Every finding on record at Huron County Medical Care Facility

Based on observation, interview, and record review, the facility failed to maintain the cleanliness of food contact surfaces and store food in a sanitary environment in the food service area, resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings include:On 07/29/2026 at 9:39 AM during the initial kitchen tour, red residue was observed on the can opener. During this observation, Director of Dining Q was interviewed on how often the can opener is cleaned, and he stated it's cleaned every day and there aren't any cleaning logs. On 07/29/2026 at 9:41 AM a wet pan was observed stacked on top of other clean pans on the clean storage rack. During this observation, Regional Director of Operations R was interviewed on whether dishes are air dried, and he stated they usually let dishes air dry before putting them on the rack. On 07/29/2026 at 9:43 AM dust accumulation and an orange residue was observed on the mixer. During this observation, Regional Director of Operations R was interviewed on when the mixer was last cleaned, and he stated it was cleaned yesterday and acknowledged that he saw the dust accumulation. On 07/29/2026 at 9:49 AM an exposed Polyvinyl Chloride (PVC) (plastic) pipe was observed hanging directly above food storage in the dry storage room. During this observation, Maintenance Director S was asked about the pipe, and he confirmed that the PVC pipe was a sewer line. According to the FDA 2022 Food Code, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, Equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations, nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.According to the FDA 2022 Food Code, 4-901.11 Equipment and Utensils, Air-Drying Required, After cleaning and sanitizing, equipment, and utensils: Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface sanitizing solutions), before contact with food.According to the FDA 2022 Food Code, 3-305.11 Food Storage, Except as specified in (B) and (C) of this section, Food shall be protected from contamination by storing the fool: In a clean, dry location.Where it is not exposed to splash, dust, or other contamination; and.At least 15 cm (6 inches) above the floor.food in packages and working containers may be stored less than 15 cm (6 inches) above the floor on case lot handling equipment as specified under S 4-204.122.Pressurized beverage containers, cased food in waterproof containers such as bottles or cans, and milk containers in plastic crates may be stored on a floor that is clean and not exposed to floor moisture.According to FDA 2022 Food Code, 3-305.12 Food Storage, Prohibited Areas, Food may not be stored: In locker rooms. In toilet rooms.In dressing rooms.In garbage rooms.In mechanical rooms.Under sewer lines that are not shielded to intercept potential drips.

Based on observation, interview and record review, the facility failed to ensure nail care was provided to two residents (#9 and 19), of four residents reviewed for Activities of Daily Living (ADL) care. Findings include:Resident 9 (R9)On 7/28/26 at 3:44 PM, an observation was made of Resident 9 (R9) sitting in a wheelchair in their room next to the bed. The Resident was interviewed, could answer limited, simple questions and did not engage in conversation. An observation was made of R9's left hand positioned in a fist and the resident was unable to open her hand. The fingers were pressed into her palm of the hand with the fingernails observed to be long with the 4th digit long and jagged, broken. An observation was made of the right hand with long fingernails with one jagged and cracked of the fourth digit with the fifth digit with the nail down to the skin. An observation was made of some old nail polish that was faded and almost completely off. A review of Resident 9's medical record revealed an admission into the facility on 1/6/23 with diagnoses that included Alzheimer's disease, diabetes, depression, dementia, and muscle weakness. A review of the Minimum Data Set assessment revealed the Resident was severely impaired for cognitive skills for daily decision making and was dependent on helper for activities of daily living that included bathing and personal hygiene.A review of the Resident's care plan revealed the Resident was to have a shower on Wednesday AM and revealed a lack of documentation of the resident's length of nail preference. A review of the progress notes for the last month revealed a lack of documentation of resident refusal of nail care. Resident 19 (R19)On 7/28/26 at 3:23 PM, an observation was made of R19 sitting in the hallway by himself in a recessed hallway area. The Resident was interviewed but was unable to answer questions and did not engage in conversation. An observation was made of the Resident's fingernails being long on the right hand and left hand with the index finger on the left hand broken and jagged. A review of R19's medical record revealed an admission into the facility on 5/13/24 with diagnoses that included epilepsy, profound intellectual disabilities, anxiety disorder and muscle weakness. A review of the MDS revealed a Brief Interview of Mental Status score of 00/15 that indicated severely impaired cognition and the Resident was dependent on a helper for most activities of daily living that included bathing and personal hygiene.A review of the Resident's care plan revealed the Resident was to have a shower on Tuesday AM and revealed a lack of documentation of the resident's length of nail preference. A review of the progress notes for the last month revealed a lack of documentation of resident refusal of nail care. On 7/29/26 at 3:47 PM, an observation was made with Nurse P of R19 sitting in the hallway in his wheelchair. An observation was made of the Resident's nails that had been trimmed but continued to have some length. The Nurse reported that they clip down to the area where there was build-up under the nail bed. The Nurse was unsure what the buildup was. The index finger on the left hand remained broken and jagged. CNA (Certified Nursing Assistant) N was asked about nail care for R19, observed the broken nail and stated, I see where it is broken, and informed the Resident she will fix it for him. CNA O was asked about Resident 9's nail care. The CNA reported the Resident's nails were long and she had bathed the resident and trimmed the nails. When asked about who does the nail polish removal, the CNAs indicated that the Activity department will put on and take off the nail polish for the residents. When asked about facility policy on nail care, the Nurse and the CNAs reported that it was to be done with the shower when needed and the Nurse indicated it would be done at any time it was needed as well as asked during the bathing activity. On 7/30/26 at 10:21 AM, an interview was conducted with the Director of Nursing (DON) regarding R9 and R19's fingernail care. When asked about facility policy on nail care completed, the DON reported that it should be done at any point and definitely on shower days. When asked about jagged nails, the DON indicated that they should be addressed as needed. The DON reported that the Nurses were to do a skin assessment after showers/bathing and that the nails were part of that assessment. A review of the facility policy titled, Activities of Daily Living (ADLs) revealed, .Policy Explanation and Compliance Guidelines: .3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. A review of the facility policy titled, Policy: All residents will be provided with a high quality of care following accepted standards of nursing care. f.Nails 1. Clean during bathing. 2. Trim as indicated. Only licensed nurses may trim diabetic residents' nails.

Based on observation, interview and record review, the facility failed to ensure clean storage of personal items for Resident #7 and, ensure enhanced barrier precautions were followed for two (Resident #4, 68) of three residents reviewed, resulting in the likelihood of contamination of toothbrush and the likelihood in the spread of infection. Findings include.Resident 7 (R7) On 7/28/26 at 11:38 AM, an interview was conducted with R7 who answered questions and engaged in conversation. An observation was made in R7's bathroom of a kidney basin positioned on a shelf in the bathroom that contained a toothbrush and toothpaste. The basin was positioned underneath the towel dispenser. A review of Resident7's medical record revealed an admission on [DATE] with diagnoses that included Spina bifida, diabetes, sepsis, and pressure ulcers. On 7/29/26 at 3:17 PM, an observation was made of R7's wound care being completed by Nurse J. The Nurse had washed her hands prior to putting on the personal protective equipment (PPE) for enhanced barrier precautions. After this surveyor washed her hands prior to putting on PPE, when reaching for the paper towel with wet hands, a basin was observed that was positioned underneath the paper towel dispenser. After completion of wound care, the Nurse went into the bathroom and washed her hands. It was observed that the Nurse reached over the basin with the Resident's personal items that included the toothbrush and toothpaste to extract the paper towel from the dispenser. The Resident's personal items were pointed out to Nurse J and discussed the potential of contamination to the items. It was reported that possible drips from washing hands may have contaminated the items. The Nurse indicated she would get new supplies for the Resident and then explained to the Resident of another option for personal storage of items. On 7/30/26 at 10:21 AM, an interview was conducted with the Director of Nursing (DON) regarding R7's storage of personal items underneath the paper towel dispenser. The DON agreed that the items should not be stored underneath the towel dispenser and that it was a concern for infection control. Resident #4 On 7/28/2026, at 9:22 AM, Certified Nursing Assistant (CNA) A who propelled Resident #4 into the shower room. On 7/28/2026, at 9:23 AM, an observation of Resident #4's door into their room revealed a caddy that housed Personal Protection Equipment (PPE) and an enhanced barrier sign. On 7/28/2026, at 9:39 AM, Resident #4 remained in the shower room along with CNA A. CNA B knocked on shower room door and entered. CNA A was standing next to Resident #4 assisting them with their shower in the common shower stall with no gown on. On 7/28/26, at 12:35 PM, a record review of Resident #4's electronic medical record revealed an admission on [DATE] with diagnoses that included Parkinson's, Diabetes Mellitus and a urinary indwelling catheter. Resident #4 had moderately impaired cognition and required assistance with Activities of Daily Living. A review of the physician orders revealed Enhanced Barrier Precautions d/t (due to) urinary catheter . Active . 3/25/2026. Resident #68 On 7/28/2026, at 10:59 AM, Upon entry into Resident #68's room, a caddy that housed PPE and an enhanced barrier sign was on the door. Resident #68 was in the bathroom on the toilet. CNA C and CNA B were assisting the resident with toileting. Both CNA C and CNA B did not have on gowns. Nurse D had a clear medication cup with ointment inside. Nurse D was asked if they planned to apply the ointment and Nurse D stated, yes. Nurse D had a glove on their left hand and held the medication cup in their ungloved right hand. Once Resident #68 was assisted to a standing position, Nurse D applied the ointment with their gloved hand. Nurse D did not have on a gown. On 7/29/2026, at 11:00 AM, a record review of Resident #68's electronic medical record revealed an admission on [DATE] with diagnoses that included Diabetes Mellitus, Difficulty in walking and Urinary tract infection. Resident #68 required assistance with Activities of Daily living and had moderately impaired cognition. A review of care plan revealed (the resident) is on enhanced barrier precautions (EBP) r/t (related to) MDRO (multi-drug-resistant organism) MRSA (Methicillin-resistant Staphylococcus aureus) Date Initiated: 06/12/2026 . Interventions/Tasks . Direct care staff to utilize gowns and gloves for all personal cares Date Initiated: 06/12/2026 . A review of the Physician orders revealed Enhanced Barrier Precautions d/t history of MDRO MRSA . Active. On 7/30/2026, at 8:40, Infection Control Nurse (IC) Nurse F was alerted of the observations of Resident #4 and #68 with a lack of PPE during cares and IC Nurse F planned to provide one on one education to the staff members and that Nurse D already alerted them of the failure to wear PPE during care on Resident #68. On 7/30/2026, at 10:29 AM, IC Nurse F provided they had educated both CNA A and C and CNA B will be educated next time they work. IC Nurse F was asked to clarify and IC Nurse F provided that CNA C thought the EBP was for Resident #68's roommate and CNA A was not aware they needed a gown while giving a shower. On 7/30/2026, at 3:15 PM, a record review of the facility provided Enhanced Barrier Precautions Date Reviewed/Revised: 2/2026 policy revealed It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Definitions: Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities . High-contact resident care activities include: . Bathing . Providing hygiene . Changing briefs or assisting with toileting . Enhanced barrier precautions should be followed outside the resident's room when performing transfers and assisting during bathing in a shared/common shower room . A review of the One on One In-Service Training Date: 07/30/2026 for both CNA A and CNA C revealed . Corrective Action: Provided education and reinforcement expectations for proper PPE usage in accordance to CDC Guidelines. Questions answered ensuring understanding .

Based on observation, interview and record review, the facility failed to maintain a sanitary kitchen, ensure that food items were dated with an opened date, that expired food was removed and/or disposed of, and that food temperatures were monitored prior to serving. This deficient practice had the potential to affect all residents who consume food prepared and served from the facility kitchen and kitchenettes of a census of 72 residents. On 7/15/25 at 10:00 AM, a tour of the kitchen was conducted with Dietary Manager C of the facility kitchen. The following items were observed:-The juice dispenser had juice in boxes that were connected to be dispensed. The boxes had a delivery date but did not have an open date. The DM was asked about facility policy and reported they should be dated. The DM reported there was a three-month shelf life after opened.-Cups and lids stacked and on a cart that was covered with a cloth, many of the cups and lids were stacked wet.-Plates were stacked and when observed with the DM, a couple of the plates were stacked wet and the tops for the plates were stacked with some of the tops wet. The DM reported the plates were stacked and ready to go to the floors. The DM reported that the dishes had been washed 20 minutes to a half hour, they were to stay on the rack to dry and stated, Didn't set long enough. -Plastic water containers were observed with a couple containers had debris inside the container. Multiple containers had whitish water sediment on the inside of the container.-Stored water cups stacked together with multiple cups wet.-Two non-stick fry pans with coating missing on the cooking surface.-Dated bread on 7/17. When asked about the date on the bread being today was 7/15, the DM reported that it was bread that was just put out and it should be dated when it was set out. -Container of molasses had a use by date on 1/25. The container of molasses was mostly gone and had molasses on the outside of the container and on the tray where other spices/cooking items were stored and in contact with the molasses debris on the tray.-Drain pipe that led to a sink area where the DM reported where staff spray off the dishes was flush with the floor drain and not elevated above the drain. The DM reported he would have Maintenance department look at it.-Multiple metal pans stacked together with a couple of the pans that were wet.-Freezer had a build up of frost inside the door towards the bottom and there was an area of wetness along the floor at the threshold of the door. The DM was asked if it was a poor seal causing the frost and water on the floor. The DM reported that he would have Maintenance look at the door. The food items inside the door with the frost built up on them appeared to be frozen.-In the walk-in refrigerator section, cucumbers with a receive date of 6/27 were observed in a box that was partially full. Multiple cucumbers were expired with mold growth on the outside of the cucumbers. After the review of the main kitchen area, the kitchenette on the 3rd floor was reviewed with the Dietary Manager. There was bread that was in the cupboard with a use by date of 7/12/25. The DM took the bread out to discard. A couple of ready to use bowls were stacked together with moisture in the bowls. A review of the 2nd floor kitchenette with the Dietary Manager revealed coffee pots with the lids loosely on top and the coffee pots were wet inside; one coffee pot was not clean inside. Bread was discarded by the DM that had a use by date of 7/12/25. A bag of buns with mold on the bottom buns was removed by the DM. The use by date on the packaging was 6/24/25. A review of the food temperature logs in the main kitchen area was reviewed. The logs were in a binder dated 7/7 to 7/14. The documents had an area on one side for temperatures under the title Kitchen the other side of the document read Dining Room. A review of the binder documents revealed the following concerns:-Dated 7/10 no dinner food temperatures were documented.-Dated 7/11, two items for lunch had temperatures documented and there was no dinner temps recorded.-Dated 7/12, No dinner food temperatures were documented.-Dated 7/13, no dinner temps were documented.The DM was asked about the facility policy on monitoring food temperatures prior to serving. The DM indicated that the temps were to be completed at the kitchen before they go to the kitchenettes and then temp again before serving the food up on the floors. A review of other food temperature logs that the DM had from the kitchenettes were reviewed and there was documentation in both areas under kitchen and dining room. [NAME] D reviewed the logs with the Surveyor and it was reported from the cook that when she does the temps, the kitchen side of the document was for the main kitchen and the other side for the floors kitchenette. When she does the temps on the floors, the temps are to go on the right side under dining room. There was one log that was not dated, and the logs did not identify if the temperature logs were from the 2nd floor or the 3rd floor kitchenettes. Copies of the July logs were requested. On 7/16/25 at 1:07 PM, a review of the temperature logs received for the month of July (July 1 to 15) had documents that did not indicate which floor the documents were from. A document with no date had three items with temperatures documented, no liquids (coffee, milk, juice) had temperatures for breakfast, lunch or dinner and there was no dinner items marked with temperatures taken. The DM was asked if cold food items and coffee needed to be temped and he reported, yes, need to do cold items and coffee. Another document that was not dated, had 4 items with temperatures for breakfast written on the kitchen side with no liquids monitored with temperatures, only 2 items for lunch had temperatures documented and no liquids monitored, the dinner meal had no temperatures recorded. The temperature logs were reviewed with the DM of missing documentation sheets, no identification from where the documents originated (kitchen, 2nd or 3rd floor kitchenette), a lack of food temperature monitoring on multiple days for the dinner meal, cold food items and liquids. The DM indicated a plan to update the forms to be used. A review of facility policy titled, Dish and Utensil Procedure, revealed, .Procedure: .Dishes and utensils shall be air dried before storage. A review of facility policy titled, Food Temperatures, revealed, .Policy Foods will be served at proper temperature to ensure food safety. Record reading on Food Temperature Log form at beginning of tray line. If temperatures do not meet acceptable serving temperatures, reheat the product of chill the product to the proper temperature. Take the temperature of each pan of product before serving. A review of facility policy titled, Labeling Food Product, revealed, Introduction: This policy establishes a consistent procedure for labeling food products prepared tn house, leftover and opened products that have been put back in storage for future use. Procedures: .3. All labels will contain: a. The complete name of the product, b. The date the product was prepared or opened, c. The date the product must be utilized by.

Based on observation, interview and record review, the facility to ensure that a urinary catheter bag and tubing were secured off of the floor for one resident (Resident #6) of one resident reviewed for urinary catheters, resulting in contamination, an improperly secured catheter bag and tubing with the likelihood of infection. Finding include:Resident #6:On 7/15/2025, at 1:18 PM, Resident #6 was in the dining room in the wheelchair. They had a urinary catheter bag hooked under their wheelchair. The tubing was secured through their left pant leg near their ankle. There was approximately eight inches of catheter tubing resting on the floor. The catheter bag cover appeared to be touching the floor. On 7/16/2025, at 9:30 AM, a record review of Resident #6's electronic medical record revealed an admission on [DATE] with diagnoses of cancer, Anemia and obstructive uropathy. Resident #6 had severely impaired cognition and required extensive assistance with all Activities of Daily Living. On 7/16/2025, at 4:10 PM, Resident #6 was up in their wheelchair in their room. CNA A assisted the resident via their wheelchair into the main dining room. There was a loop of the catheter tubing exposed and resting on the floor. The tubing was dragged on the floor through the hallway. CNA A assisted the resident to a stationary position in their wheelchair in the dining room and left out of the room. Unit Manager B was alerted of Resident #6's catheter tubing on the floor and Unit Manager B stated, they would get it cleaned and up off the floor. On 7/16/2025, at 4:20 PM, The Director of Nursing was alerted of Resident #6's urinary catheter being on the floor on two separate days. According to CDC.GOV, . Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor . According to Wikipedia, Catheter maintenance . Never placed on the floor, due to the risk of bacterial infection .

Based on observation, interview and record review the facility failed to ensure accurate physician's orders for oxygen administration for two residents (R38, R81) of two residents sampled for respiratory care, resulting in physician's orders without an oxygen flow rate. Resident #38 R38 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include pulmonary fibrosis, chronic obstructive pulmonary disease, acute respiratory failure and interstitial pulmonary disease. On 07/17/2025 at 11:39 AM, observation revealed an oxygen concentrator in the hall outside of the room of R38 it was administering oxygen at 6 liters per minute. On 07/17/2025 at 12:05 PM, record review of the physician's orders revealed an order for oxygen administration dated 07/03/2025 that read, Treatment Respiratory: Apply oxygen (per nasal cannula) to maintain O2 sat > or equal to 90%, AM, PM, NOC. The oxygen order did not specify an oxygen flow rate for R38. On 07/17/2025 at 12:25 PM, an interview was conducted with the Director of Nursing (DON). The DON was asked if the physician's orders for oxygen administration should contain a flow rate. The DON replied, I believe our physician's orders are supposed to specify flow rate. The DON reviewed the oxygen administration orders for R38 and other residents receiving oxygen and none of them have flow rates in the orders. The DON stated, I guess none of them have flow rate in the physician's orders. The DON was asked how the staff would know what the flow rate is for a resident on oxygen. The DON replied, If I was a nurse on the floor, I wouldn't know the current rate without checking the last charting. Other than that, I wouldn't know the rate. The DON was asked again if the physician's orders for oxygen administration should contain a flow rate. The DON stated, yes the order should have a flow rate. Review of policy titled, Oxygen Administration, revealed: Procedure: 1. Licensed Nurse to obtain physician order for oxygen use with parameters including flow rate, route, and duration. HCMCF has a standing order for the administration of oxygen to maintain oxygen saturation >90%. Physician is to be notified following initiation of oxygen therapy for verification of oxygen order. Resident #81 A review of Resident #81’s medical record revealed an admission into the facility on 6/30/25 with diagnoses that included acute respiratory failure with hypoxia, heart failure, and chronic obstructive pulmonary disease. On 7/15/25 at 2:35 PM, an observation was conducted of Resident #81 lying in bed with the head of the bed elevated. The Resident was observed with oxygen on wall oxygen per nasal cannula. The Resident reported his oxygen should be at 2 Liters. An observation was made of the oxygen set at just above 2 liters and just under 2.5 liters. On 7/17/25 at 11:30 AM, an observation was conducted of Resident #81 on the first floor with a visitor. The Resident had oxygen on, and the tank was observed to have oxygen. A review of Resident #81’s order for oxygen was dated 7/1/25, “Apply oxygen (per nasal cannula) to maintain O2 sat >or equal to 90% AM PM…” A review of Resident #81’s treatment record for oxygen revealed documentation that the Resident was on 4 L/min (liters per minute) on 7/4, 7/5, 7/6 with oxygen saturation (O2 sat) of 95% to 98%. On 7/7 the oxygen was set at 4 L/min in AM with O2 sat of 98%; 3.5 L/min in PM with O2 sat at 96%; and 4 L/min with O2 sat at 95% at night; the liters/min fluctuated between 3 and 4 l/min with O2 sats ranging from 98% to 94% on 7/8 to 7/10. On 7/11 the oxygen was set at 3 L/min, O2 sat at 98% in AM; 2 L/min O2 sat at 98% in PM; and 4 L/min O2 sat at 4 L/min with O2 sat 98%. From 7/12 to 7/17 the O2 was set at 2L/min with O2 ranging from 93% to 99%. There was not a corresponding oxygen order for the liters/min in the Resident’s orders. On 7/17/25 at 12:30 PM, an interview was conducted with the Director of Nursing (DON) regarding Resident #81’s oxygen order. The DON indicated the oxygen order was to have the liters ordered for oxygen for the Resident.

Based on observation, interview and record review, the facility failed to develop a baseline care plan that provided person-centered care to meet the Resident's needs for one resident (Resident #81) of one resident reviewed for baseline care planning.Findings include: Findings include:Resident #81:A review of Resident #81's medical record revealed an admission into the facility on 6/30/25 with diagnoses that included acute respiratory failure with hypoxia, heart failure, and chronic obstructive pulmonary disease. On 7/15/25 at 2:35 PM, an observation was conducted of Resident #81 lying in bed with the head of the bed elevated. The Resident was interviewed, answered questions and engaged in conversation. The Resident was observed with oxygen on wall oxygen per nasal cannula. The Resident reported his oxygen should be at 2 Liters. An observation was made of the oxygen set at just above 2 liters and just under 2.5 liters. The Resident was asked if they had an intravenous (IV) catheter in their arm. The Resident reported having an IV that could not be used, and he had to go out of the facility and get another one put in. The Resident reported he received antibiotics through the IV line. An observation was made of a [NAME] transmitter at the Resident's bedside. On 7/16/25 at 3:48 PM, an interview was conducted with Unit Manager, Nurse E regarding Resident #81's care of the IV catheter. The Nurse reported that the Resident had come into the facility with a Midline catheter for antibiotics for an infection. The Unit Manager reported issues with the catheter and the Resident went out for an IV catheter replacement. The Unit Manager was queried regarding a baseline care plan for the infection and IV catheter. The Unit Manager reviewed the Resident's care plan and determined there was not a care plan for the IV catheter. On 7/16/2 at 4:10 PM, an interview was conducted with MDS Nurse F regarding Resident #81's baseline care planning. The MDS Nurse was asked about Resident #81's baseline care plan for the IV catheter. The MDS Nurse reported that she had been off and had just returned, during her absence, the facility had a remote group helping out with the MDS (Minimum Data Set) assessments and the development of the care plans. The MDS Nurse indicated that the Resident came in with the IV and infection and that both were to be captured on the care plan on admission within a couple days. A review of the care plan revealed a lack of care planning for the IV and infection. A review of facility policy titled, Baseline Plan of Care Summary, reviewed/revised 3/2025, revealed, Policy: The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care. Procedure: 1. The baseline care plan will: a. Be developed within 48 hours of a resident's admission. b. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: i. Initial goals based on admission orders. ii. Physician orders. 2. The admitting nurse, or supervising nurse on duty, shall gather information from the admission physical assessment, hospital transfer information, physician orders, and discussion with the resident and resident representative, if applicable. b. Interventions shall be initiated addressing the resident's current needs including: i. Any health and safety concerns to prevent decline or injury. iii. Any special needs such as for IV therapy, dialysis, or wound care. 3. A supervising nurse shall verify within 48 hours that a baseline care plan has been developed.

This Citation pertains to Intake Number MI00153947. Based on observation, interview and record review, the facility failed to follow the care plan and treat a resident with dignity for one resident (Resident #1) out of three residents reviewed for dignity, resulting in frustration, arguing and forceful removal from the activity room. Findings include: Resident #1: On 7/1/25, at 9:05 AM, a record review of the facility provided investigation file regarding the mistreatment of Resident #1 was conducted. The following staff statements revealed: The Assistant Activity Director (AAD) A's statement revealed . At first, it wasn't clear to me that they were seriously arguing, so I began assisting other residents . CNA F continued to argue with the resident, and removed her hands from the table and pushed her in her wheelchair out of the activity room . CNA E's statement revealed Today, after Bingo, around 3pm, (Resident #1) was refusing to leave the activity room . She said she paid for her chips and no one was going to take them away from her. She has a tendency to do this . (CNA F) attempted to get resident to leave but she was adamant about not leaving without he purse of chips. (CNA F) took chips out of residents hands & would put them back down on the table. She also forcefully pulled on the residents wheelchair, trying to get the resident to exit the activity room. I asked (CNA F) if she need help or for me to call (staff member) who the resident has a good relationship with) She stated, No, I got it. This altercation continued for several minutes. CNA F was visibly upset & flustered . On 7/1/25, at 9:26 AM, an interview with Social Worker (SW) B was conducted regarding the Resident #1. SW B offered, they overheard CNA F talking loudly to Resident #1 and pushing them through the hallway into the elevator. On 7/1/25, at 9:45 AM, AAD A was interviewed regarding the incident between Resident #1 and CNA F. AAD A offered, they heard loud voices and entered the main activity area and saw CNA F physically moving Resident #1's hand off the bingo table and quickly pushed them out of the activity room. AAD F offered, it didn't feel right and CNA F was arguing with the resident loudly. On 7/1/25, at 10:00 AM, Social Worker (SW) C was interviewed regarding the incident involving Resident #1. SW C was in their office and overhead Resident #1 wiggling a door handling while saying out loud someone took my bingo chips. SW C assisted Resident #1 to the sunroom for coffee and attempted to calm them down. On 7/1/25, at 10:20 AM, Resident #1 was in the sunroom with coffee and a snack. Resident #1 appeared comfortable and offered that they were waiting on their mom. On 7/1/25, at 10:40 AM, a record review with the Administrator of the video surveillance from the activity room incident involving Resident #1 was conducted. At 15:09, CNA F stood up walked over to Resident #1 and moved them away from the table. CNA F pulled the resident backwards and began clearing off the bingo card/chips. Once CNA F walked down the table, Resident #1 approached the table and began reaching for the bingo chips. CNA F approached the resident pulling them away from the table. CNA F stood behind the resident holding onto the wheelchair handles, leaning over and appeared to be talking to the resident. Resident #1 grabbed at the table and held on. CNA F quickly pulled the resident back as the resident slammed their right hand down on to the table. At 15:11, AAD A was observed walking into the activity area looking over at both CNA F and Resident #1. At 15:13, CNA F quickly pushed Resident #1 out of the activity room. On 7/1/25, at 11:30 AM, CNA E was interviewed via the phone. CNA E offered when bingo was over, Resident #1 kept saying that someone stole her coat, purse and bingo chips and that CNA F was observed taking bingo chips away from the resident. CNA E offered they overhead CNA F say to Resident #1, those aren't your bingo chips, you didn't bring a purse and a coat down. CNA E offered, they remember CNA F forcefully pushing the resident out of the activity room. CNA E stated, they offered to help CNA F but CNA F said they got it. CNA E further mentioned that CNA F didn't seem themselves that day. On 7/1/25, at 12:00 PM, CNA F was interviewed via a phone call regarding the incident with Resident #1. CNA F offered, I've behavior charted many times. That day the aides were sick of dealing with her so they shoved her down to bingo. CNA F further offered, Resident #1 was calling out other resident names would get mad when we ended bingo and that is why we don't want her to come to bingo. CNA F offered, I didn't handle the situation well. I stopped. It was a bad moment. I raised my voice but I had laryngitis. CNA F was asked why they pulled the resident away from the table and CNA F offered, I was just trying to get her away from the table. It was chaos. It was too much for her. She gets over stimulated. CNA F further offered, they have worked at the facility for over twenty five years. I know it was a bad thing. In the heat of the moment, I handled the situation badly. On 7/1/25, at 12:30 PM, a record review of Resident #1's electronic medical record revealed an admission date of 08/16/2023 with diagnoses that included Dementia, Stroke and other behavioral disturbances. Resident #1 had severely impaired cognition and required assistance with Activities of Daily Living. A review of Activities I NEED: staff to provide activities for me, understand that I need to keep busy wanting to leave, asking staff to take me home, asking where my baby is avoid interrupting my activities for routine cares . I need my aides to --- invite and assist me to activities know that I enjoy reminiscing talk with me about current events ask me about my day ask me about my baby . I need activity staff to --- invite me to activities I will enjoy like bingo and live entertainment spend one-on-one time with me as needed invite me to group activities help me spend time outdoors when the weather is nice. Invite me to small group activities like crafts braking provide music for me let the nurse know if I'm having pain during activities let the nurse know if I have a change in ability give me an activity calendar so I may know what is happening in the facility weekly. Know that my favorite activities are: taking care of my baby doll and looking through magazines . I need everyone to --- treat my baby doll as if it is actual baby, encourage me to change my baby's clothes, encourage me to read books to my baby, encourage me to read magazines I enjoy such as Good Housekeeping, encourage me to attend activities know that I need reassurance often know that I get confused and will get frustrated if someone tries to tell me otherwise . A review of the progress notes revealed 06/23/2025 03:30 PM BEHAVIOR RECORD: Verbal threatening Screaming/Cursing at Others Resident Disrupted Bingo many times. Resident upset and accused other staff and Residents of cheating when they called bingo. Resident was looking for the kids. When bingo was over Resident began To scream at staff and Other Residents they stole her purse and her money Resident began To grab Tables and Chairs when Staff was trying to take her back to her room, Resident kick this staff member and call her a fat bitch for stealing her stuff and her car and Kidnapping the kids . EFFECT SELF/OTHERS: Injury/Risk of Injury to Self Interfered w/Activity/Social Other Resident were upset by her outburst and Stated they will not come back to bingo if she is playing . A review of the BASELINE CARE PLAN . MENTAL STATUS I HAVE: The potential for altered cognition, mood and Expression of unmet needs . MOVING To Move on Unit: independently via my wheelchair . On 7/1/25, at 1:15 PM, the Director of Nursing (DON) was interviewed regarding the incident with CNA F and Resident #1. The DON offered, that CNA F was sent home, terminated the day after the incident for mistreatment.

