Every finding on record at Lake Woods Nursing & Rehabilitation Center

Based on observation interviews and record review, the facility failed to maintain the kitchen exhaust system, potentially decreasing the system's ability to capture grease, smoke and particulate matter. Findings include:On 06/22/2026 at 8:58AM, observed the ventilation hood over the cookline in the main kitchen had three empty spaces that did not have a filter or spacer, and exposing the interior of the ductwork. During the observation, the Dietary [NAME] (DC) L was asked where the filters were and DC L answered they were stored on the cookline, next to cooking equipment, because they had fallen out of the tracks, of the hood, that the filters fit in. On 06/22/2026 at 10:45AM, during the interview with the Maintenance Director (MD) B it was stated the filters had fallen out of the tracks for the hood more than once. MD B indicated that filters did not seem to stay in the hood because the pins used to secure them were not the correct size and would not secure the filters into the hood. MD B said he has been in contact with the contractors who clean and service the hood system over the cookline, regarding the filter issue. According to the 2022 FDA Food Code Section 4-202.18 Ventilation Hood Systems, Filters.Filters or other grease extracting EQUIPMENT shall be designed to be readily removable for cleaning and replacement if not designed to be cleaned in place.According to the 2022 FDA Food Code Section 4-301.14 Ventilation Hood Systems, Adequacy. Ventilation hood systems and devices shall be sufficient in number and capacity to prevent grease or condensation from collecting on walls and ceilings.

Based on observation and interview, the facility failed to maintain a clean and homelike environment for 4 bathrooms of 4 bathrooms observed for cleanliness. Findings include: During an observation on 6/22/26 at 9:18 AM, the bathroom that joined rooms [ROOM NUMBERS] had a dusty metal shelf below the mirror and above the sink, a sticky floor, dim lighting, and the walls and the heating register was dirty. The air return duct had caked on dust as well. During an observation on 6/22/26 at 10:07 AM, room [ROOM NUMBER] had a dusty and dirty metal shelf below the mirror and above the sink was dusty with some residual dirty spots. The walls were dirty and the air vent fan had caked on dust. During an observation on 6/22/26 at 10:09 AM, the bathroom that joined rooms [ROOM NUMBERS] had dim lighting, the walls were dirty, and the air vent had caked on dust. During an observation on 6/22/26 at 10:12 AM, the bathroom that joined rooms [ROOM NUMBERS] had dim lighting, large area of dried spackle on the walls, and the air vent had caked on dust. During an observation and an interview, the Maintenance Director (MD) B observed the bathrooms with the concerns and agreed with the observations. MD B reported they will clean the rooms and the lighting should be better.

Based on interview and record review, the facility failed to maintain complete medical records for 1 of 17 sampled residents (R61). Findings include: A review of R61's admission Record, dated [DATE], revealed R61 was a [AGE] year-old resident that was admitted to the facility on [DATE]. In addition, R61's admission Record revealed they had multiple diagnoses that include early onset Alzheimer's Disease, anxiety, paranoid personality disorder, antisocial personality disorder, dementia with agitation and behaviors,and cerebral infarction (stroke). A review of R61's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 10 which revealed R61 was cognitively intact. A review of R61's Letters of Guardianship, dated [DATE], revealed R61's Letters of Guardianship expired on [DATE]. A review of R61's electronic medical record, dated [DATE] to [DATE], failed to reveal current Letters of Guardianship. A review of R61's electronic medical record also failed to reveal if the facility had contacted the court to obtain current Letters of Guardianship and/or obtain a court date to address guardianship. During an interview on [DATE] at 9:00 AM, Social Services Representative (SSR) A stated she would see if R61 had current Letters of Guardianship and/or if there was a court date to have guardianship re-addressed. She stated she would follow up with me when she found more information. During a second interview on [DATE] at 10:05 AM, SSR A stated she could not find R61's current Letters of Guardianship in his medical record. She stated she knew she received them from the court at some point and sent them to the medical records person to file. SSR A further stated sometime between when she sent them to be filed and now, they became lost. She stated she did not realize that they were not scanned into R61's medical record until I mentioned something to her that morning and she looked and could not find them. SSR A stated she had to contact the court to get another copy after I had spoken to her. Timely documentation of the following types of information should be made and maintained in a patient's EHR to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care. Patient documentation frequently is used by professionals who are not directly involved with the patient's care. If patient documentation is not timely, accurate, accessible, complete, legible, readable, and standardized, it will interfere with the ability of those who were not involved in and are not familiar with the patient's care to use the documentation. (ANA's (American Nursing Association) Principles for Nursing Documentation- Guidance for Registered Nurses, 2010, www.nursingworld.org, retrieved on [DATE]).

This citation is related to intakes 2963901 and 2980259Based on interview and record review, the facility failed to complete a full assessment, after a fall and before moving one resident (Resident #100) out of three residents reviewed for accidents and hazards. Findings:Resident #100 (R100) Review of an admission Record revealed R100 was a [AGE] year-old female, last admitted to the facility on [DATE], with pertinent diagnoses of dementia, weakness, difficulty in walking, and need for assistance with personal care. Review of an Unwitnessed Fall report for R100, dated 3/15/26 at 11:00 PM, revealed (a) staff heard R100 yelling and went to her room to check on her, (b) R100 was observed on the floor and told staff that she felt like she broke her right leg and that her right knee and hip hurt, (c) staff were unable to do range of motion without causing pain to R100, (d) a skin tear to the right arm was assessed, cleaned and bandaged, and (e) pain medication was given to R100. The report also described R100's reaction to the pain as (a) repeated troubled calling out, loud moaning or groaning, and crying, (b) facial grimacing, and (c) unable to console, distract or reassure. The immediate intervention implemented .to assist R100 off off the floor, provide first aide and address pain.During an interview on 4/14/26 at 6:25 AM, Registered Nurse (RN) G stated that she responded to R100's room on 3/15/25 around 11:00 PM (along with Certified Nurse Aide C) after hearing R100 yelling out. R100 laid on the floor yelling out in pain. RN G and Certified Nurse Aides (CNA) C and D got R100 up into a wheelchair, then assessed R100 and checked neuro's. R100 had significant pain in her hip and was given a Norco. R100 was moved out into the common area in the wheelchair for increased supervision and CNA D and CNA O stood R100 up to complete a more thorough skin assessment and then sat R100 back down into the wheelchair. R100 was having increased pain in her leg and a dose of Morphine was given. R100 continued to call out I broke my leg, I broke my leg. RN G and two CNA's transitioned R100 into her bed with the use of stand and pivot transfer method and R100 did not want to put weight on her leg, yelled out during the transfer, and the transfer was a rough moment for R100.Review of a hand written 'Witness Statement completed by RN G and signed 3/15/26, reflected the following information related to R100's fall on 3/15/26: (a) heard screaming from R100's room, (b) ran to the room and found R100 on the floor, R100 expressed pain in her right knee and right hip, a skin assessment revealed a 13 centimeter skin tear on the right arm, and R100 was given pain medication and placed into the wheelchair. Review of a nursing Progress Note dated 3/16/26 at midnight reflected .(R100) stated that she feels like she broke her right leg and stated that her right knee and right hip hurt.During an interview on 4/13/25 at 10:50 AM, CNA C reported that on the evening of 3/15/26, R100 was heard yelling, staff went to R100's room and found her on the floor and yelling call an ambulance I broke my leg. CNA C assisted R100 into a wheelchair with the assistance of two other staff persons. R100 was moaning in pain. During an interview on 4/13/26 at 7:09 PM, CNA D reported (a) entering R100's room and RN G and CNA C were already in the room, (b) R100 laid on the floor yelling out in pain, (c) all three staff stood R100 up and moved her to a wheelchair, and (d) R100 was yelling most of the night because she was in pain. Review of the facility policy/procedure Accident/Incident Report Fall Management last revised 06/2018, revealed .when a resident is observed on the floor and presumed to have fallen, an initial sequential assessment that includes a minimum of the following will be completed by a licensed nurse (a) full body inspection for any obvious deformity, bleeding, bruising, laceration or other signs of traumatic injury, (b) assessment for pain, (c) assessment for active followed by passive range of motion, (d) assessment of head injury with initial neurological evaluation if indicated, (e) vital signs, and (f) evaluation of indication for emergency medical treatment .The resident should not be moved until the initial evaluation is completed .the goals of lifting and moving a resident with a suspected fracture are to minimize the chance of a lifting-related injury and to minimize movement and stress on the resident's injury .to meet these goals the licensed nurse will explain the plan to the caregivers and resident prior to lifting, taking care to guard or splint the injured area before moving. Review of an article After the fall: a step by step approach to post-fall assessment revealed .It is important not to move a resident who has fallen until they are evaluated. Make sure the resident has not been seriously injured, don't assume that no injury has occurred-this can be a devastating mistake .observe leg rotation and look for hip pain, shortening of the extremity and pelvic and spinal pain. https://blog.healthpropress.com/2018/01/after-the-fall-a-step-by-step-approach-to-post-fall-assessment/

This citation pertains to intake #2708299.Based on interview and record review, the facility failed to provide services according to professional standards of practice for 1 resident (R104) of 6 residents reviewed.Findings include:Review of an admission Record revealed R104 admitted to the facility on [DATE] with pertinent diagnoses which included orthopedic aftercare and dementia.In a telephone interview on 2/9/2026 at 3:29 PM, Family Member I reported the facility did not ensure R104 went to his orthopedic follow up appointment after he admitted to the facility.Review of R104's local hospital After Visit Summary, dated 12/3/2025, revealed he was scheduled to have a post-op visit with the orthopedic specialist on 12/12/2025 at 1:45 PM.Review of R104's Interdisciplinary Documentation dated 12/12/2025 at 9:19 PM revealed .His significant other called this writer tonight and was concerned he had missed his (orthopedic follow up appointment) scheduled for today 12/12/25 at 1345 with (orthopedic surgeon), she had a reminder sent to her phone per (significant other). (orthopedic office) will need to be contacted and (appointment) made for his post op (follow up) .Review of R104's Interdisciplinary Documentation dated 12/24/2025 at 5:06 PM revealed .Resident had (follow up) visit with Ortho.In an interview on 2/10/2026 at 10:04 AM, Medical Records Manager (MRM) E reported she was on leave when R104 was admitted to the facility on [DATE] and her job duties were being covered by another staff member. MRM E reported the local hospital After Visit Summary should have been reviewed by staff at the time of his admission and necessary follow up appointments should have been scheduled. MRM E reviewed her logs and reported she could see no documentation that R104's post-op follow up appointment was noted and scheduled at the time of his admission.In an interview on 2/10/2026 at 10:40 AM, the Director of Nursing (DON) reported she was uncertain why R104 missed his post-op follow up appointment scheduled for 12/12/2025. The DON reported she could not find documentation to explain how this was missed.

Based on observation, interview and record review, the facility failed to prevent a pressure ulcer for 1 Resident (R26) of 2 Residents reviewed for pressure ulcers resulting in R26 developing a stage 3 pressure ulcer. Findings included: Review of R26 Admission Record dated 5/1/25 revealed he was [AGE] years old, admitted on [DATE] and had diagnoses that included: diabetes mellitus 2, abnormal posture, major depressive disorder, muscle weakness, muscle spasms, muscle wasting and atrophy, glaucoma, and dementia. He was his own responsible party. R26 was observed receiving a bed bath on 4/29/25 at 9:47 AM. R26's head was tilted to the left and he was unable to move his neck to an upright position. R26 was able to move his right hand and arm. R26 was not able to move his left hand, left arm or both legs. R26 yelled out in pain every time he was moved. Two Certified Nurse Aides (CNA's) provided the care. Every time they moved R26 they verbally informed him just prior to moving him. Once he was not moving, he stopped yelling. They talked to him about what kind of snack he wanted after they were done with care to distract him from his pain. They elevated his left foot on a pillow when they were completed with care. No other pressure relieving device for the foot was observed. R26's left foot was wrapped with gauze dated 4/29/25. R26's specialty air mattress was set on firm. The CNA's were asked what R26's specialty air mattress was to be set at, and they did not know the setting or change the setting when they completed the care. During an interview with the Director of Nursing (DON) on 5/1/25 at 11:12 AM, R26 had a facility acquired pressure ulcer, stage 3, ulcer on his left heel that was discovered on 3/4/25 and measured 3.0 x 3.0. The DON said R26 had a history of pressure ulcers. The DON provided a timeline of measurements for this wound. The last measurement was dated 4/04/25 and measured 3.0 x 1.1 x 0.2. The next measurement was on 4/10/25 and revealed the pressure ulcer was on the left heel and left lateral foot, measured 3.0 cm x 2.8 cm x 0.2 cm. The last measurement for the left heel and left lateral foot was dated 4/24/25 and measured 1.2 cm x 0.8 cm x 0.2. cm The DON was not able to find the cause for the pressure ulcer. Review of the facility pressure ulcer policy did not reveal any process for determining the cause of a pressure ulcer. During an interview with the DON and Nursing Home Administrator (NHA) on 4/30/25 at 2:49 PM the Surveyor reported that R26's specialty mattress was set on the firm setting yesterday and staff did not know what setting the specialty mattress was supposed to be at. The NHA said she currently had the manuals on her desk for the mattress and they were working on reviewing and implementing a plan to address this. The surveyor requested a copy of the mattress manual. The DON went to R26's room with the surveyor at this time and the mattress was set on comfort and the toggle for alternative or float was in the middle position (not the same settings as observed on 4/29/25). The DON could not say what R26's setting should be or if the toggle switch was to be in the middle position. Upon exit the facility did not provide the mattress manual or provide clarification of the proper settings for R26's mattress. R26 had a pressure-relieving boot on the end of the bed that was not on him. The DON offered to put the pressure-relieving boot on R26's foot but he refused to let her. R26's left foot was floated up on a pillow. During an interview with the DON on 5/1/25 at 11:12 AM, the DON was not able to locate any physician notes or interdisciplinary notes that discussed the cause of R26's pressure ulcer. The DON referred to R26's care plan that indicated he refuses care at times. The DON was not able to locate any documentation of R26's refusing pressure relief prior to 3/4/25 when he was noted to have a stage 3 pressure ulcer on his left heel or any discussion with R26's guardian about pressure relief refusals. The DON referred to R26's care plan which indicated that he refused care at times. The DON did not have any expectations for staff to document, reapproach or attempt to determine the reason for R26's refusal to allow care or pressure relief. During a telephone interview with R26's guardian on 5/1/25 at 12:31 PM, the guardian was not aware R26 was refusing pressure relief prior to the development of the pressure ulcer on his left heel. The guardian was aware R26 had a pressure ulcer. The guardian was aware R26 gets angry and refuses care at times but said he can get over it quickly and then allows care. The guardian said she has asked the facility to reach out to R26's brother by telephone when he is refusing care as his brother can help calm him down better than she can. Review of R26's care plan dated 4/27/25 revealed, R26 clinical condition reveals skin integrity impairment is unavoidable evidenced by his preferred sedentary preference to remain in bed despite education of associated risks. He has muscle wasting and atrophy, exposure of skin to fecal and urinary incontinence, poor nutritional intake and his chronic pain. Other risk factors include his diagnosis of diabetes resulting in altered sensation due to neurological damage and delayed wound healing. He has the propensity to decline cares, treatments and staff members that he is not familiar with. Foot drop to the left foot and pressure injury to the left foot. Hx (history) of pressure to his buttock that is resolved. Interventions included, alternating pressure mattress at preferred settings (resident and staff were not able to state preferred settings), ensure resident is wearing a (name of pressure relieving) boot while in bed to reduce pressure on heals, initiated 12/2/24 (not offered during observation on 4/29/25 and refused during observation on 4/30/25), Off-load heels in bed onto pillows as he will accept, Inspect with care and report changes promptly to charge nurse, initiated 4/27/25 (No indication to report residents refusal of pressure relief, or devices or time frame to reapproach or best approach were located or to contact guardian or his brother with refusals were located). Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, Repositioning (turning) patients is a consistent element of evidence-based pressure injury prevention (EPUAP, NPIAP, PPPIA, 2019a). The twofold aim of repositioning should be to reduce or relieve pressure at the interface between bony prominence and support surface (bed or chair) and to limit the amount of time the tissue is exposed to pressure (Maklebust and [NAME], 2016). Elevating the head of the bed to 30 degrees or less decreases the chance of pressure injury development from shearing forces (WOCN, 2016). Change the immobilized patient's position according to tissue tolerance, level of activity and mobility, general medical condition, overall treatment objectives, skin condition, and comfort (EPUAP, NPIAP, PPPIA, 2019a). A standard turning interval of 1.5 to 2 hours does not always prevent pressure injury development; repositioning intervals are based on patient assessment. Some patients may need more frequent position changes, while other patients can tolerate every-2-hour position changes without tissue injury. When repositioning, use positioning devices to protect bony prominences (WOCN, 2016). [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 1255). Elsevier Health Sciences. Kindle Edition.

Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents in the facility. Findings include: During a tour of the facility, with Maintenance Director (MD) I, at 1:44 PM on 4/29/25, observation of the Soiled Utility room, near the salon, found brown discolored water dispensed out of the hot and cold-water fixtures when the faucet above the hopper was turned on. When asked if this was an area that is regularly flushed, MD I stated they were not flushing this fixture and have been focusing on vacant rooms. During a tour of the facility, at 2:00 PM on 4/29/25, observation of the Soiled Utility room, near resident room [ROOM NUMBER], found little to no water filling the basin of the commode, indicating the hopper had not been flushed in so long the water had evaporated from the basin. Water dispense from the mop sinks hot and cold fixtures were found discolored before running clear. During a tour of the Spa room near the end of the hall, at 2:05 PM on 4/29/25, it was observed that a shower in the corner of the spa room was found with equipment and supplies on the floor of the shower area. Further review of the shower found dust accumulation on the shower hose and spray wand. When asked if this was an area that gets flushed, MD I stated that its not. When the surveyor tried to flush the water from the shower, neither the surveyor nor MD I could get the water to run. MD I stated he would look into it. During a tour of the janitors sink near the end of the hall, at 2:11 PM on 4/29/25, it was observed that no cold handle was available to turn on the cold supply on. Upon turning the hot supply into a bucket, the water was brown and discolored and turned clear. Using a [NAME] tool to open on the cold supply, dark black turning to brown water dispensed from the fixture for five to ten seconds. During a tour of the laundry room, at 2:25 PM on 4/29/25, it was observed that a hot water line near the washing machine was found not in use, with no handle and with a cap covering the hose bib where the water would dispense. When asked if this is something that gets routinely flushed, MD I stated it does not. During an interview with MD I and Director of Facilities (DOF) J it was found that the facility currently does an annual test for free chlorine. When asked if any of the free chlorine measurements are taken from the hot water supply. DOF J stated he has only been doing cold water samples. When asked if any testing is done on the two hot water systems that service the residents of this facility, Director of Facilities J stated that they will start to incorporate readings in those areas as well. A review of the facility provided document entitled .Executive Summary and Risk Assessment, dated 2021, found that: The (Water Management) team considers the water distribution system for adherence to control measure and critical limits listed in the CDC Toolkit for Controlling Legionella in Potable Water Systems which include: .Water Age, Flushing, Flush low-flow pipe runs and dead legs at least weekly. Flush infrequently used fixtures regularly.

Based on observation and interviews, the facility failed to maintain a safe, functional, sanitary, and comfortable environment. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living. Findings Include: During a tour of the facility with Maintenance Director I, starting at 1:29 PM on 4/29/25, observation of the spa room near activities, found a strong odor and bowel movement in the commode with clean folded towels stacked next to the sink. Further observation of the shower floor found an area near the front of the shower where roughly a dozen one-inch square tiles were missing. When asked if he was aware of the floor, MD I stated he was not. While looking for the missing tiles, MD I picked up a piece of trash on the shower floor and found it to be a gold tooth filling. When asked if he knew of any residents missing one, MD I was unsure. During a tour of the clean linen room, at 1:35 PM on 4/29/25, it was observed that the bottom rack of the clean linen cart was open wire shelving, leaving clean linens at the bottom of the cart open and exposed to contamination. Further observation under the linen cart found an accumulation of trash, dust, and dirt. When asked if the cart ever gets moved out of the room, MD I stated it usually stays there. During a tour of the spa room near the end of the hall, at 2:05 PM on 4/29/25, it was observed that bowel movement was in the commode and found smeared on the padded cover for the plumbing under the sink. Further observation of the room found a corner shower area not in use with dust accumulation on equipment and the shower fixture.

Based on interview and record review, the facility failed to maintain complete medical records for 2 of 17 sampled residents (R26 and R36). Findings include: Timely documentation of the following types of information should be made and maintained in a patient's (resident's) EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care- Assessments; Clinical problems; Communications with other health care professionals regarding the patient . Order acknowledgement, implementation, and management; Patient clinical parameters . Patient documentation frequently is used by professionals who are not directly involved with the patient's care. If patient documentation is not timely, accurate, accessible, complete, legible, readable, and standardized, it will interfere with the ability of those who were not involved in and are not familiar with the patient's care to use the documentation. (ANA's (American Nursing Association) Principles for Nursing Documentation- Guidance for Registered Nurses, 2010, www.nursingworld.org). R26 A review of R26's Admission Record, dated 5/1/25, revealed R26 was a [AGE] year-old resident admitted to the facility on [DATE]. R26's Admission Record revealed they had multiple diagnoses that included depression and diabetes. A review of R26's Pharmacist Medication Regimen Reviews, dated 6/1/24 to 5/1/25, revealed the pharmacist had noted potential medication and/or medication-related (e.g., reason for use of a medication, adequate monitoring of a medication, etc.) irregularities on 8/6/24, 11/4/24, and 4/3/25. However, a review of R26's medical record failed to reveal what those irregularities and/or pharmacist recommendations were. On 5/1/25 at 11:30 AM, the Nursing Home Administrator (NHA) was notified that the surveyor could not locate in R26's medical record the pharmacist's recommendations for the irregularities that were noted in the Pharmacist Medication Regimen Reviews for 8/6/24, 11/4/24, and 4/3/25. Copies of those recommendations were requested from the NHA, if they were located. On 5/1/25 at 1:15 PM, the facility provided the surveyor with copies of R26's pharmacist recommendations with supporting documentation for 8/6/24, 11/4/24, and 4/3/25. However, a second review of R26's medical record failed to reveal that these recommendations were present in the medical records. During an interview on 05/01/25 at 02:57 PM, Clinical Support (CS) G stated that R26's 8/6/24, 11/4/24, and 4/3/25 pharmacy recommendations were not in R26's medical record. CS G stated the 8/6/24 recommendation was a nursing one and they were previously not entering them into residents medical records. CS G further stated the 11/4/24 recommendation was in the pharmacy computer system, and they had to get it from there today. In addition, CS G stated the 4/3/25 recommendation had been signed by the physician but was still waiting to be uploaded into R26's medical record (it had been signed on 4/7/25- 24 days prior to this interview). R36 A review of R36's Admission Record, dated 5/1/25, revealed R36 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R36's Admission Record revealed multiple diagnoses that included congestive heart failure and osteoarthritis. A review of R36's Pharmacist Medication Regimen Reviews, dated 6/1/24 to 5/1/25, revealed the pharmacist had noted a potential medication and/or medication-related irregularity on 12/3/24. However, a review of R36's medical record failed to reveal what the irregularity and/or pharmacist recommendation was for 12/3/24. On 5/1/25 at 11:30 AM, the Nursing Home Administrator (NHA) was notified that the surveyor could not locate in R36's medical record the pharmacist's recommendation for the irregularity that was noted in the Pharmacist Medication Regimen Review for 12/3/24. A copy of the 12/3/24 pharmacist's recommendation with supporting documentation (if applicable) was requested from the NHA. On 5/1/25 at 12:10 PM, the facility provided the surveyor with a copy of R36's pharmacy recommendation for 12/3/24 with supporting documentation. However, a second review of R36's medical record failed to reveal that the pharmacist's recommendation for 12/3/24 was present in the medical record. During an interview on 05/01/25 at 01:44 PM, CS G stated R36's pharmacy recommendation for 12/3/24 was not in R36's medical record. CS G stated the recommendation had been in the pharmacy's computer system and the facility was able to obtain information from that system.

Based on observation, interview, and record review, the facility failed to prevent accident hazards by safely transporting a resident in a wheelchair for 1 (R34) and monitoring one resident (R42) known for pocketing food during meals of 6 residents reviewed for accident hazards. Findings include: A review of R34's Admission Record, dated 4/30/25, revealed R34 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, the Admission Record revealed multiple diagnoses that included unsteadiness on feet, difficulty walking, dementia, bipolar disorder, schizophrenia, Parkinsonism, generalized muscle weakness, and dizziness and giddiness. A review of R34's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 1/7/25, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 13 which revealed R34 was cognitively intact. In addition, R34's MDS revealed they had a one-sided lower extremity range of motion impairment and could operate a manual wheelchair with supervision or touching assistance (helper provides verbal cues and/or touching/steadying assistance). A review of R34's functional mobility and ADL's (activities of daily living) care plan, revised 12/13/24, revealed R34 needs encouragement to propel his own wheelchair, but staff can assist him as needed. During an observation on 04/30/25 at 12:05 PM, R34 stopped Scheduling Manager (SM) A in the hallway and asked her to take him to the Bathing room. SM A looked directly at the surveyor as they approached and walked by R34 and herself, stated she would help him after the surveyor had passed by them, and then pushed R34 in his wheelchair without foot pedals from the hallway outside room [ROOM NUMBER], down the hall, and to the Bathing room next to The Shore Nursing Station. During an interview on 05/01/25 at 08:20 AM, Certified Nursing Assistant (CNA) C stated, They (residents) need foot pedals for us to push them. CNA C further stated even if a resident can lift their feet and/or legs, staff still need to put foot pedals on their wheelchair before pushing it down the hallway. During an interview on 05/01/25 at 08:25 AM, CNA E stated residents need to have foot pedals on their wheelchair before staff can push them down the hallway. CNA E also stated that even if a resident can lift their feet and/or legs, staff still need to put foot pedals on their wheelchair before pushing it down the hallway. On 05/01/25 at 09:15 AM, a copy of the facility's policy and procedure on staff transporting residents in their wheelchairs was requested from the Nursing Home Administrator (NHA). During an interview on 05/01/25 at 01:20 PM, SM A stated staff are only supposed to push residents in their wheelchairs when they have foot pedals. SM A further stated they are never supposed to push them without foot pedals down the hallway. During an interview on 05/01/25 at 01:50 PM, Clinical Support (CS) G stated the facility did not have a policy that addressed transporting residents in wheelchairs. She stated it was a standard of practice that they do not push them without foot pedals. CS G further stated the facility goes over this subject during orientation with a slide show presentation. The surveyor requested a copy of what new employees are shown at orientation regarding transporting residents in wheelchairs. During an observation on 05/01/25 at 03:15 PM, CNA F was observed pushing R34 in his wheelchair without foot pedals down the hallway to the main dining room. A review of the facility's Nursing Orientation Checklist, undated, revealed under the topic Safety is everyone's responsibility the subtopic No Pedals, No Push. A review of the article Guidelines for Pushing Wheelchairs, dated 3/28/23, revealed, When pushing a wheelchair, safety should always be the top priority. Here are some safety guidelines to keep in mind: Always lock the wheelchair brakes before helping the user in or out of the chair. Use a firm grip on the wheelchair handles and keep your back straight and shoulders relaxed. Be aware of your surroundings and avoid obstacles and uneven surfaces. Always use the footrests when the user is sitting in the chair, and make sure they are properly adjusted. When going down ramps or inclines, always walk backward and use your body weight to control the wheelchair's speed . (https://alzheimerslab.com/guidelines-for-pushing-wheelchairs) 37872 R42 A review of R42's Admission Record, dated 5/01/25, revealed they were an [AGE] year-old resident readmitted to the facility on [DATE]. In addition, R42's Admission Record revealed multiple diagnoses that included Vascular Dementia with behavioral disturbance, affective mood disorder, insomnia, and dysphagia oropharyngeal phase. A review of R42's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 03/31/25, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 99 which revealed R42 was severely cognitively impaired. Further review of R42's quarterly MDS reflected the resident only needed assistance with Setup or Clean-up for eating. During a lunch observation on 4/29/25 at 11:37 AM, R42 was observed sitting on a couch in the fishbowl (Name of the lobby located by entrance door) waiting for lunch. Certified Nursing Assistant (CNA) N was observed placing a gown and clothing protector on the resident. CNA N provided R42 a spoon and a bowl of mechanically altered potpie and then left R42 to assist other residents with their lunch. R42 was only provided the one bowl. No beverages were provided. Staff were not observed in the immediate area due to assisting other residents with their lunch trays. After approximately 20 minutes CNA N was asked why R42 did not have anything else to eat or drink. CNA N stated, (Name of Resident) likes to mix her drinks in her food, so I will start her off with one bowl and then give her drinks in-between. CNA N provided R42 a glass of orange juice a few minutes later that she fully consumed. Further observation of R42's 4/29/25 meal service reflected that she gave up eating with her plastic spoon and switched over to using her fingers. R42 had been unsuccessful at getting the spoon into her mouth. A large portion of residents lunch was observed on her hands, down the front of her gown and clothing protector and on the table. R42 was left on her own until staff cleaned her up. Review of R42's 3-26-2025 08:22 Interdisciplinary Care Conference Documentation reflected, She remains on a puree diet with regular liquids. She has a history of pocketing food and chewing on it for a few hours after she is done eating. She enjoys her snacks and treats. Review of R42's Dietary Order dated 2/24/25, reflected resident was on Regular diet. Pureed texture. Thin consistency. Allow mechanical soft snacks per approved list. During a lunch observation on 04/30/25 at 11:37 AM, R42 was observed being brought down to the fishbowl to eat at the table. Staff placed a gown and clothing protector over the resident prior to placing her lunch in front of her (a single bowl no beverage) and handed her a plastic spoon. R42 is observed struggling to eat with the plastic spoon and would drop her food down the front of her and on the table. Resident ate approximately one in every three bites attempted. During the 4/30/24 lunch observation R42 was observed chewing the same bite of food for approximately 4 minutes. Staff were noted walking through the fishbowl delivering lunches, however, none of them appeared to be monitoring R42. Further dining observation of R42 on 04/30/25 at 12:13 PM, a concern was brought to the DON's attention about (Name of R42) possibly pocketing food in her mouth and that the resident (still) had nothing to drink. (R42 had just placed a bite in her mouth approximately a minute prior to talking with the DON.) DON stated she would get her something to drink and have someone come sit with her. DON further stated, (Name of R42) does not like anyone touching her food or assisting her with eating she does not do well with that. Staff had not been observed interacting with R42 after her lunch had been placed in front of her. On 4/30/25 at 12:18 PM, Unit Manager (UM) O sat down at the table next to R42. R42 had been chewing on the same bite of food for approximately 7 minutes when UM O asked (Name of R42) to open her mouth. UM O upon observation of residents' mouth stated, you still have quite a bit of food in there, why don't you take a drink. (Staff had just dropped off a beverage in front of the resident.) R42 proceeded to chew on the same bite for several more minutes before finally swallowing. Observation of R42 after finishing her lunch on 4/30/25, reflected most of residents' lunch had ended up on the table and on the gown, she was wearing to protect her clothing. Review of R42's Interdisciplinary Care Conference Documentation at 10:59 on 4/30/25 (Effective Date) reflected a Care Conference was held with (Name of R42's son) and the IDT. Further review of the document appeared similar to R42's 3/27/25 Interdisciplinary Care Conference Documentation. During an interview on 05/01/25 at 01:17 PM, Social Services (SS) P was asked if they had a Care Conference with (Name of R42's Son) yesterday? SS P stated, No we did not meet with him yesterday, but I did try to get a hold of him. SS P further stated she wanted to review residents care due to losing weight, and to review her code status.

Based on interview and record review, the facility failed to follow a physician order for 1 of 17 sampled residents (R36), resulting in R36 not having a digoxin level checked for over a year. Findings include: A review of R36's Admission Record, dated 5/1/25, revealed R36 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R36's Admission Record revealed multiple diagnoses that included congestive heart failure and osteoarthritis. A review of R36's Pharmacist Medication Regimen Reviews, dated 6/1/24 to 5/1/25, revealed the pharmacist had noted on 4/3/25 that the last digoxin level that had been obtained on R36 had been on 4/12/24. The pharmacist recommended that a digoxin level be obtained now then every 6 months for this medication (digoxin) with a narrow therapeutic window (medications where the concentration or dose required to be effective is very close to the concentration or dose that produces a toxic or adverse effect). A review of R36's medical record, dated 4/12/24 to 5/1/25, failed to reveal that a digoxin level had been obtained, or ordered, per the pharmacist's recommendation on 4/3/25. R36's medical record did confirm that the last digoxin level result that was in the medical record was dated 4/12/24. On 5/1/25 at 11:30 AM, the Nursing Home Administrator (NHA) was notified that the surveyor could not locate documentation in R36's medical record that a digoxin level had been obtained per the pharmacist's recommendation on 4/3/25 (or an order for when it will be drawn next). A copy of the digoxin level results or an order for the digoxin level to be obtained was requested from the NHA. A second review of R36's medical record, dated 4/12/24 to 5/1/25, revealed that an order to obtain a digoxin level now and then q6 months (every 6 months) was written on 5/1/25 at 12:08 PM (after the surveyor had asked for additional information from the NHA). A review of R36's Order Summary Report, dated 5/1/25, revealed the following: - R36 had a physician's order, dated 5/10/24, for digoxin 125 mcg (micrograms) to be given once a day. - R36 had an active order (no stop date), dated 5/10/24, for a digoxin level to be obtained every six months. During an interview on 05/01/25 at 01:44 PM, Clinical Support (CS) G confirmed that R36's digoxin level for the 4/3/25 pharmacy recommendation was ordered today after the surveyor had requested the information. CS G stated that for some reason, the facility had failed to order a digoxin level when they ordered other laboratory values (vitamin B12 and magnesium) that were also recommended on R36's pharmacy recommendation for 4/3/25. During an interview on 05/01/25 at 01:47 PM, the Director of Nursing (DON) confirmed that R36's last digoxin level that had been obtained was on 4/12/24. The DON also confirmed that R36 had an active order that had been written on 5/10/24 and did not know why another digoxin level had not been obtained six months after that (November 2024). A review of the article Digoxin monitoring and toxicity management in The Pharmaceutical Journal, dated 1/3/23, revealed, Digoxin has a narrow therapeutic window, meaning there is a small margin between the benefit of its effects and toxicity; therefore, monitoring is an important part of its use . In serious cases of toxicity, ventricular tachycardia (fast heart rate) and ventricular fibrillation (a life-threatening heart rhythm that results in a rapid, inadequate heartbeat) may occur. Adverse arrhythmias are most common in patients if there is pre-existing heart disease or in electrolyte disturbances, such as hypokalaemia (low potassium levels that can result in fatigue, muscle cramps, and abnormal heart rhythms) . (https://pharmaceutical-journal.com/article/ld/digoxin-monitoring-and-toxicity-management)

This citation refers to MI00152461 Based on interview and record review, the facility failed to protect the residents' right to be free from physical abuse for 2 of 18 residents (R58, and R60), resulting in residents being physically abused. Findings include: R60 A review of R60's Admission Record, dated 4/30/25, revealed they were an [AGE] year-old resident admitted to the facility on [DATE]. In addition, R60's Admission Record revealed multiple diagnoses that included Dementia, severe with agitation, dementia with psychotic disturbance, unsteadiness on feet, history of falls and dysphagia, and oropharyngeal phase. A review of R60's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 02/04/25, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 99 which revealed R60 was severely cognitively impaired. On 04/29/25 at 01:19 PM, an R60 was observed in the TV room sitting in a lazy boy watching TV. R60 was clean, well-groomed, however she did not participate in verbal encounter with this surveyor. During the observation Certified Nurse's Aide (CNA) C stated (Name of R60) is now on a 1-1 since she went into the wrong resident's room, and they had an incident. Review of R60's Interdisciplinary Documentation Note dated 04/12/2025 at 20:57 reflected (Name of R60) entered (Identification Number used for Resident 58's) room and mistakenly got into his bed. A staff member walking past observed resident (Identification Number used for R58) with his hands on (Name of R60's) shoulder and him make contact with an open hand to the side of her face. The staff member immediately intervened. (Name of R60) does not have any injuries and though upset at the time of the interaction, returned to her psychosocial baseline following staff support. Review of the facility two-hour report date 4/12/25 at 8:53 PM, submitted by NHA reflected the following Immediate Action: Residents were immediately separated, and (Name of R60) was assisted from the room. Both residents were assessed for injury and neither had any redness, bruising or swelling. One to one supervision was immediately implemented for (Name of R60) due to her propensity to wander into other resident's rooms and inadvertently have undesired interactions. Review of Housekeeper (HK) K's handwritten statement dated 4/12/25 reflected, I heard screaming coming from (Name of Area in the building) so I tried to find out where the screaming was coming from. When I looked in (Name of R58's) room I saw that he had (Name of R60) pinned to his bed using his hands & then releasing his hands to & started slapping her on each side of her face. I yelled for (Name of License Practical Nurse (LPN) M) and in general help and that's when (Name of Certified Nurses Aide (CNA) L) came in & stopped it. Review of CNA L's Witness Statement dated 4/12/25 reflected, I didn't see the incident I was in room [ROOM NUMBER] changing resident. I came out as soon as I heard the housekeeper yelling for (Name of LPN M). I walked (Name of R60) down to the nurse's station. She said he hit her on his arms, legs, stomach, chest, face. Review of LPN's M Witness Statement undated reflected, (Name of HK K) yelled and waved me down, reported (Name of R58) had (Name of R60) who was lying down in his bed. He was standing over her had her arms held down then started slapping her alternating sides of her face with the palm of his hand. Upon my observation he was standing in his room on the other side of his bed, and he appeared confused and (Name of R60) was crying. Review of R60's Interdisciplinary Documentation Progress Notes dated 4/14/2025 at 05:23 reflected, Up wandering a great deal of the night. Would not comply with the suggestion to go to bed. However, she was not crying much this shift. Review of R60's Short Term Care Plan Date 4/12/25 under problem potential for latent injury related to incident face, chest, and abdomen. Review of R60's Care Plan revealed: (Name of R60) has altered mobility and ADL's (Activities Daily Living) related to difficulty with motor function and increased confusion, disorientation secondary to advancing dementia, and poor safety awareness. She has a history of wandering and at times will wander in rooms in the facility requiring redirection. Date Initiated: 05/09/2023 Revision on: 09/09/2024. Intervention includes 1:1 supervision in place on each shift while (Name of R60) is awake. Date initiated: 06/12/2024 Revision on: 04/18/2025 Further review of R60's medical record reflected she was also involved in another Facility Reported Incident (FRI) on 3/20/25 at approximately 4:00 PM when R60 wandered into another room and began yelling and grasped one of the residents' arms. Facility interventions for this incident included a stop sign for the resident's doorway and a staff member has been added as a companion to (Name of R60) during the evening/sundowning hours to support (Name of R60) during times of increased confusion. Further review of R60's care plan noted that 3/21/25 the resident was placed on 15 minute checks. Review of Psychological Evaluation dated March 27, 2025, reflected the following: Referral Statement: (Name of R60) continues with some abnormal /noxious behaviors. As of late/she had entered another resident's room and there was a mild degree of physical altercation. The patient had actually grabbed that resident. R58 Review of R58's face sheet dated 5/1/25 revealed he was admitted on [DATE] and had diagnoses that included: cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (genetic brain disease), vascular dementia, diabetes mellitus 2, and major depressive disorder. He was not his own responsible party. A review of R58's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 04/14/25, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 01 which revealed R58 was severely cognitively impaired. R58 was observed in bed on 4/30/25 at 2:11 PM. R58 was lying in bed with his head at the foot of the bed. R58 was slow to respond to his name and questions. R58 had no recall of having any difficulty with other residents or of problems with other residents coming into his room.

This citation refers to MI00147470. Based on observation, interview, and record review, the facility failed to secure 1 of 3 medication carts (Harbor Medication Cart), resulting in the potential for misappropriation of resident medications. Findings include: During an observation on 10/22/24 at 07:55 AM, the Harbor Medication Cart was left unlocked (the lock was in a pulled-out position and the red/orange dot- which would indicate the cart was unlocked- was clearly visible) and unattended in the hallway outside of a resident room. In addition, because the medication cart was left unlocked, the controlled substances that were stored in the medication cart were only under a single lock vs. the requirement that controlled substances are secured by a double lock system. There were not any staff within visual range of the medication cart. Residents were also observed in the hallway at the time of the observation. During the observation on 10/22/24 at 07:55 AM, Agency Registered Nurse (RN) A returned to the Harbor Medication Cart while the surveyor was writing down information for that cart. RN A stated, uh oh and then proceeded to tell the surveyor the oncoming nurse was running late. RN A stated she was just helping out and trying to administer some medications to the residents before the next nurse came on shift. During an interview on 10/22/24 at 2:30 PM, Licensed Practical Nurse (LPN) C stated she always locks her medication cart before she walks away from it. She stated the only time she would leave her medication cart and not lock it would be if there was an emergency situation, such as a resident fell or was in imminent danger. She stated if that happened, she would ask someone to lock it for her as she responded to the emergency situation. During an interview on 10/23/24 at 11:40 AM, RN B stated she always locks her medication cart when she walks away from it. She stated she does this to prevent people from wandering by and opening it. During an interview on 10/23/24 at 12:45 PM, the Director of Nursing (DON) stated the nurses should lock their medication carts when they walk away from them. A review of the facility's Medication Storage & Stability policy and procedure, revised April 2021, revealed, 2. Only licensed nurses, consultant pharmacist, and those lawfully authorized to administer medications are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. A review of the facility's Controlled Medication Storage, Security & Disposition policy and procedure, revised December 2016, revealed, Medications listed in Schedules II, III, IV, and V are stored under double lock separated from other medications .

This citation refers to MI00147470. Based on observation, interview, and record review, the facility failed to safeguard the confidentiality of medical records for 1 of 83 facility residents (R9), resulting in the potential for unauthorized access to resident medical records and the potential for the loss of resident privacy and confidentiality of their personal health information. Findings include: During an observation on 10/22/24 at 7:55 AM, the computer screen on top of the Harbor Medication Cart was observed open to R9's electronic Medication Administration Record, (e-MAR). R9's personal and health identifying information (e.g., picture, name, room number, physician's name, and allergies) and medications were visible to anyone walking by the medication cart. No staff were visible within sight of the medication cart. During the observation on 10/22/24 at 7:55 AM, Agency Registered Nurse (RN) A returned to the Harbor Medication Cart while the surveyor was taking notes. RN A stated, uh oh and then proceeded to tell the surveyor the oncoming nurse was running late. RN A stated she was just helping out and trying to administer some medications to the residents before the next nurse came on shift. During an interview on 10/22/24 at 2:30 PM, Licensed Practical Nurse (LPN) C stated she will close her computer screen when she walks away from the medication cart by allowing it to go to sleep. LPN C stated, But it does not really hide it. If a resident walks by the med (medication) cart and touches the mouse or bumps the cart, the screen will pop back up. LPN C further stated there was not a way for the staff to hide or lock the computer screen to keep unauthorized people from seeing it when the nurse is away from the cart. LPN C stated the only way she really knows of to keep someone from using the mouse to re-open an e-MAR was to minimize the screen. She stated however the minimized screen would log her out of the computer system if it was left open for too long and she would have to completely log back in. During an interview on 10/23/24 at 11:40 AM, RN B stated she hides her computer screen (pushes a button that displays a message that the screen was hidden if someone moves the mouse) when she walks away from her medication cart. She stated she does this to prevent people from reading it as they walk by. RN B also stated she also does this to protect resident privacy. During an interview on 10/23/24 at 12:45 PM, the Director of Nursing (DON) stated the nurses should hide their computer screens when they walk away from the medication carts. A review of the facility's HIPAA (Health Insurance Portability and Accountability Act): Compliance, Confidentiality Statement & Employee Use of Protected Health Information (PHI) policy and procedure, revised January 2024, revealed, Close computer programs before leaving desktop or laptop computers.

This citation pertains to intake MI00146846. Based on interview and record review, the facility failed to allow a resident to return to the facility after being sent to the hospital for aggressive behavioral issues for one resident, Resident #1 (R1), of three residents reviewed for facility-initiated transfers, resulting in R1 being involuntary discharged to the hospital without a home to return to. Findings: Resident #1 (R1) Review of Admission Record revealed R1 was a [AGE] year-old male, readmitted to the facility on [DATE], with pertinent diagnoses which included: Dementia, Bipolar II Disorder, psychotic disorder with delusions, major depressive disorder, anxiety disorder, and obstructive sleep apnea. Review of a Minimum Data Set (MDS) assessment for R1 with a reference date of 7/29/24 revealed a Brief Interview for Mental Status (BIMS) score of 99 and was unable to participate in the cognitive interview. Further review of R1's MDS history reflected 5 discharge assessments between 6/5/24 to 9/7/24 and 4 Entry Tracking Records between 6/05/24 to 10/23/24. During an interview on 10/23/24 at 8:58 AM, R1's Guardian L revealed that the facility notified her by phone that the facility was sending R1 to the hospital because he was having behaviors and had hit staff. Guardian L stated the facility later informed her in a telephone call that they would not take him back. Guardian L stated she never received any discharge paperwork and the poor guy has now been in the hospital for almost 2 months because they cannot find placement for him. Guardian L revealed further frustration because (Name of Local Agency that provides social work and counseling) dropped R1 as a client and Neuropsych will not take him either. Review of a progress note dated 9/7/24 at 10:18 AM revealed that on 9/7/24 at 0755 Registered Nurse (RN K) gave R1 his meds while Certified Nursing Assistant (CNA K) was providing 1:1 supervision and he spit them out. R1 was pushing CNA K and punched her in the stomach twice. CNA K then threw a glass of water she was holding at R1 getting the water on his face. R1 called CNA K a b*tch as he laid down and dried off his face. RN K had CNA K leave the situation and Licensed Practice Nurse (LPN M) stayed with R1 while RN K called DON. The Administration notified the corporate office, the guardian, and called the police and EMS to have R1 taken to the ER. Review of progress note dated 09/07/2024 at 10:22 AM, reflected, Police and EMS arrived at 0830 to transport R1 to the ER. Review of a progress note dated 9/7/24 at 12:47 PM reflected that RN K was notified by the DON that R1 would not be allowed to return to the facility per direction of herself, the NHA, and [NAME] President (VP) of the company. RN K called the ER and informed the hospital staff that the facility would not allow R1 to return to the facility. Further review of progress note dated 09/07/2024 at 13:28 reflected that RN K received a call from the hospital physician caring for R1 in the ER with an update and stated that he would speak with social services at the hospital regarding the facility refusal to take resident back. RN K notified the DON of the conversation, and the DON stated that the administration was aware of the situation and would deal with the ramifications of not accepting R1 back to the facility. During an interview on 10/23/24 at 4:10 PM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) were not able to provide the 9/7/24 transfer paperwork for R1 because they stated they had not completed any. The NHA and DON were not able to provide evidence of initiating Involuntary Discharge paperwork for the resident and/or resident's Guardian because the NHA stated they had not started one. The NHA and DON confirmed that they talked to Guardian L and informed her on the telephone that the facility sent R1 to the hospital and that they were not accepting him back to the facility.

