Every finding on record at Imperial, A Villa Center

Based on observation, interview, and record review, the facility failed to ensure tube feeding (liquid nutrition administered via a tube placed into the stomach) was administered at the ordered rate for one resident (R9) of two reviewed for tube feeding. Findings include: On 04/22/2026 at 8:22 AM, R9 was in bed with the head of the bed up around thirty degrees. R9 did not respond to any query. R9 was connected to tube feeding which was actively infusing at 70 milliliters per hour (ml/hr) via an electronic pump. A review of a 3/25/26 physician order for R9's tube feeding documented, Glucerna 1.5 Cals at 75 ml/hour x 18 hours . Start at 4 PM at stop at 10 AM the next day . On 04/23/2026 at 9:03 AM, R9 was in bed with the tube feeding actively infusing at 70 ml/hr via an electronic pump. On 04/23/2026 at 9:48 AM, Licensed Practical Nurse (LPN) B was queried about the tube feeding rate for R9. LPN B reviewed their report sheet from the night nurse which documented the tube feeding rate for R9 was 70 ml/hr. LPN B reviewed the rate with Unit Manager C who reported the rate should be set at the ordered rate of 75 ml/hr and was not aware of any reason the tube feeding rate was set lower. On 04/23/2026 12:07 PM, the Registered Dietitian (RD) reported they had put R9 on the tube feeding due to significant weight loss and poor food acceptance and was not aware of any reason the rate was at 70 ml/hr. A review of the facility records for R9 revealed R9 was admitted into the facility on [DATE]. Diagnoses included Stroke and Difficulty Swallowing. The active care plan initiated 02/13/26 documented, at risk for malnutrition . Self-feeding difficulty . TF (tube feed) Glucerna 1.5 Cals at 75 ml/hr x 18 hours . A review of the Minimum Data Set (MDS) assessment dated [DATE] documented severely impaired cognition and R9 was dependent on staff for eating and all activities of daily living. A review of the progress notes by the RD dated 03/25/26 documented, .weight loss since admission. Weight loss is significant. Weight loss is (due to) d/t poor (by mouth) PO intake .Resident is currently (nothing by mouth) NPO . A review of the progress notes by the RD dated:-04/01/26 documented, .declining meals quite often . and,-04/15/26 documented, .Resident has behavior issues of declining meals and not responding to staff during mealtimes . A review of the facility policy titled, Nutritional Status Management effective 11/28/17 revealed, It is important to maintain adequate nutritional status to the extent possible to ensure each resident is able to maintain the highest practicable well-being . It is the practice. in accordance with the advance directive, to provide interventions to maintain, improve and respond to nutritional needs .

Based on observation, interview, and record review, the facility failed to ensure sufficient staff to timely administer medications to three residents (R90, R209, R240) of three reviewed for staffing concerns. Findings include: R90On 04/21/26 at 12:02 PM, R90 was observed lying in bed and reported their morning medications had not been given. A review of the April 21, 2026, Medication Administration Record (MAR) confirmed R90 had medications to be administer at 9:00 AM and had not been documented as given. At 12:58 PM, a check of the MAR revealed the morning medication for R90 had not been documented. At 1:29 PM, the Unit Manager C was with the medication cart and Licensed Practical Nurse (LPN) E at the doorway of R90's room. Unit Manger C walked away from the cart and LPN E came from inside the room back to the medication cart. The Medications that had not been documented as given timely were: Ferrous Sulfate (iron supplement), Polyethylene Glycol Powder (laxative), Multivitamin (supplement), Spironolactone (diuretic/water pill), Verapamil (lowers blood pressure), docusate sodium (stool softener), Keppra (anti-seizure medication), Potassium Chloride (supplement), and Pregabalin (for pain). Four of the nine medications not given timely were scheduled for two times a day.On 04/22/26 at 10:12 AM, Registered Nurse (RN) F was at door to R90's room about to administer medications. RN F said medications should be given an hour before or after the designated time.A review of the facility records for R90 revealed R90 was admitted into the facility 02/06/25. Diagnoses included Iron Deficiency Anemia and Seizures. The active care plan initiated 11/10/25 documented, .is on diuretic therapy . administer diuretic medications as ordered . The Minimum Data Set (MDS) dated [DATE] documented intact cognition with 13/15 Brief Interview for Mental Status (BIMS) score and setup assistance for eating and oral hygiene, dependence or substantial/maximal from staff for all other activities of daily living. R240On 04/21/26 at 1:10 PM, R240 was in bed with the head up around 45 degrees and dressed in a hospital style gown. R240 reported they had not received their 9:00 AM morning medications and that happens about once a week. R240 reported they had sharp pain with a 9/10 level in their leg and back. At 1:15 PM, the April 21, 2026, MAR was reviewed, and no medications had yet been documented as given. A review of the facility records for R240 revealed R240 was admitted into facility 03/19/25. Diagnoses included Iron Deficiency Anemia, High Blood Pressure, Pressure Ulcer of the Sacrum (lower back) and Disc Degeneration in the Lumbar spine. The MDS dated [DATE] documented intact cognition with a 15/15 BIMS score and required substantial/maximal staff assistance for bed to chair transfers, bathing and lower body dressing and partial/moderate staff assistance for upper body dressing and personal hygiene and setup for eating and oral hygiene.Further review of the April 21, 2026, MAR documented that R240 had their 9:00 AM medications administered at (time stamped at 14:04 [2:04 PM]). The following medications that had not been documented as given timely and four hours late were: Loratadine (allergies), Sertraline (anti-depressant), and Tamsulosin (urine retention). The as needed pain medication hydrocodone had not been documented as provided at the time of the interview.R209On 04/21/26 at 1:10 PM, R209 was asked if their 9:00 AM morning medications had been given, and a response was not provided. A review of the MAR for April 21, 2026, revealed R209's medications had not been documented as given.A review of the facility records for R209 revealed, R209 was admitted into the facility 08/01/25. Diagnoses included High Blood Pressure and Diabetes. The MDS dated [DATE] documented impaired cognition with a 6/15 BIMS score and the requirement of substantial/maximal assistance or dependence on staff for all activities of daily living.Further review of the April 21, 2026, MAR time stamped at 14:07 (2:07 PM) revealed, R209 had medications to be administered at 9 AM. The Medications that had not been documented as given timely and four hours late were: Amlodipine (blood pressure), Aspirin (blood thinner), Polyethylene Glycol (laxative), Dronabinol (appetite stimulant), and Magnesium (supplement). The Dronabinol and Magnesium were schedule for two times a day. On 04/22/26 at 4:46 PM, Unit Manager C reported they had a nurse call off (no show for work) and there were only two nurses for the unit instead of three. It was also reported LPN E was one of the newer nurses at the facility and been assisted by other staff but needed to work on time management. On 04/23/26 at 8:10 AM, the Director of Nursing (DON) reported they had heard about the concerns for late medications and reported they had a call off and additional staff did attempt to help out. A review of the staffing assignment sheet for 04/21/26 documented two nurses were assigned for the day shift. A review of the facility policy titled, Medication Administration-General Guidelines dated May 2022, revealed Medications are administered as prescribed in accordance with good nursing principles and practices .

This citation pertains to Intake 2971921.Based on observation, interview, and record review, the facility failed to reorder pain medication in a timely manner for two residents (R139 and R151) out of two reviewed for pain management. Findings include: R139 On 04/21/2026 at 9:36 AM, R139 was lying in bed in their room and reported they had not received their methadone (for chronic pain) in three days. R139 reported this was not the first time the facility had failed to administer their methadone timely. R139 reported they were irritable and in pain and felt they were going into withdrawal (sweating). R139 reported they felt the facility did not care. A review of the physician order dated 01/16/26 documented, Methadone HCL Oral Tablet 10 mg (miligram), Give eight tablet(s) one time a day for pain. A review of the Medication Administration Record (MAR) for April 2026 revealed the methadone was documented as not given for last three days (04/19, 04/20 and 04/21/26). The Electronic MAR (EMAR) progress notes indicated the methadone to be on order for those days. On 04/23/2026 at 10:17 AM, Unit Manager C reported they were aware R139 had been out of their methadone for a day or so and reported it was due to a fax machine not working after a power failure and further noted a second fax machine was available. On 04/23/2026 at 1:28 PM, the Director of Nursing (DON) contacted the pharmacy, and it was noted the facility backup medication list revealed a quantity of five (5) 10 mg Methadone tablets. No backup medication removal requests had been made for the dates the methadone was not documented as administered. A review of the facility records for R139 revealed, R139 was admitted into the facility on [DATE]. Diagnoses include Opioid Abuse and Post Traumatic Stress Disorder. The active care plan initiated 12/22/25, titled, has a potential for alteration in comfort related to diagnosis of pain revealed, Administer pain meds and treatments as ordered . A review of the Minimum Data Set (MDS) assessment dated , 03/23/26 documented R139 with intact cognition and independent for activities of daily living. A review of the progress note dated 04/22/2026 at 08:12 AM revealed, Writer faxed Methadone script on 4/20/26 to pharmacy. Pharmacy stated they did not receive it. Writer faxed script to doctor's office on 4/21 after pharmacy stated they haven't received a faxed script. Writer called pharmacy again today 4/22/26.Pharmacy stating they have not received a script yet. Writer faxed signed script again this morning. Writer will call pharmacy shortly to make sure they received it . A review of the 04/21/2026 at 8:07 AM Electronic Medication Administration Record (EMAR) - Note revealed, Methadone (hydrochloride) HCl Oral Tablet 10MG Give 8 tablet by mouth one time a day for pain on order . A review of the 04/19/2026 at 1:25 EMAR - Administration Note revealed, Methadone HCl Oral Tablet 10 MG, give 8 tablets by mouth one time a day for pain, Awaiting pharmacy delivery . R151 On 4/22/2026 at 10:47 AM, an interview was conducted with R151. R151 stated they had been lying in pain all night and they were just now getting some medication to aid in pain relief. R151 reported they 'have gone days without receiving medications and they will be told their medication is on order. R151 reported they have not had their Lyrica (medication used to treat nerve pain) in days and it happens often. A review of the medical record revealed R151 was admitted into the facility on 3/16/2026 with the following medical diagnoses, Primary Generalized Osteoarthritis and Back Pain. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15/15 indicating an intact cognition and required staff assistance with bed mobility and transfers. A review of the physician's orders noted the following, Pregabalin (Lyrica) 75 MG (milligram) capsule.one capsule by mouth twice daily.Status: Active. Further review of the Medication Administration Record (MAR) for April 2026 revealed Lyrica was not administered on the following days, 4/18 at 9:00PM, 4/19 at 9:00AM and 9:00 PM,4/20 at 9:00 AM and 9:00 PM, 4/22 at 9:00 AM and 9:00 PM, and 4/23 at 9:00 AM, and followed by a MAR note stated the medication was on order. On 4/23/2026 at 10:15 AM, an interview was conducted with Licensed Practical Nurse (LPN) A. LPN A reported R151's Lyrica was not available for administration during their 9:00 AM medication pass. LPN A reported they need a new script and put it in the doctors log a couple of days ago, but pharmacy has still not received it. On 4/23/2026 at 12:42 PM, an interview was conducted with the Director of Nursing (DON). The DON reported they called the pharmacy and a new script is needed, however there was an authorization to pull from the back up and were calling the nurse practitioner to obtain a new script for the Lyrica. The DON said their expectation is for the nurse to call the physician and pharmacy when a medication needs a new script. A review of the facility policy titled, Medication Ordering and Receiving from Pharmacy dated May 2022 revealed, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances and medications classified as controlled substances by state law are subject to special ordering, receipt and record keeping requirements . Controlled substances should be reordered when a 3-5 day supply remains to allow for transmittal of the required written prescription to the pharmacist .

Based on observation, interview, and record review, the facility failed to change a Peripherally Inserted Central Catheter (PICC) intravenous (IV) line dressing timely for one resident (R130) of two residents whose PICC line dressings were observed. Findings include: On 04/22/2026 at 9:32 AM, R130 was observed at the entry to their room with a PICC line in the right upper arm. The transparent dressing which covered the PICC line insertion site was dated 4/11. The dressing was rippled and pulled away from the skin in places. R130 sat on their bed and said they had a post-surgical foot wound and was receiving an antibiotic via the IV PICC line an infection. On 04/23/2026 at 10:17 AM, Unit Manager C reported a registered nurse (RN) will generally complete the PICC line dressing change and it should be done every seven days. A review of the facility records for R130 revealed R130 was admitted into the facility on [DATE]. Diagnoses included Cellulitis (infection) of the Right Lower Limb and Sepsis (systemic infection). The Minimum Data Set (MDS) assessment dated [DATE] documented an intact cognition.A physician order dated 04/08/26 documented, Change PICC line dressing every seven days.The active care plan initiated 04/08/26 documented, .active infection septic arthritis, cellulitis, with osteomyelitis (bone infection) right lower extremity/ankle . administer IV (antibiotics) ABX as ordered . and .receiving IV ABX .dressing changes to IV site as ordered .A review of the Medication and Treatment Administration Records (TAR) for April 2026 revealed documentation of a change of the dressing on 04/14 (not the 4/11 date observed on the dressing). A review of the facility policy titled, Catheter Insertion and Care dated January 2026, revealed, The purpose of this procedure is to prevent complications associated with intravenous therapy . Perform site care at established intervals and immediately if the integrity of the dressing is compromised . Change the dressing if it becomes damp, loosened or visibly soiled and: at least every seven days for a TSM (transparent semi-permeable membrane) dressing; at least every two days for sterile gauze dressing including gauze under a TSM unless the site is not obscured .

Based on observation, interview, and record review, the facility failed to maintain care equipment in working order to protect one (R81) of three residents reviewed for accident hazards. Findings include: On 04/21/2026 at 9:19 AM, R81 was interviewed at the bedside and reported they needed a new wheelchair because the current one was old. R81 reported the wheelchair brakes were broken, and they didn't feel like the chair was safe. R81 proceeded to check the wheelchair brakes, revealing the left brake was loose and not applying any pressure to the wheel or stopping the wheel from rolling. R81 reported they had mentioned this to staff in the past and were told that it would be repaired and it never was. Review of the facility record for R81 revealed they were most recently admitted into the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease and Anxiety Disorder. The Minimum Data Set (MDS) assessment dated [DATE] indicated the resident required total assistance for transfers and their cognition was intact. R81's physician orders included an active order for two-person assist with mechanical lift transfers. On 04/21/2026 at 1:17 PM, R81 was observed sitting up in their wheelchair. When asked about being transferred into the wheelchair the resident reported that staff transferred them into the chair using the mechanical lift. R81 stated I could feel the chair moving, it makes me nervous. The left brake remained non-functional by not preventing the left wheel from moving. On 04/22/2026 at 11:00 AM, R81 was interviewed at bedside and reported no one had been in to repair or replace their wheelchair and it remained in the previously observed condition. On 04/23/2026 at 1:10 PM, R81 was interviewed at bedside with the facility Director of Nursing (DON) present. The DON was made aware of the left wheelchair brake not functioning and that the resident had been transferred into the chair on 04/21/26 after the wheelchair brake had been reported to be broken by the resident. The resident indicated they felt the wheelchair slipping as they were being lowered into the seat. The DON confirmed while setting up the wheelchair for a mechanical lift transfer, staff would then be aware that the brake was not working, and the chair should not be used until the brake is repaired. Review of the facility policy Fall Evaluation Safety Guideline dated 11/28/17 revealed the following entries:- The intent of this guideline is to ensure this facility provides an environment that is free from hazards over which the facility has control .- Identification of hazards and risk factors: (A) Environmental rounds (B) Quality assurance audits.- Education: (A) Education to staff, residents, and families on environmental hazards (B) Ensure that staff are properly trained with facility equipment.

Based on interview and record review, the facility failed to provide a bed hold (a notice provided to the resident or residents representative at time of transfer which offers the resident permission to return and resume residence in the nursing facility) to one resident (R232) out of two reviewed for discharges. Findings include: A review of the medical record revealed that R232 was admitted into the facility on 1/6/2026 with the following medical diagnoses, Shortness of Breath and Hypertension. A review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 9/15 indicating an impaired cognition. R232 also required staff assistance with bed mobility and transfers. Further review of the medical revealed the following progress note dated 3/6/2026, Resident's son and daughter reported to writer that they wanted . (name of resident) sent to the hospital with the belief that [they] had a stroke. Resident vital signs are wnl (within normal limits). Writer reported family concerns to NP (Nurse Practitioner). Writer received order to send resident to hospital for CT (Cat Scan) of the head to rule out possible stroke.Further review of the transfer evaluation form showed the Documents Sent.Bed Hold Form was not checked, indicating the bed hold form had not been provided to resident or resident representative prior to transfer to hospital.On 4/22/2026 at 3:06 PM, an interview was conducted with the Director of Nursing (DON). The DON stated they were looking for the bed hold form for R232 hospital transfer but was unable to find one.On 4/23/2026 at 10:04 AM, an interview was conducted with Unit Manager (UM) H. UM H was asked what the procedure was when someone transfers to the hospital and reported staff call transportation, complete the transfer form and provide a bed hold form. UM H reported the bed hold form is signed, if able and the secretary uploads it in the chart so it can be easily accessed.On 4/23/2026 at 10:43 AM, an interview was conducted with the Director of Nursing (DON). The DON reported any resident that transfers to the hospital should receive a bed hold form.A review of a facility policy titled, Bed Hold and Return Guideline noted the following, Resident and their representative will be provided with bed hold and return information at admission and before a hospital transfer or therapeutic leave.

Based on observation, interview, and record review, the facility failed to accommodate resident needs during meal service for one sampled resident (R171) of eight reviewed for resident choice. Findings include: On 4/21/26 at 10:29 AM, during the initial tour of the facility R171 was interviewed and reported some concerns regarding the unit assignment, clothes, and food. On 4/22/2026 at 1:20 PM, R171 was observed in a chair at their doorway, with the overbed table in front of them. On 4/22/2026 at 1:23 PM, R171's meal was delivered, R171 meal was observed to have two large, thick pieces of meat, carrots, pudding, a cup of juice, and a fork. R171 was observed to ask the staff for a knife to cut the meat. The staff reported to R171 they can't have a knife, but they can get R171 a spoon. The staff person returned with a spoon, R171 was observed to try and cut the meat with their spoon. R171 was observed to push the spoon into the meat multiple times to break off a piece of meat. The staff person was asked the reason R171 could not have a knife and reported this unit has no knives. R171's meal ticket was noted, Standing orders: 8 (Fl) fluid oz (ounces) apple juice, 8 Fl oz milk whole. A review of R171's medical record noted, R171 was admitted to the facility on [DATE] with diagnosis of Dementia. A review of R171's admission Minimum Data Set (MDS) assessment noted R171 with an impaired cognition and required some assistance with activities of daily living (ADL's). On 4/22/2026 at 1:37 PM, the Dietician (RD) was asked about the missing knives and standing orders items that were missing from R171's meal tray. The RD reported standing order items are to be on the tray every meal. The RD reported the unit does not have knives and the resident's meal ticket would note if the resident needs assistance with meal set up, which includes cutting food items. On 4/23/2026 at 2:15 PM, the Director of Nursing (DON) was asked about R171 not receiving proper utensils to cut their meat. The DON reported if R171 needed their meat cut, the staff person should have either gave the knife, observed the resident with the knife, removed the knife once the resident was done, or assisted by cutting the items. A review of the facility's policy titled, Activities of Daily Living dated 5/7/2020, Purpose: Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, our facility provides necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. Guideline: In accordance with comprehensive assessment, together with respect for individual resident needs and choices our facility provides care and services for the following activities:. Dining: eating, including meals and snacks.

This citation pertains to intake 2627267.Based on observation, interview, and record review, the facility failed to implement fall care plan interventions for three sampled residents (R901, R902, and R903) of three reviewed for fall interventions. Findings include:A review of the intake summary noted, . after assisting [R901] off the toilet and returning R901 to [their] wheelchair, staff did not properly secure [R901] or ensure [R901] was seated fully in the chair. As a result, [R901] fell to the floor. On 12/16/25 at 11:50AM, R901 was observed in their room in bed and was asked about the fall and explained they remember the fall but not the details regarding the fall. R901 was asked if they had any concerns with how the fall was handled and reported no concerns. A review of R901's progress note revealed, 9/25/2025 12:11 IDT (Interdisciplinary Team) Note: writer spoke with resident regarding fall. resident stated that she does not know what happened but that she began sliding out of the chair. resident did state that she had a dry towel between her bottom and the cushion. resident allowed writer to performative ROM (range of motion) assessment, resident completed with no difficulty. Further review of R901's medical record revealed, R901 was admitted to the facility on [DATE] with diagnosis of metabolic encephalopathy (brain dysfunction). A review of R901's care plan noted, Focus: The resident is at risk for falls/injury r/t decreased mobility and weakness, HTN (Hypertension), CAD (Coronary artery disease), Diabetes, Anemia, episodes of incontinence, possible medication side effects. Date Initiated: 09/28/2025. Goal: Reduce serious injuries from falls. Date Initiated: 09/24/2025 Target Date: 03/16/2026. The resident will be free of minor injury through the review date. Date Initiated: 06/11/2025. Interventions: Event 9/24/25 Sent to ER (emergency room) for further evaluation - diagnostics at hospital stable. Will monitor for s/s (signs/symptoms) of poor positioning/ fatigue (upper physical torso) - Will add dycem (nonskid pad) and removed the towel Date Initiated: 09/24/2025. 902On 12/16/25 at 12:57 PM, R902 was observed to walk to the nurse's station with their bare feet, without any footwear on. R902 was asked by staff to put on some socks. R902 agreed and was observed to walk to their room. On 12/16/25 at 2:53PM, R902 was observed walking on the unit with socks on their feet, the socks appeared to have no grips on them.A review of R902's last fall on 11/8/2025, Resident observed sitting on [R902] buttocks on the floor on the right side of R902's bed. Resident was wearing (brand name slip on shoe), call light in reach and off. Resident stated that [R902] tripped by the phone cord while [R902] was trying to get out of the bed . Further review of R902's medical record revealed, R902 was admitted on [DATE] with diagnosis of alcohol abuse withdrawal delirium and with a cognition was assessed as impaired A review of R902's Care plan noted, Focus: R902 has impaired cognitive function or impaired thought process r/t (related to) Delirium, Alcohol use disorder. Resident sometimes has difficulty with decision-making, insight, logic, planning, and organization of thoughts. Date Initiated: 11/10/202. Goal: [R902] will demonstrate increased orientation, awareness, and comfort. Date Initiated: 11/10/2025. Interventions: Provide resident with cues and prompting and demonstration as needed. Date Initiated: 11/10/2025. Focus: FALL: Resident is at high risk for falls r/t: Cognitive deficits, Functional Deficits, History of Falls, Use of Diuretics, Use of Psychotropic Medication Date Initiated: 11/11/2025. Goal: Reduce serious injuries from falls. Date Initiated: 11/13/2025. Interventions: Event 11/8/25 Encouraged to wear nonskid socks. Remote control is place back to bed so she can adjust the bed to low position - encouraged. R903On 12/16/25 at 2:53PM, R903 was observed sitting in their wheelchair near the nurse's station, their wheelchair wheels were observed in the unlocked position. R903 position was observed leaning forward towards their legs. A review of R903's medical record revealed, R903 was admitted to the facility on [DATE] with diagnosis of Epilepsy. Care plan: Focus: [R903] has impaired cognitive function/dementia or impaired thought processes r/t (related to) dementia, encephalopathy. Date Initiated: 01/12/2024. Goal: [R903] will be able to communicate basic needs on a daily basis through the review date. Date Initiated: 10/10/2025. Interventions: Monitor cognitive decline for further progression of the disease process. Date Initiated: 07/16/2024. Focus: The resident is at risk for falls r/t (related to) Confusion, Gait/balance problems. [R903] gets up and down from his chair, unaware of [R903] limitations and decreased safety awareness, [R903] is impulsive, and attempts to ambulates. Seizure Subdural hematoma (chronic) Subarachnoid hemorrhage Delirium Known for self-lowering to the ground Date Initiated: 10/07/2023. Goal: Reduce serious injuries from falls. Date Initiated: 05/08/2025 Target Date: 01/08/2026 The resident will be free of minor injury through the review date. Date Initiated: 10/07/202. Interventions: Ensure bed brakes are locked Date Initiated: 07/16/2024. On 12/16/25 at 3:00PM, Unit Manager A was asked if R902 and R903 were at risk for falls and the type of socks R903. The unit manager explained they both are fall risk and that the wheelchair should be locked and socks with gripers are to be worn. A review of the facility's policy titled, Revised: Fall Evaluation Safety Guideline dated, 11.28.17 revealed, Purpose: To consistently identify and evaluate residents at risk for falls and those who have fallen to treat or refer for treatment appropriately and develop an organization-wide ownership for fall prevention to: To achieve each resident's maximum potential of physical functioning. To prevent or reduce injuries related to falls. Fall Evaluation: A fall evaluation is used to identify individuals who have predicting factors for falls This is evaluation is completed upon admission, quarterly, annually and with a significant change in condition. Fall prevention is achieved through an IDT1 approach of managing predicting factors and implementing appropriate interventions to reduce risk for falls.

