/15/15 at 4:00 PM. On 1/16/15 at 10:01 AM, the Nursing Home Administrator (NHA) was notified of the Immediate Jeopardy, and a written plan for removal was requested. On 1/21/15 at 2:00 PM, the Immediate Jeopardy was removed when the surveyors verified the following: All residents are at risk for this practice therefore: ? 1/3/15 @ 1:00 PM, 1/4/15, 1/5/15, & 1/6/15 In-service #1 directing staff to not use microwaves to heat beverages for residents initiated for employees who dispense hot beverages to residents 37 staff persons completed in-service. 12 RN's, 5 LPN's, 20 CNA's, 1 RT ? In-service #1 is eliminated and an expanded in-service #2 Burns and Hot Liquid Management is initiated on the morning of 1/7/15 ? 1/5/15 Nurse Managers rotating in Dining Rooms for meals educating staff and monitoring for safety - on going. This practice continues. ? 1/6/15 Signs are posted on dining room microwaves that liquids are not to be heated in the microwaves. ? 1/6/15 Posters placed in the secured dietary supply room on each floor with safe liquid education and first aid for burns. ? 1/15/15 Free standing microwaves moved to locked areas. Over-counter microwaves were rendered non-functional. ? 1/16/15 All free standing microwaves removed from Nursing. Over-counter microwaves remain nonfunctional. ? 1/20/15 @ 2:30 PM Out of 112 (name of facility) SNF staff that may dispense hot beverages to residents, 100 have completed in- service# 2 Burns and Hot Liquid Management. (Name of facility) Staff: 11 out of 11 RN's completed, 15 out of 16 LPN's completed (1 works every other weekend and will not work until completed) , 6 out of 9 Rec Therapy Staff completed( 2 are per diem and will work until it is completed, 1 works next on 1/22/15 and will complete the in-service before assuming duties) 1 Social Worker out of 1 completed, 60 CNA's out of 68 completed (3 are per diem and will complete before they are allowed to work, 2 are new hires that have not started yet but will be in-serviced on burns at orientation, 3 staff are scheduled but will be in-serviced prior to working or will be removed from the schedule. Administration 7 out of 7 are completed. ? (Name of facility) Staffing Resources Staff: Out of 47 staff 35 have completed the #2 Burns and Hot Liquid Management In-service 1 out of 3 RN's completed, 7 out of 10 LPN's completed, 27 out of 34 CNA's completed. Staffing Resources Staff will complete the in-service prior to working at (name of facility). ? Staff who dispense hot liquids who have not yet received in-service #2 will be in-serviced prior to dispensing hot liquids. Staff who have not been in-serviced will not be allowed to work. Managers/designee will be present at each meal to ensure compliance. When a resident sustained [REDACTED]. All residents are at risk for this practice therefore: ? 1/3/15 Residents were re-evaluated by nurses to determine their ability to safely manage hot liquids completed. The census on 1/3/15 was 84. 82 assessments where completed. One resident was not assessed because they were actively dying and one resident was out of the facility at a local hospital. Residents will have ? 1/5/15 Nurse Managers rotating in Dining Rooms for meals, educating staff and monitoring for safety - on going. This practice continues. ? 1/6/15 Posters placed in the secured dietary supply room on each floor with safe liquid education and first aid for burns. ? 1/7/15 In-service #2 Burns and Hot Liquid Management is initiated for staff who dispense hot liquid to residents. ? 1/7/15 in-service # 2 Burns and Hot Liquid Management is now part of the orientation packet for all staff. ? 1/16/15 1/16/15 Burn First Aid posters placed in Dining Rooms ? 1/16/15 Burn response kits containing one Liter water bottle and instant cold pack will be in place in Dining Rooms by 2:00 PM. ? 1/19/15 Dietary/Housekeeping/Maintenance Staff In-service #3 First Aid for Burns initiated. Dietary staff will complete this in-service at the beginning of each shift until all staff have completed it. All 5 Maintenance Staff have completed inservice #3. Dietary staff: 5 out of 6 Cooks have completed the in-service, 19 out of 34 Dining aides have completed the in-service, 3 out of 4 Dietary Management have completed the in-service. There are 11 Housekeeping/floor care staff. None have yet completed the in-service. Staff will be in-serviced on or before their next scheduled day. ? Dietary Process for Hot Beverage Service states the desired temperature for hot beverage service is between 140 and 145 degrees F. The temperature of the hot beverages must be re-taken in the dining room and verified to be within the desirable rage. (140-145 degrees F.) before serving residents. Hot beverages will not be served if temperature is above 145 degrees. The temperature