Based on observation, interview and record review, the facility failed to ensure 1) Resident and employee illness surveillance and monitoring, 2) Perform hand hygiene and don personal protection equipment (PPE) prior to entering a transmission-based precautions room, 3) Supply the staff with a trash receptacle for a transmission-based precautions room, and 4) Ensure that a urinary catheter bag was off the floor for one resident (Resident #20), resulting in the likelihood of contamination and spread of illnesses. Findings include. On 7/09/24, at 2:14 PM, an observation of CNA D who entered room [ROOM NUMBER] without performing hand hygiene, donned gloves but no gown or mask. The door to room [ROOM NUMBER] hand a contact isolation sign attached to an isolation caddy that housed gowns, masks and gloves. There was an additional sign posted on the door that stated contact and droplet isolation. CNA E walked to doorway and asked CNA D, do we need to and CNA D interrupted and stated, no, that's for bed 1 (Resident #42). CNA E entered the room without performing hand hygiene or donning PPE. Shortly after, CNA E exited the room and was asked if they needed to wear PPE prior to entering the room and CNA E stated, that's why I questioned it. On 7/09/24 2:20 PM, Surveyor entered room [ROOM NUMBER], CNA D was in the bathroom with only gloves on caring for the resident in bed 2. CNA D was asked if they planned to care for Resident #42 and CNA D stated, shortly. CNA E re-entered the room without performing hand hygiene nor donning PPE, placed a container of disinfectant wipes on top of the dresser and offered to CNA D be sure to wipe down the toilet. Upon exit of room [ROOM NUMBER], there was no trash can to discard the worn PPE and CNA D pulled the trash can from the bathroom and slid it near the doorway. On 7/09/24, at 2:45 PM, an observation of a staff member who entered room [ROOM NUMBER] to offer fresh fluids. The Staff member did not don any PPE prior to entering the room. On 7/10/24, at 1:09 PM, During infection control task along with the Director of Nursing (DON) and Infection Control (IC) Nurse C, a record review was conducted of the ongoing infection control line listing. There was no mapping noted of infections. IC Nurse C was asked for documentation for employee illnesses and who monitors that and IC Nurse C offered that there were yellow call-in slips that were housed in a box. A stack of yellow call-in slips was provided for review that were paper clipped together with the corresponding months attached for April, May and June. A review of the June call-in slips resulted examples of . fmla . personal . took family to doctor . vomiting . The DON offered that they get all the call-in slips and they go through them, post the call-in shift to get it covered. IC Nurse C was asked if they follow-up with the employees who call off for illnesses and IC Nurse C stated, they review them for trends. On 7/10/24, at 2:23 PM, a review of the July, 24 resident infection line listing along with IC Nurse C was conducted in the DON's office. IC Nurse C was asked what type of transmission-based isolation Resident #42 required and IC Nurse C stated, contact isolation do to shingles. IC Nurse C was asked if the sign was on the door was the entire room on contact precautions and IC Nurse C stated, no just bed 1. IC Nurse C was asked if the bathroom inside room [ROOM NUMBER] was in contact precautions and IC Nurse C stated, no all bed 1 cares are at the bedside. IC Nurse C and the DON were both asked were they sure Resident #42 didn't use the bathroom and the DON clarified that yes, (Resident #42) does get up and use the bathroom. The DON offered that they use Direct contact precautions and are to only use PPE when changing linens or caring for the infected area. A record review of the contact isolation sign along with IC Nurse C revealed, CONTACT PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person . On 7/10/24, at 2:43 PM, The DON and IC Nurse C were asked to clarify that the facility did or did not have an employee illness line list or tracking system and The DON offered that they did have employee illness line list during Covid and they do review the call-in slips. IC Nurse C and the DON were asked how they could ensure if vomiting was noted in employees and how they would related that to an outbreak in residents for example and the DON offered we review the resident's line list and if we noted two or more of the same illnesses for example e-coli we would go to the floor and do education. The DON offered that they do get emails from the scheduler for call-ins and does follow up although no documentation was provided. No documentation was offered in relation to employee illness tracking or an employee illness line list. On 7/10/24, at 3:26 PM, further interview with the IC Nurse C and the DON regarding the clarification of Direct contact precautions and that the CONTACT isolation sign hanging on door 320 did not explain Direct contact and how the staff dispose of PPE upon exit of an isolation room and the DON offered that they do educate on the need for PPE for Direct contact with the infection verbally and that there is a rolling cart near the doorway for disposal of linens and PPE/trash. The DON was alerted there was no cart for room [ROOM NUMBER]. The facility was asked to provide any further documentation of illness tracking and the most recent surveillance mapping for resident illnesses. A record review of the most recent mapping for resident illnesses was from September 2023 and the most recent employee illness tracking document was from November 2023 and was for Covid. 37666 Dining Observation On 7/08/24 at 12:00 PM in the 300 floor dining room, Certified Nursing Assistant K was observed helping a resident straighten her sock onto the residents foot, and pull it up. She did not perform hand hygiene after pulling up the resident's sock. Then the nursing assistant helped the resident with her cover up, and rearranged the items on the table, then left the tale and went to the hand sanitizer on the wall and performed hand hygiene. Resident #20 A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #20 was initially admitted to the facility on [DATE] and readmitted from the hospital on 4/8/2024 with diagnoses: with acute respiratory failure, pneumonia, urinary tract infection, morbid obesity, chronic kidney disease, heart disease, chronic pain, depression, dementia, arthritis, urinary retention, urinary catheter, hepatitis C, neuropathy, and peripheral vascular disease. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status (BIMS) score of 15/15 and needed assistance with all care. On 7/08/24 at 2:12 PM, during a tour of the facility, Resident #20 was observed lying in bed, reading a book. A urinary catheter bag was sitting on the floor; it was not hanging from the side of the bed. The hook to hang it was dangling in the air. On 7/09/24 10:03 AM, Resident #20 had a sign for Enhanced Barrier Precautions on the outside of his door with Personal Protective Equipment/PPE hanging on the door; the door was partially closed. Upon knocking, Certified Nursing Assistant/CNA J was observed making the resident's bed; he was not wearing PPE. He said the resident was across the hall in the shower. When asked if he was supposed to wear PPE, he said only if he touched the resident. He was asked if he should wear it to change the bed linens and he stated, No, they said only if we touched the resident or his wound. The CNA was asked if the resident also had a urinary catheter and he stated, Oh, yes he does have a Foley. Referenced the sign on the door with CNA J and it said to wear PPE when changing bed linens, CNA J stated, I will go put it on.

Based on observation, interview, and record review the facility failed to maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting the facility's total census of 85 residents who receive meal services. Findings include: 1. On 7/8/24 at 11:02 AM, the floor in the walk in freezer was observed soiled and with visible debris on its surfaces. On 7/8/24 at 11:04 AM, a plastic container labeled as ground ham, and a bag of gluten free bread were observed on the floor underneath the wire rack shelving. Upon observation the surveyor inquired with Dietary Manager, staff A, on if they thought these areas were being cleaned timely and sufficiently to which they replied, yes, but our stock person comes in on Tuesdays and Fridays. They help with the cleaning and organizing. On 7/8/24 at 11:09 AM, broken eggshells and a container of heavy whipping cream were observed on the flooring in the walk in cooler. At this time the surveyor inquired with staff A on if they thought the flooring was being cleaned as needed throughout the day to which they replied, usually, it looks like they just mopped in here. I'm not sure why it is like this. On 7/8/24 at 11:12 AM, a heavy accumulation of ice buildup was observed on the exposed refrigerant lines in the walk-in cooler. At this time the surveyor inquired with staff A on if they were aware of the ice buildup in the refrigerator to which they replied, no, I can talk to maintenance about this. I would expect to see that in the freezer, but not here. On 7/8/24 at 11:15 AM, the surveyor requested a copy of the kitchen's cleaning policy to review. On 7/8/24 at 12:24 PM, during a dietary tour of the second floors kitchenette the surveyor observed a container of liquid butter stored in an upper cabinet with a heavy coating of liquid butter on the exterior of the container and on the base and the sides of the cabinet. At this time the surveyor inquired with staff A on if they were aware of the current state of the cabinetry to which they stated, no, I'm not sure why this in a container to brush it on, it's supposed to be in a squeeze bottle. On 7/9/24 at 8:47 AM, the floor in the walk in freezer was again observed soiled and with visible debris on its surfaces. On 7/9/24 at 10:18 AM, record review of a document titled, cleaning checklist kitchen week of 7/1 revealed a partially filled out cleaning schedule documenting the daily cleaning tasks required to be completed by staff. Upon review the surveyor inquired with staff A on the current state of the document to which they stated, it's a work in progress document. We are still trying to find the right fit. Review of 2017 U.S. Public Health Service Food Code, Chapter 4-601.11, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, directs that: (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 2. On 7/8/24 at 12:14 PM, during a dietary tour of the third floors kitchenette the surveyor asked the Dietary Manager, staff A, how the facility cleans and sanitizes work surfaces in this area to which they stated, we have our red bucket that has our sanitizer. At this time the surveyor asked staff A if they could test a sanitizing bucket to verify its concentration to which they replied, yes. On 7/8/24 at 12:16 PM, testing of the sanitizer concentration by staff A via a test strip, and comparing its color to the test strip packaging revealed a concentration of zero. At this time a temperature taken by staff A of the chemical solution revealed a reading of 51 degrees F. Upon observation staff A stated, This might be from this morning, I'll call down to the kitchen and have them remake it now. On 7/9/24 at 9:34 AM, record review of the chemical container underneath the 3-compartment sink by the surveyor and staff A revealed the expectation to maintain the sanitizer at a concentration of 200ppm-400ppm and at a temperature of 75 degrees F. At this time the surveyor inquired with staff A on how the facility plan to achieve this result to which they stated, we change them out every four hours or as needed. Review of 2017 U.S. Public Health Service Food Code, Chapter 7-204.11 Sanitizers, Criteria, directs that: Chemical SANITIZERS, including chemical sanitizing solutions generated on-site, and other chemical antimicrobials applied to FOOD-CONTACT SURFACEs shall: (A) Meet the requirements specified in 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (Food-contact surface sanitizing solutions)P 3. On 7/8/24 at 12:38 PM, the surveyor observed a half gallon of milk resting in a half filled tray of ice cubes in the third floors dining room. At this time the surveyor asked staff A, if they could take a temperature of the remaining portion of milk from the days lunch service to which they stated, yes. On 7/8/24 at 12:41 PM, temperature verification from staff A's thermometer probe revealed a temperature of 53 degrees F. At this time the surveyor inquired with staff A on what they would normally do when identifying a potentially hazardous food product at a temperature such as this, they replied, throw it out. On 7/8/24 at 12:42 PM, upon observation the Regional Dietary Supervisor, staff B, stated, we can order some personal containers of milk to help them stay cold. Review of 2017 U.S. Public Health Service Food Code, Chapter 3-501.16, Time/Temperature Control for Safety Food, Hot and Cold Holding directs that: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (2) At 5 C (41 F) or less.

Based on observation, interview and record review, the facility failed to ensure residents were treated in a dignified manner for a Confidential Group of residents, from a group of 28 residents reviewed for dignity, resulting in residents having soiled briefs due to call lights not being answered timely, a lack of a functional outdoor patio, and no opportunity to spend their Bingo winnings due to a closed Bingo store. Findings Include: FACILITY On 7/09/24 at 2:03 PM, during a meeting with a Confidential Group of Residents, several residents on the 2nd and 3rd floors said on the 3rd shift (night shift), their call lights were not being answered timely. They said staff members would come in to answer the call light, but would turn off the call light, sometimes they would ask them what they needed and sometimes they would not, the staff would leave the room and usually not come back in to help them. Three residents said there were occasions when the staff member did not come back to assist them to the bathroom and the residents soiled themselves. The residents said they don't understand why the call lights are not answered because, if it rings for too long, the signal is sent to a supervisor. They said sometimes it takes 1 hour for someone to come in to answer the call light. During the interview on 7/9/2024 at 2:03 PM, the Confidential Group of Residents voiced concerns that the Bingo store was closed and removed. They said many residents like to play Bingo and when they won, they could use their winnings to shop at a store that was set up in the facility that had a variety of items for them to buy. The residents said the facility was going to use the area housing the Bingo store for something else, and said they would find a new location for a Bingo store for them. The residents said it had been several months and there was no solution. The residents said this was a hardship for them because the store had many items that they felt they needed and wanted to buy. On 7/9/2024 at 2:20 PM, during the interview with the Confidential Group of Residents, they said they were upset and discouraged because it was now July and the outdoor patio had not been cleaned and the table and chairs were not set up for use. They said they had a garden out there, but there was no nozzle on the hose to water the plants- tomatoes, peppers and cucumbers that they had planted. They said they could not have visitors on the patio because it was not presentable. The residents said they were very concerned, because they were supposed to have a scheduled activity outside on the patio Thursday or Friday of that week and the patio was not ready. The resident's said they felt disrespected because if it was someone's home patio, they would have cleaned it up in the Spring and now it was Summer and still not done. On 7/10/2024 at 9:45 AM, during a tour of the outdoor patio, it was observed that the tables and chairs were all clustered together near the building, except for one table with two chairs around it. The patio was large with enough space to accommodate many people. The resident's plants were observed, and the hose was laying on the ground in the middle of the patio near the plants. On 7/10/2024 at 2:30 PM, the Administrator was interviewed about the Confidential Group of Resident's concerns. She said she was not aware of their concerns about the call lights not being answered timely on the night shift. However, the Administrator said she was aware of the Bingo store being taken down. She said the facility was planning to reopen it somewhere else in the building, on July 23, 2024. Discussed with the Administrator that this meant a lot to the residents and they were not aware of a date to open the Bingo store, or why it was taking so long. They really enjoyed Bingo and spending their Bingo winnings in the Bingo store. During the interview with the Administrator on 7/10/2024 at 2:30 PM, she was asked about the outdoor patio, she said the plan was to set up the patio, but it had not been set up because a storm was coming in. Reviewed with the Administrator that it was now July, and the facility had several months to prepare the patio for resident and visitor use and had not done so. She said she was going to meet with the maintenance department and develop a plan to have the patio ready. A review of the document by the Consumer Voice, Washington DC, Nursing Home Resident's Rights, provided the following: Residents of nursing homes have right that are guaranteed by the federal Nursing Home Reform Law. The law requires nursing homes to promote and protect the rights of each resident and stresses individual dignity and self-determination . Right to a Dignified Existence: Be treated with consideration, respect, and dignity, recognizing each resident's individuality . Quality of life is maintained or improved . A homelike environment .

Based on observation, interview and record review the facility failed to effectively act upon repeated concerns from the facility's Resident Council and one resident (Resident #28) of 28 residents reviewed, resulting in resident frustration and anger that their concerns were not being addressed for 1) Call lights not being answered, 2) Food preferences and cold food, 3) The inability to entertain on the outdoor patio and 4) Removal of the Bingo store. Findings Include: FACILITY Resident Council On 7/09/24 at 2:03 PM, during a meeting with 18 members of the Resident Council, they said they were upset because their concerns were not being addressed. They said they bring their issues and concerns to the Resident Council meetings each month, but they do not feel anyone is listening or trying to resolve their issues. A review of the Resident Council meeting minutes, approved for review by the Resident Council President, identified the following: January 30, 2024 with 18 residents in attendance: Residents voiced they would like a staff member to stay with them on the independent side of the dining room during meals to help them if they needed it. February 27, 2024 with 15 residents in attendance: Residents voiced concerns that staff were not coming back when they said they would/call lights. The Registered Dietitian attended and reviewed an Always Available menu that the residents could order from and it would start soon. March 26, 2024 with 11 residents in attendance: Residents would like food to stay longer on the floor in case the wanted seconds; April 29, 2024 with 20 residents in attendance: Residents voiced concerns about room temperatures at night; When will the Bingo store open and where will it be. May 28, 2024 with 17 residents in attendance: Residents voiced concerns about dinner not being as good as breakfast or lunch and vegetable concerns; When will the Bingo store open and where will it be located- The Activity Director said she would open the Bingo store the next week ( week of June 3-June 7th, 2024. This did not happen.) June 25, 2024 with 13 residents in attendance: Residents voiced concerns that the kitchen was closing at times, in the evening before everyone received their meals; dinner meals were not as good as breakfast and lunch; they wanted to know when the Bingo store was opening and where it will be located. The Activity Director said she would open it the following week in the Activity room (week of July 22-26, 2024: this did not happen- note dated 7/3/2024 said it would open 7/23/2024). The Resident Counsel was interviewed on 7/9/2024 at 2:03:PM. Several of the residents on the 2nd and 3rd floors said on the 3rd shift (night shift), their call lights were not being answered timely. They said staff members would come in to answer the call light, but would turn off the call light, sometimes they would ask them what they needed and sometimes they would not, the staff would leave the room and usually not come back in to help them. Three residents said there were occasions when the staff member did not come back to assist them to the bathroom and the residents soiled themselves. The residents said they don't understand why the call lights are not answered because, if it rings for too long, the signal is sent to a supervisor. They said sometimes it takes 1 hour for someone to come in to answer the call light. During the meeting with the Resident Council on 7/9/2024 at 2:10 PM, the resident voiced concerns about the Meals: Breakfast usually pretty good, lunch fair to good, supper is a different cook, sometimes good sometimes not; Alternate list for meals did not happen; you cannot have a hamburger at any time unless they know around lunch time for supper or the night before same with chef salad. Gluten diet accommodated to a certain point, not enough choices. Mushy vegetables at times; food cold sometimes; Sunday morning cheese omelet cold, dry, and the cheese was not melted. The resident said they had a Food council once or twice and a suggestion box was placed on the dining room wall. Not everyone can use it. Residents said sometimes they were not served a food item that was on the menu, but other residents would receive it. They said that week they were told there were no more sugar cookies and some residents did not receive one while other residents did. They said this had happened in the past also and they were very upset that some residents received the food they were supposed to receive and others went without. Someone from the Dietary department attends the Resident Council meetings. They do not seem to address the concerns. During the interview on 7/9/2024 at 2:03 PM, the Confidential Group of Residents voiced concerns that the Bingo store was closed and removed. They said many residents like to play Bingo and when they won, they could use their winnings to shop at a store that was set up in the facility that had a variety of items for them to buy. The residents said the facility was going to use the area housing the Bingo store for something else, and said they would find a new location for a Bingo store for them. The residents said it had been several months and there was no solution. The residents said this was a hardship for them because the store had many items that they felt they needed and wanted to buy. On 7/9/2024 at 2:20 PM, during the interview with the Confidential Group of Residents, they said they were upset and discouraged because it was now July and the outdoor patio had not been cleaned and the table and chairs were not set up for use. They said they had a garden out there, but there was no nozzle on the hose to water the plants- tomatoes, peppers and cucumbers that they had planted. They said they could not have visitors on the patio because it was not presentable. The residents said they were very concerned, because they were supposed to have a scheduled activity outside on the patio Thursday or Friday of that week and the patio was not ready. The resident's said they felt disrespected because if it was someone's home patio, they would have cleaned it up in the Spring and now it was Summer and still not done. On 7/09/24 at 2:58 PM, the Activities Director L was interviewed. She said she was new in her role and started about 3 weeks prior. She said she had attended one Resident Council meeting on 6/25/24. She said she was aware of the resident's food and Bingo store concerns. She said she wasn't sure about the food concerns, but she was aware of the Resident's being upset about the Bingo store. She said there had been discussion about setting up the store, but it hadn't been done yet. During the interview, the Activities Director L was also asked about the resident's food concerns, she said she had heard about some of their concerns, but was not aware what was being done for them. She was asked if the resident's concerns identified in the Resident Council meetings were being addressed. The Activities Director said the concerns were to be placed on a form Council Concern/Recommendation Form that was then forwarded to the appropriate Manager for a response and then they returned the form to activities with the action they identified to fix the issue. The Activities Director was asked if she had copies of the forms addressing the residents' issues. She said she had the forms. Copies of the forms was requested at that time. One Council Concern/Recommendation Form was received; it was dated 5/10/2024 and provided: To: Dietary Manager (A), Concern: Residents are concerned about meal temps being cold. Please return to the Council by: Date 5/10/24, Name: (Activities Director); Staff Response: (Dietary Manager) reminded staff on temping meals and following temp logs. Educated staff at huddles. The Staff Signature, Date and Implementation Dates were all blank. On 7/10/2024 at 9:45 AM, during a tour of the outdoor patio, it was observed that the tables and chairs were all clustered together near the building, except for one table with two chairs around it. The patio was large with enough space to accommodate many people. The resident's plants were observed, and the hose was laying on the ground in the middle of the patio near the plants. On 7/10/24 at 9:53 AM, Dietary Manager A was interviewed about the residents' concerns that were being mentioned in 4 of the last 6 Resident Council meetings related to cold food, quality of the food, especially the evening dinner meal, assistance with meals and food preferences. The Dietary Manager said he had heard these concerns in the past, but didn't think it was still an issue. Reviewed with the Dietary Manager that the residents were upset about this at the Resident Council meeting on 7/9/2024 and said this was still happening. The Dietary Manager was asked about Resident specific dietary needs such as a Gluten free diet. He said there was only resident with a gluten free diet and he said he had never met with the resident 1:1 to see what she would she would like. He said the cakes the facility makes are not gluten free, but they have an Oreo type cookie. He said he did not know what the resident liked. When asked about residents not receiving menu items because the resident is told the facility ran out, he said sometimes a floor didn't have a food item, but they could try to get it from the kitchen or another floor. He said he had not seen a grievance form related to food, and he started at the facility in February 2024. When reviewing the residents' concern about the evening meal, he said he was aware, but said no intervention was enacted to correct this. On 7/10/2024 at 2:30 PM, the Administrator was interviewed about the Confidential Group of Resident's concerns. She said she was not aware of their concerns about the call lights not being answered timely on the night shift. However, the Administrator said she was aware of the Bingo store being taken down. She said the facility was planning to reopen it on July 23rd, somewhere else in the building. Discussed with the Administrator that this meant a lot to the residents. They really enjoyed Bingo and spending their Bingo winnings in the Bingo store. The residents said they had been told several previous times that the Bingo store would open and it did not. During the interview with the Administrator on 7/10/2024 at 2:30 PM, she was asked about the outdoor patio, she said the plan was to set up the patio, but it had not been set up because a storm was coming in. Reviewed with the Administrator that it was now July, and the facility had several months to prepare the patio for resident and visitor use and had not done so. She said she was going to meet with the maintenance department and develop a plan to have the patio ready. The Administrator was asked about the residents' concerns with food and she said the Dietary department was trying to work on the issues and would continue to try and find a solution, A review of the facilities policies identified the following: Activities, date implemented 1/9/2023 and revised 1/16/2024, It is the policy of this facility to provide an ongoing program to support residents in their choices of activities based on their comprehensive assessment, care plan, and preferences . Call lights: Accessibility and Timely Response, date implemented 04/2023 and revised 03/2024, The purpose of this policy is to assure the (facility) is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response . All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified . Accommodation of Food Needs, issues 5/1/2019, revised 5/3/23 and reviewed 7/10/2024, Reasonable accommodations will be made by the culinary Department to those patients/residents with food preferences . Dietary Department Objectives, issues 5/1/2019, reviewed 11/1/22, The purpose and scope of the Dietary Department is to provide a program that meets the nutritional needs of all residents/patients . Consideration is given to the patients' physical, psychological and social needs. Recognition is also given to the patient's individual eating habits . Procurement and production of food products is to be carried out to ensure the patient a sufficient quantity of wholesome and nourishing food of acceptable variety and quality . Resident and Family Grievances, date implemented 05/2008 and date reviewed/revised 2/29/24, It is the policy of this facility to support each resident's and personal representative's right to voice grievances, . without discrimination, reprisal or fear of discrimination or reprisal . Prompt efforts to resolve include facility acknowledgment of a complaint/grievance and actively working toward resolution of that complaint/grievance . 49944 Resident #28 (R28): On 07/08/24 at 11:45 AM, an interview was conducted with R28. R28 stated that they have some issues with the activity program. R28 stated that they used to have a bingo store and when you won a game of bingo you would get points. R28 stated you can redeem those points for goodies such as snacks, clothes or toiletries. R28 stated the facility closed the store about 6 months ago and have not reopened it yet, they were told the facility was doing construction in the room for staff. R28 said the store is still not open and that the residents of the building really look forward to playing bingo and going to the store. This surveyor then asked R28 if there were any other concerns they wanted addressed. R28 said that the outdoor patio area used to be lovely with lots of tables, umbrellas and a fountain that was running. R28 stated the fountain isn't set up, there are no umbrellas, the tables are dirty and the whole area is a disaster. This surveyor asked R28 if they had been on the patio at all this spring or summer and they said no. R28 said you only get so many months of nice weather in Michigan, it's a shame we can't go out there. R28 thanked this surveyor for their time and for looking into the concern. On 07/08/24 at 12:00 PM, an observation revealed the patio area had a fountain that was not functioning, no umbrellas, no cushions and all of the chairs and tables were pushed up against the building. On 07/09/24 at 01:56 PM, an interview was conducted with the Nursing Home Administrator (NHA). The NHA was asked when the bingo store closed. The NHA stated the bingo store closed in April 2024 for remodeling. The NHA was asked when the store is going to reopen? The NHA stated they remodeled the bingo store area to become an area for staff and that the new store would be in a different location and opening on July 23, 2024. On 07/09/24 at 01:59 PM, the NHA was asked about the outdoor patio area and why it was not being utilized. The NHA stated that R28 brought the concern to them last week and the NHA told the maintenance department to get new umbrellas and new cushions for the area.