This citation pertains to intake MI00146846. Based on interview and record review, the facility failed to 1.) Notify the Resident and Resident Representative in writing with the reason for a transfer out of the facility 2.) Send a discharge notice to a representative of the Office of the State Long Term Care (LTC) Ombudsman for a facility-initiated discharge, 3) Send discharge papers to the receiving hospital for 1 resident, Resident #1 (R1) of three residents reviewed for transfers and discharges, resulting in R1 receiving an involuntary discharge with no notice or place to live. Findings: Review of the Notice of Transfer or Discharge Policy and Procedure revised in July of 2023 reflects . 2. Facility -Initiated Transfer (FIT) a. The FIT-100 form, and process will be used when there is a transfer of a resident from the federally certified nursing home to another facility, such as acute care hospital, with the expectation that the resident will return to the federally certified nursing home. i. Prepare the Facility-Initiated Transfer and Appeal Form (FIT-100) ii. Provide the FIT-100 form to the resident and/or authorized representative along with an envelope and postage for an appeal request, iii. A copy of this notice will be placed in the resident's medical record iv. A monthly list of all facility-initiated transfers is provided to the Michigan Long Term Care Ombudsman at MLTCOP@meij.org. Further review of the Policy and Procedure reflected, 3. Involuntary Transfer or Discharge (ITD) and Facility-Initiated Discharge a. Prepare the ITD-100 form - Have an initial discussion with the resident and/ or authorized representative to assist in identification of transfer or discharge location b. If the destination changes and this change was initiated by the facility, and updated notice with the new destination will be issues. This change restarts the 30-day timeline for transfer or discharge. Resident #1 (R1) Review of Admission Record revealed R1 was a [AGE] year-old male, readmitted to the facility on [DATE], with pertinent diagnoses which included: Dementia, Bipolar II Disorder, psychotic disorder with delusions, major depressive disorder, anxiety disorder. Review of a Minimum Data Set (MDS) assessment for R1 with a reference date of 7/29/24 revealed a Brief Interview for Mental Status (BIMS) score of 99 and was unable to participate in the cognitive interview. Further review of R1's MDS history reflected 5 discharge assessments between 6/5/24 to 9/7/24 and 4 Entry Tracking Records between 6/05/24 to 10/23/24. During an interview on 10/23/24 at 8:58 AM, R1's Guardian L revealed that the facility notified her by phone that the facility was sending R1 to the hospital because he was having behaviors and had hit staff. Guardian L stated the facility later informed her in a telephone call that they would not take him back. Guardian L stated she never received any discharge paperwork and the poor guy has now been in the hospital for almost 2 months because they cannot find placement for him. Guardian L revealed further frustration because (Name of Local Agency that provides social work and counseling) dropped R1 as a client and Neuropsych will not take him either. During an interview on 10/23/24 at 4:10 PM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) were not able to provide the 9/7/24 transfer paperwork for R1 because they stated they had not completed any. The NHA and DON were not able to provide evidence of initiating Involuntary Discharge paperwork for the resident and/or resident's Guardian because the NHA stated they had not started one. The NHA and DON confirmed that they talked to Guardian L and informed her on the telephone that the facility sent R1 to the hospital and that they were not accepting him back to the facility. Review of R1's Medical Record revealed there was no paperwork for R1's hospital transfer/discharge on 9/7/24 located. The facility was not able to provide a copy of any paperwork prior to survey completion. Review of the facility Admission/Discharge To/From Report from 8/22/24-10/22/24 reflected that the facility discharged R1 to (Name of Local Hospital) on 9/7/24. During an interview on 10/23/24 at approximately 4:14PM, local Ombudsman O stated she was unaware R1 had an involuntary discharge to the hospital and that the resident was still there. Ombudsman O revealed the information the facility provided to their offices reflected, they sent the resident for acute care and did not check the box on if he was returning or not returning to the facility. If they (the facility) are not allowing the residents to return they are supposed to fill out the involuntary discharge paperwork. They did not follow the process or procedures. They are supposed to send a monthly list of discharges to the state. During an interview on 10/23/24 at 11:51 AM, Registered Nurse (RN) P said that R1 was not longer at the facility because the facility sent R1 to the hospital due to hitting a staff member. RN P said R1 would become combative and agitated. RN P said R1's behaviors would come on abruptly and he could walk down the hall and without warning hit or lash out at someone. RN P also stated that R1 had been at the facility for a long time and the behaviors have escalated over the last year. She stated not knowing why the behaviors had escalated and thought it could be due to disease progression. Review of R1's Care Plan initiated on 10/24/23 reflected R1 had a history of being physically and verbally aggressive with peers and staff and had behaviors since admitting to the facility. Interventions initiated on 10/23/24 included Psychoactive medication is being administered for the diagnosis of anxiety and major depression with psychotic symptoms.Identify behavioral precipitants, if possible, to assist with further defining effective dementia care and trauma informed care.With presentation of behavioral and psychological symptoms of dementia, attempt use of social interventions such as tactile stimulation, sorting objects, appropriate touch, music and sounds, etc., to increase stimulation of the senses and to decrease negative behaviors. Review of a progress note dated 9/7/24 at 10:18 AM revealed that on 9/7/24 at 0755 Registered Nurse (RN K) gave R1 his meds while Certified Nursing Assistant (CNA K) was providing 1:1 supervision and he spit them out. R1 was pushing CNA K and punched her in the stomach twice. CNA K then threw a glass of water she was holding at R1 getting the water on his face. R1 called CNA K a b*tch as he laid down and dried off his face. RN K had CNA K leave the situation and Licensed Practice Nurse (LPN M) stayed with R1 while RN K called DON. The Administration notified the corporate office, the guardian, and called the police and EMS to have R1 taken to the ER. Review of progress note dated 09/07/2024 at 10:22 AM, reflected, Police and EMS arrived at 0830 to transport R1 to the ER. Review of a progress note dated 9/7/24 at 12:47 PM reflected that RN K was notified by the DON that R1 would not be allowed to return to the facility per direction of herself, the NHA, and [NAME] President (VP) of the company. RN K called the ER and informed the hospital staff that the facility would not allow R1 to return to the facility. Further review of progress note dated 09/07/2024 at 13:28 reflected that RN K received a call from the hospital physician caring for R1 in the ER with an update and stated that he would speak with social services at the hospital regarding the facility refusal to take resident back. RN K notified the DON of the conversation, and the DON stated that the administration was aware of the situation and would deal with the ramifications of not accepting R1 back to the facility.

This citation pertains to intake #: MI00145370 Based on interviews and record review, the facility failed to protect a resident's (Resident #5) right to be free from physical abuse from another resident (Resident #4). Findings: Resident #4 (R4) Review of an Admission Record revealed R4 was an [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: dementia with agitation and behavioral disturbances and major depressive disorder. Review of a Minimum Data Set (MDS) assessment for R4, with a reference date of 4/24/24 revealed a Brief Interview for Mental Status (BIMS) score of 7, out of a total possible score of 15, which indicated R4 was severely cognitively impaired. Review of R4's Care Plan revised 4/21/24 revealed, (R4) has the potential for psychosocial distress related to: anticipated dementia progression, expressing sadness / anger / empty feeling over lost roles and status. Wanderguard is in place due to unsafe wandering. Confusion and memory loss present. DX (diagnosis) of depression. Orders for psychotropic medications .Interventions/Tasks . If/when (R4) becomes agitated, attempt to redirect by offering snack or drink. Attempt to engage him in conversation that is meaningful to him . Review of R4's Care Plan revised 4/22/24 revealed, Altered functional mobility and ADL's (Activities of Daily Living) related to generalized weakness, dementia, confusion. Resident can ambulate independently with his wheeled walker, and at a fast pace. Given his dementia being questioned will increase his agitation which can lead him to be combative with cares . Review of R4's Order Summary dated 4/17/24 and April Medication Administration Record revealed, OLANZapine Oral Tablet 5 MG (Zyprexa) Give 1.5 tablet by mouth at bedtime for depression. The medication was administered on 4/18/24 and was discontinued on 4/19/24. (Zyprexa is an antipsychotic medication). Review of R4's Care Conference dated 4/19/24 with Interdisciplinary Team and R4's Power of Attorney revealed medications, medical condition, and care plan were reviewed. The note reflected R4's behaviors of wandering and exit seeking but did not reflect R4 exhibiting combative/physical aggressive behaviors. The note did not reflect a discussion/rationale for the discontinuation of Zyprexa. (There was no documentation that an additional care conference had been completed prior to R4's transfer on 5/30/24). Review of R4's Behavioral Support Intervention Analysis revealed: 1. Start of Behavioral Log Review-4/17/24 2. End of Behavioral Log Review-4/24/24 3. Type and Number of Behaviors-(R4) has wandering noted daily. He wanders throughout the facility and into other resident's room. He has a wanderguard in place due to unsafe wandering and exit seeking Orders for Zyprexa and Remeron which are used for dx of depression . Indicating R4 was receiving Zyprexa throughout the lookback period. There were no combative behaviors noted. Review of R4's Psychiatric Evaluation dated 4/22/24 revealed, .(R4) is an 85yo (year old) male who is referred for an evaluation and medication management of his dementia with behaviors. He is currently taking Zyprexa 2.5mg nightly .Since being at Lake Woods, he has been exit seeking and wandering .He has been observed slamming doors and throwing his walker .Recommendations .Increase Zyprexa 5mg nightly .Follow up 4 wks (weeks) or sooner if indicated . Review of R4's Electronic Health Record revealed no documentation from the Interdisciplinary Team or provider for the abrupt discontinuation of the Zyprexa on 4/19/24. Review of the FDA guidelines for Zyprexa revealed the medication should not be stopped abruptly and should be done under the supervision of a provider. Review of the National Library of Medicine (NLM) article Olanzapine revealed, .Clinicians should monitor patients while discontinuing olanzapine therapy, as there is a risk of physical withdrawal and rebound symptoms. Hence olanzapine should be tapered gradually . Review of R4's Order Summary dated 4/25/24 revealed, OLANZapine Oral Tablet 5 MG (Zyprexa) Give 0.5 tablet by mouth at bedtime for depression 2.5 MGs of Zyprexa. Review of R4's Interdisciplinary Documentation dated 4/27/2024 written by Social Services (SS) K revealed, (R4) was seen on 4/22/24 by (psychiatric provider) and the IDT (Interdisciplinary Team) reviewed report, PCP (primary care provider) agreed to restart (R4's) Zyprexa. CCC (Clinical Care Coordinator) was informed and medication was restarted. SS (Social Services) will continue to assess, offering support as needed. Review of R4's Electronic Health Record revealed no documentation from the Interdisciplinary Team or provider for restarting Zyprexa at 2.5mg instead of the recommended 5mg from the psychiatric consult on 4/22/24. Review of R4's Health Care Provider Note dated 5/6/24 revealed, .There is no new medical or nursing concerns . Mood is stable, no behavioral issues . and did not reflect and change in R4's behaviors or mood. Review of R4's HCP (Health Care Provider) Visit dated 5/13/24 revealed, .No nursing concerns today . and did not reflect and change in R4's behaviors or mood. Review of R4's Interdisciplinary Documentation dated 5/15/2024 revealed, .(R4's daughter in law) informed writer that (R4) loves to tinker with things and will often attempt to disassemble things. (R4's daughter in law) talked about getting resident a busy board. Writer informed (R4's daughter in law) that she would share this info with the activity department . Review of R4's Interdisciplinary Documentation dated 5/15/2024 revealed, (R4's) roommate scheduled to discharge 5/16; resident is packing all of his belongings in belief that he is also leaving. States he is waiting for his ride. Unable to redirect from being exit seeking this round. Writer contacted son and left voicemail. Review of R4's Care Plan did not reflect R4's family member's recommendation and R4 was not provided a busy board to assist with his restlessness/agitation/wandering behaviors. Review of R4's Interdisciplinary Documentation dated 5/17/2024 revealed, .Resident has been very confused, and not knowing who he was .He was yelling at this nurse, because he was confusing me, I didn't know what he was talking about. His roommate discharged home yesterday, and I feel he's confused about that. No new interventions were implemented despite the identification of a possible psychological stressor. Review of R4's Interdisciplinary Documentation dated 5/18/2024 revealed, resident combative with staff and other residents. Resident hitting staff and throwing items such as walker at staff. Resident fell when throwing walker at CNA (Certified Nursing Assistant) talking to him. When this nurse went to evaluate resident for injuries and find out what happened from resident point of view resident refused to answer or let this nurse assess for injuries. Resident again got combative and yelling at this nurse and CNA in room. DON notified, dr notified. fall paperwork completed by staff nurse and calls completed. A linked note dated 5/20/2024 revealed, resident not combative to other residents. no resident on resident contact. Only resident to staff combative behavior. During an interview via telephone on 08/19/2024 at 3:04 PM, Nursing Home Administrator (NHA) (on leave since 8/11/24) reported she followed up with the nurse that wrote the note on 5/18/24 to ensure there had been no resident to resident abuse. The nurse clarified her documentation with the linked note on 5/20/24. Review of R4's Interdisciplinary Documentation dated 5/18/2024 revealed, Resident observed wandering into other residents rooms. When redirection was attempted by staff, he became combative, swinging his fist, throwing his walker at staff and falling onto buttocks. Writer obtained vital signs, performed pain assessment and assisted resident up onto feet returning walker. Resident educated on entering female residents rooms to which he responded I was going to my car. Resident became agitated and exit seeking, looking for the keys to his car. He removed wander guard (sic) from his ankle and proceeded to attempt to exit facility. On Call physician (name omitted) contacted and notified. New Order for Ativan 0.5 mg q 8 hours prn (every 8 hours as needed) for agitation called to (name omitted) Pharmacy. Daughter in Law (name omitted) contacted and notified of incident and changes. Review of R4's Behavioral Care Log from 4/22/24 through 5/18/24 (documentation completed twice daily) revealed R4 began displaying physical aggression on 5/18/24 which was a change from his documented baseline behaviors. Review of R4's Electronic Health Record revealed a comprehensive assessment and/or medication review was not completed with the Interdisciplinary team, the provider, and the family despite an increase in the number of R4's behaviors, the intensity of his behaviors (physical violence), and his fall. Review of R4's Interdisciplinary Documentation dated 5/19/2024 revealed, Resident awake 0530 (5:30 AM) combative with staff and trying to Hit (initials omitted) when walking by. Very disruptive . Monitor closely. Review of R4's Electronic Health Record did not reflect how staff would monitor R4 more closely (1:1 supervision, increased staffing on unit, 15 minute checks, etc). The care plan did not reflect changes in R4's monitoring. Review of R4's Interdisciplinary Documentation dated 5/19/2024 revealed, Resident came to harbor fire exit door and attempted to kick the door open. Resident was unable to open door. Resident then attempted to come behind nurses station. When this nurse attempted to redirect resident from behind desk resident started throwing hand sanitizer at this nurse. This nurse again attempted to redirect resident and resident started hitting this nurse. DON was called and resident actions reported to RN on terrace. RN on terrace already aware and making calls and arrangements for resident care. Resident made his way back to terrace on his own. Clarified with Nurse Consultant (NC) D on 08/19/2024 at 3:36 PM the nurse was completing documentation to have R4 transferred to the emergency department. Review of R4's Interdisciplinary Documentation dated 5/19/2024 revealed, Resident reported from prior nurse resident since waking after having given Ativan on prior shift has been more agitated and becoming combative staff, as another resident was walking in the hallway he wheeled toward her and started yelling at her to get away from him, we were able to intervene and keep residents safe, he was yelling at staff to not look at him, do not go near him , he propelled his walker down to the other end of the building, was kicking at fire extinguisher yelling at staff and throwing items. I called NP (Nurse Practitioner name omitted) on call, due to risk of harm to himself and others order given to send to ED (Emergency Department) for evaluation and treatment. Family (Son/POA and daughter in law names omitted) will meet resident at ED, (Nurse Practitioner name omitted) stated they would not have been able to calm him down when he gets this agitated . Indicating R4 was beginning to display aggression towards other residents, not just staff, and staff were no longer able to redirect/deescalate R4. R4 returned from the emergency department with a new order for Zyprexa 5mg. Review of R4's Order Summary dated 5/20/24 revealed, ZyPREXA Oral Tablet 5 MG (Olanzapine) Give 1 tablet by mouth one time a day for Agitation. (The dose that was recommended on 4/22/24 by the psychiatric consultant). Review of the NLM article Olanzapine revealed, .Daily administration of olanzapine leads to reaching the steady-state plasma concentration in about one week . Indicating the increased dose would not reach full efficacy for 1 week. Review of R4's Interdisciplinary Documentation dated 5/21/2024 revealed, .Continues to wander into others rooms, and use their bath rooms (sic) . Review of R4's Interdisciplinary Documentation dated 5/23/2024 revealed, Resident continues to become combative with staff when redirection is attempted. He wandered into other residents rooms this evening, taking his pants down, urinating and yelling I want everything that belongs to me or a lawsuit will be made. Review of R4's Interdisciplinary Documentation dated 5/24/2024 revealed, Resident agitated this morning, refusing to use his restroom or unit restroom, pushing past writer and entering the room of another resident. Writer attempted to assist resident and redirect out of room. He became combative, striking writer in chest with closed fist. He took his pants off and entered Room (number omitted) and used restroom. He allowed staff to assist in putting his pants back on and went back into room to eat breakfast. After eating his meal, (R4) began banging on the walls of his room . Review of R4's Electronic Health Record revealed that no new care planned interventions and/or comprehensive physical assessments were initiated despite R4 exhibiting new/worsening wandering behaviors (using other resident bathrooms and urinating in resident rooms on 5/21/24, 5/23/24, and 5/24/24). Review of R4's Interdisciplinary Documentation dated 5/24/2024 at 11:00 AM revealed, Writer witnessed resident exiting his room, ambulating without his walker, losing balance and falling onto his knees then laying on floor .Root cause determined to be Increased agitation/restlessness. Antianxiety medication administered causing lethargy. Intervention: Medication review/intervention and Discontinuation of Ativan 0.5mg . R4's antianxiety medication (ativan) was discontinued despite the root cause of the fall being identified as agitation/restlessness. Review of R4's Interdisciplinary Documentation dated 5/24/2024 at 5:30 PM revealed, Resident observed becoming combative with CNA staff when attempting to redirect to his room. Resident then went into another resident's room and laid in bed with him. When attempt was made to assist him out he threw bedside table at staff then exited room, snatched supply holder off the side of medication cart and began to snatch blankets and pillows from other residents. He knocked over walker and began throwing items in reach at staff. Writer unable to redirect at this time as resident is a threat to his own safety as well as others. On call physician (nurse practitioner name omitted) contacted and notified of events and gave verbal order to start Ativan 0.5mg PRN. DON contacted and notified. Review of R4's Interdisciplinary Documentation dated 5/24/2024 at 5:45 PM revealed, (R4) refused dinner tray and ambulated to dining room asking to be served. When tray was presented to him, he refused again. He then went into maintenance closet and took off all of his clothing, becoming combative with staff when attempting to redirect him. After being escorted to be toileted, resident ambulated to the Harbor unit, entering resident's rooms and taking their belongings. He again, became combative when redirection was attempted. When told that this was not his room, he responded It is now. After being escorted back to unit, resident wandered into other resident's rooms for approximately an hour. He then allowed staff to assist him into bed . Review of R4's Interdisciplinary Documentation written by SS K revealed, On 5/24/24 writer observed (R4) in the hallway with only a shirt on. As writer was walking towards (R4), staff approached him attempting to redirect him back to his room. Resident was agitated and aggressive with staff and writer. (R4) entered another male resident's room and refused to leave. As staff attempted to assist resident with putting a brief and pants on, (R4) continued to be aggressive with them .(R4) has had an increase in aggressive behaviors. Writer did speak with resident's daughter in law (name omitted) this morning, updating her on possible psych placement . Writer will seek psych placement for (R4). Review of R4's Interdisciplinary Documentation dated 5/25/24 revealed, About 6:30 am this morning, the CNA's observed resident walking down the hall way toward the fish bowl with his walker and no pants or pull up on, stated he needed the bathroom, CNA attempted to redirect resident in the right direction and he punched her in the face, causing a bruise near her left eye. Resident became very combative, kicking swinging his arms and cursing . Review of R4's Electronic Health Record revealed there were no new care planned interventions initiated or increased supervision for R4 to protect other residents despite increased agitation/restlessness, a fall, an escalation of behaviors to resident physical contact/getting into bed with another resident, and a physical assault on a staff member resulting in a bruised left eye. SS K documented the need to seek inpatient psychiatric services on 5/24/24 and the licensed nurse documented a concern to R4's safety as well as others (resident and staff) safety on 5/25/24. Review of R4's Interdisciplinary Documentation dated 5/25/2024 revealed, .(Nurse Practitioner name omitted) would like us to try to get urine from resident to dip . indicating a concern that R4 was exhibiting symptoms of a urinary tract infection. There were no Interdisciplinary Documentation or other progress notes completed on 5/26/24. Review of R4's Interdisciplinary Documentation dated 5/28/2024 revealed, (R5) stated that this resident punched him in his eye the day prior (5/27/24). Stated that he didn't say anything because he was embarrassed . There were no other notes documented on 5/28/24. Review of R4's Interdisciplinary Documentation dated 5/29/2024 revealed, Resident continues wandering into others rooms and attempting to exit facility through emergency doors. PRN Ativan administered for restlessness effective for only an hour .Resident difficult to redirect as he becomes combative with staff. R5's room was changed following the physical assault by his roommate (R4). There was no additional action taken by the facility to protect all residents and to prevent a possible reoccurrence prior to his transfer to the inpatient psychiatric hospital on 5/30/24 at approximately 12:00 PM. Review of R4's Petition for mental Health Treatment dated/signed 5/29/24 by SS K revealed, .History of being combative, physically and verbally aggressive with others. (R4) has confusion, short and long term memory loss present. DX (Diagnosis) of Dementia with behavioral disturbances and agitation .(R4) punched a staff member in the eye which resulted in her having a black eye. He has been delusional, combative, aggressive, throwing things at others, climbing in bed with others (sic) residents. SS K documented that she would seek psychiatric placement for R4 on 5/24/24 in an Interdisciplinary Documentation. Resident #5 (R5) Review of an Admission Record revealed R5 was an [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: mild cognitive impairment, weakness, anxiety, and major depressive disorder. Review of a Minimum Data Set (MDS) assessment for R5, with a reference date of 4/29/24 revealed a Brief Interview for Mental Status (BIMS) score of 8, out of a total possible score of 15, which indicated R5 was moderately cognitively impaired. Review of R5's Skin assessment dated [DATE] revealed, While administering resident his mighty shake, writer observed that resident had dark red bruising under his under his right eye. Writer saw resident an hour prior to assist him in toileting and did not see bruising to eye. When asked what happened he responded, (R4) punched me yesterday, I didn't say anything because I was embarrassed . Review of the Witness Statement written by Licensed Practical Nurse (LPN) O dated 5/28/24 revealed, While administering (R5) his mighty shake, writer observed that he had bruising his r (right) eye. When asked what happened, he stated, (R4) punched me. I did not witness this incident. (R5) states that it happened last night. Review of the Witness Statement written by CNA L dated 5/28/24 revealed, I did not finish anything. I was just finishing my break. Review of the Witness Statement written by CNA M dated 5/28/24 revealed, I was doing care on a resident and did not witness the incident. Review of the Witness Statement written by CNA N (no date) revealed, Did not witness anything. Review of the Witness Statements indicated insufficient staff available to provide appropriate supervision for a resident with known increased behaviors. Review of the Facility Reported Incident (FRI) investigation revealed: .(R5) reported that the cause of the bruising was due to his roommate making contact with his eye. (R5) provided several different timelines throughout interviews stating this happened the day prior, the night prior and then in the last interview a few weeks ago which would have been well before observed bruising and his first initial statements. However, (R5) has been consistent in reporting the cause of the bruising . To maintain (R5's) safety and the safety of others (R5) was offered and accepted a different room. This created a private room for (R4) which mitigated risk to others and met (R5's) preference not to room with (R4) as well as to be in a bed 1 position .(Confirming no other action was taken by the facility to protect the residents to prevent a possible reoccurrence besides R5's room change despite R4's ongoing/increasing wandering in the facility.) Coordination with (R4's) family to obtain history and best care plan were recent with revisions on 4/21/24 .(Confirming R4's care plan had not been updated with R4's increased behaviors.) Conclusion: The allegation cannot be verified or refuted due to there being no reliable witnesses at the time of the incident that caused bruising to (R5's) eye. (R5) is not a reliable historian however based on circumstantial observations including (R5's) statement, despite inconsistent timelines, new onset bruising to his right eye and observations of (R4's) increased agitation it is reasonable to conclude that an interaction took place between (R4) and (R5) that resulted in (R5) obtaining a bruise . Further review of the facility investigation revealed, .(R4) had worsening combative behaviors that were increasingly difficult to redirect. Health care provider recommended inpatient psych for medication management and resident was subsequently admitted . (Confirming the facility was aware of R4's increasing physically aggressive/assaultive behaviors and staffs difficulty/inability to redirect the resident.) Review of an email received on 08/16/2024 at 4:43 PM from the facility revealed, Zyprexa was restarted on 4/25/24 per psych provider (names omitted.) Psych consult recommendation made to increase Zyprexa was reviewed by (Nurse Practitioner name omitted) & IDT, declined increase at that time. Zyprexa increased from 2.5mg to 5mg on 5/21/24 due to increase in behaviors. Transferred to (inpatient psychiatric facility) on 5/30-6/14/24. During an interview via telephone on 08/19/2024 at 3:04 PM, NHA confirmed that R4's Care Plan had not been updated with new intervention since 4/21/24 and no other interventions had been implemented. NHA reported she had not been notified of R4 laying in another residents bed. During an interview on 08/19/2024 at 3:21 PM, SS K and DON could not provide documentation from the Interdisciplinary team and provider regarding the abrupt stopping of Zyprexa on 4/19/24 or a rationale from the provider, Interdisciplinary team, and family related to continuing/restarting Zyprexa at 2.5mg instead of the recommended 5mg by the psychiatric consultant on 4/25/24. SS K reported if she had spoken with R4's family/responsible party she would have documented it (in the Interdisciplinary Documentation). NC D reviewed R4's Electronic Health Record and confirmed there was no documentation related to the above concerns available. Review of the facility policy Abuse Prevention Overview last revised March 2019 revealed, .Prevention .2. The facility will provide supervision of staff and residents to the extent possible .3. The facility will provide a qualitative and quantitative analysis of incident accident reports. 4. The facility will develop care plans, which include interventions for behaviorally challenged residents. Respond and Identify .The facility will identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur . Protect-1. the facility will provide resident protection as indicated while an investigation is in progress as outlined in the policy for resident protection during an abuse investigation, including .*Increased supervision of the alleged victim and residents . Review of the National Library of Medicine (NLM) article Olanzapine revealed, .Daily administration of olanzapine leads to reaching the steady-state plasma concentration in about one week .Clinicians should monitor patients while discontinuing olanzapine therapy, as there is a risk of physical withdrawal and rebound symptoms. Hence olanzapine should be tapered gradually . [NAME] K, Saadabadi A. Olanzapine. [Updated 2023 [DATE]]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532903/

This citation pertains to intake #: MI00146179 Based on observation, interview, and record review, the facility failed to ensure adequate supervision for 1 of 12 residents (Resident #1) reviewed for safety, resulting in R1 left unsupervised outside. Findings: During an observation on 08/15/2024 at 7:25 AM, the front entrance/main entrance of the facility had 2 sets of doors. The first set of doors was unlocked, the second set of doors required a code to enter. There was a doorbell attached to the wall. Resident #1 (R1) Review of an Admission Record revealed R1 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: dementia, heart failure, and stage 4 kidney disease. Review of a Minimum Data Set (MDS) assessment for R1, with a reference date of 7/15/24 revealed a Brief Interview for Mental Status (BIMS) score of 6, out of a total possible score of 15, which indicated R1 was severely cognitively impaired. Review of R1's Assessment for Outdoor Independence dated 7/13/24 revealed, (R1) is alert and oriented X2 BIMS score is 6/15 indicating cognitive impairment. Resident self propels in her wheelchair and is able to transfer as a 2 assist. She has cognitive or physical impairments which could impede on her independent safety. Outdoor independence is not recommended at this time. Review of R1's Fall assessment dated [DATE] revealed, Resident is A&OX2. Resident gets short of breath easily and has poor balance she is a two assist with ambulation and transfers and 1 assist with bed mobility. Review of R1's Interdisciplinary Documentation dated 7/11/24 revealed, Per (day center) (R1) will be getting picked up for the day center M/W/F (Monday, Wednesday, and Friday) starting Friday 7/12. Schedule will be as follows: Mon PU (pick up) 9:20am DO (drop off) 3:40pm Weds PU 8:45am DO 1:40pm Fri PU 9:50am DO 2pm. Review of R1's Interdisciplinary Documentation dated 7/18/24 revealed, (R1) is a recent admission to the facility. She is [AGE] years old. She is alert and oriented x's 2-3. She scores 6 on the BIMS. She is able to communicate her needs and use her call light .She is able to transfer with one staff assistance. She has vascular wounds on her bilateral great toes which cause her some discomfort when bearing weight. She is able to propel her w/c (wheelchair) .She is at risk for falls r/t (related to) diabetic neuropathy and pain in her feet, blindness in one eye, and psychotropic medication use .She states she has pain in her neck, and her feet .(R1) is frequently incontinent. She has diuretic medication as ordered which may contribute to urge incontinence. She wears absorbent briefs . Indicating R1 required staff assistance with ADLs (Activities of Daily Living). Review of R1's Interdisciplinary Documentation dated 7/19/24 revealed, Resident had blood sugar drop to 72 and was symptomatic. Resident was given snacks and assisted to bed. (Provider name omitted) notified and aware blood sugar eval to be assessed. Per [NAME] & [NAME]/Fundamentals of Nursing, symptomatic hypoglycemia (low blood sugar) can result in diaphoresis, shakiness, confusion, loss of consciousness. Indicating R1 required nursing supervision to ensure adequate blood sugar levels and interventions to treat hypoglycemia. Review of R1's Interdisciplinary Documentation dated 7/22/24 revealed, This writer helped (R1) outside today at 9:20am when a (day center) bus was at (the attached assisted living) picking up residents for the day center, after a call was made from (day center) stating that they were outside ready for pick ups. I let the dispatcher know (R1) was being wheeled outside and would be ready. This writer saw (day center) bus pull into the parking lot and around to where (R1) was sitting. A few hours later 11:50ish am, (Registered Nurse/RN C) came wheeling (R1) inside and stated that (day center) never picked her up for the day center. (R1) reported to the nurse that her scalp was hot and that she had been sitting in the sun for a while. A call was made to (day center). (Director of Nursing) was notified. Review of a Witness Statement dated 7/31/24 written by Infection Prevention Manager (IPM) I revealed, Unaware resident was unattended outside. Brought to my attention that (day center) bus did not pick up resident for clinic visit. Resident previously observed just before bus arrival sitting outside with activities present sitting at front entrance benches. Resident was assessed by nursing at bedside and had no skin related issues. Review of R1's Short Term Care Plan-Sun Burn dated 7/22/24 revealed it was initiated due to out in sun for 3 hrs (hours). Sun burn (check) skin/scalp . Review of a Witness Statement dated 8/1/24 written by Certified Nursing Assistant (CNA) E revealed, I seen (R1) outdoors, waiting for her bus ride to an appt. (appointment) as well as other residents. The bus pulled up and did not get out to get her. And kept going but I didn't or wasn't aware she was getting picked up. Review of a Witness Statement dated 8/1/24 written by CNA G revealed, I (CNA G) was at fishbowl (receptionist desk) when I observed (R1) going outside to be picked up by (day center) around 9 am. After finishing my rounds and going back up to the fishbowl she was still outside. The statement did not reflect that CNA G went outside to determine if R1 required assistance back into the building and/or her needs were met (toileting, hydration, nutrition, pain, etc.) Review of a Witness Statement dated 8/1/24 written by Administrative Assistant-Assisted Living (AAAL) F revealed, I was at the fishbowl when the (day center) man called and said he was here to pick the residents up at the (assisted living) and MRM B asked him was he getting (R1) and he said yes after they get on the bus but he just kept driving off instead of pulling up to the nursing home and getting her. Review of a Witness Statement dated 7/31/24 written by Activity Aide (AA) H revealed, I arrived at (name of facility) (sic) at 9:30 am, I observed (R1) sitting by flower boxes. I said hello, she smiled and waved, I went inside to clock in . The statement did not reflect that AA H made additional observations of R1 following the interaction. Review of a Witness Statement dated 7/31/24 written by AA J revealed, I do not recall there being an incident. Indicating Activity Staff were not present with R1 while she was outside. Review of a Witness Statement (no date) written by Medical Records Manager (MRM) B revealed, On 7/22 (R1) was schedule for (day center). (Day center) called stating they were outside to pick up residents from the (assisted living) and (name of facility) (sic). I then told them I was wheeling (R1) outside for pick up. I saw the bus pull around the parking lot and park in front of (R1). After that I went off to a meeting. Around 11:50 AM (RN C) came in wheeling (R1) stating she had not been picked up by (day center). Instead had been left outside with Activity Staff .(Director of Nursing) was notified. During an interview on 08/19/2024 at 12:39 PM, MRM B reported that on 7/22/24 the day center van was at the attached assisted living picking up residents and wanted R1 outside. MRM B reported she wheeled R1 outside the front doors and observed the day center bus pull up. MRM B reported she was on her way to a meeting and did not observe the day center bus driver assist R1 onto the bus. MRM B reported she was notified by Registered Nurse (RN) C that R1 was never picked up and had been outside during that time. MRM B confirmed that there was a code required to enter the building at the second set of front entrance doors. If a staff member wasn't in the fishbowl (reception area enclosed with glass), a doorbell could be utilized to alert staff. MRM B reported R1 did not have access to a call light outside and was unsure if R1 had a personal cellphone. Review of R1's Inventory of Personal Effects revealed no cell phone listed. Confirming R1 did not have a personal cell phone available for use. Review of the investigative notes and witness statements revealed no Witness Statement completed by RN C. During an interview on 08/19/2024 at 1:14 PM, RN C reported she was aware that R1 had been taken outside at approximately 9:30 AM on 7/22/24 to be picked up by the day center. RN C reported she left the facility for her lunch but did not recall visualizing R1 at that time. RN C reported when she returned from lunch around 12:30 (PM) she noticed R1 by the flag pole outside of the main entrance of the facility. RN C reported she went up to R1 and asked (day center) didn't pick you up? to which R1 replied no and reported she was getting really warm and her scalp was warm. RN C reported R1 had been outside for about 3 hours. RN C reported she asked R1 why she didn't ask for assistance back into the building and reported that R1 was not very vocal and didn't want to inconvenience anyone. RN C confirmed that when she visualized R1 she was alone and did not have staff supervision. RN C confirmed that R1 could self-propel in her wheelchair but was not sure she would be able to open the front doors independently or find the doorbell. RN C reported she immediately notified management of the incident but was not asked to complete a witness statement. Review of the Facility Reported Incident (FRI) investigation revealed, .Investigation: (day center) program administrator reported to the Administrator that she was made aware resident (and day center participant) (R1) waited outside for period of time while awaiting transportation and asked if a facility reported event had been entered. Due to this allegation an investigation was initiated .Date and time of two-hour report:: 7/31/24 at 4:45 PM .Immediate Action: On 7/22/24 the resident was assisted back inside the facility by a licensed nurse. (R1) explained that she had been outside waiting for the (day center) transport to take her to the day center as planned, however the bus did not pick her up. A skin assessment was completed by a licensed nurse as (R1) stated her scalp was warm and she had erythema (redness) to her scalp but no raided, or open areas . Ambulatory Status: Extensive Assist with Walker Locomotion Status: Independent and requires one Assist to Propel Wheelchair at times . BIMS: 06/15, indicating severe cognitive impairment . Alleged Victim Interview: (R1) was able to verbalize her thoughts/feelings at the time of the missed transportation. (R1) expressed that she was frustrated (day center) did not pick her up, as this had been an ongoing issue. It is (R1's) pattern to go to the day center with (name omitted) and this is something she wanted to do. She was frustrated that she (was) waiting a long time for the bus and it did not come . Investigation Summary .(R1) was outside awaiting transport were interviewed related to their observations of (R1) and her pickup. (R1) was noted to be outside awaiting transport, not in any distress, and provided oversight by staff coming and going from the facility and outside for various reasons. (R1) was noted to be on the sidewalk just beyond the front doors. She did not request for a staff member to bring her inside, until nurse (RN C) offered, and she accepted . (R1) was visible to staff the duration of time she was outside. She was sitting at/near the flower boxes just outside the front doors which can be seen by the DON (Director of Nursing) office as well as the reception desk. Multiple staff members come and go from those doors during those times. Both staff and resident families were outside with other residents and noted that (R1) was not in distress, able to ask assistance should she need it and did when she did not want to wait any longer. Staff nurse (RN C) assisted (R1) back inside. (R1's) care plan was reviewed and indicates that she enjoys sitting outside in the warm weather. She is alert and oriented and able to make her needs known, while verbalizing her preferences. She is able to self-propel short distances in her wheelchair. When she was ready to come back inside, she verbalized it to the nurse and was assisted back in .Facility staff justifiably believed (R1) was successfully picked up and could not have predicted that the (day center) driver did not load her into the transport vehicle and take her to the day center . During an interview via telephone with Interim Nursing Home Administrator (INHA), DON, and Nurse Consultant (NC) D present on 08/19/2024 at 3:04 PM, NHA (on leave since 8/11/24) reported that the incident on 7/22/24 was not investigated/reported until 7/31/24 because staff had not notified her of the event. NHA reported the day center notified her of the incident on 7/31/24 after R1's responsible party filed a grievance with the day center regarding the bus driver leaving R1 and immediately started an investigation. NHA reported she was unable to connect with RN C to obtain her witness statement. NHA was asked to provide documentation that R1 was assessed and/or was offered to be brought inside between the observation of AA H and RN C and confirmed that there was no documentation to verify that R1 had been assessed and that her needs were met and confirmed that she was unable to identify any facility staff members that assessed R1 and/or offered to bring R1 inside during that time period. NHA reported that R1's care plan revealed that she enjoyed sitting outside in the warm weather but was not aware of the Assessment for Outdoor Independence that indicated that outdoor independence was not recommended. NHA reported she spoke with R1's responsible party and was told that R1 doesn't want to bother anybody the I'm fine kind of thing. NHA reported that R1 was observed by multiple staff while she was outside and was able to make her needs known/request to be brought inside (despite the lack of a call light system and cell phone to communicate her needs and/or notify staff of an emergency, staff assessment/communication with R1, and R1's behavior of not wanting to ask for assistance bother anybody.) During an interview on 08/19/2024 at 12:52 PM, DON and INHA reported there were no policies for transportation/resident hand off but reported the expectation would be for staff to stay with a resident until they visualized the resident on the transport bus. INHA reported that staff education regarding resident transportation was initiated following the incident. Review of the staff education Outdoor Independence and Transportation revealed, OUTDOOR INDEPENDENCE *Nurses stations and the fish bowl have an updated list of residents deemed capable of outdoor independence *Residents not on this list should never be unsupervised outside *Residents must sign out before going outside TRANSPORATION TO (day center) PROCESS *(Day center) dispatch will notify the facility when they arrive to pick up a resident *If the resident is to be transported, (Name of Facility) staff will assist the resident to the transportation vehicle for a handoff *Residents deemed not capable of outdoor independence should wait inside for transport and staff assistance.

This Citation pertains to Intake Number MI00144963. Based on observation, interview, and record the facility failed to protect the resident's right to be free from physical abuse by a resident for one resident (Resident #2) of three residents reviewed for abuse and neglect, resulting in Resident #2 being pushed, fracturing her right radius and the right femoral neck after falling. Findings include: Review of a Facility Reported Incident (FRI) submitted to the State Agency on 05/31/24 revealed there was a resident to resident altercation occurred when (Name of R1) pushed (Name of R2) stating that she was in his way near the front lobby/dining room area. Resident have been separated and assessed by a licensed nurse to have no injury. There was no harm or psychosocial distress. Resident #1 (R1): A review of R1's Admission Record, revealed R1 was a [AGE] year-old resident admitted to the facility on [DATE] with pertinent diagnosis that include Epilepsy, Bipolar Disorder, Post-Traumatic Stress Disorder, Cerebral infarction, and muscle weakness. A review of R1's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 4/15/24, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 11 which revealed R1 was mildly impaired. Review of R1's progress notes revealed an Interdisciplinary Documentation dated 5/31/2024 at 16:15, written by the DON, that noted, It was observed that resident pushed resident (identified as R2) in the entryway to the dining room. (Name of R1) states that he asked her to move several times and she was in his way, so he pushed her. (Name of R1) was very aggressive and agitated. (Name of R1) was observed with his shirt unbuttoned and yelling, using obscene language. (Name of R1) was assessed for injuries of which none were noted. (Name of R1) yelled out at writer to kick him out of here. Writer explained that was not the process. Review of R1's progress notes revealed an Interdisciplinary Documentation dated 6/01/2024 at 06:35, written by (Name of Registered Nurse (RN) D) noted, I had a conversation with resident this morning regarding incident he had last night, resident stated he is acting out because he doesn't want to be here anymore and wants to send him too someplace else. I explained having negative behaviors, using vulgar language, being disrespectful and hurting others in not the way to handle it. I asked for him to be kind, treat others with respect and to talk to me if he is feeling frustrated or getting upset before taking it out on others. I offered resident to eat his meals in his room or the day room's and he agreed to eat in the day rooms which is less stimulating of environment. Further review of R1's progress notes reflect R1 was having increasing behaviors days prior to 5/31/24 incident including: - On 5/26/2024 at 12:12, Patient observed being verbally aggressive towards staff, patient told staff to shut the fu*k up and stop talking! Staff tried to escort patient out of harbor dining room, but patient refused, writer then came to harbor DR to redirect patient to room for lunch, patient was reluctant but agreed to go to his room. Writer educated resident on behavior towards staff and staff is to monitor and identify early signs such as irritability or aggression and to redirect resident to have quiet time alone or to perform other fun activities that (Name of R1) can enjoy. - On 5/27/2024 at 07:26, Resident was cussing at CNA when she was talking to him about being kind and respectful if he were to eat in dining room for breakfast. Resident chose to have negative behaviors and told CNA said, go fuck yourself, fuck off . We then explained to resident for breakfast we would have him eat in his room. - On 5/28/2024 at 09:54, resident is expressing behaviors and outbursts of anger toward staff. This am resident was cussing at staff while in dining area. When resident was redirected to a calmer environment to help with agitation resident stated, just kick me out. resident was escorted out of dining area and incident was resolved. Review of Health Care Practitioner (HCP) Visit Progress Note dated 6/3/2024 at 13:30, revealed, . They are seen and examined today after report of violent behavior, pushing another resident over with both hands resulting in broken bones. Patient says he remembers the encounter and does not know why he did this. During an interview with a witness on 6/11/24 at 2:20 PM, Medical Records (MR) A stated, she was sitting here (front desk) when I looked up and saw (Name of R1) in his wheelchair jerk forward in his chair (right in the doorway) and then I heard and saw (through the dining room windows) (Name of R2) yell and fall to the dining room floor. She was shaking and on the floor. The nurse that was working on the cart nearby came quickly and did a full assessment including vitals. The resident stated her wrist hurt. Both residents were separated. MR A further revealed that the incident happened fast, I did not really hear anything prior to the incident. Just a sudden commotion, a raised voice, her falling. During an interview on 6/11/24 at approximately 3:00 PM, Registered Nurse (RN) D stated (Name of R1's) behaviors have been increasingly getting worse. He can't go to the dining room due to conflicts with other residents and staff. The day after the incident happened (Name of R1) told me he did it because he wanted to get out of this place. His goal was to act out and go to his former living situation. He told me he will do what he can to go back. He knows what exactly what he is doing is wrong. During an interview on 6/11/24 at 3:45 PM, Social Services (SS) B revealed that R1's guardian wants the resident treated in house by our psych provider. SS B confirmed R1's behaviors have recently increased and as a result he was started on Ativan this morning. Resident previously lived in an independent living situation, and he wants to go back. He acts out because he thinks he can get out and get free. During an interview on 6/12/24 at 10:10 AM, R1 stated, I was told I pushed someone, but I don't remember. Resident further stated, she wouldn't move, she was whining and yelling at me when she was on the floor. Resident completed the interview by stating he didn't want to talk. Resident#2 (R2): A review of R2's Admission Record, revealed R2 was a [AGE] year-old resident admitted to the facility on [DATE] with pertinent diagnosis that include Peripheral Vascular Disease, Dementia, major depressive disorder, and anxiety disorder. A review of R2's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 3/11/24, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 03 which revealed R2 was severely cognitively impaired. On 6/11/24 at 2:26 PM, R2 was observed in her bed sleeping with her arm in a sling. During an interview on 6/11/24 at 2:30 PM, Registered Nurse (RN) C stated R2 was verbalizing pain today. RN C revealed prior to her fall she would walk and was independent with most cares. She now needs assistance with her cares an allowed staff to assist her with her lunch today due to her injury and being right-handed. During an interview on 3/11/24 at approximately 3:50 PM, SS B revealed (Name of R2) had been out in about the last couple of months eating her meals in the dining room and going to watch the activities. Not necessarily participate but she would go and watch. During an observation/interview on 3/12/24 at 9:23 AM, R2 is in bed and reveals she is in pain. Resident revealed some guy/man was mean to her and pushed her down in the dining room. When asked if she felt safe resident stated, I hurt. Review of R2's progress notes revealed an Interdisciplinary Documentation dated 5/31/2024 at 16:15, written by DON, that noted, It was witnessed that resident (Identified as R1) pushed resident in the entryway of the dining room causing her to fall onto her buttocks. Residents were immediately separated and assessed for injury, (Name of R2) reported that her right wrist hurt. FROM, no tenderness with palpation, no bruising. Order obtained for X-ray of right wrist. Review of R2's progress notes revealed an Alert Note dated 5/31/2024 at 21:57, Nurse writer was in hallway at med cart when commotion was heard in dining room. Nurse (writer) put med's away and went to dining room. Resident was noted on the floor laying on her back. BP 161/74, P 96, R 19, O2 98% RA, T 97.4 temporal. Resident noted guarding right wrist. Bruising and swelling noted. Right arm elevated on pillow. Upon skin assessment, skin tear noted to right elbow measuring 4 cm x 1 cm x 0 cm. First aid applied. Awaiting x-ray. Review of progress note dated 6/01/2024 at 19:06, reflected, Writer obtained x-ray results for resident. Results read as follows: Acute fractures of the distal radius and ulna styloid process. Writer contacted physician on call and received verbal order to send to ER for further evaluation and treatment. Resident made aware and guardian made aware. Writer also informed DON. No new concerns. Review of R2's hospital After Visit Summary dated 6/01/24 -6/05/24 revealed that resident was seen an admitted to the hospital for displaced right femoral neck fracture and a comminuted intra-articular distal radius fracture on the right side with some shortening and impaction. Review of R2's progress note dated 06/05/2024 at 18:04 revealed, Care plan updated - falls, transfer status, bed mobility, dressing, toileting. Review of R2's Section GG Data Collection -2023 for discharge Effective Date 6/03/2024 revealed the resident required the following Self Care assistance at, 05. Setup or clean-up assistance: Helper sets up or cleans up: resident completes activity. Helper assists only prior to or following the activity. In the areas listed below: 1A. EATING: The ability to use suitable utensils to bring food and / or liquid to the mouth and swallow food and/or liquid once the meal has been placed before the resident. 2B. ORAL HYGIENE: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing using the equipment: 3C. TOILET HYGIENE: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment. 4D. PERSONAL HYGIENE: The ability to maintain personal hygiene, including combing hair, shaving, applying make-up, washing/drying face, and hands. (excludes baths/showers, and oral hygiene). Further review of R2's assessment reflected in all areas of Mobility she was 06. Independent: resident completes the activity by themselves with no assistance from a helper. The Mobility areas that were reviewed included: 5B. MOBILITY - SIT TO LYING: The ability to move from sitting on the side of the bed to lying flat on the bed. 6C. MOBILITY - LYING TO SITTING ON THE SIDE OF THE BED: The ability to move from lying on the back to sitting on the side of the bed and with no back support. 7D. MOBILITY SIT TO STAND: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. 8E. MOBILITY CHAIR / BED-TO-CHAIR TRANSFER: The resident ability to transfer to and from a bed to a chair (or wheelchair) 9F. MOBILITY TOILET TRANSFER: The ability to get on and off a toilet or commode. 10FF. TUB/SHOWER TRANSFER: The ability to get in and out of the tub/shower. 11I. MOBILITY WALK 10 FEET: Once standing the ability to walk at least 10 feet in a room, corridor, or similar space. Review of R2's Section GG Data Collection -2023 for Admission/5-day Effective Date 6/06/2024 revealed the resident required the following increases of Self Care assistance in the areas listed below: 2B. ORAL HYGIENE: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth and manage denture soaking and rinsing using the equipment: Partial / Moderate Assist helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. 3C. TOILET HYGIENE: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment. Substantial/maximal assistance: Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 4D. PERSONAL HYGIENE: The ability to maintain personal hygiene, including combing hair, shaving, applying make-up, washing/drying face, and hands. (excludes baths/showers, and oral hygiene). Partial / Moderate Assist helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. Further review revealed R2 now required, Substantial / maximal assist: helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and in the provides more than half the effort. In the following Mobility areas: 5B. MOBILITY - SIT TO LYING: The ability to move from sitting on the side of the bed to lying flat on the bed. 6C. MOBILITY - LYING TO SITTING ON THE SIDE OF THE BED: The ability to move from lying on the back to sitting on the side of the bed and with no back support. 7D. MOBILITY SIT TO STAND: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. 8E. MOBILITY CHAIR / BED-TO-CHAIR TRANSFER: The resident ability to transfer to and from a bed to a chair (or wheelchair) 10FF. TUB/SHOWER TRANSFER: The ability to get in and out of the tub/shower. Review of 9F. MOBILITY TOILET TRANSFER: The ability to get on and off a toilet or commode. Reflected R2 was now Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. Mobility section 11I. MOBILITY WALK 10 FEET: Once standing the ability to walk at least 10 feet in a room, corridor, or similar space. Reflected this was Not attempted due to medical condition or safety concern. Review of R2's Care Plan reflected numerous intervention/task areas have been initiated and revised on or after 6/05/24 as a result of residents fall. Abuse, is defined at S483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as defined at S483.5 in the definition of abuse, and means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

