Every finding on record at Iron County Medical Care Facility

Based on interview and record review, the facility failed to incorporate the key components of staffing needs for each resident unit and staffing needs for each shift, into their facility assessment potentially affecting all 109 residents residing in the facility. Findings include: All times are in Eastern Daylight Time (EDT) unless otherwise noted.The facility assessment, last updated 2/12/2026, was reviewed. This document indicated the assessment was completed at the facility level to serve as a record for staff and management to understand the reasoning for decisions made regarding staffing and other resources.The section titled INFORMATION ABOUT NURSE STAFFING PLANS included a table with the heading of Overall Staffing Needs. Staffing positions were as follows: RNs (Registered Nurses) Providing Direct Care LPNs (Licensed Practical Nurses) Providing Direct Care RNs Available to Provide Direct Care (includes DON [Director of Nursing] and RNs with administrative dutiesEach position had an adjoining space for the number of staff needed titled Total Needed or Average or Range. These spaces were blank. The total number of each of the types of nurses had not been recorded.The next section of the Facility Assessment was titled Staffing Needs as per Resident Unit. The Staff Positions were listed, and next to each position was Ratio of Staff to Residents. The staff positions were RN, LPN, CNA (Certified Nurse Aide), Med Tech, Nurse Aide. Next to each position was See Attachment C for the ratio of staff to resident needed.The next section of the Facility Assessment was titled Staffing Needs as per Shift (adjust as needed). For the Staff Position of RN, LPN, CNA for each shift Nights, Days and Evenings again the Ratio of Staff to Residents column listed See Attachment CDuring an interview on 6/24/2026 at 11:57 AM, the Director of Nursing (DON) reviewed the facility assessment and staffing numbers. She presented and printed Attachment C which was one page and titled Staffing Numbers - CNA. Staffing numbers for RN or LPN were not found.During an interview on 6/24/2026 at 12:22 PM, the Assistant Director of Nursing (ADON) RN A discussed the calculated nursing needs. RN A said she calculated the CNA needs but said the nursing needs changed less and said, I do not calculate the nurse staffing needs. The Facility Assessment did not include licensed nurse staffing needs for each resident unit or each shift such as day, evening, and night.

All times are in Eastern Daylight Time (EDT) unless otherwise noted.Based on record review and interview, low staffing was confirmed to have the potential to affect the entire facility population through review of reports by six Residents (#47, #50, #69, #80, #93, and one Confidential Resident [CR]) of six residents reviewed for staffing concerns.Findings include: The facility assessment, last updated 2/12/2026, was reviewed. This document indicated the assessment was completed at the facility level to serve as a record for staff and management to understand the reasoning for decisions made regarding staffing and other resources. The staffing needs for the facility were calculated in the facility assessment based on FTEs (Full Time Equivalents – or eight hours per day). The minimum and optimum need for Certified Nurse Aides (CNA) per shift was listed as follows: AM (day shift) MINIMUM TOTAL 13 and OPTIMAL TOTAL 19 PM (evening shift) MINIMUM TOTAL 13 and OPTIMAL TOTAL 19 NOC (night shift) MINIMUM TOTAL 7.5 and OPTIMAL TOTAL 14 The schedules for the past two weeks and past four weekends were reviewed and revealed: 5/29/26 evening shift schedule was blank on the posting and adequate staffing could not be determined 5/29/26 night shift schedule was blank on the posting and adequate staffing could not be determined 5/30/26 day shift schedule indicated only 11 FTE CNAs worked; 5/31/26 evening shift schedule was blank on the posting and adequate staffing could not be determined 6/20/26 day shift schedule indicated only 12 FTE CNAs worked; 6/21/26 day shift schedule indicated only 12 FTE CNAs worked; 6/21/26 night shift schedule indicated only 7 FTE CNAs worked; During an interview on 6/24/2026 at 11:57 AM, the Director of Nursing (DON) reviewed the facility assessment and staffing numbers. The posting sheets were compared to the actual worked staff schedules and found to be accurate. The discussion included staffing levels and the DON indicated she had been to the resident council several months ago and had heard concerns of not enough staff to meet the resident's needs. During an interview on 6/24/2026 at 12:22 PM, the Assistant Director of Nursing Registered Nurse (RN) A reviewed the staffing sheets and compared them to the facility assessment and stated, Yes that was a short day. The Hours per Resident Days were listed in the facility assessment and calculations revealed these numbers were not met on several of the examples presented. In conclusion the staff postings from the last 2 weeks and 4 weekends revealed 3 shifts were undocumented and 4 shifts were staffed under the assessed minimum needs of the facility as calculated and determined in the facility assessment. Review of document titled Resident Council Meeting dated 6/8/26, read in part .Call bells not being answered in a timely fashion .Resident currently stated that it depends on how busy the staff are.residents state they understand facility is short-staffed. During a group meeting on 6/23/26 at 3:43 p.m., Five Residents (#47, #50, #69, #80, and#93) of eight residents reported the following: Resident #47 stated, The facility is short staffed all of the time. Resident #50 stated, The facility is very short of staff. Resident #69 stated, I wish they could have more help.they need more staff here. Resident #80 stated, The facility is short staffed during the day. Resident #93 stated, The staff are shorthanded on the weekends. An interview was conducted with a Confidential Resident (CR) Designated Power of Attorney (DPOA) on 6/23/26 at 9:46 a.m. The DPOA for the CR stated they had concerns of the facility being short staffed, especially at nights. The DPOA stated the CR was new to the facility and prior to admission, the hospital stated they may not be able to send the resident to this facility due to short staff concerns.

Based on observation, interview, and record review the facility failed to properly label and store medications in 2 medication carts (200 Hall and 700 Hall) out of 3 medications carts observed. This deficient practice resulted in the potential for errors in medication administration and the potential for drug diversion. Findings include: On 6/23/2026 at 8:00 AM, an observation was made of the 700-unit medication cart left unattended with a clear cup of reddish liquid and a small medication cup with pudding and several different colors of crushed medication without a name or label on the cup. An interview was conducted with Licensed Practical Nurse (LPN) L who was asked if she oversaw the cart and replied, Yes. LPN L was asked if she knew whose medication was left on top of the medication cart and replied, I did not mean to leave them up there. They are for [Resident #17] I was going to give them to her, but she wanted to eat first. LPN L was asked if medications should be labeled with a resident name so she knows who they are if she gets interrupted or forgets and replied, Yeah, I should. LPN L removed the medications and put them in the third drawer of her medication cart without labeling them. On 6/23/26 at 1:20 PM, an observation was made of the 700-unit medication cart unattended with a small medication cup on top of an apple sauce with approximately 15 ml (milliliters) of white liquid without a label. LPN L was observed behind a close door of the nurses' station. LPN L was asked to come out for an interview and was asked why the medication was left, what it was, and who it was for and replied, It is for [Resident #76] and it is Mylanta. She requested it because her stomach is upset and I haven't given it to her yet. I should not have left it on top of my cart. My bad again. Review of R76's medical records, unveiled an order dated 7/3/24, Geri-Lanta Suspension. Give 10 ml by mouth every 4 hours as needed. On 6/23/26 at 4:50 PM, an interview was conducted with the Director of Nursing (DON) who was asked about medications being left on top of the medication cart, unattended, and not labeled and replied, The medications should have been discarded in the drug buster. If a resident does not want their medications at the time of dispensing, they are discarded. Medications are not to be left unattended, left of the top of the medication cart, or not labeled as to what or who they are for. On 6/24/26 at 9:40 AM, an interview was held with the Nursing Home Administrator (NHA) who was made aware of the medication storage concerns and replied, Pharmacy just went through the carts last week and said they were great. Wallets should be kept behind the nurses' station and not in the medication carts and medications need to have a residents name on them. Review of policy titled, Medication Administration, dated 4/17/24 read in part .Purpose: To ensure that a procedure exists for the proper and safe administration of resident medications following Physician orders.Procedure: Medications will be administered per MD [medical doctor] orders.A. Oral Medications.21. If resident refuses medications, document in the EHR [electronic health record] and notify Charge Nurse. If medication has been prepared and it is then refused, destroy in Drug Buster. Review of policy titled, Storage and Expiration of Medications, Biologicals, Syringes, and Needles, dated 5/5/23 read in part .Purpose/Policy: To ensure proper storage of medications.Procedure.3. General Storage Procedures.c. ICMCF should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. Observation of the 200/300 hall medication cart on 6/24/26 at 8:30 a.m., with Licensed Practical Nurse (LPN) G, found a small, unlabeled glass bottle filled with small nitroglycerin tablets, in the right side, locked compartment of the narcotic drawer, along with two wallets, two pair of eyeglasses and their cases, and an unidentified key on an antler keychain. Both wallets contained money with no documentation of the amount of funds contained within the wallets. During an interview on 6/24/26 at 8:47 a.m., Registered Nurse (RN) Supervisor F, returned to the 200/300 hall medication cart and retrieved the two wallets, two pairs of glasses and set of keys. RN Supervisor F observed the nitroglycerin bottle, confirmed it was unlabeled, and stated, We would not use this (to administer to a resident), we would use our own (medication). RN Supervisor F acknowledged the wallets, glasses and keys should not be stored in the locked, right side narcotic drawer with unlabeled medication. Review of the [Facility Name] Storage and Expiration of Medications, Biologicals, Syringes, and Needles policy, effective 10/8/20, revealed the following, in part: .[ Facility Name] should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors . [Facility Name] should destroy and reorder medications and biologicals with soiled, illegible, worn, makeshift, incomplete, damaged or missing labels .

All times are noted in Eastern Daylight Time unless otherwise noted. Based on observation and interview, the facility failed to maintain two exterior doors and one interior door, resulting in an increased potential for pest infestation and a possible decrease in satisfaction of living for residents. Findings Include:On 6/23/2026 at 1:25 PM daylight was observed coming in under the exit door #20 in the Skyway Basement, and the door sweep was missing from this door. During this observation, Maintenance Director (MD) D agreed that daylight was visible under this door and stated the door sweep needed to be replaced and that these entry doors received a lot of use, resulting in wear and tear. On 6/23/2026 at 1:34 PM the exterior door on the 200 wing vestibule was observed and had a door sweep that was damaged with a quarter inch space observed between the door and the door jamb, allowing daylight to be visible under the door. Also observed the door sweep missing from the interior door, with an approximate half inch space between the door and the threshold, allowing daylight to be visible under the door. During this observation, MD D stated that these door sweeps received a lot of wear and tear and needed to be replaced.

All times are in Eastern Daylight Time (EDT) unless otherwise noted.Based on observation, interview, and record review, the facility failed to implement fall prevention interventions for one Resident (#29) after an identified root cause to prevent subsequent falls and failed to adhere to care planned interventions to prevent hot liquid spills for one Resident (#89) of four residents reviewed for accidents and supervision.Findings include: Resident #29 (R29) On 6/3/26 at 11:03 AM, R29 was observed seated in a wheelchair in their room. A power lift recliner equipped with a remote control was positioned adjacent to the resident's bed. A quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R29's most recent admission date as 3/9/26. The MDS coded R29 with severe cognitive impairment, dementia, anxiety disorder, and a history of falls since admission. A progress note dated 1/29/26 at 3:26 PM documented concerns regarding the unsafe use of the power lift recliner by R29. The note indicated R29 was unable to consistently position the chair safely and repeatedly reclined the chair while eating despite repeated staff education regarding aspiration risk and unsafe positioning. The note read, in part: .Writer contacted resident's DPOA [Durable Power of Attorney] [name redacted] to update him regarding ongoing concerns with resident's use of power recliner. Resident has demonstrated unsafe operation of recliner remote, including inability to consistently position chair safely. Resident has also continued to recline chair while eating meals, despite repeated staff education regarding risk of aspiration and unsafe intake when reclined. The electronic medical record (EMR) documented on 4/4/26 at approximately 1:20 PM, R29 experienced an unwitnessed fall. Staff responded after hearing the resident calling for help and found R29 lying on her back on the floor with the recliner fully reclined. R29 was in the power lift recliner prior to being found on the floor. Documentation identified the suspected cause of the fall as activation of the recliner remote control, resulting in unsafe positioning of the chair and the resident sliding to the floor. The investigation further identified contributing factors including impaired safety awareness related to cognitive deficits and the resident's access to the recliner remote control. The associated incident report documented the care planned intervention as reminding the resident regarding proper operation of the recliner controls, instructing the resident to use the call light for staff assistance with repositioning, and obtaining a risk-versus-benefit agreement from the family. The incident report read, in part: .We have tried to move the control [recliner remote control] but resident must have access to controller as to not be restrained. So will remind resident on proper use of controls and utilizing call light for staff to assist when needing to reposition. Family to sign risk vs. [versus] benefits form . The fall care plan of R29 contained an intervention dated 4/22/26 that read: The risk vs benefit of me using my remote control have been discussed with family and resident. Although deemed unsafe to use, family and resident prefer to keep the remote within my reach. A Risk vs. Benefit Form completed on 4/14/26 documented the primary safety concern as Recliner Remote Control & falls. The assessment identified generalized weakness, impaired judgment due to cognitive impairment, poor trunk control, impulsivity, poor safety awareness, and a history of falls. The assessment further concluded that continued access to the recliner remote control presented a high likelihood of unsafe chair positioning leading to sliding from the chair, loss of balance due to trunk and leg weakness, impulsive activation without staff supervision, and an increased risk of falls with injury. Further review of the EMR disclosed that despite the facility's identification of the root cause of the fall and acknowledgment of R29's inability to safely operate the power recliner, the facility did not implement additional interventions designed to eliminate or substantially reduce the identified hazard. The facility continued to rely on verbal reminders and education for a resident assessed with severe cognitive impairment and impaired safety awareness. During an interview on 6/24/26 at 10:56 AM, the Director of Rehabilitation (DOR) stated Resident #29 used the power lift recliner almost daily and had undergone multiple therapy assessments because of ongoing safety concerns with the power lift recliner. The DOR stated R29 had consistently been determined to be unsafe in the power lift recliner and acknowledged, She is not safe to be in that chair. The DOR agreed that the continued exposure of R29 to the same known and foreseeable accident hazard that had previously resulted in falls increased the risk of future falls from the recliner with risk of injury to the resident. The policy titled Fall Response Policy and Procedure dated 9/23/21 read, in part: .the Risk Manager/Designee will review fall paperwork and ensures he/she:. Meets with the resident/staff if able and discusses the fall and root causes. Together they update interventions and changes to plan of care and Kardex to reduce the risk of repeat falls of the same nature.Within one week from the date of the fall, the Risk Manager/Designee reviews and completes the Fall Investigation Form to verify the root cause of the fall and ensure appropriate interventions are in place. Resident #89 (R89) Review of R89's EMR revealed admission to the facility on 1/16/25 with diagnosis including dementia, rheumatoid arthritis, and muscle weakness. R89's Quarterly MDS assessment dated [DATE] revealed she scored a 8/15 on the Brief Interview for Mental Status (BIMS) score, indicative of moderate cognitive impairment. On 6/23/2026 at 10:46 AM During breakfast observation, R89 was observed with a coffee cup with no lid sitting at the breakfast table. R89 was holding the cup with their left thumb and index finger and R89 was observed appearing to be falling asleep at the table. R89 then subsequently spilled coffee onto her lap and woke up. Staff assisted R89 and stated that the coffee was cold. On 6/24/2026 at 8:44 AM, R89 was observed at breakfast with a cup of coffee and no lid. On 6/24/2026 at approximately 12:10 PM, R89 was observed sitting at the table with a cup of coffee without a lid. R89's meal ticket was observed next to them, which read, 8 oz Coffee-Regular-Cream with EZ Lid. An interview was conducted with Resident Assistant/Staff N on 6/24/2026 at 12:15 PM. Staff N stated this was only her second day on the floor and did not know to provide R89 with an EZ Lid for her coffee. Staff N stated she did not read R89's ticket tray. Review of R89's Care Plan, read, in part, Offer me my adaptive equipment of EZ lids for my coffee per my preference. Date Initiated: 01/16/2026 Created on: 01/16/2026 An interview was conducted with the Director of Nursing (DON) on 6/24/2026. The DON confirmed that R89 should have a lid for her hot coffee. Review of the facility's Hot Liquid Safety Policy dated 6/5/2025 read, in part, Hot liquids are to be served at proper (safe and appetizing) temperatures using appropriate safety precautions .All residents are assessed for their ability to handle containers and consume hot liquids. Residents with difficulties will receive appropriate supervision and use of assistive devices to consume hot liquids. Interventions will be individualized and noted on the resident's plan of care and on the closet Kardex sheet .EZ Sip Lids will be kept available wherever coffee is served .

All times are noted in Eastern Daylight Time unless otherwise noted. Based on observation, interview, and record review, the facility failed to ensure respiratory equipment was stored in a clean and sanitary manner between resident use for three Residents (#20, #48, & #71) of three residents reviewed for respiratory care.Findings include:Resident #20 (R20)An observation made on 6/23/26 at 8:18 AM, of R20's room and oxygen equipment. R20's oxygen tubing was dated 6/11/26 and not stored in bag but draped over the oxygen concentrator with the nose piece exposed. R20 also had a bubbler attached to his oxygen concentrator dated 6/11/26.On 6/23/26 at 8:20 AM, an interview was conducted with Licensed Practical Nurse (LPN) L who was asked how often respiratory equipment is changed and replied, I think the tubing is changed weekly and dated. I am not sure about the bubbler/humification. LPN L was asked what the process was if the oxygen tubing is not in use and replied, If the tubing is not being used it is stored in a bag attached to the machine for infection purposes. LPN L confirmed R20's oxygen tubing was not stored properly in a bag and should have been changed last week.Review of R20's medical record on 6/23/26 at 8:25 AM, revealed a physician order dated 5/6/26 Oxygen at 2L [liters] via nasal cannula PRN [as needed] to maintain sats >90%.Resident #48 (R48)On 6/23/26 at 8:35 AM, an observation was made of R48's respiratory equipment. R48's oxygen humidification container was dated 6/11/26 and the nasal cannula was draped over their oxygen concentrator not stored in a bag.An observation made on 6/23/26 at 4:10 PM, of R48's room and oxygen equipment. The observations remained the same with a date of 6/11/26 on the oxygen tubing which was left unbagged and draped over their oxygen concentrator.Review of R48's medical record on 6/24/26 at 9:30 AM, revealed a physician order dated 5/12/25 Oxygen therapy if needed.Resident #71 (R71)On 6/23/26 at 9:14 AM, an observation was made of R71's oxygen concentrator tubing dated 6/4/26 and bubbler dated 6/11/26.An observation was made on 6/23/26 at 4:12 PM, of R71's oxygen equipment. Staff had not changed out and bubbler dated 6/11/26 or the tubing dated 6/4/26 which was draped over their oxygen concentrator.Review of R71's medical record on 6/23/26 at 9:35 AM, revealed a physician order dated 5/26/26 Obtain oxygen sat every shift: Place PRN oxygen to keep sats above 90%. 2L via nasal cannula.On 6/23/26 at 2:40 PM, an interview was conducted with the Director of Nursing (DON) regarding oxygen tubing and care of equipment. The DON indicated bubblers were supposed to be changed weekly, dated and any breathing/oxygen delivery device needed to be stored in a bag and not draped over the oxygen concentrators.Review of policy titled, Oxygen Use and Set-up, dated 4/30/25 read in part, .Purpose: Oxygen is administered to residents who need it consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences.Procedure.6. O2 tubing on concentrator.will be changed every 2 weeks and PRN. O2 humidifier bottles on the concentrator will be changed weekly and PRN.

All times are noted in Eastern Daylight Time unless otherwise noted. Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5% involving one Resident (#48) of three residents reviewed for medication administration, resulting in a medication error rate of 6%, with 2 errors out of 31 opportunities.Findings include:On 6/23/26 at 8:05 AM, an observation was made of Licensed Practical Nurse (LPN) L preparing medication pass for Resident #48 (R48) which included oral, subcutaneous (under the skin), and ophthalmic (eye) medications. LPN L was observed priming two units from the insulin pen while holding the pen horizontally. Error #1: LPN L was made aware she needs to prime the insulin pen holding it upward (vertically) and watch for insulin to expel from the end of the needle.Error #2: On 6/23/26 at 8:50 AM, an observation was made of LPN L administering R48's eye drops by placing one drop in her right eye. R48's right eye drop was observed to run down her cheek. LPN L then placed three drops in R48's left eye. R48's left eye drops were observed to run down her left cheek. LPN L took a tissue and wiped both of R48's eye. LPN L failed to hold the inner canthus (inner corner of the eye) of R48's eyes gently for one minute to promote absorption and reduce any potential systemic (elsewhere in the body) effect.Review of R48's physician orders, dated 12/24/25 read in part Lantus Solostar 100 unit/ml [milliliter] (3ml). Inject 18 units subcutaneously one time a day. and Systane Ultra Ophthalmic Solution.Install 2 drop in both eyes two times a day.An interview was conducted with LPN L on 6/23/26 at 1:30 PM and was asked how to administer eye drops and replied, You have to hold for three minutes. LPN L was made aware she should have held each eye for one minute and administer the drops inside the lower conjunctival sac (eye lid pocket).On 6/23/26 at 2:45 PM, an interview was held with the Director of Nursing (DON) who was made aware of the medication error rate and stated, Eye drops are to be held for a minute after administration of each eye and insulin pens need to be primed holding the pen upright.Review of policy titled, Medication Administration, dated 4/17/24 read in part .Purpose: To ensure that a procedure exists for the proper and safe administration of resident medications following Physician orders.Procedure: Medications will be administered per MD [medical doctor] orders. The Licensed Nurse is to read the EMAR [electronic medication administration record], follow the 7 rights of drug administration.right dose.F. Eye drops/Ointments.b.) Compare the label with the order to verify correct medication, dose, route, and time of administration.4. Position resident with head tilted back.c.) With other hand, pull down lower eyelid to form a pouch of the conjunctival sac, instructing resident to look up.g.) Instruct resident to close eyes slowly to allow for even distribution over the surface of the eye and apply gentle pressure to the tear duct for one minute or by gently closing the eye for 3 minutes.K. Insulin.8. Prime the insulin pen: a.) Dial 2 units by turning the dose selector clockwise. b.) With the needle pointing up, push on the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears.

All times are noted in Eastern Daylight Time unless otherwise noted Based on interview and record review, the facility failed to ensure that Medication Regimen Reviews (MRR) were reviewed, addressed by the Physician, and maintained in the clinical record for four Residents (#67, #36, #65, and #90) of five residents reviewed for MRR, resulting in the potential for the administration of unnecessary medications and adverse medication side effects. Findings include: Resident #67 (R67) Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed R67 was admitted to the facility on [DATE] with active diagnoses that included: dementia, anxiety disorder, depression, psychotic disorder, and diabetes mellitus. R67 scored a 7 of 15 on the Brief Interview for Mental Status (BIMS) assessment reflective of severe cognitive impairment. Review of R67's Electronic Medical Record (EMR) revealed no pharmacy reports were available for 10/21/24, 11/27/24, 12/26/24, 2/17/25, and 3/21/25. During an interview on 4/16/25 at 11:42 a.m., the Director of Nursing (DON) stated, I do not know where the pharmacy reports are . I should keep them, but I don't. The DON examined the EMR and acknowledged that she was unable to find the pharmacy reports. During an interview on 4/17/25 at 9:37 a.m., the DON acknowledged that there was no way to review what the pharmacist recommended, if the Medical Director (MD) or Nurse Practitioner (NP) agreed/disagreed with the recommendations, or if the MD or NP gave a reason for their decision. During and interview on 4/17/25 at 10:45 a.m., the Nursing Home Administrator (NHA) acknowledged there was no one at the facility ensuring the pharmacy consults were being addressed and stated, I know the system is broken and we are deficient. 41978 Resident #36 (R36) Review of the MDS assessment, dated 3/23/2025, revealed R36 was admitted to facility on 6/8/2017 and had diagnoses including dementia, diabetes, post-traumatic stress disorder (PTSD) and stroke. Review of R36's EMR revealed no pharmacy reports were available for 11/25/2024 and 12/20/2024. On 4/16/024 at 12:50 p.m., the DON reported all available pharmacy recommendations had been provided. Review of the pharmacy recommendations provided by the DON revealed no reports for R36 for the dates requested. Resident #65 (R65) Review of the MDS assessment, dated 2/2/2025, revealed R65 was admitted to the facility on [DATE] and had diagnoses including Chronic Obstructive Pulmonary Disease (COPD), anxiety, hypertension, diabetes and dementia. Review of R36's EMR revealed no pharmacy reports were available for 1/27/2025. On 4/17/2025 at 9:02 a.m., the DON reported all pharmacy recommendations had been provided. The DON was alerted to the missing recommendations for R36 and R65. Another request was made for the missing recommendations for R36 and R65. The reports were not received by the end of the survey on 4/17/2025 at 2:00 p.m. 35103 Resident #90 (R90) Review of R90's Admission Record revealed admission to the facility on [DATE], with current active diagnoses that included: fracture of the left femur, mild cognitive impairment, urinary tract infection and vitamin D deficiency. Review of R90's EMR revealed no pharmacy reports were available for 10/14/2024 and 12/26/2024. On 4/17/25 at 10:45 a.m., the DON confirmed all available pharmacy recommendations had been provided, and acknowledged no Medication Regimen Review reports were available for the above dates for R90. Review of the Medication Regimen Review policy, effective date: 9/11/24, revealed the following, in part: Medication Regimen Review (MRR) or Drug Regimen Review, is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication . D. The pharmacist shall document, either manually or electronically, that each medication regimen review has been completed. a. The pharmacist shall document either that no irregularity was identified or the nature of any identified irregularities . F. Written communications from the pharmacist shall become a permanent part of the resident's medical record .

Based on observation, interview, and record review, the facility failed to maintain a medication error rate less than 5% in four Residents (#95, #8, #70, & #23) of 12 residents reviewed for medication administration. This deficient practice resulted in a medication administration error rate of 13.33%, based on 4 medication errors in 30 opportunities for error. Findings include: Resident #95 (R95) R95 was admitted to the facility on [DATE] with diagnoses of dementia, Down Syndrome, hypokalemia (low potassium level), and others. R95 had a physician's order dated 4/15/25 to administer three 10 mEq (milliequivalent) Potassium Chloride ER (extended release) capsules. The order contained the instruction: Do not crush. On 4/16/25 at 12:50 PM, Registered Nurse (RN) K was observed preparing and administering medications on the 800-unit, Lilac Lane. When preparing medications for R95, RN K opened the capsules of potassium and crushed the content of the capsules before placing the crushed content in pudding. RN K was asked why the potassium medication for R95 was crushed. RN K said she was a charge nurse and did not usually administer medications, so she had another nurse prepare a list of residents who required medication to be crushed. RN K produced a sheet of paper listing residents' names. Next to R95's name was written crush. R95's physician's orders and care plan were reviewed on 4/16/25. R95 did not have a physician's order to crush medications. The care plan did not indicate medications were to be crushed. Resident #8 (R8) R8 was admitted to the facility on [DATE] with diagnoses including but not limited to hypokalemia. R8 had a physician's order dated 1/21/25 to administer two 10 mEq capsules of potassium chloride ER three times a day related to hypokalemia. The order instructions included: Do not crush. During medication administration on 4/16/25 at 12:50 PM, RN K opened the potassium ER capsules and crushed the content before placing the content in applesauce to administer to R8. After administering the medication in applesauce, RN K assisted R8 to take a sip of water from a cup. R8's physician's orders and care plan were reviewed on 4/16/25. R8 did not have a physician's order to crush medications. The care plan did not indicate medications were to be crushed. Resident #70 (R70) R70 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease and hypokalemia. R70 had a physician's order dated 1/21/25 to administer two potassium chloride 10 mEq capsules three times per day for hypokalemia. During medication administration to R70 in their room on 4/16/25 at 1:31 PM, LPN L placed one capsule of potassium chloride in R70's mouth. The potassium chloride capsules were blue in color. R70 began chewing the capsule. R70 chewed the potassium capsule continuously until their mouth and lips turned blue from the blue capsules. LPN L attempted to give R70 the second capsule while R70 was still chewing the first capsule. R70 shook her head no. LPN L exited the room and returned to the medication cart outside the room. LPN L labeled the medication cup with R70's name and placed it in the top drawer of the medication cart atop the cup containing R93's baclofen. LPN L was told R70 was still chewing the first potassium capsule. LPN L re-entered R70's room and stayed until R70 was finally able to swallow the capsule. LPN L did not offer water to R70 after the capsule was swallowed. Nurse progress notes and medication notes were reviewed on 4/17/25 at 9:04 AM. LPN L did not document the difficulty R70 had with swallowing the potassium capsules, nor was there any documentation indicating R70's physician was notified the resident did not receive the prescribed dose of medication or requesting to change the medication to liquid form. Resident #23 (R23) R23 was admitted to the facility on [DATE] with diagnoses that included constipation. R23 had a physician's order dated 1/21/25 for Senna (laxative) Oral Syrup one teaspoon (tsp) twice daily for constipation. During medication administration on 4/17/25 at 7:50 AM, LPN M removed the bottle of senna from the medication cart before removing the cap from the bottle and pouring one tsp of medication from the bottle into a medication cup. LPN M did not shake the bottle of medication prior to pouring it into the medication cup to ensure the medication was dispersed throughout the liquid for uniform distribution of the active ingredient. LPN M crushed R23's other medications and placed all medications, including the unshaken liquid senna into a cup of coffee. LPN M provided R23 the cup of coffee containing the medications. R23's physician's orders and care plan were reviewed on 4/16/25. R23 did not have a physician's order to crush medications or to administer medications in coffee. The care plan did not indicate medications were to be crushed or placed in coffee. The Director of Nursing (DON) was interviewed on 4/17/25 at 11:31 AM. The DON said the beads in potassium capsules should not be crushed. The DON said physicians' orders are required to crush, open or modify medication forms of delivery. When asked the expectation for disposition of medication if a nurse prepares a medication and a resident either refuses or is not available to administer medications, the DON said the medications were expected to be destroyed in a drug buster solution. The DON confirmed medication cups containing medications should not be labeled and stored in medication carts. The DON said nurses should be washing their hands during medication administration between residents. The DON said medications that fall on the medication cart during preparation should be disposed of in drug buster solution. The DON confirmed liquid medication should be shaken prior to pouring the medication. The DON conveyed the expectation of physician notification if a resident does not take medications as prescribed. According to the United States Food and Drug Administration (FDA), the prescribing information for potassium chloride extended-release capsules include the following, in part: . Administration and Monitoring . Take with meals and with a full glass of water or other liquid . should be swallowed immediately without chewing and followed with a glass of water or juice to ensure complete swallowing of the microcapsules . (www.accessdata.fda.gov/drugsatfda_docs/label/2018/018238s046lbl.pdf). The facility policy titled Medication Administration dated as effective 10/7/21 documented, in part: .Medications will be administered per MD orders . Perform hand hygiene prior to administering medication . Shake well to mix suspensions. 17. Crush medications as ordered. Do not crush medications with do not crush instructions. 18. Observe resident consumption of medication. 19. Perform hand hygiene after medication administration . If resident refuses medications, document in EHR (Electronic Health Record) and notify Charge Nurse. If medication has been prepared and it is then refused, destroy in Drug Buster . 24. Report and document any adverse side effects or refusals . Crushed medications require a Physician order to crush, and this must also be added to that specific medication on the EMAR [Electronic Medication Administration Record] .