Based on interview and record review, the facility failed to provide one resident (Resident #74) their 2023/2024 influenza vaccine, resulting in the likelihood of influenza contraction, hospitalization and/or death. Findings include: Resident #74: On 7/10/24, at 11:00 AM, a record review of Resident #74's immunizations revealed no influenza vaccine administration documentation. The facility was asked to provide proof of influenza vaccine documentation. A record review of Resident #74's Immunization Consent Form revealed Resident #74 gave permission for Influenza with their signature and a date of 5-13-24. On 7/10/24, at 2:27 PM, the DON offered that Resident #74 admitted with a gastrointestinal infection and was on antibiotics on and off. The DON offered that Resident #74 wasn't healthy enough to get the flu vaccine and then once they were it was passed the window to get the flu vaccine. On 7/10/24, at 3:35 PM, a record review along with the DON and the IC Nurse C of Resident 74's immunization list revealed that they received VACCINE ADMINSTERED . Sars-CoV-2 (Moderna Booster) Spikevax . Date Administered . 05/31/2024 . There was no documentation that Resident #74 received an influenza vaccine for the 2023/2024 flu season. The DON was asked if Resident #74 was healthy enough to get the COVID booster then why they weren't offered the flu vaccine and the DON again offered that they are not allowed to give flu vaccine after March 31st and the DON was asked to explain. The DON offered that the medical director doesn't allow flu vaccine administration after that. The DON was alerted that the flu vaccine doesn't expire until June 30th each year and flu still is contracted throughout spring, and what was the Medical Director's reasoning, and the DON was unsure. The DON was asked if they follow the CDC guidelines and the DON stated, yes. The DON was asked to provide documentation from CDC that states do not give flu vaccine after March 31st. The DON entered into CDC.gov and could not find any documentation that alerted long-term care facilities to not give flu vaccine after March 31st.

Based on interview and record review the facility failed to develop a baseline care plan for falls for one resident (Resident #24) of 28 residents reviewed for baseline care plans resulting in an incomplete baseline care plan and the resident sustaining falls. Findings include: Resident #24 (R24): Resident #24 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include epilepsy, depression and profound intellectual disabilities. On 07/08/24 at 01:16 PM, record review of the 802 revealed that R24 triggered on the report for falls in the facility. On 07/09/24 at 12:23 PM, record review revealed R24 had sustained falls on 05/22/24 and 07/04/24. On 07/09/24 at 12:27 PM, record review revealed R24 had a baseline care plan for falls that was dated 05/17/24, R24 was admitted to the facility on [DATE]. Record review revealed that R24 was assessed for fall risk on 05/14/24 and was a high risk for falls with a score of 22, anything higher than a score of 16 is high risk. A baseline care plan for falls was not implemented until 05/17/24, this was verified by Minimum Data Set Nurse (MDS) N, MDS N nurse was asked when the baseline care plan should be completed and they said within 48 hrs of admission. MDS N nurse was asked if falls should be addressed on the baseline care plan and they said yes. A review of the policy titled Baseline Plan of Care Summary reviewed 02/2024 revealed: Procedure: 1. The baseline care plan will: a. be developed within 48 hrs of a resident's admission. b. include the minimum healthcare information necessary to properly care for a resident including, but not limited to: i. initial goals based on admission order. ii. physician orders. iii. dietary orders. iv. therapy orders. v. social services, vi. PASARR recommendation, if applicable. 2. The admitting nurse, or supervising nurse on duty, shall gather information from the admission physical assessment, hospital transfer information, physician orders, and discussion with the resident and resident representative, if applicable. a. Once gathered, initial goals shall be established that reflect the resident's stated goals and objectives. b. Interventions shall be initiated that address the resident's current needs Including: i. Any health and safety concerns to prevent decline or injury, such as elopement, fall or pressure injury risk.

Based on observation, interview and record review the facility failed to develop and implement a resident-centered comprehensive care plan for one resident (Resident #134) of 28 residents reviewed for Care Plans, resulting in Resident #134 lacking a Care Plan with resident-specific interventions to address likes and dislikes. Findings Include: Resident #134: A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #134 was admitted to the facility on [DATE] with diagnoses: Alzheimer's Dementia, urinary retention, glaucoma, anxiety, depression, pain, restlessness and agitation, constipation kidney cyst, neuralgia and a history of migraines. The MDS assessment dated [DATE] revealed the resident had severe cognitive loss with a Brief Interview for Mental Status (BIMS) score of 3/15 and was independent with ambulation needing supervision and supervision to assist with all care. On 7/08/24 at 3:29 PM, Resident #134 was observed wandering non-stop in the hallways and trying to go into other residents rooms. A staff member was following along with him and encouraging him not to enter other resident's rooms. The resident was wandering through the entire 300 hall. On 7/8/2024 at 3:45 PM, Clinical Coordinator G said sometimes Resident #134 would walk around nonstop for 30 hours. She said he always had a 1:1 staff member with him. She said he had been this way since admission. The Clinical Coordinator said sometimes his behavior was combative and he was difficult to redirect. She said initially he was in a room on the 2nd floor, but he wandered into another resident's room and barricaded himself inside the room. He was then moved to the 3rd floor with a 1:1 staff member. On 7/9/2024 at 12:20 PM, Social Services Director L was interviewed about Resident #134. She said the resident continuously wandered in the hallways and attempted to go into other resident's rooms or through the exit doors. She said he was assigned a private room on the 3rd floor/300 hall and a staff member was always with him, after the incident on the 200 hall/2nd floor. She said after the incident the resident was transferred to a psychiatric hospital where they attempted to stabilize his medications and then he returned to the facility. She said the plan was for him to transfer to a more appropriate Dementia unit when one became available. On 7/09/24 at 3:02 PM, Activities Director M was interviewed about Resident #134. She was asked what activities had been tried with the resident. She said someone brought in a larger toy tractor for him, because he was a farmer, to take apart and it only interested him for a few minutes; they tried walking with him and said staff rotate who provides the 1:1 with him and the Activity Aides also provided some of the 1:1's. She said he liked snacks that he could have on the go, such as a cheese stick and chocolate candies. She said they were told there were 2 movies that he liked, but he didn't seem very interested in them. During the interview, the Activities Director was asked if Resident #134 liked older TV shows, or music from his generation. She said she didn't know. The Activities Director was asked if anyone asked the family; she said she wasn't sure. A review of the Care Plans for Resident #134 revealed the following: Most of the Care Plans were dated 7/9/2024: mood care plan started 7/9/4; mobility care plan started 7/9/24; Safety falls care plan 7/9/2024 with a high risk fall score of 16 and falls on 7/1/2024, 6/24/24, and lowered to the floor on 6/29/2024; Bladder management care plan 7/9/2024; pain care plan 7/9/24; visual function care plan 7/9/2024; Behavior care plan dated 7/9/2024; baseline care plan was dated 7/9/2024 and did not have resident centered interventions. The resident was admitted [DATE] and transferred to the hospital 6/6/2024 and returned to the facility 6/20/2024. The MDS admission assessment was completed on 7/1/2024 and the Care Plans on 7/9/2024, but the resident did not have person-centered interventions or a person- centered care plan to aid the staff in providing care to the resident. The Nutrition Care Plan was dated 6/5/2024 and was not resident specific. It did not include food likes or dislikes as referenced by the staff. The Activities Care Plan was dated 7/2/2024 and was not resident specific. There were no resident specific interventions. A review of the facility policy titled, Comprehensive Care Plans, It is the policy of the (facility) to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the resident's comprehensive assessment . Person-centered care means to focus on the resident as the locus of control . The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences .

Based on observation, interview and record review the facility failed to update a care plan timely for one resident (Resident #24) of 28 residents reviewed for care plan updating resulting in late care plan revision after a fall. Findings include: Resident #24: Resident #24 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include epilepsy, depression and profound intellectual disabilities. On 07/08/24 at 01:16 PM, record review of the 802 revealed that R24 triggered on the report for falls in the facility. On 07/09/24 at 12:23 PM, record review revealed R24 had sustained falls on 05/22/24 and 07/04/24. On 05/22/24 R24 sustained an observed fall, R24 rolled out of bed during morning care, no injuries were noted, the physician and guardian were notified. The Certified Nursing Assistant (CNA) was in the room providing care to the roommate when R24 was noted to roll out of bed . New intervention was to place a perimeter mattress on the bed for a tactile barrier. Fall follow up completed. On 07/04/24 at 1:45 am, a unobserved fall was sustained, neurological assessments were initiated and within normal limits, a new intervention was to place the bed in the lowest position. The physician and guardian notified on 7/4/24 of the incident, no new orders were given by the physician. On 07/09/04 an interview was conducted with Restorative Nurse O, who updates care plan interventions after an incident. Restorative nurse O was asked about the fall on 07/04/24 and when the care plan was updated. Restorative nurse O was asked who first updates the care plan after an incident, they stated that the floor nurse would enter an intervention and then they would review and update as needed. Restorative nurse O was asked when the care plan was updated for R24 after the fall on 07/04/24 and they stated it was updated on 07/09/24. Restorative nurse O was asked if that should've been updated sooner than five days after the fall and they stated yes, I am not sure how it got missed. Record review of the policy titled Fall Prevention Program, revised 02/28/2024 revealed: 6. Each resident's risk factor's and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed. 7. When a resident falls the facility will have: k. The interdisciplinary team team will review the resident's fall and will evaluate the need for further interventions at morning meetings.

Based on observation, interview and record review, the facility failed to prevent the development of a facility-acquired pressure injury and ensure timely nutritional evaluation with the development of the pressure injury for one resident (Resident #46) of three residents reviewed for pressure ulcers, resulting in a deep tissue injury to Resident #46's right heel, and the potential for lack of nutritional intervention to hasten the healing of pressure injury, and the potential of pain and discomfort. Findings include: Resident #46: A review of Resident #46's medical record revealed an admission into the facility on [DATE] with diagnoses that included heart disease, dementia, mental disorder, heart disease, diabetes and diabetic neuropathy. A review of the Minimum Data Set assessment revealed the Resident had a Brief Interview of Mental Status score of 2/15 that indicated severely impaired cognition and the Resident used a wheelchair, propelled wheelchair independently, was dependent with putting on/taking off footwear, and dependent with chair/bed-to-chair transfer. Further review of Resident #46's medical record revealed a progress note dated 4/26/24 at 5:47 AM, Incident Type: SDTI (suspected deep tissue injury) observed left lateral heel. Description of Incident: area to left lateral heel observed during skin assessment, 2.5 x 2.5 cm (centimeters) fluid filled blister with 1 x 1.3 cm purple center with surrounding blanchable redness measuring 4 x 5 cm. Progress Note dated 4/30/24 at 4:24 PM, revealed, Left medial heel, follow-up assessment, length 2.5 cm, width 2.5 cm; Tissue Type: skin intact. Fluid filled blister now intact over the SDTI. Able to visualize dark purple area under blister . Treatment: pressure injury care, cleansing and irrigation: saline; dressings: foam dressing; protective: skin/prep wipes . Interventions: support surfaces for bed; mattress; foam, support surfaces for wheelchair; cushion; foam cushions, other support surfaces: heel lifts of heel suspension device, monitor skin integrity and tissue tolerance; minimize exposure to moisture . minimize risk for shear and friction; intervention to maintain/improve nutrition & hydration status . Progress Note dated 7/2/24 at 4:31 PM, revealed, area 1: Left medial heel, follow-up assessment, length 2.2 cm, width 2.5 cm, depth: 0.1 cm, Tissue Type: partial-thickness skin loss . Current Stage: suspected deep tissue injury Healing . A review of the Nutrition evaluations revealed a quarterly assessment dated [DATE]. The next completed nutrition evaluation after the development of the SDTI, that originated on 4/26/24, was dated 5/24/24. Comments revealed, Resident continues with no sig (significant) weight changes . PO (oral) intake averaging 75-100% most meals . Resident with new pressure area to L heel. Memo sent to UM (Unit Manager) for addition of protein Jello BID (twice a day) (20g pro, 80kcal each) as res (resident) was previously receiving this and accepts it well. Encourage protein intake to promote wound healing and meet increased protein needs (95-119g (grams) 1.2-1.5g/kg (kilograms) CBW). Cont (continue) to educate res on benefits of protein and wound healing. Cont to monitor for changes in intake/appetite and for weight trend. On 7/9/24 at 2:01 PM, an interview was conducted with Wound Care Nurse (WCN)/Assistant Director of Nursing (ADON) P regarding Resident #46's pressure injury. The WCN the origination of the DTI (deep tissue injury) was on 4/26/24 at the left medial heel area, was a dark discoloration, formed a blister, the blistered area came off revealed a pink area flush with the skin and healing. The WCN was asked if the wound was facility acquired and stated, Yes that is correct. The WCN indicated they had investigated the cause and determined it might have been caused by the foot pedals on the wheelchair, had Restorative Therapy assess the wheelchair foot pedals and placed padding on the foot pedal. The WCN indicated the Resident refused to wear anything but the grip slipper/socks, refused shoes. They started a pressure relieving boot worn at night/while in bed. When asked about nutrition evaluation, the WCN was unable to find an evaluation that was timely after the Resident had developed the pressure injury. When asked if the Dietitian had been notified of the wound, the WCN indicated that all resident wounds were reviewed weekly by the IDT (interdisciplinary team) that would include the Dietitian. On 7/9/24 at 2:29 PM, an interview was conducted with the Dietitian Q regarding nutritional evaluation after Resident #46 developed the pressure injury. The Dietitian indicated the Resident had a good appetite and was taking protein Jello which the Resident had taken before but had been switched to a high protein snack due to diabetes, they went back to the protein Jello because of the wound and the prevalence of acceptance of the Jello by the Resident. When asked when she was contacted about Resident #46's facility acquired pressure injury, the Dietitian reported she did not have record of contact. When asked if she attended the IDT meetings where wounds were discussed, the Dietitian indicated she did attend. The Dietitian indicated she had seen the Resident closest to the development of the wound on 5/24/24 and stated, Typically I see them as soon as I know about it. When asked how staff contact the Dietitian, they reported by Teams, messaging, memo, and IDT. The WCN reported that the weekly IDT was a newer process they have been trying but did not indicate when the meetings had started. When asked if approximately a month after the development of the wound for a nutrition evaluation was appropriate, the Dietitian stated, Usually I would see them right away. On 7/10/24 at 9:51 AM, an observation was made of Resident #46 lying prone in bed. Wound Care Nurse P was observed doing a dressing change to Resident #46's injury to the heel area. The dressing was removed, area cleansed. The wound was pinkened and the WCN indicated it was healing well. The WCN applied the new dressing, followed hand hygiene, enhanced barrier precautions and insured comfort of the Resident. The Resident was asked to observe the other heel, consented, and the WCN removed the Resident's gripper sock with skin intact to heel area. A review of the facility document titled Pressure Ulcer Protocol and Standing Orders, revealed, Return to ADON once initiated within in 72 hours. ***Complete with all new suspected pressure injuries*** . Intervention: . Nutrition Risk Assessment - 1 x(times)/(per)week . Notify Registered Dietitian . A review of facility policy titled, Pressure Injury Prevention and Management, revised/reviewed 2/14/24, revealed, Policy: The (Facility name) is omitted to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries . g. Nursing refers residents at risk for pressure injury development or residents with existing wounds to the Registered Dietician to review nutritional requirements for wound healing .

Based on observation, interview and record review, the facility failed to ensure that Resident #58 had oxygen available in the portable oxygen tank; properly store distilled water for a CPAP machine for a resident in room [ROOM NUMBER]-2; and remove/clean a CPAP machine for Resident #70, of four residents reviewed for respiratory care, resulting in the potential for infection, respiratory illness, low oxygenation, and shortness of breath. Findings include: Resident #58: A review of Resident #58's medical record revealed an admission into the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, heart disease, and anxiety disorder. A review of the Minimum Data Set (MDS) assessment revealed the Resident had moderately impaired cognition and needed moderate assistance with bathing, upper body dressing, and toileting. A review of Resident #58 revealed an order for oxygen, Apply oxygen (per nasal cannula) to maintain O2 sat > or equal to 90%, dated 1/22/23. The document received from the facility dated 6/10/24 to 7/9/24, revealed the Resident used 2 liters of Oxygen for 8 hours each 8-hour shift documented, average total of 24 hours a day. On 7/8/24 at 2:22 PM, an observation was made of Resident #58 in her wheelchair in her room and propelling herself around in the room. The Resident had oxygen nasal cannula tubing on that was connected to an oxygen tank that hung on the back of her wheelchair. The oxygen tank was on the red and indicated it was out of oxygen. The Resident was asked questions and could answer simple questions. The Resident was asked if she could feel if she was getting any oxygen flow through the nasal cannula. The Resident moved the nasal cannula around and indicated she did not think it was flowing. There was no sound noted when the resident adjusted the nasal cannula. The Resident was asked how long she had been out of oxygen but was unsure. CNA (certified nursing assistant) T was summoned to Resident #58's room to check the Resident's oxygen tank. The CNA indicated that the tank was on red and would get another tank. Nurse U was summoned to the Resident's room and was asked to monitor the Resident's oxygen saturation (O2 sat) that showed the O2 sat was 94% to 92%. The Resident was asked if she felt short of breath but denied shortness of breath. The CNA was asked about ensuring the Resident had enough oxygen in the tank and reported she recently started the shift and had not been in to check on the Resident. On 7/10/24 at 11:19 AM, an interview was conducted with Unit Manager, Nurse R regarding Resident #58 oxygen tank in the red and no flow of oxygen. When asked how often the Resident used the oxygen, the Nurse reported, she wears it all the time, when she was out of the room, she used the portable oxygen tanks and when in the room, she was put on wall oxygen. The Nurse reported that when the tanks were low or empty, the nurse will switch it out and reported that when it was getting low they should check it more frequently. Resident #70 A review of Resident #70's medical record revealed an admission into the facility on [DATE] with diagnoses that included dementia, insomnia and sleep apnea. A review of the MDS revealed the Resident had severely impaired cognition. On 7/8/24 at 12:01 PM, an observation was made of Resident #70's room with a CPAP machine on the bedside table. There was a gallon jug of distilled water on the table that was opened, partially used and not dated with an open date. The CPAP machine had a chamber that was partially filled with water and the Resident had a nasal mask. The chamber had liquid in it and was not cleaned out and set to dry. On 7/10/24 at 9:49 AM, an interview was conducted with the Director of Nursing (DON) regarding the dating of the distilled water for CPAP/BiPAP machines when opened. When asked if the distilled water should be dated upon opening, the DON stated, Yes, I believe they should be dating those when they open them. On 7/10/24 at 10:27 AM, an interview was conducted with Unit Manager, Nurse R regarding storage and dating of distilled water used for CPAP or BiPAP machines. An observation was made of distilled water in room [ROOM NUMBER]-2, opened and partially used. When asked about dating the distilled water when opened, the Unit Manager stated, Yes they should be dating them. An observation was made of Resident room [ROOM NUMBER]-2, of the distilled water for the CPAP or BiPAP machine stored on the floor between a chair and the bedside table. The distilled water was opened, partially used and had a date of when it was opened. The Unit Manager indicated the distilled water was not to be stored on the floor and reported the Resident would put it on the floor herself. The water chamber on the machine had water inside. The Unit Manager was asked about letting the chamber dry and reported that Nursing staff were to empty them out daily and let them dry. A review of orders in the medical record, with the Unit Manager, revealed a lack of orders or documentation of drying the chamber daily. The policy for CPAP and BiPAP machines was requested. On 7/10/24 at 11:15 AM, an observation was made with Unit Manager, Nurse R of Resident #70 room. There was no CPAP machine on the bedside table and the equipment had been removed. When asked about the CPAP machine and if Resident #70 had a CPAP, the Unit Manager reported the Resident had been refusing the CPAP and it was discontinued. A review of Resident #70's medical record by the Unit Manager revealed the CPAP had been discontinued on 6/21/24. The observation of the CPAP machine with the water chamber partially filled and the distilled water not dated with an open date was reviewed with the Unit Manager. On 7/10/24 at 3:26 PM, an interview was conducted with the DON regarding storage of the CPAP machines. The DON reported the chamber is filled daily, my assumption is that it would be emptied daily and stated, If you clean the mask daily, then I would think you would clean the chamber as well. The DON reported that the facility policy did not indicate the distilled water needed to be dated. The DON indicated that the Resident in room [ROOM NUMBER]-2 had a stool where the distilled water was to be stored to keep it off the floor and the Resident had removed the water from the bedside table to the floor and that education was provided to the Resident. The CPAP/BiPAP policy had been requested but was not received by the facility.

Based on interview and record review the facility failed to follow standards of practice for laboratory testing and antibiotic use for one resident (Resident #25) of 4 residents reviewed for antibiotic use, resulting in Resident #25 receiving antibiotic treatment without appropriate laboratory tests to determine if the resident had a urinary tract infection and if the antibiotic was appropriate. Findings Include: Resident #25: Urinary Catheter or UTI A record review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #25 indicated admission to the facility on [DATE] with diagnoses: Alzheimer's dementia, diabetes, depression, peripheral vascular disease, heart disease, hypertension and a history of urinary tract infection/UTI. The MDS assessment dated [DATE] indicated the resident had severe cognitive loss and needed assistance with all care. On 7/08/24 at 11:31 AM, during a tour of the facility, Resident #25 was observed sitting in a chair in her room. She was confused and didn't answer questions. On 7/8/2024 at 12:25 PM, the Infection Prevention and Control/IPC Nurse C was interviewed about Resident #25. She said the resident had recently been treated with an antibiotic for a urinary tract infection. When asked if she had a copy of the laboratory reports: urinalysis and culture and sensitivity C&S) (used to identify a urinary tract infection and determine what the organism causing the infection was and what antibiotics were most effective to treat it), she said she would need to look it up. A review of the physician orders identified the following: Bactrim (antibiotic) 400 mg-80 mg tablet, 1 tablet twice a day for 10 days. On 7/8/2024 at 4:00 PM, the Director of Nursing provided a document titled, Risk Versus Benefit Dictation Needed, for Resident #25. It revealed the following: Type of Infection: UTI; Antibiotic initiated 400-80mg PO (by mouth) twice a day x 10 days; Date Antibiotic was initiated: 6/19/2024. Signs and Symptoms Present: Positive UA (urinalysis), increased yelling/behaviors. There was a section on the document for Diagnostics Ordered and Performed and it was blank; this included the headings for UA, Urine C&S and other. The form had a category for Rationale for Not Meeting Criteria for Infection and it revealed, No culture result/culture insufficient, no leukocytosis. There was no further explanation. The form was signed by the IPC Nurse C on 6/25/2024. The IPC Nurse had attached a sticky note to the form, but did not provide any laboratory results for the urinalysis or C&S. On 7/10/24 at 1:04 PM, Clinical Coordinator G was interviewed about Resident #25's antibiotic treatment. She provided copies of 3 urinalysis results for Resident #25: 6/19/2024, 6/22/2024 and 7/5/2024. The 6/19/2024 and 6/22/2024 urinalysis each showed positive epithelial cells of 5-10. The reference range identified none should be seen; this indicated potential contamination of the specimens. There were no C&S reports identifying an infectious organism or antibiotic sensitivity. Nurse G said she had contacted the Lab when they did not receive the C&S and she said the Lab told her they did not run the cultures. She said she was told after the 6/19/24 urinalysis to run another urinalysis but she did not know why. The 2nd urinalysis also showed 5-10 epithelial cells. She said Bactrim was ordered for the resident x 10 days without knowing if it would be effective. The last provider note was dated 6/2/2024 and did not include mention of signs and symptoms of a UTI for Resident #25. A review of a Bladder Management Care Plan for Resident #25 mentioned urinary tract infections but it had not been updated since 8/12/2022 and did not reference the resident's recent treatment with an antibiotic. A review of the facility policy titled, Antibiotic Stewardship Program, date implemented 3/10/2020 revealed, It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of this program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use . the Infection Preventionist, with oversight from the Director of Nursing, serves as the leader of the Antibiotic Stewardship Program . Medical Director serves as the primary medical point of contact for the program and serves as a liaison between the facility and other medical staff members . Nursing staff shall assess residents who are suspected to have an infection . Laboratory testing shall be in accordance with current standards of practice .

Based on observation, interview and record review, the facility failed to inform and/or educate 6 out of 6 Residents who attended the Confidential Group Meeting about the location of the survey book and ensure that results from the most recent State Survey for complaint investigations and Plans of Correction (POC) for the preceding Standard Recertification Survey were readily accessible, affecting all 78 Residents residing in the facility, resulting in Residents, Residents' Representatives, families and visitors being unable to review the survey results and Plans of Correction. Findings include: On 6/29/23 at 11:01 AM, a meeting was held with a group of fifteen Residents in a confidential group meeting. The group was asked if the results of the State inspections were available to read. The group responded that they were not aware there was a binder or that survey results were to be available. The group did not know where the book would be found to read. On 6/29/23 at 2:25 PM, an observation was made of a binder located on a wall holder near the elevator for the 3rd floor. The book was titled Resident and Public Information. The binder had one survey available that was an abbreviated survey with an exit date on 4/21/22. The facility had more recent surveys prior to the survey on 4/21/22. On 6/29/23 at 2:29 PM, an observation was made of a binder located on a wall holder near the elevator for the 2nd floor. The book was titled, Resident and Public Information. The binder had a survey that exited on 4/21/22 of an abbreviated survey and the survey results for the Standard and Abbreviated survey from 10/12/21. The Standard/Abbreviated survey had no plan of correction data available to be reviewed. On 6/29/23 at 2:40 PM, an observation was conducted with the Administrator (NHA) of the binder on the 2nd floor. The binder had the survey results from the abbreviated survey that exited on 4/21/22. The NHA indicated they should have the last survey results and stated, They should be available for the past three years. I see the last survey is not in there. The NHA was asked about information for the plan of correction. The NHA indicated that the plan of correction should be available with the most recent surveys in the binders. The NHA reported they would have the most recent surveys put into the binders and available. A review of the facility policy titled, Resident Rights, revised/reviewed 12/13/2022, revealed, .6. Information and communication . k. The resident has a right to: i. Examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility .

This Citation pertains to Intake Number MI00132818. Past Non-Compliance (PNC) was presented by the facility during investigation of the allegation and was accepted by the survey team upon exit from the facility for this citation. Following discussion with the State Manager, Past Non-Compliance was accepted with a Compliance Date of 12/09/2022. Based on observation, interview and record review, the facility failed to report a fall and ensure that fall procedures and protocols were followed after a fall for one resident (Resident #4) of five residents reviewed for falls, resulting in Resident #4 sustaining a fall with a delay in reporting and the identification of an injury timely after the fall, sustaining bruising to bilateral upper extremities and a fracture of the femoral head of the femur bone, pain, a decline in condition, ability and overall health status. Findings include: Resident #4: A review of Resident #4's medical record revealed an admission into the facility on [DATE] with diagnoses that included altered mental status, Alzheimer's disease, metabolic encephalopathy, atrial fibrillation, osteoporosis, malnutrition, heart disease, muscle weakness, and stroke. A review of the Facility Reported Incident for Resident #4 revealed the following: -Incident Summary: On 11/6/2022 at approximately 12:30 am, resident (#4) had a fall while ambulating to the bathroom with CENA (Certified Nursing Assistant) (S). It was determined on 11/7/2022, that CENA (S) failed to inform any other personnel at the facility that the fall occurred. This CENA also assisted the resident from the floor to her chair without assistance of other staff or the use of a mechanical lift. It appears that in the course of receiving this assistance manually by the CENA'S that (Resident #4) sustained bilateral bruising to her arms. (Resident #4)denies psychosocial distress and does not complain of pain in the bruised arm areas . CENA (S) has been suspended from employment at the facility while the investigation takes place. -Investigation Summary/Actions Taken: On Monday, November 7, 2022 at 6 pm facility nursing manager (name) became aware that resident (#4) had fallen while being assisted to the bathroom by CENA (S) on Sunday November 6th at approximately 12:00 am. CENA (S) admitted at that time to not following facility procedures by not reporting the fall to other facility personnel and by manually assisting the resident back to her chair by herself rather than seeking help and using a mechanical lift. This action by (CENA S) appears to have resulted in bruising to (Resident #4's) bilateral upper extremities . A BIMS (Brief Interview of Mental Status) was performed on resident (#4) at approximately 6:30 PM November 7th with a resulting score of 0/15 indicating severe cognitive deficits which is consistent with prior BIMS. -Interview with CENA (S): .CENA (S) stated that approximately 11:30 pm-12:00 am on November 5th-November 6th, (CENA S) was walking resident (#4) to the bathroom with the appropriate care planned devices and techniques when (Resident #4) fell to the floor. (CENA S) reported that she used the gait belt in her attempt to assist the resident to a standing position from the floor and she also used her arms under the resident's arm pits to help her to a standing position . By the morning of November 6, 2022, Nurse (name) [who was assigned to (Resident #4)] observed bruising to (Resident #4's) left hand and left leg pain and impaired ability to bear weight . an x-ray was ordered to be performed the following day per the physician's order . On November 7, 2022, the X-ray of the left leg was performed as ordered by the physician on November 6, 2022. The results were obtained at approximately 4 pm on November 7, 2022 as an impact fracture of the left femoral head . Upon further investigation it was determined that the fracture occurred in conjunction with the fall that was not previously reported . -Conclusion: .However, after the fall occurred, CENA (S) did not report the fall to anyone and proceeded to assist the resident back into her chair by herself. This technique was in violation of the facility policy and procedures and appears to have resulted in bilateral bruising to the resident's upper extremities . A review of Resident #4's progress notes in the medical record revealed the following: -Dated 11/6/22 at 10:44 AM, Purpose for Note: 7:20 am new or sudden onset/change in condition: C/O (complaints of) left leg pain initially then both legs. Misc. (miscellaneous) Note: At above time, CNA reported resident was having a hard time transferring and not standing well on her feet due to pain. [NAME] lift was attempted but resident screaming and yelling get that thing off me: This nurse and CNA did 2 person with resident into wheelchair, which she tolerated ok . Skin Status: New Skin Impairment: Abrasion/Bruise: Light purple bruising present to left hand slightly raised in the center, bruising to left hand middle finger, and new scattered bruises to right forearm, new from yesterday. -Dated 11/6/22 at 11:01 AM, Purpose for Note: 9:40 am new or sudden onset/change in condition: fatigue, pain, weakness . Pain: both legs, left more than right . This nurse and CNA attempted to transfer resident onto toilet at time noted above. Resident was able to stand, but had significant pain and moaning out, unable to safely pivot transfer . -Dated 11/6/22 at 1:27 PM, Physician/Consult Visit: 11/6/2022 spoke to/with resident examined resident reviewed physician orders. Concern Notes: Resident is not wanting to bear any weight to her left leg. Upon assessment, it appears that the left upper thigh is causing discomfort. When the resident coughs, she grabs at her left upper thigh and yells that it hurts. No recent trauma reported. No physical observation of trauma to the leg noted . new orders received and noted, 11/6/2022 chest x-ray 1 view, Left femur 2 view. Ok for Mobil-X to do at facility. -Dated 11/6/22 at 6:37 PM, Purpose for Note: Resident sitting in recliner, leaning to Rt side, per her usual posture. She was very sleepy. Son, (name) and D-I-L (daughter in law), were in room. They had several questions about the bruising on bilat forearms & especially on Lt hand & Lt posterior forearm. This CN (Charge Nurse) apologized that I couldn't answer where the bruising came from. I did reiterate to family that she did not have them yesterday . She did say that her pain was on her Lt posterior arm when this CN ask her. She did not c/o pelvis or Lt leg pain to this time . -Dated 11/6/22 at 11:13 PM, .Musculoskeletal Status: Musculoskeletal complaint: resident crying out in pain and grabbing left medial thigh with any movement of the extremity. There is no rotation or obvious deformity of the extremity, pedal pulse +2, warm and normal skin tone, no bruising or other indication of injury. Precautions: Will have resident remain in bed pending results of mobile X-ray of left femur [not yet completed]. Reported from previous shift that resident did not tolerate pivot or stand up lift . -Dated 11/7/22 at 9:23 AM, .Resident continues to show declines in her health and functional status. Continues to have increased incontinence both bowel and bladder, weight loss, increased behaviors as well as functional declines in her mobility ADL's (activities of daily living) . Over the weekend noted to be placed on bed rest until X-rays are performed . -Dated 11/7/22 at 2:28 PM, (X-ray company name) arrived at (facility) to complete x-rays on resident. -Dated 11/7/22 at 7:53 PM, .X-ray shows Acute Impacted femoral neck fracture to left hip . family do not want resident to go to hospital. They would like her to be treated her (here) for the pain . -Dated 11/8/22 at 1:31 PM, .left leg drawn up with knee bent this early am. Color warm and pink. Pedal pulse +1, Bruising continues to left hand, fingers and bilateral forearms, left tri-cep area . -Dated 11/8/22 at 9:49 PM, . Skin Status: Bruising noted to Lt hand, Lt forearm, Lt upper arm, & Lt inner buttock. Bruising also on Rt upper posterior arm, several small bruises on Rt forearm, & Pt posterior calf. Resident having severe pain when moved with guarding Lt leg. On 3/8/23 at 10:05 AM, an interview was conducted with the Administrator (NHA) regarding the Facility Reported Incidents reported to the State Agency. The NHA indicated that Past Non-Compliance was completed for Resident #4 with the incident of the fall not reported by the CNA (Certified Nursing Assistant) S. On 3/16/23 at 2:15 PM, an observation was made of Resident #4 dressed and in bed. The Resident was sleeping and did not arouse when her name was verbalized. The Resident appeared to be resting quietly. A wheelchair was in the room and had a non-slip pad on the seat. The Resident had a call light within reach. On 3/16/23 at 2:38 PM, an interview was conducted with the Director of Nursing (DON) and the NHA that included a review of Resident #4's fall that was not reported and the Past Non-Compliance (PNC) that was completed. The DON and NHA was informed that the PNC had been reviewed with the State Agency Manager and accepted. The DON and NHA were informed that the other Residents that were reviewed for falls had been reported and no other concerns were found. The DON and NHA were informed that staff interviews indicated that staff were educated on the PNC and were aware of facility policies. The NHA and DON were questioned about the follow up on falls and audits completed and the ongoing oversight from the Quality Assurance Committee. The NHA reported CNA S had been suspended during the investigation and employment had been terminated. The NHA had presented a past non-compliance request regarding Resident #4's fall that had not been reported timely and presented the following corrective action plan to attain and maintain compliance with F-689. -Element 1: Resident #4 was immediately assessed upon notification of the policy violation. -Element 2: The facility completed the following evaluations for all facility residents: A complete review of every resident's skin was conducted by nursing management team members including skin assessments on every resident's skin in the facility; Pain assessments were conducted on every resident in the facility; Psychosocial assessments of each resident in the same unit were conducted by the social worker; Facility nursing managers conducted a 6-month look-back review of all facility incident reports and a 2 month look back report of all charting. -Element 3: The facility immediately educated every employee in the facility on the proper policy and procedures for reporting a fall, injury, abuse and injury of unknown origin; All staff mandatory training on Abuse, Neglect, Misappropriation and Injuries of Unknown Origin scheduled for December 6 and 8, 2022. -Element 4: The facility DON or her designee will conduct audits on 10 charts weekly x 12 weeks to evaluate compliance with proper fall/incident reporting; The facility DON or her designee will conduct audits of 10 employees weekly x 12 weeks to evaluate understanding of the proper procedures for fall/incident reporting including injuries of unknown origin, abuse and neglect; Both audits will become part of the QAPI team reporting plan. -Date of completion of the Plan of Correction: 12/09/2022. The State Surveyor verified the documentation provided by the facility and conducted interviews with facility staff. During the interviews with facility staff, staff stated that they had been educated on the facility policy for falls and abuse, that included reporting of falls and were knowledgeable about the facility policies.

This Citation pertains to Intake Number MI00124713. Based on observation, interview and record review, the facility failed to prevent sexual abuse from occurring to Resident #3 when Resident #9 touched the breast area of Resident #3 for one resident (Resident #3) of four residents reviewed for abuse, resulting in sexual abuse occurring to Resident #3 with psychosocial distress using the reasonable person concept. Findings include: Resident #3: A review of Resident #3's medical record revealed the Resident was admitted into the facility on [DATE] with diagnoses that included repeated falls, femur fracture, heart failure, developmental delay and disorders of psychological development. The Resident had a guardian and co-guardian responsible for health care decisions. Review of the Minimum Data Set (MDS) assessment, dated 1/27/23, revealed the Resident had a Brief Interview for Mental Status (BIMS) of 6/15 revealed severely impaired cognition and was independent with no assistance or set up help to walk in corridor and locomotion on unit and needed extensive assistance with dressing, toilet use and personal hygiene. On 3/16/23 at 10:31 AM, Resident #3 was observed to be dressed and sitting on her bed that was bare without linen on it. The Resident was able to answer simple questions but unable to hold a meaningful conversation. The Resident indicated she felt safe in the facility and that no one had hurt her but that she had hurt her hand and indicated her right hand. Resident #9: A review of Resident #9's medical record revealed the Resident was admitted into the facility on [DATE] with diagnoses that included sepsis, depression, traumatic brain injury, muscle weakness, developmental disorder of scholastic skills (learning disability) and encephalopathy. The Resident had a legal guardian. Review of the MDS, date of assessment 5/7/21 revealed a BIMS score of 15 which indicated the Resident was cognitively intact. A review of the incident report for Resident #9 revealed the following: -Dated of incident 10/22/21 at 11:10 AM. -Description of incident: Resident was in the hallway outside of his room [ROOM NUMBER] and was observed rubbing resident (#3) breasts with both hands rubbing in a up and down motion. -Witnesses: Staff name: (CNA -) Statement: I was transferring the resident in room [ROOM NUMBER]-1 into her wheelchair when I heard (Resident #3) laugh and (Resident #9) saying something in the hallway outside of (Resident #9) room, room [ROOM NUMBER]. I opened the door of 237 to see what was going on. I was (saw) (Resident #9) rubbing (Resident #3) breasts. He was using both hands, one on each breast, rubbing up and down. I immediately stopped it by saying (Resident #9's name) get your hands off of her now. You don't touch her like that. the Residents were separated and the CNA reported the incident to the charge nurse and supervising nurse. The Director of Nursing (DON) and Social Worker - were notified. The Resident was interviewed and when asked if he inappropriately touched resident (#3). He states he was hugging her and was yelling that the CNA is a fucking bitch. Also states she is going to get kicked off this floor . Writer educated him that touching other residents is inappropriate and that he cannot do this. Writer then went in and interviewed resident (#3) asked if he touched her and she stated yes. Writer asked her where he touched her and she placed both hands on each of her breasts and motioned up and down. -Notifications: .guardian notified (name) . stated yes he does have a guardian but he is fully aware of what he is doing. -Actions: continue to observe. Resident placed on 15 minute checks and 1:1 supervision when out of his room. A review of Psychosocial Follow Up Assessment after suspected abuse/neglect for Resident #3 for the incident on 10/22/21 revealed the following: -Dated 10/22/21, What does the resident remember of the occurrence? This worker spoke to (Resident #3) about what happened with (Resident #9). This worker stated, Was (resident #9) trying to give you a hug. Res stated, Yes, while laughing and smiling. This worker asked what else he had done and (Resident#3) touched her breasts, in which res had a more serious look on her face. This worker asked (Resident #3) what the male resident did when he had touched them and she held out her hand and was rubbing the top of her hand. Res then touched her breast. This worker asked if she wanted (Resident #9) to touch her breasts like that and she shook her head no and stated, No. -Dated 10/26/21, What does the resident remember of the occurrence? This worker followed up with (Resident #3) this morning regarding the situation that occurred on Friday. This worker asked (Resident #3) if she remembered what the male resident, (Resident #9), had done on Friday. Res touched her breasts and began rubbing. This worker asked if she liked (Resident #9) and res stated, No. Does the Resident feel safe in his/her current environment? Res states she does feel safe and is happy he is no longer by her and bug me. A review of Resident #9's Behavior Record documentation included but not limited to the following: -Dated 8/24/21 at 8:26 PM, resident is getting very upset around dinner time about how he is not the first one to eat, rolls self to room and yells at staff because of it. Tonight he was extremely rude and when multiple staffed tried to talk to him about it and explain that we are short staffed and all are trying our best and would like him to try to be patient he got more upset. Resident stated no one was more important then him. He didn't care if people needed help eating and that if we don't get it together he was going to fire all of us or complain until we are fired. He also said that if residents were not able to feed themselves they should not be allowed in the dining room and they deserve to starve. CNA told him that was not kind and if he would like to start eating in his room he may. -Dated 9/3/21 at 12:43 PM, Resident refused lunch, complaining he is going to turn the kitchen in because they are taking to long to serve everyone. Telling staff to get rid of other residents so he can eat his lunch faster. -Dated 9/3/21 at 9:18 PM, Resident very rude with staff again. Whishing to fire activities, kitchen and nurse and aide. Wondering if someone from socials will talk to him? He is getting to be like this a lot more lately and it is getting out of hand. -Dated 9/7/21 at 9:28 PM, Resident was following (female Resident's name) around most of the afternoon. He would wait outside of her bedroom door and talk to her while she was in her bedroom. Resident was also making inappropriate sexual comments during care tonight. -Dated 9/10/21 at 9:06 PM, (Resident #9) was getting really close to (female Resident's name from 9/7/21) and when aide went down and brought (female Resident's name) back to her room (Resident #9) kept saying that that aide needs to go because she's nosey and always sticking her nose where it does not belong . -Dated 9/10/21 at 9:29 PM, .After dinner I was coming around to the circle hallway up to the dining room hallway and I saw (female Resident's name from 9/7/21) down at the activity door which was locked but she was trying to get in and I saw (Resident #9) following her to the door. When I got down to both of the residents I asked (female Resident) if she was tired and would like to take a walk with me to her room, but she was upset because she wanted to have a cigarette. I told her that none of us smoke and (Resident #9) then told myself that he was going to start and that everyone here is nosey, and were all going to be fired. I eventually got (female resident) away from the situation and walked her down to her room where she remained for a brief period of time. After that for about an hour or so resident was complaining about myself in the hallway and telling everyone that I was nosey but would not speak to me directly. -Dated 9/12/21 at 9:05 PM, resident following a confused resident (233) around and telling her how to use the elevator. Resident also telling her not to listen to any of the aides and nurses and just get on the elevator. When resident in (233) would say she was tired resident (#9) would tell her to sit on his lap or try to lead her to his room and lay in his bed. -Dated 9/14/21 at 9:10 PM, resident frequently making more and more sexually inappropriate comments about staff and other residents in front of them both res and staff, and about them to other people. Effect: Disrupted Living Environment. Interventions: notified nurse. Other asked res to stop multiple times by multiple people and told that it was not appropriate or allowed. Outcome: unchanged, worsened. -Dated 9/15/21 at 1:49 PM, Grabbing at other female residents and lowering them down onto his lap. -Dated 9/26/21 at 9:18 PM, right at the beginning of dinner I had to leave the dining room to assist another resident on my hallway, when I was leaving circle to go back down to the dining room I noticed (Resident #9) on his way to his bedroom visibly upset. When I got down to the dining room no one knew what had happened with him so I went back down to his room to see what was going on and when I entered his room he had broken one of the towel rods off of the wall in his bathroom and was going to head back down to the dining room to whoop some ass I told he was not going to be able to do so and that if he wanted to he could eat in his room and that I would personally bring him his dinner. After talking to him for a moment to get him to agree with this, he had told me that the reason that he was upset was because the hospitality aide had given him soup for his appetizer rather than the salad that he had asked for. When I brought him more food back to his room, he then blew up on me because his cheeseburger had been cut into pieces as per his diet and meal ticket states . Eventually myself and another CNA asked our nurse to intervene. -Dated 10/9/21 at 11:00 PM, tonight during dinner the dinning room aide gave him the drinks he usually orders as he was starting to verbalize that he was upset that he hadn't gotten a drink yet. We had not had time to pass menus at this point but we were working on it as other behaviors where happening and peoples alarms were going off. He was upset that he didn't get a milk like he had wanted and had gotten juices even though I heard him say and the aide heard him say he wanted a juice .(the Resident had left the dining area to go back to his room, became irate when he did not get an extra entree, was told he would have to wait until they were done serving everyone else. The kitchen staff ran out of the second helping entree that the Resident wanted, was offered alternatives which he refused and his anger escalated) . about 5 minutes after this he rang his bell and I got another aide to go in with me as he was getting increasingly agitated and I did not feel safe answering this alone . he went off, yelling about how he was going to rip the kitchen apart and take what he wanted. He was also yelling fuck those mother fuckers he then started rolling out of his room and we yelled for help as he started attacking the other aide in his doorway, he was hitting grabbing and ramming his wheelchair into her screaming he was done and it was time to fuck these people up and he was done putting up with it. I yelled for help and another aide came running down the hall and she started to get attacked as well as she was standing in front of another resident to protect them from (Resident #9). I ran and yelled to the nurses station that we needed help now and closed the doors to the dinning room and other hallway as he was very upset and violent at this point so no one else would get hurt. He busted through the doors and was charging to the other set of double doors that is an entrance to the dinning room by the stairwell still screaming he was going to get them and it was over and he was screaming to be let in to get them. It took 5 or 6 nurses to pull him off the door and get him back to try to calm him down and he was hitting and grabbing and swearing and rolling into people trying to knock them over so he could get into the dinning room to hurt people. -Dated 10/22/21 at 1:49 PM, Resident was in the hallway with another resident (Resident #3). I observed him using both of his hands to rub her breasts. I immediately stopped him, separated them and told my charge nurse and nurse supervisor. On 3/16/23 at 11:17 AM, an interview was conducted with Social Worker (SW) - regarding Resident #9 and the sexual abuse incident with Resident #3. The SW reported that Resident #3 walks around on the unit, unassisted. The SW reported that Resident #9 had gone up to her and had both hands touching her breast, the CNA saw it and separated the Residents immediately and reported the incident immediately. The SW reported she had follow-up visits with Resident #3 and indicated she does not recall the incident but had remembered it after it occurred. The SW reported doing follow up visits with the Resident and had talked to the Resident almost on a daily basis. Resident #9's Behavior Record documentation was reviewed with the SW. The Social Worker explained that many of the Resident's behaviors stemmed around meals, food and his insistence on being given his meals first. The SW reported that after his outburst he was apologetic and would say it would not happen again. The SW reviewed the cyclic pattern of behaviors then being apologetic/remorseful afterwards was ongoing and she would meet with the Resident to discuss his behaviors. The SW was questioned about Resident #9's sexual verbal comments to staff and residents, pulling residents onto his lap, and cornering a female resident. The SW indicated that towards the end he had a couple incidents with female residents. The SW indicated Resident #9 had cornered a female resident in the hallway and the female resident was on 15-minute checks. When asked if Resident #9 was placed on 1 to 1 staffing or 15-minute checks, the SW stated, He was not made one to one or 15-minute checks until after the incident with (Resident #3). When asked why, the SW reviewed the Residents chart and stated, I can't find the answer to that. It's not charted why we didn't. I don't know why we didn't, if it was brought up in IDT (interdisciplinary team) but just not charted. The SW reported they had other Residents on 15-minute checks and they didn't want too many 15 minute checks due to being too much for the CNAs work load. The SW indicated the Resident had been followed by psych services, had gene site testing done and medication changes and adjustments and that staff knew that he was in need to be left alone to calm down. On 3/16/23 at 2:38 PM, an interview was conducted with the Administrator (NHA) regarding the concerns of sexual abuse to Resident #3 by Resident #9 and recurrent behaviors of Resident #9 that included behaviors towards other female residents prior to the incident on 10/22/21 and lack of interventions to ensure abuse does not occur. The NHA reported that the Resident was moved to the rehab section of the facility after the incident with Resident #3 and that there were less Residents on that unit while another placement was investigated for a more suitable place for Resident #9. When asked about the subpoenas for court, the NHA reported that they had called the police after the incident and that the court case was still in process. Review of the facility policy titled, Abuse, reviewed/revised 10/25/22, revealed, .Our residents have the right to be free from instances of abuse, irrespective of any mental or physical condition; be caused any physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse . 6 . If alleged perpetrator is a resident, he/she will be placed on one on one care until reviewed by the interdisciplinary team .

Based on observation, interview and record review, the facility failed to complete weekly wound measurements/skin assessments and implement interventions in a timely manner to prevent the development of an unstageable (an ulcer that has full thickness tissue loss but is either covered by extensive necrotic tissue or by an eschar/scab) right heel pressure ulcer and prevent the worsening of the unstageable pressure ulcer for one resident (Resident #1) of three residents reviewed for pressure ulcers, resulting in the development of an unstageable right heel pressure ulcer, the worsening of the ulcer, no documentation of weekly wound measurements and pain. Findings include. Resident #1: On 4/20/22, at 11:10 AM, Resident #1 was sitting in their reclining wheelchair with bilateral heel boots on with their feet elevated. ON 4/20/22, at 11:15 AM, CNA C was asked how long Resident #1 had an air mattress and CNA C stated, the air mattress is new. ON 4/20/22, at 11:45 AM, a record review of Resident #1's electronic medical record revealed an admission on 8/3/12 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set assessment (MDS) dated [DATE] revealed Resident #1 required extensive assistance with bed mobility and did not walk. A review of the MDS dated [DATE] Section M revealed no unstageable pressure ulcer. A review of the MDS dated [DATE] Section M revealed 1 unstageable pressure ulcer. A review of the wound progress notes revealed the following: 01/05/2022 Right heel initial assessment ONSET/DISCOVERY DATE: 01/05/2022 . length (cm) (centimeter) 2.1 width 2.1 . WOUND TISSUE: pink with 1.8 cm x (by) 0.2 cm red scabbed area bordering the area at 3 o'clock . tissues damaged, but no break in skin surfaces . suspected deep tissue injury . TREATMENT: pressure injury care, protective: skin/prep wipes, TREATMENT CHANGE: not applicable (initial assessment .) INTERVENTIONS: monitor skin integrity and tissue tolerance; minimize exposure to moisture, including but not limited to, fecal and urinary contamination, perspiration, other: Prevalon Boot 01/17/2022 Right heel . length 0.4 width 0.4 TISSUE TYPE: intact brown scab . TREATMENT CHANGE: no change since last report date .INTERVENTIONS: support surfaces for bed: rotation bed, mattress: foam, other support surfaces: heel lifts or heel suspension device, positioning pillows/wedges, monitor skin integrity and tissue tolerance: minimize risk for shear and friction: intervention to maintain / improve nutrition & hydration status; 02/08/2022 Charting is from 1/31/22 RIGHT heel unstageable pressure ulcer . length 0.7 width 0.5 WOUND TISSUE: brown, hard scab . TREATMENT: protective: skin/prep wipes, . PROCEDURE RESULT: No change, no worse or better 02/16/2022 Right calcaneus (heel) . length 0.6 width 0.5 . WOUND TISSUE: brown scab intact . TREATMENT CHANGE: yes Added AGB (allevyn gentle boarder) heel due to increase pain, INTERVENTIONS: support surfaces for wheelchair . 02/21/2022 right calcaneus . length 0.5 width 0.5 TISSUE TYPE: dry brown scab like area . HEALING PROGRESS: no change There were no changes in interventions noted. 03/15/2022 Right calcaneus . length 0.5 width 0.5 WOUND TISSUE: Scab intact . TREATMENT: cleansing and irrigation: saline, dressings: foam dressing, TREATMENT CHANGE: yes AGB heel initiated INTERVENTIONS: support surfaces for bed: mattress: low air loss . There was no ulcer measurements from 2/22/22 until 3/14/22 leaving a 3 week gap in between the two most recent ulcer measurements. 03/23/2022 Right calcaneus . length 0.5 width 0.5 . Dark brown scab present to base . TREATMENT CHANGE: no change since last report date . 03/29/2022 Right calcaneus . length 0.4 width 0.4 . intact firmly brown scab to base . TREATMENT CHANGES; no change since last report date . 04/05/2022 Right Calcaneus . length 0.5 width 0.5 TISSUE TYPE: necrotic/eschar (dark scab or falling away of dead skin) . TREATMENT CHANGE: no change since last report date . 04/14/2022 Right Calcaneus . length 0.6 width 0.6 TISSUE TYPE: necrotic/eschar . TREATMENT CHANGE: no change since last report date . 04/19/2022 Right Calcaneus . length 0.9 width 0.8 TISSUE TYPE: necrotic/eschar . TREATMENT CHANGES: no change since last report date . A review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 1 x (times) wk. Monday AM first date: 12/20/2021 Per protocol . 03/03/2022 TREATMENT: MONITOR PLACEMENT: of prevalon boots to bilateral feet when in bed AM PM NOC first date: 03/03/2022 (PRESSURE INJURY) A review of the Skin Care I Need extra protection to prevent skin injury care plan revealed I have the potential for skin breakdown because I have mobility deficits, range of motion deficits, cognitive deficits . I SHOW THIS BY: . my Braden scale score is 14 on 2/11/22. I have additional risk factors for skin breakdown as noted above, along with medications in use and abnormal lab values . I need my nurses to complete skin assessments weekly and as needed . complete Braden scale assessments and initiate preventative skin care as needed .follow standards in skin care per facility policy . interventions refer to my KARDEX . MY GOAL IS keep my skin intact . A review of the Kardex revealed the following: 01/06/2022 . Prevalon boots to bilateral feet when in bed and in recliner . 02/28/2022 . Check function of LAL (low air loss) mattress every shift. Bolsters must be inflated at all times . A review of the Braden Scale 11/18/2021 revealed SCORE: 13 RISK CATEGORY: 13-14 = moderate risk for skin breakdown . A review of the Braden Scale 02/11/2022 revealed SCORE: 14 which revealed resident #1 was still at moderate risk for developing pressure ulcers. A review of the lab results dated 11/23/2021 revealed [MEDICATION(S)] Value: 3 Abnormal values rec. Low Reference Range: 3.4-5.0 On 4/20/22, at 1:20 PM, an observation of Resident #1's right heel ulcer along with Assistant Director of Nursing (ADON) A was conducted. Resident #1 was lying on their bed with bilateral heel boots on. The right heel wound scab was approximately 1 cm x 1 cm with a white outer area measuring approximately 0.5 cm x 1 cm in a crescent shape encircling the scab. ADON A touched the white area and Resident #1 pulled their leg back quickly and scowled. The white area was unchanged of color with touching. After leaving the residents room, ADON A was asked if the wound was an unstageable ulcer and ADON A stated with the scab you can't see the base of the wound. On 4/20/22, at 1:30 PM, Nurse B was interviewed regarding Resident #1's unstageable right heel ulcer. Nurse B stated, I was the nurse that found the wound. It was a deep tissue injury, looks about the same as when I found it so not much difference. Nurse B was asked if it was getting better or worse and Nurse B stated that the last time they measured it was a bit bigger. Nurse B was asked what interventions they placed for Resident #1 and Nurse B stated, air loss mattress, boots, gets repositioned every 2 hours and protein supplements. Nurse B was asked if the interventions were added before the ulcer development or after and Nurse B stated, after. Nurse B was asked if they had alerted the physician of the worsening of the ulcer and Nurse B stated that the doctor didn't come to floor but may be back later in the week. Nurse B was asked why the treatment remained the same despite not heeling and worsening of the wound and Nurse B stated, that they would call the doctor and possibly see about a wound consult. On 4/20/22, at 3:00 PM, a record review along with the Director of Nursing (DON) was conducted regarding Resident #1's right heel ulcer and interventions placed. DON was asked to clarify the date the low air loss mattress was began and DON stated, 2/28/22 The DON was asked if Resident #1 developed the unstageable pressure ulcer on 1/5/22 why they didn't order the low air loss mattress at that time and the DON stated, we started with the boots and then moved to the air mattress. A review of the right heel measurements along with the DON was conducted. DON was asked if the wound stayed about the same for a month what they should have done and the DON stated, change the treatment. The DON was made aware of Resident #1's right heel ulcer along with ADON A which revealed the resident flinching and pulling away with touch. The DON offered, I thought there was a wound consult but I don't see any charting on that. DON further offered that if the doctor wants a wound consult that they would be able to get the resident an appointment the next day. On 4/20/22, at 4:00 PM, a record review of the facility provided Skin Integrity-Prevention and Treatment Date Reviewed/Revised: 01/2021 revealed To ensure that a resident who is admitted to the facility without an alteration in skin integrity receives preventative care and does not develop skin alterations unless deemed clinically unavoidable . Braden score to be completed upon admission . Braden score protocol (see attached) to be used to trigger appropriate interventions for initial plan of care . Licensed nurse to complete a weekly skin assessment on all residents. Some residents may require skin assessments more often due to be high risk for skin integrity breakdown or existing deteriorating wounds . Treatment orders will be written at time of discovery of area . Ensure to implement corrective measures to prevent further deterioration of skin condition . Documentation of all skin conditions is to be done weekly . Pressure injuries will be staged according to the staging system devised by the National Pressure Ulcer Advisory Panel . Clinical Nurse Coordinators or their designee, are to complete root cause analysis for all facility acquired and/or non-healing pressure injuries . Common Skin Safety Interventions by Risk Factors: . MODERATE RISK 13-14 the boxes for Float Heels and Bedfast? Provide pressure reducing support surface i.e., Air Mattress, Low Air Loss were check marked. A review of the HIGH RISK 10-12 interventions revealed Daily skin inspection by LN (licensed nurse) . Supplement Turning Schedule w/small position shifts hourly were check marked. A review of the facility provided Braden Scale Protocol: revealed **Upgrade a resident's risk category if the following are present: fever, DBP<60 (diastolic blood pressure), or low serum [MEDICATION(S)]/pre-[MEDICATION(S)].