of the hot beverage must re-taken and verified to be within the desirable range. (140 to 145 degrees F.) ? The (name of facility) Dining Room Seating & Hot Liquid Assessment Policy was developed and signed by the Medical Director and Executive Director. This policy will proceed through the normal QAPI process. Although the Immediate Jeopardy was removed on 1/21/15 the facility remained out of compliance with a scope of isolated and severity of actual harm that is not immediate jeopardy due to all staff had not received the inservice education for management of hot liquids and immediate response to spills and sustained compliance had not been verified by the State Agency. Findings include: Resident #1 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE] reflected Resident #1 was an [AGE] year old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Brief Interview for Mental Status (BIMS), reflected a score of 5 out of 15 which represents severe cognitive impairment. Resident #1 required staff assistance with activities of daily living. During and observation and interview with Resident #1 in his room on 1/15/15 at 10:30 am, Licensed Practical Nurse (LPN) "D" was performing a dressing change to Resident #1's right thigh burn and Resident #1 could not recall how the burn happened. In an interview on 1/15/15 at 1:40 PM, Certified Nurse Assistant (CNA) "A" stated that Resident #1 requested some hot chocolate so she filled a cup with water and put it in the microwave. CNA "A" stated that she did not recall how long she heated the water but when she took it out, she poured a small amount onto her palm and tested the temperature, then added the cocoa and gave it to Resident #1. CNA "A" stated that a couple minutes later she heard Resident #1 say "oops" and CNA "A" discovered that Resident #1 had spilled the hot liquid onto his right thigh. CNA "A" stated she grabbed a clothing protector to sop up the liquid and immediately reported the incident to Registered Nurse (RN) "B". CNA "A" stated that she was a new employee of the facility and did not receive orientation or training on the use of the microwave or safe serving temperatures for hot liquids. CNA "A" stated that she had seen other staff use the microwave to heat up hot liquids for residents and thought it was okay. In an interview on 1/15/14 at 3:10 PM, Registered Nurse (RN) "B" stated that CNA "A" had reported to her that Resident #1 had spilled hot liquid on his right thigh and after she administered a medication to another resident, she went to see Resident #1 (who was still seated in the dining room). RN "B" stated that Resident #1 denied pain and she gave him the option of looking at it (right then) or waiting until he was ready for bed. RN "B" stated that she assessed the right thigh between 8:00 and 8:30 PM (over 2 hours after the incident) and noted that Resident #1 had suffered a 2nd degree burn. RN "B" stated that she did not receive training from the facility regarding the management of a hot liquid spill or related injury. In an interview on 1/15/15 at 3:45 PM, when asked if the facility had a policy/procedure regarding the management of a hot liquid spill, the Unit Manager, RN "C" reviewed the facility policies/procedures and stated that facility did not have one. In an interview on 1/15/15 at 1:20 PM, the Dining Service Director stated that prior to Resident #1's incident (on 1/2/15) there was not a policy/procedure for the use of the microwave and safe serving temperature but one was being developed. (# ) B. Based on observation, interview and record review the facility failed to ensure that staff followed the policy/procedure when transferring 1 resident out of 5 residents, (Resident #3) reviewed for safe transfers, in a total sample of 6 residents, resulting in Resident #3 falling during a transfer and sustaining a right arm fracture (broken bone). Findings include: Review of the facility policy/procedure titled "Transfer-One Person Assist" dated 9/1995 with a revised date of 2/2011 reflected, "Residents who are able to bear weight and assist with turning/pivoting with instruction and/or cueing will be transferred in a safe manner. Gather necessary equipment e.g. gait belt, wheel chair...explain procedure to resident...position wheel chair adjacent to the bed and lock wheel chair brakes...Assist resident to a sitting position. Ensure resident's feet touch the floor. Apply gait belt...Stand in front of resident, brace resident's legs, reach under the arms, if resident is unable to use arms to push up from bed or chair...Instruct the resident to stand on the count of three. Rock resident forward on each count, On the count of three assist the resident to stand. Support the resident by holding the gait belt. Continue to block the resident's