Every finding on record at Jackson County Medical Care Facility

Based on observation and interview, the facility failed to ensure proper storage and handling of food and disinfection of thermometers affecting up to 176 residents in the facility. Findings include: An observation on 04/14/2026 at 8:53 AM revealed the walk-in refrigerator in the kitchen contained a container of cream of mushroom soup that was labeled as prepped on 4/7/26 and a use by date of 4/13/26 and a container of green beans that was labeled as prepped on 4/8/26 and a use by date of 4/13/26. Dietary Staff (DS) H reported the food items were past their use by date and discarded them. On 04/14/2026 at 12:01 PM, DS K was asked to obtain temperatures of each food item being served in the main dining room. DS K removed a digital thermometer from their shirt pocket and placed the thermometer directly into the potato soup without first disinfecting the thermometer. DS K did disinfect the thermometer between each food item. On 04/15/2026 at 12:15 PM, the 400 unit refrigerator was observed with numerous (over twenty) individual serving cups of cream cheese and whipped spread that were not labeled with an expiration date. On 04/15/2026 at 12:23 PM, DS I was asked about the expiration date for the cream cheese and whipped spread cups. DS I was unable to locate an expiration date on any of the containers. DS I disposed of the items. On 04/15/2026 at 11:38 AM, Dietary Supervisor F reported staff were to go through the food storage daily and discard any food past the use by date. Dietary Supervisor F reported thermometers should be disinfected with an alcohol swab prior to each use and bread should not be handled with bare hands. During an observation on 04/14/2026 at 11:38 AM, Dietary Staff K was serving potato soup, egg salad sandwiches and tossed salads. Dietary Staff K went from making tossed salad, to scooping out potato soup in bowls, to touching the bread making egg salad sandwich without gloves, or hand hygiene going from one food to the other. Writer observed Dietary Staff K make several egg salad sandwiches using his bare hands, no hand hygiene was performed before or after using his bare hands touching the bread. During an observation on 04/15/2026 at 11:55 AM in the resident's refrigerator in dining room [ROOM NUMBER] hall, 6 individual cream cheese, 20 individual whipped butter spread without an expiration date. Kitchen staff removed these items from the refrigerator and threw them away. During the lunch meal on 4/14/2026 at 11:45 AM on the 200 hall, food temperatures were obtained by Dietary Aid S (DA). The temperatures were found as followed: salad 55 degrees Fahrenheit, egg salad 40 degrees Fahrenheit, blended egg salad 40 degrees Fahrenheit, and chopped salad at 50 degrees Fahrenheit.

Based on observation, interview, and record review the facility failed to ensure three out of three residents (Resident #21, 54 & 151) were treated with respect and dignity.Findings Include Resident #54 (R54) Review of the medical records reflected that R54 was admitted to the facility on [DATE]. Diagnoses of Alzheimer's Disease, Dementia and Depression. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/11/2026 revealed R54 had a Brief Interview of Mental Status (BIMS) of 11 (Moderate Cognitive Impairment) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R54 receives extensive assistance with bed mobility, total assistance with transfers, and extensive assistance with toileting; she was able to feed herself. R54 is able to make her needs known. Resident #151 (R151) Review of the medical records reflected that R151 was admitted to the facility on [DATE]. Diagnoses of Motor Neuron Disease, chronic pain, polyosteoarthritis, and difficult in walking. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/05/2026 revealed R151 had a Brief Interview of Mental Status (BIMS) of 15 (Cognitively Intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R151 is dependent on bed mobility, toileting needs, feeding, total assistance with transfers using the Hoyer lift. During the screening process on 04/14/2026 at 9:22 AM, R54 was applying lipstick and stated she was getting ready for her day. R54 discussed needs, activities she attends, number of showers/baths she gets during the week with clarity and could actively engage in our conversation. During the screening process on 04/14/2026 at 9:27 AM, R151 discussed her needs, activities she attends, favorite TV program and number of showers/baths she gets during the week. R151 was able to answer these questions with ease. R151 stated she didn't have a call light due to her motor neuron disease. R151 stated she tried using a Blow In Style call light but didn't like it up by her face all the time, as she had no use of any of her limbs. R151 stated they brought in this baby monitor, hanging off the wall so she yells out for someone to help her, and they will come in. R151 stated she didn't like that one either. During an interview on 04/14/2026 at 4:25 PM, Certified Nursing Assistant (CNA) P stated the monitor in R151's room was like a baby monitor, on all the time. CNA P stated there is a monitor on the medication cart and one in the medication room. CNA P stated R151 had tried a couple of different types, but didn't like any of them, but seems to like this one. During an observation and interview on 04/16/2026 at 7:47 AM, Licensed Practical Nurse (LPN) Q was asked to see the monitor used for R151. LPN Q pulled it from the side of the medication cart; you could hear R151's TV plainly, as it was on in her room. When asked LPN Q if he can hear the roommate at any time, LPN Q stated he hadn't that he remembered, he can only hear resident when she yells out for care. During an interview on 04/16/2026 at 8:07 AM, LPN/Unit Manager M stated R151 had the type of call light that you blow in to it, she didn't like it, was unhappy about it so they had this baby monitor already, so they put it in her room on 11/13/2025. When asked LPN/Unit Manager M stated no, R151 did not like the baby monitor at all. When asked why they left it in her room if she was not happy about it. LPN/Unit Manager M stated they had to have something in her room to call out for help. When asked if they tried any other styles of monitors and LPN/Unit Manager M stated no. During an observation on 04/16/2026 at 8:15 AM, CNA R was feeding R151 pancakes and sausage. When asked R151 if she wanted to have a private conversation with someone, had she asked to have it turned off so it can remain private, she stated no, I guess not. R151 and CNA R continued talking about the current news on the TV, writer could hear their conversation after leaving the room and being in the hallway. During an observation on 04/16/2026 at 9:49 AM, LPN Q took R151's morning medications into her room with the monitor sitting on the medication cart. You could hear LPN Q tell R151 he had her am medications for her. During an observation on 04/16/2026 at 9:56 AM, LPN Q could be heard giving roommate to R151 her am medications, you could hear LPN Q ask the roommate her date of birth , and tell her what her medications were for. This private conversation could be heard by anyone walking in the hall. During an interview on 04/16/2026 at 11:27 AM LPN/Unit Manager M and Social Worker (SW) N related to the baby monitor. LPN/Unit Manager M stated that SW N wasn't involved with the implementation of the baby monitor, she was the one who initiated it. When asked LPN/Unit Manager what other devices they had tried. LPN/Unit Manager M stated they tried the blow into type and R151 did not like that one and they had this baby monitor type, so they used that one. LPN/Unit Manger M was asked if R151 liked this baby monitor type, LPN/Unit Manager stated no, R151 didn't like this one at all, but they had to use something so they could hear her yell out for care. When asked LPM/Unit Manager if they had tried other types of call lights or monitors and LPN/Unit manager M stated no. When asked LPN/Unit Manager M what other options were given to R151, since she did not like that baby monitor. LPN/Unit Manager M stated we had to use something, and we had this baby monitor already, so we used this one. LPN/Unit Manager M was asked if R151 was her own person, decision maker and LPN/Unit Manager M stated yes. LPN/Unit Manager M was asked were they aware that the baby monitor was used when R151 did not want it, was very unhappy about it and didn't like it. LPN/Unit Manager M stated yes. LPN/Unit Manager M was asked if the monitor in place was discussed with the Interdisciplinary Team. LPN/Unit Manager M was observed looking at her computer at R151's progress notes, she stated there was no discussion of this baby monitor during the last two interdisciplinary meets nor was it charted under nursing progress notes that the baby monitor was put in place. LPN/Unit Manager M confirmed that the facility had not received permission from R151's roommates family to use this baby monitor in the room [ROOM NUMBER]/7. LPN/Unit Manager M stated the resident roommate (R54) was not fully alert and may not be aware of it being used in the joint room. LPN/Unit Manager M was asked if R54/family needed know that all conversations could be heard, including potential Health Insurance Portability and Accountability Act (HIPAA) from being disclosed without consent for R54. LPN/Unit Manager M stated she didn't think about that. LPN/Unit Manager M confirmed that the facility had not posted signage making visitators aware that there was a monitoring device being used in that room. LPN/Unit Manager M and Social Worker (SW) N conveyed if they had any other reasonable person for a roommate, they would need to give permission and acknowledgement of the device being used, prior to being used. Record review revealed that R151 nursing progress notes nor interdisciplinary team had no documentation regarding call light options. Further it was reported to LPN/Unit Manager M that during the screening process on 04/14/2026 at 9:27 AM, for this federal survey, state agency was unaware that there was a device hanging over R151's bed was active and anyone could hear the private conversations the residents, R54 and R151, in the shared room. Per the facility face sheet Resident #21 (R21) was admitted to the facility on [DATE]. Review of R21's care plans revealed R21 received Hospice services for a diagnosis of end of life. During an observation in the dining room on 4/14/2026 at 12:10 PM, Registered Nurse (RN) U, who was the visiting Hospice Nurse, was observed to enter the dining room, move a chair next to R21, who was sitting at a table eating her lunch, and sit down next to R21. RN U was observed to document on a tablet, then proceeded to place a pulse oximetry (device that goes on the finger to read oxygen level in the blood) on R21's finger, take R21's temperature, and blood pressure. R21 was observed to stop eating her lunch during the time RN U performed R21's vital sign checks. RN U had to take R21's blood pressure twice. RN U was then observed to take a tape measure and wrap it around the upper part of R21's left arm for a measurement. At 12:16 PM, R21 was observed to not be eating her lunch meal. RN U remained sitting next to R21 performing documentation on a tablet. Thirteen other residents were in the dining room, with five residents sitting at the same table as R21 who had the ability to overhear and observe R21 having her Hospice nurse visitation. At 12:20 PM RN U remained sitting next to R21. In an interview on 4/14/2026 at 12:23 PM, RN U stated that she would try not to interrupt R21's lunch by taking her back to her room to do her assessment privately then having to bring her back out again. RN U said R21 was confused and was a safety risk, stating that R21 could not be left in her room alone. During interview after this observation R21 said staff had never spoken to her about performing her assessments in the privacy of R21's resident's room outside of the common areas where other residents and staff frequent. In an interview on 4/14/2026 at 12:33 PM, Certified Nurse Aid (CNA) V stated that RN U, the Hospice nurse, would always visit and perform R21's vital sign assessment with R21 in the common areas. CNA V said wherever R21 was when RN U arrived at the facility is where RN U performed R21's assessment, and said it was always in the common area, CNA V stated that she was surprised RN U did R21's assessment while R21 was eating, and said she worked for Hospice once and you don't do that. CNA V also stated that none of the other Hospice nurses performed their visits with R21 in the common areas and said they all take R21 to her room to do her assessment. In an interview on 4/15/2026 at 12:17 PM, Director of Nursing (DON) B stated that her expectation was that the Hospice nurse take R21 back to her room to perform vital sign assessment in private as assessment in an open common area was a dignity issue.

Based on Observation, Interview and Record Review the facility failed to ensure that survey results were readily accessible to the residents of the facility with a current census of 176 residents. During a Resident Council Meeting held on 04/15/2026 at 1:00 PM with a group of 10 residents the survey process was discussed. It was conveyed that all survey results are to be available for easy access for residents and families to read. Nine out of the 10 residents stated that did not know the results of any surveys. They did not know where a binder with this information was located. They added that they wondered about the outcome of the surveys, because they never heard anything more about it once surveyors left the building. Sharing that they were now going to ask about it. During an observation on 04/15/2026 at 4:59 PM, No Survey Binder could be located upon entrance or around the main or common areas for access to residents and families.During an observation on 04/16/2026 at 3:06 PM, A State Binder was seen at the front reception desk, after reviewing the contents in the binder, the most current survey results were not provided in this binder for residents or families to review.During an interview on 04/16/2026 at 3:30 PM, LNA's assistant T randomly stuck her head in the conference room door and stated, The last, most current survey was added to the Survey Binder.Per the State Operation Manual (SOM). The resident has the right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility; Receive information from agencies acting as client advocates and be afforded the opportunity to contact these agencies.The facility must--Post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility.The SOM further directs that the facility have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years, and any plan of correction in effect with respect to the facility, available for any individual to review upon request; Post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public. The facility shall not make available identifying information about complainants or residents.

Based on interview, observation and record review the facility failed to maintain personal privacy and confidentiality of medical information in two residents (R54 and R151) of two reviewed for personal privacy.Findings IncludeResident #54 (R54)Review of the medical records reflected that R54 was admitted to the facility on [DATE]. Diagnoses of Alzheimer's Disease, Dementia and Depression.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/11/2026 revealed R54 had a Brief Interview of Mental Status (BIMS) of 11 (Moderate Cognitive Impairment) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R54 receives extensive assistance with bed mobility, total assistance with transfers, and extensive assistance with toileting; she was able to feed herself. R54 is able to make her needs known. Resident #151 (R151)Review of the medical records reflected that R151 was admitted to the facility on [DATE]. Diagnoses of Motor Neuron Disease, chronic pain, polyosteoarthritis, and difficult in walking.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/05/2026 revealed R151 had a Brief Interview of Mental Status (BIMS) of 15 (Cognitively Intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R151 is dependent on bed mobility, toileting needs, feeding, total assistance with transfers using the Hoyer lift. During the screening process on 04/14/2026 at 9:22 AM, R54 was applying lipstick and stated she was getting ready for her day. R54 discussed needs, activities she attends, number of showers/baths she gets during the week with clarity and could actively engage in our conversation.During the screening process on 04/14/2026 at 9:27 AM, R151 discussed her needs, activities she attends, favorite TV program and number of showers/baths she gets during the week. R151 was able to answer these questions with ease. R151 stated she didn't have a call light due to her motor neuron disease. R151 stated she tried using a Blow In Style call light but didn't like it up by her face all the time, as she had no use of any of her limbs. R151 stated they brought in this baby monitor, hanging off the wall so she yells out for someone to help her, and they will come in. R151 stated she didn't like that one either.During an interview on 04/14/2026 at 4:25 PM, Certified Nursing Assistant (CNA) P stated the monitor in R151's room was like a baby monitor, on all the time. CNA P stated there is a monitor on the medication cart and one in the medication room. CNA P stated R151 had tried a couple of different types, but didn't like any of them, but seems to like this one. During an observation and interview on 04/16/2026 at 7:47 AM, Licensed Practical Nurse (LPN) Q was asked to see the monitor used for R151. LPN Q pulled it from the side of the medication cart; you could hear R151's TV plainly, as it was on in her room. When asked LPN Q if he can hear the roommate at any time, LPN Q stated he hadn't that he remembered, he can only hear resident when she yells out for care. During an interview on 04/16/2026 at 8:07 AM, LPN/Unit Manager M stated R151 had the type of call light that you blow in to it, she didn't like it, was unhappy about it so they had this baby monitor already, so they put it in her room on 11/13/2025. When asked LPN/Unit Manager M stated no, R151 did not like the baby monitor at all. When asked why they left it in her room if she was not happy about it. LPN/Unit Manager M stated they had to have something in her room to call out for help. When asked if they tried any other styles of monitors and LPN/Unit Manager M stated no. During an observation on 04/16/2026 at 8:15 AM, CNA R was feeding R151 pancakes and sausage. When asked R151 if she wanted to have a private conversation with someone, had she asked to have it turned off so it can remain private, she stated no, I guess not. R151 and CNA R continued talking about the current news on the TV, writer could hear their conversation after leaving the room and being in the hallway. During an observation on 04/16/2026 at 9:49 AM, LPN Q took R151's morning medications into her room with the monitor sitting on the medication cart. You could hear LPN Q tell R151 he had her am medications for her.During an observation on 04/16/2026 at 9:56 AM, LPN Q could be heard giving roommate to R151 her am medications, you could hear LPN Q ask the roommate her date of birth , and tell her what her medications were for. This private conversation could be heard by anyone walking in the hall. During an interview on 04/16/2026 at 11:27 AM LPN/Unit Manager M and Social Worker (SW) N related to the baby monitor. LPN/Unit Manager M stated that SW N wasn't involved with the implementation of the baby monitor, she was the one who initiated it. When asked LPN/Unit Manager what other devices they had tried. LPN/Unit Manager M stated they tried the blow into type and R151 did not like that one and they had this baby monitor type, so they used that one. LPN/Unit Manger M was asked if R151 liked this baby monitor type, LPN/Unit Manager stated no, R151 didn't like this one at all, but they had to use something so they could hear her yell out for care. When asked LPM/Unit Manager if they had tried other types of call lights or monitors and LPN/Unit manager M stated no. When asked LPN/Unit Manager M what other options were given to R151, since she did not like that baby monitor. LPN/Unit Manager M stated we had to use something, and we had this baby monitor already, so we used this one. LPN/Unit Manager M was asked if R151 was her own person, decision maker and LPN/Unit Manager M stated yes. LPN/Unit Manager M was asked were they aware that the baby monitor was used when R151 did not want it, was very unhappy about it and didn't like it. LPN/Unit Manager M stated yes. LPN/Unit Manager M was asked if the monitor in place was discussed with the Interdisciplinary Team. LPN/Unit Manager M was observed looking at her computer at R151's progress notes, she stated there was no discussion of this baby monitor during the last two interdisciplinary meets nor was it charted under nursing progress notes that the baby monitor was put in place.LPN/Unit Manager M confirmed that the facility had not received permission from R151's roommates family to use this baby monitor in the room [ROOM NUMBER]/7. LPN/Unit Manager M stated the resident roommate (R54) was not fully alert and may not be aware of it being used in the joint room. LPN/Unit Manager M was asked if R54/family needed know that all conversations could be heard, including potential Health Insurance Portability and Accountability Act (HIPAA) from being disclosed without consent for R54. LPN/Unit Manager M stated she didn't think about that. LPN/Unit Manager M confirmed that the facility had not posted signage making visitators aware that there was a monitoring device being used in that room. LPN/Unit Manager M and Social Worker (SW) N conveyed if they had any other reasonable person for a roommate, they would need to give permission and acknowledgement of the device being used, prior to being used.Record review revealed that R151 nursing progress notes nor interdisciplinary team had no documentation regarding call light options.Further it was reported to LPN/Unit Manager M that during the screening process on 04/14/2026 at 9:27 AM, for this federal survey, state agency was unaware that there was a device hanging over R151's bed was active and anyone could hear the private conversations the residents, R54 and R151, in the shared room. Per the State Operation Manual (SOM).The facility must respect the residents' right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, Confidentiality is defined as safeguarding the content of information including video, audio, or other computer stored information from unauthorized disclosure without the consent of the resident and/or the individual's surrogate or representative. Right to personal privacy includes the resident's right to meet or communicate with whomever they want without being watched or overheard.

Based on observation, interview and record review the facility failed to implement a process for resident grievances to be resolved by the facility in a current facility census of 176 residents. During a Resident Council Meeting held on 04/15/2026 at 1:00 PM with a group of 10 residents' grievances were discussed. The residents shared that in order to fill out a grievance form they had to go to the Social Workers office on their unit, and the Social Workers would fill them out. Residents stated they did not know the turnaround time in getting them resolved.When asked if they had these forms at eye level and displaced throughout the facility other than the Social Workers office, the residents stated they did not have those forms available at eye level in any of the common areas. Residents in the confidential group meeting stated they did not know they could fill them out themselves or ask someone to help them. Residents stated they didn't know that. Residents shared that they were familiar with the Property Incident Report. Again, stating they did not have easy access to a Resident Concern/Grievance Forms. Residents voiced concern regarding long call light wait times, adding they had reported this concern however this was still a problem and the concerns had not been resolved. Residents in the group shared that residents from all units voiced concerns regarding staff turning off call lights without providing care, saying they will be back, and do not return. Residents asked if the call light can be turned off without providing care. When asked if this had been reported more than once, they stated they had reported these concerns many times. During an interview on 04/15/2026 at 1:37 PM, Licensed Practical Nurse (LPN) L stated she knew grievance forms existed but wasn't sure where they were. Writer observed LPN 'L going through different drawers at the nurse's station in search of the forms. None were found. During an interview on 04/15/2026 at 2:42 PM, Social Worker (SW) and LPN/UM M stated the grievance forms are outside her office door, stating residents were to bring in the completed forms to Social Worker (SW) N. Social Worker (SW) stated regarding the Property Incident Report, she liked to look through the resident's room looking for the missing clothes before sending them out to the unit managers. Writer asked what the turnaround time was, Social Worker (SW) stated she had to check the policy, usually liked to follow up within a week and then go from there. Writer asked if she also filled out Grievance forms for residents as she did for the lost and property incident reports. During an interview on 04/16/2026 at 8:46 AM, when asked Activity Director (AD) O was asked where the grievance forms were kept on the halls/units where residents could reach them from standing or sitting in a wheelchair and fill it out themselves or asking for help. AD O stated they were downstairs by the elevator, and in the social workers offices. When asked if they were anywhere else where residents could reach them, in the hallway, dining room. AD O stated no they were not. Writer explained they needed to be positioned where residents can grab one, fRecord review revealed grievances discussed during the Resident Council Meetings that were not identified as grievances, nor was a grievance form filled out tracking, patterns or resolutions. November 2025 Resident Council Meeting:TV hanging in a resident's room was crooked. Housekeeping throwing away items again from their tray table, denture glue was thrown away. Request to use a larger bathroom on shower days. Nurses are very loud at group times in main dining room and during groups held on their neighborhoods. CarePartners are very disruptive during group times. Baked chicken was over cooked and very tough. Pork Chops were over cooked. Resident reported long periods of time for her call light to be answered. Missing clothing concerns. December 2025 Resident Council Meeting: Waiting a long time for call lights to be answered. Another concern with long wait time for call lights to be answered. Waiting too long for call lights to be answered and often CNAs come in turning off the call lights and not helping or saying they will come back. Not getting cream applied to her feet. Also stating a concern with getting call lights answered by CNAs, naming the individuals that are doing this. Not getting brief changed during 3rd shift until 5:00am. CNAs are not checking her colostomy bag during 3rd shift. Resident reported CNAs were complaining about soaking through her pad and she is waiting a long time with the call lights. Carrots served were not very tender. Resident requested to have gravy on her meat and that is not always happening and doesn't like mixed veggies. Missing clothing concerns. January 2026 Resident Council Meeting: Long wait time on the call lights on 2nd and 3rd shifts. shifts. Resident had a problem with a CNA on 2nd shift. Never knows who will be their CNA for all shifts. Missing clothes concerns. February 2026 Resident Council Meeting: CNAs are on their cell phones too much. CNAs talking too loud in the hallways on 2nd shift, staff named. Clothes removed from her room for laundry when family was to do her laundry. Had to wait for call light answered r/t her needing 2 CNAs to provide care. Missing clothing concerns. March 2026 Resident Council Meeting: Staff removed personal items from the top of her dresser into a dresser drawer, and she did not like that. CNA on 2nd shift talking to her boyfriend on her phone while providing care, name of CNA given. 2nd complaint of CNA on her phone with her boyfriend while providing care, name given, added resident could hear everything she and her boyfriend were saying. CNAs have cut back on her meal portions due to her weight without her asking them to. CNAs get her up too early to take her shower and she would prefer to have showers after breakfast. Missing clothes. April 2026 Resident Council Meeting: Resident's room needs a paint touch up at the head of her bed. Resident needs her toilet looked at, low water level. level. Residents chair is still being pushed too far back in the corner, doesn't want them moving it. Running out of clothing protectors, towels and washcloths on the neighborhood, CNAs had to go find more. Same concerns by different residents, running out of clothing protectors, towels and washcloths on the neighborhood, CNAs had to go find more. Resident needs her meat chopped up more. Missing clothes concerns.Record review did not reveal any of those concerns or complaints reported during the resident council meetings being identified or documented as concerns or grievances. Per the States Operation Manual (SOM) . all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the residents. The grievance policy must include:Notifying residents individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system; Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations; Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued.

Based on interview and record review, the facility failed to refer one (R9) of one reviewed to the state-designated authority for a change in condition. Findings include:Review of the medical record revealed R9 was admitted to the facility on [DATE] with diagnoses that included hypertension and repeated falls. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/12/26 revealed R9 scored 5 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the Preadmission Screening (PAS)/Annual Resident Review (ARR) Level I Screening revealed the review was completed on 2/09/25. All questions were answered No to include The person has a current diagnosis of mental illness or dementia, The person has routinely received one or more prescribed antipsychotic or antidepressant medications within the last 14 days, and There is presenting evidence of mental illness or dementia, including significant disturbances in thought conduct, emotions, or judgement. Presenting evidence may include, but is not limited to, suicidal ideations, hallucinations, delusions, serious difficulty completing tasks, or serious difficulty interacting with others. According to R9's diagnosis list, the following diagnoses were added during R9's stay at the facility: visual hallucinations was added on 2/17/25, delusional disorder was added on 3/26/25, Alzheimer's Disease was added on 5/19/25, and auditory hallucinations was added on 8/26/25. Review of the Physician's Orders revealed R9 was first prescribed Seroquel (antipsychotic medication) on 3/28/25 for hallucinations. R9 did not have a Change in Condition Level I Screening or referral to the local Community Mental Health Services Program. In an interview on 04/16/2026 at 8:13 AM, Social Worker (SW) E reported any PASARR renewals were given to Social Services Director (SSD) D to submit. When asked when she gave R9's updated screening to SSD D, SW E reported they did not have that information. In an interview on 04/16/2026 at 9:00 AM, SSD D reported the unit social workers provided him with updated PASARR screens for him to enter into the system. When asked if he had an updated screening/change in condition for R9, SSD D checked the OBRA system and reported R9 was due for an update. SSD D reported R9's last Level I Screening was competed on 2/9/25 at which time all questions received a no response. When asked if R9 has had any changes, SSD D reported R9 was diagnosed with dementia and started an antipsychotic medication in 2025. SSD D reported R9 should have had a Change in Condition Level I Screening completed with the addition of a dementia diagnosis during her stay.

Based on observation, interview, and record review, the facility failed to ensure medications were secure and inaccessible to unauthorized staff and residents. Findings include: An observation on 4/15/26 at 3:41 PM, revealed a grey unsecured tote was sitting on the couch outside the public restroom on the Renewal Center East unit. No authorized staff were supervising the tote. There was a non-nurse staff member sitting in the dining room and a non-nurse staff member who walked by. Inside the tote was a Medication Inventory Record which revealed a list of medications that were being returned to the pharmacy. The list included one Metamucil, two Lovenox 40 milligrams (mg) injections, two Flexeril 10 mg, and 47 Singulair 10 mg. The actual medications inside the tote included two cards of Flexeril 10 mg for a total of 49 tablets, two Lovenox 10 mg injections, and one Singulair 10 mg tablet. A staff member walked by and when asked if they were the nurse for the unit, they reported no. In an interview on 4/15/26 at 3:44 PM, Licensed Practical Nurse (LPN) G walked by. When asked about the tote, LPN G reported they arrived on shift at 2:00 PM and were not the one who placed the medication tote on the couch. LPN G reviewed the paperwork inside the tote and reported the nurse on the prior shift must have set the tote on the couch. LPN G confirmed the tote included one Singulair tablet, two Lovenox injections, and 49 Flexeril tablets. LPN G reported the medications were on the couch because they were being returned to pharmacy and that was the process they always followed. LPN G reported the tote was left on the couch, pharmacy would come in between 5:45 PM and 6:15 PM, pick up the tote and leave a new one. In an interview on 4/15/26 at 3:49 PM, Director of Nursing (DON) B reported the pharmacy delivered and picked up returns twice per day around 11:00 AM and 7:00 PM, Monday through Saturday. DON B reported medications to be returned to the pharmacy should be stored in the medication cart and then handed off to the pharmacy delivery staff when they arrived. DON B was shown the grey tote with medications that was sitting on the couch on Renewal Center East. DON B reported the medications should not be there.

This citation pertains to intake #2712733Based on observations, interviews and record review, the facility failed to protect the resident's (R2) right to be free from neglect resulting in a fall with staff and suffering a fractured right humerus. Findings Include: Review of Resident #2 (R2) clinical record, including the Minimum Data Set (MDS) dated [DATE] revealed R2 was a [AGE] year-old female with diagnosis of dementia. R2 scored 6 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). Review of R2's fall risk assessment dated [DATE] indicated R2 was at high risk for falls.Review of R2's comprehensive care plan for the Activity of Daily Living (ADL) dated 11/23/25 revealed R2 required 2 staff persons for transfers using a mechanical lift assistive device stand-up lift. Review of R2's Kardex (a care guide used by Certified Nursing Assistants) that was in place on 12/26/25 revealed and confirmed that R2 required 2 staff persons for transfers using a stand-up lift. Review of the incident report, completed by RN H, dated 12/26/25 revealed Certified Nursing Assistant (CNA) C, had transferred R2 that morning after completing am care. CNA C was in the midst of transferring R2 from the bed to the wheelchair and while maneuvering the stand up lift heard a pop sound, the clasp unbuckled, right strap came off the lift and R2 fell out of the lift and onto the ground. R2 complained of right upper extremity pain with movement along with visible swelling.Record review reflected a stat x-ray was ordered of R2's right shoulder, results dated 12/26/25 at 10:12 am revealed R2 had a fracture of the surgical neck and greater tuberosity extension. On 01/15/26 at 10:37am during a phone interview with CNA C she reported R2 was transferred with only her in the resident room. CNA C stated she was a new CNA and this was her first job and had been employed at the facility since July 2025. CNA C elaborated that she was trained that R2 was a one person transfer and that everyone transfers R2 by themselves. CNA C was queried if she had access to R2's care plan or Kardex in which she replied she did have access to both. CNA C stated she did not reference it as there was no changes in her status at that time as CNA C knew R2's was a 1-person transfer. CNA C stated she only referred to the Kardex on new residents. During the same interview, CNA C stated was not aware that R2 was a two-person transfer using the stand-up lift until after she was suspended pending the investigation of the incident. When queried what occurred 12/26/25 during R2's transfer, CNA C stated she was alone with R2, completed care and was using the stand-up lift. CNA C stated she buckled R2's sling but one of the clips on the right of the lift was missing. CNA C stated she had used the same lift on Christmas Eve 12/24/25 when she saw that the sling clip/stopper was not in place. CNA C stated that she transferred R2 on Christmas Eve without incident. CNA C stated that the day after Christmas on 12/26/25 she transferred R2 with the same lift with the missing clip and decided to proceed with the transfer, as she used the same lift two days prior. CNA C said that on 12/26/25 while the resident was in the lift when she heard a pop and the buckle came apart. It came apart on the right side, where the sling loops onto the lift (where the missing clip/stopper was previously observed) on the right side. CNA C stated R2 immediately fell to the ground. CNA C stated she called to the nurse for help. On 01/15/26 at 11:40 am during an interview with R2's Licensed Practical Nurse (LPN) E it was reported that R2 was non-weight bearing with the right arm and since the fall on 12/26/25 R2's transfer status had changed from the stand-up lift to a full mechanical lift. LPN E further elaborated that R2 was able to wash her face prior to the fall and fracture and was no longer able to complete that task. R2 was observed sitting in a wheelchair in the dining room, her right arm was in a sling and R2 was unable to be interviewed due to cognitive deficits. On 01/15/26 at 12:00 pm during an interview with CNA D she reported she was routinely assigned to R2 both pre and post the fall on 12/26/25. CNA D stated R2 was a stand up lift and since the fall R2 was now a total mechanical lift. CNA D also confirmed that R2 was able to help with upper body dressing and washing her upper body on shower days and was no longer able to assist due to the right fractured humerus. CNA D also stated repositioning and rolling R2 in bed was a one person task and is now a 2 person task. CNA D stated R2 also has facial grimacing/wincing and babies the right arm since the fall. CNA D then showed this surveyor the stand up lift that R2 fell from on 12/26/25. The lift was observed to be in use on the unit and had a metal clip on the left side and a rubber type clip/stopper on the right side. CNA D stated the lift was new and came with the metal clip which had fallen off the right side of the lift and had been replaced with the black rubber stopper after R2's fall. On 01/15/26 at 12:42 pm during an interview with Maintenance worker F he reported the maintenance person assigned to R2's unit was on vacation during the time R2 fell from the lift and he was covering that area. Maintenance worker F stated he looked at the stand up lift in question along with all the other lifts and observed the missing clips/stoppers on several of the lifts and replaced them with the rubber stoppers. Maintenance worker F stated he did not catalog which lifts needed the replacement stopper/clip but had replaced several that day on 12/26/25.When queried if Maintenance would remove a metal clip and replace it with the rubber clip, Maintenance worker F stated they would not remove clips they would just replace them with a rubber clip. When queried if there were any work orders for maintenance to replace clips or notifying the department that clips were missing from the lifts, maintenance worker F said there were zero work orders or verbal reports made to maintenance about the mechanical lifts missing clips in December until after R2s fall. On 01/15/26 at 9:20am the Director of Nursing, DON B, was interviewed regarding R2s fall with staff. DON B stated that RN H primarily conducted the investigation and stated that RN H would be better to ask for investigation details. RN H was not in the facility at the time of the survey. DON B provided RN Hs personal phone number. On 01/15/26 at 2:10 pm, a phone interview was conducted with Registered Nurse (RN) H who serves as a Unit Manager. RN H stated she completed the investigation into R2's fall. RN H stated she (RN H) was aware that R2 was a 2-person transfer using the stand-up lift. RN H stated that CNA C was also trained and knew that R2 was a 2 person transfer with the lift.However, RN H reported she determined the root cause of the fall was the sling buckle was not secured appropriately. Transferring with 1 person not 2 persons was not addressed. When queried if she had observed the stand-up lift used by R2, she stated she did and could not recall if both clips were intact or if one was metal and the other rubber. RN H stated the lift was taken out of service, and maintenance worker F inspected it and reported it operated fine. When queried if she was aware Maintenance worker F found several lifts with missing clips and replaced them with the black rubber stoppers. RN H stated she was not aware of Maintenance worker F's findings about any missing clips/stoppers. When queried if a CNA was aware of missing clips on any lift, what the expectation was, RN H stated the expectation would be not to use the lift and report it to maintenance for repair. On 01/15/26 at 1:14pm, an interview with the MDS Nurse G confirmed that R2 had a significant change in condition following the fall with staff on 12/26/25 and a significant change in condition MDS was in progress due to resident's fracture. On 01/15/26 at approximately 2:30 pm, Director of Nursing (DON) B entered the conference room and was visibly rattled, and stated there was nothing wrong with the stand-up lift used by R2 on 12/26/25 and her (the report conducted and completed by RN H) report reflected that nothing was wrong with the lift, stating that (name of CNA C) did not buckle the lift. The facility incident report investigation prepared by RN H, ADON K and DON B reflected: the root cause analysis appears to be a sling malfunction. Writer attempted to explain that the facility failed to use a 2-person transfer, as determined necessary by the comprehensive care plan, during a transfer from the resident's bed to wheelchair, resulting in the resident falling to the floor and sustaining a fractured right humerus.