This citation has two Deficient Practice Statements: DPS #1: Based on observation, interview and record review the facility is placed in Immediate Jeopardy due to the facility's failure to provide supervision such as 15 minute checks and 1:1 monitoring, and implement interventions, including development of safety care plans, updated Kardex's and ensuring safety alarms were inspected and used properly for 3 residents (Resident #1, Resident #4, and Resident # 6), who fell and fractured their hips, of 6 residents reviewed for falls, resulting in Resident # 1 falling 7 times with the last fall on [DATE] causing a [MEDICAL CONDITION]; the resident died 4 days later, Resident #4 falling on [DATE] causing a [MEDICAL CONDITION]; the resident died 4 days later, and Resident #6 with multiple falls and injuries, falling on [DATE] causing a [MEDICAL CONDITION] and dying 13 days later. Immediate Jeopardy: Resident #1: Resident #1 had six unwitnessed falls with a fall on [DATE], at 3:10 PM causing a left [MEDICAL CONDITION] and hematoma to scalp. Resident #1 was in their room transferring from wheelchair to recliner. The locks on the wheelchair were unlocked. Resident #1 was on hospice services and did not get emergency care for the fracture. Resident #1 was subsequently made bedfast and had a down graded diet to advanced with ground meat ordered the next day. Resident #1 passed away on [DATE] in the facility. Resident #4: Resident #4 had a fall on [DATE], at 12:05 AM, transferring out of bed in their room causing a right [MEDICAL CONDITION]. Resident #4 had a motion alarm (sentinel) that was found under the bed and ultimately was not alarming. The facility could not provide documentation as to when the alarm was last checked to be working. Resident was on hospice service, did not leave the facility for emergency care and passed away on [DATE] in the facility. Resident #6: Resident #6 fell on [DATE] while running in the hall and sustained facial injuries including bruising and a lip laceration that required transfer to the hospital with sutures placed in the upper lip. Per the facility, Resident #6 was supposed to be monitored every 15 minutes for safety. The resident was transferred to the hospital and diagnosed with [REDACTED]. The resident was readmitted to the facility on [DATE] with 1:1 monitoring. The 1:1 monitoring was removed on the evening of [DATE] and Resident #6 fell again [DATE]. The Resident died on [DATE]. The Immediate Jeopardy began on [DATE]. The Immediate Jeopardy was identified on [DATE]. The Administrator was notified on [DATE] of the Immediate Jeopardy that began on [DATE]. The IJ Abatement (Removal) Plan was approved on [DATE] with a Removal Date of [DATE]. DPS #2: In addition to the above, based on observations, interviews, and record reviews, the facility failed to develop a Safety Care Plan or Kardex to identify and implement interventions to prevent one resident (Resident #5) from falling on the day of admission [DATE], causing a [MEDICAL CONDITION] and death 2 days later and the facility failed to provide supervision to prevent an injury for one resident (Resident #9), who sustained an injury (bruised hand) while toileting unsupervised, Findings Include: Supervision of all 5 residents was not provided. 1. Safety Care Plans or a Kardex (care guide) was not created for Resident #5 and Care planned interventions were not effective or revised to accommodate resident safety for Resident #1, Resident #4 and Resident #9. 2. Supervision and monitoring did not meet the needs of the residents. 3. Safety Alarms were not properly maintained to ensure effectiveness. Between [DATE] and [DATE] four residents of the facility suffered falls resulting in [MEDICAL CONDITION]. Three of the four residents had multiple falls dating back several months. Three of the four residents died within 4 days of the [MEDICAL CONDITION] and the fourth resident died within 13 days of the [MEDICAL CONDITION] Resident #5: A review of a Facility Reported Incident (FRI) investigation for [DATE] revealed Resident #5 was admitted to the facility at approximately 8:30 PM. He was assessed to be a safety risk. The oncoming 3rd shift (10:00 PM to 6:30 AM) staff were told the resident was in bed during report (Certified Nursing Assistant (CNA) to CNA). At 10:10 PM CNA R observed the resident sitting in a bedside chair. The CNA left the room and later returned with CNA S; the resident was talking about getting his keys. The CNA's encouraged the resident to use a call light and left the room. At approximately 10:45 PM, the CNA's were at the nurse's desk (around the corner and down another hall- not visible from the resident's room), they heard a thump and heard Resident #5 yelling for help. A review of the progress notes indicated a late entry dated [DATE] at 1:46 AM by Nurse N (this was the first documentation related to the fall), Fall not observed . heard the fall (thump) and the resident yelling Help Me . (CNA S) stated after she left the room resident had rang his call bell 5 times in 5 minutes. (CNA S) stated resident was asking her for his keys . at 10:45 PM, CNA's stated they heard the fall and the resident yelling for help, then they called this nurse. Resident was laying on his right side in the middle of his room . and stated my his is out . when attempting to straighten his left leg resident yelled out in pain . order given to send resident to ER (emergency room ) due to extreme pain . Resident Statement: . I was looking for the buttons, the buttons, my cell phone . Possible cause: loss of balance without staff assistance . There was no documentation that the Nurse caring for the resident (Nurse N) was notified by the CNA's that Resident #5 was restless, asking for his keys, transferring himself and repeatedly asking for assistance. The hospital records for Resident #5 dated [DATE]- [DATE] provided the following: Emergency Physician Record, dated [DATE] at 11:25 PM, Pt (patient) walking at ECF (extended care facility)- Pt there for Hospice ([MEDICAL CONDITION]). Pt fell unable to get up . XRAYS - [DIAGNOSES REDACTED]. Diagnostic Imaging, dated [DATE] at 12:24 AM, Impression: Transcervical fracture near the base of the neck of the left hip. Inpatient History and Physical, dated [DATE] at 1:08 AM, History of present illness: . presented to (ER) at 23:25 (11:25 PM) ([DATE]) after a fall at (the nursing home). He is known to have an unsteady gait and uses a walker . He was hospitalized . ([DATE]) with stage IV (terminal) [MEDICAL CONDITION]. He was discharged to (the nursing home) on the evening of ([DATE]) where he fell shortly after arrival . Inpatient Consultation, dated [DATE] and written by Physician RR, . (Resident #5) with a history of dementia and is also on hospice secondary to [MEDICAL CONDITION]. He got out of bed and had a fall. He had increased pain. He was taken to the ER Department where he was diagnosed with [REDACTED]. I have recommended a hemiarthroplasty (surgical repair of the hip). This patient does ambulate and does get up spontaneously and sporadically . Death Summary, dated [DATE] by Physician RR, The patient was admitted to the hospital on [DATE] because of a fall at the extended care facility . it was agreed to go forward and fix the femoral head because of his ambulatory status . He had a progressive loss of blood pressure with no compensatory ability to make it up and expired in the OR (operating room) . A review of the (nursing home facility's) Face Sheet and progress notes indicated Resident #5 was originally admitted to the facility (nursing home) on [DATE] at approximately 8:23 PM via ambulance from the hospital with Diagnoses: [REDACTED]. The Minimum Data Set (MDS) assessment was not yet completed. The resident was discharged to the hospital on [DATE] at 11:15 PM after falling in his room at 10:45 PM. A review of the facilities Admit Assessment, dated [DATE] at 9:02 PM written by Nurse P, revealed the resident had multiple bruises on admission to both legs, left hip . arms and hands and was oriented to person. A facility assessment titled, Fall Risk Assessment, dated [DATE] at 9:24 PM written by Nurse OO, indicated Resident #5 had . decreased safety awareness . balance problem with walking . ,[DATE] falls in the last 3 months . medications: [REDACTED]. [MEDICAL CONDITION], wandering . With a fall risk score of 11 . Resident is at risk of falling . A review of the Care Plans for Resident #5 indicated there were 2: Social History, dated [DATE] and an Activities of Daily Living (ADL) Care Plan, dated [DATE]; neither Care Plan mentioned the resident was a fall risk, nor interventions to aid in preventing falls. A Baseline Care Plan,/Kardex, undated, did not mention the resident was a fall risk. The Safety box said, Wanderguard: leg, left ankle. The box Interventions: was blank. A review of the physician orders did not indicate any orders for fall prevention measures. A Hospice note Patient Information Report, dated [DATE] at 1:09 PM, written by Nurse II, prior to the resident's admission to the facility on [DATE] indicated the prior facility the resident lived in said he had a change in mental status and was on his . call light for 2 hours . A hospice note dated [DATE] at 12:58 PM, written by Nurse II said the resident was . restless. Very confused . A review of the hospital record's prior to admission to the facility on [DATE], Emergency Physician Record, dated [DATE] at 10:35 PM revealed the resident was confused and receiving Hospice services for a terminal lung disorder ([MEDICAL CONDITION]). An interview with Confidential Person CC on [DATE] at 3:08 PM revealed, Previously (he) was at an AFC (Adult Foster Care) home and needed medicine for his [MEDICAL CONDITION]. He was very restless. He went to the hospital and they would not send him back because he needed someone with him for restlessness. He had a prior fall there (AFC); he fell over the oxygen cord. That night ([DATE]) he was more confused and started to see people in his room (at the AFC) and he went outside. The hospital gave him a bed alarm and said he was not supposed to get out of bed on his own. The hospital sent him to the facility (nursing home). That is why he went there (admitted to the facility); to be watched. He was there a few hours and they called me at 1:00 AM ([DATE]) and told me he had fallen and went back to the hospital. They said he broke his hip. He went in for surgery ([DATE]) and he passed away. The following staff were Interviewed about Resident #5's fall: CNA S on [DATE] at 10:52 AM, I got on shift about 9:45 PM and got report. I was told he was in bed. About 10:15 PM, when I looked, he was in his chair. They said he self-transferred on 2nd shift. He was 15-minute checks; when you check on someone and make sure they are where they are supposed to be. I was in there probably 10 times in about 45 minutes. He was looking for keys and wanting to get out of there. The other aide (CNA R) and I were in there and he was dozing off. He didn't want to get in his bed. I went to answer another light and I barely made it to the nurse's station and heard him. (CNA R) and I found him on the floor and called for the nurse immediately. CNA S was asked what measures should be provided to a confused resident who was a fall risk and asking to leave and stated, Sit with them. Help them move to wherever they are comfortable. When asked if anyone was sitting with this resident, the CNA said No. Restorative Nurse C on [DATE] at 3:27 PM, said she was responsible for investigation of accidents and falls in the facility, but the Director of Nursing (DON) assisted in completing the investigation for Resident #5. Nurse C was asked if Resident #5 was known to be at risk for falls on admission, based on his history, she stated, Yes, I believe he had a history of [REDACTED]. He was restless at his previous place. CNA R on [DATE] at 11:23 AM, I wasn't his aide the night he (Resident #5) fell , but I was there. We were in the charting room. We had just walked in and sat down and had just got done doing our rounds. We heard a thunk The last I saw him he was sitting on the side of the bed. We took off running and heard Help. We seen him on the floor and got the nurse. When we got report at 10:10 PM, they said he was in bed. Then when we went in there, he had transferred himself to the chair. The CNA was asked what safety measures were in place for the resident and stated, I think he had a low bed and he didn't have an alarm, because he had just got there. He was a little confused. The CNA was asked who gave the CNA's report about the condition of the resident and said they received report from other CNA's and not the nurses. CNA R was asked how she would find out if the resident was a fall risk, she stated, The Kardex or other CNA's. The nurse isn't there in report. On [DATE] at 3:51 PM, Assistant Director of Nursing (ADON) BB was interviewed and asked what fall prevention measures were in place for Resident #5, as he was assessed to be a fall risk and stated, What were we supposed to do, he was only here 3 hours. Resident #6: A review of a Facility Reported Incident investigation indicated Resident #6 fell on [DATE] while running in the hallway- witnessed; hitting her head and face. The resident sustained [REDACTED]. Resident #6 fell unwitnessed- on [DATE] and was found lying in the hallway with blood on the floor around her head; a skin tear and hematoma (large deep bruise) was present on the right eyebrow. The resident would not open her right eye. The resident was transferred by ambulance to the local hospital. After diagnostic testing (CT scans) of the brain, the resident was transferred to a higher acuity hospital for further treatment with a possible brain bleed on [DATE]. The 2nd hospital diagnosed the resident with a right [MEDICAL CONDITION] on [DATE]. A review of the Face Sheet and Minimum Data Set (MDS) assessment for Resident #6 revealed the resident was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS assessment dated [DATE] indicated the resident had a BIMS (Brief Interview for Mental Status) score of ,[DATE] identifying severe cognitive decline and was independent with transfers and ambulation. The resident was transferred to the hospital on [DATE] after falling and readmitted to the facility on [DATE] and died on [DATE]. A review of the progress notes provided the following: [DATE] at 10:05 AM- at 9:15 AM: 3 staff members said they saw Resident #6 running down the hallway away from the restorative room, where she was being walked to obtain her weight. The resident was noted to have a laceration to her upper lip and bleeding from the nostril area, with swelling and bruising to left eye. The resident complained of pain when repositioned with EMS (emergency medical services) and screamed out Ow. After 10 minutes of lying down her left side hip and buttock were twitching. The resident was face down on the floor. The resident was transferred to the hospital at 10:12 AM. [DATE] at 1:09 PM, the resident returned from the hospital. [DATE] at 1:21 PM, Abrasion/Bruise: Resident had bruising to under left eye. Bruising is light purple and blue in color. Bruising is observed to left side of neck . light blue and purple in color. Swelling is noted to left side of face and neck. [DATE] at 1:23 PM, . Left upper lip appears swollen. Dried blood present . [DATE] at 6:58 PM, . wincing when responding to questions . speaking minimally . [DATE] at 2:19 PM, . Level of Consciousness: lethargic. [DATE] at 11:30 PM, . resident was given flavored water and protein jello. Mins later, resident vomited. In approx. 1 hour . fed her a few died peaches and Vernors which again she vomited . she is very sleepy and must be awakened each time to take a drink . [DATE] at 4:15 PM, . Level of Consciousness: lethargic (responds slowly to verbal stimuli) . [DATE] at 7:12 AM, . Mood/Behavior: Resident noted to be resting more since fall, not getting up through night to walk around the circle . [DATE] at 6:21 PM, Resident is observed lying on the floor on her right side, large amount of frank blood noted from hitting her head . [DATE] at 11:40 PM, Type of Fall: fall not observed . Injury: . skin tear, avulsion, hematoma to right eyebrow . 6:20 PM was found on floor exact time of fall unknown . last visualized by a nurse aide leaving the dining room at 5:40 PM . by ambulance 6:35 PM (to ER). [DATE] at 1:39 PM, . arrived at facility around 12:40 PM . Clear ,[DATE] sutures above right eye. [DATE] at 2:28 PM, . bruising right hip 10 cm x 4 cm and one right above that is 5 cm x 3 cm. Both faded yellow/purple. Resident has large bruise covering face in various stages of healing . [DATE] at 5:35 PM, . Resident is skilled for: Right [MEDICAL CONDITION] and subdural hematoma . fidgety/restless . Interventions 1:1, rejects care . Interventions 1:1 . [DATE] at 5:37 PM, . resident is resistant to care at times and also attempts to get up on her own . [DATE] at 9:16 AM, . short term memory is poor . long term memory is poor . walking difficulty, balance difficulty, firm hand grip . confusion and impulsive behaviors . Interventions- there was no mention of 15 minute checks, 1:1 monitoring or a safety alarm. [DATE] at 2:15 PM, Pain: Resident appears restless and fidgeting in bed, pulling covers up and down, moving arms up and down . unable to appropriately complain of pain . [DATE] at 3:36 PM, Late Entry for: [DATE] Spoke with resident's daughter at 4:45 PM this date, daughter was present in resident's room. Regarding floor staff reporting that daughter is requesting to have alarms in place when she leaves . Alarms will notify staff she is getting up but it is possible that she would fall prior to staff getting to her . Also per (Assistant Director of Nursing (ADON) BB) resident will be one-on-one for 24 hours . The 1:1 was discontinued on [DATE]. [DATE] at 10:19 PM, Fall found on floor. Resident was on floor beside her bed. Staff had seen her 15 minutes before . The resident was not receiving 1:1 monitoring. A review of the resident's hospital records revealed the following: Emergency Physician Record, dated [DATE] at 10:00 AM, Pt confused . Fall injury to face . location of pain/injuries: head, face, mouth . upper left lip partial avulsion ( injury -torn apart) . length: 1 cm . repair: deep . Skin- #4, 4.0 [MEDICATION NAME] gut (sutures) . Clinical Impression: Contusion: head . CT done: C spine, facial, (no CT of the Head/brain) . CT Maxillofacial region: Reason for exam: Pain following fall . Soft tissue [MEDICAL CONDITION]/contusion surrounding the mouth/upper lips . Emergency Physician Record, dated [DATE] at 6:49 PM, . Chief complaint: injury to head, face . fall . stellate laceration (tear in skin caused by [MEDICATION NAME] trauma) (right forehead) (circled the entire left half of face on a picture)-ecchymosis (bruising) . alertness: slow, no response to commands . Procedures: Wound Description/Repair: length 3.5 cm, location right forehead . Skin- #9, 4.0 Visceral (sutures) . CT done: Facial, spine . Clinical Impression: Acute subdural hematoma . CT Brain dated [DATE] at 6:59 PM, CT Brain . Pain following fall with abrasions . Impression: New thin subdural effusions bilaterally, greater on the right . Resolved left parfalcine subdural hematoma. Diminished left sub frontal recent subdural hematoma . CT Maxillofacial region, dated [DATE] at 7:04 PM, . there is small left frontal region subdural hematoma, decreased in size from the previous study . Impression: . Small left frontal region subdural hematoma . Complete Metabolic Profile (bloodwork), dated [DATE] at 9:00 PM, . Sodium- 129 (low) (range low 136 and High 145) . Low sodium ([MEDICAL CONDITION]) per Mayo Clinic, (MONTH) 15, (YEAR), Low blood sodium in older adults: A concern? . signs and symptoms of [MEDICAL CONDITION] can include altered personality, lethargy and confusion . Mayo Clinic, [MEDICAL CONDITION], (MONTH) 8, (YEAR), . signs and symptoms may include: restlessness, irritability, muscle weakness . Consultation Physician WW's Note at the higher acuity hospital the Resident was transferred to on [DATE] from the local hospital- dated [DATE], Diagnostic Studies: I reviewed this patient's x-rays and CT. She has a nondisplaced peri trochanteric fracture (hip) . Normally, the patient should be able to ambulate, touchdown weight bearing with severe dementia. The patient should be unable to do it safely. Therefore, I would recommend bed-to-chair for about a month or so and then gradually progress . she will need an x-ray in about a month's time. An interview with Confidential Person AA on [DATE] at 2:09 PM, She was admitted (MONTH) 19, 2019 and it was her first fall on [DATE]. She hadn't fallen before that. The nurses said her head hit the floor. They didn't tell me how bad it was. I learned how bad the first fall was after the fact. She should have been monitored more closely. She was mobile. When she fell on the 30th ([DATE]) I was irate. I talked to the ER doctors and they said they thought there was a brain bleed and they sent her to (another hospital). No x-rays were done of the hip (at the first hospital). (The 2nd hospital) found the [MEDICAL CONDITION]. She cried out in pain. This was her 2nd fall. One of the patients down the hall found her in the hallway. Even when I was there (at the facility) there was never 15-minute checks. (We) believed this never should have happened. They should have done 1:1. I asked for 1:1. They had 1:1 for 1 night ([DATE]). She fell on [DATE]. Then they put a monitor on her ([DATE]). After the 3rd fall she just didn't come around. We put her on Hospice on the 11th ([DATE]) and she died on the 13th ([DATE]). During the interview, Confidential Person AA was asked if she was told what interventions the facility was doing to keep (Resident #6) safe and stated, No, no. They kept saying they were doing 15-minute checks, but they were not watching her. On [DATE] at 2:34 PM, an interview with Confidential Person Z provided, After the 3rd fall on ,[DATE] (2019) she (Resident #6) was pretty much comatose by ,[DATE] (2019); by ,[DATE] (2019) she was gone. I went to see her the Friday after the fall (on [DATE]), but I did not know how traumatic the 1st fall was. Her face was black and blue, much worse than they lead us to believe. She fell again ,[DATE] (2019). The Confidential Person was asked if the facility provided information on fall preventive measures and stated, There was nothing after the first fall to try and prevent it from happening again. After the 2nd fall I stayed with her in the hospital. After she returned to the facility the told us they would have someone in the room to monitor her. She tried to get up several times in the hospital. I told them she would try to get up. The following morning (after readmission on [DATE]) ,[DATE] they removed the 1:1 around the clock. They said they would do every 15-minute checks. I never saw anyone. She had the curtain to her room closed and no one came to check. There was no instance that I ever saw anyone peak their head in and check. They did not do 1:1 and she fell again. After that we stayed with her until she passed. No one gave me any specific measures for prevention, only on [DATE] when they had 1:1. The 2nd fall she laid in the hall for about 45 minutes after she left dinner. She was found by (another resident). He sounded the alarm. They said blood was dried on her head, so she had to be laying for some time. An interview with Nurse V on [DATE] at 3:05 PM about fall prevention measures for Resident #6, Proper foot wear, 15-minute checks, because she was mobile. 15-minute checks includes the CNA to visualize the resident every 15 minutes, including if there are visitors, document in CNA charting. It should be in the Care Plan and Kardex. Anyone making changes can update the Care Plan. The Kardex/Baseline Care Plan- falls should be on there. It's their (staff) responsibility to check the Kardex. During an interview with Restorative Nurse C on [DATE] at 3:27 PM related to Resident #6's falls, she was asked what interventions were put into place after the 1st fall on [DATE] and stated, She was evaluated by therapy and they said she didn't need therapy. She was impulsive, but still up and active. We were doing 15-minute checks. The nurse was asked what 15-minute checks were and stated, The CNA's check on the residents- Safety Checks every 15 minutes to make sure they are safe. They should still be doing them if there is a visitor. It is their responsibility. The Restorative Nurse was asked what the nurses' responsibility was and said, We always want to keep our resident's safe. The nurses are often passing meds. The Incident and Accident Reports for Resident #6 were reviewed with Restorative Nurse C during the interview. She was asked if the facility had investigated why the resident had 3 falls in a short amount of time, when she didn't have a history of falling at the facility and said the resident was independent with walking for the 1st 2 falls, but they hadn't assessed a possible cause for the 3 falls. The nurse was asked what measures were enacted after the 2nd fall resulting in a head injury and [MEDICAL CONDITION] and said the resident was supposed to have 1:1 supervision (a staff member always with her) after readmission, but the day she returned [DATE] the 1:1 was stopped in the evening and the resident fell again the next day [DATE]. Nurse C said 1:1 was enacted for 1 day [DATE] and a Sentinel safety alarm was enacted on [DATE]. A review of the Care Plan titled, Safety: Falls- dated [DATE], I have a Falls Risk assessment score of 12 on [DATE] indicating I am At Risk for falls with Interventions (all undated)- instruct on safety, provide education, report complaints of weakness or dizziness to my nurse, maintain facility standards of safety and follow my safety/devices/interventions to help keep me safe, 15-minute checks. Resident #6 had a severe cognitive deficit. The resident had a change of condition after the 1st fall and head injury, with sleepiness, vomiting and not wanting to ambulate as often. There was no mention of 1:1 monitoring or a safety alarm. A review of the Baseline Care Plan/Kardex was undated. The Safety section said, I am on 15-minute checks, Sentinel alarm placed at end of bed on stand when resident is not one-on-one. Alarm sounds to transmitter box. Floor mats x 2. A review of the physician orders did not reveal any orders for interventions to prevent falls. During an interview with Nurse Q on [DATE] at 10:01 AM, the Nurse was asked what fall safety measures should be enacted for a resident assessed to be a fall risk and said the resident should be assessed, including their background history and the interventions would depend on the resident's needs such as ultra-low beds, floor mats, safety alarms Sentinel alarm in the door way to alert us. Nurse Q was asked what measures were in place for Resident #6 and said she wasn't sure of the corrective measures enacted to prevent the next fall; ,[DATE] 19 fall prevention measures- When she came back, we had her on 1:1. The nurse was asked what 15-minute checks were and stated, Every 15 minutes the CNA has to check on the resident. On [DATE] at 10:20 AM, Confidential Resident WW was interviewed about Resident #6's fall and stated, I saw her on the floor, and I went for help. An interview with Nurse O about Resident #6's fall on [DATE], on [DATE] at 11:52 AM, I was the nurse for the floor. She was in the hallway not far form her room. It was paged. I had just gone on break. On [DATE] at 4:00 PM, CNA SS was interviewed about providing fall safety measures for Resident #6 and said 15 minute checks: we are supposed to check on the resident every 15 minutes to make sure they are safe. The CNA said on [DATE] during the evening, the 1:1 was discontinued for Resident #6 by a supervising nurse, because a resident on another floor needed 1:1 and the facility chose to give the 1:1 staff member to that resident. When asked how the staff would know if a resident was a fall risk, the CNA said, Now, I don't know. I don't always see it on the Kardex. On [DATE] at 3:51 PM, ADON BB was asked about fall safety interventions and said the Primary nurses would put interventions in place for the residents and the care plans would be individualized. On [DATE] at 4:00 PM, CNA SS was interviewed about providing fall safety measures for Resident #6 and said 15 minute checks: we are supposed to check on the resident every 15 minutes to make sure they are safe. The CNA said on [DATE] during the evening, the 1:1 was discontinued for Resident #6 by a supervising nurse, because a resident on another floor needed 1:1 and the facility chose to give the 1:1 staff member to that resident. When asked how the staff would know if a resident was a fall risk, the CNA said, Now, I don't know. I don't always see it on the Kardex. Resident #1: On [DATE], at 11:00 AM, a review of Resident #1's electronic medical record revealed an admission on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set assessment dated [DATE] revealed Resident #1 required assistance with transfers and had mildly impaired cognition. A review of the Resident #1's progress notes revealed 14 day note: assessment complete today . Orientation does fluctuate . Res has been noted to be transferring herself and is a fall risk Res (resident) was falling at the AFC home and has fallen once since admission here . A review of Resident #1's Fall Risk Assessment [DATE] revealed Resident is at risk for falling. A review of the Care Plan safety: Falls I have the potential to fall . I show this by: forgetting to use my assistive device revealed [DATE] Approach . maintain standards of care and use my safety devices/interventions to help keep me safe; refer to Kardex . My goal is to: not have any falls Goal Time: [DATE] Evaluation: goal not met, fell on [DATE] and [DATE] On [DATE], at 11:10 AM, a record review along with the Director of Nursing (DON) of Resident #1's fall history at the facility revealed: Fall on [DATE]; un-observed fall in room without injury. Fall on [DATE] 4:29 AM; observed fall while walking with a staff member. DON stated, the intervention was verbal one on one with the CNA to walk behind resident while ambulating. Fall on [DATE] 10:59 AM; unobserved fall in room from wheelchair to floor, Hematoma posterior head, Auto-lock breaks not engaging. Sent to maintenance for immediate repair. The DON was asked if the auto-lock breaks were not working and the DON stated, That's what it looks like. They put her in her recliner while they got the breaks fixed. The DON was asked if the auto-lock brakes were checked regularly and the DON stated, restorative do the checking of the wheelchair to see if everything looks appr

Based on observation, interview, and record review, the facility failed to safely transfer three residents (Resident #43, Resident #9, and Resident # S50) out of three residents observed for transfers from a total sample of 12 residents. This deficient practice resulted in a fractured femur and humerus for Resident #43. Findings include: Resident #43: The facility reported an incident resulting in major injury and on 6/27/17 an on-site investigation began. According to the Minimum Data Set (MDS) assessment, dated 5/18/17, Resident #43 was re-admitted on [DATE] to the facility with multiple [DIAGNOSES REDACTED]. Record review of the facility investigation revealed Resident #43 was transferred by Certified Nursing Assistant (CNA) D on 3/9/17 from the toilet to her wheelchair when Resident #43 fell into her wheelchair. Per facility investigation Physical Therapy notes, dated 3/13/17, neither a gait belt nor a walker was used during this transfer. Review of nurses notes revealed that on 3/10/17 Resident #43 was sent to a hospital and on that same day had surgery to repair a fractured femur. The humerus was inoperable and was immobilized in a sling. Review of Resident #43's Impaired Physical Mobility care plan, dated 1/27/17, reads, .Limited assist of one with transfers. Stand pivot with gait belt and walker . Limited assistance of one for ambulation with use of gait belt, rolling walker, followed by wheelchair . (Resident #43) is to ambulate to and from bathroom . The MDS, dated [DATE], indicated Resident #43 was an extensive assist with one person for transfers and ambulation prior to this incident. The MDS, dated [DATE], indicated Resident #43 was totally dependent, after the incident, for transfers and was no longer ambulatory. During an observation on 6/30/17 at 8:30 a.m., CNA E used a Maxi Lift, a mechanical full body lift, to transfer Resident #43 from her Geri chair to bed. After transferring Resident #43, CNA E stated, I forgot the stays (a support structure placed in the transfer sling). When asked where the stays were kept, CNA E searched Resident #43's room and the supply closet and could not find them. Resident #9: During an observation on 6/28/17 at 1:10 p.m., while CNA F transferred Resident #9 from her wheelchair to her bed using a Maxi Lift, the transfer sling did not have the stays in place. The same day at 1:25 p.m., CNA G transferred Resident #9 from her bed to her wheelchair using a Maxi Lift. The transfer sling did not have the stays in place. Resident S50: During an observation on 9/30/17 at 8:50 a.m., while CNA H transferred Resident S50 from her Geri chair to her bed using a Maxi Lift, the transfer sling did not have the stays in place. At this time when asked why the stays were not used, CNA H stated, Oh, yea, they're always lost. Review of the Maxi Move Instructions for Use revision 5 on 4/11 reads. .Warning: .slings with head supports have two pockets located in the head section. These should contain plastic reinforcement inserts (stays) during use. Always ensure that these reinforcement inserts have been placed inside the sling pockets before using the sling . This same document indicated injuries could occur if warnings are not followed. During an interview on 6/30/17 at 9:10 a.m., the Director of Nursing (DON) B agreed that the stays should be used with all transfer slings.

