Every finding on record at IHM Senior Living Community

This citation pertains to intake 3006508.Based on interview and record review, the facility failed to report within two hours, a fall with serious injury for one resident (R103) of three residents reviewed for falls.Findings include: Record review revealed on 04/25/2026, R103 attempted a transfer without assistance, resulting in a fall which caused serious injury. By order of the physician, 911 was called and R103 was transferred to the hospital and diagnosed with a left displaced femoral neck fracture. R103 underwent a left hip hemiarthroplasty. The post fall assessment by Nurse B described the unwitnessed fall as causing acute pain with facial grimacing. The serious injury required evaluation and treatment via emergency transport to the hospital on [DATE].The facility incident report was received via online submission to the State Agency on 04/26/2026 at 7:06 pm. Record review of progress note by Nurse B, dated 04/25/2026 at 11:01 AM revealed: Cena called writer into room, found resident lying on the floor. Writer and 2nd nurse entered room, resident lying on her back in front of closet door. Resident attempted to move left leg and complained of acute pain. Call placed to doctor, new orders to send to emergency room for evaluation and treatment.On 08/27/2026 at 3:32 PM, the Nursing Home Administrator (NHA) was interviewed and queried about the timeline for incident reporting. The NHA stated It's my understanding that the report is submitted within twenty-four hours, and the investigation report is submitted within seven days. Queried as to the process for reporting a serious injury. The NHA stated, We didn't know (R103's) injuries were serious at that time. On 08/27/2026 at 3:35 PM, the Director of Nursing (DON) was interviewed and stated, We didn't submit the report within two hours because we were unaware of the nature of (R103's) injuries when the report was submitted. The unwitnessed fall, the documentation by Nurse B of R103 being in acute pain with the observation of facial grimacing, R103's complaint of left hip/leg pain and the doctors order for an immediate transfer to the hospital was discussed with the DON. The DON stated, We didn't know it was that serious. The facility failed to report a serious injury within two hours of occurrence. The incident occurred on 04/25/2026 and the report was submitted to the State Agency on 04/26/2026. Reviewed the facility's policy titled Compliance with Reporting Allegations of Abuse/Neglect/Exploitation dated January 2026 read in part: The Administrator or designee will: a. Notify the appropriate agencies immediately: as soon as possible, but no later than 24 hours after discovery of the incident. In the case of serious bodily injury, no later than 2 hours after discovery.

Based on observation, interview, and record review the facility failed to properly store a nebulizer mask (used for breathing treatments), for one resident (R23) out of 14 residents reviewed for infection control, resulting in the potential for placing a vulnerable population at high risk for cross-contamination and infection. Findings include: On 3/26/24 at 10:19 AM R23's nebulizer mask was observed lying on a paper towel in a plastic tray not in a bag. R23 stated I use the nebulizer two to three times per day. The staff keeps my mask in the tray. On 3/27/24 at 9:06 AM R23's nebulizer mask was observed covered by paper towel in a tray. On 3/27/24 at 1:13 PM R23's nebulizer mask was observed lying directly on the bedside table and not properly stored. On 3/28/24 at 9:20 AM the Director of Nursing (DON) was interviewed and agreed nebulizer masks should be stored in a bag when not in use per the manufacturer guidelines. Review of the Electronic Medical Reord (EMR) revealed, R23 admitted to the facility on [DATE] with most recent readmission on 3/20/2024 with pertinent diagnoses which included Chronic Respiratory Failure with Hypoxia, and Chronic Obstructive Pulmonary Disease (COPD). Review of a Minimum Data Set (MDS) assessment, with a reference date of 1/31/2024 revealed R15 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15 and required oxygen therapy. Review of the manufacturer guidelines titled Nebulizer Instruction Guide undated revealed in part . Disinfect Daily: Using a clean container or bowl, soak items in three parts hot water to one part white vinegar for 30 minutes OR use a medical bacterial-germicidal disinfectant available through your provider. Be sure to follow manufacturer's instructions carefully. With clean hands, remove items from disinfectant solution, rinse under hot tap water, and air dry on a clean paper towel. Store in a zip-lock bag. NOTE-Do not towel dry nebulizer parts; this could cause contamination.

Based on interview and record review the facility failed to adequately monitor the effectiveness of a psychotropic medication (taken to exert an effect to the chemical makeup of brain) for two residents (R5 and R39) out of five residents reviewed for unnecessary medications. Findings include: R5 Record review of R5's electronic medical record revealed admission to facility on 8/17/23 with a pertinent diagnosis of Alzheimer's disease. According to the Minimum Data Set (MDS) dated [DATE], R5 had impaired cognition and required assistance with Activities of Daily Living (ADLS). Review of physician's orders documented, Lorazepam (anti-anxiety) oral tablet 0.5 mg (milligrams)- Give one tablet by mouth at bedtime for anxiety, and Risperdal (antipsychotic) oral tablet- Give one tablet by mouth one time a day for psychosis (psychiatric illness). Review of Medication Administration Record (MAR) for the month of March 2024 revealed no documentation to assess or monitor the effectiveness or side effects of psychotropic medications given. Review of R5's psychotropic care plan documented the following: Monitor/record/report to physician as needed, any side effects and adverse reactions of psychoactive medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation and blurred vision. R39 Record review of R39's electronic medical record revealed admission to facility on 2/9/24 with a pertinent diagnosis of depression. According to the Minimum Data Set (MDS) dated [DATE], R39 had impaired cognition and required assistance with Activities of Daily Living (ADLS). Review of physician's orders documented; Lexapro Oral Tablet 10 MG (antidepressant)-Give 1 tablet by mouth one time a day for Depression -Start Date- 03/01/2024 8:00 AM. Review of Medication Administration Record (MAR) for the month of March 2024 revealed no documentation to assess or monitor the effectiveness or side effects of psychotropic medications given. Review of R39's antidepressant care plan documented the following: Monitor/document/report to the physician as needed if ongoing s/s (signs and symptoms) of depression unaltered by antidepressant meds: Does not enjoy usual activities, changes in condition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, and constant reassurance. Date Initiated: 02/23/2024. During an interview on 3/28/24 at 10:43 AM with Director of Nursing (DON), when asked if nursing should be monitoring residents on psychotropic drugs daily, the DON reported that nursing should be monitoring the residents daily and it was usually documented on the MAR. It was further reported that there was no evidence documented that R5 and R39 had been monitored daily by nursing staff. Record review of policy Use of Psychotropic Medication dated 10/5/22 documented the following: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s).

Based on observation, interview, and record review the facility failed to ensure legal representatives completed or revised DNR (Do Not Resuscitate- Withholding life sustaining treatment) for two (R16 and R40) cognitively impaired residents reviewed for Advance Directives, potentially resulting in inaccurate life sustaining or life withholding medical treatment. Findings include: Resident #40 (R40) On 3/26/24 at 10:44 a.m., R40 was observed in the room, in a wheelchair sitting at the bedside. R40 appeared disheveled and agitated. R40 did not verbalize the reason for the agitation and did not want to participate in an interview. On 3/26/24 at 2:34 p.m. review of the clinical record documented R40 was initially admitted into the facility on [DATE] with diagnoses that included vascular dementia, mood disorder, anxiety disorder, and psychotic disorder. According to quarterly Minimum Data Set (MDS) assessment dated [DATE], R40 had moderately impaired cognition (BIMS 12) and required extensive one-person assistance with activities of daily living (ADLs). Review of the resident's profile on the electronic medical record indicated R40 had a DNR code status. The clinical record documented R40 had a court appointed legal guardian effective March 7, 2024. Review of the resident's advance directive indicated a Full Code status dated 7/15/23 that was signed by the legal guardian. Another code status was completed and signed by the legal guardian on 11/28/23 that documented R40 had a Full Code status. Review of the physician's order dated 3/8/24 documented DNR code status. The physician's order was signed by the physician on 3/11/24. On 3/28/24 at 1:40 p.m. Social Service Director (SSD) B was interviewed regarding R40's current code status. SSD B said R40 had a DNR code status. SSD B acknowledged the two advance directives in the electronic medical record documented Full Code statuses and was not able to confirm when the code status changed to DNR status. On 3/28/24 at 2:48 p.m. the Nursing Home Administrator and Director of Nurses was interviewed and acknowledged the discrepancy of the code statuses on the resident profile and physician's order versus the advance directive documents in the electronic medical record. The Director of Nurses said it appeared the code status appeared to be changed on the physician's order and resident profile before the advance directive was made official (signed by legal guardian, the physician, and two witnesses). 47964 R16 Record review of the Electronic Medical Record (EMR) revealed R16 was admitted into facility on 3/14/2024 with pertinent diagnoses of dementia, after care of surgery on the digestive system. Review of the EMR revealed R16 had impaired cognition with a durable power of attorney (DPOA) A. Review of R16's advanced directives revealed R16 signed a no code status (do not perform cardiopulmonary resuscitation) on 3/14/2024. Review of R16's Physician Statement of Capacity dated 4/26/2023 revealed R16 was found to be unable to make financial and medical decisions. On 3/27/24 at 11:44 AM Social Worker (SW) B was interviewed and said nursing was responsible for obtaining advance directives upon admission. On 3/28/24 at 9:28 AM the Director of Nursing (DON) was interviewed and agreed R16 should not have signed her own code status and that R16's DPOA should have signed code status since R16 was deemed incompetent. Review of the facility policy titled Advance Directives Policy and Procedure revised 1/26/17 revealed in part . During the admission process, the admission coordinator will ascertain whether the resident has an advance directive in place. For those who have completed an advance directive prior to admission a copy will be obtained and placed in the resident chart. For those who have not completed an advance directive, information will be provided on what an advance directive is and how to complete one. Sample advance directive forms are available if desired. If the resident decides to complete an advance directive, the social worker may assist with this process, however, no [NAME] SLC employees may serve as DPOAs, nor may they serve as witnesses. When the resident is being admitted to the nursing unit, they will complete a code status form with the nurse. The resident will inform the nurse of his/her wishes. Until this form is completed including a physician order, the resident is a full code. If the resident is unable to make his/her wishes known and they have an advance directive in place, the designated medical power of attorney will complete the form IF the advance directive has been enacted (resident deemed unable to make care decisions by 2 physicians or 1 physician and 1 psychologist).

This citation pertains to intake MI 193. Based on interview and record review, the facility failed to prevent the diversion of resident medication (controlled substances) for 1 of 3 sampled residents (Resident #401) reveiwed for medications, resulting in controlled substance diversion for suspected staff use. Findings include: On 4/19/21 at 9:00AM an interview was conducted with the Director of Health Care Center (A) regarding a missing narcotic blister pack (card that contained 30 narcotic pills) and the corresponding document (narcotic receipt sheet). Director (A) stated, there were missing narcotic drugs ([MEDICATION(S)]) discovered at the facility on 4/3/21 at 6PM. I was made aware of the situation on 4/4/21. The missing pills belonged to resident (401). It was also discovered the number of narcotic blister packs received from the pharmacy for resident (401) was changed from 2 to 1. After an interview with resident (401) it was revealed resident (401) received her [MEDICATION(S)] narcotic as ordered on 4/3/21. Nurse (C) was identified via my investigation as the nurse responsible for the missing narcotics in addition to the altered narcotic receipt sheet. I notified the Police Department on 4/4/21 and they spoke with nurse (C). Resident (401) was notified as well as the resident's family. They were informed they would not incur any costs for the missing medication. The nurse (C) responsible is no longer employed at the facility; she received a letter of termination from our Human Resource Department, as she never returned my calls to her cell phone after leaving the facility following the police interview. Per a record review conducted on 4/19/21 at 10:00AM resident (401) was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Minimum Data Set (MDS) with a reference date of 1/25/21 revealed the resident had a Brief Mental Status (BIMS) score of 12/15 indicating a moderate cognitive (thought process) impairment. The resident requires limited 1-person assistance with activities of daily living. The care plan dated 1/25/21 included pain management to include with a pain assessment every shift. According to the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/19/21 at 4:00 PM the Director of Health Center (A) provided the surveyor with a document entitled Controlled Substance Policy Update dated 4/9/21, that emphasized the importance of the presence of 2 nurses when narcotic medications are received from the pharmacy, and the presence of 2 nurses when the bag is opened.