This citation pertains to Intake 2648112. Based on observation, interview, and record review, the facility failed to identify elopement risk and implement interventions to safeguard one (R901) of one resident, resulting in R901 exiting the front door of the facility on 9/8/25 and again on 10/11/25 without staff awareness of the resident's whereabouts. The Immediate Jeopardy (IJ) was identified on 9/8/25 at 4:08 PM, as a result of failure to identify an elopement risk resident and implement interventions to prevent further elopement leading to a second time exiting the facility and the likelihood of other residents affected due to lack of assessment that could lead to serious harm, injury, impairment or death. Findings Include:The Administrator was notified of the Immediate Jeopardy (IJ) on 10/23/25 at 10:30 a.m.The Immediate Jeopardy began on 9/8/25. A plan to remove the immediacy was requested. The IJ was removed on 10/11/25, based on the facility's implantations of the plan of removal as verified by the Surveyor on site. Although the IJ was removed, the facility's deficient practice was not corrected and remained isolated with potential harm. A review of a complaint called into the State Agency noted, [R901] was let out the front door (on 10/11/25) by the receptionist . the receptionist thought [R901] was a visitor and let [R901] out the front door. [R901] doesn't even look like a visitor and [R901] is confused all the time. They finally found [R901] walking down the street .On 10/22/25 at 10:30 AM, R901 was observed walking around on the secure unit speaking loudly and at times knocking hard on a locked door. At 10:49 AM, Receptionist B was asked if they were working on 10/11/25 when R901 exited the facility and reported they were not at work that day and said the receptionist on duty (Receptionist A) at the time thought R901 was a visitor and buzzed (deactivating the alarm and unlocking on the front door) and let them out.At 10:52 AM, Receptionist A was asked about the 10/11/25 incident with R901 exiting the facility. Receptionist A confirmed they buzzed R901 out the front door saying they thought R901 was a visitor explaining they were a new hired and didn't know all the residents. The receptionist went on to say R901 appeared at the front door with a jacket on their forearm and thought they saw a visitor's ID tag on their shirt when later they found out R901 was outside. Receptionist A explained this was not the first time R901 left the building and had done so during Receptionist G's shift but was unable to recall the date. On 10/23/25 at 10:36 AM, Receptionist G confirmed R901exited the facility on 9/8/25 at approximately 4:08 PM, when the resident walked out following kitchen staff when they (Receptionist G) buzzed the staff out. Receptionist G was asked what they did after noticing R901 left out the building and reported they called Supervisor C. On 10/23/25 at 12:04 PM, the Receptionist Supervisor (Supervisor C) was queried regarding R901 exited out of the building on 9/8/25. Supervisor C confirmed R901 was buzzed out by Receptionist G. Upon being notified, Supervisor C went outside and found R901 standing at the end of the walkway under the car port and along with the Assistant Nursing Home Administrator E (ANHA E), assisted R901 back into the building. The supervisor was queried about R901's subsequent exit from the facility on10/11/25 and explained they received a call from the facility during the afternoon shift that R901 was buzzed out by Receptionist A. On 10/23/25 at 12:47 PM, the ANHA E was asked about R901 exiting the building on 9/8/25, and the ANHA E explained R901 was found under the car port with Supervisor C around 3:30 PM. The ANHA E further explained that the incident was reported to the DON (Director of Nursing), as a request was made to have the DON bring a wheelchair in order to assist with escorting R901 back into the building. A review of R901's medical record revealed, R901 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Schizophrenia (mental health disorder), and noted with severely impaired cognition, a high fall risk, and behaviors needing redirection. An admission elopement risk assessment dated [DATE] indicated R901 as low risk for elopement. No elopement risk assessment was completed/updated, or care plan was developed with interventions to safeguard the resident from further exiting attempts following the residents exit from the facility on 9/8/25. A nursing progress note dated 9/26/25 documented. Resident redirected.A nursing progress note dated 9/28/25 documented, Resident continues to have behaviors. Resident is very loud and experiencing auditory and visual hallucinations related to (r/t) schizophrenia diagnosis. Resident has to be constantly redirected .No elopement risk assessment was completed/updated following identified behavior of needing constant redirection. On 10/22/25 at 2:59 PM, Certified Nurse Assistant (CNA) F, who was familiar with R901 was queried. CNA F reported they were driving to the facility (on 10/11/25) when they observed R901 standing in the road at a stop sign, with their head down. CNA F explained they recognized the resident to be R901. CNA F said they got out of their car and walked up to R901 and asked them if they needed a ride and placed R901 into their car and drove R901 back to the facility at approximately 4:23 PM. CNA F reported they found R901 about two and a half blocks away from the facility and the resident appeared tired and listless. CNA F was asked if they were aware that R901 exited the building on 9/8/25 and stated, No. On 10/23/25 at 2:10 PM, R901's assigned nurse, Licensed Practical Nurse D (LPN D) was asked about the day R901 eloped on 10/11/25. LPN D explained R901 was out of their room doing their normal routine, which is walking up and down the halls and sitting in the lobby. LPN D explained they didn't know R901 had left the building until the front desk staff called to the unit. LPN D was asked if they were aware that R901 exited the building on 9/8/25 and stated, No.On 10/23/25 at 2:39 PM, the DON was asked about the incident on 9/8/25 and explained, they were made aware of R901 exiting the building by ANHA E and was present when the staff entered back into the building with R901. The DON was asked what was done after R901 exited out of the building on 9/8/25, the DON explained they did not identify R901 as an elopement risk, which did not prompt a reassessment for elopement or new care plan with intervention to safeguard R901 from further elopement attempts. On 10/23/25 at 2:45 PM, the Nursing Home Administrator (NHA) was asked about the two times R901 exited out of the building and explained they in-serviced the receptionist to correct the exits. A review of the facility's policy titled, Wandering and Elopement Guideline dated 3/16/2017 notes, The facility will provide the lease restrictive and safe environment for wandering residents at risk for elopement . Process: Upon admission, re-admission, through quarterly review and change in condition our residents will be evaluated for potential elopement risk to determine appropriate placement within the facility. Information will be obtained from representatives, observation, social history and resident interviews. At any time during a resident stay there may present indication of an elopement risk. Example: Making statements of wanting to leave, attempting to actively exit or wear coat making statements of have an appointment etc . Plan for Removal (F Tag 689) 10/23/25The facility is providing the following information to demonstrate that the immediacy of the cited deficiencies has been removed.RESIDENT AT RISKResident continues to reside in the facility and safety has been maintained. On 10/23/2025 Resident wander assessment completed with a score of 21. On 10/23/2025 Resident Care plan was reviewed by IDT and updated.Resident will continue to be monitored by psych for behaviors and medication management.IDENTIFYING OTHER RESIDENTS AT RISKResidents who are assessed as an elopement risk have the potential to be affected.On 10/23/2025 residents residing in the facility were reassessed for risk of elopement to identify those at risk.On 10/23/2025 a 100% audit was completed by the facility's clinical management team on all residents who trigger for elopement risk.Residents deemed at risk for elopement had a care-plan review to ensure appropriate interventions are in place.Residents deemed at risk for elopement are in all facility elopement binders. Binders are located on the nurse's unit and at the reception area.PROCESSES IMPLEMENTED TO PREVENT FURTHER OCCURRENCE On 10/23/2025 in-servicing for staff was initiated by DON/Designee on the elopement guideline.On 10/23/2025 to the facility took measures to ensure signage is visible throughout the building for staff and visitors to be aware of residents who may be around when walking though doors. On 10/23/2025 in-servicing for licensed nurses initiated by the DON/ Designee on ensuring a resident re assessed for wandering when showing behaviors to ensure accuracy of care plan and interventions. MONITORINGThe DON/ Designee will review 5 residents who are at risk for elopement to ensure wander/elopement assessments are current and interventions are accurate weekly x 4 weeks, then monthly x 3 months to ensure adherence to the facility's guidelines and practices.Results will be reported to the QA committee for monitoring and follow-up.The DON is responsible for substantial compliance of this Plan of Action.The facility alleges the immediacy of these discrepancies have been removed on 10/23/2025

This citation pertains to intake 2572680.Based on interview and record review, the facility failed to assess one resident (R702) prior to dialysis treatment out of one reviewed for dialysis. Findings include:A review of the medical record revealed that R702 was admitted into the facility on 7/22/2025 with the following medical diagnoses, End Stage Renal Disease and Obstructive Sleep Apnea. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition. R702 was also dependent on staff for bed mobility and transfers.A review of a dialysis communication form dated 7/23/2025 was completed and the only portions filled out were the patient's name, date and pre dialysis weight. The vital signs portion, code status, pain, any changes in condition, as well as the completed by (name and title) were noted to blank.On 7/29/2025 at 1:34 PM, an interview was conducted with the Director of Nursing (DON). The DON stated they expect residents to be assessed prior to going to dialysis, whether it be on the communication form or in the resident electronic medical record. The DON reported R702 chair time was 10:00 AM and they should have been assessed before going to dialysis, with the communication form filled out in its entirety.A review of a facility policy titled, Dialysis noted the following, .Communication between outpatient dialysis provider and facility should include: Written communication form with review of daily weights, any changes in condition or mood.

This citation pertains to intake 2572680.Based on interview and record review, the facility failed to implement care plan interventions for one resident (R702) out of three reviewed for care plans. Findings include:A review of the medical record revealed R702 was admitted into the facility on 7/22/2025 with the following medical diagnoses, End Stage Renal Disease and Obstructive Sleep Apnea. A review of the most recent Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition. R702 was also dependent on staff for bed mobility and transfers.A review of a care plan revealed the following interventions, Oxygen Settings: O2(Oxygen) via NC (Nasal Cannula) at 3 LPM (Liters Per Minute)/PRN (As Needed). Date initiated: 7/23/2025. 1500 ml (milliliter) fluid restriction-Dietary 780 ml, Nursing 720 ml (240ml AM, 240 ml PM,240 ml MN (Midnight)) d/t (due to) edema, diuretic usage and hospital dietary orders.Further review of the current physician's orders revealed there was not an order for fluid restrictions or oxygen for R702.On 7/29/2025 at 12:55 PM, an interview was conducted with Registered Dietitian (RD) A regarding the care plan intervention for the fluid restriction. RD A stated they were corporate and helping at the facility. RD A reported R702 was on dialysis and a fluid restriction is usually a standard order when someone is on dialysis. RD A reported a physician's order should have been put in before entering information on a care plan. On 7/29/2025 at 1:34 PM, an interview was conducted with the Director of Nursing (DON) regarding the oxygen care plan intervention. The DON reported they were unsure why there was an intervention for oxygen and why the MDS Nurse entered it. The DON reported that it was communicated on their admission notice form, however, it was not entered as a physician's order. The DON reported it should have been entered as a physician's order if it was needed.A review of a facility policy titled, Care plan Standard Guideline did not address implementation of interventions.

Based on interview and record review, the facility failed to transfer one (R901) of one resident to a higher level of care after complaints of unresolved, severe abdominal pain resulting in hospitalization . Findings include: On 5/14/25 at 9:23 AM, an interview was completed with Family Member A who explained on 5/6/25, R901 contacted them at approximately 5:00pm stating they were experiencing abdominal pain and the nurse provided them with a laxative. Family Member A further explained at approximately 1:26am, R901 again contacted them via phone screaming out in pain stating their abdomen continued to hurt. Family Member A further explained, they and R901 were advised by facility nursing staff the resident only wanted pain medication and if they were to leave the facility, they would have to sign out against medical advice (AMA), or if they left via EMS (emergency medical services), the resident would risk losing their bed. Family Member A explained R901 remained in the facility for 12 hours in pain and was eventually transferred to the hospital after contacting 911 on their own. Family Member A further explained R901 was admitted into the hospital for an ischemic bowel with bowel infarction (narrowing or blockage of one or more of the arteries or veins that supply the small intestine). A review of R901's medical record revealed they were admitted into the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease, Alcohol Induced Pancreatitis, Anxiety, Diaphragmatic Hernia without Obstruction or Gangrene. Further review revealed the resident was cognitively intact and required extensive assistance with bed mobility, transfers, dressing, and bathing. On 5/14/25 at 10:43 AM, Registered Nurse (RN) B was asked about the onset of R901's abdominal pain, and explained it started after dinner between 5-6:00pm on 5/6/25. A review of R901's medical record revealed the following progress notes: 5/6/2025 19:05 (7:05pm) Health Status Note . Resident c/o (complain of) of Bilateral Upper quadrant excoriated abdominal pain. followed by N/V (nausea and vomiting). Emesis x 2 (vomiting two times) noted. PRN (as needed) famotidine (acid reducer) and lactulose (used to treat constipation) given unsuccessful. Zofran (prevents nausea and vomiting) unsuccessful. Daughter at bedside. MD (medical doctor) called, new order for one time enema and stat abdominal X-ray received. Will carry on and monitor for any change in the POC (plan of care). 5/7/2025 02:01 (2:00am) Note Text: Resident complaining of stomach pain. Screaming out, and having diarrhea. [physician] notified at start of shift. At approx (approximately) 0130 (1:30am) residents daughter called and asked if she could send resident to the hospital. [Physician] notified of situation, one time dose of narcotic pain medication ordered at this time. Resident accepted pain medication, but continues to scream out in pain. Supervisor and DR (doctor) aware. X-ray results pending at this time. 5/7/2025 02:39 (2:39am) Health Status Note. Resident called EMS (emergency medical services) for abdominal pain and wants 6am scheduled pain meds at 1am. Then resident said I am going AMA with my sister I don (do) not want any meds from your facility. Asked [physician] for break through pain med, Resident took her pain med and calm down. Sister called from home and said she is coming to take resident to hospital or sign AMA papers. She arrived to see resident, seen they were comfortable and left after talking to her. 5/7/2025 07:12 (7:12am) Health Status Note. Resident called 911 to go to [hospital]. Complaints of stomach pain and diarrhea. Resident has been yelling out through out entire shift, stating that the pain medications are not working. Complaints of hot/cold, sweating and chills. Resident was given Imodium after normal findings in xray results and a one-time dose of Methadone (controlled substance) at 0200 (2:00am) per DR (doctor) order. Resident was requesting 0600 (6:00am) dose of Methadone, DR declined dose because of 0200 dose that was given. At that time, resident called 911 for an ER (emergency room ) visit. Verbal report given to EMT/paramedics and RN at [hospital] . 5/7/2025 07:49 (7:49am) Health Status Note. Resident call again 911 this morning and transfer herself to [hospital] . On 5/14/25 at 11:49 AM, an interview was completed with Licensed Practical Nurse (LPN C) regarding R901, and they explained upon starting their 7:00pm shift on 5/6/25, R901 was back and forth to the bathroom with explosive diarrhea as they complained about severe abdominal pain that continued throughout the duration of her shift that ended at 7:00am on 5/7/25. LPN C explained at approximately 1:00am she was provided with an order to provide R901 with their 6:00am pain medication and explained the medication wasn't effective, as the resident continued with pain. LPN C was asked why R901 wasn't sent to the hospital and explained the nurse supervisor didn't agree the resident needed to go to the hospital, and somehow, EMS was sent away. On 5/14/25 at 1:18 PM, an interview was completed with Nurse Supervisor D regarding R901. Nurse Supervisor D confirmed the resident transferred herself to the hospital the morning of 5/7/25, and explained the resident had complaints of pain, and was asking for their pain medications earlier than what was ordered, but had been provided earlier per order from the physician. Nurse Supervisor D explained she was informed by the floor nurse that the resident slept throughout the night. However, acknowledged the resident's daughter arrived to the facility at approximately 2:00am where there was discussion regarding the resident leaving the facility AMA or going to the hospital. Nurse Supervisor D was asked about 911 being called to the facility, and explained if a resident contacts 911, they will in turn call the facility before coming out to ensure it's a legitimate emergency. Nurse Supervisor D was asked multiple times if she spoke to emergency services regarding R901 and stated, I don't know. On 5/14/25 at 1:29 PM, an interview was completed with Staff E, and was asked about the night of 5/6/25, when R901's daughter arrived at the facility at approximately 2:00am. Staff E explained the daughter called the front desk and asked about being able to visit as R901 had been complaining of pain. Staff E explained the daughter arrived and eventually left. Staff E explained the supervisor noted that R901 is not leaving, they just want pain medication. On 5/14/25 at 1:54 PM, an interview was completed with the Director of Nursing (DON) regarding R901 and asked why the resident wasn't sent to the hospital, and explained she was informed there wasn't a change in the resident's vitals and the resident slept throughout the night which wouldn't have prompted the facility to send the resident to the hospital. Regarding the resident calling 911 on their own, the DON explained 911 typically responds to calls from residents but acknowledged that they will at times call the facility regarding the concerns prior to arrival. A review of R901's hospital records dated 5/7/25 revealed a CT scan noting acute nausea, vomiting, with constipation .distended small bowel loops throughout the left upper quadrant and midline pelvis which demonstrate marked wall edema .these findings are worrisome for ongoing or impeding ischemia . A review of the facility's Transfer and Discharge policy did not address the resident't right to contact emergency medical services.

This citation pertains to Intake: MI00149953 Based on observation, interview, and record review, the facility failed to ensure room furnishings were maintained for ten of ten resident rooms (416, 417, 418, 419, 420, 423, 425, 430, 436, and 440) on Unit D and one (R47) of one resident reviewed for homelike environment. Findings include: On 02/24/25 at 7:23 AM during the initial screening of residents the following was observed: The end cap for the hand rail at left side room of 418 was missing; In room [ROOM NUMBER], a piece of vertical trim approximately four feet long was missing off the left hand corner of the wall as the room is entered. The trim had been laid on the floor behind the door. In room [ROOM NUMBER] the baseboard heater cover was hanging down to the floor on right side behind bed one; In room [ROOM NUMBER] the cover was off the baseboard heater behind the head of both resident beds the entire length of the wall, the sheetrock at the left side of the window, had crumbled away. The window was open about one inch and the fan on the floor had a build up of dust; In room [ROOM NUMBER] the edge molding was missing from the corner at right side of the closet for bed one; In room [ROOM NUMBER] the bathroom had a crack in the ceiling which appeared to have been patched but not painted and the cover for the baseboard heater was off and on the floor: In room [ROOM NUMBER] seven vertical holes were observed in the wall behind the television which was extended on an arm away from the wall; Above the doorway for room [ROOM NUMBER], 14 feet of crown molding was away from the ceiling and wall with the nails visible behind it; In room [ROOM NUMBER] the baseboard heater appeared to be without a cover along the entire length behind the head of the resident's beds: In room [ROOM NUMBER] the cover for the baseboard heater was angle down near the center area; In room [ROOM NUMBER], the cover for the baseboard heater was observed to hang down in middle area and a metal strap was holding the right side to the unit. On 02/26/25 at 11:30 AM, the identified environmental concerns were observed with and acknowledged by the Maintenance Director. A review of the closed work orders from the maintenance reporting log dated 12/01/24 to 02/25/25 documented one heating register repair on unit C out of the 200 work orders listed. Unit D included the 400 numbered rooms. 44750 R47 On 2/25/2025 at 2:28 PM, R47 was observed in bed laying down. Their nightstand was noted to be missing the covering for the drawer and all items inside the nightstand were visible. R47 stated their nightstand had been in that condition for quite some time and they were unsure how it came to look like that. R47 stated they had asked numerous times for the nightstand to be either fixed or replaced and it still had not been done. R47 stated they have not heard anything about when it would be fixed or replaced. A review of the medical record revealed that R47 admitted into the facility on [DATE] with the following medical diagnoses, Muscle Weakness and Contracture, Left Wrist. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition. R47 also required staff assistance with bed mobility and transfers. On 2/26/2025 at 11:13 AM, an interview was conducted with Maintenance Director (MD) E. MD E stated they do room rounds everyday and see if a drawer is broken and needs to be either replaced or fixed. MD E stated the floor staff also lets them know when something needs to be fixed and put it into TELS. MD E stated they would go and look at the drawer in R47's room. A review of a facility policy titled, Accommodation of Needs and Preferences and Homelike Environment Guideline noted the following, The objective of the accommodation of resident needs and preferences is to create an individualized, home-like environment to maintain and/or achieve functioning, dignity, and well-being to the extent possible in accordance with the resident's own needs and preferences . A homelike environment is one that de-emphasizes the institutional character of the setting . A determination of homelike should include the resident's opinion of the living environment .

Based on observation, interview, and record review, the facility failed to ensure that call lights were within reach for four residents (R71, R83, R86, and R115) of five reviewed for accomodation of resident needs. Findings include: Resident #86 (R86) On 2/24/25 at 8:10 AM, R86's call light was unable to be located in R86's room. R86 was interviewed about the location of their call light and was unsure of its location. On 2/25/25 at 12:41 PM, R86's call light was observed on the floor underneath the bed. Certified nursing assistant (CNA) F entered R86's room and was interviewed and asked where R86's call light was located. CNA F stated, It's right here and proceed to pick it up off of the floor and clipped it to R86's pillow. CNA F was further interviewed and asked where R86's call light should be located. CNA F indicated that [R86's] call light should be clipped to their pillow. A record review of R86's electronic medical record (EMR) revealed that R86 was most recently admitted to the facility on [DATE] with diagnoses that included Dementia and Muscle weakness. R86's most recent quarterly minimum data set assessment (MDS) dated [DATE] revealed that R86 had a Brief interview of mental status score (BIMS) of 3/15 which indicated a severely impaired cognition. R86 required supervision and cueing for all activities of daily living (ADLs). Resident #115 (R115) On 2/24/25 at 9:14 AM, R115's call light was unable to be located/observed in the their room. R115 was interviewed about the location of their call light and was unsure of its location. On 2/25/25 at 1:02 PM, No call light was observed in R115's room. R115 was interviewed about the location of their call light and stated, I don't have one. I could use one. On 2/25/25 at 1:07 PM, Nurse/RN (Registered Nurse) G was asked the location of R115's call light. Nurse G entered R115's room and stated, It looks like we are missing a call light. Nurse G indicated that that they would report this to maintenance and have them install a call light, Right away. On 2/26/25 at 9:54 AM, an observation was made of R115's call light cord and call light being draped over and behind a small table in R115's room located approximately three feet from where R115 was lying in their bed. The call light was behind the table and out of sight. On 2/26/25 at 10:02 AM, Unit Nurse Manager/LPN (Licensed Practical Nurse) (UNM) H was interviewed about their expectations for placement of residents' call lights in their rooms. UNM H indicated that during rounding staff should make sure that call lights are in place and within reach of the resident. A RR review of R115's EMR revealed that R115 was most recently admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease and Muscle weakness. R115's most recent quarterly MDS dated [DATE] revealed that R115 had a BIMS of 3/15 which indicated a severely impaired cognition. R115 required supervision to limited assistance for all ADLs other than eating. Resident #71 (R71) On 2/24/25 at 9:43 AM, R71's call light was observed to be on the floor underneath their bed. R71 was unable to reach or locate their call light when asked about it. On 2/25/25 at 1:26 PM, UNM/RN C was interviewed and asked about their expectation for placement of R71's call light. UNM C indicated that the call light should be clipped to [R71]. A review of R71's EMR revealed that R71 was most recently admitted to the facility on [DATE] with diagnoses that included Dementia and Muscle weakness. R71's most recent quarterly MDS dated [DATE] revealed that R71 had a BIMS of 7/15 which indicated a severely impaired cognition. R71 required extensive assistance for all ADLs other than eating. Resident #83 (R83) On 2/25/25 at 1:28 PM, R83 was interviewed and asked the location of their call light. R83 indicated that they did not know the current location of their call light. While in the room speaking to R83 an observation was made of R83's call light cord and call light being draped over the head of R83's bed out of reach of the resident. UNM C was requested to come to R83's room and was asked about the location of R83's call light. UNM C indicated that the call light should be clipped to [R83]. On 2/25/25 at 1:45 PM, R83 was further interviewed and asked if their call light is frequently out of reach for them. R83 responded, Not with the CNA that I have today, but with other CNAs, yes. A review of R83's EMR revealed that R83 was most recently admitted to the facility on [DATE] with diagnoses that included Kidney failure and Muscle weakness. R83's most recent quarterly MDS dated [DATE] revealed that R83 had a 15/15 BIMS which indicated an intact cognition. R83 required extensive assistance for all ADLs other than eating. On 2/26/25 at 1:01 PM, the Administrator (NHA) was interviewed and asked about their expectations for placement of resident call lights in their room. The NHA indicated that they should be within reach of the resident. A review of a policy titled Call Lights, Reviewed: 2/13/2021 stated the following, Purpose: It is the purpose of this facility to attend to our residents needs in a timely manner. Procedure: 1. Staff should ensure that the residents call light is located within easy reach of the resident .

Based on observation, interview, and record review, the facility failed to ensure resident inhalers were dated when open in two of six medication carts. Findings include: On 02/26/25 at 9:10 AM, the Unit C back cart was observed with Licensed Practical Nurse (LPN) J. A Breo Ellipta inhaler was not dated when opened on the inhaler and was without a resident identifier and an Incruse inhaler was not dated when opened and was without a resident identifier. LPN J acknowledged the inhalers did not have an open date. On 02/26/25 at 9:26 AM, the Unit C Front cart was observed with Licensed Practical Nurse (LPN) K. Two Trelegy inhalers were observed to not be dated when opened on the inhaler and were without a resident identifier and one Incruse inhaler did not have a resident identifier on the actual inhaler. LPN K reported an open date was required on the inhaler. A review of the policy titled Medication Storage in the Facility dated April 2018 revealed, .Drugs dispensed in the manufacturer's original container will carry the manufacturer's expiration date. Once opened, these will be good to use until the manufacturer's expiration date is reached unless the medication is: 1. In a multi-dose injectable vial. 2. An ophthalmic medication. 3. An item for which the manufacturer has specified a usable life after opening . A review of the prescribing information from the Incruse manufacturers web site https://gskpro.com revealed, .Safely throw away INCRUSE ELLIPTA in the trash 6 weeks after you open the tray or when the counter reads 0, whichever comes first. Write the date you open the tray on the label on the inhaler . A review of the prescribing information from the Breo manufacturers web site www.mybreo.com revealed, ' .Safely throw away BREO ELLIPTA in the trash 6 weeks after you open the tray or when the counter reads 0, whichever comes first. Write the date you open the tray on the label on the inhaler . A review of the prescribing information from the Trelegy manufacturers web site https://gskpro.com revealed, .Safely throw away TRELEGY ELLIPTA in the trash 6 weeks after you open the tray or when the counter reads 0, whichever comes first. Write the date you open the tray on the label on the inhaler .

This citation pertains to Intake MI00149869. Based on observation, interview, and record review, the facility failed to provide dignity during care for one resident (R216) of three residents reviewed for dignity. Findings included: On 2/25/25 at 12:03 PM, R216 was observed lying in their bed awaiting staff to assist with getting dressed for the day. R216 stated ,I need to be changed, my brief and bed are wet due to my indwelling catheter (a tube inserted into the bladder) is leaking. R216 appeared tearful and stated that ,I am sitting here wet and I am late for therapy. It's not supposed to be like this. It makes me feel ashamed because I cant help myself. On 2/25/25 the medical record for R216 was reviewed and revealed R216 was admitted to the facility on [DATE] with the diagnoses of cerebral infarction with right sided weakness, depression, anxiety and diabetes mellitus. A review of the most recent minimum data set assessment (MDS) dated [DATE] noted a Brief Interview of Mental Status (BIMS) assessment is a 14 indicating intact cognition. A review of the medical record reveal a physicians order stating two person approach during care routine. On 2/26/25 at 9:00 AM, R216 was observed lying in the bed watching television. R216 stated a nursing assistant had tried to change them without assistance instead of having two people. R216 stated, I was scared and didnt want to fall out of bed so I told them no, and demanded the nursing assistant stop and go get proper help. R216 stated when the nursing assistant went to get assistance, they were left partially exposed until the 2 nursing assistants returned to help finish getting them dressed. On 2/26/25 at 10:05 AM, the Director of Nursing (DON) was asked about this incident and confirmed that there had been an investigation into the allegations. DON stated a new nursing assistant had been assisgned to R216 and was not familiar with the care orders. The nursing assistant had left the resident to get the unit manager and assistance when providing care, saying staff should be aware of care orders when providing care. The facility's Resident Rights policy dated 11/28/2017 noted: Our facility will treat each resident with respect and dignity and care for each resident in a manner an in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Resident has the right to respect and dignity.

Based on observation, interview, and record review, the facility failed to properly assess one resident (R65) out of one reviewed for self administration of medications. Findings include: On 2/25/2025 at 2:02 PM, R65 was observed sitting in bed with two medicine cups in front of them. R65 was observed putting one pill in their mouth and then another. R65 was asked what they had just taken, and they responded, A gas pill and a pain pill. R65 stated the pain pill they had taken was Norco (Narcotic) and that they don't take it often because it makes them sleepy. No staff were noted to be in the room or surrounding the area by the room. R65 stated the staff usually just leave their pills with them because they know that they are going to take them. A review of the medical record revealed that R65 admitted into the facility on [DATE] with the following diagnoses, Cerebral Palsy and Anxiety Disorder. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition. R65 also required staff assistance with bed mobility and transfers. Further review of the medical record revealed that R65 was prescribed Simethicone (Pill used for gas) once a day with meals and Norco, every six hours, as needed. No self administration assessment or care plan was noted in the medical record. On 2/26/2025 at 11:43 AM, an interview was conducted with Assistant Director of Nursing (ADON) A. ADON A stated the nurse should have been in the room with R65 while they were taking their medications, especially with a narcotic. A review of a facility policy titled, Self-Administration of Medications Management noted the following, When determining if self-administration is clinically appropriate for a resident, a licensed nurse will complete the Evaluation for Resident Self-Administration of Medications to aid in the determination of resident's ability to self-administer medication.

This citation pertains to Intake: MI00149953 Based on observation, interview and record review, the facility failed to ensure a clean environment for one resident (R211 and R165) of 10 residents reviewed for home-like environment. Findings include: A review of the complaint submitted to the State Agency revealed the following, .The room that [R211] lives in is in poor condition. The heater is exposed and looks like it's falling apart. There is brown residue all over the ground under the bed . R211 On 2/24/25 at 7:30 AM, R211 was observed lying in bed, a tube feeding pole was observed as visibly soiled, with dried tube feed formula observed dried and caked to the floor. R211's bed was observed next to a heat vent that had a damaged base board exposing the coils. Attempts to interview R211 were unsuccessful, due to their cognition. A review of R211's medical record revealed they were admitted into the facility on [DATE] with diagnoses that included Cerebral Infarction and Gastronomy Status. Further review revealed they were severely cognitively impaired, and was total dependent on staff for activities of daily living. On 2/25/25 at 9:05 AM, 12:59 PM, and 3:12 PM, the dried tube feed formula observed on the floor in 2/24/25 remained on the floor. The damaged base board of the heat vent was also observed in the same condition. On 2/26/25 at 10:18 AM, the dried tube feed formula observed on the floor in 2/24/25 remained on the floor. The damaged base board of the heat vent was also observed in the same condition. R165 On 2/24/25 at 7:36 AM, R 165 was observed in bed asleep. A tube feeding pole was observed as visibly soiled, with dried tube feed formula observed dried and caked to the floor. A review of R165's medical record revealed they were admitted into the facility 12/18/24 with diagnoses that included Anoxic Brain Damage, Chronic Obstructive Pulmonary Disease, and Dysphagia. Further review revealed that the resident was significantly cognitively impaired, and was totally dependent on staff for activities of daily living. On 2/25/25 at 9:06 AM, 11:14 AM, 12:42 PM, and 3:12 PM, the dried tube feed formula observed on the floor in 2/24/25 remained on the floor. On 2/26/25 at 11:13 AM, Maintenance Director M was asked about the exposed heat vents, and acknowledged this is an ongoing issue, and they make efforts to complete walk throughs regularly to identify issues. On 2/26/25 at 1:01 PM, the Nursing Home Administration (NHA) was informed of the observations made throughout the survey related to tube feeding liquid located on the floor, and explained it is her expectation the feed fluid is cleaning up by nursing and housekeeping when observed in the floor. A review of the facility's Accommodation of Needs and Preferences and Homelike Environment Guideline revealed, .7. The resident's environment will be maintained in a homelike manner to ensure appropriate housekeeping .

Based on observation, interview and record review, the facility failed to ensure the proper setting for a specialty mattress (low air loss) was maintained for one resident (R34) of three reviewed who had a specialty mattress. Findings include: On 02/24/25 at 12:23 PM, 02/25/25 at 8:36 AM and 12:18 PM and on 02/26/25 at 7:55 AM, R34 was observed to be supine in bed and dressed in a hospital style gown. R34 had a power unit for the specialty mattress hooked to the foot of the bed. The weight setting on the power unit was set at 400 pounds. R34 did not appear to weigh 400 pounds. R34 did not respond to queries about positioning or comfort. R34 was not observed to reposition themselves in bed. On 02/26/25 at 11:05 AM, R34 was observed to be supine in bed. The mattress setting on the power unit was observed with Unit Manager, Licensed Practical Nurse (LPN) I. The weight setting was observed to be at 400. LPN I acknowledged the weight setting was likely too high. LPN I consulted with the wound care staff and reported the mattress should have been set at 200. It was further observed the mattress pump control panel had to be unlocked in order to change the setting. A review of the record for R34 documented R34 was admitted into the facility 10/28/2009. Diagnoses included Dementia, Stroke and Diabetes. The Minimum Data Set (MDS) assessment dated [DATE] indicated severely impaired cognition, limited range of motion for both legs and one arm, and that R34 was dependent on staff to roll left and right, to bathe and for hygiene. On 02/19/25 R34 was documented to have weighed 180.2 pounds. A physician order dated 02/21/25 documented, LAL (low air loss) mattress. Monitor pump to reflect resident's weight. A review of the February 2025 Administration Record (TAR) documented the setting had been checked by the nursing staff on 02/21 on the night shift and on 02/22. 02/23, 02/24 and 02/25 on the day and night shift. A review of the facility Skin Protection Guideline dated 07/07/21 documented, Purpose: To provide evidenced based practice standards for the care and treatment of skin. To ensure residents that admit and reside at our facility are evaluated and provided individualized interventions to prevent, reduce and treat skin breakdown . Interventions for prevention, removing and reducing predicting factors and treatment for skin may include: Selection of an individualized support surfaces for bed and seating to enhance pressure redistribution .