This citation pertains to MI 830. Based on interview and record review, the facility failed to provide necessary medical services, including assessment, physician and family notification, intervention, monitoring, and treatment, for one resident (#101) who had a significant change of physical condition out of seven residents reviewed for response and intervention to change of physical condition in a sample of nine residents placing Resident #101 in immediate jeopardy to his physical wellbeing and delay of medical intervention for his significant change of physical condition due to the failure of the staff to implement procedures for the care of residents who have a change of condition. Immediate jeopardy began on or about 10:30 am on [DATE] when, according to a physical therapy treatment note, Resident #101 was weak and had a severe increase in tremors and shakiness as well as increased confusion. At that time, an oxygen saturation level was recorded at 76% on room air. The note reported that nursing (was) informed of Resident #101's decline in his respiratory status. Resident #101 had self determined to be a full code with hospitalization for sudden illness/condition on [DATE]. The nursing progress notes, dated [DATE] at 3:29 pm, indicated Resident #101 had an oxygen saturation level of 82% on room air, was experiencing weakness, fatigue, an irregular pulse, and abnormal lung sounds. Vital signs were recorded on [DATE] at 3:29 pm. Vital signs were again recorded at 10:15 pm (more than six hours later) with the oxygen saturation level recorded as ,[DATE]%, abnormal lung sounds, and a productive cough. The next entries in the clinical record were on [DATE] at 7:05 am (nine and ,[DATE] hours since the last entry) and at 11:23 am when apical pulses, abnormal lung sounds and the identification of a cough were noted. A nurses' note, dated [DATE] at 3:34 pm reported that Resident #101's medications that had been scheduled for 8:00 am had been held because he was weak and lethargic. No entries on [DATE] or [DATE] identified a notification of the physician of the oxygen saturation levels, assessment of lung sounds, change in mental status, or vital signs until [DATE] at 11:00 am (more than 24 hours after the change in Resident #101's physical condition was initially noted). Application of oxygen for the low saturation levels was not recorded in the clinical record, but an order was written for oxygen on [DATE] at 11:40 am. No plan of care related to respiratory difficulties was found in the electronic medical record. No documentation of monitoring of oxygen saturation levels or complete vital signs was recorded in the clinical record from [DATE] at 3:29 pm until a nursing note entry on [DATE] at 5:16 pm regarding events that began at about 11:00 am. According to the note, the physician was notified of Resident #101's low oxygen saturation levels that was not rising past the 80%s with him on 4 liters of oxygen on [DATE] at 11:00 am (more than 24 hours after Resident #101's change of condition.) The note continued by reporting the physician had examined Resident #101 on [DATE] at 12:30 pm and the decision was made to transfer him to the hospital. According to the facility discharge summary, dated [DATE], Resident #101 had a change in medical status, was transferred to the local hospital, where he expired. The Nursing Home Administrator was notified of the Immediate Jeopardy situation on [DATE] at 2:45 pm. Findings Include: According to the Face Sheet, printed on [DATE], Resident #101 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Resident Assessment, dated [DATE], revealed that Resident #101 was cognitively intact having scored 15 of 15 on the Brief Interview for Mental Status screening tool. The Advance Directive Information sheet, signed by Resident #101 on [DATE], indicated that he had chosen to have cardiopulmonary resuscitation performed in the event of respiratory or cardiac failure and wanted to be transferred to an acute care hospital if it was necessary for the treatment of [REDACTED]. During a telephone interview with Certified Nursing Assistant (CNA) Staff E on [DATE] at 11:10 am, she stated that she did remember caring for Resident #101 during his stay at the facility. CNA Staff E recalled that prior to [DATE], Resident #101 was able to walk with one person in his room, could hold a conversation, and that he had wheeled himself around the unit in a wheel chair. CNA E stated that on [DATE] she had worked from 6:00 am until 2:00 pm and had been assigned to care for Resident #101. CNA E said that she had gone in to resident #101's room before breakfast and he had told her that he didn't feel good. CNA E remembered that it had been the day for Resident #101's shower and he had agreed to take a shower because he thought it might help him feel better. CNA E said Resident #101 had a hard time breathing and was weaker than he had been previously. CNA E recalled that it had taken two staff members to stand and transfer him. CNA E said that after breakfast Resident #101 was having a hard time breathing, was very weak and was talking nonsense. He was really weak. CNA E said that I kept notifying the nurse that it was not him. He could barely stand. During an interview with Physical Therapist (PT) Staff C on [DATE] at 11:35 am, she stated that she could not recall Resident #101 but did review and explain the documentation she had written for therapy services for Resident #101. According to the Physical Therapy notes, PT Staff C had treated Resident #101 on [DATE] and he had performed various exercises for balance training and bed mobility. Resident #101 had also walked 100 feet with a rolling walker with the therapist holding the gait belt at his waist and then had rested and walked another 160 feet. According to the notes, the therapy session had lasted 55 minutes on [DATE]. PT Staff C had a therapy session with Resident #101 documented on [DATE]. According to the notes, the therapy session on [DATE] had lasted 45 minutes and Resident #101 had used the exercise bike for 10 minutes and had walked 100 feet, rested, and walked another 100 feet with a rolling walker. The therapy notes for [DATE] reflected that Resident #101 had been weak with a severe increase in tremors and shakiness. An oxygen saturation level had been checked during morning shower and was 76% on room air. The PT note stated that Resident #101 had an oxygen saturation level of 90% following a breathing treatment, but that with bed mobility and Resident #101 sitting on the edge of the bed, the oxygen saturation level fluctuated between 80 and 83%. The PT note, dated [DATE], recorded that Resident #101 had increased confusion and inconsistency in following verbal command. The PT note stated that Nursing informed on decline in resident ' s aerobic capacities. During the interview with PT C on [DATE] at 11:35 am, she stated that this meant he was having difficulty breathing. PT C stated that according to her notes, she could see that Resident #101 was declining and there had been a huge change in his condition on [DATE]. PT C stated that according to her note, she had stopped therapy and laid Resident #101 on his bed to evaluate him and had spent 20 minutes in his room. The note concluded by saying that Resident #101 ' s oxygen saturation levels were in the upper eighties on room air with him lying in the bed. A nursing note entry dated [DATE] at 12:00 pm reflected that on room air, Resident #101 ' s oxygen saturation was 93%, he was experiencing fatigue, and his lung sounds were diminished upon auscultation (listening with a stethoscope). On [DATE] at 5:51 pm, a nursing note entry recorded that Resident #101 ' s oxygen saturation was 90%, he was experiencing weakness, his pulse was irregular, his lung sounds were abnormal with crackles heard in the upper lobes and air flow was diminished in both lower lobes. A non- productive cough was documented as well as shortness of breath with activity. On [DATE] at 6:21 am, Resident #101 had a blood pressure reading of ,[DATE], pulse of 88, temperature of 97.4, respirations of 21 and an oxygen saturation of 94% recorded in the nursing notes. At that time, documentation of his lung sounds were upon auscultation diminished all lobes and it was noted that Resident #101 was experiencing shortness of breath with activity. On ,[DATE]//2016 at 7:09 am, Resident #101 ' s lung sounds were documented as wheezing heard in both lobes while inhaling and exhaling. Resident #101 ' s apical pulse (taken by listening to the heart beat with a stethoscope counting the heart beats, usually for a minute) was 70 before a medicated breathing treatment and 74 during and after the treatment. No oxygen saturation level, blood pressure, temperature, or respiratory rate was documented at this time. A physician order [REDACTED]. On [DATE] at 3:15 pm, the Director of Nursing, Staff B stated that the oxygen order was entered at 11:40 am on [DATE]. During a telephone interview with LPN Staff D on [DATE] at 4:15 pm, she stated that a standing order for oxygen could be written before contacting a physician. The facility policy on Oxygen Administration , with a revision date of ,[DATE], stated that the facility had a standing order for the administration of oxygen to maintain oxygen saturation >90% . The policy instructed that the physician was to be notified following initiation of oxygen therapy for verification of oxygen order. An undated facility COC (change of condition) Check list included the following: full set of vital signs, head to toe assessment, laboratory tests per standing orders, contact doctor regarding situation and any further orders needed, notify family, initiate nursing interventions that are appropriate, follow up assessments every four hours (or more often as situation dictates) and care plans updated with any new orders. On [DATE] at 3:29, the following entries were made into Resident #101 ' s record, blood pressure ,[DATE], pulse 71, temperature 96.7, respiratory rate 16, and oxygen saturation 82% on room air. Resident #101 ' s circulatory condition was described as experiencing weakness, experiencing fatigue. His pulse was described as irregular. His lung sounds were described as upon auscultation crackles heard, bilateral lung field with audible wheezing noted. No entry was made at that time regarding interventions made or notification of the physician about the low oxygen level or abnormal lung sounds. An entry for 7:46 pm on [DATE] noted that Resident #101 had a productive, hacking, painful cough and crackles and wheezing were heard in all lobes of his lungs. According to the entry, cough syrup was given to Resident #101. On [DATE] at 9:42 pm, a nursing assistant note on the behavior record reported resident refused any care and all food and drinks. He talked to family on the phone and was telling them that he thinks that he had a small stroke today and that is why he feels so bad and is refusing any cares. On [DATE] at 10:15 pm Resident #101 ' s nursing note entries included a blood pressure of ,[DATE], pulse 68, temperature 97.2, respiratory rate 20, and oxygen saturation of ,[DATE]%. Resident #101 ' s lung sounds were documented as upon auscultation wheezing heard, crackles heard, congestion heard, all lobes. A productive cough was noted as well. No entry was made at that time regarding interventions made or notification of the physician about the low oxygen level, cough, or abnormal lung sounds. On [DATE] at 10:45 am, Registered Nurse (RN) Staff F was contacted by telephone for an interview. RN Staff F had been assigned to care for Resident #101 on [DATE] from 2:00 pm until 10:00 pm. RN Staff F could not remember Resident #101 or any details of events on the afternoon shift of [DATE]. After the nursing note entry of [DATE] at 10:15 pm for Resident #101, the next entry was documented on [DATE] at 7:05 am (more than eight hours later). The entry at 7:05 am were apical pulses before treatment (medicated breathing treatment) of 65, during treatment 68, and after treatment 66. A hacking, nonproductive cough was noted and breath sounds were recorded as abnormal, crackles heard, wheezing heard, throughout entire bilateral lung field . No additional vital signs or an oxygen saturation were recorded. A nursing note entry on [DATE] at 11:23 am for Resident #101, recorded apical pulses as: before treatment 58; during treatment 60; and after treatment 58. A nonproductive, congested cough was documented and lung sounds were described as crackles heard, wheezing heard. No additional vital signs or an oxygen saturation were recorded. Upon review of the pulse rates recorded for Resident #101 from [DATE], his date of admission to the facility, through [DATE], the range of his pulse rate had been 93 to 71. No entry was made at that time regarding interventions made or notification of the physician about the low oxygen level, cough, decreased pulse rate, or abnormal lung sounds. According to the Medication Administration Record, [REDACTED]. According to a nursing note on [DATE] at 3:34 pm, the explanation for the medications not being given was unable to take asleep lethargic weakness family notified . A nursing note entry on [DATE] at 5:19 pm by LPN Unit Manager Staff J documented that a note had been received at 11:00 am regarding Resident #101 ' s oxygen saturation level not rising past the 80%s while he was on 4 liters of oxygen. The note stated that the physician was notified. The note stated that at approximately 12:30 pm, the physician had examined Resident #101 and the resident would open his eyes but had noted lethargy. The note revealed that the physician wanted to order some tests that could not be performed at the facility so after reviewing Resident #101 ' s oral intake, he decided to transfer the resident to the local hospital. LPN J recorded Resident #101 ' s blood pressure as ,[DATE]. LPN J recorded that Resident #101 ' s family was notified of the transfer to the hospital and that the ambulance had arrived at about 1:20 pm. On [DATE] at 3:55 pm, LPN Unit Manager was interviewed. LPN J stated that she was present when the physician examined Resident #101 on 101. LPN J stated that when she had entered Resident #101 ' s room on [DATE] at about 12:30 pm, he had oxygen on, but it was not connected correctly. LPN J stated that Resident #101 had looked terrible . On [DATE] at 4:15 pm, LPN D was interviewed by telephone. LPN D had been assigned to care for Resident #101 on [DATE] and [DATE] from 6:00 am to 2:00 pm each day. LPN D recalled Resident #101. LPN D stated that as she remembered Resident #101 had become ill and gone to the hospital all in one day. It all happened boom-boom-boom. On [DATE] at 8:45 am, LPN D was interviewed in person. LPN D stated she had thought about the events and found some hand written notes that she had kept and had remembered more clearly now although she couldn ' t recall if certain events happened on [DATE] or [DATE]. LPN D stated that she had done a skin assessment on Resident #101 one of the days and recalled his skin tone as a cast of grey head to toe. LPN D stated she had known Resident #101 for years as they had lived in the same town and that he had remembered her. LPN D said that on one of the days, the CNAs had told her that Resident #101 was weaker and she gave him a breathing treatment. LPN D remembered that she had spoken with the physician one day about Resident #101 ' s oxygen saturation level and had been told that she probably would not get a good reading because of his poor circulation. LPN D recalled that she had contacted unit manager LPN J about Resident #101 ' s oxygen saturation levels that were not improving after she had bumped up his oxygen to 4 liters per minute. LPN D remembered that she had been told by LPN J that the physician was on his way to the facility and she would make sure he saw Resident #101. LPN D remembered that Resident #101 ' s brother had come into the facility, that she remembered him from years ago and that they had talked for a few minutes. LPN D recalled that Resident #101 ' s brother had gone to the resident ' s room and had returned and asked her What ' s up with (resident ' s name)? LPN D said that after the physician and LPN J had gone in to see Resident #101, LPN J took over and they sent him to the hospital. On [DATE] at 8:22 am, the following entry was made into the clinical record for Resident #101: Late entry for: [DATE] Contacted Dr. (name) at 1135 to inform of residents having low O2 sats (oxygen saturation) and SOB (shortness of breath) with exertion. Received order for O2 at 2 lpm/nc. Family aware of New Order. According to the facility discharge summary, dated [DATE], Resident #101 had a change in medical status , and was transferred to the local hospital, where he expired. The immediate jeopardy was removed on [DATE]. On [DATE] at 5:15 pm, the surveyors verified the following: 1. Documentation that education for LPN D had occurred on [DATE] with regards to documentation in residents' clinical record. 2. Reassignment of LPN D had occurred. 3. Residents who were being administered oxygen had physician orders, and the oxygen was applied as ordered. 4. Nurses who were on duty were undergoing education. Although the immediate jeopardy was removed on [DATE], the facility remained out of compliance pendy the facility's ability to demonstrate sustained compliance as verified by the state agency. ( )

This citation pertains to intake MI 161. Based on observation, interview and record review, the facility failed to provide supervision to prevent the elopement and ensure the safety of 1 resident (Resident #101) who was severely cognitively impaired and had a history of [REDACTED].#101 being discovered by a visitor in a parking lot and being placed in immediate jeopardy to his health and safety and being placed at high risk for injury, serious harm or death. The immediate jeopardy began on 9/13/14 at 5:50 p.m., when Visitor #1 saw Resident #101 sitting, alone and unsupervised, in a car parked in the front parking lot, upset and crying and stating that he was "trying to go home." Prior to being found by Visitor #1 on 9/13/14, Resident #101 had self-ambulated from his room on the facility's 3rd floor unit onto the ambulance elevator, exited the elevator on the 1st floor, walked through a corridor between a hallway leading to the front door of the facility and the staff break room, and exited the facility through the ambulance door which led to the parking lot. Resident #101 was fitted with an alarm bracelet on his wrist that did not activate the ambulance door alarm system when he walked through it. He was also on 15 minute checks at the time of his elopement on 9/13/14. However, review of the CNA (Certified Nursing Assistant) daily Flow sheet (dated 9/14) revealed on 9/13/14 at "6:00 p.m." and at "6:15 p.m.", there was no documentation to show that Staff Member "M" (CNA assigned on 9/13/14 to the hall where Resident #101 resided) had initialed checking on the resident at those times. There was no evidence the resident had been visualized by staff from 5:45 p.m. to 6:30 p.m. (a total of 45 minutes). Facility staff were unaware the resident was missing from this 3rd floor room, and his alarm bracelet failed to activate the ambulance door alarm system when he eloped out the door. The immediate jeopardy was identified at approximately 9/17/14 at 10:15 a.m. The Administrator and Director of Nursing were notified on 9/17/14 at 10:23 a.m. of the immediate jeopardy that began on 9/13/14 at 5:50 p.m., due to the facility's failure to maintain alarm functioning and ensure supervision in order to prevent the elopement and ensure the safety of Resident #101, who was identified as an elopement risk and who had previously been found by staff on two prior occasions (8/17/14 and 8/26/14) outside the facility, by the same door. These deficient practices placed all 19 residents who were assessed as being at risk for elopement (in a facility census of 94 residents) at high risk for physical harm, injury and death. Findings Include: Review of the Face Sheet, Minimum Data Set (MDS, resident assessment tool, dated 8/10/14), BIMS (cognitive assessment dated [DATE]), Alteration in Cognitive Status and Behavioral Care Plans (dated 8/8/14), Nurses and Behavioral note's dated 8/1/14 through 9/13/14, revealed Resident #101 was a [AGE] year old male, admitted to the facility on [DATE], who was alert with confusion and memory loss, had a poor attention span and a BIMS score of "6" (severe cognitive impairment), and ambulated with staff assist/supervision. The resident's [DIAGNOSES REDACTED]. Review of the Physical Therapy note dated 9/1/14; stated Resident #101 was able to ambulate with "SBA (stand by assist)." Review of the Unsteady Gait, Potential for Falls and Impaired Physical Mobility care plans (dated 8/11/14), revealed Resident #101 had an unsteady gait related to decreased strength and endurance and required staff assist with ambulation and stated "assist with locomotion on and off unit (independent to limited), gait is wide and shuffled and walks with a sway." Review of the incident report (dated 9/13/14) revealed Resident #101 exited the facility (on 9/13/14) through the ambulance door, went down a 4 inch sidewalk slope directly into the parking lot, crossed the front parking lot, and got into an un-locked car. During observations made by this surveyor on 9/16/14 at 12:30 p.m., while accompanied by Staff Member "B" (Director of Maintenance), this distance was measured to be approximately 183 feet from the ambulance door to the car where Resident #101 was found. Observation was done on 9/16/14 at 12:22 p.m., on the 3rd floor near the nurse's station across from the main elevator while accompanied by Staff Member "B" (Director of Maintenance), of Resident #101 attempting to get on the elevator and stating, "I want to go out." Resident #101 was unable to be interviewed at that time due to his decreased cognitive ability and memory loss. Review of the facility Occurrence Report, dated 9/13/14, revealed on 9/13/14 (a Saturday) at approximately 6:40 p.m., Resident #101 was found by Visitor #1 outside of the facility, sitting in a car unsupervised and alone. Visitor #1 was leaving the facility and she saw Resident #101 sitting in a car alone, waving his hands and honking the horn, so she went over to see if he needed help. The resident told Visitor #1 he was going home. Visitor #1 called the police because she noticed he had a facility identification band on his wrist. She then sat with him in the car until the police came, because he started to cry and was confused. The resident went into the facility and staff were called to the lobby and informed that Resident #101 was found outside sitting in a car. Staff were unaware Resident #101 was gone, as no alarms had gone off when he exited the ambulance door (to alert staff that the door had been opened by a resident wearing an alarm bracelet). Review of the Occurrence Report (dated 9/13/14) revealed Resident #101 was fitted with an alarm bracelet, but the bracelet failed to activate the ambulance door alarm when he exited the facility on 9/13/14. Review of the nurses notes dated 9/13/14 at 10:01 p.m. stated: "Per police officer and visitor (Visitor #1), resident (Resident #101) was found in the driver's seat of a car in front parking lot honking the horn trying to go home. There were no keys in the car. Visitor had gone over to the car thinking that the person honking the car horn needed help. When she realized the person in the car didn't own the car, she called the police. The officer then escorted the resident back into the facility. This nurse (Staff Member "L", Charge Nurse, LPN) was notified by a kitchen staff member (Staff Member "O", dietary cook) that the resident was downstairs in the front lobby with the police. Possible cause: (alarm bracelet) malfunctioned." A telephone interview was done on 9/16/14 at 1:40 p.m., with Visitor #1. Visitor #1 stated that on 9/13/14 at 5:50 p.m., she was in her car leaving the facility parking lot, when she saw Resident #101 wave his hand and heard the honk of the horn of the vehicle that he was sitting in. Visitor #1 thought the resident required assistance and walked to the car and asked him if he was okay. The resident was confused and started to cry, and she saw the facility name bracelet on his arm, so she got into the car with the resident and called the police. Visitor #1 stayed with the resident until the officer arrived at approximately 6:25 p.m. Review of the Huron County Sheriff's Department report dated 9/13/14, revealed Visitor #1 called and reported Resident #101 alone in a car in the parking lot at "6:15 p.m." and the officer arrived at the facility at "6:29 p.m." Review of the Sheriff's report stated "Officer was dispatched for a subject that was wandering outside the (facility). Complainant stated that the subject was confused and lost outside of the building. I arrived on scene and spoke with (Resident #101). I noticed an alarm bracelet on his arm. I spoke with an employee of the (facility) and they informed me he must of walked out of the building without the alarm going off." An interview was done on 9/17/14 at 9:35 a.m., with Staff Member "O" (dietary cook). Staff Member "O" stated on 9/13/14, "I was on 2nd floor at about 6:30 p.m., the lady (Visitor #1) got off the elevator and said to me, 'I think you have a resident outside, I noticed his name band.' She said he (Resident #101) was trying to start a car. I called 3rd floor (nursing station) and no one answered. I found an aide (staff member "M", CNA) and told her (name of Resident #101) was outside. She said 'I thought he was in activities.' Then I told (staff member "L", Charge Nurse, LPN) and I told her the police were called. (Resident #101) is not supposed to be off the unit (without supervision)." An interview was done on 9/17/14 at 7:45 a.m., with Staff Member "L" (Charge Nurse-LPN, assigned on 9/13/14 to the unit where Resident #101 resided). Staff Member "L" stated, "I last saw him (Resident #101)...about 4:45 p.m., when I gave him his 4:00 p.m. and 5:00 p.m. meds (medications). I didn't tell (staff member "M", CNA) that he had tried to get on the elevator the prior shift (on 1st shift, per report from the 1st shift nurse and as documented on the 24 Hour Report sheet). It was 20 minutes to 7:00 and (Staff Member "O", Dietary cook) came to the unit and told me the police had my resident down stairs. I asked the Aide (Staff Member "M", CNA) what happened. The Aide said she couldn't find him and she assumed he was in activities. It could have been prevented if he (the resident) would have been a one-on-one, if we would have (had) daily alarm checks (of the resident alarm bracelets), if I would of informed the CNA (staff member "M") he (Resident #101) had tried to get on the elevator that day on 1st shift." An interview was done on 9/16/14 at 1:05 p.m., with Staff Member "D" (Charge Nurse, LPN, assigned on 9/13/14, to Resident #101's unit during the 1st shift). Staff member "D" stated, "I put it on the 24 Hour Report. He tried to get on the elevator today (9/16/14), just prior to lunch between 11:45 a.m. and 11:50 a.m.; I heard the button click. The elevator is not alarmed; I just happened to be in the hallway. I did not see him by the elevator, it's in an alcove, I heard the elevator button. It's common for him (Resident #101) to be found on another floor, on 1st or 2nd (shifts) about once a week." Review of the facility's 24 Hour Condition Report (24 nursing hour report) dated 9/13/14, stated on "day shift" (first shift): "(Resident #101) tried to get on elevator." Review of the 24 Hour Condition Report, dated 9/13/14, stated on "second shift": "(Resident #101) eloped, 1 on 1 while awake, check (alarm bracelet) q (every) shift." When this surveyor requested the facility policy (on 9/16/14) for conducting 15 minute checks, Staff Member "A" (Director of Nursing/DON) said the facility did not have one. An interview was done on 9/17/14 at 9:08 a.m., with Staff Member "M" (Nursing Assistant/CNA) who was assigned on 9/13/14 to the hall where Resident #101 resided. Staff Member "M" stated, "at 20 minutes after 6:00 p.m., I realized he (Resident #101) was not in the dining room. I checked his room, I didn't check activities. I thought he was in activities, I didn't go to activities or tell the nurse, I felt if anything bad would happen, an alarm would go off. I didn't find him. I didn't tell the nurse or look for him. He was missing about 40 minutes. I had 6 people (residents) to take care of, I feel he should of stayed on one-on-one (supervision level), I don't feel it was my fault he left, I feel the elevators should have an alarm on them for the (alarm bracelets)." Review of staff progress notes dated 8/5/14 at 12:29 p.m., stated "Res (Resident #101) removed from 1:1 (one-on-one) supervision related to a decline in health." Review of Staff Member "M's" written statement dated 9/14/14 at 3:05 p.m., stated, "Last time I saw (Resident #101) between 5:45 p.m. and 6:00 p.m. It was around 6:20 p.m. when I noticed he wasn't in the dining room or his room. My poor judgment, I believed the best, I figured he was in activities." An interview was done on 9/17/14 at 8:43 a.m., with Staff Member "P" (CNA, also assigned on 9/13/14 to the unit where Resident #101 resided). Staff member "P" stated "(name of Staff member "M") said to me she was not sure where (Resident #101) was about 6:00 p.m. I said you need to know where he is at all times. She (Staff Member "M") told me they found him outside and I asked her if she looked for him and she said "no". We (staff) had been fixing stuff for her in the past and didn't tell anyone, she has left residents unsafe before. He (the resident) was not put on one-on-one that night (after the elopement) until 8:30 p.m., they brought him back upstairs around 7:00 p.m." Review of staff progress notes dated 9/4/14 at 2:40 p.m. (prior to elopement on 9/13/14) stated: "Res (Resident #101) was walking quickly down the hallways and attempting to get on the elevator to leave. It was discussed that the safety of res (sic) is in concern as he may exit the building quickly with his increase in speed during ambulating." Review of the Physical Therapy notes dated 9/1/14 at 3:29 p.m., revealed the resident's decline in health/functional ability was behavioral and stated "no decline noted." An interview was done on 9/17/14 at 11:35 a.m., with Staff Member "I" (Social Worker/SW). Staff member "I" (SW) stated "He (Resident #101) was taken off one-on-one because he was using his wheelchair, PT (Physical Therapy) evaluated him and said it (the resident's transition between walking independently and using a wheelchair for mobility) was behavioral." An interview was done on 9/17/14 at 8:55 a.m., with Staff Member "J" (Nurse Supervisor-RN, assigned on 9/13/14). Staff member "J" stated, "He (the resident) had a history of [REDACTED]. I had sent a memo out that he had gotten out the ambulance door, that he needed to be watched (on 8/17/14), his alarm went off." Staff member "J" was unable to locate the memo she sent out on 8/17/14." An interview was done on 9/17/14 at 8:30 a.m., with staff member "K" (Ward Secretary). Staff member "K" revealed she checked all residents' alarm bracelets for functionality and (until 9/14/14), she was checking them "weekly, every Thursday." After 9/14/14 (the day Resident #101 eloped), she started checking them daily based on direction from the DON. Review of the Basic Rules for (alarm bracelets) management (manufacture guidelines, un-dated) stated: "Test each signaling device daily." The immediate jeopardy was abated on 9/15/14, based on confirmation, during observation and interviews conducted on 9/17/14 at 4:00 p.m., that the facility had implemented the following to remove the immediate jeopardy: 1. On 9/13/14 at 6:45 p.m., Resident #101 was placed on one-on-one supervision and his alarm bracelet was tested and found to be operational. 2. On 9/13/14 at 6:45 p.m., Resident #101 was assessed by staff member "L" (Charge Nurse, LPN), with no injuries noted. 3. On 9/14/14, 19 out of 94 total residents were identified to be at risk for elopement (per un-dated list of facility residents with alarm bracelets, provided to this surveyor by the DON on 9/16/14) and their care plans were reviewed by staff member "A" (the Director of Nursing/DON). 4. On 9/14/14 between 7:00 a.m. and 7:15 a.m., 19 out of 19 residents' ('alarm bracelets were checked and ensured to be functioning properly by staff member "K" (Ward Secretary). 5. On 9/14/14 between 8:00 a.m. and 8:30 a.m., 18 out of 18 residents' bracelets alarmed doors, including the ambulance door, when checked by staff member "B" (Director of Maintenance), and all were functioning properly. 6. On 9/16/14 at 12:30 p.m., 7 out of 19 (all third floor residents) alarm bracelets were checked against the ambulance door and found to be functioning properly. On 9/17/14, by 3:00 p.m., the remaining residents' alarm bracelets (a total of 12) were checked against the ambulance door and were found to be functioning properly. 7. On 9/15/14, the facility (alarm bracelet) policy was reviewed with the following added: - The Ward Secretory (Staff Member "K") would be checking all residents' alarm bracelets for functionality on a daily basis and, if any are found to be not functioning properly, she would report it to staff member "A" (Director of Nursing/DON). - A master list of all residents outfitted with alarm bracelets would be kept on each floor at the nurse's stations. - All alarm bracelets' expiration dates would be monitored by Staff Member "K" (Ward Secretory) and replaced as needed. 8. On 9/14/14, an every 15 to 30 minutes resident check protocol was developed by Staff Member "A" (the Director of Nursing/DON), which included the stipulation that residents were to be visualized every 15 minutes to 30 minutes by staff and directions for what to do if a resident was not visualized during the check times. 9. On 9/14/14 beginning at 5:00 p.m., 90 out of 107 Nursing Assistants/CNA's had been educated regarding 15 or 30 minute resident checks; this was completed by staff members "A" (Director of Nursing/DON) or Staff Member "R" (Assistant Director of Nursing/ADON). The remaining 17 CNA's would be educated on the 15/30 minute resident checks prior to their next shift assignment by Staff Member "S" (Inservice Director) or by charge nurses, or they would be notified by certified mail no later than 9/19/14. 10. All facility staff would be educated on all policy changes including the 15/30 minute resident checks and resident one-on-one supervision, initiated on 9/17/14 and to be completed by 9/19/14. 11. Beginning 9/17/14, all new employees' orientation would include the policy and procedure for alarm bracelets and 15/30 minute checks. 12. Beginning 9/16/14 at 11:54 a.m., one nurse would remain on the resident unit/floor at all times. 13. On 9/17/14 by 3:00 p.m., motion alarm sensors were placed by all elevators on the second and third floors to detect anyone attempting to get on the elevators. 14. On 9/16/14 at 12:00 p.m., the ambulance elevator was equipped with a locked gate across the first floor exit leading directly into the kitchen and to an exit door. 15. An alarm company was contacted on 9/17/14 and parts to be installed were shipped immediately to the facility for all elevators to be equipped with alarm bracelet alarm systems. 16. On 9/16/14, Staff Member "A" (the Director of Nursing/DON) completed, with all staff, the alarm bracelet activation drill at the ambulance door, with a 10 second response time. 17. Beginning the week of 9/17/14, the facility safety committee would complete weekly alarm bracelet activation drills at various times to ensure staff response remained timely. 18. Beginning on 9/17/14, the Social Service and Restorative departments would review all residents fitted with alarm bracelets plans of care for appropriateness. Although the immediate jeopardy was removed on 9/15/14, the facility remained out of compliance at a scope and severity of isolated potential for more than minimum harm pending completion of inservice training by all staff not yet inserviced and the facility's ability to sustain compliance as verified by the State Agency. It was further confirmed by this surveyor, during observations conducted on 9/16/14 (at 12:30 p.m.) and on 9/17/14 (between 8:00 a.m. and 3:00 p.m.), all 19 facility residents with alarm bracelets had been tested against the ambulance door and the bracelets were in proper functioning condition. Observation was made on 9/18/14 at 11:46 a.m. of Resident #101 on the 3rd floor, ambulating with the assist of staff. Resident #101 was observed to have an alarm bracelet on his left wrist, and it was confirmed by this surveyor (while accompanied by the DON), to be in working order and properly functioning. Observation was made on 9/18/14 at 11:45 a.m. of the ambulance elevator with motion alarms in place and in proper working order. ( )