Based on observations, interview and record review, the facility failed to assess, monitor, implement pressure relief and treat for wounds and pressures ulcers for 3 Residents (R23, R37, R48,) of 4 resident reviewed for pressure ulcers, resulting in R37 developing an unstageable pressure ulcer on his back and a new pressure ulcer on his right thigh, R48's wound on her leg increasing in size and the pressure ulcer on her buttock worsening, and R23 missing wound treatments/assessments. Findings included: Review of R48's face sheet dated 5/20/24 revealed, she a [AGE] year-old female admitted on [DATE], she had diagnoses that included: pressure ulcer of left heel, unstageable, diabetes mellitus 2, lymphedema, pressure ulcer of right buttock, stage 2, non-pressure chronic ulcer of left calf, weakness, abnormalities of gait and mobility, and need for assistance with personal care. R48 was her own responsible party. During an interview with R48 on 05/13/24 at 1:41 PM, R48 was very concerned about the wound on her left heel, back of her left leg and her buttock. R48 was on her back in bed and the back of her left leg was in contact with her mattress. There were no positioning pillows or devices visible in her room. R48 said she was not able to roll or reposition herself. R48 said staff will not tell her if her wounds are getting worse and she is unable to see her wounds herself. R48 was frustrated with not knowing when the facility was going to do her wound care and she was not aware of her transportation or follow up medical appointments. During an interview with R48 on 05/16/24 at 8:45 AM, R48 was on her back in bed with her left leg flat in full contact of the mattress. R48 was not aware of any turning schedule or plan for pressure relief. R48 said she was not able to roll or reposition herself. There were no positioning pillows visible in the room to support her off her back side. R48 was pleased that she was seen by the wound care staff that morning and had received a written note of her follow up medical appointment for her wounds. Review of R48's Activity of Daily Living (ADL) care plan dated 4/17/24 revealed was dependent for all ADL's and required assistance of 1 person or bed mobility. R48 was not able to walk. R48 required the assistance of 2 person and a lift to get in/out of a wheelchair. R48 was using incontinence products for elimination. Review of R48's potential risk for impaired skin integrity revealed the following interventions: assist with re-positioning with use of a draw sheet as needed to prevent friction/shear, measure open areas upon admission, and weekly, prn (as needed). There was no indication of how often staff were to assist with repositioning. There was no indication of where R48 had skin breakdown and devices to be used to prevent/reduce pressure when repositioning other than cushion in wheelchair, and pressure reducing mattress. During an interview with the Director of Nursing (DON) on 5/20/24 at 10:27 AM, the DON reviewed R48's medical record. The DON located information that indicated R48 was admitted with skin break down on her left heel, left leg and buttock. The DON was not able to locate any documentation on the wound sizes or stages on admission. The DON reviewed R48's hospital records and could not find full descriptions with size and stages of R48's wounds on the day of discharge. During an interview with the Director of Nursing (DON) on 5/20/24 at 10:27 AM, the DON said R48's left heel was assessed 2 days after discharge and every 7 to 8 days after the first assessment. R48's left heel was assessed to be healing. R48's back of her leg was assessed the day after admission be a vascular wound the measured 3.0 cm x 1.5 cm x 0.1 cm. The wound on R48's back of her left legs was assessed to have increased in size on 4/24/24 6.0 cm x 8.0 cm x 3.2. The DON could not locate any information that explained why the wound was increasing in size, or change in treatment. The last recorded measurements for the wound on the back of R48's left leg was done on 5/16/24, 6.9 cm x 3.8 cm x 0.1 cm. DON could not locate any documentation for the reason the wound had declined. The first assessment for the wound or R48's buttock was completed the day after her admission on 4/18/24, the wound was assessed as healed on 4/24/24. On 5/16/24 R48 was assessed as have a 0.2 x 0.7 x 0.1. There was no indication as to the cause of the wound opening again. The DON said her expectation is a full wound assessment on admission, and weekly. The DON could not locate any education for pressure relief needs, timing or risk/benefit discussion when R48 was requesting to stay up in her wheelchair. 31771 R23 Review of the Admission Record reflected R23 admitted to the facility 11/15/23 with diagnosis that included End Stage Renal Disease (on dialysis), Dementia, and History of Stroke. Review of the Admission Minimum Data Set (MDS) dated [DATE] reflected R23 received nutrition through a feeding tube. The MDS reflected R23 was at risk for developing pressure sores and admitted with one stage 2 pressure sore. Review of the Skin assessment dated [DATE] reflected moisture associated skin damage (MASD) of the sacral area. Review of the Skin assessment dated [DATE] reflected MASD of the sacral area and the addition of a stage I wound on the left ankle measuring 1 x 0.5 centimeter (cm). Review of the Physician Assistant (PA) documentation dated 1/31/24 revealed an open wound on the right hand. The PA documented that the facility identified this wound on 1/12/24 although the Skin Assessment of 1/17/24 did not include this finding. The MASD of the coccyx had progressed to a stage 2 pressure injury measuring 0.5 x 0.3 x0.1 cm. Lastly, the wound on the left ankle had increased from the size noted above to 1.8 x 1.8 x 0.1 cm. The PA documented Pressure injury of left ankle, unstageable. The policy provided by the facility titled Skin at Risk Assessment Documentation, Staging, and Treatment last revised 1/2020, was reviewed. The policy reflected, Definitions, Unstageable Pressure Injury: Full-thickness skin and tissue loss in which the extent of the tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Review of the PA wound documentation dated 2/7/24 included evaluation of the above wounds and reflected the new addition of an unstageable right ankle pressure injury. The above PA documentation of 2/7/24 for follow up on the wounds of R23 was given further review. The documentation reflected a wound on the left ankle first identified 1/17/24 and a new wound on (R23's) right ankle. The PA documentation reflected that staff state they stopped the (pressure relieving) boots. The documentation reflected the unstageable wound on the left ankle measured 1.4 x 1.5 x 0.1 cm. The new unstageable wound on the right ankle, identified after staff had stopped the boots, measured 1.1 x 1.3 x 0.1 cm. On 3/1/24 the EMR reflected a Doctor's Order Refer to Wound clinic. Review of the Wound Clinic documentation dated 3/18/24 revealed R23 had bilateral malleolus (outer ankle) ulcers. The documentation reflected the Wound Specialist measured the wound on the left ankle to be 2.4 x 2.2 x 0.3 cm (an increase in size from 2/7/24) and the right ankle wound measured 1.5 x 1 x 0.2 cm. The Wound Specialist recommended a change in treatment using Santyl, Aquacel and soft wraps. The Wound Specialist also documented Patient is in need of protective boots the PRAFO type boots (pressure-relieving boots) and to follow-up approximately one month. Review of the Treatment Administration Record (TAR) for R23 reflected the change in treatment to santyl and daily dressing changes recommended by the Wound Specialist had been implemented. The EMR reflected the one month follow up with the Wound Specialist was scheduled for 4/24/24. However, no documentation was found that this appointment was kept. Also, the medical record does not reflect the PRAFO type boot recommended 3/18/24 were implemented until 5/8/24. This is approximately seven weeks after the Wound Specialist's recommendation. The medical record reflected that in the month following the Wound Specialist evaluation when the recommended PRAFO boots were not implemented the left ankle wound worsened from 2.4 x 2.2 x 0.3 cm in size to 3.3 x 3 x 0.4 cm documented on 4/19/24. Similarly, the wound on the right ankle worsened from 1.5 x 1 x 0.2 cm to 2.0 x 2.0 x 0.1cm. Review of the TAR for April 2024 for R23 revealed that five dressing changes to the left ankle were not documented as completed and four dressing changes to the right ankle were not documented as completed. On 5/16/24 at 12:27 AM an interview was conducted with the Director of Nursing (DON) and Corporate Consultant (CC) U in the office of the Nursing Home Administrator (NHA). The DON reported R23 was wearing padded boots but these were stopped, as noted by the PA on 2/7/24, because the DON felt the boots were the cause of the wounds. The DON reported that the family of R23 felt the wounds were getting worse and R23 was then seen by the Wound Specialist. The DON reported that she was disappointed the Wound Specialist had recommended implementation of the pressure-relieving boots despite documentation that the wounds had worsened. The DON reported she had discussions with the in-house medical provider about the pressure-relieving boots but was not able to provide any documented rationale for not implementing the Wound Specialist's recommendation. The medical record Progress Notes for R23 were reviewed and revealed: -Interdisciplinary Team (IDT) entry on 2/21/24 at 7:55 AM by the Registered Dietician (RD) that R23 continues with impaired skin integrity. R23 has multiple co-morbidities that are compromising healing of her wounds . weight has been stable .Will continue to follow wound healing progression. -IDT entry on 2/23/24 at 10:58 AM by the RD, stable target weight. -IDT entry on 2/26/24 at 2:23 PM, weight has been unstable, fragile skin and palpable bony prominences, (R23) has multiple diagnosis contributing to the unavoidable areas of pressure injury development they are severe protein caloric malnutrition .she requires assistance with mobility .has double incontinence (bowel and bladder) .Her Care Plan has interventions in place to promote wound healing. -IDT entry 3/18/24 at 7:27 AM, (R23) continues with wounds to her right and left ankle .all of which are healing very well. This is the same date R23 was evaluated by the Wound Specialist and a trend of increasing size in wound measurements was documented. The IDT documentation suggests wounds, in general, are unavoidable for R23. However, no documentation was found that indicated why each wound was unavoidable when it was identified. The MDS dated [DATE] Section GG reflects R23 is dependent on staff for repositioning off pressure areas. The Progress Notes do not reflect R23 refuses repositioning or has demonstrated an inability to tolerate repositioning. R23 is dependent on the facility to provide sufficient healing nutrition via feeding tube. R23 has double incontinence, is unable to perform self-care, and is dependent on the facility for monitoring when cleaning the skin of urine and stool is needed. Review of the EMR comprehensive Care Plan reflects, despite the identification of impaired skin and several wounds since 1/11/24, no interventions have been added or revised since the Care Plan for impaired skin was initiated on 11/23/23. Review of the EMR did not reveal that the recommended follow-up Wound Clinic evaluation had transpired. No documentation was found in the EMR that the Wound Specialist had been informed that the recommended PRAFO boots were not implemented, that nine wound treatments during April 2024 were not documented as completed, or that the wounds had worsened. Other than documentation by RD, no IDT documentation was found of efforts to mitigate alleged unavoidable factors or co-morbidities that contribute to impaired skin. As of survey exit no further documentation was provided by the facility. 31197 R37 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R37 admitted to the facility on [DATE] with diagnosis of (but not limited to) bilateral below the knee amputations, traumatic brain injury, heart failure, and neuromuscular dysfunction of the bladder. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which represented R37 was cognitively intact. During an interview on 5/15/24 at 10:36 AM, R37 stated that staff were not changing his dressings to his back and suprapubic catheter like they were supposed to. R37 said he has a foul odor coming from one of them. During an observation and interview on 5/15/24 at approximately 10:50 AM, Licensed Practical Nurse (LPN) H and Certified Nurse Assistant (CNA) I repositioned R37 in bed and while he was turned onto his left side, this Surveyor and staff observed a dressing to the mid back that had a date of 5/14/24 on it. There was a scab noted to the right upper leg that was approximately the size of a quarter without a dressing. R37 stated a staff member told him it was like a blister and it had an odor to it. According to the Skin assessment dated [DATE] 4:29 PM there were no open areas or pressure ulcers. According to the progress notes on 5/14/24 at 11:19 PM reflected, While applying biofreeze (muscle ointment) I felt patch on the residents back he has a wound on the middle of his back approximately 2-3 in x 3/4 width. The area was cleaned and dressing was applied. It was also noted he has scabs on the right leg from adhesive and the catheter that was about the size of a quarter. During a follow up interview and record review on 5/15/24 at 10:50 AM, LPN H stated there were no orders entered at this time for the wound care and she would look into it. At approximately 12:30 PM, LPN H confirmed that there were no treatment orders and no short term care plan initiated for the new unstageable pressure ulcer to the mid back or open area to the right thigh. According to the Skin assessment dated [DATE] locked at 1:54 PM, reflected a new open are to the mid back (no measurements) and dressing was applied. A new open area to the right upper thigh area 1 cm x 3 cm left open to the air. The note reflected the wound nurse would follow up tomorrow. According to the Wound Measurement assessment completed on 5/16/24, reflected a new unstageable pressure ulcer to the mid lower back that was 6.8 cm x 1.8 cm x 0.1 cm and a new unstageable pressure ulcer to the right thigh that did not contain a measurement. The facility failed to ensure that newly developed skin issues are thoroughly assessed including a measurement, initiate a short term care plan and obtain a treatment order from the physician.

This citation refers to MI00139088. Based on observation, interview, and record review, the facility failed to prevent an elopement resulting in an immediate jeopardy when one Resident (R14) who was a known elopement risk, of three residents reviewed for elopement risk, was let outdoors by a staff member who did not know the resident. This deficient practice resulted in the elopement and potential for serious harm, injury, impairment, or death to R14 and all other residents assessed as an elopement risk. Findings include: The Immediate Jeopardy (a situation in which entity noncompliance has placed the health and safety of residents in its care at risk for serious injury, serious harm, serious impairment or death) began on 6/17/23 when R14 eloped from the facility. The Nursing Home Administrator was notified of the Immediate Jeopardy on 9/7/23 at 4:20 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 6/19/23 and the deficient practice corrected on 6/26/23, prior to the start of the survey and was therefore past noncompliance. A review of R14's Admission Record, dated 9/7/23, revealed R14 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R14's Admission Record revealed multiple diagnoses that included dementia with agitation, dementia with behaviors, and dementia with psychotic disturbance. A review of R14's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 5/30/23, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 99 which revealed R14 was unable to complete the assessment. A staff assessment of R14's mental status revealed he had short-term and long-term memory problems with inattention and disorganized thinking. The staff assessment also revealed R14 had severely impaired cognitive decision-making skills. SITUATION A review of R14's progress notes, dated 6/1/23 to 6/24/23, revealed the following: - Interdisciplinary Documentation, dated 6/1/23, revealed, he is at increased risk for exit seeking [proper name of wristband alert device] is in place . - Interdisciplinary Documentation, dated 6/2/23, revealed, Resident exit seeking frequently this shift and needing frequent redirection. Also needing reminders to not push others who are in w/c (wheelchair). Other residents are getting upset as [name of R14] pushes them without asking ect (etcetera) . Will continue to redirect and inform oncoming nurse of behaviors. - Interdisciplinary Documentation, dated 6/8/23, revealed, Has [proper name of wristband alert device] in place for exit seeking behaviors. - Interdisciplinary Documentation, dated 6/13/23, revealed, Has [proper name of wristband alert device] in place for exit seeking behaviors. - Interdisciplinary Documentation, dated 6/14/23, revealed, Has [proper name of wristband alert device] in place for exit seeking behaviors. - Interdisciplinary Documentation, dated 6/17/23, revealed, [Name of R14] was noted to be outside of the facility and staff were notified. Staff assisted resident back into the facility without incident. An assessment was completed by [name of Licensed Practical Nurse (LPN) T] and resident is free from injury or distress. 1:1 (one-to-one) supervision initiated . - Interdisciplinary Documentation, dated 6/20/23, revealed, This entry is for 6/17/2023. At 1530 (3:30 PM) [name of Certified Nursing Assistant (CNA) P] reported to [name of LPN T] that [R17] reported to her that he witnessed [name of R14] outside walking toward [name of the 5-lane main road a block from the facility]. [Name of LPN T] immediately reported it to all staff, then called [name of Clinical Care Coordinator (CCC) W] then 911. [Name of CNA P] immediately went outside to look for [name of R14]. A few other CENA (certified nursing assistants) got in their vehicle to search for [name of R14]. They found him approximately 1 mile away on [name of a 5-lane main road approximately a mile from the facility] walking on side walk heading south. [Name of R14] was wearing a T-shirt, jogger pants, socks, and tennis shoes. Outside temp (temperature) at time 73 degrees. [Name of R14] stated that someone told him he could leave and that he was going to visit his sister. Complete head to toe assessment complete no injuries noted, [Name of R14] not short of breath or sweaty upon return to the facility. Vital signs stable. All door alarms assessed and are in working order, all residents with [proper name of wristband alert device] assessed, all in place and functional . - Interdisciplinary Documentation, dated 6/24/23, revealed, [Name of R14] was exit seeking this morning, he would tell writer see you later and attempt to open the exit doors. [Name of R14] was easily redirected away from the exit doors. Resident's mood and behavior were at baseline. He displayed no s/s (signs or symptoms) of agitation or distress. [Proper name of wristband alert device] is in place due to unsafe wandering and exit seeking . A review of staff statements for R14's elopement on 6/17/23 revealed the following: - Dietary Aide (DA) O's written and signed statement, dated 6/19/23, revealed on 6/17/23 at around 3:30-4:30 PM she let a family out of the facility. She stated there were residents in the immediate area. DA O stated a man (R14) said I need out to go home. She stated she debated letting him out, but after waiting a few minutes she decided to let him out because she thought he was a family member. DA O stated she should have found the nurse and double checked to make sure the man (R14) was not a resident. But she did not want to insult [a] family member if it (he) was [a family member]. DA O stated she used the code to let R14 out, but the door alarmed, and she did not know how to turn it off. She stated a couple of aides came and turned off the alarm for her. DA O stated she later learned that the man was a resident (R14) and not a visitor. - Activity Aide (AA) Q's written and signed statement, dated 6/22/23, revealed a resident informed her that R14 had walked off and he was unsure if [name of R14] should be out. She stated she and CNA P went out the front [door] to see if they could see R14, but they could not. AA Q stated she then went back into the building and notified LPN T (R14's nurse). - Housekeeper (HSK) R's written and signed statement, dated 6/22/23, revealed on 6/17/23 at 2:00 PM, she had seen R14 standing in the lobby with other residents. HSK R stated around 3:00 PM, she had been asked by a nurse if she had seen R14. She stated she told her (the nurse) that she had last seen R14 around 2:00 PM in the lobby. HSK R stated she helped to search for R14. She stated around 3:45 PM to 4:00 PM, she saw two CNA's coming in the front door with R14. HSK R stated she heard R14 say, They knew where I was at because someone knew I was leaving. - CNA P's typed and unsigned statement, undated, revealed she was returning to the facility from break when a resident informed her that R14 had left the building. She stated she told the housekeeper to report it to the nurse and she jumped into her car to search for R14. CNA P stated she searched down [name of the 5-lane main road a block from the facility] and the side streets looking for R14. - CNA G's typed and unsigned statement, undated, revealed on 6/17/23 at approximately 3:30 PM, a resident told her and CNA U that R14 was walking up the street. She stated Registered Nurse (RN) V told her, CNA N, and CNA U to go outside and look for him. CNA G stated they took CNA N's car and started searching for R14. She stated at approximately 4:00 PM, they found R14 walking on the sidewalk on [name of a 5-lane main road approximately a mile from the facility]. CNA G stated R14 was unharmed. She stated R14 told them he was going home when they asked him where he was going. CNA G stated they offered R14 a ride, assisted him into the car, and drove him back to the facility. - CNA N's typed and unsigned statement, undated, revealed on 6/17/23 at approximately 3:30 PM, LPN T told her that R14 had gotten outside. She stated she informed other staff of this and started walking up the street looking for R14. CNA N stated she did not see him, so she, CNA G, and CNA U left in her car and started driving around. She stated they found R14 at approximately 4:00 PM walking up [name of a 5-lane main road approximately a mile from the facility] on the sidewalk near the [name of an ice cream shop] one mile from the facility. CNA N stated when they asked him where he was going R14 told them he was going home. CNA N stated they offered him a ride, assisted him into the car, and drove him back to the facility. - LPN T's typed and unsigned statement, undated, revealed on 6/17/23 at 2:40 PM, R14 was standing near the Terrace Nursing station. She stated she was not aware that R14 had left the Terrace unit until CNA P told her that someone said R14 was seen outside. - CNA U's typed and unsigned statement, undated, revealed on 6/17/23 at approximately 3:30 PM, a resident told her and CNA G that R14 was walking up the sidewalk toward [name of the 5-lane main road a block from the facility]. CNA U stated she immediately went outside to look for him. She stated her, CNA G, and CNA N jumped into CNA N's car and found R14 walking up [name of a 5-lane main road approximately a mile from the facility] on the sidewalk at 4:00 PM. CNA U stated R14 told them he was going home when they asked him where he was going. She stated they offered him a ride, assisted him into the car, and drove him back to the facility. - RN V's typed and signed statement, dated 6/17/23, revealed on 6/17/23 at around 3:25 PM, she had been informed that a resident had been observed outside the facility walking toward [name of the 5-lane main road a block from the facility]. She stated she notified staff that there was an elopement and headed outside through the administration lobby doors. RN V stated she saw CNA U and CNA G searching the neighborhood west of the facility. She stated she went east along [name of the 5-lane main road a block from the facility] for a few blocks and then returned to the facility after she did not see R14. - R17's typed and unsigned statement, undated, revealed on 6/17/23 at approximately 3:20 PM he was outside the facility on the sidewalk. He saw R14 walking on the sidewalk toward [name of the 5-lane main road a block from the facility]. He stated when he came back into the building, he told a staff member because it was not normal to see R14 outside. During an interview and observation on 9/7/23 at 10:00 AM, the Nursing Home Administrator (NHA) visibly startled and deeply inhaled suddenly (gasped) when the surveyor dropped their clipboard on the nurse's station desk (it made an unintended loud noise because it was heavily loaded with papers). The NHA stated the noise the clipboard made was a gunshot. The surveyor asked the NHA why she thought the noise was a gunshot and she stated that the area around the facility was not necessarily safe. CCC W was also present at the nurse's station during the interview. CCC W also visibly startled and deeply inhaled suddenly (gasped) when the surveyor dropped their clipboard on the nurse's station desk. CCC W verbalized that she also thought the noise the clipboard made was a gunshot and agreed with the NHA that the area around the facility was not necessarily safe. A review of video footage of incident on 6/17/23 was conducted on 9/7/23 at 11:30 AM with the NHA. The NHA stated the time stamp on the video camera footage was 7 minutes fast from actual time, so there will be a time difference between the video camera footage and what the time the facility listed in their investigation. The NHA also stated the facility does not have any cameras that cover the outside of the facility, so the only video camera footage they have was from the camera in the front lobby. The NHA verbally identified by name all staff and residents in the video during the viewing. The following is a timeline of the incident using the video camera time stamp: - 3:05 PM- R14 wandering in lobby. Walking on and off camera. R14 not going near exterior lobby door. - 3:18 PM- R14 talking with a visitor in front of exterior lobby door. - 3:19 PM- DA O observed inputting the door code on the panel and letting the visitor out exterior lobby door. R14 tried to follow the visitor, but DA O stopped him before he went through the exterior lobby door. DA O then appeared to be walking around the lobby looking around (possibly for staff) while R14 stood in front of the exterior lobby door. - 3:20 PM- DA O observed talking with R14 in front of the exterior lobby door, entered the door code on the panel, and let R14 outside. As R14 was leaving through the exterior lobby doors, R14 and DA O waved good-bye to each other. R14 was observed turning left on the sidewalk (in the direction of the 5-lane main road located a block from the facility) after exiting through the door and walking off camera. - 3:27 PM- R17 was observed outside in front of the exterior lobby door talking with AA Q and pointing in the direction that R14 was seen walking after he exited the building and walked off camera. AA Q came into the facility through the exterior lobby doors with R17, CNA P was seen going in the direction R17 had pointed, and AA Q was seen walking off camera. - 4:02 PM- R14 entered the facility through the exterior lobby door with staff. *Total time R14 was out of the facility was 42 minutes. A second review of the video footage of incident on 6/17/23 was conducted on 9/7/23 at 2:10 PM with the NHA. There was only one other resident observed in the lobby area on 6/17/23 from 3:05 PM to 3:20 PM. That resident was observed across the lobby from the exterior doors and did not go near those doors during this time. In addition, the NHA verified that this other resident was not an elopement risk and did not have a wristband alert device. Therefore, the only wristband alert device that would have set off the alarm when R14 exited through the exterior lobby doors would have been R14's. During an observation on 9/8/23 at 7:50 AM with one other surveyor, the most likely direct route that R14 would have taken from the facility to where he was found by staff on 6/17/23 was driven. The surveyors noted that R14 could have taken a sidewalk along the main roads the entire route (except for having to cross a parking lot between where the facility property ended and where the sidewalk began again along the 5-lane main road one block from the facility). However, R14 would have had to cross at least the one 5 lane main road, even if it was at the crosswalk where the main road that was one block from the facility met the other main road (another 5-lane road) that he was found on. This would be considering that R14 was actually found across the street from the ice cream shop and not on the same side of the road as the ice cream shop. The total driven mileage was 0.9 miles per the car's odometer. However, R14 could have easily walked one mile since the car used could not be driven up to the facility's exterior lobby door or over the curb and grass area to the sidewalk running along the initial 5 lane main road. During an observation on 9/8/23 at 7:50 AM with one other surveyor, the most likely direct route that R14 would have taken from the facility to where he was found by staff on 6/17/23 was observed to have moderate traffic on both 5 lane main roads. In addition, the ice cream shop where he was found (or found by) appeared to not have been in business for some time (the paint was faded, and the building and grounds appeared to be neglected with trash and weeds growing along the building and the building grounds). The neighborhood around the ice cream shop was observed to have boarded up and abandoned buildings, houses in disrepair, and cars that seemed to be abandoned and/or in need of serious repair in parking lots/driveways. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included. The Immediate Jeopardy that began on 6/17/23 was removed on 6/19/23 when the facility began staff education (including the facility's elopement policy, the search and activation process, posting elopement risk residents, not sharing door codes, risks associated with using the wristband alert device codes versus the standard door codes to open the doors, and steps to verify residents versus visitors and the standard and wristband alert device codes were reset (changed). The deficient practice was corrected on 6/26/23 after the facility increased the visibility of the resident elopement risk posting; reviewed and revised, if necessary, resident care plans; increased activities for residents on the dementia unit during the late afternoon/sundowning hours (the time when residents with dementia can become more confused as the day gets later and the light of the day starts to fade) to decrease aimless wandering; performed a successful elopement drill to test staff retention of educational knowledge; and completed education for all facility staff. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation is related to intake # MI000- 9. Based on interview and record review, the facility failed to thoroughly assess, monitor, provide interdisciplinary coordination of care, and obtain medical care for one resident (Resident #6) reviewed for care received after a fall, resulting in two additional falls, multiple bruises to the face and hand, delayed medical treatment, and a delay in diagnosing and care of a urinary tract infection. Findings include: Resident #6 (R6) Review of a Face Sheet revealed R6 was an [AGE] year old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. R6 had severe cognitive impairment. Review of an Incident/Accident Report, (IR) dated 07/02/20 at 17:15, revealed R6 sustained an unwitnessed fall and was observed laying on the floor, supine, looking straight up at the ceiling. The initial assessment was negative. Staff assisted R6 to a standing position and R6 stated my head hurts. Staff observed a small laceration on the back of R6's head with minimal bleeding, initiated a short term care plan (STCP) for the [MEDICAL CONDITION] and initiated neurological assessments per facility protocol. R6 was not sent to the hospital for additional evaluation. Notes located at the end of the IR indicated 7/7/20: there was no injury and 7/7/20 Actions: med review. Review of R6's medical record revealed a medication review was not completed until 08/13/20. Review of a STCP for R6, initiated on 7/2/20 at 17:15, was for staff to monitor a small cut to the back of the head, revealed a GOAL date of 7/5/20, and contained the following entries: (a) one entry on 7/2/20 at 2000, (b) one entry on 7/3/20 at 1600, (c) no entries for 7/4/20, and (d) no entries for 7/5/20. During an interview on 08/24/20 at 2:25 P.M., RN, Clinical Support (RN,CS) W stated that STCP's are initiated for a minimum of 3 days, more of indicated. RN,CS W also indicated that the expectation for staff was to completely and accurately monitor neurological assessments after an unwitnessed fall. Review of a Neurological Assessment, initiated on 7/2/20 at 1715 for R6, revealed the following omissions in documentation: (a) on 7/2/20 at 2215 no documentation present for monitoring of respirations (if they are regular or shallow and irregular), (b) on 7/3/20 at 0015 no documentation present for monitoring of respirations (if they are regular or shallow and irregular), (c) on 7/3/20 at 0215 no documentation present for monitoring of respirations (if they are regular or shallow and irregular), (d) on 7/3/20 at 0415 no documentation present for monitoring of respirations (if they are regular or shallow and irregular), (e) on 07/03/20 at 1015 no documentation present for pupil response time, extremity movement and strength, response to speech, and whether R6 had experienced a [MEDICAL CONDITION], headache or vomiting. Accurate and consistent recording of neurological observations is essential to establish the patient's neurological status and to illustrate any changes. Nurses need appropriate training in order to achieve accurate assessment. Nurses play a vital role in the early detection of any change in a patient's neurological status, and are in a prime position to alert the appropriate medical practitioner to a potentially critical deterioration in the patient's condition. (https://www.nursingtimes.net/clinical-archive/neurology/neurological-observations/ 3.article) Review of nursing progress notes, revealed an entry on 07/03/20 at 13:34 for a skin assessment. The next entry made for R6 in the nursing progress notes was dated 07/08/20 at 12:18, equating to 5 days without a nursing progress note for R6. According to Legal and Ethical Issues in Nursing, 6th Edition, (Guido, G, 2017), a major responsibility of all health care providers is that they keep accurate and complete medical records. From a nursing perspective, the most important purpose of documentation is communication. The standards for record keeping attempt to ensure, patient identification, medical support for the selected diagnoses, justification of the medical therapies used, accurate documentation of that which has transpired, and preservation of the record for a reasonable time period. Documentation must show continuity of care, interventions used, and patient responses. Nurses' notes are to be concise, clear, timely, and complete. Review of a Fall Management assessment for R6, dated 7/14/20, revealed the following: (a) cognition-did not display any restlessness, lethargy, resists care, does not follow or understand direction, or wandering, (b) balance-maintained balance as required, (c) mobility- ambulates without problems or device, and (d) history-one to two falls in past 90 days. The summary was as follows: R6 has had 1 falls this quarter no injury. Therapy has worked with her to improve her balance. she wears appropriate foot wear. She exercises right to self determination. She is on fall contributing medications [MEDICATION NAME] and [MEDICATION NAME] and are necessary. Resident is able to ambulate with steady gait. Interventions in place to mitigate risk for injury. Review of a Therapy Screen 2.1 summary, dated 07/14/20 at 1400, read as follows: Fall noted 7/2/2020. staff reports patient demonstrating increase LOB (loss of balance) unsteadiness throughout hallway ambulation. Pt.(patient) to benefit from skilled PT services in order to address balance, ambulation, and strength. Review of a Physical Therapy Treatment Encounter Note (PTTEN) dated 07/22/20 at 4:43 P.M. revealed R6 exhibiting more confused behavior upon arrival, unsteady and at risk for falls, redirecting to complete tasks. Review of a PTTEN dated 07/23/20 at 12:46 P.M. revealed R6 had noted lower extremity unsteadiness with transfers and turning. Review of a Interdisciplinary Care Conference note, dated 07/23/20, made no mention of the fall sustained on 7/2/20 nor the concerns raised by physical therapy on 07/22/20 and 07/23/20, regarding R6's fall risk. Review of a nursing progress note, dated 07/26/20 at 2138, revealed R6 was being monitored thru out the day, there was a change in her posture she developed a full body droop to the right, her walking was unsteady, stumbling many times. towards the end of the shift she was no longer able to walk without assistance. No documentation was located that indicated that following the 07/26/20 nursing assessment, additional interventions were put into place to ensure the safety of R6, until seen by a prescriber. The next nursing note for R6, located in the medical record, was dated 08/11/20 at 14:22 and reflected the following: multiple bruises on face post fall. moaned with movement. Neuro check WNL (within normal limits)-would not open eyes. There was no documentation found in the progress notes, prior to 8-11-20 and after 07/02/20, that discussed a recent fall or injury. Review of the first physician progress notes [REDACTED].), (d) physical therapy to evaluate and treat. The 07/27/20 physician progress notes [REDACTED]. Review of lab results, dated 07/28/20, for R6 revealed results for the CBC and CMP and that the results for the TSH and [MEDICATION NAME] were pending. The lab results did not have a prescriber's initials or a date indicating that they were reviewed. Further review of R6's medical records did not indicate that the lab results for the ordered TSH and [MEDICATION NAME] were ever received. Review of a Physical Therapy Treatment Encounter Note (PTTEN) dated 07/28/20 at 4:16 P.M. revealed R6 was exhibiting confused behavior and needing redirecting to complete tasks, verbose. Review of a PTTEN dated 07/29/20 at 4:29 P.M. revealed R6 was exhibiting some decrease in safety awareness. Review of a PTTEN dated 07/30/20 at 3:44 P.M. revealed R6 was asleep in bed and needing encouragement to participate in therapy and was exhibiting more fatigue affecting safety with ambulation and requiring more assistance with negotiation around obstacles and turns. Review of a PTTEN dated 08/3/20 at 12:58 P.M. revealed .in pt's room, req (required) min assist due to lateral leaning to the right side with LOB (loss of balance) x2. Review of a PTTEN dated 08/4/20 at 12:35 P.M. indicated that R6 tends to wander around the facility ambulating without AD (assistive device) however staff report increased unsteadiness and balance problems, increasing trunk leaning, at risk for falls. Review of a Care Plan indicated that R6 was able to ambulate independently until 8/13/20 and could be left alone on the toilet. The care plan had not been updated to reflect the physical therapy findings of increased fall risks. Review of an Incident/Accident Report, (IR) dated 08/08/20 at 20:25, revealed R6 sustained an unwitnessed fall after following a staff person quickly in the hallway and then fell . Staff observed R6 lying on the left side with head facing the fishbowl. Skin check performed with observed bumps/bruises to left side of face and hand. Immediate corrective action is to replace worn down grippy socks with new ones. Review of an IR dated 08/08/20 at 20:30, 5 minutes after the first fall, revealed R6 sustained another unwitnessed fall when staff observed R6 lying on the floor face down next to the nurses station. R6 was tearful and skin assessment revealed a hematoma to the forehead. After vitals were taken and footwear was applied (R6) went walking around quickly by herself. The IR then indicated that the corrective action was to have 15 minute checks and resident was encouraged to stay by nurses station to have neuro checks completed. Review of a STCP for R6 to monitor multiple bumps and bruises sustained during two falls on 08/08/20, was not initiated until 08/11/20. Review of a Neurological Assessment, initiated on 08/08/20 for R6, revealed the following omissions in documentation: (a) on 8/10/20 at 0010 no documentation present for monitoring of respirations (if they are regular or shallow and irregular), no monitoring for pupil size and reaction to light and level of consciousness, and no monitoring for extremity response, speech response, or [MEDICAL CONDITION] activity, headache or vomiting, (b) on 8/10/20 at 0410 no documentation present for monitoring of respirations (if they are regular or shallow and irregular), no monitoring for pupil size and reaction to light, and no monitoring for level of consciousness, extremity response or speech response, (c) on 8/10/20 at a time that was written illegibly, no documentation was present for monitoring of any of the assessments required on a neurological assessment, (d) on 8/11/20 at no documentation present for monitoring the monitoring of R6's level of consciousness, extremity response, response to speech, or whether R6 was experiencing [MEDICAL CONDITION] activity, a headache or vomiting, (e) on 08/15/20, 08/16/20, and 08/17/20, no documentation present for vomiting. Review of a physician progress notes [REDACTED]. risk, (d) R6 had 2 falls on the eighth .has significant bruises under her eyes .bruising on left hand and chin .we will be checking orthostatic blood pressures daily for 3 days .we will get an x-ray of facial bones and skull .at the time of the examination today (R6) was lying in bed and appeared to be comfortable but is not answering any questions .staff feel she is more drowsy that usual. Review of a radiology report, dated 08/10/20, revealed the following findings for the skull x-rays: Conclusion-Incomplete study as occipital skull not included in lateral view, otherwise unremarkable skull, repeat study to include occipital skull in lateral view recommended. The radiology report had been initialed by (presumably) a prescriber. Review of R6's medical record revealed no new orders for a repeat x-ray of the skull nor a repeat radiology report of the skull. Review of a nursing progress note, dated 08/12/20 at 1800, revealed that R6 was sent to a local emergency department for further evaluation related to two falls sustained on 08/08/20. Review of an emergency room Report, dated 08/12/20 at 1817, revealed the following note: [AGE] year-old female who presents from the Cove who presents to the ED today for fall with multiple bruising. Patient is brought in by EMS. Unfortunately, is reported the patient is nonverbal at baseline. Therefore, most of the information is obtained from EMS as well as nursing staff. According to EMS providers, patient had a unwitnessed fall on Saturday, approximate 4 days ago. This happened twice. Each time being unwitnessed. Unsure if patient lost consciousness or had any head trauma. At the time, patient was not brought in for medical evaluation. Apparently, today after seeing the significant bruising to the patient's head and face, they decided to call 911 to have the patient brought into the ED for evaluation. On speaking with the patient herself, she actually does respond in Spanish. She does localize to pain and discomfort in her head and face. She denies having any chest pain or any abdominal pain or any pain in her extremities .Patient does have a small amount of bruising to the left anterior chest .of note, given the significant facial bruising in different stages of healing, I was concerned for possible neglect. I did discuss the case with our medical social workers who did their own evaluation of the patient. Please see their note for further details. Adult Protective Services was contacted. Patient's guardian was contacted as well. Per medical social workers, the guardian will follow up with the patient. Review of an Emergency Department Provider Note, dated 08/12/20, illustrated R6's extent of bruising in multiple stages of healing.

This citation is related to intake # MI000- 5 Based on interview and record review, the facility failed to monitor skin breakdown and a worsening pressure ulcer with necrotic (dead) tissue that lead [MEDICAL CONDITION] (an infection in the blood stream) and [DIAGNOSES REDACTED] (an infection in the bone) for one resident (Resident #13), resulting in the need for (a) emergency treatment, (b) extensive surgery, (c) stabilization in the ICU (intensive care unit), and (d) PICC (peripherally inserted central catheter) line placement and ongoing IV (intravenous) antibiotic therapy for an infection that ultimately lead to the death of R13. Findings: Resident #13 (R13) Review of a Face Sheet revealed R13 was a [AGE] year old male, originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment section G, for R13, dated 02/06/20, 04/08/20, and 05/05/20, reflected the need for 2+ person physical assist for bed mobility, toilet use, and bathing. Review of an MDS assessment section M (skin conditions), for R13 dated 01/30/20 reflected the following: QUESTION: Resident has a pressure ulcer/injury, a scar over a bony prominence, or a non-removable dressing/device ANSWER: no, QUESTION: Is the resident at risk for developing pressure ulcers/injuries ANSWER: yes, QUESTION: Does the resident have one or more unhealed pressure ulcers/injuries ANSWER: no, QUESTION: Does the resident have MASD (moisture associated skin damage) ANSWER: no, QUESTION: Is resident receiving applications of ointments/medications other than to the feet ANSWER: no, QUESTION: Is resident on a turning/repositioning program ANSWER: no Review of an MDS assessment section M (skin conditions), for R13 dated 04/08/20 reflected the following: all answers remained the same from 01/30/210 assessment except for the following: QUESTION: Is resident receiving applications of ointments/medications other than to feet ANSWER: yes. Review of an MDS assessment section M (skin conditions), for R13 dated 04/13/20 reflected the following: QUESTION: Does the resident have one or more unhealed pressure ulcers/injuries ANSWER: yes, QUESTION: Number of unstageable pressure injuries presenting as deep tissue injury ANSWER: one, QUESTION: Number of these unstageable pressure injuries that were present upon admission/entry or re-entry ANSWER: one. Review of an MDS assessment section M (skin conditions), for R13 dated 05/05/20 reflected the following: QUESTION: Resident has a pressure ulcer/injury, a scar over a bony prominence, or a non-removable dressing/device ANSWER: yes, QUESTION: Is the resident at risk for developing pressure ulcers/injuries ANSWER: yes, QUESTION: Does the resident have one or more unhealed pressure ulcers/injuries ANSWER: yes, QUESTION: Does the resident have MASD (moisture associated skin damage) ANSWER: no, QUESTION: Number of unstageable pressure injuries presenting as deep tissue injury ANSWER: one, QUESTION: Is resident on a turning/repositioning program ANSWER: no, QUESTION: Is resident receiving nutrition or hydration intervention to manage skin problems ANSWER: no, QUESTION: Is resident receiving pressure ulcer/injury care ANSWER: no. Review of an Admission Assessment for R13, dated 02/07/20 at 1400, revealed skin warm, dry, and intact. Resident denies pain, resting comfortably in bed. The skin portion of the admission assessment, were staff note all skin issues was blank. Review of R13's electronic medical record showed that the last physician progress notes [REDACTED]. During an interview on 09/02/20 at 12:40 P.M., RN, Clinical Support (RN,CS) W indicated that pre-covid, the facility had a wound care specialist that would come in regularly and manage wounds. RN,CS W stated that currently wounds are managed by nursing and the physician. Review of a progress note skin assessment, dated 4/28/20 at 22:12, indicated the following findings: Skin assessment complete. Skin warm dry . Periarea red on buttocks/rectal area barrier cream applied. Groin area without redness. No redness to high risk pressure points. During an interview on 09/01/20 at 9:50 A.M., RN,CS W stated that skin assessments were completed every 7 days. Review of the electronic medical record for R13 did not produce a skin assessment for 05/05/20. Review of a electronic Medication Administration Record [REDACTED]. one time a day for abrasion to right buttock. Treatment began 05/05/20 and continued through 05/17/20. There was no indication in the electronic record if the treatment had been completed on 05/07/20. Review of a progress note wound tracking, dated 5/11/20 at 14:39, indicated the following findings: Location: coccyx Length: 5cm, (centimeters) Width: 4.5cm, Depth: closed and dark purple area at this time. Stage: DTI (deep tissue injury) Treatment: apply skin prep and allevyn, encourage frequent position changes to relieve pressure from his coccyx. R13 was completely dependent on staff for repositioning in bed. During an interview on 09/01/20 at 10:55 A.M., RN,CS W reported that a short term care plan had not been initiated for R13's coccyx wound. A short term care plan, dated 04/13/20, was available in the medical record for a tissue concern related to R13's right heel. Review of progress notes interdisciplinary documentation, dated 05/12/20, indicated that facility staff discussed R13 with a physician on 05/08/20 and 05/12/20 and no mention of R13's coccyx skin concerns were noted. Review of a progress note interdisciplinary documentation, dated 5/17/20 at 13:15, revealed VSS (vital signs stable). No s/s (signs or symptoms) of respiratory distress. Denies pain, but moans when turning/repositioning. Review of Physician order [REDACTED].every day shift and as needed .start date: 5/17/20. Review of the care plans for R13 revealed no mention of the coccyx skin concerns nor any new interventions to address the skin breakdown. Review of an Orders-Administration Progress Note, dated 05/18/20 at 01:59, indicated that R13 was sent to isolation due to elevated fever. 120, 144, 24, 91% O2, 180/125. constant cough, red face, hot, sweaty, SOB (short of breath), difficult breathing. Doctor was called and received orders to send to hospital. Received a phone call resident was admitted . Review of a Hospital Transfer Form, dated 05/17/20 and prepared by a facility nurse, indicated that R13 was sent to the hospital for a Fever. Vital signs on the transfer form listed blood pressure as 180/125, heart rate at 144, respirations were 24, and temperature was 99.8. Additional information about R13 that was listed on the transfer form included that R13 had a wound to buttock. Review of hospital records, dated 05/17/20 through 05/22/20, revealed the following information regarding the level of care needed and received by R13 while in the hospital: (a) [AGE] year-old male with [MEDICAL CONDITION] and dementia who presented via EMS (ambulance) from a local SNF (skilled nursing facility). They were concerned because of his sacral decubitus ulcer appearing necrotic, was foul smelling, and he developed a fever. (b) Patient was admitted with likely sacral decubitus ulcer infection,[MEDICAL CONDITION] and toxic metabolic [MEDICAL CONDITION], (c) patient was started on [MEDICATION NAME] and [MEDICATION NAME]. Plastic surgery was consulted and his Eliquis held. Blood cultures obtained and 2 of 2 ultimately positive for coag negative staph, (d) plastic surgery took patient for debridement of the wound on 5/19/20, (e) the surgical procedure was a right ischial wound debridement including skin, subcutaneous tissue, muscle and bone, measuring 8cm x 8cm, (f) tissue samples were sent for culture and bone was sent for pathology. Tissue culture grew ESBL (extended spectrum beta-lactamase) E. coli. Antibiotics were changed to Ertapenem and an infectious disease consult placed. Bone pathology showed acute osteo[DIAGNOSES REDACTED] and final recommendations are for 42 days IV Ertapenem 1 gram daily, (g) repeat blood cultures were obtained and a PICC line was placed after blood cultures remained negative for 48 hours. Initial plan was to return patient to his SNF. However, LTAC (long term acute care) was considered more appropriate location after plastic surgeon evaluated his wound four days post-op and there were signs of progressive necrosis, (h) Phone call placed to patient's brother, who is not his legal guardian, but is involved in his care. Brother was concerned about the wound care patient was getting at his SNF, and (i) [DIAGNOSES REDACTED]. Review of a State of Michigan Death Certificate for R13 revealed cause of death as: (a) [MEDICAL CONDITION], (b)[MEDICAL CONDITION], and (c) sacral decubitus ulcer infection.