Based on observation, interview and record review, the facility failed to document interventions, and prevent the development of a pressure ulcer (damage to skin from prolonged pressure to skin), for one resident (R165), of four residents reviewed for pressure ulcers. Findings include: On 2/24/25 at 7:36 AM, R165 was observed asleep in bed. A positioning wedge was noted on the resident's left side, feet elevated with pillows. A review of R165's medical record revealed they were admitted into the facility 12/18/24 with diagnoses that included Anoxic Brain Damage, Chronic Obstructive Pulmonary Disease, and Dysphagia. Further review revealed that the resident was significantly cognitively impaired, and was totally dependent on staff for activities of daily living. Further review of R165's medical record revealed a Nursing Evaluation dated 12/19/24 documented the resident had a stage 2 pressure sore (Partial-thickness skin loss with exposed dermis) to their left buttock, left heel very dry and cracked, right heel very dry and cracked, and scar on their chest from prior surgery. Further review of R165's medical record revealed the following progress note: 12/19/2024 15:25 (3:25pm) Skin/Wound Note (Narrative) Wound Care New Admission Skin observation .Bilateral Buttock: Blanchable redness, MASD (moisture associated skin damage). treatment-cleanse with ph balance, pat dry and apply triad cream. A review of R165's physician orders noted the following interventions for R165's skin integrity: Order: 12/26/24 Foam boots as tolerated every day and night shift for prevention. Order: 12/24/24 LAL (low air loss) mattress. Monitor pump to reflect resident weight every day and night shift for monitoring. A review of R165's care plan revealed the following, Focus: The resident has potential for impairment to skin integrity r/t (related to) decreased mobility and dependence on staff for pressure offloading and repositioning, anti-coagulant use, TF (tube feeding) to meet nutrition and hydration needs .Entire skin is highly moist, Dated Initiated: 12/19/2024 .Interventions: Apply barrier cream per facility protocol/PRN (as needed) Date Initiated: 12/19/2024. Encourage that heels are elevated while resident is lying in bed as tolerated Date Initiated: 12/19/2024. Dietary Consult as needed. Date Initiated: 12/19/2024 Monitor skin when providing cares, notify nurse of any changes in skin appearance. Date Initiated: 12/19/2024. Use draw sheet when turning/repositioning. Date Initiated: 12/19/2024. Use pillow/cushion for pressure offloading and repositioning as needed. Date Initiated: 12/19/2024. Lotion to dry skin PRN. Date Initiated: 12/19/2024. Skin assessments to orders and PRN. Date Initiated: 12/19/2024. Turn and reposition every 2 hours as tolerated. Date Initiated: 12/19/2024. A review of R165's January (2025) Treatment Administration Record (TAR) revealed the orders for the monitoring of the LAL and the application of the foam boots were not documented as completed for 12 days. Further review of the resident's medical record revealed the following progress note, 1/7/2025 13:59 (1:59pm) Skin/Wound Note(Narrative). Resident has new unstageable (pressure injury) to coccyx. Further review revealed the following wound care progress note dated 1/7/25, .Sacrum is an acute unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 6cm (centimeters) length x 9cm width x 0.2 cm depth, with an area of 54sq (square) cm and a volume of 10.8 cubic cm . On 2/26/25 at 10:29 AM, the Assistant Director of Nursing (ADON)/Wound Care Nurse was asked about the development of R165's unstageable wound, and explained when the resident was admitted , they had a deep tissue injury (DTI) on their buttocks and sacrum, which opened two weeks after admission. She further explained the resident's skin has a lot of moisture and has poor tissue perfusion. The ADON was asked about R165's interventions upon admission and indicated the resident had foam boots, triad treatments and a distribution mattress. The ADON was asked about the missing documentation on the resident's TAR, she indicated that she would address this with management. On 2/26/25 at 2:08 PM, the Director of Nursing (DON) was asked about the development of R165's sacrum wound, and explained that upon admission, the resident's skin was already compromised and the wound on the resident's sacrum was a DTI and not MASD. The DON further explained the wound care team documented this incorrectly, and were later educated. A review of the facility's Skin Protection Guideline revealed the following, Purpose: To provide evidenced based practice standards for the care and treatment of skin. To ensure residents that admit and reside at our facility are evaluated and provided individualized interventions to prevent, reduce and treat skin breakdown .

Based on observation, interview, and record review, the facility failed to institute and operationalize appropriate infection control principles and practices per the Centers for Disease Control and Prevention (CDC) guidance and professional standards of practice, while caring for residents who were confirmed to be Covid-19 (a highly contagious and severe respiratory infection disease) positive or suspected Persons Under Investigation (PUI) for being positive of Covid-19, affecting 10 Residents (R600, R601, R602, R603, R604, R605, R606, R607, R608 and R609) and up to an additional 38 residents (totaling 48 residents) who resided on the memory care unit. This deficient practice resulted in 1) The facility not isolating Covid-19 positive and suspected PUI Covid-19 positive residents on the memory care unit, in addition to them not wearing proper PPE (Personal Protective Equipment) when intermingling with Covid-19 negative residents, 2) Staff not knowledgeable or made aware of Covid-19 positive and PUI Covid-19 positive residents residing on the memory care unit, 3) Staff observed not wearing proper PPE when entering rooms to provide care for Covid-19 positive and suspected PUI Covid-19 positive residents and 4) The likelihood for continued transmission of infection, causing serious injury, serious harm, serious impairment or death. Findings include: On 1/25/2022 at 8:50 AM, the Director of Nursing (DON) was asked if there were any COVID positive residents in the facility. The DON stated that they had a PUI unit (Patient Under Investigation for COVID) and a COVID Positive unit which was Unit A. The DON also explained that they had COVID positive residents on the memory care unit however, they were wanderers and unable to be maintained in their rooms. On 1/25/2022 at 9:07 AM, during the initial tour of the locked memory care unit, seven resident room doors were noted with signage reflecting Droplet Precaution including signage of the need for PPE prior to entering the rooms. Of the seven resident rooms with the noted signage, only two residents were observed to be in their beds asleep. During the tour, PPE supplies were not observed outside of the rooms with the Droplet Precaution signage. Only two bins were observed on the unit that were filled with disposable gowns. In addition, no residents were observed wearing masks nor were observed redirected by facility staff to wear masks or maintain appropriate distancing. On 1/25/2022 at 9:09 AM, the Assistant Nursing Home Administrator (ANHA) and Recreation Staff G were observed walking down the hallways of the memory care unit with droplet and contact precaution signs. The ANHA and Recreation Staff G were asked what they were doing, and they explained that the residents on the unit often tear the signage off of the doors, and they had to replace them daily. The ANHA was asked if she could identify the COVID-19 positive residents on the unit, along with those who were under investigation, however she was unable to provide an answer. On 1/25/2022 at 9:12 AM, an unidentified nurse on the memory care unit was asked how many residents on the unit were COVID-19 positive, and how many residents were PUI for exposure to COVID-19, and he stated, I'm not sure yet, I just got here an hour ago. I will have to let you know. On 1/25/2022 at 9:15 AM, R604 was observed walking out of their room that was noted to have Droplet Precaution and Contact Precaution signage on the door. R604 was observed walking into other residents' rooms and into the dining area. R604 was observed walking out of the dining room carrying a comforter. R604 placed the comforter in the room next to their room and continued walking down the hall. R604 was without proper PPE and not maintaining appropriate distancing (6 feet apart) during observation. On 1/25/2022 at 9:22 AM, the Infection Control Preventionist (ICP) was asked for the number of COVID positive residents on the memory care unit, and explained that they had three positive residents (R600, R601, and R602) confirmed through a rapid Covid-19 test and a PCR (Polymerase Chain Reaction) test, and that there were currently seven residents that who tested positive via a rapid Covid-19 test and were currently awaiting a PCR test (R603, R604, R605, R606, R607, R608, R609). The ICP was asked how they were cohorting the residents on the unit, and she explained that, Staff are pretty good about keeping residents separated and knowing which residents are positive. The ICP also explained that they had initially placed positive roommates together but, It's difficult to get them to stay in their rooms .We try to put their meals in their rooms but they won't stay, and they won't wear masks . On 1/25/2022 at 9:25 AM, Licensed Practical Nurse (LPN) D was observed at the medication cart outside of R604's room. LPN D was interviewed and asked if R604 was their assigned resident and if R604 was under PUI or if they were COVID-19 positive. LPN D stated, Yes (R604) is mine .I'm just the agency nurse .I'm not sure what (R604) is .I don't know who's positive on this unit .they are not doing things right on this unit. On 1/25/2022 at 9:38 AM, 17 residents were observed in the dining room unmasked sitting in chairs at tables with other residents, walking in and out of the dining room. Three staff were observed in the dining room. The staff were not observed to redirect or encourage the residents to distance themselves from other residents or wear masks. An unidentified CNA (Certified Nursing Assistant) was asked if they knew of any residents in the dining room that were COVID-19 positive or PUI. The unidentified CNA stated that they were not sure because they had just returned to work. R604 was observed in the dining room unmasked, sitting less than one foot distance, next to an unsampled resident. At that time, R601 (found to be COVID-19 positive) was observed sitting in a wheelchair at a small table with an unsampled resident who had not tested positive for COVID-19. On 1/25/2022 at 9:47 AM, an unidentified nurse was observed entering R600's room that had droplet and contact signage on the door, wearing only a N95 mask and a face-shield. The nurse was observed performing vitals on the resident at that time. On 1/25/2022 at 9:49 AM, the Assistant Nursing Home Administrator (ANHA) and Recreation Staff were observed in the dining room. They were not observed to redirect (encourage proper PPE use and appropriate distancing) the residents in the dining room. On 1/25/2022 at 9:55 AM, Nurse Manager B was observed in the dining room. Nurse Manager B was observed walking and looking around the dining room. Nurse Manager B was interviewed and queried if aware of any COVID-19 positive residents or PUI residents currently in the dining room and they said, Yes. They are both in this room. Although this is a locked unit, we don't force them to stay in their rooms .They wont keep their mask on or stay in their room .They can eat and sit in the dining room because we can't control them like that. On 1/25/2022 at 10:00 AM, R601 was observed sitting in the dining room unmasked, and sitting across from an unsampled resident who had not tested positive for COVID-19. There were also 17 other residents observed in the dining room at this time, either unmasked or wearing their masks inappropriately while sitting, or aimlessly wandering in and out of the dining room. There were approximately three staff members also in the dining room, including a nurse at their medication cart who was not observed to redirect or encourage the residents to distance themselves or wear masks. On 1/25/2022 at 10:05 AM, the Medical Director, Nursing Home Administrator (NHA), ANHA, Unit Manager B, ICP and DON came to the memory care unit, and were asked about COVID-19 positive residents intermingling with residents that were Covid-19 negative. The Medical Director indicated that they had ongoing policies and mechanisms in place to prevent the spread of COVID-19, and that the residents who were positive and/or exposed were provided with monoclonial treatment. The ICP indicated that they attempt to separate the residents but they are unable to because they walk through barriers like zombies. At 10:05 AM R601 was still observed sitting in the dining room, and was pointed out as someone with COVID-19 intermingling with negative residents. No verbal response was provided from the facility, however the resident who is non-ambulatory was wheeled out of the dining room at that time. The ICP was asked about staff knowledge of who were COVID-19 positive on the unit, and they indicated that there were morning huddles in which staff were made aware. It was brought to their attention, that two facility nurses were asked who was Covid-19 positive and who was not, and they were unaware. Unit Manager B was asked if a morning huddle had occurred this morning, and they stated, No, not yet. It was then explained that the nurses on the unit were agency nurses. On 1/25/2022 at 2:49 PM, an interview was completed with the DON and ICP. The ICP was asked if the facility had a current outbreak and stated, Yes and further explained that they had an outbreak that began on the memory care unit on 10/27/21, which was able to be contained to that unit. The ICP explained, that was when the monoclonial intervention was used for the entire unit with the consent of the resident representatives for those who were Covid-19 positive, and for those who had not yet tested positive. The ICP stated that there were no Covid-19 cases in the facility between 11/15/21 and 12/15/21 and the processes that was put into place to prevent the spread of Covid-19 included disinfecting high touch areas, handwashing, and ensuring there was one resident per table. The ICP explained that the next Covid-19 positive case was on 1/9/22 which ultimately led to subsequent infections on the memory care unit. The ICP also explained that, It's difficult to contact trace because they (residents) are so ambulatory .we do encourage them, and we can redirect them and serve their food in their rooms and put a mask on them when they tolerate it, but it is non-stop . On 1/26/2022 at 9:22 AM, an unsampled resident was observed wandering into the room of R602 who is COVID-19 positive. There were no staff to redirect this resident out of the room. On 1/26/2022 at 9:34 AM, R606 who was COVID-19 positive, was observed wandering around the unit unmasked. There was no redirection provided by staff. Also at this time, an unidentified maintenance worker was observed on the unit buffing the floors. There was no eye protection observed on their face as they buffed the floors of the entire unit. On 1/26/2022 at 9:50 AM, during an observation on Unit A (the Covid-19 positive and PUI Unit), Nurse Practitioner H was observed leaving out of a room, without proper eye protection. Nurse Practitioner H was interviewed and asked if they wore eye protection and a gown while in the resident's room and stated, This resident is not Covid positive. Nurse Practitioner H was asked if the resident was a PUI for possible Covid-19 and replied, You can talk to one of the nurses .I'm the Nurse Practitioner. A review of R601's medical record noted an admitted [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R601's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R604's medical record noted an admitted [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R604's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R600's medical record revealed that they were admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the most recent Minimum Data Set assessment (MDS) revealed that the resident was severely cognitively impaired and required supervision to extensive assistance for Activities of Daily Living (ADLs). Further review of their medical record revealed that they tested positive for Covid-19 on 1/17/2022, and had orders to be on contact/droplet precautions until 1/27/2022. A review of R606's medical record revealed that they were admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the most recent MDS revealed that the resident was severely cognitively impaired and required supervision to extensive assistance for ADLs. Further review of their medical record revealed that they tested positive for Covid-19 on 1/24/2022, and had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R609's medical record revealed that they were admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the most recent MDS revealed that they were severely cognitively impaired and required supervision to extensive assistance for ADLs. Further review of their medical record revealed that they tested positive for Covid-19 on 1/24/2022, and had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/27/2022 at 3:30 PM, the NHA was interviewed regarding the infection control concerns identified, and she explained that it was unfortunate and that they are working to do better. A review of the facility's policy Infection Prevention and Control Interim Guideline for Suspected or Confirmed Coronavirus (COVID-19) effective 3/26/20 noted the following: All recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown .All residents must adhere to social distance of 6 feet and wear facemasks .Residents will be reminded to practice social distancing and perform frequent hand hygiene . Anytime residents leave their room, they are expected to wear a facemask .Prompt detection, triage and isolation of potentially infected residents . A resident with known or suspected COVID-19, immediate infection prevention and control measures will be put into place .For resident on Contact Precautions: staff don gloves and isolation gown before contact with resident and his/her environment .For resident on Droplet Precautions: staff don gloves, isolation gown, facemask, and eye protection .Full PPE should be worn per CDC guidelines of the care of any resident with known or suspected COVID-19 per CDC guidance on conservation of PPE .If widespread COVID-19 transmission occurs in the facility, healthcare personnel should wear full PPE for the care of all residents irrespective of COVID-19 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .Residents with confirmed COVID-19 infection will be kept in isolation with transmission-based precautions for at least 10 days with symptoms improving and fever free for 24 hours .Negative PCR or positive nucleocapsid antibody after at least 10 days isolation. In the event of a facility outbreak, institute outbreak management protocols: o Define authority (Infection Preventionist, DON, Administrator, Medical Director / designee, etc.) o Immediate reporting/notification and consultation with the Local/State Public Health Department for specific directions to include, for example: o Place residents in private rooms on standard, contact, droplet (airborne if available) precautions. o Cohort residents identified with same symptoms/COVID-19 confirmation o Implement consistent assignment of employees o Only essential staff to enter rooms/wings o Facilities with memory care units may treat resident as suspected COVID-19. Encourage residents on memory care to use face mask if and when possible. Encourage residents on memory care unit to wash hands frequently if and when possible. o Limit only essential personnel to enter the room with appropriate PPE and respiratory protection. o Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for [CONDITION(S)]-CoV-2 fourteen (14) days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit). o Exposed residents may be permitted to room share with other exposed residents if space is not available for them to remain in a single room. The NHA was notified of the Immediate Jeopardy on 1/26/22 at 10:25 AM and a plan of correction was requested to remove the immediacy that began on 1/9/22. The facility provided the following removal plan. Immediate Jeopardy was removed on 1/26/22 as validated by the team on 01/27/22. Removal Plan: The facility is providing the following information to demonstrate that the immediacy of the cited deficiencies have been removed. RESIDENT AT RISK 1. On 1.25.2022 3 identified COVID-19 positive residents and 8 PUI residents on the Memory Care were unmasked and not isolated from other residents and staff. Identified residents have been placed on appropriate isolation and transmission-based precautions within the Memory Care Unit. Resident residing on the Memory Care Unit continue to be monitored for signs and symptoms of COVID-19. 2. On 1.25.2022 staff on the Memory Care Unit were unable to identify which residents tested positive for COVID-19 and who was on isolation precautions. Identified COVID-19 positive residents have been placed in a COVID-19 designated area within the Memory Care Unit with appropriate isolation precautions. 3. All residents residing in the facility are at potential risk for the spread of infection related to improper Personal Protective Equipment utilization. IDENTIFYING OTHER RESIDENTS AT RISK 1. All 48 residents currently residing on the Memory Care Unit were audited on 1.25.2022 by the Clinical Management Team. a. An audit consisted of the Clinical Management Team assessing all residents on the Memory Care for unit for signs and symptoms of COVID-19. b. An audit consisted of reviewing all [MEDICATION(S)] testing that was completed on 1.24.2022 and continues routinely per CDC Guidelines. Any additional residents who tested positive for COVID-19 have been placed on a COVID-19 designated area within the Memory Care Unit. c. An audit on 1.26.2022 was conducted by the Clinical Management Team assessing all facility staff to ensure they were appropriately utilizing Personal Protective Equipment per CDC Guidelines. Any identified deficiencies were immediately corrected. The identified root cause analysis is that COVID-19 positive residents residing on the Memory Care Unit are not placed on contact and droplet precautions and were not identifiable to the staff. PROCESSES IMPLEMENTED TO PREVENT FURTHER OCCURRENCE 1. On 1.26.2022 the Regional Vice President of Clinical Services educated the DON and Infection Control Preventionist on appropriately cohorting COVID-19 positive residents on the Memory Care Unit per CDC Guidelines. 2. The Administrator, DON, and Infection Control Preventionist have implemented a designated COVID-19 isolation area within the Memory Care Unit. On 1.26.2022 the DON/Designee started education for all staff on the newly implemented COVID isolation area with appropriate signage for staff to identify positive residents. 3. 1.26.2022 the DON/Designee started re-education for all staff on the appropriate use of Personal Protective Equipment. 4. All new hires will receive training on the facility's practice of COVID-19 isolation, Transmission-Based Precautions and the proper use of PPE. MONITORING BEGINNING 1.26.2022 1. The DON/Designee will review any resident who tested positive for COVID-19 daily x 12 weeks. After 12 weeks, the need for daily review will be re-evaluated by the Regional Vice President of Clinical Services. Any resident testing positive will be reviewed by the Regional Vice President of Clinical Services, DON, Medical director, and Infection Preventionist for appropriate implementation of isolation and transmission-based precautions. 2. The DON/Designee will review appropriate signage of the COVID-19 isolation area daily x 12 weeks. After 12 weeks the need for daily review will be re-evaluated by the Regional Vice President of Clinical Services. 3. The DON/Designee will conduct audits weekly x 4 and monthly x 3 month on the appropriate use of Personal Protective Equipment Date of compliance is 1.26.2022. Although the immediacy was removed on 1/26/22, the facility's deficient practice remained out of compliance at widespread with actual harm that is not immediate jeopardy.

This citation pertains to: MI 345 and MI 383. Based on interview and record review the facility failed to ensure significant weight loss was communicated to the attending physician, the care plan was updated with interventions for weight loss and weights were monitored weekly upon admission per facility policy for one sampled resident (R913) of three whose weights were reviewed, resulting in significant weight loss of 62 pounds over four months without notification of the medical team. Findings include: A review of the facility record for R913 revealed R913 was admitted into the facility on [DATE] and discharged by family/resident request to the hospital on 06/01/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] and 05/05/21 indicated intact cognition with a 15/15 Brief Interview for Mental Status (BIMS) score and the need for extensive assist of one or two people for bed mobility, transfer, toilet use, personal hygiene and bathing. Eating required set up. The 05/05/21 MDS indicated a 10 percent weight loss and a weight of 205 pounds. The 02/02/21 MDS indicated a weight of 248 pounds. A review of the nursing care plan revealed R913 had an .actual self care performance deficit for ADLs (dated 02/13/21). The care plan indicated the need for two persons for transfer and toilet use and one person for bathing and showering. Eating required set up. The Care Plan also documented a fluid deficit dated 03/16/21 and R913 required (intravenous) IV fluids. The care plan Obese status related to sedentary life style dated 01/26/21 indicated, Fluid shift related to CHF .Pitting [CONDITION(S)] (fluid retention) to bilateral lower extremities (BLE) .at risk for malnutrition related to CHF, Diabetes and High Blood Pressure. Interventions dated 01/28/21 included: Evaluate any weight changes. Determine percentage changed and follow facility protocol for weight change .Obtain and document weight per MD orders and facility protocol .provide and serve supplements as ordered. Prostat (daily) QD .(Registered Dietitian) RD to evaluate and make diet recommendations as needed. The care plan did not reflect the ongoing weight loss nor document interventions related to the weight loss of R913 from admission to discharge. A review of the documented weights for R913 revealed: 1/28/2021 16:34 248.0 lbs;1/29/2021 10:46 248.0 lbs;1/30/2021 14:53 248.0 lbs 2/18/2021 16:45 235.6 lbs; 3/5/2021 14:01 251.8 lbs; 4/8/2021 15:52 220.0 Lbs; 4/11/2021 16:46 216.0 lbs; 4/23/2021 16:15 202.1 lbs; 4/29/2021 15:00 205.0 lbs; 5/7/2021 16:13 205.8 lbs; 5/11/2021 16:08 196.8 lbs; 5/20/2021 12:56 197.2 lbs; 5/28/2021 11:47 186.0 lbs. A total weight loss of 62 pounds. A review of the RD notes revealed: A dietary evaluation note dated 01/28/21 at 4:10 PM which documented, Current intake is 76-100% .Eats independently .no weight on admission .may benefit from planned weight loss program .weight and fluid shifts anticipated (related to) r/t CHF diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .follow weight protocol .Resident not referred to MD (physician) for malnutrition . A resident desire to lose weight was not documented. A Weight Change Note dated 03/04/21 at 12:01 PM revealed Weight warning .value 235.6#(pounds), BMI (body mass index) 31.9 suggests resident is obese. Resident has had a significant weight loss of 5% in the last three weeks. Meal completions average 92% or 1840 calories in last 10 days. Writer suspects weight loss due to fluid shifts given that nutrition assessment dated ,d+[DATE] cites + 2 - 3 BLE [CONDITION(S)] and MD (physician) note dated 2/9 cites no [CONDITION(S)] . Notification of the physician was not documented. The 2/9 note was by the Nurse Practitioner. A Weight Change Note dated 04/12/21 at 1:41 PM revealed, Weight Warning: Value: 216 (pounds) .current body weight of 216# indicates significant weight loss at 14.2%. Weight loss due to fluid shifts with history of [CONDITION(S)] present upon admission. Resident is on a regular diet and is eating greater than 75% of most meals daily .Will proceed with current nutrition interventions, continue to monitor weights an adjust POC and needed. Notification of the physician was not documented. A resident desire to lose weight was not documented. A Quarterly Nutrition assessment dated [DATE] at 8:51 AM revealed, .current intake 51-75% .resident has one month weight gain or loss 5% or greater - 6.5%/- 14.2 lbs x 30 days r/t both fluid shift and varied appetite. 1 month weight loss was not planned. Resident has 3 month weight gain or loss 7.5% or greater, - 17.0%/42.2 pounds x 90 days mainly related to fluid shift, [CONDITION(S)] noted in admission note and then no [CONDITION(S)] 2/9 MD note .3 month weight loss was planned .per resident appetite is good but not happy with food here .ice cream is added per resident preferences .Goal is to maintain weight without any significant change .Diuretic med on board may result in weight flux .No [CONDITION(S)] noted .resident not referred to MD for malnutrition . The Weight Change Note dated 05/10/21 indicated, resident is on planned weight loss program .goal is to maintain weight without a significant change although a gradual weight loss could be beneficial of overall health . Notification of physician about weight loss was not documented. A Nurse Practitioner (NP) note dated 05/07/21 revealed no [CONDITION(S)], a weight of 205 pounds and no indication of notification about significant weight loss. R913 had lost 43 pounds. A nursing noted dated 04/26/21 at 8:12 PM indicated no [CONDITION(S)]. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/29/21 at 12:30 PM, the Director of Nursing (DON) was asked about the monitoring of the significant weight loss for R913. The DON reported weight loss is discussed weekly by the nursing team and the dietitian. The DON also mentioned the scales had been recalibrated. The DON was asked for documentation of the Physician being made aware of the 65 pound weight loss. The Dietitian provided the weight change notes and RD notes-These did not indicate any physician notification of the weight loss. At 4:25 PM the DON reported they did not have any progress notes by the attending physician. A review of the Nurse Practitioner notes revealed no documentation they had been notified of the significant weight loss. A review of the facility policy, Weight Monitoring Guidelines dated 04/06/18 and revised 07/01/19, revealed, Purpose: The facility measures and records weights to ensure accuracy and provide information for the evaluation of clinical status unless clinically contraindicated with physician justification. To provide guidance on timely consultation and weight parameters. Residents will be weighed; documentation will be recorded in PCC (Point Click Care: electronic medical records): Upon admission and re-admission. Hospital weights should be verified and compared to facility admission and / or re-admission weight. Daily for three days. Weekly for four weeks post admission and or until the weight is determined to be stable. Monthly by the 7th of each month. Anytime as needed with a change in condition or specified by NAR committee. As specified by the physician or mid-level practitioner. The Licensed Nurse: Will verify the accuracy of the weight by comparing the weight with the most recently recorded weight. Direct a re-weight for variances < or > 5 pounds. Consult with the physician and dietitian / designee with a confirmed 5 % weight variances in 30 days and 10% in 6 months and / or as ordered by the physician with weight parameters. For residents on daily weights for fluid volume overload prevention and monitoring weight notification parameters should be discussed with the physician and at minimum consultation should be completed with a 5 pound weight change in 1 week for residents with heart failure or fluid volume overload risk. Monitor weight reports produced inside PCC for significant changes and for gradual insidious changes that may indicate a risk factor for nutrition or hydration status and / or clinical condition. Dietitian: Review significant weight change reports daily for review and evaluation. Review weight reports at least weekly to ensure residents with weight variances of 5% in 30 days and 10% in 6 months are reviewed and evaluations for nutritional risk and timely interventions is completed. Review weight reports for significant weight changes following the 7th of the month. Refer residents with significant weight changes to the NAR committee for review.