feet and knees. Turn/pivot the resident..." Resident #3 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE] reflected Resident #3 was an [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, Resident #3 was cognitively intact and required staff assistance with activities of daily living. Review of the Accident/Incident report dated 1/4/15 at 2:40 PM, reflected that Resident #3 was transferring from the wheel chair to the bed with the assistance of Certified Nurse Assistant (CNA) "J" when Resident #3 fell . The report reflected that Resident #3 sustained pain to the right upper arm/shoulder and an x-ray was ordered. In an interview and observation on 1/16/15 at 3:30 PM, Resident #3 was observed with the right arm in an immobilizer (sling) resting on her bed. Resident #3 stated, "I was suppose to have gone home in a few days but I can't now that I broke my arm." Resident #3 stated that CNA "J" applied the left wheel chair brake and Resident #3 applied the right brake and told CNA "J" that the brake (right side) was hard to engage. Resident #3 could not recall if CNA "J" rechecked the right brake to make sure it was engaged. Resident #3 stated, "I don't know why she (CNA "J") didn't have her gait belt that day and I do remember that part and that I didn't have one on during the transfer. I needed something to grab on to and when I stood the wheel chair slid back on the right side and I kept ahold of it and down I went. I knew right away that I broke my arm...the pain is manageable." In a second interview on 1/20/15 at 12:40 PM, Resident #3 stated that she did not recall wearing a gait belt during the transfer on 1/4/15. Resident #1 stated, "I did not have a gait belt on me otherwise she (CNA "J") would have had something to hold on to me with. The brake (right side) was hard to apply on the wheel chair and when I stood up it gave way then I fell ." Resident #3 stated that CNA "J" was on her left side during the unsuccessful transfer (not in front of Resident #3). In an interview on 1/16/15 at 2:10 PM, CNA "J" stated that she has been a CNA at the facility approximately one year and last received training regarding safe transfers at the facility skills fair in July of 2014. CNA "J" demonstrated on this Surveyor how she attempted to transfer Resident #3. CNA "J" applied the gait belt and then stood on the left side of Resident #3 and placed her right hand behind on the gait belt just behind Resident #3's right hip and placed her left hand on the gait belt on Resident #3's left side (left hip area). During this demonstration CNA "J" remained on Resident #3's left side and slightly behind Resident #3. CNA "J" stated that during the transfer the right side of the wheel chair slid backwards and Resident #3 had a her right hand still holding on to the chair when Resident #3 lost her balance and began to go to the floor. CNA "J" stated that she directed Resident #3 to let go of the wheel chair. CNA "J" stated that Resident #3 immediately stated that she broke her arm. CNA "J" denied standing in front of Resident #3 during the transfer.(# )

Based on interview and record review the facility failed to assess for range of motion (ROM) after a resident fall in 1 of 3 residents (Resident #4), reviewed for falls in a total sample of 6 residents resulting in the delay of treatment for [REDACTED]. Resident #4 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE] reflected Resident #4 was an [AGE] year old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, Resident #4 had severe cognitive impairment and required staff assistance with all activities of daily living. During the intial tour on 1/14/15 at approximately 11:00 AM, Resident #4 was observed seated in a power chair with his right arm in an immobilizing sling. Resident #4 was unable to answer specific questions regarding the fall or the arm fracture. Review of the facility policy/procedure titled, "Falls Program, Post Fall Procedure" dated 7/1996 and last revised on 1/2013 reflected, "Following each fall incident, the charge nurse/designee...assess extremities for symmetry, shortening of a limb, internal or external rotation, and response to range of motion...if a fracture or other significant injury is suspected do not move the resident and notify the physician and emergency medical services." Review of the Accident/Incident report dated 1/7/15 at 9:45 PM, reflected that during a transfer from the wheel chair to the toilet, Resident #4's knees buckled and he was lowered to the floor. RN "I" documented, "ROM WNL (within normal limits) with no pain." In an interview on 1/15/15 at 1:40 PM, RN "I" stated that she assessed Resident #4 after his knees buckled and was lowered to the floor. RN "I" stated that after she assessed Resident #4, he was assisted off the floor