Based on interview, and record review the facility failed to ensure accurate advance directive (legal documents that allow a person to identify decisions about end-of-life care ahead of time) information was in place for one resident (#319) of one resident reviewed for advance directives from a total sample of 35 residents. Findings included: Resident #319 (R319) Review of the medical record revealed R319 was admitted to the facility 01/16/2025 with diagnoses that included end stage renal disease, dependence on renal dialysis, gastro-esophageal reflux, congestive heart failure (CHF), atherosclerotic heart disease (plaque build up in artery wall), hyperlipidemia (high fat content in blood), obstructive sleep apnea, type 2 diabetes, hypothyroidism (low thyroid hormone), morbid obesity, anemia (low number of red blood cells), cancer of kidney, hypertension, and spinal disc degeneration. Review of R319's medical record demonstrated a physician order for advance directives of DNR (Do Not Resuscitate). No facility document entitled DO-NOT-RESUSCITATE ORDER was found in R319's medical record, that was entered 01/21/2025. In an interview on 01/23/25 at 09:08 a.m. Unit Manager (UM) C explained that when a resident is admitted , the social worker would discuss the advance directives with the resident. UM C explained that the social worker would then obtain a resident signature and two witness signatures. UM C explained that then the document entitled DO-NOT-RESUSCITATE ORDER would be sign by the attending physician. UM C explained once the document entitled DO-NOT-RESUSCITATE ODER was completed a physician order would be entered for into the medical record. UM C explained that the completed DO-NOT-RESUSCITATE ORDER document would be scanned into the medical record. UM C confirmed that R319 had a physicians order which stated DNR (Do not Resuscitate), that had been entered 01/21/2025. UM C could not locate the document DO-NOT-RESUSCITATE ORDER in R319's medical record. In an interview on 01/23/2025 at 09:13 a.m. Social Worker (SW) D explained that she was responsible to discuss advance directives with newly admitted residents at the facility. SW D explained that she would assist resident to complete the document entitled DO-NOT-RESUSCITATION ORDER. SW D explained that once the resident signed the document, two witnesses would sign the document, then the document would be signed by the physician. SW D explained that once the document DO-NOT-RESUSCITATE ORDER is completed a physician order would be written and the completed document would be scanned in the resident's medical record. SW D could not locate R319's DO-NOT-RESUSCITATE ORDER document and explained it still must be in the physician folder, located at the nurse's station. SW D could not explain why an DNR order was present in R319's medical record but not the completed DO-NOT-RESUSCITATE ORDER document. SW D then proceeded to the nurse's station and located R319's DO-NOT-RESUSCITATE ORDER document. Review of R319's DO-NOT-RESUSCITATE ORDER document (which was located in the physicians folder) contained R319's signature on 01/21/2025, two witness signatures signed on 01/21/2025, but no physician signature. In an interview on 01/23/2025 at 09:24 a.m. Director of Nursing (DON) B explained that a resident's advance directive is reviewed upon admission with the social worker or physician. DON B explained that a completed document entitled DO-NOT-RESUSCITATE ORDER is completed, which includes the resident's signature, two witness signatures, then a physician signature. DON B explained once the document DO-NOT-RESUSCITATE ORDER is completed then an order for Do not Resuscitate would be written. DON B confirmed that R319 did not have a completed document DO-NOT-RESUSCITATE ORDER in his medical record and should have not had a completed DNR order until the document had been completed. DON B could not explain why the DNR order for R319 had been written prior to the completion of the DO-NOT-RESUSCITATE ORDER document.

Based on interview and record review the facility failed to ensure a Preadmission/Annual Resident Review (PAS/ARR) was completed after the 30 day exemption period and failed to notify the State Agency Health Authority for 1 Residents ( #62) of 3 residents reviewed for PAS/ARR. Findings include: Review of the clinical record reflected Resident # 62 (R62) was admitted to the facility with diagnoses that included major depression. Review of R62's PAS/ARR 3877 screening dated 8/24/23 reflected R62 had a mental illness diagnosis and was prescribed an anti-depressant medication. Review of the 3878 dated 8/26/23 reflected R62 was on a 30 day exemption and was expected to be discharged from the facility within the next 30 days. There was no further level I or level II screenings, no indication or documentation that the State Mental Health Authority was aware R62 resided at the facility and no documentation regarding R62 not meeting criteria or needing level II assessment from Community Mental Health. Further review of R62's clinical record reflected R62 had psychotropic medication changes (wellbutrin was ordered on 10/5/24) and a new diagnosis of anxiety was added on 10/07/24. On 01/27/25 at 09:11 AM, during an interview with Case Manager/ Social Service Director X he reported the Social Workers on each unit was responsible for tracking the PAS/ARR were due including 30 day exemptions and they were to notify Case Manager/ Social Service Director X who completes them and was responsible for submitting them to Community Mental Health (CMH). R62's medical record was reviewed with Case Manager/ Social Service Director X who agreed there was no further required documentation related to PAS/ARR. Case Manager/ Social Service Director X then went into the portal for CMH to ensure the PAS/ARR was updated and possibly just not entered into the medical record. Case Manager/ Social Service Director X confirmed there was no information in CMH portal and offered no explanation as to how/why the required documentation was not completed.

Based on observation, interview and record review, the facility failed to formulate comprehensive Care Plans for two (Resident #92 and Resident #370) of 35 reviewed for Care Plans. Findings include: Resident #92 (R92) Review of the medical record reflected R92 was admitted to the facility on [DATE], with diagnoses that included atrial fibrillation (irregular heartbeat). The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/9/24, reflected R92 scored 7 out of 15 (cognitively impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 1/21/25 at 9:31 AM, R92 was observed in a recliner chair watching television. Review of the Physician Orders revealed R92 had an active order with at start date of 10/42/24 for Eliquis 5 milligrams (a blood thinning medication). Review of R92's Care Plan revealed no Care Plan for the anticoagulant. In an interview on 1/27/25 at 1:59 PM, Director of Nursing (DON) B reviewed the Care Plan for R92 and confirmed that there was no Care Plan for the anticoagulant use for R92. DON B stated that the expectation would be to have a Care Plan in place for the high risk medication. Resident #370 (R370) Review of the medical record reflected R370 was admitted to the facility on [DATE] and readmitted to the facility on [DATE], with diagnoses that included end stage renal disease and dependence on dialysis. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/18/25, reflected R370 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 1/22/25 at 8:52 AM, R370 was observed in bed watching television. R370 confirmed that she attended outside dialysis appointments and shared her routine for her dialysis days. Review of R370's Care Plan and Physician Order's revealed an absence of any mention of dialysis including when she attended, where she attended, and required assessments. In an interview on 1/24/25 at 8:41 AM, Registered Nurse (RN) W stated that typically dialysis residents had a dialysis Care Plan and Physician Orders however, when asked to located R370's Care Plan and orders, RN W confirmed an absence of both. In an interview on 1/24/25 at 12:49 PM, Nursing Unit Manager V stated that residents receiving dialysis services would typically have a dialysis Care Plan and Physician Orders however, it was identified that day that R370 did not have a Care Plan or Physician Orders. In an interview on 1/27/25 at 1:56 PM, Director of Nursing (DON) B stated stated that dialysis Care Plans and Physician orders were an important part of Care to ensure effective communication and assessments were being completed.

Based on observation, interview and record review the facility failed to provide assistance with activities of daily living (ADL) for one (R12) of five residents reviewed for ADL's, resulting in the potential for unmet needs. Findings include: Review of the clinical record revealed R9 was admitted into the facility on [DATE] with diagnoses that included: congestive heart failure and arthritis. According to the Minimum Data Set (MDS) assessment dated [DATE], R12 scored 9/15 on the Brief Interview for Mental Status exam (which indicated moderately impaired cognition). Section GG (Functional Abilities and Goals) of MDS assessment dated [DATE] indicated resident was dependent (Helper does all of the effort. Resident does none of the effort to complete the activity.) with personal hygiene. Review of the photo taken of resident on admission revealed short facial hair, stubble only, no beard. On 1/22/25 at 9:23 AM, R12 was observed lying in bed on his back. R12 was noted to have a long, full, unkempt beard. When asked on what his preference was he reported that he prefers to be shaved and not to have a beard. R12 stated that he has reported this to staff in the past. On 1/24/25 at 2:22 PM, R12 was observed lying in bed on his back with a full, ungroomed beard. He reported that he still has not been shaved and did not express a preference for who shaved him. On 1/27/25 at 10:36 AM, R12 was observed to still have a long, full, unkempt beard. Review of R12's Kardex (document used by facility staff to communicate the needs of the residents) revealed I am dependent on staff for my AM/HS care/personal hygiene .Use an electric razor for shaving. Review of R12's task log titled Personal Hygiene revealed resident required substantial/maximal assistance to fully dependent for Personal hygiene tasks for the past 30-day span (12/29/24 through 1/27/25). During an interview on 1/27/25 at 10:41 AM, Certified Nursing assistant (CNA) Y was asked on how she would determine a male's preference for shaving. CNA Y reported that she would look at their Kardex or ask the resident if they are coherent. When asked about the facial care for R12 she reported that he prefers to have the beautician shave him and he has an appointment for that sometime this week. During an interview on 1/27/25 at 10:46 AM, Unit Manager (UM) V reported that preferences for facial hair for men would be found in the residents Kardex. When asked if she was aware of R12's preference for who shaves him UM V reported that he doesn't have a preference to see the beautician for shaving. She further reported that if it was his preference to be shaved by the beautician it should be indicated in his Kardex as such. UM V reported that the CNA's should be offering to shave him or helping him get set up so that he can shave himself and that she could reach out to R12's nephew if his razor needed to be replaced. UM V reported that she would ensure the resident got shaved. Review of the facilities policy titled Activities of Daily Living (ADL) updated 12/29/23, documented in part The facility must provide care and services in accordance with CMS (Centers of Medicare and Medicaid Services) regulations for the following activities of daily living: hygiene-bathing, dressing, grooming and oral care . Review of the facilities policy titled Shaving Male Residents updated 12/5/20, documented in part Nursing department will pursue and provide such care as the Resident desires and provide comfort to the Resident .Purpose: To provide cleanliness and improve morale and well-being .Offer Resident the opportunity to shave self: if unable, then assist .Use new safety razor or Resident's personal electric razor .

Based on observation, interview and record review the facility failed to provide proper assistive devices to maintain hearing for one (Resident 25) of one reviewed for specialty services, resulting in unmet needs. Findings include: Review of the clinical record revealed R25 was admitted into the facility on [DATE] with diagnoses that included: Alzheimer's disease and major depressive disorder. According to the Minimum Data Set (MDS) assessment dated [DATE] R25 had adequate hearing with hearing aids. A review of R25's Kardex (document used by facility to communicate the needs of the resident) revealed no documentation of hearing aids. On 1/22/25 at 9:33 AM, R25's roommate reported that R25 was missing her hearing aids and had been for an extended period. On 1/22/25 at 9:42 AM, R25 was observed sitting up in recliner with television on without hearing aids in place. R25 was able to answer yes/no questions when spoken to in a loud voice and at a slow pace. R25 confirmed she was missing her hearing aids. On 1/23/25 at 12:18 PM, R25 was observed sitting in recliner with television on. No hearing aids in place. On 1/23/25 at 12:26 PM during an interview with LPN U she reported R25 had thrown away her hearing aids in the past despite interventions put in place and she no longer wears them. LPN U reported that family was aware of R25 not currently having any hearing aids and that resident can hear if you enunciate and speak slowly. On 1/24/25 at 1:07 PM during an interview with Social work director X he reported being aware R25 was missing her hearing aids and that R25's family member had stopped by to see him. He was unsure of an exact date but recalled it was a while ago but not years ago. Social work director X turned away from his desk and attempted to locate a paper in a drawer full of paperwork. He reported that there should be a missing item report for the missing hearing aids. At the end of the interview SW director X reported that he would continue to look for documentation related to R25's missing hearing aids. On 1/24/25 at 2:25 PM during an interview with R25's family member Z, in R25's room, she stated that R25 has had two pairs of hearing aids go missing since being in the facility. Family member Z reported that R25 should have her hearing aids to help with conversations and for her to hear the television. Family member Z reported R25 enjoys watching TV but is not able to hear it without her hearing aids. Family member Z stated that the floor staff is aware of the missing hearing aids but was unable to recall specifically who was told or when (reported that it had been at least one year since R25 has had her hearing aids). On 1/27/25 at 9:47 AM during a telephone interview with R25's family member AA, he reported that R25 has not had her hearing aids for at least a year and he felt that she could really use them as she reported feeling isolated. He further reported they have to speak directly into her ear to communicate with her. R25's family member AA stated that a facility social worker is supposed to see her each week as the family had reported R25's report of feeling isolated. On 1/27/25 at 10:51 AM during an interview with unit manager V she reported that the facility is working on getting R25 new hearing aids based on a recent email from Social Work Director X. When quired about why care plan interventions related to hearing aids had been removed she reported she was not aware of the reason why but they had been removed by an MDS (Minimum Data Set) nurse. On 1/27/25 at 2:50 PM during an interview with NHA (nursing home administrator) A she reported that there is a lot of confusion around R25's hearing aids and confirmed she does not currently have hearing aids. NHA A further reported that the facility is working on getting R25 a new pair of hearing aids and they plan to have her seen by a local audiologist as soon as possible. A review of the facilitate policy titled Grievances/Complaints: Resident & Non-Employee documented in part, Investigations will be done promptly, with every effort to complete the investigation and hold outcome meeting with in ten working days .Every action will be taken to resolve grievances within 30 days .

Based on observation, interview and record review the facility failed to justify continued use of psychotropic medications for one residents (#154) of five residents reviewed. Findings include: Resident #154 (R154) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R154 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), heart disease, major depressive disorder, transient ischemic attach (small stroke), cerebral infarction, dementia with anxiety, adjustment disorder with anxiety and depression, and delusional disorders. The MDS reflected R154 had a BIM (assessment tool) score of 9 which indicated her ability to make daily decisions was moderately impaired, and she required partial to moderate physical assist with dressing, hygiene, toileting, bathing and transfers. Continued review of the MDS reflected R154 had not had any behaviors including delusions, hallucinations, physical or verbal. R154 was observed throughout the survey dates of 1/21-1/24 to be pleasant, up daily for meals and socially engaging with staff, other residents and visitors. Review of R154's Physician's Orders, dated 9/26/24 though current, for antipsychotic Seroquel 75 mg daily at bedtime for delusions. Continued review reflected R154 had physician order for antidepressant Effexor 225 mg daily for depression with order start date 8/1/24 to current. Review of the Medication and Treatment Administration Record, dated 12/1/24 through 1/27/25, reflected, Is the resident experiencing any concerns with mood/mental health or any behaviors this shift? If yes, please document what s/sx resident is presenting in behavior PN/ note section? every shift for Mood and behavior monitoring. The documents reflected a response of, No for both months on every shift. Review of the Psychiatric consult, dated 9/13/24, reflected R154 was on Effexor 225 mg daily and Seroquel 100 mg daily. Continued review reflected physician completed chart review discussed case with facility staff who reported R154 psychiatric condition had remained unchanged. Continued review reflected R154 had record of depressive symptoms that were not distressful to R154. Consult reflected R154 appeared happy, smiled throughout exam and denied depression or anxiety. Note reflected, Documentation reviewed for this visit includes: current medication list, any recent changes to psychiatric medications, recent labs and diagnostic testing results/behavior tracking tool which were all considered as a part of the plan of care. Based on the data obtained and discussions with patient and staff, this provider concludes: a change in medication was considered but will not be implemented/recommended as current plan is most effective at present time. (Seroquel was reduced 13 days later on 9/26/24.) Continued review reflected, Continue to monitor for anxiety agitation, aggression and document. Encourage relaxation techniques and distraction. Promote non-pharmalogical method to assist with processing frustration and adjustment challenges . Review of the Psychiatric Consult, dated 12/23/24, reflected R154 was on Effexor 225 mg daily and Seroquel 75 mg daily. Consult reflected provider reviewed chart and discussed R154 and reported R154 psychiatric condition had remained unchanged. Continued review reflected R154 had record of depressive symptoms that were not distressful. The Consult reflected no dose reduction was recommended. Review of the Behavior Well Being assessments, dated 1/25/24, 4/2/24, 6/17/24, 9/24/24, 10/23/24 and 12/12/24, for R154, reflected section labeled, Behavior Incident Huddle Review with response, There have been no incident huddle reviews this past quarter. Continued review of the assessment dated [DATE] reflected R154 had irritability, agitation, and hallucinations and delusional thinking at times. Review of the Behavior Tracking, dated 9/24/24 through 12/31/24, reflected R154 had seven documented behaviors three months that included wandering or refusal of care.(Reviewed by psychiatric services as not be distressing to R154). Review of the facility Behavior log, dated 1/1/25 through current reflected R154 had 4 documented behaviors that including wandering, yelling and/or screaming. Review of the Electronic Medical Record, dated 9/19/24 through current, reflected R154 had five falls including with injury. Review of R154 Psychosocial Note, dated 1/22/2025 at 1:01 p.m., reflected, Quarterly Note: [named R154] overall mood is stable with her current psychotropic medication regiment .She reports no concerns with her appetite, sleep appetite or activity participation. [named R154] has been pleasant and cooperative with her care partners and reports she is receiving good care and treatment . During a telephone interview on 1/24/25 at 3:45 PM, Social Worker (SW) BB reported, would expect Certified Nurse Aids to document behaviors in facility Electronic Medical Record under tasks and Nurses and Social Workers to document in Progress Notes. SW BB reported facility completed Behavior Well Being assessments quarterly. SW BB reported R154 had behaviors that included delusions/hallucinations, refusal of care, irritation and agitation. SW BB reported behaviors documented in tasks and progress notes were reviewed quarterly. SW BB reported recalled R154 had behaviors after September Gradual Dose Reduction(GDR) but unsure if documented in R154 medical record but should have been. SW BB reported would review R154 medical record upon return to the facility, prior to survey exit, for supporting documentation. A request was made for clinical documentation for the continued use of Seroquel 75 mg without a gradual dose reduction. Documentation was not received prior to the survey exit.

Based on interview and record review, the facility failed to follow best practices to prevent infections including the spread of coronavirus and continued exposure to coronavirus in 15 of 174 residents (Resident #17, #18, #26, #32, #48, #74, #84, #89, #100, #110, #123, #133, #137, #147, #284), resulting in the hospitalization of R147, the continued spread of coronavirus and decreased quality of life. Findings include: The Centers for Disease Control and Prevention published recommendations for updated COVID-19 Vaccine for the 2023/2024 Fall/Winter Virus Season: Vaccination remains the best protection again's COVID-19 related hospitalization and death. Vaccination also reduces your chance of suffering the effects of Long COVID, with can develop during or following acute infection and last for an extended duration. The vaccines became available for administration beginning in mid October 2023. However, the facility had not administered the COVID vaccine to residents who requested to be vaccinated as part of infection prevention and control. Resident #32 (R32) Minimum Data Set (MDS) assessment dated [DATE] indicated she admitted to the facility on [DATE], had a brief interview for mental status (BIMS), a short performance-based cognitive screener, score of 04 (00-07 Severe Impairment). The same MDS indicated she had the diagnoses of diabetes and renal failure. In review of COVID outbreak report provided on 12/06/23; R32 had a temperature on 11/02/23, had not had a history of COVID, and had not had the updated COVID vaccine. The same document revealed R32 could exit quarantine on 11/13/23. R32 shared a room and bathroom with Resident #137. The same COVID outbreak report revealed 4 residents tested positive for COVID-19 on 11/03/23 (Resident #32, #74, #26, #100) and their roommates tested negative for COVID on the same day (Resident #18, #137, #123, #110). On 11/03/23, there was an opportunity to move COVID positive residents with other COVID positive residents; and move exposed residents in rooms with other exposed residents. The same report revealed R32's roommate, R137 tested positive for COVID on 11/09/23. R74's roommate, R18 tested positive for COVID on 11/06/23. R26's roommate tested positive for COVID on 11/06/23. R100's roommate, R110 tested positive for COVID-19 and had a cough and congestion on 11/17/23, 14 days after R100 tested positive for COVID-19. The same report indicated 2 staff tested positive for COVID on 11/03/23. Resident #137 (R137) R137's MDS dated [DATE] revealed she admitted to the facility on [DATE] and had a BIMS score of 15 (13-15 Cognitively Intact). The COVID outbreak report provided on 12/06/23 revealed R137 developed a cough and congestion and tested positive for COVID on 11/09/23, 6 days after her roommate. R137's COVID vaccination status was not up to date and was waiting to receive the updated vaccine, according to the list of residents that had signed a consent to receive the updated COVID vaccine provided during the survey. Resident #147 (R147) R147's MDS assessment dated [DATE] indicated she admitted to the facility on [DATE], had a BIMS score of 15 (13-15 Cognitively intact). R147's admission record indicated she resided on Unit 4 and had the diagnoses of Chronic Obstructive Pulmonary Disease (COPD, lung disease), heart failure, diabetes and a history of COVID-19. R147's Transfer form dated 11/30/23 at 8:24 AM revealed her blood pressure was 97/50 millimeters of mercury (mm Hg, normal 120/80), and her pulse oximetry (oxygen in bloodstream) was 89 percent (%, normal 95 to 100%). The same form revealed R147 had a new cough, abnormal lung sounds, weakness, and difficulty breathing. Hospital notes dated 11/30/23 indicated R147 had shortness of breath, worsening swelling of her upper extremities, and tested positive for COVID-19. R147 reported she had nasal discharge the week prior that lasted three days. The same note indicated that may have been the onset of R147's COVID symptoms. R147 received three doses of DuoNeb's (breathing treatment to open airways) and intravenous Lasix (diuretic) and was admitted to the hospital for continued treatment. R147's returned to the facility on [DATE] and was readmitted into the same room with roommate Resident #89, whom did not have signs or symptoms of COVID/respiratory illness. R147's COVID vaccination status was not up to date and was waiting to receive the updated vaccine, according to the list of residents that had signed a consent to receive the updated COVID vaccine provided during the survey. Resident #89 (R89) R89's MDS dated [DATE] revealed she was admitted to the facility on [DATE], had a BIMS score of 12 (08-12 Moderate Cognitive Impairment), and had the diagnoses of diabetes and heart failure. Covid outbreak report provided on 12/06/23 indicated R89 tested positive for COVID-19 on 12/06/23 and had symptoms including a cough and congestion. R89's COVID vaccination status was not up to date and was waiting to receive the updated vaccine, according to the list of residents that had signed a consent to receive the updated COVID vaccine provided during the survey. Resident #48 (R48) On 12/4/23 at 8:56 AM R48 was observed seated in her wheelchair, in the hallway on Unit 4, wearing a mask. R48 stated she had just returned from dialysis and was pissed off that she had to stay in room with a COVID positive resident, who was coughing up a lung, per her report. R48 reported she went out of the building for dialysis every Monday, Wednesday, and Friday. R48's MDS dated [DATE] revealed she was admitted to nursing home on 10/14/21, had a BIMS score of 15 (13-15 Cognitively Intact), and diagnoses included cancer, end-stage renal failure, and pulmonary disease. R48's COVID vaccination status was not up to date and was waiting to receive the updated vaccine, according to the list of residents that had signed a consent to receive the updated COVID vaccine provided during the survey. The same document indicated R48 shared a room and bathroom with Resident #17. Resident #17 (R17) COVID outbreak report provided on 12/06/23, indicated R17 had symptoms of a low-grade temperature and chills that began on 11/27/23 and tested positive for COVID on 11/27/23. R17's COVID vaccination status was not up to date and was waiting to receive the updated vaccine, according to the list of residents that had signed a consent to receive the updated COVID vaccine provided during the survey. In review of the COVID outbreak report provided on 12/06/23, R17 was the only resident that test positive for COVID on 11/27/23. In review of Unit 4's census on 11/27/23, there was an empty room available on that unit; and the census in the facility was 179 and had 194 beds. Resident #84 (R84) COVID outbreak report provided on 12/06/23, indicated R84 symptoms of congestion and runny nose began on 11/06/23, and was the first resident on Unit 4 to have symptoms. R284's electronic medical record indicated she admitted to the facility on [DATE], less than 14 days after R84 tested positive for COVID. COVID outbreak report provided on 12/06/23, revealed R284 symptoms began and tested positive for COVID on 11/28/23. R284 shared a room and bathroom with Resident #133. Resident #133 (R133) R133's MDS dated [DATE] revealed she was admitted to the facility on [DATE], had a BIMS score of 13 (13-15 Cognitely Intact), and had a diagnosis of cancer. COVID outbreak report provided on 12/06/23, revealed R133 symptoms began and tested positive for COVID on 12/02/23 COVID outbreak report provided on 12/06/23, revealed R133's symptoms began and tested positive for COVID on 12/02/23. Registered Nurse/Infection Control Practitioner (ICP) C was interviewed on 12/06/23 at 1:05 PM and stated the local health department in the past had provided COVID-19 vaccines and no longer provided that service. The facility pharmacy did not have the vaccine in stock. ICP C indicated the facility currently had a COVID-19 outbreak. The interdisciplinary team considered implementing a positive COVID-19 unit, but the Director of Nursing (DON) instructed to keep residents in the same rooms. DON B was on vacation during the annual survey. ICP C stated the COVID-19 outbreak started on Unit 3, a resident tested positive first, following a staff member that worked on that unit. All residents on Unit 3 were tested for COVID-19. ICP stated they tried to keep staff dedicated to that unit. No education was provided, staff were instructed on what to wear. A N-95 mask was to be worn at all times and not changed when exiting a COVID-19 positive room to care for a resident that was not COVID positive. ICP stated no new admissions were placed on Unit 3 during the outbreak. ICP confirmed that residents positive for COVID-19 that had roommates that were negative COVID19 were not moved to a private room. The facility had 194 beds and the census was 174 on the day of the interview. ICP C stated a COVID-19 vaccine clinic was set for vaccines to be administered on 12/12/23 from 10:00 AM to 4:00 PM. ICP C stated in the same interview that COVID negative residents cohorting with COVID positive residents was not reported to the health department, that she just updated the department with names of COVID positive residents. ICP C stated in the same interview, she had not received any recommendations from the local health department. ICP C stated she identified a trend with one roommate testing positive after their roommate tested positive, but no changes to the practice were made. During the same interview ICP was asked if a COVID negative resident was rooming with a COVID-19 resident, and sharing a bathroom, what was the cleaning protocol; ICP stated she would have to ask the housekeeping department. ICP C stated the privacy curtain was pulled between roommates when one roommate tested positive for COVID and the other resident tested negative for COVID. ICP C and Nursing Home Administrator NHA A were interviewed on 12/07/23 at approximately 9:00 AM, and stated they had followed CDC's recommendations. In an electronic mail document presented to survey team by ICP on 12/06/23, the local health department provided a link to the CDC's website: Infection Control: severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) CDC, under Nursing Homes instructed: placement of residents with suspected or confirmed SARS-CoV-2 infection ideally, residents should be placed in a single-person room. If limited single rooms are available, or if numerous residents are simultaneously identified to have known SARS-CoV-2 exposures or symptoms concerning for COVID-19, residents should remain in their current location. CDC's article Testing and Management Considerations for Nursing Home Residents with Acute Respiratory Illness Symptoms when severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and Influenza Viruses are Co-circulating, last reviewed 11/14/23, instructed residents in the facility who develop symptoms of acute illness consistent with influenza or COVID-19 should be moved to a single room, if available, or remain in their current room, pending results of viral testing. They should not be placed in a room with new roommates, nor should they be moved to a COVID-19 care unit (if one exists), unless they are confirmed to have COVID-19 by SARS-CoV-2 testing. Residents confirmed to have SARS-CoV-2 infection should be placed in a single room, if available, or housed with other residents with only SARS-CoV-2 infection. If unable to move a resident, he or she could remain in the current room with measures in place to reduce transmission to roommates (e.g., optimizing ventilation). Article titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Updated May 8, 2023, revealed the National Institute for Occupational Safety and Health (NIOSH) recommended respirators with N95 filters be used for a patients with SARS-CoV-2 infection, during care of a patient on Droplet Precautions, and N95 mask should be removed and discarded after the patient care encounter and a new one should be donned. 27306 On 12/05/23 at 09:35 AM, room [ROOM NUMBER] was observed to have a trash receptacle for disposal of contaminated personal protective equipment (PPE) inside the room, near the door. There was no lid on the trash receptacle. The discarded, contaminated PPE was nearing the top of the receptacle. On 12/05/23 at 09:21 AM, room [ROOM NUMBER] was observed to have a trash receptacle for disposal of contaminated PPE in the bathroom. There was no lid on the trash receptacle. The discarded, contaminated PPE was nearing the top of the receptacle. On 12/06/23 during the lunch meal 2 unidentified staff were observed on unit 4, neither staff were observed to have worn the face shield that the facility deemed required on unit 4. 38383 On 12/05/23 at 09:45 AM, room [ROOM NUMBER] was observed to have a trash receptacle for disposal of contaminated personal protective equipment (PPE) inside the room, near the door. There was no lid on the trash receptacle. The discarded, contaminated PPE was nearing the top of the receptacle. On 12/05/23 at 10:01 AM, room [ROOM NUMBER] was observed to have a trash receptacle for disposal of contaminated PPE in the bathroom. There was no lid on the trash receptacle. The discarded, contaminated PPE was nearing the top of the receptacle. On 12/05/23 at approximately 10:25 AM, room [ROOM NUMBER] was observed to have a trash receptacle for disposal of contaminated PPE in the bathroom. There was no lid on the receptacle, and it was overflowing with discarded, contaminated PPE. 46955 On 12/05/23 at 12:21 PM, Registered Nurse (RN) K was observed to prepare multiple medications for administration to Resident #100 (R100). RN K was observed to move medication cart to just outside of R100's open door, place a tissue on top of the cart and then place an empty medication cup on top of the tissue. RN K proceeded to dispense Duloxetine 1 capsule and Potassium 1 tablet directly from each blister pack into the medication cup as well as Senna 1 tablet from a medication bottle. RN K was then observed to remove R100's Thiamine blister pack from the medication cart, pop one tablet from the blister pack which landed on the tissue positioned beneath the medication cup, pick up the Thiamine tablet with her bare fingers and place the tablet directly into the medication cup containing R100's Duloxetine, Potassium, and Senna Tablets. RN K then proceeded to the doorway of R100's room with the cup of medications, questioned R100 regarding her Senna tablet and as R100 refused the medication, RN K returned to and reopened the medication cart, reached into the medication cup containing R100's medications with her bare fingers, removed the Senna tablet, and placed in a drug disposal bottle in the bottom drawer of the cart. RN K then returned to R100's room, mixed the 3 remaining medications with a small amount of pudding and administered them one at a time via spoon. On 12/06/23 at 8:26 AM, RN K was observed to prepare multiple medications for administration to Resident #159 (R159). RN K was observed to place an empty medication cup on a Styrofoam tray on top of the medication cart, remove multiple blister packs containing R159's medications from the medication cart, dispense Glipizide and Tamsulosin directly from the individual blister pack into the medication cup, and dispense Eliquis directly from the blister pack into her bare right hand and then place in medication cup already containing the Glipizide and Tamsulosin. After next dispensing Ferosul from a stock medication bottle and Lasix from R159's blister pack into the same medication cup, RN K was observed to unlock the medication cart narcotic box, remove R159's Tramadol and Neurontin blister packs and dispense 1 tablet of each directly into her bare left hand and then place into the medication cup with remainder of prepared medications. RN K was then observed to dispense R159's Amlodipine, Hydroxyzine, and Jardiance from the individual blister packs directly into the same medication cup prior to dispensing R159's Magnesium. RN K was observed to remove a Magnesium bottle from the medication cart, remove lid, dispense three tablets directly onto the inside lid of the bottle, hold 1 tablet against the inside lid with a bare finger, dispense the remaining two tablets from the lid into the medication cup and then proceed to dump the 1 remaining tablet that had been secured against the inside of the lid with a bare finger back into the magnesium bottle that still contained numerous tablets, replace lid to bottle, and place bottle back in medication cart. RN K confirmed that the Magnesium bottle was a house stock medication from which any resident that received Magnesium would be dispensed from. RN K then proceeded to dispense R159's remaining three medications (Metoprolol Succinate, Multiple Vitamin, and Sertraline) into the same medication cup, entered room, provided medication cup to R159, with R159 observed to take all medications with sips of coffee. In an interview on 12/06/23 at 8:44 AM, Licensed Practical Nurse/Nursing Supervisor (LPN/NS) L stated that with oral medication preparation, the nurse should complete hand hygiene, use either a Styrofoam tray or tissue barrier, and make sure that the medication was not touched when putting them into the medication cup. LPN/NS L stated that when a medication was dispensed from a blister pack, the blister pack should be held over the medication cup on the barrier and dispensed directly into the cup. LPN/NS L further stated that if a medication was popped outside of the medication cup and landed on the barrier beneath, that the medication should be wasted and a new one dispensed. Per LPN/NS L, when medications were dispensed from a stock medication bottle, the ordered number of pills would be dispensed directly onto the inside of the medication bottle cap and then placed directly into the medication cup using caution to not touch the inside of the cap or the medication. LPN/NS L further stated that as long as the inside of the lid or any extra pills were not touched, the extra pills could be placed back into the bottle. Upon conclusion of the interview, LPN/NS L reiterated that no touching of the medication whatsoever with bare hands should ever be happening and that all staff were provided with exactly that education. In an interview on 12/6/23 at 1:38 PM, Infection Preventionist (IP) C stated that the nurse managers monitored infection control practices during medication pass audits, did not know at what frequency these audits were completed, but would expect that if an isolated infection control concern was observed during an audit that the nurse manager would just provide education at that time but if a pattern was noted, would expect that she would be notified. IP C denied that she had completed any infection control audits pertaining to medication administration or knowledge that any nurse manager had identified any infection control issues during their medication pass audits.

Based on interview and record review, the facility failed to ensure that four of five residents reviewed for vaccinations (Residents #101, #50, #51, #133) were up to date on their Prevnar 20/Pneumococcal 20/PVC 20 vaccine, resulting in residents potentially getting pneumonia, having medical complications and decreased quality of life. Findings include: Resident #50 (R50) Review of the electronic medical record (EMR) revealed R50's last pneumonia vaccine (Prevnar 13) was administered on 3/12/2015 and refusals or consents were not found after that date. Resident #51 (R51) Review of EMR revealed R51's last pneumonia vaccine (Prevnar 13) was administered on 9/22/2015 and refusals or consents were not found after that date. During an interview on 12/6/2023 at 1:06 PM, the Infection Control Preventionist (ICP) C was asked about the pneumonia vaccines and she stated that if a resident declined to have the pneumonia vaccine, then they ask them again the next year to see if they want it. ICP C said she would check into the last pneumonia vaccination for R50 and R51. During another interview on 12/7/2023 in the morning, the Infection Control Preventionist (ICP) C stated that no residents were offered PCV 20 because she didn't think of it. Review of the Pneumococcal Vaccine Policy with an effective date of 6/13/2002 and a review date of 7/21/2023 revealed under Procedure and #14, For adults [AGE] years and older who have received the PCV-13 but have not completed their recommended pneumococcal vaccine series with PPSV-23, 1 dose of PCV-20 may be used if PPSV-23 is not available. If PCV-20 is used their pneumococcal vaccinations are now complete. 38383 Resident #133 (R133): Review of the medical record reflected R133 was [AGE] years old and admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included malignant neoplasm of the brain (cancer), epilepsy (seizure disorder) and dementia. R133's immunization history reflected they received Pneumovax Dose 1 on 11/22/21. Dose 1 was documented as pneumococcal polysaccharide PPV23. The immunization history reflected R133 was not eligible for Prevnar 13 (pneumococcal conjugate vaccine). There was no documentation reflective of additional pneumococcal vaccinations being offered. An email from Nursing Home Administrator (NHA) A on 12/07/23 at 11:49 AM reflected R133 had not been offered any additional pneumococcal vaccinations. According to the Centers for Disease Control and Prevention (CDC) guidance titled, Pneumococcal Vaccination: Summary of Who and When to Vaccinate, .There are 2 types of pneumococcal vaccines recommended in the United States: Pneumococcal conjugate vaccines (PCVs, specifically PCV15 and PCV20) [and] Pneumococcal polysaccharide vaccine (PPSV23) .Adults 19 Through [AGE] years Old With Certain Risk Conditions .For adults with any of these conditions or risk factors: .Immunocompromising conditions include: .Diseases or conditions treated with immunosuppressive drugs or radiation therapy ++ . ++ Includes .malignant neoplasms . (https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html) According to the CDC's PneumoRecs VaxAdvisor found at https://www2a.cdc.gov/vaccines/m/pneumo/pneumo.html, it was recommended that R133 receive one dose of PCV15 or PCV20 at least 1 year after their last dose of PPSV23. 27306 Resident 101 (R101) According to the clinical record including the Minimum Data Set (MDS) dated [DATE], Resident # 101 (R101) was admitted t the facility with diagnoses that included heart failure, diabetes, chronic obstructive pulmonary disease, epilepsy and Covid. Review of the MDS reflected R101 had limited range of motion of both upper extremities and scored 8 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). R101's immunization history reflected they received Pneumovax Dose 1 on 09/14/12. Dose 1 was documented as pneumococcal polysaccharide PPV23. The immunization history reflected R101 was not eligible for Prevnar 13 (pneumococcal conjugate vaccine). There was no documentation reflective of additional pneumococcal vaccinations being offered. On 12/07/23 at 10:50 AM, during an interview with Infection Preventionist Control Nurse (ICP) C , acknowledged R101 was eligible and should have been but was not offered the Prevnar 20 vaccine- which the facility did have in house but had not offered the vaccine to any residents with the exclusions of new admissions. ICP Nurse C elaborated that she had been so concerned and involved with Respiratory Syncytial Virus (RSV) and Covid that the pneumococcal vaccines have been overlooked.