Based on observation, interview, and record review, the facility failed to provide nail care for three Residents (R#3, #4 and #20) out of a sample of four residents reviewed for activities of daily living, resulting in unmet Activity Daily Living (ADLs) needs, loss of dignity, and emotional distress. Resident #3 On 2/1/2021 at 11:28 a.m., R#3 was observed sitting in her wheelchair alert and oriented to person, place, and time. The Resident was able to express adls needs. The Resident was asked, how was the care at the facility? R#3 held out her hands and stated, I was trying to cut my nails, but I can't manage to hold the scissors to cut them. R#3 fingernails on the left hand was observed short, and the fingernails on the right hand was long. R#3 was asked, did she asked the staff to assist in trimming her fingernails. R#3 stated, Yes, a couple of times. R#3 was asked, did she ask for assistance today (2/1/2021)? The resident stated, No, but I asked someone a couple of days ago. R#3 was unable to recall whom she asked for assistance to trim her nails. On 2/1/2021 at 11:35 a.m., unit manager A was interviewed. Unit Manage A and the surveyor observed R#3 fingernails. R#3 stated to Unit Manager A I cut them myself. Unit Manager A stated to R#3, You have to let someone cut them for you. R#3 stated, Well, I kept asking someone to cut them and they didn't. Unit Manager A immediately left out the resident's room and spoke with Certified Nursing Assistant C to instruct her to trim R#3's fingernails. On 2/1/2021 at 11:40 a.m., review of R#3's clinical record documented the Resident was initially admitted into the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED].), vitamin B12 deficiency, [MEDICAL CONDITIONS], lack of coordination, and Nonexudative age-related [MEDICATION NAME] degeneration (characterized by the degeneration of the retina .). According to the Annual Minimum Data Set (MDS) assessment dated [DATE], R#3 had moderately impaired cognition and required extensive assistance of one-person for ADLs particularly with hygiene, bath, dressing and required extensive assistance of two- person with bed mobility and transfers. On 2/1/2021 at 11: 43 a.m., review of the Resident's ADLs care plan revision date 10/9/2018 documented, R#3 has self-care deficits in ADLs: bathing, dressing, grooming, transfers, bed mobility, walking, wheeling, toileting, requiring supervision/set up assistance to extensive assistance. Deficit related but not limited to [MEDICAL CONDITION], episodes of dizziness secondary to [DIAGNOSES REDACTED] A noncancerous tumor on the main nerve leading from the inner ear to the brain), congested heart failure, arthritis . Prefers hydro. Bath days Tuesday's and Friday's with one assist .Please assist with cleaning/trimming fingernails as needed. Resident #4 On 2/1/2021 at 11:56 a.m. R#4 was observed sitting in her room alert and unable to make needs known. R#4's hands was observed with long fingernails and appears dirty. On 2/1/2021 at 11:58 a.m., review of R#4's clinical record documented the Resident was initially admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Quarterly Minimum Data Set (MDS) assessment dated [DATE], no documented BIMS Score observed, Cognitive Skill for daily decisions-Severely impaired and required extensive assistance of one-person for ADLs particularly with hygiene, bath, dressing and required extensive assistance of two- person with bed mobility and transfers with Hoyer lift (A assistive device that allows patients in hospitals and nursing homes and people receiving home health care to be transferred between a bed and a chair or other similar resting places, by the use of electrical or hydraulic power) . On 2/1/2021 at 12: 00 p.m., review of the Resident's ADLs care plan revision date 10/9/2018 documented, R#4 has self-care deficits in ADLs related but not limited to decreased mobility, impaired cognition secondary to [MEDICAL CONDITION] with [MEDICAL CONDITION], dysphagia .Provide extensive up to total assistance of one to two staff for bathing, dressing, grooming, eating, bed mobility, wheeling, transferring, and toileting. Shower per schedule Tuesday's and Friday's with 1-2 total assist. Remove facial hair as needed, Trim, file, and clean fingernails when needed. Resident #20 On 2/1/2021 at 12:08 p.m., observed R#20 sitting in a Geri chair alert an unable to be interviewed. Observed the resident with long fingernails to both hands. Observed the resident's hand in a fist shape position with her fingernails pressing against the inner hands. On 2/1/2021 at 12:20 p.m., review of R#20's clinical record documented the Resident was initially admitted into the facility on [DATE] and with [DIAGNOSES REDACTED]. According to the Quarterly Minimum Data Set (MDS) assessment dated [DATE], no BIMS Score was observed. R#20 appears to be confused and required extensive assistance of one-person for all adls, bed mobility and transfers. On 2/1/2021 at 12: 28 p.m., review of the Resident's ADLs care plan revision date 6/8/2020 documented, R#20 has self-care deficits related but not limited to right femur fracture, right pubic fractures, [MEDICAL CONDITION], muscle weakness, cognitive communication deficit, [MEDICAL CONDITION], dementia, and oxygen dependence .1-2-person extensive assist for bed mobility, dressing, bathing, and grooming/oral care .Bathing: Tuesday's and Friday's with 1-person extensive assist. Remove facial hair, clean/trim fingernails weekly and as needed . On 2/3/2021 at 12:53 p.m., the facility's policy titled, Activities of Daily Living (ADLs) with no date documented, Philosophy Statement: Facility will provide appropriate level of assistance in order for resident to maintain their Best ability to perform day to day activities .The Facility will ensure a resident's abilities in ADLS do not deteriorate unless deterioration is unavoidable .This includes the resident's ability to :1. Bathe, dress, and groom . A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal oral hygiene .

Based on observation, interview, and record review the facility failed to properly maintain the exterior garbage disposal area in a clean and sanitary manner, resulting in the potential attraction of pest and rodents. This deficient practice has the potential to all affect all 52 residents in the facility. Findings include: On 10/08/19 at 01:15 PM, Trash debris and dried liquids was observed around the exterior of the garbage disposal. When queried, Resource Manager H advised maintenance is responsible for cleaning the garbage disposal area. During a review of the facility's policy Trash and Recycle Area H-Wing, it noted Procedure: Check the area daily and throughout the day surrounding the dumpsters. Ensure that the dumpster lid is always kept closed, and that there is no visible debris on the surrounding grounds. According to the 2013 FDA Food Code, 5-501.15 Outside Receptacles. (A) Receptacles and waste handling units for REFUSE, recyclables, and returnable used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers. (B) Receptacles and waste handling units for REFUSE and recyclables such as an on-site compactor shall be installed so that accumulation of debris and insect and rodent attraction and harborage are minimized and effective cleaning is facilitated around and, if the unit is not installed flush with the base pad, under the unit.

Based on observation, interview, and record review the facility failed to properly maintain dietary areas in sanitary conditions and maintain proper food temperatures and time control resulting in potential cross contamination and foodborne illness for all 52 residents in the facility. Findings include: During the initial kitchen tour on 10/08/19 at 9:00 AM, the following was observed: 1. A full shallow pan and a ¼ shallow pan of sliced turkey with a use by date of 10/7/19 in the walk-in cooler. 2. Opened goat cheese with a use by date of 8/26/19, another bag of goat cheese with a use by date of 9/28/19, opened slice cheese with a use by date of 10/3/19, and a gallon of 2% milk with an expiration date of 10/6/19 in the dairy walk-in cooler. 3. Opened bags of mild cheddar cubes, pepper [NAME] cubes, and swiss cubes not dated in the dairy walk-in cooler. During review of the facility's policy Sanitation & Infection Control Labeling & Dating, it noted All foods are labeled, dated, and securely covered and use-by dates are monitored and followed. According to the 2013 FDA Food Code, 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; P (2) Is in a container or PACKAGE that does not bear a date or day; P or (3) Is appropriately marked with a date or day that exceeds a temperature and time combination as specified in 3-501.17(A). P 4. Exterior of the dish machine heavily soiled with mineral deposits on the back side. When queried, Resource Manager H advised the dish area is cleaned nightly, but a deep cleaning is done once a month. During a review of the facility's policy Descaling Dishwasher, it noted .2. Clean the dishwasher thoroughly and daily. 3. Descale when you notice limescale buildup or at routinely scheduled times. According to the 2013 FDA Food Code Section 4-501.14[NAME]washing Equipment, Cleaning Frequency. A WAREWASHING machine; the compartments of sinks, basins, or other receptacles used for washing and rinsing EQUIPMENT, UTENSILS, or raw FOODS, or laundering wiping cloths; and drainboards or other EQUIPMENT used to substitute for drainboards as specified under § 4-301.13 shall be cleaned: (A) Before use; (B) Throughout the day at a frequency necessary to prevent recontamination of EQUIPMENT and UTENSILS and to ensure that the EQUIPMENT performs its intended function; and (C) If used, at least every 24 hours. 5. 1 quart of Resource 2.0 with a use by date of 9/3/19 in the 1EF Unit refrigerator. 6. Food debris and grease deposits observed in the 1EF Unit microwave. 7. Food debris observed in the 2G Unit microwave. When queried, Resource Manager H advised the unit microwaves and refrigerators are cleaned by housekeeping. During a review of the facility's policy Microwave Cleaning policy, it noted 1. Microwave will be checked daily by environmental services. 2. If visibly soiled they cleaned. 3. If nursing spills any food or drink it will be cleaned at that time. According to the 2013 FDA Food Code, 4-602.12 Cooking and Baking Equipment. . (B) The cavities and door seals of microwave ovens shall be cleaned at least every 24 hours by using the manufacturer's recommended cleaning procedure. On 10/08/19 at 01:00 PM, a test tray was received, and the temperature of the food items was taken, the milk temperature was 54 degrees. When queried, Resource Manager H advised well that's not good, we may have to check out the cooler. According to the 2013 FDA Food Code, 3-501.19 Time as a Public Health Control. (A) Except as specified under (D) of this section, if time without temperature control is used as the public health control for a working supply of TIME/TEMPERATURE CONTROL FOR SAFETY FOOD before cooking, or for READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is displayed or held for sale or service: (1) Written procedures shall be prepared in advance, maintained in the FOOD ESTABLISHMENT and made available to the REGULATORY AUTHORITY upon request that specify: Pf (a) Methods of compliance with Subparagraphs (B)(1)-(3) or C)(1)-(5) of this section; Pf and (b) Methods of compliance with § 3-501.14 for FOOD that is prepared, cooked, and refrigerated before time is used as a public health control. Pf Time - maximum up to 4 hours (B) If time without temperature control is used as the public health control up to a maximum of 4 hours: (1) The FOOD shall have an initial temperature of 5ºC (41ºF) or less when removed from cold holding temperature control, or 57°C (135°F) or greater when removed from hot holding temperature control; P (2) The FOOD shall be marked or otherwise identified to indicate the time that is 4 hours past the point in time when the FOOD is removed from temperature control; Pf (3) The FOOD shall be cooked and served, served at any temperature if READY-TO-EAT, or discarded, within 4 hours from the point in time when the FOOD is removed from temperature control; P and (4) The FOOD in unmarked containers or PACKAGES, or marked to exceed a 4-hour limit shall be discarded. P Time - maximum up to 6 hours (C) If time without temperature control is used as the public health control up to a maximum of 6 hours: (1) The FOOD shall have an initial temperature of 5ºC (41ºF) or less when removed from temperature control and the FOOD temperature may not exceed 21ºC (70ºF) within a maximum time period of 6 hours; P (2) The FOOD shall be monitored to ensure the warmest portion of the FOOD does not exceed 21ºC (70ºF) during the 6-hour period, unless an ambient air temperature is maintained that ensures the FOOD does not exceed 21ºC (70ºF) during the 6-hour holding period; Pf (3) The FOOD shall be marked or otherwise identified to indicate: Pf (a) The time when the FOOD is removed from 5ºC (41ºF) or less cold holding temperature control, Pf and (b) The time that is 6 hours past the point in time when the FOOD is removed from cold holding temperature control; Pf (4) The FOOD shall be: (a) Discarded if the temperature of the FOOD exceeds 21°C (70°F), P or (b) Cooked and served, served at any temperature if READY-TO-EAT, or discarded within a maximum of 6 hours from the point in time when the FOOD is removed from 5ºC (41ºF) or less cold holding temperature control; P and (5) The FOOD in unmarked containers or PACKAGES, or marked with a time that exceeds the 6-hour limit shall be discarded. P (D) A FOOD ESTABLISHMENT that serves a HIGHLY SUSCEPTIBLE POPULATION may not use time as specified under (A), (B) or (C) of this section as the public health control for raw EGGS.

Based on interview and record review, the facility failed to ensure prompt mail delivery on Saturdays for twelve residents, granted anonymity, who attended the resident group meeting, resulting in resident dissatisfaction and the potential for delay in receipt of personal mail. Findings include: A resident group meeting was held on 10/9/19 at 10:00 AM with twelve residents, all of whom were alert and oriented and able to express themselves without difficulty. Group attendees were queried, Is mail delivered on Saturdays? The twelve residents present in the meeting indicated they did not receive mail on Saturdays. When queried if they wanted Saturday mail delivery, all twelve residents stated they wanted Saturday mail delivery. On 10/9/19 at 11:13 AM, the facility Administrator and Director of Nursing (DON) were queried about mail delivery in the facility. They said, The Sisters deliver the mail. It's their job. The DON identified, Resident Coordinator, Staff G as the person that oversees mail delivery in the facility. On 10/9/19 at 11:19 AM, Staff G was queried about mail delivery in the facility. In summary, Staff G stated that after the mail was initially sorted out according to units by central business office employees, it was further sorted out alphabetically and a Sister would deliver the mail to the residents in the nursing home. When queried, How many days a week does this process happen?, Staff G said, Monday through Friday. They don't do the mail on Saturday. When queried about why there was no mail delivery on Saturday, Staff G said, Because the Sisters that pass the mail are volunteers and they only work Monday through Friday. If the mail comes here on Saturday, there is no one to sort it. When queried about how she feels about mail not being delivered on Saturday, Staff G said, I don't really have a comment either way. When queried, If your birthday was Saturday, how would you feel if you had to wait until Monday to get birthday cards?, Staff G said, I would like to get them on Saturday. On 10/9/19 at 1:13 PM, when the facility Administrator was queried about Saturday mail delivery in the facility, she said, The post office does not deliver mail on Saturdays, because we don't have any one to receive the mail and sort it. The Administrator provided the State surveyor a copy of the definition of Promptly as stipulated in the Code of Federal Regulation Requirements for States and Long Term Care Facilities. The definition indicated the following: Promptly means delivery of mail or other materials to the resident within 24 hours of delivery by the postal service (including a post office box) and delivery of outgoing mail to the postal service within 24 hours, except when there is no regularly scheduled postal delivery and pick-up service. The facility policy titled, IHM Mail Delivery Policy, undated, was reviewed and documented the following: It is the policy of IHM Senior Living Communities to deliver and send all resident mail requiring U.S. Postal Services and postage in a secure manner on a prompt, daily schedule that is in compliance with all state and federal regulations.

Based on observation, interview, and record review, the facility failed to maintain, change, and store oxygen tubing for two residents (Resident #7, #301) of two reviewed for oxygen/respiratory care, resulting in an increased potential for respiratory infection and respiratory distress. Findings include: Resident #7 In an observation on 10/8/19 at 9:34 a.m., Resident #7 sat in a chair and wore Oxygen. Resident #7's short oxygen tubing had no date and a green oxygen tubing had a date of 9/1/19 on a piece of tape. Review of a Admission Record revealed, Resident #7 admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment, with a reference date of 2/12/19, revealed Resident #7 had moderate cognitive impairment and required oxygen. In an observation on 10/9/19 at 10:24 a.m., Resident #7's green oxygen extension tubing laid on the floor near an oxygen concentrator and not in a bag. In an interview and observation on 10/9/19 at 10:25 a.m., Nurse I reported oxygen extension tubing is changed monthly. When asked to verify the date on the green oxygen extension tubing, Nurse I stated 9/1. Nurse I then picked the oxygen tubing off the floor and placed it on Resident #7's chair and not in a bag. In an interview on 10/9/19 at 10:32 a.m. Nurse I reported the green oxygen extension tubing should have been changed (MONTH) 1st and stored in a bag when not in use. Review of a Oxygen Tubing Change for Oxygen Concentrator; Extended and Short policy with a revised date of (MONTH) 21, 2019 revealed, Policy/Procedure Statement: 1. The short tubing and nasal cannula will be changed every other week or as needed by the nursing staff on Sunday day shift 2. The extended tubing that connects to the short tubing from nasal canula will be changed on an as needed basis when soiled or on a monthly basis. 3. The extended tubing will be tagged with a label indicating the date the tubing was changed, initials of person changing it, & the resident's room number . 6. When the cannula and long tubing are not in use, coil the tubing and canula neatly in a plastic bag and place at the bedside. This prevents the tubing from collecting additional dust and from falling on the floor. In an observation on 10/9/19 at 12:13 p.m., Resident #7 sat in the dining room and short oxygen tubing had no date. In an interview on 10/9/19 at 12:15 p.m., Nurse J reported Resident #7's oxygen tubing had no date. Nurse J then reported the date should be on a piece of tape on the oxygen tubing. In an interview on 10/9/19 at 2:04 p.m., The Director of Nursing (DON) reported when oxygen is not in use it should be bundled up and placed in a bag. The DON reported she was unsure of when oxygen tubing should be changed. In an interview on 10/9/19 at 2:27 p.m., The DON reported the short oxygen tubing should be changed every two weeks and green extension tubing monthly. The DON reported the oxygen tubing should have a piece of tape with the date of change. Resident #301 In an observation on 10/8/19 at 9:48 a.m., Resident #301 laid in bed and wore oxygen. In an observation on 10/9/19 at 12:22 p.m., Resident #301 sat in a chair and wore oxygen. Resident #301's short oxygen tubing had no date. Review of a Admission Record revealed, Resident #301 admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of a Order Summary Report for Resident #301 revealed, . Oxygen per nasal cannula at _3_L/min continuous three times a day for oxygen protocol . with a start date of 10/7/19.