This pertains to intakes M 6483 Based on Interview and record review, the facility failed to provide treatment and develop person centered interventions and approaches for dementia care for 1 (Resident #4), resulting in the potential for staff to appropriately care for a resident with dementia. Findings include: Resident #4 Review of a Face Sheet revealed Resident #4 is a [AGE] year old female originally admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #4 had a Brief Interview for Mental Status (BIMS) that indicated she is severely cognitively impaired and required extensive assistance of one person for transfers, limited assistance of one person physical assist for eating. Review of a Policy titled Accident/Incident Report, Fall Management last revised 6/18 revealed: It is the policy of this facility to complete an accident incident report for unexplained bruises or abrasions; accidents or incidents where there is injury or the potential to result in injury; falls; and resident to resident altercations. Purpose: To establish a standard for accident/incident completion and to evaluate the facility responsibility to make every effort to decrease the likelihood of a recurrence by investigating incidents, understand how they occur and applying appropriate action. Review of a Policy titled Skin at Risk Assessment last revised March 2015 revealed: It is the policy of this facility to assess resident risk factors for impaired skin integrity and intervene as indicated utilizing the admission plan of care and Minimum Data Set as formal assessment tools. Purpose: To ensure prompt identification and intervention for residents at risk of impaired skin integrity corresponding to risk factors. Review of a Policy titled Identification of Abuse last revised 11/2016 revealed: It is the policy of this facility to encourage any employee who has reasonable cause to believe that a resident has been subject to abuse, neglect, exploitation or endangerment to report it to the facility Administrator and/or Director of Health Care Services.Examples: . Injuries of Unknown Source: An injury should be classified as an injury of unknown source when both of the following conditions are met: The source of the injury was not observed by any person or the source of the injury could not be reasonably explained by the resident; and The injury is suspicious because of the extent of the injury or the location of the injury Resident #4 Review of an unwitnessed incident/accident report for Resident #4 revealed: On 9/9/19 at 6:30 a.m. Resident #4 had an unwitnessed fall Observed resident sitting on buttock in upright position, back against the heater registered and feet towards the entrance of room Bed in low position with mat parallel with the bed. Call light within reach. Stated had to use the restroom Bim score is 99 signifying cognitive impairment. Intervention will offer toileting between 6-7 am as resident allows. (sic) Review of an unwitnessed Bruise incident/accident report dated 9/12/19 at 1:00 p.m. for Resident #4 revealed: Bruise, at approximately 415 a.m. (CNA) reported to (LPN) that (Resident #4) had a swollen eye. (LPN) observed swollen discoloration of left eye into the hair/scalp. Notified Pw Services order from (Physician) to send to (emergency room ). Immediate Action Taken: Upon return from ER a skin assessment completed. Reddish/brown area of discoloration to left forehead measures 10 cm (centimeters) X 11 cm, dark purple bruising with [MEDICAL CONDITION] covering left eyelid, bruise to right side of head into the hairline dark to med purple in color, measures 4 cm X 5 cm reddish/brown area to the left should 8 cm X 4 cm, left forearm small bruise from possible IV site as there is tape residue at that spot. Bil(ateral) lower extremities were free from bruising except for a small healing superficial abrasion less than .5 cm on her left knee, ROM (range of motion) was completed without complaints of discomfort . Notes: 9/12/19 actions: Sent to ER for Evaluation. Upon return completed skin assessment . 9/26/19: Event summary: (Resident #4) was sent to the ER due to bruising on her forehead. When evaluated in the ER, (Resident #4) was diagnosed with [REDACTED]. (Resident #4) has several compression deformities in her [MEDICATION NAME] region from a traumatic injury in 2017. Investigation begun.9/26/19, Investigation 5: This writer (RN S) was notified during report that blood was pooling into right eye, Right eye lids are purple and swollen. (Nursing Home Administrator (NHA)) notified. At 1200 (Resident #4) asked to go to bed. This writer explained that it was almost time for lunch. (Resident #4) did not want lunch, she wanted to lay down. She also denied need to void and did not want to be toileted. She was laid down on middle, scoop mattress, and mattresses laid down on both sides of her. At 1415 (2:15 p.m.) CNA notified this writer that (Resident #4) had crawled off of her mattress, undressed herself and was laying topless with brief applied. Brief dry. No injury noted, and (Resident #4) denied pain. 9/26/19, Conclusion 2: An MRI (magnetic resonance imaging) was ordered and is scheduled to rule out a neuro[DIAGNOSES REDACTED] due to the presentation of racoon eyes, battle sign and other symptoms (sic) Review of Hospital records dated 9/12/19 for Resident #4 revealed: (Emergency Department) Physician note: She was sent with a pre-arrival note, she apparently fell on Monday but was not evaluated in the emergency department. They say she had no bruising over the course of the week but today when they evaluated her, she had multiple bruises that had developed overnight. Today is Thursday. At her baseline she is normally awake and alert, confused and will answer some questions intermittently. Today on arrival she is not answering any questions she will only respond that her name is (Resident #4). On physical exam she does complain of abdominal pain. I did call the nursing home, they sent her in today as she developed bruising from her fall on Monday. They report one fall on Monday. They deny any other falls. They do not know when her last bowel movement was. No recent [MEDICAL CONDITION] activity. No medication changes. they state that she uses a walker to ambulate and has frequent falls. Constitutional: . c-collar in place, she has multiple bruises with different stages on her head and extremities. Ecchymosis with significant [MEDICAL CONDITION] of her left eyelid, she is unable to open her left eye without assistance due to the swelling. Gastrointestinal: . she says ow when I palpate her abdomen diffusely. mild pain with passive ROM (range of motion) of left shoulder . Integumentary . Diffuse ecchymosis on her bilateral forehead, left eye, bilateral shoulders, bilateral hips, right anterior thigh, left forearm, sacrum. Small skin abrasion to her right knee. CT (computerized tomography) spine without contrast, 9/12/19, Impression: 1. Acute minimal compression deformity of the T1 (upper [MEDICATION NAME] vertebrae between the cervical (neck) and the lumbar (lower part of body) vertebral body. No acute cervical fracture identified.Maxillofacial without contrast, Impression: 1. Moderate left periorbital (tissue surrounding the orbit of the eye) soft tissue swelling without fracture. Abdominal and Pelvis with contrast, Impression: Subacute compression fractures of T8 and T12. Healing left superior and inferior pubic rami fractures and left T10 and T11 rib fractures. The healing left rib fractures are new since the 6/25/2019 exam.Emergency Department Course: . Patient has diffuse bruising over her body, it does not appear consistent with one fall that occurred on Monday. She does have a history of recurrent falls per chart review. CT imaging is consistent with a new stable compression fracture at T1 . I did also consult with social workers as the patient has multiple fractures, she has multiple bruises and they started on Adult Protective Services case. They (the Nursing Home) say that they have instituted as many fall precautions as possible for her. Nursing Home states that her urine output has been unchanged. Will hold on antibiotics until culture results. Social work did feel that she was safe for discharge.Microbiology, urine culture and sensitivity collected 9/12/19 and resulted 9/14/19: positive for Escherichia coli (E. coli bacteria) and gram negative Bacilli (bacteria), which indicated a urinary tract infection with two different bacteria. Review of Physician order [REDACTED]. Review of a physician progress notes [REDACTED].#4 revealed: (Resident #4) has not had any further falls since previous fall which resulted in hospitalization . She has not had and [MEDICAL CONDITION] activity. However, she does have very significant bruising around both eyes (raccoon sign) and bruising behind both ears (battle sign). Staff reports she has been very lethargic. I am sending her to the emergency room . CT of multiple locations did show a T4 compression fracture, no other fractures or abnormalities. Summary of Plans: Resident with known head trauma has battle sign and raccoon eyes. Review of a physician progress notes [REDACTED].#4 revealed: . Summary of Plans: Resident overall is declining. She is not nearly as alert as she has been in the past and is more somnolent. She has been seen in the emergency room in hospital on numerous occasions over the pas couple of months. Other than a T4 compression fracture, no other abnormalities have been found on CT. (sic) Review of an other unwitnessed Incident/Accident Report dated 9/26/19 at 21:55 (9:55 p.m.) for Resident #4 revealed: Entered (Resident #4's) room she was laying on mattress between her mattress and roommates' bed with head toward windows, noted an area of discoloration with swelling above the right eye. (Resident #4) has had no recent falls, when up in wheelchair was not visualized hitting head on table. (Resident #4) unable to give description. (Resident #4) could not identify any occurrence or persons related to this bruise. Immediate Action Taken: Assessed noted no other new injures .no witnesses found. Notes: Consult for hematology ordered. 10/9/19 Root cause/conclusion: (Resident #4) did not recall hitting her head and based off of positioning it does not appear the injury would be due to hitting her head. (Resident #4) had a bruise of unknown origin on 09/14/19 that began with unknow swelling. HCP was consulted and ordered a hematology consult. (Resident #4) has an upcoming MRI of the brain on 10/3/19 to r/o (rule out) other possible causes such as myeloma. (sic) No incident report for 9/14/19 was presented to this surveyor. Review of an Unwitnessed Incident/Accident Report dated 9/29/19 at 7:00 a.m. for Resident #4 revealed: (Resident #4) was observed sitting in her doorway on her buttocks prior to tipping over on her right side by (CNA). (CNA) reported that she had observed (Resident #4) laying in bed a few minutes prior to seeing her in the doorway. (Resident #4) was assisted with toileting at 4 a.m. prior to. When asked what she trying to do, or where she going, she said I don't know. Notes: . 10/9/19, A soft shell protective helmet was ordered for (Resident #4) to wear while she is in bed in the event, she feels the need to express her right to self-determination. Care plan updated to reflect need to toilet (Resident #4) around 7 a.m. if observed awake and restless. (sic) Review of an MRI (magnetic resonance imaging) dated 10/3/19 for Resident #4 revealed: .Woke up 2 weeks ago with eye swollen shut, dementia, evaluate for mass. Findings: There is no diffusion restriction to suggest acute/subacute ischemia. mass effect or midline shift is identified. a small hematoma persists along the right frontal scalp. (sic) Review of an Unwitnessed Incident/Accident Report dated 10/12/19 at 11:10 a.m. for Resident #4 revealed: Registered Nurse (RN) Q was in halling passing medication and (Resident #4) was in the geri chair behind her. (RN Q) heard an increase noise, look behind her and observed (Resident #4) laying on the floor next to the geri chair. Across from day room, (CNA) at giving breakfast back against (Name) door. Chair next to (Resident #4), breakfast tray fell (Resident #4) was facing west. When asked what happened? What were you trying to do? She did not answer my questions. Currently her BIMS score is 99 unable to cooperate with interview. 10/23/19, Conclusion, (Resident #4) continues to be impulsive and self determined. The staff have her at the nurses' station with her breakfast tray on the over bed table. She did not ask for anything and as the nurse walked past (Resident #4) she stood and fell to the floor. Added to the careplan is for (Resident #4) to wear her helmet. (sic) Review of a physician progress notes [REDACTED].#4) . has had repeated falls recently. Fortunately she has not had any falls in the past couple of weeks. Fall precautions are in place and include a helmet, and her mattresses are on the floor. Physical exam: .Eyes: Ecchymosis (subcutaneous spot of bleeding with diameter larger than 1 centimeter) around bilateral eyes which is improving. No new contusions. Ears/Nose/Mouth/Throat: Periorbital and lid hematoma, post auricular hematomas, hematomas are fading. Summary of Plans: .She has had numerous evaluations both here and in the emergency room in hospital with lab work, CTs (computed tomography), MRI (magnetic resonance imaging). Will ask pharmacy to review medications for possible contributions to fall and appetite. Review of an Unwitnessed Incident/Accident Report dated 11/10/19 at 21:20 (9:20 p.m.) for Resident #4 revealed: . nurse noted (Resident #4) on ground, sitting up, scooting on buttocks from hallway into T.V. room. Restless and crying throughout second shift; going to bed per request, then scooting out of room multiple times, toileted and placed back chair multiple times. Foot rests off of wheelchair. Non-slip grip socks applied. Continuously removing helmet. In hallway adjacent to T.V. room in wheelchair in sight of nurse seconds before the fall. Immediate Action Taken: Alert buy agitated and crying. Unable to clearly communicate. Restless, . Crab walking from hallway . (physician) notified and ordered to send to E.R. for evaluation (related to) pain.Conclusion: (Resident #4) had been Restless and crying throughout second shift; going to bed per request, then scooting out of room multiple times, toileted and placed back in chair multiple times. Footrests off of wheelchair. Non-slip grip socks applied. Continuously removing helmet. In hallway adjacent to T.V. room in wheelchair in sight of nurse seconds before the fall. There are no allegations of abuse or willful neglect. The careplan was followed and despite she fell , this incident does not meet the reporting BHS criteria. (sic) Review of a Physician Assistant Progress Note dated 11/20/19 for Resident #4 revealed: (Resident #4) is seen today because staff state she has been restless. Resident readmitted to the facility yesterday after being hospitalized for [REDACTED]. Resident was having quite a bit of restlessness prior to her hospitalization . Staff state resident has not been showing signs of pain. They state she will stand up from her wheelchair with no facial grimace or other signs of pain. At this time resident is sitting in her wheelchair. She is quite restless, asking to go back to bed. Staff state she will ask to go to bed, then a few minutes later will ask to get back into her wheelchair.Plan: I would recommend a referral to BCS (Behavioral Care Services) for further evaluation. Review of an Other unwitnessed Incident/Accident Report dated 12/4/19 at 13:30 (1:30 p.m.) for Resident #4 revealed: (CNA) was assisting (Resident #4) from her chair and observed an abrasion on each of (Resident #4's) elbows. (Resident #4) had been sitting in the hallway in a geri chair. 12/15/19, Conclusion: A review of the environment and (Resident #4's) movements identified the arm rest on the chair (Resident #4) sits in has vinyl. (Resident #4) uses her elbows to push up from the chair. Careplan was reviewed and updated with dressing that are protective, long sleeves or glen. (Resident #4) frequently removes them, covering for the vinyl geri chair. Review of a Nurse Practitioner Progress Note dated 12/12/19 for Resident #4 revealed: . she does have dementia which appears to be declining. She has multiple episodes of falls with most recent one incurring a left [MEDICAL CONDITION]. Incisions healing now but she is showing restlessness especially at night and evenings and is not on several mattresses on the floor which allows her to roll around. Family has signed onto hospice on for this dramatic decline in status. Today staff is wondering if we can discontinue her [MEDICATION NAME] ([MEDICAL CONDITION] medication) 50 (micrograms) once daily. After review of her chart we are unable to find a recent TSH ([MEDICAL CONDITION] stimulating hormone lab). She is asymptomatic. Summary of Plans: Patient is in steady decline at this time. Obtain TSH to determine need to discontinue the [MEDICATION NAME]. Continue hospice care as this is definitely appropriate. Review of an Unwitnessed Incident/Accident Report dated 12/14/19 at 21:15 (9:15 p.m.) for Resident #4 revealed: Resident was sitting in a chair at the nursing station, in general observance of the staff. She attempted to get out of chair and unable to stand fell to the floor. The staff member was unable to get to (Resident #4's) side to intervene. (Resident #4) was observed lying on her left sided. Conclusion: (Resident #4) has been restless and has been difficult finding a comfort level. She will rest for a short period of time (sic) (there is no conclusion). Review of physician progress notes [REDACTED].#4 revealed: (Resident #4 is on hospice care. She requires one-on-one due to behaviors consisting of agitation to the point where she will literally climb over the arms of her Geri chair. I discussed her status, behaviors, medications with the staff. We are going to increase her [MEDICATION NAME] ([MEDICATION NAME], a pain medication) to every 2 hours and her [MEDICATION NAME] to every 4 hours. Physical exam: . Resident is sitting in her Geri chair; at this time she is not agitated or combative, but staff is having a difficult time keeping her ears seated in her chair. Summary of Plans: Resident is on hospice care and is becoming agitated and difficult to control or redirect. She has a history of repeated falls with injuries. She has a history of [MEDICAL CONDITION] disorder, not [MEDICAL CONDITION] activity reported recently. It does seem that her agitations is somehow pain related, the exact location of pain or discomfort is not determined. (sic) Review of the Care Plan for Resident #4 revealed a long detailed focus and is unclear what the main focus is and implemented on 7/3/19 and last revised on 12/26/19. Not all interventions were implemented, and some were not person centered to Resident #4's [DIAGNOSES REDACTED]. 7/4/19 Keep in observation while up in wheeled chair. 8/2/19 Place Dycem to wc (wheelchair) cushion to prevent slipping. 7/13/19 remove from dining room when meal is done. 8/2/19 Remove foot pedals from wc when not transporting. Encourage (Resident #4) to remain in common areas, as she allows, to encourage opportunities for supervision. 9/9/19 offer toileting between 6am and 7am as resident allows. 9/12/19/ Remove bed and place mattress on the floor. place additional mattress on opposite side of bed continue scoop mattress. Sign on bathroom door to keep it closed to mitigate injury. Bedside dresser moved away from bed. Foam to radiator edges to mitigate injury. 9/26/19 Hematology consult. 9/29/19 if AWAKE AND RESTLESS IN BED GET UP IN W/C AS RESIDENT ALLOWS. 9/30/19 Interdisciplinary team collaboration identified the need for a helmet, order placed. 10/12/19-helmet to be worn in and when up in her chair as resident allows 12/13/19 Sit at residents' side when in w/c. Offer to lay done if shows signs of restlessness such as freq changes of position, eye closing resting head in hands Date Initiated: 07/03/2019. Revision on: 12/26/2019. Cancelled Date: 12/26/2019. (sic) Review of a Care Plan for Resident #4 revealed: Focus: CANCELLED: (Resident #4) has the potential for psychosocial distress related to: anticipated dementia progression, expressing sadness, anger, empty feeling over lost roles and status. Prior to being admitted , (Resident #1) resided at The Cove assisted living facility. (Resident #1) has a dx of depression and dementia. She speaks softly when conversing with others. (Resident #1) has short and long term memory loss present, dx of Dementia with behaviors and Cognitive Communication Deficit present. She has had a decline in her appetite due to declining health. PW Services serve as guardian for (Resident #1). She is under the care of Harbor hospice. (Resident #1) has a dx of agitation, restless and [MEDICAL CONDITION]. Date Initiated: 07/09/2019. Revision on: 12/26/2019. Cancelled Date: 12/26/2019. (sic) No true interventions in place to address dementia and behaviors or revisions. In an interview on 1/3/19 at 11:00 a.m., Licensed Practical Nurse (LPN) J reported she finished working the weekend night shift on Monday, September 9th and returned to work on 9/12/19 at 10:00 p.m. when her shift started. LPN J remembers during shift change, the previous nurse from the day shift told her that Resident #4 had a bruise/bump above her left eye on her forehead from a fall she had on Monday, 9/9/19. At 11:00 p.m., LPN J reported she made her rounds on her residents and observed Resident #4 had a puffy eye and was black and blue and almost swollen closed. LPN J proceeded to ask the CNA's (Certified Nursing Assistants) on duty received report from the day shift CNA's as well but did not expect to see Resident #4 with the puffy, black and blue eye either and they had not seen the resident in a couple days either. LPN J reported she started to worry because the report did not match the observation of Resident #4. LPN J reported she started to look at progress notes and other medical records to determine if this incident was something new or not and could not find much documentation. LPN J reported that at 2:00 a.m., Resident #4's eye was getting worse and swollen completely closed. LPN J reported she called the Director of Nursing and sent Resident #4 to the emergency room around 4:00 a.m. In an interview on 1/3/19 at 12:57 p.m., the Director of Nursing (DON) reported Skin Assessments are in the Short Term Care Plans (STCP), not under skin assessments. The DON reported they do not chart when bruises are resolved and once the bruises start to improve, they stop charting them in the STCP. In an interview on 1/6/19 at 2:15 p.m., the Director of Nursing (DON) reported she felt that the acute fracture on 9/12/19 for Resident #4 that was diagnosed at the hospital was an old fracture, even though the hospital called it acute, and felt it was from a couple years ago when a telephone pole fell on the resident. The DON reported Resident #4 had severe bruising, was confused and impulsive. Resident #4 would wear a helmet and then take it off many times. The DON continued to report Resident #4 slept on a mattress on the floor and would scoot on the floor on her bottom. When queried about the 9/12/19 investigation and how it combined with the 9/26/19 investigation, the DON reported she did not know because she did not do the investigation and that the previous administrator who is no longer at the facility did the investigation. The DON and the Corporate Consultant were not able to clearly explain the incidents on 9/9/19, 9/12/19 and the 9/26/19 or the investigation and outcome/conclusion. The three incidents seemed to mesh with each other. This surveyor asked them if they could not understand it, how was this surveyor to understand it. No witness statements from staff noted. When queried about witness statements, the DON reported she puts in the interviews with staff in the reports but does not collect written statements from the staff. This surveyor asked the DON to review and organize the investigations. When queried about documenting the skin conditions in the STCP again, the DON reported they just documents the skin condition until it is no longer acute. When queried about where the details of the skin concerns were such as measurements and locations, the DON just shrugged her shoulders. In an interview on 1/7/19 at 9:30 a.m., the Director of Nursing (DON), Corporate Consultant (CC) C and the Clinical Care Coordinator (CCC) F reported the intervention for Resident #4 on 9/9/19 was to offer toileting between 6:00 a.m. and 7:00 a.m. and did not know why Resident #4 was found on her buttocks on the floor and did not know how she got the bruise on her eye on 9/12/19 at 11:00 p.m. CC C reported the bruise/swelling on Resident #4 was up on her hairline and blood pooled down to her eye and that the ER doctor said the bruise/swelling was from Monday 9/9/19. When queried about the fracture from 9/12/19, CC C reported that anytime anyone goes to the ER they call it an acute fracture. The DON and CC C reported Resident #4 was not a 1:1 supervision and that a 1:1 supervision was not something the facility utilizes. The CC C reported she discontinued the Short Term Care Plan (STCP) skin assessments from 9/26/19 and started to document in the progress notes because she was concerned about Resident #4 and wanted to be the only one to assess her as opposed to several other nurses documenting differently about the same thing and reported she could not write what she wanted in the STCP. CC C reported she felt this was a very strange investigation and wanted to follow up. We reviewed the rest of Resident #4's incident/accident reports and the facility reported as follows: 9/29/19, Resident #4 is to come to the nurses' station when she is awake and restless. 10/12/19, Resident #4 is to wear a helmet and be with staff in the general area for close supervision. 11/10/19, The DON and CC C was not sure what was going on with this investigation, changed their story and said Resident #4 was not on close supervision at this time and they decreased her [MEDICATION NAME] ([MEDICAL CONDITION] medication) due to her grogginess. 12/4/19, they reported Resident #4 just rocked back and forth in her Geri chair which caused abrasions on her elbows. 12/14/19, they reported the unwitnessed fall was witnessed and never put the witness in the report. In an interview on 1/8/19 at 9:33 a.m., Registered Nurse (RN) Q reported Resident #4 required continuous supervision. RN Q was queried about the 10/12/19 incident with Resident #4 and reported she was down the hall with the medication cart and Resident #4's main assigned CNA went on break, which left 2 other CNA's at the desk. The CNA's called RN Q to come back down the hall where Resident #4 was laying on the floor. RN Q asked the CNA's where they were and they told her they were coming down the hall and saw Resident #4 on the floor, but the report said they were at the nurses' station, which is not what the CNA's told her. Review of Hospice documentation revealed Resident #4 admitted to Hospice on 11/27/19. 12/3/19-Anxiety high at start of this visit. Anxiety level 0/10 at end of this nurse visit. (Hospice CNA) provided care with warm soothing approach, which was effective to ease pt's (patient's) restlessness.Received report via phone from (Director of Nursing). Constant restlessness over past 9 hours Staff are providing 1:1 supervision for safety. This RN sat with resident for 45 minutes. Distraction therapy Consult in person with (DON) at end of the visit. Pt is resting peacefully at this time. 12/5/19- Found (Resident #4) seated in broda chair at nurses' desk. Staff are providing close supervision for safety. Right elbow has open are due to sheering. Wound is superficial. Open are is oval in shape, and approx. 2 cm in diameter. Surrounding skin is bright pink and irritated. 12/10/19-Phoned SNF (skilled nursing facility) and spoke with facility nurse . She stated that (Resident #4) is good at the moment. Pt is currently sleeping in recliner chair, near the nurses' desk. (SNF Nurse) explained that pt was moderately restless today. Pt likely fell asleep due to exhaustion. She did not give any [MEDICATION NAME] (pain medication) or [MEDICATION NAME] (antianxiety medication) today (although they are ordered on routine basis now.) (SNF Nurse) offered explanation for not giving meds, as they are not effective, or may not be necessary. This RN offered education that pt likely has chronic pain due to recent (fracture) of (left) hip, and previous (fracture) of ribs and spine. Routine [MEDICATION NAME] is ordered to maintain comfort. Routine [MEDICATION NAME] added last week in effort to prevent anxiety, which was severe.12/11/19- Received 2nd call from (DON). She reports ongoing restlessness. She requests Hospice CNA focus on providing 1:1 attention. (DON) explained, staff are taking turns to provide 1:1 attention for (patient) . 12/13/19-Problem with [MEDICATION NAME] dosing. While at facility, Nurse (Name) and I checked [MEDICATION NAME] bottle from (Pharmacy). Dropper is small, and maximum dose on dropper is 1 mg (milligram). Nurses report they have been giving 1 mg. Dose ordered is 1ML (milliliter)/(2mg). Consult in person with (DON) . She will request he (Physician) write new order . This is a 50% increase from what she was actually getting. 12/14/19- Visit made to assess patient after anxiety meds ([MEDICATION NAME]) increased. Pt is resting in a High backed w/c (wheelchair) by the nursing desk. Assisted nurse in removing and changing the dressing on both elbows. Open are on the left elbow is 0.75 cm (centimeters) (diameter) with yellow/green drainage. Color of the drainage may be due to the use of [MEDICATION NAME] on the wound.12/26/19- Hospice RN visit. Actively dying. Nonresponsive during assessment and reposition. (Left hip has 2 areas of discoloration, which are violet in color and irregular shapes. (Right) hip normal in color. Coccyx is dark brown discoloration over coccyx area. Small wounds/abrasions of both elbows are covered with dressings.Per facility, (patient) passed away at 12:30 p.m . Death is due to dementia. (sic)

This pertains to intake M 6483 Based on interview and record review, the facility failed to provide sufficient staffing to meet the needs of a dementia resident in 1 (Resident #4), in a total 17 residents reviewed, resulting in a resident safety compromised and unsupervised, staffing only to the census and not the needs of the residents resulting in multiple injuries and hospitalization s. Findings include: Resident #4 Review of a Face Sheet revealed Resident #4 is a [AGE] year old female originally admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #4 had a Brief Interview for Mental Status (BIMS) that indicated she is severely cognitively impaired and required extensive assistance of one person for transfers, limited assistance of one person physical assist for eating. Review of a Nursing Progress Note dated 8/26/19 for Resident #4 revealed: Note Text: (Resident #4) increasingly restless, unable to relax, continued to lean forward in her wheelchair, staff laid her down in bed, continued to be restless, this nurse went to get a geri chair for her to sit in at Nurse's station, dietary staff sitting in room with (Resident #4), upon returning to (Resident #4's) room with chair, staff stated that she became unresponsive, (Resident #4) not responding to staff calling her name, or to stimuli . transported to (hospital). (sic) Review of an unwitnessed incident/accident report for Resident #4 revealed: On 9/9/19 at 6:30 a.m. Resident #4 had an unwitnessed fall Observed resident sitting on buttock in upright position, back against the heater registered and feet towards the entrance of room Bed in low position with mat parallel with the bed. Call light within reach. Stated had to use the restroom Bim score is 99 signifying cognitive impairment. Intervention will offer toileting between 6-7 am as resident allows. (sic) Review of an unwitnessed Bruise incident/accident report dated 9/12/19 at 1:00 p.m. for Resident #4 revealed: Bruise, at approximately 415 a.m. (CNA) reported to (LPN) that (Resident #4) had a swollen eye. (LPN) observed swollen discoloration of left eye into the hair/scalp. Notified Pw Services order from (Physician) to send to (emergency room ). Immediate Action Taken: Upon return from ER a skin assessment completed. Reddish/brown area of discoloration to left forehead measures 10 cm (centimeters) X 11 cm, dark purple bruising with [MEDICAL CONDITION] covering left eyelid, bruise to right side of head into the hairline dark to med purple in color, measures 4 cm X 5 cm reddish/brown area to the left should 8 cm X 4 cm, left forearm small bruise from possible IV site as there is tape residue at that spot. Bil(ateral) lower extremities were free from bruising except for a small healing superficial abrasion less than .5 cm on her left knee, ROM (range of motion) was completed without complaints of discomfort . Notes: 9/12/19 actions: Sent to ER for Evaluation. Upon return completed skin assessment . 9/26/19: Event summary: (Resident #4) was sent to the ER due to bruising on her forehead. When evaluated in the ER, (Resident #4) was diagnosed with [REDACTED]. (Resident #4) has several compression deformities in her [MEDICATION NAME] region from a traumatic injury in 2017. Investigation begun.9/26/19, Investigation 5: This writer (RN S) was notified during report that blood was pooling into right eye, Right eye lids are purple and swollen. (Nursing Home Administrator (NHA)) notified. At 1200 (Resident #4) asked to go to bed. This writer explained that it was almost time for lunch. (Resident #4) did not want lunch, she wanted to lay down. She also denied need to void and did not want to be toileted. She was laid down on middle, scoop mattress, and mattresses laid down on both sides of her. At 1415 (2:15 p.m.) CNA notified this writer that (Resident #4) had crawled off of her mattress, undressed herself and was laying topless with brief applied. Brief dry. No injury noted, and (Resident #4) denied pain. 9/26/19, Conclusion 2: An MRI (magnetic resonance imaging) was ordered and is scheduled to rule out a neuro[DIAGNOSES REDACTED] due to the presentation of racoon eyes, battle sign and other symptoms (sic) Review of Hospital records dated 9/12/19 for Resident #4 revealed: (Emergency Department) Physician note: She was sent with a pre-arrival note, she apparently fell on Monday but was not evaluated in the emergency department. They say she had no bruising over the course of the week but today when they evaluated her, she had multiple bruises that had developed overnight. Today is Thursday. At her baseline she is normally awake and alert, confused and will answer some questions intermittently. Today on arrival she is not answering any questions she will only respond that her name is (Resident #4). On physical exam she does complain of abdominal pain. I did call the nursing home, they sent her in today as she developed bruising from her fall on Monday. They report one fall on Monday. They deny any other falls. They do not know when her last bowel movement was. No recent [MEDICAL CONDITION] activity. No medication changes. they state that she uses a walker to ambulate and has frequent falls. Constitutional: . c-collar in place, she has multiple bruises with different stages on her head and extremities. Ecchymosis with significant [MEDICAL CONDITION] of her left eyelid, she is unable to open her left eye without assistance due to the swelling. Gastrointestinal: . she says ow when I palpate her abdomen diffusely. mild pain with passive ROM (range of motion) of left shoulder . Integumentary . Diffuse ecchymosis on her bilateral forehead, left eye, bilateral shoulders, bilateral hips, right anterior thigh, left forearm, sacrum. Small skin abrasion to her right knee. CT (computerized tomography) spine without contrast, 9/12/19, Impression: 1. Acute minimal compression deformity of the T1 (upper [MEDICATION NAME] vertebrae between the cervical (neck) and the lumbar (lower part of body) vertebral body. No acute cervical fracture identified.Maxillofacial without contrast, Impression: 1. Moderate left periorbital (tissue surrounding the orbit of the eye) soft tissue swelling without fracture. Abdominal and Pelvis with contrast, Impression: Subacute compression fractures of T8 and T12. Healing left superior and inferior pubic rami fractures and left T10 and T11 rib fractures. The healing left rib fractures are new since the 6/25/2019 exam.Emergency Department Course: . Patient has diffuse bruising over her body, it does not appear consistent with one fall that occurred on Monday. She does have a history of recurrent falls per chart review. CT imaging is consistent with a new stable compression fracture at T1 . I did also consult with social workers as the patient has multiple fractures, she has multiple bruises and they started on Adult Protective Services case. They (the Nursing Home) say that they have instituted as many fall precautions as possible for her. Nursing Home states that her urine output has been unchanged. Will hold on antibiotics until culture results. Social work did feel that she was safe for discharge.Microbiology, urine culture and sensitivity collected 9/12/19 and resulted 9/14/19: positive for Escherichia coli (E. coli bacteria) and gram negative Bacilli (bacteria), which indicated a urinary tract infection with two different bacteria. Review of a physician progress notes [REDACTED].#4 revealed: (Resident #4) has not had any further falls since previous fall which resulted in hospitalization . She has not had and [MEDICAL CONDITION] activity. However, she does have very significant bruising around both eyes (raccoon sign) and bruising behind both ears (battle sign). Staff reports she has been very lethargic. I am sending her to the emergency room . CT of multiple locations did show a T4 compression fracture, no other fractures or abnormalities. Summary of Plans: Resident with known head trauma has battle sign and raccoon eyes. Review of a physician progress notes [REDACTED].#4 revealed: . Summary of Plans: Resident overall is declining. She is not nearly as alert as she has been in the past and is more somnolent. She has been seen in the emergency room in hospital on numerous occasions over the pas couple of months. Other than a T4 compression fracture, no other abnormalities have been found on CT. (sic) Review of an other unwitnessed Incident/Accident Report dated 9/26/19 at 21:55 (9:55 p.m.) for Resident #4 revealed: Entered (Resident #4's) room she was laying on mattress between her mattress and roommates' bed with head toward windows, noted an area of discoloration with swelling above the right eye. (Resident #4) has had no recent falls, when up in wheelchair was not visualized hitting head on table. (Resident #4) unable to give description. (Resident #4) could not identify any occurrence or persons related to this bruise. Immediate Action Taken: Assessed noted no other new injures .no witnesses found. Notes: Consult for hematology ordered. 10/9/19 Root cause/conclusion: (Resident #4) did not recall hitting her head and based off of positioning it does not appear the injury would be due to hitting her head. (Resident #4) had a bruise of unknown origin on 09/14/19 that began with unknown swelling. HCP was consulted and ordered a hematology consult. (Resident #4) has an upcoming MRI of the brain on 10/3/19 to r/o (rule out) other possible causes such as myeloma.This incident does not meet reporting requirements for BHCS due to no change in LOC (level of conscience) or injury. (sic) No incident report for 9/14/19 was presented to this surveyor. This was not reported to the State Agency. Review of an Unwitnessed Incident/Accident Report dated 9/29/19 at 7:00 a.m. for Resident #4 revealed: (Resident #4) was observed sitting in her doorway on her buttocks prior to tipping over on her right side by (CNA). (CNA) reported that she had observed (Resident #4) laying in bed a few minutes prior to seeing her in the doorway. (Resident #4) was assisted with toileting at 4 a.m. prior to. When asked what she trying to do, or where she going, she said I don't know. Notes: . 10/9/19, A soft shell protective helmet was ordered for (Resident #4) to wear while she is in bed in the event, she feels the need to express her right to self-determination. Care plan updated to reflect need to toilet (Resident #4) around 7 a.m. if observed awake and restless. this incident does not meet reporting requirements due to no injury or change in condition. (sic) Review of an MRI (magnetic resonance imaging) dated 10/3/19 for Resident #4 revealed: .Woke up 2 weeks ago with eye swollen shut, dementia, evaluate for mass. Findings: There is no diffusion restriction to suggest acute/subacute ischemia. mass effect or midline shift is identified. a small hematoma persists along the right frontal scalp. (sic) Review of an Unwitnessed Incident/Accident Report dated 10/12/19 at 11:10 a.m. for Resident #4 revealed: Registered Nurse (RN) Q was in halling passing medication and (Resident #4) was in the geri chair behind her. (RN Q) heard an increase noise, look behind her and observed (Resident #4) laying on the floor next to the geri chair. Across from day room, (CNA) at giving breakfast back against (Name) door. Chair next to (Resident #4), breakfast tray fell (Resident #4) was facing west. When asked what happened? What were you trying to do? She did not answer my questions. Currently her BIMS score is 99 unable to cooperate with interview. 10/23/19, Conclusion, (Resident #4) continues to be impulsive and self determined. The staff have her at the nurses' station with her breakfast tray on the over bed table. She did not ask for anything and as the nurse walked past (Resident #4) she stood and fell to the floor. Added to the careplan is for (Resident #4) to wear her helmet. this incident does not meet the reporting criteria for BHS. (sic) Review of a physician progress notes [REDACTED].#4) . has had repeated falls recently. Fortunately she has not had any falls in the past couple of weeks. Fall precautions are in place and include a helmet, and her mattresses are on the floor. Physical exam: .Eyes: Ecchymosis (subcutaneous spot of bleeding with diameter larger than 1 centimeter) around bilateral eyes which is improving. No new contusions. Ears/Nose/Mouth/Throat: Periorbital and lid hematoma, post auricular hematomas, hematomas are fading. Summary of Plans: .She has had numerous evaluations both here and in the emergency room in hospital with lab work, CTs (computed tomography), MRI (magnetic resonance imaging). Will ask pharmacy to review medications for possible contributions to fall and appetite. Review of an Unwitnessed Incident/Accident Report dated 11/10/19 at 21:20 (9:20 p.m.) for Resident #4 revealed: . nurse noted (Resident #4) on ground, sitting up, scooting on buttocks from hallway into T.V. room. Restless and crying throughout second shift; going to bed per request, then scooting out of room multiple times, toileted and placed back chair multiple times. Foot rests off of wheelchair. Non-slip grip socks applied. Continuously removing helmet. In hallway adjacent to T.V. room in wheelchair in sight of nurse seconds before the fall. Immediate Action Taken: Alert buy agitated and crying. Unable to clearly communicate. Restless, . Crab walking from hallway . (physician) notified and ordered to send to E.R. for evaluation (related to) pain.Conclusion: (Resident #4) had been Restless and crying throughout second shift; going to bed per request, then scooting out of room multiple times, toileted and placed back in chair multiple times. Footrests off of wheelchair. Non-slip grip socks applied. Continuously removing helmet. In hallway adjacent to T.V. room in wheelchair in sight of nurse seconds before the fall. There are no allegations of abuse or willful neglect. The careplan was followed and despite she fell , this incident does not meet the reporting BHS criteria. (sic) Review of a Nursing Progress Note dated 11/10/19 for Resident #4 revealed: nurse noted (Resident #4 on ground, (physician notified and ordered to sent to ER (emergency room ) for evaluation r/t (related to) pain. Review of a Physician Assistant Progress Note dated 11/20/19 for Resident #4 revealed: (Resident #4) is seen today because staff state she has been restless. Resident readmitted to the facility yesterday after being hospitalized for [REDACTED]. Resident was having quite a bit of restlessness prior to her hospitalization . Staff state resident has not been showing signs of pain. They state she will stand up from her wheelchair with no facial grimace or other signs of pain. At this time resident is sitting in her wheelchair. She is quite restless, asking to go back to bed. Staff state she will ask to go to bed, then a few minutes later will ask to get back into her wheelchair.Plan: I would recommend a referral to BCS (Behavioral Care Services) for further evaluation. Review of an Other unwitnessed Incident/Accident Report dated 12/4/19 at 13:30 (1:30 p.m.) for Resident #4 revealed: (CNA) was assisting (Resident #4) from her chair and observed an abrasion on each of (Resident #4's) elbows. (Resident #4) had been sitting in the hallway in a geri chair. 12/15/19, Conclusion: A review of the environment and (Resident #4's) movements identified the arm rest on the chair (Resident #4) sits in has vinyl. (Resident #4) uses her elbows to push up from the chair. Careplan was reviewed and updated with dressing that are protective, long sleeves or glen. (Resident #4) frequently removes them, covering for the vinyl geri chair. This event does not meet the reporting criteria of BHS. Review of a Nurse Practitioner Progress Note dated 12/12/19 for Resident #4 revealed: . she does have dementia which appears to be declining. She has multiple episodes of falls with most recent one incurring a left [MEDICAL CONDITION]. Incisions healing now but she is showing restlessness especially at night and evenings and is not on several mattresses on the floor which allows her to roll around. Family has signed onto hospice on for this dramatic decline in status. Today staff is wondering if we can discontinue her [MEDICATION NAME] ([MEDICAL CONDITION] medication) 50 (micrograms) once daily. After review of her chart we are unable to find a recent TSH ([MEDICAL CONDITION] stimulating hormone lab). She is asymptomatic. Summary of Plans: Patient is in steady decline at this time. Obtain TSH to determine need to discontinue the [MEDICATION NAME]. Continue hospice care as this is definitely appropriate. Review of an Unwitnessed Incident/Accident Report dated 12/14/19 at 21:15 (9:15 p.m.) for Resident #4 revealed: Resident was sitting in a chair at the nursing station, in general observance of the staff. She attempted to get out of chair and unable to stand fell to the floor. The staff member was unable to get to (Resident #4's) side to intervene. (Resident #4) was observed lying on her left sided. Conclusion: (Resident #4) has been restless and has been difficult finding a comfort level. She will rest for a short period of time This incident does not meet the BHS reporting criteria. The careplan is updated to reflect the intervention. (sic) (there is no conclusion). Review of physician progress notes [REDACTED].#4 revealed: (Resident #4 is on hospice care. She requires one-on-one due to behaviors consisting of agitation to the point where she will literally climb over the arms of her Geri chair. I discussed her status, behaviors, medications with the staff. We are going to increase her [MEDICATION NAME] ([MEDICATION NAME], a pain medication) to every 2 hours and her [MEDICATION NAME] to every 4 hours. Physical exam: . Resident is sitting in her Geri chair; at this time she is not agitated or combative, but staff is having a difficult time keeping her ears seated in her chair. Summary of Plans: Resident is on hospice care and is becoming agitated and difficult to control or redirect. She has a history of repeated falls with injuries. She has a history of [MEDICAL CONDITION] disorder, not [MEDICAL CONDITION] activity reported recently. It does seem that her agitations is somehow pain related, the exact location of pain or discomfort is not determined. (sic) Review of the Care Plan for Resident #4 revealed a long detailed focus and is unclear what the main focus is and implemented on 7/3/19 and last revised on 12/26/19. Not all interventions were implemented, and some were not person centered to Resident #4's [DIAGNOSES REDACTED]. 7/4/19 Keep in observation while up in wheeled chair. 8/2/19 Place Dycem to wc (wheelchair) cushion to prevent slipping. 7/13/19 remove from dining room when meal is done. 8/2/19 Remove foot pedals from wc when not transporting. Encourage (Resident #4) to remain in common areas, as she allows, to encourage opportunities for supervision. 9/9/19 offer toileting between 6 am and 7 am as resident allows. 9/12/19/ Remove bed and place mattress on the floor. place additional mattress on opposite side of bed continue scoop mattress. Sign on bathroom door to keep it closed to mitigate injury. Bedside dresser moved away from bed. Foam to radiator edges to mitigate injury. 9/26/19 Hematology consult. 9/29/19 if AWAKE AND RESTLESS IN BED GET UP IN W/C AS RESIDENT ALLOWS. 9/30/19 Interdisciplinary team collaboration identified the need for a helmet, order placed. 10/12/19-helmet to be worn in and when up in her chair as resident allows 12/13/19 Sit at residents' side when in w/c. Offer to lay done if shows signs of restlessness such as freq changes of position, eye closing resting head in hands Date Initiated: 07/03/2019. Revision on: 12/26/2019. Cancelled Date: 12/26/2019. (sic) Review of a Care Plan for Resident #4 revealed: Focus: CANCELLED: (Resident #4) has the potential for psychosocial distress related to: anticipated dementia progression, expressing sadness, anger, empty feeling over lost roles and status. Prior to being admitted , (Resident #1) resided at The Cove assisted living facility. (Resident #1) has a dx of depression and dementia. She speaks softly when conversing with others. (Resident #1) has short and long term memory loss present, dx of Dementia with behaviors and Cognitive Communication Deficit present. She has had a decline in her appetite due to declining health. PW Services serve as guardian for (Resident #1). She is under the care of Harbor hospice. (Resident #1) has a dx of agitation, restless and [MEDICAL CONDITION]. Date Initiated: 07/09/2019. Revision on: 12/26/2019. Cancelled Date: 12/26/2019. (sic) No true interventions in place to address dementia and behaviors or revisions. Review of a Progress Note dated 12/26/19 for Resident #4 revealed: Hospice RN visit: (Patient) passed away at 12:30 p.m. In an interview on 1/3/20 at 11:00 a.m., Licensed Practical Nurse (LPN) J reported she finished working the weekend night shift on Monday, September 9th and returned to work on 9/12/19 at 10:00 p.m. when her shift started. LPN J remembers during shift change, the previous nurse from the day shift told her that Resident #4 had a bruise/bump above her left eye on her forehead from a fall she had on Monday, 9/9/19. At 11:00 p.m., LPN J reported she made her rounds on her residents and observed Resident #4 had a puffy eye and was black and blue and almost swollen closed. LPN J proceeded to ask the CNA's (Certified Nursing Assistants) on duty received report from the day shift CNA's as well but did not expect to see Resident #4 with the puffy, black and blue eye either and they had not seen the resident in a couple days either. LPN J reported she started to worry because the report did not match the observation of Resident #4. LPN J reported she started to look at progress notes and other medical records to determine if this incident was something new or not and could not find much documentation. LPN J reported that at 2:00 a.m., Resident #4's eye was getting worse and swollen completely closed. LPN J reported she called the Director of Nursing and sent Resident #4 to the emergency room around 4:00 a.m. In an interview on 1/6/20 at 2:15 p.m., the Director of Nursing (DON) reported she felt that the acute fracture on 9/12/19 for Resident #4 that was diagnosed at the hospital was an old fracture, even though the hospital called it acute, and felt it was from a couple years ago when a telephone pole fell on the resident. The DON reported Resident #4 had severe bruising, was confused and impulsive. Resident #4 would wear a helmet and then take it off many times. The DON continued to report Resident #4 slept on a mattress on the floor and would scoot on the floor on her bottom. When queried about the 9/12/19 investigation and how it combined with the 9/26/19 investigation, the DON reported she did not know because she did not do the investigation and that the previous administrator who is no longer at the facility did the investigation. The DON and the Corporate Consultant were not able to clearly explain the incidents on 9/9/19, 9/12/19 and the 9/26/19 or the investigation and outcome/conclusion. The three incidents seemed to mesh with each other. This surveyor asked them if they could not understand it, how was this surveyor to understand it. No witness statements from staff noted. When queried about witness statements, the DON reported she puts in the interviews with staff in the reports but does not collect written statements from the staff. This surveyor asked the DON to review and organize the investigations. When queried about documenting the skin conditions in the STCP again, the DON reported they just documents the skin condition until it is no longer acute. When queried about where the details of the skin concerns were such as measurements and locations, the DON just shrugged her shoulders. In an interview on 1/7/20 at 9:30 a.m., the Director of Nursing (DON), Corporate Consultant (CC) C and the Clinical Care Coordinator (CCC) F reported the intervention for Resident #4 on 9/9/19 was to offer toileting between 6:00 a.m. and 7:00 a.m. and did not know why Resident #4 was found on her buttocks on the floor and did not know how she got the bruise on her eye on 9/12/19 at 11:00 p.m. CC C reported the bruise/swelling on Resident #4 was up on her hairline and blood pooled down to her eye and that the ER doctor said the bruise/swelling was from Monday 9/9/19. When queried about the fracture from 9/12/19, CC C reported that anytime anyone goes to the ER they call it an acute fracture. The DON and CC C reported Resident #4 was not a 1:1 supervision and that a 1:1 supervision was not something the facility utilizes. The CC C reported she discontinued the Short Term Care Plan (STCP) skin assessments from 9/26/19 and started to document in the progress notes because she was concerned about Resident #4 and wanted to be the only one to assess her as opposed to several other nurses documenting differently about the same thing and reported she could not write what she wanted in the STCP. CC C reported she felt this was a very strange investigation and wanted to follow up. We reviewed the rest of Resident #4's incident/accident reports and the facility reported as follows: 9/29/19, Resident #4 is to come to the nurses' station when she is awake and restless. 10/12/19, Resident #4 is to wear a helmet and be with staff in the general area for close supervision. 11/10/19, The DON and CC C was not sure what was going on with this investigation, changed their story and said Resident #4 was not on close supervision at this time and they decreased her [MEDICATION NAME] ([MEDICAL CONDITION] medication) due to her grogginess. 12/4/19, they reported Resident #4 just rocked back and forth in her Geri chair which caused abrasions on her elbows. 12/14/19, they reported the unwitnessed fall was witnessed and never put the witness in the report. In an interview on 1/8/20 at 9:33 a.m., Registered Nurse (RN) Q reported Resident #4 required continuous supervision. RN Q was queried about the 10/12/19 incident with Resident #4 and reported she was down the hall with the medication cart and Resident #4's main assigned CNA went on break, which left 2 other CNA's at the desk. The CNA's called RN Q to come back down the hall where Resident #4 was laying on the floor. RN Q asked the CNA's where they were and they told her they were coming down the hall and saw Resident #4 on the floor, but the report said they were at the nurses' station, which is not what the CNA's told her. In an interview on 1/8/20 at 2:24 p.m., Certified Nursing Assistant (CNA) U reported most days the facility will run with four CNA's on her unit, sometimes six CNA's. But when they have 6 CNA's, they decrease in staffing fast. CNA U reported today there was 5 CNA's on her unit and the Terrace unit (dementia unit) was short. So they sent a CNA down to that unit and she later went home with a personal problem. CNA U reported people don't like working the Terrace because some of the residents have behaviors. CNA U reported some staff refuse to work on the Terrace unit and make excuses why they cannot work down there and will say they were not trained to work down there. In an interview on 1/8/20 at 4:30 p.m., the Nursing Home Administrator (NHA) reported the facility has a new Human Resources person who has only been here a couple months and did not assign the education. NHA agreed that not all employee trainings were up to date or complete at this time. In an interview on 1/9/20 at 8:45 a.m., the Staff Scheduler (SS) Y reported she scheduled staff according to the census and the matrix. SS Y reported Resident #4 was not a 1:1 supervision but she had extra supervision with a CNA buddy who is more like a talk buddy and is around for patient comfort. (CNA buddy is not a CNA and is not a licensed position.) SS Y reported that the facility does run short of CNA's sometimes and did not know of any staff who did not like working on the Terrace unit and that some staff requested to go to that unit. During an observation on 1/9/20 at 9:06 a.m., five residents observed in the nursing station on the Terrace unit without supervision. One CNA observed in the dining room assisting a resident. Her demeanor was assertive and had a flat affect toward the resident. At this time, another CNA observed walking down the hall to the Terrace Nursing station and did not engage with the residents gathered around and started talking to the housekeeping staff with back towards the residents. During an observation and an interview on 1/9/20 at 9:15 a.m., CNA Buddy (CB) Z arrived to the nursing station and reported she did not have a CNA license and was there for the safety of the residents and to supervise in the hallways. If the CNA's needed help changing sheets or other non-resident related tasks, she is able to assist with that as well. CB Z reported she started working at the facility in the middle of December. Review of Hospice documentation revealed Resident #4 admitted to Hospice on 11/27/19. 12/3/19-Anxiety high at start of this visit. Anxiety level 0/10 at end of this nurse visit. (Hospice CNA) provided care with warm soothing approach, which was effective to ease pt's (patient's) restlessness.Received report via phone from (Director of Nursing). Constant restlessness over past 9 hours Staff are providing 1:1 supervision for safety. This RN sat with resident for 45 minutes. Distraction therapy Consult in person with (DON) at end of the visit. Pt is resting peacefully at this time. 12/5/19- Found (Resident #4) seated in broda chair at nurses' desk. Staff are providing close supervision for safety. Right elbow has open are due to sheering. Wound is superficial. Open are is oval in shape, and approx. 2 cm in diameter. Surrounding skin is bright pink and irritated. 12/10/19-Phoned SNF (skilled nursing facility) and spoke with facility nurse . She stated that (Resident #4) is good at the moment. Pt is currently sleeping in recliner chair, near the nurses' desk. (SNF Nurse) explained that pt was moderately restless today. Pt likely fell asleep due to exhaustion. She did not give any [MEDICATION NAME] (pain medication) or [MEDICATION NAME] (antianxiety medication) today (although they are ordered on routine basis now.) (SNF Nurse) offered explanation for not giving meds, as they are not effective, or may not be necessary. This RN offered education that pt likely has chronic pain due to recent (fracture) of (left) hip, and previous (fracture) of ribs and spine. Routine [MEDICATION NAME] is ordered to maintain comfort. Routine [MEDICATION NAME] added last week in effort to prevent anxiety, which was severe.12/11/19- Received 2nd call from (DON). She reports ongoing restlessness. She requests Hospice CNA focus on providing 1:1 attention. (DON) explained, staff are taking turns to provide 1:1 attention for (patient) . 12/13/19-Problem with [MEDICATION NAME] dosing. While at facility, Nurse (Name) and I checked [MEDICATION NAME] bottle from (Pharmacy). Dropper is small, and maximum dose on dropper is 1 mg (milligram). Nurses report they have been giving 1 mg. Dose ordered is 1ML (milliliter)/(2mg). Consult in person with (DON) . She will request he (Physician) write new order . This is a 50% increase from what she was actually getting. 12/14/19- Visit made to assess patient after anxiety meds ([MEDICATION NAME]) increased. Pt is resting in a High backed w/c (wheelchair) by the nursing desk. Assisted nurse in removing and changing the dressing on both elbows. Open are on the left elbow is 0.75 cm (centimeters) (di