Based on observation, interview and record review the facility failed to implement the care plan for one resident (R#101) of 22 residents reviewed for care plans, resulting in hunger and frustration. Findings include: According to the clinical record including the Minimum Data Set (MDS) dated [DATE], Resident # 101 (R101) was admitted to the facility with diagnoses that included heart failure, diabetes, chronic obstructive pulmonary disease, epilepsy and Covid. Review of the MDS reflected R101 had limited range of motion of both upper extremities and scored 8 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). On 12/05/23 at 09:23 AM, while donning personal protective equipment (PPE) outside of R101's door, there was a constant clicking/banging, the sound was coming from inside R101's room. Upon entering the room, R101 was observed sitting up in recliner chair his over bed table was approximately a foot in front of him to his right, R101 was holding a plate with his left hand, the plate consisted of 2 hard boiled eggs cut open, sausage links and R101 was observed to be holding a regular (non-weighted or built up) fork in his right hand, R101 kept trying to stab the egg and missing it, hitting the plate over and over (hence the clicking/banging) there were noticeable tremors of both hands. Resident # 101 was not able to make contact with the eggs or sausage links. The sausage links were not cut up bite sized and R101 was not able of completing the task of feeding himself without assistance. Upon approach R101 reported he was hungry - resident was queried if he thought he could make stab the food if the plate was placed on the over bed table, R101 responded he could not reach the over bed table. On 12/06/23 at 08:46 AM, R101 observed sitting in his recliner next to bed, his breakfast was observed sitting on the over bed tray, which consisted of a divided plate (still covered) that held 3 sausage links and two hard boiled eggs (nothing was cut up) a bottle of hot sauce next to plate, orange slices in a bowl tightly wrapped in plastic wrap was observed on the upper left hand corner of the tray. Regular silverware (not weighted) was wrapped in a napkin and 5 full glasses of water was observed . When queried - how are you today? R101 stated that he was hungry and asked writer to turn on call light so he could get some help with his breakfast. When queried how long ago his breakfast was delivered, R101 stated he was not sure. On 12/06/23 at 12:03 PM, R101 was observed sitting in his recliner, feeding him self lunch, R101 was observed holding a regular fork (not weighted) with his right hand which was observed to have significant tremors. The divided plate was observed to have turkey, carrots dressing, non of which had been eaten along with 2 full glasses of unthickened water, a bowl of strawberries were observed still wrapped in clear plastic wrap. R101's right hand was observed to have a significant tremor. Certified Nursing Assistant (CNA) O was interviewed and stated R101 didn't need assistance eating and his tray was all set. Review of R101's monthly December physician orders reflected non-therapeutic diet, regular texture, nectar thick Liquids consistency and weighted silverware , divided plate with meals. written on 10/05/22. Review of the Kardex (tool used by the Certified Nurse Aide to guide them as to the care needs of a specific resident) dated 12/06/23 indicated R101 was to have Nectar-thick liquids and was to be provided with built up utensils and a plate divider for meals. The kardex also indicated that when R101 had severe bilateral upper extremity tremors he was to be assisted with feeding tasks and supervision as appropriate. Review of R101's Nutritional care plan dated 7/10/20 with a most recent revision date of 11/08/23 reflected I have BUE (bilateral upper extremity) tremors which can sometimes affect my ability to feed myself. Some of the interventions for the identified problem were 1. Weighted silverware and divided plate to help with self-feeding. The care plan also reflected R101 preferred to eat some items with a large soup spoon (non of which was observed as being provided during the survey), the care plan also reflected R101 was to have nectar-thick liquids, and when having increased difficulty feeding himself due to hand tremors to offer assistance.

Based on observation, interview and record review the facility failed to ensure one resident (R#101) of one reviewed for assistance with meals was provided the physician ordered dishware/utensils, beverage consistency and physical assistance needed to for meals, resulting in hunger and frustration. Findings include: According to the clinical record including the Minimum Data Set (MDS) dated [DATE], Resident # 101 (R101) was admitted t the facility with diagnoses that included heart failure, diabetes, chronic obstructive pulmonary disease, epilepsy and Covid. Review of the MDS reflected R101 had limited range of motion of both upper extremities and scored 8 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). On 12/05/23 at 09:23 AM, while donning personal protective equipment (PPE) outside of R101's door, there was a constant clicking/banging, the sound was coming from inside R101's room. Upon entering the room, R101 was observed sitting up in recliner chair his over bed table was approximately a foot in front of him to his right, R101 was holding a regular plate with his left hand, the plate consisted of 2 hard boiled eggs cut open, sausage links, two clear glasses of water, one glass of orange juice and R101 was observed to be holding a regular (non-weighted or built up) fork in his right hand, R101 kept trying to stab the egg and missing it, hitting the plate over and over (hence the clicking/banging) there were noticeable tremors of both hands. Resident # 101 was not able to make contact with the eggs or sausage links. The sausage links were not cut up bite sized and R101 was not able of completing the task of feeding himself without assistance. Upon approach R101 reported he was hungry - resident was queried if he thought he could make stab the food if the plate was placed on the over bed table, R101 responded he could not reach the over bed table. On 12/06/23 at 08:46 AM, R101 observed sitting in his recliner next to bed, his breakfast was observed sitting on the over bed tray, which consisted of a divided plate (still covered) that held 3 sausage links and two hard boiled eggs (nothing was cut up) a bottle of hot sauce next to plate, orange slices in a bowl tightly wrapped in plastic wrap was observed on the upper left hand corner of the tray. Regular silverware (not weighted) was wrapped in a napkin and 5 full glasses of unthickened water was observed . When queried - how are you today? R101 stated that he was hungry and asked writer to turn on call light so he could get some help with his breakfast. When queried how long ago his breakfast was delivered, R101 stated he was not sure. On 12/06/23 at 12:03 PM, R101 was observed sitting in his recliner, feeding him self lunch, R101 was observed holding a regular fork (not weighted) with his right hand which was observed to have significant tremors. The divided plate was observed to have turkey, carrots dressing, non of which had been eaten along with 2 full glasses of unthickened water, a bowl of strawberries were observed still wrapped in clear plastic wrap. R101's right hand was observed to have a significant tremor. Certified Nursing Assistant (CNA) O was interviewed and stated R101 didn't need assistance eating and his tray was all set. Review of R101's monthly December physician orders reflected non-therapeutic diet, regular texture, nectar thick Liquids consistency and weighted silverware and divided plate with meals. which was written on 10/05/22. Review of the Kardex (tool used by the Certified Nurse Aide to guide them as to the care needs of a specific resident) dated 12/06/23 indicated R101 was to have Nectar-thick liquids and was to be provided with built up utensils and a plate divider for meals. The kardex also indicated that when R101 had severe bilateral upper extremity tremors he was to be assisted with feeding tasks and supervision as appropriate. On 12/06/23 at 12:16 PM, during an interview with Unit Manager (UM) M she reported R101's hand tremors fluctuated and were worse on someday's, when queried why the Physician order and kardex reflected R101 was to have nectar thick liquids, why he provided thin liquids on breakfast 12/5 and breakfast and lunch on 12/06, UM M reported it was because R101 refused the thickened liquid, when asked where that was documented and if there was education provided to R101 on the need for the nectar thick liquids, Um M stated she didn't know. When queried why the three meal observations did not contain any weighted silverware as ordered by R101's physician, UM M did not respond. Review of the medical record did not reflect any refusals from R101 that pertained to acceptance of assistance for eating, thickened liquids or weighted silverware.

Based on observation, interview and record review, the facility failed to ensure timely optometry services for one (Resident #67) of one reviewed for vision, resulting in lack of timely eye care services and the potential for delayed treatment. Findings include: Review of the medical record reflected Resident #67 (R67) admitted to the facility on [DATE], with diagnoses that included diabetes and vascular dementia. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/24/23, reflected R67 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 12/04/23 at 10:13 AM, R67 was observed in his room and reported for about nine months, he had been wanting to see the eye doctor. He reported he had told five or six staff that he wanted to see the eye doctor, but it had not done any good yet. R67 stated he could hardly get around any longer because he could not see. He reported he had glasses, but they were not doing much. An eye care visit summary for 9/13/22 reflected R67 had dry eye, in both eyes. Recommendations included artificial tears twice daily, indefinitely, as well as lid scrub pads to both eyes every morning for 90 days. There was notation for Follow-Up: Priority Comprehensive 11/05/2022. There were no eye care visit notes in R67's medical record since the last date of service for 9/13/22. In an interview on 12/06/23 at 03:03 PM, Nursing Home Administrator (NHA) A reported R67 was on the list to be seen for eye care services on the next visit, per R67's request. NHA A reported there were no additional eye care visit notes after 9/2022, and the facility was reaching out to the provider to see if there had been any additional visits. During an interview on 12/06/23 at 03:07 PM, Nursing Administrative Assistant (NAA) F reported being responsible for ancillary services, such as eye care. She reported R67 was on the list to be seen, and optometry would be visiting the facility on 12/7/23 for a planned visit. NAA F reported the Social Worker sent her an email on 11/30/23, requesting R67 be added to the list to see the eye doctor due to his report of having trouble reading. NAA F stated that was the first request she had been made aware of for R67 since his last eye care visit (in 9/2022). NAA F was unable to state why there was no follow-up in R67's medical record, as recommended for 11/5/22. She reported her process was to provide the Unit Managers with the list of who was seen and any recommendations. No additional eye care visit notes were received prior to the survey exit on 12/7/23.

Based on observation, interview and record review, the facility failed to 1) ensure timely assessment and follow-up of weight loss for one (Resident #103); and 2) implement additional interventions to prevent continued weight loss for three (Resident #52, #103 and #152) of four reviewed for nutrition, resulting in the potential for further weight loss. Findings include: Resident #103 (R103): Review of the medical record reflected R103 admitted to the facility on [DATE], with diagnoses that included pneumonia, chronic obstructive pulmonary disease (COPD) and diabetes. On 12/06/23 at approximately 08:35 AM, R103 was observed in her room, seated in her wheelchair, with her legs stretched out, head back and eyes closed. A breakfast plate was observed in front of her, and she was not making attempts to consume her meal. Two staff were observed to put on gowns and gloves, in addition to their N95s and face shields, and enter the room. The door was closed behind them. Upon a follow-up observation, staff were no longer present in the room, and R103's plate was no longer in her room. A staff member was queried on R103's acceptance of her breakfast, and she stated she was unsure. She indicated she did not know how much R103 ate or if she was offered anything else. She indicated another CNA may know. The Comprehensive Nutritional Assessment, dated 9/18/23, reflected R103 had a possible four pound/three percent weight loss over the past month (if using a weight from her prior admission to the facility). The plan was to continue to monitor R103's weight weekly, with a goal for weight maintenance/no further weight loss. On 12/5/23, R103's Food Acceptance Record for the past 30 days reflected varying amounts were consumed at meals, including 0-25% up to 76-100%. A Physician's Order, dated 9/19/23, reflected R103 was to receive one carton of a health shake twice daily and preferred chocolate flavored. A Physician's Order, with a revision date of 9/20/23, reflected R103 was on a non-therapeutic diet, soft texture, thin consistency liquids and was to receive a divided plate for meals. R103's medical record, including the Medication Administration Record (MAR), was not reflective of the percentage of health shake that was accepted. On 12/05/23 at 02:56 PM, R103's medical record reflected the following weight history: 11/22/2023: 153.8 pounds (Lbs) 11/14/2023: 161.2 Lbs 11/10/2023: 165.8 Lbs 11/2/2023: 153.8 Lbs 10/19/2023: 151.4 Lbs 10/18/2023: 157.2 Lbs 10/12/2023: 165.4 Lbs 10/4/2023: 152.4 Lbs 9/27/2023: 144.2 Lbs 9/19/2023: 144.0 Lbs 9/12/2023: 140.4 Lbs On 11/10/2023, R103 weighed 165.8 lbs. On 11/22/2023, the resident weighed 153.8 pounds, which was a -7.24 % loss. The medical record did not reflect that R103 had been weighed since 11/22/23. Review of R103's Progress Notes reflected a Nutrition/Dietary Note, dated 9/19/23, which reflected R103's family reported she liked health shakes, so an order would be initiated for health shakes twice daily. Review of R103's Progress Notes reflected a Weight Change Note had not been entered since 8/15/23, during their prior admission to the facility. During an interview with Registered Dietitian (RD) F and RD G on 12/06/23 at 01:38 PM, it was reported that R103 was on the weekly weight list. When asked why there had been no recorded weight since 11/22/23, it was reported that R103 had a weight of 147.2 lbs from 12/5/23 that had not been recorded in the medical record. When asked why almost two weeks had passed since R103 had been weighed, it was reported she had a weight on 11/29/23, which was 158.2 lbs. That weight was not recorded in R103's medical record. RD G entered R103's 11/29/23 and 12/5/23 weights into the medical record during the interview with the State Agency. During the same interview, it was reported that R103 had been on weekly weights since admission, which would continue until there was a month worth of weights that were stable. Follow-up weights were to be obtained if the weight was off by five pounds from the previous weight. When asked about the expectation for the time frame to obtain follow-up weights, it was reported they tried to get them before the end of the week. When asked about the trend they were seeing with R103's most recent weights, it was reported that her weights went up and down, and her weight from 12/5/23 was close to what it was upon admission. It was reported that their thought was R103's baseline weight was in the 140 pound range. When asked about nutritional interventions for R103, it was reported that health shakes had been implemented due to not always eating three full meals a day. When asked how acceptance of health shake consumption was monitored, it was reported that done by speaking to the nurses. A check mark on the MAR meant the shake was accepted. Additional dietary interventions included a divided plate at meals to assist with self-feeding. It was reported that an intervention for R103 was to keep her on weekly weights. 30337 Resident #152 (R152) 12/04/23 at 8:48 AM R152 was observed sitting in a chair in her room, with a plate of food placed directly on lap and eating. R152 Minimum Data Set (MDS) assessment dated [DATE] revealed she admitted to the facility on [DATE], had a diagnosis of Alzheimer's Disease, a brief interview for mental status (BIMS, a brief performance-based cognitive screener) score of 04 (00-07 Severe Impairment) and needed set-up assistance for eating. Care plan for alteration in nutritional status with last revision date of 9/27/23, indicated because of R152's dementia, it could affect her ability to recall the importance of adequate daily nutrition and she could miss a meal because of sleeping through it. The same care plan instructed to observe for any signs/symptoms of diet distress (pocketing of food, slow eating, food falling from her mouth while eating, choking/coughing) and report to the nurse. R152's goal was to accept an average of 50 percent (%) or more at meals. In review of R152's electronic medical record, on 6/23/23, the resident weighed 124.8 pounds (lbs.) On 12/01/23, R152 weighed 101.6 pounds which was an 18.59 % severe weight loss over 6 months. On 9/22/23, R152 weighed 111.2 lbs. in which was an 8.63 % severe weight loss over 3 months. In review of R152's last nutritional progress notes, dated 9/28/23 at 11:07 AM, she previously had maintained her weight in the 124-129 lbs. range from July 2022-July 2023. R152 feeds herself the regular diet which she accepts and tolerates well, so unclear etiology for her potential weight loss. RD did speak R152's daughter and it was agreed upon for her to begin receiving health shakes for supplementation with goal for weight maintenance and no further weight loss. During an interview with Registered Dietician (RD) H on 12/05/23 at 2:55 PM, she stated she had implemented a health shake three times a day and were monitoring R152's weight. RD H stated R152 was accepting the health shake on and off. At times R152 may sleep through a meal and was offered something when she got up. RD H and G stated the facility did not have a restorative dining program or fortified diets (increased calorie foods). RD H stated a substantial night-time snack had not been considered for R152 and stated that was a good idea. In review of R152's food acceptance over the last 30 days, she accepted 26 to 50 % of meals 39 times; and five meals she ate 0 to 25 %. On 12/06/23 at 8:17 AM R152 was observed in dining room eating breakfast and taking very small bites. R152 was seated at a table with two other residents. On 12/06/23 at 8:43 AM R152 still eating her breakfast, her eggs were untouched and she had ate a few bites of toast and 1/2 strip of bacon. The other residents that were seated at the same table had finished eating and were no longer seated. 48637 Resident #52 (R52) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R52 admitted to the facility on [DATE] and had diagnoses of right scapula (shoulder blade) fracture, depression, chronic pain, constipation, and anxiety disorder. Brief Interview for Mental Status (BIMS) score was a 13 which indicated her cognition was intact (13-15 cognitively intact). During an interview on 12/4/2023 at 12:13 PM, R52 was eating lunch in her room. R52 stated that she thought she lost weight since admission. She was eating a salad and a ham sandwich and said, I want some baked potato chips and asked for it when I saw a staff member and I'm still waiting for it. During another interview on 12/6/2023 at 2:41 PM, R52 reported that she asked for ice cream and chips again yesterday and no one brought it to her. She (R52) said she doesn't get what she wants typically so sometimes she doesn't ask for food items and she was pretty sure she had lost weight. R52 said, I don't even get ice water and I like ice in my water. Instead, I get water that gets warm and I don't like drinking warm water. Review of R52's weights in the electronic medical record (EMR) revealed: 11/4/2023: 125.2 pounds (lbs) 10/9/2023: 125.0 lbs 9/15/2023: 133.0 lbs 9/8/2023: 133.4 lbs 9/5/2023: 132.2 lbs 8/30/2023: 135.0 lbs 8/24/2023: 138.8 lbs 8/11/2023: 140.2 lbs On 08/11/2023, R52 weighed 140.2 lbs. On 11/4/2023, R52 weighed 125.2 pounds which was a severe weight loss of 10.70 percent (%) loss in 3 months. Review of R52's EMR revealed that a comprehensive nutrition assessment was completed on 8/21/2023 and the next nutrition note was the quarterly assessment completed on 11/16/2023 by Registered Dietitian (RD) H. During an interview on 12/5/23 at 2:29 PM, RD H and RD I were asked if the EMR had any other nutrition notes (besides the comprehensive nutrition assessment and quarterly assessment note) between 8/21/2023 and 11/16/2023. RD H and RD I both looked on their computer and couldn't find any other notes. RD I stated that there wasn't anything in the EMR but there were probably emails between staff regarding her weight loss. When asked what was done after the weight loss noted on 10/9/2023, RD H said that health shakes were started on 11/15/2023 when she was completing her (R52's) quarterly assessment. When asked about the supplements being started on 11/15/2023 and not after the weight loss noted on 10/9/2023, RDH stated that R52 had good food acceptance so she thought it was fluid loss which wasn't as concerning as actual weight loss. RD H said that sometimes residents are put on weekly weights when weights drop. Per the EMR a reweight wasn't completed after the 10/9/2023 weight was obtained and the next weight was obtained on 11/4/2023. RD H verified that R52 did not have another weight after 10/9/2023 until 11/4/2023. She (RD H) said the RDs review monthly weights and if the weight was off, they let the nurse know and ask for a reweigh. RD I said that they used to have meetings about weight loss before the pandemic but they don't have any specific meetings now because it wasn't efficient and they now have an email thread with staff regarding anyone with weight loss. Review of Weight Policy and Procedure with no effective date and a review date of 4/5/2022 revealed, Residents weighing greater than 100 pounds with a five (5) pound loss or gain from one weight to the next (or a 3 pound or more loss/gain for Residents less than 100 pounds), require a re-weight to be done as soon as possible. If the loss or gain is verified, the weight will be documented. It also states, The IDT will attempt to determine the cause of the loss/gain/discrepancy and implement any approaches necessary to address the issue. Care Plans will be updated accordingly along with Kardex for CNAs. A Resident with weight loss/gain may be added to the weekly weight list if the team feels it is necessary.

This citation pertains to Intake MI 826. Based on observation, interview and record review, the facility failed to effectively assess for changes in skin integrity according to facility policy and professional standards of practice to prevent pressure injuries for one Resident (#10) of three residents reviewed for pressure injuries. This deficient practice resulted in harm when changes in skin integrity were not promptly identified leading to Resident #10 developing a facility acquired, Stage 3 pressure injury and a facility acquired, unstageable pressure injury. Findings include: Resident #10 An observation on 6/28/2021 at 2:20 p.m., revealed Resident#10 asleep, sitting in a reclining chair. Resident #10's legs were resting on the footrest of the recliner. Resident #10 was wearing cushioned heel protecting boots on both feet at the time of the observation. Resident #10 was admitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #10's Minimum Data Set (MDS) assessment, dated 6/2/2021, revealed Resident #10 had severe cognitive impairment and required extensive, two-person assistance for bed mobility, transfers, and toilet use. Further review of Resident #10's MDS assessment revealed Resident #10 required extensive, one-person assistance for dressing and personal hygiene and was totally dependent upon staff for bathing. A review of the wound care nurses' documentation for Resident #10, titled Skin & Wound Evaluation, and dated 6/2/2021, revealed Resident #10 had acquired a Stage 3 (full-thickness skin loss) injury to the right buttock. Further review revealed the following, in part: 23. Acquired: 1. In-House Acquired . 24. How long has the wound been present? (Wound age when first assessed .) Exact Date: 5/31/2021 . C. Wound Bed: 3. Slough (yellow or tan moist, non-viable tissue) . % (per cent) Slough: 1. 100% of wound filled. A review of the Resident #10's Skin & Wound Evaluation, dated 6/7/2021, revealed Resident #10 had acquired a right heel, unstageable (full-thickness pressure injury in which the condition of the wound bed is not visualized due to the presence of slough (moist, non-viable tissue) or eschar (black or brown dead tissue) but if removed would reveal a Stage 3 (full-thickness) or 4 (full-thickness, bone visible) pressure injury). Further review revealed the following, in part: 23. Acquired: 1. In-House Acquired . 24. How long has the wound been present? (Wound age when first assessed) . Exact Date: 6/6/21 . B. Wound Measurements: Length 1.9 cm (centimeters). Width 1.1 cm. Depth 0.1 cm. C. Wound Bed: 4. Eschar . % Eschar: 1. 100% of wound filled . F. Wound Pain: 8. Pain: 7/10 (seven on a scale of one to ten, with ten being the highest pain intensity) . 10. Notes on Pain: Resident states ow and my heel is sore! when assessing and removing sock. Further review of Resident #10's Skin & Wound Evaluation(s), provided by the Director of Nursing (DON), revealed as of the most recent evaluation, dated 6/29/21, the pressure injury on Resident #10's right heel remained unstageable and measured 2.3 cm long, 1.6 cm wide and 0.1 cm deep, an increase from the first recorded measurement on 6/7/2021. In an interview with the Director of Nursing on 6/29/2021 at 8:05 a.m., this Surveyor requested to be present during Resident #10's wound care. The DON reported she would inform the Wound Care Nurse to summons this Surveyor to observe Resident #10's wounds. At 8:28 a.m., the DON reported Resident #10's wound care had already been completed; therefore, no observation could be obtained. At that time, a request was made by this Surveyor to be present during Resident #10's next toileting to observe the wound dressings and to observe the care provided. At 8:35 a.m., the DON reported staff would toilet the resident at 9:30 and were expecting this Surveyor to observe. In an interview on 6/29/2021 at 9:30 a.m., certified nurse aid (CNA) C reported Resident #10 would not be toileted at that time because Resident #10 had declined care at that time. CNA C reported Resident #10 alerted staff when there was a need to be toileted. CNA C reported she would summons this surveyor to observe the next time Resident #10 called for assistance. As of the end of the survey, this Surveyor was not alerted to Resident #10's toileting or provision of care and no observations of Resident #10's wounds or toileting care could be obtained. In an interview on 6/29/2021 at 1:44 p.m., Registered Nurse (RN) E reported she was the Wound Care Nurse at the facility and had completed the Skin & Wound Evaluation(s) for Resident #10. RN E reported the pressure injury on Resident #10's right buttock was healed and the pressure injury on Resident #10's right heel remained unstageable. RN E confirmed both of Resident #10's wounds were unstageable when first identified. When asked how often skin assessments were performed on the residents, RN E reported certified nurse aides should be assessing for skin issues during daily care of the residents and nursing staff complete COMS skin assessments weekly during resident's scheduled showers. RN E reported concern that Resident #10's right buttock and right heel pressure injuries had not been identified prior to 5/31/2021 and 6/6/2021, respectively. When asked if changes to skin integrity would have been noticeable on assessment prior to the development of a Stage 3 and an unstageable pressure injury, RN E reported Stage 3 and unstageable pressure injures develop over time and do not happen overnight. RN E reported the facility had begun re-educating staff on how to conduct full-skin assessments and on the identification and documentation of changes in skin integrity. When asked what the concern was if skin assessments were not effectively completed, RN E reported inaccurate or incomplete skin assessments may cause delay in treatment and implementation of interventions to prevent worsening of wounds. A review of Resident #10's COMS - Skin Only Evaluation(s), provided by the DON, revealed the following skin evaluations: 5/01/2021 20:37 (8:37 p.m.) 5/08/2021 20:37 (8:37 p.m.) 5/15/2021 15:13 (3:13 p.m.) 5/22/2021 20:21 (8:21 p.m.) 5/29/2021 16:45 (4:45 p.m.) 6/5/2021 21:14 (9:14 p.m.) 6/12/2021 19:20 (7:20 p.m.) 6/19/2021 20:25 (8:25 p.m.) 6/26/21 19:41 (7:41 p.m.) Further review of the COMS - Skin Only Evaluation(s), for Resident #10 revealed the following documentation on each of the above referenced evaluations: Skin. Does the resident have current skin issues? b. No. A review of Resident #10's physician orders revealed no wound care orders were initiated for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed no wound care orders initiated for Resident #10's right heel pressure injury prior to 6/7/2021. A review of Resident #10's Comprehensive Care Plan revealed a Risk for Pressure Injury Care Plan, initiated on Resident #10's admission to the facility on [DATE] that included the following intervention: Monitor skin daily during care for areas of breakdown. In an interview on 6/29/2021 at 2:50 p.m., the DON reported full body skin assessments were conducted by nursing staff once weekly during resident's scheduled showers. The DON reported the purpose of the skin assessments was to identify any changes in skin integrity and for early identification of pressure injuries to allow for interventions to be implemented to prevent worsening and to promote healing of any wounds. The DON confirmed all abnormal skin conditions should be reported on the COMS - Skin Only Evaluation(s). During a review of Resident #10's COMS - Skin Only Evaluation(s), from 5/01/2021 through 6/26/2021, the DON confirmed there was a concern that the assessments were incomplete due to the lack of documentation of the Resident's respective existing pressure injuries. The DON reported there had been confusion among staff regarding what to document in the evaluations. The DON agreed due to staff confusion regarding completion of the COMS - Skin Only Evaluation(s), there was a concern that wounds would go undetected. A review of the facility policy, titled Prevention and Management of Pressure Injuries, dated 11/18/2011 and reviewed 6/10/2021, revealed the following, in part: Purpose: To identify, assess, monitor, and implement appropriate interventions for all Residents at risk for the development of pressure injuries. The facility will follow and be consistent with current standards of practice. Procedure: 4. During care/shower once weekly, the nurse inspects skin for any new skin issues, such as bruise, skin tear, redness, open area, etc. 7. Injuries will be monitored and will have periodic documentation, weekly measurements, including location, wound bed appearance, exudate, peri-wound observations, signs and symptoms of infection and notification of appropriate parties; if present, exudate, including color, odor, and pain. A review of the facility policy, titled, Standard of Practice, presented by the DON as the CNA care policy, dated 4/01/2020, revealed the following, in part: The following have been determined as Standard of Practice: 18. Skin observed during care/shower, report anything abnormal to nurse.

This citation pertains to intakes MI 900 and MI 911. Based on observation, interview and record review, the facility failed to provide adequate supervision for 1 (Resident #7) of 2 reviewed for falls, resulting in Resident #7 sustaining a fall with fractures and hospitalization . Findings include: Review of the medical record and Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was a [AGE] year old female resident re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#7 had clear speech, understood, understands, was moderately impaired cognitively and required extensive assistance of two staff for transfers. Review of the incident note dated 6/9/19 at 3:39 p.m., written by Registered Nurse (RN) R revealed, (Resident #7) was eating .and had requested to go to bed. Two CENAs (Certified Nursing Assistants P and Q) were assisting the resident into bed using a Hoyer and sling. During transfer from WC (wheelchair) to bed using a Hoyer lift with two CENAs, (Resident #7) slid out of the Hoyer sling onto the floor. Resident description was that she stated that she fell .EMS (Emergency Medical Services) was called by writer while the second nurse stayed with the resident .Resident stated 10/10 (10 out of 10) lower back pain and right hip pain. There is a minimal amount blood noted to the bilateral ears. Based on resident c/o (complaint of) pain and blood on residents bilateral ears she was sent to (Name of Hospital) ED (emergency department) .Hoyer and sling were taken out of commission and a work order placed for maintenance to check proper function of the Hoyer and sling . During an observation and interiview on 6/12/19 at 9:35 a.m., Resident #7 was lying in her bed, appeared to be in pain and stated as such. When asked about the incident of her falling from the sling Resident #7 stated she really couldn't remember everything, All I remember was I was being lifted and then, they dropped me. I don't know how it happened .They lift me too damn much, I am afraid they are going to drop me again. During an interview on 6/12/19 at 10:12 a.m., Maintenance Director [NAME] stated, We brought it (the Hoyer lift and sling) down to inspect it, it was right in front of our office. There was nothing wrong with it. This surveyor confirmed with the Maintenance Director [NAME] that there was nothing wrong with both the lift and the sling. Maintenance Director [NAME] stated, Yes, we brought them down, looked at both, there was nothing wrong with either. During an observation on 6/12/19 at 10:30, this surveyor confirmed that both the Hoyer lift and the sling that were used to transfer Resident #7 appeared to be in proper working order. Review of the hospital Trauma History and Physical report dated 6/9/19 at 7:04 p.m. revealed Resident #7 arrived at the emergency department on 6/9/19 at 1:31 p.m Further review of this report revealed, ASSESSMENT: (Resident #7) is a 90 y.o (year old) female how presented to the ED with back pain after falling out of a Hoyer lift .INJURY LIST: 1. Bilateral sacral fracture 2. Compression deformity of T1 ([MEDICATION NAME] vertebrae) 3. Questionable left scapular (shoulder blade) tip fracture 4. Left clavicle fracture 5. Sternal fracture .PLAN: (Resident #7) seen and evaluated as a trauma consult. admitted to the SICU (Surgical Intensive Care Unit) under the trauma services . During an interview on 6/12/19 at 12:17 p.m., when asked about Resident #7's fall RN R stated, I was (Resident #7's) nurse that day. I was told that she was on the floor. When asked if this fall was preventable RN R stated, Yes, they (CNAs P and Q) could have checked the loops on the lift and then check them again, for sure a double check was needed. Review of the facility's Counseling Form for CNA P dated 6/9/19 revealed, Specifics of the incident: Resident in room .slid out of the Hoyer sling while being transferred from the WC to the bed using the Hoyer lift. This resulted in a fall .Expected result of the counseling: During all transfers CENAs must be aware of Hoyer sling loops being secure. The legs of the Hoyer must be in widest position while moving resident. One CENA will remain at the head of the resident using loops provided. The Second CENA will stay at the foot of the resident controlling the remote and moving the lift. Review of the facility's Counseling Form for CNA Q dated 6/9/19 revealed, Specifics of the incident: Resident in room .slid out of the Hoyer sling while being transferred from the WC to the bed using the Hoyer lift. This resulted in a fall .Expected result of the counseling: During all transfers CENAs must be aware of Hoyer sling loops being secure. The legs of the Hoyer must be in widest position while moving resident. One CENA will remain at the head of the resident using loops provided. The Second CENA will stay at the foot of the resident controlling the remote and moving the lift. Review of the disciplinary hearing document for CNA P dated 6/11/19 revealed that during this hearing CNA P was asked, Please explain how this incident could have been prevented. Per this document CNA P responded, If one of us could have stayed behind her we could have caught her. Review of the disciplinary hearing document for CNA Q dated 6/11/19 revealed that during this hearing CNA Q was asked, Please explain how this incident could have been prevented. Per this document CNA Q responded, If I would have been in position it would have been prevented. During this survey, multiple attempts to reach CNA P were made with no success. During a telephone interview on 6/17/19 at 1:45 p.m., when asked about Resident #7's fall from the Hoyer lift, CNA Q stated, My co-worker asked me to help transfer (Resident #7). She had everything connected, I went into spot. My partner was the one that operated the machine. She started to lift (Resident #7) up and everything was fine, then I turned (Resident #7) sideways and there was nothing wrong it was perfectly fine. Then my co-worker tried to push (Resident #7) onto the bed and that is when she fell . I guess the sling slipped out the loop. When asked if there was anything wrong with the sling or the lift, CNA Q stated, No not to my knowledge. When asked if she placed her hands the loops to confirm they were securely attached, CNA Q stated, No I did just looked at them. Review of the Investigation document undated, revealed, (Resident #7) was lifted high enough to transfer into bed. Once resident was fully in the air, the second CENA repositioned resident by her legs so that they would not hit the Hoyer machine. The first CENA then moved the Hoyer machine almost to the bed when she heard a pop. The left head strap then came undone from the Hoyer machine. The CENAs tried to catch the resident or lessen the fall, but were unsuccessful. Resident hit the floor on her back and was positioned perpendicular to the bed. Staff noted that resident did hit her head .Conclusion: .Staff put the sling under the resident and applied all 4 straps, but the equipment did not secure appropriately subsequently causing resident to fall out of the Hoyer lift sling. When second CENA arrived to the room, she stated that they both visually checked that the straps were attached to the Hoyer machine, but they did not physically double check equipment for strap placement. Upon moving the machine, the left head strap came off and resulted in the resident falling to the ground.

Based on observation, interview and record review the facility failed to prevent neglect due to not following the care plan for one resident #4 and failed to prevent resident to resident abuse involving 1 sampled resident (#4), and 2 supplemental residents (#33 and #34) of 10 residents reviewed for abuse and neglect, from a total sample of 28, resulting in actual physical abuse and neglect occurring in the facility. The facility policy Evaluation of Falls/Fall Risk, dated 11/18/2011 and reviewed 6/2/17, reflected It is the policy (of) (facility name) to prevent or manage Resident falls and to identify the root case of the falls .Procedure: 1 .You must always follow the Point Click Care kardex that tells how to take care of the Resident. Not following a Resident's kardex, the Resident could be injured Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected Resident #8 was a [AGE] year of female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS reflected Resident #8 had a BIM (assessment tool) score of 1 which indicated her ability to make daily decisions was severely impaired, and she required one person physical assist with locomotion on unit(prior to 6/19/17 fall), transfers, toileting, dressing, hygiene, and bathing. During the initial facility tour on 7/17/17 at 9:07 a.m., Unit Manager (UM) WW and Social Worker (SW) BB reported Resident #8 had a fall about 6 weeks ago that resulted in a fracture of a facial bone. SW BB reported Resident #8 was in the dining room and self transferred without the use of a walker and fell . SW BB stated, (Resident #8) was famous for that, I have been walking for [AGE] years. In an observation on 7/17/17 at 3:00pm Resident #8 was noted to be in her room sitting in recliner and appeared pleasantly confused. Resident #8 was talkative and pleasant but responses were not related to questions asked. Review of the facility Electronic Medical Record (EMR) Progress Notes on 7/17/17 at 4:00 p.m., Resident #8 had a fall in the dining room on 6/19/17 with a fracture to the right cheek bone and laceration and was sent to the emergency room for evaluation. In an observation on 7/17/17 at 5:15 p.m. Resident #8 was noted to be in the dining room with 3 other res. at the table independently eating meal. Review of the facility Incident Report dated 6/19/17 at 6:30 p.m., reflected Resident #8 had an unwitnessed fall in the south dining room that resulted in maxillary alveolar fracture and facial laceration under the left eye. The Incident Report reflected under, Notes: FALL HUDDLE: .All care plan interventions were followed . Included in the Incident Report and the investigation were witness statements for 3 staff members that did not witness the fall related to providing resident care to other residents. Review of the Activities of Daily Living (ADL) Care Plan, dated 12/11/15 with interventions dated 4/22/16 and revised on 9/9/16, reflected Resident #8 had interventions in place at the time of the fall on 6/16/17 that included, I WALK TO DINE FOR MEALS. I NEED 1PA, FWW AND W/C TO FOLLOW. PLEASE LEAVE ME IN MY W/C AT MEALS SO THAT I MAY LEAVE THE TABLE WHEN I AM READY . The Care Plan reflected under, Position: CNA, RN/LP, RNA, hospi, which indicated the intervention appeared on the Certified Nurse Aide Kardex. Review of the Morse Fall Scale, dated 5/3/17, reflected Resident #8 was at a high risk for falls with a score of 90. Review of the Nursing Progress Note, dated 6/19/17 at 4:35 p.m., for Resident #8 reflected, Resident up walking with walker, not able to redirect to sit down in dining room for dinner or in her own room. Resident persistent that she has to get her walk in. This nurse walked with resident down hallway and back to the atrium. Review of the Hospital Records, CT Head WO Contrast report, dated 6/19/17, reflected Resident #8 had an acute [MEDICAL CONDITION] and posterior walls of the left maxillary sinus with left orbital preseptal swelling and also layering hyperdense hemorrhage within the left maxillary sinus. The anterior wall fracture was mildly depressed. In an observation on 7/18/17 at 1:10 p.m., Resident #8 was noted to be in the dining room sitting at a table alone eating independently. Staff frequently stopped for conversation. In an observation and interview on 7/18/17 at 1:25 p.m., this surveyor entered Resident #8's room, after receiving an approval to observe care from staff and resident. Resident #8 was noted to be seated on the toilet with pants and brief around knees, in the bathroom with Certified Nurse Aid (CNA) M close by. CNA M was noted to have gait belt around her waist. CNA M advised Resident #8 to stand up after toileting and hold onto walker in front of the toilet. CNA M performed personal care and pulled up Resident #8's pants and brief without the use of the gait belt. CNA M placed the gait belt around Resident #8's waist after pulling pants up and ambulated Resident #8 from the bathroom to the recliner with the use of the gait belt and walker. Resident #8 did not appear steady on feet with ambulation. CNA M exited Resident #8's room and reported Resident #8 required one person assist with walker for transfers. CNA M reported she transferred Resident #8 from the dining room to her room to use bathroom in the wheelchair(wc) and transferred Resident #8 from wc to the toilet without the use of the gait belt. CNA M reported she ask Resident #8 to stand and hold onto the walker while CNA M pulled up pants then applied the gait belt because it is easier to do when residents standing. CNA M reported for meals Resident #8 requires one person assist to the dining room with assist of the walker and would sit in a regular chair. CNA M reported she would check the Kardex to verify current transfer status. CNA M reported that at the lunch meal that day CNA M transferred Resident #8 to the dining room in a wheelchair per the resident request but usually ambulates Resident #8 with one person assist with walker and usually uses regular chair in dining room. CNA M reported she had been employed with the facility for 18 months. In an interview on 7/18/17 at 2:20 p.m., this surveyor asked CNA B how she would know what resident transfer status was. CNA B replied she would check Kardex first. In an interview on 7/18/17 at 5:10 p.m., CNA E reported she had worked at facility for 2 years and had routinely worked on the closed unit. CNA E reported she worked the day of Resident #8's fall on 6/19/17. CNA E reported she was on atrium duty at the time of the fall and verified witness statement. CNA E reported she did not witness fall but reported Resident #8 was sitting in the main dining room table by wall (farthest from nurses station) in a regular chair. CNA E reported she had transferred Resident #8 from her room to the dining room with a one person assist with the use of a walker and the gait belt at about 3:30 p.m.-4:30 p.m. for dinner at about 5:00 p.m. CNA E reported the fall occurred after dinner when she heard loud noise while on atrium duty. CNA E reported she was watching 2 other residents at the time, and saw Resident. #8 on floor about 15-20 ft away from seat at the table on the floor bleeding from under eye with walker remaining by the seat at the table. CNA E reported Resident #8 would often get up without help and stated, She does what she wants to do. This surveyor asked CNA E, how do you know res transfer status? CNA E reported by asking Resident #8 or looking at the kardex. CNA E reported Resident #8's transfer status, at the time of the 6/19/17 fall, was ambulate with walker with one person assist including to the meals. CNA E reported Resident #8 usually ambulates with walker and one person assist but occasionally request to remain in wheelchair for transfers. In a telephone interview on 7/19/17 at 10:20 a.m., Registered Nurse (RN) Z reported she was worked on 6/16/17 when Resident #8 fell in the dining room. RN Z reported she did not witness the fall but heard a loud noise from the dining room while standing at the medication cart in the hall. RN Z reported Resident #8 had been sitting in the dining room in a regular chair at a table by the wall, farthest from the nurse station. RN Z reported after hearing the loud noise she entered the dining room and saw Resident #8 laying on the floor about 12 to 15 feet away from her table with blood on her face. RN Z reported Resident #8 had a 2-3 inch laceration under the left eye with a gold ball sized hematoma on the left cheekbone and a bloody nose. RN Z reported after Resident #8 was cared for she notified the second shift supervisor, doctor, family, and left a message for the Director of Nursing(DON) B and the Administrator A. In an interview on 7/19/17 at 3:00 p.m., DON B reported she had been notified of Resident #8 6/19/17 fall on 6/20/17. DON B reported after a fall she reviews the fall huddle sheet, care plans, toilet schedule, Emergency Reports, investigations, and medications. After reviewing Resident #8's care plans in place prior to the 6/19/17 fall DON B reported Resident #8's care plan indicated she was a one person assist for transfers. This surveyor asked if the Resident #8's Care Plan intervention that included, I WALK TO DINE FOR MEALS. I NEED 1PA, FWW AND W/C TO FOLLOW. PLEASE LEAVE ME IN MY W/C AT MEALS SO THAT I MAY LEAVE THE TABLE WHEN I AM READY, was in place prior to the 6/19/17 fall. DON B stated, Yes, I missed that. In an interview on 7/19/17 at 3:45 p.m. Unit Manager S reported she had received a call on 6/19/17 related to Resident #8's fall and notified the DON B and Administrator A. In a second interview on 7/19/17 at 4:10 p.m., DON B reported it was her expectation that CNA's follow the Kardex. DON B reported it was her expectation that if a Resident is a one person assist the staff are expected to use a gait belt prior to transferring a resident from surface to surface. In an interview on 7/19/17 at 4:12 p.m., Administrator(ADM) A reported she had been with the facility for 8 years. ADM A reported she was notified of Resident #8's fall and did not report to the state agency because they ruled out neglect. ADM A reported the staff followed Resident #8's Care Plans. After ADM A reviewed Resident #8's Care Plans prior to the 6/19/17 fall, ADM A reported she did not see the intervention that reflected, I WALK TO DINE FOR MEALS. I NEED 1PA, FWW AND W/C TO FOLLOW. PLEASE LEAVE ME IN MY W/C AT MEALS SO THAT I MAY LEAVE THE TABLE WHEN I AM READY. ADM A stated, If I would have been aware of the Care Plan not being followed I would have reported. The facility neglected to provide the resident with necessary care planned interventions. ADM A reported she did not report the fall to the state agency. In an interview on 7/19/17 at 4:40 p.m., CNA XX reported Resident #8 walks to dine to a regular chair unless Resident is weak and requests wheelchair. CNA XX reported the staff are expected to follow the Kardex. Based on section 483.5 of the State Operations Manual Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse .physical abuse, and mental abuse . Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The facility policy Abuse Program Resident rights, Dignity & Respect, dated 5/8/08 and reviewed 10/25/16, reflected It is the policy of (facility name) that mistreatment, neglect, and abuse of Residents .is strictly prohibited. (Facility name) shall adhere to the following procedures for screening and training CarePartners, protecting Residents, and prevention, identification, investigation, and reporting of abuse and neglect, mistreatment or misappropriation of property. (Facility name) Policy & Procedure is in accordance with State and Federal regulations for the prevention of Resident Abuse. Based on the Minimum Data Set (MDS) assessment, dated 6/12/17, Resident #4 was a [AGE] year old severely cognitively impaired female admitted to the facility on [DATE] who [DIAGNOSES REDACTED]. Resident #4's Brief Interview for Mental Status score on the above MDS was 1 out of 15 indicating severe cognitive impairment. Based on the above MDS Resident #4 was independently ambulatory with supervision and required staff assistance with bathing, dressing and toileting. Resident #4 was observed independently ambulating on her living unit on 7/17/17 at 12:20 PM and 7/19/17 at 11:30 AM. Based on review of Historical Incidents printed on 7/17/17 Resident #4 had the following six incidents of physical aggression toward other residents: 1) on 3/16/17 at 9:30 AM Resident #4 was walking in the hallway with supplemental Resident #33 and pulling on Resident #33's shirt. Resident #33 was getting upset and wanted to be left alone when a staff member intervened, Resident #4 pushed Resident #33 in the back as Resident #33 was walking away, 2) on 3/20/17 at 10:45 PM Resident #4 approached Resident #2 who was seated at a table in the dining room. Resident #4 was speaking pleasantly to Resident #2 and when Resident #2 turned his face toward Resident #4, Resident #4 slapped Resident #2 in the face., 3) on 3/23/17/at 6:30 PM in the unit common area (atrium) Resident #4 was observed hitting supplemental Resident #35 in the back of the neck with her elbow., 4) on 4/4/17 at 11:12 AM Resident #4 walked up to a female resident seated in a hallway chair and kicked the resident in the left shin. When staff asked her not to kick, Resident #4 stated she would kick the staff also., 5) on 4/8/17 at 3:47 PM Resident #4 was in supplemental Resident #34's room. Resident # 34 stated please get out and when the Certified Nursing Aide (CNA) held out a hand to Resident #4 to assist her out of the room Resident #4 punched the CNA's wrist, turned suddenly and punched Resident #34 in the chest before she could be coaxed out of the room., and 6) on 4/9/17 at 6:10 PM Resident #4 was walking past a female resident sitting peacefully in the dining room Resident #4 turned and slapped the female resident in the mouth. There was no evidence any of the above incidents were provoked by the residents who were hit by Resident #4. Based on what a reasonable person would experience, the above Residents would not have welcomed the physical aggression inflicted on them by Resident #4. Review of the physician orders [REDACTED].#4's unprovoked slapping of Resident #2. On 3/21/17 the [MEDICATION NAME] order was discontinued and the mood stabilizing medication [MEDICATION NAME] 125 mg twice daily was ordered by MD FF. On 7/19/17 at 9:15 AM Unit Manager (UM) Registered Nurse (RN) T stated the [MEDICATION NAME] was discontinued by MD FF at UM RN T's request to not use an antipsychotic medication as the first choice for treatment of [REDACTED]. On 3/24/17 after Resident #4 returned from the hospital emergency room evaluation where no medical conditions were found, MD FF added the prescription for [MEDICATION NAME] 25 mg twice daily and [MEDICATION NAME] (an antianxiety medication) cream 1 mg twice daily. On 3/27/17 the [MEDICATION NAME] dose was doubled to 50 mg twice daily. Social Worker BB requested a psychiatric review for Resident #4 on the same date. On 3/31/17 the [MEDICATION NAME] cream was changed to as needed twice daily by MD FF. On 4/5/17 MD FF, in collaboration with Psychiatric Nurse Practitioner (PNP) EE, doubled the [MEDICATION NAME] dose to 250 mg twice daily and decreased the [MEDICATION NAME] to 75 mg at bedtime. The care plan I am a new admission to the facility ., dated 3/15/17 and revised 3/29/17, reflected Resident #4 .may become physically and verbally abusive . The interventions identified were assessing regularly for pain (3/15), conversing and being near others (3/15), exit seeking after husband visits-redirect with music, food and friends (3/16), likes music and dancing (3/15), likes to be busy, will help set/clean tables, fold clothes-short attention span and will not sit for long (3/19) and grew up on a lake-loved fishing and sailing (3/20). The care plan for ADLs (activities of daily living), dated 3/15/17, reflected the following interventions; I get frustrated when other residents will not assist me to get home. If I .begin to get upset please intervene and attempt to redirect me. (3/16), has been known to verbally and physically lash out at others (3/29), I will physically lash out if I am touched without being able to see you. I have done this all of my life. Do not approach me from behind. Face me when you speak to me (4/4), and observe me when I approach others (4/6). The care plan related to activities, dated 3/17/17, reflected the Resident had a short attention span, liked exercise, music, dancing, playing ball, magazines and television, and wanted to be assisted to group activities. The above interventions were observed on the electronic Kardex used by the CNAs when giving care. On 7/19/17 at 9:15 AM UM RN T stated the unit staff were not involved in developing interventions for Resident #4's aggressive behaviors toward other residents on the unit. In addition, UM RN T stated the Behavior Management Team discussed medications Resident #4 was on to control her aggressive behaviors but did not discuss interventions the staff could take to protect Resident #4 and other residents on the unit when the Resident was physically aggressive toward them. Review of progress notes in the electronic medical record (EMR) reflected Resident #4 had hit, kicked or slapped staff on 3/20/17, 3/22/17, 3/23/17, 3/30/17, 4/1/17, 4/2/17, 4/4/17, 4/8/17 and 4/9/17. Social Worker BB documented in the EMR progress notes that Resident #4 could be impulsive on 3/16/17 at 11:28 AM, was pleasant and turned aggressive instantly on 3/27/17 at 3:03 PM, pleasant but increasingly anxious on 3/28/17 at 11:19 AM, forgetful, impulsive, anxious, easily agitated and can strike others with little provocation, fond of other male residents but has experienced conflict with others on 3/29/17 at 6:16 PM and agitated for delusions that no one would take her home on 4/9/17 at 7:14 PM. Interventions related to aggression toward other residents were added to Resident #4's care plan as follows; 1) after the 3/16/17 incident-I get frustrated when other residents will not assist me to get home. If I .begin to get upset please intervene and attempt to redirect me. (3/16), 2) after the 3/20/17 incident-none , 3) after the 3/23/17 incident-has been know to verbally and physically lash out at others (3/29). The intervention was not added until 6 days after the incident and did not direct staff on how to address this behavior to prevent verbal or physical abuse of other residents by Resident #4., 4) after the 4/4/17 incident-I will physically lash out if I am touched without being able to see you. I have done this all of my life. Do not approach me from behind. Face me when you speak to me (4/4) which did not relate to the kicking behavior of the incident, and observe me when I approach others (4/6). The intervention did not give specific guidance to staff related to what to do when Resident #4 approached other residents, 5) after the 4/8/17 incident-no new interventions. Resident #4 was sent to the hospital geriatric psychiatry unit for evaluation and treatment after the sixth incident on 4/9/17.

Based on observation, interview, and record review, the facility failed to provide supervision during a meal (Resident #5) and prevent falls (Resident #2, #8, & #22) for 4 of 16 residents reviewed for incidents/accidents, in a total sample of 28 residents, resulting in a burn with blisters (Resident #5) and fall related injuries (Resident #2, #8, #22). Findings include: On 7/17/17 at 12:30 PM Resident #5 was observed sitting in a wheelchair near the nurses station. Resident #5's most recent Minimum Data Set (MDS) 3.0 dated 5/1/17, introduced the Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents, score of 9 out of 15, indicating his cognition was moderately impaired (decisions poor; cues/supervision required). In review of the incident report titled # 3161 Choking dated 3/27/17 at 12:03 PM, Resident #5 was choking in the unit dining room, required the Heimlich maneuver, and a piece of hot dog was expelled . Speech Therapy Plan of Care dated 3/29/17 revealed Resident #5 was a [AGE] year old with a history of a stroke and swallowing difficulties since May 2016. The same plan of care document, under precautions, indicated to position at 90 degree angle during and 20 minutes after supervised oral intake, low endurance- needs frequent rests, slow processing and to discharge from speech therapy services with meal supervision in place. In review of Resident #5's alteration in nutritional status care plan dated 8/18/16, he required enteral feedings at the time of his admission and progressed with speech therapy to tolerate oral feedings. The same care plan revealed I require 1:1 supervision for all meals. Do not place my food in front of me until you are ready to sit down with me. In review of Resident #5's potential to become dehydrated care plan dated 8/18/16, staff were instructed to offer assistance with fluids as needed. Resident #5's Progress Notes dated 4/7/17 at 9:58 AM revealed resident observed raising arm in DR (dining room), CNA (certified nursing assistant) acknowledged resident, observing pant were wet, transferred resident into BR (bathroom), removed wet pant, observing reddened area to left thigh with line of blisters. Area cleansed and dried, cream applied, physician and guardian office notified. In review of the incident report titled # 3194 Injury of, dated 4/7/17 at 9:30 AM, Resident #5's injury following the incident was a burn to the front of his left thigh. The same incident report revealed Resident #5's pain level was assessed using a Pain Assessment in Advanced Dementia (PAINAD) Scale, and Resident #5's score was a 2 out of 5, with negative vocalization and tensed body language assessed at the time of the injury. The same incident report indicated the were no witnesses found and no statements were included in the report. 7/19/17 at 9:30 AM, Registered Nurse (RN) X stated Resident #5 was drinking coffee from a Styrofoam cup with a plastic lid prior to the coffee burn incident on 4/7/17. RN X stated during the same interview that staff had not realized Resident #5 had spilled coffee on his lap until he was assisted to the bathroom. RN X stated the staff thought his lap was wet because he had been incontinent. During an interview on 7/19/17 at 11:30 AM, CNA II stated Resident #5 had removed the lid from his coffee cup prior to the coffee burn incident on 4/7/17. 7/19/17 at 11:35 AM, CNA JJ stated she was sitting in the dining room at the far table facing everyone during breakfast assisting other residents on 4/7/17 when Resident #5 spilled his coffee. CNA JJ indicated during the same interview that there were no other staff sitting with Resident #5, assisting him with his breakfast meal on 4/7/17 and that she hadn't realized he had burned himself until she took him to the bathroom. CNA JJ stated during the same interview that Resident #5 had a history of [REDACTED]. 7/19/17 at 12:00 PM, RN X stated Resident #5's coffee burn incident on 4/7/17 occurred during the breakfast meal and that she must not have adjusted the time on the incident report to reflect the actual time of the event. Based on the Minimum Data Set (MDS) assessment, dated 1/10/17 and 4/3/17, Resident #2 was an [AGE] year old severely cognitively impaired male whose [DIAGNOSES REDACTED]. The Brief interview for Mental Status in the above MDSs reflected scores of 0 out 15 and 1 out of 15 respectively indicating severe cognitive impairment. The above MDSs reflected Resident #2 required the assistance of two staff for transfers, ambulation, toileting, bathing and eating. The above MDSs reflected Resident #2 was independent in his wheelchair with supervision and was frequently incontinent of urine and stool. Based on a telephone interview with Resident #2's responsible party UU on 7/18/17 at 4:50 PM, the resident had a history of [REDACTED]. Resident #2 was observed in his wheelchair with one to one staff supervision on 7/17/17 at 12:25 PM, 7/18/17 at 12:00 noon and 7/19/17 at 12:30 PM. On 7/17/17 at 12:25 PM Resident #2 was talkative and pleasant but responses were not related to questions asked. On 7/18/17 at 4:50 PM Resident #2's Responsible Party (RP) UU was interviewed by telephone. RP UU stated the facility was not addressing Resident #2's falls satisfactorily. RP UU stated the Resident was in a wheelchair and could stand a little but had no feeling in his legs. RP UU stated a seat belt had been repeatedly requested and pictures of several things like a lap buddy (fabric covered foam piece that goes in front of a seated resident and is attached between the arm rests to prevent unassisted rising) and various seat belts had been provided to Director of Nursing (DON) B and Medical Director (MD) VV during a care meeting. RP UU stated DON B and MD VV would not look at the pictures. RP UU stated you wear a seat belt in a car, why not in a wheelchair? RP UU stated one to one supervision had been requested several months ago and was denied by the facility. RP UU stated one to one supervision for 30 days was begun only after the 6/20/17 fall with a broken nose and Resident #2 had had no falls since then. RP UU stated the local Ombudsman HH had been involved with the concerns and had hit the same brick wall with the facility. On 7/18/17 at 1:08 PM Ombudsman HH was interviewed by telephone and stated she had been involved with Resident #2's RP UU's concerns since 2/2017. Ombudsman HH stated a chair that prevented the Resident from rising independently was suggested but the facility stated they had a no restraint policy. Ombudsman HH stated one to one supervision was requested and denied as the facility stated they did every 15 minute checks. Ombudsman HH stated she was unable to substantiate that every 15 minute checks were done as there was no documentation of the checks in the electronic medical record (EMR) or on paper. Ombudsman HH stated a tilt back wheelchair had been suggested along with suggestions from the Long Term Care Ombudsman's office such as a merry walker (an enclosed wheeled rectangular device with a seat that a resident can walk inside, usually made out of PVC pipe), a lap tray with activities on it while he was awake and orthotic knee supports to give staff time to get to him when he stood up. Ombudsman HH stated it was outside her scope of practice to say what was a restraint. The facility policy Evaluation of Falls/Fall Risk, dated 11/18/2011 and reviewed 6/2/17, reflected It is the policy (of) (facility name) to prevent or manage Resident falls and to identify the root case of the falls .Procedure: .12. The investigation shall include any co-existing symptoms, modifying factors, location, time and context .Falling has causes, and history of falls, especially in the preceding 90 days, is a strong indicator of future falls. If the cause is identified and corrected, this could reduce or eliminate falling .17. When care planning for the Resident, the care plan should reflect cause-specific interventions to prevent or minimize Resident fall risk, falls and complications from falls. Care plan interventions are to be progressive and person specific .If falling recurs despite the initial approach, then try other interventions unless you can explain nothing was relevant .22 Consider any possible reasons for falling besides those already identified until falls stop or markedly decline .There shall be a justification for a decision not to pursue additional interventions in Residents who continue to fall .23. The staff shall review falls and assess for trends and patterns such as particular time of day, location, medications or medication combinations . The facility incident reports reflected Resident #2 had 12 falls between 2/3/17-6/20/17 (falls prior to 2/3/17 had been reviewed during a previous survey). Eight of the falls occurred between 4:30-11:00 PM. Four of the falls occurred between 11:00 AM-2:00 PM with only one of the falls occurring before 1:45 PM. Review of the incident reports and Fall Huddle (a meeting, immediately after the fall, of staff present and/or caring for a resident at the time of the fall to review the circumstances of the fall and plan interventions to prevent further falls) documentation for the falls reflected the following: 1) on 2/3/17 at 6:15 PM Resident #2 was found on the floor in the hallway near his room. The resident sustained [REDACTED]. The Resident was not able to say what happened or what he was doing prior to being found on the floor. According to the Fall Huddle, dated 2/3/17, the Resident had been seen by staff at 5:30 PM in the dining room, 45 minutes before the fall. Resident #2 had a shoe on his right foot and a sock on the left foot, the wheelchair brakes were not locked and he had urinary or bowel urgency. The intervention added to care plan was to assist to use toilet after dinner. The Notes section of the incident report, written by UM T on 2/6/217 reflected .CP's (care plans) reviewed and intervention added to assist resident to bathroom after supper. Review of the care plan for Falls, dated 1/31/17 and revised on 7/16/17, reflected the intervention Assist me to toilet after dinner but before 1800 (6:00 PM) was added on 2/6/17, 3 days after the fall, and discontinued on 6/20/17., 2) on 2/15/17 at 1:52 PM Resident #2 attempted to stand from his wheelchair at 11:45 AM and fell on to his stomach in the dining room sustaining a small scratch near his left eye from his glasses breaking. I was going to the post office. The fall was witnessed by the unit secretary who could not reach the Resident before he fell . Based on the Fall Huddle, dated 2/15/17, staff had assisted him to sit down in his wheelchair just prior to witnessing him stand and fall during the lunch meal. On 2/20/17 the intervention If you see me attempting to stand, please intervene and ask me what I need assistance with. was added to the care plan for falls., 3) on 2/18/17 at 7:10 PM Resident #2 was observed on the floor in the dining room and had a skin tear on the right elbow and back of right hand. The Resident stated he was going home, up north. Resident #2 reported right hip pain and was sent to the emergency room for evaluation. No injury was found and the Resident was [DIAGNOSES REDACTED]. Based on the Fall Huddle, dated 2/18/17, the Resident was watching a movie in his wheelchair with shoes on and had been observed less than 30 seconds prior to the fall. The section were all Care Plan interventions followed? reflected the No box was checked and assist to bathroom after dinner was the response to the question If not, what was missing? The section When were they toileted last? was blank. The Resident was noted to be an extreme high fall risk. possible one on one in the How could this fall have been prevented section. On 2/21/17 the Notes section of the incident report by UM T reflected the same intervention as for the fall on 2/15/17. 4) on 3/12/17 at 1:37 PM Resident #2 was observed lying on his right side on the floor in the dining room where he had been observed seated eating a piece of pie five minutes before. No injuries were noted. The Resident was wearing gripper sox and said he was going to his truck. Based on the Fall Huddle dated 3/12/17, the Resident had been toileted at 12:00 noon and was going to talk with another resident so he stood up and started walking toward that resident. The box for following care plan interventions was blank and no additional interventions were recommended. On 3/13/17 the Notes by UM T on the incident report reflected the intervention Set me up with an activity after lunch such as painting a bird house or reading a men's magazine. The intervention was added to the care plan on 3/13/17., 5) on 3/24/17 at 4:50 PM Resident #2 was observed lying on his left side on the floor in the hallway next to his wheelchair approximately 50-60 feet from the dining/atrium area. The Resident stated he fell . The resident sustained [REDACTED]. The Resident's attending physician Medical Doctor (MD) FF assessed him and then requested an evaluation by the local hospital emergency room where all tests were negative for injury. The Fall Huddle dated 3/24/17, reflected the Resident had been observed 10 minutes before the fall, had shoes on, had been toileted at 1:06 PM (3 hours and 44 minutes before the fall) and that the care plan was followed. No new interventions were documented. Review of the care plan for activities of daily living (ADL), dated 1/31/15 and revised on 5/24/17, reflected the intervention Timed voiding Q (every) 3 hours was initiated on 2/23/17 and discontinued on 6/15/17. The care plan for toileting was not followed. On 3/30/17 the Note by UM T on the incident report reflected care plans reviewed and undated. The only intervention added to the falls care plan on 3/30/17 was If you see me entering other residents (sic) rooms please redirect me to common areas. The ADL care plan had the intervention Monitor and assist at meal (sic) added on 3/30/17. On 4/12/17 the intervention I am a Q 15 minute check. Eyes must be on me at least every 15 minutes was added to the falls care plan. 6) on 4/20/17 at 11:00 AM Resident #2 was observed on the floor of the unit dining room sustaining a bruise on the left shoulder and a skin tear on the right forearm. The Resident stated he was going to get the car from (female name) and stated tailbone, knee and back were sore. The nurse practitioner was notified and back X-rays were ordered which were negative for injury. Based on the Fall Huddle, dated 4/20/17, the Resident was at the dining room table drinking a soda after being toileted and was seen by staff 2 minutes before the fall. Based on the nursing progress notes at 7:05 PM the Resident was not able bear weight on his left leg during a transfer and complained of pain in his left thigh. An X-ray of the left femur on 4/21/17 at a private physician's office reflected satisfactory healing of a previous femur fracture and no new fractures. On 4/22/17 a bone scan was completed on the left hip. The facility was notified on 4/24/17 there were degenerative changes noted but no fractures identified and the Resident could resume weight bearing as tolerated with the left leg. A subsequent X-ray (date unknown) of the Resident's pelvis, left hip and knee reflected a non-displaced fracture of the suprapubic rami (pelvis)., 7) on 5/8/17 at 9:30 PM a Certified Nursing Aide (CNA) heard Resident #2 slide out of his wheelchair and say ouch. No injuries were found. The Resident stated he was trying to get ice for (female name). Based on the Fall Huddle, dated 5/8/17, a written statement reflected the CNA had asked the Resident to sit still and wait for her to help him approximately 2 minutes before he slid out of the chair. The same Fall Huddle form reflected 30 sec. (seconds) prior in the section When was the Resident last seen? It was unclear who saw the Resident at that time. The Resident was wearing non-slip socks and had been toileted at 8:44 PM. A therapy screen was requested and treatment was begun on 5/9/17., 8) on 5/13/17 at 2:15 PM Resident #2 was observed on the floor near the bathroom in another resident's room sustaining a skin tear on the back of his right hand The Resident stated he had to go to the bathroom. Based on the Falls Huddle, dated 5/13/17, Resident #2 had been transferred from his bed into his wheelchair minutes before the fall and was seen at 2:05 PM propelling his wheelchair. Nurses and CNAs were giving shift change report. Resident #2 was wearing non-slip socks, the wheelchair breaks were not in use and he had been toileted at 1:00 PM. Resident #2 was receiving physical therapy. The interventions At shift change please know my location on the unit and report any events from the previous shift and Assist me into a recliner if I am tired but do not wish to go to bed were added to the falls care plan on 5/13/17., 9) on 5/19/17 soon after 10:00 PM Resident #2 was observed by the on-coming nurse sliding out of his wheelchair onto the foot pedals of the wheelchair landing on his buttocks with a mechanical lift sling underneath him. The Resident stated he was trying to get the grey thing (sling). No injuries were observed. Based on the Falls Huddle, dated 5/19/17, the Resident was inside the nursing station with staff related to agitation and anxiety. The Resident had non-slip socks on, had been seen 4 minutes before the fall and had been toileted around 9:00 PM. The Pertinent information section reflected only 2 CNAs were scheduled on the unit and neither of the two were present for the fall. The Notes on the incident report by UM T on 5/24/17 reflected there were more than two CNAs on the unit as it was shift change. The intervention remove hoyer (lift) sling from under res (resident) while in w/chair (wheelchair) was added to the falls care plan on 5/19/17 and discontinued on 6/10/17., 10) on 5/25/17 at 6:30 PM Resident #2 was found sitting on his buttocks on the floor of the Atrium in front of his wheelchair next to a recliner chair. The Resident stated I had to get there. According to a visitor who witnessed the fall Resident #2 .started to stand up, then slid on his right side to the floor, he did not hit his head, he just slid. Based on the nursing note on the same date at 5:59 PM, Resident #2 was placed at the nursing station with the unit secretary for close observation after the fall. Review of the Fall Huddle, dated 5/25/17, reflected no written statements from the staff on duty. The nurse completing the form documented there were no injuries found and that the Resident had been seen by staff minutes before the fall. Resident #2 had been toileted at 2:21 PM and was wearing non-skid socks. There were two pages attached to the to Fall Huddle form. The first one was a hand written instruction to Please read (Resident's name) fall care plan. Sign & date that you have done so & understand. with the fall care plan attached. The page was signed by 7 staff members. The second page reflected the typed instruction While performing atrium duty it is essential that you remain in the atrium until someone is there to relieve you. This is essential in preventing falls and the ATRIUM should be your main focus. Other tasks should be delegated to your co-workers so you can focus on the atrium. Thank you! There was no documentation of where the staff member assigned to the Atrium was at the time of the fall. The Notes section of the incident report written by UM T on 5/30/17 reflected Resident #2 had been incontinent at the time of the fall, had been to an outside appointment most of the day and was ambulatory with physical therapy but did not understand he could not walk unassisted. The note also stated that after outside appointments Resident #2 often believed he needed to go back to work. The new intervention was to Please monitor me VERY closely on days I have outside Dr. appointments. Following these appointments I tend to be more exit seeking and anxious d/t (due/to) worrying about my family. Close monitoring will help ensure my safety. 11) on 5/29/17 at 4:30 PM Resident #2 was witnessed by a visitor sliding out of his wheelchair to the floor onto his buttocks in the dining room by the bird cage. No injuries were found. Review of the Fall Huddle, dated 5/29/17, reflected the Resident had been observed sitting in his wheelchair by the bird cage five minutes before the fall. A CNA was present in the atrium (adjacent to the atrium, both dining rooms are open to the atrium). The Resident was wearing non-skid socks and had been toileted at 3:00 PM. One side of the anti-rollback brakes on the wheelchair were not functioning and were fixed by maintenance. The Notes section of the incident report written by UM T on 6/1/17 reflected the video camera recorded Resident #2 standing up from his wheelchair and taking a few steps, the stepping backwards to sit in his wheelchair. The wheelchair rolled back and the Resident slid to the floor on his buttocks. Rear anti-tip devices were added to the wheelchair., 12) on 6/20/17 at 6:35 PM Resident #2 was observed face down in the doorway of room 102 sustaining a laceration and hematoma (blood pooling under the skin) to the left side of his face. Resident #2 stated Oh I don't know when asked what he was doing. Review of the Fall Huddle, dated 6/20/17, reflected the Resident had been seen two minutes before the fall in the atrium at the nursing station and had been toileted at 6:20 PM. Room 102 was approximately 50-60 feet from the nursing station. Resident #2 was wearing surgical shoes (flat hard soled shoe that does not bend with fabric top that either laces or has a Velcro closure) as he had had amputations of both great toes on 5/30/17. The surgical shoes would have made walking more difficult for the Resident as they do not bend like regular shoes. The Notes section of the incident report written by UM T on 6/23/17 reflected the above information and that the Resident had been transported to the emergency room by ambulance for treatment. Resident #2 was diagnosed with [REDACTED]. An anitbiotic was prescribed for the UTI and no treatment for [REDACTED]. Review of the care plan for falls, dated 1/31/15 and revised on 6/28/17, reflected Resident #2 was at risk for falls related to a history of falls, impaired balance, impulsive actions, weak knees, incontinence, behaviors, dementia and poor safety awareness. The care plan reflected the above interventions had been added to the care plan after each fall. The Kardex used by the staff when giving care reflected all of the above interventions. On 7/19/17 at 9:15 AM UM T was interviewed and stated Resident #2 was on the standard every two hour checks when he fell on [DATE], 2/15/17, 2/18/17, 3/12/17 and 3/24/17. UM T confirmed there had been no change in the frequency of supervision for Resident #2 in 2/2017 despite the Resident having three falls in a fifteen day period with the 2/18/17 fall requiring evaluation in the emergency room . No major injuries occurred with the February falls. Two more falls occurred on 3/12/1/7 and 3/24/17 (which required an emergency room evaluation), before every 15 minute checks were started on 4/12/17. UM T confirmed there had been a meeting with RP UU and his sibling, the attending physician FF, Social Worker (SW) BB, Ombudsman VV, UM T and DON B related to Resident #2's falls. UM T stated the RP UU wanted alarms put on the Resident and a seat belt, lap buddy/tray or a merry walker. DON B explained the items requested were restraints and the facility was restraint free. In addition, Physician FF explained Resident #2's medications. UM T stated RP UU and his sibling did not understand what a restraint was even after the discussion and said you wear a seat belt in a car, why not in a wheelchair? UM T stated the every fifteen minute checks were agreed to by Administrator A and DON B and presented to RP UU and his sibling. UM T confirmed there was no facility documentation of the every fifteen minute checks and stated she watched the video camera tapes for each fall that occurred in the halls, atrium or dining areas. ON 7/19/17 at 12:50 PM SW BB confirmed the care meeting above and the issues discussed. SW BB stated she had given RP UU an article related to the use and safety of wheelchair seat belts and effective strategies to use in place of a seat belt. SW BB stated RP UU felt put off by the responses of the facility and felt they were curt and not explained well. SW BB confirmed that the fifteen minute checks were not documented and stated she would have started the checks long before they were started on 4/12/17. On 7/19/17 at 1:50 PM Therapy Director CC stated Resident #2 had been seen by Occupational Therapy from 2/24/17-3/24/17 and by Physical Therapy from 5/9/17-6/8/17. Therapy Director CC stated a wheelchair seat tilted toward the back had been trialed for Resident #2 in the past and he was too strong for it to prevent rising. Therapy Director CC stated a high back wheelchair, geri chair (a wheeled reclining chair a resident can't propel on their own) and a recliner chair had also failed to prevent the Resident from rising unassisted. Therapy Director CC stated the use of a seat belt raised a concern that Resident #2 would stand with the seat belt on and bring the wheelchair on top of him when he fell causing more serious injury. On 7/19/17 at 2:00 PM Activity Aide (AA) DD stated there was an activity aide assigned to the unit from 8:30 AM-5:00 PM daily Monday-Friday and shared with the whole facility on the weekends. AA DD stated Resident #2 was always thinking there was something he should be doing. AA DD stated Resident #2 had a short attention span but did like woodworking and painting bird houses, especially if there was a purpose, i.e. for the children. AA DD stated the Resident also liked balloon ball, food preparation, dancing and sitting outside on the swing. AA DD stated the Resident was often harder to engage in activities after 4:00 PM. On 7/19/17 at 4:25 PM DON B stated RP UU brought up the use of restraints for Resident #2 and knew the facility was restraint free but still wanted a seat belt to be used. DON B stated RP UU did have pictures of some of the restraints he was suggesting. DON B stated she did not say anything to RP UU about the restraint but Medical Director VV told RP UU the Resident would stand up with the seat belt in place. DON B stated the facility had been restraint free for about one year. DON B stated fifteen minute checks would be documented if the order was fifteen minute checks but not if it was observe every fifteen minutes. The order reflected fifteen minute checks. DON B stated falls were reviewed at the morning management meeting and the facility had recently instituted the plan for the DON to be notified of all falls as there had been an increased number of falls in the facility. ON 7/19/17 at 3:30 PM Administrator A confirmed conversations with RP UU related to seat belt use and why it wasn't a good idea. Administrator A stated she had talked with RP UU in 2016 related to why alarms were not used in the facility and the research behind it. Administrator A stated it was clear what we were doing wasn't working and what RP UU wanted was not good related to Resident #2's falls. Administrator A stated Resident #2 was very strong and a restraint in the wheelchair would have been more dangerous when he stood up. Administrator A stated fifteen minute checks were started in 4/2017 then the one to one supervision on 6/20/17. Administrator A stated the fifteen minute checks should have been documented and didn't know why they were not documented unless someone was afraid they wouldn't be documented properly. Administrator A stated Ombudsman HH had been involved with the facility related to RP UU's concerns and had suggested every fifteen minute checks or one to one supervision. Administrator A stated she had told Ombudsman HH it would have been hard to do with the staffing available at the time. Administrator A stated the one to one supervision for Resident #2 would .be extended 30 days probably once and re-evaluated (at the end of the first 30 days). Resident (R) #22 was an [AGE] year old female admitted to the facility on [DATE]. The Electronic Medical Record (EMR) reflected R22's [DIAGNOSES REDACTED]. The most recent Quarterly Minimum Data Set (QMDS: resident assessment tool) completed on 6/5/17 reflected R22 had a Brief Interview for Mental Status (BIMS) score ranged between 00-07 severe cognitive impairment, she required supervision of 1 person to ambulate, and was occasionally incontinent of her bowel and bladder. On 7/19/17 at 1:32 PM R22 was observed in the dining room/TV room listening to a musician playing the guitar. R22 was observed to be cleanly groomed/clothed with a shirt, pants, shoes and a sweater on. She had a walker with tennis balls on the the back legs. Later the same day at 2:42 PM, R22 was observed participating in physical therapy. A brace was observed at her chest, extending slightly upward just under her neck, that was concealed under her shirt. During record review on 7/19/19 at around 10:30 AM, the health status note documented by Licensed Practical Nurse (LPN PP) on 6/17/17 at 5:15 AM reflected R22 was observed sitting in the middle of the room, before the bathroom entrance. When approached R22 stated, Trying to go to the bathroom. Neurological checks, vital signs, and a skin assessment were documented as being initiated. A hematoma was present the size of a palm, on the right side of R22's head which she referred to as painful. The on-call doctor was contacted, whom ordered R22 be sent to a local hospital for further evaluation. The Computed Tomography scan (CT) of R22's spine and head obtained from the hospital on [DATE] results reflected: Large subcutaneous hematoma over the right posterior parietal region. The CT of Lumbar-sacral spine reflected: Acute superior end plate compression fracture of the body of L2 (Lumbar Spine Vertebrae). The un-witnessed incident report dated 6/17/17 at 5:15 AM, was similar to the the health status note. Yet, it contained a fall huddle note. The fall huddle note reflected R22 was toileted at 1:40 AM but after reviewing the tape, the documentation was not correct, and a Nursing Assistant (NA) was suspended. On 7/19/19 at 2:31 PM Unit Manager Registered Nurse (UMRN T) was interviewed. She was queried about the incident report that occurred on 6/17/17. UMRN T revealed NA NN was the NA who cared for R22 that night, and had since been terminated. UMRN T was asked when had R22 been toileted prior to her fall. She replied, R22 was toileted at 1:40 AM, but that was incorrect. When asked what was incorrect UMRN T revealed, NA's are to touch the resident and touch the screen. After care the NA's are immediate

Based on observation, interview and record review the facility failed to monitor and treat elevated blood ammonia levels for 1 of 3 residents reviewed for medical monitoring (#31) and complete post fall neurological assessments for 1 of 4 residents reviewed for falls (#33) from a total sample of 4 residents resulting in delayed identification of elevated blood levels of ammonia for Resident #31 requiring hospitalization and the potential for a delay in identification of a post fall brain bleed leading to death for Resident #33. Findings include: Resident #31 Based on the Minimum Data Set (MDS) assessments, dated 11/21/16 and 1/6/17, Resident #31 was a [AGE] year old cognitively intact female whose [DIAGNOSES REDACTED]. Based on the Brief Interview for Mental Status (BIMS) in the above MDS Resident #31 scored 15/15 indicating she was cognitively intact. The above MDS reflected Resident #31 was to have staff assistance with bathing, dressing, toileting, transfers and ambulation and she was independent with wheelchair use. Review of the Medication Administration Records (MAR) from 5/1/2016-January 30, 2017 reflected Resident #31 was receiving [MEDICATION NAME] (a laxative and ammonia detoxicant) 30 ml (20 gm) in varying doses for constipation from 5/2016 to 6/27/16. Based on the MAR from 6/28/16-1/30/17 the [MEDICATION NAME] was being administered for elevated ammonia levels in the blood. When [MEDICAL CONDITION] decreases the ability of the liver to break down ammonia the ammonia levels build up in the blood causing mental confusion ([MEDICAL CONDITION]). Based on the manufacturer's recommendation in Specialized Long-Term Care Nursing Drug Handbook 2008, pages 550-551, when bacteria in the digestive system break down [MEDICATION NAME] an acid environment is created which inhibits the absorption of ammonia into the blood stream and pulls ammonia from the blood stream into the digestive system where is can be excreted in the stool. In the same reference the manufacturer states blood levels of ammonia should be monitored when treating a resident for liver [MEDICAL CONDITION]. The Nurse Practitioner (NP) progress notes, dated 6/17/16 and 6/28/16, reflected Resident #31 was receiving [MEDICATION NAME] related to elevated blood levels of ammonia. The ammonia levels were not mentioned again in the progress notes by physician C (7/24/16 and 9/12/16) or NP D (9/27/16 and 10/4/16) until Physician C's note on 10/12/16. On 10/12/16 Physician C's progress note reflected Resident has been taking [MEDICATION NAME] since 2015 for elevated ammonia level seen in the hospital. However she has not been reevaluated since then .Stop [MEDICATION NAME] .monitor labs without [MEDICATION NAME] . Review of the Physician Telephone Orders, dated 10/12/16, reflected D/C (discontinue) [MEDICATION NAME] .ammonia (level) on 10/25/16. There was no laboratory data related to the Resident's blood ammonia level at the time the [MEDICATION NAME] was discontinued. On 10/15/16 Physician C's progress note reflected no overt clinical change without [MEDICATION NAME] The clinical record reflected Resident #31 was admitted to the hospital 10/25/16-11/7/16 with [DIAGNOSES REDACTED]. Blood levels of ammonia obtained during the hospital stay reflected the following levels (normal range 11-35 UMOL/L); 1) 10/25/16-52 UMOL/L, 2) 10/27/16-56 UMOL/L, and 3) 10/31/16-30 UMOL/L. Resident #31 was discharged from the hospital on [DATE]. The hospital Discharge Summary, dated 11/7/16, did not reflected any [DIAGNOSES REDACTED]. The hospital Discharge Medication List, dated 11/7/16, did not contain any orders for [MEDICATION NAME]. Physician C initialed the medication list 11/7/16 and hand wrote Agreed for the MEDICATION ORDERS FOR [REDACTED]. No laboratory tests were ordered to monitor the Resident's blood ammonia levels. Progress notes from NP D, dated 11/8/16, 11/10/16, 11/15/16 and 11/29/16, did not reflect any mention of the Resident #31's [MEDICAL CONDITION] [DIAGNOSES REDACTED]. The 11/29/16 note did reflect liver function tests had been done (no date referenced) but an ammonia level was not included. Progress notes from Physician C, dated 11/9/16 and 12/2/16, did not reflect any mention of the Resident's [MEDICAL CONDITION] [DIAGNOSES REDACTED]. On 12/5/16 Resident #31 was transferred to the hospital related to mental status changes, shortness of breath and tremors. Blood levels of ammonia obtained during the hospital stay reflected the following levels (normal range 11-35 UMOL/L); 1) 12/5/16-107 UMOL/L at 2:20 AM, 2) 12/5/16-70 UMOL/L at 6:40 AM, 3) 12/6/16-66 UMOL/L, 4) 12/7/16-53 UMOL/L, 5) 12/8/16-53 UMOL/L and 6) 12/9/16-51 UMOL/L. Resident #31 was discharged from the hospital on [DATE]. The hospital Discharge Summary, dated 12/10/16, reflected [DIAGNOSES REDACTED]. The summary reflected Resident #31 was treated with [MEDICATION NAME] three times daily during the hospitalization . The hospital Discharge Medication List, dated 12/10/16, did not contain any orders for [MEDICATION NAME]. A hand written note on the Discharge Medication List for Resident #31 reflected All meds (medications) approved per (NP D's name) for the MEDICATION ORDERS FOR [REDACTED]. Physician C's progress note, dated 12/12/16, reflected Resident was hospitalized with altered mental status, found to have an elevated ammonia level again [MEDICATION NAME] dose was given aggressively for several days in the hospital and then backed off to maintenance dosing again, and her altered mental status completely resolved . The Treatment section of the same note reflected 1. Hyperammonemia Notes: Continue maintenance [MEDICATION NAME] and monitor Ammonia levels . The Current Medications section of the same progress note did not reflect [MEDICATION NAME] as a prescribed medication and no physician order for [REDACTED]. The Physician's Telephone Orders, dated 12/19/16, reflected a verbal order from NP D for an ammonia blood level on 12/20/16 for Resident #31 related to increased confusion. On 12/20/16 NP D's progress note reflected .Resident seen today due to an abnormal lab. Her serum ammonia level is 119 .Treatment .4. Others Notes: we will add [MEDICATION NAME] 30 ml (20 gm) p.o. (by mouth) every day for five days and recheck serum ammonia level on 12/26/16. The laboratory report, dated 12/20/16 at 8:05 AM, reflected the ammonia blood level was 113 UMOL/L (not 119 as documented in the progress note above). On 12/26/16 at 1:30 PM the laboratory report reflected Resident #31's ammonia level was 90 UMOL/L after six doses of [MEDICATION NAME] 20 gm. On 12/27/16 NP D's progress note reflected Treatment .4. Increased ammonia level Notes: The patient is not exhibiting any mental status changes. The elevated ammonia is probably secondary to the [MEDICATION NAME] that she takes for mood and behavior. Continue to monitor. If the patient has altered mental status, we will check a serum ammonia, but at this time there will be no more [MEDICATION NAME] to lower the ammonia level as long as she is not showing symptoms. The Current Medications section of the progress note did not reflect Resident #31 was prescribed [MEDICATION NAME]. On 1/2/17 Resident #31 was evaluated by NP D related to a fall on 12/31/16. NP D documented an elevated serum ammonia level of 81 UMOL/L (obtained on 12/31/16) and Treatment 4. Hyperammonemia Notes: The patient takes [MEDICATION NAME]. She does not have altered mental status; therefore, we will not continue to give her [MEDICATION NAME]. The Current Medications section of the progress note did not reflect Resident #31 was prescribed [MEDICATION NAME]. Review of the orders section of the electronic medical record (EMR) reflected [MEDICATION NAME] 10 GM/15 ML 30 ml by mouth in the morning had been ordered on [DATE] and was to be given daily with no stop date identified even though the Physician's Telephone Order form dated 12/20/16 reflected [MEDICATION NAME] 30 ml PO qd (daily) x (times) 5 days. Review of the MAR, dated 12/1/6-12/31/16, reflected [MEDICATION NAME] Solution 10 GM/15 ML Give 30 ml by mouth in the morning for ammonia levels. There was no stop date and the [MEDICATION NAME] was given daily from 12/21/16-12/31/16. On 1/5/17 NP D's progress note reflect resident #31 continued to have periods of confusion. An ammonia level was requested for 1/9/17 and the [MEDICATION NAME] was to be continued even though the 1/2/17 progress note stated it was not to be continued. The MAR, dated 1/1/17-1/31/17, reflected Resident #31 was receiving [MEDICATION NAME] 30 ml daily from 1/1/17-1/17/17. The laboratory report dated 1/6/17 at 12:02 PM reflected an increased ammonia level of 106 UMOL/L while receiving the daily dose of [MEDICATION NAME]. There was no evidence either Physician C or NP D evaluated this ammonia level. Physician C saw Resident #31 on 1/13/17 related to her Restless Leg Syndrome and did not address the increased ammonia level from 1/6/17. On 1/18/17 Physician C's progress note reflected .Due to worsening fatigue and suspected cognitive slowing, labs drawn and showed Ammonia level 116 .Treatment 1. Increased ammonia level Start [MEDICATION NAME] 20 GM, 1 packet, Orally, Once a day (again, Resident #31 was already on this dose) Notes: resume [MEDICATION NAME], repeat labs soon. However, the Physician's Telephone Order form dated the same day reflected the [MEDICATION NAME] was increased to 20 GM four times a day and an ammonia level was to be drawn on 1/20/17. The ammonia level of 116 UMOL/L documented above was ordered on [DATE] according to Physician's Telephone Order form and obtained on 1/17/17 at 7:45 AM (not 1/20/16 as ordered) according to the laboratory report. On 1/20/17 at 12:45 PM the laboratory report reflected an ammonia level of 70 UMOL/L and Physician C reduced the [MEDICATION NAME] to 20 GM twice daily. No orders were written for follow-up ammonia levels until 1/23/17 when the Physician's Telephone Order form reflected an order for [REDACTED]. The Physician's Telephone Order form on the same date at 12:30 PM reflected the [MEDICATION NAME] was to be increased to four times a day. On 1/30/1/7 at 12:30 PM the above information was reviewed with Registered Nurse (RN) Unit Manager (UM) E. RN UM E stated I don't know what the NP and Physician were thinking related to monitoring Resident #31's ammonia levels. RN UM E confirmed there was a lack of monitoring of ammonia levels for the Resident following her hospital stays in 11/2016 and 12/2016. RN UM E was not aware the [MEDICATION NAME] order dated 12/20/16 had not been transcribed correctly. Resident #33 Based on the Minimum Data Set assessments, dated 10/28/16, Resident #33 was a [AGE] year old severely cognitively impaired female whose [DIAGNOSES REDACTED]. Based on the Brief Interview for Mental Status in the above MDS Resident #33 scored 1/15 indicating she was severely cognitively impaired. The above MDS reflected Resident #33 was dependent on staff for eating, bathing, dressing, toileting, transfers and ambulation. Based on the Morse Fall Scale used by the facility to assess fall risk Resident #33 was a high risk for falls with a score of 55 on 10/21/16. A score of 45 and higher indicated high risk according to the scale. The only fall Resident #33 had in the facility was on 12/18/16. The care plan related to fall risk for Resident #33, dated 10/21/16, reflected the interventions of having the bed in the lowest position and wearing non-skid footwear when out of bed. The care plan related to activities of daily living, dated 10/21/16, reflected interventions of two person assist with toileting (10/25), transfers (10/25) and ambulation to the bathroom (12/7). Based on the MARs, dated 10/21/16-12/31/16, Resident #33 had received the anticoagulant (increases the amount of time it takes for blood to form a clot) [MEDICATION NAME] daily in varying doses since her admission for blood clot prevention. Anticoagulation creates an increased risk of bleeding from any tissue injury. Based on the [MEDICATION NAME]/[MEDICATION NAME]/INR Flowsheet the most recent laboratory analysis of the clotting time of Resident #33's blood in the facility was on 12/12/16 and reflected a therapeutic INR (International Normalized Ratio) of 2.0 on 5 mg of Coumdain daily. INR is the measure used to assess the affect of [MEDICATION NAME] on blood clotting with the therapeutic range for blood clot prevention identified as 2.0-3.0. Based on the hospital laboratory results on 12/18/16 at 8:44 AM the INR remained therapeutic at 2.69. The facility policy and procedure Neurological Checklist, revised 6/2016 and reviewed 11/11/16, reflected It is the policy of the facility that neuro (neurological) checks will be completed on Residents with every unwitnessed fall, witnessed fall that head was struck, and when [MEDICAL CONDITION](stroke) is suspected. PURPOSE: To assess Residents for early neurological changes and report to the medical provider. PROCEDURE: Assessment: 1. Vital Signs: Blood Pressure: assess for increase or decrease. Pulse: Slowing or increased rate. Respirations: Assess for changes. 2. Orientation: Place, person, date/time. Observe for change from baseline. 3. Eye Responses: Eye lid movement (opened spontaneously, only to verbal stimuli, only to painful stimuli or not at all). 4. Pupil Responses-Assess: Size, Reaction to light, Unilaterally (one side) dilated pupils. Note: Elders with prior eye diseases and some will have unequal pupils at baseline. 5. Hands-Right/Left: Assess if responses are the same. Note: Be aware of baseline to determine if there are any changes. 6. Arms-Right/Left: Check of (sic) responses are the same. Note: Be aware of baseline to determine if there are any changes. 7. Legs-Right/Left: Have Elder lift leg as you are pushing down. Check if responses are the same. Note: Be aware of baseline to determine if there are any changes. 8. Medical Provider and Family/Responsible Party must be notified with changes from baseline. Assessment Time Frames: Baseline: Completed at time of incident. And then every 15 minutes x (times) 4, 30 minutes x 2, every on hour x 2, Then every shift for 72 hours (3 days) . Based on the facility computer generated incident report, dated 12/18/16 at 3:22 AM and completed by Licensed Practical Nurse (LPN) F, Resident #33 was found on the floor at her bedside with her bed in the lowest position (approximately 12 inches from the top of the mattress to the floor). No external injuries were found and the Resident's range of motion of her arms and legs and level of consciousness were unchanged from her baseline. According to the report the fall was not witnessed and Resident #33 was not able to say what had happened. On 1/26/17 at 2:07 PM Certified Nursing Aide (CNA) G was interviewed by telephone. CNA G confirmed her written statement, dated 12/19/16, related to Resident #33 on 12/18/16 was accurate. CNA G stated she and CNA H had taken Resident #33 to her room at approximately 1:45-2:00 AM and performed incontinence care while the Resident was in bed. CNA G stated the Resident wanted to stay in bed so she was positioned on her right side with a pillow at her back and her paddle type call light (flat call light about 3.5 inches in diameter that is activated by minimal pressure) under her buttocks so it would be activated if the Resident attempted to get up. CNA G stated she then passed out linen to resident rooms on the unit and when she arrived at Resident #33's room about 15 minutes later the Resident was on the floor sitting up, awake and almost laughing. CNA stated she pulled the call light out of the wall (creating an emergency type signal) so the nurse would come to the room. CNA G stated she went to the door of the room, saw CNA H in the hallway and told her to get the nurse. CNA G stated LPN I and CNA H came to the room and after LPN I assessed Resident #33 the three staff assisted the Resident into her wheelchair and brought her into the atrium (common area by the nursing station, dining room and activity room) where she remained for the rest of the shift. On 1/26/17 at 10:22 AM LPN I was interviewed by telephone and stated on 12/18/16 at approximately 2:00-2:30 AM she observed Resident #33 on the floor sitting straight up with her back to the bed and legs straight out in front of her. LPN I stated the Resident was unable to state what had happened. LPN I stated she checked the range of motion of all the Resident's limbs, examined her head both visually and by touching it all over, obtained vitals signs and completed a neurological check before bringing Resident #33 out to the atrium area in her wheelchair for the remainder of the shift. LPN I stated no obvious injuries were found. Review of the Neurological Checklist for Resident #33, dated 12/18/16, reflected vital signs, orientation, eye response, pupil response, hand, arm and leg movement were documented as assessed at 2:45 AM (LPN I), 3:00 AM (LPN F), 3:15 AM (LPN F), 3:30 AM (LPN F), 3:45 AM (LPN F) and 4:15 AM (LPN I). Only vital signs, orientation and eye response were documented at 4:45 AM, 5:15 AM and 6:15 AM. The 4:45 AM, 5:15 AM and 6:15 AM entries were all unsigned, however, LPN I confirmed she had documented the data during an interview on 1/30/17 at 3:00 PM. Review of the video recording without audio of Resident #33's hallway on 12/18/16 reflected LPN I walked toward the Resident's room with the vital signs machine at 2:20 AM. Review of the video recording without audio of the atrium on 12/18/16 between 2:20-6:23 AM reflected Resident #33 was brought into the atrium in a wheelchair at 2:24 AM by CNA H followed by LPN I. LPN I obtained vital signs, completed a pupil check with a flashlight and observed the Resident #33 moving both arms but did not have the Resident try to raise her legs while the nurse was pushing down on them. There was no documentation on the Neurological Checklist or the nursing progress notes for the observed assessment at 2:27 AM. The first documentation time on the Neurological Checklist was 2:45 AM, however, no assessment of any kind was observed between 2:34-2:57 AM. At 2:57 AM LPN I talked to Resident #33 and picked up the blanket to look at her legs. No vital signs or assessments were observed being completed even though there was documentation on the Neurological Checklist at 3:00 AM. At 3:13 AM LPN F was observed obtaining vital signs and completing a pupil check. No assessment of the leg function against resistance was observed even though it was documented on the Neurological Checklist by LPN F. At 3:35 AM and 3:49 AM LPN F was observed obtaining Resident #33's vital signs but no pupil check was done with a flashlight nor was there an assessment of the leg function against resistance even though it was documented by LPN F at 3:30 AM and 3:45 AM. At 4:20 AM LPN I was observed taking vitals signs only even though a complete assessment was documented on the Neurological Checklist at 4:15 AM. Vital signs, orientation and eye response were documented on the Neurological Checklist at 4:45 AM, however the only observed contact with the Resident by LPN I was at 4:43 AM when the Resident was given something in a small cup to swallow followed by a drink out of a larger cup. The MAR indicated [REDACTED]. There was no observed neurological assessment at 5:15 AM despite vital signs, orientation and eye responses being documented by LPN F. There was no neurological assessment observed or documented on the Neurological Checklist at 5:45 AM (the time the first of the every hour checks should have been done). The video recording reflected that after LPN I gave Resident #33 something orally at 4:43 AM no formal assessment of the Resident was completed by any nurse until 6:17 AM. Based on the observations above Resident #33 did not have a thorough neurological assessment at any time from 2:24-6:23 AM. There was no visual evidence to identify if there were any signs of neurological changes such as pupil response/size, slurred speech, loss of speech, changes in gaze (only looking in one direction), rapid eye movement back and forth ([DIAGNOSES REDACTED]), ability to follow commands or headache before Resident #33 was unresponsive at 6:17 AM. The video recording was reviewed with Interim Director of Nursing (IDON) B and RN UM N on 1/26/17 at 4:00 PM. IDON B stated she had not seen the video recording prior to 1/26/17 as she had not been involved in the facility investigation. RN UM N stated she had watched the video and created the written time line but had been looking at Resident #33 not whether the documented neurological assessments matched the video recording. IDON B stated the neurological assessment should include vital signs and pupil checks with a light source. Both IDON B and RN UM N confirmed neurological assessments were not completed and the documentation did not match the observations on the video recording as stated in the above paragraph. During a private interview on 1/30/17 at 1:55 PM LPN F stated she was the charge nurse for the facility for the 10:00 PM-6:30 AM shift on 12/17/16-12/18/16 and was the nurse on Unit 2 (next to Unit 1 where Resident #33 resided) when LPN I called for help with vital signs and neurological assessments for Resident #33. LPN F stated I did the 3:00 AM check in the atrium, I'm not sure why it wasn't seen (on the video). LPN F stated she checked Resident #33's eyes to see if she was tracking (following an object with the eyes as it is moved around) and looked at her pupils but didn't use the flashlight to check pupil reaction as she was supposed to. LPN F stated Resident #33 was talking and stated oooh, that's cold when the blood pressure cuff was put on her arm. LPN F stated she had asked CNA G if Resident #33 was acting as she usually did and CNA G told LPN F the Resident was. LPN F could not explain how pupil responses and arm and leg responses against resistance were documented at 3:00 AM, 3:15 AM, 3:45 AM and 4:15 AM when there was no evidence on the video recording that they had been completed. LPN F stated she had not viewed the video recording of 12/18/16. During a private interview on 1/30/17 at 3:00 PM LPN I stated the 2:45 AM documentation on the Neurological Checklist was the information obtained during the initial assessment of Resident #33 completed in her room but could not explain why the assessment observed on the video at 2:27 AM was not documented. LPN I could not explain where the data for the 3:00 AM documentation was obtained when there was no observed assessment on the video between 2:27-3:13 AM. LPN I stated neurological assessments included checking pupils for reaction to light with a flashlight. LPN I stated that if she hadn't used the flashlight it was because Resident #33 wasn't acting any different and usually if the pupils change the resident would be acting differently. LPN I initially stated she had missed completing the 4:45 AM and 5:45 AM assessments then said she thought she had written them on a different piece of paper and couldn't find it. LPN I stated she had not viewed the video recording of 12/18/16. Review of the video recording without audio of the atrium on 12/18/16 between 2:20-6:23 AM reflected Resident #33 was brought into the atrium in a wheelchair at 2:24 AM by CNA H. Resident #33 was observed looking around, moving both arms, moving both legs at times, repositioning herself in the wheelchair, watching the television monitor, removing the blanket on her lap and reaching down toward the wheelchair foot pedals until 5:25 AM. Between 5:25-5:37 AM Resident #33 was alternating between bending forward with her head down over her knees and sitting up straight. Between 5:37-5:45 AM Resident #33 was seated in the wheelchair with her body turned toward her left side and her left buttock toward the front edge of the seat while her head was resting on the back of the wheelchair near the hand grip. At 5:53 AM Resident #33 slowly bent forward then sat up and leaned her head on the back of the chair again. At 6:00 AM Resident #33 readjusted herself sitting straight up and moving both arms. At 6:05 AM the Resident supported her head with her left hand while sitting up and at 6:14 AM she readjusted herself slightly. At 6:15 AM Resident #33 slumped into the chair on her left side with her head resting on the back of the chair. At 6:16 AM the Resident moved her left arm twice. At 6:17 AM Resident #33 was not moving and CNAs G and H were observed repositioning Resident #33 in the wheelchair and calling LPNs I and J to see the Resident. Resident #33's vital signs are taken at 6:19 AM (documented at 6:15 AM) and at 6:20 AM RN K arrived to assess the Resident. At 6:23 AM Resident #33 was taken out of the atrium by CNA G and RN K. Between 2:24-5:10 AM CNAs G and H were observed sitting with Resident #33 for up to 15 minutes at a time on multiple occasions. Between 5:10-6:10 AM Resident #33 remained in the atrium with staff passing by periodically as they performed their end of shift duties for other residents on the unit. At 6:04 AM CNA H covered Resident #33 with a blanket. On 1/26/17 at 12:34 PM CNA H was interviewed by telephone. CNA H stated that on 12/18/16 Resident #33 had remained in her wheelchair in the Unit 1 atrium from approximately 2:30-6:30 AM after she was found on the floor in her room. CNA H stated Resident #33 was acting like her normal self when she last saw her about 5:00 AM when CNA H began morning care for other unit residents. CNA H stated that she reposition Resident #33 in her wheelchair with CNA G at about 6:20 AM and noticed the Resident was pale, felt clammy, had drool on the left side of her face and was slumped down in her chair. CNA's written statement, dated 12/18/16, reflected Resident #33's pulse felt weak to CNA H, she had left facial drooping and her face was cold to touch. CNA H stated LPNs I and J were notified immediately. On 1/26/17 at 2:07 PM CNA Gstated that on 12/18/16 Resident #33 had remained in her wheelchair in the Unit 1 atrium from approximately 2:30-6:30 AM after she was found on the floor in her room. CNA H stated Resident #33 was acting like her normal self when she last saw her about 5:10 AM when CNA G began morning care for other unit residents. CNA G stated CNA H saw something was wrong with Resident #33 at shift change (6:00-6:30 AM) and called LPNs I and J to the Resident's side immediately. CNA G stated she and LPNs I and J assisted Resident #33 to bed. CNA G stated the Resident was lethargic, pale and opened her eyes then got sweaty later. CNA G stated oxygen was put on the Resident, neurological assessments were done by the nurses and she stayed at the Resident's bedside until the ambulance EMTs (Emergency Medical Technicians) came at about 7:30-7:45 AM. On 1/26/17 at 10:49 AM LPN J was interviewed by telephone and confirmed the information in her written statement, undated, related to Resident #33 on 12/18/16 was accurate. The written statement reflected LPN J was getting morning report from LPN I at 6:15 AM when one of the third shift CNAs said there was something wrong with Resident #33. LPN J stated Resident #33 was slouched down in her chair, tilted to the left side with the left side of her face drooping, not responding to verbal or physical stimulation and had drool coming from her mouth. LPN J stated the Resident's oxygen saturation (oxygen content of the blood, normal range equal to or more than 90%) was 88% so oxygen was put on at 2L/min. LPN J stated Resident #33 was then put in bed. LPN J stated that when the EMTs arrived Resident #33 had labored breathing, flushed (reddish) skin and her pupils were fully constricted (pin point). LPN J stated she notified the physician who ordered the Resident to be sent to the hospital for evaluation. On 1/26/17 at 10:49 AM LPN I was interviewed by telephone and confirmed the information in her written statement, undated, related to Resident #33 on 12/18/16 was accurate. The written statement reflected a CNA had noticed Resident #33 slumped in her wheelchair with her eyes closed during shift change between 6:00-6:30 AM on 12/18/16. LPN I stated she and LPN J checked the Resident's vital signs and were not able to get her to respond to touch or verbal stimuli so the Resident was laid in bed and oxygen was started. The interview reflected that during the same time frame Resident #33 was leaning to her left and drooling. The EMT Billing Review reflected they arrived at 7:30 AM on 12/18/16 and left for the hospital at 7:58 AM. The EMT assessment reflected Resident #33 was unresponsive, drooling, her skin was flushed, she had snoring respirations with clear breath sounds and her oxygen saturation was 99% on 2 L/min of oxygen, her pupils were pin point and her Glascow Coma Score (GCS) was 5 out of a possible 15, indicating severe neurological impairment. The Billing Review reflected Resident #33 was given the narcotic reversal medication [MEDICATION NAME] by nose spray with no change in her alertness. According to the [MEDICAL CONDITION] Alliance of Utah, https://biau.org, the GCS is used to assess [MEDICAL CONDITION]. The scale assesses the best responses for eye opening, verbal response and motor response (movement of arms and legs). The minimum score is three and the maximum score is fifteen. Scores between 3-8 usually indicate a coma state and a poor chance of recovery. Based on the hospital Emergency Department Chart Resident #33 arrived a 8:07 AM. The initial assessment reflected her pupils to be dilated to 3 (1-5 scale for size) with minimal to sluggish reaction on the right and no reaction on the left, snoring respirations and a GCS of 7 (severe impairment). The Emergency Department (ED) physician Progress Notes dictated by Physician L reflected there was no obvious head trauma but a significant brain bleed was suspected. The CT scan without contrast, dated 12/18/16 at 9:40 AM, impression section reflected 1. Large left-sided acute (new) and subacute (old) subdural (between the brain and the lining of the brain (dura)) hemorrhages (bleeding), measured up to 2.8 cm (approx 1/2 inch) in width and extending along the entire left cerebral hemisphere (left side of the brain) with shift of midline (dividing line between the right and left sides of the brain) to the right measuring 1.3 cm (3/16 inch). There is marked left cerebral mass effect and uncal (pressure on the inner part of the temporal or side lobe moves it downward and puts pressure on the brainstem) herniation as described above. 2. No acute intra-axil (inside the brain) hemorrhage or evidence of acute infarct (loss of circulation related to blocked blood flow). The above progress note reflected .We're attempting to contact the family to arrange goals of care as this is a grave injury . The subacute subdural bleed identified above indicated a previous injury and may have been related to the Residents fall at home on 10/11/16. In addition, X-ray results of the hip/pelvic region on the same date reflected new nondisplaced fractures of the right upper pelvic ramus (front of pelvis) and the top of the left femur (thigh bone). Healing of the previous fracture (10/19/16) of the right femur was also noted. According to t

Based on observation, interview and record review the facility failed to maintain a hazard free environment for 1 resident (#2) of 9 residents reviewed for falls and accidents hazards from a total sample of 29 residents. Resulting in a fractured left humerus and sutures placed in the left ear and left brow. Findings include: Throughout the survey of 6/16/2015 to 6/19/2015 the facility dining room was observed to be utilized as a dining room, activity room and lounge and television area. According to the facility admission record dated 7/02/2014, Resident #2 was a [AGE] year old female admitted to the facility 6/16/2014 with [DIAGNOSES REDACTED]. A facility incident report dated 1/15/2015 reflected Resident #2 fell on [DATE] left foot got caught on the transition strip while entering the dining room. The incident report further reported Resident #2 was bleeding on facial area and transferred to the hospital. The physician progress notes [REDACTED].#2 sustained a left displaced proximal humeral fracture and had 2 sutures in left brow and 2 sutures in left ear. The root cause identified on the facility incident report was identified as a new vinyl flooring and been installed in the dining room on 1/14/2015 (from an outside contractor with the oversight from the facility Maintenance Director H) over the existing floor thus altering the height of the transition strip which caused Resident #2 to trip and fall over it. A review of the facility investigation dated 1/15/2015 revealed there was 1 witness to Resident #2's fall. Certified Nursing Assistant (CNA) I . CNA I written witness statement revealed on 1/15/2015 at approximately 8:00 a.m., she observed Resident #2. Resident tripped over the dividing piece for the carpet and wood floor. On 6/17/2015 at 11:00 a.m. during an interview with CNA I she reported that she observed Resident #2 ambulate with a cane per her care plan and was entering the dining room on 1/15/2015 at 8:00 a.m., I saw her trip over that piece of strip on the floor that divides the carpet to the wood. On 6/17/2015 at 11:30 a.m., during an interview with Resident #2's permanently assigned CNA J she reported she too witnessed the fall. I was right there, she fell forward over the strip on the floor. On 6/17/2015 at 11:45 a.m., during an interview with the Maintenance Director H he reported that after Resident #2 fell he was called upon to inspect the flooring. Maintenance Director H reported it was not a height difference as reported in the facility incident report. Staff H stated, The contractor that was here the day before, used the old strip and did not secure it to the floor, it was loose. I watched the video of the fall, there was just enough room where her foot got caught. Maintenance Director H further stated that he left facility on 1/14/2015 prior to the contractor finishing the flooring. It would have been better to have nothing there instead of the old strip, since it wasn't even secured. On 6/18/2015 at 10:45 a.m., during an interview with the Maintenance Director H he reported there was no work order for the strip to be repaired. I don't think you could see it wasn't secured until you really looked at it. On the morning of 6/18/2015 during an interview with the Director of Nursing (DON)B she reported that the dining rooms are used throughout the day and evening for meals, activities and a lounge area. When DON B was queried about the transition strip not being secured to the floor she reported Maintenance Director H would know more about it than she would. ( )

This citation pertains to MI 202 and MI 232 Based on observation, interview and record review the facility failed to use a gait-belt for 2 of 2 residents reviewed for falls (#5 and #8) out of 9 sampled residents, resulting in a fall with fracture (#5) and a fall with the potential for repeated fall/injury (#8). Findings include: Resident #5 was an [AGE] year old female resident, originally admitted to the facility on [DATE]. The January 2014 physician's orders [REDACTED]. In addition, the physician's orders [REDACTED]. According to the 2007 Drug Information Handbook for Nursing reflected that adverse reactions for Zestril included: hypotension, headache, nausea, and weakness; Tenormin included: bradycardia, hypotension, edema, heart failure, fatigue, confusion, mental impairment, and dizziness; Lasix included: orthostatic hypotension, dizziness, lightheadedness, headache, and acute hypotension. The facility's "Unusual Occurrence Report" dated 1/1/14 at 12:00 a.m. reflected Resident #5 fell by dropping to her knees, resulting in significant injury and bruising. The "Nurse's Record" dated 1/1/14 at 12:00 p.m. reflected the doctor was notified, and ordered the resident to be sent to the local hospital's emergency room . The local hospital record dated 1/1/14 at 12:52 p.m. under Progress Notes reflected "...Patient is concerned of knee pain after missing her bed while attempting to adjust herself in bed. She fell to her left knee she has pain to her left knee she denies loss of consciousness she denies hitting her head. She is on Coumadin here with pain x-ray showed evidence of a fracture of the distal femur..." The imaging services report reflected the following left knee (2 views) x-ray impression: 1. Acute displaced distal femoral fracture, just proximal to prosthetic femoral component as described. 2. Nondisplaced fracture left fibular neck. Upon record review it was discovered in the "Facility Investigation Report-5 Working Days", that "...Cena (nursing assistant) stated she did have her gait belt with her but it would not fit this resident due to her large abdominal girth..." On 1/23/14 at 2:19 p.m. the Restorative CNA (nursing assistant) ("I") revealed that Resident #5 received restorative services at least 3 times a week (when she was up to it, which was almost always for walking). Staff I was asked how she ambulated Resident #5 while providing care. Staff I stated she would put a walker in front of Resident #5, put the gait belt on her, lift the gait belt from the back to assist her up and follow her while she used her walker. Staff I was asked what gait belt size she used. Staff I revealed that, she had a standard sized gait belt with a clip on it for Resident #5 and never used a real large one on her. However, after the fall she did obtain a larger sized gait belt for her. Staff I revealed she had obtained a larger gait belt for Resident #5 since her discharge to the hospital. During an interview with NA ("G") on 1/24/14 at 8:00 a.m., Staff G revealed that on the day of the incident Resident #5 was upset and aggravated. Staff G stated she thought Resident #5 may have had an urinary tract infection. Staff G revealed that when Resident #5 came out of the rest room with her walker she stayed by Resident #5, and adjusted her bedding/pad before she got to the bed. Upon Resident #5 coming to the bed, she dropped to the floor on her knees. Staff G revealed she did not use the gait belt for Resident #5, but did have it with her. The gait belt she had was standard sized, but that Resident #5 was a large lady. Staff G revealed she had cared for Resident #5 for 3 years. Yet, Staff G did not state she tried to obtain a larger gait belt for transfer, informed facility staff of the need for a larger gait belt, nor did nursing notes reflect Staff G had requested a larger gait belt. Prior to transferring Resident #5 Staff G revealed she had referred to the care guide, which was in a book at the nurses station. Staff G stated, "...The care guide listed she was a stand by assist (SBA) with gait-belt to ambulate..." On 1/24/14 at 2:13 p.m. the acting Nurse Manager ("B") revealed she was not present when the incident occurred. She was aware that Resident #5 was sent to the emergency room , and the facility had obtained an extra large gait upon Resident #5's return. Lastly, Staff B revealed that Staff I stated the gait belt she used for Resident #5 was OK. Resident #5's "Falls" care plan updated 6/29/13 reflected the following approaches: -"... Approach Start Date: 04/09/2013 Provide the following assistance for ambulation: 1 person w/ (with)walker. SBA Gait belt. Approach Start Date: 04/09/2013 Provide the following assistive device for me for all transfers: 1 person w/ walker. SBA Gait belt..." The "Individual Plan Report" used by nursing assistants obtained from Cozy Corners on 1/24/14 around 12:15 p.m. reflected, "...I need sba and a gait belt for ambulation..." The facility's "Evaluation of Falls/Fall Risk" policy and procedure dated 11/18/11 reflected under #14. "Residents gait and balance, as well as mobility devices shall be examined to determine structural soundness and appropriateness..." The "Body Mechanics" policy and procedure dated 12/12 reflected for #2. "...Plan the transfer before attempting to move the resident...Apply gait belt and if you choose apply back brace to yourself..." Resident #5's most recent fall evaluation dated 12/18/13 reflected a score of 13 (10 or higher =fall risk), Resident #5 was at risk for falls related to adverse reactions associated with the above medications, and the quarterly Minimum Data Set (MDS) reflected Resident #5 required extensive assist by one person for transfers, and limited assistance of one person for ambulating in her room. The facility had knowledge of Resident #5 risks for falls, and approached developed to care for the resident but failed to implement them. ( ) Resident #8 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #8 was a [AGE] year old female, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed Resident #8 scored 6/15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS), transferred and walked in the corridor with supervision and 1 person physical assist, did not use any mobility devices, and was steady at all times while walking. Review of Resident #8's Activities of Daily Living (ADLs) care plan dated 10/11/13, revealed interventions that included: 1) Provide SBA (stand by assist) for transfers with gait belt (initiated 10/14/13), 2) Provide 1 person assist with ambulation, use gait belt and walker with w/c (wheelchair) to follow (initiated 10/11/13). Review of Resident #8's Falls care plan dated 10/11/13, revealed interventions that included: 1) provide SBA with gait belt for transfers (initiated 10/14/13), 2) provide 1 person assist with walker for ambulation using gait belt and w/c to follow (initiated 10/11/13), 3) provide motion alarm at all times except when ambulating (initiated 12/23/13). Review of the Fall Risk Evaluation dated 11/12/13, revealed Resident #8 scored 28. A resident who scores a 10 or higher is at risk for falls. Review of Resident #8's Bedside Kardex Report (Certified Nursing Assistant care guide) printed 1/17/13 and was located in her room on the inside of her dresser door, listed all of the following: "Mobility: ADL-Locomotion off unit wheelchair for long distances ADL-locomotion on unit-w/c or ambulate with SBA ADL-walk in corridor 1 person assist ADL-walk in room-SBA I use w/c for long distances, assist me as needed provide 1 P (person) assist with ambulation, use gait belt and walker with w/c to follow... Transferring" ADL-Transferring SBA and provide 1 P assist for transfers with gait belt". There was not a specific date for each intervention. Review of the Unusual Occurrence Report dated 12/19/13 at 10:30 am, revealed "nurse (Licensed Practical Nurse "C") witnessed resident (Resident #8) stumbling backwards while amb (ambulating) and resident fell on floor hitting head". In an interview on 1/22/14 at 3:05 pm, Certified Nursing Assistant (CNA) "D" reported that Resident #8 did not require any assistance with ambulation and she "walked completely by herself". CNA "D" reported that sometimes she held Resident #8's hand when she walked. When queried if Resident #8 required a gait belt for ambulation, CNA "D" stated "not that I have noticed". CNA "D" reported that on 12/19/13, before Resident #8 fell , Resident #8 was sitting in the atrium. CNA "D" reported that she was in another resident's room during the fall. In an interview on 1/22/14 at 2:00 pm, Licensed Practical Nurse (LPN) "C" reported that Resident #8 was independent with transfers and ambulation and that the information would be on the care plans. LPN "C" reported that on 12/19/13, Resident #8 was either sitting in the atrium and got up to come to the nurse's station or had come down the hallway towards the nurse's station. LPN "C" reported that she was behind the nurse's station with the unit manager. LPN "C" stated "I saw her take a couple steps, staggered, and fell backwards" and that she could not get to Resident #8 fast enough. When queried when she first saw Resident #8 approaching the nurse's station, LPN "C" reported that Resident #8 was approximately 10 to 15 feet away from the nurse's station. When queried if she would have done anything differently had she known Resident #8 was a 1 person assist with a gait belt for ambulation, LPN "C" stated "If I had seen her sooner, I would have got up and walked with her or got someone. I wouldn't have let her walk by herself". LPN "C" seemed shocked, stating "Really?", when this surveyor told her that Resident #8's care plan revealed she was a 1 person assist with a gait belt for ambulation. Review of Resident #8's Physician's Telephone Orders dated 12/30/13, revealed "change motion alarm schedule to motion alarm at all times except when ambulating". An observation on 1/22/14 at 9:20 am, revealed Resident #8 ambulating near the nurses station. There was a staff member near her, but no gait belt or walker in use. An observation on 1/23/14 at 9:25 am, revealed Resident #8 was sitting in the chair across from the nurse's station. There was not a motion alarm in place and staff was not near her the whole time. In an interview on 1/22/14 at 2:35 pm, Nursing Supervisor (NS) "E" reported that Resident #8 was a 1 person assist with a gait belt for ambulation. In a second interview on 1/23/14 at 9:35 am, NS "E" reported that Resident #8 should have had her motion alarm in place while sitting in the chair across from the nurse's station. NS "E" reported that the Bedside Kardex was confusing and it seemed as though the CNAs were getting mixed information with all of the different ambulation statuses. An observation on 1/23/14 at 9:45 am, revealed a staff member placed a motion sensor near Resident #8 while she was sitting in the chair. An observation on 1/23/14 at 2:15 pm, revealed Resident #8 was ambulating in the hall with Restorative Aide (RA) "F". Resident #8 did not have a gait belt in place. RA "F" reported that Resident #8 refused the gait belt. An observation on 1/24/14 at 9:05 am, revealed Resident #8 was seated in the chair across from the nurse's station. There was not a motion sensor in place. Staff was in and out of the atrium. Review of Resident #8's care plans, nurse's notes, bedside Kardex report, and CNA documentation revealed no indication that she refused to allow staff to use a gait belt. ( )

Based on observation, interview, and record review, the facility failed to implement care planned fall interventions and prevent falls for 4 (Resident #20, #21, #22, and #24) of 6 residents reviewed for falls from a total sample of 6, resulting in Resident #20, #21, #22, and #24 sustaining falls after fall interventions were not implemented. Findings include: Review of the Evaluation of Falls/Fall Risk policy and procedure dated 11/18/11 and revised 6/12, revealed "1...You must always follow the Caretracker profile that tells how to take care of the resident. Not following a resident's profile, the resident could be injured...7. Licensed personnel shall document in the medical record the vital signs, evaluation for possible injuries (pain, swelling, bruising, decreased mobility or range of motion and administration of first aid)..." Resident #20 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #20 was a [AGE] year old male, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS revealed Resident #20 had severe cognitive impairment. Review of Resident #20's falls care plan dated 9/26/12, revealed interventions that included 2 person assist with transfers, a pommel cushion in his wheelchair for positioning, a self-release alarm belt in his wheelchair, and motion alarm while in room and bed. Review of the Visual/Bedside Kardex Report (care guide) printed 3/18/14, revealed Resident #20 required a self- release seatbelt alarm activated when in his wheelchair, pommel cushion in chair, and a motion alarm while in his room and bed. The Visual/Bedside Kardex Report revealed Resident #20 required a gait belt and 2 person assist for all transfers. Review of Resident #20's Fall Risk Evaluation dated 3/12/14, revealed he scored 16 (score of 10 or higher represents a risk of falls) and that staff would continue with interventions. An observation on 3/18/14 at 10:10 am, revealed Resident #20 in his room with his back on the seat of his wheelchair and his feet on the floor. There were no alarms sounding. Certified Nursing Assistant (CNA) "C" observed Resident #20 and called for help. CNA "C" and the other staff member positioned Resident #20 into his wheelchair and took him to the area in front of the nurse's station. An observation on 3/18/14 at 10:20 am, revealed Resident #20 was near the nurse's station, had his pommel cushion in place and his seat belt around him. Resident #20's seatbelt alarm was not activated. CNA "C" was then approached regarding the alarm. CNA "C" reported that the alarm was not activated when she observed Resident #20 sliding out of his wheelchair and that the seatbelt was still intact across his neck/chest area. CNA "C" reported that she forgot to activate the alarm when she positioned Resident #20 back in his wheelchair. In an interview on 3/18/14 at approximately 11:30 am, CNA "D" reported that she was the CNA assigned to care for Resident #20 on 3/18/14. CNA "D" reported that she went on break around 10:00 am. CNA "D" reported that before her break, a hospice CNA was performing care for Resident #20. CNA "D" reported that hospice CNAs typically gave report before they left and facility staff were to check on the resident. CNA "D" reported she was still on break when the hospice aide left. In an interview on 3/18/14 at 11:55 am, Hospice CNA "E" reported that he cared for Resident #20 from 9:05 am until 9:40 am. Hospice CNA "E" reported that when he arrived to Resident #20's room, Resident #20 was in the bathroom alone. Hospice CNA "E" reported that another staff member assisted with transferring Resident #20 into bed so that he could get Resident #20 cleaned up. Hospice CNA "E" reported that during care, Resident #20 tried to stand up and get out of bed. Hospice CNA "E" reported that he had to transfer Resident #20 to his wheelchair by himself. Hospice CNA "E" demonstrated that he put his hands around Resident #20's waist and transferred him. Hospice CNA "E" reported that Resident #20's pommel cushion and seat belt were in place, but stated "I can't remember if I turned the alarm on or not". When queried how he knew what each resident's needs were, Hospice CNA "E" reported he had a care plan in the resident's chart. Hospice CNA "E" stated "They (the facility) have a new system (kiosk for point click care) now and I'm waiting to get trained on that. In an interview on 3/19/14 at 12:00 pm, Assistant Director of Nursing (ADON) "H" reported that she could not find any documentation that Hospice CNA "E" had been trained on accessing the kiosk. ADON "H" reported that Hospice CNA "E" had full access to Resident #20's chart and care plans so he should have known what type of care was needed. Resident #21 Review of the Face Sheet and MDS dated [DATE], revealed Resident #21 was a [AGE] year old female, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS revealed Resident #21 had moderately impaired cognition. Review of Resident #21's falls care plan dated 1/31/14, revealed interventions that included, do not leave unattended in the bathroom, motion alarm while in bed, and seatbelt alarm "make sure alarm is working". Review of the Visual/Bedside Kardex printed 3/18/14, revealed not to leave Resident #21 in the bathroom unattended, motion alarm activated while she was in bed, and a self-release seat belt alarm activated when she was up in her wheelchair. Review of the Fall Risk Evaluation dated 1/30/14, revealed Resident #21 scored 22 (10 or higher represents a risk for falls). Review of the Health Status Note dated 3/15/14, revealed "at 1645 (4:45 pm) nurse heard a door being rattled from walking down the hall, and walked into room 307, opened the bathroom door and found resident (Resident #21) sitting on bottom on floor, back against wall and wheelchair next to toilet with seatbelt unattached and alarm not sounding..." Review of the incident report dated 3/15/14, revealed Resident #21's seatbelt was unattached and alarm was not sounding. The incident report also revealed that Resident #21 had "improper footwear". In an interview on 3/18/14 at 2:55 pm, CNA "F" reported that she was assigned to care for Resident #21 on 3/15/14. CNA "F" reported that she last observed Resident #21 in the dining room, with the alarm activated, before she signed out for break at 4:05 pm. CNA "F" reported as she was coming back from break, she heard someone calling out and that's when Resident #21 was observed on the floor in the bathroom, with her pants off and her shoes in the seat of the wheelchair. CNA "F" reported that Resident #21's alarm was not sounding. In an interview on 3/18/14 at 3:05 pm, Licensed Practical Nurse (LPN) "G" reported that she was the nurse on duty 3/15/14. LPN "G" reported that she observed Resident #21 on the floor in the bathroom with her pants down. LPN "G" reported that Resident #21's wheelchair seatbelt was unattached, but the alarm was not sounding. LPN "G" reported that she marked improper footwear on the incident report because "she (Resident #21) must have had something other than non-skid socks. She must have had regular socks". When queried if Resident #21 often attempts to self-transfer, LPN "G" reported that Resident #21 does while in her room. Resident #22 Review of the Face Sheet and MDS dated [DATE], revealed Resident #22 was an [AGE] year old male, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS revealed Resident #22 scored 9/15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). Review of the Fall Risk Evaluation dated 1/29/14, revealed Resident #22 scored 21 (10 or higher represents a risk for falls). The reverse side of the form, under the intervention section, revealed "If use w/c (wheelchair) place alarm pad in seat from recliner". Review of Resident #22's falls care plan dated 1/10/14 and revised on 2/16/14 and 3/18/14, revealed interventions including a pressure alarm pad for his recliner chair and a seatbelt alarm for his wheelchair. Review of the ADL care plan dated 1/10/14, revealed an alarm pad for his recliner, and a seatbelt alarm for his wheelchair. The ADL care plan revealed "I attempt to ambulate by myself..." Review of Resident #22's Visual/Bedside Kardex Report printed 3/18/14, revealed "monitor-safety check-I have a chair pad alarm in my recliner and a seatbelt alarm in my wheelchair". Review of the physician's orders [REDACTED].#22's had a seatbelt alarm in his wheelchair. In an interview on 3/19/14 at 3:00 pm, Unit Manager (UM) "M" reported that Resident #22's sensor pad in his wheelchair was changed to seatbelt alarm on 3/18/14. Review of the incident report dated 3/15/14, revealed Resident #22 was observed lying on the floor in his room in front of his wheelchair. The incident report revealed that Resident #22 had "just returned to room" from the dining room "propelling himself in w/c". The incident report revealed "other info...res. (resident) kardex states res. Recliner pad alarm is to be moved to w/c when in w/c but alarm was not in w/c..." In an interview on 3/19/14 at 2:55 pm, Registered Nurse (RN) "L" reported that she was not assigned to Resident #22 at the time of the fall, but she was sitting at the nurse's station when another resident propelled herself in her wheelchair to the nurse's station and pointed down the hall. RN "L" reported that she proceeded down the hall and observed Resident #22 on the floor face down in front of his wheelchair, which was in the doorway. RN "L" reported that no alarms were sounding. In a telephone interview on 3/18/14 at 3:21 pm, CNA "J" reported that on 3/15/14, she transferred Resident #22 to his wheelchair. CNA "J" reported that she was not aware that Resident #22 needed an alarm in his wheelchair and that she did not check his kardex. When queried why she did not check Resident #22's kardex that day, CNA "J" stated "I usually have taken care of him before so I know his routine". In a telephone interview on 3/18/14 at 3:25 pm, RN "K" reported that she was the charge nurse on 3/15/14 when Resident #22's fall occurred. RN "K" reported that Resident #22 did not have an alarm in his wheelchair. RN "K" reported that she checked the kardex and noticed that Resident #22's alarm was to be moved from his recliner to his wheelchair when he was in his wheelchair. Review of the Fall Risk Evaluation intervention section dated 3/15/14, revealed "res. Kardex states seat pad alarm is to be transferred from recliner to w/c when res. in w/c-this did not occur..." Review of the physician's notes dated 3/17/14, revealed Resident #22 sustained an abrasion above his eyes and a concussion. Resident #24 Review of the Face Sheet and MDS dated [DATE], revealed Resident #24 was an [AGE] year old female, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS revealed Resident #24 scored 10/15 (moderate cognitive impairment) on the BIMS. Review of Resident #24's falls care plan dated 1/16/14, revealed stand by assist for transfers. Review of Resident #24's Visual/Bedside Kardex Report printed 3/18/14, revealed "ADL(activities of daily living)-walk in corridor-I am a 1 person transfer using front wheel walker and gait belt...Nursing rehab/restorative: walking program: ambulate resident with front wheel walker with CGA (contact guard assist) using gait belt with wheelchair to follow 150-200 feet 3X/week (3 times per week) ongoing as tolerated to prevent decline". Review of the Fall Risk Evaluation dated 1/8/14, revealed Resident #24 scored 20 (10 or higher represents fall risk) Review of the incident report dated 3/16/14, revealed "resident fell while walking with restorative aide in the main dining room..." There was no documentation in the medical record that the fall occurred. Review of the Counseling Form dated 3/17/14, revealed CNA "I" did not follow Resident #24's schedule of care by not using a gait belt with ambulation. In a telephone interview on 3/18/14 at 3:11 pm, CNA "I" stated that Resident #24 was a "very good walker". CNA "I" reported that she routinely ambulated Resident #24 three times per week. CNA "I" reported that she ambulated Resident #24 on 3/16/14 from her room to the dining room. CNA "I" reported that Resident #24 was used a walker with a wheelchair to follow. When queried if she used a gait belt on Resident #24, CNA "I" stated "No". When queried if Resident #24 should have a gait belt for ambulation, CNA "I" stated "I went back and checked and yes there should have been. She was such a great walker. I know that's no excuse. I actually didn't think to put a gait belt on her". When queried if she used a gait belt for Resident #24 prior to this incident, CNA "I" stated "to be honest no I was not". CNA "I" reported that she did not recall a recent inservice for the plan of correction regarding falls, gait belts, and alarms. CNA "I" reported that if she signed the paper, she received the education. Review of "All Staff 1:1 POC", revealed "please follow the POC (point of care) kardex to ensure you are following the plan of care...Please remember gait belts are part of your uniform at work. All residents who are not independent for transfers, require a gait belt for transfers and ambulation. Please ensure you use a gait belt to prevent injury to yourself and the resident". The education was signed by CNA "I" on 3/2/14. ( )

This citation refers to Intake # MI 428. Based on observation, interview and record review, the facility failed to meet professional standards of care in 1 resident (#101) of 3 residents out of a total sample of 3 residents when two nurses in the facility did not provide [MEDICAL CONDITION] care according to physician's orders [REDACTED]. Findings include: Resident #101 was a [AGE] year old female who was admitted to the facility on [DATE]. Resident #101 had a [DIAGNOSES REDACTED]. The neurology consult, dated 9/18/2013, indicated Resident #101 had severe mental [MEDICAL CONDITION]. On 11/7/2013, a record review of the physician's history and physical indicated Resident #101 had experienced multiple aspiration episodes resulting in pneumonia, intubation and placement of a [MEDICAL CONDITION] to assist in respiratory care. A [MEDICAL CONDITION] is a surgical opening in the throat. A tube is placed through the opening into the lungs to assist respiratory suctioning. (Fundamentals of Nursing, Concepts, Process, and, Practice, Mosby, Perry, P., Potter, A., 1985). On 11/7/2013, a record review of physician admission orders [REDACTED]. On 11/7/2013, a record review of the Facility's [MEDICAL CONDITION] Care Policy and Procedure, dated 8/18/1982 and reviewed on 10/8/2009, noted the purpose of [MEDICAL CONDITION] care was "to maintain a clean and open airway". On 11/8/2013 at 2:30 PM, the Director of Nursing (DON) was interviewed. The DON stated she was informed on 11/5/2013 that Licensed Practical Nurse (LPN) #6 and Registered Nurse (RN) #7 did not follow physician's orders [REDACTED]. On 11/8/2013 at 1:00 PM, RN #7, day shift nurse, was interviewed. He stated he was unable to do [MEDICAL CONDITION] care on Resident #101 (to maintain a clean and open airway) because he was too busy to do so that day. He stated he passed the [MEDICAL CONDITION] care on to the nurse on the afternoon shift, expecting that LPN #6 would do the [MEDICAL CONDITION] care. When asked, RN #7 admitted he could have done the [MEDICAL CONDITION] care (to maintain a clean and open airway) for Resident #101 instead of processing physician orders [REDACTED]. On 11/8/2013 at 1:40 PM, LPN #6 was interviewed. LPN #6 stated the day shift nurse reported he did not do [MEDICAL CONDITION] care during his 8 hour shift for Resident #101. LPN #6 reported she also did not do [MEDICAL CONDITION] care on her 8 hour shift for Resident #101. LPN #6 stated she did not have time to do this care (to maintain a clean and open airway) during her shift. When asked, LPN #6 stated she did not tell anyone she was "overwhelmed" and confirmed that she did not ask for help with resident care from any of the other nurses working the afternoon shift in the facility. She admitted that, at 10:00 PM on 11/4/2013, at the end of her shift she used her time to process a delivery from pharmacy of medications to her unit. LPN #6 stated she spent time checking in the medications instead of providing [MEDICAL CONDITION] care on Resident #101. The nurse is obligated to follow the physician's orders [REDACTED]. (Fundamentals of Nursing, Concepts, Process, and, Practice, Mosby, Perry, P., Potter, A., 1985). "Nurses must obey the orders of the physician in charge of a patient, unless an order would lead a reasonable person to anticipate injury if it were carried out", according to Creighton in Law Every Nurse Should Know, 5th Edition, page 98. On 11/12/2013 at 11:25 AM, in a telephone interview with Medical Examiner #13, he stated his final report would reflect the cause of death as "asphyxia due to obstruction of the [MEDICAL CONDITION]" and the manner of death as "accident". ( )

Based on interview and record review, the facility failed to follow their Plan of Correction (POC), completion dated 11/20/13, to conduct random weekly reviews for [MEDICAL CONDITION] care documentation and document daily [MEDICAL CONDITION] observations for 2 of 2 residents (#101, #102) resulting in the potential for failure to perform appropriate [MEDICAL CONDITION] care, respiratory distress an irreversible clinical outcome. Findings include: According to the 60-day Minimum Data Set (resident assessment), dated 12/7/13, Resident #101 had significant cognitive impairment, short and long-term memory problems and was able to make simple, daily decisions about his care. Resident #101 required 2 staff for bed mobility, transfers, dressing, hygiene and toileting, 1 staff assist for tube feedings and bathing and was incontinent of bowel and bladder. According to the Care Plan, dated 5/22/13, Resident #101 was to [MEDICAL CONDITION] every shift. On 11/17/13 at 11:00 am, Registered Nurse Supervisor (RN) "10" was interviewed after she identified herself as the unit manager of the unit with the current residents requiring [MEDICAL CONDITION] care. When asked, RN 10 said that she was not [MEDICAL CONDITION] for Resident #101 on her daily audits because it was not an item on her weekly "Manager Audits" form. RN 10 presented a blank audit form, updated on 10/12/13, which did not [MEDICAL CONDITION] monitoring listed. When asked if she was aware that the plan of correction included for the [MEDICAL CONDITION] sites included audits of checking documentation [MEDICAL CONDITION] and observing her residents'[MEDICAL CONDITION], RN 10 said, "I'm not [MEDICAL CONDITION]," and shook her head back and forth. When asked if she attended the inservices [MEDICAL CONDITION], RN 10 said that she, "was there for part." When asked if she was notified, by anyone, about [MEDICAL CONDITION] and documentation, RN 10 said, "No". When asked, RN 10 said that she was aware of the citations issued [MEDICAL CONDITION] in the recent complaints survey. According to documentation on Resident #101's December 2013 TAR,[MEDICAL CONDITION] was not initialed as completed for 3 of 48 opportunities. On 12/17/13 at 1:30 p.m., the missing documentation [MEDICAL CONDITION] on the Resident #101's December 2013 TARs was shown to RN 10. On 12/18/13 at approximately 10:45 a.m., the Director of Nurses (DON) 2 was interviewed. The DON 2 was asked about the Plan of Correction which stated, "Trach care record reviews and observations will be documented on the Unit Manager check sheet weekly and provided to the DON for review. The DON will review the Unit Manager audit check sheets weekly and note any trends and patterns of concerns [MEDICAL CONDITION] and documentation." When asked if she received the weekly audits from RN 10, DON 2 said, "Yes". When asked what she though about the POC's weekly audits' failure to [MEDICAL CONDITION] documentation, and the documentation of daily rounds for observing for trachs working properly, placement of trachs and cleanliness ensuring no obstruction was not being done, DON 2 said , "It went right by me. I didn't notice trachs weren't on those audit sheets". When asked how the POC elements were communicated to RN 10, DON 2 said that the new audit form [MEDICAL CONDITION] added was sent to RN 10 by e-mail. When asked when the last Quality Assurance meeting was held, DON 2 said, "Yesterday". When asked if any issues [MEDICAL CONDITION] documentation were brought up during the meeting, DON 2 said, "No". DON 2 offered that she was not involved with the development of plans of correction, and had not seen this one. On 12/18/13 at 12:10 p.m., Administrator (ADM) 1 was interviewed. When asked how she writes the Plan of Correction for for citations, ADM 1 said, "I write the draft and forward it to the DON for correction/discussion", and, "I include other staff as appropriate". ADM 1 said that plans of correction were discussed at weekly nursing supervisor meetings, although nursing staff come and go at these meetings as they are often called away. When asked if she recalled if RN 10 was at the meeting where [MEDICAL CONDITION] audits was discussed, ADM 1 conveyed she didn't remember for sure. The facility failed to monitor documentation and performance [MEDICAL CONDITION] as listed in the Plan of Correction, dated 11/20/13. ( ) According to the facility admission record, dated 12/13/13, Resident #102 was a [AGE] year old male, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set (resident assessment), dated 11/12/13, Resident #102 had severe cognitive impairment. Resident #102 required 2 staff for bed mobility, transfers, dressing, hygiene, bathing, toileting and was incontinent of bowel and bladder. According to the care plan, dated 5/22/13, Resident #102 was to [MEDICAL CONDITION] every shift. On 11/17/13 at 11:00 am, Registered Nurse Supervisor (RN) "10" was interviewed after she identified herself as the unit manager of the unit with the current residents requiring [MEDICAL CONDITION] care. When asked, RN 10 said that she was not [MEDICAL CONDITION] for Resident #102 because it was not an item on her weekly "Manager Audits" form. RN 10 presented a blank audit form, updated on 10/12/13, which did not [MEDICAL CONDITION] monitoring listed. When asked if she was aware that the plan of correction included for the [MEDICAL CONDITION] sites included audits of checking documentation [MEDICAL CONDITION] and observing her residents'[MEDICAL CONDITION], RN 10 said, "I'm not [MEDICAL CONDITION]," and shook her head back and forth. When asked if she attended the inservices [MEDICAL CONDITION], RN 10 said that she, "was there for part." When asked if she was notified, by anyone, about [MEDICAL CONDITION] and documentation for resident #102, RN 10 said, "No". When asked, RN 10 said that she was aware of the citations issued [MEDICAL CONDITION] in the recent complaints survey. According to documentation on the November 2013 Treatment Record (TAR), [MEDICAL CONDITION] was not initialed as completed for 1 of 25 opportunities. On the December 2013 TAR,[MEDICAL CONDITION] was not initialed as completed for 1 of 13 opportunities. On 12/17/13 at 1:30 p.m., the missing documentation [MEDICAL CONDITION] on the November and December 2013 TARs was shown to RN 10. On 12/18/13 at approximately 10:45 a.m., the Director of Nurses (DON) 2 was interviewed. The DON 2 was asked about the Plan of Correction which stated, "Trach care record reviews and observations will be documented on the Unit Manager check sheet weekly and provided to the DON for review. The DON will review the Unit Manager audit check sheets weekly and note any trends and patterns of concerns [MEDICAL CONDITION] and documentation." When asked if she received the weekly audits from RN 10, DON 2 said, Yes". When asked what she though about the POC's weekly audits' failure to [MEDICAL CONDITION] documentation, and the documentation of daily rounds for observing for trachs working properly, placement of trachs and cleanliness ensuring no obstruction was not being done, DON 2 said , "It went right by me. I didn't notice trachs weren't on those audit sheets". When asked how the POC elements were communicated to RN 10, DON 2 said that the new audit form [MEDICAL CONDITION] added was sent to RN 10 by e-mail. When asked when the last Quality Assurance meeting was held, DON 2 said, "Yesterday". When asked if any issues [MEDICAL CONDITION] documentation were brought up during the meeting, DON 2 said, "No". DON 2 offered that she was not involved with the development of plans of correction, and had not seen this one. On 12/18/13 at 12:10 p.m., Administrator (ADM) 1 was interviewed. When asked how she writes the Plan of Correction for for citations, ADM 1 said, "I write the draft and forward it to the DON for correction/discussion", and, "I include other staff as appropriate". ADM 1 said that plans of correction were discussed at weekly nursing supervisor meetings, although nursing staff come and go at these meetings as they are often called away. When asked if she recalled if RN 10 was at the meeting where [MEDICAL CONDITION] audits was discussed, ADM 1 conveyed she didn't remember for sure. The facility failed to monitor documentation and performance of [MEDICAL CONDITION] care as listed in the Plan of Correction, dated 11/20/13. ( )

This citation refers to Intake #MI 428 Based on observation, interview and record review, the facility failed to ensure that 1 resident (#101) out of 3 residents out of a total sample of 3 residents received [MEDICAL CONDITION] care according to physician's orders [REDACTED]. Findings include: Resident #101 was a [AGE] year old female who was admitted to the facility on [DATE]. Resident #101 had a [DIAGNOSES REDACTED]. The neurology consult, dated [DATE], indicated Resident #101 had severe mental [MEDICAL CONDITION]. Resident #101 had a [MEDICAL CONDITION] and a Percutaneous Endoscopic Gastrostomy (PEG) for tube feeding in place. According to documentation received in the Facility Reported Incident 24 hour form, on [DATE], Resident #101 did not receive [MEDICAL CONDITION] care from Registered Nurse (RN) #7 during the day shift (6 AM to 2 PM) and during the afternoon shift (2 PM to 10 PM) from Licensed Practical Nurse (LPN) #6. At 10:20 PM, Resident #101 was found in Cardiac and [MEDICAL CONDITION] arrest (not breathing and with no pulse). Cardiopulmonary Resuscitation (CPR) was initiated and was unsuccessful. Resident #101 died . On [DATE], Resident #102 and Resident #103 were observed receiving [MEDICAL CONDITION] care as ordered by their attending physician. Both residents were sharing the same room. Each resident had a clean [MEDICAL CONDITION] dressing in place and was receiving humidified oxygen through the [MEDICAL CONDITION] opening. On [DATE] at 2:45 PM, Human Resources (HR) #14 was interviewed. HR #14 stated that LPN #6 was terminated from the facility because she did not give Resident #101 [MEDICAL CONDITION] care as ordered by Resident #101's attending physician. According to HR #14, when she interviewed LPN #6 during the investigation of the incident, she asked LPN #6 if she provided any nursing care for Resident #101 and LPN #6 said she gave Resident #101 her medications and did the tube feeding. HR #14 conveyed that LPN #6 stated she did not have time to provide [MEDICAL CONDITION] care to resident #101. On [DATE] at 9:30 AM, RN #3 identified herself at the afternoon facility shift supervisor who did not have an assignment of residents on the afternoon of [DATE] as she had one new admission. RN #3 said she made frequent rounds on all the facility units and would check with the nursing staff to see if anyone needed assistance with resident care. RN #3 said she asked LPN #6 if she needed help and was told by LPN #6 that she did not need help and was "OK". RN #3 did not provide any documentation that supported offering nursing staff assistance during the shift. During the [DATE] 9:30 am interview, RN #3 said she knew Resident #101 and, when asked to describe what Resident #101 was like, RN #3 said Resident #101 smiled a lot, had decreased cognitive abilities, was not able to speak and was unable to turn her call light on. RN #3 said Resident #101 was 100% dependent on staff for all activities of daily living, resident #101 was dependant on "everything". On [DATE] at 10:00 AM, Resident #101's Attending Physician (MD) #4 was interviewed in the facility. She said she was the primary physician for Resident #101. MD #4 said she was surprised to hear Resident #101 had died as "she was doing well and was up in a chair earlier that day ([DATE])". MD #4 said she called the Medical Examiner (ME) #13 to inform him that, after the code on [DATE], facility staff discovered Resident #101's inner canula on her [MEDICAL CONDITION] was occluded. ME #13 decided to perform an autopsy as a result of the additional information from MD #4. On [DATE] at 10:30 AM, LPN #5 was interviewed in person. LPN #5 reported being the midnight shift nurse who received report from LPN #6. LPN #5 said she was informed by LPN #6 that she did not do [MEDICAL CONDITION] care during the afternoon shift and that RN #7 did not do [MEDICAL CONDITION] care on the day shift. Following receiving report, LPN #5 stated she immediately went to assess Resident #101 at approximately 10:20 PM. LPN #5 stated she was concerned receiving report that Resident #101 did not receive [MEDICAL CONDITION] care for over 16 hours and immediately went to evaluate Resident #101's airway. When LPN #5 went into the room, she observed Resident #101's face was "white" and Resident #101 was not breathing and had no pulse. LPN #5 stated that knowing the resident did not receive [MEDICAL CONDITION] care in over 16 hours she pulled the inner canula from the [MEDICAL CONDITION] and turned the oxygen up to 100% delivery. Cardio-pulmonary Resuscitation (CPR) was started. After the code was terminated by the physician on call, LPN #5 noted that facility shift supervisor RN #3 had the inner canula from the [MEDICAL CONDITION] in her hand and, when LPN #5 looked at it, the canula was totally occluded. LPN #5 stated she observed RN #3 opened a [MEDICAL CONDITION] cleaning kit and had difficulty pushing a pipe cleaner through the opening of the inner cannula. LPN #3 reported she does not know what happened to the inner canula after the completion of the code. On [DATE] at 11:30 AM, Certified Nursing Assistant (CNA) #11 was interviewed. CNA #11 stated she was assigned to care for Resident #101 on the afternoon shift on [DATE]. During the initial rounds, Resident #101 was in bed, sitting up and smiling. During the shift, CNA #11 observed Resident #101 began coughing. CNA #11 stated she reported this to LPN #6 at least three separate times. CNA #11 stated she was told by LPN #6 "this was normal behavior" for Resident #101. CNA #11 reported that she turned and repositioned Resident #101 and noted increased coughing and clear mucous in Resident #101's mouth during the shift. On [DATE] at 1:00 PM, RN #7 was interviewed. He stated Resident #101 had no respiratory difficulty during his shift. RN#7 was asked if assessed the resident airway and if he checked her breath sounds during the shift, RN #7 said he did not. However, RN #7 was asked if he checked the placement of the PEG tube before hanging a tube feeding and he stated he did. RN #7 demonstrated where he placed his stethoscope on Resident #101 to assess the correct placement of the PEG tube. When asked why he did not assess the residents airway and breath sounds when he was done checking Resident #101's abdomen, RN #7 did not have a response. RN #7 admitted that he did not do [MEDICAL CONDITION] care during the shift but felt he could pass the [MEDICAL CONDITION] care (to maintain an open and clear airway) on to the afternoon shift and it would be done. When asked if he could have stayed on shift to provide for airway assessment of resident #101 he admitted he could have stayed over and completed [MEDICAL CONDITION] care before he went home but chose not to do so. On [DATE] at 1:40 PM, LPN #6 was interviewed. LPN #6 stated day shift RN #7 reported he did not do [MEDICAL CONDITION] care for Resident #101 (to maintain a clean and open airway). LPN #6 reported she also was also unable to do [MEDICAL CONDITION] care for Resident #101 because she "didn't have time". LPN #6 was asked how long it took to do [MEDICAL CONDITION] care and she stated it took approximately 15 to 20 minutes. LPN #6 reported that she did not perform [MEDICAL CONDITION] care at her previous employment and she had observed [MEDICAL CONDITION] care in the facility. LPN #6 stated that she did not complete a return demonstration with any nursing staff at the facility. LPN #6 stated she had worked at the facility less than 90 days. LPN #6 added that she had done [MEDICAL CONDITION] care many times for Resident #101 since being employed at the facility. LPN #6 was asked if she checked the placement of the PEG tube before hanging a tube feeding and she stated she did. LPN #6 demonstrated where she placed the stethoscope on Resident #101 to assess the correct placement of the PEG tube. When asked why she did not assess the airway and breath sounds when she was checking Resident #101's abdomen, LPN #6 had no response. LPN #6 was asked who she contacted to inform that she was not able to complete resident [MEDICAL CONDITION] care as ordered. LPN #6 did not convey that she was offered help by another facility nurse. LPN #6 was asked who she contacted to ask for additional help in completing her assignment and LPN #6 said she did not notify anyone herself. LPN #6 commented that a pharmacy delivery came at 10:00 PM and she spent approximately 15 minutes checking in medications before she went home as opposed to using those minutes to provide [MEDICAL CONDITION] care to resident #101, who at this time had not had [MEDICAL CONDITION] care in over 16 hours. On [DATE] at 2:30 P.M. the Director of Nursing (DON) #2 was interviewed. DON #2 stated she was not aware until [DATE] that Resident #101's inner canula on her [MEDICAL CONDITION] was occluded. On [DATE] at 3:00 PM, Staff Development Registered Nurse (SD) #9 was interviewed. SD #9 stated that, during orientation, nurses are shown how to do [MEDICAL CONDITION] care and then assigned to do a return demonstration of [MEDICAL CONDITION] care to indicate their knowledge of the procedure. According to SD #9, LPN #6 did "observe" [MEDICAL CONDITION] care during orientation. SD #9 said LPN #6 was told to go to room [ROOM NUMBER] in the facility, where there were 2 residents with [MEDICAL CONDITION] in place, and schedule a return demonstration of [MEDICAL CONDITION] care in front of the nurses caring for those residents. SD #9 provided no documentation of the [MEDICAL CONDITION] care return demonstration and was unable to confirm that LPN #6 did the return demonstration. SD #9 did not have a copy of LPN #6's skills checklist during the time LPN #6 was providing [MEDICAL CONDITION] care to residents. SD #9 stated there were some issues with LPN #6. LPN #6 was noted to be lacking in interpersonal skills as noted by complaints from families who indicated LPN #6 would only give one word answers to their questions. In addition, LPN #6 was not working as a team player and would not follow up when CNAs came to her with concerns and problems. On [DATE] at 11:25 AM, in a telephone interview with Medical Examiner #13, he stated he planned to cite the cause of death as "asphyxia due to obstruction of the trachea" and the manner of death as "accident". ( )

Based on interview and record review, the facility failed to follow their Plan of Correction (POC), completion dated 11/20/13, to conduct random weekly reviews for [MEDICAL CONDITION] care documentation and document daily [MEDICAL CONDITION] observations for 2 of 2 residents (#101, #102) resulting in the potential for failure to perform appropriate [MEDICAL CONDITION] care, respiratory distress an irreversible clinical outcome. Findings include: According to the 60-day Minimum Data Set (resident assessment), dated 12/7/13, Resident #101 had significant cognitive impairment, short and long-term memory problems and was able to make simple, daily decisions about his care. Resident #101 required 2 staff for bed mobility, transfers, dressing, hygiene and toileting, 1 staff assist for tube feedings and bathing and was incontinent of bowel and bladder. According to the Care Plan, dated 5/22/13, Resident #101 was to [MEDICAL CONDITION] every shift. On 11/17/13 at 11:00 am, Registered Nurse Supervisor (RN) "10" was interviewed after she identified herself as the unit manager of the unit with the current residents requiring [MEDICAL CONDITION] care. When asked, RN 10 said that she was not [MEDICAL CONDITION] for Resident #101 on her daily audits because it was not an item on her weekly "Manager Audits" form. RN 10 presented a blank audit form, updated on 10/12/13, which did not [MEDICAL CONDITION] monitoring listed. When asked if she was aware that the plan of correction included for the [MEDICAL CONDITION] sites included audits of checking documentation [MEDICAL CONDITION] and observing her residents'[MEDICAL CONDITION], RN 10 said, "I'm not [MEDICAL CONDITION]," and shook her head back and forth. When asked if she attended the inservices [MEDICAL CONDITION], RN 10 said that she, "was there for part." When asked if she was notified, by anyone, about [MEDICAL CONDITION] and documentation, RN 10 said, "No". When asked, RN 10 said that she was aware of the citations issued [MEDICAL CONDITION] in the recent complaints survey. According to documentation on Resident #101's December 2013 TAR,[MEDICAL CONDITION] was not initialed as completed for 3 of 48 opportunities. On 12/17/13 at 1:30 p.m., the missing documentation [MEDICAL CONDITION] on the Resident #101's December 2013 TARs was shown to RN 10. On 12/18/13 at approximately 10:45 a.m., the Director of Nurses (DON) 2 was interviewed. The DON 2 was asked about the Plan of Correction which stated, "Trach care record reviews and observations will be documented on the Unit Manager check sheet weekly and provided to the DON for review. The DON will review the Unit Manager audit check sheets weekly and note any trends and patterns of concerns [MEDICAL CONDITION] and documentation." When asked if she received the weekly audits from RN 10, DON 2 said, "Yes". When asked what she though about the POC's weekly audits' failure to [MEDICAL CONDITION] documentation, and the documentation of daily rounds for observing for trachs working properly, placement of trachs and cleanliness ensuring no obstruction was not being done, DON 2 said , "It went right by me. I didn't notice trachs weren't on those audit sheets". When asked how the POC elements were communicated to RN 10, DON 2 said that the new audit form [MEDICAL CONDITION] added was sent to RN 10 by e-mail. When asked when the last Quality Assurance meeting was held, DON 2 said, "Yesterday". When asked if any issues [MEDICAL CONDITION] documentation were brought up during the meeting, DON 2 said, "No". DON 2 offered that she was not involved with the development of plans of correction, and had not seen this one. On 12/18/13 at 12:10 p.m., Administrator (ADM) 1 was interviewed. When asked how she writes the Plan of Correction for the citations, ADM 1 said, "I write the draft and forward it to the DON for correction/discussion", and, "I include other staff as appropriate". ADM 1 said that plans of correction were discussed at weekly nursing supervisor meetings, although nursing staff come and go at these meetings as they are often called away. When asked if she recalled if RN 10 was at the meeting where [MEDICAL CONDITION] audits was discussed, ADM 1 stated, "I didn't remember for sure." The facility failed to monitor documentation and performance [MEDICAL CONDITION] as listed in the Plan of Correction, dated 11/20/13. ( ) According to the facility admission record, dated 12/13/13, Resident #102 was a [AGE] year old male, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set (resident assessment), dated 11/12/13, Resident #102 had severe cognitive impairment. Resident #102 required 2 staff for bed mobility, transfers, dressing, hygiene, bathing, toileting and was incontinent of bowel and bladder. According to the care plan, dated 5/22/13, Resident #102 was to [MEDICAL CONDITION] every shift. On 11/17/13 at 11:00 am, Registered Nurse Supervisor (RN) "10" was interviewed after she identified herself as the unit manager of the unit with the current residents requiring [MEDICAL CONDITION] care. When asked, RN 10 said that she was not [MEDICAL CONDITION] for Resident #102 because it was not an item on her weekly "Manager Audits" form. RN 10 presented a blank audit form, updated on 10/12/13, which did not [MEDICAL CONDITION] monitoring listed. When asked if she was aware that the plan of correction included for the [MEDICAL CONDITION] sites included audits of checking documentation [MEDICAL CONDITION] and observing her residents'[MEDICAL CONDITION], RN 10 said, "I'm not [MEDICAL CONDITION]," and shook her head back and forth. When asked if she attended the inservices [MEDICAL CONDITION], RN 10 said that she, "was there for part." When asked if she was notified, by anyone, about [MEDICAL CONDITION] and documentation for resident #102, RN 10 said, "No". When asked, RN 10 said that she was aware of the citations issued [MEDICAL CONDITION] in the recent complaints survey. According to documentation on the November 2013 Treatment Record (TAR), [MEDICAL CONDITION] was not initialed as completed for 1 of 25 opportunities. On the December 2013 TAR,[MEDICAL CONDITION] was not initialed as completed for 1 of 13 opportunities. On 12/17/13 at 1:30 p.m., the missing documentation [MEDICAL CONDITION] on the November and December 2013 TARs was shown to RN 10. On 12/18/13 at approximately 10:45 a.m., the Director of Nurses (DON) 2 was interviewed. The DON 2 was asked about the Plan of Correction which stated, "Trach care record reviews and observations will be documented on the Unit Manager check sheet weekly and provided to the DON for review. The DON will review the Unit Manager audit check sheets weekly and note any trends and patterns of concerns [MEDICAL CONDITION] and documentation. When asked if she received the weekly audits from RN 10, DON 2 said, Yes". When asked what she though about the POC's weekly audits' failure to [MEDICAL CONDITION] documentation, and the documentation of daily rounds for observing for trachs working properly, placement of trachs and cleanliness ensuring no obstruction was not being done, DON 2 said , "It went right by me. I didn't notice trachs weren't on those audit sheets". When asked how the POC elements were communicated to RN 10, DON 2 said that the new audit form [MEDICAL CONDITION] added was sent to RN 10 by e-mail. When asked when the last Quality Assurance meeting was held, DON 2 said, "Yesterday". When asked if any issues [MEDICAL CONDITION] documentation were brought up during the meeting, DON 2 said, "No". DON 2 offered that she was not involved with the development of plans of correction, and had not seen this one. On 12/18/13 at 12:10 p.m., Administrator (ADM) 1 was interviewed. When asked how she writes the Plan of Correction for for citations, ADM 1 said, "I write the draft and forward it to the DON for correction/discussion", and, "I include other staff as appropriate". ADM 1 said that plans of correction were discussed at weekly nursing supervisor meetings, although nursing staff come and go at these meetings as they are often called away. When asked if she recalled if RN 10 was at the meeting where [MEDICAL CONDITION] audits was discussed, ADM 1 stated, "I didn't remember for sure." The facility failed to monitor documentation and performance of [MEDICAL CONDITION] care as listed in the Plan of Correction, dated 11/20/13. ( )

REFER TO INTAKES MI 406 AND MI 991. BASED ON OBSERVATIONS, INTERVIEWS, AND RECORD REVIEWS, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION TO PREVENT ACCIDENTS FOR 2 (#500 AND #501) OF 6 SAMPLED RESIDENTS REVIEWED FOR FALLS AND SAFE TRANSFERS FROM A TOTAL SAMPLE OF 6, WHEN RESIDENT #501 WAS LEFT UNATTENDED ON THE TOILET AND fell AND WHEN RESIDENT #500'S FOOT WAS BUMPED BY A TABLE LEG DURING POSITIONING, RESULTING IN A LACERATION REQUIRING SUTURES FOR RESIDENT #501 AND A FOOT INJURY FOR RESIDENT #500. FINDINGS INCLUDE: RESIDENT #501 RESIDENT #501, [AGE] years OLD, WAS admitted TO THE FACILITY INITIALLY ON 10/23/12, PER THE ADMISSION RECORD. A PHYSICIAN'S HISTORY & PHYSICAL (H&P) REPORT, DATED 10/24/12, NOTED THAT RESIDENT #501 HAD A PAST MEDICAL HISTORY THAT INCLUDED HIGH BLOOD PRESSURE, CORONARY HEART DISEASE, HEART ATTACK, [DIAGNOSES REDACTED](HEART ARRHYTHMIA), STROKE, FRACTURED ANKLE, AND FRACTURED HIP. RESIDENT #501, ACCORDING TO THE MINIMUM DATA SET (MDS) assessment dated [DATE], REQUIRED EXTENSIVE TO TOTAL CARE FOR MOST ACTIVITIES OF DAILY LIVING. THE RESIDENT WAS DEPENDENT ON STAFF FOR TOILETING, PER THE MDS. A MENTAL STATUS QUESTIONNAIRE, DATED 11/20/12, INDICATED THE RESIDENT HAD SOME COGNITIVE DECLINE. IN AN INTERVIEW ON 4/15/13 AT 3:30 P.M., UNIT MANAGER #1 SAID RESIDENT #501'S COMPUTER PROFILE GUIDING CNA (CERTIFIED NURSING ASSISTANT) CARE FOR THE DATE 2/26/13 DOCUMENTED THAT RESIDENT #501 REQUIRED STAFF TO REMAIN IN THE BATHROOM WHEN BEING TOILETED. ACCORDING TO AN INCIDENT REPORT, DATED 2/26/13, RESIDENT #501 fell AND WAS TRANSFERRED TO THE HOSPITAL FOR A LACERATION ON THE SCALP. REGISTERED NURSE (RN) #11 WAS INTERVIEWED BY TELEPHONE ON 4/16/13 AT 9:20 A.M. RN #11 SAID SHE PROVIDED CARE FOR RESIDENT #501 ON 2/26/13. RN #11 SAID THAT SHE ADMINISTERED MORNING MEDICATIONS TO RESIDENT #501 ON 2/26/13, AND RESIDENT #501'S CONDITION WAS UNCHANGED (FROM HER NORMAL BASELINE) AT THAT TIME. AT APPROXIMATELY 11:30 A.M., CNA #22 TOLD HER (RN #11) THAT RESIDENT #501HAD BEEN ON THE TOILET; AND WHEN SHE (CNA #22) RETURNED TO THE RESIDENT'S BATHROOM, RESIDENT #501WAS ON THE FLOOR. RN #11 SAID THAT RESIDENT #501'S FOREHEAD WAS BLEEDING, AND THAT SHE COMPLAINED OF PAIN IN HER LEFT HIP. ACCORDING TO RN #11, RESIDENT #501 WAS ALERT WHEN SHE (RN #11) ENTERED THE BATHROOM. THE RESIDENT, PER THE NURSE, SAID SHE HAD "BLACKED OUT" PRIOR TO THE FALL. RN #11 SAID THAT STAFF SHOULD HAVE STAYED IN THE BATHROOM DURING TOILETING BECAUSE OF THE RESIDENT'S CONFUSION. RN #11 STATED THAT RESIDENT #501 WAS THEN TRANSFERRED TO THE HOSPITAL FOR FURTHER EVALUATION AND TREATMENT. RESIDENT #501 AND HER HUSBAND WERE INTERVIEWED ON 4/16/13 AT 10:45 A.M. RESIDENT #501 STATED THAT HER LEFT ARM WAS "USELESS" AND HER LEFT LEG WAS WEAK. RESIDENT #501 SAID THAT STAFF WERE NOT WITH HER IN THE BATHROOM ON 2/26/13 WHEN SHE fell OFF THE TOILET. THE RESIDENT SAID SHE "CAME TO" AND DIDN'T REMEMBER WHEN HAPPENED PRIOR TO THE FALL. RESIDENT #501 IDENTIFIED THE SCAR ON HER FOREHEAD AS THE LOCATION WHERE THE INJURY HAD BEEN. SHE SAID THE SMALL BUMP ON HER FOREHEAD WAS STILL SORE, AND HER NECK HAD BEEN SORE SINCE HER FALL. THE HUSBAND OF RESIDENT #501 SAID HE WAS IN THE RESIDENT'S ROOM ON 2/26/13, BUT THE TELEVISION WAS ON, AND HE DID NOT HEAR HIS WIFE FALL. RESIDENT #501, DURING THE INTERVIEW ON 4/15/13 AT 10:45 A.M., COULD CARRY ON A NORMAL CONVERSATION, EVEN INITIATING CONVERSATION. HER MEMORY WAS GOOD. HOWEVER, RESIDENT #501, AT TIMES, MADE COMMENTS WHICH WERE NOT ACCURATE. CNA #17 WAS INTERVIEWED ON 4/15/13 AT 2:30 P.M. SHE SAID SHE ASSISTED CNA #22 WITH THE TRANSFER OF RESIDENT #501 ONTO THE TOILET ON 2/26/13. SHE SAID SHE WAS UNAWARE THAT RESIDENT #501 WAS NOT TO BE LEFT UNATTENDED DURING TOILETING. SHE SAID THAT RESIDENT #501 WAS TOLD TO PULL THE EMERGENCY CORD WHEN SHE WAS READY TO BE TRANSFERRED BACK INTO THE WHEELCHAIR. CNA #17 SAID THAT SHE AND CNA #22 SAW THE EMERGENCY LIGHT AND FOUND RESIDENT #501 ON THE FLOOR WHEN THEY ENTERED THE BATHROOM. CNA #22 WAS ASSIGNED TO RESIDENT #501 ON 2/26/13 AND ASSISTED WITH THE TRANSFER FROM WHEELCHAIR TO TOILET. SHE DID NOT RETURN PHONE CALLS AS THE SURVEYOR REQUESTED. HOSPITAL RECORDS WERE REVIEWED ON 4/15/13. A PHYSICIAN'S HISTORY & PHYSICAL (H&P), DATED 2/26/13, INDICATED THAT RESIDENT #501 WAS BROUGHT TO THE HOSPITAL FOLLOWING A FALL. THE CT (COMPUTERIZED TOMOGRAPHY) SCAN OF THE HEAD WAS "ESSENTIALLY NORMAL" AS WERE X-RAYS OF THE HIP. THE LACERATION ON THE FOREHEAD WAS REPAIRED. RESIDENT #501 WAS KEPT IN THE HOSPITAL OVERNIGHT BECAUSE OF THE HEAD INJURY AND THE FACT THAT RESIDENT #501 WAS BEING TREATED WITH A MEDICATION TO PREVENT STROKE DUE TO A BLOOD CLOT. RESIDENT #501 WAS OBSERVED DURING A TRANSFER FROM THE WHEELCHAIR TO THE TOILET ON 4/15/13 AT 12:30 P.M., OBSERVATION REVEALED CNA #4 AND CNA #5, USING A GAIT BELT, TRANSFERRING RESIDENT #501 TO THE TOILET. EVEN THOUGH A GAIT BELT WAS BEING USED, CNA #4 GRABBED RESIDENT #501'S PANTS DURING THE TRANSFER ONTO THE TOILET. DURING THE TRANSFER BACK INTO THE WHEELCHAIR AFTER TOILETING, CNA #4 FAILED TO LOCK THE BRAKES ON HER SIDE OF THE WHEELCHAIR. SHE DID NOT OFFER ANY EXPLANATION WHEN THIS WAS BROUGHT TO HER ATTENTION. FACILITY POLICY, DATED 12/12, INDICATED THAT WHEELCHAIRS ARE TO BE LOCKED DURING TRANSFERS. THE POLICY INDICATED THAT GAIT BELTS ARE TO BE USED TO LIFT RESIDENTS TO AN UPRIGHT POSITION AND TO LOWER RESIDENTS TO A SEATED POSITION. ( ) RESIDENT #500 RESIDENT #500, [AGE] years OLD, WAS ORIGINALLY admitted to the facility on [DATE]. ACCORDING TO A SOCIAL SERVICE NOTE ON 1/9/13, RESIDENT #500 RECEIVED TOTAL CARE FOR ALL ACTIVITIES OF DAILY LIVING. RESIDENT #500 HAD A [DIAGNOSES REDACTED]. RESIDENT #500 KNEW HER NAME AND COULD MAKE SOME OF HER NEEDS KNOWN. THERE WERE NO MOOD OR BEHAVIOR ISSUES. SHE RECEIVED HOSPICE SERVICES. A PHYSICIAN'S H&P, DATED 11/9/12, DOCUMENTED THAT RESIDENT #500 HAD THE FOLLOWING Diagnoses: [REDACTED]. ACCORDING TO RN #3, INTERVIEWED ON 4/15/13 AT 2:10 P.M., A HOSPICE AIDE REPORTED TO THE NURSE ON DUTY ON 3/27/13 THAT RESIDENT #500'S LEFT GREAT TOENAIL WAS CRACKED HORIZONTALLY AND DARK BLOOD WAS NOTED ON THE SOCK. THE LATERAL TOP AND BOTTOM OF RESIDENT #500'S LEFT FOOT, EXTENDING ACROSS THE TOP AND BOTTOM OF THE TOES, WAS SWOLLEN AND DEEP PURPLE IN COLOR. THE RESIDENT SAID THE FOOT HURT "A LITTLE BIT." THE PHYSICIAN WAS NOTIFIED, AND TREATMENT ORDERS WERE OBTAINED. AN X-RAY ON 3/27/13 DOCUMENTED A POSSIBLE FRACTURE OF THE 4TH METATARSAL OF THE LEFT FOOT. (A METATARSAL IS ONE OF THE FIVE LONG BONES OF THE FOOT LOCATED BETWEEN THE ANKLE AND THE TOES.) RN #3, DURING THE 4/15/13 INTERVIEW, SAID THAT CNA #23 WAS ASSIGNED TO RESIDENT #500 DURING THE AFTERNOON SHIFT ON 3/26/13. CNA #23 HAD SAID THAT SHE TRANSFERRED RESIDENT #500 BY HERSELF INTO THE WHEELCHAIR FROM BED USING A MECHANICAL LIFT, EVEN THOUGH THE 3/23/13 CARE PLAN FOR ACTIVITIES OF DAILY LIVING INDICATED THAT RESIDENT #500 WAS A TWO PERSON TRANSFER. CNA #23 THEN WHEELED RESIDENT #500 TO THE DINING ROOM AND POSITIONED HER IN HER WHEELCHAIR AT A TABLE. ACCORDING TO RN #3, THE ROUND DINING TABLES FIT FOUR PEOPLE AND EACH TABLE HAD FOUR LEGS. CNA #23 TOLD RN #3 THAT RESIDENT #500'S FOOT BUMPED ONE OF THE TABLE LEGS WHILE SHE TRIED TO POSITION THE RESIDENT AT THE TABLE. ACCORDING TO RN #3, CNA #23 DID NOT NOTIFY ANYONE ABOUT THE INJURY WHEN IT OCCURRED AND WAS NOT TRUTHFUL ABOUT HER TRANSFER OF THE RESIDENT OR THE INJURY WHEN INITIALLY QUESTIONED ABOUT IT THE NEXT DAY. CNA #16 WAS INTERVIEWED ON 4/15/13 AT 2 P.M. CNA #16 SAID THAT SHE PROVIDED CARE FOR RESIDENT #500 PRIOR TO 3/26/13. RESIDENT #500, PER CNA #16, WAS CONFUSED, AND NEVER COMBATIVE. CNA #23, WHO PROVIDED CARED FOR RESIDENT #500 DURING THE AFTERNOON SHIFT ON 3/27/13, DID NOT RETURN CALLS TO THE SURVEYOR FOR AN INTERVIEW AS REQUESTED. ( )