This citation pertains to intakes: MI 814. Based on interview and record review the facility neglected to provide an escort during a medical appointment for one Resident #901 (R901) with [DIAGNOSES REDACTED]. After being dropped off by transportation the resident was told that the appointment was canceled. At 4:15 PM, the facility was notified by the transportation company that the resident was no longer at the Physician's office. Resident #901 was located by the facility staff at 4:45 PM, approximately four blocks away from the Physician's office sitting in front of a building on a wall, without their wheelchair, confused and disoriented. This resulted in an Immediate Jeopardy (IJ) and the likelihood for serious physical and/or psychosocial harm, injury, impairment, or death. The Immediate Jeopardy (IJ) started on 8/3/2020 and was identified on 8/6/2020. The Administrator was notified of the Immediate Jeopardy on 8/6/2020 and was asked for a plan to remove the immediacy. The IJ was removed on 8/6/2020, based on the facility's implementation of the removal plan as verified onsite on 8/7/2020. Although the immediacy was removed, the facility's deficient practice was not corrected and remained isolated with actual harm that is not immediate jeopardy. Findings Include: A review of the intake summary revealed, (R901) was transported to a scheduled cardiologist appointment on 8/3/2020. Resident (R901) independently left cardiologist and walked to the nearby automotive (Museum) which is in close proximity of the cardiologist office. Scheduled transportation company could not locate resident (R901) at the cardiologist office however facility staff located (R901) at the (Museum). Responsible party notified. Resident was assessed and found no noted injuries and returned safely to the facility at or around 5PM . A review of R901's medical record revealed R901 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R901's Minimum Data Set (MDS) assessment, dated 7/10/2020 noted a moderat cognitive impairment with a BIMS score of 8/15 and required assistance with activities of daily living. A review of the Physician's history and physical completed on 7/7/2020 revealed, Chief Complaint: Weakness and [MEDICAL CONDITION]. History of present illness: (R901) . past medical history of [REDACTED]. (R901) had history of polysubstance abuse. (R901) also was diagnosed with [REDACTED]. (R901) was admitted to the hospital . (R901) was seen today. (R901) is confused, oriented x1 (times 1) to 2. (R901) is anxious at times . Physical Examination: General: The patient is alert and oriented x1 to 2. (R901) is confused . Assessment and plan: 1. Physical debility. Continue supportive care. Continue PT (Physical Therapy) and OT (Occupation Therapy). 2. [MEDICAL CONDITION] with [MEDICAL CONDITIONS]. Continue supportive care. Continue to monitor . 4. [MEDICAL CONDITION]. Continue [MEDICATION NAME] 20 mg (milligrams) daily, Indreal 10 mg three times a day for anxiety, [MEDICATION NAME] 12.5 mg twice a day, and continue to monitor . On 8/06/2020 at 3:44 PM, during an interview with the Administrator a policy was requested for escorts. The Administrator stated, We do not have an escort policy. The closest thing we have is the transfer/discharge policy. The policy provided did not address escorts and safety of a resident on an outgoing appointment with or without an escort. The Administrator explained the resident (R901) did not show any clinical indication that they required a escort. (R901) did not show any elopement risk, was able to follow directions, and had been to the office before without incident. The Administrator was asked if R901 was safe walking around in the streets lost. The Administrator explained that the office (physician's office) may not have given the resident clear directions. A document provided by the facility explained the need for supervision during medical appointments: How the facility identified resident (s) affected and residents with potential to be affected by the same deficient practice: Residents' medical appointments/consultations will be reviewed by IDT (Inter-Disciplinary Team) prior to transportation to determine if facility supervision is required. Unit clerks and licensed Nurses educated on informing the DON (Director of Nursing)/ADON (Assistant Director of Nursing)/Unit Managers prior to transferring to scheduled medical appointments to determine need for facility supervision . However, there was no documented evidence that these interventions were in place or implemented for R901. On 8/6/2020 at 1:20 PM, the Unit A Clerk (UC) was asked about if this was R901's first time at this physician's office for an appointment, the UC said, No. The UC was asked the process for residents that have outgoing appointments. UC stated, The office sometimes sets up the appointments and sends us the dates and times. UC was asked if they make follow up calls to ensure the appointments are current. UC stated, I usually don't call. The UC was asked what happened when R901 went to the appointment on 8/3/2020, UC stated, They notified (R901) when (they) got there that it had been rescheduled. UC was asked if R901 has had an escort with them for appointments before, UC stated, (R901) has had an escort before. UC was asked the reason R901 needed an escort, UC stated, Because (R901) had a [MEDICAL CONDITION] and has some confusion. The UC was asked to explain the process for residents to get an escort, the UC stated, I let the staffing coordinator know who needs an escort. I send a weekly list of who needs an escort to the staffing coordinator, and they assign them an Aide. On this appointment the Unit Nurse and myself were not on the floor at the time (R901) was leaving, so if I were there, I would have saw something was missing. The UC was asked to explain how transportation works for the appointments. The UC stated, Generally they will check them in and let the office know the number to call for a pickup. They (transportation) will push the residents in a wheelchair into the office, then the staff would take the resident into the back. It was said that the Physician's Office called and told them (R901) was ready to be picked up. When transportation got there (R901) was gone. (R901's) wheelchair was still at the office and (R901) was gone. They (transportation) called us and asked us if (R901) had made it back to the facility and that is when we found out that (R901) was not there. The UC was asked about how far is the Physician's office from the facility, the UC said, About 5 miles away. The UC was asked what happened next after the facility was notified of R901 being missing. The UC stated, I jumped in the car with a Housekeeper (HK) that was getting off work and asked her to take me to look for (R901). I found (R901) on a (Major road) (R901) was sitting on the wall, like a short wall. The UC was asked what did R901 say when you found them. The UC stated, (R901) said, 'I tried to go in the building Automotive (Museum), but they would not let me in'. The UC was asked about how far away from the office building was R901 found, UC said, about a quarter to 1/2 mile or 4 blocks. I asked (R901) what (they) were doing, (R901) looked at us and gave me a hug and said, 'I been looking for you.' I said I been looking for you too. (R901) said 'I looked around the office and didn't know anyone and thought I would walk back (facility)'. The Resident stated that (they) thought (they) were at (our facility) and tried to go in. It was actually the Automotive (Museum) building it kind of looks like our facility. (R901) said they knocked on the door and asked them to call their emergency contact. I waited there with Resident until Unit Manager (UM) came to us. The UM assessed (R901), while the HK went back to the building to pick up (R901's) wheelchair. UC continued and stated, This was (R901's) third or fourth appointment in that office and has always had an escort. UC was asked if they sent the information to the Staffing Coordinator , the UC stated, Yes. I made a copy out of my appointment book and highlight who needs aides. A request was made at that time for a copy of the highlighted form with the appointments that was given to the staffing coordinator. It was not provided by the end of this survey. On 8/6/2020 at 1:25 PM, Staffing Coordinator was asked about the appointment for R901 and the process for assigning an escort to residents with appointments. The Staffing Coordinator stated, I had just got assigned to do this job some days before that this occurred. I did not know how to do it and I never got any information about this resident's (R901) appointment. The only paper for appointments was from the other Unit Clerk. I found out about this resident the next day when someone told me about it. Even in the Morning meeting there was no appointment going out for that day. I was told the UC was going to sit with me. Just met UC today (8/6/2020). During the two days of doing the job I had two appointments that went out during that time. On 8/6/2020 at 1:33 PM, the UM was asked about R901's appointment and said, I knew (R901) had an appointment, but I didn't see (R901) leave, because I had an emergency going on down the hall. I knew it was a late appointment around, at 4:30 PM. The UM continued, They (transportation) called us if the Resident was in the building (facility) because (R901) was not at the physician's office. The office said they last saw (R901) around 3:45 PM, they call the van and (R901) was waiting and that (R901) was not there now, they had walked outside and still did not see (R901). We Googled it and saw that it was about a 10-minute drive and went to look for (R901). Two of us went one way and the other two went another way. The UM was asked in what condition did they find (R901) and stated, (R901) was sitting at a building that looked like this (the Nursing facility) (R901) had their envelope and said, 'They wouldn't let me in.' (R901) had no injuries they were just worried why they (wrong building) would not let (them) in the facility. The UM was asked R901's cognition, UM stated, (R901) has days that (they) are confused. The UM was asked if R901 was assigned an escort for their medical appointments, UM stated, I can't say for sure if (R901) had one. On 8/6/20 at 3:21 PM, during a phone interview with the Physician's office, Office Manager A was asked about the appointment with R901. Office Manager A stated, We had been calling the number we have on file to reschedule the appointment. When (R901) came in we explained to (them) the appointment had been rescheduled and gave (R901) paperwork. Not 20 minutes after (R901) was dropped off we called transportation we saw (R901) sitting in the lobby, but that was a busy Monday. (R901) is very quiet and (they) answered back and just waited. (R901) normally has someone with (them). According to a Google search the Physician's office and the location where R901 was located was approximately a 15-minute walk and 0.7 miles. On 8/7/2020 at 9:01 AM, the Administrator was asked how the facility determines when a resident requires an escort, what assessment the facility used to determine if a resident needs an escort, and the procedure for assigning an escort. The Administrator explained, that the facility did not have a policy for escorts, and that the clinical staff will determine if a resident needs an escort. The Administrator was asked if there is a place where this information is documented. The Administrator stated that she would have to look into finding that information. On 8/7/2020 at 12:30 PM, the Inter-Disciplinary Team (IDT) was interviewed and asked about R901's cognition and decision-making ability. The MDS Nurse stated, Some confusion. Therapy Manager stated, (R901) was impaired with (their) memory and at times would report to be age [AGE] years old and talk about holding a baby. The Director of Nursing (DON) was asked about the process to assign escorts, We do walking rounds and ask the residents some general questions while reviewing their hospital records. We would determine at that time if they would need an escort. The DON was asked if R901 had an escort for outgoing appointments. The DON stated, We decided that (R901) would have one, then a week later we decided that (R901) didn't need one. The DON was asked were the IDT documents the decisions regarding escorts, the DON explained that they talk about it during rounds with the unit manager. The Social Worker (SW) was asked when did the guardianship process start, SW stated, When (R901) got here, because sometimes (R901) cognition would fluctuate and needed help to make decisions. SW was asked their assessment of R901's cognition, SW stated, Sometimes I would have to give (R901) clues, sometimes (R901) would not remember why (they) were here (at the facility). (R901) Brief Interview for Mental Status (BIMS) was between a 2-3/15 (severe cognitive impairment). The IDT was asked for the policy regarding assessing and assigning escorts for outgoing medical appointments, the DON explained that they (facility) did not have an escort policy. Further review of R901's medical record revealed the following documents: Guardianship document. Order appointing Guardian AD Litem (GAL)/Attorney Lawyer-Guardian AD Litem, dated 7/20/2020, 9:00 AM, (R901), Legally Incapacitated Individual and all other interested persons as provided by statue or court in respect to the following proceedings . Psych Note: July 7, 2020 . Pt (Patient) suffered [MEDICAL CONDITION] due to the MVC (motor vehicle collision), and (R901) has impaired memory and reasoning . (R901) has no memory of the collision and (R901) is confused in time. At time (R901) uses word substitutions. (R901) reported that (R901) is a [AGE] year old . Psych Note: July 14, 2020 . (R901) has been participating in care and in .therapies. (R901) has had intermittent outburst, particularly when awaking, and in the early evening. (R901) is more confused and suspicious at these times. Once calm, (R901) mood is pleasat and cooperative throughout the day . treatment plan: [REDACTED]. Assessment and Plan: [MEDICAL CONDITION] disorder, [MEDICAL CONDITION] type. Plan: Individual psychotherapy. Obsessive-compulsive behavior. Anxiety disorder, unspecified- long hx (history) mental illness, ocd (Obsessive-compulsive disorder) traits/behaviors . Psych Note: July 15, 2020. Complaint: new eval-assess hx, tx (treatment) plan, efficacy, goals, for concerns, side effects . (R901) has dx (diagnosis) polysubstance use, UDS (Urine Drug Screen) was positive from cocaine and benzodiazepines . (R901) does appear to have cognitive impairment and memory loss . (R901's family) is (their) RP (responsible party) working on obtaining LG (legal guardianship) for this pt . (R901) has been moody, labile, screaming at staff and hollering, cursing at staff, threatened to hit them, . (R901) is easily angered . Medical Decision Making: Nature of the Presenting Problem: High severity or unstable or significant New problem requiring immediate attention . 7/14/2020 12:33 (PM) *Health Status Note (nurses note) Text: writer sitting at nurses desk and heard res (resident) scream stating im going to break this window if I don't get out of here res walked to nurses station and writer reminded res to keep collar on at all times res mumbled im getting out of here and walked back to her room frequent monitoring. 7/15/2020 16:37 (4:37 PM) *Health Status Note (nurses note) Text: Pt has been throwing things and making outburst. Has hx of TBI ([MEDICAL CONDITION]) and is experiencing what it appears as memory loss. Writer has been giving pt reminders of where (R901) is, the year, and what made (R901) come to the facility. Pt is difficult to comfort and to redirect. 7/20/2020 13:17 (1:17 PM) *Daily Skilled Note Reason for Skilled Services: Reason for skilled services: Skilled therapy services - Resident is receiving skilled services for: Physical Therapy Occupational Therapy Special precautions: neck collar to be worn at all times Cognition: Orientation: Person Place The resident requires supervision for safety. There has not been a change in the resident's baseline cognition . Mood/Behavior: Neurological: Abnormal Neuro Check Findings: Cardiovascular: Abnormal. Care plan: Focus: The resident has a behavior problem of losing control of emotions, lashing out at staff and family members, and becoming verbally aggressive. Resident will scream in the hallway and throw things in (their) room. r/t (related to) dx of TBI. Date initiated: 7/14/2020. Goal: Resident will show a decrease in negative behaviors by next review date. Target date 10/28/2020. Interventions: Assist the resident to develop more appropriate methods of coping and interacting such as talking about (their) feelings 1:1 with staff . Explain all procedures to the resident before starting and allow the resident several minutes to adjust to changes. Date Initiated: 7/14/2020. 8/3/2020 13:27 (1:27 PM) *Social Service Note SW followed up with resident and (R901) was informed (R901) was accepted into (Facility) and (R901's) discharge date is 8/4/20. (Facility) will be providing transportation upon discharge from the facility. SW reminded resident of the guardianship hearing date which is scheduled for 8/6/20. SW also personally served the resident again the following documents: Order Appointing GAL, Petition for Appointment of Guardian, Zoom Hearing Instructions and Notice of Rights. SW to follow up and assist as needed. 8/3/2020 18:04 (6:04 PM) *Health Status Note (nurses note) Text: resident arrived back from scheduled appointment at approximately 5:20 PM. Resident VS (vitals signs) 128/64-76-18-97.4-spo2 (peripheral capillary oxygen saturation) 99% r/a (room air). Skin assessment completed, with noted small psoriasis areas to (R901's) elbows, BIL (Bilateral) Lower extremity's, and BIL inner and outer ankles. Resident denies any pain and or discomfort at this time. Provided resident with (their) Dinner, and is sitting in bed at this time. A review of the facility's new policy titled Resident Safety and Medical Appointments dated, 08/7/2020, noted, Policy: To ensure resident safety. Responsible Party: Clinical. Guideline Resident Safety: Staff shall use various sources to identify risk factors for residents, including the information obtained from the medical history, physical exam, observation of resident, BIMS score, history of elopement, and the MDS. The Interdisciplinary Team shall analyze the information obtained from assessments and observations to identify any specific accident hazards or risks for that resident. The care team shall target interventions to reduce the potential for accidents. Implementing interventions to reduce accident risks and hazards shall include the following: The facility-oriented and resident-oriented approaches to safety are used together to implement a system approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjust interventions according. Resident supervision is core component of the systems approached to safety. The identified hazards in the environment. The type of frequency of resident supervision may differ among residents and over time for the same resident. Resident supervision may vary, may need to be increased or decreased if there is a change in the resident's condition. Process: Resident Observation and Evaluation: The licensed nurse will: Evaluate physiological and psychological needs of the resident and identify risk factors and hazards that may potentially affect the resident. Plan for Removal (F Tag 600) The facility is providing the following information to demonstrate that the immediacy of the cited deficiencies has been removed. RESIDENT AT RISK Resident identified #901 was admitted to the facility on [DATE] with a BIMS score of 8 and A&O x2 and currently has a BIMS score of 13 and is A& O x3, with early morning fluctuations in cognition. Resident #901 does not have a guardian in place nor does the resident have a DPOA as she is currently able to make decisions and her needs known independently. On 8/3/2020 at or around 2:00pm, resident #901 was transported to an off-site medical appointment by a contracted transportation company. The medical office rescheduled the appointment and contacted the transportation company to arrange resident's #901 return to the facility. Resident #901 was transported to the same medical office on July 20, 2020 and July 28, 2020 independently, without an escort, and without incident. Resident #901 left the medical office and did not wait for transportation to arrive as resident #901 and did not indicate the reason why she did not wait upon interview. Facility was immediately notified that Resident#901 was not at the pick-up location by the transportation company. Facility staff immediately went to retrieve the resident who was in close proximity to the medical office. Resident #901 was in the presence of facility staff at or around 4:55 pm and was returned to the facility at about 5:20pm. Resident was assessed and no injuries were noted. Resident #901 stated that she should have never left the medical office, apologized and appeared to be relieved that staff quickly located her. Resident #901 refused medical treatment as requested by her sister, as Resident #901 stated that she was okay. Resident #901 became increasing agitated and anxious with family member level involvement. On 8/4/2020 Social Services noted that Resident #901 did not appear to be in any distress and did not observe any signs of negative outcomes from this incident. Social Services reviewed Resident #901 scheduled discharge for 8/4/2020. Resident #901 no longer resides in the facility and is not expected to return. IDENTIFYING OTHER RESIDENTS AT RISK Residents who have scheduled medical consultation appointments outside of the facility have the potential to be affected. An audit was completed by facility nurse management team on all residents with scheduled medical consultation appointment. a. The audit consisted of the nurse management team assessing facility residents for a potential need for supervision during medical appointments. Areas of assessment of resident to include a comprehensive review of BIMS; history of elopement; physical exam, observation and Medical History. PROCESSES IMPLEMENTED TO PREVENT FURTHER OCCURRENCE 1. 8.6.2020 facility took further measures to implemented supervision for any resident with a scheduled medical consultation. 2. In-servicing for all Unit Managers and Unit Clerks was completed on 8.6.2020 by the In-service Director and Administrator that supervision is required for residents who have scheduled medical appointments. In servicing for all licensed nursing staff also began on 8.6.2020 related to supervision at off-site appointments. At this point 70% of required staff have been in-serviced. 3. Facility has developed a Resident Safety and Medical Appointments guideline and has been deemed appropriate by the QA committee. Residents who have medical appointments will be escorted by a facility staff member. Physician order [REDACTED].> Care plan to reflect current status. MONITORING 1. Off-site appointments will be reviewed the day prior by the DON/Designee; the Unit Manager for the assigned unit will be responsible for scheduling facility staff to accompany resident at off-site medical consultation appointments. 2. DON/Designee will review 100% of residents scheduled for off-site appointments weekly times 4 weeks and then monthly thereafter times 3 months to ensure adherence to the facility policies and practices in regard to supervision and safety medical appointments. 3. Results will be reported to the QA committee for monitoring and follow-up. 4. The DON is responsible for substantial compliance of this Plan of Action

Based on observation, interview, and record review, the facility failed to ensure safe transfer from bed to wheelchair for one sampled resident (R603) of four reviewed, resulting in a metatarsal (bone in the foot) fracture, swelling, and pain. Findings include: On 7/30/20 at 11:35 AM, while touring the facility, R603 was observed lying in bed. When queried regarding care at the facility, R603 stated, My foot got caught yesterday. When queried regarding the details of the incident R603 was referring to, R603 indicated they were being transferred yesterday (7/29) to their wheelchair by a Certified Nursing Assistant (CNA) when their foot got caught on the wheelchair. R603 stated, I had my arms around the aide's neck. The aide was (CNA A) - she is here today. I put my arms around her neck when she lifted me up and turned me around to put me in the chair, that's when my foot got caught. I got an X-Ray and it's broken. I was screaming it hurt so bad. She kept going, I don't know why she didn't stop. When asked if they had a broken foot, R603 stated, No, it's fractured, my little pinky (toe) on my right foot. (Licensed Practical Nurse (LPN) B) was my nurse. The resident was then asked how staff normally transfer them out of bed. R603 stated, I put my arms around their neck and they lift me up. When asked what staff uses to lift them, the resident stated, Their arms and hands, and motioned to their waist/under their arms. When asked if staff uses a gait belt, or if CNA A used a gait belt on 7/29, R603 stated, No. When asked if they could move themselves out of bed or move their legs over to the edge of the bed, R603 stated, No. They need to help me turn myself in bed. When asked if CNA A physically picked them up off the bed to the wheelchair, R603 stated, Yes. When she went to turn me around, that's when my right foot got caught. Oh God, I never had so much pain, I screamed out. She didn't stop there, she went ahead and put me in my chair. A review of R603's medical record and Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was receiving hospice services, was originally admitted into the facility on [DATE] and most recently re-admitted on [DATE] with medical [DIAGNOSES REDACTED]. Further review revealed a Brief Interview for Mental Status (BIMS) score of 15/15 indicating an intact cognition. R603's MDS indicated the resident required extensive assistance from one staff for bed mobility, locomotion, dressing, and hygiene, and required extensive assistance from two staff for transfers. The resident's care plan was reviewed and revealed: (R603) has an ADL (activity of daily living) self-care performance deficit r/t (related to) Limited Mobility, OA ([MEDICAL CONDITION]), pain in right and left knees. Date Initiated: 04/04/2018 (no review/revision date present) .TRANSFER: The resident requires limited assistance by (1) staff to move between surfaces .Date Initiated: 04/04/2018 (no review/revision date present). R603's PT (Physical Therapy) Evaluation and Plan of treatment for [REDACTED].= Mod (A) (moderate assistance) .Transfers = Max (A) (maximum assistance) .Basic Mobility - Lying to Sitting on Side of bed = Partial Moderate Assistance (3/6), Sit to Lying = Partial Moderate Assistance (3/6) .Sit to Stand = Substantial/Maximal Assistance (2/6), Chair or Bed to Chair Transfer = Substantial/Maximal Assistance (2/6) . A review of R603's progress notes revealed the following: 7/29/2020 12:20 (12:20 PM) .(nurses note) Note Text: Writer observed resident being placed in wheelchair with right leg crossed over the left, when pivoted resident right foot got caught in wheelchair. Swelling is apparent no discoloration and resident is complaining that (they) can not bare any weight on the right foot. NP (nurse practitioner) notified, orders as follows: right foot x-ray. Signed by LPN B. 7/29/2020 19:13 (7:13 PM) .(nurses note) Note Text: Radiology report received: Results - There is a fracture involving base fifth metatarsal (outer bone in the foot that connects to the little toe). There is associated soft tissue swelling. No foreign body is seen. Conclusion-acute right foot fracture as descried (sic) above. (Physician) notified orders as follows: Podiatrist consult. On 7/30/20 at 11:50 AM, CNA A was interviewed. When queried regarding R603's transfer and injury sustained on 7/29, CNA A stated, When transferring (R603), (they) crossed (their) legs, I didn't know until I set them in the chair. CNA A was asked how she transferred the resident and responded, One person from seating position to the chair. When asked if they used a gait belt, CNA A stated, No. When asked if the resident was facing her when she transferred them, CNA A stated, Yes. When asked what they held onto to transfer the resident, CNA A stated, My arms were up under (them) (indicated under the arms/around the waist) and I held their pants in the back to give more support. CNA A indicated she was the only person transferring the resident, and that LPN B had come to the doorway. When asked how staff is expected to conduct a proper one-person transfer, CNA A stated, Normally we would have a gait belt around the waist and they would still be in a seated position but we would grab the gait belt. On 7/30/20 at 12:00 PM, LPN B was interviewed and queried regarding R603's transfer and injury sustained on 7/29. LPN B explained they had opened the door to see the resident being transferred and that the resident's legs were crossed with the right foot getting caught on the wheelchair. LPN B was asked how staff is supposed to perform a one-person transfer from bed to wheelchair. LPN B stated, I don't typically transfer. All I know is I guess she's supposed to use a gait belt. I don't think she had one. When I opened the door all I was looking at was the foot, I saw it was going to get stuck. When asked if it was just CNA A transferring the resident, LPN B stated Yes. When asked if R603's arms were around CNA A's neck, LPN B stated, Yes. When asked where the aides arms were on the resident, LPN B stated, I don't remember specifically. I am guessing around the waist to support. On 7/30/20 at 12:05 PM, the Therapy Director (TD) was interviewed and queried regarding one-person staff transfers. When queried regarding how one staff member is to transfer a resident from bed to chair, the TD stated the facility policy is to use a gait belt. The TD stated, Everyone had been trained on using the gait belt. When asked if a staff member is supposed to perform a transfer by picking the resident up with their (staff's) arms around the resident's waist, the TD stated, No. On 7/30/20 at 12:28 PM, the Director of Nursing (DON) was interviewed and queried regarding the incident/accident (I/A) report for R603's transfer and injury on 7/29. When reviewing the report, it was noted that the I/A read, Was the resident injured? No.Additional Information: BP (blood pressure) 142/99 (normal is at or below 120/80), P (pulse) 98, Swelling in right foot. When queried regarding the report, the DON stated, I know they were doing an X-Ray, I do not know the result. When queried regarding the expectation of how staff are supposed to perform a one-person transfer, the DON stated, I'm not sure what you mean, it depends on if they are weight bearing, etc. When asked how a staff member should perform a transfer if the resident is sitting on the edge of the bed and moving to a wheelchair, and if the staff should be holding the resident around the waist and picking them up, the DON responded, The aide should not be putting their arms under the armpits. The DON indicated staff should be using a gait belt. When asked if she knew if CNA A had used a gait belt for R603's transfer, the DON stated, I do not. On 7/30/20 at 12:55 PM, an observation of R603's right foot was made with LPN B. R603 was observed to have their feet up on pillows in bed and was wearing regular socks. Upon removing R603's socks, the skin was observed. There was no bruising or redness present, however, the outer right foot area (where the 5th metatarsal bone is located) had obvious swelling when compared with the left foot. On 7/30/20 at 1:23 PM, the Nursing Home Administrator (NHA) was queried regarding one-person transfers of residents and gait belt use. The NHA stated, I'm going to refer that to the DON. A review of the facility's policy titled, Gait Belt Use, dated 11/28/17, revealed: Purpose: A gait belt .provides a secure grasping surface to aid during transfer and ambulation. Commonly used for residents who are at risk for falls and those who require assistance during transfer Prior to gait belt utilization review the resident plan of care to validate use of the gait belt is not contraindicated .Transferring the resident: If the resident has one-sided weakness, position the destination surface (wheelchair, commode or chair) on the resident's unaffected side. Position yourself close to the resident to face each other. Grasp both sides of the gait belt using an underhand grip. While firmly gripping the gait belt, keep your back straight, bend your knees slightly, position your feet in a wide stance to maintain proper body mechanics and begin rocking back and forth to overcome forces resisting transfer. Instruct the resident on a count of three to push off of the surface to encourage independence. Allow the resident to stand for a moment to ensure balance. Instruct the resident to pivot and to bear as much weight as possible on the unaffected side .Pivot on your back foot, guiding the resident to the destination surface. Maintain contact between the destination surface and the resident's legs to ensure proper positioning prior to the resident sitting. Flex your knees and hips while assisting the patient onto the destination surface .After reaching the destination surface, keep a firm grip on the gait belt and gently lower the patient onto the surface. Tell the patient to reach and grasp the arm resent using them to bear some weight if possible . A review of the facility's policy titled, Activities of Daily Living (ADLs), effective 5/7/20, revealed: In accordance with the comprehensive assessment, together with respect for individual resident needs and choices our facility provides care and services for the following activities: .Mobility: Transfer and ambulation, including walking . Our collaborative professional team, together with the resident and / or resident representative: 1. Will recognize and evaluate an inability to perform ADLs or a risk for decline in any ability to perform ADLs; 2. Develop and implement interventions in accordance with the resident's evaluated need, goals for care, preferences and will address the identified limitation in an ability to perform ADLs; 3. Monitor and evaluate the resident's response to care plan interventions and treatment; 4. Revise the approaches as appropriate. The facility provided a document titled Observational Competency: Mobility, Transfer & Ambulation, undated, which was reviewed and revealed the following: 1. Assess the patient ' s ability to transfer. 2. Identify need for transfer equipment and additional assistance. 3. Know when to use and not to use a gait belt. 4. Explain the procedure to the patient and ensure privacy as appropriate. 5. Assist patient to sitting position on side of bed: a. Raise head of bed to a level the patient can tolerate b. Face patient and far corner of the bed c. Place feet apart for a wider base of support d. Place hand under patient ' s shoulders and the other hand under the patient ' s thighs. e. Move patient ' s lower legs and feet over side of bed while you are shifting weight to rear leg so patient is sitting on the side of the bed. Keep your hips and knees bent while completing the task and keep the patient close to you to protect your back. f. Provide support as needed and lower the head of the bed and the height of the bed so the patient ' s feet touch the floor. 6. Transfer patient from bed to chair: a. Position chair at approximately 45-degree angle to bed b. Apply gait belt if not already in place. c. Assume a wider base of support by keeping feet apart; flex hips and knees while keeping your back straight. Place knees in line with the patient ' s knees to block patient ' s knees and feet. d. Grasp gait belt and rock patient up to standing position at the count of three while holding the patient close to your body. If patient is able to assist, instruct the patient to scoot forward towards the edge of the bed, lean forward and then push up with both hands to standing position. e. Pivot on foot farther from chair and have patient grasps armrests of the chair as able and lower patient into chair.