Based on observation, interview and record review the facility failed to ensure valid medical justification for indwelling catheter use for one sampled resident (R#24) out of a total sample of 13, resulting in the use of an indwelling catheter that was not clinically warranted and the increased potential for urinary tract infection. Findings include: Resident #24 Record review revealed that R#24 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Nursing assessment dated [DATE] indicated the resident was oriented to person and place. The assessment documented an indwelling catheter for Stage III pressure ulcer (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Sough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling) measuring 0.3 centimeter (cm) x 0.2 cm x .1 cm. A physician order [REDACTED]. On 10/08/19 at 1:03 PM (the day after the wound was assessed as Stage III), during a wound care observation with Nurse B the nurse said that the wound had healed and was now a reddened area. The indwelling catheter was observed still in use. Review of a physician progress notes [REDACTED]. (Name of R#24) was discharged to home last week, and was doing therapy, she improved on her ADLs (activities of daily living) and nutrition going off tube feedings onto oral meals. On getting home she started to have abd (abdominal) pain, difficult to get her to eat or help with ADLs. She came to the hospital and has been admitted . She has significant anxiety too associated with her dementia. Redirection helped with it today. Orders reviewed and agreed with. ROS (range of service) limited by her dementia. BP (blood pressure) 171/77, HR (heart rate) 76, RR (respiration rate) 20. no fever, glucose- 112, wt 143.8 lbs, head no acute trauma, sclera clear, no new pupil changes swallowing grossly ok, lungs clear, heart regular pacemaker in place. No abd (abdominal) rebound or rigidity, no distention, bowels are active. Anxiousness during exam improved with reassurance and redirection. Alert, but not communicative very much. In wheelchair, assist with mobility and transfers and meds, meals and bathing and all ADLs. Plan to have therapy and continue orders and plans as reviewed and agreed with. The physician's note did not address the residents current skin (pressure ulcer assessment), or the medical justification for the continued use of the indwelling catheter. On 10/09/19 at 12:37 PM, during an interview with the facility's Director of Nursing (DON) she said that the wound was a Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. (MONTH) also present as an intact or open/ruptured serum-filled blister) and the indwelling catheter should had been discontinued. At 12:44 PM, during an interview with Minimum Data Set (MDS) Nurse D she stated, we have tried to tell the nurses not to stage wounds, just document a description to reflect what the nurse sees and put interventions/treatments in place to prevent the wound from worsening. Review of the facility's policy titled, Indwelling catheter care and maintenance of the male and female resident dated 8/20/04 revised 10/8/19 documented, Philosophy Statement: Reduction of urinary tract infection with proper management of the indwelling catheter .Physician will document criteria when ordering catheter insertion and assess appropriateness for continued use.

Based on interview and record review the facility failed to timely administer medications as indicated by the residents plan of care for one sampled resident (R#101) from a total sample of 13 resulting in the potential for subtherapeutic medication levels. Findings include Resident #101 On 10/08/19 at 10:34 AM, during a tour of the second floor nursing station R#101's Daughter-in-Law was complaining that the resident was a diabetic (high blood sugars) and had high blood pressure, stating he did not get any of his afternoon medication last evening. He arrived into the facility yesterday (10/7/19) around 3:30-4:00 PM (from the local hospital). They should have had plenty of time to order his medications. R#101's caregiver (at home) said, I give him his medications (at home) at 8 AM and 8 PM, he has not received any medications since he left the hospital yesterday morning. Along with his Daughter-in-Law, his home caregiver, his assigned nurse (staff B) and the Unit Manager (staff F) all entered the room to talk with the resident. The Daughter-in-Law stated the resident called her that morning with concerns that he hadn't received his medications yet, and that is why she came to the facility. Staff F explained that R#101's medications were entered into the computer last evening by the admitting nurse and scheduled them to start this morning (16 hours after the resident was admitted into the facility). At this time the medications had still not arrived from the pharmacy. Staff B said that she was obtaining some of his medications from (Name of back up medication delivery system), had called the attending physician and notified him of the delayed medications and obtained a new order for one of his medications that is not available in the back up system. The Daughter-in-Law said, Why didn't anyone call us, we could have brought in his medicine from home? He too sick not to get his medication. Record review revealed that R#101 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The admission nursing assessment dated [DATE] documented the resident cognition was intact. Review of the hospital discharge medication list (medications that were marked to continue at discharge) dated 10/7/19 documented the resident last received his scheduled medication at the hospital at 8:29 AM. The discharge medication list documented the resident should have received the following 11 medications between 8-9 PM that night: -Eliquis-Blood thinner -[MEDICATION NAME]-Antianxiety -[MEDICATION NAME] CD-for high blood pressure -[MEDICATION NAME]-sinus medication -[MEDICATION NAME]-for high blood sugar -Humalog insulin- for elevated blood sugar -Dou-Neb-breathing treatment for [REDACTED].>-Mag-Ox-magnesium supplement -[MEDICATION NAME]-for high blood pressure -Potassium chloride-Potassium supplement -[MEDICATION NAME]-antianxiety and sleep disorder. At 4:02 PM, during an interview with staff F she was asked about the delay in obtain the resident's medication to which she replied, The admitting nurse was 'new' and didn't get to enter the medications into the computer until late in the shift, she scheduled the medications to start to begin being administered the next morning. She should have called the pharmacy and had the medication 'drop shipped' (delivered to the facility within a 4 hour window). Review of the 11/2018 (Name of Pharmacy) information sheet hanging at the nurses station documented; -Admissions-Monday-Friday, Order by 9:00 AM; Delivery window 2 PM-5 PM. -Order by 9:00 PM; Delivery window 2 AM-5 AM. If medication is needed prior to your next scheduled tote delivery and is not in your starter/emergency/back-up supply, please follow your regular process to submit the order, then call to request the medications STAT (as soon as possible). On 10/9/18 at 10:37 AM, the Director of Nursing was asked about the procedure for ordering medications for a newly admitted resident to which she responded, The admitting nurse is to obtain orders from the attending physician and enter the medications into the computer system. Review of the facility's policy titled, Resident Admission Procedure dated 8/30/05, revised 9/30/19 documented, 8. Within 2 hours of admission, the nurse will .Contact the attending physician to verify orders and request orders as needed. Physician will electronically sign the physician order [REDACTED].

Based on observation, interview and record review the facility failed to properly perform hand hygiene with wound care, as well as, properly position indwelling catheter for one sampled resident (R#24) from a total sample of 13, resulting in the potential for the spread of infection. Findings include: Resident #24 Pressure Ulcer/Injury On 10/08/19 at 1:03 PM, during a wound care observation with Nurse B the nurse was observed to donn a pair of gloves and proceed to cleanse a wound on the resident's buttocks. After cleansing the wound, with the same gloved hands, Nurse B applied the ordered treatment and apply a border dressing. The nurse then reached into her uniform pocket, with the same gloved hands, and obtained a pen and dated the dressing. The nurse then removed her gloves and washed her hands. At the completion of the wound care observation, Nurse B was asked about the observation and stated, I should have washed my hands, and put on a new pair of gloves after I cleaned the wound. During this same observation, Certified Nurse Assistant (CENA) C who was assisting with positioning R#24, was observed to have the resident's indwelling catheter hanging on the pant pocket of her uniform. The CENA was asked about the observation and replied, It's just a habit. I always hang it (the indwelling catheter) on my uniform because we are getting ready to transfer her. When asked if she thought that practice might be an infection control concern CENA C stated, No. It has a (dignity) bag on it. Record review revealed that R#24 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Nursing assessment dated [DATE] indicated the resident was oriented to person and place. At 2:36 PM, during an interview with Nurse A (who is also the Infection Control Coordinator), she was told about the observations and stated, the nurse should have washed her hands after she cleansed the would. She should not have put her hands in her pocket with the dirty gloves on. I've never seen anyone hang an indwelling catheter on they're uniform. I will provide them with some education. 10/09/19 12:37 PM, During an interview with the facility's Director of Nursing (DON) she said that she was made aware of the infection control concerns and the Infection Control nurse did educate the employees. Review of the facility's policy titled, Clean dressing change dated 10/8/19 documented, It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination .12. Cleanse the wound as ordered, taking care to not contaminate other skin surfaces or other surfaces of the wound (i.e. clean outward from the center of the wound) .14. wash hands and put on clean gloves . Review of the facility's policy titled, Indwelling catheter care and maintenance of the male and female resident dated 8/20/04 revised 10/8/19 documented, Philosophy Statement: Reduction of urinary tract infection with proper management of the indwelling catheter .6. When transferring a resident, the drainage bag should be clipped to the bed or chair as appropriate.

This Citation pertains to Intake MI 546 Based on interview and record review, the facility failed to immediately report allegations of abuse for one (Resident #601 ) of three residents reviewed for abuse, resulting in allegations of abuse that were not reported to the Nursing Home Administrator or the State Agency timely and the potential for feeling of not being protected or unsafe within the facility, and for abuse to continue without being reported. Findings include: Resident #601 Review of a Abuse policy with a revised date of 11/7/17 revealed, . All allegations of mistreatment, neglect, abusive behavior, or misappropriation of resident property will be thoroughly investigated, responded to, and appropriately reported .If the events that cause suspicion . b) do not result in serious bodily injury, the individual shall report the suspicion not later than 24 hours after forming the suspicion . Review of a clinical record revealed, Resident #601 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment, with a reference date of 6/6/19, revealed Resident #601 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 12, out of a total possible score of 15. Resident #601 required total dependence of two staff with transfers and toileting. Review of a Progress Note with a created date 8/12/19 at 4:47 p.m. revealed, Reported to writer that during peri care attempt resident noted with increased agitation and being combative. Resident bit staff and scratched staff x 2. Unable to render care due to combativeness. Writer able to redirect resident and transport resident to Main [NAME] lounge. In an interview on 8/30/19 at 12:10 p.m., The Director of Nursing (DON) stated (Certified Nursing Assistant (CNA) D) came to my door and said (Resident #601) bit me. The DON then reported she had no knowledge that Resident #601 was being forced to be changed or go to bed. The DON reported if residents are forced against their rights, it would be reported to the State. In an interview on 8/30/19 at 12:24 p.m., Activity Aide [NAME] stated I told (Nurse A) about what happened because I knew that they would not tell the whole story. Activity Aide [NAME] then reported a request was made to speak to the DON about the observation that was made around 4:30 p.m. while doing activities with the residents. In an interview on 8/30/19 at 12:50 p.m., CNA C reported being in the dining and observed CNA F came to get Resident #601. Resident #601 asked not to go. CNA C reported Nurse A was informed of the incident. CNA C then reported the incident was a form of abuse. In an interview on 8/30/19 at 1:05 p.m., The Administrator reported the DON informed her about the incident. The Administrator then reported receiving a forwarded email the following day from the Activities Director about the incident. Activity Aide [NAME] sent the email to the Activities Director the day of the incident. The Administrator reported after an investigation was conducted, they did not feel that abuse occurred, therefore they did not report it to the State Agency.

Linked to Intake MI 505 Based on interview and record review the facility failed to provide adequate supervision to prevent falls and ensure safety, affecting one Resident # 56 (R#56) out of thirteen residents sampled during survey, resulting in multiple falls and hospitalization with fracture of right femur. Findings include: On 1/8/19, record review revealed R#56 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to Minimum Data Set ((MDS) dated [DATE] resident had severe cognitive impairment and required extensive assist with Activities of Daily Living (ADLs) and transfers. On 1/9/19, record review of Morse Fall Assessment conducted on admission rated R#56 as a High Risk for Falling. Further review of incident and accidents reports revealed R#56 had seven falls during stay at facility. Each incident and accident report gave a root cause for fall. 3/2/18- Resident's mental status. 3/5/18- Resident was restless and trying to get out of chair. 3/14/18- Resident unaware of limitations. 4/2/18- Tried to transfer/confused. 4/12/18- Resident tried to self-transfer out of bed. 4/13/18- Resident is unaware of own limitations and attempts to stand when she falls. 4/14/18- Resident being non- complaint with waiting for assistance and forgetting own limits. On 1/9/19, review of Fall Care Plans. Interventions documented on 3/5/18- When Resident is restless, will provide 1 on 1 assistance, 4/13/18- Check every 15 minutes to ensure safety. Review of Kardex revealed Monitors- Continue check every 15 minutes to ensure safety - Safety- When Resident is restless provide 1 on 1 assistance. Review of chart did not show any documentation of monitoring for restlessness or safety checks every 15 minutes. On 1/10/19, review of Therapy notes revealed, PT (Physical Therapy)-Therapist Progress and Discharge Summary- Analysis of Functional Outcome/Clinical Impression- Pt is unable to make further progress at this time limited by cognitive deficits and severe receptive and [MEDICAL CONDITION]. Impact of Burden of Care/Daily Life - Pt unable to return home safely or perform ADLs independently safe at this time (dated 4/6/18). OT (Occupational Therapy)-Therapist Progress and Discharge Summary- Analysis of Functional Outcome/Clinical Impression - . Pt with impaired safety awareness and requires assistance to complete self-care tasks. Impact of Burden of Care/Daily Life -Pt requires assistance with all self-care tasks and safety awareness (dated 4/6/18). Therapy Screen- 4/13/18- Fall- Reason- self transfer from chair. Comment- Pt in recliner chair in common area self-transferring on 4/12,4/13. PT (Physical Therapy) d/c (discontinued) on 4/6 with poor safety awareness, cognition deficits, assist with all mobility. On 1/10/19 at 9:10 a.m., Interviewed Physical Therapy Manager (PTM), when asked if resident was evaluated when falls occurred, PTM stated, R#56 was receiving therapy during 4 of the falls and we did a therapy screen. When asked the reason for falls, PTM replied, Resident was very impulsive and always getting up. On 1/10/18 at 9:30 a.m., Interviewed Director of Nursing (DON), when asked the reason why R#56 had seven falls in a short period of time, DON stated, Resident was very impulsive and was constantly trying to get up. When asked since the Resident had impaired cognition and impulsive, do you believe that some of the interventions put into place to prevent falls were not personalized for this Resident's needs. DON stated, Yes. When asked if there was any documentation of monitoring resident for restlessness and providing 1 on assistance or check every 15 minutes to ensure safety, DON stated, No we don't have any documentation. When asked after a few falls why Resident wasn't put on a constant 1 on 1 supervision, DON stated, We tried to see if family could come in and stay, but that was not a possibility. When asked if it was the responsibility of the facility to keep the resident safe, DON stated, Yes. When asked if better interventions could have prevented the resident from having seven falls, DON stated, In retrospect, yes it could have prevented falls. When asked if the Resident received a new fracture after the last fall, DON stated, Yes. When asked if the facility had a Fall Policy, DON stated Yes, it was written in November. When asked if policy was updated related to R#56's falls, DON stated, Yes. On 1/10/18, record review of Hospital X-Ray hips bilateral without pelvis 2 views. 4/14/18- Impression-periprosthetic fracture involving the femoral stem right femur. On 1/10/18, review of Fall Policy revealed Each resident will be assessed for the risks of falling via the Morse Fall Assessment tool and will receive care and services in accordance with the level of risk to minimize the likelihood of falls.