This citation pertains to intake number MI 911. An unannounced survey was conducted from 10/07/2013 through 10/08/2013. Based on observation, interview and record review, the Facility failed to prevent a fall with injury by not utilizing wheelchair pedals during resident transport in accordance with facility policy for 1 (#1) of 3 residents reviewed for falls from a sample of 3 and one (#4) supplemental sample resident, resulting in Resident #1 falling from her wheelchair and receiving sutures in the hospital for a head laceration and the potential for injury for resident #4. Findings include: Resident #1 was a [AGE] year old male admitted to the Facility with [DIAGNOSES REDACTED]. Review of Resident #1's most recent Minimum Data Set- Significant change in status assessment dated [DATE] reflects Resident #1's cognitive status as "never/rarely made decisions with both short- and long-term memory impairment. Resident #1's cognitive status assessment further reflected that Resident #1 had continuous and non-fluctuating difficulty focusing attention (difficulty following what was said). Review of the Facility's "Resident Occurrence" report dated 09/23/2013 at 6:45 PM reflected Licensed Practical Nurse (LPN) "C" heard Certified Nursing Assistant (CNA) "B" "...yell for help..." and LPN "C" "observed the resident (#1) laying (on the floor) on his right shoulder with his right leg over his left leg..." and a "laceration noted above right eye with medium amount of blood noted coming from laceration...laceration ran about the length of his (Resident #1's) eyebrow and was open." The Facility's "Resident Occurrence" report further reflected that Resident #1 was triaged and treated by the Facility staff while awaiting EMS (Emergency Medical Services). Resident #1 was taken to the emergency room where he received 6 sutures to close the laceration above his right eye. Review of Resident #1's care plan, dated 09/06/2013, reflected under "wheelchair use: pedals: pedals have been removed and are for transport only. Resident (#1) is able to propel wheelchair minimally but requires staff assistance for transportation." Review of Resident #1's kardex (CNA care plan), dated 09/06/2013 reflected under "other: (wheelchair) pedals for transport only." An interview was conducted with CNA "B" on 10/07/2013 at 4:00 PM. CNA "B" stated (on the evening of 9/23/13) he had observed Resident #1 leaning forward (as demonstrated by CNA "B" leaning with his elbows on his thighs and his head over his knees) in his wheelchair with his arms "shaking". CNA "B" stated he had assisted Resident #1 to sit up in his wheelchair and then began transporting (pushing Resident #1 in his wheelchair, without the wheelchair pedals in place to support the resident's feet) to his room to lie down. CNA "B" stated Resident #1 was alert and "watching me and I started wheeling him to his room..." CNA "B" stated, while he was transporting Resident #1 to his room, CNA "B" heard the resident in room 316 call his name. CNA "B" stated he had seen the resident's feet (from room 316) coming into the hallway as CNA "B" was walking past pushing Resident #1 in his wheel chair and stated, "...it took a few steps to stop..." and "I was past her (the resident in room 316's) room a couple of steps (when stopped)..." CNA "B" stated when he turned to look at the resident in room 316, "...as quick as I turned around, I heard (Resident #1) hit the floor. I spun around to (Resident #1). He (Resident #1) was on his right side on the floor and I could see the blood coming out of his head...I yelled for help." CNA "B" stated "I think he had his grey tennis shoes on. If I had it to do differently, I'd have put on the (wheelchair) pedals." Review of the Facility's "Wheel Chairs - Use of" policy and procedure, effective date 06/26/1990 and revised date 2/2004, reflected under "Policy: NOTE: Wheel chairs must have both pedals in place before use unless the care plan indicates otherwise." Facility residents were observed to be in the main lobby of the Facility on 10/08/2013 at 12:05 PM awaiting bus transport to an activity. Activities Director "H" was observed to push supplemental sample Resident #4 around two other residents to the front of the line awaiting the bus. There were no wheelchair pedals on Resident #4's wheelchair. There was an audible scraping of Resident #4's feet on the carpet during the time Activities Director "H" was transporting Resident #4 to the front of the line of other residents. When asked how it was determined if a resident needed wheelchair pedals to be transported by staff, Activities Director "H" stated, "if the resident could pick up their feet, they didn't need pedals." When asked if Resident #4 could, or did, pick up her feet during the observed transport, Activities Director "H" stated she didn't know if Resident #4 had picked up her feet or not. During an interview conducted earlier that morning, on 10/08/2013 at 9:00 am., when asked how use of wheelchair pedals were determined, Licensed Practical Nurse (LPN) "C"stated "...(it) depends on how they're (the residents) are assessed...(and) if it's Kardexed (documented on the kardex, which is the Facility's CNA care plan) or care planned for foot pedals to be on the wheelchair when transporting." An interview was then conducted with Restorative Nurse Manager "D" on 10/08/2013 at 10:55 am. Restorative Nurse Manager "D" stated she was responsible for assessments "...including transfers and device needs." Restorative Nurse Manager "D" stated, "the staff shouldn't be pushing someone in the wheelchair, but guiding them to allow the resident to self propel." Restorative Nurse Manager "D" stated, "We have the bags (for foot pedal storage)that go on the backs of the wheelchairs but we don't use them, they are uncomfortable for the residents." Restorative Nurse Manager "D" stated, "The (wheelchair) pedals (for Resident #1) were in his room the day after his fall, so I knew they were in the room (Resident #1's room)." An interview with the Director of Nursing was conducted 10/08/2013 at 11:10 am. The Director of Nursing defined "transporting" a resident as, "the staff is doing the moving of the resident's wheelchair and a "self-propelling" resident as a resident "...using (their) feet or hands to move independently." An interview with CNA "E" was conducted on 10/08/2013 at 12:20 PM. When asked how it was determined if a resident needed wheelchair pedals during transport, CNA "E" stated "if they don't pick up their feet, we use pedals." An interview with CNA "F" was conducted on 10/08/2013 at 10:25 am. When asked how it was determined if a resident needed wheelchair pedals during transport, CNA "F" stated "When you transport, you use them. If they don't have them (the wheelchair pedals) then you go find them (the wheelchair pedals)." An interview with CNA "G" was conducted on 10/08/2013 at 10:35 am. When asked how it was determined if a resident needed wheelchair pedals during transport, CNA "G" stated "when a resident is unable to keep (their) feet up." /

THIS CITATION PERTAINS TO INTAKES #MI 962, MI 073, AND MI 212. BASED ON OBSERVATIONS, INTERVIEWS AND RECORDS REVIEW, THE FACILITY FAILED TO PROVIDE THE NECESSARY SUPERVISION AND/OR ASSISTIVE DEVICES FOR 2 OF 3 SAMPLED RESIDENTS (#102 AND #103), REVIEWED FOR ACCIDENTS, FROM A TOTAL SAMPLE OF 5, RESULTING IN FALLS FOR BOTH RESIDENTS. RESIDENT #102 SUSTAINED A RIGHT FIBULA FRACTURE AND RESIDENT #103 SUSTAINED A LEFT HIP FRACTURE. FINDINGS INCLUDE: RESIDENT #102: ACCORDING TO THE FACE SHEET DATED 10/04/2012, RESIDENT #102 WAS A [AGE] year OLD FEMALE ORIGINALLY admitted TO THE FACILITY 04/08/2010 AND REadmitted [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM (MDS) data set [DATE] DOCUMENTED THAT RESIDENT #102 HAD NO COGNITIVE IMPAIRMENTS, HAD TWO RECENT FALLS WITH ONE "MAJOR INJURY," EXPERIENCED FUNCTIONAL LIMITATIONS IN A LOWER EXTREMITY, REQUIRED A WALKER AND WHEELCHAIR FOR MOBILITY, COULD NOT BALANCE WITHOUT HUMAN ASSISTANCE, REQUIRED MINIMALLY ONE STAFF MEMBERS ASSISTANCE WITH AMBULATION AND TWO STAFF MEMBERS ASSISTANCE WITH TRANSFERS, TOILETING AND PERSONAL HYGIENE. PHYSICIAN ORDERS [REDACTED].#102 FIVE TO SEVEN TIMES WEEKLY. A FALL assessment dated [DATE] REVEALED THAT RESIDENT #102 WAS AT "RISK FOR SIGNIFICANT CONSEQUENCES," WITH A SCORE OF 47. A CARE PLAN DATED 9/14/2012 DOCUMENTED THAT RESIDENT #102 WAS TO AMBULATE ONLY WITH SKILLED THERAPISTS, BECAUSE OF HER "SIGNIFICANT" RISK FOR FALLS, HER DECLINING FUNCTIONAL STATUS, UNSTEADY GAIT, POOR BALANCE, RECENT FALL HISTORY, JOINT PAIN, ARTHRITIS, WEAKNESS, AND DIZZINESS. A CARE PLAN DATED 9/26/2012 DOCUMENTED THAT STAFF WERE TO "ENSURE (THE) USE OF SAFETY MEASURES" THAT INCLUDED GRIPPER SOCKS, GRIPPER PAD UNDER HER WHEELCHAIR CUSHION, A BED ALARM, A WHEELCHAIR ALARM, WHEELCHAIR AUTO-LOCK BRAKES, WHEELCHAIR ANTI-TIP BARS, A GAIT BELT, MINIMALLY ONE PERSON TO ASSIST WITH ALL TRANSFERS, AND NOT TO BE LEFT ALONE WHILE TOILETING. NURSING NOTES DATED 9/27/2012 AT 10:23 P.M., WRITTEN BY LICENSED PRACTICAL NURSE (LPN) #1, DOCUMENTED THAT RESIDENT #102 fell AND SUBSEQUENTLY DEVELOPED RIGHT ANKLE AND KNEE PAIN RATED "8 OUT OF 10, " WHEN CERTIFIED NURSING ASSISTANT (CNA) #1 LEFT THE RESIDENT UNSUPERVISED, "STANDING AT (THE) SINK IN HER BATHROOM," WHICH HAD A "WET, CLUTTERED" FLOOR. ADDITIONALLY, LPN #1 DOCUMENTED THAT BECAUSE RESIDENT #102 NEEDED TRANSFER ASSISTANCE, SAFETY DEVICES AND PERSONAL ALARMS IN BOTH HER WHEELCHAIR AND BED, CNA #1 SHOULD NEVER HAVE LEFT HER STANDING UNATTENDED IN ANY BATHROOM. IN A WRITTEN STATEMENT DATED 9/28/2012, CNA #1 WROTE THAT ON 9/27/12, SHE (CNA #1) LEFT RESIDENT #102 STANDING UNSUPERVISED AT HER BATHROOM SINK AND SHE (#102) fell . DESPITE THIS FALL ASSESSMENT THE STAFF FAILED TO MAKE ANY IMMEDIATE CHANGES TO THE RESIDENTS CARE PLAN. NURSING NOTES DATED 9/28/2012 DOCUMENTED THAT RESIDENT #102 EXPERIENCED DIFFICULTY AMBULATING DUE TO CONTINUED RIGHT ANKLE AND KNEE PAINS. PER THE NURSING NOTES, IT WAS NECESSARY FOR STAFF TO LOWER HER TO THE FLOOR AT 10:42 P.M. DESPITE THIS FALL ASSESSMENT STAFF FAILED TO MAKE ANY IMMEDIATE CHANGES TO THE RESIDENT'S CARE PLAN. ON 9/28/2012 THE PHYSICIAN ORDERED RESIDENT #102 A RIGHT ANKLE X-RAY. THE RADIOLOGY REPORT DATED 9/28/2012 REVEALED NO NEW FRACTURES OR DISLOCATION OF THE RIGHT ANKLE, THE DISTAL TIBIA OR THE FIBULA (LOWER LEG), THOUGH SOFT TISSUE SWELLING WAS NOTED. NURSING NOTES DATED 9/29/2012 AT 1:19 P.M., DOCUMENTED RESIDENT #102 INITIALLY REFUSED TO ATTEND THERAPY DUE TO PAIN IN HER RIGHT ANKLE. NURSING STAFF ADMINISTERED NARCOTIC PAIN MEDICATION FOR THE RIGHT ANKLE PAIN VOICED BY RESIDENT #102 AT 8:37 A.M., AND FOR THE RIGHT ANKLE AND RIGHT KNEE AT 4:27 P.M., AND 7:23 P.M. ON 9/30/2012 AT 1:00 P.M., STAFF DOCUMENTED THAT RESIDENT #102 "...COMPLAINED OF NOT RECEIVING ENOUGH PAIN MEDICATION...SHE WAS IN SEVERE PAIN." AT 4:18 P.M., AND 7:47 P.M., RESIDENT #102 RECEIVED NARCOTIC MEDICATIONS FOR PAIN IN "BOTH LEGS." BILATERAL KNEE PAIN WAS DOCUMENTED AGAIN ON 10/01/2012. ON 10/02/2012 AT 2:32 P.M., STAFF DOCUMENTED AN "IMPAIRMENT...(OF HER) RIGHT KNEE..." AT 3:57 P.M., 5:31 P.M., 7:38 P.M. 9:06 P.M., NARCOTIC PAIN MEDICATIONS WERE ADMINISTERED FOR BILATERAL KNEE PAIN. THERAPY NOTES DATED 10/03/2012 DOCUMENTED RESIDENT #102 COMPLAINED OF "INCREASED PAIN IN (HER) RIGHT KNEE DURING THERAPY." ON 10/03/2012 THE PHYSICIAN ORDERED A RIGHT KNEE X-RAY FOR RESIDENT #102. THE RADIOLOGY REPORT DATED 10/03/2012 REVEALED AN "ACUTE RIGHT FIBULAR FRACTURE." RESIDENT #103: ACCORDING TO THE FACE SHEET DATED 12/13/2012, RESIDENT #103 WAS A [AGE] year OLD FEMALE admitted TO THE FACILITY 9/08/2012, REadmitted [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM (MDS) data set [DATE] DOCUMENTED THAT RESIDENT #103 HAD SEVERELY IMPAIRED DECISION MAKING WITH BOTH LONG AND SHORT TERM MEMORY LOSS, COULD NOT BALANCE, DID NOT WALK, HAD FUNCTIONAL IMPAIRMENTS OF ALL EXTREMITIES, RECENTLY fell AND SUSTAINED A MAJOR INJURY, REQUIRED MINIMALLY TWO STAFF MEMBERS TO ASSIST WITH ALL TRANSFERS, GETTING DRESSED, EATING, TOILET USE AND PERSONAL HYGIENE. A FALL assessment dated [DATE] DOCUMENTED THAT RESIDENT #103 HAD TWO FALLS PRIOR TO ADMISSION AND REMAINED AT "HIGH RISK FOR FALLS" WITH A SCORE OF 37. A CARE PLAN DATED 9/19/2012, SINCE DISCONTINUED, FURTHER IDENTIFIED RESIDENT #103 AT RISK FOR CONTINUED FALLS DUE TO HER DECLINE IN FUNCTIONAL STATUS, DECLINE IN COGNITIVE STATUS, INTERMITTENT CONFUSION, IMPAIRED HEARING, POOR SAFETY AWARENESS, AND HER HISTORIES OF DEHYDRATION, FAINTING AND DEMENTIA. TO MINIMIZE HER RISK FOR FALLS STAFF WERE TO "ENSURE (THE) USE OF SAFETY MEASURES THAT INCLUDED A LOW BED, BED ALARM, WHEELCHAIR GRIPPER CUSHION, CHAIR ALARM, WHEELCHAIR AUTO-LOCK BRAKES, ANTI-TIP BARS AND GRIPPER SOCKS. ACCORDING TO NURSING NOTES DATED 10/28/2012 STAFF WITNESSED "RESTLESS" BEHAVIOR FROM RESIDENT #103 THROUGHOUT THE NIGHT SHIFT, AS SHE ATTEMPTED TO CRAWL OUT OF BED. HOWEVER, DESPITE ONGOING SIMILAR ASSESSMENTS THAT SHIFT, STAFF GOT RESIDENT #103 INTO HER WHEELCHAIR AT 4:40 A.M., AND PLACED SOCKS ON HER FEET WITH "POOR GRIPPERS," BEFORE THEY LEFT HER UNSUPERVISED IN THE DINING ROOM, WITH ONLY INFREQUENT, RANDOM VISUAL CHECKS DOCUMENTED, AND SHE fell AT 6:15 A.M. DURING AN INTERVIEW 12/14/2012 AT 1:20 P.M., ASSISTANT DIRECTOR OF NURSING (ADON) #1 CLARIFIED THAT "POOR GRIPPERS" MEANT THE RUBBER TREAD REQUIRED FOR SAFETY ON THE BOTTOMS OF THE SOCKS WAS "ALMOST COMPLETELY WORN OFF." ADON #1 FAILED TO EXPLAIN WHY UNSAFE FOOTWEAR WOULD HAVE BEEN PLACED ON A CONFUSED RESIDENT EXHIBITING SELF-TRANSFER AND AMBULATION ATTEMPTS. A NURSING assessment dated [DATE] AT 8:24 A.M., DOCUMENTED THAT RESIDENT #103 COMPLAINED OF LEFT FEMUR PAIN THAT INCREASED WITH MOVEMENT. NURSING STAFF IMMEDIATELY NOTIFIED THE PHYSICIAN. ON 10/28/2012 THE PHYSICIAN ORDERED STAFF TO SEND RESIDENT #102 TO THE LOCAL AREA HOSPITAL FOR FURTHER EVALUATION AND TREATMENT. DIAGNOSTIC IMAGING NOTES FROM A LOCAL AREA HOSPITAL DATED 10/28/2012 AT 11:25 A.M., REVEALED RESIDENT #103 SUSTAINED A "COMMINUTED FRACTURE TRAVERSING THE BASE OF THE LEFT FEMORAL NECK (A HIP FRACTURE)."