This pertains to intakes M 6483 and M 7865 Based on observation, interview and record review, the facility failed to provide adequate supervision and interventions to prevent falls for 1 (Resident #4) from a total sample of 17, resulting in bruising, fractures, and hospitalization s. Findings include: Resident #4 Review of a Face Sheet revealed Resident #4 is a [AGE] year old female originally admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #4 had a Brief Interview for Mental Status (BIMS) that indicated she is severely cognitively impaired and required extensive assistance of one person for transfers, limited assistance of one person physical assist for eating. Review of a Policy titled Accident/Incident Report, Fall Management last revised 6/18 revealed: It is the policy of this facility to complete an accident incident report for unexplained bruises or abrasions; accidents or incidents where there is injury or the potential to result in injury; falls; and resident to resident altercations. Purpose: To establish a standard for accident/incident completion and to evaluate the facility responsibility to make every effort to decrease the likelihood of a recurrence by investigating incidents, understand how they occur and applying appropriate action. Review of a Policy titled Skin at Risk Assessment last revised March 2015 revealed: It is the policy of this facility to assess resident risk factors for impaired skin integrity and intervene as indicated utilizing the admission plan of care and Minimum Data Set as formal assessment tools. Purpose: To ensure prompt identification and intervention for residents at risk of impaired skin integrity corresponding to risk factors. Review of a Policy titled Identification of Abuse last revised 11/2016 revealed: It is the policy of this facility to encourage any employee who has reasonable cause to believe that a resident has been subject to abuse, neglect, exploitation or endangerment to report it to the facility Administrator and/or Director of Health Care Services.Examples: . Injuries of Unknown Source: An injury should be classified as an injury of unknown source when both of the following conditions are met: The source of the injury was not observed by any person or the source of the injury could not be reasonably explained by the resident; and The injury is suspicious because of the extent of the injury or the location of the injury Resident #4 Review of an unwitnessed incident/accident report for Resident #4 revealed: On 9/9/19 at 6:30 a.m. Resident #4 had an unwitnessed fall Observed resident sitting on buttock in upright position, back against the heater registered and feet towards the entrance of room Bed in low position with mat parallel with the bed. Call light within reach. Stated had to use the restroom Bim score is 99 signifying cognitive impairment. Intervention will offer toileting between 6-7 am as resident allows. (sic) Review of an unwitnessed Bruise incident/accident report dated 9/12/19 at 1:00 p.m. for Resident #4 revealed: Bruise, at approximately 415 a.m. (CNA) reported to (LPN) that (Resident #4) had a swollen eye. (LPN) observed swollen discoloration of left eye into the hair/scalp. Notified Pw Services order from (Physician) to send to (emergency room ). Immediate Action Taken: Upon return from ER a skin assessment completed. Reddish/brown area of discoloration to left forehead measures 10 cm (centimeters) X 11 cm, dark purple bruising with [MEDICAL CONDITION] covering left eyelid, bruise to right side of head into the hairline dark to med purple in color, measures 4 cm X 5 cm reddish/brown area to the left should 8 cm X 4 cm, left forearm small bruise from possible IV site as there is tape residue at that spot. Bil(ateral) lower extremities were free from bruising except for a small healing superficial abrasion less than .5 cm on her left knee, ROM (range of motion) was completed without complaints of discomfort . Notes: 9/12/19 actions: Sent to ER for Evaluation. Upon return completed skin assessment . 9/26/19: Event summary: (Resident #4) was sent to the ER due to bruising on her forehead. When evaluated in the ER, (Resident #4) was diagnosed with [REDACTED]. (Resident #4) has several compression deformities in her [MEDICATION NAME] region from a traumatic injury in 2017. Investigation begun.9/26/19, Investigation 5: This writer (RN S) was notified during report that blood was pooling into right eye, Right eye lids are purple and swollen. (Nursing Home Administrator (NHA)) notified. At 1200 (Resident #4) asked to go to bed. This writer explained that it was almost time for lunch. (Resident #4) did not want lunch, she wanted to lay down. She also denied need to void and did not want to be toileted. She was laid down on middle, scoop mattress, and mattresses laid down on both sides of her. At 1415 (2:15 p.m.) CNA notified this writer that (Resident #4) had crawled off of her mattress, undressed herself and was laying topless with brief applied. Brief dry. No injury noted, and (Resident #4) denied pain. 9/26/19, Conclusion 2: An MRI (magnetic resonance imaging) was ordered and is scheduled to rule out a neuro[DIAGNOSES REDACTED] due to the presentation of racoon eyes, battle sign and other symptoms (sic) Review of Hospital records dated 9/12/19 for Resident #4 revealed: (Emergency Department) Physician note: She was sent with a pre-arrival note, she apparently fell on Monday but was not evaluated in the emergency department. They say she had no bruising over the course of the week but today when they evaluated her, she had multiple bruises that had developed overnight. Today is Thursday. At her baseline she is normally awake and alert, confused and will answer some questions intermittently. Today on arrival she is not answering any questions she will only respond that her name is (Resident #4). On physical exam she does complain of abdominal pain. I did call the nursing home, they sent her in today as she developed bruising from her fall on Monday. They report one fall on Monday. They deny any other falls. They do not know when her last bowel movement was. No recent [MEDICAL CONDITION] activity. No medication changes. they state that she uses a walker to ambulate and has frequent falls. Constitutional: . c-collar in place, she has multiple bruises with different stages on her head and extremities. Ecchymosis with significant [MEDICAL CONDITION] of her left eyelid, she is unable to open her left eye without assistance due to the swelling. Gastrointestinal: . she says ow when I palpate her abdomen diffusely. mild pain with passive ROM (range of motion) of left shoulder . Integumentary . Diffuse ecchymosis on her bilateral forehead, left eye, bilateral shoulders, bilateral hips, right anterior thigh, left forearm, sacrum. Small skin abrasion to her right knee. CT (computerized tomography) spine without contrast, 9/12/19, Impression: 1. Acute minimal compression deformity of the T1 (upper [MEDICATION NAME] vertebrae between the cervical (neck) and the lumbar (lower part of body) vertebral body. No acute cervical fracture identified.Maxillofacial without contrast, Impression: 1. Moderate left periorbital (tissue surrounding the orbit of the eye) soft tissue swelling without fracture. Abdominal and Pelvis with contrast, Impression: Subacute compression fractures of T8 and T12. Healing left superior and inferior pubic rami fractures and left T10 and T11 rib fractures. The healing left rib fractures are new since the 6/25/2019 exam.Emergency Department Course: . Patient has diffuse bruising over her body, it does not appear consistent with one fall that occurred on Monday. She does have a history of recurrent falls per chart review. CT imaging is consistent with a new stable compression fracture at T1 . I did also consult with social workers as the patient has multiple fractures, she has multiple bruises and they started on Adult Protective Services case. They (the Nursing Home) say that they have instituted as many fall precautions as possible for her. Nursing Home states that her urine output has been unchanged. Will hold on antibiotics until culture results. Social work did feel that she was safe for discharge.Microbiology, urine culture and sensitivity collected 9/12/19 and resulted 9/14/19: positive for Escherichia coli (E. coli bacteria) and gram negative Bacilli (bacteria), which indicated a urinary tract infection with two different bacteria. Review of Physician order [REDACTED]. Review of a physician progress notes [REDACTED].#4 revealed: (Resident #4) has not had any further falls since previous fall which resulted in hospitalization . She has not had and [MEDICAL CONDITION] activity. However, she does have very significant bruising around both eyes (raccoon sign) and bruising behind both ears (battle sign). Staff reports she has been very lethargic. I am sending her to the emergency room . CT of multiple locations did show a T4 compression fracture, no other fractures or abnormalities. Summary of Plans: Resident with known head trauma has battle sign and raccoon eyes. Review of a physician progress notes [REDACTED].#4 revealed: . Summary of Plans: Resident overall is declining. She is not nearly as alert as she has been in the past and is more somnolent. She has been seen in the emergency room in hospital on numerous occasions over the pas couple of months. Other than a T4 compression fracture, no other abnormalities have been found on CT. (sic) Review of an other unwitnessed Incident/Accident Report dated 9/26/19 at 21:55 (9:55 p.m.) for Resident #4 revealed: Entered (Resident #4's) room she was laying on mattress between her mattress and roommates' bed with head toward windows, noted an area of discoloration with swelling above the right eye. (Resident #4) has had no recent falls, when up in wheelchair was not visualized hitting head on table. (Resident #4) unable to give description. (Resident #4) could not identify any occurrence or persons related to this bruise. Immediate Action Taken: Assessed noted no other new injures .no witnesses found. Notes: Consult for hematology ordered. 10/9/19 Root cause/conclusion: (Resident #4) did not recall hitting her head and based off of positioning it does not appear the injury would be due to hitting her head. (Resident #4) had a bruise of unknown origin on 09/14/19 that began with unknown swelling. HCP was consulted and ordered a hematology consult. (Resident #4) has an upcoming MRI of the brain on 10/3/19 to r/o (rule out) other possible causes such as myeloma.This incident does not meet reporting requirements for BHCS due to no change in LOC (level of conscience) or injury. (sic) No incident report for 9/14/19 was presented to this surveyor. Review of an Unwitnessed Incident/Accident Report dated 9/29/19 at 7:00 a.m. for Resident #4 revealed: (Resident #4) was observed sitting in her doorway on her buttocks prior to tipping over on her right side by (CNA). (CNA) reported that she had observed (Resident #4) laying in bed a few minutes prior to seeing her in the doorway. (Resident #4) was assisted with toileting at 4 a.m. prior to. When asked what she trying to do, or where she going, she said I don't know. Notes: . 10/9/19, A soft shell protective helmet was ordered for (Resident #4) to wear while she is in bed in the event, she feels the need to express her right to self-determination. Care plan updated to reflect need to toilet (Resident #4) around 7 a.m. if observed awake and restless. this incident does not meet reporting requirements due to no injury or change in condition. (sic) Review of an MRI (magnetic resonance imaging) dated 10/3/19 for Resident #4 revealed: .Woke up 2 weeks ago with eye swollen shut, dementia, evaluate for mass. Findings: There is no diffusion restriction to suggest acute/subacute ischemia. mass effect or midline shift is identified. a small hematoma persists along the right frontal scalp. (sic) Review of an Unwitnessed Incident/Accident Report dated 10/12/19 at 11:10 a.m. for Resident #4 revealed: Registered Nurse (RN) Q was in halling passing medication and (Resident #4) was in the geri chair behind her. (RN Q) heard an increase noise, look behind her and observed (Resident #4) laying on the floor next to the geri chair. Across from day room, (CNA) at giving breakfast back against (Name) door. Chair next to (Resident #4), breakfast tray fell (Resident #4) was facing west. When asked what happened? What were you trying to do? She did not answer my questions. Currently her BIMS score is 99 unable to cooperate with interview. 10/23/19, Conclusion, (Resident #4) continues to be impulsive and self determined. The staff have her at the nurses' station with her breakfast tray on the over bed table. She did not ask for anything and as the nurse walked past (Resident #4) she stood and fell to the floor. Added to the careplan is for (Resident #4) to wear her helmet. this incident does not meet the reporting criteria for BHS. (sic) Review of a physician progress notes [REDACTED].#4) . has had repeated falls recently. Fortunately she has not had any falls in the past couple of weeks. Fall precautions are in place and include a helmet, and her mattresses are on the floor. Physical exam: .Eyes: Ecchymosis (subcutaneous spot of bleeding with diameter larger than 1 centimeter) around bilateral eyes which is improving. No new contusions. Ears/Nose/Mouth/Throat: Periorbital and lid hematoma, post auricular hematomas, hematomas are fading. Summary of Plans: .She has had numerous evaluations both here and in the emergency room in hospital with lab work, CTs (computed tomography), MRI (magnetic resonance imaging). Will ask pharmacy to review medications for possible contributions to fall and appetite. Review of an Unwitnessed Incident/Accident Report dated 11/10/19 at 21:20 (9:20 p.m.) for Resident #4 revealed: . nurse noted (Resident #4) on ground, sitting up, scooting on buttocks from hallway into T.V. room. Restless and crying throughout second shift; going to bed per request, then scooting out of room multiple times, toileted and placed back chair multiple times. Foot rests off of wheelchair. Non-slip grip socks applied. Continuously removing helmet. In hallway adjacent to T.V. room in wheelchair in sight of nurse seconds before the fall. Immediate Action Taken: Alert buy agitated and crying. Unable to clearly communicate. Restless, . Crab walking from hallway . (physician) notified and ordered to send to E.R. for evaluation (related to) pain.Conclusion: (Resident #4) had been Restless and crying throughout second shift; going to bed per request, then scooting out of room multiple times, toileted and placed back in chair multiple times. Footrests off of wheelchair. Non-slip grip socks applied. Continuously removing helmet. In hallway adjacent to T.V. room in wheelchair in sight of nurse seconds before the fall. There are no allegations of abuse or willful neglect. The careplan was followed and despite she fell , this incident does not meet the reporting BHS criteria. (sic) Review of a Physician Assistant Progress Note dated 11/20/19 for Resident #4 revealed: (Resident #4) is seen today because staff state she has been restless. Resident readmitted to the facility yesterday after being hospitalized for [REDACTED]. Resident was having quite a bit of restlessness prior to her hospitalization . Staff state resident has not been showing signs of pain. They state she will stand up from her wheelchair with no facial grimace or other signs of pain. At this time resident is sitting in her wheelchair. She is quite restless, asking to go back to bed. Staff state she will ask to go to bed, then a few minutes later will ask to get back into her wheelchair.Plan: I would recommend a referral to BCS (Behavioral Care Services) for further evaluation. Review of an Other unwitnessed Incident/Accident Report dated 12/4/19 at 13:30 (1:30 p.m.) for Resident #4 revealed: (CNA) was assisting (Resident #4) from her chair and observed an abrasion on each of (Resident #4's) elbows. (Resident #4) had been sitting in the hallway in a geri chair. 12/15/19, Conclusion: A review of the environment and (Resident #4's) movements identified the arm rest on the chair (Resident #4) sits in has vinyl. (Resident #4) uses her elbows to push up from the chair. Careplan was reviewed and updated with dressing that are protective, long sleeves or glen. (Resident #4) frequently removes them, covering for the vinyl geri chair. This event does not meet the reporting criteria of BHS. Review of a Nurse Practitioner Progress Note dated 12/12/19 for Resident #4 revealed: . she does have dementia which appears to be declining. She has multiple episodes of falls with most recent one incurring a left [MEDICAL CONDITION]. Incisions healing now but she is showing restlessness especially at night and evenings and is not on several mattresses on the floor which allows her to roll around. Family has signed onto hospice on for this dramatic decline in status. Today staff is wondering if we can discontinue her [MEDICATION NAME] ([MEDICAL CONDITION] medication) 50 (micrograms) once daily. After review of her chart we are unable to find a recent TSH ([MEDICAL CONDITION] stimulating hormone lab). She is asymptomatic. Summary of Plans: Patient is in steady decline at this time. Obtain TSH to determine need to discontinue the [MEDICATION NAME]. Continue hospice care as this is definitely appropriate. Review of an Unwitnessed Incident/Accident Report dated 12/14/19 at 21:15 (9:15 p.m.) for Resident #4 revealed: Resident was sitting in a chair at the nursing station, in general observance of the staff. She attempted to get out of chair and unable to stand fell to the floor. The staff member was unable to get to (Resident #4's) side to intervene. (Resident #4) was observed lying on her left sided. Conclusion: (Resident #4) has been restless and has been difficult finding a comfort level. She will rest for a short period of time This incident does not meet the BHS reporting criteria. The careplan is updated to reflect the intervention. (sic) (there is no conclusion). Review of physician progress notes [REDACTED].#4 revealed: (Resident #4 is on hospice care. She requires one-on-one due to behaviors consisting of agitation to the point where she will literally climb over the arms of her Geri chair. I discussed her status, behaviors, medications with the staff. We are going to increase her [MEDICATION NAME] ([MEDICATION NAME], a pain medication) to every 2 hours and her [MEDICATION NAME] to every 4 hours. Physical exam: . Resident is sitting in her Geri chair; at this time she is not agitated or combative, but staff is having a difficult time keeping her ears seated in her chair. Summary of Plans: Resident is on hospice care and is becoming agitated and difficult to control or redirect. She has a history of repeated falls with injuries. She has a history of [MEDICAL CONDITION] disorder, not [MEDICAL CONDITION] activity reported recently. It does seem that her agitations is somehow pain related, the exact location of pain or discomfort is not determined. (sic) Review of the Care Plan for Resident #4 revealed a long detailed focus and is unclear what the main focus is and implemented on 7/3/19 and last revised on 12/26/19. Not all interventions were implemented, and some were not person centered to Resident #4's [DIAGNOSES REDACTED]. 7/4/19 Keep in observation while up in wheeled chair. 8/2/19 Place Dycem to wc (wheelchair) cushion to prevent slipping. 7/13/19 remove from dining room when meal is done. 8/2/19 Remove foot pedals from wc when not transporting. Encourage (Resident #4) to remain in common areas, as she allows, to encourage opportunities for supervision. 9/9/19 offer toileting between 6 am and 7 am as resident allows. 9/12/19/ Remove bed and place mattress on the floor. place additional mattress on opposite side of bed continue scoop mattress. Sign on bathroom door to keep it closed to mitigate injury. Bedside dresser moved away from bed. Foam to radiator edges to mitigate injury. 9/26/19 Hematology consult. 9/29/19 if AWAKE AND RESTLESS IN BED GET UP IN W/C AS RESIDENT ALLOWS. 9/30/19 Interdisciplinary team collaboration identified the need for a helmet, order placed. 10/12/19-helmet to be worn in and when up in her chair as resident allows 12/13/19 Sit at residents' side when in w/c. Offer to lay done if shows signs of restlessness such as freq changes of position, eye closing resting head in hands Date Initiated: 07/03/2019. Revision on: 12/26/2019. Cancelled Date: 12/26/2019. (sic) Review of a Progress Note dated 12/26/19 for Resident #4 revealed: Hospice RN visit: (Patient) passed away at 12:30 p.m. In an interview on 1/3/20 at 11:00 a.m., Licensed Practical Nurse (LPN) J reported she finished working the weekend night shift on Monday, September 9th and returned to work on 9/12/19 at 10:00 p.m. when her shift started. LPN J remembers during shift change, the previous nurse from the day shift told her that Resident #4 had a bruise/bump above her left eye on her forehead from a fall she had on Monday, 9/9/19. At 11:00 p.m., LPN J reported she made her rounds on her residents and observed Resident #4 had a puffy eye and was black and blue and almost swollen closed. LPN J proceeded to ask the CNA's (Certified Nursing Assistants) on duty received report from the day shift CNA's as well but did not expect to see Resident #4 with the puffy, black and blue eye either and they had not seen the resident in a couple days either. LPN J reported she started to worry because the report did not match the observation of Resident #4. LPN J reported she started to look at progress notes and other medical records to determine if this incident was something new or not and could not find much documentation. LPN J reported that at 2:00 a.m., Resident #4's eye was getting worse and swollen completely closed. LPN J reported she called the Director of Nursing and sent Resident #4 to the emergency room around 4:00 a.m. In an interview on 1/3/20 at 12:57 p.m., the Director of Nursing (DON) reported Skin Assessments are in the Short Term Care Plans (STCP), not under skin assessments. The DON reported they do not chart when bruises are resolved and once the bruises start to improve, they stop charting them in the STCP. In an interview on 1/6/20 at 2:15 p.m., the Director of Nursing (DON) reported she felt that the acute fracture on 9/12/19 for Resident #4 that was diagnosed at the hospital was an old fracture, even though the hospital called it acute, and felt it was from a couple years ago when a telephone pole fell on the resident. The DON reported Resident #4 had severe bruising, was confused and impulsive. Resident #4 would wear a helmet and then take it off many times. The DON continued to report Resident #4 slept on a mattress on the floor and would scoot on the floor on her bottom. When queried about the 9/12/19 investigation and how it combined with the 9/26/19 investigation, the DON reported she did not know because she did not do the investigation and that the previous administrator who is no longer at the facility did the investigation. The DON and the Corporate Consultant were not able to clearly explain the incidents on 9/9/19, 9/12/19 and the 9/26/19 or the investigation and outcome/conclusion. The three incidents seemed to mesh with each other. This surveyor asked them if they could not understand it, how was this surveyor to understand it. No witness statements from staff noted. When queried about witness statements, the DON reported she puts in the interviews with staff in the reports but does not collect written statements from the staff. This surveyor asked the DON to review and organize the investigations. When queried about documenting the skin conditions in the STCP again, the DON reported they just documents the skin condition until it is no longer acute. When queried about where the details of the skin concerns were such as measurements and locations, the DON just shrugged her shoulders. In an interview on 1/7/20 at 9:30 a.m., the Director of Nursing (DON), Corporate Consultant (CC) C and the Clinical Care Coordinator (CCC) F reported the intervention for Resident #4 on 9/9/19 was to offer toileting between 6:00 a.m. and 7:00 a.m. and did not know why Resident #4 was found on her buttocks on the floor and did not know how she got the bruise on her eye on 9/12/19 at 11:00 p.m. CC C reported the bruise/swelling on Resident #4 was up on her hairline and blood pooled down to her eye and that the ER doctor said the bruise/swelling was from Monday 9/9/19. When queried about the fracture from 9/12/19, CC C reported that anytime anyone goes to the ER they call it an acute fracture. The DON and CC C reported Resident #4 was not a 1:1 supervision and that a 1:1 supervision was not something the facility utilizes. The CC C reported she discontinued the Short Term Care Plan (STCP) skin assessments from 9/26/19 and started to document in the progress notes because she was concerned about Resident #4 and wanted to be the only one to assess her as opposed to several other nurses documenting differently about the same thing and reported she could not write what she wanted in the STCP. CC C reported she felt this was a very strange investigation and wanted to follow up. We reviewed the rest of Resident #4's incident/accident reports and the facility reported as follows: 9/29/19, Resident #4 is to come to the nurses' station when she is awake and restless. 10/12/19, Resident #4 is to wear a helmet and be with staff in the general area for close supervision. 11/10/19, The DON and CC C was not sure what was going on with this investigation, changed their story and said Resident #4 was not on close supervision at this time and they decreased her [MEDICATION NAME] ([MEDICAL CONDITION] medication) due to her grogginess. 12/4/19, they reported Resident #4 just rocked back and forth in her Geri chair which caused abrasions on her elbows. 12/14/19, they reported the unwitnessed fall was witnessed and never put the witness in the report. In an interview on 1/8/20 at 9:33 a.m., Registered Nurse (RN) Q reported Resident #4 required continuous supervision. RN Q was queried about the 10/12/19 incident with Resident #4 and reported she was down the hall with the medication cart and Resident #4's main assigned CNA went on break, which left 2 other CNA's at the desk. The CNA's called RN Q to come back down the hall where Resident #4 was laying on the floor. RN Q asked the CNA's where they were and they told her they were coming down the hall and saw Resident #4 on the floor, but the report said they were at the nurses' station, which is not what the CNA's told her. In an interview on 1/8/20 at 2:24 p.m., Certified Nursing Assistant (CNA) U reported most days the facility will run with four CNA's on her unit, sometimes six CNA's. But when they have 6 CNA's, they decrease in staffing fast. CNA U reported today there was 5 CNA's on her unit and the Terrace unit (dementia unit) was short. So they sent a CNA down to that unit and she later went home with a personal problem. CNA U reported people don't like working the Terrace because some of the residents have behaviors. CNA U reported some staff refuse to work on the Terrace unit and make excuses why they cannot work down there and will say they were not trained to work down there. In an interview on 1/9/20 at 8:45 a.m., the Staff Scheduler (SS) Y reported she scheduled staff according to the census and the matrix. SS Y reported Resident #4 was not a 1:1 supervision but she had extra supervision with a CNA buddy who is more like a talk buddy and is around for patient comfort. (CNA buddy is not a CNA and is not a licensed position.) SS Y reported that the facility does run short of CNA's sometimes and did not know of any staff who did not like working on the Terrace unit and that some staff requested to go to that unit. Review of Hospice documentation revealed Resident #4 admitted to Hospice on 11/27/19. 12/3/19-Anxiety high at start of this visit. Anxiety level 0/10 at end of this nurse visit. (Hospice CNA) provided care with warm soothing approach, which was effective to ease pt's (patient's) restlessness.Received report via phone from (Director of Nursing). Constant restlessness over past 9 hours Staff are providing 1:1 supervision for safety. This RN sat with resident for 45 minutes. Distraction therapy Consult in person with (DON) at end of the visit. Pt is resting peacefully at this time. 12/5/19- Found (Resident #4) seated in broda chair at nurses' desk. Staff are providing close supervision for safety. Right elbow has open are due to sheering. Wound is superficial. Open are is oval in shape, and approx. 2 cm in diameter. Surrounding skin is bright pink and irritated. 12/10/19-Phoned SNF (skilled nursing facility) and spoke with facility nurse . She stated that (Resident #4) is good at the moment. Pt is currently sleeping in recliner chair, near the nurses' desk. (SNF Nurse) explained that pt was moderately restless today. Pt likely fell asleep due to exhaustion. She did not give any [MEDICATION NAME] (pain medication) or [MEDICATION NAME] (antianxiety medication) today (although they are ordered on routine basis now.) (SNF Nurse) offered explanation for not giving meds, as they are not effective, or may not be necessary. This RN offered education that pt likely has chronic pain due to recent (fracture) of (left) hip, and previous (fracture) of ribs and spine. Routine [MEDICATION NAME] is ordered to maintain comfort. Routine [MEDICATION NAME] added last week in effort to prevent anxiety, which was severe.12/11/19- Received 2nd call from (DON). She reports ongoing restlessness. She requests Hospice CNA focus on providing 1:1 attention. (DON) explained, staff are taking turns to provide 1:1 attention for (patient) . 12/13/19-Problem with [MEDICATION NAME] dosing. While at facility, Nurse (Name) and I checked [MEDICATION NAME] bottle from (Pharmacy). Dropper is small, and maximum dose on dropper is 1 mg (milligram). Nurses report they have been giving 1 mg. Dose ordered is 1ML (milliliter)/(2mg). Consult in person with (DON) . She will request he (Physician) write new order . This is a 50% increase from what she was actually getting. 12/14/19- Visit made to assess patient after anxiety meds ([MEDICATION NAME]) increased. Pt is resting in a High backed w/c (wheelchair) by the nursing desk. Assisted nurse in removing and changing the dressing on both elbows. Open are on the left elbow is 0.75 cm (centimeters) (diameter) with yellow/green drainage. Color of the drainage may be due to the use of [MEDICATION NAME] on the wound.12/26/19- Hospice RN visit. Actively dying. Nonresponsive during assessment and reposition. (Left hip has 2 areas of discoloration, which are violet in color and irregular shapes. (Right) hip normal in color. Coccyx is dark brown discoloration over coccyx area. Small wounds/abrasions of both elbows are covered with dressings.Per facility, (patient) passed away at 12:30 p.m . Death is due to dementia. (sic)