This citation has two deficient practices. Deficient practice #1 pertains to Intake # 2. Based on interview and record review the facility failed to assess, monitor, order, and administer insulin for a resident with Diabetes affecting one resident (R905) of one resident reviewed for Diabetes care with the likelihood of undetected hyper/[DIAGNOSES REDACTED] (high or low blood sugars) and medical complications. Findings include: On 06/23/20 record review of R905's EHR (Electronic Health Record) revealed R905 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The initial MDS (Minimum Data Set) assessment dated [DATE] revealed R905 had a BIMS (Brief Interview for Mental Status) score of eight indicating a moderately impaired cognition and needed extensive assistance with ADLs (Activities of Daily Living.) Record review of R905's hospital discharge record dated 04/17/2020, indicated prescriptions for insulin [MEDICATION NAME] (long acting insulin) injection 15 units (dose) SQ (subcutaneous or just under the skin) every morning, and insulin [MEDICATION NAME] (fast acting insulin) 2-12 units (sliding scale), SQ every six hours as needed for blood sugar coverage. The hospital record also indicated that R905's blood sugars ranged from 108 to 204 ( normal blood sugar levels are under 100.) Record review of the admission H&P (history and physical), signed by Physician J and dated 04/17/2020 under Assessment and Plan, 9. Type 2 diabetes mellitus. Continue to monitor blood sugar. Continue with [MEDICATION NAME] (long acting insulin) 15 units in the morning and insulin sliding scale. Monitor blood sugar closely. Record review of R905's MAR (Medication Administration Record) for April 2020 revealed no order for the monitoring of blood sugars, no order for [MEDICATION NAME] 15 units every morning, and no order for insulin sliding scale. Record review of R905's MDS section I (Active Diagnoses), dated 04/28/2020 indicated R905 [DIAGNOSES REDACTED]. On 06/23/20 at 12:26 PM, the ADON (Assistant Director of Nursing) Nurse K was asked about the facility's policy and procedure regarding following-up on newly admitted resident's assessments, care plans, and orders and stated, The Unit Manager should have done a chart review and MDS should have caught it too. The Unit Manager there now is new. On 06/23/20 at 12:48 PM, the MDS/ Care Plan Coordinator, Nurse L was asked about the facility's policy and procedure on following up on care plans triggered by medical [DIAGNOSES REDACTED]. On 06/23/20 at 1:33 PM, Physician J was contacted by phone and asked about R905 not having blood sugar monitoring and insulin orders upon admission to the facility and stated, (R905) did have an order for [REDACTED]. Review of the facility's policy and procedure titled, Expanded Assessment Guidelines dated, Effective Date 11.28.2017, revealed under definitions, The accuracy of the assessment means that the appropriate, qualified health professional correctly document the resident's medical, functional and psychosocial problems . The initial comprehensive assessment provide baseline data for ongoing assessment of resident progress. The policy and procedure did not address missed medical orders, assessing, monitoring, or treating Diabetes. Deficient Practice Statement #2 This citation pertains to intake # 8. Based on interview and record review, the facility failed to arrange for transportation to the wound clinic for one resident (#912) of one reviewed for transportation, resulting in a lack of coordination and follow up by the surgeon. Findings include: On 6/19/20 at 11:24 AM, Confidential Witness A was interviewed and explained that Resident #912 had a wound that was to be followed by the wound clinic and that the facility refused to send the resident to the wound clinic. Confidential Witness A stated, (Resident #912) was in the hospital for their wounds, they were infected, when we were discharged I scheduled an appointment for 3/20/20, a week after discharge, and was told by the facility they were not allowing residents to go out, so I had to cancel it. The clinic was mad when I called (to cancel) and told me to schedule it as soon as possible. (Resident #912) passed away (in the facility), it says right on the death certificate, 'wound infection'. A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #912 was admitted to the facility on [DATE] and then readmitted on [DATE] with the following Diagnoses: [REDACTED]. Resident #912 had a Brief Interview for Mental Status (BIMS) score of 14, indicating an intact cognition. Resident #912 needed total assistance with transfers and bed mobility. A record review of the Progress Notes revealed the following: 2/20/20-Health Status Note (nurses note) Note Text: Resident received from hosp (hospital) at 1930 (7:30) pm via stretcher on ambulance. Resident is A&OX4 (alert and oriented), Quadriplegic (paralyzed from the neck down), h/o (history of) [MEDICAL CONDITION] (infection in the wound) . Resident has stage 4 (a deep wound caused by pressure that extends through to the bone) out coccyx wound and lt (left) heel has stage 2 wound, bilateral lower extremities are dry and scaly. Resident has PICC (peripherally inserted central catheter) line on right arm for I/V (Intravenous) ABT (antibiotic) . A record review of the hospital transfer discharge instructions dated 3/13/20 revealed the following note: Follow up & future appointments-follow up with (name of wound clinic) for wound healing in 1 week(s) Specialty: Wound Care. Further record review revealed that the Resident had went to the hospital on [DATE] and had their wound debrided (a surgical procedure in which the dead tissue is removed from the wound to reveal the wound bed) and was readmitted to the facility on [DATE]. On 6/24/20 at 12:13 PM, Wound Care Nurses H and I were queried in regards to Resident #912 having a wound and an order from the hospital to be followed at the wound clinic and stated, (Resident #912) was a hard one, they came in with the wounds and was also on IV antibiotics for it. On 6/24/20 at 1:00 PM, Unit Manager E was interviewed in regard to Resident #912 not following up with the wound clinic as ordered and stated,We were told not to send any one out, unless it was an emergency, from the corporate. The corporate lady that is here now told me we can now (schedule follow up appointments) for essential visits. On 6/24/20 at 1:15 PM, a request for a policy in regards to outside appointments was requested from the NHA but not received by the end of the survey. On 6/24/20 at 1:35 PM, the Nursing Home Administrator (NHA) was interviewed in regard to Resident #912 not being allowed to follow up with the wound clinic and stated, We weren't sending anyone out, per corporate. We were only sending people out for [MEDICAL TREATMENT]. The NHA was asked if the attending physician was aware and stated, Yes The NHA was asked to provide documentation but did not provide it by the end of survey. On 6/24/20 at 1:37 PM, Doctor (Dr.) D was interviewed in regard to Resident #912 to be followed by the wound clinic. Dr. D stated, I was only there to see wounds. I get consulted by the facility and I see them. I know that there was someone that had to go to the wound clinic but they had trouble with transportation and had me see them, but I don't recall the name (of the resident). On 6/24/20 at 1:57 PM, Unit Clerk F was queried on the process of setting up appointments and stated, I don't recall (Resident #912) going out. When I get an appointment, I tiger text it to the Assistant Director of Nursing and the Director of Nursing and they determine if it is essential or not. Back then, no one was going out because of what was going on (the pandemic). We were only sending people out for [MEDICAL TREATMENT]. On 6/24/20 at 2:35 PM, the Nurse Practitioner (NP) C was interviewed and queried in regard to Resident #912 being hospitalized for [REDACTED]. According to NP C, they were not aware that Resident #912 was to be followed from the wound clinic. On 6/24/20 at 4:00 PM, (Hospital) Wound Care Director B was queried via phone in regard to Resident #912 having to be followed by the clinic and stated, We did not see (Resident #912) because they canceled. Some facilities were not allowing residents to come, but we were open during this whole pandemic and were seeing our patients.

This citation pertains to intake #MI 248. Based on interview and record review, the facility failed to ensure an environment was free of accident hazards while providing care, for one (#502) of two reviewed for accidents, resulting in a laceration to the head. Findings include: A review of Resident #502's medical record revealed Resident #502 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Nurse admission evaluation noted, Musculoskeletal Weakness: Has weakness. Site: General muscle weakness. Weight Bearing Restrictions: Has weight bearing restrictions. Describe: unable to stand by (self), due to unsteady gait. Activities of Daily Living (ADL's) Resident needs assistance with ADL's 1. Yes . A review of Resident #502's care plan revealed, Focus: The resident has (Specify) actual. potential for an ADL self-care performance deficit r/t (related to). Date initiated 8/21/19. Goal: the resident will maintain current level of function in (Specify) through the review date. Interventions: Resident requires physical assistance. Monitor/document/report PRN (as needed) any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in functions. Continued review of Resident #502's medical record revealed a progress note, 9/9/2019 00:30 (12:30 AM) Health Status Note: CNA (Certified Nursing Assistant B) came to writer at 10:00pm and said that resident was in bed and she rolled (Resident #502) over to change (their) brief and (Resident #502) hit (their) head on the nightstand and start(ed) bleeding. Resident was checked and assessed, ice pack applied and the bleeding stop. Normal saline was use to clean the wound and kerflix applied to (Resident #502's) head . (Physician) was notified at 10:21PM, order received was to initiate neuro check and continue to monitor. Resident daughter was notified at 10:25pm. Progress Note: 9/9/2019 04:15 Health Status Note: Resident was observed laying on (Resident #502's) left side of body facing towards (their) bed on the floor. When staff approached resident (Resident #502) was yelling, kicking, and swinging (their) arms being non-complaint . was unable to verbalize why (Resident #502) was on the floor. Skin tear to left FA (forearm), laceration noted to posterior skull near left side. First aide rendered to both sites. ROM (Range of Motion) completed on all extremities . Neuro-checks imitated and . Stat skull X-Ray ordered . Progress Note: 9/9/2019 01:15 AMA (Against Medical Advice) Note Resident interview summary: Resident said that (they) hit (their) head on the nightstand when the CNA was changing (their) brief . A review of the facility's form titled, Report of Resident Incident dated 9/8/19, noted, .Was the resident injured? Yes. Minor injury (Abrasion, Bruise, Laceration, Pain, Skin tear, Sprains) . On 10/3/19 at 12:48 PM, CNA B was interviewed via phone. CNA B was asked to explain the incident with Resident #502. CNA B stated, I was removing the hoyer pad from under (Resident #502). I had moved (their) nightstand earlier that day so that (Resident #502) would not hit it. (They) must have moved it back. I rolled (Resident #502) and (they) tapped (their) head, it was not a hard hit for it to start bleeding. (Resident #502) wants everything close to (them), (they) move the furniture a lot. On 10/3/19 at 1:39 PM, the Director of Nursing (DON U) was asked the procedure for providing care in bed. The DON stated, Make sure the area is clear, pillows, and devices are removed and check the positioning in the bed. At this time the DON U was asked for a policy and procedure for ADL's/bed mobility. A policy was not provided by the end of this survey.

This citation pertains to Intake: 3 Based on observation, interview, and record review, the facility failed to turn and reposition every 2 hours and to ensure preventative measures were implemented to prevent a pressure ulcer for one (R400) of three sampled residents reviewed for pressure ulcers, resulting in a facility acquired unstageable pressure ulcer. Findings include: On 9/10/19 at 9:42 AM, R400 was observed in bed on their back with their head turned toward the left with contractures, and a [MEDICAL CONDITION] with humidified oxygen in place. On 9/10/19 at 11:55 AM, R400 was observed in the same position as they were at 9:42 AM, which was on their back with their head toward the left. On 9/10/19 at 1:26 PM, R400 was observed in the same position, on their back with their head toward the left. R400 was not observed out of bed the entire morning. On 9/10/19 at 10:25 AM, an interview was conducted with Confidential Family Member A via telephone. Confidential Family Member Astated, (R400) has been there since (MONTH) and has a bad bed sore. They do not turn (R400) and they are always in the same position in bed. They're supposed to get out of bed every day, but they wouldn't get (R400) up. I had to ask them to at least get (R400) out of bed three days a week since they were not getting them up. (R400) went to the hospital for pneumonia and that's when I noticed that they had a bed sore. They did not tell me that (R400) had a bed sore. I've talked to the Administrator and the Director of Nursing (DON) several times and nothing is being done. (R400) can't move or speak and the neurologist said they are not sure if they can see or hear. I can't take care of (R400) at home. I know it is a lot of work, but the aides just sit around and now (R400) has a very large bed sore. They said that a wound specialist is on the case, but it is not working. On 9/10/19 at 10:40 AM, an interview with nurse B regarding the wound on R400. Nurse B said, I'm not the regular wound care nurse. I picked-up an extra shift today. I'll just clean it and apply a new dressing. On 9/10/19 at 11:00 AM , observation of the resident's wound with nurse B revealed an odor from the wound on the right side of the resident's buttock. The wound was unstageable with serosanguineous drainage. There appeared to be slough and darken edges. Nurse B applied an ointment and a dry dressing. On 9/10/19 at 11:15 AM, record review revealed that R400 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] noted that the resident was totally dependent on staff for care. Resident had a Braden Scale score of eight (9-23 predicts the risk for developing pressure ulcer, and 8 or below placed the resident at severe risk for wounds). Review of the Alteration in skin breakdown care plan, dated 6/10/19 noted: Evaluate and treat per physician's orders [REDACTED]. Review of a physician's orders [REDACTED]. On 8/1/19 at 1:49 PM an order written [REDACTED]. Review of the Skin Observation document dated 6/14/19 and 7/7/19 noted no skin issues. Review of the Skin Observation document dated 7/15/19 noted: Reddened area with dark spot around it- coccyx. Review of the Skin Observation document dated 7/24/19 noted: Sacrum stage one: blanchable Left buttock: stage two wound, healed scab on right side of right foot. Review of the Wound Assessment Details Report dated 7/31/19 noted: Pressure Ulceration .[MEDICATION NAME] (pale, pink or red)+60 percent (%), Necrotic soft, Serosanguineous drainage, Measurement 1.7 centimeter (cm) by 2.0 cm by 0 with the area measuring 3.4 cm Review of the Wound Assessment Details Report dated 8/6/19 noted: Right buttock Pressure Ulceration . Measurement 1.7 cm by 2.0 cm by 0 with the area measuring 3.4 cm Review of the Wound Assessment Details Report dated 8/14/19 noted: Right buttock Pressure Ulceration . Measurement 1.7 cm by 2.0 cm by 0 with the area measuring 3.4 cm Review of the Wound Assessment Details Report dated 8/23/19 noted: Right buttock Pressure Ulceration .Moderate drainage .measurements 2.5 cm by 3.0 cm by unknown with the area measuring 7.5 cm Review of the Wound Assessment Details Report dated 9/2/19 noted: Right buttock Pressure Ulceration .Necrotic soft, Serosanguineous drainage .measurements 2.5 cm by 3.0 cm by unknown with the area measuring 7.5 cm Review of the Skin Observation dated 9/9/19 noted new skin issue, Right buttock, right, stage four open wound. There were no documented evidence of a turn schedule or turning program in the resident's medical record. A review of a progress noted written by Licensing Practical Nurse (LPN) C on 9/9/19 at 2:03 noted : Writer helped Certified Nurse Assistant( CNA) changed patient's (pt) brief and bedding. When changing, noticed stage 3 wound on right butt cheek. Writer cleaned and packed wound, applied bandaged signed and dated. initiated new wound orders. On 9/10/19 at 1:29 PM, Unit Manager [NAME] was interviewed regarding the turning protocol and if R400 was out of bed this morning. Unit Manager [NAME] stated,It is the Certified Nursing Assistant's (CNA) job to turn and reposition the residents every two hours. They should be doing it. Unit Manager [NAME] was asked if they follow up to ensure that the residents on their unit were being turned. Unit Manager [NAME] stated, Sometimes I am very busy. The CNA should be repositioning the residents. The family said they only wanted R400 out of bed three times per week. I was meaning to change that order last week. Unit Manager [NAME] was asked if they consult with the physician regarding changes in orders. The Unit Manager [NAME] said, Yes I do. I forgot to write the order last week. Unit Manager [NAME] was asked is they were aware of the worsening of R400's wound and they stated, Yes, you are right. R400 should be turned every two hours. On 9/10/19 at 2:45 PM, the Director of Nursing (DON) was interviewed regarding R400's worsening wounds and pressure ulcer prevention policy. The DON stated, I've only been here about two weeks. We are working on this. The residents should be turned and repositioned as ordered. We need to work on decreasing wounds. A review of the facility's policy, titled, Skin Management, noted: Interventions for the prevention of pressure ulcers will be individualized to meet the specific needs of the resident. Interventions to be implemented can include, but are not limited to: Positioning. Residents assessed at risk for breakdown will be placed on a turning and positioning program. Newly developed skin issues within the facility will be investigated to determine cause. A review of the Turning and Repositioning Program policy noted the following: All residents who are unable to reposition or turn themselves will be placed on the turning program. The turning schedule will occur at designated times. The Charge Nurse will observe and assist with the turning and positioning as needed. Nursing assistants will document turning and repositioning in the EMR.

This citation pertains to intake MI 597. Based on observation, interview, and record review, the facility failed to address and prevent a significant amount of weight loss for one resident (R#106) of two reviewed for weight loss, resulting in a weight loss of 18 pounds (lbs) over a six month period. Findings include: On 2/12/19 at 6:33 AM, R#106 was observed in their bed. The resident was unable to verbally answer questions, but was able to answer simple yes or no questions by shaking or nodding their head. The resident's tongue appeared dry, with a whitish film. The resident appeared cachectic (thin, wasted-away), with sunken eyes and dry, peeling lips. R#106 was observed to be receiving enteral nutrition via a feeding tube in the abdomen. On 2/12/19 at 8:49 AM, Certified Nursing Assistant (CNA) C was queried regarding R#106's dry appearance. CNA C indicated the resident was not to have anything by mouth, and that the nurses took care of moistening the resident's mouth and lips. On 2/12/19 at 9:17 AM, Unit Manager (Nurse A) was asked to observe R#106's and then was questioned regarding their appearance. Nurse A stated CNAs are supposed to provide hydrating mouth and lip care to the residents. Nurse A was asked if the dietician had seen R#106 recently, to which they responded We got a new one, maybe 2 or 3 weeks ago, I don't know if she's seen (R#106) yet. Nurse A was then asked if R#106 appeared to have lost weight. Nurse A stated, I think so (in regards to weight loss), I have a paper with residents with weight loss I don't know if they're on there. The resident was then asked to open their mouth, and Nurse A was asked if the resident appeared dry to her. Nurse A stated, Oh. Yes, I'll go get some stuff for (them). On 2/12/19 at 9:26 AM, Nurse A provided a printed-off list titled, Weights and Vitals Exceptions. This list was reviewed with Nurse A and revealed the following for R#106: [DATE] 14:59: (Weight:) 109.5 lbs .Comparison Weight 8/28/2018, 127.6 lbs, -14.2%, -18.1 lbs When queried regarding the 18.1 lbs weight loss (loss of 14.2% of body weight), Nurse A replied, Oh, (R#106) went down. I can call the dietician for you, I'm not sure if she's seen (the resident) yet. Further review of R#106's medical record revealed the following weights since 8/28/2018: 2/7/2019 14:59 109.5 Lbs 1/31/2019 14:59 110.4 Lbs 1/15/2019 14:59 111.0 Lbs 12/11/2018 14:26 115.8 Lbs 11/20/2018 11:43 118.6 Lbs 11/14/2018 09:12 114.8 Lbs 10/16/2018 14:20 119.2 Lbs 10/8/2018 10:50 118.3 Lbs 9/11/2018 16:45 122.4 Lbs 8/28/2018 09:27 127.6 Lbs Continued review revealed the following: 11/15/2018 11:49 *Care Conference Note Note Text: Care conference held. TF (tube feeding) in place and recently increased to minimize weight loss. TF to be balanced with s/sx (signs/symptoms) resp distress. P[NAME] (Plan of Care) reviewed. Dietary No further nutrition/dietary notes were found upon search in the medical record progress notes, and no significant weight change notes were found upon searching. The 11/15/2018 dietary note was the only dietary note found from (MONTH) (YEAR) through 2/12/19. On 2/12/19 at 10:08 AM, Dietician D was interviewed regarding R#106's weight loss. Dietician D indicated they were new to the facility. Dietician D stated, I brought (R#106) up to the Nurse Manager (Nurse A) to see what was going on with that. I know the resident has a tube feeding. My question was, are they actually giving it to (them)? It's not good that (they're losing weight). I'm wondering the same as you. No one on a tube feeding should be losing that much weight - what is going on? Nursing suggested ordering a pre-[MEDICATION NAME] but nothing after that. I'm going to keep them on weekly weights now because they're getting enough calories. I'm just doing what I can do now because yes, again, the weight loss is a concern. On 2/12/19 at 12:06 PM, the Director of Nursing (DON) was interviewed. When queried regarding R#106's weight loss, the DON stated, I'm not aware of that weight loss. No one brought it to my attention, I haven't had the chance to look at their file. The DON was then asked what the expectation is of weight loss in residents receiving tube feedings and replied, The expectation would be for someone to not lose that much weight. A review of R#106's care plan revealed the following: Focus: Resdnt (sic) unable to consume adequate po (oral) intake due to NPO (nothing by mouth) status .dependent upon enteral feeding to meet nutritional needs which increases risk for aspiration, dehydration, and or wt (weight) loss . Goal: Resident will meet nutritional needs safely via G tube (feeding tube) AEB (as exhibited by) I will have no episodes of aspiration, no episodes of aspiration and/or significant change in wt status . Interventions: Monitor skin turgor and mucous membranes for s/s (signs/symptoms) of adequate hydration . RD (Registered Dietician) to evaluate monthly and PRN (as needed), monitor caloric intake and estimate needs and make recommendations for change to Tube Feeding PRN . I will be weighed wklyx4 (weekly times four weeks) upon admission and thereafter monthly and prn for changes . A review of R#106's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was admitted into the facility on [DATE] and readmitted on [DATE] with medical [DIAGNOSES REDACTED]. A review of the facility's policy titled, Weight Monitoring Guideline, effective (MONTH) (YEAR), revealed, Monitor weight reports produced inside (electronic medical record) for significant changes and for gradual insidious changes that may indicate a risk factor for nutrition or hydration status and/or clinical condition .Review significant weight change reports daily for review and evaluation .Review weight reports at least weekly to ensure residents with weight variances of 5% in 30 days and 10% in 6 months are reviewed and evaluations for nutritional risk and timely interventions is completed .

Based on observation, interview and record review, the facility failed to prevent and protect one sampled resident (R214) from being physically abused by R399, resulting in R214 being shaking, shoved, and punched in the face and out of the wheelchair to the floor. Findings included: On 9/12/18 at 8:30 AM, R214 was observed in room sleep and did not wake for interview. On 9/14/18 at 12:00 AM R214 was observed sitting in a wheelchair in the main dining area. On 9/14/18 at 11:45 AM a called was made to Certified Nurse Assistant (CNA O) and a voice mail was left. On 9/14/18 at 11:48 AM a called was made to Licensed Practical Nurse (LPN P) and a voice mail was left. On 9/14/18 at 3:18 PM LPN P called and during the interview via phone, LPN P was asked about the incident with R214 and R399. LPN P stated, I was the Nurse that day. It happened little before 12 midnight. The CNA came to me and told me she saw the resident being shoved. When I got there (R214) was on the floor. I took (R214) away into an unoccupied room. LPN P was asked the expectations of a CNA during a physical incident. LPN P stated, Never leave the resident If you see something. Try stop it or calm the situation down and separate the residents. LPN P was asked did R214 fearfully of R399. LPN P stated, Not before this incident, afterward yes (R214) was scared. When I took (R214) to the other room (R214) expressed to me that (they) were nervous. LPN P was asked if R214 had any injuries from the incident. LPN P stated, I didn't see any, but was told that (R214) had an abrasion on the elbow. On 9/13/18 at 9:00 AM a review of R214 clinical record that the resident was was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) revealed that R214 had a severely impaired cognition and required limited assist with activities of daily living. Continued review revealed a note authored by LPN P,: Progress note: 7/28/18 00:47 (12:34 AM). Nursing Description: Approximately at 12:00 am on 7/28/18 the Certified Nursing Assistant (CNA O) came and got the Nurse stating that in room (room number) there was an altercation going on, she said the resident from (R399) was pushing and shoving the resident in (R214). As I approached the room the resident in bed 2 was observed on the floor. The resident from (R399) told me that he was tired of the resident in (R214) turning on the light because he was trying to sleep. The supervisor was notified and the resident in bed 2 was moved to a unoccupied room, statements were taken from all parties. Resident from (R399) said I told him to turn off the light and he keeps turning it on, the resident from (R214) said he was looking for something so that's why he had the light on. The resident from bed 1 said he has had the light on all day and I want it off now, the resident from (R214) was removed from the room as requested from the supervisor. 09/13/18 09:14 AM during a review of the facility's investigation revealed the following: Witness Report. 7/27/18. Approximate time 11:00 p.m. Witness Name: (CNA O) . Did you actually witness the incident Yes . If you witness the incident, please describe what you saw happen: I heard (R399) yelling turn the light off, (R399) was shaking (R214's) wheelchair. Very hard I told him to stop. I went and got the Nurse. When I told (R399), (R399) did stop and walked away at that time I went to get the Nurse . Summary Of Occurrence. On 7/27/18 approximately 11:15pm CNA O witness (R399) physically shoving and shaking (their) roommate (R214) in (the) wheelchair. CNA (CNA O) asked (R399) to stop. (R399) walked away from (R214). CNA (CNA O) exited the room to summon Licensed Practical LPN (LPN P). Both LPN and CNA (LPN P and CNA O) immediately return to room to find (R214) on the floor. When queried as to what happened (R214) said (R399) had punched (them) in the face and knocked (them) out of (their) wheelchair. (R399's) response to (R214) explanation was I told (them) to turn off the light and (they) keeps turning it on. (They) had the light on all day. According to (R214) was looking for (their) check . 7/27/18: At approximately 11:28p, two police officers arrives at the facility . The officers determined (R399) to be the aggressor. Determined it was assault and battery. (R399) was placed under arrest and transported to (local police station). 7/28/18: Director of Nursing (DON), conducted a full body assessment on (R214) there were no findings of any bruising or cuts. There was a small abrasion noted on his left elbow . 9/14/18 at 12:26 PM during an interview, the Administrator was asked to explain the expectation of staff during a physical altercation and why wasn't R214 kept safe after witnessing the physical altercation. The Administrator stated, The CNA, thought it was ok leave, because the Resident walked away from R214 after she told (them) to stop. We educated her on what she should have done. The Administrator was asked what did the education address. The Administrator stated, Don't leave the resident and to stand there and yell for help if you have to. Review of the facility's policy titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property dated 11/28/2017, noted, . Protection. Abuse Policy Requirements: It is the policy of this facility that the resident(s) will be protected from the alleged offender(s). Procedure: Immediately upon receiving a report of alleged abuse, the Administrator, and or designee will coordinate deliver of appropriate medical and/or psychological care and attention. Ensuring safety and well-being for the vulnerable individual are of utmost priority. Safety security and support of the resident . Procedures must be in place to provide the resident with a safe, protected environment during the investigation: The alleged perpetrator will immediately be removed and resident protected .

This citation pertains to intake # Based on observation, interview and record review, the facility failed to identify behavioral triggers and implement effective interventions to prevent aggressive, violent behavior towards staff members and residents for one resident (#508) of three residents reviewed for abuse, resulting in continued aggressive behavior, feelings of frustration and the choking of Resident #507. Findings include: A review of the face sheet and Minimum Data Set (MDS) assessment revealed that Resident #508 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] revealed that Resident #508 had a Brief Interview of Mental Status (BIMS) score of 14 out of 15, indicating an intact cognition. On 8/30/18 at 9:15 AM, an interview was completed with Confidential Witness A. According to Confidential Witness A, on 8/28/18, while in the locked unit (a unit with residents that are severely cognitively impaired), she heard screaming and ran towards the sound and observed Resident #508 in the dining room sitting in a chair bending down towards the floor with their hands around Resident #507's throat. Resident #507 was screaming. On 8/30/18 at 10:40 AM, Resident #507 was observed in the locked unit standing near a staff member rubbing the staff member's back in a comforting manner. Resident #507 was nonverbal. There were several confused residents present throughout the unit. A review of the face sheet and MDS assessment revealed that Resident #507 was admitted into the facility on [DATE] with an [MEDICAL CONDITION] diagnoses. The quarterly MDS dated [DATE] revealed that Resident #507 had a severely impaired cognition. A review of a Progress Notes for Resident #507 dated 8/28/18 revealed that they were laying on the floor with (Resident #508) bending over and choking them. There was bruising and four scratches noted on their left side of the neck as a result of the incident. A review of the Progress Notes for Resident #508 revealed the following behavioral notations: 1/17/18 9:36 AM (Nursing)-Resident at nurse's station dressed in winter coat and gear demanding to leave to visit their friend .Explained rules of unit .Refuses to use W/C (wheel chair) and walked back to room after attempting to leave east door of unit. Will monitor. 1/18/18 12:29 PM (Social Services)- .This resident LG (Legal Guardian) reported that this resident has a HX (history of) leaving group home placement .recently the police picked them up and brought them back to the facility (group home) .resident ended up on the streets or homeless shelter church and they could not be found . 1/22/18 5:19 PM (Social Services)- .(Legal Guardian) reported on 1/15/18 (Resident #508) was scheduled for discharge from hospital .(Resident #508) had gone missing (from hospital) .a lady called the police and reported (Resident #508) was found walking on the street . 2/19/18 12:25 PM (Social Worker/SW B)-Staff reported, heard yelling out 'get out of my room' several times from hallway. Staff reported followed sound .(Resident #508) sitting in wheelchair sideways, floor nurse standing in front of them and behind nurse was two residents (wandered into Resident #508's room). Staff immediately redirected the other two residents out of the room .It was reported that staff nurse stated she heard yelling and ran down to the room. When she got there she saw (other resident) with their hands on (Resident #508)'s shoulder pushing them into the wall and bumping their head on the glove container. 3/4/18 6:07 AM (Nursing)-Resident was observed by writer sitting in w/c (wheel chair) by window with plastic tore down from window and bolts loosen from window seal . metal piece from window seal was observed in resident hand . 3/13/18 4:43 PM (SW B)-Staff reported that the resident made a phone call to one of their friends and asked the friend to bring a screw driver to the facility. They were overheard on the phone stating that they want to leave this place . 4/23/18 2:58 PM (SW B)- .Resident displays safety awareness concerns .Resident present anxious and distraught behavior at times r/t (related to) placement . 5/7/18 4:44 PM (SW B)-Staff reported resident to resident incident .CNA (Certified Nursing Assistant) stated both residents were standing against the wall when one resident was pushing the other residents head into the wall repeatedly. (Resident #508) reported that (other resident) hit them first. 5/1/18 4:46 PM (Nursing)-Staff reported Resident displayed increased mood and behavior changes at this time. Resident displayed verbal behavior AEB (as evidenced by): shouting and cursing at SW. Resident displays upset and angry AEB: Resident observed lying in bed, agitated, sitting up and then laying down while in bed. Resident stated that they finished therapy and they can walk so they want to go home . 5/21/18 3:41 PM (Nursing)-Change in behaviors, Resident noted to be verbally aggressive throughout the day when other resident walk near them or is by their door. Resident also exhibiting yelling out behaviors when roommate leaves the door to bedroom open . 5/23/18 3:17 PM (SW B)-Resident expressed desire to speak with someone about their emotions and how they feel about placement .Resident present fluctuation in agitation when other residents approach/or come near them while in dining room . 5/24/18 1:38 PM (SW B)-Staff reported heard noise coming from room .Staff went to the room .observed resident .standing in the room. (Resident #508) able to recall reported res to res (resident to resident) incident. (Resident #508) reported that the other resident (room mate) hit and knocked their eyeglasses off their face . 5/30/18 1:00 PM (SW B)-(Room mate) was inside room .(Room mate) reported that (Resident #508) closed the door from the outside and held the door shut and refused to let them out of room .(Room mate) yelled to open the door to the resident outside the door while holding the door. Staff reported heard yelling . 7/19/18 9:48 PM (Nursing)-Writer was informed by staff that the resident was trying to get coffee off the food cart when the resident was told that they were not allowed to be in the cart then resident started to hit the staff member with their wheel chair, the resident also kicked the staff member and grabbed a hold of her arms refusing to let go. Writer observed that the resident had the staff member pinned between their wheel chair and the food cart . 7/26/18 10:12 PM (Nursing)-Received call as resident was reported to be barricaded in another patients room. Upon arrival on unit, went to room .and was able to push door open as wheel chair was blocking the door. (Resident #508) was sitting in recliner in room and watching residents TV (television). Spoke with resident regarding behavior and being in peers room. Able to talk resident into leaving room and coming into hall to talk with RN (Registered Nurse). Spoke of his frustration with being here . 8/14/18 8:15 PM (Nursing)-Resident was pushing another resident on their wheel chair when they landed on their buttocks . 8/14/18 5:47 PM SW B)-It is reported Resident is non compliant .continues to ignore staff . 8/23/18 8:49 PM (Nursing)-Pt (Patient/Resident #508) refuse to leave out of room. Staff informing resident that it is another female resident room and they need to provide care .Pt became physically aggressive .male cena (CNA) assisting resident out of room pt refusing and becoming physically aggressive kicking, swinging, and grabbing a hold of staff. 8/28/18 11:49 PM (Nursing)-(Resident #508) was observed bending over in a chair choking (Resident #507) . 8/29/18 2:50 AM (Nursing)- .one on one monitoring continues, pt states they don't want to be here. 8/29/18 11:41 AM (Nursing)-Resident c/o (complains of) abdominal pain .refusing medication. EMS (Emergency Medical Services) here to transport resident .resident refused to get on stretcher and go to hospital .MD (Medical Doctor) ordered resident to be petitioned for making unsafe decisions for themselves r/t abdominal pain secondary to anxiety with worsening impulsive behaviors putting themselves and others at safety risk. On 8/30/18 at 2:00 PM, an interview was completed with SW C. SW C was queried in the rationale for Resident #508 to be in a unit with severely confused residents. SW C stated, (Resident #508) was an elopement risk. The unit that they were on has different (locked) doors. (Resident #508) was real alert but unable to make their own decisions. We considered taking them off the unit but they had tried to get out through the window (while on the unit). On 8/30/18 at 2:32 PM, the Director of Nursing (DON) was queried in regards to the long term plans of Resident #508. The DON stated, We were going to try to find more appropriate placement for (Resident #508). We have a meeting with the brother tomorrow. (Resident #508) is still in the hospital. We were going to try to find a lesser restrictive setting. They may not come back here possibly. On 8/30/18 at 3:03 PM, SW B was queried regarding the placement of Resident #508 on the locked unit that housed severely confused residents. SW B stated, We moved him after the choking incident. When he comes back we are going to put him on a different unit. The Guardian had expressed concerns of the safety and behavior (of Resident #508). A record review of the care plans was completed for Resident #508 and revealed the following: Created 8/14/18 Focus- The Resident has ineffective individual coping (actual) r/t noncompliance, disease process, impaired adaptive behavior and problem solving skills. They wander into other residents room and sits and watches TV. They are difficult to redirect. Goal- Will display a decrease in intrusive wandering behavior. During review period will show an improvement in response to staff making requests. Created 7/20/18 Focus- (Resident #508) presents alteration in behavior r/t Resident becomes very agitated and anxious when staff re-direct them. Resident is fidgety and restless daily. Resident makes frequent false allegations/statements about staff. Resident exhibits aggressive physical behavior and uses profanity with staff. Goal- The resident will have no evidence of behavior problems by review date. Interventions- Provide a calm and safe environment to allow resident to express feelings as needed. Anticipate and meet the resident's needs. Intervene as necessary to protect the rights and safety of others .Remove from situation and take to alternate location as needed. Created 1/16/18 Focus- (Resident #508) is an elopement risk r/t Impaired safety awareness, reported exit seeking behavior . Interventions did not include necessity of being on a locked unit. Created 1/23/18 Focus- The resident has a mood problem . Goal- The resident will demonstrate adjustment to nursing home placement . The resident will identify appropriate diversional activities . Created 7/20/18 Focus- (Resident #508) is potentially physically aggressive r/t Anger, Dementia, History of harm to others, Poor impulse control . Goal- The resident will find alternative behavior options with the help of medication and staff interventions and will not harm self or others . A record review was completed of the facility policy titled, Behavior Management Policy revised 12/6/17. The policy stated, #3 Residents noted with an increase in behaviors negatively affecting self or other residents .will be reviewed by the Behavior Management Committee. The team will explore the root cause of behaviors/mood. The team can then identify target behaviors and an individualized plan of care . A record review was completed of the facility policy titled, Abuse Policy effective 11/28/17. The policy stated the following: It is the policy of the Facility that each resident be free from 'Abuse'. Abuse can include verbal, mental, sexual, or physical abuse, corporal punishment or involuntary seclusion .Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for Protection .

This citation pertains to intake MI 573 Based on observation, interview, and record review, the facility failed to provide adequate supervision during a shower for one (#803) of 3 residents reviewed for falls out of a total of 7 sampled residents, resulting in the resident falling out of a shower chair and sustaining a fractured left knee. Findings Include: On 7/11/17 at 11:32 AM, Resident #803 was observed lying in the bed. Resident #803 was asked about his fractured knee. Resident #803 stated, It happened the second Monday in June that my left knee was fractured and I went to the hospital. I can't walk on it. In the shower, she asked me if I could wash myself. She was going to come down here and make my bed. I asked her if the chair was locked. She said yes. Next thing I knew, I was on the floor and landed on my knee . On 7/11/17 at 11:48 AM, a review of the clinical record revealed that Resident #803 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], indicated that Resident #803 was cognitively intact, did not ambulate, and required supervision and the physical assistance of one person during bathing. On 7/12/17 at 9:10 AM, a review of the Unusual Occurrence, dated 5/15/17 at 8:40 PM, stated, CENA (Competency Evaluated Nurse) stated she turned to get a towel while patient was washing himself up and he stood up trying to wash his private area and the chair tipped forward. The post-fall follow-up comments stated, During shower care with CNA (Certified Nurse Aide) E, resident attempted to reposition self to wash groin and tipped shower chair causing him to fall. Resident complained of pain and left knee noted to be swollen .On 6/1/17 PACE completed CT of left knee showing fracture medial femoral condyle in left knee. A review of the CT Scan, dated 6/1/17, stated, Findings: There is a fracture of the medical femoral condyle with intra-articular extension. The fracture fragment is mildly displaced both medially and proximally . On 7/12/17 at 9:22 AM, CNA E was asked about the events in the shower room that resulted in Resident #803's fall. CNA E stated, He's an afternoon shower. I'd not given him a shower before. I helped him get into the wheelchair and then one person assisted him into the shower chair .He said he could do his torso, that he needed help with his back and his legs. So I turned to get a towel on the shower bed and I don't know if he was trying to lean to the left or rise up to wash his groin, but the chair tipped over. It tipped over. It tipped over toward the right. When I saw him he was in a side lying, fetal position with his right hand down and he was on his right side. There was more pressure on his butt and hip than on his legs. His legs were up. CNA E was asked to demonstrate in the shower room the events that occurred. On 7/12/17 at 9:35 AM, in the north shower room, on Unit C, CNA E showed the chair she had put Resident #803 in and that she had pushed Resident #803 into the shower stall so his back was to the shower head and he faced the opening of the shower stall. CNA E revealed she had placed the clean linen in a plastic bag and put it on the shower bed, which was in the far corner along the same wall as the shower stall. The shower bed was positioned approximated 6-8 feet from the entry to the shower stall. CNA E stated, I walked over to the shower bed to get a towel. I heard a thud and when I turned around, he was on the floor. CNA E was asked if she had tried to intervene when she saw Resident #803 starting to rise. CNA E stated, I didn't see him when he started to rise. He was on the floor in front of the shower stall. CNA E was asked how she knew Resident #803 had fallen. CNA E stated, I heard a thud and when I turned, he was on the ground. I know I'm not supposed to leave them or turn my back on them. They in-serviced me after it happened, but it was done by PT (Physical Therapy) on transfers, using the gait belt, Hoyer lift and sit-to-stand lift. CNA E was asked if the in-service addressed the placement of items needed to care for the resident close so continued supervision could be provided. CNA E stated, No. I had nothing to do with that. Observation of the shower stall failed to reveal a surface close to the shower stall that would allow staff to remain close to the resident, during a shower, without getting linens wet. On 7/12/17 at 11:30 AM, the above observation was discussed with the Assistant Director of Nursing (ADON)/Safety Officer. The ADON revealed they had CNA E demonstrate in the Administrator's office the events that occurred in the shower, but not in the shower room. The ADON was asked if CNA E had demonstrated the distance she had to go to get the towels. The ADON stated, She said she turned and to me that means, feet planted and turn at the waist. The ADON was asked about the corrective measure of CNA E being in-serviced on transfer technique when the fall was unrelated to transfers. The ADON had no explanation. On 7/12/17 at 1:00 PM, a review of the Fall Management Guidelines Policy and Procedure, reviewed 4/7/17, stated, Each resident is assisted in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices, and/functional programs as appropriate to minimize the risk of falls .

This citation pertains to intakes MI 959 MI 020 Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to 2 (#801 and #804) of three residents reviewed for falls out of a total of 7 sampled residents, resulting in avoidable fall incidents and injury for Resident #804 that included multiple rib fractures. Findings include: Resident #804 On 4/5/17 at 11:07 AM, a review of the clinical record revealed that Resident #804 was readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], indicated that Resident #804 had moderately impaired cognition, was sometimes physically and verbally symptoms towards others and wandered daily. The nursing care plan, dated 3/21/17, documented requires redirecting when in others room, exit seeking at times, wandering, becomes agitated when being redirected. Some approaches listed to deal with the behaviors were Encourage resident to be in common areas with line of sight by staff when up out of room, monitor for whereabouts of resident frequently, redirect and remove resident from others rooms and any unsafe situation. A review of the facility incident report, dated 3/10/17 at 5:30 p.m., Unit B, documented Resident was observed in (Resident #803's) room by staff laying face down with blood coming from chin area . This was not Resident #804's room. Another incident report, dated 3/10/17 at 5:30 p.m., documented, Resident in room yelling Get out get out of my room writer went to room. Resident observed standing over another resident (#804) who was face down on floor. Resident (#803) stated, I told her to get out, so I pushed her. Resident #804 had wandered into Resident #803's room and was pushed by a resident in that room and fell . The facility's investigation stated, Resident #804 wanders daily is easily distracted, rambles, and is fidgety .Resident #804 returned to facility on 3/13/17 with left 8/9 rib fracture .Resident #804's fall was not witnessed by staff; however the Resident #803 states he pushed her because he wanted her to get out of his room . A review of the chest x-ray in the hospital records for Resident #804, dated 3/10/17, documented Clinical Data: Fall Comparison Multiple prior chest radiographs most recently dated April 29, 2016 .There are acute mildly displace fractures involving the posterolateral left eighth, and ninth ribs. There is also a fracture of the left fifth rib .Impression: Acute mildly displacing left eight and ninth posterolateral rib fractures without evidence of pneumothorax. On 4/5/17 at 11:37 AM, while sitting at the nursing station, on the closed unit, Resident #804 was observed ambulating about. Resident #804 walked from the nursing station to the dining room to the exit doors. Unit Secretary B repeatedly went to redirect Resident #804. Resident #804 was not resistant to being redirected. She smiled and talked nonsensically and complied with Unit Secretary B's requests. Unit Secretary B was asked about Resident #804's wandering the day she was found on the floor. Unit Secretary B stated, (Resident #803) does this thing where he yells 'get out of my room'. She was already on the floor. The nurse was at room 225. He (Resident #803) said he pushed her and then he said he didn't push her. The nurse's weren't there when he said it. He said that to me when he was in the dining room. Unit Secretary B was asked if Resident #804 had a tendency to wander into other peoples' rooms. Unit Secretary B stated, Yes. She is only in her room when she sleeps. Other than that she just walks. It was observed that Resident #804's room was to the left of the nursing station down the hall and then down a hallway to the right. Resident #803's room was at the end of the hallway directly in front of the nursing station. She walks and she's fast. She's that quiet and that quick. It was dinner service and we have more than her that is a walker. We have others that walk a lot. Unit Secretary B and Unit Manager C who was also present during the interview, revealed they try to keep the residents in the dining room with activities. Neither staff person had an explanation how Resident #804 was able to walk from her room past the nursing station and not be observed before entering Resident #803's room. On 4/5/17 at 2:03 PM, a review of the clinical record revealed that Resident 3803 was readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS, dated [DATE], indicated that Resident #803 had severely impaired cognition and had physical and verbal behaviors towards others. A review of the nursing notes, dated 12/18/16 at 11:45 PM, documented, Nurse overheard loud noise and looked down hallway observed (anonymous resident) on right side of body laying on floor next to (Resident #803's) room. Resident #803 was coming out of room in wheelchair. Nurse asked Resident #803 what happened and Resident #803 stated, I pushed her cause she was in my room . Resident #803 had a history of [REDACTED]. On 4/6/17 at 11:36 AM, the Director of Nursing (DON) was asked about monitoring Resident #804 and a review of the nursing staffing was done. The DON revealed that on 3/10/17 there was adequate staff, but had no explanation why Resident #804 was not noticed going down the hallway before entering the room of the Resident #803's room. Resident #801 A review of the clinical record revealed that Resident #801 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS, dated [DATE], indicated that Resident #801 had severely impaired cognition and required extensive assistance from staff to complete activities of daily living. The nursing care plan, dated 8/4/16, documented History of fall, non-compliance with safety measures in place, lack of self limitation, impaired cognition, poor safety awareness, unsteady gait at times. Does not ask staffing for assistance . On 4/5/17 at 9:07 AM, during a telephone interview, and interested individual stated, Resident #801 got up out of the wheelchair in activities and was pushing the wheelchair and when she went to sit down the wheelchair go away from her and she fell . The activity's person said they are not allowed to touch the residents. If that is the case why are they in there. She should have gone and gotten the nurse when she first stood up. On 4/5/17 at 11:00 AM, a review of the incident report, dated 2/4/17 at 4:50 PM, Unit B, TM room, stated, Staff observed resident pushing straight back chair into wheelchair when asked to stop and sit in wheelchair; Resident attempted to sit in wheelchair when wheelchair rolled backward causing resident to fall to floor onto buttocks. There was no injury. On 4/5/17 at 1:48 PM, Activity Aide F was asked about the role of the activity staff on the afternoon shift. Activity Aide F stated, The dining room is called the TM (Treasured Memory) room .The TM person is there to prevent falls. There is a TM person and an activity person. I didn't see her fall. My back was to her. I saw her on the floor. I was assisting another resident with sitting back down because she was trying to stand up and I turned around and she was on the floor. I did not see her pushing a chair. The activity aide revealed there were about 20 residents in the TM room at that time. Activity Aide F was asked who was the activity person in the room with her. That day, I don't think there was one. They called off. I didn't touch her, I went into the hallway to tell the nurse. There might not have been anyone else in the room or they should have seen her first. On 4/5/17 at 2:08 PM, the activity director was asked about the role of the activity staff on the afternoon shift on the closed unit. The activity director presented her schedule and revealed that from 8:30 AM to 3:30 PM there are usually three activity staff in the facility. But from 3:30 PM to 8:00 PM there is one person in the TM room. The activity director was asked why the staffing when done to one on the closed unit when evening time is when residents with dementia are most active. The activity director gave no explanation. On 4/6/17 at 11:36 AM, the DON was asked about Resident #801's fall. The DON revealed she had adequate nursing staff that day. The DON was asked about the reduction of activity staff in the TM room after 3:30 PM when residents with dementia are more active. The DON replied, I understand. The incident report was reviewed with the DON where it described the resident pushing the chair before the fall, but failed to mention how staff physically intervened in an attempt to prevent the fall. On 4/6/17 at 11:30 AM, a review of the facility's Fall Management Guidelines, revised 6/20/16, stated, Each resident is assisted in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices, and/or functional programs as appropriate to minimize the risk for falls .

Based on interview and record review, the facility failed to provide prompt, adequate, appropriate care and treatment for one (#102) of five sampled residents reviewed for hydration from a total of five, resulting in on-going, unaddressed critical lab values, and emergency hospitalization for [MEDICAL CONDITION] (elevated sodium level) and hypovolemia (decreased blood flow/shock) due to dehydration. Findings include: On [DATE] at 12:30 PM, resident #102's family representative (Rep) was interviewed by phone. The Rep stated that the facility delayed appropriate medical treatment for the resident, resulting in hospitalization on [DATE] for dehydration and subsequent death on [DATE]. The Rep said that the resident had to be fed and was not consistently eating about two weeks prior to hospitalization . When asked why they were told the resident was being transported to the hospital, the Rep said, They did labs, but never told us what the results were. The doctor just said that (resident #102) had gallstones, but they didn't do the tests that they were supposed to do. When asked if intravenous (IV) fluids or a feeding tube were discussed, the Rep said, no. On [DATE] at 3 PM and on [DATE] at 9 AM, the facility's clinical records and hospital clinical records for resident #102 were reviewed and revealed the following: Per the facility records- Resident #102 was admitted on [DATE] with diagnoses that included dementia, stroke, diabetes, [MEDICAL CONDITION], and [MEDICAL CONDITION] per the admission face sheet and medication administration records (MARs). There was no [DIAGNOSES REDACTED]. Resident #102 was prescribed a pureed diet with nectar thick liquids and one to one feeding assistance with meals. A Speech Therapy (ST) Discharge Summary dated [DATE] noted that the resident received ST from [DATE]-[DATE] for dysphagia (difficulty swallowing). Upon discharge from ST, the following was noted: The resident was safe in swallowing pureed foods and nectar thick liquids, however, requires one to one feed for assistance and encouragement of meal consumption. This was also noted by the Registered Dietician (RD) in the resident's Nutritional History dated [DATE]. Resident #102's care plans on Nutritional Status and Dehydration/Fluid Maintenance, both dated [DATE] and created by the RD, noted the following: Goal: Maintain adequate fluid balance. Approaches: Provide one to one feeding assistance; Analyze labs as available; Monitor for signs/symptoms dehydration. Advance Directives for resident #102 signed [DATE] noted that preferred treatment options included: artificial nutrition (tube feedings, artificial hydration (by IV), antibiotic therapy, minor/major surgery, and transfer to an acute care hospital. The resident did not want cardiopulmonary resuscitation or use of life sustaining hospital equipment. The following sequence of events occurred at the facility: -An order dated [DATE] for STAT (immediate) abdominal X-ray and ultrasound for abdominal pain; [DATE]-schedule CAT scan of abdomen. -A progress note dated [DATE]-the resident's Rep was notified that a CAT Scan was scheduled for [DATE]. -A progress note dated [DATE]-The Rep was notified of the CAT Scan results (gallstones) and the Physician Assistant (PA) gave an order for [REDACTED]. -Per the lab report for tests performed on [DATE], the following levels indicating dehydration, were obtained: Creatinine=2.03 high (normal range=0XXX,[DATE].03). Sodium=151 critically high (normal range=,[DATE]). Per a handwritten note on the lab report by a nurse dated [DATE], the physician was notified and ordered increase fluids, repeat labs [DATE]. -A progress note dated [DATE]-critical lab sodium 151. -An order dated [DATE] for lab tests on [DATE] and to increase fluids. -Per a lab report dated [DATE]: Creatinine increased to 2.19. Sodium=151 critically high. Per a handwritten note on the lab report by a nurse: increase fluids. -An order dated [DATE] for lab tests. -Per a lab report dated [DATE]: Creatinine increased to 2.41. Sodium=151 critically high. Per a handwritten note on the lab report, dated [DATE]: Spoke to (physician).wants results faxed to office for review. (There were no further documented progress notes by nursing staff after [DATE].) -A progress note dated [DATE] by the PA-Again attempt (to) schedule HIDA Scan of gallbladder. Orders dated [DATE]-Please schedule HIDA Scan of gallbladder as ordered on [DATE]; Order for lab tests dated [DATE]-The order did not include testing for chloride and creatinine levels. There was no further documented progress note by the PA or physician after [DATE]. A document titled SBAR Communication Form and Progress Note dated [DATE] was reviewed and noted: Mental status change.pulse 109.respiratory rate 18.increase lethargic.Resident appears to be more lethargic. Resident has a mental status change. New orders to send to hospital.reported to.PA. -A verbal order from the PA dated [DATE]-Transfer to the hospital. -A Nursing Home To Hospital Transfer Form dated [DATE]-.heart rate 126, respiratory rate 22. The hospital records for resident #102 revealed the following sequence of events: -Emergency department nursing triage note-blood pressure: ,[DATE], pulse: 127/minute, respirations: 34/minute. -Orders dated [DATE]-IV fluids at 2,000 milliliters (ml) per hour over 1 hour STAT (immediately) then repeat STAT, then 200 ml per hour for 10 hours, then 150 ml per hour for 6 hours. -Emergency department physician notes dated [DATE]-She's had decreased appetite over the past 2 days. No vomiting, diarrhea.Also states that she had history on ultrasound last month of (gallstones).Patient does have pain with palpation diffusely over her entire abdomen.Impression.dehydration, [MEDICAL CONDITION].Patient had profound electrolyte abnormalities including sodium of 183.elevated.creatinine.elevated hepatic (liver) function panel.I did consult with ICU (intensive care unit) as I do feel patient needed ICU care given multi-organ system failure.Blood pressure declined in the emergency room and for a while was not responding to IV fluid hydration. -An ultrasound result dated [DATE]-Impression: (gallstones) without.evidence of acute [MEDICATION NAME] (inflammation of the gallbladder). -A consultation report dated [DATE]-Nephrology (kidney specialist) was consulted secondary to elevated creatinine and electrolyte abnormalities.No known history of kidney problems.Assessment.Multiple organ dysfunctio[DIAGNOSES REDACTED]-kidney, liver, cardiac, bone marrow.Severe [MEDICAL CONDITION] with hypovolemia secondary to dehydration.Plan.continue (IV fluids) at 200 milliliters (ml) per hour.Sodium has dropped from 183 to 174 in about 9 hours. poor prognosis. -A Nephrology consult report dated [DATE]-Toxic appearance.Severe [MEDICAL CONDITION] with hypovolemia secondary to dehydration.poor prognosis. -An ST evaluation dated [DATE]-Patient's (Rep) reports intake decreased over 3 weeks.no swallow response stimulated. -A Death Note dated [DATE]- pronounced dead on [DATE] at 10:15 AM. On [DATE] at 4 PM, resident #102's facility clinical record was reviewed with the Administrator, the Director of Nursing (DON), nurse unit managers 'B' and 'D', and nurse 'H', who wrote the SBAR Communication Form. When asked what was done to address the resident's dehydration, they said that the resident's fluids were increased. When asked how and asked to provide documentation that this was done, they looked through the resident's record and provided MARs dated ,[DATE] and ,[DATE]. The MARs noted Encourage Fluids and the amount provided to the resident each day from 7 AM-7 PM and 7 PM-7 AM shifts. The MARs indicated that the resident was provided between ,[DATE] mls of fluid from nursing staff per day. The MARs did not note how much of the fluids were actually consumed. There was no documented indication that the resident's fluids were increased. The staff did not provide any nurse aide ADL Tracking Forms for the resident indicating how much fluid was consumed each meal. The last documented ADL form in the record, was dated ,[DATE]. The RD noted in the resident's [DATE] Nutritional History that the resident's daily estimated fluid needs=1,800 mls. On [DATE] at 10:15 AM, the Administrator deferred to the resident's physician for further information. At 10:20 AM, the PA was interviewed by phone, who stated that the physician was out of town, but was very familiar with resident #102. The PA was asked why there was no indication that the resident's critical lab values were appropriately and promptly treated. However, the PA persistently addressed a urinalysis result dated [DATE] by repeating, There was only 2+ bacteria in her urine and she was not symptomatic of having a UTI (urinary tract infection) that required antibiotics. The PA added, She had gallstones (indicating that resident #102 had poor fluid intake due to abdominal pain.) I ordered a HIDA Scan, but there was a scheduling problem and it wasn't done. When asked about his order to increase fluids and specifically how that was to be achieved and monitored, the PA said, Well, if there were to be specifics (documented in the order), I can listen to your suggestions as to what they should have been. When the resident's death at the hospital was discussed, the PA said, Everything that happened was incidental. We (he and the resident's physician) take care of our own residents at (hospital name) and I don't think she went there. When told that she died there, the PA said, Well, I didn't see her. The hospital records indicated that the physician and the PA did not see the resident at the hospital. She was treated and pronounced dead by other hospital staff. On [DATE] at 6 PM, a review of the facility's undated Resident Hydration and Prevention of Dehydration policy noted: This facility will endeavor to provide adequate hydration and to prevent and treat dehydration.Nursing will assess for signs and symptoms of dehydration during daily care. Nurses' aides will provide and encourage intake of bedside, snack, and meal fluids on a daily and routine basis as part of daily care. Intake will be documented in the medical records. Aides will report intake of less than 1200 ml/day to nursing staff. If potential inadequate intake and/or signs and symptoms of dehydration are observed, intake and output monitoring will be initiated and incorporated into the care plan.Physician will be informed. Orders may be written for extra fluids to be encouraged between meals and/or with medication passes. A specific minimal amount should be included in the order (e.g. 240 ML fluids BID (twice a day) with medication pass). Encourage fluids is not an adequate order.If laboratory results are consistent with actual dehydration, the physician may initiate IV hydration. hospitalization will be recommended, as necessary. ( )

This citation pertains to MI 684 Based on observation, interview and record review, the facility failed to implement appropriate safety measures and ensure safety devices were in place and functioning properly for one (#501) of three residents reviewed for falls from a total sample of five residents resulting in a fall with a dislocated fractured humerus and a hematoma and bruise to the right cheek. Findings include: On 2/26/14 at 10:30 a.m., resident #501 was observed near the nursing station seated in a wheel chair. A sling was observed on the resident's right arm. The resident smiled when greeted and did not answer when asked how she was. On 2/26/14 at 2:30 p.m., a review of the clinical record documented the following: A review of the admission face sheet documented resident #501 was readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the resident's most recent quarterly Minimum Data Set ((MDS) dated [DATE] documented the resident was cognitively moderately impaired for decision making skills and required one person physical assist of all activities of daily living. Additionally, the MDS coded the resident as having no falls. A review of resident #501's fall risk assessment dated [DATE] documented the resident was at high risk for falls. A review of nursing notes documented: On 2/5/14 at 6:00 p.m., "...CNA heard yelling coming from patient's room...pt observed on floor...range of motion performed facial grimacing and pain right arm, noted hematoma/bruise on right cheek...". Physician ordered X-ray. On 2/6/14 at 12:09 a.m., "Call from lab about X-ray results...resident had dislocated right shoulder...". On 2/6/14 at 2:40 a.m., "X-ray results are finely in Dr. informed. Order to send resident out was received." A review of physician orders [REDACTED]. On 2/5/14, X-ray to Right humerus and right forearm. Pain related to fall. On 2/6/14, transfer to Hospital. A review of resident #501's "Fall" care plan dated 5/1/13 documented the resident had interventions that included "call light within reach at all times while in room, and check position and placement of wheel chair or bed sensor every shift." A review of resident #501's CNA care guide dated 8/6/13 documented: Safety precautions bed and chair alarms. Monitor frequently-resident self ambulates with unsteady gait. According to the Unusual Occurrence Report dated 2/5/14 at 6:00 p.m., resident #501 was observed on the floor on the right side of her body at the foot of the bed. There was a bruise/hematoma on the resident's right cheek. The resident complained of pain to her right arm. X-rays were ordered and found to have dislocation of the right humerus. Review of facility Unusual Occurrence reports provided by the Director of Nursing (DON) revealed resident #501 had one previous fall with injury on 11/28/13 that resulted in two skin tears to the resident's right shin. According to the Facility's 24 hour and 5 day reports dated 2/6/14 and 2/12/14 respectively, on 2/5/14 at 6:00 p.m. Certified Nurse Assistant "L"observed resident #501 on the floor after the resident was last seen asleep in bed at 5:45 p.m. CNA "L" called for the nurse and reported the incident. The resident transferred to the hospital and readmitted back to the facility on [DATE]. On 2/27/14 at 3:00 p.m., during a phone interview, CNA "L" stated, "I didn't know the resident was a fall risk. She had an alarm but it was not sounding. I heard her moaning loudly. She was on the floor and said her hip was hurting when I touched her. She should have been on the fall program. The other resident's who are at risk for falls have yellow tags (bands) on their arms and tags on the doors to indicate they need close monitoring to prevent falls." On 2/27/14 at 4:20 p.m., during an interview and record review with Safety Coordinator "M" explained she was aware of resident #501 being a fall risk, but the previous DON would not allow her (Safety Coordinator) "M" to put residents on the 400 unit to be on the "Fall Prevention Program." However, Safety Coordinator "M" did not respond as to why resident #501 was not on the Fall Prevention Program since January 2014 when the new DON was appointed. Safety Coordinator "M" explained she completed the post fall investigation and was not aware the resident's alarms did not alarm to alert staff that the resident had changed positions. On 2/27/14 at 5:00 p.m., during an interview and record review with the Director of Nursing (DON) when asked about the resident #501's fall with injury on 2/5/14 she stated she was aware there was a problem and she was working on a new protocol for preventing falls in the facility. On 2/27/14 at 5:15 p.m., a review of the facility's "Fall Management Guidelines" policy dated 1/2009 documented: #2. residents identified at risk for falls will have a care plan developed and implement appropriate fall prevention interventions. ( )

THIS CITATION CONTAINS MULTIPLE DEFICIENT PRACTICE STATEMENTS. REFER TO INTAKE MI 835. BASED ON INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO PROVIDE APPROPRIATE ASSISTANCE AND SUPERVISION TO PREVENT FALLS FOR ONE (#101) OF 8 SAMPLED RESIDENTS REVIEWED FOR FALLS FROM A TOTAL SAMPLE OF 10, RESULTING IN A FALL WITH HEAD TRAUMA. FINDINGS INCLUDE: RESIDENT #101 WAS A [AGE] year OLD RESIDENT admitted to the facility on [DATE]. ACCORDING TO THE ADMISSION history and physical examination [REDACTED]. REVIEW OF THE MINIMUM DATA SET (MDS) assessment dated [DATE] REVEALED RESIDENT #101 WAS COMPLETELY DEPENDENT ON STAFF FOR ALL ACTIVITIES OF DAILY LIVING (ADL), REQUIRING 2 PERSON ASSISTANCE IN BED MOBILITY AND TRANSFERS. ACCORDING TO THE NEUROSURGERY FOLLOW-UP, DATED 3/11/13, RESIDENT #101 WAS AWAKE AND ALERT BUT NON-VERBAL, "MOVES RIGHT SIDE WELL, NO MOVEMENT ON LEFT SIDE. DOES NOT OBEY COMMANDS." RESIDENT # 101 WAS ASSESSED AS "HIGH RISK" FOR FALLS ON 2/11/13. ACCORDING TO THE FACILITY INCIDENT REPORT DATED 3/18/13 AT 10:00 AM, "GRANDMOTHER (FAMILY MEMBER #6) TURNED PATIENT TO THE SIDE THEN WENT TO HALLWAY TO CALL STAFF. RESIDENT (#101) fell FROM BED." THE INCIDENT REPORT DOCUMENTED THAT THIS FALL WAS UNWITNESSED. RESIDENT #101 WAS SUBSEQUENTLY SENT TO A LOCAL ACUTE CARE FACILITY FOR EVALUATION. DURING AN INTERVIEW WITH CERTIFIED NURSING ASSISTANT (CNA) #3 ON 4/11/13 AT 3:00 PM, CNA #3 STATED THAT SHE WAS THE NURSE AIDE ASSIGNED TO RESIDENT #101 WHEN HE fell , ON 3/18/13. CNA #3 RECALLED PUTTING RESIDENT BACK IN BED 45 MINUTES BEFORE THE FALL OCCURRED. CNA #3 STATED, "THE TWO TREATMENT NURSES WERE TO APPLYING TREATMENT TO HIS BOTTOM AND WHEN THEY WERE DONE (WITH THE TREATMENT), I (#3) WAS TOLD BY ONE OF THE NURSES THAT (RESIDENT #101) HAD URINATED ON THE PAD AND THE PAD WAS WET WITH URINE." ACCORDING TO CNA #3, SHE DID NOT ENTER RESIDENT #101'S ROOM, BUT IMMEDIATELY WENT TO THE LINEN ROOM TO GET FRESH CLEAN PADS. CNA #3 RECALLED HEARING A CRASH AS SHE WAS COMING BACK TO THE ROOM WITH THE CLEAN LINEN. CNA # 3 SAW RESIDENT #101'S GRANDMOTHER STANDING OUTSIDE IN THE HALLWAY WHEN SHE HEARD THE CRASH. CNA #3 STATED THAT SHE IMMEDIATELY WENT INTO THE ROOM AND SAW RESIDENT #101 ON THE FLOOR, FACE DOWN AND BLEEDING FROM THE HEAD. RESIDENT #101 WAS NOT WEARING A BRIEF AND THERE WAS NO PAD ON THE BED. CNA #3 FURTHER DESCRIBED THAT RESIDENT #101'S BED WAS NOT IN THE LOWEST POSITION AND HAD BEEN SET AT A HIGHER LEVEL THAN ITS NORMAL HEIGHT OR POSITION. WHEN ASKED, CNA #3 STATED THAT THERE HAD BEEN NO BED ALARM. RESIDENT #101 DID NOT HAVE ONE. CNA #3 STATED, "IT WAS NOT THE FAMILY'S JOB TO POSITION THE RESIDENT (#101), OR DO ADLS, OR TO WATCH HIM SO HE DOES NOT FALL." THE TREATMENT NURSE, LICENSED PRACTICAL NURSE (LPN) #4 WAS INTERVIEWED ON 4/12/13 AT 11:45 AM. LPN #4 STATED THAT RESIDENT #101 HAD A HEALING STAGE 2 PRESSURE SORE ON HIS BOTTOM, TREATED WITH A TOPICAL CREAM AND THAT SHE AND ANOTHER TREATMENT NURSE PROVIDED THIS TREATMENT TO RESIDENT #101 ON 3/18/13. DURING TREATMENT, LPN #4 STATED THAT SHE HAD REMOVED THE POSITIONING WEDGE FROM BEHIND THE RESIDENT WHILE SHE PERFORMED THE TREATMENT. DURING THE TREATMENT, RESIDENT #101 URINATED ON THE PAD AND ON THE SHEET. BOTH LPN #4 AND THE OTHER TREATMENT NURSE LEFT RESIDENT #101'S ROOM AFTER FINISHING THE TREATMENT AND INFORMED CNA #3 THAT RESIDENT #101 NEEDED TO BE CHANGED. AS CNA #3 WAS ON HER WAY BACK TO THE RESIDENT'S ROOM WITH CLEAN PAD AND LINEN, RESIDENT #101 fell OFF THE BED. ACCORDING TO LPN #4, RESIDENT #101 HAD BEEN LEFT IN BED WITH NO PAD OR BRIEF, AND WITH THE POSITIONING WEDGE (TO PREVENT ROLLING OUT) NOT REAPPLIED AND THE BED NOT IN THE LOWEST POSITION WHEN SHE (#4) AND THE OTHER TREATMENT NURSE LEFT THE ROOM. "GRANDMA (FAMILY MEMBER #6) WAS IN THE ROOM WHEN WE LEFT HIM." CHARGE NURSE LPN #5 WAS INTERVIEWED ON 4/12/13 AT 3:15 PM. LPN #5 STATED THAT ON 3/18/13, SHE HEARD A LOUD SCREAM. RESIDENT #101'S GRANDMOTHER (FAMILY MEMBER #6) WAS YELLING. RESIDENT #101 WAS LYING ON THE FLOOR UP AGAINST THE WALL. ACCORDING TO LPN #5, RESIDENT #101 WAS BLEEDING FROM A HEAD LACERATION. LPN #5 STATED THAT SHE CLEANED RESIDENT #101 UP. HIS GRANDMOTHER (FAMILY MEMBER #6) TOLD LPN #5 THAT SHE WAS WAITING FOR THE CNA TO COMEBACK WITH THE LINENS. ACCORDING TO LPN #5, FAMILY MEMBER #6 TOLD HER (#5) THAT SHE (#6) HAD ROLLED RESIDENT #101 ON HIS SIDE AND THAT RESIDENT #101 fell AFTER SHE (#6) LEFT THE ROOM. LPN #5 STATED, "OUR POLICY IS ABSOLUTELY NOT TO LET FAMILY DO THE NURSING CARE TO THE RESIDENT. WE DO NOT LEAVE THE FAMILY TO WATCH THE RESIDENT UNATTENDED. THE CNA LEFT THE RESIDENT UNATTENDED WHILE SHE GOT FRESH LINENS. THE CNA DID NOT PUT THE WEDGE UNDER THE RESIDENT." LPN #5 SAID THAT ALTHOUGH RESIDENT #101'S GRANDMOTHER WAS ALWAYS INVOLVED WITH RESIDENT #101'S CARE, SHE (#6) WAS NOT EXPECTED TO PERFORM THE ADLS FOR THE RESIDENT AND THAT STAFF MEMBERS WERE NOT TO RELY ON FAMILY MEMBERS IN MAINTAINING SAFETY OR SUPERVISION. FAMILY MEMBER #6 HAD NOT HAD ANY KIND OF TRAINING REGARDING RESIDENT #101'S SAFETY PRECAUTIONS, TURNING OR REPOSITIONING. WHEN FAMILY MEMBER #6 WAS INTERVIEWED ON 4/17/13 AT 11:03 AM, SHE STATED THAT SHE DID NOT TURN OR REPOSITION RESIDENT #101. SHE FURTHER EXPLAINED THAT RESIDENT #101 WAS ALREADY ON HIS SIDE AFTER THE TREATMENT NURSES APPLIED THE TREATMENT TO HIS BOTTOM. FAMILY MEMBER #6 STATED THAT SHE (#6) HAD STARTED WASHING HIM UP, BECAUSE THE NURSE LEFT WITHOUT CHANGING HIM AND HE HAD URINE ON THE SHEETS AND PAD. FAMILY MEMBER #6 RECALLED THAT SHE HAD MAINTAINED RESIDENT #101 IN THE SAME POSITION (ON HIS SIDE) AS THE TREATMENT NURSES LEFT HIM. FAMILY MEMBER #6 WENT ON TO SAY THAT CNA #3 CAME IN THE ROOM AFTER SHE (#6) HAD CLEANED RESIDENT #101'S PRIVATE AREA BUT DID NOT HAVE THE CLEAN PAD SO SHE (CNA #3) LEFT TO GET THEM. ACCORDING TO FAMILY MEMBER #6, AFTER A WHILE (MORE THAN 5 MINUTES), WHEN CNA #3 DID NOT COME BACK, SHE (#6) BECAME CONCERNED SO SHE (#6) DECIDED TO LEAVE THE ROOM. FAMILY MEMBER #6 STATED THAT SHE STOOD THE HALLWAY BY THE DOOR WHEN SHE SAW CNA #3 COMING, BUT HEARD A "LOUD THUMP." CNA #3 AND FAMILY MEMBER #6 FOUND RESIDENT #101 ON THE FLOOR BLEEDING. RESIDENT #101 fell on THE SAME SIDE WHERE HIS SURGICAL "FLAP" (RIGHT SIDE) WAS. WHEN ASKED FAMILY MEMBER #6 DENIED RECEIVING TRAINING OF ANY KIND ON TURNING, REPOSITIONING, PROVIDING ACTIVITIES OF DAILY LIVING CARE AND/OR SAFETY MAINTENANCE FOR RESIDENT #101. RESIDENT #101'S CARE PLAN FOR SAFETY/RISK FOR FALL DATED 2/11/13 WAS REVIEWED. THERE WAS NO INDICATION IN THE CARE PLAN THAT FAMILY MEMBERS WERE TO PERFORM ACTIVITIES OF DAILY LIVING, BE INVOLVED IN POSITIONING, OR INVOLVED IN SUPERVISION AND MAINTAINING RESIDENT #101'S SAFETY. REVIEW OF THE CLINICAL RECORD REVEALED THAT THERE WAS NO EVIDENCE THAT FAMILY MEMBER #6 RECEIVED TRAINING OF ANY TYPE ON HOW TO PROVIDE ACTIVITIES OF DAILY LIVING, INCLUDING PROPER POSITIONING AND SAFETY PRECAUTIONS, AND NO EVIDENCE THAT FACILITY STAFF MEMBERS VERIFIED THAT FAMILY MEMBER #6 WAS CAPABLE OF PROVIDING SUCH CARE. ACCORDING TO THE HOSPITAL history and physical examination [REDACTED]. THE HOSPITAL H&P NOTED THAT DIFFERENTIAL [DIAGNOSES REDACTED]. RESIDENT #101 UNDERWENT A COMPUTER TOMOGRAPHY (CT) SCAN OF HIS HEAD THAT INDICATED NEW CEREBROSPINAL FLUID ACCUMULATION OUTSIDE THE CRANIUM. ACCORDING TO THE HOSPITAL RECORDS, "NEUROSURGERY EXAMINED CT AND PATIENT (#101) PLACED IN NEUROSURGICAL INTENSIVE CARE UNIT." ( ) .

THIS CITATION PERTAINS TO INTAKE NUMBER MI 523 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO IMPLEMENT EFFECTIVE PREVENTATIVE INTERVENTIONS AND FREQUENT REPOSITIONING TO PREVENT PRESSURE SORES FOR ONE (RESIDENT #510) OF TWO SAMPLED RESIDENTS REVIEWED FOR PRESSURE SORES FROM A TOTAL OF ELEVEN SAMPLED RESIDENTS, RESULTING IN THE DEVELOPMENT OF NEW PRESSURE ULCERS. FINDINGS INCLUDE: ON 3/12/13 AT 10:55 A.M., DURING A WOUND CARE OBSERVATION, RESIDENT #510 WAS OBSERVED LYING IN BED IN A SUPINE POSITION (ON HER BACK). A DRESSING WAS OBSERVED TO RESIDENT #510'S LEFT EAR AND WAS DATED "3/12/13." RESIDENT #510'S HEAD WAS POSITIONED TO THE LEFT, TOWARD THE AFFECTED EAR AND HER LEFT EAR WAS PRESSED AGAINST THE AIR MATTRESS. THE HEAD OF RESIDENT #510'S BED WAS ELEVATED. ALTHOUGH RESIDENT #510 HAD A [MEDICAL CONDITION] AND A TUBE FEEDING, THE TUBE FEEDING WAS NOT INFUSING AT THE TIME OF THE OBSERVATION. FURTHER OBSERVATIONS REVEALED A POSITIONING WEDGE HAD BEEN APPLIED TO RESIDENT #510'S LEFT SIDE. THE POSITIONING WEDGE WAS LOOSELY LYING ON RESIDENT #510'S BED. ADDITIONALLY, RESIDENT #510'S KNEES WERE OBSERVED TO BE IN DIRECT CONTACT WITH EACH OTHER. THERE WAS NO BARRIER OR CUSHION IN PLACE TO PREVENT BONE ON BONE PRESSURE WHICH WOULD RESULT IN THE DEVELOPMENT OF PRESSURE ULCERS. RESIDENT #510 WAS WEARING CUSHIONED BOOTS. A WOUND CARE OBSERVATION AND DRESSING CHANGE ON 3/12/13 AT 10:55 A.M., REVEALED THE FOLLOWING: LEFT EAR PRESSURE SORE: OBSERVATION UPON REMOVAL OF THE DRESSING REVEALED SCANT SEROUS DRAINAGE. THE RIM OF RESIDENT #510'S LEFT EAR HAD CARTILAGE EXPOSED AND, ACCORDING TO THE TREATMENT NURSE (LICENSED PRACTICAL NURSE/LPN #3), THE WOUND MEASURED 3.8 CENTIMETERS (CM) WIDTH (W) X 4.9 CM (L) LENGTH X 0.8 CM DEPTH (D). THE WOUND WAS CLEANSED WITH NORMAL SALINE SOLUTION. [MEDICATION NAME] CREAM AND A DRY DRESSING WERE APPLIED. POST DRESSING CHANGE, RESIDENT #510'S HEAD WAS IN THE LEFT LYING POSITION. THERE WAS NO POSITIONING DEVICE IN PLACE TO PREVENT FURTHER PRESSURE TO RESIDENT #510'S LEFT EAR. LPN #3 REPORTED, "...THE WOUND TO HER EAR IS A STAGE III PRESSURE SORE. SHE (RESIDENT #510) HAS A TENDENCY TO TURN HER HEAD TO THE LEFT..." SACROCOCCYGEAL/BILATERAL BUTTOCKS PRESSURE SORE: OBSERVATION UPON REMOVAL OF THE DRESSING REVEALED A MALODOROUS STAGE IV COCCYX PRESSURE SORE THAT EXTENDED OVER BILATERAL BUTTOCKS AND MEASURED 8.6 CM (L) X 11.4 CM (W) X 1.3 CM (D). THE WOUND HAD MODERATE SEROSANGUINOUS DRAINAGE, NECROTIC BASE WITH IRREGULAR EDGES. THE POSITIONING WEDGE WAS NOT PROPERLY POSITIONED TO RELIEVE PRESSURE TO RESIDENT #510'S COCCYX/BUTTOCKS PRESSURE SORE. ON 3/12/13 AT 11:45 A.M., DURING AN INTERVIEW, LPN #2, WHO WAS PRESENT DURING THE DRESSING CHANGE, REPORTED, "...SHE (RESIDENT #510) SHOULD HAVE SOMETHING PREVENTATIVE IN PLACE. THERE IS NO EXCUSE; ESPECIALLY FOR HER EAR..." WHEN ASKED IF THE FACILITY CONSIDERED PLACING A NECK ROLL OR OTHER PREVENTATIVE DEVICE TO RELIEVE PRESSURE TO RESIDENT #510'S EAR IN LIGHT OF HER TENDENCY TO POSITION HER HEAD TO THE LEFT, LPN #2 REPORTED, "...I HAD MENTIONED THE NECK ROLL..." ON 3/12/13 AT 11:56 P.M., DURING AN INTERVIEW, LPN #3 WAS QUERIED ABOUT REPOSITIONING AND PREVENTATIVE MEASURES AND REPORTED, "...HER (RESIDENT #510) LEFT EAR DRESSING WAS COMING OFF THIS MORNING, SO I PUT A NEW ONE ON. THAT'S WHY IT WAS DATED FOR TODAY. LPN #3 FURTHER REPORTED, "...SHE (RESIDENT #510) KEEPS TURNING HER HEAD TO THE LEFT AND SHE'S A HOSPICE PATIENT, SO I WOULD SAY HER WOUNDS WERE UNAVOIDABLE..." WHEN QUERIED ABOUT POSITIONING DEVICES AND FREQUENTLY REPOSITIONING RESIDENT #510, LPN #3 REPORTED, "...WELL, I GUESS IN THE CASE OF HER LEFT EAR, IT WAS AVOIDABLE..." ON 3/12/13 AT 12:55 P.M., DURING AN INTERVIEW, THE DIRECTOR OF NURSING (DON) REPORTED, "...I FEEL THAT HER (RESIDENT #510) WOUNDS ARE UNAVOIDABLE BECAUSE SHE'S A HOSPICE PATIENT, BUT POSITIONING IS ALSO VERY IMPORTANT. SHE WAS admitted WITH MULTIPLE SORES AND I THINK SHE'S COMFORT MEASURES ONLY..." WHEN ASKED IF THE FACILITY'S POLICY ON HOSPICE RESIDENTS, OR THE HOSPICE NURSE DIRECTED STAFF NOT TO REPOSITION RESIDENT #510 BECAUSE SHE WAS A HOSPICE RESIDENT, THE DON REPORTED, "...THERE IS NO POLICY THAT SAYS YOU ARE NOT TO REPOSITION THE RESIDENTS. I DO AGREE THOUGH, THERE SHOULD BE SOME SORT OF POSITIONING DEVICES IN PLACE..." WHEN QUERIED ABOUT RESIDENT #510'S POSITIONING AS IT RELATED TO HER [MEDICAL CONDITION], THE DON CONCURRED THAT "...STAFF PLACE HER IN SUPINE POSITION IN LIGHT OF HER [MEDICAL CONDITION]" THE DON DID NOT COMMENT WHEN ASKED IF THE FACILITY CONSIDERED REPOSITIONING TO BE CONTRAINDICATED IN PATIENTS WITH TRACHEOSTOMIES. A physician's orders [REDACTED]. THE PO READ, "...ADMIT TO HOSPICE CARE, CONTINUE MEDS (MEDICATIONS), WOUND CARE..." A REVIEW OF THE FACILITY'S "ADMISSION AND DISCHARGE SUMMARY" REVEALED THAT RESIDENT #510 WAS A [AGE] year OLD FEMALE WHO WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE] REVEALED THAT RESIDENT #510 HAD SEVERELY IMPAIRED COGNITIVE SKILLS FOR DAILY DECISION MAKING, LONG AND SHORT TERM MEMORY PROBLEMS AND WAS TOTALLY DEPENDENT ON STAFF FOR ALL ACTIVITIES OF DAILY LIVING (ADLS) INCLUDING BED MOBILITY, TRANSFERS, DRESSING, EATING, TOILETING, PERSONAL HYGIENE AND BATHING. A REVIEW OF RESIDENT #510'S "ADMISSION NURSING ASSESSMENT" (UNDATED) REVEALED THAT RESIDENT #510 WAS admitted TO THE FACILITY WITH MULTIPLE UNSTAGEABLE PRESSURE SORES TO THE ANTERIOR (FRONT) SURFACE OF HER BODY AND SOME BRUISING TO HER POSTERIOR (BACK) BODY. THERE WAS NO DOCUMENTED EVIDENCE THAT RESIDENT #510 HAD PRESSURE ULCERS TO HER LEFT EAR OR TO HER SACROCOCCYGEAL/BILATERAL BUTTOCKS UPON ADMISSION. ACCORDING TO THE FACILITY'S "BATH AND SKIN REPORT" DATED 2/14/13 REVEALED, "...NO NEW PROBLEMS FOUND DURING CARE ON SKIN..." A BATH AND SKIN REPORT DATED 2/18/13 READ, "...BED BATH ONLY. PRESSURE SORE (AREA ON BUTTOCKS CIRCLED), APPLIED CREAM. ANY SKIN BREAKS? YES..." THERE WAS NO INDICATION THAT THE NURSE HAD BEEN INFORMED OF THE FINDINGS OR THAT TREATMENT HAD BEEN INITIATED BY THE NURSE OR PHYSICIAN. FURTHER, THE AREA THAT REQUIRED THE NURSE'S SIGNATURE HAD NOT BEEN SIGNED. A BATH AND SKIN REPORT DATED 2/25/13 READ, "...BED BATH ONLY. DRY SKIN (AREA OF LEFT HEAD CIRCLED), OPEN SORE BUTTOCK, OPEN PRESSURE SORE (AREA ON COCCYX AND BUTTOCKS CIRCLED). ANY SKIN BREAKS? YES..." THE BATH AND SKIN REPORT HAD NOT BEEN SIGNED BY THE NURSE. AN "INTERDISCIPLINARY PROGRESS NOTE" DATED 2/25/13 REVEALED, "...SKIN INTEGRITY CONSULT ON COCCYX AREA AND LEFT EAR WOUND CONSULT WRITTEN..." ALTHOUGH THE ABOVE DOCUMENTATION INDICATED THAT A WOUND CONSULT WAS WRITTEN FOR THE ABOVE MENTIONED AREAS, AND AN OPEN AREA HAD BEEN IDENTIFIED, THE FACILITY'S "WOUND/SKIN HEALING RECORD" DATED 2/26/13 NOTED, "...DATE OF ONSET 2/26/13, ORIGINAL STAGE III, LEFT EARLOBE..." ANOTHER WOUND/SKIN HEALING RECORD DATED 2/26/13, DOCUMENTED "...DATE OF ONSET 2/26/13, ORIGINAL STATE III, COCCYX BILATERAL BUTTOCKS..." A physician's orders [REDACTED]. ANOTHER PO DATED 2/26/13 READ, "...SANTYL (MEDICATION FOR REMOVING NECROTIC/DEAD TISSUE FROM WOUNDS) QD + PRN S NS (EVERYDAY AND AS NEEDED WITH NORMAL SALINE) CLEANSE TO SACROCOCCYX AND BILATERAL BUTTOCKS, PRESSURE ULCER..." A PO DATED 3/1/13 READ, "[MEDICATION NAME] (USED TO TREAT AND PREVENT INFECTIONS IN WOUNDS) QD AND PRN AFTER NS CLEANSE TO L (LEFT) EARLOBE... A "QUALITY OF LIFE - SKIN" DOCUMENT DATED 2/27/13 DOCUMENTED, "...NEW WOUND ON SACROCOCCYX BILATERAL BUTTOCKS UNSTAGEABLE, MEASUREMENTS 12.0 CM X 10.0 CM NECROTIC EDGES WITH SLOUGH COVERING..." A WOUND CARE SPECIALIST NOTE DATED 3/1/13 DOCUMENTED THE treatment for [REDACTED]. [MEDICATION NAME] QD LEFT EARLOBE. FREQUENTLY REPOSITION. FLOAT BILATERAL LOWER EXTREMITIES..." VARIOUS OBSERVATION DURING THE INVESTIGATION REVEALED THAT RESIDENT #510 HAD NOT BEEN FREQUENTLY REPOSITIONED AND HER HEELS HAD NOT BEEN FLOATED AS ORDERED BY THE WOUND CARE SPECIALIST/PHYSICIAN. A REVIEW OF RESIDENT #510'S "ALTERATION IN SKIN" CARE PLAN REVEALED THAT THE PLAN HAD EVALUATION DATES OF 3/1/13, THEN 3/6/13, THEN 3/8/13 (SIGNED IN THAT ORDER) AND INCLUDED THE FOLLOWING INTERVENTIONS, "...KEEP CLEAN AND DRY, ASSESS SKIN DAILY AND DURING BATH BI-WEEKLY BY CENA (CERTIFIED NURSING ASSIST/CNA), TURN AND REPOSITION EVERY 2 HOURS AND AS TOLERATED, POSITIONING DEVICES WHILE IN BED: WEDGE, PILLOWS..." A REVIEW OF RESIDENT #510'S "AT RISK FOR SKIN IMPAIRMENT" CARE PLAN DATED 2/8/13 REVEALED THAT THE PLAN INCLUDED THE FOLLOWING INTERVENTIONS, "...REPOSITION FREQUENTLY, OBSERVE SKIN DAILY AND REPORT CHANGES, WEEKLY HEAD TO TOE SKIN ASSESSMENT..." THERE WAS NO DOCUMENTED EVIDENCE IN THE CLINICAL RECORD THAT WEEKLY SKIN ASSESSMENTS HAD BEEN CONDUCTED BY THE NURSING STAFF IN ACCORDANCE WITH THE PLAN OF CARE. FURTHER, PILLOWS HAD NOT BEEN USED TO FLOAT RESIDENT #510'S HEELS OR USED TO AVOID BONE TO BONE CONTACT BETWEEN RESIDENT #510'S KNEES IN ORDER TO PREVENT PRESSURE ULCER DEVELOPMENT. ADDITIONALLY, RESIDENT #510 WAS OBSERVED AT VARIOUS TIMES DURING THE INVESTIGATION LYING ON HER BACK IN THE SAME POSITION. ON 3/15/13 AT 10:35 A.M., RESIDENT #510 WAS OBSERVED LYING ON HER BACK. A NECK ROLL WAS OBSERVED AROUND RESIDENT #510'S NECK TO PREVENT HER FROM COMPLETELY TURNING TO THE LEFT WHERE PRESSURE WOULD BE FURTHER EXERTED TO HER LEFT EAR. HOWEVER, THE PREVENTIVE DEVICE WAS OBSERVED TO HAVE BEEN APPLIED IMPROPERLY AND WAS SLIDING IN AN UPWARD POSITION. LPN # #6 WAS INFORMED THAT THE POSITIONING DEVICE WAS IMPROPERLY APPLIED AND ALSO INFORMED OF OTHER ISSUES NOT RELATED TO POSITIONING. WHEN ASKED IF THE ASSIGNED NURSE OR CNA MADE FREQUENT ROUNDS TO ENSURE POSITIONING DEVICES WERE IN PLACE, LPN #6 OFFERED NO RESPONSE AND THEN REPORTED, "...I'LL TAKE CARE OF IT RIGHT NOW..." ON 3/15/13 AT 10:40 A.M., DURING AN INTERVIEW, THE WOUND CARE SPECIALIST/PHYSICIAN (WCS) WAS ASKED WHY POSITIONING DEVICES HAD NOT BEEN IMPLEMENTED TO AVOID EXCESSIVE PRESSURE TO RESIDENT #510'S LEFT EAR, THE WCS REPORTED, "HER (RESIDENT #510) NECK TENDS TO CONTRACT TOWARDS THE LEFT. STAFF WOULD HAVE TO KEEP REPOSITIONING HER IN ORDER TO AVOID THIS. I'VE SUGGESTED SAND WEDGES TO HELP WITH POSITIONING..." WHEN QUERIED ABOUT THE LACK OF EFFECTIVE INTERVENTIONS AND THE FACILITY'S FAILURE TO IMPLEMENT INTERVENTIONS THAT HAD BEEN ORDERED IN ACCORDANCE WITH physician's orders [REDACTED]. A REVIEW OF THE FACILITY'S "PRESSURE ULCER AND SKIN CARE MANAGEMENT" POLICY DATED DECEMBER 2008 REVEALED, "...A RESIDENT WHO ENTERS THE FACILITY WITHOUT PRESSURE ULCERS DOES NOT DEVELOP PRESSURE ULCERS UNLESS THE RESIDENT'S CLINICAL CONDITION DEMONSTRATES THAT THEY WERE UNAVOIDABLE; AND A RESIDENT HAVING PRESSURE ULCERS RECEIVES NECESSARY TREATMENT AND SERVICES TO PROMOTE HEALING, PREVENT INFECTION AND REDUCE THE RISK OF NEW PRESSURE ULCERS DEVELOPING..." THE FACILITY'S ADMINISTRATIVE STAFF, WOUND CARE SPECIALIST AND NURSING STAFF COULD NOT EXPLAIN WHY STAFF FAILED TO FREQUENTLY REPOSITION RESIDENT #510, WHO WAS IDENTIFIED AS AT RISK FOR THE DEVELOPMENT OF PRESSURE ULCERS, AS INDICATED BY THE physician's orders [REDACTED].