THIS CITATION PERTAINS TO INTAKE # MI 312. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ADEQUATELY IMPLEMENT ASSISTIVE DEVICES TO PREVENT ACCIDENTS FOR 1 (#101) OF 4 SAMPLED RESIDENTS, ALL REVIEWED FOR FALLS, FROM A TOTAL SAMPLE OF 4, RESULTING IN A FALL WITH INJURY. FINDINGS INCLUDE: RESIDENT #101: ACCORDING TO THE FACE SHEET DATED 6/27/2012, RESIDENT #101 WAS admitted to the facility on [DATE]. RESIDENT #101 HAD SEVERAL DIAGNOSES, WHICH INCLUDED UNSPECIFIED CEREBRAL DEGENERATION, ALZHEIMER'S DISEASE AND ARTHRITIS. ACCORDING TO THE CARE PLAN DATED 6/26/2012 RESIDENT #101 HAD SELF-CARE DEFICITS AND REQUIRED EXTENSIVE ASSISTANCE WITH TOILETING. ACCORDING TO THE CARE PLAN DATED 6/26/2012, RESIDENT #101 HAD IMPAIRED MOBILITY AND REQUIRED LIMITED TO EXTENSIVE ASSISTANCE WITH ALL TRANSFERS, AND EXTENSIVE ASSISTANCE WITH LOCOMOTION. ACCORDING TO THE CARE PLAN DATED 6/26/2012, RESIDENT #101 WAS AT RISK FOR FALLS AND REQUIRED A BED ALARM AND AN ALARMED PAD IN ALL CHAIRS USED BY RESIDENT #101 TO ALERT STAFF OF UNSAFE ATTEMPTS TO AMBULATE. ACCORDING TO THE NURSE'S NOTE DATED 6/27/2012, RESIDENT #101 WAS OBSERVED AMBULATING UNASSISTED IN HER ROOM BY FACILITY STAFF USING A WHEELCHAIR AS A WALKING AID. ACCORDING TO THE RESIDENT OCCURRENCE REPORT, A STAFF MEMBER (LICENSED PRACTICAL NURSE #2) IMMEDIATELY ENTERED THE ROOM TO ASSIST RESIDENT #101, BUT AS HE (#2) DID, "...THE RESIDENT fell TO THE FLOOR..." DURING A TELEPHONE INTERVIEW ON 7/6/2012 AT 11:20 A.M., THE CERTIFIED NURSE ASSISTANT (CNA #1) SAID RESIDENT #101 WAS UP SEVERAL TIMES THAT NIGHT AND EACH TIME, "THE ALARM SOUNDED AS WE GOT HER OUT OF BED." CNA #1 SAID THAT AT ABOUT 4:30 A.M., SHE (#1) PASSED BY RESIDENT #101'S ROOM AND SAW SHE WAS RESTING IN BED. CNA #1 SAID A FEW MINUTES LATER, THE LICENSED PRACTICAL NURSE (LPN #2) WAS GOING DOWN THE HALL AND CALLED FOR HELP. CNA #1 SAID SHE RAN TO RESIDENT #101'S ROOM, BUT BY THE TIME SHE (CNA #1) GOT THERE, RESIDENT #101 WAS ON THE FLOOR AND THE SAFETY ALARM WAS NOT SOUNDING. CNA #1 CLARIFIED THAT RESIDENT #101 HAD GOTTEN HERSELF UP AND OUT OF BED, WHICH SHOULD HAVE CAUSED THE ALARM TO SOUND, ALERTING STAFF TO HELP HER SAFELY WALK TO THE BATHROOM. CNA #1 SAID THE ALARM DID NOT WORK, AND RESIDENT #101 fell BECAUSE SHE (#101) DID NOT GET THE HELP SHE NEEDED TO BE SAFE. CNA #1 SAID SHE HAD SEEN RESIDENT #101 IN THE PAST HANDLING THE ALARM, BUT HAD NOT SEEN HER COMPLETELY DISABLE IT (THE ALARM) BEFORE. IN A SIGNED UNDATED STATEMENT, LPN #2 REPORTED THAT AT APPROXIMATELY 4:49 A.M., HE (LPN #2) WAS WALKING PAST RESIDENT #101'S ROOM AND SAW #101WALKING, WHILE PUSHING A WHEELCHAIR, IN THE DIRECTION OF THE BATHROOM. LPN #2 SAID AS HE ENTERED THE ROOM, RESIDENT #101 "...fell on HER LEFT SIDE AND SHE (RESIDENT #101) IMMEDIATELY CRIED IN PAIN..." ACCORDING TO THE SIGNED STATEMENT, RESIDENT #101'S "...BED ALARM DID NOT SOUND ...THE (SENSOR) PAD WAS UNPLUGGED FROM THE BOX..." THE SURVEYOR UNSUCCESSFULLY ATTEMPTED TWICE TO REACH LPN #2 FOR AN INTERVIEW. ACCORDING TO THE RESIDENT OCCURRENCE REPORT DATED 6/27/2012, RESIDENT #101 SAID THAT "...HER LEFT LEG WAS HURT." RESIDENT #101'S LEFT LEG "...WAS ROTATED OUT AND APPEARED TO BE SHORTER THAN HER RIGHT LEG ..." RESIDENT #101 WAS SENT TO THE LOCAL AREA HOSPITAL WHERE ACCORDING TO THE DIAGNOSTIC IMAGING REPORT DATED 6-27-2012 RESIDENT #101 SUFFERED AN INTERTROCHANTERIC FRACTURE OF THE LEFT HIP (BROKEN HIP). ACCORDING TO THE NURSE'S NOTE DATED 6/27/2012 THE POSSIBLE CAUSE FOR THE FALL WAS LISTED AS "...BED PAD ALARM WAS UNHOOKED FROM THE BOX ..." MAKING IT UNABLE TO FUNCTION AS NECESSARY. ACCORDING TO THE FACILITY INVESTIGATION REPORT DATED 6/29/2012, WHEN STAFF (LPN #2) SAW RESIDENT #101 AMBULATING IN THE ROOM ON 6/27/2012, HER ALARM WAS NOT SOUNDING. ACCORDING TO THE FACILITY INVESTIGATION REPORT "...UPON FURTHER INVESTIGATION, THE ALARM CORD WAS UNATTACHED FROM THE ALARM BOX, WHICH IS WHY THE ALARM DID NOT SOUND..." IN AN INTERVIEW ON 7/6/2012 THE DIRECTOR OF NURSING (DON #1) SAID THAT ACCORDING TO HER INVESTIGATION, RESIDENT #101 WAS WALKING UNASSISTED IN HER ROOM, AND ALTHOUGH LPN #2 SAW RESIDENT #101 WHILE SHE WAS STILL STANDING, HE COULD NOT REACH HER IN TIME TO PREVENT HER FALL. THE REQUIRED SAFETY ALARM FAILED TO ALERT STAFF IN TIME OF HER ATTEMPT TO GET OUT OF BED. DON #1 SAID THAT AFTER THE ALARM FAILED TO ALERT STAFF, RESIDENT #101 fell AND FRACTURED HER HIP. DON #1 SAID THAT ACCORDING TO THE INTERVIEWS ASSOCIATED WITH HER INVESTIGATION, NURSING STAFF MEMBERS HAD IN THE PAST CAUGHT RESIDENT #101 "...TRYING TO DISCONNECT THE ALARM..." BUT HAD NOT REPORTED THIS TO ANYONE AS A SAFETY CONCERN. DON #1 SAID SHE ASSESSED ALL ALARMS IN THE FACILITY AFTER RESIDENT #101'S FALL AND FOUND THAT SIX OF THE OTHER RESIDENT ALARMS HAD BROKEN CORDS OR HAD PADS THAT WERE MALFUNCTIONING THAT MADE THE ALARMS NOT WORK PROPERLY. ( )

This citation pertains to intake number MI 502. Based on observation, interview, and record review, the facility failed to ensure the safety of and provide adequate supervision for 2 (Resident #101 and Resident #102) of 6 sampled residents from a total sample of 6 residents resulting in an Immediate Jeopardy when: 1) Resident #101 ignited his oxygen cannula on 6/6/11 at 4:20 p.m. while smoking unsupervised, with oxygen, outside the facility and sustained second degree burns, and when 2) Resident #102, who wore a wanderguard bracelet, left the facility undetected by facility staff on 6/15/11 and returned to the facility through the Park entrance door at 5:59 p.m. at which time the wanderguard alarm sounded, alerting staff of his return. These deficient practices place Resident #101, Resident #102, and 23 additional cognitively intact residents, who wish to exit to the facility grounds, at high risk of serious harm, injury, and/or death. Findings include: Resident #101: Resident roster, dated 6/17/11, indicated Resident #101 was cognitively intact. Review of Resident #101's face sheet revealed [DIAGNOSES REDACTED]. Review of the Respiratory Insufficiency Care Plan, dated 5/9/11, revealed Resident #101 had oxygen via nasal cannula at 1-4 liters. Review of the Potential for Variability in Respiratory Status Care Plan, dated 5/9/11, revealed Resident #101 had "multiple [DIAGNOSES REDACTED]. Review of the "Resident Occurrence" report dated 6/6/11 at 4:20 pm revealed Resident #101 was in the park "by himself smoking a cigarette. Oxygen tubing was out of nose, by feet on amigo (motorized electric scooter) platform. Lit cigarette fell on platform. Resident #101 bent down to pick up lit cigarette; the oxygen tubing caught fire. Resident #101 came to the 3rd floor by elevator and stated help me I need a nurse". The assessment indicated "expiratory wheeze. Shaky...Reddened painful area to left hand, right eyebrow, right lower check, mustache and upper lip, nose. No blister to note." Review of the Nurse's Notes dated 6/6/11 at 6:28 pm revealed Resident #101 had "Reddened painful area to left hand, right eyebrow, right lower check, mustache and upper lip, nose. No blister to note" Review of the Nurse's Notes dated 6/7/11 at 10:13 am revealed Resident #101 had a blister on his left index finger that measured 3.0 cm (centimeter) x 0.5 cm, and a blister on his left middle finger that measured 2.0 cm x 0.25 cm. On 6/17/11 at 9:30 a.m. this surveyor observed Resident #101's burned items with the Director of Nursing (DON) #2. Observation revealed melted, black colored cannula and head piece, separated by burning/melting from the oxygen tubing supply hose. One end of the supply hose was black in color and melted. A pair of flannel pajamas had an approximate 4"(inch) x 6" of material missing (burned edged) from the right leg cuff area. Pictures taken by facility staff revealed a black scorched area on the pavilion floor showing the amigo tire print. In an interview on 6/17/11 at 11:45 a.m. Occupational Therapist (OT) #4 reported she had met Resident #101 on the elevator on 6/6/11. OT #4 stated, "Resident #101's hands were shaking and Resident smelled of smoke...Resident #101 said he burned himself". In an interview on 6/20/11 at 3:30 pm LPN (Licensed Practical Nurse) #5 stated she came to work at 3:00 pm on 6/6/11. LPN #5 said she did not know Resident #101's whereabouts at the time, but said, "(Resident #101) usually goes out on a daily basis". LPN #5 reported that at about 4:30 pm, Resident #101 came off the elevator saying "I need help". LPN #5 stated she observed the right side of Resident #101's face "all burnt, reddened, left hand fingers were red; no blisters immediately or through the night. (Resident #101's) mustache was burnt off in spots. Nose on tip and bridge were burnt". She said there was no burn to Resident #101's leg but there were particles on leg that "looked like from ashes." Review of the Physician Interim Orders dated 6/6/11 revealed orders for Resident #101 to receive the following: "Silvadene Cream (sulfonamide/silver antibacterial used as a topical burn cream on burns) every 8 hours to reddened area/burns to left hand, right eyebrow, right lower check, nose, mustache and upper lip after cleansing with soap and water". Review of the Physician Interim Orders dated 6/7/11 revealed the following order for Resident #101: "Monitor Blisters to left and middle finer (finger) (sic) daily AM (morning) first date: 06/07/2011 (until healed) Per protocol (Doctor Name/Nurse Name)". There was no documented physician notes providing indication of actual observation of Resident #101's injuries by an attending physician. Review of the Psychiatric Evaluation - History of present illness dated 6/9/11 and signed by the physician indicated Resident #101, "...experienced second degree burn around his nose". According to the Centers for Disease Control, Emergency Preparedness and Response, Mass Casualties: Burns, (July, 2006) second degree burns involve the first two layers of the skin. Signs of second degree burns include deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, possibly some loss of skin. Observations on 6/20/11 revealed that the approximate distance Resident #101 traveled to the elevator from the burn spot in the park pavilion was about 300 feet. Resident #101 was interviewed and observed on 6/17/11 at 11:30 am in Resident's room. Resident #101 requested the interview to be confidential. Observations revealed no indication of burns. Resident #102: Resident roster, dated 6/17/11, indicated Resident #102 was cognitively intact. Review of care plan "Impaired physical mobility..." revealed Resident #102's primary mode of locomotion was a wheelchair. Review of nurse's notes, dated 6/14/11 at 10:31 p.m., revealed smoking material and a lighter were found in Resident #102's possession. Review of a "Message" (method to convey information by computer to staff), dated 6/15/11 at 6:37 a.m., revealed wanderguard was to be placed on Resident #102, 5 minute safety checks were to be initiated, and "Resident is NOT to go outside unsupervised at any time". Review of the Nurse's Note, dated 6/15/11 at 5:59 p.m., revealed the Park door alarm was sounding (indicating Resident #102 returned from outside). Resident #102 returned to the nurses' station with friends. LPN #6 documented that Resident #102 required facility staff to accompany him outside. LPN #6 indicated, "...did not hear first floor door alarm sound when Resident went outside". In an interview on 6/24/11 at 3:00 p.m., LPN #7 said she had heard the Park door alarm sound when Resident #102 and 2 friends entered the building around 6:00 pm on 6/15/11. LPN #7 said she did not hear door alarm sound when Resident #102 exited the building. LPN #7 stated, "The wanderguard alarm can be by-passed by entering a code on keypad. If not, 'West Park door open' is announced over the public speaker system". LPN #7 reported that a code entry was required to silence the alarm. LPN #7 reported there were no wanderguard detectors in the elevator, but there were 2 wanderguard sensors in the hall on the 1st floor main doors (to the left off the elevator), and 1 wanderguard sensor at the Park door (to the right off the elevator). In an interview on 6/28/11 at 4:05 p.m., LPN #6 confirmed the content of her nurse's note, dated 6/15/11 at 5:59 p.m., and stated, "No. No one knew (Resident #102) left the unit". Resident #102 was interviewed on 6/20/11 at 4:50 pm in Resident's room. Resident #102 said he "wants to smoke". Resident #102 said, "...leaves grounds on outings with family and smokes...I am not going to be here (at facility) forever". Review of facility policy "Smoking-Residents-Employee-Visitors", dated 4/5/05, revealed "visitors may smoke outside the building, employees may smoke...in the designated area outside the building" and "Smoking is prohibited on the Facility premises by residents". On 6/28/11 at 10:40 am, the Administrator was notified of the Immediate Jeopardy which began on 6/6/11 at 4:20 pm when Resident #101 ignited his oxygen cannula while smoking unsupervised, with oxygen, outside the facility and sustained second degree burns; and when Resident #102, who wore a wanderguard bracelet, left the facility undetected by facility staff on 6/15/11 then returned to the facility through the Park entrance door at 5:59 p.m. at which time the wanderguard alarm sounded, alerting staff of his return. These deficient practices place Resident #101, Resident #102, and 23 additional cognitively intact residents, who wish to exit to the facility grounds, at high risk of serious harm, injury, and/or death. The surveyor verified on 6/30/11 at 3:00 pm that the facility implemented the following to remove the immediate jeopardy: 1. On 6/9/11, Resident #101 was placed on 1:1 supervision and will remain on 1:1 supervision when outside the facility. 2. On 6/28/11, Resident #102 was placed on 1:1 supervision when outside the facility and was educated on the need to sign out of the facility whenever going outside. 3. On 6/28/11, 25 of 99 residents were identified to be 'at risk' due to the failure of the facility to monitor, supervise, and ensure that safety is maintained outside the facility. Effective on 6/29/11, all 25 of the 25 residents will be required to notify nursing staff and sign out of the facility, prior to exiting the building. Facility residents were informed of this by the Nurse Manager and formal letters were being mailed to the resident/responsible party on 6/29/11. 4. On 6/28/11, the Smoking Policy was reviewed and revised to include employee restrictions, facility/property restrictions, and resident/responsible party signature of receipt of the 'no smoking' policy. 5. On 6/28/11, the Wanderguard policy was revised to include that the wanderguard door codes will be changed quarterly and as indicated and a weekly testing of the wanderguard system will occur. 6. On 6/28/11, the policy regarding resident outdoor use was developed and included resident supervision, sign in/out records, and residents who are identified as at risk for elopement or who are suspected of or observed smoking- will be supervised at all times when utilizing the outdoor living areas. 7. On 6/29/11, the Director of Nursing, the Nurse Manager and the In-Service Director educated 88 of 220 facility staff on the changes made to the smoking policy, the wanderguard policy, and the newly developed policy regarding residents who go outside. Facility staff will not be allowed to return to work until they have received the in-service on the updated procedures. While the Immediate Jeopardy was removed on 6/29/11 at 4:00 pm, the facility remained out of compliance at a scope of "isolated" and severity of "no actual harm with potential for more than minimal harm, that is not immediate jeopardy", due to the fact that not all staff members had been in-serviced and that sustained compliance had not been verified by the State Agency.

THIS CITATION PERTAINS TO INTAKE NUMBER MI 080. BASED ON INTERVIEWS AND RECORDS REVIEW, THE FACILITY FAILED TO PREVENT FALLS IN 1 OF 4 SAMPLED RESIDENTS (#102) RESULTING IN RESIDENT #102 SUSTAINING A CONCUSSION, SCALP LACERATIONS OF HER LEFT FOREHEAD, HEMATOMA (COLLECTION OF BLOOD TRAPPED IN SKIN TISSUE) OF HER LEFT HEAD, AND PUNCTURE WOUNDS TO HER RECENTLY AMPUTATED LOWER EXTREMITY. FINDINGS INCLUDE: THE FACE SHEET REVEALED RESIDENT #102 WAS A [AGE] year OLD WOMAN admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM DATA SET ((MDS) dated [DATE], RESIDENT #103 WAS SEVERELY COGNITIVELY IMPAIRED, EXPERIENCED BOTH LONG AND SHORT TERM MEMORY LOSS, WAS TOTALLY DEPENDENT ON TWO FACILITY STAFF MEMBERS FOR TRANSFERS (MOVEMENTS FROM SURFACE TO SURFACE), EXPERIENCED FUNCTIONAL LIMITATION IN RANGE OF MOTION (ROM) OF ALL EXTREMITIES, AND WAS IDENTIFIED AT RISK FOR FALLS AS SHE HAD EXPERIENCED A FALL WITHIN THE PAST 2 TO 6 MONTHS. THE CARE PLAN INITIATED 10/11/10 AND THE CNA CARE GUIDE (DIRECTED CARE PROVIDED BY NURSE AIDES) INITIATED 10/11/10, SPECIFIED RESIDENT #102 WAS TO UTILIZE A PERSONAL SAFETY ALARM (PSA) WHILE IN HER WHEELCHAIR. ACCORDING TO THE RESIDENT OCCURRENCE FORM DATED 11/11/10 (UN-TIMED) AND THE FACILITY INVESTIGATION REPORT DATED 11/29/10 (UN-TIMED), RESIDENT #102 WAS FOUND FACE DOWN AND LEANING TO HER LEFT SIDE ON THE FLOOR OF A THIRD FLOOR SUN ROOM BY FACILITY STAFF ON 11/10/10 AT 7:30 P.M. THE REPORT INCLUDED THE PERSONAL SAFETY ALARM WAS NOT SOUNDING, AND THE ALARM'S CLIP DEVICE WAS "NO LONGER CLIPPED TO THE RESIDENT'S BACK," BUT WAS OBSERVED DANGLING OVER THE BACK OF RESIDENT #102'S WHEELCHAIR. RESIDENT #102 WAS REPORTED TO HAVE SUSTAINED AN INJURY TO THE AREA OVER HER LEFT EYE AND PUNCTURE WOUNDS TO THE RECENT SITE OF A LEFT ABOVE AMPUTATION. RESIDENT #102 WAS SENT TO A LOCAL HOSPITAL FOR EVALUATION. THE EMERGENCY PHYSICIAN RECORD DATED 11/10/10 (UN-TIMED) REVEALED RESIDENT #102 HAD EXPERIENCED A CONCUSSION, LEFT SCALP LACERATION, HEMATOMA OF HER LEFT HEAD, AND PUNCTURE WOUNDS OF THE RESIDUAL LIMB (STUMP) OF A RECENTLY AMPUTATED LEFT LOWER EXTREMITY. RESIDENT #102 WAS DOCUMENTED TO HAVE RECEIVED SUTURING OF HER SCALP LACERATION, A PRESSURE DRESSING TO HER RESIDUAL LIMB, AND WAS admitted TO THE HOSPITAL FOR OBSERVATION. DURING AN INTERVIEW ON 1/24/11 AT 2:30 P.M., A CERTIFIED NURSE AIDE (CNA, WITNESS #7) SAID, "I WAS ASSIGNED TO THE RESIDENT (#102) ON 11/10/10 DURING THE SECOND SHIFT (IDENTIFIED AS 2:00 P.M. THROUGH 10:00 P.M.). THE RESIDENT (#102) WAS VERY CONFUSED, DIDN'T FOLLOW DIRECTIONS VERY WELL, AND DIDN'T REALIZE HER LIMITATIONS. THE STRING TO HER PERSONAL SAFETY ALARM WAS QUITE LONG, AND IT DETACHED FROM HER PRETTY READILY WITHOUT PULLING THE MAGNETIC PIECE APART, THEREFORE NOT SETTING THE ALARM OFF. THE RESIDENT HAD GONE AND RETURNED FROM A DOCTOR'S APPOINTMENT EARLIER. ANOTHER CNA TOLD ME SHE HAD PUT THE RESIDENT'S PSA BACK ON, BUT I DIDN'T RE-CHECK THAT. LATER, I WENT BY THE SUN ROOM AND SAW THE RESIDENT ON THE FLOOR; THERE WERE NO ALARMS GOING OFF. I DID SEE THE ALARM BOX ON THE WHEELCHAIR, BUT THE CORD THAT WAS SUPPOSED TO BE ATTACHED TO THE RESIDENT WAS DRAPED OVER THE BACK OF THE WHEELCHAIR, NOT TO THE RESIDENT. I WAS THE FIRST STAFF MEMBER TO FIND HER." DURING AN INTERVIEW ON 1/24/11 AT 3:40 P.M., A CNA (WITNESS #11) SAID, "I CAME TO THE SUN ROOM AFTER SOMEONE YELLED OUT THE RESIDENT (#102) HAD FALLEN. I SAW THE RESIDENT ON THE FLOOR. THERE WAS NO ALARM SOUNDING. THE ALARM BOX WAS ON THE WHEELCHAIR, BUT THE STRING/CLIP OF THE ALARM WAS LAYING OVER THE BACK OF THE WHEELCHAIR. THE CLIP ALARM WAS NOT ATTACHED TO THE RESIDENT." DURING AN INTERVIEW ON 1/25/10 AT 10:00 A.M., A NURSE (WITNESS #16) SAID, "I WENT TO THE SUN ROOM AFTER SOMEONE YELLED OUT THAT A RESIDENT HAD FALLEN. I SAW THE RESIDENT (#102) ON THE FLOOR. I DON'T REMEMBER SEEING THAT SHE HAD A CLIP ALARM ON. I DID SEE THE ALARM BOX ON HER WHEELCHAIR. I DIDN'T HEAR AN ALARM GOING OFF." DURING AN INTERVIEW ON 1/25/11 AT 12:10 P.M., A PHYSICAL THERAPIST (WITNESS #17) SAID, "SHE (RESIDENT #102) HAD A DEFICIT FOR SAFETY AWARENESS. SHE WAS CONSIDERED A RISK FOR FALLS; HER STANDING BALANCE WAS POOR." DURING AN INTERVIEW ON 1/25/11 AT 1:40 P.M., AN OCCUPATIONAL THERAPIST (WITNESS #19) SAID, "THE RESIDENT (#102) SAFETY RISK WAS HIGH. SHE NEEDED THE PSA." DURING AN INTERVIEW ON 1/26/11 AT 11:35 A.M., THE DIRECTOR OF NURSING SAID, "IF A PSA IS SUPPOSED TO BE USED ON A RESIDENT, AND A STAFF MEMBER SEES THAT IT'S NOT CONNECTED, ANY STAFF MEMBER CAN APPLY IT." DURING AN INTERVIEW ON 1/26/11 AT 11:55 A.M., THE NURSING HOME ADMINISTRATOR SAID, "IF A PSA IS SEEN BY FACILITY STAFF, AND UNHOOKED, IT SHOULD BE REPORTED TO THE FIRST NURSE FOUND."

THIS CITATION PERTAINS TO INTAKE NUMBER MI 254. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT THE SERVICES PROVIDED OR ARRANGED BY THE FACILITY MEET PROFESSIONAL STANDARDS OF QUALITY AS IT RELATES TO CARE OF SUSPECTED FRACTURES OR DISLOCATIONS IN 1 (#101) OF 4 SAMPLED RESIDENTS, RESULTING IN RESIDENT # 101 ' S DISTAL FEMUR REINJURY BEING INTENTIONALLY ROTATED CAUSING INCREASED PAIN AND SUFFERING AS WELL AS UNDUE EMOTIONAL DISTRESS. FINDINGS INCLUDE: ACCORDING TO " NURSING ASSISTING: ESSENTIALS FOR LONG-TERM CARE 2ND EDITION " BY BARBARA ACELLO, CENGAGE LEARNING, 2004, IF AN RESIDENT ' S EXTREMITY HAS A SUSPECTED DISLOCATION OR UNSTABLE FRACTURE FACILITY STAFF SHOULD IMMOBILIZE THE AREA TO PREVENT MOVEMENT OF THE EXTREMITY. " ...IF THE AREA APPEARS OUT OF SHAPE, BENT OR DEFORMED, DO NOT ATTEMPT TO STRAIGHTEN IT ... " ACCORDING TO THE FACILITY ' S ONLINE EMPLOYEE TRAINING PROGRAM SILVERCHAIRLEARNING.COM, ... " IF A FRACTURE OF SERIOUS INJURY IS SUSPECTED ...DO NOT MOVE RESIDENT ... " RESIDENT # 101: ACCORDING TO THE FACE SHEET DATED 8/24/2010 RESIDENT # 101 WAS AN [AGE] year OLD FEMALE THAT HAS LIVED IN THE FACILITY SINCE 1/30/2010. THE MINIMUM (MDS) data set [DATE], INDICATED THAT RESIDENT # 101 HAD MODERATELY IMPAIRED COGNITIVE ABILITIES AND REQUIRED THE ASSISTANCE OF STAFF WITH ALL ACTIVITIES OF DAILY LIVING. RESIDENT # 101 HAD SEVERAL [DIAGNOSES REDACTED]. ACCORDING TO THE NURSE ' S NOTES DATED 8/24/2010 THE ATTENDING PHYSICIAN WAS CALLED RELATED TO A CHANGE IN RESIDENT # 101 ' S CONDITION. RESIDENT # 101 ' S RIGHT LEG WAS INTERNALLY ROTATED (FOOT POINTING INWARD) AND RESIDENT # 101 WAS EXPERIENCING AN INCREASE IN PAIN. ACCORDING TO THE SIGNED STATEMENT DATED 8/27/2010 FROM THE CERTIFIED NURSE ASSISTANT (CNA) #1 RESIDENT # 101 ' S LEG ... " SEEMED TO BE TURNED INWARD. IT WAS DIFFICULT TO STRAIGHTEN IT OUT, AND SHE WAS IN PAIN WHEN WE DID THIS ... " ON 8/21/2010 AT 12:30 PM CNA #1 SAID RESIDENT # 101 SEEMED TO BE IN MORE PAIN THAT DAY. CNA #1 WENT IN TO CHECK ON RESIDENT # 101 AND FOUND THAT HER RIGHT LEG WAS TURNED INWARD. CNA # 1 SAID SHE TRIED TO REALIGN RESIDENT # 101 ' S LEG BY ROTATING THE LEG OUTWARD WITHOUT REMOVING BRACE. CNA # 1 REENACTED THE ATTEMPT TO REALIGN RESIDENT # 101 ' S LEG INTO ALIGNMENT. CNA # 1 SAID SHE GRASPED RESIDENT # 101 ' S FOOT AND ATTEMPTED TO ROTATE THE FOOT OUTWARD. CNA # 1 SAID THAT WHEN THE ROTATING LEG RESIDENT # 101 ' S BEGAN SCREAMING. CNA # 1 SAID SHE THEN RELEASED RESIDENT # 101 ' S LEG AND THE LEG ROTATED INWARD AGAIN. CNA #1 SAID SHE THEN WENT TO GET THE NURSES. ACCORDING TO THE ELECTRONIC MAIL STATEMENT DATED 8/28/2010 AT 10:40 AM FROM THE LICENSED PRACTICAL NURSE (LPN) #3 RESIDENT # 101 ' S LEG WAS STRAIGHTENED PRIOR TO REAPPLYING THE BRACE. ON 8/21/2010 AT 12:20 PM LPN #3 SAID THAT AROUND 9:15 ON 8/24/2010 SHE WENT TO ASSESS RESIDENT #101 ' S LEG. RESIDENT # 101 WAS FOUND IN " ...EXTREME PAIN ..." LPN #3 SAID THAT RESIDENT # 101 ' S LEG APPEARED SHORTER AND THE FOOT WAS ROTATED INWARD. LPN #3 SAID SHE AND LPN #4 ELEVATED RESIDENT # 101 ' S LEG, STRAIGHTENED RESIDENT # 101 ' S LEG BY ROTATING IT OUTWARD " ...INTO PROPER ALIGNMENT ... " AND THEN REAPPLIED THE VELCRO BRACE THAT WENT FROM MID THIGH TO ANKLE. LPN #3 SAID THAT WHEN THE ROTATING LEG RESIDENT # 101 ' S BEGAN SCREAMING IN PAIN. ACCORDING TO THE SIGNED STATEMENT DATED 8/31/2010 FROM THE LICENSED PRACTICAL NURSE (LPN) #4 RESIDENT # 101 ' S FOOT WAS ROTATED ' ...OUTWARD 2-3 INCHES TO REAPPLY (THE) BRACE ... " ON 8/21/2010 AT 1:40 PM LPN #4 SAID THAT WHEN SHE WENT TO ASSESS RESIDENT # 101 ' S WOUND, SHE FOUND THAT RESIDENT # 101 ' S FOOT WAS ROTATED INWARD. LPN #4 SAID THAT WITH LPN #3 ' S HELP SHE OPENED RESIDENT #101 ' S VELCRO BRACE, ROTATED RESIDENT # 101 ' S LOWER LEG TO REALIGN IT INTO THE BRACE AS RESIDENT SCREAMED. LPN # 4 SAID SHE THEN CLOSED RESIDENT # 101 ' S BRACE, AND CALLED THE UNIT MANAGER SO THAT THE DOCTOR COULD BE NOTIFIED. ON 9/22/2010 AT 11:00 AM THE NURSE MANAGER SAID THAT NURSING STAFF SHOULD NOT EVER MANIPULATE AN EXTREMITY WITH A POSSIBLE DISLOCATION OR FRACTURE IS SUSPECTED. THE NURSE MANAGER SAID THAT MOVING THE LEG COULD HAVE CAUSED FURTHER INJURY AND HEMORRHAGE (BLEEDING). THE NURSE MANAGER SAID THAT SHE REVIEWED RESIDENT # 101 ' S CLINICAL RECORD AND THAT THERE WAS " ...A LOT OF PAIN INVOLVED ... " FOR RESIDENT # 101. THE NURSE MANAGER SAID THAT ACCORDING TO THE SIGNED STATEMENTS RESIDENT # 101 ' S FRACTURED LEG WAS PAINFULLY MANIPULATED BY THREE STAFF MEMBERS. THE NURSE MANAGER SAID STAFF ARE TRAINED NOT TO MANIPULATE A SUSPECTED FRACTURED OR DISLOCATED EXTREMITY. THE NURSE MANAGER SAID "...I WOULD HOPE IT WOULD NOT HAPPEN AGAIN, BUT IT COULD..." ( )