This citation pertains to Intake #MI 438. Based on interview and record review, the facility failed to prevent the diversion of resident medication (controlled substances) for four sampled residents (R#'s 33, 55,57,58) out of a total sample of 13 resulting in controlled substance diversion for suspected staff use. Findings include: On 01/10/19 at 11:51 AM, During an interview with the Assistant Health Services Director (Nurse G) and the facility's Director of Health Services (DON) they were asked about missing partially filled narcotic blister packs (cards which contain individually packed medications) and corresponding drug control sign out sheets (pink sheets) that they had reported to the State Agency. The DON went on to say that, on 9/15/18 at 9:30 am she received a call from weekend manager (Nurse B). Nurse B said that she had been called by a midnight shift nurse (Nurse H) because of missing partial control substance cards and pink sheets that when with them. Nurse H reported to Nurse B that she was looking for pink sheets and thought there was a partial narcotic medication card missing for (R#33). Nurse H indicated that on 9/14/18 R#33 had several doses of narcotic medication left, but by that night (when she returned on shift), the pharmacy had sent a whole new blister pack of medication for (R#33). Review of the schedule revealed that Nurse J had worked the afternoon shift. Nurse G went on to say that later on 9/15/18 she received an e-mail from Nurse K noting a blister pack of (name of narcotic medication) was missing for (R#55). The DON said that on 9/17/18 Nurse G found a empty blister pack in a shed box belonging to (R#57). The empty blister pack was labeled for 10 doses of a narcotic medication that was delivered to the facility on [DATE] and the corresponding pink slip was missing. On 9/19/18 during a review of the residents that are prescribed controlled substances revealed that (R#58) reported that he did not receive his pain pill on the night of 9/15/18, yet it was signed as given by Nurse J. The DON stated, It appears that Nurse J had been removing control drugs from the locked narcotic drawer along with the associated count sheet .The nurse was removed from the schedule and employment terminated on 9/20/18. Resident #33 Record review revealed that R#33 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set assessment dated [DATE] indicated the residents cognition was moderately impaired. Section J Health Assessment-Pain indicated the resident experienced frequent pain which made it hard to sleep at night and limited daily activity. Resident #55 Record review revealed that R#55 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set assessment dated [DATE] indicated the residents cognition was intact. Section J Health Assessment-Pain indicated the resident experienced occasional pain at a level of 2 (10 being the greatest pain level). Resident #57 Record review revealed that R#57 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set assessment dated [DATE] indicated the residents cognition was intact. Section J Health Assessment-Pain indicated the resident experienced occasional pain at a level of 8 (10 being the greatest pain level). Resident #58 Record review revealed that R#58 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set assessment dated [DATE] indicated the residents cognition was intact. Section J Health Assessment-Pain indicated the resident experienced occasional pain at a level of 9 (10 being the greatest pain level). Review of the facility's policy titled, Abuse, Neglect and misappropriation of property policy and procedure for all staff serving licensed areas revised 11/1/16 documented, Misappropriation of resident property mean the deliberate misplacement, exploitation or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent .residents have the right to be free from verbal, sexual,physical and mental or emotional abuse, corporal punishment, involuntary seclusion, mistreatment, neglect and misappropriation of their property.

This citation pertains to Intake #MI 438. Based on interview and record review the facility failed to follow an implemented plan of correction for the prevention of further diversion of narcotic medication for four sampled residents (R#'s 7,41,48 and 54) resulting in the potential for further narcotic drug diversion. Findings include: On 1/10/19 at 9:00 am, Nurse L was asked about the facility's procedure on narcotic medication. Nurse L stated, When the narcotic medication (in the form of a blister pack) and corresponding controlled record sheet (pink sheet) comes in from the pharmacy two nurses verify the amount received by co-signing the top of the pink sheet. When the blister pack becomes empty, two nurses verify the empty pack along with the completed pink sheet and co-sign the bottom of the pink sheet. Nurse L was asked what happens to the blister pack and corresponding pink sheet of a narcotic medication if the resident was discharged , or the medication order changed and they're was narcotic remaining in the blister pack. Nurse L responded, We pull blister pack with the remaining medication and corresponding pink sheet and give a supervisor. Nurse L was asked if the supervisor co-signed the narcotic medication with the nursing staff to which she responded, No. We only get co-signatures when the narcotic arrives from pharmacy and when the blister pack is empty. At 9:25 am, Unit Manager Nurse M verified that she does not co-sign to verify remaining narcotics that are given to her by the nursing staff. On 01/10/19 at 11:51 AM, during an interview with the Assistant Health Services Director Nurse G and the Health Services Director (DON) they indicated that on 9/15/18 it alleged that a nurse was removing controlled drugs from the locked narcotic box along with the associated count sheet. On 9/17/18 the facility implemented a corrective action .When discontinuing a controlled substance, please do the following: .Both nurses will sign the bottom of the pink sheet. On 01/10/19 at 01:38 PM, along with Unit Manger N the narcotic box in the supervisors office was reviewed. Observation revealed the following: Resident #7 [MEDICATION NAME] 5 mg (produces calming effect). 14 tablets remain in the blister pack. There were no two nurse signatures on the bottom of the controlled substance record (pink) sheet. [MEDICATION NAME] 5 mg. 20 tablets remain in the blister pack. There were no two nurse signatures on the bottom of the controlled substance record sheet. [MEDICATION NAME]-ACET (pain pill) 5-325 milligram (mg). 8 tablets remain in the blister pack. There were no two nurse signatures on the bottom of the controlled substance record sheet. Record review revealed that R#7 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set assessment dated [DATE] indicated the residents cognition was intact. Resident #41 [MEDICATION NAME]-acetamin 7.5-32. 4 tablets remain in the blister pack. There were no two nurse signatures on the bottom of the controlled substance record sheet. [MEDICATION NAME]-acteamin 7.5-32. 30 tablets remain in the blister pack. There were no two nurse signatures on the bottom of the controlled substance record sheet. Record review revealed that R#41 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set assessment dated [DATE] indicated the residents cognition was intact. Resident #48 Tramodol HCL 50 mg. 13 tablets remain in the blister pack. There were no two nurse signatures on the bottom of the controlled substance record sheet. Record review revealed that R#48 was admitted into the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set assessment dated [DATE] indicated the residents cognition was intact. Resident #54 [MEDICATION NAME] (antianxiety) 0.25 mg. 3 tablets remain in the blister pack. There were no two nurse signatures on the bottom of the controlled substance record sheet. There was only one nurse signature on the top received portion of the pink sheet. [MEDICATION NAME] (antianxiety) 0.25 mg. 26 tablets remain in the blister pack. There were no two nurse signatures on the bottom of the controlled substance record sheet. [MEDICATION NAME] (antianxiety) 0.25 mg. 30 tablets remain in the blister pack. There were no two nurse signatures on the bottom of the controlled substance record sheet. Hydorocodone- Acetamin 7.5-32. 20 tablets remain in the blister pack. There were no two nurse signatures on the bottom of the controlled substance record sheet. There was only one nurse signature on the top received portion of the pink sheet. Record review revealed that R#54 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set assessment dated [DATE] indicated the residents cognition was intact. Unit Manger, Nurse N was asked about the co-signatures to verify the narcotic count accuracy to which she stated, The only time that two nurses sign is when the sheet is empty. Review of corrective action plan dated 9/17/18 put into place after the medication diversion was alleged documented, When discontinuing a controlled substance, please do the following: .Both nurses will sign the bottom of the pink sheet. The DON was asked why two nurses were not co-signing the narcotic sheets when there were remaining narcotics in the blister pack to which she responded, I though they were. We have dropped the ball on monitoring that intervention.

This citation pertains to Intake #MI 438. Based on interview and record review the facility failed to timely report an allegation of narcotic medication misappropriation to the State Agency for four sampled residents (R#'s 33, 55, 57, and 58) from a total sample of 13, resulting in the delay in reporting misappropriation of medication. Finding include: On 01/10/19 at 11:51 AM, During an interview with the Assistant Health Services Director (Nurse G) and the facility's Director of Health Services (DON) they were asked about missing partially filled narcotic blister packs (cards which contain individually packed medications) and corresponding drug control sign out sheets (pink sheets) that they had reported to the State Agency. The DON went on to say that, on 9/15/18 at 9:30 am she received a call from weekend manager (Nurse B). Nurse B said that she had been called by a midnight shift nurse (Nurse H) because of missing partial control substance cards and pink sheets that when with them. Nurse H reported to Nurse B that she was looking for pink sheets and thought there was a partial narcotic medication card missing for (R#33). Nurse H indicated that on 9/14/18 R#33 had several doses of narcotic medication left, but by that night (when she returned on shift), the pharmacy had sent a whole new blister pack of medication for (R#33). Review of the schedule revealed that Nurse J had worked the afternoon shift. Nurse G went on to say that later on 9/15/18 she received an e-mail from Nurse K noting a blister pack of (name of narcotic medication) was missing for (R#55). The DON said that on 9/17/18 Nurse G found a empty blister pack in a shed box belonging to (R#57). The empty blister pack was labeled for 10 doses of a narcotic medication that was delivered to the facility on [DATE] and the corresponding pink slip was missing. On 9/19/18 during a review of the residents that are prescribed controlled substances revealed that (R#58) reported that he did not receive his pain pill on the night of 9/15/18, yet it was signed as given by Nurse J. Resident #33 Record review revealed that R#33 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set assessment dated [DATE] indicated the residents cognition was moderately impaired. Section J Health Assessment-Pain indicated the resident experienced frequent pain which made it hard to sleep at night and limited daily activity. Resident #55 Record review revealed that R#55 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set assessment dated [DATE] indicated the residents cognition was intact. Section J Health Assessment-Pain indicated the resident experienced occasional pain at a level of 2 (10 being the greatest pain level). Resident #57 Record review revealed that R#57 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set assessment dated [DATE] indicated the residents cognition was intact. Section J Health Assessment-Pain indicated the resident experienced occasional pain at a level of 8 (10 being the greatest pain level). Resident #58 Record review revealed that R#58 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set assessment dated [DATE] indicated the residents cognition was intact. Section J Health Assessment-Pain indicated the resident experienced occasional pain at a level of 9 (10 being the greatest pain level). The DON stated, It appears that Nurse J had been removing control drugs from the locked narcotic drawer along with the associated count sheet. We did not report the event to the State Agency until 9/19/18 (4 days after the suspected drug diversion) because we had not viewed this as a reportable event until we put all the pieces together. Review of the facility's policy titled, Abuse, Neglect and misappropriation of property policy and procedure for all staff serving licensed areas revised 11/1/16 documented, Reporting to Law Enforcement of Crimes Occurring in Health Care Facility .if the events that causes the suspicion: .b) do not result in serious bodily injury, the individual shall report the suspicion not later than 24 hours after forming the suspicions .