This refers to intakes M 5275, M 7865, and M 6483 Based on interview and record review, the facility failed to implement and revise meaningful person centered care plans to meet the needs of 3 (Resident #4, Resident #7, and Resident #11) from a total sample of 17 residents reviewed for care plans, resulting in the needs of residents not being met. Findings include: Resident #4 Review of a Face Sheet revealed Resident #4 is a [AGE] year old female originally admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #4 had a Brief Interview for Mental Status (BIMS) that indicated she is severely cognitively impaired and required extensive assistance of one person for transfers, limited assistance of one person physical assist for eating. Resident #7 Review of a Face Sheet revealed Resident #7 is a [AGE] year old male originally admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #7 had a Brief Interview for Mental Status (BIMS) indicating he is severely cognitively impaired and is totally dependent on 2 staff for transfers and extensive assistance of 2 staff for toileting. Resident #11 Review of a Face Sheet revealed Resident #11 is a [AGE] year old female originally admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #11 had a Brief Interview for Mental Status (BIMS) indicating she is severely cognitively impaired and required limited assistance of one person for transfers. Resident #4 Review of an unwitnessed incident/accident report for Resident #4 revealed: On 9/9/19 at 6:30 a.m. Resident #4 had an unwitnessed fall Observed resident sitting on buttock in upright position, back against the heater registered and feet towards the entrance of room Bed in low position with mat parallel with the bed. Call light within reach. Stated had to use the restroom Bim score is 99 signifying cognitive impairment. Intervention will offer toileting between 6-7 am as resident allows. (sic) Review of an unwitnessed Bruise incident/accident report dated 9/12/19 at 1:00 p.m. for Resident #4 revealed: Bruise, at approximately 415 a.m. (CNA) reported to (LPN) that (Resident #4) had a swollen eye. (LPN) observed swollen discoloration of left eye into the hair/scalp. Notified Pw Services order from (Physician) to send to (emergency room ). Immediate Action Taken: Upon return from ER a skin assessment completed. Reddish/brown area of discoloration to left forehead measures 10 cm (centimeters) X 11 cm, dark purple bruising with [MEDICAL CONDITION] covering left eyelid, bruise to right side of head into the hairline dark to med purple in color, measures 4 cm X 5 cm reddish/brown area to the left should 8 cm X 4 cm, left forearm small bruise from possible IV site as there is tape residue at that spot. Bil(ateral) lower extremities were free from bruising except for a small healing superficial abrasion less than .5 cm on her left knee, ROM (range of motion) was completed without complaints of discomfort . Notes: 9/12/19 actions: Sent to ER for Evaluation. Upon return completed skin assessment . 9/26/19: Event summary: (Resident #4) was sent to the ER due to bruising on her forehead. When evaluated in the ER, (Resident #4) was diagnosed with [REDACTED]. (Resident #4) has several compression deformities in her [MEDICATION NAME] region from a traumatic injury in 2017. Investigation begun.9/26/19, Investigation 5: This writer (RN S) was notified during report that blood was pooling into right eye, Right eye lids are purple and swollen. (Nursing Home Administrator (NHA)) notified. At 1200 (Resident #4) asked to go to bed. This writer explained that it was almost time for lunch. (Resident #4) did not want lunch, she wanted to lay down. She also denied need to void and did not want to be toileted. She was laid down on middle, scoop mattress, and mattresses laid down on both sides of her. At 1415 (2:15 p.m.) CNA notified this writer that (Resident #4) had crawled off of her mattress, undressed herself and was laying topless with brief applied. Brief dry. No injury noted, and (Resident #4) denied pain. 9/26/19, Conclusion 2: An MRI (magnetic resonance imaging) was ordered and is scheduled to rule out a neuro[DIAGNOSES REDACTED] due to the presentation of racoon eyes, battle sign and other symptoms (sic) Review of Hospital records dated 9/12/19 for Resident #4 revealed: (Emergency Department) Physician note: She was sent with a pre-arrival note, she apparently fell on Monday but was not evaluated in the emergency department. They say she had no bruising over the course of the week but today when they evaluated her, she had multiple bruises that had developed overnight. Today is Thursday. At her baseline she is normally awake and alert, confused and will answer some questions intermittently. Today on arrival she is not answering any questions she will only respond that her name is (Resident #4). On physical exam she does complain of abdominal pain. I did call the nursing home, they sent her in today as she developed bruising from her fall on Monday. They report one fall on Monday. They deny any other falls. They do not know when her last bowel movement was. No recent [MEDICAL CONDITION] activity. No medication changes. they state that she uses a walker to ambulate and has frequent falls. Constitutional: . c-collar in place, she has multiple bruises with different stages on her head and extremities. Ecchymosis with significant [MEDICAL CONDITION] of her left eyelid, she is unable to open her left eye without assistance due to the swelling. Gastrointestinal: . she says ow when I palpate her abdomen diffusely. mild pain with passive ROM (range of motion) of left shoulder . Integumentary . Diffuse ecchymosis on her bilateral forehead, left eye, bilateral shoulders, bilateral hips, right anterior thigh, left forearm, sacrum. Small skin abrasion to her right knee. CT (computerized tomography) spine without contrast, 9/12/19, Impression: 1. Acute minimal compression deformity of the T1 (upper [MEDICATION NAME] vertebrae between the cervical (neck) and the lumbar (lower part of body) vertebral body. No acute cervical fracture identified.Maxillofacial without contrast, Impression: 1. Moderate left periorbital (tissue surrounding the orbit of the eye) soft tissue swelling without fracture. Abdominal and Pelvis with contrast, Impression: Subacute compression fractures of T8 and T12. Healing left superior and inferior pubic rami fractures and left T10 and T11 rib fractures. The healing left rib fractures are new since the 6/25/2019 exam.Emergency Department Course: . Patient has diffuse bruising over her body, it does not appear consistent with one fall that occurred on Monday. She does have a history of recurrent falls per chart review. CT imaging is consistent with a new stable compression fracture at T1 . I did also consult with social workers as the patient has multiple fractures, she has multiple bruises and they started on Adult Protective Services case. They (the Nursing Home) say that they have instituted as many fall precautions as possible for her. Nursing Home states that her urine output has been unchanged. Will hold on antibiotics until culture results. Social work did feel that she was safe for discharge.Microbiology, urine culture and sensitivity collected 9/12/19 and resulted 9/14/19: positive for Escherichia coli (E. coli bacteria) and gram negative Bacilli (bacteria), which indicated a urinary tract infection with two different bacteria. Review of Physician order [REDACTED]. Review of a physician progress notes [REDACTED].#4 revealed: (Resident #4) has not had any further falls since previous fall which resulted in hospitalization . She has not had and [MEDICAL CONDITION] activity. However, she does have very significant bruising around both eyes (raccoon sign) and bruising behind both ears (battle sign). Staff reports she has been very lethargic. I am sending her to the emergency room . CT of multiple locations did show a T4 compression fracture, no other fractures or abnormalities. Summary of Plans: Resident with known head trauma has battle sign and raccoon eyes. Review of a physician progress notes [REDACTED].#4 revealed: . Summary of Plans: Resident overall is declining. She is not nearly as alert as she has been in the past and is more somnolent. She has been seen in the emergency room in hospital on numerous occasions over the pas couple of months. Other than a T4 compression fracture, no other abnormalities have been found on CT. (sic) Review of an other unwitnessed Incident/Accident Report dated 9/26/19 at 21:55 (9:55 p.m.) for Resident #4 revealed: Entered (Resident #4's) room she was laying on mattress between her mattress and roommates' bed with head toward windows, noted an area of discoloration with swelling above the right eye. (Resident #4) has had no recent falls, when up in wheelchair was not visualized hitting head on table. (Resident #4) unable to give description. (Resident #4) could not identify any occurrence or persons related to this bruise. Immediate Action Taken: Assessed noted no other new injures .no witnesses found. Notes: Consult for hematology ordered. 10/9/19 Root cause/conclusion: (Resident #4) did not recall hitting her head and based off of positioning it does not appear the injury would be due to hitting her head. (Resident #4) had a bruise of unknown origin on 09/14/19 that began with unknown swelling. HCP was consulted and ordered a hematology consult. (Resident #4) has an upcoming MRI of the brain on 10/3/19 to r/o (rule out) other possible causes such as myeloma.This incident does not meet reporting requirements for BHCS due to no change in LOC (level of conscience) or injury. (sic) No incident report for 9/14/19 was presented to this surveyor. Review of an Unwitnessed Incident/Accident Report dated 9/29/19 at 7:00 a.m. for Resident #4 revealed: (Resident #4) was observed sitting in her doorway on her buttocks prior to tipping over on her right side by (CNA). (CNA) reported that she had observed (Resident #4) laying in bed a few minutes prior to seeing her in the doorway. (Resident #4) was assisted with toileting at 4 a.m. prior to. When asked what she trying to do, or where she going, she said I don't know. Notes: . 10/9/19, A soft shell protective helmet was ordered for (Resident #4) to wear while she is in bed in the event, she feels the need to express her right to self-determination. Care plan updated to reflect need to toilet (Resident #4) around 7 a.m. if observed awake and restless. this incident does not meet reporting requirements due to no injury or change in condition. (sic) Review of an MRI (magnetic resonance imaging) dated 10/3/19 for Resident #4 revealed: .Woke up 2 weeks ago with eye swollen shut, dementia, evaluate for mass. Findings: There is no diffusion restriction to suggest acute/subacute ischemia. mass effect or midline shift is identified. a small hematoma persists along the right frontal scalp. (sic) Review of an Unwitnessed Incident/Accident Report dated 10/12/19 at 11:10 a.m. for Resident #4 revealed: Registered Nurse (RN) Q was in hall passing medication and (Resident #4) was in the geri chair behind her. (RN Q) heard an increase noise, look behind her and observed (Resident #4) laying on the floor next to the geri chair. Across from day room, (CNA) at giving breakfast back against (Name) door. Chair next to (Resident #4), breakfast tray fell (Resident #4) was facing west. When asked what happened? What were you trying to do? She did not answer my questions. Currently her BIMS score is 99 unable to cooperate with interview. 10/23/19, Conclusion, (Resident #4) continues to be impulsive and self determined. The staff have her at the nurses' station with her breakfast tray on the over bed table. She did not ask for anything and as the nurse walked past (Resident #4) she stood and fell to the floor. Added to the careplan is for (Resident #4) to wear her helmet. this incident does not meet the reporting criteria for BHS. (sic) Review of a physician progress notes [REDACTED].#4) . has had repeated falls recently. Fortunately she has not had any falls in the past couple of weeks. Fall precautions are in place and include a helmet, and her mattresses are on the floor. Physical exam: .Eyes: Ecchymosis (subcutaneous spot of bleeding with diameter larger than 1 centimeter) around bilateral eyes which is improving. No new contusions. Ears/Nose/Mouth/Throat: Periorbital and lid hematoma, post auricular hematomas, hematomas are fading. Summary of Plans: .She has had numerous evaluations both here and in the emergency room in hospital with lab work, CTs (computed tomography), MRI (magnetic resonance imaging). Will ask pharmacy to review medications for possible contributions to fall and appetite. Review of an Unwitnessed Incident/Accident Report dated 11/10/19 at 21:20 (9:20 p.m.) for Resident #4 revealed: . nurse noted (Resident #4) on ground, sitting up, scooting on buttocks from hallway into T.V. room. Restless and crying throughout second shift; going to bed per request, then scooting out of room multiple times, toileted and placed back chair multiple times. Foot rests off of wheelchair. Non-slip grip socks applied. Continuously removing helmet. In hallway adjacent to T.V. room in wheelchair in sight of nurse seconds before the fall. Immediate Action Taken: Alert buy agitated and crying. Unable to clearly communicate. Restless, . Crab walking from hallway . (physician) notified and ordered to send to E.R. for evaluation (related to) pain.Conclusion: (Resident #4) had been Restless and crying throughout second shift; going to bed per request, then scooting out of room multiple times, toileted and placed back in chair multiple times. Footrests off of wheelchair. Non-slip grip socks applied. Continuously removing helmet. In hallway adjacent to T.V. room in wheelchair in sight of nurse seconds before the fall. There are no allegations of abuse or willful neglect. The careplan was followed and despite she fell , this incident does not meet the reporting BHS criteria. (sic) Review of a Physician Assistant Progress Note dated 11/20/19 for Resident #4 revealed: (Resident #4) is seen today because staff state she has been restless. Resident readmitted to the facility yesterday after being hospitalized for [REDACTED]. Resident was having quite a bit of restlessness prior to her hospitalization . Staff state resident has not been showing signs of pain. They state she will stand up from her wheelchair with no facial grimace or other signs of pain. At this time resident is sitting in her wheelchair. She is quite restless, asking to go back to bed. Staff state she will ask to go to bed, then a few minutes later will ask to get back into her wheelchair.Plan: I would recommend a referral to BCS (Behavioral Care Services) for further evaluation. Review of an Other unwitnessed Incident/Accident Report dated 12/4/19 at 13:30 (1:30 p.m.) for Resident #4 revealed: (CNA) was assisting (Resident #4) from her chair and observed an abrasion on each of (Resident #4's) elbows. (Resident #4) had been sitting in the hallway in a geri chair. 12/15/19, Conclusion: A review of the environment and (Resident #4's) movements identified the arm rest on the chair (Resident #4) sits in has vinyl. (Resident #4) uses her elbows to push up from the chair. Careplan was reviewed and updated with dressing that are protective, long sleeves or glen. (Resident #4) frequently removes them, covering for the vinyl geri chair. This event does not meet the reporting criteria of BHS. Review of a Nurse Practitioner Progress Note dated 12/12/19 for Resident #4 revealed: . she does have dementia which appears to be declining. She has multiple episodes of falls with most recent one incurring a left [MEDICAL CONDITION]. Incisions healing now but she is showing restlessness especially at night and evenings and is not on several mattresses on the floor which allows her to roll around. Family has signed onto hospice on for this dramatic decline in status. Today staff is wondering if we can discontinue her [MEDICATION NAME] ([MEDICAL CONDITION] medication) 50 (micrograms) once daily. After review of her chart we are unable to find a recent TSH ([MEDICAL CONDITION] stimulating hormone lab). She is asymptomatic. Summary of Plans: Patient is in steady decline at this time. Obtain TSH to determine need to discontinue the [MEDICATION NAME]. Continue hospice care as this is definitely appropriate. Review of an Unwitnessed Incident/Accident Report dated 12/14/19 at 21:15 (9:15 p.m.) for Resident #4 revealed: Resident was sitting in a chair at the nursing station, in general observance of the staff. She attempted to get out of chair and unable to stand fell to the floor. The staff member was unable to get to (Resident #4's) side to intervene. (Resident #4) was observed lying on her left sided. Conclusion: (Resident #4) has been restless and has been difficult finding a comfort level. She will rest for a short period of time This incident does not meet the BHS reporting criteria. The careplan is updated to reflect the intervention. (sic) (there is no conclusion). Review of physician progress notes [REDACTED].#4 revealed: (Resident #4 is on hospice care. She requires one-on-one due to behaviors consisting of agitation to the point where she will literally climb over the arms of her Geri chair. I discussed her status, behaviors, medications with the staff. We are going to increase her [MEDICATION NAME] ([MEDICATION NAME], a pain medication) to every 2 hours and her [MEDICATION NAME] to every 4 hours. Physical exam: . Resident is sitting in her Geri chair; at this time she is not agitated or combative, but staff is having a difficult time keeping her ears seated in her chair. Summary of Plans: Resident is on hospice care and is becoming agitated and difficult to control or redirect. She has a history of repeated falls with injuries. She has a history of [MEDICAL CONDITION] disorder, not [MEDICAL CONDITION] activity reported recently. It does seem that her agitations is somehow pain related, the exact location of pain or discomfort is not determined. (sic) Review of the Care Plan for Resident #4 revealed a long detailed focus and is unclear what the main focus is and implemented on 7/3/19 and last revised on 12/26/19. Not all interventions were implemented, and some were not person centered to Resident #4's [DIAGNOSES REDACTED]. 7/4/19 Keep in observation while up in wheeled chair. 8/2/19 Place Dycem to wc (wheelchair) cushion to prevent slipping. 7/13/19 remove from dining room when meal is done. 8/2/19 Remove foot pedals from wc when not transporting. Encourage (Resident #4) to remain in common areas, as she allows, to encourage opportunities for supervision. 9/9/19 offer toileting between 6 am and 7 am as resident allows. 9/12/19/ Remove bed and place mattress on the floor. place additional mattress on opposite side of bed continue scoop mattress. Sign on bathroom door to keep it closed to mitigate injury. Bedside dresser moved away from bed. Foam to radiator edges to mitigate injury. 9/26/19 Hematology consult. 9/29/19 if AWAKE AND RESTLESS IN BED GET UP IN W/C AS RESIDENT ALLOWS. 9/30/19 Interdisciplinary team collaboration identified the need for a helmet, order placed. 10/12/19-helmet to be worn in and when up in her chair as resident allows 12/13/19 Sit at residents' side when in w/c. Offer to lay done if shows signs of restlessness such as freq changes of position, eye closing resting head in hands Date Initiated: 07/03/2019. Revision on: 12/26/2019. Cancelled Date: 12/26/2019. (sic) Review of a Progress Note dated 12/26/19 for Resident #4 revealed: Hospice RN visit: (Patient) passed away at 12:30 p.m. In an interview on 1/3/20 at 11:00 a.m., Licensed Practical Nurse (LPN) J reported she finished working the weekend night shift on Monday, September 9th and returned to work on 9/12/19 at 10:00 p.m. when her shift started. LPN J remembers during shift change, the previous nurse from the day shift told her that Resident #4 had a bruise/bump above her left eye on her forehead from a fall she had on Monday, 9/9/19. At 11:00 p.m., LPN J reported she made her rounds on her residents and observed Resident #4 had a puffy eye and was black and blue and almost swollen closed. LPN J proceeded to ask the CNA's (Certified Nursing Assistants) on duty received report from the day shift CNA's as well but did not expect to see Resident #4 with the puffy, black and blue eye either and they had not seen the resident in a couple days either. LPN J reported she started to worry because the report did not match the observation of Resident #4. LPN J reported she started to look at progress notes and other medical records to determine if this incident was something new or not and could not find much documentation. LPN J reported that at 2:00 a.m., Resident #4's eye was getting worse and swollen completely closed. LPN J reported she called the Director of Nursing and sent Resident #4 to the emergency room around 4:00 a.m. In an interview on 1/3/20 at 12:57 p.m., the Director of Nursing (DON) reported Skin Assessments are in the Short Term Care Plans (STCP), not under skin assessments. The DON reported they do not chart when bruises are resolved and once the bruises start to improve, they stop charting them in the STCP. In an interview on 1/6/20 at 2:15 p.m., the Director of Nursing (DON) reported she felt that the acute fracture on 9/12/19 for Resident #4 that was diagnosed at the hospital was an old fracture, even though the hospital called it acute, and felt it was from a couple years ago when a telephone pole fell on the resident. The DON reported Resident #4 had severe bruising, was confused and impulsive. Resident #4 would wear a helmet and then take it off many times. The DON continued to report Resident #4 slept on a mattress on the floor and would scoot on the floor on her bottom. When queried about the 9/12/19 investigation and how it combined with the 9/26/19 investigation, the DON reported she did not know because she did not do the investigation and that the previous administrator who is no longer at the facility did the investigation. The DON and the Corporate Consultant were not able to clearly explain the incidents on 9/9/19, 9/12/19 and the 9/26/19 or the investigation and outcome/conclusion. The three incidents seemed to mesh with each other. This surveyor asked them if they could not understand it, how was this surveyor to understand it. No witness statements from staff noted. When queried about witness statements, the DON reported she puts in the interviews with staff in the reports but does not collect written statements from the staff. This surveyor asked the DON to review and organize the investigations. When queried about documenting the skin conditions in the STCP again, the DON reported they just documents the skin condition until it is no longer acute. When queried about where the details of the skin concerns were such as measurements and locations, the DON just shrugged her shoulders. In an interview on 1/7/20 at 9:30 a.m., the Director of Nursing (DON), Corporate Consultant (CC) C and the Clinical Care Coordinator (CCC) F reported the intervention for Resident #4 on 9/9/19 was to offer toileting between 6:00 a.m. and 7:00 a.m. and did not know why Resident #4 was found on her buttocks on the floor and did not know how she got the bruise on her eye on 9/12/19 at 11:00 p.m. CC C reported the bruise/swelling on Resident #4 was up on her hairline and blood pooled down to her eye and that the ER doctor said the bruise/swelling was from Monday 9/9/19. When queried about the fracture from 9/12/19, CC C reported that anytime anyone goes to the ER they call it an acute fracture. The DON and CC C reported Resident #4 was not a 1:1 supervision and that a 1:1 supervision was not something the facility utilizes. The CC C reported she discontinued the Short Term Care Plan (STCP) skin assessments from 9/26/19 and started to document in the progress notes because she was concerned about Resident #4 and wanted to be the only one to assess her as opposed to several other nurses documenting differently about the same thing and reported she could not write what she wanted in the STCP. CC C reported she felt this was a very strange investigation and wanted to follow up. We reviewed the rest of Resident #4's incident/accident reports and the facility reported as follows: 9/29/19, Resident #4 is to come to the nurses' station when she is awake and restless. 10/12/19, Resident #4 is to wear a helmet and be with staff in the general area for close supervision. 11/10/19, The DON and CC C was not sure what was going on with this investigation, changed their story and said Resident #4 was not on close supervision at this time and they decreased her [MEDICATION NAME] ([MEDICAL CONDITION] medication) due to her grogginess. 12/4/19, they reported Resident #4 just rocked back and forth in her Geri chair which caused abrasions on her elbows. 12/14/19, they reported the unwitnessed fall was witnessed and never put the witness in the report. In an interview on 1/8/20 at 9:33 a.m., Registered Nurse (RN) Q reported Resident #4 required continuous supervision. RN Q was queried about the 10/12/19 incident with Resident #4 and reported she was down the hall with the medication cart and Resident #4's main assigned CNA went on break, which left 2 other CNA's at the desk. The CNA's called RN Q to come back down the hall where Resident #4 was laying on the floor. RN Q asked the CNA's where they were and they told her they were coming down the hall and saw Resident #4 on the floor, but the report said they were at the nurses' station, which is not what the CNA's told her. In an interview on 1/8/20 at 2:24 p.m., Certified Nursing Assistant (CNA) U reported most days the facility will run with four CNA's on her unit, sometimes six CNA's. But when they have 6 CNA's, they decrease in staffing fast. CNA U reported today there was 5 CNA's on her unit and the Terrace unit (dementia unit) was short. So they sent a CNA down to that unit and she later went home with a personal problem. CNA U reported people don't like working the Terrace because some of the residents have behaviors. CNA U reported some staff refuse to work on the Terrace unit and make excuses why they cannot work down there and will say they were not trained to work down there. In an interview on 1/9/20 at 8:45 a.m., the Staff Scheduler (SS) Y reported she scheduled staff according to the census and the matrix. SS Y reported Resident #4 was not a 1:1 supervision but she had extra supervision with a CNA buddy who is more like a talk buddy and is around for patient comfort. (CNA buddy is not a CNA and is not a licensed position.) SS Y reported that the facility does run short of CNA's sometimes and did not know of any staff who did not like working on the Terrace unit and that some staff requested to go to that unit. Review of Hospice documentation revealed Resident #4 admitted to Hospice on 11/27/19. 12/3/19-Anxiety high at start of this visit. Anxiety level 0/10 at end of this nurse visit. (Hospice CNA) provided care with warm soothing approach, which was effective to ease pt's (patient's) restlessness.Received report via phone from (Director of Nursing). Constant restlessness over past 9 hours Staff are providing 1:1 supervision for safety. This RN sat with resident for 45 minutes. Distraction therapy Consult in person with (DON) at end of the visit. Pt is resting peacefully at this time. 12/5/19- Found (Resident #4) seated in broda chair at nurses' desk. Staff are providing close supervision for safety. Right elbow has open are due to sheering. Wound is superficial. Open are is oval in shape, and approx. 2 cm in diameter. Surrounding skin is bright pink and irritated. 12/10/19-Phoned SNF (skilled nursing facility) and spoke with facility nurse . She stated that (Resident #4) is good at the moment. Pt is currently sleeping in recliner chair, near the nurses' desk. (SNF Nurse) explained that pt was moderately restless today. Pt likely fell asleep due to exhaustion. She did not give any [MEDICATION NAME] (pain medication) or [MEDICATION NAME] (antianxiety medication) today (although they are ordered on routine basis now.) (SNF Nurse) offered explanation for not giving meds, as they are not effective, or may not be necessary. This RN offered education that pt likely has chronic pain due to recent (fracture) of (left) hip, and previous (fracture) of ribs and spine. Routine [MEDICATION NAME] is ordered to maintain comfort. Routine [MEDICATION NAME] added last week in effort to prevent anxiety, which was severe.12/11/19- Received 2nd call from (DON). She reports ongoing restlessness. She requests Hospice CNA focus on providing 1:1 attention. (DON) explained, staff are taking turns to provide 1:1 attention for (patient) . 12/13/19-Problem with [MEDICATION NAME] dosing. While at facility, Nurse (Name) and I checked [MEDICATION NAME] bottle from (Pharmacy). Dropper is small, and maximum dose on dropper is 1 mg (milligram). Nurses report they have been giving 1 mg. Dose ordered is 1ML (milliliter)/(2mg). Consult in person with (DON) . She will request he (Physician) write new order . This is a 50% increase from what she was actually getting. 12/14/19- Visit made to assess patient after anxiety meds ([MEDICATION NAME]) increased. Pt is resting in a High backed w/c (wheelchair) by the nursing desk. Assisted nurse in removing and changing the dressing on both elbows. Open are on the left elbow is 0.75 cm (centimeters) (diameter) with yellow/green drainage. Color of the drainage may be due to the use of [MEDICATION NAME] on the wound.12/26/19- Hospice RN visit. Actively dying. Nonresponsive during assessment and reposition. (Left hip has 2 areas of discoloration, which are violet in color and irregular shapes. (Right) hip normal in color. Coccyx is dark brown discoloration over coccyx area. Small wounds/abrasions of both elbows are covered with dressings.Per facility, (patient) passed away at 12:30 p.m . Death is due to dementia. (sic) Resident #7 In an interview on 1/7/20 at 1:06 p.m., Confidential Informant (CI) 1B reported that right before Christmas a Certified Nursing Assistant (CNA) was rough with care with Resident #7 and complained of a CNA, but did not know her name, of pushing him around. CI 1B reported she has seen the CNA at the facility but did request the CNA to not care for Resident #11 again. CI 1B reported she felt that even the CNA intimidated the charge nurse. CI 1B reported one time she came to visit Resident #11 and he was in bed and his pants were ripped and his backside was hanging out. Then the staff just covered him with a clothing protector and the facility still had not replaced his pants. Resident #7 never has his own socks and he is missing his blue blanket. Requested concern forms for Resident #7 on 1/7/20 at approximately 2:00 p.m. and was reported there were no concern forms to this surveyor. During an observation and an interview on 1/7/20 at 3:55 p.m., Certified Nursing Assistant (CNA) H and CNA I wer

Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistance to prevent falls for 2 residents (#11 and #23), of 4 residents reviewed for falls, resulting in Resident #11 falling and Resident #23 falling and sustaining a traumatic hematoma of the forehead and an odontoid fracture (fractured neck). Findings include: Resident #23 Review of Resident #23's face sheet dated 3/11/19 revealed she was an [AGE] year-old admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Resident #23 was not her own responsible party. Review of Resident #23's Minimum Data Set (MDS) nursing assessment tool dated 3/9/18 revealed Resident #23's cognitive pattern assessment score was 2 (moderated impaired -decisions poor, cues/supervision required). Resident #23 required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of the facility five-day report reviewed Certified Nurse Aide (CNA) G found Resident #23 on the floor next to her bed on 3/9/19 at 8:30 PM. CNA G had offered to assist Resident #23 to the toilet (unknown time), and Resident #23 had declined. Resident #23 had suffered 3 lacerations to her forehead and was complaining of neck pain. Staff called Emergency Medical Services (EMS), and Resident #23 went the emergency room (ER) for evaluation. The facility interview of CNA G revealed Resident #23 enjoys spending time in her room and was in her room before shift change. Resident #23 did not want to get up to use the restroom around 4:00 to 4:30 PM. Resident #23 did not want to go to the dining room for dinner. Resident #23 ate 25% to 50% of her dinner, rang her light and said she had completed her meal. Between 6:30 and 7:00 PM CNA G changed Resident #23's gown and took her to the bathroom. At 8:30 PM Resident #23 was sleeping but did not appear to be in a fully asleep so CNA G offered toilet assistance and Resident #23 declined. Review of Resident #23's incident and accident report for 3/9/19 at 21:40 (9:40 PM) revealed Resident #23 had an unwitnessed fall on 3/9/19 at 21:40 (9:40 PM) and was found on her back next to her bed. Resident #23's bed was in low position, locked, call light in reach and grippy socks on (no indication of where Resident #23's wheelchair was lo her indicated or objects Resident #23 could have hit her head on when she sustained 3 lacerations to her head). During an interview with CNA G on 3/20/19 at 2:06 PM, CNA G confirmed the information in the facility interview and said she had rarely worked with Resident #23 before 3/9/19. CNA G stated that she could not recall where Resident #23's wheelchair was when she found Resident #23 on the floor with her face covered in blood. CNA G did recall when she was in the room earlier that night Resident #23's wheelchair was at the end of her bed. CNA G was not aware of any special instruction for fall prevention other than call light in place and grippy socks. CNA G was not aware if Resident #23 had a history of [REDACTED]. CNA G was aware Resident #23 was on 1:1 (one on one) care now and was aware that 1:1 care was not care planned. She knew Resident #23 was on 1:1 care now because the nurse on the unit informed her. During an interview with CNA MM on 03/20/19 at 2:15 PM, CNA MM recalled providing Resident #23 with dinner tray on 3/9/19 prior to her fall, CNA MM was aware Resident #23 attempts to self-transfer at times and did not have any recall were Resident #23's wheelchair was located when she pass the dinner tray. CNA MM said when she provides care for Resident #23 she usually keeps her wheelchair next to her bed. During an interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on 3/20/19 at 2:29 PM, the Surveyor asked if the facility had mapped items in Resident #23's room for location after the fall on 3/9/19. The NHA administrator said no. The Surveyor asked if anyone said anything about where Resident #23's wheelchair was at the time of the fall. The NHA said she interviewed CNA G and CNA G could not remember at the time of the fall but recalled it was at the end of the bed earlier that night. The surveyor told the DON that staff informed her they usually keep the wheelchair next to Resident #23's bed as she has a history of self-transfers and the DON responded that would not be appropriate and it was not care planned. The DON did not locate any information on the care plan for wheelchair location or history of self-transfers. Upon questioning, the DON stated staff did not place the 1:1 on Resident #23's care plan because they were still evaluating her (no indication of when 1:1 started). During a telephone interview with Registered Nurse II on 03/21/19 at 3:19 PM, RN II said she frequently worked on Resident #23's unit and had worked with her the day before she fell on [DATE]. RN II said Resident #23 was usually confused and did not always use her call light. Resident #23 does attempt to self-transfer. When asked what interventions are used to prevent falls she said the wheelchair was not to be in sight when the Resident was in bed, and they check on her more frequently when is agitated (The last known location of Resident #23's wheelchair on 3/9/19 when she fell was in sight at the end of her bed). Resident #23 was observed in bed on 03/19/19 at 11:01 AM with a large bandage on her forehead and neck brace. Resident #23was asked what happened and she said, I was sitting in a box they started beating on me a week ago. Resident #23 had a CNA sitting in a chair next to her, and the CNA said she was providing 1:1 care for Resident #23 today. Resident #11 Review of Resident #11's Minimum Data Set ((MDS) dated [DATE] revealed she was a [AGE] year-old, admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Resident #11 scored 14/15 on the Brief Interview of Mental Status (BIMS), indicating normal cognition. She required limited assistance of one person for bed mobility, transfers, and dressing. She required extensive assistance with toilet use and hygiene. During an interview with Resident #11 on 3/19/19 at 10:48 AM, surveyor asked Resident #23 if she had any falls in the last year. Resident #11 said yes, and it was because she was left on the toilet too long and her butt hurt. Resident #11 said she needs help, and staff leaves her on the toilet too long and when they do not answer the call light, and she was in pain, and she took herself off the toilet. During an interview with the Director of Nursing (DON) on 3/21/19 at 10:48 AM, the DON acknowledged some of Resident #11's falls have been off the toilet and the care plan documented Resident #11 can be left alone on the toilet (no time frames recorded to indicate how long resident #11 can tolerate being on that toilet). When asked whether or not the DON had any information like computerized call light times to indicate how long Resident #11 had to wait for help after putting on her call light and the DON said she did not have any information on that. Review of Resident #11's incident report dated 5/4/18 at 20:00 (8:00 PM) documented Resident #11 had an unwitnessed fall in the bathroom. Resident #11 had her call light on for assistance. Resident #11 self-transferred and fell . The report did not indicate how long resident #11 had been in the bathroom or how long she had to wait for assistance after turning on her call light. Review of Resident #11's incident report dated 8/4/18 documented Resident #11 fell attempting to self-transfer to the toilet. There was no documentation showing the last time staff assisted the resident to the bathroom. Review of Resident #11's incident report dated 8/4/18 documented Resident #11 fell attempting to self-transfer to the toilet. There was no documentation showing the last time staff assisted the resident to the bathroom. Review of Resident #11's incident report dated 10/16/18 documented that the resident had an unwitnessed fall off the toilet. Resident #11 was reaching for the toilet paper. There was no record of how long the resident sat waiting on the toilet. Review of Resident #11's incident report dated 1/27/19 at 11:56 AM, documented Resident #11 fell trying to get her wheelchair to go to the bathroom. There was no indication of when staff last assisted Resident #11 to the toilet. Review of Resident #11's incident report dated 2/6/19 documented that Resident #11 had an unwitnessed fall in the bathroom. Staff last assisted Resident #11 to the bathroom approximately 10 minutes before the fall. Review of Resident #11's Activity of Daily Living (ADL) care plan dated initiated 3/28/18 documented, ABLE TO LEAVE ON TOILET: do not leave naked on the toilet and perform care am care. Have her complete remaining care after transferring to w/c (wheelchair). Revision on 3/21/19 (after an interview with the DON). Review of Resident #11's Activity of Daily Living (ADL) care plan dated initiated 3/28/18 under falls there was no indication how long Resident #11 was able to tolerate sitting on the toilet.

Based on observation, interview and record review, the facility failed to ensure that 2 Residents (Resident #65 and #72) received adequate care to prevent the development of pressure ulcers, resulting in Resident #65 developing 2 unstageable pressure ulcers on the resident's heals, and Resident #72 developing a pressure ulcer on the coccyx and a wound on to the right foot. Findings Include: Resident #65 According to the facility face sheet dated 3/20/19 at 9:35 AM, Resident #65 was readmitted into the facility on [DATE] with the Diagnosis: [REDACTED]. On 3/20/19 at 11:20 AM, Resident #65 was observed laying in his bed sleeping with pressure relieving boots on both feet. On 03/20/19 at 11:27 AM, review of the Residents 60-day Minimum Data Set (MDS), dated [DATE] - section M revealed that Resident #65 had two, Stage 2 Pressure Ulcers that were facility acquired. Review of Resident # 65's skin care plan revealed the following interventions: Heels elevated in bed as tolerated; Inspect heels with care and report to charge nurse as indicated. Revision on: 04/04/2018 Skin: Apply barrier cream with incontinence care prn; inspect skin with bathing and care; report impaired skin integrity to charge nurse. 2/6/19 skin prep to bilateral heels every shift, Wear grippy socks and pillow boots except during transfer as (Name of Resident) allows prop heels on pillows while in bed. APM Mattress Revision on 2/11/19. Review of Resident #65's skin assessment revealed that on 1/30/19 at 10:12, Skin is dry, pink, warm, and intact. Resident is free of [MEDICAL CONDITION], openness, and skin markings to body folds, bony prominences, and high-pressure areas. Patient fistula to left forearm thrill palpated bruit auscultated. No distal [MEDICAL CONDITION]. Heels firm. Pedal pulses present and palpable. Skin turgor is non-tenting. Review of 2/6/19 at 09:41 AM Skin Assessment revealed, Shower and skin assessment not done related power outage until almost 9:00 am. During an interview on 3/21/19 at 1:26 PM, Resident #65's Daughter CC stated the staff did not notify her about the skin injury. I found out when I went into the facility, and my dad was crying uncontrollably. He stated that he had blisters on his heels and that feet hurt, so I put on a pair of gloves on and looked, and sure enough, he had ugly looking blisters. Resident #65's Daughter CC stated, she was blindsided, and would have appreciated a call in a situation like this from the facility but stated she has had to get after them before this for not contacting her about issues regarding her father's care. Resident #65's Daughter CC stated the nurse informed her that her dad got his blisters as a result of him rubbing his feet against the sheet. On 3/20/19 at 8:55 AM, during an interview with Registered Nurse and Clinical Care Coordinator (RNCCC) J revealed that the Physician Assistant was going to check the Resident #65's wounds on his heels and while they performed the daily dressing change today. RNCCC J revealed that the PA comes in once a week to monitor the progress of the resident's Pressure Ulcers on his heels. On 3/20/19 at 2:33 PM, Resident #65's feet were observed touching the wood board at the end of the bed and had to be boosted up in the bed by Physician Assistant (PA-C) Y and RNCCC J, before being able to access the resident's feet. Both of R#65's ankles had a bandage on them with a 3/19 date. During the observation of R#65's pressure ulcer care, PA-C Y revealed that the resident's Pressure Ulcers were unstageable due to the amount of eschar and they had been since they developed back on 2/6/18. Review of the first progress note dated 2/6/19 from PA-C Y revealed the following: (Name of Resident #65) is seen today because staff state he has wounds on both of his heels. The wounds were noted today. Further review of the progress note reflected the skin, Area of dark red nonblanchable discoloration to the right heel measuring 2.0 x 4.7 cm, no open areas, no drainage, area is tender to palpation. Wound on left heel measures 3.0 x 4.0 cm, the periphery of the wound has dark red discoloration, the middle aspect of the wound is a bulbous lesion with pink tissue visible to the base except at the most central area where there is a small drainage, the area is tender to palpation. Assessment: Pressure injury of right heel, unstageable, Pressure injury of left heel, unstageable. Review of the progress note dated 2/13/19 from PA-C Y revealed the following: Wound on the right heel measures 2.5 x 4.0 cm, the wound is 75% eschar and 25% slough, there is scant serous drainage with no odor, the wound edges are intact and attached. Wound on the left heel measures 1.1 x 1.7 cm, the wound base is 60% eschar and 40% [MEDICATION NAME] tissue, there is no drainage and no odor, the edges are intact and attached Review of the progress note dated 2/27/19 from PA-C Y revealed the following: Wound on the right heel measures 2.5 x 4.0 cm, the wound is 70% eschar and 30% [MEDICATION NAME] tissue, there is no drainage and no odor, the wound edges are intact and attached. Wound on the left heel measures 2.3 x 3.2 cm, the wound base is 100% eschar, there is no drainage and no odor, the edges are intact and attached. Review of the progress note dated 3/06/19 from PA-C Y revealed the following: Wound on the right heel measures 1.6 x 2.8 cm, the wound is 100% eschar, there is peeling, thickened [MEDICATION NAME] tissue around the eschar, there is no drainage and no odor, the wound edges are intact and attached. Wound on left heel measures 1.0 x 1.7 cm, the wound base is 50% eschar and 50% [MEDICATION NAME] tissue, there is no drainage and no odor, the wound edges are intact and attached Assessment: Pressure injury of right heel, unstageable. Pressure injury of left heel, unstageable. [MEDICAL CONDITIONS]. Review of the progress note dated 3/13/19 from PA-C Y revealed the following: Wound on the right heel measures 1.9 x 3.0 cm, the wound base is 100% eschar, there is no drainage and no odor, the wound edges are intact and attached. Wound on left heel measures 1.0 x 1.2 cm, the wound base is 100% eschar, and there is no drainage and no odor, the wound edges are intact and attached. Assessment: Pressure injury of right heel, unstageable. Pressure injury of left heel, unstageable. [MEDICAL CONDITIONS]. During an interview on 03/21/19 at 02:25 PM, RNCCC J, revealed that she had been responsible for putting R#65's pressure ulcer under section M. Risk for unhealed Pressure Ulcer. RNCCCJ stated, I documented them as a stage 2 pressure ulcer because they were blisters when they first started out. I did not go with the PA's [DIAGNOSES REDACTED]. RNCCC J stated she coded the MDS section on (MONTH) 18th. On 3/22/19 at 09:54 AM, during an interview with the Director of Nursing (DON) stated that if you have fluid stage blister it would be considered a stage 2. The DON further expressed that, at this point, I would call R#65's pressure ulcers as an unstageable PU. When asked why the pressure ulcers were entered as stage 2 on the MDS when the PA diagnosed R #65's wounds as unstageable, the DON stated, I don't think it was an intention to miss lead, I just don't think (name of) RNCCC J had all the information. The DON confirmed that the PA and RNCCC J are certified to do wound care and do weekly rounds on the wounds together. During the interview, the DON revealed that for root cause analysis they used boots on the resident's feet, then looked at nutrition, sleeping surface, and at positioning. I think the resident's sores were not noticed right away because of the color of the resident's skin. It takes a little longer to see a change in the skin tone and the redness. Resident #72 Review of Resident #72's face sheet dated 3/19/19 revealed Resident #72 was a [AGE] year-old admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Resident #72 had a family member listed as her guardian. During an interview with Resident #72's guardian on 3/20/19 at 10:55 a.m., Resident #72's guardian said Resident #72 had a history of [REDACTED]. Resident #72's guardian said she visited frequently and found Resident #72 soaked in urine up in her wheelchair (provided dated and time-stamped photographs after making this statement that showed Resident #72 in the facility in her wheelchair with clothing in her groin area wet). Resident #72's guardian said that because of the discomfort Resident #72 would slide out of her wheelchair and continue to get skin break down. Resident #72's Guardian reported that the facility did not keep Resident #72's feet protected, and she developed a sore on her foot that required surgical treatment. During an interview with the Director of Nursing (DON) on 3/20/19 at 3:00 p.m., the DON confirmed Resident #72 had a history of [REDACTED].#72 was again noted to have skin break down on 3/7/19 on the coccyx that was a stage II ulcer measuring 2.3 cm x 1.2 cm x 0.2. The DON was unable to find a care plan that indicated any pressure relief schedule. The DON was unable to locate any tissue tolerance assessment that would show how often Resident #72 required pressure relief. The DON confirmed that Resident #72 had slid out of her wheelchair on more than one occasion since admission. The DON denied any knowledge of Resident #72's daughter finding the resident soaked in urine. The skin assessments and skin care plan requested by surveyor were not received by staff before exit. Review of Resident #72's physician progress notes [REDACTED]. Ulcer to the coccyx area measures 0.8 x 0.5 x 0.1 cm, and the wound base is 100% [MEDICATION NAME] tissue, there is scant serous drainage with no odor, wound edges are intact and attached with some maceration. [DIAGNOSES REDACTED]. Resident #72's wound tracking note dated 3/7/19 at 9:17 a.m., documented , Coccyx 2.3 cm x 1.2 cm x 0.1 cm stage 100% [MEDICATION NAME] tissue. Resident #72's wound tracking note dated 3/7/19 at 9:13 a.m. documented, Right later foot, 1.4 cm x 1.2 cm x 0.3 cm 10% slough, 80% granulation tissue, scant serous drainage. Resident #72 was observed in bed on 03/22/19 at 12:45 p.m. having her foot dressing changed. Resident #72 did complain of right foot pain during the dressing change but was cooperative and pleasant with staff throughout the treatment. Review of Resident #72's incident reported dated 5/4/18 at 20:30 (8:30 PM) documented Resident #72, was observed sleeping in a wheelchair with a Hoyer sling underneath and had slid down in wheelchair which was going to make it more difficult to get into bed. (Initials of aide) was with resident while other aide was getting Hoyer lift from hallway and resident proceeded to slide down lift pad while other aide had just arrived in room. Resident (#72) was gently guided to floor. The conclusion documented that Resident #72 had been up before 9:00 a.m. and had most likely become tired and fell asleep in her wheelchair before the staff got her in bed. There was no indication resident #72 had been out of her chair all day or how many attempts were made to get her out of her wheelchair. Review of Resident #72's incident report dated 9/2/18 at 18:30 (6:30 PM) documented Resident #73 had an unwitnessed fall while sitting in the dining room. A family member in the room reported that Resident #73 slid out of her wheelchair. (There was no indication how long Resident #72 had been up in the chair on 9/2/18 before she slid to the floor.) Review of Resident #72 incident report dated 3/1/19 documented, (Name of resident) was sitting in the lobby. She had finished eating and was placed there for socialization with other residents. Her chair was sitting up a 90-degree angle. She slid forward out of the wheelchair on to the foot pedals of the wheelchair. (There was no indication how long Resident #72 had been up in her wheelchair before sliding out of her wheelchair).

Based on observation, interview, and record review, the facility failed to implement interventions to prevent a fall for three residents (Residents #27, 35 and 66), and failed to thoroughly investigate a fall for two residents to prevent further falls (Resident #35 and 66), the facility also failed to assure the footwear worn was in good repair for one resident to prevent falls (Resident #1) and failed to assure that foot rests on wheelchairs were implemented during propelling to prevent injury for two residents (Resident #27 and 37), out of 7 residents reviewed for falls and 4 residents reviewed for accidents, from a total sample of 31 residents resulting, in a fall with a fracture, a fall with a [MEDICAL CONDITION], ongoing falls, the potential for a fall and the potential for serious injury while being propelled in a wheelchair. Findings include: Resident #35 According to a facility face sheet dated 11/30/17 at 4:51 PM, Resident #35 was an [AGE] year old female admitted into the facility on [DATE] and readmitted to the facility on [DATE] with the cumulative Diagnoses: [REDACTED]. During an interview with Daughter J on 11/28/17 03:16 PM, Resident #35 she revealed that Resident #35 fell here month after she arrived. The resident had gotten up to go to the bathroom and used bedside table to walk. Resident #35 rebroke her right hip. Review of a progress note dated 10/4/2017 7:37 PM, Note Text: At 1900, Certified Nurses Aid (CNA) QQ notified Registered Nurse (RN) RR that (name of Resident #35) had fallen in her bathroom, in between toilet and far wall. She was sitting up, leaning with back against toilet and to the right, where she had a previous [MEDICAL CONDITION]. Wheel chair was near her bed, on the other side of the room, but bed side table was near entrance to bathroom. CNA QQ had asked at 1830 (6:30 PM) if (name of Resident #35) needed anything, and declined. CNA SS checked on Resident 335 at 1850, and (name of Resident #35) was still sitting beside her bed in her wheelchair. (Name of Resident) said she was getting up to take herself to the bathroom. Denied hitting head, but complained of 10/10 pain, pointing towards her right leg/hip. Alert and oriented to self. PERRLA (pupils equal, round and react to light and accommodation). Denied hitting head. 10/10 pain in right leg/hip area. BP elevated- 189/62, P 89, T 98.2, RR 22. (Name of Resident #35) was unable to move lower right extremity at all by herself. Resident was not moved out of position to further assess. Notified (name of facility physician)- ordered to be sent to (name of local acute care emergency room ). Notified emergency contact #1 (daughter), and notified DON B. EMS (Emergency Medical Services) transferred to (name of local acute care hospital). During an interview on 12/01/17 9:50 AM with DON B and Unit Manager (UM) S regarding Resident #35's fall with a right femur (upper leg) refracture following repair of a right [MEDICAL CONDITION], revealed Resident #35's was in the assisted living next door. Resident #35 was considered a fall risk upon admission. DON B stated there was no key to the numbers on the fall assessment but confirmed that Resident #35 was a fall risk. The initial intervention to prevent falls upon admission for Resident #35 was non skid foot wear and Also the intervention of bedside commode. Resident #35 was found on the floor of her bathroom on 10/4/17 at 7:00 PM. The fall was unwitnessed. DON B stated at 6:30 PM a CNA went in to get meal tray asked Resident #35 if she needed to toilet and and resident said, no. As the CNA went out Resident #35's door and down hall, she heard yelling. Another CNA went into room Resident #35's room and this observation was made 10 min before Resident #35's fall. DON B stated Resident #35 was sitting in wheelchair, by bed, reading a letter. DON B confirmed that Resident #35 was not independent with walking, assistance was needed. No call light was on. Resident #35 was confused upon admission, and is more confused recently. DON B stated there was a sign on door of the bathroom to have staff assist. DON B confirms that there was no mention of if door to bathroom was open or closed so Resident #35 could read or see the sign. Resident #35 said she got up to go to bathroom. The resident told staff, I've been walking fine all day. and had been walking with therapy being praised by therapy and family. Resident #35 apparently used over bed table like a walker to go to the bathroom. The overbed table was found at the entrance of the bathroom door. DON B was asked what does fall risk 8 mean? DON B confirmed the incident report does not mention if she was wearing non skid footwear. DON B stated the bedside commode was not next to where she was seated in her wheelchair. According to a document for Resident #35 dated 10/5/17 (no time noted) titled History and Physical from a local acute care facility reflected, This is an [AGE] year old female who approximately 1 month ago sustained an intertrochanteric right [MEDICAL CONDITION] which underwent antegrade intramedullary nailing (by name of physician) on 9/3/17. Then , just last evening she states that she fell while at home. She was unable to give me any details regarding the fall: however she states that I think I tripped. No one was around during the fall and she lives alone per the patient. She had a mid and distal thigh pain (upper and lower) was ultimately brought to (name of acute care facility) where plain films (X-rays) demonstrated a distal femur fracture (large leg/thigh bone, lower portion broken) . This document reflected that Resident #35 required another surgery to repair this break. Resident #66 According to a facility face sheet dated 11/30/17 at 4:59 PM, Resident #66 was a [AGE] year old male admitted into the facility on [DATE] with the Diagnoses: [REDACTED]. During a review of an Minimum Data Set assessment for Resident #66 reviewed on 11/30/17 02:31 PM with an Assessment Reference Date (ARD) of 11/22/17 Bed mobility: self-performance Limited assistance, Bed mobility: support provided One person physical assist Transfer: self-performance Extensive assistance Transfer: support provided Two+ persons physical assist, Walk in room: self-performance Activity did not occur Walk in room: support provided ADL (activity of daily living) activity itself did not occur, Walk in corridor: self-performance Activity did not occur Walk in corridor: support provided ADL activity itself did not occur, Locomotion on unit: self-performance Limited assistance Locomotion on unit: support provided One person physical assist, Locomotion off unit: self-performance Extensive assistance, Locomotion off unit: support provided One person physical assist, Dressing: self-performance Extensive assistance Dressing: support provided One person physical assist Eating: self-performance Supervision Eating: support provided Setup help only Toilet use: self-performance Extensive assistance Toilet use: support provided Two+ persons physical assist, Personal hygiene: self-performance Extensive assistance Personal hygiene: support provided One person physical assist. always incontinent of bowel and bladder. Brief interview for mental status (BIMS) Summary Score 06 indicating Resident #66 was cognitively impaired. On 12/04/17 at 11:15 AM, a record review of incident reports was completed for Resident #66 regarding falls. 1) According to an incident report dated 10/20/17 at 6:45 AM, Resident #66 was observed supine (lying face up) on the floor mat beside his bed. His feet were toward the bed and his head was toward the window. I was trying to get there. Resident #66 stated. Resident #66 was in his room in his wheelchair. Per his care plan Resident #66 was not to be left in his room, in his wheelchair. No new intervention was developed and added to the care plan to prevent another fall. 2) Review of a incident report dated 11/15/17 at 10:00 PM for Resident #66 was completed. Resident #66 was observed kneeling next to the bed with blood on the right side of his face. Resident #66 stated, oh h***, I don't know what happened. The Certified Nurses Aid (CNA) had stepped out to get new sheets. There is no documentation of if Resident #66 was in his bed or in his wheelchair before the fall. Resident #66 was placed on 15 minute checks and neurological checks to assess for a head injury. 11/6/17 in the morning, there was a change in Resident #66's level of consciousness (L(NAME)) and he was transported to the hospital around 9:00 AM. Resident #66 had experienced a small [MEDICAL CONDITION] (cut) over the right supraorbital (above the eye, eyebrow) arch as a result of the fall. UTI (urinary tract infection) and abscess (a fluid filled area under the skin) in the right posterior thigh that the emergency room resident incised (opened) and drained and may have contributed to the resident change in L(NAME). During an interview on 12/05/17 at 09:44 AM with DON B, she revealed no fall risk scores are done. DON B stated upon admission the facility was aware Resident #66 was a fall risk. Resident 366 had experienced a broken hip before admission. A review of incident reports was completed with DON B and UM S: 1) 10/20/17 6:45 AM Resident #66 had experienced an unwitnessed fall. DON B was asked what intervention had been developed after a root cause analysis of the fall. DON B revealed night shift CNA W found the resident incontinent in bed, CNA W cleaned him up and put the resident in the wheelchair and continued with his rounds. The door of the resident's bathroom was open and the night CNA was in the resident room adjoining the bathroom. The night CNA said she was leaving but CNA W didn't hear this. DON B confirmed that Resident #66 was to be out of his room when he was in his wheel chair. DON B stated CNA JJ was educated about reviewing care plans. There was no new intervention developed due to root cause analysis added to the care plan. The care plan had not been followed. 2) 11/5/17 at 10:00 PM, Resident #70 experienced an unwitnessed fall. DON B was not able to ascertain from the incident report if the resident was in bed or in his wheel chair. UM S stated Resident #66 was usually in bed early and at 10:00 PM resident was probably in bed. DON B reviewed progress notes in the electronic medical records and could not find if Resident #66 was in bed or in his wheelchair before his fall. The facility new intervention to prevent a fall was to move Resident #66 to bed 1 and have medications reviewed. UM S stated all of the sudden on 11/5/17 in the morning there was a change in his normal self, more lethargic. Neurological checks were ok UM S stated, but Resident #66 was sent to the hospital. No sutures were needed for laceration on his eyebrow. Steri strips were used to close the laceration. The investigation into Resident #66's fall was not through in defining where Resident #66 was before he fell to develop a root cause analysis and develop interventions to prevent another fall due to that root cause analysis. According to a facility policy titled, Fall Risk assessment dated ,[DATE] reflected, it is the policy of this facility to manage risk factors that may contribute to falls through identification and implementation of corresponding interventions .Procedure: 1) A fall risk assessment will be completed on admission, with the comprehensive assessment, quarterly assessment, significant change assessment and prn (as needed) post fall. 2) If the resident has had any falls within the last 30 days the resident will be considered at higher risks for falls . 4) A review of the circumstances surrounding past falls will be considered when establishing preventative interventions. 5) A plan for prevention will be instituted and included in the resident's comprehensive plan of care. According to The Fundamentals of Nursing (Potter and Perry, 6th Edition, 2005), Nursing interventions are prioritized to provide safe and efficient care .The client's mobility problem is an obvious priority because of its influence on skin integrity and risks for falls. The nurse plans individualized interventions based on the severity of risk factors and the client's developmental stage, level of health, lifestyle, and culture .nursing interventions are directed toward maintaining the client's safety in all types of settings. Nursing measures for providing a safe environment include health promotion, developmental interventions, and environmental interventions .To promote an individual's health, it is necessary for the individual to be in a safe environment to practice a life style that minimizes risk of injury. According to Geriatric Nursing Protocols for Best Practice, Second Edition. (2003) Springer Series on Geriatric Nursing, The majority of all falls that occur in the acute care setting involve individuals over the age of 65 .The increased risk of falling in older adults may be due to a number of age-related changes, such as altered visual acuity, decreased reaction time, decreased balance and muscle strength .Nurses in the acute care setting have the most contact with patients and are in key positions to evaluate these individuals and implement interventions to decrease falls .A prior history of falls is frequently cited in the literature as a risk factor contributing to falls. Once an older adult has fallen, there is a significant increased risk that he or she will fall again under similar circumstances .a major concern with a fall is the subsequent fear of falling that can occur. Fear of falling has been cited as one of the most serious and debilitating psychological consequences of a fall .The intention of a fall prevention program in acute care is not only to prevent falls, but also to provide patients with nursing care that focuses on improving and maintaining the functional ability of older patients. Resident #37 According to a facility electronic medical record face sheet, Resident #37 was a [AGE] year old female admitted into the facility on [DATE] with the Diagnoses: [REDACTED]. An observation was made on 11/10/17 at 12:24 PM, Resident #37 was being propelled in a wheelchair into the main dining room by her Son R, without foot rests on the wheelchair. He was propelling quickly. Resident #37's feet were tucked under the wheelchair. Resident #37 was wearing canvas pull on shoes. An observation was made on 11/30/17 01:05 PM Resident #37 was being propelled in wheelchair without foot rests on the wheelchair by Son R down the Harbor Hall. On 12/01/17 at 09:43 AM During an interview with DON Band UM S, DON revealed staff can walk along side where you can see the residents feet while pulling the wheelchair without foot rests. DON B stated they have educated Son R regarding the use of wheelchair foot rests with his mother in the past. A policy was requested regarding wheelchair propelling from DON B. DON B stated it was a standard of practice to stand to next to the wheelchair when you assist, not propel. DON B stated if staff, family, etc. are propelling a wheelchair, the expectation is foot rests be on the wheelchair. During an interview on 12/05/17 01:28 PM with DON B she stated there is no facility policy regarding wheel chair transport. DON B provided 3 incident reports for Resident #37 and there were none regarding injury during propelling the wheelchair or foot injury for Resident #37. Resident #1 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) score indicated Resident #1 was severely cognitively impaired and required limited to extensive assistance for activities of daily life (ADLs). Specifically for the ADL of dressing he was coded as needing the extensive assistance of 2 or more people. On 11/28/17 at 10:13 AM, Resident #1 was observed in hallway, self-propelling in his wheelchair. The tread on the left heel of his shoe was observed to be flopping off. On 12/01/17 09:35 AM, Resident # 1 was observed in the hallway, self-propelling in his wheelchair. Resident #1 was viewed to be in a different pair of shoes than on 11/28/17 and the soles of both shoes were observed to be not attached in the toe areas. An interview was completed on 12/01/17 at 10:24 AM, with Certified Nursing Assistant (CNA) HH. CNA HH stated that Resident #1 needed total assist for dressing, 2 people for transfer. CNA HH confirmed she had helped dress Resident #1 today. She stated that she noticed his shoes were in disrepair, and didn't know if it had previously been reported since he is not a resident she is typically assigned to. CNA HH stated that social services would be notified if clothing was noted to be in disrepair. An interview was completed on 12/01/17 at 10:38 AM with Social Services Coordinator (SSC) X., and she stated that if staff noticed clothing is in disrepair they would inform her and she would talk to the family. She stated she had a report on Tuesday this week that some of Resident #1's clothes were in disrepair. SSC X stated the CNA who reported this didn't specify what was in disrepair. SSC X stated that if items were in poor repair would think that they would dress him in other things as Resident #1 does have an extensive closet. SSC X was informed about the concerns observed related to two different pairs of shoes and stated she would follow up on it. On 12/01/17 at 12:05 PM, Resident #1 was viewed self-propelling in his wheelchair in the hall. He was viewed to be wearing shoes that were in good condition. A review of the documented care plan provided by the facility on 12/1/2017 revealed the fall intervention of less bulky shoes when in w/c (wheelchair) to prevent falls. The document further revealed under the focus area of potential risk for falls the intervention of review and modify environmental factors as indicated. Resident #27 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #27 was a [AGE] year old female initially admitted to the facility on [DATE] and most recently admitted on [DATE] with [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) score indicated Resident #27 was severely cognitively impaired and required limited to extensive assistance for activities of daily life (ADLs). Specifically for the ADL of dressing she was coded as needing the extensive assistance of 2 or more people, for locomotion in and off the unit she was coded as needing 1 person limited assistance. On 11/28/17 at 11:51 AM, CNA L was observed propelling Resident #27 in her wheelchair into the Terrace dining area with no foot rests on the wheelchair. CNA L was observed a few minutes later propelling Resident #27 in her wheelchair up to table without foot rests. Resident #27 was viewed to be in slipper socks. On 11/30/17 at 04:01 PM, Resident #27 was viewed to be asleep in the hall across from the nurse's station sitting in a wheelchair. Registered Nurse (RN) P was viewed to step behind the wheelchair and move Resident #27. No foot pedals observed to be on the wheelchair at this time. Resident #27 was viewed to be in slipper socks. On 12/01/17 at 09:40 AM, Resident #27 was observed to be asleep in the Terrace dining room. She had slipper socks on and was sitting in her wheelchair with no foot rests. Staff were viewed entering and exiting the dining room intermittently while Resident #27 was observed in the dining area for approximately 20 minutes. No staff were observed in the Terrace dining area for approximately 5 minutes at a time on two occasions during this observation. Staff were also not present at the nurse's station which is separated by the Terrace dining area by a window during these times. On 12/01/17 at 10:27 AM, an interview was completed with CNA HH. She stated 3rd shift gets Resident #27 up and dressed, and she not sure they if can put shoes on due to swelling. CNA HH stated Resident #27 has foot rests on at times but they are taken off when she is seated only has them on during transfers. CNA HH said that Resident #27 has a history of the rests getting in the way and are risk of injury for her when just seated. A review of an incident report dated 11/24/2017 revealed At 1345 Beth was being toileted and her grippie socks were soiled .removed her socks and there was a scab and some fresh blood on the tip of her second toe of the right foot .family was asked to bring shoes. A review of the documented care plan provided by the facility on 12/1/2017 revealed (Resident #27) to wear shoes or slippers/shoes as she allows when out of bed. Also noted as a FALL INTERVENTION is not to be in the terrace room unattended. On 12/01/17 at 11:55 AM, an interview was completed with Social Services Coordinator (SSC) X. She stated that per the electronic medical record, nursing called on shoes for Resident #27. SSC X stated she will follow up with the family. On 12/01/17 at 12:04 PM, SSC X stated they do have shoes for Resident #27 and they were observed in SSC X's hand, she stated they will put be put on after Resident #27 finishes lunch. According to Mosby's Textbook for Long-Term Care Nursing Assistants 7th edition, in the Wheelchair Safety Section, Make sure the person's feet are on the foot plates (wheelchair foot pedals) before moving the chair. The person's feet must not touch or drag on the floor when the chair is moving. Never push a person in a wheelchair without feet resting on the footplates (foot pedals).