Based on observation, interview and record review, the facility failed to ensure hand hygiene was performed during fresh water pass and catheter care, for 7 Residents (R11, R32, R33, R38, R50, R52 and R55), out of 22 sample residents reviewed for hand hygiene. This deficient practice resulted in the potential for cross-contamination of infectious organisms between residents in the facility. All times noted are Eastern Daylight Savings Time (EDST) unless otherwise noted. Findings include: During an observation of fresh water pass on 4/15/25 at 2:08 p.m. , Certified Nurse Aide (CNA) A was observed delivering fresh water mugs and removing the previously used water mugs from resident rooms. CNA A delivered fresh water and removed previously used water mugs from R11's, R32's, R33's, R52's, R50's, and R38's rooms, without the performance of hand hygiene between rooms. During an interview on 4/15/25 at approximately 2:30 p.m., when asked if they had performed hand hygiene between rooms while passing fresh water and removing used water mugs from resident rooms, CNA A stated, No, I did not do any hand hygiene between the rooms. I should probably grab hand sanitizer for my pocket. We have one (hand sanitizer bottle) at the nurses' station. CNA A acknowledged understanding of the importance of hand hygiene between touching each residents clean and dirty water mugs. R55 During R55's catheter care observation on 4/16/25 at 2:04 p.m., CNA O and CNA C both donned Enhanced Barrier Precautions (EBP) which included gloves. CNA O performed the care, while CNA O was assist with positioning of R55. CNA O used a clean, wet cloth to cleanse R55's catheter tubing and genitals. CNA O realized a clean incontinence brief was required and left R55's bedside with the dirty gloves used to cleanse R55's genitals still on their hands. CNA O opened the Resident's closet doors by grabbing the handles with their contaminated gloves, retrieved a clean incontinence brief, and closed the closet door. R55's brief was changed with CNA O still wearing the contaminated gloves. CNA O and CNA C both assisted R55 with his clothing and application of protective boots to both feet. CNA O remained in contaminated gloves touching clothing, the protective boots and environmental surfaces. During an interview on 4/16/25 at 2:17 p.m., CNA O was asked to explain the purpose of Enhanced Barrier Precautions. CNA O stated, It is to protect him from UTIs (urinary tract infections). CNA O agreed they did touch the cabinet handles, protective booties and resident clothing with their dirty gloves and acknowledged they should have performed hand hygiene and donned clean gloves after cleaning R55's genitals and catheter tubing. During an interview on 4/16/25 at 2:20 p.m., Registered Nurse (RN) B was asked when hand hygiene and donning of clean gloves should be performed during catheter care. RN B said gloves should be removed when dirty and hand hygiene performed before touching other environmental surfaces. RN B acknowledged the risk for cross-contamination between residents and staff when environmental surfaces were contaminated by the CNA O's dirty gloves. Review of the Hand Hygiene policy, effective date 2025, revealed the following, in part: . All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility . The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves . During an interview on 4/17/25 at 11:00 p.m., the above observations were discussed with the Director of Nursing (DON). The DON expressed understanding of the deficiency concern related to the failure to perform hand hygiene and the potential for cross-contamination of infectious organisms within the facility.

All times recorded in Eastern Daylight Time (EDT), unless otherwise noted. Based on observation, interview and record review, the facility failed to 1. Ensure oxygen was administered per physician order and; 2. Ensure maintenance of oxygen and nebulizer equipment in a sanitary manner, for one Resident (#65) of one resident reviewed for oxygen administration. Findings include: Resident #65 (R65) Review of the Minimum Data Set (MDS) assessment, dated 2/2/2025, revealed R65 was admitted to the facility on [DATE] and had diagnoses including Chronic Obstructive Pulmonary Disease (COPD), anxiety and dementia. Further review of the MDS revealed R65 scored 10 out of 15 on the Brief Interview for mental Status (BIMS), indicating the Resident had moderate cognitive impairment. On 4/15/2025 at 2:38 p.m., R65 was observed sleeping in bed and was receiving supplemental oxygen via nasal cannula from a portable oxygen concentrator with a flow rate of three liters per minute (3 L/min). A tag attached to the oxygen tubing was dated 3/13/2025. On 4/16/25 at 1:15 p.m., R65 was observed sleeping in bed and was receiving supplemental oxygen via nasal cannula from a portable oxygen concentrator with a flow rate of 3 L/min. The tag attached to the oxygen tubing remained dated 3/13/2025. Review of R65's Electronic Medical Record (EMR) revealed an active physician order, dated 9/4/2025 at 11:30 a.m. [Central Savings Time] for O2 [oxygen] @ [at] 2 LITERS [per minute] AS NEEDED - Does not want humidified water. Review of R65's EMR, including progress notes, assessments, and the April 2025 Medication and Treatment Administration Records (MAR's and TAR's) revealed no indication for the increased rate of oxygen administration observed above in the physician's order section. The most recent oxygen order was dated 9/4/2024 and directed staff to provide a flow rate of 2 L/min as needed. Review of R65's most recent vital signs, dated 4/15/2025 at 8:53 a.m. (Central Daylight Time), revealed R65 was assessed as having an oxygen saturation level of 97% on room air. R65's April 2025 MAR and TAR revealed no documentation indicating R65 was receiving supplemental oxygen. During an interview on 4/17/2025 at 9:05 a.m., the Director of Nursing (DON) reported oxygen was to be administered per physician order and if a greater need is identified, nursing staff should conduct and document an assessment indicating the change in condition requiring administration of a higher rate of oxygen than what was ordered. The DON reported staff should also notify the physician and document the notification, along with any new orders, in the EMR. On 4/17/2025 at 9:20 a.m., R65 was observed lying in bed, awake, receiving supplemental oxygen via nasal cannula from a portable oxygen concentrator set to deliver 3 L/min. The tubing was again observed to be dated 3/13/2025. Further observation revealed a nebulizer atop R65's nightstand with tubing attached leading from the machine with the medication chamber and mouthpiece lying directly on the nightstand without a protective barrier between the equipment and the top of the nightstand. It was noted during the observation an illegible date was written in black marker on the side of the medication chamber. At the time of the observation R65 reported she was feeling shorter of breath lately and was unaware of what concentration of oxygen she was receiving from the concentrator. R65 reported her most recent nebulizer treatment was administered the previous day, on 4/16/2025. During an interview on 4/17/2025 at 9:25 a.m., Licensed Practical Nurse (LPN) G stated, if a resident required an increase in supplemental oxygen above what was ordered, nursing should document the change in condition in a progress note and notify the physician to report changes and obtain a new order for the higher rate. LPN G reviewed R65's EMR and stated the active order was for supplemental oxygen at 2 L/min as needed. LPN G reported he could not find an assessment documented in the EMR warranting the increase of R65's supplemental oxygen from 2 L/min to 3 L/min. During an observation of R65 immediately following the interview, LPN G confirmed R65 was being administered oxygen at 3 L/min and stated, I have no idea why. LPN G was asked about the date on the oxygen tubing. LPN G confirmed the tubing dated 3/13/25 was out of date and reported facility protocol was to change the tubing weekly. LPN G was alerted to the nebulizer tubing with medicine chamber and mouthpiece portions resting directly on the top of the nightstand. LPN G detached the tubing and reported the equipment should have been cleaned and stored in a plastic bag. During an interview on 4/17/2025 at 11:15 a.m., facility Infection Preventionist (IP) I reported the facility protocol was for oxygen tubing to be replaced and appropriately dated every two weeks. IP I was queried about the maintenance of nebulizer equipment and reported nursing staff were responsible to ensure appropriate care and storage of the administration sets. IP I reported the tubing, medication chamber and mouthpiece should be disassembled after each use, cleansed and dried, then stored in a plastic bag. IP I provided the facility policy at the time of the interview. Review of the facility policy titled, Cleaning & Disinfecting Nebulizers, effective date 2025, revealed the following: After each aerosol treatment, remove the cup. Mask or mouthpiece and wash with warm water and mild dish detergent. Thoroughly rinse the parts to remove all soap and residue. Allow the parts to air dry on a clean surface using a paper/cloth barrier between them. Review of the facility policy, titled, Oxygen Use and Set-Up, provided by the DON with an effective date of 3/18/2020, revealed the following: The physician standing order for oxygen is only for emergency purposes for 24 hours. If oxygen is started, notify the physician and obtain an order for oxygen to include liter flow/min, frequency of oxygen an oxygen saturation checks and conserving devices if used. O2 tubing on concentrator and companions on wheelchairs will be changed every 2 weeks and prn [as needed] . The nurse is responsible for beginning oxygen therapy per MD [physician] orders: turning on O2 companions, setting flow rate, checking to ensure there is proper flow from the nasal cannula and checking oxygen saturations each shift for any resident receiving oxygen therapy.

Based on interview and record review, the facility failed to prevent duplicate drug therapy of Vitamin D for one Resident (#90) of five residents reviewed for unnecessary medications. This deficient practiced resulted in an excessive dose of D3 and the potential for Vitamin D toxicity. All times noted are Eastern Daylight Savings Times (EDST) unless otherwise noted. Findings include: Resident #90 (R90) Review of R90's Admission Record revealed admission to the facility on [DATE], with current active diagnoses that included: fracture of the left femur, mild cognitive impairment, urinary tract infection and vitamin D deficiency. Review of available Medication Regimen Review (MRR) reports for R90 revealed the following, in part: 1. Consultation Report Date 5/30/24, Comment: [R90] receives ergocalciferol (vitamin D2) 50,000 units weekly on Thursdays. vitamin D3 is more efficiently absorbed and utilized by the body and may be better at increasing and maintaining vitamin D in the body. Recommendation: Please consider changing from ergocalciferol (vitamin D2) to vitamin D3 50,000 units weekly on Thursdays . Physician Response: I accept the recommendation(s) above, please implement as written. Signed by R90's Physician on 6/3/24. 2. Consultation Report Date 6/28/24. Comment: [R90's] prescriber accepted a pharmacy recommendation to change vitamin D2 to vitamin D3 on 6/3/24. This medication change occurred however the vitamin D2 did not get discontinued. Recommendation: Please discontinue vitamin D2 per pharmacy recommendation. Review of R90's June 2024 Medication Administration Record (MAR) revealed ergocalciferol (vitamin D2) 1.25 MG (milligrams) (50,000 units) continued to be administered on 6/6, 6/13, 6/20, and 6/27/24 per a physician order with a Start Date of 4/4/24, and a discontinue date of 7/3/24. An additional physician order for Cholecalciferol (vitamin D3) (50,000 units), with a Start Date of 6/5/24, was administered to R90 on 6/5, 6/12, 6/19, and 6/26/24 resulting in duplicative administration of vitamin D weekly (100,000 units total) to R90 during the month of June 2024. During an interview on 4/17/25 at 10:56 a.m., the Director of Nursing (DON) and Assistant Director of Nursing (ADON ) N were asked about R90's May and June pharmacy Consultation Reports. The DON and ADON N reviewed R90's physician orders, pharmacy recommendations and MAR documentation. Both confirmed R90 received duplicative administration of vitamin D throughout June 2024. The DON acknowledged she was unaware this duplication had occurred. The DON stated, The audit side of this (medication regimen review) is what I was not seeing because of the (different) electronic process. There is a process for double-checking (physician orders) but I believe this was just missed. Review of the Medication Regimen Review policy, effective date 9/11/24, revealed the following, in part: Medication Regimen Review (MRR) or Drug Regimen Review, is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes: I. Review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities .

Based on interview and record review, the facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) committee met at least quarterly with the required committee members. This deficient practice placed all 115 residents in the facility at risk for quality care concerns. Findings include: (All times are recorded in Eastern Daylight Time unless otherwise noted.) During an interview on 4/24/24 at 1:34 PM, the Risk Manager, Registered Nurse (RN) G reviewed the QAPI policy, the attendance documentation for the QAPI meetings and identified the people and positions who were in attendance. The QAPI meeting sign in sheets revealed: 6/28/23: The Director of Nursing (DON), Nursing Home Administrator (NHA), Medical Director, Infection Preventionist (IP), and more than two others were present. 9/27/23: The DON, NHA, IP and more than two others were present. The Medical Director or designee was not present. 11/29/23: The DON, IP and more than two others were present. The Medical Director and NHA were not present. 1/16/24: The DON, NHA, IP and more than two others were present. The Medical Director was not present. 2/28/24: The NHA and more than two others were present. The Medical Director, DON, and IP were not present. 4/12/24: The NHA, Medical Director, IP and more than two others were present. The DON was not present. The facility 2024 Quality Assurance & Performance Improvement (QAPI) PLAN dated as Updated on 4/19/24 read in part: The QAPI Committee provides the backbone for QAPI. The core members are the Medical Director or his/her designee, the DON, the Infection Preventionist, the Administrator, owner, or board member and department leaders .

This citation pertains to intakes MI00140019 and MI00140881. Based on interview and record review, the facility failed to prevent misappropriation of narcotic medication for one Resident (R266) of two residents reviewed for misappropriation. Findings include: All time recorded in Eastern Daylight Time (EDT) unless otherwise noted. R266 was admitted to the facility on [DATE] with diagnoses including unspecified fracture of T7-T8 vertebra (spinal fracture) and ankylosing spondylitis of the thoracic region (inflammatory arthritis affecting the spine). Review of R266's Minimum Data Set (MDS) assessment, dated 10/2/2023, revealed R266 was cognitively intact. Review of R266's Controlled Substance Proof of Use Record, revealed the following: Hydrocodone-Acet [acetaminophen] 5MG [milligram] - 325MG give 1 Tablet By Mouth Every 4-6 Hours As Needed. Amount Received: 30. Date Received: 9/26/23. Further review of the Record revealed the following doses of the medication were signed out by Registered Nurse (RN) H as administered to R266: 9/28/2023 at 2130 (9:30 p.m.), one tablet. Review of R266's September 2023 Medication Administration Record (MAR) revealed the hydrocodone-acetaminophen 5mg-325mg was not signed as administered to R266 by RN H on 9/28/2023 at 9:30 p.m. Review of the [RN H] Drug Diversion Investigation, signed by the Director of Nursing (DON), Assistant Director of Nursing (ADON) and the Nursing Home Administrator (NHA), dated 10/6/2023, revealed the following, in part: On 09/28/2023: At 2130 [9:30 p.m.], [RN H] Trillium Neighborhood nurse, signed out a PRN [as needed] Norco [hydrocodone-acetaminophen] 5/325 tablet for [R266] in the narcotic sign out log. At 2347 [11:47 p.m.] DON received a phone call from [Licensed Practical Nurse (LPN) J] stating that [R266] was requesting a PRN Norco for his back pain at 2230 [10:30 p.m.] and when the neighborhood nurse [LPN I] went to sign it out it was noted that [RN H] had signed one out at 2130 [9:30 p.m.] in the narcotic sign out log but not in the EMAR . [R266] was adamant that he had not received a PRN Norco at 2130 . [R266] was able to tell [LPN J] the time he received his Norco's for that day, and this was noted to be accurate within 10 minutes per the EMAR. [R266] stated that something was wrong, and he was upset about this . Further review of [RN H] Drug Diversion Investigation, revealed the following, in part: On 9/29/2023: At 0830 [8:30 a.m.] the personnel record for [RN H] was reviewed . She was given a discipline on 2/10/2023 for careless documentation. This was in relation to administering a controlled substance to a resident and signing it out in the EMAR [electronic Medication Administration Record] but not on the narcotic sign out log . At 0900 [9:00 a.m.] [RN H] was called . notified she needed to come to the facility for interview . [RN H] was asked about the discrepancy . she stated she did give it to him sometime after 9pm [sic] . she stated he was asleep and she had to wake him up . [RN 'H] was told going out to her vehicle during her shift without permission as well as her history of increased PRN administration versus other nurses is suspicious behavior. It was interated [sic] to her that the issue of her increased PRN administration has been discussed with her in the past as well . [RN H] was told she would need to drug test . When asked by [ADON] if she has ingested anything that could come up on this drug test that we need to know about before . [RN H] stated, I am not going to get drug tested . I am not going to do it. [NHA] informed [RN H] that this would then be immediate termination. She stated understanding . During an interview on 4/24/2024 at 3:15 p.m., the DON reported RN H was terminated due to refusal to submit to drug testing and refusal to submit to testing was treated as a positive test result per facility policy. The DON confirmed RN H, prior to the current incident involving R266, was written up for inconsistent documentation due to signing out narcotic medications on the proof of use log but not documenting the administration of the medication in the MAR. The DON reported this as the previous incident involving RN H referred to in the [RN H] Drug Diversion Investigation, document. The DON stated RN H was re-educated after the first incident, but no change in policy occurred as a result of the incident at that time. During an interview on 4/24/2024 at 3:30 p.m., the NHA confirmed RN H was terminated due to failure to submit to drug testing after the discrepancy in R266's record was identified. The NHA stated refusing the drug test was considered a positive test result according to facility policy. An attempt to reach RN H by telephone was conducted on 2/24/2024 at 3:34 p.m., no connection could be made. A review of the facility policy titled Medication Administration, effective 10/7/2021, revealed the following, in part: Sign MAR after administered . A review of the facility policy titled Drug and Alcohol Abuse Policy, last revised 10/16/2021, revealed the following, in part: Refusal to submit (to an alcohol or drugs/controlled substance test) means that an employee: 1. Fails to provide adequate sample without a valid medical explanation after he or she has received notice of the requirement for the urine, breathe or blood sample. 2. Engages in conduct that clearly obstructs the testing process . An employees' refusal to submit to a required alcohol or drugs/controlled substances test will be treated as a positive test . During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included:1. Immediate termination of RN H from employment and notification of the appropriate licensing board and law enforcement; 2. Immediate audit of all Controlled Substance Proof of Use Log(s), in reconciliation with resident MARs for residents residing in the Trillium Neighborhood; 3. Psychosocial and pain assessments for all Trillium residents prescribed control substance medications, including R266; 4. Revision to the Medication Administration policy to include the requirement of verification by two licensed nurses for the administration of as needed controlled substance medications; 5. Licensed clinical staff education on the Code of Conduct, Drug and Alcohol Abuse Policy, and the updated Medication Administration policy, completed on 10/11/2024; 6. Formation of the Drug Diversion Committee, charged with auditing procedural compliance with audits showing compliance as of 4/16/2024. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on interview and record review, the facility failed to report injuries of unknown source to the state agency for two Residents (R87 and R34) of two residents reviewed for abuse. Findings include: All times are recorded in Eastern Daylight Time unless otherwise noted. Resident #87 (R87) was admitted to the facility with a primary diagnosis of Alzheimer's Disease. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of two of fifteen, indicating R87 was severely cognitively impaired. The MDS documented R87 as having impaired range-of-motion in both upper extremities and both lower extremities. The MDS assessed R87 as being dependent on staff for all Activities of Daily Living (ADL) including mobility and transfers. The MDS indicated R87 was unable to stand or walk. R87 required a mechanical lift to transfer with the assistance of 2 staff. R87's care plan documented the use of a specialized wheelchair for mobility. The care plan indicated R87 was dependent on staff to propel the wheelchair. On 3/3/24 at approximately 4:55 p.m., staff found R87 lying on the floor in the sitting area at the end of the 700-unit. R87 was lying in the corner of the room with facial injury and bleeding. R87 was sent to the hospital emergency department where a CT scan was obtained and revealed facial fractures. The CT read in part: . Acute minimally displaced/depressed fracture of the anterior wall of the left maxillary sinus (cheek area) with a small amount of hemorrhage layering within the sinus, and an acute nondisplaced orbital floor fracture on the left involving the infraorbital canal (eye socket). The Director of Nursing (DON) was interviewed on 4/23/24 at 3:43 p.m. The DON provided a written investigation dated 3/5/24. The written investigation consisted of interviews with staff assigned to the 700-unit on 3/3/24. The DON admitted the new cameras were not yet installed on 3/3/24 so she could not validate the employees' statements. The DON produced a form 'In-depth Case Review For: Resident Falls as an incident report. The form documented in part: doesn't know what happened. Unable to tell what happened. walked into living room saw her on the floor on her left side went to check her blood on floor& her eye [sic]. The DON said the event was not reported to the state agency. Registered Nurse (RN) C was interviewed on 4/23/24 at 3:15 p.m. RN C confirmed she was the staff member who found R87 on the floor in the sitting room on 3/3/24. RN C said she entered the sitting room just prior to dinner and observed R87 lying on the floor repeatedly saying, Help me, help me. RN C stated R87's wheelchair was toward the center of the room and the resident was in the corner of the room approximately 10-12 feet from the wheelchair. RN C said R87 could not explain how the injury was sustained due to confusion and dementia. Certified Nursing Assistant (CNA) F was interviewed on 4/23/24 at 3:29 p.m. CNA F said he saw R87 approximately 20 minutes before the resident was found on the floor. CNA F said on 3/3/24 he saw R87 in her wheelchair in the sitting room at the end of the 700-unit hall pushing on the exit door. CNA F said he moved R87's wheelchair away from the exit door to the middle of the sitting room. CNA F said R87 asked for water, and he left the sitting room to obtain water for R87. CNA F said he got busy passing another resident's meal tray before he could deliver water to R87. CNA F said he heard RN C calling out R87 was on the floor before he could obtain the water and return to R87. The Nursing Home Administrator (NHA) was interviewed on 4/24/24 at 8:22 a.m. The NHA was asked if R87's event on 3/3/24 was reported to the state agency. The NHA confirmed it was not reported because the investigation results ruled out abuse. (*Note: Facility was not able to immediately rule out abuse) 49735 Resident #34 (R34) Review of R34's Minimum Data Set (MDS) comprehensive assessment, dated 7/17/23, revealed admission to the facility on [DATE] with a primary diagnosis of Alzheimer's Disease. R34 scored 3 of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The MDS revealed R34 required substantial to maximum assistance with transferring from the bed to a chair. R34's care plan documented, I have short term memory impairment and confusion . According to a Facility incident report, staff found R34 on the floor of her room on 11/29/24 at 1:30 a.m. R34 was sent to the hospital for x-rays and a CT scan and returned to the facility. R34 continued to experience pain and was sent back to the hospital on 12/1/24. Additional testing revealed a left inferior pelvic fracture, an anterior pelvic fracture, and a patella (kneecap) fracture. During an interview on 4/24/24 at 3:22p.m., the Director of Nursing (DON) did not explain the reason a report was not made to the state agency regarding a resident with severe cognitive impairment who sustained multiple fractures and had been hospitalized . The source of the injury was unwitnessed and R34 could not explain how the injury was sustained due to severe cognitive impairment, short term memory loss, and confusion. Review of facility policy Incident Reporting Procedure 2.d. Major/Adverse Event with an effective date of January 25, 2021, read in part: Major/Adverse event: an incident that reached the resident and caused significant or permanent harm. These incidents are to be reported to the Administrator, and to the State Health Department. i. Any incident requiring hospitalization .

Based on Interview and record review the facility failed to conduct a thorough and complete investigation for an incident for one Resident (#34) of four residents reviewed for incidents. This deficient practice could result in adverse outcomes and unmet care needs. Findings include: (All times are recorded in Eastern Daylight Time unless otherwise noted.) Resident #34 (R34) Review of R34's Minimum Data Set (MDS) comprehensive assessment, dated 7/17/23, revealed admission to the facility on [DATE], with active diagnoses that included: Alzheimer's disease, anxiety disorder, major depressive disorder, type 2 diabetes, chronic pain, congestive heart failure, and primary hypertension. R34 scored 3 of 15 on the Brief Interview for Mental Status (BIMS) reflective of severe cognitive impairment. The MDS reveals that R34 requires substantial to maximum assistance to transfer. Review of facility incident report titled In-depth Case Review dated 1/29/23 revealed R34 had a incident on 11/29/23 at 1:30. R34 was found on the floor next to her wheelchair complaining of left pelvic pain. Incident report revealed CNA was doing rounds and heard R34 moaning on the floor next to the wheelchair. R34 was sent to the hospital for xrays and a CT scan. Results from the hospital revealed a left inferior pelvic fracture, an anterior pelvic fracture, and a patella (kneecap) fracture. During an interview on 4/24/24 at 3:22p.m., the Director of Nursing (DON) acknowledged R34 had an incident and the investigation into the incident was not completed. Review of facility Incident Report Procedure: Incident Investigation 10.b, read in part investigations should be started within 2 working days . investigations and actions should be completed by fourteen days for all incidents.

Based on observation, interview, and record review, the facility failed to assess and monitor pressure injuries to promote the healing of a facility-acquired pressure injury for One Resident (R109) of six residents reviewed for pressure injuries. Findings include: All times are recorded in Eastern Daylight Time unless otherwise noted. Resident #109 (R109) was admitted to the facility on [DATE]. A Minimum Data Set (MDS) Assessment completed on 12/20/24 documented R109 had no pressure injuries at the time of the assessment. During an interview on 4/23/24 at 9:23 a.m., R109 stated, They told me I have a sore on my bottom from laying on my back. R109 said he did not know how long the wound had been there. When asked if nurses had been assessing and treating the area, R109 said the nurses did not look at it, but instructed him to refrain from lying on his back. A form 'Acute & Chronic Wound Assessment V2' was reviewed. The form documented R109 had a facility-acquired left gluteal pressure injury identified on 3/7/24. The form included wound measurements but did not include the stage of the pressure injury. There were no additional 'Acute & Chronic Wound Assessment V2' forms in the medical record. There were no further assessments or documentation regarding the pressure injury on R109's gluteal area. A form 'Skin & Wound Evaluation V7.0' dated 3/18/24 assessed a facility-acquired pressure injury staged as Deep Tissue Injury (DTI: persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue) to R109's left heel. In the area labeled exact date of identification, the date 3/12/24 was entered, six days prior to the assessment being completed on 3/18/24. No additional assessments or documentation of the pressure injury to the left heel were in R109's record. A nurse's progress note dated 4/3/24 at 3:46 p.m. read in part: . had a stage 1 (pressure injury) on his coccyx which has healed and a DTI (Deep Tissue Injury) on left heel which as of this note [sic] has healed . There were no assessments of a coccygeal pressure injury in R109's medical record. Registered Nurse (RN) C was interviewed on 4/23/24 at 9:27 a.m. RN C was asked if R109 had pressure injuries. RN C replied R109 had pressure injury to his sacral area. On 4/24/24 at 8:06 a.m., The Director of Nursing (DON) was asked if R109 had pressure injuries. The DON said she did not know and accessed R109's electronic medical record. She announced R109 had an assessment completed on 3/18/24 for a pressure injury on R109's left heel. When asked if the pressure injury was still present, the DON said she did not know. The DON reviewed R109's medical record and said she could not locate additional information in the health record regarding the pressure injury on R109's left heel. The DON said there were no additional areas of skin impairment documented. When the DON was asked the status of the pressure injury to the left gluteal area identified on 3/7/24, the DON said she would have to get an updated log of pressure injuries. The DON reviewed R109's medical record and said there was no additional documentation of a wound on R109's left gluteus, and there were no measurements or assessments documented regarding the presence of a gluteal wound. When asked regarding assessment and monitoring of the pressure injury on R109's coccyx, the DON said she was not aware R109 ever had a wound on his coccyx. The DON was asked if R109's physician was aware of R109's pressure injuries and if the physician had assessed and documented on the pressure injuries. The DON reviewed R109's medical record and said there was no physician documentation on the pressure injuries. Skin assessment documentation for the previous two months and documentation of weekly assessments for pressure injuries were requested but not provided by the end of the survey. The DON was asked regarding assessment, monitoring, documentation, and dates of resolution for R109's wounds on the left heel, coccyx, left buttock, and sacrum. The DON confirmed most of the requested information was not in R109's medical record and provided a form '(name of facility) - Pressure Injury Tracking Form' and said it was the updated pressure injury log. R109 was not listed on the log. On 4/24/24 at 9:45 a.m., a skin assessment for R109 was observed being completed by Licensed Practical Nurse (LPN) D with the assistance of Certified Nursing Assistant (CNA) E. The skin assessment revealed a stage II pressure injury (Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) on R109's sacrum measuring 0.5 cm x 0.25 cm x 0.1 cm. LPN D was asked when the pressure injury on R109's sacrum was identified. LPN D stated, I don't know for sure, but he's had it a while. CNA E was asked when R109 developed the pressure injury on the sacrum. CNA E said the wound was identified more than a week prior to 4/24/24 but she could not specifically recall the date it was first observed. When asked if the Treatment/Wound nurse or DON were aware of the pressure injury, CNA E said she was pretty sure the Wound Nurse was aware, and added, She hasn't seen it yet, but I'll ask her to take a look at it today. CNA documentation for R109 from 3/27/24 through 4/24/24 was reviewed and revealed no documentation of open areas or areas of skin impairment. Nurses' progress note documentation did not reveal assessments, monitoring, or treatment to R109's sacral wound. R109's physician orders were reviewed. There were no orders for treatment or activated standing orders for treatment to R109's sacrum. The policy 'Standing orders for Pressure Injuries' dated 4/25/22 read in part: .a. If an area of redness or open areas is [sic] identified, measures [sic] the wound, and complete the appropriate charting. The policy 'Pressure Injury Risk Assessment and Risk Reduction' dated 2/24/22 read in part: . Residents determined to be at an increased risk for pressure injuries will have weekly skin assessments completed by Licensed Nursing Staff and documented in electronic medical record [sic]. These residents will also have skin audits completed by Nursing Assistants with baths/showers and daily cares. Interventions will be implemented in accordance with MD orders.

Based on interview and record review the facility failed to report Payroll Based Journal (PBJ) information to CMS (Centers for Medicare and Medicaid). This deficient practice resulted in inaccurate reporting of staffing levels with the potential to affect all 115 residents. Findings include: (All times are recorded in Eastern Daylight Time unless otherwise noted.) Review of the CMS PBJ Staffing Data Report FY (fiscal year) Quarter 1 2024 (October 1- December 31) revealed the metric No RN hours and Failed to have Licensed Nursing Coverage 24 hours/day Triggered with Infraction dates being: No RN hours on- 10/8, 10/14, 10/15, 10/21, 10/22, 10/28, 10/29, 11/4, 11/5, 11/11, 11/12, 11/18, 11/19, 11/25, 11/26, 12/2, 12/3, 12/9, 12/10, 12/16, 12/17, 12/23, 12/24, 12/30, and 12/31. Failed to have licensed nursing coverage 24 hours/day-10/14, 10/15, 10/21, 10/22, 10/28, 10/29, 11/4, 11/5, 11/11, 11/12, 11/18, 11/19, 11/25, 11/26, 12/2, 12/3, 12/9, 12/10, 12/16, 12/17, 12/23, 12/24, 12/30, and 12/31. An interview was conducted on 4/24/24 at approximately 11:55a.m., with Registered Nurse (RN) C. When ask if RN C was responsible for PBJ data submission, RN C acknowledged she was responsible and indicated the facility missed the deadline for submitting the PBJ information to CMS.

Based on observation, interview, and record review, the facility failed to label multi-dose, insulin medications and ophthalmic (eye) medications according to pharmacy recommendations and professional standards of practice and ensure proper storage of medications in three of three medication carts reviewed for medication storage. This deficient practice resulted in the potential for administration of expired medications and decreased therapeutic effects of administered medications. Findings include: All times are recorded in Eastern Standard Time. On 4/19/23 and 3:20 PM, the Lilac Lane of 700 hall medication cart was observed with Licensed Practical Nurse (LPN) C, the following discrepancies were noted: a. Two multi-dose bottles of ophthalmic latanoprost medication eye drops, were opened and undated. b. Three multi-dose insulin glargine pens, two were dated as opened on 4/5/23 and had an expiration dated for 7/5/23, a third was dated as opened on 4/12/23 and had an expiration dated for 7/12/23. c. One loose white, round pill identified as carbamazepine 100 mg tablet was found in the bottom of the second medication cart drawer. d. One multi-dose bottle of artificial tear ophthalmic lubricant drops was dated as opened on 1/19/23 and had no expiration date recorded. e. One multi-dose bottle of ophthalmic drops of loteprednol etabonate medication was dated as opened on 1/19/23 and had no expiration date recorded. f. One multi-dose bottle of ophthalmic drops of prednisone acetate medication was dated as opened on 3/3/23 and had an expiration date of 6/2025. These discrepancies were brought to the attention of LPN C, who confirmed that they were opened, and the multi-dose medications were not properly dated. LPN C replied, There is an orange sign hanging on the cupboard in the nurses' station that says; all insulins 28 days. On 4/20/23 and 8:30 AM, the [NAME] West of 500 hall medication cart on the right [East] was observed with Registered Nurse (RN) G, the following discrepancy was noted: One multi-dose insulin aspart pen was dated as opened 4/20/23 and had an expiration dated for 6/4/23. On 4/20/23 and 8:40 AM, the [NAME] West of 500 hall medication cart on the right [West] was observed with RN G, the following discrepancies were noted: a. One loose white, round, half tab pill identified as furosemide 40 mg tablet was found in the bottom of the second medication cart drawer. b. One loose pink, round pill identified as metoprolol 25 mg tablet was found in the bottom of the second medication cart drawer. These discrepancies were brought to the attention of RN G, who confirmed that they were opened, and that the multi-dose medications were not properly dated. RN G replied, There should not be any loose medication in the medication cart. On 4/20/23 at 12:00 PM, an interview was conducted with the Director of Nursing (DON). The DON was asked what her expectations were for multi-dose insulin pens and ophthalmic solutions and how these items should be dated and responded, I expect there to be an opened date and an expiration date on the pens and bottles. The DON was asked how long should the insulin pens being stored in the medication cart were good for and responded, They are good for twenty-eight days and then are discarded. The DON was asked what her expectations were for the neatness of the medication carts and was asked if loose pills should be in the medication carts and responded, No. The medication carts should be clean and free from any loose pills. Review of facility policy titled, Storage and Expiration of Medications, Biologicals, Syringes, and Needles, dated 10/8/2020, read in part, .Procedure: .3 .c. [facility name] should ensure that all medications and biologicals, including treatment items, are securely stored .5. Once any medication or biological package is opened, [facility name] should follow manufacture/supplier guidelines with respect to expiration dates for opened medications. Staff should record the date opened on the medication container .9. [facility name] should ensure that the medications and biologicals for each resident are stored in the containers in which they were originally received . Review of facility policy titled, 5.3 Storage and Expiration Dating of Medications, Biologicals, dated 7/21/22, read in part, APPLICABILITY This Policy 5.3 sets forth the procedures relating to the storage and expiration dates of medications, biologicals, syringes and needles. PROCEDURE .4. Facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier. 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened .5.3 If a multi-dose vial of an injectable medication has been opened or accessed (e.g., needle-punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. 5.4 When an ophthalmic solution or suspension has a manufacturer's shortened beyond use date once opened, facility staff should record the date opened and the date to expire on the container. 17. Facility personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis .

Based on observation, interview, and record review, the facility failed to follow the menu and did not serve planned meal items according to 13 resident tray cards out of 20 meals observed on the Trillium Wing. This deficient practice resulted in the potential for inadequate intake and unmet nutritional needs. Findings include: During breakfast service in the Trillium Dining Room and on the Trillium hallway on 4/20/23 beginning at 8:28 AM, 10 breakfast trays were observed to have 4 oz (ounce) juices served, while the portion size of 8 oz was specified on the tray card. The Dietary Cook (Staff O) was serving the food and assembling the trays for the residents. Staff O stated the staff member responsible for pouring the juice knows the residents and there was a list used to pour the beverages prior to the meal service. Staff O did not have 8 oz juices poured so he said he was using the juices that were available. Other observations on 4/20/23 at the breakfast meal included three trays did not receive assorted cold cereal as indicated on the tray cards. Two tray cards revealed coffee had been chosen but no coffee was on the tray. One tray card specified 2 each Prunes which were not included on the tray. The tray for Resident 66 (R66) was observed to have a diet of regular with puree texture. While 1 cup P. (pureed) French Toast was listed to be served, no pureed French Toast was on the plate. During the service of the breakfast hall trays on 4/20/23, R264 was observed to have a diet listed on his tray card which included a diabetic restriction of Consistent Carbohydrate (CC4). The tray card indicated 1pkt (packet) Assorted Jelly SF (Sugar Free). The meal was being set up by Certified Nurse Aide (CNA) N, who was observed to open the packet of regular jelly to spread it on R264's toast. When questioned, CNA N confirmed the tray had the wrong jelly and went to request the correct SF jelly needed for a CC4 diet. During an interview on 4/20/23 at 9:37 AM, the Certified Dietary Manager (CDM) M presented the planned therapeutic menus. The breakfast menu indicated the portion size for juice was 8 oz. CDM M stated she would expect 8 oz servings or two 4 oz cups of juice to be served per the planned menu. The facility policy titled Dietary Services - Staffing dated 7/8/22 read in part: The facility will provide sufficient support personnel to safely and effectively carry out the supportive functions of the Food and Nutrition Services. These functions include, but are not limited to: . c. Providing meals and/or supplements in accordance with residents' needs .

This citation pertains to Intake # 3 and Intake # 0. Based on observation, interview and record review, the facility failed to prevent abuse of two Residents (#1 and #4), from five reviewed for abuse. This deficient practice resulted in psychosocial harm with fear and helplessness for Resident #4 and the potential for physical and psychosocial harm, based on the reasonable person standard, for Resident #1. Findings include: Resident #4 The facility Abuse Investigation, dated 3/22/22, confirmed a written allegation of abuse of Resident #4, by Certified Nurse Aide (CNA) H. The Summary concluded, .Upon completion of our investigation, the facility could find evidence to substantiate this alleged abuse. The Summary revealed Resident #4 was severely cognitively impaired with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #4 had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident was unable to make her needs known and was dependent on staff to provide extensive assistance for all care. The Witness Statement, dated 3/16/22, submitted by CNA G revealed, .Each time I worked with [CNA H] comments were said both to and about the resident and each time [CNA H] was rougher during cares .When we reached the resident's room [CNA H] said I f#ck#ng hate these 2 (describing the two residents who resided in the room, Resident #4 and the roommate), it's always sh#t and playing in it like a one year old. As we went into the residents room we saw the resident (#4) was in need of changing as she had a BM [bowel movement] [CNA H] grabbed the blankets off the resident [and] threw them on the floor .then started pulling the residents pajamas off in a rough way and saying you are so f#ck#ng disgusting. The resident started crying and tensed up her entire body, she was very visibly scared and upset. The second time I witnessed [CNA H] treating the resident this way was the same type of behavior only I noticed the resident started to cry and held her blankets very tight when she saw [CNA H] .[CNA H] left the room and returned with a draw sheet .and wrapped it tightly around the residents mid-section and said There you go, now try playing in your sh#t. I removed the draw sheet and covered the resident properly. [CNA H] has made the comment several times that she cant (sic) stand those two ladies . (Resident #4 and her roommate) . The facility interview of CNA G, dated 3/17/22 confirmed the details of the allegation and further revealed a second witness, CNA I. During a phone interview on 7/8/22 at 12:26 p.m., CNA G confirmed the details of her written allegation of abuse of Resident #4 by CNA H. CNA G said she and CNA H went into the Resident's room on rounds when CNA H stated, I f#ck#ng hate these two. I hate to go into this room. CNA G said the Resident was awake and had feces on her hands. CNA G said CNA H jerked the light chain on, without explaining to the Resident what was happening, and whipped the blankets off and was rough about it. CNA H said, f#ck#ng playing in your own sh#t again. CNA G said Resident #4 began crying and curled up into the fetal position and hugged her legs in her arms. The Resident was fearful and looked afraid. She tensed up when CNA H grabbed her, jerking, and pulling on her to roll her for care. The Resident was on the edge of the bed facing CNA H. CNA G said the events happened weeks prior to her written allegation, but she couldn't remember the exact dates. CNA G confirmed CNA H's behaviors happened more than once. The facility interview, dated 3/18/22 of CNA I revealed, .Did you hear or witness anything yourself in relation to this .I heard [CNA H] say to [Resident #4] Ugh, you're so disgusting. The interview also revealed Resident #4 tensed up when approached suddenly and was more cooperative if cares were explained first. A follow up facility interview of CNA I on 3/22/22 at 2:13 p.m., confirmed the beginning of January 2022 as the timeframe when CNA I witnessed the alleged abuse on the night shift. CNA I said in the interview she just got off her training and didn't know how to respond when CNA H said, You're so disgusting to Resident #4. CNA I confirmed CNA H would mumble other derogatory remarks under her breath related to the Resident. Unsuccessful attempts were made to interview CNA I by phone on 7/8/22 at 10:30 a.m. and 1:45 p.m. The facility interview of Licensed Practical Nurse (LPN) J, dated 3/17/22, revealed, Have you ever witnessed this employee mistreat a resident in any way? A little verbally forceful at times . During a phone interview on 7/8/22 at 1:36 p.m., LPN J confirmed CNA H would be verbally coarse with residents at times, and stated, She can be forceful with residents, verbally. When asked how Resident #4 expressed fear and anxiety, LPN J said the Resident covered herself with blankets and curled up in a ball, since admission, when fearful or anxious. During an interview on 7/8/22 at 2:15 p.m., Family Member (FM) K was asked how she knew if/when Resident #4 was frightened. FM K said when the Resident was frightened, she would mumble faster and get agitated meaning wave her arms, cry, tense up and curl up in a ball. FM K said the Resident might squeeze you hard. During a tour of the facility on 7/7/22 at 12:00 p.m., Resident #4 was observed in the room in a geri chair. The Resident smiled at this Surveyor upon introduction but was unable to verbally communicate effectively. This Surveyor asked if she was well, to which the Resident mumbled positively. When asked if anyone ever hurt her at the facility, the Resident immediately began mumbling quickly, unintelligibly, and loudly, and lifting and waving her arms, fidgeting with head movements and a distressed change to her expression, which was flat upon entrance to the room. When asked if the night shift was a problem, Resident #4 immediately tensed her whole body. This Surveyor stopped questioning the Resident and assured her she was safe. On 7/8/22 at 9:00 a.m., Resident #4 was observed in the 600-hall dining room being assisted appropriately with breakfast by another CNA. The Resident smiled at this Surveyor when approached and was re-introduced. On 7/8/22 at 10:46 a.m., an unsuccessful attempt was made to interview CNA H by phone. CNA H was no longer employed at the facility at the time of the survey. The Witness Statement, dated 3/16/22, authored by CNA H revealed no abnormal behaviors by Resident #4 while providing cares on the night shift, despite facility documented non-compliance and pinching/grabbing behaviors with cares, per the investigation file. The Statement noted CNA I as a co-worker who could vouch for CNA H but did not specifically confirm or deny any alleged abuse or mistreatment. The facility interview, dated 3/16/22, with CNA H revealed, Have you had any concerns when you have been assigned to this resident .She has behaviors .Has the resident had any behavioral symptoms .impacting care .She fights (grabs) when changing her . This was incongruent with CNA H's Witness Statement that Resident #4 had no behaviors but was not addressed in the facility interview. Resident #4's Care Plan revealed, .I have a functional deficit .I am severely cognitively impaired and confused .Please lead me through me daily routine and anticipate my needs. Date Initiated: 05/09/2019 .Explain to me what you are going to do before you do it and while you are doing it step by step so I know what to expect. Date Initiated: 05/13/2022 . Resident #1 The facility Abuse Investigation, dated 5/31/22, confirmed a resident-to-resident altercation on 5/24/22 at 7:26 p.m. Video footage of the incident was reviewed on 7/8/22 at 11:00 a.m. with the DON and ADON D. The footage clearly showed Resident #2 approached Resident #1 from the rear on the 500 hall, a secure memory care unit. Both Residents were independently walking in the hallway, when Resident #2 reached her arms forward and pushed Resident #1 forward and into the wall and handrail, causing Resident #1 to fall into the wall and rail, then to the floor. Resident #2 kept walking onward as staff approached the scene. Both the DON and ADON D nodded in agreement when this Surveyor asked if a reasonable person would be frightened, traumatized, fearful or intimidated, if pushed from the rear without provocation or foresight. The Investigation noted a 2 centimeter (cm) by 3cm abrasion to Resident #1's right knee. Resident #1 was able to state at the time, She pushed me from behind, while pointing at Resident #2, according to the facility Investigation. According to the Investigation, both Residents had dementia and were independently ambulatory. The Statement, dated 5/24/22, authored by CNA L revealed Resident #1 stated Resident #2 pushed her from behind. The Statement, dated 5/24/22, authored by LPN J revealed Resident #1 stated Resident #2 pushed her from behind, and noted the 2cm by 3cm abrasion. The Behavior Meeting Notes, dated 5/25/22, revealed Resident #1 was walking in the hall and stopped when Resident #2 pushed her down. Resident #1 fell forward then down to the floor. Camera footage was reviewed with the behavior team. Neither Resident #1 nor #2 were interviewable at the time of the survey. The policy Resident Abuse Prevention and Investigations Policy and Procedure, dated 10/20/2020, revealed, Purpose/Policy: the full intent of both Federal and State governments as outlined in the Federal and State licensure requirements is to eliminate the threat of abuse, in any form, to residents of nursing homes .Scope: All staff .Abuse: Willful infliction of injury .intimidation .resulting physical harm, pain, or mental anguish .Verbal Abuse: defined as the use of oral .gestured language that willfully includes disparaging and derogatory terms to residents .within their hearing distance, regardless of their age, ability to comprehend, or disability .In order to prevent abuse .the facility will provide .supervision of staff and residents .Residents will receive ongoing monitoring to identify and address .physical and verbal abuse .those totally dependent on staff for care those with difficulty communicating .

This citation pertains to Intake # MI 343 Based on observation, interview and record review, the facility failed to immediately report an allegation of abuse to the State Agency (SA), for one Resident (#4), from five reviewed for abuse. This deficient practice resulted in continued abuse by staff of Resident #4, with accompanying fear. Findings include: The facility Abuse Investigation, dated 3/22/22, revealed the facility Director of Nursing (DON) was informed of a written abuse allegation of staff abuse to Resident #4, on 3/16/22 at 10:00 a.m. The summary confirmed the Administrator (NHA) was informed on 3/16/22 at 10:05 a.m. The summary also indicated the staff reporter who submitted the written allegation (Certified Nurse Aide (CNA) G) was educated on timely reporting of abuse allegations. The facility investigation timeline confirmed the allegation was reported to the SA on 3/16/22. The Witness Statement, dated 3/16/22, authored by CNA G, revealed, First I would like to say that I have tried figuring dates but was unable to. Each time I worked with [CNA H] comments were said both to and about the resident and each time she was rougher during cares .The dates I witnessed this was the last 2 shifts worked with [CNA H]. The Statement indicated more than one instance of abuse of Resident #4 by CNA H. The Statement continued and revealed, .When we reached the resident's room [CNA H] said I f#ck#ng hate these 2 (describing the two residents who resided in the room, Resident #4 and the roommate.), It's always sh#t and playing in it like a one-year-old. As we went into the residents room we saw the resident (#4) was in need of changing as she had a BM [bowel movement] [CNA H] grabbed the blankets off the resident [and] threw them on the floor .then started pulling the residents pajamas off in a rough way and saying you are so f#ck#ng disgusting. The resident started crying and tensed up her entire body, she was very visibly scared and upset. The second time I witnessed [CNA H] treating the resident this way was the same type of behavior only I noticed the resident started to cry and held her blankets very tight when she saw [CNA H] .[CNA H] left the room and returned with a draw sheet .and wrapped it tightly around the residents mid-section and said There you go, now try playing in your sh#t. I removed the draw sheet and covered the resident properly. [CNA H] has made the comment several times that she cant (sic) stand those two ladies .(Resident #4 and her roommate) . During an interview on 7/8/22 at 2:15 p.m., Family Member (FM) K was asked how she knew if/when Resident #4 was frightened. FM K said when the Resident was frightened, she would mumble faster and get agitated meaning wave her arms, cry, tense up and curl up in a ball. FM K said the Resident might squeeze you hard. During a tour of the facility on 7/7/22 at 12:00 p.m., Resident #4 was observed in the room in a geri chair. The Resident smiled at this Surveyor upon introduction but was unable to verbally communicate effectively. This Surveyor asked if she was well, to which the Resident mumbled positively. When asked if anyone ever hurt her at the facility, the Resident immediately began mumbling quickly, unintelligibly, and loudly, and lifting and waving her arms, fidgeting with head movements and a distressed change to her expression, which was flat upon entrance to the room. When asked if the night shift was a problem, Resident #4 immediately tensed her whole body. This Surveyor stopped questioning the Resident and assured her she was safe. The facility investigation dated 3/22/22 concluded abuse occurred. During a phone interview on 7/8/22 at 12:26 p.m., CNA G was asked about the statement of allegation she authored on 3/16/22. CNA G said the behaviors in the allegation happened weeks prior, but she was uncertain, as a new CNA, if they met the criteria and didn't know what to do. CNA G said it bothered her so much she finally had to say something. CNA G confirmed CNA H's behaviors happened more than once. The facility interview, dated 3/17/22, of CNA G revealed, .What prevented you from reporting .unsure of whether it was abuse .Now that you know it was abuse, you know what to do about it & the proper steps to take? I would take [the alleged perpetrator] with me out of the room to the nurse & immediately report. I understand our policy. I just wasn't sure it was actually categorized as abuse. The facility interview of CNA I on 3/22/22 at 2:13 p.m. confirmed a second witness to abuse of Resident #4 and revealed the timeframe for the witnessed alleged abuse was January 2022. CNA I said she just got off her training and was new and didn't know how to respond. CNA I confirmed CNA H verbally abused the Resident in her presence and mumbled other derogatory remarks under her breath related to the Resident. During the exit conference on 7/8/22 at 3:03 p.m. the NHA, DON and Assistant DON (ADON) D all confirmed the allegation was not immediately reported to the NHA or the SA. The policy Resident Abuse Prevention and Investigations Policy and Procedure, dated 10/20/2020, revealed, .Any employee witnessing any type of abuse will immediately notify the Charge Nurse and/or their direct supervisor .The Charge Nurse or a direct supervisor will notify the Administrator immediately of any allegation of abuse or incident .The facility will report the following situations to the appropriate State or Federal Agencies .The facility will report .immediately (with-in 2 hours hours) .Allegation of abuse .

Based on interview and record review, the facility failed to ensure the physician supervised the medical care for one Resident (#1) from three reviewed for physician services, when the physician did not document the medical services provided. This deficient practice resulted in the lack of coordination of care, untreated severe low sodium with corresponding falls, resulting in a [CONDITION(S)], mentation changes and hospitalization , with subsequent death. Findings include: ALL TIMES ARE RECORDED IN EASTERN DAYLIGHT TIME (EDT) According to the electronic medical record (EMR) Admission Record, printed [DATE], Resident #1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . It was noted [CONDITION(S)] was not listed as a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During a phone interview on [DATE] at 3:28 p.m., Family Member (FM) A said Resident #1 had at least 4 falls during her stay at the facility and was transferred to the emergency department (ED) on [DATE], and subsequently to a larger hospital in another community, then passed away at the larger hospital on [DATE]. FM A said she spoke with the Resident's primary physician (MD) B, who said he was unaware of one of the falls. FM A confirmed the Resident was transferred to a larger hospital, where she was admitted to the ICU (Intensive Care Unit) for critically low sodium levels, a [CONDITION(S)], [CONDITION(S)] and [CONDITION(S)] (whole body blood infection) from a [CONDITION(S)]. During a phone interview on [DATE] at 10:45 a.m., MD B confirmed he was Resident #1's primary physician. MD B said he was not aware of one of the Resident's falls until his conversation with FM A. MD B also said the Resident was in [CONDITION(S)] (CHF), and he made several changes to the medication regimen, including diuretics, which MD B said were not working. When asked why he didn't consider a fluid restriction to combat the Resident's low sodium levels and CHF, MD B said the Resident would probably not comply anyway. Resident #1's EMR was absent any progress notes from MD B regarding any physician visits, medication changes or any other care provided, supervised or treated, including any rationale for medication changes or other orders, including laboratory orders. During a second phone interview on [DATE] at 3:17 p.m., MD B confirmed he wrote no progress notes and said he was a little behind on them. MD B said nurses rounded with him and noted what happened. MD B confirmed legal and ethical standards of practice did not endorse the practice of nurses documenting his care. The facility Discharge Summary, dated [DATE], revealed Resident #1 was severely cognitively impaired. Laboratory reports noted the following sodium levels: [DATE] 131 mEq/L (milliequivalents per liter for all lab values) [DATE] 132 [DATE] 127 [DATE] 125 [DATE] 123 [DATE] 114 (a critically low value, meaning life threatening) All of the above laboratory reports were initialed by MD B. Fall Reports noted the following falls: [DATE], [DATE], [DATE], two falls on [DATE] at 9:30 a.m. and again at 1:00 p.m. The ED note, dated [DATE], authored by MD C, revealed, .presents from skilled nursing facility by EMS (emergency medical services/ambulance) for concerns regarding altered mental status and low sodium. Although the history was not provided by the skilled nursing facility provider, patient apparently had a fall yesterday, and EMS noted rotation and shortening of her right leg .(no CHF was noted in the history section of the note) .Sodium 117 .Potassium 3.1 Chloride 76 .Magnesium 1.4 (all low values) .Blood, Urine 1+ .[MEDICATION(S)], Urine 2+ .White Blood Cells, 15 Red Blood Cells 8 .Bacteria 3+ (all indicative of [CONDITION(S)]) .Assessment and Plan Patient with [CONDITION(S)] (low sodium), urinary tract infection, and right hip fracture .following review of records with inpatient provider, it was found that patient has responded better to fluid restriction for past episodes of [CONDITION(S)] rather than saline hydration .The plan of care, goals of care were extensively discussed .with the patient's nursing home provider . An attempt to contact MD C was unsuccessful on [DATE] at 4:25 p.m. Nursing progress notes revealed MD B had a physician visit with Resident #1 on [DATE] and [DATE], with no corresponding physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on [DATE] at 10:30 a.m., Assistant Director of Nursing (ADON) (RN) D said MD B told the facility he did not want to be notified of laboratory (lab) values for residents that only slightly off normal. RN D said MD B only wanted to be called for Grossly aberrant or critical lab values. RN D also said MD B gave no specific parameters regarding notification of lab values, only that individual resident situations be considered. During an interview on [DATE] at 11:51 a.m., RN D and RN E were present. RN D said MD B made rounds at the facility on Mondays, Wednesdays, and Fridays, and signed off on the rounds book with each visit. Both RNs confirmed the rounds book included non-critical information about Residents between visits, including falls, labs, etc. During an interview on [DATE] at 12:29 p.m., RN F confirmed her role as the Risk Manager for the facility and said she reviewed all falls and participated in monthly falls meetings. When asked about Resident #1's falls and any trends noted with the Resident's lab values, RN F said the facility was conducting an internal investigation regarding Resident #1's situation, as a result of the falls meeting and a complaint received by the family. During an interview on [DATE] at 12:51 p.m., RN E confirmed a facility investigation regarding Resident #1, due to her concern on [DATE] about the Resident's low sodium, without corresponding physician notes. RN E said during her investigation into the condition, she discovered a nurse manager notified MD B about the Resident low sodium trends but was told by MD B it was normal for the Resident. RN E said there was a meeting with the Administrator (NHA), MD B, herself, RN F and the Corporate Compliance Nurse RN G, but she never received a conclusion regarding the facility's investigation. The note provided by the facility as part of the investigation, dated [DATE] revealed, . investigating residents (sic) change in mentation and behaviors. On [DATE] .had a verbal discussion with Charge nurse .regarding change in mentation and potential for sodium imbalance .would discuss with (MD B) on .[DATE] .reviewed chart .no new orders for labs .till [DATE] .spoke with (charge nurse) .why (MD B) didn't order labs .stated that the last labs were normal, and he (MD B) did not feel it needed to be done immediately. Review of the medical record indicates all sodium labs collect(ed) (sic) have been low and trending abnormal, see below. Upon review of the medical record as of this time there is no dictated physician charting in progress notes or misc .[DATE] Sodium .131 (L)-no new orders .[DATE] Sodium 132 (L) No new orders .[DATE] Sodium 127 (L) . No new orders .[DATE] Sodium 125 (L) no new orders .[DATE] Sodium 114 (L) Critical Value resident Sent out to ED .Falls [DATE] [DATE] [DATE] [DATE] x2 falls The Incident Report Form, dated [DATE], noted a clinical incident inconsistent with standard operations and related to patient/clinical care at a Major/Adverse Event Any incident that reached the person and caused significant or permanent harm including physical or psychological harm. Includes but not limited to: Any incident leading to a higher level of care/hospitalization .Treatment not associated with standard of care causing an unanticipated outcome . The same Incident Report Form had hand written notes at the bottom which revealed, Res has had numerous CMP (complete metabolic profile, which includes the sodium level) which indicate a trend in decreased sodium .has not been addressed. Res has had significant change in mentation .no dictated notes in (EMR) or MD notes. No progress notes noting or referencing [CONDITION(S)] (low sodium) . During an interview on [DATE] at 2:58 p.m., RN D confirmed there were no physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked about the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on [DATE] at 4:05 p.m., RN G confirmed her role as Corporate Compliance officer and was asked about the facility investigation regarding Resident #1's care. RN G said she reviewed the complaint with the Complaint Officer (Staff) H, and the investigation was part of a QAPI (quality assurance and performance improvement) project and she could not disclose information about the investigation, which was still open. RN G said the investigation resulted from normal chart reviews. When asked, from a compliance standpoint, if the absence of any physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . RN G confirmed physicians are required to document their own work and rounds and cannot be delegated to anyone, including nurses. RN G confirmed Resident #1's condition was significantly changed as a result of the [CONDITION(S)]. Staff H joined the interview at 4:20 p.m. and confirmed he received a complaint from Resident #1's family sometime in [DATE]. Staff H confirmed the complaint was still open and ongoing. The complaint file was requested at that same time, along with any policy addressing physician care, visits, and documentation. The facility complaint timeline, received as part of the facility complaint investigation, revealed, .[DATE] .filing complaint .(MD B) (Family Member I) 'I recorded him' (Meaning MD B) 'he was sarcastic' .(NHA) informed about (MD B's) bedside manner (NHA) informed me of internal investigation ongoing .(MD B) understands certainly could respond better .investigation ongoing (RN E) concerns (meaning concerns in July about Resident #1's falls and low sodium) .[DATE] .printed records-delivered to residence (FM I's residence)-no MD notes none . The NHA was unavailable throughout the survey. The Incident Investigation Summary, hand dated [DATE], revealed, Clinical Incident: Fall with major injury and critical sodium level. Significance: Major/Adverse event. Date of incident: [DATE]. Incident Description: Resident had multiple falls, significant mentation changes, and ultimately a critical sodium leading to an emergency room transfer. Timeline: [DATE]: (sodium)=131 .Reviewed by (MD B with no progress note) fell from wheelchair. [DATE]: Fall in bathroom. Note entered in Doctor book .[DATE]: Consistent (nursing) notes stating resident could not follow directions to use call bell .[DATE]: .Labs showed (sodium) 132 .[DATE]: .Note in Doctor book stating resident drinking lots of fluids. [DATE]: Resident noted to have change in mentation and behaviors. Charge was notified to discuss with (MD B) .[DATE]: (MD B) visit. (MD B) said lab results were normal and did not need to be done immediately .[DATE]: (short of breath) O2 88% (oxygen saturation levels in blood value 88% is very low) added to doctor book, given oxygen. [DATE]: (sodium) 127, Chloride=84 [DATE]: (MD B) visit (no progress note in chart) adjusted meds, ordered labs. [DATE]: .weight down 5.5 pounds Aug. 1: Witnessed fall in bathroom (at 9:30 a.m.). Another fall at (1:00 p.m.). Aug: 2 Call from (lab) with critical low (sodium) 114. (MDB) notified and resident sent to ED. Increased lethargy. Aug. 6: No dictation from (MD B) in the patients (sic) medical record to review. The summary was absent a root cause, action plan or any follow up. The document Payment Services and Rights, page 12 of 36, revealed, Physician Services .Physician visits are generally scheduled at least once every thirty .days . The document was confirmed on [DATE] by RN D as dated 2016 and part of the resident rights booklet provided to residents on admission and there was no official policy related to physician services. Resident #1 died at the hospital on [DATE].

Based on observation, interview, and record review, the facility failed to: 1) implement effective surveillance of a COVID-19 outbreak to control the spread of infection; 2) establish adequate communication between departments to limit the spread of infection from employees and residents; 3) follow transmission-based precautions with proper PPE (personal protective equipment) use; 4) effectively perform proper staff/visitor entrance screening; 5) provide consistent staffing assignments for direct-care staff; and 6) eliminate group dining for staff in facility's cafe. This deficient practice resulted in Immediate Jeopardy. Data as of Exit Conference on 10/1/20: per Staff H -Five COVID-19 resident deaths, 51 positive residents, and 27 positive staff Data as of 10/4/20: per MDHHS website: Eight COVID-19 deaths, 56 positive residents, and 39 positive staff (All times reflect Eastern Time Zone) Immediate Jeopardy was identified at F 880 on 9/24/2020 during an abbreviated COVID-19 Infection Control Focused Survey and complaint survey. The Assistant Administrator (Staff) G was notified of the Immediate Jeopardy at 4:00 p.m. on 9/24/2020 and an Abatement Plan was requested at this time and approved. The Immediate Jeopardy was removed on 9/30/20 following an additional on-site visit to verify the implementation of the Plan to limit the potential spread of COVID-19 per CDC, (Centers for Disease Control and Prevention) and CMS (Centers for Medicare and Medicaid Services). The Immediate Jeopardy began on 9/24/2020 when Surveyor entered the building at 10:30 a.m., and immediately identified visitor screening concerns, and then continued with multiple observations of staff inappropriate PPE use with COVID-19, and review of incomplete COVID-19 surveillance data to include contact tracing for residents and staff and the increased spread of COVID-19 throughout the facility from prior week testing results. The noncompliance remained at a widespread level until a second visit on 9/30/2020. Following removal of immediacy on 9/30/20, deficient practice continued at widespread potential for more than minimal harm level until confirmation of appropriate real time surveillance and infection control precautions are confirmed. Findings include: SCREENING/COMMUNICATION CONCERNS On 9/24/20 at 10:30 a.m., while approaching the facility's external facility entrance door noted a sign which read, CURRENT COVID-19 STATUS 12 POSITIVE EMPLOYEES 21 POSITIVE RESIDENTS These are not cumulative numbers-they are residents and employees who are isolated or off work currently. * Part of Cedar is now a COVID-19 Positive Unit * part of Cedar is a Quarantine Unit with Symptomatic Residents * part of Cedar is a Quarantine Unit for Admits and Returns * Willows is a Quarantine Unit *(NAME)is a Quarantine Unit . September 22, 2020. Upon gaining entrance and directed down a long, narrow service hallway, Staff W took a tympanic (no touch) temperature and stated the result aloud. Next, Staff W directed Surveyors to complete a screening form which was located down an adjoining hallway. Two overbed tables were observed with each containing screening forms, bin, and an ink pen. No alcohol-based hand sanitizer was observed on either table or any cleaning/disinfecting supplies. Staff W had not provided any education and/or further direction for the performance of hand hygiene, adherence to PPE, social distancing, and/or the need for re-screening prior to exiting building. Several unidentified staff were observed at this time not adhering to social distancing which included Staff G and Human Resource Director (Staff) X when both approached the Surveyors. The entrance hallway intersection (where the screening was performed) was very busy with foot traffic due to several office locations: human resource, dietary, laundry, housekeeping, and another exterior door accessed for smoking breaks. At no time did any staff voice the need for staff to separate and/or allow individual passage down these hallways. COMMUNICATION/SURVEILLANCE/PPE USE CONCERNS On 9/24/2020 at 10:45 a.m., during the Entrance Conference when asked who was the facility's Infection Preventionist, Staff G identified Infection Preventionist/Registered Nurse (Staff) H was new to the facility and shared the responsibility and oversight from Corporate Compliance Officer (Staff) LL. Since Staff LL was not present during the Entrance Conference, Staff H was asked to explain how staff were expected to apply (don) and removed (doff) PPE when entering and exiting the COVID-19 wings. Staff H responded she was not sure and indicated that she had not observed the process by staff. When asked about the facility's entrance door sign which indicated 12 positive COVID-19 for staff and 21 for residents dated two days prior, Staff H said she was aware of 25 residents and indicated more positive results were anticipated due to residents exhibiting signs/symptoms of COVID-19 and said some lab results were still pending. When asked what staff were expected to wear inside the facility on non-quarantine wings, Staff G responded non-clinical staff wore KN95 masks and a faceshield or goggles. When asked why the entrance screener was not wearing a faceshield, Staff G said she should have been wearing one. Infection Control Surveillance Data was requested from Staff G for review and an opportunity to interview Staff LL. PPE CONCERNS During an interview on 9/24/20 at 12:34 p.m., Staff LL confirmed faceshields and goggles not provided by the facility, required approval from Infection Control (Staff H or Staff LL) or Purchasing before being worn by staff in the facility. On 9/24/20 at 11:20 a.m. during an Initial Tour, the Spruce Wing was found with closed double doors and sign which read, KN95 MASK REQUIRED FOR ENTRY ONTO UNIT: REQUIRED PPE FOR THIS UNIT: KN95 MASK FACE SHIELD. While reading the signage, Staff MM opened the double door and entered Spruce while wearing only a surgical mask (not a KN95) and without a faceshield and walked the entire length of the hallway to the housekeeping closet. No PPE or hand hygiene supplies were located outside the double doors of Spruce. On 9/24/20 at 11:28 a.m., while on Trillium Wing, Registered Nurse (RN) M was observed walking down the hallway with a faceshield that only covered her eyes exposing her KN95 mask. When RN M was asked about the shorter faceshield said in part, I altered it. On 9/24/20 at 11:43 a.m., Cedar Wing's double doors were found closed with the following sign which read, N95 MASK REQUIRED FOR ENTRY ONTO UNIT REQUIRED PPE FOR THIS UNIT: N95 MASK WITH SURGICAL MASK . No PPE or hand hygiene supplies were located outside the double doors of Cedar. DEDICATED STAFF and PPE CONCERNS On 9/24/20 at 11:43 a.m., while on Birch Wing, Certified Nurse Aide (CNA) P was asked if Birch was the only wing she worked, CNA P responded no and indicated she had worked on both Willow (COVID-19 Quarantine Wing) and(NAME)this same week. During an observation soon after, Resident #9 (room [ROOM NUMBER]) was seen seated in a wheelchair (in her doorway) directly next to Activity Aide (Staff) Q. Resident #9 was wearing a facemask but it was incorrectly positioned under her chin exposing her nose and mouth. Staff Q who was standing in very close proximity (less than one foot) in the doorway next to Resident #9 was wearing an N95 mask and faceshield. To the left of the doorway a Contact & Droplet Isolation signage was noted which read in part, EVERYONE MUST: . Gloves and mask when entering the room Gowns are required before entering . Staff Q, when asked why he was not wearing a gown and gloves as the sign indicated, immediately proceeded out of Resident #9's room and applied a gown and gloves. On 9/24/20 at approximately 11:46 a.m., RN R, who was passing medications on Birch Wing, was noted to be wearing a KN95 mask and goggles. When asked about the goggles, RN R stated they were her own from home and not provided by the facility. RN R was asked why Resident #9 was in Contact & Droplet Isolation. RN R said because her roommate, Resident #13, tested positive for COVID-19 and moved to Cedar Wing. When asked about Resident #9's COVID-19 test results, RN R said she was unaware of her results but knew testing was completed on Tuesday (9/22/2020). When asked if any residents currently on Birch had refused testing for COVID-19, RN R indicated Resident #13 (room [ROOM NUMBER]) had refused and not been tested . Review of Resident #9's Progress Note, 9/29/20, read, Resident received a COVID Rapid Test on 9/28/20 which was positive. Resident moved to Cedar in room [ROOM NUMBER]B. While still on Birch, Housekeeper (Staff) S was observed wearing a pair of black and green goggles. When asked about the goggles, Staff S indicated they were her own from home and not provided by the facility. On 9/24/20 between 11:57 a.m. and 12:17 p.m., Staff T, Staff U and Staff V were observed through the glass window on the 3rd floor Accounts Payable /MDS Office without a facemask being worn. SURVEILLANCE CONCERNS On 9/24/20 at 12:05 p.m., Staff H was asked for the current week's (September 21st/22nd resident and staff) COVID-19 positive test results since the Infection Control Surveillance Binder for September 2020 (just received by Staff H) only had resident line entries from the previous week. Staff COVID-19 line-lists were not found. When asked why the infection mapping, obtained from the same binder, did not show COVID-19 infections or quarantine for some identified residents found during initial tour observations, Staff H said the mapping was not updated because she was unable to identify where residents currently were in the facility that had been moved since obtaining additional positive results (contact tracing). On 9/24/20 at 12:18 p.m., Staff G was asked again for the facility's Resident Matrix (CMS-802) since it was still not provided since the Entrance Conference meeting at 10:45 a.m. and the opportunity to interview Staff LL. PPE/SURVEILLANCE/DEDICATED STAFFING CONCERNS On 9/24/20 at 12:34 p.m., Staff LL, Assistant Director of Nursing (ADON) B, ADON J, Staff G and Interim Nursing Home Administrator (NHA) entered the conference room. Staff LL was asked to explain how staff were expected to apply (don) and removed (doff) PPE when entering and exiting the COVID-19 units. Staff LL did not answer the question. When Staff LL was asked if she had performed any observations (surveillance) of staff on the COVID units with PPE use, Staff LL indicated she had not. When asked why September's infection mapping did not match initial tour observations of residents observed in Contact & Droplet Isolation, Staff LL replied she didn't know and said the mapping must not have been updated. This Surveyor shared the observations of several staff without the use of faceshields and masks within their offices. The NHA and Staff G said non-clinical staff were permitted to remove faceshields and masks if their office doors were closed. This Surveyor asked if any non-clinical staff had recently tested positive for COVID-19; Staff G confirmed there had been some non-clinical staff who did test positive. This Surveyor addressed multiple concerns with the COVID-19 outbreak management based on observations, interviews, and record reviews for the following: entrance screening, multiple staff observations of inadequate PPE use, direct care staff working various wings within the same week, the increased movement of residents to various wings thus increasing exposure risk and directly affecting the ability to perform resident and staff tracing. During an interview on 9/24/20 at 1:39 p.m., Staff W indicated she had just returned from Birch Wing where she had provided feeding assistance. Staff W returned to continue staff/visitor entrance screenings. On 9/24/20 at 1:50 p.m., Staff H said additional COVID-19 test results came in last night (9/22/20) and was expecting additional results today. When asked about Resident #9's test results, Staff H said she didn't know because she was unfamiliar how to navigate the computer program to obtain the results since she was recently hired in September 2020. When asked where Resident #14's was sent to from Birch (where she was COVID-19 positive), Staff H indicated she had been moved to Cedar Wing. When asked why COVID positive residents were being moved to other Wings when positives cases were identified at this point throughout the facility, Staff H responded, Yes, that's a big problem. On 9/24/20 at 2:05 p.m., Staff LL, ADON J, ADON B, and Staff G returned to the conference room where this Surveyor was located. Staff LL indicated an additional 6 positive COVID results have been identified but was unable to identify who the individuals were at this time since no data was in-hand. This Surveyor requested the most recent lab reports and staff illness surveillance. During an interview on 9/24/20 at 2:40 p.m., Staff H said three staff (one nurse and two dietary aides who worked on Willow Wing) who were found to have positive COVID-19 results the second week of September (8th and 9th). When asked about the first positive results for residents were identified, Staff H said September 14th and 15th and indicated these residents were both symptomatic and asymptomatic and resided on Willow (locked, Memory Care Unit). Staff H said that the positive residents were moved off Willows and sent to Cedar. When asked why positive residents were moved off the locked unit (where potential exposure had already occurred to other residents due to residents' mobility and dementia and inability to restrict to individual rooms) to Cedar, Staff H said, It's concerning. There's too many hands in the puzzle. I don't know what's going on. Staff H said she felt leaving all residents on Willow (either known positive or not) would have been the best solution to control the spread. On 9/23/20 at 3:25 p.m., Staff LL reported a positive COVID-19 test result received on a staff person who was interviewed earlier today by Surveyor. During an interview on 9/24/20 at 3:39 p.m., Dietary Manager (DM) GG, said she brought her googles she had been wearing from home but indicated she had asked Purchasing to verify if they were acceptable a few minutes prior to this interview. COMMUNICATION CONCERNS During an interview on 9/24/20 at 12:05 p.m., Staff H expressed difficulty in answering Surveyor's questions since she was new to the facility and indicated she had not even received any orientation to her role as Infection Preventionist. In addition, Staff H said she was not shown how to access COVID-19 lab results for facility and staff. During an interview on 9/25/20 at 8:53 a.m., Staff H said Administration had a Department Head meeting on September 19th to discuss to COVID-19 outbreak but said she was not invited to the meeting nor was she asked for any input prior to the meeting. Staff H said nine additional staff had tested positive and 21 residents the same week. Review of Staff H's own September 2020 Timeline read in part, 9/17/20 .Reminded that Infection Prevention is not being notified of infections .9/19/20 .Sat (Saturday) Department head meeting called in pm (afternoon) when (+) tests began returning to develop plan. (Infection prevention was not included in this meeting) .9/22/20 .Reminded Infection Preventionist is not being notified of infections and those being moved to quarantine. See 8 am meeting minutes-Infection Preventionist not part of meeting .9/23/20 .Reminded Infection Preventionist not being notified of Infections (and) those moving to quarantine . PPE CONCERNS During a phone interview on 9/25/20 at 9:47 a.m., Licensed Practical Nurse (LPN) K was asked if she had observed any staff entering the building at the start of her shift without a facemask in place. LPN K said yes and estimated at least 2-3 staff were observed in the last week that entered the building, walked down the service hallway to the screening station, and then put on a new mask. LPN K verified other staff were present at the same time. When asked about removing her facemask and/or faceshield on the unit with residents, LPN K said she has pulled her mask down to breathe and lift her faceshield to see the computer to document. When asked about dedicated staff, LPN K said two Certified Nurse Aides (CNAs) had worked on Willows with positive COVID-19 residents and then both were scheduled to work on a wing without any positive and/or quarantine residents. LPN K confirmed the lack of dedicated staff between positive and non-isolation wings was concerning, since contact tracing was very difficult with staff working all over the facility. Review of electronic medical record showed Resident #15 tested positive for COVID-19 on 9/18/20. Resident #15 was on Cedar on 9/17/20, moved to Willow on 9/25/20, and lastly placed on(NAME)on 9/27/20 where he passed away. During a telephone on 9/29/20 at 3:08 p.m., Staff H was asked about Resident #15's death and movement to three different wings after testing positive for COVID-19. Staff H said she was not informed and did not have an answer as to why. Staff H expressed concern and indicated the actions of moving residents probably contributed to COVID-19 spread throughout the facility for both residents and staff. During a telephone interview on 9/29/20 at 4:29 p.m., Staff G, Staff LL and Nursing Home Administrator (NHA) confirmed COVID-19 positive residents had been identified now on Willow, Birch, Cedar, Trillium,(NAME) and Skyway (six of eight wings). When asked about Resident #12 leaving the facility for a routine chiropractic appointments, Staff LL said she was not aware Resident #12 had left over the weekend. Review of Resident #12's electronic medical record showed she left the facility for chiropractic appointments on 9/21/20 and again on 9/28/20 without evidence the physician was notified to determine the necessity when the facility was experiencing the outbreak of COVID infections. Review of vital signs for routine COVID-19 shift screenings showed Resident #12 had a temperature of 100.2 Fahrenheit on 9/29/20. During an interview on 9/30/20 at 3:26 p.m., Nurse Practitioner (NP) N confirmed Resident #12 had just tested positive for COVID-19. During an observation on 9/30/20 at 1:54 p.m., the facility's café doors were found wide open revealing six staff members inside eating without masks and faceshields. Staff EE when asked confirmed the café doors were supposed to be kept closed. A second observation on 9/30/20 at 4:23 p.m., revealed seven staff inside the café without masks or faceshields. PPE/COMMUNICATION CONCERNS During a second on-site visit on 9/30/20 at approximately 1:05 p.m. ADON B and the DON both said they had repeatedly tried to communicate their concerns with Administration's decision which directed positive and/or symptomatic residents to be moved to other wings throughout the facility. Both ADON B and the DON felt the decision caused an increased risk of transmission to other residents and staff. On 9/30/20 at 3:01 p.m., while on Trillium Wing, three unidentified residents were noted in close proximity to one other (less than three feet) conversing in the hallway while seated in their wheelchairs. One of the three residents had a facemask positioned underneath her nose. During an observation on 9/30/20 at 3:04 p.m., PPE supplies did not contain any hand hygiene supplies outside of Birch and Willow Wings. The type of required N95 mask for Birch was incorrectly posted on a sign. Staff LL was notified by this Surveyor immediately upon discovery. On Birch Wing, Resident #13 was observed in the hallway (seated in her wheelchair) with a mask under her nose and a Styrofoam cup in her hand. RN E and CNA FF were observed without wearing the required PPE of gowns/gloves as indicated on the doors of Birch. When RN E was asked why Resident #13 was in the hallway and not restricted to her room, RN E said she was transferred off Willows and was very difficult to keep inside of her room due to her advanced dementia and behaviors. RN E when asked if she was aware of any positive residents on Birch indicated she was not aware of any but knew additional testing had been done and results were pending. When asked about any residents symptomatic for COVID-19 on Birch, RN E said she was aware of at least two. When asked about dedicated staffing, both RN E and CNA FF confirmed they both worked on Cedar the previous day. During an interview on 9/30/20 at 3:26 p.m., Staff G, Staff LL, ADON B, the DON, and Nurse Practitioner N were present. When asked about staff communal dining and the concern with the removal of masks and faceshields, Staff G and Staff LL confirmed they had not considered it (as a risk for transmission). When the observation on Birch of Resident #13 was shared, Nurse Practitioner N confirmed Resident #13 had tested positive for COVID-19. When asked why RN E was not made aware of Resident #13's positive result, the DON said, That is concerning. When asked about staff surveillance of PPE in Transmission-Based Precautions (isolation for COVID-19), Staff G confirmed no observations were made until after the weekend beginning on September 28, 2020. Review of facility's policy/procedure Novel Coronavirus Prevention and Response revised 6/5/20, read in part, The Infection Preventionist will assess facility risk associated with COVID-19 through surveillance activities .Implement heightened surveillance activities .Support hand hygiene .making sure .alcohol-based hand rubs are available .Promote easy and correct use of personal protective equipment . Review of facility's policy/procedure Outbreak Infection Control Measures revised 2/2020, read in part, Control measures .restriction of transfers and admission to and from nursing unit(s) and/or the entire facility . Review of facility's policy/procedure Emergency Staffing Plan, 4/22/20, read in part, Discontinue offering employee meals . Review of CDC Coronavirus Disease 2019 (COVID-19) Clinical Care Guidance, revision 9/10/2020, read in part, The incubation period for COVID-19 is thought to extend to 14 days, with the median time of 4-5 days from exposure to symptom onset .Atypical presentation occur often, and older adults and persons with medical comorbidities may have delayed presentation of fever and respiratory symptoms .Another study of skilled nursing facility residents who were infected with [DIAGNOSES REDACTED]-CoV-2 after contact with a healthcare worker with COVID-19 demonstrated that half of the residents were asymptomatic or pre-symptomatic at the time of contact tracing, evaluation, and testing .

This citation pertains to intake #MI 089. Based on interview and record review, the facility failed to ensure demonstrations of competency by nursing staff involving one Resident (#152) of one sampled resident reviewed for a significant change of condition. This deficient practice resulted in harm due to staff not performing consistent assessments, evaluations, and prompt responses to residents' needs leading to hospitalization for further treatments, pain, distress, and the potential for further clinical compromise. Findings include: According to Resident #152's Minimum Data Set (MDS) assessment, dated 11/6/19, showed an admission date of [DATE], with the following major Diagnoses: [REDACTED]. The Brief Interview for Mental Status (BIMS) reflected 3/15 which reflected severe impaired cognition. Resident #152 had inattention and disorganized thinking and required supervision with bed mobility, transfers, and ambulation. Review of Resident #152's Medical Doctor (MD) Y's assessment, dated 1/27/20, read, Patient had recent closed pelvic fractures. Her pain is still not controlled adequately . Review of Resident #152's Nurse Progress Notes, dated 1/26/20 at 10:48 read, . the resident (R#152) has not been up and out of bed since Thursday (1/20/20), that prior to Thursday the resident had the capability to walk independently, resident is now having right hip pain discomfort, when going to move the leg or roll the resident in bed she will grimace in discomfort and grab the right hip area . Review of Resident #152's Nurse Progress Note, dated 1/26/20 at 10:39 read, resident (R#152) not able to turn herself in bed without yelling in pain, and when doing QADL's (activity of daily living per shift) and rolling her in bed she will yell and hold her right hip not able to move with out screaming RN assessed and will follow up . Review of Resident #152's Nurse Progress Note, dated 1/25/20 at 20:42 read, .Resident a no void this tour (shift) with fluids pushed all shift. Review of Resident #152's Nurse Progress Note, dated 1/24/20 at 19:49, written by Registered Nurse (RN) X, Aide reports resident in pain, C/O (complaint of) pain with attempts to sit up in bed. Refused out of bed until 1900 for cares/toileting. Resident C/O could not stand. Appears to favor left leg. Informed charge and physician. Bladder scan shows 460 ml (milliliter) but resident would not void . Review of Resident #152's Nurse Progress Note, dated 1/23/20 at 20:46 read, Resident in bed all of shift, .Tylenol given for temp 100.6 T, Resident refused supper meal . During an interview on 2/27/20 at 2:43 p.m., Assistant Director of Nursing (ADON) L was asked if and when the physician was notified after review of Resident #152's Nurse Progress Notes from 1/23/20 through 1/25/20 with the following signs and symptoms of a change of condition: sudden and increased pain, inability to ambulate, inability to stand, inability to turn in bed, favoring one leg, refusing out of bed, no urine output, decreased oral intake. ADON L responded, I can't find anything (physician notification). When asked if there was a delay in notification to Resident #152's physician, ADON responded, Yes. And then ADON L indicated she would have called (sooner). Review of facility's MD Y staff communication book (found at the central nurses' station) reflected no entries for Resident #152 for the time period of 1/23/20 through 1/25/20. During an interview on 2/27/20 at 3:40 p.m., Charge Nurse, RN W was asked to show shift change nursing communication sheets from 1/22/20 through 1/25/20 for Resident #152. RN W said they were shredded. Review of Resident #152's Care Plan for Pain, 5/9/2019, read, .Monitor/document/report to MD PRN (as needed) s/sx (signs and symptoms) or complications related to .Joint pain .Decline in mobility .pain after exercise or weight bearing . Review of facility's Policy and Procedure for Significant Change revised 6/19/2017, read, It is the policy of this facility to identify significant changes of a resident's clinical status in a timely manner .

Based on observation, interview, and record review, the facility failed to prevent Resident to Resident physical abuse, resulting in harm, for one Resident (#3) of three residents reviewed for abuse. This deficient practice resulted in a fall with injury (fractured right hip) requiring surgical repair, increased pain, and decreased Activity of Daily Living (ADL) function. Findings include: Review of Resident #3's Minimum Data Set (MDS) assessment, assessment reference date of 7/7/19, revealed Resident #3 was admitted to the facility with the following Diagnoses: [REDACTED]. Resident #3 required supervision for walking in the corridor but was independent in bed mobility, and transfers. Resident #3 scored 6 of 15 on the Brief Interview for Mental Status (BIMS), reflective of severely impaired cognition and resided in the secure (locked) dementia unit within the facility. Resident #3 used a walker for mobility assistance. Review of Resident #2's MDS assessment, assessment reference date 8/12/19, revealed Resident #2 had the following active Diagnoses: [REDACTED]. Resident #2 required supervision for walking in the corridor. Resident #2 scored 8 of 15 on the BIMS, reflective of moderate cognitive impairment, walked without the use of any mobility device (walker), and resided in the facility secure (locked) dementia unit. Review of an Altercation Investigation Form, dated 8/23/19, revealed Resident #3 was found .lying on her right side on top of her walker .States . She (Resident #2) pushed me . Resident #2 was listed as the perpetrator on the Altercation Investigation Form and was documented with no known history of abuse. Both Resident #2 and #3, were alert, confused per norm. The form was completed by Registered Nurse (RN)/Assistant Director of Nursing (ADON) [NAME] Review of the Falls Investigation, dated 8/23/19, revealed the following in part: Time: 1315 (1:15 p.m. Central Standard Time (CST)) . Was an injury sustained as a result of the fall? Yes . Right hip pain - at ED (Emergency Department) for Eval (evaluation) .What do you believe to be the root cause of this fall? Resident to Resident altercation with Resident (#2) . Another resident pushed me down . Review of Resident #3's hospital Discharge Instructions dated 8/29/19, revealed the following, in part: Diagnoses: [REDACTED].Has comminuted right proximal femur fracture and severe dementia .She should be NWB (non-weight bearing) to touchdown for now on the right, as she is able to cooperate .she may be transferred with maximum assist and a walker or lift as she is able to do so .Initially she should be transported to clinic on a gurney, NOT a wheelchair . Review of Resident #3's MDS, assessment reference date 9/27/19, revealed Resident #3 required extensive two-person assistance with bed mobility, transfers, toilet use, and dressing following the resident to resident altercation resulting in a fall with major injury. Review of Resident #3's (MONTH) 2019 Medication Administration Record [REDACTED]. The following physician orders [REDACTED].#3's 8/23/19 fall with major injury during the resident to resident altercation with Resident #2: 1. [MEDICATION NAME] Solution 10 MG/ML (milligrams per milliliter), Inject 4 mg subcutaneously one time only for right hip pain for 1 Day. Start Date: 8/23/19. 2. [MEDICATION NAME], 325 MG (milligrams), Give 2 tablet by mouth every 6 hours as needed for PAIN, Start Date 8/30/19. Documented as administered on both 8/30 and 8/31. Review of Resident #3's (MONTH) 2019 MAR indicated [REDACTED]. On 10/3/19 at 8:55 a.m. Resident #3 was observed eating breakfast while seated in a high-back wheelchair with attached footrests. Resident #3 ate independently. A white binder containing resident behavior tracking logs was lying on a nearby table, with a pink cover sheet that read: ALL STAFF: If a resident is hitting another resident this is considered abuse and must be reported immediately - so that it can be reported to the state within 2 hours, signed by Social Worker (SW) E, dated 9/6/19. On 10/3/19 at 9:30 a.m., when asked why there was a STOP sign barrier posted outside of Resident #2 (alleged perpetrator's) room, SW F stated, Because . we don't want her to hurt someone. When asked if Resident #2 had hurt someone before, SW F nodded her head up and down, in an affirmative response. Review of Resident #2's Care Plans revealed the following, in part: .I have a private room d/t difficulty getting along with anyone .I can be verbally abusive to other residents, arguing with roommates over personal space, threatening physical violence .I have hit another resident, attempted to kick, and fought over a walker resulting in a fall of the other resident .with interventions that included: Separate me from other residents that I may be having conflicts with, Date Initiated: 5/13/16. Re-direct other residents out of my personal space, Date Initiated 3/20/19 . On 10/3/19 at 9:45 a.m., when asked if Resident #2 had shown physical or verbal aggression toward other residents, SW G stated, .It is not her first resident to resident altercation . she does not like other people in her space. People will just be walking by her door, and with dementia they talk to her (Resident #2), and she does not like people in her space. It seems like that is when she gets into resident altercations . When asked why Resident #2 was moved out of the secure (locked) unit, RN G stated, .Thinking of the safety of other residents - that was the best solution - on how we could make sure our other residents were safe . When asked about the resident to resident altercation between Resident #2 and Resident #3, SW G stated, (Resident #2) grabbed her (Resident #3) and pulled her down to the ground .Yes, I would say this is definitely a resident to resident altercation. (Resident #2) was definitely aggressive . On 10/3/19 at 11:40 a.m., when asked about the altercation between Resident #2 and Resident #3, Certified Nurse Aide (CNA) I stated, (Resident #3) was adamant (Resident #2) pushed her .she (Resident #2) has gotten in altercations with residents and staff before . When asked about adequate supervision for Resident #2 and Resident #3 while walking in the secure unit hallways, CNA I stated, That doesn't always happen. We don't have the staff for that (adequate supervision of Residents #2 and #3) . On 10/3/19 at 12:59 p.m., when asked about the altercation and observation of the surveillance video, ADON A stated, .I do agree (Resident #2) has a history of resident to resident altercations .One of (Resident #2's} causes of aggression would be people getting near her room . Anyone walking by her room could set her off. (Resident #2's) personal space includes the area outside her door . When asked what caused Resident #3's fall with injury, ADON A stated, I would have to say (Resident #2) . ADON A said the surveillance video showed Resident #2 pushing Resident #3 on the head, pushing her (Resident #3) to the floor. ADON A also said Resident #2 was moved off of the secure unit because .We felt moving her off the unit would be the best for the safety of the residents on our unit . On 10/3/19 at 1:36 p.m., the 8/23/19 surveillance video of the resident to resident altercation, between Resident #2 and Resident #3, was reviewed with Admission Coordinator (Staff) C. Resident #3 was viewed ambulating with a walker, walking past Resident #2's room. Resident #2 exits her room immediately after Resident #3 walked past the room door. A verbal altercation can be seen, but audio is not present. Resident #3 throws a newspaper/magazine at Resident #2. Resident #2 kicks the magazine back at Resident #3. The object did not make contact with either resident. Resident #3 bends over to pick up the magazine, as Resident #2 appears to push her right sleeve up, then approaches Resident #3 and grabs Resident #3's hair on the top/back of her head and pushed her head downward, toward her feet, lower and lower, until Resident #3 was unable to maintain her balance, and fell to the floor. No staff were present in the hallway during this resident to resident altercation to provide supervision and/or redirect the residents. During an interview at this same time, Staff C said the surveillance video of the altercation was reviewed on 8/23/19, between 1:30 p.m. and 6:30 p.m. Staff C stated, (Resident #2) caused (Resident #3's) fall and she (Resident #3) broke her hip. Staff C agreed it was resident to resident abuse, and indicated they (ADON A and Staff C) knew pretty quickly what had happened, because it was right after the fall (same day) that the surveillance video was viewed by ADON A and Staff C. Review of the facility Investigation Report revealed the following, in part: .(Resident #3) requires supervision for walking in room and corridor, locomotion on unit . (Resident #2) requires supervision with ambulation .1314:38 (1:14 p.m. (CST)) (Resident #2) then sets an object on the floor and walks toward (Resident #3). 1314:45 (1:14 p.m.) (Resident #3) is bending over the object to pick it up when (Resident #2) grabs her (Resident #3) by the hair. 1314:51 (1:14 p.m.) (Resident #3) is pushed to the floor and lands on her right side with her walker partially underneath her. 13:15:00 (1:15 p.m.) (Resident #2) picks up the object she set down and walks away. 13:15:52 (1:15 p.m.) staff arrives . Review of Resident #3's Fall Care Plan revealed the following interventions: 1. Check on me frequently throughout shift and if I'm around other residents who like to get close to me, please re-direct me away from them. Date Initiated: 7/18/19. 2. Please monitor me and all other residents in general activity area to prevent negative encounters which may affect my safety. Date Initiated: 6/29/18. On 10/3/19 at 3:17 p.m., when asked about the resident to resident altercation, Corporate Compliance Officer/Staff D stated, I would say yes, if she (Resident #3) was grabbed by the hair and pushed down I would consider that a resident to resident altercation, potentially abuse . When asked why the police were contacted, Staff D stated, That is what we were obligated to do . If we had a concern their there might have been an issue - that somebody harmed somebody else . On 10/3/19 at 4:30 p.m. the Nursing Home Administrator (NHA) was asked about reporting of the resident to resident altercation to the police. The NHA stated, We would report to the police right away if we expect abuse .

All times are Eastern Standard Time Based on interview and record review, the facility failed to provide proper transfer in a motorized lift resulting in harm for one (Resident #6) of three residents reviewed for accidents. This deficient practice resulted in a fall with major injury including multiple fractures for Resident #6. Findings include: According to the Face Sheet dated 10/14/18, Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 99, indicative of severe cognitive impact and an inability to be understood. The Plan of Care, revised on 10/23/18, reveals Resident #6 is now on comfort care and on bedrest due to injuries. According to the ABUSE INVESTIGATION dated 10/18/18, and signed by the Nursing Home Administrator (NHA), director of Nursing (DON), and the Assistant DON, Resident #6 was being transferred from her bed to her wheelchair with the mechanical lift when the lift clip came off causing the bottom strap of the sling to come undone on the left side and resident landed on her face/stomach. Laceration to her forehead, bilateral closed [MEDICAL CONDITION], closed fracture of proximal end of right humerus and bilateral nasal bone fractures. According to the Emergency Department (ED) Notes, written on 10/18/18, Resident #6 had been seen in the ED on 10/14/18 with nasal bone fractures and [MEDICAL CONDITION], then returned to the ED for concerns for arm injury. T Resident #6 was then brought to the ED on 10/15/18, for concern for leg injury and noted to be hypotensive by EMS. Imaging studies dated 10/18/18, from the Emergency Department Provider Notes, written by physician V, read, Imaging Studies R humerus: Comminuted fx (fracture) of humerus with possible hematoma. CT (computed tomography) head: .Bilateral nasal bone fx. CT abd (abdomen)/pelvis: Comminuted intertrochanteric fx of both hips, non-displaced fx of proximal R femoral shaft. Hemorrhage into R abductor muscles. Omitted from the facilities ABUSE INVESTIGATION was the information that Resident #6 also sustained a non-displaced fx of the proximal R femoral shaft. The INCIDENT REPORT, dated 10/14/18 and written by Registered Nurse (RN) W, read, Resident (#6) was being transferred from her bed to her chair with the (mechanical) lift when the lift broke causing the resident to roll out of the lift sling face forward onto the ground from approx 3 feet .(name of witnesses) (CNAI) and (CNA J). A hand written paper included in the INCIDENT REPORT, read, .(J) did a re-enactment of the transfer of (Resident #6), with the DON and ADON present .They then attached her (mechanical) sling to the lift- the blue hook on the top and the black on the bottom . Review of the (mechanical) Lift Equipment Monthly Preventive Maintenance Checklist for the (YEAR) calendar year, reveals monthly maintenance checks were completed through (MONTH) for the specific lift involved in the accident which injured Resident #6. The same document reads, under WORK ORDER DESCRIPTION/PM, Checked-everything OK and under Description of Work/Repair Made, Out of service due to resident fall, checked by maintenance worker G on 10/15/18. In an interview on 10/24/18 at ~9:45 a.m., maintenance worker, G stated, We test every machine with weights every single month. Maintenance worker G pointed to the weights that were stacked against the wall and stated, We put those weights on every lift and lift them as if it was a person. We were dumbfounded when we heard the lift broke. The incident happened on a Sunday, and right away we brought it in and checked it, and we went through the whole thing, and there was absolutely nothing wrong with it. The clip was off, and we replaced it, but there's no way that clip is coming out when we have weight on the lift. Maintenance worker H proceeded to demonstrate how difficult it was to remove the clip and took two attempts to put it back on the arm that holds the cloth sling. On 10/24 at 1:23 p.m., Maintenance worker M was interviewed regarding the (mechanical) lifts. M stated, The clips could pop out if the sling isn't put in properly. I was a CNA before, and I've never seen one pop out when the slings are right. It could pop out if the sling isn't put in correctly though . but no one has ever fallen out out. According to the manufacturer's instructions, found on line, for the specific lift that was used, page 2 of the Safety Instructions read, Before using the lift, make certain that: o the lifting accessory (sling) is correctly and securely applied to the patient, so that no personal injury can occur o the lifting accessory (sling) is correctly applied to the lifting equipment o the sling's strap loops are correctly fastened to the slingbar hooks when the sling strap is extended, but before the patient is lifted from the underlying surface. In an interview with CNA I on 10/24/18 at 10:40 a.m., I stated, My partner, (J) was on the left and I was on the right, then she came where I was and operated the lift and I went to get the wheelchair .I know I hooked up the right, always blue on the top (of the sling strap) and purple on the bottom. When asked if she ever used a different color band, like black, I stated, No, never black, it's blue on top and purple on the bottom. Then CNA I took this surveyor into a utility closet where a lift was and completed a demonstration on how the sling was attached. I placed the blue loop from the top of the sling into the sling bar past the safety clip and then placed the purple loop from the bottom of the sling into the sling bar past the safety clip. In an interview on 10/24/18 at ~ 10:55, J stated, I feel horrible. I feel guilty. We were getting her (Resident #6) up for breakfast. I was hooking her up and it was taut and I lifted her, and the clip fell off. I didn't even have a chance to get the legs (of the lift) open. She rolled in the air on the floor. I was 100% positive it was hooked up right, with black on the bottom. When asked if she was sure it was black and not purple, J stated, No, I always use the bottom one (loop), the black. In an interview on 10/24/18 at 12:55 p.m. with CNA's K and L, who were getting ready to use the (mechanical) lift on a resident, were asked what the difference would be if one side used the black loop and the other side used the purple loop. K stated, One side would be higher, it'd be tilted. It's about 4 difference between the two. On 10/24/18 at 3:10 p.m., the DON was asked if CNA's are trained on the (mechanical) lifts. The DON stated, When they take their CNA classes, they learn how to use the lifts. (I) and (J) have been CNAs forever, since before I got here it isn't part of their (CNA's) competency tests but it probably will be from now on.

Based on observation, interview and record review, the facility failed to provide adequate supervision and assistance devices to prevent injury from a fall for 1 Resident (#602) of 4 residents reviewed for safety/supervision from a total sample of 4 residents. This deficient practice resulted in harm to Resident #602 when he fell while exiting a facility van in his wheelchair. The fall caused a sternal fracture, severe pain requiring increased levels of pain medication and emotional distress for this resident. Findings include: All times noted are Central Standard Time (CST). Review of the Minimum Data Set (MDS) Assessments dated 6/12/15, 9/12/15, 12/13/15 and 3/14/16 revealed Resident #602 is an [AGE] year old man, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On the MDS assessment dated [DATE], Resident #602 scored a 15/15 on the Brief Interview for Mental Status, reflective of being cognitively intact. Resident #602 required extensive 2+ person assist for bed mobility and transfers. Review of a facility Abuse Investigation involving Resident #602, dated 7/9/15, revealed a 7/6/15 fall .In the transport van .he flipped his w/c (wheelchair) backwards and hit his head. Resident was sent by ambulance .to .ED (Emergency Department) . Review of the 7/6/15 Emergency Physician Record - Fall at 1230 (12:30 p.m.) revealed Chief Complaint: Fall injury to chest. Resident #602 had complaints of right anterior chest pain, with a [DIAGNOSES REDACTED]. Review of an Emergency Physician Record - Trunk Injury dated 7/8/15 at 12:20 p.m., two days after the fall, revealed Resident #602 was seen for complaints of severe chest pain. The Record documented .moderate distress .tenderness (chest) .decreased breath sounds . Review of Resident #602's Radiology Report dated 7/8/15 revealed: .IMPRESSION (x-ray findings): Acute fracture of proximal sternum (breastbone) . Review of Patient Care Instructions, dated 7/8/2015 at 2:26 p.m. contained within the Abuse Investigation documentation for Resident #602 read, in part: .Sternal fractures usually take 6 to 12 weeks to heal .This is a potentially dangerous condition. Internal bruising of the heart, lungs or abdominal organs can cause life-threatening complications . Review of Resident #602's Electronic Medication Administration Record (eMAR) revealed: Pain Rate every shift documented with moderate to severe pain (5 to 10 on pain scale rating) on 7/8, 7/9, 7/10,7/12, 7/13, 7/14, 7/19 and 7/20/2015 following the 7/6/2015 fall. Per the July 2015 eMAR, Resident #602 was prescribed and/or received the following narcotic analgesics for pain relief following the 7/6/15 fall: 6/4/14 - Roxicodone (opioid) Tablet 5 mg - give 1 table by mouth every 4 hours as needed for Pain; noted as administered on 7/7, 7/8, 7/9, 7/10, 7/19, and 7/24/15. 7/8/15 - Morphine Sulfate 10 mg/ml - inject 4 mg every 2 hours as needed for sternal pain .Discontinue when Dilaudid comes in. 7/9/15 - Fentanyl (opioid) 25 mcg/hr (hour) every 72 hours; 7/13/15 Fentanyl increased to 50 mcg/hr every 3 days; 7/16/15 Fentanyl increased to 75 mcg/hr every 3 days. D/C (Discontinued) Date 9/23/15. 7/9/15 - Dilaudid (opioid) 1 mg/ml - Use 0.5 mg intravenously every 3 hours as needed for Pain; 7/10/15 increased to Dilaudid 2 mg/ml (same instructions as above); 7/13/15 continued Dilaudid 2 mg/ml (same instructions as above). D/C Date 9/23/15. Review of July, 2015 Nursing Notes revealed Resident #602 had complaints of pain documented in the nursing notes on 7/6, 7/7, 7/8, 7/9, 7/10, and 7/13/15. Resident #602 complained of .Sternum pain of (level) '10' . on 7/19, and .Resident (#602) was yelling, screaming and cursing in pain . on 7/24/15. Review of the 9/12/15 MDS Assessment for Resident #602 revealed pain was documented as present. The previous MDS assessments dated 6/12/15 (prior to 7/6/15 fall) and following on 12/13/15 and 3/14/16 reflected no pain concerns. During an interview on 6/3/16 at 8:35 a.m. Resident #602 confirmed he had a fall in the facility transport van .about a year ago . When asked to describe what happened, Resident #602 stated, .I broke bones .that .really hurt .Both people (transport staff) were on the ground - usually one stood behind my wheelchair as I went up the ramp and the other one did the lift (operated the mechanical lift from outside the vehicle), and I didn't have anti-tip (bars) on my wheelchair. Resident #602 confirmed there was no staff member behind his wheelchair to assist him in exiting the van via the mechanical lift on 7/6/15. In another interview on 6/6/15 at 2:55 p.m., Resident #602 stated, (I) Don't remember hearing them say 'Don't move' - No, they didn't say that ., when asked about further details of the 7/6/15 fall. Review of the Facility Transport - Basic Rules policy, revised 5/1/2014 revealed the following, in part: .8. You need to be able to see and assist the resident at all times . On 6/3/16 at 9:20 a.m., Resident #602 was observed as he prepared for transport in a facility van. On 6/3/16 at 9:20 a.m., when Resident #602 was asked if this was the van where the fall occurred, Resident #602 stated No, (it was the) Ford Van. On 6/3/16 at 9:50 a.m. Director of Maintenance staff B stated, .Anyone that is using those vans are trained by our staff on how to use it (the mechanical lift) .We give them instructions on how to use the electrical control switch and emergency measures (for mechanical lift) if anything does go wrong Staff B acknowledged that maintenance staff did not train the transport staff on how to safely secure a resident or release a wheelchair from the facility vans. On 6/3/16 at 10:42 a.m. this Surveyor observed the Ford Van in the presence of Certified Nurse Aide (CNA) I. This Ford Van had similar mechanical lift positioning and safety strap equipment to secure a wheelchair into the van, as the van this Surveyor observed preparing to transport Resident #602 on 6/3/16. On 6/3/16 at 11:15 a.m. Occupational Therapist (OT) K was asked to provide this Surveyor with the last wheelchair assessment for Resident #602's transport wheelchair. A Wheelchair Safety Checklist for Resident #602's transport wheelchair (#173), dated and signed on 6/5/2014, was produced and reviewed. The Checklist showed .8. Anti Tippers - No . OT K explained, .It (Anti Tipper) prevents the (wheel) chair from falling backwards .I haven't heard of anyone falling backwards with Anti Tippers on (their wheelchair) . OT K stated, .We would not have put them on the chair unless he had falls from his chair, and I don't think we were aware of any falls . When informed this Surveyor had observed Anti Tippers on Resident #602's wheelchair that day, OT K commented that she did not know and stated, .We (Therapy) did not put them on, Maintenance does not always notify therapy if they do put on Anti Tippers . Review of Resident #602's Fall Care Plan, revised 5/17/16 revealed the following intervention: Anti Tippers installed on wheelchair, Date Initiated: 07/06/15. Review of the July 2015 Vehicle Mileage Log for the Ford 2011 facility transport van revealed Certified Nurse Aide (CNA) C and CNA M had transported Resident #602 on 7/6/15. On 6/3/16 at 1:30 p.m. CNA C was asked if she remembered a transport incident involving Resident #602. CNA C stated, I was outside of the van (to operate the lift). She (CNA M) unhooked the transport hooks from the (wheelchair) wheels, Resident #602 unhooked the seatbelt, unlocked his chair, and started to move toward the lift. As (Resident #602) was moving forward onto the lift, CNA M was not behind the wheelchair, and he started to tip back once he got his front two wheels onto the lift edge .I don't think he had Anti Tippers on his wheelchair. In a follow-up interview on 6/6/16 at 1:50 p.m. CNA C reported that she was a fill-in transport CNA; it was not her usual assigned position. CNA C was asked if she had received transport training prior to Resident #602's fall. CNA C stated, No, I did not get training. On 6/3/16 at 1:41 p.m., CNA M reported that she was a fill-in for transports, and it was not her usual assigned position. When asked to describe Resident #602's fall in the van, CNA M reported that Resident #602 liked to take his own seatbelt off, and had taken it off that day. CNA M continued, The Easy Stand (device for transfers) was in the van also . as (Resident #602) was turning, I was turned toward the back (of the van) and the Easy Stand, and I heard CNA C say, 'Don't come out!' .I turned around and (Resident #602) was turning himself on the lift - he tipped on the lift .He didn't have the legs (double ambutee) to hold him(self) down in front, plus he had a bag with his blanket, his notebook and anything he needed at dialysis (on the back of the wheelchair). He should have had Anti Tipper legs on his wheelchair .once he fell , my hands were on him . CNA M confirmed that she had removed the vehicle straps (hooks) that prevented Resident #602's wheelchair from moving before she turned toward the back of the van, away from Resident #602. CNA M, when asked how she had been trained for safe transport of residents stated, .I was trained by the girls that do it. You go with them on runs (transports). The CNA's train each other . When asked to review the two Transport/Transportation policies provided to this Surveyor by the facility, CNA M stated, .I have never seen these .I don't recall ever seeing these. Review of a Facility policy for Using Lift (and) Securing Lift (undated) read in part: Using Lift .Staff member to stand behind wc (wheelchair) on lift as long as does not exceed 800 lbs (pounds) or if wc/chair is too big and unsafe to stand on lift (eg: geri chair/large wc) . Securing W/C (Wheelchair): W/C are to face forward .the blue van has hooks instead of straps - hook back straps to cross bar under wc and front straps to front bars by footrests .front straps are to be placed at an outside angle from front wheel .Ratchet straps until tight .Back straps are in an inside angle from back wheel straight back .Pull tight .There should be no slack in straps .Lock wheels on W/C .Put seat belt on .To release, reverse orders. (Seat belt off, wheelchair locks off, back hooks off, and then front hooks off). On 6/6/16 at approximately 3:45 p.m. RN R was asked to provide documentation of completion of transport training for CNA C and CNA M which included how to safely secure and release a resident into/out of the facility transport vans. A Transport Inservice sign in sheet, dated 3/15/16 (8 months after Resident #602's 7/6/15 injury) was provided and noted to be signed by CNA M. CNA C's signature or initials were not present on the in-service sign-in sheet. On 6/3/16 at 2:10 p.m., the Director of Nursing (DON) confirmed the transport CNA's are train by other transport drivers. The DON stated, We have CNA's train CNA's. The DON stated, No, they do not get any written instruction on transport of residents. The DON reported that she had never performed a quality review nor had CNA's been observed performing transports to assure staff were safely transporting residents in the facility vans. When the DON was asked if there was anything that may have prevented Resident #602 from falling backward in the van she stated, If he (Resident #602) had Anti Tip wheels on, I suppose that would have prevented the fall. If there had been someone behind him, they could have prevented the fall. On 6/6/16 at 9:20 a.m., Nurse Risk Manager/Registered Nurse (RN) R was asked to review the Transport Policies. RN R stated, I am not sure that is the way they do it - that is the way that they are supposed to do it (secure a resident into the vehicle) . RN R acknowledged .he (Resident #602) could not have tipped his chair over if the wheels were secured (to the van) .If she (CNA M) was in arm's reach, she could have tried to help .You are in the back of the van, and you need to be watching him, that is why you are back there . On 6/6/16 at 10:39 a.m., Assistant Director of Nursing (ADON) O was asked if a staff person behind Resident #602 could have prevented his fall. ADON O reviewed the witness statements from 7/6/15 and stated, She (CNA M) didn't say where she was in this witness statement. A person behind him should have been able to stop this (fall) . ADON O confirmed that Anti Tippers were placed on Resident #602's wheelchair following the fall on 7/6/15. ( )

THIS CITATION HAS TWO DEFICIENT PRACTICE STATEMENTS; (A) AND (B). (A) BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT THE MISTREATMENT (PHYSICALLY RESTRICTING RESIDENTS ARM/HANDS BEHIND HER BACK AND AGAINST HER WILL) OF ONE RESIDENT (#101) OF FOUR COGNITIVELY IMPAIRED ELDERLY RESIDENTS WHO RESIDE IN THE SPECIAL CARE UNIT REVIEWED FOR ABUSE, NEGLECT AND MISTREATMENT FROM A TOTAL OF 170 RESIDENTS IN THE FACILITY PLACING RESIDENT #101 IN IMMEDIATE JEOPARDY TO HER HEALTH AND SAFETY. THE FACILITY ALSO FAILED TO IMPLEMENT ITS OWN ABUSE PREVENTION AND INVESTIGATIONS PROCEDURES. THIS WITNESSED INCIDENT OF MISTREATMENT WAS REPORTED TO THE FACILITY'S ADMINISTRATOR WHO THEN FAILED TO RECOGNIZE THE ACT AS MISTREATMENT, FAILED TO REPORT THE INCIDENT TO THE STATE AGENCY, AND FAILED TO PUT IN PLACE INTERVENTIONS TO PREVENT FURTHER MIStreatment of [REDACTED]. THE IMMEDIATE JEOPARDY WAS IDENTIFIED ON 1/18/12 AT 10:00 A.M. CENTRAL STANDARD TIME (CST). ALL TIMES SHOWN IN THIS REPORT WILL BE SHOWN AS CENTRAL STANDARD TIME. THE IMMEDIATE JEOPARDY BEGAN ON 1/4/12 AT 8:52 P.M., WHEN CERTIFIED NURSE AIDE (CNA) 'A', WHO WAS ASSIGNED TO PROVIDE DIRECT ONE ON ONE (1:1) SUPERVISION TO RESIDENT #101 DUE TO AGITATION, INAPPROPRIATELY HELD RESIDENT #101 BY HER WRISTS/ARMS, DOWN/BEHIND HER BACK AND AGAINST HER WILL. THIS WITNESSED INCIDENT OF MISTREATMENT WAS REPORTED TO THE FACILITY'S ADMINISTRATOR, WHO THEN FAILED TO REPORT THE INCIDENT TO THE STATE AGENCY BECAUSE, PER THE FACILITY ADMINISTRATOR, "THE CNA WAS DOING HIS BEST TO CONTROL TWO RESIDENTS AT THE SAME TIME." THE FACILITY ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON 1/18/12 AT 10:14 A.M. THE IMMEDIATE JEOPARDY WAS REMOVED ON 1/18/12 AT 3:15 P.M. AFTER THIS SURVEYOR VERIFIED THE FOLLOWING: -ON 1/18/12, THE DIRECTOR OF NURSING (DON) SUSPENDED CNA 'A' FOR A SUBSTANTIATED FINDING OF MIStreatment of [REDACTED]. -RESIDENT #101 HAS BEEN ASSESSED AND IT WAS DETERMINED SHE SUSTAINED NO INJURIES OR CHANGE OF BEHAVIOR SINCE THE INCIDENT. -ON 1/18/12, THE MANAGEMENT TEAM INTERVIEWED, BOTH IN PERSON AND BY TELEPHONE, THE NURSING STAFF WORKING REGULARLY IN THE SPECIAL CARE UNIT TO IDENTIFY ANY OTHER INCIDENTS IN THE PAST TWO WEEKS IN WHICH THE NURSING STAFF PERCEIVED THAT ANY RESIDENTS WERE MISTREATED. THE MANAGEMENT TEAM WILL IMMEDIATELY REPORT ANY INCIDENTS TO THE ADMINISTRATOR AND DON WHO WILL IMMEDIATELY REPORT THE ALLEGATIONS TO THE STATE AND INITIATE THE INVESTIGATION. THEY WILL SUSPEND ANY STAFF ALLEGED TO HAVE MISTREATED RESIDENTS PENDING THE RESULTS OF THE INVESTIGATION. -ON 1/18/12, THE NURSING CONSULTANT CONDUCTED A TELEPHONE TRAINING WITH THE ADMINISTRATOR AND NURSING LEADERSHIP, CLARIFYING THE FACT THAT ALL ALLEGATIONS THAT ARE RECEIVED VERBALLY OR IN WRITING MUST BE REPORTED TO THE STATE AGENCY WITHIN 24 HOURS, REGARDLESS OF THE RESULTS OF THE INVESTIGATION. -ON 1/18/12, THE ADMINISTRATOR REVIEWED AND REVISED THE FACILITY'S ABUSE PREVENTION POLICY TO INCLUDE THE REPORTING OF ANY ALLEGATIONS OF ABUSE. -ON 1/18/12, THE DON AND HER LEADERSHIP TEAM DEVELOPED AN IN-SERVICE FOR THE NURSING STAFF ON THE SPECIAL CARE UNIT. THE AGENDA INCLUDED: A) PROHIBITION OF MISTREATMENT AND THE EXAMPLE OF PHYSICALLY RESTRAINING A RESIDENT'S LIMBS PREVENTING THEM FULL MOVEMENT; B) METHODS TO DEAL WITH RESIDENTS WHEN THEY BECOME PHYSICALLY AGGRESSIVE THAT DOES NOT INVOLVE PHYSICALLY RESTRAINING LIMBS TO PREVENT CONTACT WITH ANOTHER PERSON (STAFF OR RESIDENT); AND C) THE OBLIGATION TO IMMEDIATELY REPORT ANY OBSERVATION OF MISTREATMENT TO THE ADMINISTRATOR AND DON. -ON 1/18/12, BY THE END OF THE FIRST SHIFT, THE NURSING MANAGEMENT TEAM BEGAN THE TRAINING ON THE SPECIAL CARE UNIT, AND WILL CONTINUE AT THE CHANGE OF EACH SHIFT FOR THE NEXT 24 HOURS. -ON 1/19/12 AT 2:00 P.M., NURSING LEADERSHIP WILL HOLD AN IN-SERVICE FOR NURSING STAFF ON THE SPECIAL CARE UNIT WHO ARE NOT SCHEDULED TO WORK BETWEEN 1/18/12 DAY SHIFT AND 1/19/12 AFTERNOON SHIFT. THEY WILL NOTIFY THE NON-SCHEDULED EMPLOYEES BY TELEPHONE. AS OF 1/19/12 AT 3:00 P.M., ALL NURSING STAFF REGULARLY ASSIGNED TO THE SPECIAL CARE UNIT WILL HAVE COMPLETED THE TRAINING, WITH THE EXCEPTION OF ANY UNAVAILABLE (I.E., VACATION, ILLNESS, ETC.) NURSING STAFF FROM THE SPECIAL CARE UNIT, WHO WILL BE TRAINED ON THEIR FIRST SHIFT AFTER RETURNING TO WORK. -ON 1/18/12, THE DON INITIATED A QUALITY ASSURANCE STUDY IN WHICH THERE ARE RANDOM OBSERVATIONS OF CARE ON THE SPECIAL CARE UNIT ON ALL SHIFTS THREE TIMES PER WEEK TO DETERMINE IF NURSING STAFF IS PROPERLY DEALING WITH DIFFICULT BEHAVIORS. THIS WILL ALSO INCLUDE INTERVIEWING ONE STAFF MEMBER ON EACH SHIFT WEEKLY TO DETERMINE IF HE/SHE OBSERVED ANY MISTREATMENT. THIS STUDY WILL CONTINUE UNTIL OTHERWISE DIRECTED BY THE QUALITY ASSURANCE COMMITTEE. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE CONTINUES AT AN ISOLATED LEVEL, WITH POTENTIAL HARM TO ALL RESIDENTS DUE TO: -THE FACILITY'S NEED TO COMPLETE TRAINING WITH ALL NURSING STAFF ON THE SPECIAL CARE UNIT REGARDING PROHIBITION OF MIStreatment of [REDACTED]. -THE FACILITY'S NEED TO COMPLETE THEIR QUALITY ASSURANCE STUDY WITH RANDOM OBSERVATIONS OF THE SPECIAL CARE UNIT AND INTERVIEWS WITH STAFF MEMBERS ONCE WEEKLY. FINDINGS INCLUDE: A REVIEW OF A FORM TITLED "ABUSE INVESTIGATION" DATED 1/5/12, SHOWED THAT ON 1/4/12 AT APPROXIMATELY 8:45 P.M., CNA 'A' GRABBED RESIDENT #101'S ARMS AND PUT THEM BEHIND HER BACK AND HELD THEM THERE. THIS INCIDENT WAS WITNESSED BY CNA 'C', CNA 'D', AND CNA 'E'. CNA 'E' REPORTED THE INCIDENT TO REGISTERED NURSE (RN) 'B' WHO THEN ATTEMPTED TO CONTACT THE ADMINISTRATOR AND NOTIFIED THE DON. CNA 'A' WAS SENT HOME AFTER THE INCIDENT OCCURRED ON 1/4/12 AT THE DIRECTION OF THE DON PENDING THE FACILITY'S INVESTIGATION. ON 1/5/12, SURVEILLANCE VIDEO WAS REVIEWED BY THE ADMINISTRATOR, DIRECTOR OF NURSING AND THE COMPLAINT OFFICER. THIS FACILITY ABUSE INVESTIGATION READS IN PART, "...FROM THE 5 STATEMENTS THAT WERE RECEIVED THREE WHO WERE IN THE VICINITY AT THE TIME OF THE INCIDENT DID NOT HEAR ANY VERBAL ABUSE AND THE 2 STATEMENTS THAT INDICATED THAT THEY HEARD VERBAL ABUSE WERE NOT IN THE VICINITY AT THE TIME OF THE INCIDENT. ACCORDING TO FINDINGS ON THE CAMERA, THE EMPLOYEE FOLLOWED PROPER PROTOCOL TO PROTECT THE OTHER EMPLOYEE AND HIMSELF FROM INJURY WITHOUT MALICIOUS INTENT OR UNDO FORCE. THEREFORE ABUSE CANNOT BE SUBSTANTIATED." THIS ABUSE INVESTIGATION REPORT WAS SIGNED BY THE DIRECTOR OF NURSING AND FACILITY'S ADMINISTRATOR AND DATED 1/5/12. ATTACHED TO THIS FACILITY ABUSE INVESTIGATION DATED 1/5/12 ARE WRITTEN WITNESS STATEMENTS FROM CNA 'E', CNA 'C', CNA 'D', CNA 'I', CNA 'J'. THE WITNESS STATEMENTS FROM CNA'S 'E', 'C', 'D' ALL REPORT OBSERVING WHAT THEY BELIEVED TO BE ABUSE. CNA 'E'S WRITTEN STATEMENT DATED 1/4/12 READS, "...I NOTICED (RESIDENT #101) SITTING IN A CHAIR. (CNA 'A') STANDING BEHIND HER. I OBSERVED (CNA 'A') HOLDING RES HANDS (BY THE WRIST) BEHIND RES BACK. I INFORMED CNA THAT IT WAS ABUSE TO DO THAT HE STATED HE WAS GOING TO KEEP DOING IT UNTIL SHE STOPPED HITTING. I TOLD HIM HE COULD GET WRITTEN UP. HE (CNA 'A') STATED (SO LET THEM WRITE ME UP). CNA 'C'S WRITTEN STATEMENT DATED 1/4/12 READS, "I...DID WITNESS (CNA 'A') HOLDING (RESIDENT #101) ARMS BEHIND HER BACK." CNA 'D'S WRITTEN STATEMENT DATED 1/4/12 READS, "ME AND (CNA 'C') WERE IN THE D.R. (DINING ROOM) WHEN SHE STARTED BECOMING COMBATIVE WITH (CNA 'C'). (CNA 'A') CAME UP BEHIND (RESIDENT #101) AND GRABBED HER HANDS AND HELD THEM BEHIND HER BACK AT THE SAME TIME (CNA 'E') CAME DOWN AND TOLD HIM TO STOP, THAT IT WAS ABUSE BUT HE DIDN'T STOP. SHE TOLD HIM HE WOULD GET WRITTEN UP AND HE SAID HE DIDN'T CARE - TO WRITE HIM UP...". THE WRITTEN STATEMENT PROVIDED BY CNA 'I' READS, "IN REGARD TO (CNA 'A'), I DID NOT WITNESS ANY PHYSICAL ABUSE. BUT I DID HEAR VERBAL ABUSE. THE RESIDENT HAD ASK HIM TO MOVE YOUR FOOT OFF OF MINE AND HE SAID NO, FOR YOU TO STAY HERE, IT'S YOUR (F---ING) FAULT THAT YOU ARE BEHIND THE TABLE." CNA 'J'S WRITTEN STATEMENT DATED 1/4/12 READS, "IN REGARDS TO (CNA 'A') - I DID NOT WITNESS ANY PHYSICAL ABUSE. BUT I DID WITNESS "VERBAL" ABUSE. A REVIEW OF THE FACILITY'S POLICY TITLED "ABUSE PREVENTION & INVESTIGATIONS POLICY & PROCEDURE IN RESIDENT ABUSE CASES" DATED 9/9/11 READS IN PART, "THE FULL INTENT OF BOTH FEDERAL AND STATE GOVERNMENTS AS OUTLINED IN THE FEDERAL AND STATE LICENSURE REQUIREMENTS IS TO ELIMINATE THE THREAT OF ABUSE, IN ANY FORM, TO RESIDENTS OF NURSING HOMES....ABUSE, AS USED THROUGHOUT THIS POLICY, IS DEFINED IN THE FEDERAL REGISTER, F-223 (SEE ATTACHED DEFINITIONS). FACILITY EMPLOYEES, FAMILY MEMBERS, OR VISITORS WILL NOT USE ANY FORM OF VERBAL, MENTAL, SEXUAL, OR PHYSICAL ABUSE TO INCLUDE CORPORAL PUNISHMENT, INVOLUNTARY SECLUSION, EXPLOITATION OR NEGLECT OF RESIDENTS....ANY EMPLOYEE WITNESSING ANY TYPE OF ABUSE WILL IMMEDIATELY NOTIFY THE CHARGE NURSE...THE CHARGE NURSE WILL NOTIFY THE ADMINISTRATOR IMMEDIATELY OF ANY ALLEGATION OF ABUSE OR INCIDENT...THE FACILITY WILL REPORT...AS SOON AS POSSIBLE, NOT TO EXCEED 24 HOURS AFTER DISCOVERY OF INCIDENT...ABUSE WITH OR WITHOUT INJURIES...AFTER THE ADMINISTRATOR HAS BEEN NOTIFIED, THE COMPLAINT OFFICER OR DESIGNEE WILL IMMEDIATELY CONDUCT A THOROUGH IN-HOUSE INVESTIGATION TO DETERMINE WHAT HAPPENED AND...NOTIFY THE BUREAU OF HEALTH CARE SYSTEMS...COMPLETE THE FACILITY INCIDENT REPORT (BHS-OPS 362) AND SUBMIT...DURING AND SUBSEQUENT TO ITS INVESTIGATION, THE FACILITY WILL TAKE PROTECTIVE AND CORRECTIVE ACTIONS TO PROTECT THE RESIDENTS AND PREVENT FURTHER INCIDENTS...ONCE THE INVESTIGATION IS DONE, THE ADMINISTRATOR, ASSISTANT ADMINISTRATOR, COMPLAINT OFFICER AND THE DIRECTOR OF NURSING WILL DETERMINE JOINTLY IF ABUSE DID OCCUR..." A FORM TITLED AND UNDATED "IRON COUNTY MEDICAL CARE FACILITY DEFINITIONS" ATTACHED TO THE FACILITY'S ABUSE PREVENTION & INVESTIGATIONS POLICY & PROCEDURE IN RESIDENT ABUSE CASES READS IN PART, "ABUSE: WILLFUL INFLICTION OF INJURY, UNREASONABLE CONFINEMENT...PHYSICAL ABUSE: IS NOT LIMITED TO HITTING, SLAPPING, PINCHING, AND KICKING. IT ALSO INCLUDES CONTROLLING BEHAVIOR THROUGH CORPORAL PUNISHMENT...". THE FACILITY CONCLUDED THERE WAS NO VERBAL ABUSE, HOWEVER, THE FACILITY MAKES NO DETERMINATION OR DEMONSTRATE EVIDENCE THAT THE ALLEGATIONS OF PHYSICAL ABUSE OR CONSIDERATION OF MISTREATMENT WERE FULLY INVESTIGATED. NO EVIDENCE WAS FOUND TO SHOW THE FACILITY REPORTED THE INCIDENT OF ALLEGED ABUSE TO THE STATE AGENCY. RESIDENT #101'S MEDICAL RECORD WAS REVIEWED. HER FACE SHEET SHOWED SHE IS AN [AGE] year OLD WOMAN admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. HER MOST RECENT MINIMUM DATA SET (MDS) ASSESSMENT PRIOR TO THIS INCIDENT WAS DATED 10/13/11, AND REVEALED THAT SHE SCORED 5 OUT OF 15 ON HER BRIEF INTERVIEW FOR MENTAL STATUS (BIMS) INDICATING SHE HAD SEVERE COGNITIVE IMPAIRMENT. HER Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'S DEMENTIA TREATMENT, [MEDICATION NAME] FOR ANXIETY ON A SCHEDULED BASIS, WITH ADDITIONAL [MEDICATION NAME] EVERY THREE HOURS AS NEEDED AND [MEDICATION NAME] TO TREAT DEPRESSION. ON 1/17/12 AT 10:45 A.M., THE SURVEILLANCE VIDEO OF RESIDENT #101 WAS WATCHED. DUE TO POOR VIDEO QUALITY, THE VIDEO WAS VIEWED AGAIN ON A DIFFERENT COMPUTER AT 12:00 NOON. ALL INDIVIDUALS IN THE VIDEO WERE IDENTIFIED BY THE ADMINISTRATOR AND THE DON. THERE WAS NO AUDIO COMPONENT TO THIS VIDEO. THE VIDEO SHOWED THAT ON 1/4/12 AT APPROXIMATELY 8:43 P.M., CNA 'A' WAS IN THE SPECIAL CARE UNIT DINING ROOM, SITTING AT A TABLE WITH RESIDENT #101. RESIDENT #103 WAS SEATED AT A SEPARATE TABLE NEARBY. CNA 'A' WAS THE ONLY STAFF PERSON PRESENT IN THE DINING ROOM AT THIS TIME, ALTHOUGH LICENSED PRACTICAL NURSE (LPN) 'F' WAS BEHIND THE NURSES STATION PARTITION THAT HAS GLASS WINDOWS LOOKING OVER THE DINING ROOM. ON FIVE OCCASIONS, CNA 'A' LEFT RESIDENT #101 AND WALKED APPROXIMATELY FIVE FEET AWAY TO ASSIST RESIDENT #103, WHO WAS IDENTIFIED AS BEING AT RISK FOR FALLS, BACK INTO HER CHAIR AFTER RESIDENT #103 MADE ATTEMPTS TO STAND UP. AT APPROXIMATELY 8:50 P.M., CNA 'C' AND CNA 'D' ARE SEEN ENTERING THE ROOM. CNA 'C' SAT DOWN AT THE TABLE NEXT TO RESIDENT #101 (ON RESIDENT #101'S RIGHT SIDE AND WITH HER BACK TO THE CAMERA) WHILE CNA 'D' SAT A FEW FEET AWAY BUT FACING RESIDENT #101, CNA 'C' AND THE CAMERA. CNA 'A' THEN TOOK RESIDENT #103 FOR A WALK AND RETURNED TO THE ROOM WITHOUT HER AT 8:52 P.M. AT 8:52:46 P.M., CNA 'A' WAS SEEN GOING TO THE LEFT OF RESIDENT #101, BEHIND HER BACK/CHAIR AS RESIDENT #101 FACED CNA 'C' TO HER RIGHT. DUE TO THE POOR QUALITY OF THE VIDEO, IT COULD NOT BE DETERMINED WHAT ELSE TOOK PLACE AT THIS TIME. RESIDENT #101'S RIGHT ARM CANNOT BE SEEN FROM 8:52:46 UNTIL 8:53:54, DURING WHICH TIME CNA 'A'S" HANDS COULD NOT BE SEEN AT ALL. AT 8:53:21 P.M., CNA 'E' WALKED INTO THE ROOM; AT 8:53:34, SHE WALKED OVER TO THE TABLE WHERE CNAS 'A', 'C', AND 'D' WERE PRESENT WITH RESIDENT #101. AT 8:53:46, CNA 'E' WALKED BEHIND CNA 'C'S" BACK AND STOOD FACING CNA 'A'. CNA 'E' THEN WALKED AWAY, TOWARD THE NURSES STATION, AND SOON AFTER, LEFT THE ROOM. AT 8:53:54, RESIDENT #101'S ARM COULD BE SEEN AGAIN. AFTER WATCHING THE VIDEO ON A SECOND COMPUTER, WITH THE VIDEO QUALITY STILL VERY POOR, THE ADMINISTRATOR WAS ASKED ON 1/17/12 AT APPROXIMATELY 12:15 P.M., IF, WHEN HE WATCHED THE VIDEO ON 1/5/12, HE COULD SEE WHAT WAS HAPPENING IN THE VIDEO ANY BETTER THAN THIS SURVEYOR COULD SEE IT NOW. THE ADMINISTRATOR STATED, "NO." HE WAS THEN ASKED HOW HE DETERMINED THAT NO ABUSE HAD OCCURRED IF HE COULD NOT SEE THE EVENTS CLEARLY ON THE VIDEO. HE STATED, "WE MADE THE DETERMINATION THAT THERE WAS NO ABUSE BASED ON THE CIRCUMSTANCES. (CNA 'A') WAS TRYING TO MANAGE TWO RESIDENTS--HE HAD HIS HANDS FULL. HE (CNA 'A') CAME TO THE ASSISTANCE OF ANOTHER AIDE TO KEEP THE RESIDENT (#101) FROM HITTING HER. HE (CNA 'A') admitted THAT HE HELD HER (RESIDENT #101)ARMS FOR A SHORT PERIOD OF TIME, BUT NOT IN AN INTENTIONALLY HARMFUL WAY." ON 1/17/12 AT 11:30 A.M, THE DIRECTOR OF NURSING (DON) WAS INTERVIEWED. THE DON STATED, "(CNA 'A') IS WORKING ON A DIFFERENT UNIT. THERE'S SO MANY RUMORS GOING AROUND. I TOLD HIM IT WAS IN HIS BEST INTEREST. WE SENT HIM HOME THAT NIGHT. HE'S BACK TO WORK NOW." A REVIEW OF THE FACILITY STAFFING/ASSIGNMENT SHEETS DATED 1/4/12, 1/6/12, 1/7/12, 1/8/12, 1/10/12, AND 1/17/12 SHOWS CNA 'A' WAS ON DUTY. CNA 'E' WAS INTERVIEWED ON 1/17/12 AT 12:55 P.M.. SHE STATED, "I WENT TO (THE SPECIAL CARE UNIT) TO GET A NEWSPAPER ON MY BREAK. (CNA 'A', CNA 'C' AND CNA 'D') WERE AT THE TABLE WITH (RESIDENT #101). (CNA 'A') WAS STANDING BEHIND (RESIDENT #101). HE WAS HOLDING HER WRISTS BEHIND HER BACK. I TOLD HIM, 'THAT'S ABUSE, YOU KNOW.' HE SAID, 'LET THEM WRITE ME UP.' (RESIDENT #101) TOLD HIM, 'LET MY ARMS GO;' HE SAID, 'NO.' (RESIDENT #101) WAS MAD; SHE WASN'T COMPLAINING OF PAIN. I WENT TO THE NURSES STATION; (LPN 'F') WAS IN THERE. I LEFT AND REPORTED IT TO (REGISTERED NURSE (RN) 'B') RIGHT AWAY; SHE WAS THE CHARGE NURSE THAT NIGHT." CNA 'D' WAS INTERVIEWED ON 1/17/12 AT 1:10 P.M. SHE STATED, "(CNA 'C') AND I WERE SITTING THERE WITH (RESIDENT #101) DOING 1:1 SUPERVISION BECAUSE (RESIDENT #101) HAD FALLEN EARLIER THAT EVENING. (RESIDENT #101) HAD BEEN COMBATIVE, TRYING TO HIT (CNA 'C'). NO, (CNA 'C') DIDN'T ASK FOR HELP FROM (CNA 'A'); HE JUST CAME OVER. I THINK HE USED MORE FORCE THAN HE SHOULD HAVE--I JUST DIDN'T LIKE THE BEHIND-THE-BACK THING--LIKE A POLICE. (CNA 'A') TOOK BOTH OF HER HANDS AND HELD THEM BEHIND HER BACK. (CNA 'E') CAME IN AND TOLD HIM IT WAS ABUSE. (RESIDENT #101) YELLED AT HIM TO STOP--HE DIDN'T. HE LET GO OF HER HANDS AFTER (CNA 'E') LEFT THE ROOM." CNA 'C' WAS INTERVIEWED BY TELEPHONE ON 1/18/12 AT 1:35 P.M. SHE STATED, "I WAS SITTING THERE DOING 1:1 SUPERVISION WITH (RESIDENT #101). IT HAPPENED SO FAST. (CNA 'A') CAME UP BEHIND HER AND GRABBED HER ARMS AND PUT THEM BEHIND HER BACK. HE DIDN'T HOLD THEM LIKE THAT VERY LONG--HARDLY NO TIME AT ALL. ANOTHER AIDE CAME IN AND TOLD HIM, 'THAT'S ABUSE.' (CNA 'A') SAID, 'GO AHEAD AND WRITE ME UP.' (RESIDENT #101) TOLD HIM, 'LET GO OF MY ARMS.' HE DIDN'T LET GO. I WAS APPALLED. YES, I DID FEEL THAT IT WAS ABUSIVE. MY DAD RESIDES HERE; I WOULD HATE TO COME IN AND SEE THEM DOING THAT TO MY DAD. (RESIDENT #101) HAD BEEN TRYING TO HIT ME; THAT'S PART OF THE UNIT--YOU TAKE IT ALL IN STRIDE. THEY'VE TRAINED US VERY WELL. YOU HAVE TO HAVE PATIENCE. NO, IT'S NOT OKAY TO HOLD A RESIDENT'S WRISTS." LICENSED PRACTICAL NURSE (LPN) 'F' WAS INTERVIEWED ON 1/17/12 AT 2:45 P.M. SHE STATED, "(RESIDENT #101) WAS ON 1:1 SUPERVISION BECAUSE SHE HAD FALLEN EARLIER IN THE SHIFT AND I DIDN'T WANT HER TO FALL AGAIN. HER AGITATION DID NOT QUIT. NO, I DID NOT SEE OR HEAR ANYTHING ABUSIVE. I WAS IN THE NURSES STATION BUT THERE'S A POST ON MY LEFT--I COULDN'T SEE (CNA 'A') OVER THERE WITH (RESIDENT #101)." ON 1/17/12 AT 3:00 P.M., CNA 'A' WAS OBSERVED IN THE FACILITY, DRESSED IN WORKING ATTIRE AND INTERVIEWED. HE STATED, "(RESIDENT #101) WAS ABOUT TO HIT (CNA 'C'). I HELD HER WRISTS AT HER SIDES FOR ABOUT 5-6 SECONDS. I WOULD NEVER INTENTIONALLY HURT A RESIDENT." RN 'B' WAS INTERVIEWED ON 1/18/12 AT 11:38 A.M. SHE STATED, "I WAS ONE OF THE CHARGE NURSES THAT NIGHT. AFTER (CNA 'E') REPORTED IT TO ME, WE TOOK A LOOK AT (RESIDENT #101), HER SKIN, HOW SHE MOVED HER ARMS. THERE WAS NO SWELLING OR REDNESS, NO INJURY." RESIDENT #101 WAS OBSERVED ON 1/17/12 AT 10:20 A.M. IN THE DINING ROOM OF THE SPECIAL CARE UNIT. SHE HAD NO COMPLAINTS AND COULD NOT REMEMBER THE INCIDENT OF 1/4/12. THERE WAS NO BRUISING NOTED TO EITHER OF HER FOREARMS OR HANDS. SHE WAS CALM BUT ATTENTION-SEEKING DURING THIS OBSERVATION. B) BASED ON INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT THE MISAPPROPRIATION OF RESIDENT PROPERTY FOR ONE RESIDENT (#102) OF FOUR RESIDENTS REVIEWED FOR MISTREATMENT, NEGLECT, ABUSE, AND MISAPPROPRIATION OF PROPERTY FROM A TOTAL OF 170 RESIDENTS IN THE FACILITY. FINDINGS INCLUDE: A REVIEW OF THE FACILITY'S MISAPPROPRIATION INVESTIGATION DATED 12/27/11, REVEALED THAT ON 12/20/11, IT WAS REPORTED TO THE COMPLAINT OFFICER THAT A JACKET BELONGING TO RESIDENT #102, WAS BEING TAKEN AND USED BY CNA 'H' WHILE RESIDENT #102 WAS hospitalized from [DATE]-12/20/11. DURING IT'S INVESTIGATION, THE FACILITY REVIEWED SURVEILLANCE VIDEO AND IT WAS CONFIRMED THAT CNA 'H' HAD USED RESIDENT #102'S JACKET. THE FACILITY PROVIDED THIS SURVEYOR A LIST OF DATES WHEN CNA 'H' WAS OBSERVED TO BE WEARING RESIDENT #102'S JACKET: 12/7/11 DURING BREAKS, 12/8/11 ON BREAKS AND 12/10/11 ALL DAY. STAFF MEMBER 'G' WAS INTERVIEWED ON 1/18/12 AT 10:07 A.M. SHE STATED, "I NOTICED THAT (RESIDENT #102'S) ROOM SMELLED LIKE CIGARETTE SMOKE WHEN I WAS CLEANING IN THERE. I TRACKED IT DOWN TO A YELLOW COLUMBIA JACKET SHE HAD GOTTEN FOR HER BIRTHDAY A FEW MONTHS AGO. I KNEW (RESIDENT #102) DOESN'T SMOKE; SHE HAS BREATHING PROBLEMS. SO THAT'S WHEN I STARTED PAYING ATTENTION. I NOTICED (CNA 'H') WEARING IT ON BREAK ONE DAY. WHEN SHE BROUGHT IT BACK, I TOOK THE JACKET TO LAUNDRY FOR THEM TO WASH IT AND TOLD THEM TO PUT A HOLD ON IT UNTIL (RESIDENT #102) CAME BACK FROM THE HOSPITAL. I REPORTED IT TO THE ASSISTANT ADMINISTRATOR THE NEXT DAY." DURING A TELEPHONE INTERVIEW WITH CNA 'H' ON 1/18/12 AT 10:20 A.M., SHE STATED, "I DIDN'T THINK IT WAS THAT BIG A DEAL. IT WAS COLD THAT DAY--I WORE IT FOR AN HOUR OR TWO. I'VE WORKED HERE FOR EIGHTEEN YEARS; I NEVER READ THE ENTIRE CODE OF CONDUCT. I WASN'T THINKING. I'VE NEVER TAKEN A RESIDENT'S POSSESSION HOME. I'VE NEVER STOLEN ANYTHING. I'M NOT SURE IF I WORE IT OUTSIDE--I MIGHT HAVE. I THINK I WORE IT ONCE OR TWICE. I GOT SUSPENDED ON 12/21/11." THE FACILITY'S POLICY AND PROCEDURE TITLED "ABUSE PREVENTION & INVESTIGATIONS POLICY & PROCEDURE IN RESIDENT ABUSE CASES" AND DATED 4/28/11, REVISED 9/9/11, INCLUDES AN ATTACHMENT WITH DEFINITIONS. THIS ATTACHMENT DEFINES MISAPPROPRIATION OF RESIDENT PROPERTY AS "THE DELIBERATE MISPLACEMENT, EXPLOITATION, OR WRONGFUL TEMPORARY OR PERMANENT USE OF A RESIDENT'S BELONGINGS OR MONEY WITHOUT THE RESIDENT'S CONSENT." REVIEW OF THE FACILITY'S MISAPPROPRIATION INVESTIGATION, DATED 12/27/11, REVEALED THAT RESIDENT #102 WAS hospitalized from [DATE] THROUGH 12/20/11 AND THEREFORE COULD NOT HAVE GIVEN HER CONSENT FOR CNA 'H' TO WEAR HER JACKET ON 12/7/11, 12/8/11 OR 12/10/11. ( ) --

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE EACH RESIDENT RECEIVED ADEQUATE SUPERVISION TO PREVENT ACCIDENTS FOR TWO RESIDENTS (#4 AND #1) OF FIVE RESIDENTS REVIEWED FOR FALLS FROM A TOTAL POPULATION OF 173. THESE FAILURES RESULTED IN RESIDENT #4 SUSTAINING A LEFT HIP FRACTURE REQUIRING SURGICAL REPAIR AND RESIDENT #1 SUSTAINING A BRUISED HIP. FINDINGS INCLUDE: A REVIEW OF THE FACILITY'S INVESTIGATION REPORT DATED 11/29/11, REVEALS ON 11/23/11 AT 1:25 P.M., RESIDENT #4 WAS FOUND ON THE FLOOR IN HER ROOM. ACCORDING TO THE REPORT, SHE HIT HER LEFT TEMPLE ON THE FOOTBOARD OF HER ROOMMATE'S BED AND fell THE REST OF THE WAY TO THE FLOOR. THIS REPORT READS, "...A HOUSEKEEPER (STAFF "B") SAW RESIDENT (#4) GET HERSELF TANGLED UP IN HER OXYGEN TUBING AND FALL. NO BRUISING ABRASIONS OR LUMPS NOTED AT (L) (LEFT) TEMPLE. (L) HIP TO HAVE RED AREA WITH SOME PAIN... AT 19:15 (7:15 P.M.) RESIDENT COMPLAINED OF (L) HIP PAIN WORSENING. ORDERS WERE RECEIVED TO SEND RESIDENT (#4) TO THE ED (EMERGENCY DEPT.) FOR FURTHER EVALUATION..." A "CT (COMPUTED TOMOGRAPHY) LEFT LOWER EXTREMITY" DATED 11/23/11, REVEALED "FINDINGS: THERE IS A SLIGHTLY IMPACTED FRACTURE OF THE LEFT FEMORAL NECK WITH INTACT JOINT." RESIDENT #4 WAS admitted TO THE HOSPITAL FOR SURGICAL REPAIR. DURING THE ABBREVIATED SURVEY PERIOD 12/20/11 TO 12/21/11, THE CLINICAL RECORD OF RESIDENT #4 WAS REVIEWED. ACCORDING TO THE FACE SHEET, RESIDENT #4 IS A [AGE] year OLD FEMALE admitted to the facility on [DATE] AND RE-admitted to the facility on [DATE], AFTER SURGICAL REPAIR FOR THE LEFT HIP FRACTURE. HER [DIAGNOSES REDACTED]. A REVIEW OF THE MINIMUM DATA SET ASSESSMENT (MDS) assessment dated [DATE], SHOWS RESIDENT #4'S COGNITION AT A 6 (SEVERELY IMPAIRED). SHE NEEDED STAND BY ASSIST FOR TRANSFERS IN HER ROOM AND ONE PERSON PHYSICAL ASSIST FOR TOILETING NEEDS. A REVIEW OF THE FACILITY DOCUMENT TITLED "FALL RISK ASSESSMENT" WITH THE LATEST REVISION DATE OF 11/07/11, SHOWED RESIDENT #4 SCORED AT A 12. "TOTAL SCORE OF 10 OR MORE REPRESENTS HIGH RISK" FOR FALLS. A REVIEW OF THE "FALL" PREVENTION CARE PLAN FOR RESIDENT #4 WITH A REVIEWED DATE OF 11/07/11, REVEALED THE FOLLOWING PROBLEM STATEMENT: "RESIDENT (#4) IS AT RISK FOR FALLS DUE TO ALZHEIMER'S DISEASE WITH IMPAIRED COGNITION, MEMORY AND SAFETY AWARENESS, UNSTEADY GAIT, ADVANCED COPD....", WITH APPROACHES SUCH AS, "FREQUENTLY REORIENT AND REPETITIVELY REINFORCE USE OF CALL LIGHT AND ENSURE IT IS WITHIN REACH AT ALL TIMES AND PROVIDE SAFE ENVIRONMENT E.G.: ROOM FREE FROM CLUTTER, WELL LIT....". A REVIEW OF RESIDENT #4'S ACTIVITIES OF DAILY LIVING CARE PLAN SHOWS THAT STAND-BY ASSIST IS REQUIRED WHEN RESIDENT #4 AMBULATES TO THE BATHROOM WITH OXYGEN FOR TOILETING NEEDS. AN INTERVIEW WAS CONDUCTED WITH HOUSEKEEPING STAFF "B" ON 12/21/11 AT 10:00 A.M. STAFF "B" STATED SHE WAS DIRECTLY ACROSS FROM RESIDENT #4'S ROOM WHEN SHE SAW RESIDENT #4 GET OUT OF HER BED AND BEGIN AMBULATING TOWARDS THE BATHROOM WITHOUT STAFF ASSISTANCE. RESIDENT #4 WAS SEEN CARRYING HER OXYGEN TUBING IN HER HANDS AND AS SHE APPROACHED THE BATHROOM, SHE BACKED HERSELF INTO THE TOILET BECAUSE OF HER OXYGEN TUBING. SHE fell FORWARD STRIKING HER HEAD ON THE FOOTBOARD AND THEN fell TO THE FLOOR WITH A "THUD". HOUSEKEEPING STAFF "B" WENT ON TO SAY, THAT RESIDENT #4 HADN'T USED HER CALL LIGHT WHEN NEEDING TO USE THE BATHROOM. HOUSEKEEPING STAFF "B" STATED, "IT'S CUZ SHE'S GOTTA GO, SHE HAS DIARRHEA." AN OBSERVATION AND INTERVIEW WAS CONDUCTED WITH CERTIFIED NURSE AIDES (CNAS) "C" AND "D" ON 12/21/11 AT 9:50 A.M. AND 10:05 A.M. RESPECTFULLY. THEY WERE OBSERVED PLACING A PRESSURE SENSITIVE ALARM UNDER RESIDENT #4 WHILE SHE WAS LYING IN HER BED AND PLACING A PRESSURE ALARM IN HER WHEEL CHAIR. ACCORDING TO NURSING NOTES DATED 12/20/11, RESIDENT #4 HAD BEEN readmitted TO THE FACILITY APPROXIMATELY 19 HOURS EARLIER FROM THE HOSPITAL. CNAS "C" AND "D" STATED RESIDENT #4 HAS NEVER HAD ANY ALARMS ON HER BED OR IN HER WHEELCHAIR TO ALERT STAFF WHEN SHE (RESIDENT #4) WAS GETTING UP FROM BED. THEY WENT ON TO SAY, SHE "BARELY OR NEVER" USED HER CALL LIGHT TO GET HELP. CNA "C" STATED "SHE SOMETIMES COMES TO THE DOORWAY AND YELLS FOR US." AN INTERVIEW WAS CONDUCTED WITH REGISTERED NURSE (RN) "E" ON 12/21/11 AT 9:00 A.M. THIS SURVEYOR ASKED WHY RESIDENT #4 WAS CONSIDERED A "HIGH FALL RISK", RN "E" REPLIED, "BECAUSE SHE (RESIDENT #4) HAS DECREASED SAFETY AWARENESS, DEMENTIA, DECREASED STANDING STABILITY AND SEVERE COPD." WHEN RN "E" WAS ASKED ABOUT ALARMS EVER BEING INSTITUTED ON RESIDENT #4 FOR SAFETY, SHE REPLIED, "NO IT DOESN'T LOOK LIKE ALARMS WERE THERE BEFORE HER FALL". RN "E" WAS HOLDING AND REFERRING TO RESIDENT #4'S "FALL" CARE PLAN. THE CLINICAL RECORD OF RESIDENT #1 WAS REVIEWED DURING THE ABBREVIATED SURVEY ON 12/20/11 TO 12/21/11. ACCORDING TO THE FACE SHEET RESIDENT #1 IS A [AGE] year OLD FEMALE admitted to the facility on [DATE] AND RE-admitted to the facility on [DATE] AFTER SURGICAL REPAIR FROM A FRACTURED HIP. HER [DIAGNOSES REDACTED]. THE MOST RECENT MDS ASSESSMENT SHOWED RESIDENT #1'S MENTAL STATUS AS SEVERELY IMPAIRED. SHE REQUIRED LIMITED ASSISTANCE OF ONE STAFF MEMBER FOR TRANSFERS AND AMBULATION IN THE HALLWAY (RESTORATIVE STAFF PROGRAM). SHE NEEDED EXTENSIVE ASSISTANCE OF ONE STAFF FOR TOILETING. A REVIEW OF THE FACILITY REPORTED INCIDENT (FRI) DATED 11/23/11, REVEALED THAT ON 11/17/11 AT 12:45 P.M., RESIDENT #1 WAS FOUND SITTING ON THE FLOOR IN HER BATHROOM IN FRONT OF HER TOILET LEANING ON HER LEFT ELBOW. AT TIME OF THE FALL, THERE WAS NO PAIN OR INJURY NOTED. THE NEXT DAY ON 11/18/11 AT 11:00 A.M., RESIDENT #1 COMPLAINED OF PAIN TO HER RIGHT FEMUR/HIP. SHE WAS EXAMINED BY STAFF AND ORDERS OBTAINED TO SEND HER TO THE ED FOR EVALUATION. NO FRACTURE WAS FOUND. THE INJURY WAS LIMITED TO BRUISES. ACCORDING TO THE FRI, LICENSED PRACTICAL NURSE (LPN) "F" WAS IN THE ROOM NEXT TO RESIDENT #1'S WHEN SHE REPORTEDLY HEARD RESIDENT #1'S PERSONAL ALARM (CLIPS TO CLOTHING) GOING OFF (RINGING). RESIDENT #1 WAS FOUND SITTING ON THE TOILET. LPN "F" REPORTED ATTACHING A PERSONAL ALARM TO RESIDENT #1 AND INSTRUCTED HER TO USE THE CALL LIGHT WHEN SHE WAS FINISHED. LPN "F" LEFT RESIDENT #1 ALONE AND RETURNED TO THE ROOM NEXT DOOR. LPN "F" THEN HEARD RESIDENT #1'S CHAIR ALARM SOUNDING AND RETURNED TO THE BATHROOM TO FIND RESIDENT #1 SITTING ON THE FLOOR WITH HER PERSONAL ALARM REMOVED. A REVIEW OF RESIDENT #1'S "FALL" CARE PLAN REVEALED FROM 07/2011 UNTIL 12/2011, RESIDENT #1 HAD SIX FALLS; ALL RECORDED AS "FOUND SITTING ON BATHROOM FLOOR OR ON KNEES HANGING ONTO BAR IN THE BATHROOM." THE "ADL INSTRUCTION SHEET" (CNA CARE PLAN) LISTS RESIDENT #1 AS NEEDING "1 PERSON LIMITED ASSIST FOR TRANSFERS AND EXTENSIVE ASSIST FOR TOILETING." AN INTERVIEW WAS CONDUCTED WITH LPN "F" VIA TELEPHONE ON 12/21/11 AT 10:30 A.M. LPN "F" VERIFIED THE INFORMATION IN THE FACILITY REPORT. LPN "F" COULD NOT RECALL THE MAGNETIC DOOR ALARM SOUNDING FOR RESIDENT #1, ONLY HER PERSONAL ALARM AND CHAIR ALARMS WERE SOUNDING. THIS SURVEYOR ASKED LPN "F" WHAT MADE RESIDENT #1 A FALL RISK, SHE REPLIED, "HER (RESIDENT #1'S) MEDICATIONS, HER CONDITION... SHE DOESN'T UNDERSTAND... SHE SHOULDN'T BE LEFT ON THE TOILET ALONE... ." AN INTERVIEW WITH CNA "J" WAS CONDUCTED VIA TELEPHONE ON 12/20/11 AT 3:25 P.M. CNA "J" STATED SHE WAS CHARTING IN THE NURSES STATION WHEN RESIDENT #1 fell ; "YOU CAN'T HEAR THE ALARMS IN THERE." CNA "J" WAS ASKED BY THIS SURVEYOR, "WHEN CAN A RESIDENT BE LEFT ALONE IN THE BATHROOM?" SHE REPLIED "OUR POLICY IS TO NOT LEAVE RESIDENTS ALONE IN THE BATHROOM WHEN THEY HAVE ALARMS ON." AN INTERVIEW WAS CONDUCTED WITH REGISTERED NURSE (RN) "I" AT 12/21/11 AT 8:40 A.M., SHE STATED "RESIDENTS WITH COGNITIVE IMPAIRMENT SHOULD NEVER BE LEFT ALONE ON THE TOILET... IT'S A RULE, A GIVEN, A STANDARDS OF PRACTICE." THIS SURVEYOR ASKED IF RESIDENT #1 SHOULD HAVE BEEN LEFT ALONE ON THE TOILET. RN "I" REPLIED "NO, SHE HAS A FALLS HISTORY." A REVIEW OF THE FACILITY "FALLS POLICY AND PROCEDURE" AND DATED "BOARD APPROVED 05/27/10", READS "POLICY: IT IS THE POLICY OF THIS FACILITY TO ASSESS EACH RESIDENT'S RISK FOR FALLS AND INJURIES... AND TO FACILITATE AN INTERDISCIPLINARY APPROACH TO CARE PLANNING TO PREVENT FALLS. ALL RESIDENTS WHO HAVE FALLEN WILL BE GIVEN... AND WILL BE ASSESSED FOR CAUSE AND PREVENTION OF RECURRENT FALLS." ( )

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO UTILIZE THE ASSESSED BODY WEIGHT TO DETERMINE THE APPROPRIATE MECHANICAL LIFT SLING AND CARE PLAN ACCORDINGLY FOR ONE (#1) OF SIX RESIDENTS REVIEWED FOR USE OF A MECHANICAL LIFT, RESULTING IN A FALL WITH INJURY. FINDINGS INCLUDE: DURING THE SURVEY PERIOD OF 3/14/11 THROUGH 3/17/11, THE CLINICAL RECORD OF RESIDENT #1 WAS REVIEWED. THE FACE SHEET REVEALED RESIDENT #1 IS A [AGE] year-old FEMALE WITH [DIAGNOSES REDACTED]. A REVIEW WAS PERFORMED OF A FACILITY REPORTED INCIDENT INVESTIGATION DATED 3/03/11. THE REPORT REVEALED ON 2/28/11 AT 7:30 A.M. DURING A TRANSFER WITH A "LIKO" MECHANICAL LIFT, RESIDENT #1 SLID OUT OF THE TRANSFER SLING AND LANDED ON THE FLOOR. THE RESIDENT HAD A SWOLLEN RIGHT SHOULDER AND A 1 1/2 INCH HEMATOMA TO HER HEAD. THE RESIDENT WAS SENT TO THE emergency room . THE X-RAY REPORT DATED 2/28/11 REVEALED A FRACTURED CLAVICLE, NON-DISPLACED FRACTURES OF THE SCAPULA, MANUBRIUM (UPPER PART OF THE STERNUM OR CHEST BONE), ANTERIOR FIRST RIB, AND A CLOSED HEAD INJURY. RESIDENT #1 RETURNED BACK to the facility on [DATE]. PER RESIDENT #1'S "ACTIVITY OF DAILY LIVING" (ADL) INSTRUCTION SHEET DATED 2/18/11, RESIDENT #1 REQUIRED THE ASSIST OF ONE STAFF MEMBER AND A "LIKO" MECHANICAL LIFT WITH SLING TO TRANSFER HER SAFELY BETWEEN SURFACES (BED TO CHAIR ETC.). PER RESIDENT #1'S ADL CARE PLAN DATED 4/30/10, RESIDENT #1 WAS IDENTIFIED AS NEEDING THE "LIKO" LIFT FOR ALL TRANSFERS. HOWEVER, PRIOR TO 3/04/11, THE CARE PLAN DID NOT IDENTIFY/DIRECT FACILITY STAFF AS TO WHICH SLING (BASED ON THE RESIDENT'S SIZE/WEIGHT) WAS TO BE USED. AN INTERVIEW WAS HELD WITH THE DIRECTOR OF NURSING (DON) ON 3/15/11 AT 1:15 P.M., CONCERNING HOW RESIDENTS WERE ASSESSED FOR THE APPROPRIATE "LIKO" LIFT SLING SIZE. THE DON SAID THE FACILITY FOLLOWED/USED THE MANUFACTURER'S RECOMMENDED SLING BASED ON THE RESIDENT'S WEIGHT. THE DON STATED, "(RESIDENT #1) HAD BEEN USING THE MEDIUM (GREEN) SLING... SHE WAS ASSESSED AND THE MEDIUM GREEN CROSS-OVER SLING HAS BEEN USED SINCE 10/07." A REVIEW OF THE "LIKO UNIVERSAL SLING" MANUFACTURER'S RECOMMENDATIONS (NOT DATED) FOR "LIKO" LIFT SLING SIZING PER WEIGHT WAS REVIEWED FOLLOWING THE ABOVE INTERVIEW WITH THE DON. THE GREEN SLING SIZE MEDIUM WAS TO BE USED BY RESIDENTS WEIGHING BETWEEN 132 AND 198 POUNDS. A REVIEW OF RESIDENT #1'S BODY WEIGHTS, RECORDED ON THE "VITAL SIGN RECORD" SHEET FROM 6/01/10 THROUGH 2/28/11, WAS PERFORMED DURING THE SURVEY. RESIDENT #1'S WEIGHTS RECORDED FOR THE MONTHS OF 6/10, 7/10, 8/10, 10/10, 11/10, 12/10, AND THROUGH 1/23/11 RANGED FROM 126.1 TO 131.7 POUNDS. RESIDENT #1'S WEIGHTS WERE OUTSIDE THE MANUFACTURER'S WEIGHT RANGE FOR A SAFE TRANSFER. RESIDENT #1'S RECORDED WEIGHTS FROM 1/31/11 THROUGH THE DATE OF THE FALL OUT OF THE SLING, ON 2/28/11, RANGED FROM 129.2 TO 131.7. FURTHERMORE, THESE WEIGHTS WERE OUTSIDE THE MANUFACTURER'S WEIGHT RANGE FOR A SAFE TRANSFER USING THE MEDIUM/GREEN SLING. AN INTERVIEW ON 3/16/11 AT 2:00 P.M. WITH THE DON REVEALED THE FACILITY HAD NO DOCUMENTATION ON EVALUATING AND CARE PLANNING FOR RESIDENT #1 WHILE HER WEIGHT WAS BELOW THE MANUFACTURER'S MINIMUM RECOMMENDATIONS FOR THE MEDIUM SLING USED ON THE RESIDENT. ( ) --

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE PAIN WAS ADEQUATELY ADDRESSED FOR ONE (#6) OUT OF 20 RESIDENTS REVIEWED FOR EFFECTIVE PAIN MANAGEMENT. THIS FAILURE IN EFFECTIVE PAIN MANAGEMENT RESULTED IN RESIDENT #6 EXPERIENCING A DECREASE IN MOBILITY/POSTURE AND A DECLINE IN MOOD AND SOCIAL ENGAGEMENT AS EXHIBITED BY IRRITABILITY, ANGER, AGITATION, AND DIFFICULTY WITH SLEEPING. FINDINGS INCLUDE: A REVIEW OF RESIDENT #6'S MEDICAL CHART REFLECTS RESIDENT #6 IS [AGE] years OLD. RESIDENT #6 WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. AN OCCUPATIONAL THERAPY (OT) EVALUATION COMPLETED 6/14/10 STATES RESIDENT #6 HAS "SIGNIFICANT PAIN IN LUE (LEFT UPPER EXTREMITY)." THE OT EVALUATION ALSO READS "PAIN DESCRIBED IN LEFT SHOULDER. S/P (status [REDACTED]." ON 6/22/10, THE FOLLOWING NOTATION WAS RECORDED IN THE PHYSICIAN COMMUNICATION BOOK CONCERNING RESIDENT #6: "OT REPORTS LEFT SHOULDER PAIN AND (DECREASED) ROM (RANGE OF MOTION). CAN SHE HAVE TYLENOL DAILY?" THERE IS NO DOCUMENTATION IN THE COMMUNICATION BOOK OR THE PHYSICIAN ORDER/ PROGRESS NOTE THAT REFLECT THE PHYSICIAN ACKNOWLEDGED RESIDENT #6'S NEED FOR PAIN RELIEF. THE MINIMUM DATA SET (MDS), dated [DATE], SHOWS RESIDENT #6 HAD A MODERATE LEVEL OF DAILY PAIN. THE Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. RECORD REVIEW REFLECTS RESIDENT #6 RECEIVED OT THERAPY DURING THE PERIOD OF 6/14/10-6/30/10. THE THERAPY INCLUDED ROM (RANGE OF MOTION) WITH HOT PACK THERAPY FOR PAIN. HOWEVER, OT WAS DISCONTINUED ON 6/30/10. THE OT DISCHARGE SUMMARY FOR RESIDENT #6 READS, "UNABLE TO MEET GOALS. PLATEAU OF PROGRESS." THE RESIDENT ASSESSMENT PROTOCOL DATED 9/23/10 TITLED "ADL FUNCTIONAL REHABILITATION POTENTIAL" FOR RESIDENT #6 READS: "LIMITED ROM AND PAIN IN LEFT SHOULDER." ON 10/5/10, THE FOLLOWING NOTATION WAS RECORDED IN THE PHYSICIAN COMMUNICATION BOOK CONCERNING RESIDENT #6'S PAIN: "(RIGHT) SHOULDER PAIN THAT IS SOMETIMES MODERATE. IRRITABLE OR SAD MOOD THAT MIGHT BE PAIN. CAN SHE HAVE A DAILY [MEDICATION NAME]?" THERE IS NO DOCUMENTATION IN THE COMMUNICATION BOOK OR THE PHYSICIAN ORDER [REDACTED]. ON 10/18/11, RESIDENT #6 HAD A FALL. RESIDENT #6 SUFFERED FACIAL LACERATIONS, AND BRUISED HER RIBS. X-RAYS REVEALED NO FRACTURES. HOWEVER, DUE TO THE FALL WITH BRUISES, THE PHYSICIAN ORDERED [MEDICATION NAME], 50 MG, EVERY 6 HOURS, AS NEEDED, FOR PAIN. RESIDENT #6 CONTINUED TO EXPERIENCE PAIN. THE FOLLOWING NURSES NOTES WERE FOUND IN THE FILE: 10/23/10, 1:20 P.M.: "RESIDENT HAVING SEVERE (RIGHT) RIB-BACK PAIN. GIVEN [MEDICATION NAME] @ 0640 (6:40 A.M.) PRIOR TO GETTING OUT OF BED. ALLOWED IN BED ABOUT 1 HOUR BEFORE ABLE TO MOVE. TRANSPORTED VIA W/C (WHEELCHAIR). 1240 (12:40 P.M.): [MEDICATION NAME] REPEATED FOR COMFORT. CONTINUES TO HAVE TENDERNESS ACROSS BACK." 10/24/10, 6-2 SHIFT: "RESIDENT C/O (COMPLAINS OF) SEVERE (RIGHT) SIDED PAIN. PRN [MEDICATION NAME] AND TYLENOL GIVEN X 2 THIS TOUR WITH SOME RELIEF NOTED." 10/27/10, 12:45 P.M.: "[MEDICATION NAME] GIVEN THIS AM. WHEN ASKED IF SHE WAS HAVING PAIN, STATED, 'YES, IT HURTS.'" 10/29/10, 1300 (1:00 P.M.): "[MEDICATION NAME] GIVEN UPON AWAKENING. C/O'S SEVERE BACK PAIN TO CNA'S (CERTIFIED NURSE AIDES)." 11/6/10, 1:00 P.M.: "RESIDENT IRRITABLE UPON AWAKENING. EASILY UPSET AND DISGUSTED. WHEN ASKED IF SHE'S HAVING PAIN, STATED 'YES, WHAT DO YOU THINK?' [MEDICATION NAME] GIVEN WITH AM MEDS." IN NOVEMBER 2010, RESIDENT #6 RECEIVED PRN PAIN MEDICATION 30 TIMES, WITH THE PAIN NOTED TO BE SEVERE AT TIMES. NO ORDER FOR SCHEDULED PAIN MEDICATION WAS OBTAINED FROM THE PHYSICIAN. ON 12/11/10, THE FOLLOWING NOTATION WAS RECORDED IN THE PHYSICIAN COMMUNICATION BOOK CONCERNING RESIDENT #6'S PAIN; "(RIGHT) RIB PAIN HAS RESOLVED. OTHER PAIN PERSISTS. PERHAPS BACK. [MEDICATION NAME] IS GIVEN 1-2 X A DAY. CAN IT BE SCHEDULED?" THERE IS NO DOCUMENTATION IN THE COMMUNICATION BOOK OR THE PHYSICIAN ORDER/ PROGRESS NOTE ORDERING A CHANGE IN RESIDENT #6'S PLAN OF CARE ADDRESSING RESIDENT #6'S ONGOING PAIN. RESIDENT #6 REMAINED ON PRN PAIN MEDICATION ONLY. ON 12/21/10, RESIDENT #6'S MDS WAS UPDATED, A QUARTERLY PAIN ASSESSMENT WAS COMPLETED, AND THE QUARTERLY CARE CONFERENCE WAS HELD. IN SECTION J, "PAIN MANAGEMENT" OF THE MDS, RESIDENT #6 IS NOTED TO BE RECEIVING PRN PAIN MEDICATION ONLY. THE MDS INDICATED RESIDENT #6 VOCALLY COMPLAINED OF PAIN, SHOWED PAIN IN HER FACIAL EXPRESSIONS AND PROTECTIVE BODY MOVEMENTS AND POSTURE. FREQUENCY OF PAIN WAS MARKED, "POSSIBLE PAIN DAILY OBSERVED." A WRITTEN ASSESSMENT COMPLETED ON 12/21/10 READS, "...HX (HISTORY) OF [MEDICAL CONDITION] AFFECTING LEFT SHOULDER. INCIDENTAL FINDING OF RIB X-RAY REVEALED S SHAPED SCOLIOSIS, SPONDYLOARTHROSIS, AND ELEVATION OF HUMERUS. MEDICATION NURSE REPORTS FREQUENT NON-VERBAL SIGNS OF PAIN. WHEN QUESTIONED STATES SHE fell S 'LIKE[***]' BACK OR GENERAL BODY PAIN IS SUSPECTED. TOLERATES [MEDICATION NAME] WITHOUT GI DISTRESS OR CONFUSION ONE OR TWO TIMES A DAY. COULD BENEFIT FROM DAILY SCHEDULED [MEDICATION NAME]. WRITTEN MESSAGE TO MD." RESIDENT #6'S "CARE CONFERENCE INTERDISCIPLINARY TEAM AND ATTENDANCE" NOTE DATED 12/21/10 REFLECTS RESIDENT #6 IS "OFTEN IRRITABLE AND FEELS 'LIKE[***]." UNDER THE THERAPY SECTION, THIS NOTATION APPEARS; "PT (PHYSICAL THERAPY) HAS EVALUATED AND BELIEVES SHE WOULD BENEFIT FOR REDUCTION OF BACK PAIN. PT IS SEEKING MD APPROVAL." FAMILY NOTICED, "A STOOPED POSTURE AND SHUFFLED GAIT THAT SHE NEVER HAD BEFORE." "STEP-DAUGHTER AGREES WITH PRESENCE OF PAIN AND PT (PHYSICAL THERAPY)." IN DECEMBER 2010, RESIDENT #6 RECEIVED 44 DOSES OF PRN PAIN MEDICATION. IN JANUARY 2011, RESIDENT #6 RECEIVED 45 DOSES OF PRN PAIN MEDICATION IN 24 DAYS. (THE OTHER 6 DAYS SHE WAS IN THE HOSPITAL.) ACCORDING TO THE PHYSICIAN'S PROGRESS NOTES, ON 1/26/11, THE PHYSICIAN SAW RESIDENT #6 FOR THE FIRST TIME SINCE 10/22/10. NO NEW ORDER WAS WRITTEN FOR PAIN MEDICATION FOR RESIDENT #6. ON 2/3/11, THE FOLLOWING NOTE BY A NURSE WAS LEFT IN THE PHYSICIAN COMMUNICATION BOOK CONCERNING RESIDENT #6: "REC'D (RECEIVED) [MEDICATION NAME] 36 TIMES IN MONTH OF JAN (JANUARY) PRN (AS NEEDED). NO SCHEDULED PAIN MED." ON 2/7/11, THE MEDICAL DIRECTOR ORDERED [MEDICATION NAME] TO BE GIVEN TWICE A DAY SCHEDULED AND EVERY FOUR HOURS AS NEEDED. ON 2/9/11, THE MEDICAL DIRECTOR INCREASED THE SCHEDULED [MEDICATION NAME] TO BE GIVEN THREE TIMES A DAY. ON 2/14/11, THE FAMILY PHYSICIAN DISCONTINUED THE [MEDICATION NAME] STATING, BY VOICE ORDER, ACCORDING TO A NOTATION IN THE MEDICAL RECORD, THAT THERE WAS A DRUG INTERACTION WITH THE [MEDICATION NAME]. NO ALTERNATIVE SCHEDULED PAIN MEDICATION WAS ORDERED TO REPLACE THE DISCONTINUED SCHEDULED [MEDICATION NAME]. RESIDENT #6 REMAINED ON PRN PAIN MEDICATION ONLY. THE 19 DAYS OF FEBRUARY THAT RESIDENT #6 WAS NOT ON SCHEDULED PAIN MEDICATION, SHE RECEIVED 22 DOSES OF PRN PAIN MEDICATION. ON 2/23/11 AT 10:00 A.M., A NURSING NOTE READS, "RESIDENT AGITATED THIS AM. (UP IN DINING ROOM) FOR BREAKFAST. VERY IRRITABLE AND CRABBY. WHEN HANDED GLASS OF JUICE AT BREAKFAST, RESIDENT UPSET AND THREW GLASS BACK ON MEAL TRAY... RESIDENT GIVEN TYLENOL DUE TO BODY PAIN. QUESTIONABLE. WHEN ASKED HOW SHE FEELS, STATED 'LIKE[***]' VERY SHORT TEMPER." ON 2/24/11 AT 1:15 P.M., THIS NOTE WAS WRITTEN IN THE NURSE'S NOTE: "RESIDENT IRRITABLE. VERY CRABBY. FACIAL EXPRESSION APPEARS AS IN PAIN. TYLENOL GIVEN." ON 3/4/11, A "SOCIAL SERVICE BEHAVIOR AND/OR MOOD REFERRAL" WAS SENT TO RESIDENT #6'S SOCIAL WORKER. THE REFERRAL READS: "RESIDENT UP AT NOC. IN AND OUT OF OTHER RESIDENTS' ROOMS. WHEN TRYING TO REDIRECT RESIDENT BECOMES SARCASTIC. CANNOT SIT STILL IN CHAIRS, ON TOILET, OR IN BED. HAS BEEN UP FOR DAYS. RESIDENT HAS BEEN AGITATED AND MORE CONFUSED. STAFF HAS TRIED ONE ON ONE, TOILETING, TALKING WITH RESIDENT, OFFERED SNACK. WHEN ASKED IF RESIDENT HAS PAIN SHE REPLIES, 'I DON'T KNOW.' WHEN TRYING TO TALK WITH RESIDENT SHE BECOMES ANGRY AND YELLS." NURSES NOTES WERE REFERENCED FOR 2/11; 2/23; 2/24 X 2; 2/25; 2/26; 3/3 X 2. THE SOCIAL WORKER'S WRITTEN REPLY, AT THE BOTTOM OF THE REFERRAL PAGE READS: "RESIDENT MAY BE IN PAIN AND MAY NEED PAIN MEDS RESTARTED. WILL ASK PHYSICIAN TO RESTART PAIN MEDS." ON 3/4/11, THE PHYSICIAN ORDERED [MEDICATION NAME] ([MEDICATION NAME] 5/325 MG) TO BE GIVEN TO RESIDENT #6 AS A SCHEDULED PAIN MEDICATION ALONG WITH TYLENOL, 325 MG, EVERY FOUR HOURS, AS NEEDED. AN INTERVIEW WAS CONDUCTED WITH NURSE "K" ON 3/17/11 AT 9:30 A.M. NURSE "K" STATED SHE HAD LONG BELIEVED RESIDENT #6 NEEDED MORE PAIN MEDICATION FOR UNCONTROLLED PAIN. NURSE "K" STATED SHE HAD TALKED WITH BOTH THE DOCTOR AND THE FAMILY SEVERAL TIMES. SHE STATED THE FAMILY DID NOT BELIEVE THE RESIDENT WAS IN PAIN. HOWEVER, NURSE "K" STATED SINCE STARTING THE SCHEDULED PAIN MEDICATION, RESIDENT #6 HAS BEEN SLEEPING QUITE WELL AND EVEN EATING BETTER. NURSE "K" STATED RESIDENT #6 IS STAYING IN THE GROUP AREA MORE IN THE LAST WEEK, EVEN THOUGH SHE DOES NOT INTERACT MUCH WITH PEOPLE. SHE STATED RESIDENT #6 CAN SIT STILL AND IS HARDLY EVER IRRITABLE AND CRABBY LIKE SHE USED TO BE. NURSE "K" ATTRIBUTED THE IMPROVEMENT IN RESIDENT #6'S MOOD AND BEHAVIOR TO IMPROVED PAIN CONTROL. RESIDENT #6 WAS OBSERVED IN THE DINING ROOM ON 3/17/11 AT 8:30 A.M. SHE WAS COOPERATIVE IN WALKING WITH THE STAFF, AND IN EATING HER BREAKFAST AT THE TABLE. RESIDENT #6 EXHIBITED NO DISTRESS AND SHE WAS ABLE TO SIT THROUGH THE ENTIRE MEAL. ( ) --

THERE ARE TWO DEFICIENT PRACTICE STATEMENTS UNDER THIS DEFICIENCY. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE ASSISTIVE DEVICES FOR ONE (#1) OF SEVEN RESIDENTS REVIEWED FOR TRANSFERS USING A MECHANICAL LIFT AND FAILED TO PROVIDE ADEQUATE SUPERVISION FOR ONE (#7) OF FIVE RESIDENTS REVIEWED FOR FALLS OUT OF A TOTAL SAMPLE OF 27 RESIDENTS. THESE FACILITY FAILURES RESULTED IN BOTH RESIDENTS FALLING WITH RESIDENT #1 BEING HARMED, SUFFERING WITH MULTIPLE FRACTURES. FINDINGS INCLUDE: A REVIEW WAS PERFORMED OF A FACILITY REPORTED INCIDENT INVESTIGATION DATED 3/03/11. THE REPORT REVEALED ON 2/28/11 AT 7:30 A.M. DURING A TRANSFER WITH A "LIKO" MECHANICAL LIFT, RESIDENT #1 SLID OUT OF THE TRANSFER SLING AND LANDED ON THE FLOOR. THE RESIDENT HAD A SWOLLEN RIGHT SHOULDER AND A 1 1/2 INCH HEMATOMA TO HER HEAD. THE RESIDENT WAS SENT TO THE emergency room . THE X-RAY REPORT DATED 2/28/11 REVEALED A FRACTURED CLAVICLE, NON-DISPLACED FRACTURES OF THE SCAPULA, MANUBRIUM (UPPER PART OF THE STERNUM OR CHEST BONE), ANTERIOR FIRST RIB, AND A CLOSED HEAD INJURY. RESIDENT #1 RETURNED BACK to the facility on [DATE]. DURING THE SURVEY PERIOD OF 3/14/11 THROUGH 3/17/11, THE CLINICAL RECORD OF RESIDENT #1 WAS REVIEWED. THE FACE SHEET REVEALED RESIDENT #1 IS A [AGE] year-old FEMALE WITH [DIAGNOSES REDACTED]. PER RESIDENT #1'S "ACTIVITY OF DAILY LIVING" (ADL) INSTRUCTION SHEET DATED 2/18/11, RESIDENT #1 REQUIRED THE ASSIST OF ONE STAFF MEMBER AND A "LIKO" MECHANICAL LIFT WITH SLING TO TRANSFER HER SAFELY BETWEEN SURFACES (BED TO CHAIR ETC.). PER RESIDENT #1'S ADL CARE PLAN DATED 4/30/10, RESIDENT #1 WAS IDENTIFIED AS NEEDING THE "LIKO" LIFT FOR ALL TRANSFERS. HOWEVER, PRIOR TO 3/04/11, THE CARE PLAN DID NOT IDENTIFY/DIRECT FACILITY STAFF AS TO WHICH SLING (BASED ON THE RESIDENT'S SIZE/WEIGHT) WAS TO BE USED. AN INTERVIEW WAS HELD ON 3/15/11 AT 10:45 A.M. WITH CERTIFIED NURSE AIDE (CNA) "T". CNA "T" RECITED HOW SHE TRANSFERRED RESIDENT #1 ON 2/28/11 USING THE "LIKO" LIFT WITH THE GREEN SLING (WITH RESIDENT #1'S NAME ON IT). CNA "T" STATED, DURING THE TRANSFER RESIDENT #1 MOVED AND STARTED TO SLIDE OUT OF THE GREEN TRANSFER SLING. CNA "T" CONTINUED TO STATE HOW SHE TRIED TO STOP THE RESIDENT FROM SLIDING BUT WAS UNSUCCESSFUL. AN INTERVIEW WAS HELD ON 3/15/11 AT 9:25 A.M. WITH PHYSICAL THERAPY (PT) STAFF "P". PT STAFF "P" SAID THE THERAPY DEPARTMENT ASSESSES EACH RESIDENT AND DECIDES WHAT TYPE OF TRANSFER EACH RESIDENT NEEDS. WHEN PT "P" WAS ASKED IF THE THERAPY DEPARTMENT DETERMINES THE SLING SIZE, SHE RESPONDED, "NO, THAT IS UP TO THE DIRECTOR OF NURSING, AND THE TWO ASSISTANT DIRECTORS OF NURSING." AN INTERVIEW WAS HELD WITH THE DIRECTOR OF NURSING (DON) ON 3/15/11 AT 1:15 P.M., CONCERNING HOW RESIDENTS WERE ASSESSED FOR THE APPROPRIATE "LIKO" LIFT SLING SIZE. THE DON SAID THE FACILITY FOLLOWED/USED THE MANUFACTURER'S RECOMMENDED SLING BASED ON THE RESIDENT'S WEIGHT. THE DON STATED, "(RESIDENT #1) HAD BEEN USING THE MEDIUM (GREEN) SLING... SHE WAS ASSESSED AND THE MEDIUM GREEN CROSS-OVER SLING HAS BEEN USED SINCE 10/07." A RECORD REVIEW OF THE "LIKO UNIVERSAL SLING" MANUFACTURER'S RECOMMENDATIONS (NOT DATED) FOR LIKO LIFT SLING SIZING PER WEIGHT WAS REVIEWED FOLLOWING THE ABOVE INTERVIEW WITH THE DON. THE GREEN SLING SIZE MEDIUM WAS TO BE USED BY RESIDENTS WEIGHING BETWEEN 132 AND 198 POUNDS. A REVIEW OF RESIDENT #1'S BODY WEIGHTS, RECORDED ON THE "VITAL SIGN RECORD" SHEET FROM 6/01/10 THROUGH 2/28/11, WAS PERFORMED DURING THE SURVEY. RESIDENT #1'S WEIGHTS RECORDED FOR THE MONTHS OF 6/10, 7/10, 8/10, 10/10, 11/10, 12/10, AND THROUGH 1/23/11 RANGED FROM 126.1 TO 131.7 POUNDS. RESIDENT #1'S WEIGHTS WERE OUTSIDE THE MANUFACTURER'S WEIGHT RANGE FOR A SAFE TRANSFER. RESIDENT #1'S RECORDED WEIGHTS FROM 1/31/11 THROUGH THE DATE OF THE FALL OUT OF THE SLING, ON 2/28/11, RANGED FROM 129.2 TO 131.7. FURTHERMORE, THESE WEIGHTS WERE OUTSIDE THE MANUFACTURER'S WEIGHT RANGE FOR A SAFE TRANSFER USING THE MEDIUM/GREEN SLING. A RECORD REVIEW OF RESIDENT #1'S CHART REVEALED THERE WAS NO EVIDENCE OF ANY RE-EVALUATIONS OF THE APPROPRIATE SLING SIZE USING THE AVAILABLE WEIGHTS RECORDED. THERE WERE 6 MONTHS WHERE THE MEDIUM/GREEN SLING SIZE WAS NOT WITHIN THE MANUFACTURER'S RECOMMENDED WEIGHT PARAMETER FOR THE RESIDENT. ON 2/28/11, WHEN THE RESIDENT SLID OUT OF THE LIFT, THERE WAS NO WEIGHT RECORDED. RESIDENT #1'S MOST RECENT WEIGHT, PREVIOUS TO 2/28/11, WAS ON 2/21/11 AND RECORDED AT 131.7 POUNDS. THIS WEIGHT WAS NOT WITHIN THE MANUFACTURER'S RECOMMENDED WEIGHT CRITERIA FOR A SAFE TRANSFER. RESIDENT #1 fell OUT OF THE SLING AND SUFFERED FRACTURES OF HER CLAVICLE, SCAPULA, MANUBRIUM, ANTERIOR FIRST RIB, AND A CLOSED HEAD INJURY. AN INTERVIEW WAS PERFORMED ON 3/16/11 AT 2:00 P.M. WITH THE DON. DURING THE INTERVIEW, THE DON REVEALED THE FACILITY HAD NO EVIDENCE OF RE-ASSESSING/CARE PLANNING THE APPROPRIATE ASSISTIVE DEVICE/ MECHANICAL LIFT SLING FOR RESIDENT #1 WHEN HER WEIGHT WAS BELOW THE MANUFACTURER'S RECOMMENDATION FOR THE USE OF THE MEDIUM/GREEN SLING. ( ) DURING THE SURVEY PERIOD OF 3/14/11 THROUGH 3/17/11, THE CLINICAL RECORD OF RESIDENT #7 WAS REVIEWED. THE FACE SHEET REVEALED RESIDENT #7 IS A [AGE] year-old MALE, RE-admitted to the facility on [DATE] FOLLOWING hospitalization . RESIDENT #7'S [DIAGNOSES REDACTED]. DURING THE SURVEY PERIOD, A FACILITY REPORTED INCIDENT (FRI) WAS REVIEWED. THE FRI DESCRIBES A FALL WHICH RESIDENT #7 SUSTAINED ON 3/7/11. IN ADDITION, IT WAS DISCOVERED THAT RESIDENT #7 SUSTAINED TWO SUBSEQUENT FALLS WHICH OCCURRED ON 3/8/11 AT 6:00 A.M. AND ON 3/8/11 AT 5:30 P.M. DURING AN INTERVIEW WITH ADON "L" ON 3/16/11 AT 9:45 A.M., SHE VERIFIED THE FOLLOWING INTERVENTIONS WHICH WERE PUT IN PLACE FOR RESIDENT #7 UPON ADMISSION IN AN EFFORT TO PREVENT HIM FROM FALLING. RESIDENT #7 WAS TO HAVE BED ALARM ON WHILE IN BED, CHAIR ALARM WHILE UP IN WHEELCHAIR, AND A PERSONAL ALARM ON AT ALL TIMES. THESE MEASURES WERE IN PLACE WHEN RESIDENT #7 fell on [DATE]. THE FACILITY THEN ADDED "FIFTEEN MINUTE CHECKS" OF THE RESIDENT. ALL MEASURES WERE IN PLACE WHEN RESIDENT #7 fell A SECOND TIME, ON 3/8/11 AT 6:00 A.M. THE FACILITY THEN PUT RESIDENT #7 ON "ONE-TO-ONE (1:1) SUPERVISION", PLACED A LIPPED MATTRESS ON HIS BED, AND MOVED RESIDENT TO A ROOM CLOSER TO THE NURSES' STATION. THE "NURSING PROCESS NOTE" SHOWED THAT ON 3/8/11 AT 5:30 P.M., RESIDENT #7 fell A THIRD TIME. A REVIEW OF THE FACILITY'S INCIDENT REPORT DATED 3/8/11, REGARDING THE FALL (OCCURRING ON THE SAME DATE) WAS PERFORMED DURING THE SURVEY. IT WAS FOUND THAT CNA "O" WAS ASSIGNED THE "1:1 SUPERVISION" OF RESIDENT #7 AT THE TIME OF THE THIRD FALL (DATED 3/8/11 AT 5:30 P.M.). THE INCIDENT REPORT STATED "ANOTHER RESIDENT'S FAMILY CAME TO DOOR AND ASKED (CNA "O") A QUESTION. (CNA "O") WENT TO THE DOORWAY, AT WHICH TIME (RESIDENT #7) ATTEMPTED TO STAND UP, fell AND HIT HIS HEAD." A STATEMENT WRITTEN BY CNA "O" DATED 3/8/11, WAS REVIEWED DURING THE SURVEY. CNA "O" STATED (IN THIS WRITTEN STATEMENT) SHE "WAS AT THE DOORWAY OF RESIDENT'S ROOM TO ANSWER QUESTIONS ASKED BY ANOTHER RESIDENT'S FAMILY" WHEN RESIDENT #7 "fell on THE FLOOR AND HIT HIS HEAD." AN INTERVIEW WAS PERFORMED WITH THE DIRECTOR OF NURSING (DON) ON 3/17/11 AT 10:00 A.M. DURING THE INTERVIEW, SHE WAS ASKED IF SHE EXPECTED THE "1:1" STAFF PERSON TO BE ABLE TO VIEW THE RESIDENT AT ALL TIMES; SHE REPLIED "YES". THE DON PROVIDED A COPY OF THE FACILITY'S POLICY TITLED "ONE TO ONE MONITORING" DATED 3/31/2009. THIS POLICY READS: "...(3) WHEN STAFF IS CARRYING OUT ONE TO ONE MONITORING, THEY ARE TO HAVE RESIDENT IN VIEW AT ALL TIMES" AND "...(7) IF STAFF MEMBER NEEDS TO LEAVE ROOM, THEY ARE TO USE CALL LIGHT FOR OTHER STAFF TO RELIEVE." ( ) BASED ON OBSERVATION AND INTERVIEW, THE FACILITY FAILED TO SAFELY STORE POTENTIALLY HAZARDOUS CLEANING CHEMICALS FROM POTENTIAL ACCESS FOR SIX (#16, #17, #18, #19, #20, AND #21) COGNITIVELY IMPAIRED, MOBILE RESIDENTS RESIDING ON THE 500 HALL, OUT OF A TOTAL OF 175 RESIDENTS IN THE FACILITY. THE FACILITY FAILURE TO PREVENT RESIDENT ACCESS TO THESE CHEMICALS COULD RESULT IN RESIDENTS EXPERIENCING SKIN IRRITATION, INJURY, OR INTERNAL DAMAGE SHOULD CHEMICALS ACCIDENTALLY BE CONSUMED. FINDINGS INCLUDE: ON 3/14/11 AT APPROXIMATELY 2:30 P.M., AN INITIAL TOUR OF THE FACILITY REVEALED A CONTAINER OF "CLOROX GERMICIDAL WIPES" IN THE 500 RESIDENCE HALL OUTSIDE ROOM 512. THE CONTAINER WAS ON TOP OF A PLASTIC CONTAINER AND WAS READILY ACCESSIBLE TO RESIDENTS ON THAT UNIT. THE CONTAINER INDICATED THAT "SODIUM HYPOCHLORITE" WAS THE ACTIVE CHEMICAL INGREDIENT FOR THIS PRODUCT AND PRINTED THE FOLLOWING WARNING ON THE LABEL, "HAZARDOUS TO HUMANS AND DOMESTIC ANIMALS". NO RESIDENTS WERE OBSERVED IN THE AREA AT THE TIME OF THE OBSERVATION. THE DIRECTOR OF NURSING WAS IMMEDIATELY INFORMED OF THE POTENTIAL HAZARD AND THE CONTAINER WAS REMOVED TO A SAFE LOCATION. A CONTINUATION OF THE INITIAL TOUR, ON 3/14/11 AT APPROXIMATELY 2:40 P.M., REVEALED AN UNLOCKED "SOILED LINEN ROOM" ADJACENT TO THE "NORTH" NURSING STATION AND IN PROXIMITY TO THE ENTRANCE OF THE 500 HALL RESIDENCE WING. UPON ENTERING THE ROOM, A TRIGGER SPRAY BOTTLE LABELED, "BLEACH SOLUTION" WAS READILY ACCESSIBLE ON THE COUNTER. ANOTHER TRIGGER SPRAY BOTTLE LABELED, "GERMICIDAL CLEANER" WAS ALSO ACCESSIBLE ON THE COUNTER. THE WARNINGS ON THE GERMICIDAL CLEANER READ, "AVOID CONTACT WITH EYES". A GALLON CONTAINER OF LIQUID CLOROX BLEACH WAS ACCESSIBLE ON AN UPPER SHELF. THIS CONTAINER WOULD BE ACCESSIBLE TO AMBULATORY RESIDENTS BUT WOULD BE OUT OF REACH OF RESIDENTS IN WHEELCHAIRS. THE READY ACCESS TO THIS SOILED LINEN ROOM WAS REPORTED TO THE DIRECTOR OF NURSING IMMEDIATELY ON 3/14/11 AT APPROXIMATELY 2:45 P.M. AND MAINTENANCE STAFF WAS OBSERVED WORKING ON THE LOCKING MECHANISM TO THE DOOR AT 3 P.M. ON THE FOLLOWING MORNING, 3/15/11, AT APPROXIMATELY 9:30 A.M., THE ENTRY DOOR TO THE SAME SOILED LINEN ROOM WAS UNLOCKED PROVIDING EASY ACCESS TO THE SAME CLEANING CHEMICALS IDENTIFIED IN THE OBSERVATION MADE ON THE PREVIOUS DAY, 3/14/11. ON 3/16/11 AT APPROXIMATELY 9:30 A.M., AN INTERVIEW WAS CONDUCTED WITH SOCIAL WORK STAFF "F" IN HER OFFICE AT THE END OF THE 500 HALL. STAFF "F" IDENTIFIED THAT RESIDENTS #16, #17, #18, #19, #20, AND #21 RESIDED ON THE 500 WING AND ALL HAD VARIOUS LEVELS OF CONFUSION AND COGNITIVE DEFICITS. THESE RESIDENTS WERE ALSO IDENTIFIED BY STAFF "F" AS BEING ABLE TO MOVE ABOUT THE 500 UNIT AND THE GENERAL FACILITY BY THEMSELVES EITHER IN WHEELCHAIRS OR VIA INDEPENDENT AMBULATION. THESE RESIDENTS WOULD BE THE INDIVIDUALS MOST LIKELY TO HAVE CONTACT WITH IMPROPERLY STORED CLEANING CHEMICALS IN THEIR IMMEDIATE ENVIRONMENT ON THE 500 UNIT. ( ) --

BASED ON RECORD REVIEW, THE FACILITY FAILED TO EFFECTIVELY DEVELOP AND IMPLEMENT APPROPRIATE PLANS OF ACTION TO CORRECT IDENTIFIED QUALITY OF CARE DEFICIENCIES. THIS FACILITY'S LACK OF QUALITY ASSESSMENT AND ASSURANCE ACTIVITIES IS DEMONSTRATED THROUGH REPEATED FAILURES OF THE FACILITY TO PROVIDE AN ENVIRONMENT FREE OF ACCIDENT HAZARDS AND TO PROVIDE RESIDENTS WITH ADEQUATE SUPERVISION/ASSISTIVE DEVICES WHICH RESULTED IN ONE (#1) RESIDENT FALLING AND FRACTURING MULTIPLE BONES AND ONE (#7) RESIDENT FALLING MULTIPLE TIMES OUT OF A TOTAL SAMPLE OF 27 RESIDENTS. FINDINGS INCLUDE: DURING THE STANDARD SURVEY CONDUCTED 3/14/11 THROUGH 3/17/11, THERE WERE TWO DEFICIENT PRACTICE STATEMENTS REGARDING FAILURE TO ENSURE THE RESIDENTS' ENVIRONMENT REMAINS AS FREE OF ACCIDENT HAZARDS AS POSSIBLE. THE FIRST DEFICIENT PRACTICE WAS DUE TO THE FACILITY'S FAILURE TO PROVIDE ADEQUATE ASSISTIVE DEVICES FOR ONE (#1) RESIDENT REVIEWED FOR TRANSFERS USING A MECHANICAL "LIKO" LIFT AND FAIILURE TO PROVIDE ADEQUATE SUPERVISION FOR ONE (#7) RESIDENT WHO HAS HAD MULTIPLE FALLS. THESE FACILITY FAILURES RESULTED IN BOTH RESIDENTS FALLING WITH RESIDENT #1 BEING INJURED, SUFFERING WITH MULTIPLE BONE FRACTURES AS A RESULT OF THE FALL. A REVIEW WAS PERFORMED OF A FACILITY REPORTED INCIDENT INVESTIGATION DATED 3/03/11. THE REPORT REVEALED ON 2/28/11 AT 7:30 A.M. DURING A TRANSFER WITH A "LIKO" MECHANICAL LIFT, RESIDENT #1 SLID OUT OF THE TRANSFER SLING AND LANDED ON THE FLOOR. THE RESIDENT HAD A SWOLLEN RIGHT SHOULDER AND A 1 1/2 INCH HEMATOMA TO HER HEAD. THE RESIDENT WAS SENT TO THE emergency room . THE X-RAY REPORT DATED 2/28/11 REVEALED A FRACTURED CLAVICLE, NON-DISPLACED FRACTURES OF THE SCAPULA, MANUBRIUM (UPPER PART OF THE STERNUM OR CHEST BONE), ANTERIOR FIRST RIB, AND A CLOSED HEAD INJURY. RESIDENT #1 RETURNED BACK to the facility on [DATE]. THE FACILITY WAS PREVIOUSLY CITED FOR THIS DEFICIENT PRACTICE INVOLVING A MECHANICAL LIFT DURING AN ABBREVIATED SURVEY CONDUCTED 8/18/09. THE FACILITY FAILED TO ENSURE THAT A RESIDENT WAS TRANSFERRED IN A SAFE MANNER, USING A MECHANICAL "LIKO" LIFT WHICH RESULTED IN THE RESIDENT FALLING FROM THE LIFT. DURING THE SURVEY PERIOD OF 3/14/11 THROUGH 3/17/11, A FACILITY REPORTED INCIDENT (FRI) WAS REVIEWED. THE FRI DESCRIBES A FALL WHICH RESIDENT #7 SUSTAINED ON 3/7/11. IN ADDITION, IT WAS DISCOVERED THAT RESIDENT #7 SUSTAINED TWO SUBSEQUENT FALLS WHICH OCCURRED ON 3/8/11 AT 6:00 A.M. AND ON 3/8/11 AT 5:30 P.M. THE FACILITY WAS ALSO PREVIOUSLY CITED FOR THIS DEFICIENT PRACTICE DURING AN ABBREVIATED SURVEY CONDUCTED ON 5/25/10 AT A PATTERN LEVEL. DURING THIS SURVEY, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION AND/OR ASSISTIVE DEVICES TO PREVENT ACCIDENTS FOR FIVE OF FIVE RESIDENTS REVIEWED WHO fell AT THE FACILITY. MOST RECENTLY, HOWEVER, DURING AN ABBREVIATED SURVEY CONDUCTED ON 1/26/11, THE FACILITY WAS CITED DUE TO THEIR FAILURE TO UTILIZE NECESSARY ASSISTIVE DEVICES, SPECIFICALLY, FOOT PEDALS ON A WHEELCHAIR FOR A RESIDENT, RESULTING IN THE RESIDENT DROPPING HIS FEET AND CATAPULTING OUT OF THE WHEELCHAIR, HITTING THE FLOOR AND SUFFERING A BRUISE TO HIS FOREHEAD. THEN, DURING THE FIRST REVISIT TO THE 1/26/11 ABBREVIATED SURVEY CONDUCTED ON 3/8/11, THE FACILITY AGAIN FAILED TO PROVIDE ASSISTIVE DEVICES (WHEELCHAIR FOOTRESTS) TO PREVENT INJURY FOR ANOTHER RESIDENT WHO WAS REVIEWED FOR USING WHEELCHAIRS. THE SECOND DEFICIENT PRACTICE IDENTIFIED DURING THE SURVEY PERIOD OF 3/14/11 THROUGH 3/17/11 WAS DUE TO THE FACILITY'S FAILURE TO SAFELY STORE POTENTIALLY HAZARDOUS CLEANING CHEMICALS FROM POTENTIAL ACCESS FOR SIX (#16, #17, #18, #19, #20, AND #21) COGNITIVELY IMPAIRED, MOBILE RESIDENTS RESIDING ON THE 500 HALL. THE FACILITY WAS PREVIOUSLY CITED FOR THIS DEFICIENT PRACTICE DURING THE STANDARD SURVEY CONDUCTED 1/13/10, WHEN THE FACILITY FAILED TO GUARD AGAINST POTENTIAL ACCIDENT HAZARDS WHEN WATER TEMPERATURES AT THE RESIDENTS' BATHROOM TAPS WERE MEASURED AT UP TO 124.1 DEGREES FAHRENHEIT. THESE REPEAT CITATIONS DEMONSTRATE THAT THE FACILITY'S QUALITY ASSESSMENT AND ASSURANCE ACTIVITIES ARE NOT EFFECTIVE IN IDENTIFYING THE ROOT CAUSES REQUIRED IN THE DEVELOPMENT AND IMPLEMENTATION OF ACTION PLANS FOR THOSE AREAS NEEDING IMPROVEMENT. ( )