Based on interview and record review the facility failed to document interventions for range of motion, effecting one Resident #1 out of 13 Residents reviewed for limited range of motion, resulting in the potential for contractures (muscle or tendon that's shortened or tighten to the point it cannot stretch normally). Findings Include: On 1/8/19, record review R#1's medical chart revealed admission into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), R#1 had severe impaired cognition and was total dependence on Activities of Daily Living (ADLS) and transfers. On 1/8/19, further review of R#1's medical chart revealed that it was documented in ADL care plan and Kardex (Care guide for Certified Nursing Assistants to follow) that the Resident should be provided ROM (Range of Motion) to all extremities daily to decrease the risk of contractures. During this review documentation of daily ROM was not found in Resident's chart. ON 1/9/19 at 1:30 p.m., during interview with Director of Nursing (DON), when asked if any evidence was available to prove R#1 had received ROM on daily basis since intervention was initiated on 9/27/18, DON stated, no there is not any documentation available to show where R#1 received range of motion exercises. When asked the reason this important documentation was not done. DON stated, When Physical Therapy Manager created the intervention, frequency was not put into computer and it was over looked until this point. On 1/10/19 at 9:15 a.m., during interview with Physical Therapy Manager (PTM), when asked if she had forgotten to put the frequency in the computer which would trigger the interventions and Nursing staff would be reminded to document daily ROM exercises, PTM stated, Yes. On 1/10/19, record review of Prevention of Decline in Range of Motion dated 1/9/19 revealed the following: Policy: Residents who enter the facility without limited range of motion will not experience a reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motion is unavoidable. Definitions: Range of Motion means the full movement potential of a joint. Policy Explanation and Compliance Guidelines: 1. The facility in collaboration with the medical director, director of nurses and as appropriate, physical/occupational consultant shall establish and utilize a systematic approach for prevention of decline in range of motion, including the assessment, appropriate care planning, and preventive care. 2. Assessment for Range of Motion a. Licensed nurses will assess resident's range of motion (such as current extent of movement of his/her joints and the identification of limitations) on admission/readmission, quarterly, and upon a significant change. b. Residents who exhibit limitations in range of motion, initially and thereafter, will be referred to the therapy department for a focused assessment of range of motion. c. Nursing assistants will report any significant changes in range of motion, as noted during daily care activities, to the resident's nurse when any changes are noted. d. The assessment should include identified risks which could impact resident's range of motion including, but not limited to: i. Immobilization; ii. Neurological conditions causing functional limitations; iii. Any condition where movement may result in pain, spasms or loss of movement; iv. Clinical conditions such as immobilized limbs or digits because of injury, fractures or surgical procedures including amputations. 3. Appropriate Care Planning a. Based on the comprehensive assessment, the facility will provide interventions, exercises and/or therapy to maintain or improve range of motion. b. The facility will provide treatment and care in accordance with professional standards of practice. This includes, but is not limited to: i. Appropriate services (specialized rehabilitation, restorative, maintenance). ii. Appropriate equipment (braces or splints). iii. Assistance as needed (active assisted, passive, supervision). c. Care plan interventions will be developed and delivered as described by the functional maintenance plan. d. Interventions will be documented on the resident's person-centered care plan. Documentation should include, but not limited to: i. Type of treatments; ii. Frequency and duration of treatments; iii. Measurable objectives; iv. Resident goals. e. A nurse with responsibility for the resident will monitor for consistent implementation of the care plan interventions. Refusals of care or problems associated with range of motion exercises will be documented in the medical record. f. Modifications to the plan of care will be made as needed. g. The resident/resident's representative will be included in the development of the restorative/rehabilitation care plan and provided the risks and benefits of the treatments. 4. Preventive Care a. Staff will be educated on the risk factors for a decline in range of motion on a regular basis b. Staff will be educated on basic, restorative nursing care that does not require the use of a qualified therapist or licensed nurse oversight. This training may include, but is not limited to: i. Maintaining proper positioning and body alignment. ii. Encouraging and assisting residents, as needed, in turning and position changes. iii. Encouraging residents to remain active and assisting with any exercises according to the plan of care. iv. Assisting residents in adjustment to their disabilities and use of any assistive devices. v. Assisting residents with range of motion exercises, performing passive range of motion for residents unable to actively participate. 5. General Guidelines for Range of Motion a. Explain the procedure to the resident then ask permission to proceed. b. Move each joint through its range of motion three times unless otherwise instructed. c. Move each joint gently, smoothly, and slowly through its range of motion. d. Stop an exercise before the point of pain, e. Report pain to the nurse.

F 600 This citation pertains to intake MI 386 On observation, interview, and record review, the facility failed to maintain an environment free of verbal and physical abuse for a vulnerable resident (#19), resulting in the potential for the abuse of additional residents in the facility that are unable to voice concerns related to abusive behaviors from facility staff. Findings include: According to Facility Reported Incident (FRI), the RN, Health Service Director (DON), a call was received from the PM supervisor (B) of an incident regarding a CNA (E) and a resident (19). The CNA (E) was witnessed via another CNA (D), yelling at the resident with the use of profanity (i.e. telling the resident to shut the [***] up), and covering her mouth with her hand. In addition to yelling at the resident and covering her mouth, after the resident became incontinent of stool during a transfer to her Geri chair, CNA (E) commented to the resident she had already pooped enough. The CNA's E and D lowered the resident into her Geri chair and attempted to snap the resident's brief, but she was holding her hand in front of the brief. CNA (E) took the resident's hand and pushed it into her chest, and using profanity told the resident to move her hand. A statement was received from CNA (E), she initially denied the allegation, stating she told the resident, shhh. The aide was suspended pending the results of the facility investigation. The PM charge nurse (B) observed no visible signs of injury to the resident's face. A decision was made to terminate CNA (E). A termination of employment document written via the director of human resources (I) was provided to CNA (E) on 10-3-18 that summarized the allegations (claims that someone has done something wrong) against the CNA E and the evidence to support the allegations. CNA E signed the document on 10-3-18. According to a record review conducted on 1/9/19, resident ( 19) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. ( a disorder of the nervous system that affects movement). A MDS (minimum data set) with a reference date of 11-13-18 indicated the resident was severely cognitively (thought processes) impaired. Resident (19) was totally dependent on 2 people for transfers to or from bed, chair, and wheelchair. The resident was always incontinent ( can not control) of urine and bowel. On 1/10/19 at 12:40 PM, an Interview was conducted with the DON regarding verbal and physical abuse allegations involving the the resident. She stated, she was proud of the CNA that witnessed and reported the incident. The DON stated CNA E never returned to the building after the witnessed incident. The Don stated, the resident does not like to receive care and will often yell out when receiving care from staff. A document entitled, Abuse, Neglect, & Misappropriated of Property: Policy & Procedure for all Staff serving in Licensed Areas, with a revision date of 11-1-1-16 was provided via the DON defined Abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. There is a presumption that all instances of abuse of all residents, even those in a coma, cause some degree of physical harm, pain, or mental anguish. Abuse involves a willful, purposive and assertive action. Verbal abuse is defined as the use of oral language that willfully includes disparaging and derogatory terms to residents. Physical abuse not only includes hitting, slapping, pinching, and kicking, it also includes controlling behavior through corporal punishment. Generally, there is a presumption that physical abuse has occurred whenever there has been some type of impermissible or unjustifiable physical contact with a resident.