HIS CITATION PERTAINS TO INTAKE: MI 203. BASED ON INTERVIEWS AND RECORD REVIEWS, THE FACILITY FAILED TO RE-EVALUATE AND IMPLEMENT APPROPRIATE, "UPDATED" FALL INTERVENTIONS TO PREVENT SUBSEQUENT FALLS FOR 1 (#101) OF 4 SAMPLED RESIDENTS REVIEWED FOR SAFETY, FROM A TOTAL SAMPLE OF 4, RESULTING IN THE POTENTIAL FOR ADDITIONAL FALLS. FINDINGS INCLUDE: ACCORDING TO THE CLOSED MEDICAL RECORD, RESIDENT #101 WAS A [AGE] year OLD FEMALE WHO admitted to the facility on [DATE] WITH MULTIPLE [DIAGNOSES REDACTED]. THE MINIMUM DATA SET assessment dated [DATE], IDENTIFIED RESIDENT #101 AS HAVING SEVERE COGNITION DEFICITS, WITH POOR SAFETY AWARENESS. ON 4/23/12, A CARE PLAN FOR FALLS NOTED THAT RESIDENT #101 WAS ABLE TO INDEPENDENTLY AMBULATE, AS ASSESSED BY THE THERAPY DEPARTMENT STAFF AND NURSING STAFF. ACCORDING TO THE FACILITY'S UNUSUAL OCCURRENCE REPORT DATED 4/27/12 AT 10:45 P.M., RESIDENT #101 WAS OBSERVED TO BE LYING ON THE FLOOR, IN FRONT OF HER NIGHT STAND. RESIDENT #101 DID NOT DISPLAY ANY SIGNS OF INJURY AND WAS RETURNED TO BED WITHOUT INCIDENT. A REVIEW OF THE CARE PLAN FOR FALLS DID NOT REVEAL ANY UPDATED INTERVENTIONS AFTER THE RESIDENT fell FROM HER BED ON 4/27/12. ACCORDING TO THE FACILITY'S UNUSUAL OCCURRENCE REPORT DATED 4/29/12 AT 7:30 P.M., RESIDENT #101 WAS OBSERVED TO BE AMBULATING IN THE DINING ROOM, THEN STAGGERED AND fell , HITTING THE BACK OF HER HEAD AND SUSTAINING A SMALL BUMP. THE PHYSICIAN WAS NOTIFIED, BUT NO ADDITIONAL TREATMENTS WERE PRESCRIBED. A REVIEW OF THE CARE PLAN FOR FALLS REVEALED THE FOLLOWING UPDATED INTERVENTION ON 4/29/12: OBSERVE AND ASSIST WITH ALL AMBULATION. THE INTERVENTION DID NOT ADDRESS HOW STAFF WOULD BE ABLE TO DETERMINE WHEN RESIDENT #101, WHO WAS SEVERELY COGNITIVELY IMPAIRED AND APHASIC, STARTED TO AMBULATE WHEN IN HER ROOM AND/OR NOT DIRECTLY IN VIEW OF STAFF. ACCORDING TO THE FACILITY'S UNUSUAL OCCURRENCE REPORT DATED 4/30/12 AT 11:00 P.M., RESIDENT #101 WAS OBSERVED TO BE LYING ON HER STOMACH ON THE FLOOR, NEXT TO HER BED, WITH HER CLOTHES REMOVED AND STOOL ALL OVER HER. RESIDENT #101 WAS DOCUMENTED NOT TO HAVE ANY NEW INJURIES. A REVIEW OF THE CARE PLAN FOR FALLS REVEALED THE FOLLOWING UPDATED INTERVENTION ON 4/30/12: CHECK ON RESIDENT AT BEGINNING OF SHIFT. AGAIN, THE INTERVENTION DID NOT ADDRESS HOW STAFF WOULD BE ABLE TO DETERMINE WHEN RESIDENT #101 GOT OUT OF BED TO USE THE BATHROOM. ACCORDING TO THE FACILITY'S EVALUATION OF FALLS/FALL RISK POLICY DATED 11/18/11, "CURRENT INTERVENTIONS MAY BE INSUFFICIENT AND ALTERNATE INTERVENTIONS SHOULD BE TRIED. THERE SHALL BE JUSTIFICATION FOR A DECISION NOT TO PURSUE ADDITIONAL INTERVENTIONS IN A RESIDENT WHO CONTINUES TO FALL." DURING AN INTERVIEW ON 6/1/12 AT 10:30 A.M., THE DIRECTOR OF NURSING (DON) AND ASSISTANT DIRECTOR OF NURSING (ADON) SAID THAT RESIDENT #101'S CARE PLAN FOR FALLS WAS UPDATED TO INCLUDE THE FOLLOWING: OBSERVE AND ASSIST WITH AMBULATION, AND TO CHECK ON RESIDENT AT THE BEGINNING OF EVERY SHIFT. THERE WAS NO DOCUMENTATION TO SUPPORT WHY A PERSONAL SAFETY ALARM OR FLOOR MAT WAS NOT PROVIDED TO THE RESIDENT. RESIDENT #101 WAS UNABLE TO COMPREHEND USING A CALL LIGHT OR MAKE HER NEEDS KNOWN. NEITHER THE DON NOR THE ADON COULD EXPLAIN HOW STAFF WOULD BE ABLE TO DETERMINE WHEN RESIDENT #101 NEEDED ASSISTANCE TO AMBULATE, OR USE THE BATHROOM, IF SHE (#101) WAS NOT DIRECTLY IN VIEW OF STAFF. NEITHER THE DON NOR THE ADON COULD EXPLAIN WHY A FLOOR MAT WAS NOT IMPLEMENTED AND/OR APPROPRIATE. ACCORDING TO THE HOSPITAL'S RECORDS, RESIDENT #101 PRESENTED TO THE emergency room WITH UNEQUAL PUPILS, (THE RIGHT PUPIL BEING LARGER THAN THE LEFT) ON 5/5/12. THE HOSPITAL'S COMPUTED TOMOGRAPHY (CT) SCAN OF RESIDENT #101'S HEAD SHOWED BILATERAL LARGE SUBDURAL HEMATOMAS (BLEEDING WITHIN THE SKULL) WITH AREAS OF ACUTE HEMORRHAGE (RAPID ONSET, RECENT) AND CHRONIC (SLOW ONSET, OLDER) HEMORRHAGES. ON 5/7/12, RESIDENT #101 WAS diagnosed with [REDACTED]. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE A SAFE ENVIRONMENT AND ADEQUATE SUPERVISION TO PREVENT FALLS FOR TWO (#202 AND #204) OF 4 SAMPLED RESIDENTS REVIEWED FOR SAFETY, FROM A TOTAL SAMPLE OF 4 RESIDENTS, RESULTING IN FALLS WITH INJURIES. FINDINGS INCLUDE: RESIDENT #202 RESIDENT #202 WAS A [AGE] year OLD FEMALE WHO WAS admitted to the facility on [DATE] AND REadmitted on [DATE]. RESIDENT #202 HAD [DIAGNOSES REDACTED]. PER THE MINIMUM DATA SET (MDS) ASSESSMENTS DATED 1/14/12 AND 6/21/12, RESIDENT #202 HAD SEVERELY IMPAIRED COGNITION. SHE REQUIRED EXTENSIVE TO TOTAL ASSISTANCE WITH ACTIVITIES OF DAILY LIVING. THE CARE AREA ASSESSMENT (CAA) DATED 1/14/12, DOCUMENTED THAT RESIDENT #202 REQUIRED A FALLS CARE PLAN TO MAINTAIN SAFETY AND MINIMIZE RISK FOR FALLS. REVIEW OF RESIDENT #202'S FALL CARE PLAN DATED 3/11/11 REVEALED THAT RESIDENT #202 WAS AT RISK OF FALLS RELATED TO A HISTORY OF CEREBRAL VASCULAR ACCIDENT (CVA) (STROKE), WEAKNESS, ARTHRITIS AND DEMENTIA. INTERVENTIONS TO ADDRESS RESIDENT #202'S FALL RISK INCLUDED PLACING A FLOOR PAD NEXT TO HER BED, AND PROVIDING A 2 PERSON MECHANICAL LIFT FOR TRANSFERS, AS WELL AS OTHER INTERVENTIONS. RESIDENT #202'S CLINICAL RECORD CONTAINED A NURSE'S NOTE DATED 7/12/12 AT 3:15 PM, THAT DOCUMENTED THAT RESIDENT #202 WAS OBSERVED ON THE FLOOR OF THE SHOWER ROOM, FACE DOWN, CONSCIOUS, IN PAIN WITH BLOOD AROUND HER HEAD. PER THE FACILITY UNUSUAL OCCURRENCE REPORT DATED 7/13/12, ON 7/12/12, RESIDENT #202 WAS OBSERVED LYING ON THE SHOWER ROOM FLOOR FACE DOWN WITH A LARGE AMOUNT OF BLOOD POOLED AT HER HEAD. RESIDENT #202'S LOWER LEFT EXTREMITY WAS OBSERVED TO BE ROTATED AND SHORTER THAN RIGHT. ACCORDING TO THE UNUSUAL OCCURRENCE REPORT, THE CAUSE OF THIS SITUATION WAS THAT RESIDENT #202 HAD BEEN LEFT ALONE IN AN UNUSUAL ENVIRONMENT. RESIDENT #202'S RESPONSIBLE PARTY AND PHYSICIAN WERE NOTIFIED AND PHYSICIAN ORDERS [REDACTED]. THE FACILITY REPORTED THE INCIDENT TO THE STATE AGENCY WITHIN 24 HOURS AND STARTED AN INVESTIGATION. PER THE REPORT'S FACILITY INVESTIGATION SUMMARY DATED 7/13/12, RESIDENT #202 WAS LEFT UNATTENDED IN HER WHEELCHAIR IN THE SHOWER ROOM AND SHE fell . SHE WAS SENT TO THE emergency room AND HAD SUTURES TO LACERATIONS ON LEFT FOREHEAD AND BELOW LEFT EYE. THE NURSE AND CERTIFIED NURSING ASSISTANT (CNA) INVOLVED IN THE INCIDENT WERE TERMINATED FROM THE FACILITY. ON 7/17/12 AT 2:57 PM RESIDENT #202 WAS OBSERVED IN HER ROOM ASLEEP IN A LOW BED, EQUIPPED WITH A SCOOP MATTRESS. RESIDENT #202 HAD A CALL LIGHT WITHIN HER REACH. SHE HAD SUTURES TO A LACERATION ABOVE THE LEFT EYEBROW AND SUTURES TO A LACERATION AT THE OUTER LEFT CORNER OF HER EYE, BRUISING UNDER LEFT EYE AND ON HER LEFT POSTERIOR HAND. A FLOOR MAT WAS STANDING ON EDGE, FOLDED IN HALF BETWEEN THE WALL AND BEDSIDE TABLE. ON 7/17/12 AT 3:00 PM RESIDENT #202'S ASSIGNED NURSE, LICENSED PRACTICAL NURSE (LPN) #2 WAS APPROACHED BY THE SURVEYOR AND QUERIED REGARDING RESIDENT #202'S FALL INTERVENTIONS. LPN #2 STATED SHE WOULD NEED TO CONSULT THE PROFILE IN THE COMPUTER SYSTEM. AFTER LPN #2 CONSULTED THE CARE PROFILE, SHE SAID THAT RESIDENT #202 WAS TO HAVE A FLOOR MAT WHILE IN BED. THE SURVEYOR AND LPN #2 OBSERVED RESIDENT #202 IN HER ROOM AND LPN #2 VERIFIED THE FLOOR MAT WAS NOT IN PLACE. LPN #2 PLACED THE MAT ON THE FLOOR BESIDE RESIDENT #202'S BED. ON 7/17/12, AT 3:05 PM, THE RN (REGISTERED NURSE), UNIT MANAGER (UM #15) FOR RESIDENT #202'S UNIT WAS INFORMED BY THE SURVEYOR AND LPN # 2 THAT THE FLOOR MAT WAS NOT IN PLACE. THE UNIT MANAGER HAD NO EXPLANATION AS TO WHY THE MAT WAS NOT IN PLACE AT THAT TIME. UM #15 IDENTIFIED THAT CNA #3 WAS ASSIGNED TO PROVIDE CARE TO RESIDENT #202 AT THAT TIME. CNA #3 WAS INTERVIEWED AT 3:10 PM. HE (#3) SAID THAT HE HAD RECEIVED REPORT FROM THE DAY SHIFT CNA (#7) WHO SAID EVERYTHING WAS "ALL SET." HE SAID, "I DID NOT NOTICE THE (FLOOR) MAT WAS NOT DOWN WHEN I CHECKED HER (RESIDENT #202)." DURING AN INTERVIEW ON 7/19/12 AT 12:00 PM UM #15 SAID, "ON TUESDAY (7/17/12)...THE SAFETY MAT SHOULD CERTAINLY HAVE BEEN IN PLACE, ESPECIALLY SINCE SHE (RESIDENT #202) WAS A RECENT FALL." ON 7/19/12 AT 12:12 PM, THE CNA (CERTIFIED NURSING ASSISTANT) #7 WHO HAD BEEN ASSIGNED TO RESIDENT #202 DURING THE DAY SHIFT ON 7/17/12 WAS INTERVIEWED BY PHONE. SHE SAID SHE WAS AWARE RESIDENT #202'S CARE PLAN INCLUDED A FLOOR MAT. SHE WAS UNABLE TO EXPLAIN WHY THE MAT WAS NOT IN PLACE AT THE TIME OF THE SURVEYOR'S OBSERVATION. ON 7/19/12 AT 11:10 AM, CNA #6 WAS INTERVIEWED PER PHONE. SHE STATED SHE AND ANOTHER CNA (#8) WERE ASSIGNED TO DO RESIDENT SHOWERS ON 7/12/12. SHE SAID THEY SHOWERED 1 RESIDENT AND THEN SHE (CNA #6) LEFT TO GET RESIDENT #202 FOR HER SHOWER. CNA #6 SAID WHEN SHE RETURNED TO THE SHOWER ROOM WITH RESIDENT #202, THE SHOWER ROOM WAS EMPTY. ACCORDING TO CNA #6, SHE (#6) PLACED RESIDENT #202 ON THE SCALE IN HER WHEELCHAIR TO WEIGH HER. CNA #6 SAID SHE (#6) THEN NOTICED THAT SHE (#6) DID NOT HAVE THE LIFT SLING AND LEFT RESIDENT #202 ALONE IN HER WHEELCHAIR ON THE SCALE IN THE SHOWER ROOM TO GO RETRIEVE THE SLING. CNA #6 SAID, "HER (#202) ROOM WAS CLOSE ...I WAS OUT OF THE SHOWER ROOM LESS THAN A MINUTE ...AS I WAS COMING BACK ANOTHER CNA (NOT IDENTIFIED) SAID (NAME OF RESIDENT #202) WAS ON THE FLOOR ...IT NEVER OCCURRED TO ME THAT WOULD HAPPEN." THE SURVEYOR ASKED CNA #6 IF THE FACILITY POLICY ALLOWED RESIDENTS TO BE LEFT ALONE IN THE SHOWER ROOM. CNA #6 SAID, "NO, I JUST DIDN'T THINK. I WAS IN A HURRY. IT WAS STUPID. I HAVE HAD PLENTY OF PEOPLE SAY DON'T LEAVE THEM (RESIDENTS) ALONE IF THEY ARE AT RISK OR TRY TO STAND." CNA #6 SAID, "THEY (THE FACILITY) TERMINATED ME." DURING THE INTERVIEW ON 7/19/12 AT 12:00 PM, UM #15 SAID THAT BOTH LPN #16, THE ASSIGNED NURSE FOR RESIDENT #202 ON 7/12/12 AND CNA #6 HAD BEEN TERMINATED. ACCORDING TO UM #15, LPN #16, AFTER SEEING RESIDENT #202 ON THE FLOOR, LEFT THE RESIDENT AND RAN FOR HELP. ACCORDING TO UM #15, LPN #16, WHO WAS A NEW NURSE, SAID SHE LEFT TO GET HELP AND admitted SHE WAS NERVOUS. UM #15 WENT ON TO SAY THAT SHE (#15) HERSELF WAS PRESENT AT THE TIME OF RESIDENT #202'S FALL. SHE (#15) ENTERED THE SHOWER ROOM AND OBSERVED RESIDENT #202 ON THE FLOOR NEAR THE SCALE, BLEEDING. UM #15 SAID THAT SHE (#15) PROVIDED FIRST AID TO RESIDENT #202. UM #15 SAID SHE (RESIDENT #202) SAID TO HER (#15) THAT SHE (#202) WAS HURT AND, "HELP ME, DON'T LEAVE ME." AN UNSUCCESSFUL ATTEMPT WAS MADE TO CONTACT LPN #16 PER PHONE. THE STATEMENT WRITTEN BY LPN #16 ON 7/12/12, DURING THE FACILITY INVESTIGATION WAS REVIEWED. LPN #16 DOCUMENTED SHE HEARD STAFF YELL THAT A RESIDENT WAS ON THE FLOOR IN THE SHOWER ROOM. LPN #16 DOCUMENTED THAT WHEN SHE ENTERED THE SHOWER ROOM SHE OBSERVED (NAME OF RESIDENT #202) ON THE FLOOR FACE DOWN WITH BLOOD ALL AROUND HER HEAD. LPN #16 DOCUMENTED THAT RESIDENT #202 WAS CONSCIOUS, AND ABLE TO SAY, "PLEASE HELP ME." ON 7/19/12 AT 9:55 AM THE RN, ADON (ASSISTANT DIRECTOR OF NURSING) #5 WAS INTERVIEWED. SHE (#5) SAID THAT SHE HAD CONDUCTED THE INVESTIGATION AND INTERVIEWED THE STAFF INVOLVED. SHE SAID THAT CNA #6 admitted SHE LEFT RESIDENT #202 ALONE IN THE SHOWER ROOM, WHILE SEATED IN HER WHEELCHAIR. ADON #5 SAID, "SHE (CNA #6) LEFT HER (RESIDENT #202) ALONE IN THE SHOWER ROOM UNSUPERVISED. THEY ARE NEVER SUPPOSED TO DO THAT." THE ADON SAID LPN #16 SAW RESIDENT #202 ON THE FLOOR BLEEDING AND LEFT HER (#202) TO GO GET HELP. THE ADON SAID SHE (LPN #16) WAS A NEW NURSE AND LATER admitted SHE PANICKED. ADON #5 SAID CNA #6 WAS TERMINATED FOR LEAVING RESIDENT #202 UNSUPERVISED AND LPN #16 WAS TERMINATED FOR LEAVING RESIDENT #202 WITHOUT ASSESSING HER AND PROVIDING CARE. ON 7/17/12 AT 1:50 PM AND ON 7/19/12 AT 3:00 PM THE DON (DIRECTOR OF NURSING) WAS INTERVIEWED. ON 7/17/12 THE DON SAID RESIDENT #202 WAS LEFT ALONE ON THE SCALE IN THE SHOWER ROOM BY A CNA AND fell . AFTER THE INVESTIGATION BOTH THE CNA AND NURSE INVOLVED WERE TERMINATED. ON 7/19/12 DURING THE EXIT CONFERENCE WHEN THE SURVEYOR INFORMED THE DON AND ADMINISTRATOR THAT A DEFICIENT PRACTICE WAS FOUND RELATED TO RESIDENT #202, THE DON SAID, "I DO TOO, I AGREE." PER THE HOSPITAL EMERGENCY REPORT DATED 7/12/12 AT 3:49 PM RESIDENT #202 WAS SEEN AND THEN treated for [REDACTED]. CT (COMPUTERIZED TOMOGRAPHY) OF THE HEAD REVEALED NO ACUTE INTRACRANIAL PROCESS, AND LEFT HIP X-RAY REVEALED NO DISLOCATION OR DEFINITE FRACTURE. THE FACILITY POLICY AND PROCEDURE TITLED "RESIDENT SHOWER" DATED 6/21/12, DOCUMENTED UNDER PROCEDURE NUMBER 5, "DO NOT LEAVE RESIDENT ALONE." THE FACILITY POLICY AND PROCEDURE TITLED "RESIDENT CARE PLAN," DATED 7/25/11, DOCUMENTED UNDER PROCEDURE NUMBER 9, "RESIDENT CARE PLANS GIVE DIRECTION OF CARE, EXPLICIT INSTRUCTIONS FOR CARE, ESTABLISH CONTINUITY OF CARE AND PROVIDE COMMUNICATION WITH THE HEALTH TEAM AND THE RESIDENT." RESIDENT # 204 RESIDENT #204 WAS A [AGE] year OLD FEMALE WHO WAS admitted to the facility on [DATE]. RESIDENT #204 HAD [DIAGNOSES REDACTED]. PER THE MDS (MINIMUM DATA SET) ASSESSMENTS DATED 1/23/12 AND 7/1/12, RESIDENT #204 HAD SEVERELY IMPAIRED COGNITION. SHE REQUIRED EXTENSIVE ASSISTANCE OF 1 PERSON WITH ALL ACTIVITIES OF DAILY LIVING. RESIDENT #204 HAD A CARE PLAN FOR FALLS, DATED 1/26/12, THAT NOTED THAT RESIDENT #204 WAS AT RISK FOR FALLS RELATED TO HER [DIAGNOSES REDACTED]. INTERVENTIONS TO ADDRESS HER FALL RISK INCLUDED A MOTION ALARM ON AT NIGHT ON BED OR CHAIR FOR SAFETY, STAND BY ASSISTANCE OR AT TIMES 1 PERSON ASSISTANCE FOR TRANSFERS, AND WHEN RESIDENT #204 WAS IN HER RECLINER, SHE WAS TO BE SLOPED BACKWARD TO PREVENT FALLING OUT OF THE CHAIR. RESIDENT #204'S INDIVIDUAL PLAN REPORT, PRINTED BY FACILITY STAFF DURING THE INVESTIGATION, NOTED THAT RESIDENT #204 WAS TO WEAR A WANDERGUARD (A DEVICE THAT TRANSMITS A SIGNAL WHICH ACTIVATES AN ALARM WHEN THE SIGNAL IS RECEIVED, USUALLY AT A DOORWAY), AND HAVE A MOTION ALARM AT NIGHT FOR BED OR CHAIR. FURTHERMORE, ACCORDING TO THE REPORT, RESIDENT #204 WAS UNABLE TO FOLLOW COMMANDS, WAS FULL WEIGHT BEARING WITH STAND-BY OR 1 PERSON ASSIST, AND REQUIRED THAT HER RECLINER CHAIR TO BE SLOPED BACK TO PREVENT SLIPPING OUT. ADDITIONAL INTERVENTIONS FOR RESIDENT #204 INCLUDED KEEPING TABLES AND OTHER HARD OBJECTS OUT OF HER REACH WHILE SITTING, AND MONITORING HER WHILE AMBULATING OR SITTING TO PREVENT HER FROM BUMPING HER HANDS ON HARD OBJECTS. PER THE FACILITY UNUSUAL OCCURRENCE REPORT DATED 7/14/12 AT 4:45 PM, LPN #17 DOCUMENTED THAT SHE (#17) LOOKED UP FROM THE MEDICATION CART (WHILE PASSING MEDICATIONS) AND OBSERVED THAT RESIDENT #204, WHO HAD BEEN SITTING IN THE HALL, HAD PUSHED OVER THE TRAY TABLE THAT WAS IN FRONT OF HER, TRIPPED OVER IT AND LANDED FACE FIRST ONTO THE FLOOR. RESIDENT #204 WAS BLEEDING FROM A SMALL LACERATION ON THE BRIDGE OF HER NOSE AND OUT BOTH NARES. RESIDENT #204 WAS CRYING DURING HER ASSESSMENT AND HOLDING HER SHOULDERS. RESIDENT #204 WAS SENT OUT TO A LOCAL ACUTE CARE HOSPITAL FOR TREATMENT. THE FACILITY REPORTED THE INCIDENT TO THE STATE AGENCY WITHIN 24 HOURS AND STARTED AN INVESTIGATION. PER THE REPORT DATED 7/15/12, RESIDENT #204 TRIPPED AND fell AND AN EMERGENCY EVALUATION WAS DONE. PER THE 5 DAY REPORT SENT 7/20/12, THE INVESTIGATION SUMMARY DOCUMENTED THAT CNA #13 ACKNOWLEDGED SHE WAS AWARE OF RESIDENT #204'S CARE PROFILE, WHICH INCLUDED NOT PLACING A TABLE NEXT TO THE RESIDENT. THE INVESTIGATION SUMMARY DOCUMENTED THAT CNA #13 RECEIVED DISCIPLINE FROM THE UNIT MANAGER RELATED TO NOT FOLLOWING RESIDENT #204'S PLAN OF CARE. ON 7/17/12 AT 2:40 PM, RESIDENT #204 WAS OBSERVED IN A COMMON AREA ACROSS FROM THE NURSE'S STATION. RESIDENT #204 WAS IN A RECLINER CHAIR, WITH HER FEET ELEVATED. SHE WAS OBSERVED WITH BRUISING TO HER BILATERAL EYE AREAS, CHEEK BONES AND ABOVE UPPER LIP. SHE HAD 3 SMALL SCABBED AREAS ON THE BRIDGE OF HER NOSE. RESIDENT #204 WAS NOT ABLE TO PARTICIPATE IN AN INTERVIEW. ON 7/19/12 AT 2:15 PM, CNA #13 WAS INTERVIEWED. SHE STATED THAT RESIDENT #204 WAS ON HER REGULAR ASSIGNMENT ON THE AFTERNOON SHIFT AND THAT SHE (#13) HAD PROVIDED CARES FOR HER (#204) APPROXIMATELY 9 DAYS IN THE PREVIOUS 2 WEEKS. SHE SAID THAT RESIDENT #204'S HUSBAND USUALLY CAME IN AT ABOUT 4:00 TO 4:30 PM AND WOULD SIT WITH THE RESIDENT IN HALL OUTSIDE HER ROOM AND FEED HER DINNER. CNA #13 SAID THAT SHE (#13) USUALLY TOILETED RESIDENT #204 BEFORE HER SPOUSE GOT THERE THEN WOULD WAIT FOR HER HUSBAND TO ARRIVE BEFORE SITTING HER (#204) IN A DINING CHAIR IN THE HALL OUTSIDE HER ROOM. CNA #13 SAID ON THE DAY OF THE FALL, SHE (#13) TOILETED THE RESIDENT AND SET HER IN THE CHAIR IN THE HALL ABOUT 4:20 PM. CNA #13 STATED THAT SHE (#13) THEN PLACED THE TRAY TABLE IN FRONT OF RESIDENT #204, GAVE HER (#204) SOFT FOAM SHAPES TO KEEP HER BUSY AND THEN WENT ON BREAK. WHEN ASKED IF THE RESIDENT'S HUSBAND WAS PRESENT AT THAT TIME, CNA #13 SAID NO. WHEN ASKED IF SHE (#13) INFORMED ANY OTHER STAFF MEMBER THAT RESIDENT #204 WAS SITTING IN THE HALL BY HERSELF, CNA #13 SAID THAT SHE HAD NOT, BUT ADDED, "HER HUSBAND IS USUALLY HERE." CNA #13 SAID THAT "SHE (RESIDENT #204) DOES NOT USUALLY GET UP. I WAS SURPRISED SHE DID." WHEN CNA #13 WAS ASKED IF SHE WAS AWARE OF RESIDENT #204'S CARE GUIDE, CNA #13 SAID THAT SHE (#13) "DIDN'T SEE THE TABLE (INSTRUCTION), ONLY THE HARD SURFACES PART AND DIDN'T THINK OF THE TABLE AS A HARD SURFACE." ON 7/19/12 AT 1:30 PM CNA #11 WAS INTERVIEWED. CNA #11 SAID SHE OFTEN ASSISTED RESIDENT #204 WITH FEEDING. SHE SAID THAT RESIDENT #204 ATE BREAKFAST AND LUNCH IN THE DINING ROOM AND HER HUSBAND FEEDS HER IN THE HALL WHEN HE IS IN THE BUILDING FOR DINNER. CNA #11 SAID THAT RESIDENT #204 "CANNOT BE LEFT ALONE. SHE WILL GET UP. SHE MUST BE SUPERVISED. WE LEAVE HER WITH US IN THE DINING ROOM UNTIL HER HUSBAND ARRIVES AND HE LETS US KNOW WHEN HE IS HERE AND ASKS US TO ASSIST HIM. HE THEN TELLS US WHEN HE'S LEAVING. SHE IS NOT LEFT ALONE." CNA #11 SAID, SHE WAS NOT PRESENT WHEN RESIDENT (#204) fell , BUT WAS TOLD THAT SHE WAS LEFT IN THE HALL ALONE WITH THE TRAY TABLE IN FRONT OF HER. CNA #11 SAID. "SHE (RESIDENT #204) PER HER CARE PLAN AND CARE TRACKER, IS NOT TO HAVE ANYTHING IN FRONT OF HER. SHE CAN'T SEE AND IS NOT LEFT UNSUPERVISED. I HAVE ONLY SEEN HER IN THE RECLINER TIPPED BACK OR IN BED WITH ALARMS, ALONE." WHEN ASKED IF IT IS COMMON KNOWLEDGE THAT RESIDENT #204 WAS NOT TO BE LEFT ALONE, CNA #11 ANSWERED, "YES, BECAUSE SHE WILL GET UP. THAT IS WHY WE NEVER LEAVE HER OR PLACE ANYTHING IN FRONT OF HER." ON 7/19/12 AT 2:00 PM CNA #12 WAS INTERVIEWED PER PHONE. CNA #12 STATED SHE PROVIDED CARE FOR RESIDENT #204 AS PART OF HER REGULAR ASSIGNMENT ON DAY SHIFT FIVE DAYS PER WEEK. SHE SAID THAT RESIDENT #204 COULD NOT MAKE HER NEEDS KNOWN AND REQUIRED ANTICIPATION OF HER NEEDS. CNA #12 SAID THAT SHE (#12) WAS NOT AT THE FACILITY WHEN RESIDENT #204 fell , BUT WAS TOLD SHE (#204) "WAS IN A CHAIR WITH A TABLE IN FRONT OF HER." CNA #12 SAID, "I DON'T KNOW WHY SHE WAS LIKE THAT. WE NEVER LEAVE HER UNATTENDED. I NEVER SAW ANYONE LEAVE HER ALONE LIKE THAT." WHEN ASKED, CNA #12 SAID SHE WOULD NOT LEAVE RESIDENT #204 ALONE BECAUSE SHE (#204) WOULD GET UP. CNA #12 SAID THE RESIDENT CARE PLAN INSTRUCTED NURSING STAFF THAT SHE (#204) WAS NOT TO HAVE ITEMS IN FRONT OF HER. ON 7/19/12 AT 2:30 PM, RN #14 WAS INTERVIEWED. RN #14 SAID THAT RESIDENT #204 WAS SUPERVISED IN THE DINING ROOM FOR MEALS UNLESS HER HUSBAND WAS THERE TO FEED HER. RN #14 SAID SHE HAD ONLY OBSERVED RESIDENT #204 GET UP ON HER OWN A COUPLE OF TIMES. RN #14 SAID SHE (#14) WAS AWARE THAT RESIDENT #204 WAS NOT TO HAVE ANYTHING, SUCH AS THE TRAY TABLE, IN FRONT OF HER. THIS WAS NOT FOLLOWED WHEN RESIDENT #204 fell . RN #14 SAID, "NORMALLY IF HE (HER HUSBAND) IS NOT HERE, THEY (FLOOR STAFF) TAKE HER (#204) INTO THE DINING ROOM UNTIL HE GETS HERE." ADON #5 WAS INTERVIEWED REGARDING RESIDENT #204'S FALL. ADON #5 SAID THE ASSIGNED CNA, #13, SET HER (#204) UP WITH THE TRAY TABLE IN THE HALL, EXPECTING HER HUSBAND TO COME AND FEED HER. RESIDENT #204 STOOD AND KNOCKED THE TABLE OVER AND fell FACE FIRST INTO THE FLOOR. ADON #5 SAID THAT ONE OF THE NURSES (#17) SAW IT HAPPEN BUT COULD NOT GET TO RESIDENT #204 IN TIME TO PREVENT THE FALL. LPN #17 WAS OUT OF THE FACILITY AND COULD NOT BE CONTACTED BY PHONE. THE STATEMENT WRITTEN BY LPN #17 DURING THE FACILITY INVESTIGATION ON 7/16/12 WAS REVIEWED. IT DOCUMENTED THAT LPN #17 WAS STANDING AT THE (MEDICATION) CART AND LOOKED UP AND THE TRAY TABLE WAS KNOCKED DOWN IN FRONT OF (NAME OF RESIDENT #204) AND SHE STEPPED OVER IT AND fell BEFORE ANYONE COULD GET TO HER. SHE DOCUMENTED THAT RESIDENT #204 NORMALLY ATE IN THE HALL WITH HER HUSBAND AND HE WAS NOT THERE. LPN #17 DOCUMENTED THE THAT RESIDENT'S CARE PROFILE CLEARLY SAID, "NO HARD OBJECTS NEXT TO HER." ON 7/17/12 AT 2:35 PM, CNA #1 WAS INTERVIEWED. ACCORDING TO CNA #1, SHE (#1) WAS COMING FROM ANOTHER HALLWAY WHEN SHE AND THE NURSE LPN #17, WHO WAS AT HER MEDICATION CART, OBSERVED RESIDENT #204 STAND, ATTEMPTED TO WALK AND FALL STRAIGHT FORWARD WITHOUT PUTTING HER HANDS OUT. CNA #1 SAID THAT RESIDENT #204'S NOSE WAS BLEEDING AT THE BRIDGE. ACCORDING TO CNA #1, NO ONE WAS WITH RESIDENT #204. PER THE emergency room REPORT, DATED 7/14/12 AT 5:33 PM, RESIDENT #204 WAS SEEN AND treated for [REDACTED]. THE COMPUTED TOMOGRAPHY (CT) SCAN OF THE HEAD SHOWED NO ACUTE INTRACRANIAL PROCESS. THE X-RAY OF RESIDENT #204'S RIGHT SHOULDER REVEALED NO ACUTE FRACTURE OR DISLOCATION. A SKULL X-RAY REVEALED ACUTE COMMINUTED DISPLACED FRACTURES INVOLVING BILATERAL NASAL BONES WITH OVERLYING SOFT TISSUE SWELLING AND A SMALL HEMATOMA. ON 7/19/12 AT 3:05 PM THE DON WAS INTERVIEWED REGARDING RESIDENT #204'S FALL. THE DON REVIEWED RESIDENT #204'S CARE PROFILE. SHE SAID SHE WAS NOT FAMILIAR WITH THE RESIDENT BUT SAID, "AS A NURSE OR CNA, IF I READ THIS (CARE PROFILE), I WOULD NOT LEAVE HER UNSUPERVISED ." THE FACILITY POLICY AND PROCEDURE TITLED "RESIDENT CARE PLAN," DATED 7/25/11, DOCUMENTED UNDER PROCEDURE NUMBER 9, "RESIDENT CARE PLANS GIVE DIRECTION OF CARE, EXPLICIT INSTRUCTIONS FOR CARE, ESTABLISH CONTINUITY OF CARE AND PROVIDE COMMUNICATION WITH THE HEALTH TEAM AND THE RESIDENT." ( )

This citation pertains to intake MI 622. Based on observation, interview, and record review, the facility failed to provide adequate supervision in 1 of 3 sampled residents (Resident #103) from a total sample of 3, who were identified as at risk for falls, resulting in Resident #103 sustaining a right hip fracture from a fall after being left unattended in the bathroom. Findings include: Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #103 was a [AGE] year old male readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, Resident #103 had moderate cognitive impairments and required limited to extensive staff assistance with activities of daily living. The MDS revealed Resident #103 had a history of [REDACTED]. On 3/13/12 at 10:24 AM, Resident #103 was observed in bed with eyes closed, family member at bedside. Surveyor returned to Resident #103's room on 3/13/12 at 3:30 PM and was notified by a staff member the resident had been transferred to the hospital, Surveyor unable to interview Resident #103. Review of the "Fall Risk Assessment" dated 2/22/12 revealed Resident #103 was identified as a "high" fall risk. Review of the Fall Care Plan, dated 3/1/12, revealed Resident #103 was "at high risk for falls related to impaired cognition, history of frequent falls, muscle weakness and difficulty walking". Per the Fall Care Plan, interventions included "keep a tab alarm on me at all times, provide a walker and one-person assist for all ambulation, provide one-person assist for all pivot transfers". Review of the "Unusual Occurrence Report" dated 3/5/12 at 7:30 PM, revealed the "description of the incident" as follows: "this nurse called by (Certified Nurses Aide (CNA) #12) to resident's bathroom, resident (Resident #103) lying on floor after trying to get self off toilet after (CNA #12) briefly left the room to obtain supplies". Review of the Facility Investigation Summary, dated 3/6/12, revealed "on the evening of 3/5/12 (CNA #12) helped (Resident #103) into his bathroom. She (CNA #12) momentarily left to retrieve a gown for the resident and upon returning to the room observed the resident on the bathroom floor". In an interview on 3/13/12 at 11:28 AM, CNA #12 stated she assisted Resident #103 to the bathroom, positioned him on the toilet and left the room to get some supplies, wipes and a gown, and "maybe was gone 30 seconds". CNA #12 stated when she entered back into the room the family member present in Resident #103's room, stated "I think he is on the floor". CNA #12 stated she then observed Resident #103 on the floor in the bathroom. CNA #12 stated she was "taught not to leave a resident alone in the bathroom...he has a tab alarm...it tells you that he is a high fall risk...I understand that, I take full responsibility for it..." In an interview on 3/13/12 at 2:00 PM, CNA #16 stated she had assisted Resident #103 to the bathroom in the past, prior to the fall. CNA #16 stated when she toileted Resident #103, she left him in the bathroom, while she remained outside the door with her ear to the door, and upon peeking her head back in the bathroom, Resident #103 had walked over to the sink from the toilet. CNA #16 stated she had "never met the man before"..."I didn't read the care tracker (care guide for aides) for him, I was just answering a call light". Review of the Physician order [REDACTED].#103. Review of the Radiology Report (x-ray) dated 3/5/12, revealed Resident #103 sustained an "acute intertrochanteric femoral fracture with mild displacement with varus angulation" (femur fracture). Review of the Physician order [REDACTED]. ( )

THIS CITATION PERTAINS TO MI 354 BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT ACCIDENTS AND PROVIDE APPROPRIATE SUPERVISION IN 1 OF 2 SAMPLED RESIDENTS (#502) WHO WERE AT RISK FOR BURNS FROM MOIST HOT PACKS, IN A TOTAL SAMPLE OF 4 RESIDENTS, RESULTING IN RESIDENT #502 RECEIVING A SECOND DEGREE BURN TO HIS RIGHT KNEE AFTER AN APPLICATION OF A MOIST HOT PACK. FINDINGS INCLUDE: REVIEW OF THE FACE SHEET IN THE MEDICAL RECORD (UNDATED) REVEALED RESIDENT #502 WAS A [AGE] year OLD MALE admitted to the facility on [DATE]. REVIEW OF THE MINIMUM DATA SET ((MDS) dated [DATE] REVEALED RESIDENT #502'S [DIAGNOSES REDACTED]. THE MDS REVEALED RESIDENT #502 REQUIRED TOTAL DEPENDENCE WITH ACTIVITIES OF DAILY LIVING (ADL'S). REVIEW OF THE COGNITION CARE PLAN DATED 2/8/11 REVEALED RESIDENT #502 WAS "COGNITIVELY IMPAIRED WITH NO ABILITY TO MAKE DECISIONS FOR HIMSELF RELATING TO HIS CARE OR TREATMENT DUE TO HIS SEVERE TRAUMATIC BRAIN INJURY SECONDARY TO AUTOMOBILE ACCIDENT." REVIEW OF A "RESTORATIVE CARE PROGRAM" DOCUMENT DATED 4/29/09 REVEALED RESIDENT #502 WAS discharged FROM PHYSICAL THERAPY AND BEGAN A RESTORATIVE PROGRAM WITH MOIST HOT PACKS FOR 20 MINUTES ON HIS RIGHT KNEE TO IMPROVE RANGE OF MOTION AND CONTRACTURES. REVIEW OF THE MEDICAL RECORD REVEALED RESIDENT #502 DID NOT HAVE A CARE PLAN FOR MOIST HOT PACKS. IN AN INTERVIEW ON 2/22/12 AT 3:00 PM, PHYSICIAN #5 REPORTED SHE DID NOT ORDER THE MOIST HOT PACKS AND WAS UNAWARE OF RESIDENT #502'S MOIST HOT PACK TREATMENTS. PHYSICIAN #5 REPORTED SHE DID NOT THINK THE MOIST HOT PACKS WERE APPROPRIATE FOR RESIDENT #502 AND WOULD NOT HAVE ORDERED THEM FOR RESIDENT #502 DUE TO HIS LACK OF COMMUNICATION WITH STAFF. REVIEW OF A NURSE'S NOTE DATED 1/12/12 REVEALED RESIDENT #502 HAD A BULL'S EYE RASH ON HIS RIGHT KNEE AND WAS SENT TO THE HOSPITAL TO RULE OUT LYME'S DISEASE OR A SPIDER BITE. REVIEW OF A HOSPITAL DOCUMENT DATED 1/12/12 REVEALED RESIDENT #502 HAD CELLULITIS (SKIN INFECTION). REVIEW OF A LABORATORY REPORT DATED 1/12/12 REVEALED RESIDENT #502'S WOUND CULTURES TO HIS RIGHT KNEE WERE NEGATIVE FOR INFECTION. REVIEW OF A physician's orders [REDACTED].#502'S RIGHT KNEE THREE TIMES A DAY FOR SEVEN DAYS. REVIEW OF A NURSE'S NOTE DATED 1/13/12 REVEALED ON 1/13/12 AT 6:25 AM, REGISTERED NURSE (RN) #3 OBSERVED RESIDENT #502'S RIGHT KNEE AND IT APPEARED "LESS REDDENED" WITH NO INDURATION OR FLUID FILLED BLISTER. IN AN INTERVIEW ON 2/17/12 AT 10:45 AM, RESTORATIVE CERTIFIED NURSING ASSISTANT (CNA) #4 REPORTED ON 1/13/12 AT APPROXIMATELY 6:30 AM, SHE APPLIED THE MOIST HEAT PACKS TO RESIDENT #502'S KNEES AND SET HER TIMER FOR 20 MINUTES AND LEFT THE ROOM. CNA #4 REPORTED AFTER THE TIMER WENT OFF, SHE TOOK THE MOIST HOT PACKS OFF HIS KNEES. CNA #4 REPORTED SHE DID NOT ASSESS RESIDENT #502'S KNEES PRIOR, DURING, OR AFTER APPLYING THE MOIST HEAT PACK AND WAS UNAWARE THAT RESIDENT #502 HAD A RASH ON HIS RIGHT KNEE. CNA #4 REPORTED SHE WAS NOT IN RESIDENT #502'S ROOM WHILE THE MOIST HOT PACKS WERE ON HIS KNEES. IN AN INTERVIEW ON 2/21/12 AT 11:25 AM, RN #3 REPORTED ON 1/13/12 AT 6:45 AM, SHE WENT INTO RESIDENT #503'S ROOM TO ADMINISTER MEDICATIONS AND OBSERVED THE MOIST HOT PACKS ON BOTH KNEES. RN #3 REPORTED ON 1/13/12 AT 8:30 AM, SHE WENT BACK INTO RESIDENT #502'S ROOM TO APPLY BACTROBAN OINTMENT TO HIS RIGHT KNEE AND OBSERVED A LARGE REDDENED AREA WITH A SMALL BLISTER IN THE CENTER. REVIEW OF A physician progress notes [REDACTED]. THE NOTE REVEALED RESIDENT #502'S RIGHT KNEE LESION WAS A SECOND DEGREE BURN CAUSED BY THE MOIST HOT PACK. THE NOTE REVEALED THE PHYSICIAN ORDERED SILVADENE (BURN CREAM) TWICE A DAY TO RESIDENT #502'S RIGHT KNEE UNTIL CLEAR. REVIEW OF THE MOIST HOT PACK'S POLICY AND PROCEDURE DATED 4/02 REVEALED A MOIST HOT PACK WAS "A FORM OF MOIST HEAT APPLIED LOCALLY WHICH PRODUCES A HEATING EFFECT TO THE SUPERFICIAL SKIN OF THAT AREA. THE PACKS ARE SILICA GEL IN A COTTON PACK, WHICH IS STORED IN A HYDROCOLLATOR UNIT AT 157-168 DEGREES FARENHEIT." THE DOCUMENT REVEALED CONTRAINDICATIONS OF HOT PACKS INCLUDED "ACUTE INJURY OR INFLAMMATION, IMPAIRED SENSATION, AND/OR MENTATION." THE DOCUMENT REVEALED "THE RESIDENT MUST BE SUPERVISED WHILE RECEIVING THE HOT PACK AND/OR A CALLING DEVICE PROVIDED TO THE RESIDENT" AND "THE SKIN MUST BE CHECKED AFTER 5 MINUTES AND AGAIN AFTER 10 MINUTES TO SEE IF IT IS TOO HOT." THE DOCUMENT REVEALED A physician's orders [REDACTED]. IN AN OBSERVATION ON 2/17/12 AT 9:10 AM, RESIDENT #502 WAS IN BED AND WAS UNABLE TO RESPOND TO VERBAL STIMULI. RESIDENT #502 APPEARED WELL-GROOMED AND COMFORTABLE. RESIDENT #502'S KNEE APPEARED SLIGHTLY PINK IN COLOR WITH FLAKING SKIN IN THE CENTER. ( )