Based on observation, interviews, and record review, the facility failed to prevent pressure ulcers and follow physician orders to treat pressure ulcers for 1 Resident (#3), of 4 Residents reviewed for pressure ulcers of a total sample of 15 Residents, resulting in Resident #3 developing an unstageable pressure ulcer on his left heel and not having any signs of healing. Findings: Resident #3 Review of Resident #3's face sheet revealed he was a [AGE] year old male admitted on [DATE] and had the following diagnoses, [MEDICAL CONDITION] Disease (affects blood circulation in the brain ), Dysphagia (swallowing problems) and Dementia. Resident #3 was not his own responsible party. Review of Resident #3's Minimum Data Set (MDS) revealed is cognition was moderately impaired. On 10-7-14 at 3:40 p.m. Resident #3 was observed in bed in his room. Resident #3 had his left heel pressing into his mattress (no pressure relief) and his heel protector with no straps sitting on the bed next to his left leg. Resident #3 had socks on both feet. Licensed Practical Nurse (LPN) "C" removed Resident #3 socks and Resident #3 had a dressing dated 10-7-14 on his left heel. LPN "C" removed the dressing on Resident #3's left heel and there was a dark dry spot approximately 2 cm round on the dressing. Resident #3 heal was completely black with an area approximately 2 cm round with an obvious break in the skin and indented. During an interview with Clinical Care Coordinator, Registered Nurse (RN) "G" on 10-7-14 at 3:45 p.m. this Surveyor pointed out to RN "G" that Resident #3 was not using his heel protector in bed and his left heel was pressing into the mattress and RN "G" said she was aware Resident #3 removes his heel protector. This Surveyor asked RN "G" what other ways the facility had attempted to do pressure relief with Resident #3 and RN "G" said she was not aware of any other pressure relief attempted. Review of the wound tracking progress note for Resident #3 dated 9-4-14 at 3:22 p.m., signed by RN "G" documented Resident #3 had a 2 cm x 2 cm x 0.02 cm stage II ulcer on the left medical heel and the surrounding area was discolored and measured 5 cm x 4 cm. "Treatment: santyl to eschar area cover with 2 x 2 and Alyven (a type of dressing) heel wrap with Kerlix." Review of the wound tracking progress note dated 9-15-14 at 12:52 p.m. signed by RN "G" documented, "Length: 2 cm, Width :2 cm, Depth: no depth, Stage unstageable, Treatment: skin prep to area, Other: scabbed area coving old stage II located on his left inner heel." Review of the wound tracking progress note dated 9-30-14 at 10:44 a.m. signed by RN "G" documented, "Length: 2 cm, Width: 2 cm, Depth: no depth, Stage: dry scabbed area unstageable, Treatment: skin prep every shift, Other: location on left inner heel." Review of the wound tracking progress note dated 10-7-14 at 10:44 a.m., signed by RN "G" documented, "Length: 2 cm, Width: 2 cm, Depth: no depth, Stage: unstageable covered with eschar, Treatment: skin prep cover with [MEDICATION NAME] (a type of dressing) every day, Other: located on left inner heel." During an interview with RN "G" on 10-8-14 at 9:30 a.m., this Surveyor asked to review Resident # 3's skin care plan for intervention related to his pressure ulcer on his left heel, RN "G" provided an altered mobility and Activities of Daily Living care plan. This Surveyor asked what preventative measures were in place for Resident #3 prior to his pressure ulcer and RN "G" was unable to locate any pressure ulcer prevention interventions. This Surveyor asked what preventive measures were placed for Resident # 3 after it was discovered he had a pressure ulcer on his left heel. RN "G" pointed to the intervention, "Prevlon boot on when in bed heels to be floated while in bed as he will tolerate with a start date of 10-3-14 (one month after the ulcer was discover on Resident #3's left heel). Resident #3 was observed on 10-9-14 at 2:00 p.m. sitting in the hall in his wheel chair with socks (no shoes on both feet) Resident #3 had his right leg crossing his left leg (all weight from both legs pushing down on left leg) and his left foot flat on the floor (no pressure relief for left heel with non stageable pressure ulcer). Certified Nurses Aide (CNA) "F" was providing 1:1 care for Resident #3 and this Surveyor asked if they was anything care planned for Resident #3 to have pressure relief on his left heel when he was up in his wheel chair and CNA "F" said, "no". During an interview with RN "G" on 10-9-14 at 2:10 p.m., this Surveyor asked what pressure relieving measures were in place for Resident #3 when he was up in his wheel chair and RN "G" they did not have anything that was safe for Resident #3 when he was up in his wheel chair for pressure relief because he was impulsive and could stand and fall. This Surveyor reminded RN "G" the facility had Resident #3 on 1:1 care. RN "G" then instructed CNA "F" to put Resident #3's Prevlon boot on his left foot while up in his wheel chair. CNA "F" took the Prevlon boot from Resident #3's room and placed it on Resident #3's left foot. The boot was loose fit due to the straps were removed and stuffing was protruding where the straps had been, this Surveyor asked if the boot should have straps and CNA "F" said "yes" and sent another CNA to get another boot. CNA "F" applied another boot with straps. CNA "F" asked Resident #3 if the boot felt all right and Resident #3 said, "it is fine". Review of Resident #3's physician orders revealed he had an order dated, 9-4-14, Stage II left medial heel apply Santyl gel to eschar cover with 2 x 2 Alyven heel wrap with Kerlix, change every day, no shoes. Review of Resident #3's order Recap Report, revealed an order for [REDACTED]. Review of Resident #3's order Recap Report, revealed an order for [REDACTED]. Review of Resident #3's order Recap Report, revealed an order for [REDACTED]. Review of Resident #3's treatment record revealed a hand written treatment record that documented Resident #3 received Santyl gel, a 2 x 2 Alyven dressing to his Left heel on 9-4-14, 9-6-14 through 9-10-14 one time a day. After the 9-10-14 a line was drawn and "dc" (discontinue) was written. The treatment for 9-5-14 was not documented. (the order was for this treatment to be provided daily through 9-15-14). Another hand written treatment for [REDACTED]. No physician order was found to support this treatment. Another treatment was documented as, "apply skin prep to left heel every shift, leave open to air" showed the treatment was started on 9-12-14 and treatments were left blank (not given) on the 2-10 shift on 9-13-14, 9-14-14, 9-19-14, 9-21-14, 9-23-14 through 9-25-14. The treatments were left blank (not given) 6-2 shift on 9-21-14 and 9-25-14. The treatment for 10-6 shift was left blank (not given) for 9-24-14. (total of 9 missing treatments with no documentation of the resident refusing or why the treatments were held) No physician order was found to support this treatment until 9-15-14 and that order ended on 10-2-14 and restarted on 10-6-14 for one time a day only. During an interview with RN "G" on 10-9-14 at 2:10 p.m. this Surveyor asked RN "G" to review the treatment record and physician orders for Resident #3's wound. RN "G" could not locate any orders for several treatments and had no explanation for the missing treatments. This Surveyor asked who monitors that the nurses are following doctors orders and providing treatments as ordered and RN "G" indicated it was her job but she has not had time since the facility started the electronic record for treatments and orders.

This citation pertains to intake MI 032. Based on observation, interviews, and record review, the facility failed to revise the plan of care to ensure the safety of 1 (#101) of 5 sampled residents from a total sample of 5 residents, resulting in Resident #101 sustaining a second fracture of her right thumb. Findings include: Review of Resident #101's medical record revealed an [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her minimum data set ((MDS) dated [DATE] indicated she was severely impaired with cognitive skills, had physically and verbally aggressive behaviors, required extensive assistance of two persons for transfers, extensive assistance of one person for ambulation and hygiene. Review of incident report for Resident #101 dated 7/25/13 revealed Resident #101 was found with her right thumb bruised and swollen and an Xray was obtained. Review of incident report dated 8/9/13 for Resident #101 dated 8/9/13 indicated a re-check Xray completed and results identified a new fracture at the base of the proximal phalanx of the right thumb. Radiology report for Resident #101's right hand, dated 7/25/13 revealed a conclusion of a [MEDICAL CONDITION] phalanx of the thumb (bone in the end of the thumb), nondisplaced. The conclusion indicated the fracture was likely acute and Resident #101's bones were demineralized. A follow-up radiology report for Resident #101's right hand revealed conclusion #1: no evidence of healing of the distal phalanx [MEDICAL CONDITION] thumb. The fracture fragment appears slightly more displaced. Conclusion #2: There is a new fracture at the base of the proximal phalanx of the thumb (bone of the thumb near the hand). Resident #101's psychosocial plan of care dated 3/19/12 indicated she was at risk for distress related to cognitive impairment, [MEDICAL CONDITION] and behavioral disturbances. Resident #101's plan of care indicated she exhibited impulsive, restless behaviors with poor safety awareness, along with verbal and physical and verbal aggression toward staff. Resident #101's plan of care also stated Resident #101 will look in rooms, through open doors for her husband, become upset, tearful and angry when she can't find him. Interventions listed on the plan of care were dated 3/7/12, through 3/19/12 with one intervention of 15 minute checks through the end of the shift on 5/10/13. There were no new interventions listed after the fracture occurred to Resident #101's right thumb on 7/25/13, or the new fracture on 8/9/13. Resident #101's activities of daily living plan of care dated 2/16/12 listed interventions were updated on 6/11/13 to include tab alarm when in wheelchair, 7/26/13 to include right hand splint on at all times. One undated intervention listed indicated Resident #101 was to be taken to quiet place for prayer and meditation during times of increased agitation. Short term care plan for Resident #101 indicated a [MEDICAL CONDITION] thumb with approaches to include right hand spika splint and assess circulation and surrounding skin. In an interview on 8/21/13 at 3:30 PM, RN Clinical Care Coordinator #4 (CCC#4) stated she felt Resident #101 may have injured her right hand grabbing and pulling at the hand rail in the hall while attempting to pull herself down the hall. CCC #4 stated no changes had been made to Resident #101's plan of care to prevent further fractures or injuries since she had fractured her thumb on 7/25/13. CCC #4 stated no changes had been made to Resident #101's plan of care to prevent additional injury since the second fracture on 8/9/13. In an interview on 8/22/13 at 11:05 am, Director of Nursing #2 (DON #2) stated Resident #101 grabbed and pulled herself around using the side rails and Resident #101 also pulled on sinks and grabbed bars in the bathrooms, and would also pull on doorknobs. DON #2 stated during Resident #101's movements she had enough impact to cause a fracture and that Resident #101's physician had stated Resident #101 could easily have a fracture from minimal amount of impact. The surveyor asked DON #2, since Resident #101 had sustained the first fracture on 7/25/13 and the physician had informed staff of the ability for Resident #101 to easily sustain fractures, what changes had been made to Resident #101's plan of care to prevent further injuries and DON #2 stated just the splint. DON #2 stated the splint and orthopedic physician consult were the only changes made to Resident #101's plan of care after the second fracture sustained by Resident #101 on 8/9/13. During an observation on 8/21/13 at 1:00 PM, the surveyor observed Resident #101 as she attempted to open the shower room door near the Terrace Unit nurse's station by pulling on the handle of the door with her right (fractured) hand.. The door had a lever type handle on it, and was locked with a code type device. Resident #101 was unable to get the door open and appeared to become agitated. Resident #101 shook the handle of the door up and down aggressively with her right hand for approximately 3 minutes. Multiple facility staff members walked by but did not assist Resident #101 or attempt to calm her. Resident #101 then aggressively grabbed the side rail in the hall and pulled herself quickly to the nurse's desk, used her feet to get around multiple residents, then grabbed the hand rail again and pulled herself down to the end of the hall. In an interview on 8/22/13 at 2:30 PM, CNA #14 stated Resident #101 would wander into other Resident rooms by grabbing their doors and forcing them open. CNA #14 stated other residents would become angry with Resident #101 because she would get into their things, and they would strike out at Resident #101. CNA #14 stated if staff try to redirect Resident #101 she would become combative, striking out at staff. In an interview on 8/22/13 at 3:00 PM, CNA #15 stated Resident #101 was violent. CNA #15 stated when staff attempted to provide PM care, Resident #101 would hit staff, kick staff and spit at staff. In an interview on 8/22/13 at 3:20 PM, LPN #5 stated Resident #101 hit at things and people if she was in a bad mood or angry. LPN #5 stated if Resident #101 was trying to get through a doorway and couldn't get though she would hit the door frame. LPN #5 stated she did not think Resident #101 broke her thumb on the hand rail but that she injured herself by hitting something. #

This citation pertains to intake #MI 773 Based on observation, interview and record review, the facility failed to provide the necessary assistance with eating for 1 of 6 sampled residents (Resident #102), from a total of 6 sampled residents, resulting in an Immediate Jeopardy when Resident #102 was served a meal in bed, which included a hot beverage and was not provided assistance with eating. Resident #102 spilled thickened hot cocoa onto her leg and sustained a second degree burn on her left outer thigh. This deficient practice places all residents in the facility, who require assistance with eating and drink hot liquids, at risk for serious harm, injury, and/or death. Findings include: Review of the Face Sheet revealed Resident #102 was admitted to the facility on [DATE] and was a [AGE] year old woman with [DIAGNOSES REDACTED]. Review of physician orders for Resident #102, dated 12-10-12, documented, "change liquids to nectar thicken until pneumonia resolves." Review of nursing progress notes for Resident #102, dated 12-13-12, 10:00 PM, revealed Resident #102 had spilled hot cocoa on her left thigh and had a red area measuring 13 cm by 11 cm. Review of the Incident/Accident Report for Resident #102, dated, 12-13-12 at 7:30 PM and signed by Licensed Practical Nurse (LPN) #1, revealed that Resident #102 was found in bed with food and liquid spilled on her when LPN #1 was going to give her medications and Certified Nurse's Aide (CNA) #1 was changing Resident #102. The report indicated that LPN #1 and CNA #1 noticed a red area on Resident #102's left thigh that measured 13 cm by 11 cm. Review of the facility 24 hour report, dated 12-13-12, revealed that on 12/13/12 at 6:00 PM, CNA #2 gave Resident #102 her dinner tray while she laid in bed and there was thickened hot chocolate on the tray. The report indicated CNA #1 and LPN #1 went into Resident #102's room on 12-13-12 at approximately 7:20 PM where LPN #1 observed a burn like area on Resident #102's left thigh and placed a cool washcloth on the area. In an interview on 12/18/12 at 2:20 PM, CNA #3 said she cared for Resident #102 on 12-13-12 and that Resident #102 did not eat breakfast or lunch that day and was unable to hold a cup independently to drink. CNA #3 said at shift change (approximately 2:00 PM) she told CNA #1 that Resident #102 was a total feed. In an interview on 12/18/12 at 3:25 PM, CNA #1 said she was told at shift change that Resident #102 required total care for feeding, but that she did not tell CNA #2, who passed Resident #102's dinner tray, that Resident #102 was a total feed. During a telephone interview, on 12-20-12 at 10:05 AM, CNA #2 stated she did not get the report that Resident #102 was a total feed. CNA #2 said she provided Resident #102 her food tray with thickened hot cocoa at 6:00 PM and did not remove the lid from the hot cocoa (increases risk of spill when resident removes and holds temperature longer). CNA #2 said she observed Resident #102 start eating and did not recall where the hot cocoa was placed on the tray when she left the room. In an interview on 12/18/12 at 2:00 PM, LPN #3 said she cared for Resident #102 on 12-13-12 during the 1st shift. LPN #3 reported that at shift change (approximately 2:00), she told LPN #1 that Resident #102 did not eat on her shift and required total assistance to drink. In an interview on 12/18/12 at 2:55 PM, LPN #1 said she had received report for Resident #102 that she needed assistance to drink and had not eaten. LPN #1 reported when she was making walking rounds, she saw Resident #102 sitting up in bed drinking thickened water and thought she was doing better. LPN #1 stated she unaware why CNA #1 did not pass Resident #102's dinner tray that night, but that CNA #2 would not have known Resident #102 was a total feed if CNA #1 did not tell her. Review of the physician progress notes [REDACTED]. The physician documented that Resident #102 had a second-degree burn on her leg. Review of the Treatment Administration Record (TAR) dated 12/14/12 at 8:30 AM revealed Resident #102 had an irregular stage II blister, hyper pigmented (darkened) area on her left thigh that measured 13 cm x 11 cm. The TAR had documentation indicating, "Slough tissue noted. " During an observation of Resident #102 in bed on 12-18-12 at 10:02 AM, Resident #102 attempted to respond to the nurses questions (her mouth moved), but no sound was heard. The nurse removed the dressing on Resident #102's left outer thigh and an irregular open area was observed. The outer edges were red and the major portion of the wound was a round area at the distal end (toward the knee) that was covered with cream color slough. The area appeared to be 13 cm x 11 cm. During an interview with Occupational Therapist (OT) #1 on 12-18-12 at 10:30 AM, OT #1 reviewed Resident #102 hot liquid assessment, dated, 9-26-12, the document revealed Resident #102 was evaluated to be safe with a standard mug with no lid. The Surveyor asked if this assessment was done in bed and OT #1 said it was not. The Surveyor asked if OT #1 would say that Resident #102 was safe in bed with hot liquids from this assessment and OT #1 said she could not say Resident #102 would be safe in bed with hot liquids based on this assessment. During an interview with Physical Therapist (PT) #1 on 12-18-12 at 10:50 AM, PT #1 explained she did Resident #102's hot liquid assessment on 9-26-12 and had never observed her with hot liquids in bed. PT #1 could not say that Resident #102 would have been safe in bed with a hot liquid based on that assessment. During a telephone interview with Dietary Aide (DA) #1 on 12-19-12 at 10:55 AM, DA #1 explained all hot liquids she prepared on 12-13-12 for the evening meal had temperatures taken and they were between 130-140 degrees Fahrenheit. DA #1 did not recall making Resident #102's thickened hot cocoa, but said all staff are trained to keep the temperature between 130 degrees Farenheit and 140 degrees Farenheit. DA #2 was observed on 12-19-12 in the kitchen preparing hot liquids for Residents. DA #2 took the temperature of the hot water in a large insulated container and it was 150 degrees Fahrenheit. DA #2 cooled the water with ice to a temperature of 140 degree Farenheit before making thick hot cocoa with the water. DA #3 was observed on 12-19-12 pouring hot coffee from a thermos into individual mugs for Residents in the main dining room. The Surveyor requested that DA #3 take the temperature of the first mug. It was 140 degrees Farenheit. Review of the facility policy and procedure for Hot liquids/Microwave Use revealed in item #4 that a 3rd degree burn can occur from contact with a liquid at 140 degree Fahrenheit in 5 seconds, can occur from a hot liquid at 133 degree Fahrenheit in 16 seconds, and can occur from a 120 degree Fahrenheit contact in 3 minutes. In an interview on 12/18/12 at 4:00 PM, Director of Nursing (DON) #1 and Administrator #1 reported there were no policies or procedures prior to Resident #102's burn, for assessing a resident's ability to eat and drink after a significant change of condition. On 12-19-12 at 11:55 AM, Administrator #1 was notified of the Immediate Jeopardy that was identified on 12-19-12 and began on 12/13/12 when Resident #102, who had a known significant change in physical status (recent diagnosed of pneumonia with physical decline), was found in bed by Certified Nurse Aide (CNA) #1 on 12-13-12 at 7:20 PM with a reddened area on her left outer thigh after a thickened hot cocoa spill. On 12-20-12 the Surveyor confirmed that the facility implemented the following to remove the Immediate Jeopardy. 1. The Physician was notified of the burn and orders were received on 12/13/12 at 7:30 PM. 2. On 12/13/12, first aid was provided to the burn area. 3. On 12/13/12, the Director of Health Care Services was notified and began interviewing staff and taking statements. 4. On 12/13/12, education was initiated to nursing staff regarding serving hot liquids. 9 CNA's, 3 LPN's and 1 RN received education at that time. Any nursing staffs not yet educated will not be allowed to work until education has been completed. 5. On 12/13/12 , Resident #102 had a short term care plan developed regarding care of the burn. 6. On 12/13/12, Resident #102's care plan was updated that no hot liquids were to be provide with out direct supervision. 7. On 12/14/12, the policy and procedure for monitoring temperatures of hot liquids was reviewed and dietary staff were observed to be following the policy correctly. 8. On 12/14/12, 74 of 74 residents were reviewed regarding their choice to eat in bed. Three residents care plans were reviewed and updated. On 12/14/12, the three residents who choose to eat in bed are provided with thermal lined clothing protectors for meals, and are supervised with hot liquids. 9. As of 12/19/12, 72 of 72 residents were reassessed by the nursing management for significant change which may impact their ability to manage hot liquids; none were identified. 10. Between 12/13/12 and 12/19/12, 49 of 78 nursing staff employees were in-serviced regarding hot liquid safety and 3 of 23 dietary staff were in-serviced. The reaming employees have been notified per telephone that the in-service must be completed prior to their next scheduled shift. Although the Immediate Jeopardy was removed on 12/19/12, the facility remained out of compliance at a scope of isolated and a severity of harm with potential for more than minimal harm that is not Immediate Jeopardy due to all staff had not yet been in-serviced and sustained compliance had not been verified by the State Agency. ( )

THIS CITATION PERTAINS TO MI 925 BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE THE NECESSARY CARE AND SERVICES TO ATTAIN THE HIGHEST PRACTICABLE PHYSICAL WELL-BEING ( IMMEDIATELY PERFORM CARDIOPULMONARY RESUSCITATION (CPR) AND INITIATE EMERGENCY MEDICAL SERVICES (EMS) ON A FULL CODE RESIDENT) IN 1 OF 8 SAMPLED RESIDENTS (RESIDENT #501) WHO HAD ADVANCED DIRECTIVES FOR CPR IN PLACE, FROM A TOTAL SAMPLE OF 10 RESIDENTS, RESULTING IN AN IMMEDIATE JEOPARDY WHEN RESIDENT #501, WHO WAS A FULL CODE, WAS FOUND UNRESPONSIVE ON [DATE] AT 12:15 AM AND CPR AND THE EMS RESPONSE SYSTEM WERE NOT INITIATED BY FACILITY STAFF. THIS DEFICIENT PRACTICE PLACED 30 RESIDENTS, IDENTIFIED AS BEING FULL CODE, AT RISK FOR SERIOUS HARM, INJURY, AND/OR DEATH. FINDINGS INCLUDE: REVIEW OF THE FACE SHEET AND THE MINIMUM DATA SET (MDS), dated [DATE], REVEALED RESIDENT #501 WAS A [AGE] year OLD MALE admitted to the facility on [DATE]. THE MDS INDICATED RESIDENT #501 HAD NO COGNITIVE IMPAIRMENTS (BRIEF INTERVIEW MENTAL STATUS WAS 15), WAS ABLE TO MAKE HIMSELF UNDERSTOOD, HAD CLEAR COMPREHENSION, AND REQUIRED TOTAL ASSISTANCE WITH TRANSFERS, DRESSING, HYGIENE, AND BATHING. REVIEW OF A HOSPITAL RECORD, DATED [DATE], REVEALED RESIDENT #501'S [DIAGNOSES REDACTED]. REVIEW OF THE RESIDENT PREFERRED TREATMENT OPTION FORM, DATED [DATE], REVEALED RESIDENT #501 HAD CHOSEN THE OPTION OF STATUS 4. THE FORM REVEALED STATUS 4 WAS WAS WHEN "THE RESIDENT IS TO BE hospitalized for [REDACTED]. SUCH TREATMENTS ARE TO INCLUDE RESUSCITATION AND SURGICAL INTERVENTION." THE FORM REVEALED RESIDENT #501 WANTED FULL CARDIOPULMONARY RESUSCITATION (CPR). REVIEW OF THE FACILITY'S ADVANCED DIRECTIVE POLICY AND PROCEDURE, DATED ,[DATE] AND REVISED ,[DATE], REVEALED THE FOLLOWING: "IT IS THE POLICY OF THIS FACILITY TO HONOR THE HEALTH CARE DECISIONS MADE BY RESIDENTS WITH DECISION MAKING CAPACITY OR THE RESIDENTS' LEGAL REPRESENTATIVE IF THE RESIDENT HAS BEEN DEEMED NOT CAPABLE OF MAKING DECISIONS." THE FORM REVEALED RESIDENT #501 WANTED FULL CARDIOPULMONARY RESUSCITATION (CPR). THE FORM WAS SIGNED BY RESIDENT #501, TWO WITNESSES, AND A PHYSICIAN. REVIEW OF A PHYSICIAN'S DETERMINATION OF DECISION MAKING CAPABILITY FORM, DATED [DATE] AND SIGNED BY A PHYSICIAN, REVEALED RESIDENT #501 WAS CAPABLE OF PARTICIPATING IN MEDICAL TREATMENT DECISIONS IN AN INTERVIEW ON [DATE] AT 12:05 PM, CERTIFIED NURSING ASSISTANT (CNA) #3 REPORTED ON [DATE] AT APPROXIMATELY 10:15 PM AND ON [DATE] AT APPROXIMATELY 11:15 PM, HE ANSWERED RESIDENT #501'S CALL LIGHT AND OBSERVED RESIDENT #501 IN BED AND IN NO DISTRESS. CNA #3 REPORTED ON [DATE] AT APPROXIMATELY 11:30 PM, HE TOLD RN #4 THAT HE WAS GOING TO WAIT TO TAKE RESIDENT #501'S VITAL SIGNS BECAUSE RESIDENT #501 WAS SLEEPING AND RESIDENT #501 NORMALLY DID NOT GET MUCH SLEEP. CNA #3 REPORTED ON [DATE] AT 12:15 AM, HE WENT INTO RESIDENT #501'S ROOM TO CHECK ON HIM AND HE WAS NOT MOVING. CNA #3 REPORTED HE TOUCHED RESIDENT #501'S HANDS AND THEY WERE COLD. CNA #3 REPORTED RESIDENT #501 WAS NOT BREATHING AND HE COULD NOT PALPATE A PULSE. CNA #3 REPORTED THAT HE IMMEDIATELY NOTIFIED RN #4. CNA #3 STATED HE CHECKED RESIDENT #501'S BLOOD PRESSURE WITH AN AUTOMATED BLOOD PRESSURE MACHINE AND RESIDENT #501 DID NOT HAVE A BLOOD PRESSURE. CNA #3 REPORTED THAT RN #4 STATED THAT RESIDENT #501 HAD EXPIRED AND RN #4 INSTRUCTED CNA #3 TO DO POST-MORTEM CARE FOR RESIDENT #501. IN AN INTERVIEW ON [DATE] AT 12:50 PM, CNA #5 REPORTED ON [DATE] AT APPROXIMATELY 10:15 PM, SHE HEARD RESIDENT #501'S BELL, BUT SHE DID NOT ANSWER HIS BELL BECAUSE ANOTHER CNA ANSWERED IT. CNA #5 REPORTED ON [DATE] AT APPROXIMATELY 12:30 AM, CNA #3 CALLED HER INTO RESIDENT #501'S ROOM AND SHE OBSERVED RESIDENT #501 WAS NOT BREATHING AND WAS COLD TO THE TOUCH. CNA #5 REPORTED CNA #3 IMMEDIATELY NOTIFIED RN #4 AND RN #4, CALLED OUT RESIDENT #501'S NAME, CHECKED HIS VITAL SIGNS, AND FELT HIS BODY. CNA #5 REPORTED RN #4 STATED HE WAS GONE AND ASKED HER AND CNA #3 TO CLEAN HIM UP. IN AN INTERVIEW ON [DATE] AT 9:40 AM, RN #4 REPORTED ON [DATE] AT APPROXIMATELY 11:30 PM, RESIDENT #501 WAS OBSERVED TO BE SLEEPING IN BED, WAS BREATHING, HAD HIS OXYGEN ON, THE HEAD OF HIS BED WAS ELEVATED 45 DEGREES, AND HIS TUBE FEEDING WAS RUNNING. RN #4 REPORTED SHE ASKED RESIDENT #501 IF HE WANTED TYLENOL (PAIN MEDICATION) TO WHICH RESIDENT #501 STATED, "NO, I'M TIRED." RN #4 REPORTED ON [DATE] AT 12:36 AM, CNA #3 AND CNA #5 NOTIFIED HER TO COME AND LOOK AT RESIDENT #501. RN #4 REPORTED RESIDENT #501 HAD A "DEATH LOOK." RN #4 REPORTED "DEATH LOOK" MEANT THAT RESIDENT #501 APPEARED WHITE IN COLOR, WAS STARTING TO GET STIFF, AND WAS COLD TO TOUCH ON HIS HANDS, FACE, AND LEGS. RN #4 REPORTED SHE CHECKED BOTH RADIAL AND CAROTID PULSES ON RESIDENT #501 AND NONE WERE PALPATED. RN #4 REPORTED SHE THEN CHECKED RESIDENT #501'S APICAL PULSE AND LUNG SOUNDS WITH A STETHOSCOPE AND NONE WERE AUSCULTATED. RN #4 REPORTED SHE OBSERVED RESPIRATIONS WERE ABSENT FOR RESIDENT #501. RN #4 REPORTED SHE INSTRUCTED CNA #3 TO TAKE RESIDENT #501'S BLOOD PRESSURE AND NONE WAS PRESENT. RN #4 STATED THAT SHE DID THINK ABOUT PERFORMING CPR BUT, WITH HER EXPERIENCE, RN #4 FELT HE WAS GONE FOR TOO LONG DUE TO THE WAY HE LOOKED, THE ABSENCE OF VITAL SIGNS, AND HIS SKIN TONE. RN #4 REPORTED SHE THOUGHT TRYING TO PERFORM CPR WOULD NOT SAVE HIM. RN #4 REPORTED SHE WAS AWARE THAT RESIDENT #501 WAS A FULL CODE BECAUSE SHE HAD TO BRING THE CRASH CART DOWN TO RESIDENT #501'S ROOM IN THE PAST DUE TO [MEDICAL CONDITION], BUT THAT HE HAD VITAL SIGNS THEN. RN #4 STATED "I SHOULD HAVE INITIATED CPR AND CALLED 911." RN #4 REPORTED SHE PRONOUNCED RESIDENT #501 DEAD ON [DATE] AT 12:36 AM, NOTIFIED THE PHYSICIAN ON [DATE] AT 1:00 AM, AND RECEIVED ORDERS TO RELEASE RESIDENT #501'S BODY TO THE FUNERAL HOME. PER THE AMERICAN RED CROSS FIRST AID AND SAFETY HANDBOOK (2011), "A PERSON IN [MEDICAL CONDITION] IS UNCONSCIOUS, NOT BREATHING AND HAS NO HEARTBEAT." THE HANDBOOK REVEALED THAT A PERSON IN [MEDICAL CONDITION] WILL HAVE THE GREATEST CHANCE OF SURVIVAL IF THERE IS 1) EARLY ACCESS TO THE EMERGENCY MEDICAL SERVICES (EMS) SYSTEM, 2) EARLY CPR, 3) EARLY DEFIBRILLATION, AND 4) EARLY ADVANCED MEDICAL CARE. THE HANDBOOK ALSO REVEALED THAT "WITHOUT EARLY CPR AND DEFIBRILLATION, THE CHANCE FOR SURVIVAL IS GREATLY REDUCED." THE HANDBOOK MENTIONED THAT "ONCE YOU BEGIN CPR, DO NOT STOP EXCEPT IN ONE OF THESE SITUATIONS....ANOTHER TRAINED RESPONDER OR EMS PERSONNEL TAKE OVER." REVIEW OF AN INTERDISCIPLINARY NOTE, DATED [DATE] AT 2:30 AM AND WRITTEN BY REGISTERED NURSE (RN) #4, REVEALED RESIDENT #501 WAS IN RESPIRATORY DISTRESS AND RN #4 NOTIFIED THE PHYSICIAN AND EMERGENCY MEDICAL SERVICES (EMS) AND RESIDENT #501 WAS SENT TO THE HOSPITAL. REVIEW OF AN INTERDISCIPLINARY NOTE, DATED [DATE] AT 1:30 AM AND WRITTEN BY RN #4, REVEALED RESIDENT #501 WAS IN RESPIRATORY DISTRESS AND RN #4 NOTIFIED THE PHYSICIAN AND EMS AND RESIDENT #501 WAS SENT TO THE HOSPITAL. ON [DATE] AT 2:27 PM, THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY THAT BEGAN ON [DATE], AND WAS IDENTIFIED ON [DATE], WHEN THE FACILITY FAILED TO PROVIDE CARDIOPULMONARY RESUSCITATION (CPR) AND INITIATE EMERGENCY MEDICAL SERVICES FOR RESIDENT #501 WHO WAS FOUND UNRESPONSIVE ON [DATE] AT 12:15 AM. ON [DATE], THIS SURVEYOR CONFIRMED THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. ON [DATE], AN AD HOC MEETING OF THE QUALITY ASSURANCE COMMITTEE MET TO REVIEW THE INCIDENT AND PROVIDE RECOMMENDATIONS TO PREVENT FURTHER OCCURRENCES. THESE INCLUDED: A.) SUSPENSION OF THE LICENSED NURSE INVOLVED IN THE INCIDENT UNTIL THE INVESTIGATION WAS COMPLETED B.) REVIEW OF THE ADVANCED DIRECTIVES POLICY AND PROCEDURE (UPDATED [DATE]) C.) IDENTIFICATION OF 30 LIKE RESIDENTS WITH FULL CODE STATUS OUT OF A TOTAL OF 77 RESIDENTS AND REVIEW OF THEIR "PREFERRED TREATMENT OPTION" DOCUMENT. 2. ON [DATE], INITIATION OF EDUCATION REGARDING "EXECUTING ADVANCED DIRECTIVES" FOR ALL LICENSED STAFF. THE EDUCATION INCLUDED THAT THE NURSE WAS TO FOLLOW THE RESIDENT'S WRITTEN DIRECTIVES FOR ADMINISTRATION OF CPR WHEN A FULL CODE STATUS WAS DESIRED AND THAT RESUSCITATION MAY ONLY DISCONTINUED BY A physician's orders [REDACTED]. 3. ON [DATE], 3 NURSES OUT OF 17 NURSES RECEIVED FACE TO FACE EDUCATION. ON [DATE], 1 NURSE OUT OF 17 RECEIVED FACE TO FACE EDUCATION. BY [DATE], ALL 17 NURSES RECEIVED FACE TO FACE EDUCATION. ONE NURSE, WHO WAS HIRED AND BEGAN CLINICAL ORIENTATION ON [DATE], RECEIVED THE EDUCATION ON THAT SAME DAY. 4. BEGINNING [DATE], NEWLY HIRED NURSES WOULD RECEIVE THIS EDUCATION DURING ORIENTATION. 5. ON [DATE], 10 OF 17 NURSES WERE NOTED TO HAVE CURRENT BASIC LIFE SUPPORT CERTIFICATION. THE DIRECTOR OF HEALTH CARE SERVICES ALSO HAD CURRENT BASIC LIFE SUPPORT CERTIFICATION. ALTHOUGH IMMEDIATE JEOPARDY WAS REMOVED ON [DATE], THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF ISOLATED AND A SEVERITY OF NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY DUE TO ALL EDUCATION HAD NOT YET BEEN COMPLETED AND SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY. ( )

This citation pertains to MI 613. Based on observation, interview, and record review the facility failed to provide adequate supervision during a mechanical lift in 1 of 2 residents (#105), from a total sample of 6 residents, resulting in a broken hip. Findings include: Review of the Face Sheet revealed Resident #105 was a [AGE] year old female admitted to the facility on [DATE]. Review of the physician progress notes [REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #105 was rarely/never understood and was severely cognitively impaired. The MDS revealed Resident #105 required total dependence of two plus persons for transfer and bed mobility and used a wheelchair for locomotion on the unit. The MDS revealed Resident #105 had impairment of both lower extremities on both sides. Review of the Interdisciplinary Rehabilitation Screen dated 1/19/12 revealed Resident #105 was "total assist" for bed mobility, "mechanical lift x 2 assist" for "change in transfer" and "mobility" was "mechanical lift x 2 assist." Review of Care Plan "Potential for altered mobility and Activities of Daily Living (ADL)'s related to decreased cognition and mobility" dated 2/17/12 revealed Resident #105 was a "transfer mechanical lift follow guide for sling type and loop attachment." Review of the Nurses Interdisciplinary Notes dated 4/3/12 at 6:25 A.M. revealed Resident #105 had her "left forehead bumped on Hoyer lift during transfer from bed into geri chair". The Nurses Note revealed Resident #105's physician and son were contacted and Resident #105 had a raised area to her left forehead. The report dated 4/20/12 revealed Resident #105's Certified Nurse Aide (CNA) had reported Resident #105's right leg was easier to move. Resident #105's legs had "always been very stiff". Resident #105's physician was notified and an X-ray ordered, the results were a right hip fracture. Resident #105 was sent to the hospital for evaluation and treatment. The Facility Incident Report revealed that on 4/10/12 Resident #105 was "transferred from bed to geri chair when suddenly twitched, as the CNA was positioning (Resident #105) over the geri chair" and "lowered to the floor while still in the sling by staff but sustained no injury." Review of Mechanical Lift Guidance dated 12/6/11 revealed Resident #105 was "Minimum of 2 person assist". Review of the Mechanical Lift Guidance dated 12/6/11 revealed Resident #105's "general procedure" was to "4. Both assistance (sic) should verify loop attachment and security as the lift rises", "5. One assistant operates and steers the lift", "6. The second assistant is responsible for safely guiding the resident and sling into the desired transfer location". In an interview on 4/23/12 at 9:37 A.M., Director of Nursing (DON) #2 stated there was an incident on 4/20/12 with Resident #105 had gotten a right hip fracture. DON #2 stated the only recent incident with Resident #105 was from 10 days ago "when in lift" Resident #105 was "unsteady" and "eased to the floor" and she stated "10 days later noticed a leg problem (4/20/12)." In an interview on 4/23/12 at 2:10 P.M., CNA #16 stated that on 4/10/12, "at around 5 A.M. I go in with the Hoyer" to transfer Resident #105 from bed to geri chair. CNA #16 stated, "I did it myself". CNA #16 stated she lifted Resident #105 out of her bed and pulled Hoyer into the hall where the geri chair was placed and CNA #16 pulled the Hoyer towards the doorway of Resident #105's room. CNA #16 stated, "I slipped out the doorway behind the geri chair" and then pulled Resident #105 toward the geri chair. CNA #16 stated "it (Hoyer) swing to the right" and then the Hoyer "started to come over" so CNA #16 lowered Resident #105 to the floor and got LPN #17. CNA #16 stated she "had to slide her (Resident #105) down my body." Per the manufacturer's instruction for lift operation the EZ Lift could be operated by 1 person "however, with some patients it is best to use two people." In an interview on 4/24/12 at 10:00 A.M., CNA #15 stated on 4/10/12 she had viewed Resident #105 "on the lift with CNA #16". CNA #15 stated Resident #105 was "babbling like always, I touched her cheek and took about 4 steps away and heard a noise." CNA #15 stated, "I turned around" and "the Hoyer was tipping over sideways." CNA #15 stated Resident #105 told her 'Oh, Lord they threw me on the floor.' CNA #15 stated Resident #105 had ended up on the outside and behind the geri chair in the hallway on the floor. In an interview on 4/24/12 at 10:25 A.M., Licensed Practical Nurse (LPN) #17 stated on 4/10/12 Resident #105 was already on the floor "on her back and her right side". LPN #17 stated Resident #105 stated her right inner thigh was sore but that Resident #105's right inner thigh was not red. LPN #17 stated Resident #105 was positioned on the Hoyer lift pad and placed into the geri chair. LPN #17 was asked by Surveyor if Hoyer lifts were done by only 1 person, LPN #17 stated "I know they do it with 1 person" and "sometimes they use 2 people." Review of the Nurses Interdisciplinary Notes dated 4/10/12 at 6:00 A.M. revealed Resident #105 was "observed resident lying on the floor. no injuries. complaint of pain right inner thigh being sore." In an interview on 4/23/12 at 1:47 P.M., Restorative aide #10 stated the "girls (CNA's) were shorthanded (4/20/12) on AB hall so I started with her (Resident #105), I noticed her right leg over the left" and "I found that kind of weird (Resident #105 normally had stiffness in both legs) and went to get nurse LPN". In an interview on 4/23/12 at 1:40 P.M., LPN #9 stated "the rehab girl called me in there" into Resident #105's room. LPN #9 stated Resident #105's right leg was moved over her left leg" and it was not normal for Resident #105's legs to be crossed. In an interview on 4/23/12 at 2:40 P.M., CNA #15 stated on 4/20/12 she and CNA #12 in the morning had moved Resident #105 with the Hoyer lift. CNA #15 stated Resident #105 had "just her normal everyday talk" during the transfer. CNA #15 stated Resident #105 was placed in the geri chair and taken to the T.V. room. CNA #15 stated later "around 5:30 P.M. X-ray man was looking for her (Resident #105)". CNA #15 stated Resident #105 was Hoyer transferred back into bed and the X-ray was performed. Review of the facility Radiology Report dated 4/20/12 at 10:52 P.M. revealed Resident #105 had a fracture (broken) of the right femur (long bone in leg). Review of Physician Order's dated 4/20/12 at 6:30 P.M. revealed an order for [REDACTED]. Review of the Emergency Department Physician Note dated 4/20/12 at 7:37 P.M. revealed Resident #105 "had been appearing to be in pain" and did moan when her right hip was moved. Review of the X-Ray results from the Hospital dated 4/20/12 at 9:06 P.M. revealed Resident #105 had an "impacted fracture (broken bone) of the proximal right femur (large leg bone). Review of the Operative Note Final Report dated 4/21/12 at 11:10 P.M. revealed Resident #105 had surgery to repair her right hip fracture and the physician noted during surgery Resident #105's hip had appeared "to have some evidence of early healing" (which indicated fracture was not acute). An observation on 4/24/12 at 9:45 A.M. revealed Resident #105 laying in bed on her back with eyes closed and call light within reach. An observation on 4/24/12 at 11:00 A.M. revealed Resident #105 laying in bed on her back with eyes closed and call light within reach.

Complaint Intake #MI 162 Based on observation, interview, and record review the Facility failed to provide adequate supervision to prevent accidents (falls) in 1 of 3 sampled residents (#101) with falls, from a total sample of 4 residents, resulting in actual harm (hip fracture). Findings include: Resident #101 Per the incident report dated 1/06/12 Resident #101 fell in the A/B dining room at "1715" (5:15 PM); an x-ray was obtained; Resident #101 sustained a fracture to her left hip and was sent to the hospital. Per the operative note dated 1/08/12 Resident #101 had surgery to repair a fracture to her left intertrochanteric proximal femur. Per the Minimum (MDS) data set [DATE] Resident #101's [DIAGNOSES REDACTED]. In an observation on 2/08/12 at 2:45 PM Resident #101 was seated in a wheelchair near the A/B Nurses' Station; she was rubbing both thighs and knees. Resident #101 complained of pain in her right arm and knees and numbness in her legs. In an observation on 2/08/12 at 3:20 PM, with the assistance of Nurse Aide #19, Resident #101 stood at the grab bar in her bathroom. Nurse Aide #19 touched the back of Resident #101's head; Resident #101 said, "that hurts". Initially Nurse Aide #19 said she did not feel any bump then admitted to a small raised area to the back and left side of the crown of Resident #101's head. Resident #101 sat on the commode and began to rub both legs from her hips to knees. Two small healed incisions were noted on Resident #101's hip and thigh. Resident #101 pointed to the top incision and said "that is where it hurts." In an interview on 2/09/12 at 11:00 AM, Licensed Practical Nurse (LPN) #14 said, "on 1/06/12 at approximately 3:00 PM, (Resident #101) was in her bed demanding the police be called. I could hear her from the hall." LPN #14 said she worked on another unit in the Facility and was "not familiar with this hall." LPN #14 said she had "no prior experience" with Resident #101. LPN #14 said she did not know the names of the aides who were on duty on 1/06/12 and was unable to identify them for the Surveyors. LPN #14 said on 1/06/12 at approximately 3:00 PM she assisted Resident #101 out of bed and into a wheelchair and "whispered in the ear" of a Nurse Aide (#A), "'I need her to be monitored.'" LPN #14 said she "explained how I found her (Resident #101) calling out for the police. I told her (the unidentified Nurse Aide #A) I'm not familiar with this hall. The Nurse Aide (#A) said 'I'll take care of that,' grabbed Resident #101's wheelchair and was taking her to the dining room." LPN #14 said at approximately 5:00 PM on 1/06/12 she inadvertently woke Resident #101, who was now asleep in her own bed. LPN #14 said Resident #101 said, "'I want to get up."' LPN #14 then activated Resident #101's call light and Nurse Aide #A came into the room. LPN #14 said she told Nurse Aide #A "'I need you to monitor this patient"'. LPN #14 said she witnessed Nurse Aide #A transfer Resident #101 to her wheelchair stating,"'I'll take her to the dining room' and I saw them leave the room." In an interview on 2/08/12 at 3:27 PM Nurse Aide #10 said on 1/06/12 she and Nurse Aide #11 were told by LPN #14 at approximately 5:00 PM to take Resident #101 to the dining room and "'don't leave her (Resident #101) alone."' Nurse Aide #10 said she and Nurse Aide #11 took Resident #101 to the A/B dining room via wheelchair. In a second (telephone) interview on 2/13/12 at 10:20 AM, Nurse Aide #10 said on 1/06/12 at approximately 5:00 PM neither she or Nurse Aide #11 informed Activity Aide #17 and Nurse Aide #15 that per LPN #14, Resident #101 was not to be left alone and required increased monitoring due to agitation. Nurse Aide #10 said she, "Didn't say anything to anybody." In a telephone interview on 2/09/12 at 3:25 PM Activity Aide #17 said on 1/06/12 she and Nurse Aide #15 were serving pre-supper beverages in the A/B dining room when "someone" (she did not remember who) brought Resident #101 into the A/B dining room in her wheelchair. Activity Aide #17 said the unknown staff person said, "'Here's (name of Resident #101)'" and left the room. In an interview on 2/09/12 at 11:50 AM, Nurse Aide #15 said on 1/06/12 she was "not sure who" brought Resident #101 into the A/B dining room but remembers the person said, "'Here's (name of Resident #101).' Nothing else was said." Nurse Aide #15 said the time Resident #101 arrived in the dining room must have been about 5:30 PM. In a telephone interview on 2/14/12 at 2:30 PM, Nurse Aide #15 said on 1/06/12 after arriving in the A/B dining room at 5:00 PM Resident #101 was "teary, crying and agitated and she stated she 'wanted to go somewhere'. I told her 'just a minute', turned away from her and continued serving a drink to another resident." Nurse Aide #15 reported she heard a fall alarm sound and turned around and Resident #101 "was on the floor. (Resident #101) said, 'I broke my leg!' and (Activity Aide #17) said she seen her bump her head on the wall." In the telephone interview on 2/09/12 at 3:25 PM, Activity Aide #17 said on 1/06/12 after she assisted Resident #101 to her place at the table Resident #101 "moved her wheelchair against the wall (backed up and pivoted the chair so that the back of the wheelchair was against the wall next to her table and she faced the center of the dining room). I turned around to get a clothing protector and I heard a beep (fall alarm sound). I was at the other end of the width of the dining room (from Resident #101). I turned around and (Resident #101) just pushed herself up out of the chair. Her hands were not on the chair. Her butt was off the chair. Her legs were still kinda crossed with her right in front of the left at the ankles. They were not quite crossed. Her right foot was in front of her left-not quite in front-it was a little bit right of her left foot not dead center in front of it. She was kinda crouched. She attempted to step forward with her right foot that was already in front of her left foot. She started to fall to her left. She by-passed her chair and landed on her hip. She hit her shoulder and head on the wall. The back left side of her head. (Resident #101) was screaming about her hip hurting. She said it was 'broken.'" In the interview on 2/09/12 at 11:50 AM, Nurse Aide #15 said on 1/06/12 after "someone put (Resident #101) in the spot by the wall" Resident #101 was "very agitated-almost crying. She was making noise and talking" (Nurse Aide #15 demonstrated screwing up her face and speaking in a harsh voice.) Nurse Aide #15 said she had her back to Resident #101 she did not see Resident #101 fall. Nurse Aide #15 said she, "heard the alarm. I turned around (and saw Resident #101) on the floor on her butt leaning to the left like on her elbow. Her left leg was out straight. Her right leg was folded up Indian style. I can't recall if her right was on top or under her left.(Resident #101) said, 'I broke my leg! I broke my leg.'" ( & )

Complaint Intake Number: MI 162 Based on observation, interview, and record review the Facility failed to provide the necessary care and services to maintain the highest practicable physical well-being (moved a fallen resident with suspected serious injury before she was assessed by a licensed nurse, repeatedly moved a resident with a suspected [MEDICAL CONDITION] from bed and wheelchair, failed to assess the back of the head for injury even though she was seen hitting the back of her head on the wall, and delayed pain medications and treatment) in 1 of 3 residents sampled for falls (#101), from a total sample of 4 residents, resulting in the potential for secondary injury and a delay in treatment causing an exacerbation of pain. Findings include: "General Trauma Interventions: Keep the victim lying down or in the position in which he or she is found..." (Phipps, W. J., Monahan, F. D., Sands, J. K., Marek, J. F., & Neighbors, M. (2003) Medical-Surgical Nursing Health and Illness Perspectives (7th ed.). St. Louis: Mosby.). "Spinal injuries include fractures, contusions, and compressions of the vertebral column, usually the result of trauma to the head or neck. The real danger lies in possible spinal cord damage...The primary treatment after spinal injury is immediate immobilization to stabilize the spine and prevent cord damage." Stabilization of the head and neck is done prior to moving the victim to prevent secondary injuries such as paralysis from destabilization of a cervical vertebrae fracture..." (Diseases: Causes and [DIAGNOSES REDACTED].). Pennsylvania: Springhouse.). "Secondary injury results from the body's response to the initial trauma ..." Phipps, W. J., Monahan, F. D., Sands, J. K., Marek, J. F., & Neighbors, M. (2003) Medical-Surgical Nursing Health and Illness Perspectives (7th ed.). St. Louis: Mosby. Per the Facility's Accident/Incident Report Policy & Procedures most recent revision date "1/11" when a resident fall was witnessed or when a "resident is observed on the floor and presumed to have fallen" a full assessment "will be completed by the Licensed Nurse...The resident should not be moved until the initial evaluation is completed. If an injury is suspected, the Resident should not be moved until Emergency Medical personnel arrive...The goals of lifting and moving a resident with a suspect fracture are to minimize the chance of a lifting-related injury and minimize movement and stress on the resident's injury." Resident #101 Per the incident report dated 1/06/12 Resident #101 fell in the A/B dining room at "1715" (5:15 PM); an x-ray was obtained; Resident #101 sustained a fracture to her left hip and she was sent to the hospital. In an interview on 2/09/12 at 3:25 p.m. Activity Aide #17 said on 1/06/12 at approximately 5:30 PM she saw Resident #101 fall after standing up from her wheelchair. Activity Aide #17 said Resident #101 attempted to step forward with her right foot that was already in front of her left foot. Resident #101 started to fall to her left, by-passed her chair and landed on her hip. Activity Aide #17 said Resident #101 hit her shoulder and the back left side of her head on the wall and was screaming about her hip hurting. "She said it was 'broken.'" In the interview on 2/09/12 at 11:50 a.m. Nurse Aide #15 said on 1/06/12 she had her back to Resident #101 she did not see Resident #101 fall. Nurse Aide #15 said she, "heard the alarm. I turned around (and saw Resident #101) on the floor on her butt leaning to the left like on her elbow. Her left leg was out straight. Her right leg was folded up Indian style. I can't recall if her right was on top or under her left. (Resident #101) said, 'I broke my leg! I broke my leg.'" In the interview on 2/09/12 at 11:50 a.m. Nurse Aide #15 said she left Resident #101 on the floor with Activity Aide #17 and went to find the nurse. Finding no one at the Nurses' Station or in the corridor, Nurse Aide #15 said she "called out, 'Somebody get (name of LPN #14).' I didn't see anyone." Nurse Aide #15 said she returned to the A/B dining room and found Resident #101 and Activity Aide #17 "still sitting in the same spot." Nurse Aide #15 said she and Activity Aide #17 "lifted" Resident #101 from the floor, sat her in her wheelchair and wheeled her from the A/B dining room to the Nurses' Station. In the telephone interview on 2/09/12 at 3:25 p.m. Activity Aide #17 said on 1/06/12 after she saw Resident #101 fall and hit her head on the wall she "ran over" to Resident #101. Activity Aide #17 said Resident #101 was "screaming about her leg hurting. She said it was broken. I got my hands behind to hold her from the floor. My hands were under some of her body. I don't think she was trying to stand up. She did quiet down. (Resident #101) did not say she 'wanted to get up.' (Nurse Aide #15) yelled or ran out for (LPN #14). Then she came back and was taking her vitals. (Nurse Aide #15) said, 'Will you help me get her back in her wheelchair?' We lifted her. (Nurse Aide #15) must have had a gait belt. We lifted around and under her arm and put her in the chair." When asked why she moved an obviously injured resident from the floor Activity Aide #17 said, "Because (Nurse Aide #15) asked me to help her." Activity Aide #17 said she "thought (Nurse Aide #15) knew what she was doing. I just followed her." In an interview on 2/09/12 at 9:55 a.m. Nurse Aide #12 said she was assigned to care for Resident #101 on the second shift on 1/06/12. Nurse Aide #12 said she heard a fall alarm sound and upon entering the A/B dining room she saw Resident #101 "sitting on the side of her wheelchair on the floor yelling, 'My hip! My hip! I broke my hip!' She was leaning on her broken hip-the left. Her legs were not crossed. They were straight out. Her back and head were touching the wall. (Activity Aide #17) was standing next to (Nurse Aide #15) & (Nurse Aide #15) was kneeling talking to her." Nurse Aide #12 said Resident #101 did not try to stand. "She did not move." Nurse Aide #12 said later she saw Nurse Aide #15 and Licensed Practical Nurse (LPN) #14 wheeling Resident #101 in her wheelchair in the corridor. Nurse Aide #12 said Resident #101 was "whining and crying in pain" as she was being wheeled down the corridor towards her room. Nurse Aide #12 said she "had to check on (Resident #101)'s roommate every 15 minutes. (Resident #101) was still crying. She was in bed covered up, lying on her back with both feet flat on the mattress and her knees bent". In an interview on 2/08/12 at 3:27 p.m. Nurse Aide #11 said on 1/06/12 she heard a noise and "thought somebody was fighting" in the A/B dining room. She looked in and saw Resident #101 "on the floor leaning towards the wall with her feet closest and her head further away. She was not agitated when they (Nurse Aide #15 & Activity Aide #17) were getting her up. She was calm. She wasn't fighting or nothing." In a telephone interview on 2/13/12 at 10:20 a.m. Nurse Aide #10 said on 1/06/12 she saw "someone wheeling" Resident #101 out of the A/B dining room and Resident #101 was "crying. She said, 'I broke my hip!'" Nurse Aide #10 said a while later LPN #14 asked her to help her to do an assessment of Resident #101 in her room. Nurse Aide #10 Resident #101 was lying on a mattress on the floor and crying. Nurse Aide #10 said Resident #101 said, "'I can't move my leg.'" In an interview on 2/09/12 at 11:00 a.m., LPN #14 said on 1/06/12 Nurse Aide #15 brought Resident #101 to the A/B Nurses' Station and reported she had fallen and hit her forehead on the wall in the dining room. LPN #14 said Nurse Aide #15 "wanted me to look at (Resident #101)'s head and her leg. I did not go into the dining room at all. I never went into the dining room. I checked her leg. I lifted her pant leg and checked her knee. There were no cuts or bruises but (Resident #101) kept saying 'OW! OW!' I checked her forehead and there was no bruising." LPN #14 said she never checked the back of Resident #101's head. In an observation on 2/08/12 at 2:45 p.m. Resident #101 was seated in a wheelchair near the A/B Nurses' Station. A small bump was felt on the back/left side of crown on Resident #101's head. Resident #101 said, "that hurts!" and touched the bump on her head. Per the Interdisciplinary Notes dated 1/06/12 at "21:30" (9:30 p.m.) LPN #20 stated she examined Resident #101 at "18:10" (6:10 p.m.) after a reported fall and she "instructed (staff) to get STAT x-ray of left lower extremity." In a telephone interview on 2/14/12 at 11:42 a.m. LPN #20 said on 1/06/12 she was the supervisory nurse on duty on the second shift. LPN #20 said LPN #14 called her to "give a second opinion" of Resident #101's injury. LPN #20 said Resident #101 was lying on a mattress on the floor on her right side with her left hand touching her upper left thigh. LPN #20 said Resident #101 was quiet and very calm. LPN #20 said she did not change Resident #101's position and assessed normal range of motion of Resident #101's right lower extremity. LPN #20 said she was unable to perform full range of motion to Resident #101's left lower extremity due to Resident #101 experiencing pain with movement of her left leg. LPN #20 said she did not roll Resident #101 onto her back to assess whether her left leg was shorter than the right and/or rotated outwards (signs of possible [MEDICAL CONDITION]) because Resident #101 was "moaning a little and had her hand on her left hip. (Resident #101) said it kinda hurt." LPN #20 said in that position Resident #101's left leg "didn't look like it" was shorter than the right or rotated outwards. LPN #20 said she told LPN #14 to call the physician and get an order for [REDACTED].#14 called her with the x-ray results. Per the hospital History & Physical dated 1/06/12 Resident #106 was examined supine (on her back) in bed and her "left lower extremity is short compared to the right." In the telephone interview on 2/14/12 at 11:42 a.m. LPN #20 said during the examination of Resident #101 on 1/06/12 LPN #14 informed her that Resident #101 had fallen in the dining room before supper and Nurse Aide #15 & Activity Aide #17 "brought (Resident #101) to the Nurses' Station. I said 'uh-no.' I discussed with LPN #14 that "they shouldn't have brought her to you. You should have went to her." LPN #20 said LPN #14 told her Resident #101 had "behaviors on and off all that day. That was not unusual for her. The Charge Nurse said she instructed the nurse aide assigned 'don't leave her alone' and she took her to an activity. She said the activity aide and a nurse aide were in the dining room." When asked if the staff should have moved Resident #101 from the floor before the licensed nurse examined her LPN #20 said, "It never should have happened." In a telephone interview on 2/09/12 at 3:15 p.m. X-Ray Technician #21 said on 1/06/12 he received instructions to go to this Facility "as soon as possible" to x-ray a resident. "A couple of hours later" the instructions "turned into 'STAT.' The Facility called two times." In a telephone interview on 2/14/12 at 11:01 a.m. X-ray Office Manager #16 said the x-ray of Resident #101's hip was taken on 1/06/12 at 8:20 p.m. Per the Interdisciplinary Notes signed by LPN #14 the x-ray results of Resident #101's left hip were obtained and known at "18:10" (6:10 p.m.) however, in a telephone interview on 2/14/12 at 11:01 a.m. X-ray Office Manager #16 said the x-ray of Resident #101's hip was taken on 1/06/12 at 8:20 p.m. In the telephone interview on 2/09/12 at 3:15 p.m. X-Ray Technician #21 said when he arrived on 1/06/12 Resident #101 was lying on a mattress on the floor in room [ROOM NUMBER]. X-Ray Technician #21 said he told the staff he could not take an x-ray with the patient lying on a mattress on the floor. X-Ray Technician #21 said, "a very young nurse and an older white female put (Resident #101) in a wheelchair" and took her to another room where they "put her on the bed. After the x-ray was taken an aide came in ready to transfer her back." X-Ray Technician #21 said he then "read it and told her (LPN #14) it (Resident #101's left hip) was fractured." In a telephone interview on 2/13/12 at 10:20 a.m. Nurse Aide #10 said on 1/06/12 around "7:00 or 8:00" p.m. she saw Resident #101 "being wheeled between room [ROOM NUMBER] & room [ROOM NUMBER] bed-2. (Resident #101) was crying and moaning at that time. He (the x-ray technician) told (LPN #14) he needed (Resident #101) up in a higher bed (in order to perform an x-ray)." Nurse Aide #10 said on 1/06/12, "then the man did the x-ray." Nurse Aide #10 said after the x-ray she saw LPN #14 & Nurse Aide #15 wheeling Resident #101 from room [ROOM NUMBER] back to room [ROOM NUMBER] and Resident #101 "was crying." In a telephone interview on 2/13/12 at 5:10 p.m. LPN #14 said on 1/06/12 she and Nurse Aide #15 lifted Resident #101 from the wheelchair and onto the mattress after she fell in the dining room. LPN #14 said she and Nurse Aide #15 lifted Resident #101 off the mattress in room [ROOM NUMBER] and into her wheelchair, took her to room [ROOM NUMBER], lifted her out of the wheelchair and onto the bed in room [ROOM NUMBER] and after the x-ray was taken they lifted Resident #101 off the bed in room [ROOM NUMBER] and put her into her wheelchair, took her back to her room [ROOM NUMBER] and then lifted her out of the wheelchair and returned her to the mattress on the floor. Per the physician's orders [REDACTED].#101's January 2012 the narcotic pain medication [MEDICATION NAME] ER 15 mg was administered on 1/06/12 at "19:00" (7:00 p.m.) per routine. However, in Resident #101's Interdisciplinary Note dated 1/06/12 LPN #14 made an entry written at "18:10" (6:10 p.m.) stating she administered 30 mg (twice the ordered dose) of [MEDICATION NAME] at "19:00" (7:00 p.m.). In other words LPN #14 wrote at 6:10 p.m. that she gave medications 40 minutes later at 7:00 p.m. Per the Interdisciplinary Note dated 1/06/12 at "18:10" (6:10 p.m.) and signed by LPN #14, LPN #14 said she notified the ambulance service to transport Resident #101 to the hospital and called the emergency room to notify them of Resident #101's arrival however, per the Ambulance run sheet dated 1/06/12 the 9-1-1 call was not received at "18:10" but was received three hours later at "21:04" (9:04 p.m.), the ambulance was dispatched at "21:05" (9:05 p.m.) and arrived at the scene at "21:14" (9:14 p.m.). Per the Ambulance Patient Care Report dated 1/06/12 Resident #101 "fell out of her wheelchair hitting her head on the wall and falling on the floor...Nurse stated that she gave the pt 30 mg [MEDICATION NAME] PO (by mouth) at 8:00 PM...Arrived to find the patient laying on her right side in her bed on the floor...Patient complained of hip pain...Patient rated pain 8 on pain scale" (of 1 to 10 with 10 being extreme pain). Per the emergency room Physician's note dated 1/06/12 Resident #101 said her hip was hurting. "Patient does have pain to palpation over her left hip and decreased range of motion secondary to pain." Per the Minimum (MDS) data set [DATE] Resident #101's [DIAGNOSES REDACTED]. In an observation on 2/08/12 at 2:45 p.m. Resident #101 was seated in a wheelchair near the A/B Nurses' Station; she was rubbing both thighs and knees. Resident #101 complained of pain in her right arm and knees and numbness in her legs. ( & )

This citation pertains to intake #MI 182 Based on observation, interview and record review, the Facility failed to provide adequate supervision and assistive devices (bathroom call light) in 1 of 5 sampled Residents (#102) from a total sample of 5 residents, resulting in Resident #102 (a 2 person toilet assist) sustaining a left fractured ankle after being lowered to the floor in the bathroom during a 1 person transfer. on 5/6/11 at approximately 5:30 PM when Resident #102 (a 2 person toilet assist), refused to stand after being toileted, was lowered to the floor and subsequently was diagnosed with [REDACTED]. Findings include: Review of the clinical record face sheet revealed Resident #102 was a [AGE] year old woman, first admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of the Facility's fall potential assessment dated [DATE] revealed Resident #102 was assessed at 20 (10 or higher is a risk for falls). Review of the Fall Care Plan dated 1/4/08 revealed an intervention for Resident #102 to have "two assist with toileting....Resident will stand then refuse to ambulate and attempt to sit on the floor..." Another intervention was written to "two assist with transfers with a gait belt. Observe for gait unsteadiness". In a telephone interview on 6/21/11 at 3:05 PM, Registered Nurse (RN) "E" reported she was the Charge Nurse for Resident #102 on 5/6/11 for the evening shift. RN "E" said it was very busy that evening and there was no Supervisor in the Facility at 5:30 PM to help her. RN "E" said she recalled an incident regarding Resident #102 being lowered to the floor by a CNA and that she didn't think there was any injury. When asked if she assessed Resident #102 while she was on the floor, RN "E" said, "By the time I got there she was already off the floor. I'm pretty sure I looked at her. It sounds like I may have neglected to document that." RN "E" said she was giving medications to another resident and was unable to leave at the time of the incident but vaguely remembered Resident #102's bathroom call light wasn't flashing. RN "E" stated, "They said it had already been reported." RN "E" reported she did not fill out a slip to notify maintenance that Resident #102's bathroom light was not working, did not notify a supervisor, or provide another assistive device for Resident #102 to be able to notify staff when help is needed in the bathroom. When asked who "they" were that she referred to, RN "E" was unable to recall. In a telephone interview on 6/21/11 at 11:30 AM, Certified Nurse Aide (CNA) "D" said on 5/6/11 at approximately 5:30 PM, she was in a room with a Resident (not on the sample), when she heard CNA "C" call for help. CNA"D" said she went to the room and saw Resident #102 and CNA "C alone in the bathroom with Resident #102, who was on the toilet. CNA "D" said she was trying to help Resident #102 stand up while CNA"C" was trying to clean bowel movement up but Resident #102 said "No" and started hitting them. CNA "D" said she had lowered Resident #102 independently to the floor because she would not stand. CNA "D" stated RN "E" didn't hear them call for help. When asked if she pulled the bathroom call light CNA "D" said "no". When asked if CNA "C" had pulled the bathroom call light CNA "D" said "yes, but the light was not on (didn't flash and you couldn't hear it)". On 6/21/11 at 12:55 PM, during a telephone interview, CNA "C" reported that on 5/6/11 at approximately 5:30 PM she transferred Resident #102 from her bed to the bathroom without assistance from another staff member. When Resident #102 was finished, CNA "C" said she tried to turn on the bathroom call light but it wasn't working. CNA "C" said she looked out into the hall and saw a Resident and asked that Resident if there were any Nursing staff that she could go get to help her but there were none. CNA "C" said she waited and then called out and CNA "D" came to assist. CNA "C" reported that Resident #102 started to "ease off the toilet" and was lowered to the floor by CNA"D" independently because she was getting the wipes ready and did not notice until Resident #102 was on the floor. CNA "C" said CNA"D" went to get RN "E" but after about 15 minutes another CNA (CNA "G") came into the bathroom. CNA "C" reported that she, CNA "D", and CNA "G" tried to lift Resident #102 off the floor but the gait belt was sliding. CNA "C" stated, "We made multiple attempts but only got Resident #102 to her knees". CNA "C" said they were able to eventually get Resident #102 into a wheelchair but that Resident #102 yelled, "no, no, no" the entire time. CNA "C" said after supper they tried to get Resident #102 to stand again and she said, "no, no, no" again. CNA "C" said they got Resident #102 into bed the same way they got her off the floor, two of the CNA's lifted her arms and another one CNA lifted her legs, because she was refusing to stand. When asked if she noticed any abrasions on Resident #102's left leg, CNA "C" said, "I did notice a little scrape on her lower leg". CNA "C" said she reported it to RN "E". Review of the Facility's incident report dated 5/6/11 at 5:30 PM (not written and signed as assessed until 5/7/11) revealed Resident #102 had, "noted left foot pain to touch, no specific area of pain noted". Review of the X-Ray dated 5/8/11, interpreted by Radiologist, under Findings/Conclusion was written: "1. Subtitle linear lucency, distal fibula metadiaphysis, highly concerning for a non-displaced fracture. 2. Mild medial and lateral soft tissue swelling." During a telephone interview on 6/22/11 at 12:45 PM, Radiologist #1 stated he was a Muscular/Skeletal Expert who had a private practice prior to his job of reading and interpreting X-rays. When asked to explain the X-ray dated 5/8/11 that he interpreted of Resident #102's fractured left ankle, Radiologist #1 said the fracture was a result of one of two things; "1. a direct contusion (blow to the leg) or 2. Insufficiency fracture (caused by severe osteoporosis), but if there was no accident and given her history of little ambulation she may have a lower bone mineralization and it probably was from standing. The only way you can tell if she had osteoporosis in her lower legs would be by a bone density test. Only if it was very significant would it show up on an x-ray (osteoporosis). The type of fracture was most likely due to standing because of the area that the fracture occurred in. The Fulcrum is in that area and that is generally where fractures tend to occur more from stress of standing for someone with weakened bones". According to Kapit, W. & Elson L. M. (1977) "The Anatomy Coloring Book". New York: Harper & Row. "The Tibia is the stoutest bone of the body. It transmits the body weight to the ankle joint directly." Review of the behavior tracking log for Resident #102 revealed no recorded behaviors prior to 5/20/11. Review of the Nurse's Notes dated 5/8/11 at 8:00 AM for Resident #102 revealed, "was reported that staff was attempting to transfer resident refused to stand-stating no, no. Staff assisted resident to sit on floor. Sat down on feet. Left foot warm to touch and tender to touch. X-ray of left foot and ankle was ordered." Nurse's notes at 11:45 AM said mobile x-ray called and said left ankle negative with linear lucency and soft tissue swelling." Nurse's notes dated 5/9/11 at 1:00 PM indicated Resident #102 was "up in wheelchair per Hoyer lift and two assist related to refuses to stand on left foot. Moans when foot is touched". Review of the transfer record dated 5/11/11 (no time), revealed Resident #102 was transferred to a Hospital Emergency Department due to pain and swelling of her left foot and ankle. Review of the Hospital Emergency Department record for Resident #102 dated 5/11/11, under "Extremities" documented, "She (Resident #102) has a little superficial abrasion near the left ankle. She holds it still versus almost any other part of her body she moves nonstop." The Hospital Emergency Department [DIAGNOSES REDACTED]. Acute urinary tract infection. 2. Acute left ankle fracture distal fibula. 3. Down's Syndrome." An observation on 6/17/11 at 12:10 PM revealed Resident #102 was sitting in a wheelchair with her left foot on a foot rest. Her left lower leg had a splint on it. An interview was attempted but due to cognitive deficits Resident #102 was not able to tell the Surveyor how she fractured her leg. #

This citation pertains to intake numbers MI 293 and MI 471. Based on observation, interview, and record review, the facility failed to provide a safe environment and adequate supervision for 2 of 10 sampled residents (Resident #101 and Resident #106), resulting in an Immediate Jeopardy when, 1) on 1/17/11, Resident #101 exited the facility undetected for 20 minutes, without winter clothing, fell , landing in the snow 15 yards from a city road putting Resident #101 at high risk of serious injury, harm, impairment, or death, and 2) on 2/17/11, Resident #106 exited the facility undetected, without winter clothing, for an undetermined amount of time, then fell on the pavement putting Resident #106 at high risk of serious injury, harm, impairment, or death, and placing 13 additional residents, who were assessed as risk of elopement, at a high risk of serious injury, harm, impairment, or death. Findings Include: Per the facility "Wandering Resident/Elopement" policy and procedure, "Revised: October 2008", "...Facility staff will insure that all exit alarms are responded to immediately...When any door alarm sounds the facility staff shall: a) Check the alarm panel to determine which door has been opened. DO NOT ASSUME someone else has already done this; b) Check the exit door for any exiting resident by means of a visual check. Visual check means observing the area around the exit, and may require leaving the building and checking the grounds...d) Reset the door alarm after it is determined by visual check that no residents have exited the facility inappropriately, or is returned to the facility...." In an interview with Administrator #2, on 2/22/11 at 12:30 PM, she stated the facility did not have surveillance cameras and had no "alarm panel" as listed in the "Wandering Resident/Elopement" policy and procedure. Resident #101 Resident #101 no longer resided at the facility at the time of the survey. Per the hospital "Emergency" report, dated 1/16/11, "Impression and Plan/ED (Emergency Department) course: Patient presents with a history and exam consistent with frequent falls, likely related to alcoholism, history of alcoholic dementia, history of withdrawals..." Review of the "MDS" (Minimum Data Set), dated 1/28/11, revealed Resident #101 had active [DIAGNOSES REDACTED]. Per a "Facility Incident Report", dated 1/18/11, "(Resident #101) ...admitted to the facility on [DATE] at 1915 (7:15 PM) from (hospital) where he was seen in the emergency room ...The smell of alcohol was strong and he did admit to alcohol intake on a daily basis, his blood alcohol in the ER (emergency room ) was at .132 (.132%)....2030 (8:30 PM) - Call from the plow truck man (snow plow truck driver #17) to (LPN #10 - licensed practical nurse) stating a man fell in the snow bank... later identified as (Resident #101)...Vital signs 97.2 (body temperature/Fahrenheit), 21 (respirations), 148/88 (blood pressure)..." The outside air temperature, on 1/17/11 at 8:30 PM, was 28 degrees Fahrenheit with 4 inches of snow on the ground in the city where the facility was located. (http://www.weather.com/weather/monthly/USMI0584?month=-1). Review of the clinical record revealed the "Admission Care Plan", signed by CCC (Clinical Care Coordinator) #4 and dated 1/16/11 (not timed), contained two problem areas, one labeled "Adjustment to nursing home/potential for other psychosocial concerns", and a physical therapy plan of care. There was no plan of care for AW (Alcohol Withdrawal) and Resident #101 was not identified at risk for elopement. In an interview with Clinical Care Coordinator #4, on 2/14/11 at 1:26 PM, she stated she knew Resident #101 was, "..a big alcoholic" when she wrote the "Admission Care Plan" and knew he had been "drinking" alcohol before he was admitted to the (hospital) Emergency Center on 1/16/11 at 2:24 PM and subsequently admitted to the facility on [DATE] at 7:10 PM. Per a "Reporting Officer Narrative" from the "(City) Police Department", dated 1/17/11 at 20:11 (8:11 PM), "(Caller #38) advised that she observed a man in a plow truck assisting an elderly male, approximately [AGE] years old, wearing pajamas, covered in snow into a truck. (Caller #38) advised that she discovered that the elderly man walked out of the nursing home and the man in the tow truck was assisting him inside the his truck to take him home..." In an interview, on 2/16/11 at 3:35 PM, the snow plow truck driver #17 stated he first saw the man (Resident #101), on 1/17/11 around 8:00 PM, with a walker, on a sidewalk near near an exit door in the middle of the west side of the front of the building (the snow plow truck driver pointed to the egress door between C Hall and D Hall) walking towards the cars in the parking lot. Snow plow truck driver #17 stated he stopped his truck to allow the man (Resident #101) to cross the road in front of him and then continued plowing. Snow plow truck driver #17 stated he again saw the man (Resident #101), approximately 15 yards from the city street, crawling towards the street on his hands and knees in the snow, with his walker laying in next to him. "He was crawling in the snow. I couldn't lift him up...two ladies and a man stopped ...called the police....a big black guy helped me (get Resident #101 into snow plow truck driver #17 truck)...he (Resident #101) was in my truck about 5 minutes...I had to help (the police) get him (Resident #101) inside". According to the snow plow truck driver #17, 15 minutes elapsed from the time he first saw Resident #101 until he was returned inside the facility. In an interview, on 2/14/11 at 3:25 PM, with LPN (Licensed Practical Nurse) #9, she stated she was working D Hall (the hall where Resident #101 resided) and was Resident #101's second shift nurse on 1/17/11. LPN #9 stated she saw Resident #101 in his room at 7:00 PM, but did not hear a door alarm nor see Resident #101 exit the building that night. LPN #9 stated she knew Resident #101 had a history of [REDACTED].#101 asked for a room change around 6:00 PM, "because he didn't like his roommate". LPN #10 stated she received a phone call by LPN #10 alerting her that a resident was outside and soon afterwards saw LPN #10 assisting Resident #101 back into the building through the front entrance. In an interview, on 2/14/11 at 4:20 PM, nurse aide #11 stated she was working E Hall second shift on 1/17/11. Nurse aide #11 stated that, between 5:45-6:00 PM, she saw Resident #101 going back and forth from the Day Room (between D Hall and E Hall) to the Activity Center (located in the Administration offices lobby outside of E Hall) and when she asked Resident #101 what he was doing, Resident #101 told her he was looking for his room. In an interview, on 2/14/11 at 5:07 PM, nurse aide #13 stated she was assigned to Resident #101 on second shift, on 1/17/10. Nurse aide #13 stated when she got back from her break at 8:10 PM, she was told that Resident #101 had moved to a different room on "D" hall and was no longer assigned to her. Nurse aide #13 stated she saw Resident #101 at 7:30 PM before her break and then again at 8:30 PM, "when he came in" (from outside). Nurse aide #13 stated Resident #101's feet were wet and his pants were wet up to his knees, he was wearing pajama bottoms and a long sleeved T-shirt, dress shoes with rubber soles, but Resident #101 was not wearing a hat, gloves, or a coat. Per "Interdisciplinary Notes", dated 1/17/11 at 8:30 PM, LPN #9 documented, "Nurse assisted resident (Resident #101) into the building from outside via main door. Alert with confusion, stating the "Russian mob" (enemy) was out to get him. Asked was he hurt, stated no. Asked how long was he outside, stated 4 minutes. Asked how did he get outside, stated out the side door when a man in a truck came to pick me up and bring me here. Denies pain, ...ROM (range of motion) all extremities without difficulty. Body audit noted bruise on left hip and hand. Wanderguard (alarm bracelet) applied to right ankle 1:1 (one staff to one resident)". In an interview, on 2/14/11 at 4:00 PM, LPN #10 stated she was working the "C" Hall on 1/17/11 when she received a telephone call from a snow plow truck driver stating an elderly man was seen walking in the parking lot, had fallen and was talking about "Nazis" and the building being blown up. LPN #10 stated, "I went out the front doors...went to the truck and knew it was (Resident #101)". LPN #10 stated she noticed Resident #101 was "shaking and very anxious" saying he was afraid to go into the building. LPN #10 stated a visitor assisted to help her bring Resident #101 into the building. LPN #10 stated the facility egress door alarms were checked and were all but one was working properly; the the alarm on the door that the snow plow truck driver identified as the door near where he first saw Resident #101 (the egress door between C Hall and D Hall). LPN #10 stated the egress door between C Hall and D Hall alarmed when it was tested , but sounded "like a call light" and the alarm immediately discontinued when the door closed instead of sounding, even after the door was closed. LPN #10 stated the alarm was intended to be to be manually turned off with a key that was in her medication cart. LPN #10 stated she observed that the key slot was in not the correct vertical position, rather it was in a horizontal position, causing the alarm to discontinue sounding once the door closed. On 2/14/11 at 6:15 PM, this surveyor was accompanied by Administrator #2 on a facility wide tour of the egress doors and their alarms. Administrator #2 stated the door was not used as an exit, only as an emergency door. This surveyor noted that the egress door between C Hall and D Hall had no signs on the door (nothing to indicate it was only to be used in an emergency exit) and an "Exit" sign was lit, hanging above it. Administrator #2 showed this surveyor a flat metal plate that had an opening (slot) for a key in it, on the wall opposite the door. Administrator #2 stated that when the key slot was turned to the horizontal position, the door alarm would sound when the door was opened and shut off when the door was closed and if the key slot was in the vertical position, the alarm would sound when the door was opened and not shut off until the key was inserted and turned to the horizontal position and it was then supposed to be repositioned back to the vertical position. In addition, the exit door between the E hall and the Administration Lobby (referred to as the D/E Administration door) had a handicapped button that opened the door and stayed open with a 15 second delay. When this surveyor voiced concern about the 15 second delay on D/E Administration door, Administrator #2 stated she thought it was appropriate to have the 15 second delay on the door for staff convenience. This surveyor observed the two doors in the Activity center exited into the Administration Lobby, there two doors in the Administration lobby that led to the Assisted Living facility, and there were 2 egress doors in the Administration lobby that opened to outdoors. These 6 doors were not locked or alarmed at any time of day or night, also for staff convenience, per Administrator #2. During the survey, this surveyor interviewed the 2 nurses (LPN #9 and LPN #10) and 5 nurse aides (#1, #11, #12, #13, and #14), that were working second shift on on C Hall, D Hall, and E Hall, on 1/17/10 on second shift. All denied hearing a door alarm or witness Resident #101 exit the building. Resident #106 Per the MDS, dated [DATE], Resident #106 was admitted to the facility on 2/02/11, had Alzheimer's Disease, disorganized thinking, and wandered daily. Per Resident #106's face sheet, Resident #106 resided in the D Hall of the facility. Per the "Care Plans...Safety" for Resident #106, dated 2/10/11, "Resident #106 is at potential risk for falling related to being in a unfamiliar environment and [DIAGNOSES REDACTED].#106) will be provided with individual safety measures to sustain a safe environment within the preference and assessment for independence and safety to keep him free from preventable injury...Wanderguard to ankle.." Per a "Facility Incident Report", dated 2/18/11, "(Resident #106) was admitted on [DATE] with [DIAGNOSES REDACTED].#106) demonstrates short and long term memory deficits...Assisted Living (resident assistant #22), stated that she heard an alarm and observed a male in a wheelchair inside the foyer by the (Assisted Living) mailroom door. He was ambulating and pushing his wheelchair. She asked his name and called the D/E hall nurse. (Resident #106) attempted to enter room 105 and she assisted him to the (Assisted Living) lobby restroom. (Resident #106) stated that he had fallen and she noted dirt on his left pant leg and redness of his left knuckle. (LPN #10) and (LPN #9) responded and returned him to the nursing home...Conclusion: (Resident #106) opened the D/E door (D/E Administration door) which provides access to the lobby by pressing the handicap power door release...reentered through the (Assisted Living) mail room entrance..." The outside air temperature, on 2/17/11 at 7:26 PM, was 46.4 degrees Fahrenheit with wind gusts of 35.7 miles per hour for the city where the facility was located. (http://www.wunderground.com//history/airport/KRNP/2010/12/26/DailyHistory.html?req) In an interview with Assisted Living resident assistant #22, on 2/22/11 at 11:00 AM, she stated she was working second shift, on 2/17/11, in the Assisted Living building (connected to the facility via the Administration lobby) and was seated at the reception desk, at 7:20 PM, by the front entrance, when she heard an alarm. She got up and looked through the window of the mailroom entrance and saw a man inside the foyer pushing a wheel chair and there was a box on the wheel chair that was alarming. Resident assistant #22 said the man was wearing blue sweatpants, a red sweatshirt and shoes but did not have on a hat, gloves, or a coat. Resident assistant #22 stated that the man told her he fell and she saw that his left pant leg and left shoulder were wet and dirty. She said he pointed to his left "pinky knuckle" and told her it was hurting. She stated she then phoned to alert the nurses at the Skilled Nursing Facility. The resident assistant #22 stated the man then walked towards a resident's room and was "doing the potty dance" outside the door. She stated she stopped the man and took him to the restroom, that his hands were warm, and when he finished in the bathroom she placed him into the wheelchair in the Assisted Living lobby, at which time LPN #9 and LPN #10 arrived and identified the man as Resident #106. Resident assistant #22 stated that after LPN #9 and LPN #10 took Resident #106 back to the Skilled Nursing facility, they returned and all three went outside where they observed the "green pad" from Resident #106's wheel chair laying in the Assisted Living facility's parking lot. In a telephone interview, on 2/22/11 at 4:01 PM, LPN #9 stated she saw Resident #106 in his wheel chair at 7:00 PM, in the D Hall moving toward the front lobby right (in the opposite direction of D/E Administration door) before she left the D Hall on an errand. LPN #9 stated she had been off the unit for about 3 minutes and was in the boiler room, a little after 7:00 PM, when she heard an overhead alert, "Please check Administration door". She stated she returned to the unit and immediately resumed passing medications and after a few minutes passed she received a phone call from someone from the Assisted Living facility. LPN #9 stated she and LPN #10 went to the Assisted Living lobby, identified Resident #106 sitting in a wheel chair, and then performed an assessment on Resident #106. LPN #9 stated she observed a small abrasion on Resident #106's face near his left eye, an abrasion on his left knee and red knuckles on his left hand. In an interview, on 2/22/11 at 12:06 PM, maintenance director #18 he stated he measured the distance between the Administration Lobby's egress exit at the back of the building to the mailroom door at the front of the Assisted Living building and the shortest total distance was 63 yards. In an interview, on 2/22/11 at 3:20 PM, nurse aide #28 stated she was working E Hall on second shift on 2/17/11. Nurse aide #28 said she didn't know how Resident #106 "got out" and that the alarm at the D/E Administration door, "goes off multiple times all day...that alarm goes off every 5 minutes of the day...its a busy hall...it goes off about 150 times (during second shift)". Nurse aide #28 stated that when she was serving dinner in the Activity Center in the Administration lobby, she saw Resident #106 trying, unsuccessfully, to exit the D/E Administration door, on 2/17/11 at around 5:45 PM. In an interview, on 2/23/11 at 1:45 PM, Activities Director #33 stated resident could easily slip through the D/E Administration door and exit the facility during evening because often there is only one activity aide to conduct the evening activities and that aide must go into the units to get residents and bring them to the Activity room, leaving the other residents alone in the Activity room when she does so. The Activities Director #33 also stated that the Activities Room was open 24 hours a day, 7 days a week because, "The room has to be open at 7:00 AM for breakfast". In an interview, on 2/23/11 at 10:05 AM, nurse aide #13 stated she worked D Hall on second shift on 2/17/11. Nurse aide #13 stated she normally checked the D/E Administration door when it alarmed but did not hear the alert or alarm go off that night. Nurse aide #13 said, "I am so busy with residents coming back from supper. Break time is between 7:00 and 8:00 (PM), which leaves one CNA (nurse aide) on the floor for 30 minutes". In a telephone interview, on 2/22/11 at 3:55 PM, nurse aide #11 stated she was assigned to Resident #106 but was on break, in the break room, at the time Resident #106 "went outside" on 2/17/11. Per Resident #106's "Interdisciplinary Notes", dated 2/17/11 at 7:55 PM, signed by LPN #9, "Resident noted sitting in his wheel chair lobby of (Assisted Living facility) Asked ... happenen(d) stated he doesn't know...lateral side left eye small abrasion 0.4 cm x 0.3 cm. L (left) hand knuckles red. Abrasion L knee. Denies pain. Able to move all extremities without difficulty. ...neuro (neurological) checks within normal limits..." Resident #106's "Neurological Assessment" flow sheet revealed, on 2/17/11 at 7:30 PM, Resident #106's blood pressure was 120/68, his temperature was 99.2 degrees Fahrenheit, his pulse was 73 beats per minute, his respirations were 18 per minute and his neurological check was within normal limits. On 2/23/11, this surveyor accompanied staff to check the function of the 15 Wanderguard bracelets in use on the residents identified at risk for wandering and all functioned properly. During the survey, this investigator interviewed 2 nurses (LPN #9 and LPN #10) and 3 nurse aides (#11 and #13 and #28) that were working 2/17/11 on second shift on C Hall, D Hall and E Halls, and all denied witnessing Resident #106 exit the building. On 2/22/11 at 12:40 PM, Resident #106's wife #21 stated someone from the facility called her to tell her that her husband (Resident #106) followed a lady outside but didn't get very far. Resident #106's wife stated, "I'm glad he didn't get away...They kept apologizing". Resident #106 was alert and smiling but did not respond when spoken to by this surveyor. On 2/23/11 at 1:35 PM, Administrator #2 was notified of the Immediate Jeopardy that began on 1/17/10 as a result of the facility's failure to provide supervision to prevent elopement and ensure the safety of two residents (Resident #101) when he eloped from the facility for 15 minutes on 1/17/11 without staff knowledge, and was found outside alone, in below freezing weather, without protective winter clothing, crawling in the snow 15 yards towards from a city road, and (Resident #106) when he eloped from the facility for 20 minutes on 2/17/11 without staff knowledge, and was observed entering an entrance in the Assisted Living facility without protective winter clothing, and placing 13 additional residents, who were assessed to be at high risk of elopement, at a high risk for elopement with the potential for serious injury, harm, impairment and or death. On 3/01/11, the Surveyor confirmed that the facility implemented the following to remove the Immediate Jeopardy on 2/22/11: 1). On 1/17/11, resident #101 was returned to the facility at 8:30 PM and assessed by nursing; no injury was identified and Resident #101 was placed on 1:1 supervision. 2). On 1/17/11 at 8:30 PM, the door alarm key (for the egress door between C Hall and D Hall) was turned to the horizontal position which allowed the alarm to sound continuously when the door was opened until the alarm was manually erset by staff. 3). On 1/17/11 at 8:35 PM, a Wanderguard bracelet was placed on Resident #101 and checked for proper function. 4) On 1/17/11, education on wandering resident safety precautions was initiated. All of the 141 employees received the training that was completed on 1/23/11. 5). On 1/18/11, care plans for the 15 facility residents identified as an seeking risk were reviewed and updated. 6). On 1/18/11, maintenance director #18 checked the function of all of the facility doors and alarm systems and all were working properly. 7). On 1/19/11, the facility began checking and logging exit door alarms for functionality every four hours. 8). On 2/17/11, at 7:30 PM, resident #106 was returned to his room and a body audit was conducted, vital signs taken and the abrasion on his left hand, left lateral side of the eye, and left knee were cleansed. 9). On 2/17/11, at 7:30 PM, neuro checks were initiated for Resident #106, he was placed on 1:1 supervision, and his Wanderguard was tested and found to be functioning properly. 10). On 2/22/11, the facility reviewed and updated the "Wandering Resident/Elopement" policy and procedure. 11). Reeducation on wandering resident safety precautions was initiated on 2/18/11 and completed for all 141 facility employees and for 37 of the 39 Assisted Living facility employees on 2/22/11. The last employee has been notified that she is not allowed to work until the inservice is completed. 12). On 2/18/11, the maintenance director #18 disabled the D/E Administration handicap power door release and added a Wanderguard antenna with an 8 foot sweep; the facility began checking and documenting the function of the D/E Administration alarm every four hours. 13). On 2/18/11, the facility began performing elopement drills and will continue to conduct elopement drills 2 times per week for 12 weeks. 14). On 2/22/11, the facility began staff monitoring of the D/E administration door during non-business hours (4:30 PM - 8:00 AM). 15). On 2/23/11, door alarms were ordered for the for unalarmed doors in the Administration lobby (one east egress, one west egress and two leading to the Assisted Living facility to be installed by 2/25/11. Although the Immediate Jeopardy was removed on 2/22/11, the facility remains out at a scope of isolated and severity of no actual harm, but potential for more than minimal harm that is not immediate jeopardy due to all staffs have not received the education listed above and sustained compliance had not been verified by the State Agency. ( )