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION TO PREVENT FALLS AND INJURY FOR ONE (#801) OF NINE RESIDENTS REVIEWED FOR FALLS OF A TOTAL OF 13 SAMPLED RESIDENTS, RESULTING IN RIGHT ORBITAL BRUISING (AROUND THE RIGHT EYE) AND RIB FRACTURES. FINDINGS INCLUDE: ON 9/12/12 AT 9:50 A.M., RESIDENT #801 WAS OBSERVED IN A "RECLINER CHAIR" IN THE TELEVISION ROOM. THE RESIDENT WAS ALERT AND VERBAL. IT WAS OBSERVED THAT THE RESIDENT'S RIGHT ORBITAL AND RIGHT TEMPLE HAD A DARK PURPLISH BRUISE. ACCORDING TO NURSE "E", RESIDENT #801 HAD A "FALL" ON 9/8/12 IN THE HALLWAY TOWARDS THE DINING ROOM. RESIDENT #801 WAS OBSERVED WEARING GERI SLEEVES ON BOTH ARMS.. WHEN RESIDENT #801 WAS ASKED WHAT HAPPENED TO HER RIGHT EYE, THE RESIDENT STATED "AN AIRPLANE LANDED ON HER TWO DAYS AGO." ON 9/12/12 AT 12:20 P.M., RESIDENT #801 WAS OBSERVED IN HER ROOM IN A WHEELCHAIR. THE RESIDENT WAS VERBAL. WHEN RESIDENT #801 WAS ASKED ABOUT HER HAND SLEEVES, THE RESIDENT STATED, "I HAVE THE SAME THING (POINTED TO HER RIGHT EYE) IN MY RIGHT HAND." HOWEVER, THE RESIDENT REFUSED TO SHOW WHAT WAS UNDER THE RIGHT HAND SLEEVE. RESIDENT #801 DENIED ANY PAIN. PER RECORD REVIEW ON 9/12/12 AT 12:35 P.M., RESIDENT # 801 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF THE RESIDENT'S MEDICATION PROFILE REVEALED THE FOLLOWING MEDICATIONS WERE ADMINISTERED TO THE RESIDENT: METOPROLOL (FOR BLOOD PRESSURE), PAROXETENE (ANTIDEPRESSANT)CARBIDOPA/LEVODOPA (FOR PARKINSONS) LYRICA (FOR PAIN) XANAX (FOR ANXIETY)AND ISOSORBIDE (CARDIAC MEDICATION ). REVIEW OF THE RESIDENT'S CLINICAL RECORD REVEALED THE RESIDENT HAD MULTIPLE FALLS FROM 1/31/12 UNTIL 9/8/12. REVIEW OF THE INCIDENT REPORTS REVEALED THE FOLLOWING: 1) ON 1/31/12 AT 9:30 P.M., THE BED ALARM WAS SOUNDING OFF, THE RESIDENT WAS FOUND ON "BUTT" NEXT TO BED WITH LEGS STRAIGHT OUT. ACCORDING TO THE INCIDENT REPORT, THE RESIDENT STATED SHE WAS "TRYING TO GET DRESSED." A FALL RISK ASSESSMENT WAS COMPLETED AND THE RESIDENT WAS IDENTIFIED AS A "HIGH FALL RISK" WITH A SCORE OF 18. (A SCORE OF 10 AND ABOVE WAS REFERRED TO AS HIGH RISK FOR FALL). THE resident sustained [REDACTED]. 2) ON 2/11/12 AT 4:30 P.M., RESIDENT #801 GOT OUT OF BED TO USE THE BATHROOM. THERE WAS NO DOCUMENTATION WHETHER THE ALARM SOUNDED. THE resident sustained [REDACTED]. 3) ON 2/15/12 AT 7:00 P.M., RESIDENT #801 WAS FOUND LYING ON HER LEFT SIDE WITH KNEES IN A FETAL POSITION. THE ALARM WAS 'GOING OFF'. THE INCIDENT REPORT DOCUMENTED THAT THE RESIDENT "WAS TRYING TO WALK AWAY FROM THE WHEELCHAIR." THE resident sustained [REDACTED]. 4) ON 4/16/12 AT 8:15 P.M., THE RESIDENT "GOT" UP FROM BED AND fell IN DINING ROOM. THE BED ALARM DID NOT "GO OFF". THE DIRECTOR OF NURSING WAS QUERIED IF THE BED WAS IN THE DINING ROOM AS PER THE INCIDENT REPORT, THE DIRECTOR OF NURSING WAS NOT ABLE TO EXPLAIN. 5) ON 7/23/12 AT 5:30 P.M., THE RESIDENT ATTEMPTED TO WALK AND fell on LEFT SIDE. THE resident sustained [REDACTED]. 6) ON 7/25/12 AT 4:30 A.M., THE RESIDENT "TRIED TO GO BY HERSELF TO THE BATHROOM". THE RESIDENT HAD A FALL WHILE WALKING TO THE BATHROOM. THE INCIDENT REPORT DID NOT ADDRESS WHETHER THE resident sustained [REDACTED]. 7) ON 7/31/12 AT 7:50 P.M., THE RESIDENT GOT UP FROM THE RECLINER BY HERSELF, LOST BALANCE AND fell LANDING ON RIGHT SIDE. 8) ON 9/8/12 AT 9:00 P.M., THE RESIDENT WAS OBSERVED ON THE FLOOR IN THE HALLWAY BY THE DOOR OF THE DINING ROOM. PER INCIDENT REPORT, THE RESIDENT "NEEDED TO GO TO THE TOILET". REVIEW OF THE NURSES NOTES DATED 9/8/12 AT 1:00 P.M. REVEALED THAT THE RESIDENT HAD INCREASED AGITATION. "KEEPS TRYING TO GET OUT OF CHAIR". THE RESIDENT WAS MEDICATED WITH XANAX (FOR ANXIETY) AT 2:00 P.M., THE NURSES NOTES DOCUMENTED THAT THE MEDICATION WAS INEFFECTIVE. THE NEXT NURSES NOTES WAS ON 9/8/12 AT 2130 (9:30 P.M.)WHEN THE RESIDENT WAS FOUND ON THE FLOOR. REVIEW OF THE XRAY REPORT DATED 9/9/12 REVEALED RIB FRACTURE OF THE 8TH AND THE 9TH RIB. DURING AN INTERVIEW ON 9/13/12 AT 11:00 A.M., NURSE "D" STATED THAT THE INCIDENT ON 9/8/12 , THE RESIDENT WAS FOUND ON THE FLOOR IN THE HALLWAY. RESIDENT #801 AMBULATED WITHOUT ANY WALKER OR PERSON ASSISTANCE FROM THE TELEVISION ROOM TO THE DINING ROOM WHICH WAS APPROXIMATELY 40 FEET IN DISTANCE. ACCORDING TO NURSE "C ", THE ALARM WAS SOUNDED WHEN THE RESIDENT GOT OFF THE RECLINER, HOWEVER, THE NURSE WAS IN THE OTHER HALLWAY. WHEN QUERIED WHERE THE NURSING ASSISTANTS WERE WHEN THE ALARM WAS SOUNDING, NURSE "C" STATED THE TWO NURSING ASSISTANTS WERE WITH OTHER RESIDENTS GIVING CARE. REVIEW OF THE QUARTERLY MDS (MINIMUM DATA SET) DATED 7/13/12 REVEALED, RESIDENT #801 REQUIRED EXTENSIVE ASSISTANCE WITH ONE PERSON ASSIST FOR TRANSFER, AMBULATION BOTH IN THE ROOM AND IN THE CORRIDOR OR HALLWAY, DRESSING, LOCOMOTION , BED MOBILITY AND THE USE OF THE TOILET. ACCORDING TO THE MDS ASSESSMENT, RESIDENT #801 WAS NOT STEADY, ONLY ABLE TO STABILIZE WITH HUMAN ASSISTANCE MOVING FROM SEATED TO STANDING POSITION, TURNING AROUND, SURFACE TO SURFACE TRANSFER AND WALKING. ACCORDING TO THE MDS, RESIDENT #801 WAS CONFUSED AND WAS MODERATELY IMPAIRED FOR COGNITION AND DECISION MAKING. REVIEW OF THE RESIDENT'S CARE PLAN FOR FALL DIRECTED THE STAFF TO ASSIST RESIDENT FOR TOILETING AS PER SCHEDULE AND AS NEEDED. THE CARE PLAN ALSO DIRECTED THE STAFF TO ASSIST WITH TRANSFERS AS NEEDED. DURING AN INTERVIEW ON 9/12/12 AT 3:35 P.M., THE DIRECTOR OF NURSING STATED THAT AN INVESTIGATION WAS CONDUCTED. REVIEW OF THE INVESTIGATION "SUMMARY" REVEALED THAT THE AFTERNOON NURSE WAS NOT IN THE NURSING STATION/UNIT BUT WAS UNAVAILABLE ON ANOTHER UNIT ASSISTING ANOTHER NURSE AT THE TIME OF THE FALL. THERE WERE TWO NURSING ASSISTANTS WHO HEARD THE ALARM SOUND BUT WERE NOT ABLE TO RESPOND OR PROVIDE SUPERVISION TO RESIDENT #801 BECAUSE THEY WERE "DOING" CARE TO OTHER RESIDENTS. REVIEW OF THE FACILITY'S POLICY ON FALL PREVENTION REVISED ON 7/15/11 REVEALED THAT A RESIDENT WHO WAS DETERMINED AS HIGH RISK FOR FALLS ..CLOSELY MONITOR RESIDENTS WHO RECEIVE SLEEP MEDICATIONS, PSYCHOTROPICS, CARDIAC, AND MULTIPLE MEDICATIONS. RESIDENT #801 RECEIVED MULTIPLE MEDICATIONS: ISOSORBIDE (CARDIAC MEDICATION), METOPROLOL (BLOOD PRESSURE MEDICATION), XANAX (ANTIANXIETY MEDICATION), CARBIDOPA/LEVEDOPA (FOR PARKINSONISM), PAROXETENE (FOR DEPRESSION), LYRICA (FOR PAIN) AND DOCUSATE (STOOL SOFTENER) SENOKOT STOOL STIMULANT) AND ASPIRIN. ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 475 BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE SUPERVISION AND IMPLEMENT INTERVENTIONS TO ENSURE THE SAFETY OF 1 OF 9 SAMPLED RESIDENTS (RESIDENT #501), RESULTING IN AN IMMEDIATE JEOPARDY WHEN RESIDENT #501, WHO WAS IDENTIFIED AS A FALL RISK, SUSTAINED A FALL WITH A CLOSED HEAD INJURY WHICH REQUIRED hospitalization AND RESULTED IN HER SUBSEQUENT DEATH. FINDINGS INCLUDE: ACCORDING TO THE FACILITY'S INCIDENT/ACCIDENT REPORT DATED [DATE], RESIDENT #501 WAS OBSERVED IN HER ROOM ON THE FLOOR AT 2:15 P.M., "...LYING FACE UP FLAT ON HER BACK..." BY RESIDENT #505 WHO WAS WALKING BY RESIDENT #501'S ROOM AT THE TIME OF THE FALL. A REVIEW OF THE FACILITY'S INCIDENT/ACCIDENT REPORT DATED [DATE] DOCUMENTED THE FOLLOWING: "...RESIDENT (#501) UP AT LIB WITHOUT CALLING FOR ASSISTANCE USING CALL LIGHT THAT WAS WITHIN REACH AT TIME OF FALL, RESIDENT (#501) STATED GOING TO WHEELCHAIR FROM RECLINER...". THE FACILITY'S INCIDENT/ACCIDENT REPORT DOCUMENTED THAT RESIDENT #501 WAS OBSERVED TO HAVE A "6 CM (CENTIMETER) DIAMETER HEMATOMA" (A COLLECTION OF BLOOD, USUALLY CLOTTED, IN A TISSUE OR ORGAN, CAUSED BY A BREAK IN A BLOOD VESSEL). A DIAGRAM INDICATED THAT THE HEMATOMA WAS LOCATED ON THE BACK, RIGHT SIDE OF RESIDENT #501'S HEAD. VITAL SIGNS TAKEN BY FACILITY STAFF AT THE TIME OF THE FALL WERE RECORDED AS: BLOOD PRESSURE (,[DATE]), PULSE (84), RESPIRATIONS (18), TEMPERATURE (96.4 DEGREES FARENHEIT), PULSE OXIMETRY (96%), GLUCOSE (145). RESIDENT #501 WAS TRANSFERRED TO A NEARBY HOSPITAL, VIA AMBULANCE, FOR EVALUATION AND TREATMENT. A REVIEW OF THE FACILITY'S SUMMARY OF INVESTIGATION DATED [DATE], DOCUMENTED THE FOLLOWING: "..XXX[DATE] 1415 (2:15 P.M.), STAFF SUMMONED TO ROOM BY RESIDENT (#501). CENA's (CERTIFIED NURSING ASSISTANTS) OBSERVED RESIDENT LYING BACK ON FLOOR IN FRONT OF HER RECLINING CHAIR. CALL LIGHT IN REACH ON HER RECLINER WAS NOT ACTIVATED. RESIDENT (#501) INFORMED STAFF SHE HAD ATTEMPTED TO SELF-TRANSFER FROM THE RECLINER TO HER WHEELCHAIR. FACILITY NURSE ASSESSED RESIDENT (#501). RESIDENT (#501) COMPLAINED OF PAIN AT BACK OF HEAD. NOTED TO HAVE APPROXIMATE 6 CM RAISED AREA ON THE BACK OF HER HEAD. NEURO CHECKS FOUND RESIDENT TO BE ALERT AND ORIENTED TO PERSON AND TIME. GRASPS (HAND STRENGTH) TO BE EQUAL BILATERALLY AND PUPILS EQUAL, ROUND AND REACTIVE TO LIGHT. VITAL SIGNS DEMONSTRATED ELEVATED BLOOD PRESSURE, AND PULSE OXIMETRY NOTED TO BE WITHIN NORMAL LIMITS FOR THE RESIDENT (#501). RESIDENT (#501) ASSISTED TO CHAIR PER THREE STAFF ASSIST. RESIDENT (#501) TRANSFERRED TO NEARBY HOSPITAL emergency room VIA 911 AT 1445 (2:45 P.M.). RESIDENT (#501) RETURNED TO FACILITY FOR "SUPPORTIVE CARE" AT 1930 (7:30 P.M.) ACCOMPANIED BY DPOA (DURABLE POWER OF ATTORNEY). RESIDENT (#501) WAS NOTED TO BE UNRESPONSIVE UPON RETURN. DPOA REPORTED TO NURSING SUPERVISOR RESIDENT FOUND TO HAVE "BLEEDING IN THE BRAIN". RESIDENT (#501) EXPIRED AT 0130 (1:30 AM) ON [DATE]...". ACCORDING TO THE EMERGENCY MEDICAL SYSTEM (EMS) RUN SHEET DATED [DATE], EMERGENCY PERSONNEL ARRIVED AT THE FACILITY AT 3:04 P.M. TO FIND RESIDENT #501 IN HER ROOM. PROVIDER IMPRESSION: "DYSPNEA (DIFFICULTY BREATHING)-SOB (SHORTNESS OF BREATH), TRAUMA INJURY." MECHANISM OF INJURY: "FALL." EMS RESPONDERS DOCUMENTED RESIDENT #501'S VITAL SIGNS AS: BLOOD PRESSURE (,[DATE]), PULSE (110), RESPIRATIONS (20), PULSE OXIMETRY (91%), PAIN SCALE RATED 8 OUT OF TEN. THE EMS RUN SHEET DOCUMENTED THE FOLLOWING: "...ON SUNDAY [DATE] WE FIND A [AGE] year OLD FEMALE PATIENT PRESENTING WITH HEADACHE/BACK PAIN WHICH OCCURRED ON SUNDAY [DATE]...". "...DISPATCHED PRIORITY 1 TO ABOVE LOCATION (FACILITY) FOR A FEMALE PATIENT WHO fell GETTING UP FROM HER WALKER WITH A SEAT. UPON ARRIVAL, FIRE DEPARTMENT HAD PATIENT C-COLLARED AND STATED THAT SHE HAD A KNOT ON THE BACK OF HER HEAD...". "...UPON PLACING PATIENT (#501) ON LONG BACK BOARD PATIENT BEGAN COMPLAINING OF PAIN IN THE MIDDLE OF HER BACK AND SHORTNESS OF BREATH. PLACED PATIENT ON CARDIAC MONITOR, OXYGEN AND IV (A WAY OF PROVIDING FLUIDS THROUGH THE VEIN) ESTABLISHED...". A REVIEW OF THE HOSPITAL TRIAGE REPORT, DATED [DATE], REVEALED THAT RESIDENT #501 WAS AT MODERATE TO HIGH RISK FOR FALLS AND had a history of [REDACTED]. A REVIEW OF THE EMERGENCY PHYSICIAN RECORD DATED [DATE] REVEALED: CHIEF COMPLAINT: "FALL." ONSET/DURATION: "JUST PRIOR TO ARRIVAL" "YESTERDAY." "fell FROM STANDING POSITION." SEVERITY OF PAIN: "MODERATE." LOCATION OF PAIN: "HEAD, NECK, LOWER BACK." "DIZZINESS, WEAKNESS, BACK PAIN." "...CLINICAL IMPRESSION: LARGE RIGHT SUBDURAL HEMATOMA...". A CT (COMPUTED TOMOGRAPHY) HISTORY /DOCUMENTATION REPORT DATED [DATE] DOCUMENTED THAT RESIDENT #501 HAD COMPLAINTS OF "BACK PAIN", WAS "CONFUSED" AND HAD "LOSS OF CONSCIOUSNESS". THE CT REPORT FURTHER DOCUMENTED: "...PT (PATIENT) (#501) fell TWICE YESTERDAY ([DATE]) AND TODAY, WOUND TO HEAD, UNRESPONSIVE, UNABLE TO RAISE ARMS UP...". A HOSPITAL RADIOLOGY REPORT DATED [DATE] INDICATED THAT A CT (COMPUTED TOMOGRAPHY) SCAN OF RESIDENT #501'S HEAD AND BRAIN WAS ORDERED TO RULE OUT A BLEED DUE TO FALL. THE REPORT, DATED [DATE] REVEALED THE FOLLOWING: "...THERE IS A LARGE RIGHT FRONTOTEMPORAL AND PARIETAL SUBDURAL HEMATOMA ON THE RIGHT RESULTING IN SIGNIFICANT MASS EFFECT ON THE RIGHT LATERAL VENTRICLE AND APPROXIMATELY 1.3 CENTIMETERS MIDLINE SHIFT...". "...IMPRESSION: LARGE RIGHT-SIDED SUBDURAL HEMATOMA WITH SIGNIFICANT MASS EFFECT OR MIDLINE SHIFT...". A HOSPITAL RADIOLOGY REPORT DATED [DATE], INDICATED THAT A CT SCAN OF RESIDENT #501'S CHEST WAS ORDERED TO RULE OUT A PULMONARY EMBOLISM. THE REPORT REVEALED THE FOLLOWING: "...THERE IS MODERATE RIGHT AND SMALL LEFT PLEURAL EFFUSION (EXCESSIVE FLUID SURROUNDING THE LUNGS)...". A REVIEW OF THE HOSPITAL emergency room (ER) ASSESSMENT FORM DATED [DATE] AT 5:38 P.M., REVEALED: "(RESIDENT #501)...RETURNED FROM CT (COMPUTED TOMOGRAPHY). UNRESPONSIVE TO PAIN. SNORING RESPIRATIONS. PUPILS ARE FIXED ("Non-Reactive pupils are one of the cardinal signs of brain death". J Neurol Neurosurg Psychiatry. 