THIS CITATION PERTAINS TO INTAKE: MI 826 BASED ON INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION AND ASSISTANCE FOR 1 OF 9 SAMPLED RESIDENTS (RESIDENT #109), RESULTING IN RESIDENT #109 FALLING OFF THE SHOWER CHAIR AND SUSTAINING A LACERATION TO THE RIGHT FOREHEAD AREA. FINDINGS INCLUDE: ACCORDING TO THE FACILITY'S UNUSUAL OCCURRENCE REPORT DATED 1/26/11, ON 7:50 P.M., RESIDENT #109 fell FORWARD OUT OF A SHOWER CHAIR WHILE RECEIVING A SHOWER AND SUSTAINED A LACERATION OVER HER RIGHT EYEBROW THAT REQUIRED SUTURES TO REPAIR. ON 5/17/11 AT 10: A.M. CERTIFIED NURSE ASSISTANT (CNA) #8 SAID RESIDENT #109 HAD A TENDENCY TO LEAN FORWARD IN HER CHAIR AND NEEDED FREQUENT VERBAL REMINDERS AND PHYSICAL SUPPORT WITH AT LEAST 1 HAND TO SIT UPRIGHT WHILE IN A SEATED POSITION. CNA #8 SAID RESIDENT #109 WAS SITTING UP ON HER OWN IN THE SHOWER CHAIR WHEN SHE (CNA #8) WENT AROUND THE HALF WALL IN THE SHOWER ROOM TO GET A TOWEL. CNA # 8 SAID RESIDENT #109 fell FORWARD AND HIT HER FOREHEAD ON THE FLOOR BEFORE SHE (CNA #8) COULD GET BACK AROUND THE WALL TO SUPPORT THE RESIDENT. THE NURSE WAS NOTIFIED AND ASSISTED RESIDENT #109 TO A SHOWER TABLE. RESIDENT #109 WAS ASSESSED AND THEN SENT TO THE HOSPITAL FOR STITCHES. RESIDENT #109 WAS IDENTIFIED TO BE A ONE-PERSON ASSIST AT THAT TIME. WHEN ASKED, CNA #8 SAID THE FACILITY DID NOT HAVE SEAT BELTS ON THE SHOWERS CHAIRS. CNA #8 SAID SHE LEFT RESIDENT #109 UNSUPPORTED AND UNSUPERVISED ON THE SHOWER CHAIR BECAUSE SHE THOUGHT THE RESIDENT COULD SUPPORT HERSELF FOR A FEW SECONDS. ACCORDING TO THE CLOSED MEDICAL RECORD, RESIDENT #109 WAS A [AGE] year OLD FEMALE WHO WAS admitted to the facility on [DATE] WITH MULTIPLE [DIAGNOSES REDACTED]. MULTIPLE NURSE'S NOTES, SPEECH THERAPY NOTES, AND PHYSICAL THERAPY NOTES FROM 8/10 THROUGH 4/28/11 DESCRIBED RESIDENT #109'S POSTURE AS BENT FORWARD AT THE NECK AND WAIST, WHICH PLACED THE RESIDENT'S HEAD ALMOST TO HER LAP, CAUSING INABILITY TO EAT OR BALANCE SELF IN A SEATED POSITION. ON 12/27/10, THE PHYSICAL THERAPIST DOCUMENTED A RECOMMENDATION TO PLACE RESIDENT #109 IN A RECLINING CHAIR WITH FOOT RESTS AND WITH THE USE OF A LAP BUDDY (A POSITIONING CUSHION TO PREVENT A RESIDENT FROM FALLING FORWARD OUT OF A WHEELCHAIR). A REVIEW OF RESIDENT #109'S CARE PLAN, CARE CARD, physician's orders [REDACTED]. ON 12/27/10, AN INTER-OFFICE MEMORANDUM FROM THERAPY TO NURSING REGARDING RESIDENT #109 DOCUMENTED THE RESIDENT'S NEED FOR WHEELCHAIR POSITIONING AND TILTING THE CHAIR BACK WITH FOOT RESTS ON AT ALL TIME AND TO CONTINUE WITH RESTRAINT. ON 5/13/11 AT 12:45 P.M., THE THERAPY DEPARTMENT MANAGER SAID THE INTER-OFFICE MEMORANDUM HAD BEEN SIGNED BY THE NURSE WHO RECEIVED THE RECOMMENDATION AND THE PHYSICIAN SHOULD HAVE BEEN NOTIFIED. THE DEPARTMENT MANAGER CLARIFIED THAT "RESTRAINT" WAS REFERRING TO THE LAP BUDDY, OR POSITIONING CUSHION. THE THERAPY DEPARTMENT MANAGER COULD NOT EXPLAIN WHY THIS RECOMMENDATION WAS NOT PLACED ON A CARE PLAN OR CARE CARD FOR RESIDENT #109 AT THAT TIME. ON 5/15/11 AT 1:15 P.M., THE DIRECTOR OF NURSING (DON) SAID RESIDENT #109 WAS DETERMINED TO BE A 2 PERSON ASSIST WHILE IN THE SHOWER ON 1/26/11. HOWEVER, THE DON COULD NOT EXPLAIN WHY THE STAFF WOULD LEAVE RESIDENT # 109 UNATTENDED OR UNSUPPORTED IN THE SHOWER EVEN IF THE RESIDENT WAS A 1 PERSON ASSIST. ( )

The citation pertains to Intake #'s: and . Based on observation, interview and record review, the facility failed to protect one (#503) of four sampled residents from physical abuse related to rough handling during care, resulting in a fractured humerus and pain. Findings include: After complaining of pain on 3/25/11, resident #503 was sent out to a local area hospital emergency room for evaluation of her pain and changes in her mental status. In the emergency room resident #503 complaint of pain in her left arm. X-rays were taken, it was discovered resident #503 had a fracture of her left elbow. Resident #503 stated "the nurse (CNA #E) that was fired broke my arm." According to the hospital x-ray report dated 3/25/11 for resident #503's left elbow, there was a nondisplaced supracondylar fracture of her left humerus with associated soft tissue swelling. On 3/21/11 at 10:45 a.m. resident #503 was observed to be alert and oriented. She was lying in bed on her back and complained of pain in her left arm. Resident #503 stated, "The nurse (identified as CNA #E) grabbed my arm and pulled on it." It was revealed resident #503 was hard of hearing, it was discovered and reported on 2/28/11 at 6:00 p.m. resident #503 was in her room lying in bed on her right side with her back to the door during day shift. CNA #E approached resident #503 and grabbed her left arm and pulled her towards the left side of her bed. CNA #E did not explain to resident #503 what she was about to do. An interview with resident #503's roommate on 3/29/11 at 1:30 p.m. who was alert, oriented to details of her observations revealed she observed care being provided to resident #503 she stated that CNA (#E) was rough with her (resident #503) when she provided care on 2/28/11. An interview with nurse #Q revealed there was a noticeable bruise on resident #503's left hand. She stated resident #503 identified CNA #E as the person who made the bruise on her left hand. On 3/21/11 at 11:15 a.m. an interview with the Director of Nursing revealed CNA #E did not explain care to resident #503 prior to approaching her (#503) for care on 2/28/11, at 6:00 p.m. on 2/28/11 it was reported resident #503 stated the CNA (#E) was mean to her and startled her because she walked into her room unannounced and did not explain what she was going to do prior to grabbing onto resident #503's arm. On 3/21/11 at 2:55 p.m., review of the nurse's note documentation dated 2/28/11 at 3:00 p.m. revealed resident #503 stated CNA #E twisted her arm, complained her arm hurt and stated CNA #E broke her watch. On 2/28/11 at 5:30 p.m., the nurse's notes documentation revealed it was noticed resident #503 had a bruise on her left hand. According to her daily care plan resident #503 required assistance with repositioning and transfers. Review of the the most comprehensive minimum data set assessment dated [DATE] resident #503 was alert and oriented, she required extensive assistance with activities of daily living. Review of the facility 24 hour investigation report revealed a CNA (#E) pulled on resident #503's arm to move her. The x-ray report revealed resident #503 had a nondisplaced supracondylar fracture of her left humerus with associated soft tissue swelling. On 3/29/11 at 1:30 p.m. resident #503 was observed lying in bed on her back, she was alert and oriented. She had a sling on her left upper extremity extending to her hands. She verbalized her arm was painful and stated, "that nurse (CNA #E) broke my arm." Review of the facility policy entitled 'Abuse and Neglect Prohibition-Teaching Tool" revised May, 2010 revealed "Harm" is a negative outcome that has compromised the resident's ability to maintain or reach the highest practicable physical, mental, or psychosocial well being." Resident #503 experienced a fractured elbow and pain resulting from the 2/28/11 facility reported incident. On 3/25/11 at 10:03 a.m. a review of CNA #E's personnel file revealed written warning dated 10/18/10 at 11:00 a.m. related to her failure to provide appropriate care to residents. Resident #503 did not receive an explanation that CNA #E was going to transfer/reposition her from the right to the left side of her bed nor did resident #503 receive an explanation of what CNA #E was going to do prior to CNA #E grabbing her left hand. Review of the facility's policy entitled "Personal care needs" revised June, 2006 according to the personal care procedures the second step was to "explain the procedure" to the resident. Resident #503 was not informed of what CNA #E was going to do resulting in a fracture of her left elbow.

The citation pertains to Intake #'s: , , and . Based on observation, interview and record review, the facility failed to utilize the appropriate transfer technique for one (#502) of five sample residents, resulting in fractures of her lower extremities. Findings include: Resident #502: On 3/2/11 resident #502 was transferred to a local area hospital emergency room for treatment of [REDACTED].#G. According to the facility's description of the fall on 3/1/11, "it was discovered that on 3/1/11 around 8:00 p.m. the patient (#502) again was lowered to the floor in her room during transfer assistance." According to the nurse's notes dated 3/2/11 at 6:00 a.m. resident #502 had discoloration noted to her left arm. On 3/2/11 at 11:10 a.m. resident #502 complained of pain in her left leg. X-rays were ordered of her left arm and left leg which revealed resident #502 had a left femur fracture. Nurse #P documented in her statement dated 3/10/11 she observed resident #502 resting on the floor next to her bed with her wheelchair behind her on 3/1/11. According to the facility's further investigation report dated 3/11/11, CNA #G (Certified nursing assistant) did not report the inappropriate transfer that resulted in resident #502's fall until 3/9/11. CNA #G admitted to the nurse manager #B she did not check the bed to ensure the bed was locked to prevent the bed from moving during the transfer process. Resident #502 had surgery on 3/11/11 for internal fixation of her left hip with a side plate, multiple trans-cortical screws, cerclage wires and 52 staples. On 3/22/11 at 2:45 p.m. during an interview with CNA #G she stated the bed was moving during her transfer of resident #502 and both she and resident #502 started falling and went down to the floor. CNA #G also stated she didn't understand what resident #502 was saying because she (#502) doesn't speak English. She (#502) was making noise (described by CNA #G as moaning). CNA #G admitted she did not lock resident #502's bed prior to transferring her from her wheelchair to her bed. CNA #G stated she did report the fall to the nurse at the nurse's station, however, she did not report to the nurse that she lowered resident #502 to the floor during an inappropriate transfer technique. Nurse #P who observed and received report of resident #502's fall on 3/1/11 at 8:00 p.m. did not complete an incident/accident report or investigate the fall until after it was reported to the Assistant Director of Nursing on 3/9/11. Review of resident #502's clinical record revealed she was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The most current comprehensive minimal data set assessment dated [DATE] revealed resident #502 required assistance with transfers, dressing, hygiene and grooming. On 3/22/11 at 3:40 p.m. resident #502 was observed to be alert, sitting in her wheelchair in the hall near the main dining room without assistance or supervision. However, on 3/23/11 at 11:00 a.m. a review of the hospital medical records for resident #502 revealed she had a complete oblique fracture of her femur with lateral displacement and a distal fracture relative to the proximal fragment area. On 3/23/11 at 11:45 p.m., during a family interview it was revealed resident #502 was readmitted to a local area hospital, for a non-displaced peri-prosthetic fracture on her right leg that was discovered on 3/22/11 at 2:00 p.m. during her orthopedic appointment and was related to her fall on 3/1/11. The scheduled surgery for [REDACTED]. Review of the facility policy entitled "Transfer Between Surfaces" dated December, 2008 revealed "it is better to have another staff member assist with a transfer than to risk injury." The policy also included "Lock wheels and remove armrest closest to resident." The wheels of resident #502's bed was not locked prior to transfer. The facility policy entitled "Fall Management Guidelines" revised January, 2009 revealed "Fall refers to unintentionally coming to rest on the ground, floor, or other lower level. An episode where a resident lost his/her balance and would have fallen, if not for staff intervention, is considered a fall. A fall without injury is still a fall. When a resident is found on the floor, a fall is considered to have occurred. If a resident rolled off a bed or mattress that was close to the floor, this is a fall." The facility policy entitled "Fall Management Guidelines" also revealed when a fall occurs, assess the resident for injury. The licensed nurse will complete: Incident/Accident Report, 24 Hour Report and Initiate the Interdisciplinary Post-Fall Assessment. There was no documented evidence the nurse completed an incident/accident report on 3/1/11, did not include resident #502's fall on the 24 hour report and did not initiate the interdisciplinary post-fall assessment on 3/1/11.

This citation pertains to Intake # MI 096. Based on interviews and records review, the facility 1) failed to assure that one of six sample residents (#101) was free from sexual abuse when another resident approached her, grabbed her breast, and said, "I want your pussy", resulting in #101 feeling violated and vulnerable, with emotional distress, causing isolation and depression Findings include: According to the facility's report to the State Agency, dated 8/17/10, Resident #101 was sitting in her wheelchair in the hallway by the window in the atrium at 2:15 PM on 8/17/10, when Resident #100 "rolled up beside her in his wheelchair and reached out and grabbed her breast". The report continued, "(Resident #101) told him to stop it and he stated, 'I want your pussy'; (Resident #100) then made a move to reach for her pubic area, but (Resident #101) pushed his hand away." According to the report, a staff member, Activities Aide #16, was walking by, when Resident #101 called to him and reported the occurrence, as Resident #100 wheeled himself away. According to the facility's occurrence report, dated 8/17/10, Activities Aide #16 separated the residents, asking Resident #100 if he "touched that woman". According to the occurrence report, Resident #100 answered, "Yes, I did". Activities Aide #16, took Resident #101 into the dining room, where an activity was in progress. Activities Aide #16 also reported the occurrence to the unit manager. Resident #100: According to the admission record, Resident #100 was an [AGE] year old man, who was admitted to the facility on [DATE], when he transferred to the facility from another facility. According to the admission history and physical examination [REDACTED]. The most recent quarterly Minimum Data Set ( MDS), dated [DATE], documented that Resident #100 had impaired short-term and long-term memory, with difficulty making decisions in new situations. The MDS scores for Activities of Daily Living (ADLs) showed that Resident #100 was independent for most activities, needing supervision for walking in the hallways and for toileting. For bathing, Resident #100 needed extensive assistance. According to the MDS, Resident #100 used a wheelchair, which he propelled himself, to move about the facility. According Resident #100's clinical record, he was observed sexually assaulting another female resident two weeks earlier. A Social Progress Note, dated 8/2/10, Resident #100 was observed touching a female resident's breast and inner upper thigh area, "reportedly exposing his penis". During an interview on 9/10/10 at 12:30 PM, the 8/2/10 occurrence was reported to the State Agency and investigated, with no resulting citations. According to the 8/2/10 Social Progress Note, Resident #100 "was warned of (possible) negative consequences of actions and advised to pull curtain or ask for staff assistance to pull curtain and pleasure self in own bed in own room behind privacy curtain when he feels the urge". The Social Progress Note continued: "Resident stated he understood"...and "Staff will closely observe resident's whereabouts and actions". A Plan of Care was written on 8/3/10 for the problem of "Ineffective Sexuality Pattern". The stated goal for the Plan of Care was: "Resident will not exhibit inappropriate sexual behavior". The interventions listed were: "1) Monitor residents whereabouts/behaviors; 2) psychiatric evaluation/treatment as needed/ordered; 3) offer resident materials expreracy to sexually please self; 4) explain negative outcomes of displaying inappropriate sexual behavior; 5) encourage resident to talk about any sexual urges he may feel towards staff/residents with psych/social work staff members; and 6) encourage group activities as will allow". The "Daily Care Plan" is used to communicate each resident's care needs to nurse aides. For August of 2010 entries included: "Falling Star Program, Bed against wall, Assist to bed after dinner, Keep urinal in reach, and Shave daily". There was no entry regarding supervision of Resident #100 or monitoring of his whereabouts. A Monthly Summary Form, dated 8/3/10, completed by a staff nurse, did not mention inappropriate behavior. The note referenced an entry into Nurses' Notes, dated 8/2/10. However, the surveyor was unable to locate an entry into Nurses' Notes dated 8/2/10. Notations made during an Initial Psychiatric Diagnostic Evaluation, dated 8/4/10, included "History of Present Illness: [AGE] year old man with history of dementia is reported to be exposing his genitals to people and reportedly toward a female patient inappropriately. Patient reported to have a history of this, but it has been a long time." Under "Discussion/Other Recommendations", the 8/11/10 note read: "will monitor-hopefully recent behaviors are a one time incident...do not want to start any new medications now". Nurses' Notes contained one entry for each day from 8/12/10 through 8/16/10. Each note documented that there were no "display(s) of sexually inappropriate behavior observed". There were no flow sheets or other forms of documentation in the clinical record that detailed Resident #100's whereabouts or supervision during this period. A "Mood and Behavior Management Team Progress Note", dated 8/13/10, noted that Resident #100 "displayed sexually inappropriate behavior toward a female resident". The Mood and Behavior Management Committee Recommendations were "Nursing staff to monitor daily and document on behavior that are inappropriate for 2 weeks". On 8/3/10, 8/4/10, and 8/5/10, entries into social work notes documented an observation for each day that Resident #100 "was observed sitting quietly with no displays of sexually inappropriate behavior." The was no time frame for any of the observations documented. A social work note entry, date 8/17/10 read; "Another resident reported this resident touched her left arm as she was sitting in the facility hallway. The female resident asked resident to stop touching her. Resident proceeded to touch resident's left breast and then reached in, attempting to grab her crotch and stating, 'I want some pussy'." At 4:45 PM, on 9/10/10, an interview was held with Activities Aide (AA) #16. AA#16 said he entered the hallway from a dining room, where he had been staffing a resident activity ob 8/17/10, when Resident #101 called out to him, saying, "Sir! Sir! That man touched me!" AA# 16 said, "The only man around was asleep in a wheelchair behind her". AA # 16 said he looked around and saw Resident #100. "He was wheeling fast in the other direction." AA #16 said he caught up with Resident #100 and asked him if he "touched" Resident #101. According to AA #16, Resident #100 admitted that he did, but later denied it when questioned by the Unit Manager. AA # 16 said Resident #101 seemed to be "more offended than upset", so he took her into the activity room. Then he notified the Unit Manager. The Unit Manger for D Unit, Manager #18, was interviewed on 9/10/10 at 5:00 PM. Manager #18 said AA # 16 came to her and said Resident #101 told him a male resident touched her and that Resident #100 was the only male resident in there vicinity, and he admitted to AA #16 that he had "touched" Reisdent #101. According to Manager #18, she and a social worker interviewed Resident #100 in his room and he admitted touching Resident #101 inappropriately during this interview. Manager #18 said she reported the event to the Director of Nursing, Manager #5, leaving the social worker with Resident #100. Manager #18 said Manager #5 told her to assign someone to supervise Resident #100 one-on-one. Manager #18 said Resident #100 remained on one-to-one supervision until he was transferred to another facility on 8/30/10. A Psychological Evaluation, dated 8/18/10, described Resident #100 as "cooperative and pleasant", "alert", and "oriented to name and place". Resident #100's thought process was described as "concrete and vague with poverty of thought". The notation beside "thought content" was "acknowledges feeling 'stressed'-unable to specify". The "Discussion/Case Formulation" section of the report read: "Disinhibition of advanced dementia combined with need for intimacy and human contact". The "Recommendations" read: "(Resident #100) is being followed by psychiatry" and "1) (Resident #100) gave verbal consent to follow-up appointment; 2) continued efforts to re-direct resident to his private space in his room; and 3) further plan to follow." A "Follow-up Psychiatric Evaluation", also dated 8/18/10 stated: "it is reported again that he touched a patient on her breasts. He denied this happened. Initially, he did admit that this happened." A "Quarterly Psychosocial Assessment", dated 8/20/10, noted "increased behavior of sexual abuse toward another resident on two different occasions". A "Mood and Behavior Management Team Progress Note", dated 8/25/10, read "Resident touched a female resident's breast and attempted to touch her crotch. He also made sexually inappropriate comments as well". Under "Recommendations", the entry read: "Provide one on one monitoring (staff), locate alternate placement." According to a Nurses' Note, dated 8/31/10, Resident #100 was transferred to another facility on that date. Resident #101: According to the admission record, Resident #101 was a [AGE] year old woman, who was admitted to the facility on [DATE] for physical rehabilitation and continuing intravenous antibiotic therapy following hospitalization for hypertension, [MEDICAL CONDITION], diabetes mellitus, [MEDICAL CONDITION] (narrowing of the blood vessels supplying the heart), [MEDICAL CONDITION], a [MEDICAL CONDITION] disorder (convulsions) and [DIAGNOSES REDACTED] (voluminous diarrhea caused by a strain of the ,[MEDICAL CONDITION]. bacteria). It was noted that Resident #101 was legally blind. A facility history and physical examination unsteady on gait and balance". According to a nursing assessment, dated 6/10/10, Resident #101 required assistance from two staff members to transfer into and out of her wheelchair. A "Restraint Assessment", dated 6/25/10 noted that Resident #101 was alert, oriented to person, place, and time, able to follow directions, and blind. An undated physical therapy care plan noted that Resident #101 needed stand-by assistance to move about in bed and transfer into and out of her wheelchair, and to move about the facility in her wheelchair. An admission care plan, dated 6/24/10, noted that Resident #101 required "total assistance" from staff because of her [MEDICAL CONDITION]. According to a Social Progress Note, dated 8/17/10, Resident #101 reported a male resident approached her as she was sitting in the hallway and grabbed her left arm. Resident #101 asked him to stop touching her. The male resident proceeded to touch her left breast. He then reached in, attempting to grab her crotch, stating, "I want some pussy". Resident #101 informed an activities staff member of the incident. A social service plan of care, dated 8/18/10, added a Problem that read: "Resident is upset r/t male resident exhibiting sexually inappropriate behavior toward her". The intervention listed for that problem read: "Follow-up to provide explanations, comfort, reassurance, etc." A psychiatric progress note, dated 8/19/10, documented that Resident #101 "reported that another resident touched her breast and made a vulgar request of her". According to this note, Resident #101 "has been anxious and upset since then... waking up at night and having nightmares...feels afraid to come out of her room". The assessment portion of the note read: "[MEDICAL CONDITION], recurrent...having more anxiety and depression after recent episode with another resident". A Social Progress Note, dated 8/20/10, documented that a social service worker attempted to persuade Resident #101 to leave her room and join an activity. An entry into Social Progress Notes, dated 8/30/10, recorded that a social services worker spoke with Resident #101, informing her that "the male resident (Resident #100) would no longer be around to have contact with her". According to this note, Resident #101 expressed relief. An interview was held with Resident #101 on 9/20/10 at 1:05 PM. Resident #101 was sitting up in bed. Her head was turned to the right side and leaning on her right shoulder. Resident #101 said she was just released from the hospital and having significant pain. She expressed concern that she could not support her head. Resident #101 was clean, well groomed, and neatly dressed. She did not look at the surveyor during this conversation. When questioned about the occurrence with Resident #100, Resident #101 said he did not hurt her physically, but she was feeling vulnerable and that it "bothered (her) emotionally". Resident #101 said she was "beginning to feel better about that". Resident #100 was not interviewed, as he was no longer residing at the facility. At the time of the 8/17/10 incident between Residents #100 and #101, Resident #100 was residing on Unit D and Resident #101 was residing on Unit A. During an interview on 9/10/10 at 1:55 PM, Nurse #8, who regularly worked unit A, said she did not remember Resident #101. She said she was not aware of an occurrence between Resident #101 and a male resident. CNA #9, who worked on Unit A, said she was never assigned to care for Resident #101 and did not know her, during an interview on 9/10/10 at 2:00 PM. CNA #9 said she knew Resident #100 from having worked on Unit D prior to being assigned to Unit A. However, she said she was unaware of an occurrence between Residents #100 and #101. Nurse #10 was interviewed at 2:05 PM on 9/10/10. She said she works on Unit A. Nurse #10 said she remembered caring for Resident #101. However, she said she was not aware of an occurrence between Resident #101 and a male resident. An interview was held with a Unit A CNA, CNA #11 on 9/10/10 at 2:10 PM. CNA #11 said she remembered answering Resident #101's call light, but she did not know about a occurrence between Resident #101 and a male resident. CNA #12, a Unit A CNA, was interviewed at 2:15 on 9/10/10. CNA #12 said she did not remember Resident #101. During her interview at 2:20 PM on 9/10/10, CNA #13 said she generally worked on Unit A. CNA #13 said she remembered Resident #101, but did not provide care for her. CNA #13 said she found out about an "altercation" between Resident #100 and Resident #101 after the fact. Another Unit A CNA, CNA #14, was interviewed on 9/10/10 at 2:30 PM. CNA #14 said she remembered caring for Resident #101, but did not know anything about an occurrence between Resident #101 and a male resident. CNA #14 said Resident #101 was moved to Unit C. An interview was held with the Unit Manager for Unit C, Manager #15, on 9/10/10 at 2:35 PM. Manager #15 said Resident #101 was on her Unit, then transferred to an area hospital. She said she was not aware of an occurrence between Resident #101 and a male resident. On 9/20/10 at 2:10 PM, an interview was held with a social service worker, SW #33, who was assigned to Resident #100. According to SW #33, Resident #100 had been residing at the facility for several years, but "recently got a little touchy-feely with female residents". SW #33 said she was aware of two occurrences where Resident #100 touched female residents inappropriately. She said Resident #100 approached both women in the facility hallways. The first occurrence, which she dated as "sometime in July", was observed by a staff member. The second woman reported the occurrence. According to SW #33, the second woman, who was alert and oriented, "needed a lot of reassurance because she was very uneasy". When asked about the plan of care developed for Resident #100 after the first occurrence, Staff #33 said the plan of care called for a psychiatric consultation and for staff to observe Resident #100's whereabouts. When asked if Resident #100 was placed on one-to-one supervision, Staff #33 said, "No, not until after the second occurrence". At 2:38 on 9/20/10, an interview was held with CNA # 35, who worked on Unit D. CNA #35 said she began to work at the facility in June, so she was not yet employed by the facility at the time of Resident #100's first incident of inappropriate sexual behavior with a female resident. CNA #35 said Resident #100 was not supervised on-on-one until after the second occurrence. Nurse #36, who was assigned to work on Unit D, was interviewed on 9/20/10 at 2:07 PM. According to Nurse #26, Resident #100 had no additional supervision after the first occurrence, but did after the second occurrence of sexual misconduct with a female resident. Nurse #39, who worked on Unit D, was interviewed on 9/20/10 at 3:18 PM. Nurse #39 said she was aware of only one occurrence of inappropriate sexual conduct involving Resident #100. Nurse #39 said the facility assigned CNAs to provide one-to-one supervision after this event, which she dated as "the end of August or beginning of September". Although Resident #100 was observed publicly engaging in inappropriate sexual conduct with a woman resident on 8/2/10, the facility failed to provide adequate supervision to assure the safety of female residents, resulting in a second occurrence with another woman resident, Resident #101, on 8/17/10 and causing her well documented emotional pain, distress, anxiety, and depression. ( )