with a gait belt and the assistance of 3 people. When asked if all joints (including the right arm) were assessed for ROM before Resident #4 was moved, RN "I" stated, "No, but I should have." Review of the x-ray report dated 1/10/15 (3 days after fall on 1/7/15) reflected a questionable right distal humerus fracture (broken upper arm). In an interview on 1/15/15 at 3:50 PM, the Director of Nursing (DON) stated that Resident #4's nurse noticed on 1/10/15 (3 days after the fall) that Resident #4's right arm was swollen and painful, the doctor was called and an x-ray and ultrasound was ordered. The DON stated that the x-ray indicated a possible fracture so Resident #4 was sent to the emergency roiagnom on [DATE] where the right arm fracture was confirmed and a cast was placed. The DON stated that Resident #4 did not have another fall or incident that could have caused the arm fracture. Review of the "Discipline Record" dated 1/16/15 reflected Registered Nurse (RN) "I" was disciplined because she, "Did not complete a full assessment post resident fall."(# )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO TRAIN STAFF ON APPROPRIATE AND SAFE USE OF THE SIT TO STAND LIFT FOR 2 (#301, #304) OUT OF 3 SAMPLED RESIDENTS REVIEWED FOR LIFT TRANSFER SAFETY OUT OF 11 RESIDENTS THAT REQUIRE THE SIT TO STAND LIFT RESULTING IN A LEFT SHOULDER DISLOCATION FOR RESIDENT #301 AND THE POTENTIAL FOR INJURY FOR THE OTHER RESIDENTS REQUIRING THE SIT TO STAND LIFT FOR TRANSFERS. FINDINGS INCLUDED: AN UNANNOUNCED SURVEY WAS CONDUCTED FROM 09/06 THROUGH 09/09/2013. RESIDENT #301 WAS AN [AGE] year OLD FEMALE WITH [DIAGNOSES REDACTED]. REVIEW OF THE FACILITY'S "ACCIDENT/INCIDENT REPORT-RESIDENT/VISITOR" DATED 08/25/2013 AT 8:30 PM, RESIDENT #301 WAS BEING TRANSFERRED BY CERTIFIED NURSING ASSISTANT (CNA) "A" "USING THE SARA LIFT (SIT TO STAND LIFT-(A LIFT USED FOR RESIDENTS THAT CAN PARTIALLY BEAR WEIGHT TO BE TRANSFERRED FROM ONE SURFACE TO ANOTHER)) - RESIDENT LET GO AND GOT BOTH ARMS OUT OF THE SLING. RESIDENT HAS 10/10 LEFT UPPER ARM PAIN." UNDER "INJURY" SECTION OF THE "ACCIDENT/INCIDENT REPORT-RESIDENT/VISITOR" THE PHYSICIAN ORDERED RESIDENT #301 TO BE SENT OUT TO THE HOSPITAL. AN XRAY WAS DONE ON 08/26/2013 AT 1:23 AM OF THE LEFT ARM AT THE HOSPITAL AND REFLECTED A "DISLOCATION OF THE GLENOHUMERAL JOINT (SHOULDER)". THE emergency room PHYSICIAN'S NOTES DICTATED ON 08/26/2013 (UNTIMED) REFLECT THAT RESIDENT #301'S LEFT SHOULDER WAS UNABLE TO BE REDUCED (PUT BACK INTO PLACE) TIMES ONE ATTEMPT RELATED TO SIGNIFICANT SWELLING IN THE LEFT SHOULDER JOINT "WHICH MADE REDUCTION DIFFICULT" THEREFORE THE emergency room PHYSICIAN SEDATED RESIDENT #301 AND SUCCESSFULLY REDUCED. RESIDENT #301 WAS discharged BACK TO THE FACILITY WITH A LEFT ARM SLING. REVIEW OF RESIDENT #301'S 08/26/2013 MINIMUM DATA SET (ASSESSMENT TOOL), RESIDENT #301 HAD A BRIEF INTERVIEW FOR MENTAL STATUS (BIMS) OF 6/10 INDICATING MODERATELY IMPAIRED ABILITY FOR SHORT AND LONG TERM MEMORY. RESIDENT #301 WAS INTERVIEWED IN HER ROOM ON 09/09/2013 AT 3:05 PM. RESIDENT #301 STATED SHE DID NOT REMEMBER THE INCIDENT ON 08/25/2013. RESIDENT #301 WAS ORIENTED TO PERSON ONLY AS SHE THOUGHT SHE WAS IN A HOTEL AND IT WAS 1974. A TELEPHONE INTERVIEW WAS CONDUCTED WITH CERTIFIED NURSING ASSISTANT (CNA) "A" ON 09/09/2013 AT 11:00 AM. CNA "A" STATED THAT "THEY (THE FACILITY) JUST TRAINED US WITH THE SARA LIFT (SIT TO STAND LIFT) BY OUR PRECEPTORS (ANOTHER CNA) BUT NO NURSE WATCHED YOU..." REVIEW OF CNA "A's" "NEW HIRE SKILL COMPETENCY CHECKLIST:CNA" DATED 01/17/2012 REFLECTED UNDER "SKILLS (TO BE COVERED BY A REGISTERED NURSE)" "USE OF MECHANICAL LIFTS (HANDOUTS) RETURN DEMONSTRATION" REFLECTED AN "R" IN THE "HOW EVALUATED" BOX. BASED ON THE KEY, AN "R" IN THE BOX INDICATED "REVIEWED" AND NOT RETURN DEMONSTRATED ("RD"). AN INTERVIEW WAS CONDUCTED WITH LICENSED PRACTICAL NURSE (LPN) "B" ON 09/09/2013 AT 2:45 PM. LPN "B" STATED SHE WAS THE NURSE RESPONSIBLE FOR RESIDENT #301 ON THE NIGHT OF THE INCIDENT. LPN "B" CONFIRMED THAT SHE HAD NOT BEEN TRAINED ON HOW TO UTILIZE THE SIT TO STAND LIFT. LPN "B" STATED THAT THE CNA'S "TRAINED EACH OTHER". LPN "B" STATED THAT CNA "A" "TOLD ME JUST BEFORE THE INCIDENT THE SLING WAS TOO BIG SO I TOLD HER TO GET A SMALLER ONE. SHE DIDN'T BECAUSE SHE (CNA"A") SAID AT ABOUT 9:15 PM (08/25/2013 THE NIGHT OF THE INCIDENT) THAT THE SLING HAD BEEN TOO BIG." LPN "B" STATED SHE DID NOT CHECK THE SLING AT THAT TIME "BECAUSE I WAS WORRIED ABOUT HER (RESIDENT #301). AN INTERVIEW WAS CONDUCTED WITH CERTIFIED NURSING ASSISTANT "D" ON 09/09/2013 AT 1:55 PM. CNA "D" STATED SHE HAD BEEN EMPLOYED WITH THE FACILITY FOR APPROXIMATELY 6 YEARS AND "HAD NEVER BEEN TRAINED ON LIFTS OR SIT TO STAND BY ANYONE BUT ANOTHER CNA." AN INTERVIEW ON 9/9/2013 WAS CONDUCTED WITH THE DIRECTOR OF NURSING. THE DIRECTOR OF NURSING STATED STAFF DOES NOT HAVE TO RETURN DEMONSTRATE PROFICIENCY WITH ABILITY TO UTILIZE THE SARA LIFT (SIT TO STAND LIFT). AN INTERVIEW WITH THE ADMINISTRATOR WAS CONDUCTED 9/9/2013 AT 1:35 PM. THE ADMINISTRATOR STATED "AFTER THIS INCIDENT, WE REALIZED THERE WERE HOLES IN OUR PROCESS (FOR LIFT TRAINING). WE ARE CURRENTLY RE-DOING THE SYSTEM NOW." ON 09/09/2013 AT 3:30 PM AN OBSERVATION WAS MADE OF RESIDENT #304 BEING TRANSFERRED FROM HER BED TO HER WHEELCHAIR IN HER ROOM BY TWO CERTIFIED NURSING ASSISTANTS "E" AND "F". CNA "F" APPLIED THE SIT TO STAND LIFT SLING AROUND RESIDENT #304's" TORSO, BUCKLING ONE OF TWO TORSO STRAPS WITHOUT UNTWISTING IT. THEN CNA "F" APPLIED THE STRAP AROUND RESIDENT #304's" CALVES, BUCKLING THE STRAP WITHOUT UNTWISTING IT. THE TORSO SLING WAS VERY LOOSE WHILE RESIDENT #304 WAS SITTING ON THE BED AND AS THE LIFT ASSISTED RESIDENT #304 TO A STANDING POSITION AT GAP OF AT LEAST 4-6" WAS OBSERVED IN THE FRONT OF THE SLING AFTER TENSION WAS APPLIED BY THE LIFT ARMS. REVIEW OF THE FACILITY'S "MECHANICAL LIFT, PARTIAL STANDING LIFT" POLICY AND PROCEDURE, REVISED DATE NOVEMBER 2011, SECTION "B. 10" INDICATED "ATTACH SAFETY BELT SNUGLY AROUND THE WAIST." AN INTERVIEW WITH THIRD FLOOR REGISTERED NURSE (RN) UNIT MANAGER "H" ON 09/09/2013 AT 3:50 PM WAS CONDUCTED. RN UNIT MANAGER "H" STATED "THE CNA'S SIZE THE SLINGS BY TRIAL AND ERROR. THERAPY OCCASIONALLY DOES SOME SIZE EVALS. I SAID WE HAVE TO EDUCATE THESE PEOPLE (THE CNA'S). THERE WASN'T REALLY A PROCESS BEFORE (RESIDENT #301's" NAME)'s INCIDENT. THE CNA'S ARE SELF-TAUGHT." ( }

THIS CITATION PERTAINS TO INTAKE MI 107. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE NECESSARY CARE AND SERVICES TO MAINTAIN THE HIGHEST PRACTICABLE PHYSICAL WELL-BEING IN 1 OF 4 SAMPLED RESIDENTS (#103), FROM A TOTAL SAMPLE OF 4 RESIDENTS, RESULTING IN AN UNTREATED FRACTURE OF RESIDENT #103's LEFT ELBOW, DECREASED RANGE OF MOTION, AND PAIN FOR RESIDENT #103, FROM HER ADMISSION ON 3/14/12 UNTIL SHE WAS TRANSFERRED TO THE hospital on [DATE]. FINDINGS INCLUDE: REVIEW OF RESIDENT #103's MEDICAL RECORD REVEALED SHE WAS A [AGE] year OLD FEMALE WHO WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. RESIDENT #103's MINIMUM DATA SET ((MDS) dated [DATE] INDICATED SHE HAD MODERATE IMPAIRMENT OF HER COGNITIVE SKILLS, REQUIRED EXTENSIVE ASSISTANCE OF ONE PERSON FOR TRANSFERS AND TOILETING, HAD FREQUENT PAIN WHICH SHE RATED AS A 6 OUT OF 10, AND DID HAVE A FALL IN THE MONTH PRIOR TO HER ADMISSION TO THE FACILITY. RESIDENT #103's FALLS CARE PLAN, WHICH WAS UNDATED, BUT DID HAVE INTERVENTIONS DATED FOR 3/14/12, INDICATED SHE WAS AT RISK FOR FALLS RELATED TO HER HISTORY OF FALLS AND THAT SHE HAD MULTIPLE FALLS PRIOR TO ADMISSION TO THE FACILITY. RESIDENT #103'S PAIN CARE PLAN DATED 3/14/12 INDICATED SHE HAD PAIN RELATED TO [MEDICAL CONDITION], A SKIN TEAR AND BRUISING FROM PREVIOUS FALLS. REVIEW OF NURSE'S NOTES FROM ASSISTED LIVING CENTER (WHERE RESIDENT #103 LIVED PRIOR TO ADMISSION TO NURSING FACILITY) FOR RESIDENT #103, DATED 3/13/12 REVEALED RESIDENT #103 WAS FOUND ON THE FLOOR IN FRONT OF HER BATHROOM, WITH A SKIN TEAR ON HER LEFT ELBOW. NURSE'S NOTES FROM THE ASSISTED LIVING CENTER FOR RESIDENT #103 DATED 3/14/12 INDICATED RESIDENT #103 WAS FOUND SITTING ON THE FLOOR AND STATED SHE HAD FALLEN. THE NURSE'S NOTES DATED 3/14/12 ALSO INDICATED SHE HAD A SECOND SKIN TEAR ON HER LEFT ELBOW JUST BELOW THE PREVIOUS SKIN TEAR ON LEFT FOREARM, JUST BELOW THE ELBOW. FACILITY ADMISSION NURSING ASSESSMENT FOR RESIDENT #103 DATED 3/15/12 INDICATED A TOTAL BODY SKIN ASSESSMENT REVEALED A 3 CENTIMETER BY 4 CENTIMETER SKIN TEAR AND A BRUISE ON RESIDENT #103'S LEFT ELBOW, BRUISING ON RESIDENT #103'S RIGHT LOWER ARM, A 1.5 CENTIMETER BY .9 CENTIMETER SKIN TEAR ON THE BACK OF HER RIGHT LOWER LEG, A HEALING SCAB ON HER LEFT KNEE, AND A RED AREA ON HER BUTTOCKS. REVIEW OF THE PHYSICIAN HISTORY AND PHYSICAL FOR RESIDENT #103, DATED 3/16/12, REVEALED FACILITY PHYSICIAN #13 DOCUMENTED THAT RESIDENT #103 WAS admitted TO THE FACILITY AFTER MULTIPLE FALLS IN ASSISTED LIVING, WITH A REVIEW OF SYSTEMS WHICH INCLUDED MULTIPLE FALLS, AND A PHYSICAL EXAM OF THE SKIN INDICATED ABNORMAL SKIN FINDINGS TO INCLUDE ABRASIONS TO RESIDENT #103's RIGHT LOWER EXTREMITY (LEG) AND LEFT KNEE. REVIEW OF THE ENTIRE HISTORY AND PHYSICAL FORM DID NOT REVEAL ANY DOCUMENTATION REGARDING THE SKIN TEAR OR BRUISING ON RESIDENT #103'S LEFT ELBOW. NURSE'S NOTES FOR RESIDENT #103, DATED 3/16/12 AT 3:36 AM INDICATED RESIDENT #103 WAS GIVEN MEDICATION FOR ARM PAIN AND GENERAL DISCOMFORT. NURSE'S NOTES FOR RESIDENT #103, DATED 3/20/12 AT 7:22 AM INDICATED RESIDENT #103 COMPLAINED OF PAIN TO HER LEFT ELBOW AND IT WAS REPORTED TO FACILITY PHYSICIAN # 13. NURSE'S NOTES FOR RESIDENT #103, DATED 3/20/12 AT 3:07 PM INDICATED RESIDENT #103 COMPLAINED OF LEFT ELBOW PAIN, WITH HER LEFT ELBOW OBSERVED AS SWOLLEN, WARM AND TENDER TO TOUCH, AND HER RANGE OF MOTION WITHIN NORMAL LIMITS BUT PAINFUL FOR RESIDENT #103 TO COMPLETE, AND RESIDENT #103 STATED, "I FEEL BETTER JUST NOT MOVING IT". NURSE'S NOTES FOR RESIDENT #103 DATED 3/21/12 AT 6:02 PM, INDICATED RESIDENT #103'S LEFT ELBOW WAS SLIGHTLY SWOLLEN, WARM, PINK, AND PAINFUL TO THE TOUCH. NURSE'S NOTES FOR RESIDENT #103 DATED 3/22/12 AND 3/23/12 INDICATED RESIDENT #103'S LEFT ELBOW CONTINUED TO BE PAINFUL SWOLLEN AND WARM. NURSE'S NOTES FOR 3/23/12 AT 4:57 AM INDICATED RESIDENT #103 COMPLAINED OF PAIN AND SORENESS IN HER LEFT ELBOW, WITH NO HEAT OR REDNESS NOTED AND THAT HER LEFT ARM WAS ELEVATED ON A SMALL PILLOW PER RESIDENT #103's REQUEST. NURSE'S NOTES FOR 3/23/12, 3/24/12, AND 3/25/12 INDICATED RESIDENT #103 COMPLAINED OF PAIN IN HER LEFT ELBOW AND STATED PAINFUL WHEN TOUCHED. NURSE'S NOTES FOR RESIDENT #103 DATED 3/26/12 AT 7:37 AM INDICATED RESIDENT #103 WAS UP TO THE TOILET 3 TIMES AND DID COMPLAIN OF PAIN TO HER ELBOW, CONTINUED TO COMPLAIN OF PAIN AFTER MEDICATION WAS GIVEN FOR PAIN, DID SLEEP AT TIMES BUT WAS RESTLESS. THE NURSE'S NOTES INDICATED RESIDENT #103'S ELBOW CONTINUED TO BE BRUISED, RED AND SWOLLEN. NURSE'S NOTES DATED 3/26/12 AT 7:51 AM INDICATED RESIDENT #103 COMPLAINED OF ELBOW DISCOMFORT AND WAS GIVEN PAIN MEDICATION WITH LITTLE RELIEF. NURSE'S NOTES DATED 3/26/12 AT 3:46 PM INDICATED RESIDENT #103 COMPLAINED OF ELBOW PAIN NOT RELIEVED BY PAIN MEDICATION, WITH LEFT ELBOW SWOLLEN, WARM AND PINK, THE RESIDENT COULD MOVE THE ELBOW, BUT MOVEMENT WAS PAINFUL, THE PHYSICIAN WAS NOTIFIED, AND AN XRAY WAS ORDERED. NURSE'S NOTES DATED 3/27/12 AT 12:43 AM INDICATED XRAY RESULTS REVEALED "ACUTE MILDLY DISPLACED [MEDICAL CONDITION] OF ULNA" NURSE'S NOTES INDICATED THE ON CALL PHYSICIAN WAS NOTIFIED OF THE RESULTS WHO ORDERED RESIDENT #103 BE SENT TO THE emergency room . THE NURSE'S NOTES INDICATED RESIDENT #103'S SON WAS NOTIFIED, BUT DID NOT WANT TO HAVE RESIDENT #103 SENT TO THE HOSPITAL THAT NIGHT. THE NURSE'S NOTES INDICATED RESIDENT #103 STATED, "THE PAIN IN MY ELBOW IS THE WORST PAIN I'VE EVER HAD IN MY LIFE -TAKE ME TO THE GENERAL HOSPITAL". THE SON OF RESIDENT #103 WAS CALLED AGAIN, AND THE NURSE'S NOTES INDICATED RESIDENT #103'S SON REFUSED TO HAVE RESIDENT #103 SENT TO THE HOSPITAL THAT NIGHT, AND THAT RESIDENT #103'S DAUGHTER WOULD PICK HER UP IN THE MORNING AND TAKE HER TO THE emergency room . THE NURSE'S NOTES INDICATED RESIDENT #103 WAS ABLE TO FALL ASLEEP FOR 2 HOURS ON 3/27/12. NURSE'S NOTES FOR RESIDENT #103, DATED 3/27/12 AT 2:09 PM INDICATED RESIDENT #103'S DAUGHTER ARRIVED AT THE FACILITY TO TAKE RESIDENT #103 TO THE HOSPITAL. physician progress notes [REDACTED].#13 WAS ASKED TO SEE RESIDENT #103 REGARDING PAINFUL LEFT ELBOW AND PER STAFF SHE HAD SIGNIFICANT INFLAMMATION AND TENDERNESS AND AN ABRASION FROM A FALL. THE PROGRESS NOTES INDICATED RESIDENT #103 WAS IN MILD DISTRESS WITH POSITIVE TENDERNESS AND WARMTH AND MINIMAL PAIN WITH RANGE OF MOTION IN THE ELBOW. THE PROGRESS NOTES LISTED AN ASSESSMENT OF [MEDICAL CONDITION] WITH A PLAN FOR ANTIBIOTICS. PHYSICIan order for [REDACTED]. IN AN INTERVIEW ON 4/6/12 AT 1:00 PM, PHYSICIAN #13 STATED ON 3/20/12, HE WAS ASKED TO SEE RESIDENT #103 BY NURSING BECAUSE SHE WAS HAVING PAIN IN HER LEFT ELBOW. PHYSICIAN #13 STATED HE WAS AWARE RESIDENT #103 HAD EXPERIENCED A FALL WITH AN INJURY TO HER LEFT ELBOW, BUT THAT FALL HAD OCCURRED PRIOR TO HER ADMISSION TO THE NURSING FACILITY. PHYSICIAN #13 STATED HE DID OBSERVE SWELLING, PAIN WITH RANGE OF MOTION, AND AN ABRASION ON RESIDENT #103's LEFT ELBOW, BUT THE SWELLING WAS AROUND THE ABRASION. THE SURVEYOR ASKED PHYSICIAN #13 WHY HE DID NOT ORDER AN XRAY OF RESIDENT #103'S LEFT ELBOW ON 3/20/12 AND PHYSICIAN #13 STATED BECAUSE HE WAS NOT SUSPICIOUS OF A FRACTURE AT THAT TIME AND HE STARTED RESIDENT #103 ON ANTIBIOTICS FOR [MEDICAL CONDITION]. WHEN THE SURVEYOR ASKED PHYSICIAN #13 WHY HE ORDERED AN XRAY OF RESIDENT #103'S LEFT ELBOW ON 3/26/12, HE STATED BECAUSE RESIDENT #103'S PAIN PERSISTED. DURING AN INTERVIEW ON 4/6/12 AT 1:30 PM, RESIDENT #103 WAS OBSERVED IN HER ROOM, SITTING ON THE EDGE OF HER BED, WITH HER LEFT ARM IN A CAST, RESTING ACROSS HER CHEST, IN A SLING. RESIDENT #103 POINTED TO HER ELBOW AND TOLD THE SURVEYOR IT WAS BROKEN. WHEN ASKED HOW THAT HAPPENED, RESIDENT #103 STATED SHE HAD FALLEN. RESIDENT #103 STATED HER ELBOW STILL HURT FROM TIME TO TIME, BUT IT IS MUCH BETTER NOW THAT "THIS THING" IS ON IT (POINTED TO CAST). RESIDENT #103 STATED BEFORE THEY SENT HER TO THE HOSPITAL, IT WAS REALLY BAD. #

This citation refers to intake #MI 196 Based on interview and record review, the Facility failed to provide the necessary care and services (adequate assessment and monitoring of right knee), to attain and maintain the highest practicable physical well-being for 1 of 5 sampled Residents (#701), who presented with a painful right knee on [DATE] and a swollen, painful right knee on [DATE] resulting in tissue damage and a delay in treatment for [REDACTED]. Findings include: Review of the closed, clinical record revealed Resident #701 was a 91 near old woman, admitted to the facility on [DATE] and re-admitted on [DATE], following surgical repair of her Right Fractured Knee. Her [DIAGNOSES REDACTED]. The record indicated Resident #701 died on [DATE]. Review of the certificate of death dated [DATE], revealed Resident #701's body was removed from the Facility and brought to a Funeral Home without request for autopsy and no written cause of death. Review of the nurse's notes dated [DATE] at 2:30 PM, revealed Resident #701 was found on the floor mat, next to her bed with no apparent injury identified. Review of the POS rolling or getting out of bed". Review of the nurse's notes dated [DATE] at 2:20 PM, revealed Resident #701 "appeared painful in her legs or knees when repositioning her in bed. Tylenol was given and she remained in bed all shift". Nurse's notes dated [DATE] at 3:45 AM revealed Resident #701 had an elevated temperature of 101.3 degrees. In an interview on [DATE] at 2:00 PM, Certified Nurse Assistant (CNA) #7 said she worked on [DATE] and at about 7:30 AM she was getting Resident #701 ready for the day. CNA #7 said, while Resident #701 was in bed, she noticed her right knee was swollen and painful. CNA #7 said she did not notify the Charge Nurse first but pivot-transferred Resident #701 by herself from bed to a wheelchair. CNA #7 said Resident #701, "winced a bit", when she transferred her and then she reported to (Licensed Practical Nurse/LPN #6) that Resident #701 had a painful, swollen right knee. Review of the nurse's notes dated [DATE] at 6:00 AM, revealed Resident #701 had a fever of 100.6 degrees, chills, was moaning and Tylenol was given. Review of the Physician order [REDACTED].#701's right knee and report any changes to the Physician. The nurse's notes on [DATE] at 10:30 PM, revealed Resident #701's right knee was red and swollen and ice was applied, however no changes in her care plan were made and there was no documentation that the Physician was notified of the changes in her knee (redness). In an interview on [DATE] at 2:17 PM, while reviewing Resident #701's Treatment Administration Record for the month of February 2012, LPN #6 said on [DATE] in the morning (did not know the time), CNA #7 reported to her Resident #701's right knee was swollen and painful. LPN #6 said she called the Physician who instructed her to monitor Resident #701's right knee for changes. When asked how she monitored Resident #701's right knee to identify changes, LPN #6 said she "looked at it". LPN #6 said she did not measure the knee to obtain objective monitoring. LPN #6 said she did not instruct CNA #7 to keep Resident #701 off her right leg while it was painful and swollen. LPN #6 said she did not give any instructions to CNA #7, who cared for Resident #701, to prevent damage to her right knee in order to maintain the highest practicable physical well-being for Resident #701. LPN #6 said, "I probably should have had them not transfer her and leave her in bed." Review of the Facility's pain management record dated [DATE] through [DATE] revealed Resident #701 suffered moderate to severe pain in her right leg/knee. On [DATE] at 2:00 PM the pain was rated at 8 on a scale of ,[DATE] with 10 being the worst possible. Tylenol was given however, there was no documentation as to whether the Tylenol was effective or not. In an interview on [DATE] at 2:00 PM, CNA #7 said she worked on [DATE] and said she continued to transfer Resident #701 from bed to wheelchair by herself, even though throughout the night the nursing staff had been "icing" Resident #701's leg because of her pain and swelling. CNA #7 said she pivot transferred Resident #701 onto the toilet and back into bed with a second person because Resident #701 seemed tired. When asked why she didn't use two people in the morning when she got Resident #701 our of bed and into the wheelchair, CNA #7 said, "we were really busy in the morning". Review of the Facility incident report dated [DATE] at 5:00 AM, revealed Resident #701 was observed with bruising to her right inner thigh approximately 19 inches long, dark purple in color and 12 inches long of dark purple bruising to her right outer thigh. Resident #701's right knee had increased swelling with yellow bruising alongside the knee with dark purple bruising on the back of her right knee. An ice pack was applied to Resident #701's right knee and the Physician was called for an X-ray. Tylenol was given for her pain. Review of the Physician order [REDACTED]. Review of the Physician order [REDACTED].#701 to the hospital emergency room . Review of the Radiology Report dated [DATE] at 9:58 PM, for Resident #701's Right Knee under "Conclusion" was written: "Acute Mildly Displaced Supracondylar Fracture". Review of the Hospital emergency room report dated [DATE] at 10:10 PM, for Resident #701, under History of Present Illness was written, "This [AGE] year old female who lives in an extended care facility who apparently fell forward out of her wheelchair and had an x-ray done of her right knee which apparently showed a fracture. She presented to the ED for evaluation. The patient ...is a completely unreliable historian. Daughter is at the bedside and states that she does not walk. She does not stand to transfer. ...She was told she fell within the last 24 hours but does not know any other specific details. She states other than her Dementia she had been in fairly good state of health for her age." Review of the Facility's nursing admission assessment dated [DATE] revealed Resident #701 returned from the hospital following surgical repair of her fractured right leg with 35 staples. #

This citation pertains to intake #MI 362 Based on observation, interview, and record review, the Facility failed to provide adequate supervision and assistive devices (two assist with transfers and a gait belt and assessment following an accident), to prevent an accident for 1 of 5 sampled Residents (#703), resulting in Resident #703 falling while being assisted in the bathroom with one CNA instead of two and a delay in treatment with subsequent Fractured Left Rib. Findings include: Review of the clinical record face sheet, revealed Resident #703 was a [AGE] year old woman who was admitted to the facility on [DATE]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #703 had [DIAGNOSES REDACTED]. Per the MDS, Resident #703's Brief Interview of Mental Status (BIMS) score was 15 out of a possible 15 indicating Resident #703 was cognitively intact. Per the MDS Resident #703 transferred with extensive assist of 2. Review of the care plan dated 7/15/10 under the problem titled: "Potential for Falls due to poor balance related to Parkinson's Disease and Osteoarthrosis," had an intervention changed on 1/9/12 which instructed nursing to provide "2 assist for transfers at all times due to falls occurring during transfers". Review of the Facility's incident and investigation report dated 2/26/12 at 6:00 AM, revealed Resident #703 was being assisted to the bathroom by Certified Nurse Assistant (CNA) #8 when Resident #703 fell and hit her left side on the toilet seat riser handle and sink. Resident #703 was transferred with one assist instead of two which placed her at risk for an accident. An X-ray was done and a fractured Left T6 rib found. CNA #8 was given a written reprimand. Resident #703, in an interview on 3/13/12 at 10:25 AM, said on 2/26/12 at about 6:00 AM, she wanted to use the bathroom and was assisted by one CNA (did not know her name). Resident #703 said she grabbed for the handle bar, missed the bar and fell and hit her side on the toilet and broke her rib. Resident #703 said before the fall she always had only one CNA assist her with transfers but now she has two. Resident #703 said they use a gait belt now too but they didn't always use one before. Resident #703 said it's still a little sore but they give her Tylenol for it. CNA #8 said, in an interview on 3/15/12 at 8:50 AM, she assisted Resident #703 to the bathroom at 6:00 AM on 2/26/12 by herself because she was not aware Resident #703 required two persons to assist her. CNA #8 said Resident #703 "hit the sink and I grabbed her right hand to help her stand and she grabbed the handle bar with her left hand. I left her in the wheelchair and went and told (named Licensed Practical Nurse/LPN#9). CNA #8 said she was given a care guide that night and she had it in her pocket but did not check it to see how to care for Resident #703. In a phone interview on 3/15/12 at 9:15 AM, LPN #9 said she was the Charge Nurse on 2/26/12 at 6:00 AM and was in the middle of another incident with a different Resident (not on the sample) when CNA #8 told her Resident #703 lost her balance when she was assisting her in the bathroom. LPN #9 said CNA #8 told her Resident #703 "landed kind of hard on the commode". LPN #9 said she did not go and assess Resident #703 and did not notify the family or the Physician. LPN #9 said, "there's nothing more I can tell you. I was wrong. I should have gone and assessed her." Review of the Mobile X-ray dated 2/26/12 at 6:37 PM revealed Resident #703 had an "Acute to Subacute Fracture of Left T6 Rib". #