1988 July; 51(7): 1002.) LEFT PUPIL MORE PINPOINT THAN RIGHT. BOTH PUPILS ARE PINPOINT..." REVIEW OF THE HOSPITAL DISCHARGE SUMMARY REPORT DATED [DATE] DOCUMENTED THE FOLLOWING: "...ON [DATE] THIS PATIENT (#501) WAS TREATED AT NEARBY HOSPITAL..". "...RESIDENT #501 HAS A LARGE HEMORRHAGE IN HER BRAIN. WE ARE SENDING HER HOME FOR HOSPICE CARE. SHE IS NOT CONSCIOUS AND NOT IN PAIN...". A physician's orders [REDACTED]." "...OXYGEN AT ,[DATE] LITERS PER MASK AT ALL TIMES...". "...Diagnosis: [REDACTED].B. (SHORTNESS OF BREATH)...". ACCORDING TO THE FACILITY'S ADMISSION RECORD, RESIDENT #501 WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. A REVIEW OF THE physician progress notes [REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE] INDICATED THAT RESIDENT #501 HAD MODERATELY IMPAIRED COGNITION, SHORT TERM AND LONG TERM MEMORY PROBLEMS, COULD USUALLY UNDERSTAND OTHERS, HAD A MENTAL FUNCTION THAT VARIED OVER THE COURSE OF THE DAY, AND HAD PERIODS OF DISORGANIZED SPEECH. THE MDS FURTHER INDICATED THAT RESIDENT #501 REQUIRED LIMITED TO EXTENSIVE ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING (ADLS) INCLUDING BED MOBILITY, TRANSFERS, AMBULATION, DRESSING, TOILETING, PERSONAL HYGIENE AND BATHING. ADDITIONALLY, THE MDS INDICATED THAT RESIDENT #501'S TEST FOR BALANCE REVEALED THAT RESIDENT #501 REQUIRED PARTIAL PHYSICAL SUPPORT DURING TEST; OR STANDS (SITS) BUT DOES NOT FOLLOW DIRECTIONS FOR TEST. RESIDENT #501 REQUIRED THE USE OF CANE OR WALKER AND THE USE OF A TRANSFER AID DURING TRANSFERS. THE RESIDENT ASSESSMENT PROTOCOL (RAP) PORTION OF THE MDS DOCUMENTED THE FOLLOWING: "..XXX[AGE] year OLD RESIDENT IS AT RISK FOR FALLS DUE TO DAILY USE OF ANTIANXIETY (MEDICATIONS), IMPAIRED MOBILITY REQUIRING USE OF ROLLING WALKER, OCCASIONAL INCONTINENCE, IMPAIRED JUDGEMENT, HISTORY OF FALL OCCURRING IN THE PAST ,[DATE] DAYS, AND REMOTE HISTORY OF FALLS RESULTING IN FRACTURE OF HIP. RESTRAINT FREE ALARM (RFA) IN USE...". "..XXX[AGE] year OLD RESIDENT REQUIRES LIMITED TO EXTENSIVE ASSISTANCE WITH COMPLETION OF ADLS DUE TO IMPAIRED MOBILITY, IMPAIRED BALANCE, AND POOR MEMORY SECONDARY TO DEMENTIA. ALSO, REMOTE HISTORY OF FRACTURED HIP..."."...HER (#501) POOR JUDGEMENT PLACES HER AT RISK FOR DECLINE...". A REVIEW OF RESIDENT #501'S ADMISSION NURSING assessment dated [DATE] DID NOT ADDRESS RESIDENT #501'S AMBULATORY STATUS, BUT DID INDICATE THAT RESIDENT #501 NEEDED PHYSICAL AND OCCUPATIONAL THERAPY. RESIDENT #501'S PHYSICAL THERAPY (PT) EVALUATION DATED [DATE] INDICATED THAT RESIDENT #501 WAS AT MODERATE RISK FOR FALLS AND HAD POOR FALL RECOVERY. THE PHYSICAL THERAPY EVALUATION NOTE FURTHER DOCUMENTED: "...PRECAUTIONS/COMPLICATIONS: DECREASED MEMORY, FALL RISK, DECREASED SAFETY AWARENESS...". "...RESTRAINT USE: W/C (WHEELCHAIR) SEATBELT..." A REVIEW OF RESIDENT #501'S FALLS CARE PLAN, REVISED [DATE], DOCUMENTED: "...RISK FOR FALLS CHARACTERIZED BY HISTORY OF FALLS, INJURY, MULTIPLE RISK FACTORS RELATED TO VASCULAR DEMENTIA, TREMORS, ANTIPSYCHOTIC USE...". RESIDENT #501'S FALL CARE PLAN LISTED THE FOLLOWING INTERVENTIONS: "...TRANSFER AND CHANGE POSITIONS SLOWLY...". "..ENCOURAGE RESIDENT (#501) TO USE HAND RAILS OR ASSISTIVE DEVICES PROPERLY, USE OF GAIT BELT FOR TRANSFERS, STANDARD LAVY (BATHROOM) CHAIR, WHEEL CHAIR AND WHEELED WALKER...". "...TWO (2) ASSISTS UNTIL REEVALUATED BY PT ESPECIALLY WITH AMBULATION...". RESIDENT #501'S FALLS CARE PLAN REVEALED THAT RESIDENT #501 fell (LOWERED TO FLOOR) ON [DATE] AND AGAIN ON [DATE]. FURTHER RECORD REVIEW OF THE FACILITY'S INCIDENT/ACCIDENT REPORTS REVEALED ON [DATE], RESIDENT #501 WAS OBSERVED "SITTING ON BOTTOM ON BATHROOM FLOOR." "...AFTER REMOVING ROBE, RESIDENT #501 BEGAN TO TURN TO SIT ON WALKER AND SAT BEFORE SHE WAS ALIGNED WITH SEAT. CNA LOWERED HER TO THE FLOOR AND NOTED AT THAT TIME LEFT LEG WAS CAUGHT IN LEGS OF WALKER...". "...RESIDENT #501 LOST BALANCE...". THE INCIDENT/ACCIDENT REPORT IDENTIFIED THAT RESIDENT #501 WAS TAKING "PSYCHOTROPIC MEDICATIONS" AND HAD "BALANCE DIFFICULTIES - LEG WEAKNESS." ON [DATE], RESIDENT #501 WAS OBSERVED "SITTING ON BOTTOM WITH BACK AGAINST RECLINER CHAIR." "...RESIDENT'S DPOA STATES THAT SHE WAS TRANSFERRING RESIDENT FROM HER WHEELCHAIR TO HER RECLINER CHAIR WHEN HER LEGS JUST GAVE OUT ON HER AND THE DPOA HAD TO LOWER THE RESIDENT TO THE FLOOR...". FURTHER, RESIDENT #501'S FALLS CARE PLAN INDICATED THAT RESIDENT #501'S RESTRAINT FREE ALARMS (RFA) WERE RE-ORDERED TO BE APPLIED TO HER CHAIR AND BED AT ALL TIMES EFFECTIVE [DATE]. THERE WAS NO DOCUMENTED EVIDENCE IN RESIDENT #501'S CLINICAL RECORD THAT INDICATED THAT RFA'S/SENSOR ALARMS OR ANY OTHER PREVENTIVE INTERVENTIONS WERE IMPLEMENTED PRIOR TO RESIDENT #501'S FALL ON [DATE] WHICH RESULTED IN HER (#501) DEATH. A REVIEW OF RESIDENT #501'S COGNITIVE LOSS CARE PLAN, REVISED [DATE], DOCUMENTED "...RESIDENT #501 HAS VASCULAR DEMENTIA AS EVIDENCED BY SHORT TERM MEMORY LOSS, PERIODS OF INCREASED CONFUSION AND POOR SAFETY AWARENESS...". A REVIEW OF RESIDENT #501'S MOOD CARE PLAN, REVISED [DATE], DOCUMENTED "...RESIDENT #501 HAS VASCULAR DEMENTIA AND HAS POOR SAFETY AWARENESS...". "...RESIDENT #501 IS NOT AWARE OF HER LIMITATIONS...". ON [DATE] AT 10:00 A.M., DURING AN INITIAL TOUR OF THE FACILITY, WHILE ACCOMPANIED BY THE ASSISTANT HEALTH SERVICES DIRECTOR (AHSD), THE AHSD REPORTED THE FOLLOWING: "...SHE (#501) WAS IN HER RECLINER AND SHE GOT UP BY HERSELF AND fell . HER CALL LIGHT WAS ATTACHED TO HER CHAIR. MOST TIMES SHE WOULD USE THE CALL LIGHT WHEN SHE NEEDED ASSISTANCE...". WHEN ASKED IF RESIDENT #501 HAD ANY TYPE OF ALARM SYSTEM IN PLACE TO ALERT STAFF IF SHE (#501) WOULD ATTEMPT TO SELF TRANSFER OR AMBULATE INDEPENDENTLY, THE AHSD SAID: "...SHE (#501) HAD A RESTRAINT FREE ALARM (RFA) (SENSOR ALARM) UNTIL NOVEMBER OF 2010...". WHEN ASKED IF RESIDENT #501 HAD AN RFA/SENSOR ALARM AT THE TIME OF THE FALL, THE AHSD SAID "NO". THE AHSD FURTHER REPORTED "...SHE (#501) DESIRED NOT TO HAVE AN ALARM ANYMORE. WE DID A TRIAL PERIOD AND SHE WAS SUCCESSFUL SO THE RFA/SENSOR ALARM WAS REMOVED IN NOVEMBER...". WHEN ASKED IF THERE WERE ANY OTHER ALARMS OR INTERVENTIONS PUT INTO PLACE ONCE THE RFA/SENSOR ALARM WAS REMOVED, THE AHSD SAID "NO". WHEN ASKED IF RESIDENT #501 HAD ANY FALLS SINCE THE RFA/SENSOR ALARM WAS REMOVED IN [DATE], THE AHSD SAID "...SHE (#501) HAD A FALL IN [DATE] AND THIS PAST SATURDAY..." (REFERENCING THE FALL ON [DATE] WHICH RESULTED IN RESIDENT #501'S DEATH). WHEN ASKED IF THE RESTRAINT FREE ALARMS/SENSOR ALARMS, OR ANY OTHER FALL PRECAUTIONS WERE PUT INTO PLACE AFTER RESIDENT #501 fell IN [DATE], THE AHSD SAID "...NO, WE DIDN'T PUT THE RFA BACK INTO PLACE...". THE AHSD COULD NOT EXPLAIN WHY NO INTERVENTIONS WERE PUT INTO PLACE IN DECEMBER OF 2010 AFTER RESIDENT #501 fell . WHEN ASKED OF RESIDENT #501'S COGNITION, THE AHSD SAID "...SHE (#501) WAS ALERT AND ORIENTED AT TIMES, DEPENDING ON THE DAY...". WHEN ASKED HOW FACILITY STAFF BECAME AWARE THAT RESIDENT #501 HAD FALLEN, THE AHSD SAID THAT ONE OF THE FACILITY'S RESIDENTS (RESIDENT #505) WAS WALKING BY HER (#501) ROOM AND CALLED FOR HELP. ON [DATE] AT 11:25 A.M., AN INTERVIEW WAS CONDUCTED WITH RESIDENT #505 WHO REPORTED THE FOLLOWING: "...I (#505) WAS ON MY WAY TO LOOK AT SOME ART DOWNSTAIRS AND I PASSED BY HER (#501) ROOM. I HEARD A THUMP SO I TURNED AND SAW HER ON THE FLOOR IN HER ROOM. SHE (#501) WAS ON HER BACK WITH HER KNEES BENT. SHE KEPT YELLING "HELP, HELP" AND SHE WAS CRYING...". "...SHE WASN'T FAR FROM HER RECLINER. SHE DIDN'T REMEMBER TO CALL ANYBODY. SHE HAD MEMORY ISSUES...". "...I WAVED AND CALLED FOR THE STAFF TO COME AND HELP AND THEY CAME RIGHT AWAY..." ON [DATE] AT 11:56 A.M., AN INTERVIEW WAS CONDUCTED WITH LPN #1 WHO REPORTED THE FOLLOWING: "...I (LPN #1) WAS HER (#501) ASSIGNED NURSE ON [DATE]. THE FALL WAS BETWEEN 2:15 P.M. AND 2:30 P.M. BUT I WAS OFF THE FLOOR WHEN IT ACTUALLY HAPPENED...". "...I (LPN #1) LAST SAW HER (#501) AROUND 2:00 P.M.. I HAD TO GET HER VITAL SIGNS BECAUSE THE MIDNIGHT NURSE TOLD ME THAT SHE (#501) WASN'T FEELING WELL ON THE MIDNIGHT SHIFT AND COMPLAINED OF FEELING WEAK. SHE (#501) WASN'T FEELING WELL EARLIER THAT MORNING EITHER (MORNING OF [DATE]). SHE (#501) REFUSED BREAKFAST AND JUST WANTED TO SLEEP. AS PROTOCOL, WE ALSO CHECK VITAL SIGNS WHEN THE RESIDENTS HAVE HAD A FALL...". "...A COUPLE OF DAYS PRIOR, SHE (#501) BECAME REALLY WEAK AND STARTED TO FALL. HER DURABLE POWER OF ATTORNEY (DPOA) ASSISTED HER IN ORDER TO PREVENT HER FROM FALLING...". WHEN QUERIED ABOUT WHAT INTERVENTIONS WERE IN PLACE TO PREVENT FALLS, LPN #1 SAID "...SHE (#501) HAD A BLUE STAR ON HER DOOR AND HER CALL LIGHT...". WHEN ASKED IF RESIDENT #501 HAD ANY ALARMS OR OTHER FALL PREVENTION DEVICES IN PLACE TO PREVENT FALLS OR TO ALERT STAFF IF RESIDENT WOULD ATTEMPT TO SELF TRANSFER OR AMBULATE INDEPENDENTLY, LPN #1 SAID "...THERE WAS NO ORDER FOR FLOOR MATS, BED ALARMS OR CHAIR ALARMS AT THE TIME...". WHEN ASKED TO RECALL THE EVENTS THAT TRANSPIRED SURROUNDING RESIDENT #501'S FALL, LPN #1 SAID "...I RETURNED TO THE FLOOR AT 2:30 P.M., AND I WENT INTO HER (#501) ROOM AND OBSERVED HER SITTING IN HER WHEELCHAIR. LPN #2 WAS CHECKING HER VITAL SIGNS...". "...HER (#501) EYES WERE OPEN AND SHE WAS ABLE TO RESPOND TO QUESTIONS. SHE (#501) COMPLAINED OF HEAD PAIN AND I OBSERVED REDNESS AND SWELLING TO THE BACK OF HER HEAD. THE AREA ON THE BACK OF HER (#501) HEAD FELT HARD BUT THERE WERE NO OPEN AREAS OBSERVED...". "...I (LPN #1) ASKED HER WHAT HAPPENED AND SHE (#501) SAID SHE WAS TRYING TO GET OVER TO HER WHEELCHAIR. HER THOUGHTS WERE DISORGANIZED...". "...I (LPN #1) NOTIFIED THE DOCTOR AND HE SAID TO SEND HER OUT TO THE HOSPITAL..." ON [DATE] AT 12:34 P.M., AN INTERVIEW WAS CONDUCTED WITH CNA #1 WHO REPORTED THE FOLLOWING: "...SHE (#501) WOULD ALWAYS TRY TO DO THINGS ON HER OWN. I WOULD HAVE TO REMIND HER TO USE HER CALL LIGHT...". "...ON THE MORNING OF THE FALL ([DATE]), SHE (#501) WASN'T FEELING WELL. I GOT HER UP TO THE BATHROOM THEN SHE (#501) WANTED TO STAY IN BED AND SHE REFUSED HER BREAKFAST...". "...I WENT BACK TO CHECK ON HER (#501) AROUND 9:00 A.M., AND SHE TOLD ME TO LEAVE HER ALONE...". "...HER LEGS HAD BEEN GIVING OUT EVEN THE DAY BEFORE HER FALL. SHE COULD USE HER ROLLING WALKER BY HERSELF AT ONE POINT BUT THEN SHE NEEDED TO USE HER WHEELCHAIR...". "...SOMEONE HAD TO TRANSFER HER BECAUSE SHE WAS TOO WEAK AND HER KNEES WERE BUCKLING. EVEN ON THE 19TH, SHE WAS VERY WEAK AND HER KNEES WOULD BUCKLE. HER LEGS WOULDN'T HOLD UP...". WHEN ASKED TO RECALL THE EVENTS THAT TRANSPIRED ON [DATE], THE DAY RESIDENT #501 HAD FALLEN, CNA #1 STATED, "...I HEARD A RESIDENT CALL OUT THAT RESIDENT #501 HAD FALLEN. WE (CNA #1 AND CNA #2) RAN DOWN THERE AND SAW HER (#501) ON THE FLOOR ON HER BACK WITH HER KNEES BENT. HER (#501) HER HEAD WAS FLAT ON THE GROUND NEXT TO THE LEGS OF HER OVERBED TABLE...". "...I ASKED HER (#501) WHAT HAPPENED AND SHE SAID SHE WAS TRYING TO GET TO HER WHEELCHAIR AND fell . SHE (#501) SAID HER HEAD HIT THE LEGS OF THE TABLE AND IT BOUNCED AND BOUNCED AGAIN...". "...LPN #2, CNA #2 AND I (CNA #1) GOT HER UP IN HER WHEELCHAIR AFTER THE FALL AND I SAW REDNESS AND A LARGE AREA OF SWELLING ON THE BACK OF HER HEAD...". "...HER (#501) DPOA ARRIVED AND HELD ICE ON HER HEAD UNTIL EMS ARRIVED...". "...SHE (#501) COMPLAINED OF HOW BAD IT HURT. SHE JUST KEPT REPEATING HOW BAD HER HEAD HURTS...". WHEN ASKED WHY RESIDENT #501 WAS TRANSFERRED TO HER WHEELCHAIR INSTEAD OF IMMOBILIZING HER TO PREVENT THE POSSIBILITY OF FURTHER INJURY, CNA #1 SAID, "I JUST DID WHAT I WAS TOLD." ON [DATE] AT 3:52 P.M., AN INTERVIEW WITH THE HEALTH SERVICES DIRECTOR (HSD) WAS CONDUCTED. WHEN ASKED WHY RESIDENT #501'S RFA/SENSOR ALARM WAS NOT REAPPLIED PRIOR TO HER FALL ON [DATE] WHICH WOULD HAVE ALERTED STAFF IF RESIDENT #501 WOULD ATTEMPT TO SELF TRANSFER OR AMBULATE INDEPENDENTLY, THE HSD SAID, "...BECAUSE THE FALL WAS NOT RELATED TO HER GETTING UP ON HER OWN. SHE (#501) HAD BEEN USING HER CALL LIGHT IN THE PAST. THE TIME THAT SHE (#501) WAS IN THE BATHROOM, IT WASN'T REALLY A FALL SO WE WOULDN'T HAVE REAPPLIED THEM (ALARMS) AT THAT TIME...". WHEN ASKED WHAT INTERVENTIONS WERE PUT INTO PLACE IN LIGHT OF RESIDENT #501'S REPORTED WEAKNESS, LOSS OF BALANCE AND BUCKLING AT THE KNEES, THE HSD SAID "...THE INTERVENTIONS WERE JUST TO MAKE SURE WE GAVE CLEAR INSTRUCTIONS...". THE HSD FURTHER STATED THAT RESIDENT #501 WANTED THE RFA/SENSOR ALARM DISCONTINUED AND THEREFORE, IT WAS DISCONTINUED. WHEN ASKED IF RESIDENT #501'S DPOA WAS NOTIFIED THAT THE ALARMS WERE REMOVED, THE HSD OFFERED NO RESPONSE. THE HEALTH SERVICES DIRECTOR (HSD) COULD NOT EXPLAIN WHY RESIDENT #501'S RFA/SENSOR ALARM OR OTHER INTERVENTIONS WERE NOT PUT INTO PLACE TO ALERT STAFF TO RESIDENT #501'S ATTEMPTS TO SELF TRANSFER OR AMBULATE INDEPENDENTLY AND SUBSEQUENTLY PREVENT FALLS. ON [DATE] AT 11:40 A.M., THE PHYSICAL THERAPIST ASSISTANT (PTA)/PROGRAM DIRECTOR WAS INTERVIEWED. WHEN ASKED IF RESIDENT #501 WAS ASSESSED AS HAVING A NEED FOR A RFA/SENSOR ALARM, THE PTA STATED, "...WE PICKED UP THE CASE LOAD ON [DATE]. HER (#501) ENDURANCE WAS POOR ON ADMISSION. HER STANDING TOLERANCE GOAL WAS 15 MINUTES. HER STANDING TOLERANCE AT THE TIME OF THE FALL (ON [DATE]) WAS ,[DATE] MINUTES. SHE HAD LOWER EXTREMITY PAIN AND HIP AND KNEE ISSUES THROUGH HER HISTORY HERE...". "...SHE (#501) WAS ORDERED A RFA/SENSOR ALARM, CONTACT GUARD, MINIMAL ASSISTANCE AND USE OF A GAIT BELT WITH HANDS ON WHEN AMBULATING...". "...SHE (#501) WAS STILL CONTACT GUARD IN DECEMBER OF 2010 AND REQUIRED ASSISTANCE GETTING UP...". WHEN QUERIED ABOUT RESIDENT #501'S RFA/SENSOR ALARM BEING DISCONTINUED ON [DATE], THE PTA REPORTED "...SHE (#501) DIDN'T SET OFF HER ALARM. SHE USED HER CALL LIGHTS AND WAS COMPLIANT WITH REQUESTING WHAT SHE NEEDED...". WHEN ASKED ABOUT RESIDENT #501'S INCIDENT ON [DATE] WHERE RESIDENT #501 BECAME WEAK AND EXPERIENCED LOSS OF BALANCE WHILE IN THE BATHROOM, THE PTA SAID "...WE WOULD HAVE LOOKED AT THE ROOT CAUSE, WHICH WAS WEAKNESS...". THE PTA FURTHER STATED "...SHE (#501) HAD THE ALARM UNTIL [DATE]. LOOKING AT THE THERAPY DOCUMENTATION, I'M NOT SEEING THAT THE PHYSICAL THERAPY DEPARTMENT WAS INVOLVED IN THAT DECISION TO REMOVE HER ALARMS...". THE PTA REFERENCED A THERAPY NOTE IN RESIDENT #501'S CLINICAL RECORD, DATED [DATE] THAT REVEALED THE FOLLOWING NOTATION:"...RFA (SENSOR ALARM) TAKEN AWAY, BUT THIS THERAPIST STRONGLY DISAGREES DUE TO PATIENT'S (#501) LOSS OF BALANCE WITH ACTIVITIES, POOR POSTURE WITH STRIDE AND DECREASED SAFETY..." ON [DATE] AT 4:05 P.M., LPN #2 WAS INTERVIEWED AND REPORTED THE FOLLOWING: "...CNA #2 TOLD ME THAT SHE (#501) WAS ON THE FLOOR. I (LPN #2) WENT TO HER ROOM AND SHE WAS ON THE FLOOR IN A SUPINE POSITION WITH HER HEAD ON THE FLOOR. I ASKED RESIDENT #501 IF SHE WAS OK. SHE SAID "WELL, MY HEAD HURTS"...". "...WE GOT A GAIT BELT AND PUT IT AROUND HER AND GOT HER UP TO STAND. WE PUT HER IN HER WHEELCHAIR. THERE WAS SWELLING TO THE BACK OF HER HEAD...". WHEN ASKED IF RESIDENT #501 HAD ANY ALARMS IN PLACE TO ALERT STAFF WHEN SHE ATTEMPTED TO SELF TRANSFER AND AMBULATE INDEPENDENTLY, LPN #2 SAID "NO". WHEN ASKED WHO MADE THE DECISION TO MOVE RESIDENT #501 FROM THE FLOOR AND NOT IMMOBILIZE HER, LPN #2 SAID "THAT WOULD BE ME". LPN #2 FURTHER SAID "...I KNOW THAT I SHOULDN'T HAVE MOVED HER, BUT EVERYTHING JUST HAPPENED SO FAST...". ON [DATE] AT 9:40 A.M., CNA #2 WAS INTERVIEWED AND REPORTED "...RESIDENT #505 WAS YELLING THAT RESIDENT #501 NEEDED HELP. WE (CNA #1 AND CNA #2) RAN TO HER ROOM. SHE (#501) WAS MOANING AND CRYING OUT THAT HER HEAD AND BACK WAS HURTING. SHE (#501) SAID THAT HER HEAD BOUNCED. I (CNA #2) ASKED HER WHAT SHE WAS DOING AND SHE TOLD ME THAT SHE WAS TRYING TO GET TO HER WHEELCHAIR, WHICH WAS QUITE A DISTANCE FROM WHERE SHE WAS SITTING...". "...WE THOUGHT EVERYTHING WAS FINE. HER (#501) BLOOD PRESSURE WAS JUST HIGH. WE USED A GAIT BELT TO PUT HER IN HER WHEELCHAIR. SHE (#501) WAS SHAKING AND WANTED HER FRIEND (DPOA). SHE (#501) HIT REALLY HARD. SHE (#501) COMPLAINED OF DIZZINESS WHEN WE GOT HER IN IN THE WHEELCHAIR...". CNA #2 FURTHER REPORTED "...NORMALLY SHE WALKS WITH HER ROLLING WALKER, BUT ON THE 19TH AND 20TH I HAD TO TRANSFER HER WITH A WHEELCHAIR BECAUSE SHE SAID HER LEGS WERE TOO WEAK. SHE WAS REALLY WEAK AND WAS MOVING REALLY SLOW AND COMPLAINING OF LEG PAIN...". WHEN ASKED IF SHE (CNA#2) REPORTED RESIDENT #501'S COMPLAINTS OF WEAKNESS TO THE NURSING STAFF, CNA #2 SAID "...I TOLD LPN #1 BUT I'M NOT SURE WHAT SHE DID...". ADDITIONALLY, CNA #2 SAID "...HER (#501) MEMORY WAS OFF AND ON. SHE (#501) HAS FORGOTTEN TO CALL SOMEBODY FOR HELP IN THE PAST...". "...SHE WAS STUBBORN AND WANTED TO DO THINGS HER WAY...". ON [DATE] AT 11:00 A.M., RESIDENT #501'S DURABLE POWER OF ATTORNEY (DPOA) REPORTED "...THE STAFF CALLED ME AND I WENT TO HER (#501) ROOM. I FOLLOWED HER TO THE HOSPITAL. SHE (#501) WAS IN A COMA AND DIDN'T KNOW ANYBODY...". THE DPOA FURTHER SAID "...SHE (#501) CAME HERE FROM A MEMORY CARE UNIT BECAUSE HER MEMORY WASN'T THE GREATEST...". "...SHE (#501) WAS WEAK AND HER LEGS WOULD GIVE OUT...". WHEN ASKED IF SHE (DPOA) HAD BEEN MADE AWARE THAT RESIDENT #501'S RFA/SENSOR ALARM HAD BEEN REMOVED ON [DATE], THE DPOA SAID "...NO. I THOUGHT SHE HAD IT ALL THIS TIME...". ON [DATE] AT 5:14 P.M., THE ADMINISTRATOR WAS INFORMED OF THE IMMEDIATE JEOPARDY AS A RESULT OF THE FACILITY'S FAILURE TO PROVIDE ADEQUATE SUPERVISION AND FAILURE TO REAPPLY RESIDENT #501'S RESTRAINT FREE ALARMS (SENSOR ALARMS) TO ALERT STAFF WHEN AND IF RESIDENT #501 ATTEMPTED TO SELF TRANSFER OR AMBULATE INDEPENDENTLY. RESIDENT #501 SUBSEQUENTLY fell IN HER ROOM WHILE ATTEMPTING TO AMBULATE INDEPENDENTLY AND WITHOUT SUPERVISION ON [DATE]. RESIDENT #501 SUSTAINED A HEAD INJURY AND WAS TRANSFERRED TO A NEARBY HOSPITAL FOR EVALUATION AND TREATMENT. THERE, RESIDENT #501 WAS diagnosed with [REDACTED]. RESIDENT #501 WAS RETURNED TO THE FACILITY WHERE SHE (#501) SUBSEQUENTLY died on [DATE] AT 1:30 A.M. ON [DATE], THE SURVEYOR VERIFIED THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. ON [DATE] AT 1:30 A.M., RESIDENT #501 EXPIRED IN HER ROOM. 2. ON [DATE], FALL PREVENTION POLICY AND PROCEDURE WAS AMENDED TO DEFINE WHEN IT IS APPROPRIATE TO MOVE A RESIDENT AFTER SUSTAINING A FALL. 3. ON [DATE] FALL RISK PROCEDURES WERE UPDATED TO REFLECT A CHANGE IN FREQUENCY OF REASSESSING FOR FALL RISK. ALL RESIDENTS WILL BE ASSESSED UPON ADMISSION AND EVERY WEEK FOR THE NEXT FOUR WEEKS PLUS QUARTERLY AND WITH SIGNIFICANT CHANGE. 4. ON [DATE], FALL RISK ASSESSMENTS WERE COMPLETED ON ,[DATE] RESIDENTS WERE WERE CURRENTLY IN THE FACILITY. 5. ON [DATE], ,[DATE] RESIDENTS WERE REASSESSED FOR THEIR RISK FOR FALLS. 6. ON [DATE], ,[DATE] OF THE RESIDENTS IDENTIFIED AS FALLS RISKS WERE REASSESSED BY THERAPY STAFF. 7. ON [DATE], ,[DATE] OF THE RESIDENTS IDENTIFIED AS BEING AT RISK FOR FALLS WERE REASSESSED BY THE RESTORATIVE THERAPY NURSE. 8. ON [DATE], ,[DATE] OF THE RESIDENTS IDENTIFIED AS BEING AT RISK FOR FALLS HAD THEIR CARE PLANS REVIEWED AND UPDATED TO REFLECT IDENTIFIED NEEDS OF EACH INDIVIDUAL RESIDENT. 9. ON [DATE] AND [DATE], ,[DATE] RESIDENT CARE GUIDES WERE REVIEWED AND UPDATED WITH INTERVENTIONS AS APPROPRIATE. ,[DATE] RESIDENTS AT RISK FOR FALLING HAVE BLUE STARS AND YELLOW NAME TAGS AT THE DOORWAY TO THEIR ROOMS TO IDENTIFY THEIR FALL RISK STATUS. ,[DATE] RESIDENTS ARE ROUNDED ON EVERY TWO HOURS TO ENSURE A SAFE ENVIRONMENT. ,[DATE] RESIDENTS AT RISK FOR FALLS HAVE RESTRAINT FREE ALARMS (RFA) IN PLACE. RESTORATIVE CENA'S (CERTIFIED NURSING ASSISTANTS) EVALUATE THE FUNCTIONALITY OF ANY RESTRAINT FREE ALARMS THAT ARE IN PLACE ON A WEEKLY BASIS. 10. AS OF [DATE], THE STAFF IN-SERVICED ON RISK FACTORS AND PREVENTION OF FALLS, WHAT TO DO IF A RESIDENT FALLS, AND ASSESSMENT AND APPROPRIATE INTERVENTIONS AFTER A FALL WHICH INCLUDED: 41 OF 44 NURSING STAFF, 74 OF 79 CNAS, 23 OF 25 HEALTH SERVICES MANAGEMENT STAFF, 31 OF 33 FOOD SERVICE STAFF, 16 OF 18 HOUSEKEEPING STAFF, 5 OF 5 ACTIVITY STAFF, 11 0F 11 PASTORAL CARE STAFF, 12 OF 14 THERAPY STAFF, 5 OF 5 MOTHER HOUSE MANAGEMENT STAFF, 5 OF 5 MAINTENANCE STAFF, 2 OF 2 INFORMATION SYSTEMS STAFF. ALL REMAINING STAFF WILL BE IN-SERVICED UPON RETURN TO WORK. WHILE THE IMMEDIATE JEOPARDY WAS REMOVED ON [DATE], THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF ISOLATED AND A SEVERITY OF THE POTENTIAL FOR MORE THAN MIMIMAL HARM DUE TO ALL STAFFS HAD NOT BEEN IN-SERVICED AND SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY.