Every finding on record at Lakepointe Senior Care and Rehabilitation Center

This citation pertains to Intake 3106836.Based on observation, interview, and record review, the facility failed to implement a care plan to meet the psychosocial needs for one resident (R2) of three whose care plans were reviewed. Findings include: On 08/11/2026 at 3:46 PM and on 08/13/26 at 10:56 AM, R2 was seated in a wheelchair in their room. R2 reported they had moved to their current unit about two months ago and believed one of the nurses (Licensed Practical Nurse (LPN) A was not giving them the correct medication. R2 reported two nurses were care planned to give the medication, and this was not always happening, so they were still not getting the correct medication when LPN A worked, which caused them anxiety and pain. A progress note dated 08/05/26 at 9:45 AM, documented, .changed medication administration times to have 2 nurses present during medication pass . A review of the active care plan documented, Mood: I was admitted to the facility on psychotropic medication due to my diagnosis of Depression, Anxiety (disorder) D/O and Schizophrenia. I was evaluated psych services and given (additional) add'l diagnosis of Schizoaffective D/O-Bipolar Type, (General Anxiety Disorder) GAD, (attention deficit disorder) ADHD, Adjustment D/O, Mood D/O and Major Depression . Administer my medication as ordered. Date Initiated: 09/06/2025. Two person Staff approach at all times for safety. Date Initiated: 09/08/2025. Behavior .It has also been reported that I am medication seeking, demanding medication and then accusing the staff of being a junkie, taking my medication themselves . Date Initiated: 09/16/2025 . Revision on: 08/04/2026 . Further review of the care plan documented a one person assist for showers and transfers initiated on the same dates and the care plan did not specifically address the need for two nurses or staff to be present during medication pass. A review of the psych note dated 08/07/26 documented the visit was to address resident concerns about nursing and medications and food. The note documented prior resident concerns with nurses and medication and food. The note further documented a pattern of medication refusals and subsequent medication changes. A review of a progress note authored by Licensed Practical Nurse (LPN) A dated 07/19/2026 (12:33 AM) 00:33 revealed .Medication Administration .Note: oxycodone (opioid pain medication) HCl (hydrochloride) Oral Tablet 5 MG (milligram) Give 1 tablet by mouth every 6 hours for Pain, writer and staff Certified Nurse Assistant (CNA) LR in to give medication, resident says this is not the correct medication, wants to see the packaging from pharmacy that it came in. Writer retrieves packaging from narcotic box on medication cart and shows it to resident. Resident does then agree that the pill in the medication cup is the ordered medication and takes it. On 08/12/2026 at 3:43 PM, the midnight schedule for August 2026 for R2's wing was reviewed with the Unit Manager E. The schedule documented LPN A worked: 8/1, 8/2, 8/4, 8/5, and 8/6/26. A review of the progress notes for these dates revealed no documentation a second nurse or staff member was present for the medication administrations. The Unit Manager acknowledged the issue with R2's medication and LPN A had come to their attention in the last couple of weeks or so. A nurse progress noted dated 08/02/26 at 4:46 AM, documented LPN A went to (R2s) room for medication pass . The note did not indicate a second staff member was present. On 08/12/2026 at 4:13 PM and on 08/13/26 at 12:50 PM, the Director of Nursing (DON) acknowledged the concern by R2 about LPN A and reported R2's medication administration schedule had been changed to 7 AM, 3 PM and 11 PM to coincide with the ongoing and off going nurses to have the second nurse available to witness the medication pass. It was not confirmed that two nurses or staff were always present during care or the medication pass. Documentation of two staff for the medication administration for R2 was requested but not provided prior to survey exit. A review of the Resident Information sheet revealed, R2 was admitted in the facility on 09/05/25 with diagnoses that included, Anxiety Disorder, Schizophrenia, Bipolar Disorder and Major Depression. The Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition with a 15/15 Brief Interview for Mental Status score and independent or the need for one person assistance for activities of daily living.A review of the policy titled, Care Planning-Interdisciplinary Team revised December 2008, revealed, Our facility's Care Planning Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident . The resident, the resident's family, and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions the resident's care plan .

Based on observation, interview, and record review, the facility failed to apply personal protective equipment (PPE) and properly store a nebulizer (breathing) mask for one resident (R133) on enhanced barrier precautions (EBP) out of seven reviewed for infection control. Findings include:On 8/11/2026 at 11:00 AM, R133 was observed being taken in the room after receiving a shower. A butterfly was on the door that indicated R133 was on EBP and listed gloves and a gown be worn for high care activities (e.g. bathing, dressing, care). Staff were noted to be in room and getting R133 off the shower bed, dressing them, and putting them in bed. Staff were observed to only have gloves on. On 8/11/2026 at 2:21 PM, R133's nebulizer mask was observed on the nightstand, the mask appeared to have residue on the inside and was sitting on the nightstand with no barrier.On 8/12/2026 at 9:26 AM, R133's nebulizer mask was observed on the nightstand, the mask appeared to have residue on the inside and was sitting on the nightstand with no barrier.On 8/12/2026 at 1:14 PM, Certified Nursing Assistant (CNA) J was observed in R133's room and changing their brief. CNA J was noted to only have on gloves. CNA J was asked if they were aware R133 was on EBP and what PPE should be worn the CNA stated they saw the butterfly and should have worn a gown during care.A review of the medical record revealed R133 was admitted into the facility on 5/19/2026 with the following medical diagnoses, Acute Respiratory Failure with Hypoxia and Encounter for attention to Gastrostomy (R133 has a tube in stomach that they are fed through). A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 0/15 indicating an impaired cognition and required staff assistance for bed mobility and transfers. On 8/13/2026 at 10:58 AM, R133's nebulizer mask was observed on the nightstand, the mask appeared to have residue on the inside and was sitting on the nightstand with no barrier.On 8/13/2026 at 1:02 PM, an interview was conducted with the Infection Control Preventionist (ICP) who stated they expect staff to wear a gown and gloves when performing high care activities such as, bathing, dressing, and incontinence care and nebulizer masks should be cleaned and stored in a bag when not in use. A review of a facility policy titled, Nebulizer noted the following, .EQUIPMENT CLEANING:10. Following medication administration, disconnect nebulizer cup/mask/mouthpiece from tubing, rinse equipment with hot water and place on paper towel to completely air dry.11. Remove gloves and wash hands.12. Once nebulizer cup/mask/mouthpiece is completely dried place in storage bag.A review of a facility policy titled, Enhanced Barrier Precaution - Policy - Procedures noted the following, Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing.

Based on observation, interview, and record review, the facility failed to maintain a homelike environment affecting one resident (R9) of two residents reviewed for environment. Findings include:On 8/11/26 at 10:05 AM, R9 was observed lying in bed watching television and was able to answer simple questions. A large (about the size of a tennis ball) brown stain was observed on the privacy curtain near their bed. When asked about the curtain, R9 stated, that looks nasty and should be cleaned. R9 was unsure how long the stain had been there.On 8/11/26 at 2:10 PM, R9 was observed lying in bed looking out the window. The brown stain on the privacy curtain was clearly visible from the hallway.On 8/12/26 at 10:02 AM, R9 was observed lying in bed watching television. The large brown stain was observed as before on the privacy curtain.A record review revealed R9 was originally admitted on [DATE] and recently readmitted on [DATE] with medical diagnoses including Vascular Dementia, and Right Hemiparesis (muscle weakness). A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 0/15 indicating an impaired cognition and required staff assistance for bed mobility and transfers. On 8/12/2026 at 11:46 AM, during a tour of R9's room with the Nursing Home Administrator (NHA) the soiled privacy curtain was observed hanging between resident beds. The NHA acknowledged the soiled curtain and confirmed environmental rounds are completed daily. A review of the facility's policy titled, Quality of Life - Homelike Environment revealed that residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Cleanliness and order; .

Based on observation, interview, and record review, the facility failed to revise the care plan for one resident (R05) of one resident reviewed for care plans. Findings include:R5On 8/25/25 at 9:30 AM, R5 was observed laying in their bed with their leg hanging over the bed. When asked about care, R5 shook their head and stated, it's okay. A review of the Electronic Medical Record (EMR) revealed R5 was originally admitted on [DATE] with pertinent diagnosis of Dementia, Delusion Disorders, and adjustment disorder. Further review revealed a Brief Interview for Mental Status score which indicated intact cognition and required maximum assistance with all activities of daily living.A review of R5's EMR revealed Behavior Notes on 8/1/25, 8/3/25, 8/9/25, 8/11/25, 8/15/25, 8/21/25 and 8/23/25, indicating R5 exhibited behaviors of trying to disconnect, pull out or unscrewing their tube feeding (tube inserted into the stomach for food and fluids).Review of R5's EMR care plan dated 7/16/25 and revised 8/7/25, with a focus of Mood / Behaviors did not show any interventions for the behavior of disconnecting the tube feeding.On 8/27/25 at 1:35 PM, the Director of Nursing (DON) was queried about R5 behaviors and lack of interventions and said R5's behaviors were redirected after each incident of disconnecting the tube feeding. The DON indicated their expectations regarding care plans were care plans should be updated and/or revised due to specific changes and as needed per care plan policy.A review of the policy titled, Care Planning - Interdisciplinary Team documented, the facility's care planning/ interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident.

Based on observation, interview, and record review, the facility failed to provide adequate facial hair grooming for one (R65) of five residents reviewed for activities of daily living (ADL) care. Findings include: On 08/25/25 at 10:21 AM, R65 was observed lying in bed and appeared to be sleeping. It was observed that a notable amount of facial hair was present on their chin and jawline. Review of the facility record for R65 revealed an initial admission date of 09/13/21 with diagnoses including Chronic Pain Syndrome, Muscle Weakness, and Chronic Obstructive Pulmonary Disease. Review of R65's care plan dated 06/09/25 revealed the ADL Focus area that included the intervention Hygiene/Grooming: 1 PA (person assist) Please remove any facial hair growth. The ADL care plan Goals statements included I will be neat, clean, and well-groomed daily through next review. The Kardex (nursing assistant care instructions) associated with R65's care plan included the instruction Ask if I would like to be shaved. On 08/26/2025 at 2:05 PM, R65 was interviewed in their room and asked how they feel about the facial hair present on their chin and jawline. They stated that they don't care for it and they prefer to have it kept clean shaven. The facial hair remained present as observed the previous day. The length and thickness of the hair appeared to be roughly four to five days of growth. On 08/27/2025 at 11:27 AM, R65 was interviewed in their room and asked if they recalled how often they were shaved and they stated Not often enough, usually on my shower day, I think. I really don't like when it's not clean. It bothers me enough that I thought about getting it removed permanently but I knew someone who tried that, and it didn't work. I wish they would do it at least every other day. R65 was asked if they ever refuse an offer to have their facial hair shaved and they stated No, I don't think I have. On 08/27/2025 at 1:53 PM, the facility Director of Nursing (DON) reported their expectation is that staff should offer to shave the resident per their care plan or when they notice facial hair growing in. Review of the facility policy Activities of Daily Living dated 07/01/08 included the Purpose statements .1. To assist resident in achieving maximum functional ability with dignity and self-esteem .2. To provide assistance to residents as necessary.

Based on observation, interview and record review the facility failed to ensure call lights were maintained within reach for dependent residents for six residents (R117, R6, R118, R48, R482, and R108) of eight reviewed for call light placement. Findings include: R117 A fall report dated 07/20/24 documented R117 had a fall from their bed. The reported indicated R117 rolled out of bed due to agitation. On 08/06/24 at 1:26 PM, R117 was observed to be in bed. The call light for R117 was observed to be looped over the bracket of the tube feeding machine. The machine/pole was at the top edge of the bed and away from the side of the bed around two feet. On 08/07/24 at 8:29 AM, R117 was observed to be in bed, on their left side, angled toward the door. The call light was on the floor around the base of the tube feed stand. On 08/07/24 at 7:55 AM, 8:29 AM, and 9:16 AM, R117 was observed to be in bed. The call light was at foot of tube feed pole. At 10:54 AM and 1:43 PM, R117 was observed to be on their left side in bed. The call light was on the floor at the feet of the tube feed pole. A review of the record for R117 revealed R117 was admitted into the facility on [DATE]. Diagnoses included Stroke, Malnutrition and Heart Attack. The Minimum Data Set (MDS) assessment dated [DATE] indicated severely impaired cognition and total dependence for all Activities of Daily Living, bed mobility and transfer. The care plan dated 02/27/27 documented .Please help me get turned while in bed or in my wheelchair .Bed Mobility 2 (person assist) PA .Call light accessible .I have cardiac issues .Anticipate needs if unable to communicate them myself . On 08/08/24 at 8:57 AM, the clinical care coordinator/unit manager (CCC) O for R117 was asked about call light use by R117 and reported R117 had used it prior to the decline but currently did not use it much. On 08/08/24 at 12:04 PM, call light position for residents was reviewed with the Director of Nursing (DON). The DON reported call lights should be in reach unless otherwise documented in the plan of care. 50223 R6 On 08/06/24 at 9:21 AM, R9 was observed sitting on the side of their bed. R9's call light was observed hanging on the wall behind their bed out of reach. R9 was asked do you have a call light? R9 stated No. All I have to do is yell. On 08/07/24 at 10:36 AM, R9 was observed sleeping in bed. R9's call light was observed on the floor under their bed out of reach. On 08/07/24 at 1:06 PM, 2:17 PM, and 4:07 PM, R9's call light was observed to still be on the floor under their bed out of reach. On 08/08/24 at 1:08 PM, R9 was observed sitting in their recliner. R9's call light was observed on their bed across the room out of reach. A review of R6's record reveals that they were admitted to the facility on [DATE] with a diagnosis of heart failure, unspecified, and dementia. A review of R6's minimum data set (MDS) reveals a brief interview for mental status (BIMS) score of 6 indicating cognitive impairment. R48 On 08/06/24 at 8:53 AM, R48 was observed lying in bed. R48's call light was observed hanging on the wall above the head of their bed out of reach. R48 was asked, do you have a call light. R48 stated, no. On 08/06/24 at 10:20 AM, 12:06 PM, and 2:39 PM, R48 was observed sitting up in a medical recliner in their room. R48's call light was observed on the floor, under their bed across the room out of reach. On 8/8/24 at 1:05PM, R48 was observed sitting up in their chair. R48's call light was observed hanging on the wall above the head of their bed across the room out of reach. A review of R48's record revealed that they were admitted to the facility on [DATE] with a diagnosis of neurocognitive disorder with lewy bodies and unspecified dementia. A review of the MDS revealed a BIMS score of 11 indicating cognitive impairment. R108 On 08/06/24 at 9:23 AM, 10:17 AM , 12:20 PM, 08/06/24 at 12:21 PM, and 2:26 PM, R108 was observed in bed with head elevated. R108's call light was observed hanging on wall above head of bed out of reach. On 08/07/24 at 8:17 AM, 10:34 AM, and 1:06 PM, 2:17 PM, and 4:04 PM, R108 was observed in bed with head elevated. R108's call light was observed hanging on wall above head of bed out of reach. 08/08/24 at 8:01 AM, 8:30 AM, R108 was observed in bed. R108's call light was observed out of the residents reach. On 08/08/24 at 08:47 AM, during an interview certified nurse assistant CNA A was asked if R108 was supposed to have a call light. CNA A stated, yes. CNA A was observed to look at R108's call light hanging on the wall and then placed it on R108's bed within their reach. A review of R108's record revealed they were admitted to the facility on [DATE] with a diagnosis of acute on chronic congestive heart failure and acute on chronic respiratory failure, unspecified dementia. A review of the MDS revealed a BIMS score of 6 indicating cognitive impairment. R118 On 08/06/24 at 10:41 AM, R118 was observed in bed. R118 stated, can I get some pain medication? R118 was asked if they had their call light. R118 responded, No. R118's call light was observed to be on the floor under their bed out of reach. On 08/06/24 at 12:23 PM, R118 was observed to be yelling I need a pain pill! R118's call light was observed to be on the floor behind the back of their bed out of reach. On 08/08/24 at 1:09 PM, R118 was observed in bed and their call light was observed to still be out of reach as previously described. R118 was asked if they had their call light. R118 stated no. R118 was asked, what happens if you need help? R118 responded, I yell. A review of R118's record revealed they were admitted to the facility on [DATE] for a diagnosis of delusional disorders and other chronic pain. A review of the MDS revealed a BIMS score of 12 indicating cognitive impairment. R482 08/06/24 at 10:08 AM, R482 was observed in bed. R482's call light was observed on the floor next to their bed out of reach. On 08/07/24 at 10:38 AM, 11:57 AM, and 01:08 PM, R482 was observed sitting up in their chair. R482's call light was observed on their bed by the pillow not in reach. A review of R482's record revealed they were admitted to the facility on [DATE] with diagnosis of cerebral infarction due to embolism of right cerebellar artery. A review of the MDS revealed a BIMS score of 00 indicating cognitive impairment. On 08/08/24 at 9:06 AM, during an interview, Licensed Practical Nurse (LPN) B explained the policy is call lights are within reach and if someone can't use a regular call light they use a different type that can go under their pillow. On 08/08/24 at 9:37 AM, during an interview, the Director of Nursing (DON) explained it was their expectation everyone should have a call light in reach and that if a resident prefers it in a certain place like on their bed side table, they try to follow their preferences. A review of the facility's policy titled Call Light Policy states: POLICY: Call lights will receive consistent and adequate response in order to best meet the individual needs of each resident. PROCEDURE: 1. Call lights will be placed within reach of the resident 2. Call light activation will be identified by a light above the resident doorway and an audible alarm at/near each nursing station or a paging system with monitors. 3. Call lights will remain on until staff is available to meet the resident needs/requests. 4. Call light responses will be prioritized based on need, not necessarily in order received. 5. Priority responses may include but are not limited to: falls, injury, and medical emergency 6. Each staff member is responsible to respond to call lights and provide assistance as their level of training allows. 7. Call light response time may vary dependent on time of day, individual resident need, and the number of call light requests at any given time. 8. Concerns related to call light response time will be documented utilizing the Concern/Grievance procedure and followed up through QAPI and/or resident council.

Based on observation, interview, and record review, the facility failed to administer PEG (Percutaneous Endoscopic Gastrostomy) tube feeding and medication via feeding tube per physician's orders or one (R482) out of one reviewed for PEG tube use. Findings include: R482 On 08/07/24 at 2:26 PM, R482 was observed in their medical recliner chair. A tube feeding pump was observed in the room which was powered off. No tube feeding bottles or tube feeding were observed in the room. On 8/7/24 at 4:15 PM, R482 was observed in their chair. Tube feeding is observed infusing at 65ml (milliliters) per hour through a pump. The pump was observed to show a remaining volume of 1220ml. On 08/08/24 at 8:05 AM, R482 was observed lying in bed on their back. No tube feeding was observed infusing or in the room. The pump was observed next to the resident's bed powered off. There was no tube feeding bottle or tubing noted in the room. A review of R482's record revealed they were admitted to the facility on [DATE] with diagnosis of cerebral infarction due to embolism of right cerebellar artery. A review of the minimum data set revealed a Brief interview for mental status score of 00 indicating cognitive impairment. A review of R482's physician orders revealed the following order: Enteral feed every shift for nutrition and hydration Tube feeding: Jevity 1.5 @ 65ml/hr x 20hrs (up 2pm/down10am)or until dose complete = 1300ml/1950 calories via pump. Flush PEG tube with 65ml/hr water while TF (tube feeding) is infusing. A review of R482s medication orders revealed an order for Levothyroxine to be administered at 5:00AM. On 08/08/24 at 8:38 AM, during an interview, Licensed Practical Nurse (LPN) B confirmed R482 has tube feeding that is supposed to infuse from 2PM until 10 AM. LPN B was asked why R482's tube feeding was not currently infusing. LPN B stated let me check with the night nurse, (they) are still here and gestured to the nurses station. On 08/08/24 at 8:40 AM, a concurrent interview was conducted with LPN E and Clinical Care Coordinator (CCC) C. LPN E stated, The order is for it to infuse for that time frame or until the volume is complete. LPN E was asked if they knew why it was taken down early. and comfirmed they were the one that took the tube feeding down. LPN E was asked what time they stopped the tube feeding. LPN E just a little bit ago like 8:15AM. LPN E was asked if nurses put in a progress note or anything when tube feeding is started stopped or flushed. CCC C explained that they do not put in a note and that they just follow what the physician order says. CCC C was asked if R482's tube feeding is being held before and after the administration of levothyroxine. CCC C stated it doesn't have to be held for that and explained that the pharmacy that the facility used to use told them that it did not have to be held. On 08/08/24 at 9:12 AM, during an interview, Registered Dietician (RD) stated t R482 gets Jevity 1.5 at 65ml per hour and it should it be running for 20 hours. RD was told that R482's tube feeding was not started until sometime after 2:30PM and was already stopped sometime prior to 8:05AM. RD confirmed the resident would not be getting (their) caloric needs. R482 consumes nothing by mouth so we don't want to pause it for too long. On 08/08/24 at 9:37 AM, during an interview, the DON explained that tube feeding should be held for residual amounts over 100 (ml) and the doctor should be notified and it should also be held if the resident needs to lay flat during care or changing. The DON stated, the orders say the dose and time to hang and take it down. if something happens in between that's abnormal they would put an order to hold it and they should let each other know and put in a nurses note. The DON was asked if tube feeding should be held before and after the administration of Levothyroxine. The DON stated pharmacy has not made that recommendation. The pharmacy told us that Levothyroxine only interacts with soy, dairy and caffeine. On 08/08/24 at 10:02 AM, The DON was provided the manufacturers label for Jevity 1.5 which listed three soy containing ingredients and also included a warning that the product contains milk and soy. The DON stated, I will have to get with pharmacy about this. A review of the manufacturer's recommendation for Levothyroxine states Take Synthroid with only water and on an empty stomach. Wait 30 minutes to 1 hour before eating or drinking anything other than water A review of the facility's policy titled Enteral Nutritional Feeding states the following: Enteral Feeding Includes: PURPOSE: To provide liquid nourishment and adequate hydration through a tube, into the stomach. ENTERAL TUBE FEEDING: The physician order is to include the following: a. Formula b. Route c. Rate d. Gravity or pump e. Start and stop times f. Total amount of water intake to be consumed in 24 hours 1. The Dietician or Licensed Nurse will determine how water allowance is distributed, and this will be documented in the medical record 2. Checking Residual- a. Will be completed per physician order only b. Use a syringe to aspirate stomach secretions. c. If residual is present follow physician orders for replacement of feeding contents, holding of feeding, or disposal of content. d. If concerns with abdominal distention, pain, nausea, vomiting, of obstruction Notify physician for further orders 3. When pump is used follow manufactures directions for use. 4. Change and date enteral tubing with each new bottle of formula 5. Syringe is labeled and dated and replaced every 24 hours. 6. Closed tube feeding formula will hang no longer than 48 hours and open systems no longer than 8 hours unless otherwise specified by the manufacturer. 7. Administration of tube feeding and water flushes will be documented in the medical record Nursing .MONITORING THE RESIDENTS ON ENTERAL FEEDINGS: 1. Monitor resident's receiving tube feedings for complications which may include diarrhea, constipation, abdominal distention, nausea, vomiting, and aspiration 2. Notify the physician for any complications. 3. Head of bed must be elevated 30-45 degrees at all times during feeding and for at least 30 minutes after the feeding unless otherwise indicated per order/plan of care.

Based on observation, interview, and record review, the facility failed to maintain the dignity of one (R101) of six residents reviewed for dignity. Findings include: Review of the facility record for R101 revealed an admitted [DATE] with diagnoses that included Heart Failure and Dementia. The record also indicated R101 was legally blind. On 08/06/24 at 10:38 AM, R101 was observed laying in bed and it was noted a list of hand written care instructions were posted above the head of the bed. The first item on the list stated He is a feeder. On 08/07/24 at 11:51 AM, R101 was observed in their room and the sign above the head of the bed stating He is a feeder remained in place. On 08/08/24 at 10:14 AM, R101 was observed laying in bed and the sign stating He is a feeder remained posted above the head of the bed. R101 was asked about the signs and stated I don't know what they are. On 08/08/24 at 1:42 PM, the facility Director of Nursing (DON) reported they were not aware of the sign referring to the resident as He is a feeder. The DON reported their expectation is that type of wording would not be used or posted. A facility policy addressing resident dignity was requested but not received. The facility did provide the document Know Your Rights - Your Medicaid Care and Coverage in a Nursing Facility. This document included the section Quality of Your Medical Care which included the entry These services must be provided in a confidential and dignified manner .

Based on observation, interview, and record review the facility failed to implement care plan interventions for three residents (R40, R108 and R482) of six reviewed for care planning. Findings include: On 8/6/24 at 9:49 AM, R40 was interviewed regarding the care and services they were receiving at the facility and indicated that they had experienced multiple falls at the facility. A review of R40's electronic medical record (EMR) progress note section revealed the following, 5/25/2024 23:13 (11:13 PM) Nurses: [R40] said [they] fell on the floor trying to get a cake from [their] roommate's daughter's boyfriend. Nurse and aide did not [witness] the fall. Roommate's granddaughter witnessed the fall. [They] said [R40] fell on the floor trying to [get] cake. They said [R40] fell on [their] back, but did not hit [their] forehead. [R40] told the writer and the aide [they] fell on the floor and hit [their] forehead, but later said [they] did not hit [their] forehead, but rather the back of [their] head. Witness said [R40] fell on the floor, but did not hit the back of [their] head. A review of an incident and accident (I/A) report involving R40 dated 5/25/2024 22:44 (10:44 PM) indicated that [R40] had a fall in their room witnessed by their roommate's sister. Per the I/A resident assessments were completed and vitals were taken. No injuries indicated. Resident Description: I fell but did not hit my head. 5/30/24 IDT (Interdisciplinary Team) met to review and concur .Intervention: Medication review by physician. A review of R40's fall care plan interventions revealed the following, Interventions .Physician to review medication administration post fall, assess 6[00 AM] medications given concurrently. Date Initiated: 12/04/2023. Post fall 12/12/23: antihypertensive medication reviewed my MD (Medical doctor), d/c (Discontinue) Metroprolol. Check orthostatic BP (Blood pressure) Bid (Two times a day) x 3 days and report abnormal results to physician. Date Initiated: 12/12/2023. Further review of R40's fall care plan revealed there was no documented intervention following R40's fall on 5/25/24. A further review of R40's EMR revealed psychiatric visit documentation provided by [Psychiatric provider agency] which indicated that R40's psychotropic (mental health) medication was reviewed by the psychiatric provider on 6/21/24. There was no observed documentation in R40's record which indicated the physician had reviewed R40's prescribed medication following their fall on 5/25/24. R40's EMR revealed R40 was most recently admitted to the facility on [DATE] with diagnoses which included Anemia (deficiency of red blood cells) and Muscle weakness. R40's most recent quarterly minimum data set assessment (MDS) dated [DATE] revealed that R40 had an intact cognition and was independent-required partial assistance for all activities of daily living (ADLs). On 8/7/24 at 2:20 PM, the Director of Nursing (DON) was interviewed regarding their expectations for recommendations being implemented and followed, and new interventions being placed on a resident's care plan following a fall and indicated the expectation was recommendations be, Implemented and followed up on. The DON was further interviewed regarding implementation of the recommendation following R40's fall on 5/25/24. The DON confirmed the physician did not document their review of R40's medication per the recommendation. 50223 R108 On 08/06/24 at 9:23 AM, 10:17 AM, 10:40 AM, 12:20 PM, 08/06/24 at 12:21 PM, and 2:59 PM, R108 was observed lying in bed. R108's heels were observed to be resting directly on the bed. Heel protector boots were observed in a wheelchair behind the door in the room. R108's call light was observed hanging on wall above the head of the bed out of the residents reach. On 08/07/24 at 8:30 AM, R108 was observed in bed. Heel protector boots were observed in the corner of the room. R108's call light was still hanging on the wall above R108's head of their bed out of reach. On 08/07/24 at 10:34 AM, 11:55 AM and 2:59 PM, R108 was observed lying in bed. The heel protector boots were observed in the closet. R108's call light was observed hanging on the wall above the head of their bed out of their reach. On 08/07/24 at 4:04 PM, R108 was observed lying in bed. Heel protector boots were observed still in R108's closet. R108 was asked if they were supposed to wear heel protector boots when they're in bed. R108 stated, yes. R108 was asked if they wore them at all today. R108 stated I don't think so. R108's call light was observed hanging on the wall above the head of their bed out of their reach. On 08/08/24 at 8:01 AM, R108 was observed in bed. Heel protector boots were observed to still be in the closet. R108's call light was observed hanging on the wall above the head of their bed out of reach. On 08/08/24 at 8:47 AM, during an interview, certified nurse assistant (CNA) D was asked if R108 was supposed to wear heel protector boots while in bed. CNA D responded they have never noticed R108 to have boots on. On 08/08/24 at 9:00 AM, during an interview CNA A was asked if R108 is supposed to be wearing heel protector boots. CNA A stated yes. CNA A was observed to look at R108 then look around room and in closet. CNA A was then observed applying the heel protector boots. CNA A was asked if R108 was supposed to have a call light. CNA A stated, yes. CNA A was observed to look at R108's call light hanging on the wall and then placed it on R108's bed within their reach. A review of R108's record revealed they were admitted to the facility on [DATE] with a diagnosis of acute on chronic congestive heart failure and acute on chronic respiratory failure, unspecified dementia. A review of the minimum data set (MDS) revealed a Brief interview for mental status (BIMS) score of 6 indicating cognitive impairment. A review of R108's care plan revealed the following interventions: BLE soft boots on during the day to prevent contracture; Call light accessible R482 On 08/06/24 at 10:08 AM, R482 was observed in bed. R482's heels were observed resting directly on the bed. One heel protector was observed across the room in R482's (medical recliner) chair. R482's call light was observed on the floor next to their bed out of their reach. On 08/06/24 at 12:28 PM and 08/06/24 at 2:29 PM, R 482 was observed in their chair with their heels resting directly on the chair cushion. On 08/07/24 at 8:25 AM, A heel protector was observed on R482's right foot only. R482's left heel was observed resting directly on the bed. 08/07/24 at 10:38 AM, 11:57 AM, and 1:08 PM, A heel protector was observed on R482's right foot only. R482's left heel was observed resting directly on the bed. R482's call light was observed on their bed by the pillow not in reach. 08/07/24 at 2:26 PM, and 4:15PM, R482 was observed lying in bed. A heel protector was observed on R482's right foot only. R482's left heel was observed resting directly on the bed. On 08/08/24 at 8:05 AM, R482 was observed lying in bed with heels resting directly on bed. On 08/08/24 at 8:58 AM, during an interview in R482's room CNA A was asked if R482 was supposed to be wearing heel protectors. CNA A stated yes CNA A was asked if they are supposed to be on both feet. CNA A stated both, because (their) not moving. CNA A was asked if R482 repositions themselves at all. CNA A stated I'm not very familiar with (them) but just by looking at (them) I'd say not enough, and we should be doing it. I'll go down and get (them) some heel protectors. On 8/8/24 at 1:02 PM, R482 was observed in their chair on their back with their heels resting directly on the chair cushion. A review of R482's record revealed they were admitted to the facility on [DATE] with diagnosis of cerebral infarction due to embolism of right cerebellar artery. A review of the MDS revealed a BIMS score of 00 indicating cognitive impairment. A review of R482's care plan states: assist me with floating my heels. Please help me get turned and repositioned while in bed or in my wheelchair/chair; Call light accessible A review of the facility's policy titled Care Plans-Comprehensive states the following: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the residents medical, nursing, mental, and psychological need is developed for each resident. 1. Our facility's care planning interdisciplinary team in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 2. The comprehensive care plan is based on a thorough assessment that includes but is not limited to the MDS. 3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associate with identified problems; c. Build on the resident's strengths; d. Reflect the residents expressed wishes regarding care and treatment goals; e. Reflect treatment goals, timetables and objectives in measurable outcomes; f. Identify the professional services that are responsive for each element od care; g. Aid in the preventing or reducing declines in the residents functional status and/or functional levels; h. Enhance the optimal functioning of the resident by focusing in a rehabilitative program and j. Reflect currently recognized standards of practice for problems areas and conditions.

Based on observation, interview, and record review, the facility failed to revise the care plan for one (R101) of six residents reviewed. Findings include: Review of the facility record for R101 revealed an admitted [DATE] with diagnoses that included Heart Failure and Dementia. The record also indicated that R101 was legally blind and stated under Special Instructions that all personal items should be within reach. On 08/06/24 at 10:38 AM, R101 was observed laying in bed. Their water cup was on the over-bed table next to the wall at the head of the bed, out of the residents reach. On 08/07/24 at 11:51 AM, R101 was observed laying in bed. Their water cup was on the over-bed table next to the wall at the head of bed as it was the previous day. R101 was asked if they were able to reach their water cup if they wanted a drink and they stated No. On 08/08/24 at 10:14 AM, R101 was observed laying in bed. Their water cup was on the over-bed table adjacent to the head of bed, out of the resident's reach. Review of R101's care plan revealed no indication the resident should not have access to their water cup. On 08/08/24 at 1:48 PM, the facility Director of Nursing (DON) reported their understanding was that R101's water cup was kept out of reach as the resident has difficulty managing the cup independently due to impaired coordination and vision impairment. The DON reported their expectation is that the availability or placement of the resident's water cup as well as ensuring the resident is offered assistance for drinks of water between meals should be specifically addressed in the resident's care plan. Review of the facility policy Care Plans-Comprehensive revealed the entry Revisions: 8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change.

Based on observation, interview, and record review, the facility failed to safely secure medications for two (R6 and R29) of two residents reviewed for medication storage. Findings include: R6 On 08/07/24 at 8:16 AM and 08/07/24 10:36 AM, R6 was observed sleeping in bed. Timolol eye drops were observed on R6's bedside table within reach of R6. A review of R6's record reveals they were admitted to the facility on [DATE] with a diagnosis of heart failure, unspecified, and dementia. A review of R6's minimum data set (MDS) reveals a brief interview for mental status (BIMS) score of 6 indicating cognitive impairment. A review of R6 physician orders revealed no order for medication self-administration. R29 On 08/06/24 at 9:10 AM, 10:55 AM, 12:40 PM, and 2:23 PM, albuterol 90mcg (microgram) inhaler, artificial tears eye drops, and nasal spray medications were observed on R29's nightstand within R29's reach. On 08/07/24 at 8:09 AM, the albuterol 90mcg inhaler, artificial tears eye drops, and nasal spray medications were observed on R29's nightstand still within R29's reach. A review of R29's record revealed they were admitted to the facility on [DATE] with a diagnosis of periprosthetic fracture around internal prosthetic right hip joint. A review of R29's MDS revealed a BIMS score of 14 indicating cognitive impairment. A review of R29's physician orders revealed no orders for medication self-administration. On 08/07/24 at 10:45 AM, during an interview Clinical Care Coordinator (CCC) C was brought to the room of R6 and R29 and shown the medications at bedside. CCC C was asked if the medications are supposed to be kept at the bedside for the two residents. CCC C stated, As much as I'd love to say yes the answer is no. I'll take care of it. A review of the facility's policy titled Medication Administration states: Residents can self-administer medications when specifically authorized by the attending physician in accordance with procedures for self-administration of medication.

Based on observation, interview, and record review, the facility failed to secure on oxygen tank for one (R108) of one resident reviewed for oxygen therapy. Findings include: R108 On 08/06/24 at 9:23 AM, 10:17 AM, 10:40 AM, and 12:20 PM, an unsecured portable oxygen tank was observed in R108's room. On 08/07/24 at 8:17 AM, 10:34 AM, 11:55 AM, 2:17 PM, and 4:04 PM, R108 was observed in bed wearing oxygen per nasal canula via concentrator. An unsecured portable oxygen tank was observed in R108's room. A review of R108's record revealed they were admitted to the facility on [DATE] with a diagnosis of acute on chronic congestive heart failure and acute on chronic respiratory failure, unspecified dementia. A review of the minimum data set (MDS) revealed a Brief interview for mental status (BIMS) score of 6 indicating cognitive impairment. On 8/8/24 at 2:05 PM, during an interview, Clinical Care Coordinator (CCC) C was asked how portable oxygen tanks should be stored while in a resident's room. CCC C explained they can be in a metal wheeled holder or secured in a bag if it's on a wheelchair. A facility policy on oxygen storage was requested and not returned by the completion of the survey.

Based on observation, interview, and record review, the facility failed to consistently implement interventions to maintain or improve range of motion (ROM) and/or mobility, affecting three residents (R6, R22, and R77), resulting in the potential for further functional decline in joint motion and mobility. Findings include: Resident #6 (R6) On 6/26/23 at 9:31 AM, R6 was observed lying in bed. R6 did not respond to inquiry and was unable to be interviewed. On 6/26/23 at 2:36 PM, R6 was observed to still be lying in bed. A review of R6's record and Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was admitted into the facility on [DATE], most recently readmitted on [DATE], and is severely cognitively impaired. Further review revealed that the resident requires total assistance from one to two staff for activities of daily living (ADLs), mobility, and transfers. R6's medical diagnoses include Hemiplegia and Hemiparesis Following Cerebral Infarction, Generalized Muscle Weakness, Dysphagia, Adjustment Disorder With Mixed Anxiety and Depressed Mood, Aphasia Following Cerebral Infarction, Vascular Dementia, Unspecified Severity with Other Behavioral Disturbance, and History of Pneumonia. On 6/26/23 at 1:45 PM, Confidential Witness V was interviewed regarding any concerns with R6's care at the facility. Witness V indicated that they felt the resident had experienced a decline in their ability to perform ADLs. Witness V stated that the resident did have behaviors and was resistant to care in the past but had previously been able to be up and out of bed. Witness V then stated, Now (R6) just doesn't get out of the bed at all. Witness V had concerns related to ensuring that R6 received services to maintain mobility. A review of R6's most recent therapy discharge summaries revealed that the resident was discharged from Physical Therapy (PT) on 5/20/23 and Occupational Therapy (OT) on 5/22/23 with recommendations for restorative services (range of motion and bed mobility specifically). Both PT and OT determined that R6's prognosis to maintain current level of functioning was, Good with consistent staff follow-though (of restorative services). Further review of R6's record revealed the following physician order: RNP (restorative nursing program) .Active .6/1/2023. A review of R6's task documentation revealed the following: -Task: Nursing Rehab: rolling on alternating sides every 2 hours. Not Applicable, was documented for the above task on 6/1/23, 6/7/23, 6/8/23, 6/14/23, and 6/21/23. -Task: Nursing Rehab: Passive ROM (range of motion) to BUEs and BLEs (bilateral upper extremities and bilateral lower extremities) in suppose position in all possible planes. Not Applicable, was documented for the above task on 6/1/23, 6/5/23, 6/8/23, 6/14/23, 6/21/23, and 0 minutes spent providing the above task was documented on 6/12/23. Six documented refusals were noted since 6/1/23. On 6/27/23 at 8:27 AM, R6 was observed sitting upright in bed with their head down. R6 appeared to be sleeping. On 6/27/23 at 10:46 AM, R6 was observed lying in bed and appeared to be sleeping. Resident #22 (R22) A review of R22's record and MDS assessment dated [DATE] revealed that the resident was admitted into the facility on [DATE] and is mildly cognitively impaired. Further review revealed that the resident requires extensive assistance from staff for toileting, dressing, and bed mobility, total assistance for transfers, and limited assistance for personal hygiene. R22's medical diagnoses include Hemiplegia and Hemiparesis Following Cerebral Infarction, Dysarthria and Dysphagia Following Cerebral Infarction, Generalized Muscle Weakness, Chronic Pain Syndrome, Contracture, Diabetes, Polyneuropathy, Anxiety Disorder, Adjustment Disorder with Depressed Mood, and Obesity. Further review of R22's hospital records upon initial admission into the facility did not indicate that the resident was admitted with contractures. On 6/26/23 at 8:35 AM, during the initial tour, R22 was observed in bed, lying on their back at approximately 45 degrees. An adaptive walker with forearm support was noted in the corner of the resident's room. R22's left leg was bent up and lying on a pillow. R22 was observed without any supportive devices on, such as a splint or brace. When queried regarding therapy or restorative services, the resident stated they were not receiving any. R22 was asked how often they are moved in bed to which the resident responded, Never. Only when I have a bowel movement and they have to come change me. That's the only time they move me. R22's bed was observed without assist bars. On 6/26/23 at 10:05 AM, R22 was observed lying in bed and appeared to be sleeping. R22 was observed without any braces/orthotic support devices on and their left leg remained bent up on a pillow. On 6/26/23 at 11:02 AM, R22 remained in bed and appeared to still be sleeping. Two blue orthotic support devices (braces) were noted on the floor near the resident's bedside dresser. R22 was observed without any brace/devices on and their left leg remained bent up on a pillow. On 6/26/23 at 12:25 PM, R22 was observed lying in bed. R22 used the bed remote to lift the head of their bed up so they could eat, however, the resident was unable to further adjust themselves in bed on their own. R22 continued to have no braces/orthotic support devices on and their left leg remained bent up on a pillow. On 6/26/23 at 2:36 PM, R22 was observed to still be lying in bed. R22 was again interviewed at this time and stated staff hadn't moved them all day. R22 was asked if staff attempted to put any braces, splints, or orthotic devices on their extremities. R22 replied, No, and added that they had, Waited all day yesterday for someone to move (them) and no one did anything. On 6/26/23 at 3:54 PM, Certified Nursing Assistant (CNA) I and CNA J were preparing to provide incontinence care to R22. CNA I indicated that she had worked midnight shift (leaving around 7 AM this morning) and had come back to work afternoon shift. R22 stated they had not been changed since they last saw CNA I this morning. R22 repeatedly denied that they had been changed on day shift. CNA J told R22 and this surveyor that she believed what the resident was claiming. R22 became tearful and stated, You see? They don't get me up, they don't walk me, nothing. R22 continued to have no splint/braces/orthotic support devices on and their left leg remained bent up on a pillow. The staff were queried regarding assist bars on R22's bed. CNA I stated that to her knowledge, R22 has not had assist bars on their bed any time recently. R22 was observed to need the assistance of both CNA I and CNA J to turn in bed and receive incontinence care. The staff were then queried regarding knowledge of R22's mobility history and capabilities. CNA J indicated she was familiar with R22 because the resident had been on C wing in the past, where CNA J normally works. CNA J stated that R22 had been, better, when they were on C wing. CNA J elaborated that R22 had been up out of bed at that time and able to do some things for themselves. CNA J commented that R22 hasn't been doing those things now that they are on the A wing. R22's left leg remained bent up. When this surveyor attempted to inquire about R22's left leg, the resident became very tearful and upset. R22 stated that it is painful when staff stretch their leg out. CNA I carefully placed a pillow underneath R22's left leg. When queried regarding when the pain in their left leg started, R22 indicated the pain had started worsening approximately one year ago and stated, When I came over here (to A wing), because they wouldn't get me up and wouldn't walk with me. R22 became tearful again. R22's left arm and hand appeared bent, but the resident indicated that they still have some mobility in their left arm/hand because they try to, work on it themselves. On 6/27/23 at 8:23 AM, R22 was observed lying in bed, eating breakfast. R22 was unable to effectively use their left arm/hand. R22 was observed without any braces/orthotic support devices on and their left leg was bent up and resting on a pillow. R22 stated, They still didn't put my brace on. On 6/27/23 at 9:50 AM, R22 was observed lying in bed and appeared to be sleeping. R22 was observed without any braces/orthotic support devices on and their left leg was bent up and resting on a pillow. On 6/27/23 at 10:25 AM, R22 remained in bed and expressed frustration that, They just leave me in bed all day. The two blue orthotic support devices (braces) remained on the floor near the resident's bedside dresser. R22 was observed without any brace/devices on and their left leg remained bent up on a pillow. R22 was asked if staff applied their braces or did any restorative/range of motion with them yesterday to which the resident replied, No. On 6/27/23 at 10:29 AM, the Regional Clinical Director (RCD) was interviewed and stated that staffing doesn't allow for designated restorative staff, and it is a program that was recently reviewed across the board. On 6/27/23 at 11:43 AM, R22 was observed lying in bed and appeared to be sleeping. R22 was observed without any braces/orthotic support devices on. The two blue orthotic support devices (braces) near the resident's bedside dresser. On 6/27/23 at 12:26 PM, R22 was observed to still be lying in bed. R22 was again interviewed at this time and stated that staff had not attempted to put any braces, splints, or orthotic devices on their extremities. R22 added that they had only been changed one time this morning. On 6/28/23 at 9:09 AM, Licensed Practical Nurse (LPN) L was interviewed and indicated she was R22's assigned nurse today. LPN L was queried regarding if R22 experiences pain. LPN L indicated that the resident does have pain and has multiple medications ordered to manage it. LPN L was then queried if she ever sees R22 be active or get up out of bed. LPN L stated they had not worked on the unit in a while but could not recall recently seeing the resident get up/be active. On 6/28/23 at 9:18 AM, CNA K was interviewed and indicated that she was R22's assigned aide today. CNA K was queried if she had been informed that floor CNAs were responsible for carrying our restorative nursing services. CNA K responded, Not really, kind of .We do it (range of motion) when we get [residents] dressed. CNA K indicated she would have to look at the charts to determine which residents need specialized restorative services. CNA K was then asked if she had received training in restorative services to which she replied, No .ROM and things like that are part of regular CNA training .but haven't gotten 1:1 training. CNA K was then queried specifically regarding R22 and their required restorative services. CNA K indicated that she believes the resident needs to have their left leg straightened multiple times a day. CNA K stated, It's bent, it is very uncomfortable for (R22). The resident usually screams. CNA K indicated that R22 never refused restorative services attempts to her knowledge. On 6/28/23 at 11:41 AM, the Director of Nursing (DON) was interviewed and queried regarding who is responsible for carrying out and documenting Restorative Nursing Program (RNP) tasks. The DON stated that CNAs working the floor are assigned those duties. The DON acknowledged that she has identified the RNP tasks as not being completed per order. The DON was asked if there would be any reason for Not Applicable to be documented for an ordered RNP task. The DON responded, No, and indicated that if the CNA's encountered any issues with RNP tasks, they should report to nursing. When asked, the DON was unsure if the facility had provided training for the RNP to nursing/CNA staff. A review of R22's record revealed the following orders: -Restorative Nursing. Active 3/3/2023. -Pt (patient) would benefit from bilateral assist bars to promote participation in bed mobility and ADLs (activities of daily living). Active 11/2/2021. -Patient to wear Left knee extension brace up to 4 hrs/ day while monitoring s/s (signs/symptoms) of redness or discomfort, pain as tolerated by patient. Active 5/19/2022. -Left hand and elbow brace be worn by patient up to 4 hours a day as tolerated. Active 5/19/2022. The facility was asked to provide restorative documentation for R22. The facility provided RNP documentation (left knee and elbow brace application) that began in May 2022 to present day (consistent with above orders). A review of the documentation revealed that for the majority of days in May 2022 through December 2022 and January 2023 through May 2023, Not Applicable, or no documentation was present at all to indicate that R22's left knee brace and left elbow brace were applied per order. Further review of the brace task documentation from June 2023 revealed that, Not Applicable was documented on 6/1/23, 6/13/23, 6/15/23, 6/19/23, 6/20/23, and 6/22/23 and 0 minutes spent providing the brace task was documented on 6/5/23, 6/6/23, 6/7/23, 6/10/23, 6/11/23, 6/21/23. No documentation was present for 6/24/23 nor 6/26/23. The RNP documentation was also noted to include range of motion documentation that was initiated in March 2023. A review of the range of motion documentation titled, LLE and LUE PROM (left lower extremity and left upper extremity passive range of motion) in supine position in all possible planes within pain free ROM: 10 REP, revealed that from March 2023 through May 2023, Not Applicable, or no documentation was present at all to indicate that range of motion was provided to R22. Further review of the range of motion task documentation from June 2023 revealed that, Not Applicable was documented on 6/2/23, 6/7/23, 6/13/23 through 6/17/23, and 6/23/23 and 0 minutes spent providing the ROM task was documented on 6/9/23, 6/11/23, 6/24/23, and 6/25/23. A review of R22's Physical Therapy (PT) discharge summary dated 4/26/22 revealed: Diagnoses: .Contracture, left knee Onset 3/16/2022 . Assessment and Summary of Skilled Services: .PT sessison (sic) was focused on imprvoing (sic) PROM of Left knee extesion (sic) strength of RLE in all major muscles by performing supine and [NAME] (sic) position exercises with resistance using nakle (sic) wt (weight), improving core strength to faciliatte (sic) sittign (sic) tolerance and blance (sic) dynamic sittign (sic) balance improvement training while crossing midline and reaching in various planes, consulted orthotics to get knee extension brace on LLE assess for proper tolerance w/o any s/s of pain, redness or discomfort to preven (sic) development (sic) of further contractures, improving independence with rolling on each side, supine <> sit t the EOB, W/C (wheelchair) mobility training on level [NAME] (sic) to facilitate functional mobility . Patient made substantial functional gains in response to skilled interventions .continue with HEP, Knee extension brace on LLE for 4 hrs/day .Prognosis to Maintain CLOF (current level of functioning) = Good with consistent staff follow-through . 38207 R77 On 6/26/23 at 10:03 AM,. during an initial tour of the facility R77 was observed to have contracted fingers on their right hand. R77 was interviewed and asked if they received therapy and/or restorative therapy related to their contracture. R77 indicated that they did not receive any therapy at the current time and indicated that they would like to receive restorative therapy. On 6/27/23 at 10:27 AM, An observation was made of R77 continuing to have contracted fingers on their right hand. R77 denied having any pain. On 6/28/23 at 9:20 AM, the Acting Therapy Program Director (TPD) B was interviewed regarding R77's contracted fingers and asked if R77 was involved in any therapy and/or a restorative program related to their contracture. TPD B indicated that R77 was able to partially straighten their fingers and stated, It takes them some time. TPD B further indicated that R77 was supposed to be receiving Passive range of motion (ROM) exercises to their fingers, hands, and upper body, for maintenance. TPD B indicated that staff should be documenting ROM exercises when offered and/or completed with R77. TPD B reviewed R77's most recent Occupational Therapy (OT) Discharge Summary dated 5/31/23 which indicated the following, Discharge Recommendation: RNP (Restorative Nursing Program). TPD indicated that there should be a goal and interventions on R77's care plan regarding restorative care. On 6/28/23 at 9:24 AM, a review of R77's electronic medical record (EMR) revealed no care plan goal/interventions regarding restorative care and no documentation in R77's EMR of them having received/being offered ROM exercises. On 6/28/23 at 9:26 AM, further review of R77's EMR revealed that R77 was most recently admitted to the facility on [DATE] with diagnoses that included Cerebral infraction (Stroke) and Chronic respiratory failure. R77's most recent annual minimum data set assessment (MDS) dated [DATE] revealed that R77 had an intact cognition and required one to two persons, total dependence to extensive assistance, for all activities of daily living (ADLs) other than eating. On 6/28/23 at 9:29 AM, the Director of Nursing (DON) was interviewed regarding the provision of restorative care for R77 and indicated that a restorative care goal should be documented on the resident's care plan and ROM documentation should be documented under the Task section in R77's EMR. The DON stated, If it's not documented, it didn't happen. On 6/28/23 at 3:38 PM, a facility policy titled Restorative Program Revision: 2/21/2018 was reviewed and stated the following, Purpose and Policy Statement: Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility will provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish .Process: Candidates for the restorative nursing program may be identified in the following ways: After discharge from a skilled therapy service .1. Following identification of need the interdisciplinary team will put a plan in place that identifies the restorative approaches that will support the resident .2. The applicable restorative interventions will be assigned which may include .ROM .

Based on observation, interview and record review, the facility failed to ensure incontinence care was provided timely for four sampled residents (R16, R22, R34, R49) of six reviewed for Activities of Daily Living (ADLs) and quality of care, resulting in and the potential for unmet care needs and dissatisfaction with the care provided. Findings include: R49 On 6/26/23 at 8:35 AM, R49 was observed in bed lying on their back, heels flat on the mattress. Certified Nursing Assistant (CNA) P was observed in the room at this time, and was asked to view the linen of R49. Upon CNA P lifting the covers off of R49, their brief was observed saturated with urine, causing a wet urine perimeter around the resident onto the fitted sheet. CNA P explained that they had recently arrived for their shift, and found R49 in this manner. A review of R49's medical record revealed that they were admitted into the facility on [DATE] with disagnoses that included Alzheimer's Disease, Diabetes, and Anxiety. Further review of R49's medical record revealed a Minimum Data Set assessment indicating a Brief Interview for Mental Status score of 6/15 indicating a severely impaired cognition, and required total dependence for toileting, bed mobility and transfers. R16 On 6/26/23 at 8:54 AM, a strong urine smell permeated the room of R16 who was sitting on the edge of their wheelchair wearing a brief that was full of bowel movement and urine. The brief was observed to be so full that it was drooping. R16's bed linens were observed to be saturated with urine and feces, while gnats were observed flying througout the room and all over the bed. Attempts to interview R16 about their brief were made however, they appeared confused at this time. CNA P was observed taking all of the linen off of the bed, and wiping the mattress down with sanitation wipes. CNA P was asked about the condition of the room, and explained that finding R16's room in this condition occurs often, and that it can sometimes be worse, with urine located on the floor. A review of R16's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included Schizophrenia, Dysphagia, and Anxiety. Further review of R16's medical record revealed a Quarterly Minimum Data Set assessment dated for 6/7/23 indicating a Brief Interview for Mental Status score of 14/15 indicating an intact cognition, and required extensive assistance with bed mobility, transfers and toileting. On 6/28/23 at 11:54 AM, the Director of Nursing (DON) was asked about their expectation regarding residents that were found wet and soiled. The DON explained that no one should be soaked through their bed linen, and that the expectation is that that CNA rounds should be completed in a manner that the replacement CNA should find and make sure their residents are clean and dry. 38207 R34 On 6/26/23 at 11:43 AM, R34 was interviewed regarding care and services at the facility and indicated that they had been waiting to be changed and had not yet been changed on this shift. R34 was asked when they requested to be changed most recently. R34 stated, You don't ask to be changed. They tell you, they get you on their rounds. They do their rounds and you have to wait for hours. I don't think they have enough help here, they can't afford it. At 11:46 AM, R34 engaged their call light. R34 stated The aide was here this morning and said 'I'll be back' R34 indicated that the aide never returned to assist them. R34 stated, I feel like the bottom of a boat. R34 indicated that they had urinated multiple times in their brief this morning while waiting for staff to change them. At 12:03 PM, Certified Nursing Assistant (CNA) T answered R34's call light. There were no gloves in R34's room and CNA T indicated that they would go obtain some gloves and then change R34. On 6/28/23 at 3:45 PM, a review of R34's electronic medical record (EMR) revealed that R34 was admitted to the facility on [DATE] with diagnoses that included Unilateral primary osteoarthritis (deterioration of cartilage in joints of body) and Dementia. R34's most recent quarterly minimum data set assessment (MDS) dated [DATE] revealed that R34 had an intact cognition and required one person extensive assistance for toileting. The bowel/bladder section of R34's MDS indicated that R34 was Frequently incontinent. 39918 R22 A review of R22's record and Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was admitted into the facility on [DATE] and is mildly cognitively impaired. Further review revealed that the resident requires extensive assistance from staff for toileting, dressing, and bed mobility, total assistance for transfers, and limited assistance for personal hygiene. R22's medical diagnoses include Hemiplegia And Hemiparesis (weakness/paralysis) Following Cerebral Infarction, Dysarthria and Dysphagia (difficulty speaking and difficulty swallowing) Following Cerebral Infarction, Generalized Muscle Weakness, Chronic Pain Syndrome, Contracture, Diabetes, Polyneuropathy, Anxiety Disorder, Adjustment Disorder with Depressed Mood, and Obesity. On 6/26/23 at 3:54 PM, Certified Nursing Assistant (CNA) I and CNA J were preparing to provide incontinence care to R22. CNA I indicated that she had worked midnight shift (leaving around 7 AM this morning) and had come back to work afternoon shift. R22 stated they had not been changed since they last saw CNA I this morning. R22 was observed with a wet and soiled brief. R22 was also noted with significant body odor. R22 required a full bed change, as the resident's sheets were soiled with what appeared to be bowel movement under their left back/shoulder area. Both CNA's indicated that the off-going shift reported having changed R22. R22 repeatedly denied that they had been changed on day shift exclaiming, They didn't change me! CNA J told R22 they believed what the resident was claiming. R22 became tearful and stated, You see? They don't get me up, they don't walk me, nothing. On 6/27/23 at 12:26 PM, R22 was observed lying in bed. R22 was interviewed and stated that they had only been changed one time this morning. A review of R22's care plan revealed: Goal: Will attain/maintain as clean and dry dignified state as possible through the next care review date. Date Initiated: 06/22/2021, Revision on: 06/16/2023. Intervention: Provide incontinent care/products as needed. Date Initiated: 06/08/2021, Revision on: 06/22/2021. A review of the facility policy titled, Activities of Daily Living dated 07/01/08 with no revision date, revealed, Purpose: to assist resident in achieving maximum functional ability with dignity and self esteem. 2. To provide assistance to residents as needed .6. To improve quality of life.

Based on observation, interview, and record review, the facility failed to maintain a clean, odor- and pest-free environment, affecting five residents (R7, R42, R29, R98 and R16) and current residents residing on the A and B units, resulting in the lack of a home-like living space, persistent foul odors, and resident dissatisfaction. Findings include: On 6/26/23 at 8:05 AM, an overwhelming feeling of stuffy, humid air and overpowering urine odor was noted upon entering the facility, as well as upon walking through various hallways to a conference room near the administrator's office. On 6/26/23 at 8:26 AM, during the initial tour, R7 was interviewed in their room. During the interview, the resident swatted multiple small flying bugs away from their face. No direct source for the bugs was noted in the resident's room. R7 indicated that the bugs were bothering them. A review of R7's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident is cognitively intact. On 6/26/23 at 10:00 AM, multiple small flying bugs were noted flying around the A unit nurses' station. Registered Nurse (RN) G was noted to be swatting the bugs away while sitting at a computer. On 6/26/23 at 10:06 AM, multiple small flying bugs were noted flying around the A unit dining room, where an unidentified resident was present with a staff member. On 6/26/23 at 12:25 PM and at 2:36 PM, an overpowering urine odor was noted throughout the A unit hallway. On 6/26/23 at 2:47 PM, a urine odor was noted in the hallway at the high-numbered end of the B unit. On 6/26/23 at 4:16 PM, the overpowering urine odor was still noted throughout the A unit hallway. RN M was interviewed at the A unit nurses' station and queried regarding the urine odor noted throughout the unit. RN M indicated that some staff may have gotten used to the smell, and explained that on the A wing, there were a few residents with behavioral/incontinent issues that spill or get urine on the floor. On 6/27/23 at 8:51 AM, a stale urine odor was noted in the hallway at the high-numbered end of the B unit. On 6/27/23 at 9:50 AM, an overpowering urine odor persisted throughout the A unit hallway. On 6/27/23 at 12:03 PM and at 12:34 PM, a lingering urine odor was noted at the high end of B unit and a strong urine odor was noted throughout the B unit. On 6/27/23 at 2:11 PM, the Maintenance Director brought in staff reports of pests from last few months. Per the reports, on 6/25/23, flying ants were reported in room B5-2; on 4/25/23, flying ants were reported in room B-15; and on 1/4/23 (two reports), ants were reported in rooms A1 and A8. The Maintenance Director stated they would take care of what they could as far as pest sightings, but also had pest control come in regularly. The facility provided bi-weekly pest control service reports from 4/20/23 to 6/15/23. The service reports indicated that food debris was often found, sanitation issues were often found in patient care areas, and that treatment for drain flies and flies is on-going. On 6/27/23 at 4:11 PM, the end of B unit hallway was noted with a vague, stale urine odor. On 6/28/23 at 2:00 PM, R42 was interviewed in their room regarding concerns about pests and/or odors within the facility. R42 indicated that they frequently noted odors of urine/feces as well as small flying bugs throughout the facility. R42 claimed that they had flies in their room yesterday and indicated that they personally do not keep open food items in their room, but that other residents on the B unit do. R42 stated, It's bothersome to me, and added that food trays sometimes do not get collected, which will attract flies. R42 was then queried regarding the location of the foul odors to which the resident replied, Over on A wing it, smells like poop and pee - All. The. Time! R42 added that foul odors were occasionally noted on the B unit. R42 handed over a can of air freshener and stated that they will go into the hallway and spray it when foul odors are noted. A review of R42's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident is cognitively intact. On 6/28/23 at 11:41 AM, the Director of Nursing (DON) was interviewed regarding her awareness of any environmental concerns within the facility. The DON indicated that she was unable to do walking rounds as regularly as she used to, so had not observed anything consistent. The DON indicated that odors such as urine could be smelled during brief changes but would expect them to dissipate quickly. The DON was unaware of any pest control issues but indicated that she would expect nurse managers in the facility to report any problems with pests and/or odors. On 6/28/23 at 2:34 PM, a small flying bug was noted flying around the conference room next to the Nursing Home Administrator's (NHA) office. On 6/28/23 at 11:38 AM, during the Quality Assurance review with the NHA, the administrator reported the expectation is that gnats should be reported and entered in the reporting portal (TELS) as it is on all the computers. The schedule for carpet cleaning was reviewed which indicated cleaning of the carpet is scheduled a couple times monthly for each unit. It was also reported that a professional carpet cleaning service is scheduled in two times a year but had not been in yet this year. Cleaning schedules were further reviewed with Housekeeping Supervisor R who reported there were three known rooms on the A unit and one on the B unit that exhibited ongoing urine odors. 40384 On 6/26/23 at 8:30 AM, during initial tour of the A wing, a strong urine smell was observed. Upon entry into the room of R29 and R98, the floor was extemely sticky, full of debris, and the walls were observed with stains. The bathroom was observed to have debris on the floor, and bowel movement smeared all over the toilet seat. Attempts to interview R29 and R98 was unsucessful as they were confused. An observation of R98's wheelchair was made, which appeared covered in caked on debris, food and dirt. On 6/26/23 at 8:54 AM, upon reaching and entering the room of R16, located on the A wing, the urine smell increased. R16's bed was observed saturated with urine and bowel movement. In addition, their were gnats flying throughout the room and all over the bed. Certified Nursing Assistant (CNA) P was observed taking all of the linen off of the bed, and wiping the mattress down with sanitation wipes. CNA P was asked about the condition of the room, and explained that finding R16's room in this condition occurs often, and that it can sometimes be worse, with urine being located on the floor. On 6/27/23 at 10:06 AM, during a confidential group meeting, the residents were asked about their wheelchairs being cleaned. One resident stated, Our wheechairs are never cleaned. They used to be done on the midnight shift. Another resident agreed, and explained that their wheelchair did need to be cleaned, as they have debris located in the crevices of their wheelchair. On 6/28/23 at 11:00 AM, the Quality Assurance interview was conducted with the Administrator. The Administrator reported that any wheelchair issues should be reported in the reporting portal (TELS). The Administrator reported maintenance was responsible for mechanical repairs and the nursing assistants were responsible for the cleaning. The Administrator reported they were not sure of the wheelchair cleaning schedule but noted they believed they were cleaned weekly and as needed on the night shift and that there were sufficient staff on the night shift to get them cleaned. On 6/28/23 at 11:54 AM, the Director of Nursing (DON) was asked about the cleaning of resident wheelchairs. The DON explained that every unit has a schedule that coincides with resident showers, and that the CNA's are responsible for cleaning them on the midnight shift, and that the unit managers should be ensuring compliance. A review of the Rights of Residents in Michigan Nursing Facilities included in the facility's Admission Packet documented on page six under the heading Safe Environment, You have the right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatments and supports for daily living safely.

Based on interview and record review, the facility failed to accurately document medication administration in the medical record for two residents (R31 and R62) resulting in falsified documentation and the potential for unmet care needs and/or inaccurate assessments. Findings include: R31 On 6/27/23 at 8:36 AM, R31 was interviewed in their room. The resident was lying in bed and noted to be under contact isolation precautions for an infection. R31 was queried regarding any pain they have. The resident indicated that they have neuropathy in their extremities and have not received their scheduled gabapentin (anticonvulsant medication that is commonly used to treat nerve pain) in days. R31 expressed feeling very frustrated and also appeared so. The resident expressed a desire to leave the facility. R31 was queried regarding the severity of their nerve pain and rated it as a 10 out of 10 (severe pain). A review of R31's medical record revealed that the resident was initially admitted on [DATE] and most recently readmitted to the facility from the hospital on 6/21/23 with medical diagnoses including Obesity, Urinary Tract Infection, Hyponatremia, Seizures, Acquired Absence of Left Leg Below Knee, Chronic Pain Syndrome, Anxiety, Depression, Diabetes, Bipolar Disorder, and Adjustment Disorder. R31's Minimum Data Set (MDS) assessment dated [DATE] indicated that the resident is moderately cognitively impaired. A review of R31's orders revealed the following: -Gabapentin Oral Capsule 400 MG (Gabapentin) Give 1 capsule by mouth three times a day for neuropathy -Start Date- 06/21/2023 .-D/C Date- 06/27/2023. A review of R31's June 2023 MAR and facility-provided controlled medication logs revealed that since R31's re-admission into the facility on [DATE], the resident had not received any doses of their scheduled gabapentin (17 scheduled doses missed until the order was discontinued during the survey). Although nursing staff checked off on the MAR that R31's gabapentin was administered at 2200 (10 PM) on 6/22/23 and 6/23/23 as well as 0600 (AM) on 6/24/23, there were no corresponding progress notes found to indicate that the medication was given from a backup supply nor was the facility able to provide a controlled medication log for the gabapentin or any of the marked administrations. R62 On 6/27/23 at 8:57 AM, R62 was interviewed. When queried regarding any concerns with missed medication, R62 indicated that recently, they recalled being told that the facility did not have some of their scheduled gabapentin. A review of R62's medical record revealed that the resident was initially admitted into the facility on [DATE] with medical diagnoses including Dementia, Psychotic Disturbance, Polyneuropathy, Chronic Pain Syndrome, and Diabetes. R62's Minimum Data Set (MDS) assessment dated [DATE] indicated that the resident is mildly cognitively impaired. A review of R62's orders revealed the following: -Gabapentin Oral Tablet (Gabapentin) Give 400 mg by mouth three times a day for neuropathy Give with 800 mg tabs to equal 1200 mg -Start Date- 06/20/2023. -Gabapentin Tablet 800 MG Give 1 tablet by mouth every 8 hours related to POLYNEUROPATHY, UNSPECIFIED .give w/ (with) 400 mg for total of 1200 mg -Start Date- 06/07/2021. Multiple progress notes from 6/20/23 to 6/25/23 were entered into R62's record that the facility was awaiting a C2 form and delivery from the pharmacy for the 400 mg gabapentin. Although nursing staff checked off that R62's scheduled 400 mg gabapentin was administered three times on 6/20/23, as well as once on 6/22/23, 6/23/23, and 6/24/23, there were no corresponding progress notes found to indicate that the medication was given from a backup supply nor was the facility able to provide a controlled medication log for the gabapentin or the marked administrations dated prior to 6/26/23. On 6/27/23 at 9:49 AM, the Regional Clinical Director (RCD) was interviewed and indicated that the facility did not have any controlled medication logs for R31's gabapentin that was ordered on 6/21/2023 and confirmed that the resident had not been receiving that medication since re-admission. At 10:28 AM, the RCD approached indicated that the gabapentin for R31 had been discontinued due to being unavailable, and that an alternate pain medication had been ordered per a discussion with the physician and resident. The facility's policy titled, Medication Administration, dated 01/21, states the following: Medications are administered as prescribed in accordance with manufacturers ' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication.

This citation pertains to Intake MI00137906. Based on interview and record review, the facility failed to have ordered medication available to administer to three residents reviewed (R31, R62, and R74) resulting in multiple missed doses of scheduled medication and the potential for poor pain management. Findings include: R74 On 6/26/23 at 8:44 AM, during the initial tour, R74 was interviewed. The resident indicated that their biggest issue with the facility was that they had run out of their pain medication multiple times, resulting in missed doses. R74 indicated that approximately one week ago, they missed multiple scheduled doses of their ordered percocet (narcotic pain medication), lasting longer than 24 hours. A review of R74's medical record revealed that the resident was admitted into the facility on [DATE] with medical diagnoses including Osteoarthritis (OA), Obesity, Diabetes, and Anxiety. R74's Minimum Data Set (MDS) assessment dated [DATE] indicated that the resident is cognitively intact. A review of R74's care plan revealed: -Focus: PAIN MANAGEMENT I have potential for pain r/t (related to) Anemia, OA of Bilateral Hips, left wrist pain, polyneuropathy, and BPH (benign prostatic hyperplasia). Date Initiated: 04/19/2023. -Intervention: medications as ordered Date Initiated: 04/19/2023. A review of R74's orders revealed the following: -Percocet (Oxycodone w/ Acetaminophen) Oral Tablet 10-325 milligram (MG) Give 1 tablet by mouth four times a day for pain -Start Date- 04/21/2023. A review of R74's June 2023 Medication Administration Record (MAR) revealed that R74 did not receive their scheduled percocet at all on 6/21/23 (four missed doses), and did not receive their scheduled midnight dose of percocet on 6/22/23 (for a total of five consecutive missed doses of pain medication). A review of R74's progress notes revealed that the signing/sending/pharmacy receipt of the controlled medication prescription form (C2 form) contributed to the missed doses. On 6/26/23 at 4:16 PM, Registered Nurse (RN) M and RN G were interviewed regarding any issues with pharmacy they have experienced while working at the facility. Both nurses indicated that they frequently run into issues with the facility's contracted pharmacy service, resulting in residents missing scheduled doses of medication. Both nurses added that they are often told by pharmacy that a missing medication is coming with the next delivery. However, when the delivery arrives, the missing medication is not there. RN G stated that off the top of her head, she could recall that both R31 and R62 had missed doses of medication despite staff contacting the pharmacy multiple times by phone and fax. R31 On 6/27/23 at 8:36 AM, R31 was interviewed in their room. The resident was lying in bed and noted to be under contact isolation precautions for an infection. R31 was queried regarding any pain they have. The resident indicated that they have neuropathy in their extremities and has not received their scheduled gabapentin (anticonvulsant medication that is commonly used to treat nerve pain) in days. R31 expressed feeling very frustrated and also appeared so. The resident expressed a desire to leave the facility. R31 was queried regarding the severity of their nerve pain and rated it as a 10 out of 10 (severe pain). A review of R31's medical record revealed that the resident was initially admitted on [DATE] and most recently readmitted to the facility from the hospital on 6/21/23 with medical diagnoses including Obesity, Urinary Tract Infection, Hyponatremia, Seizures, Acquired Absence of Left Leg Below Knee, Chronic Pain Syndrome, Anxiety, Depression, Diabetes, Bipolar Disorder, and Adjustment Disorder. R31's Minimum Data Set (MDS) assessment dated [DATE] indicated that the resident is moderately cognitively impaired. A review of R31's orders revealed the following: -Xanax Oral Tablet 0.25 MG (Alprazolam) Give 1 tablet by mouth every 12 hours related to GENERALIZED ANXIETY DISORDER . -Start Date- 06/21/2023 .-D/C (discontinue) Date- 06/22/2023. -Gabapentin Oral Capsule 400 MG (Gabapentin) Give 1 capsule by mouth three times a day for neuropathy -Start Date- 06/21/2023 .-D/C Date- 06/27/2023. A review of R31's June 2023 Medication Administration Record (MAR) revealed that R31 did not receive two scheduled doses of Xanax 0.25 mg (controlled anti-anxiety medication) that were ordered on 6/21/23 and 6/22/23, due to not having the medication on-hand from pharmacy. Further review of R31's June 2023 MAR and facility-provided controlled medication logs revealed that since R31's re-admission into the facility on [DATE], the resident had not received any doses of their scheduled gabapentin (17 scheduled doses missed until the order was discontinued during the survey). Although nursing staff checked off on the MAR that R31's gabapentin was administered at 2200 (10 PM) on 6/22/23 and 6/23/23 as well as 0600 (AM) on 6/24/23, there were no corresponding progress notes found to indicate that the medication was given from a backup supply nor was the facility able to provide a controlled medication log for the gabapentin or any of the marked administrations. R62 On 6/27/23 at 8:57 AM, R62 was interviewed. When queried regarding any concerns with missed medication, R62 indicated that recently, they recalled being told that the facility did not have some of their scheduled gabapentin. A review of R62's medical record revealed that the resident was initially admitted into the facility on [DATE] with medical diagnoses including Dementia, Psychotic Disturbance, Polyneuropathy, Chronic Pain Syndrome, and Diabetes. R62's Minimum Data Set (MDS) assessment dated [DATE] indicated that the resident is mildly cognitively impaired. A review of R62's orders revealed the following: -Gabapentin Oral Tablet (Gabapentin) Give 400 mg by mouth three times a day for neuropathy Give with 800 mg tabs to equal 1200 mg -Start Date- 06/20/2023. -Gabapentin Tablet 800 MG Give 1 tablet by mouth every 8 hours related to POLYNEUROPATHY, UNSPECIFIED .give w/ 400 mg for total of 1200 mg -Start Date- 06/07/2021. A review of R62's June 2023 Medication Administration Record (MAR) and facility-provided controlled medication logs revealed that R62 had been receiving the 800 mg gabapentin per order. The facility-provided controlled medication logs revealed, however, that R62 did not start receiving the additional 400 mg doses of gabapentin until 6/26/23 despite being ordered on 6/20/23. Multiple progress notes from 6/20/23 to 6/25/23 were entered into R62's record that the facility was awaiting a C2 form and delivery from the pharmacy for the 400 mg gabapentin. Although nursing staff checked off that R62's scheduled 400 mg gabapentin was administered three times on 6/20/23, as well as once on 6/22/23, 6/23/23, and 6/24/23, there were no corresponding progress notes found to indicate that the medication was given from a backup supply nor was the facility able to provide a controlled medication log for the gabapentin or the marked administrations dated prior to 6/26/23. On 6/27/23 at 9:49 AM, the Regional Clinical Director (RCD) was interviewed and indicated that the facility did not have any controlled medication logs for R31's gabapentin that was ordered on 6/21/2023 and confirmed that the resident had not been receiving that medication since re-admission. On 6/27/23 at 10:28 AM, the RCD approached indicated that the gabapentin for R31 had been discontinued due to being unavailable, and that an alternate pain medication had been ordered per a discussion with the physician and resident. On 6/28/23 at 11:41 AM, the Director of Nursing (DON) was interviewed regarding her knowledge of any pharmacy issues or medication administration difficulties at the facility. The DON claimed that the pharmacy the facility contracts with was recently having a problem with receiving faxes. The DON explained that staff had been sending the same C2 forms repeatedly to the pharmacy for some ordered medications, yet the pharmacy was claiming they did not receive them. When queried, the DON did not believe that the issue had been caused by nurses or providers failing to identify when a medication needed to be re-ordered. A review of the facility's policy/procedure titled, Medication Administration General Guidelines, dated 01/21, revealed, Medications are administered as prescribed in accordance with manufacturers ' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication .Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record .Medications are administered in accordance with written orders of the prescriber .The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications .2. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (for example, the resident is not in the nursing care center at scheduled dose time, or a starter dose of antibiotic is needed), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN (as needed) documentation. If two consecutive doses of a vital medication are withheld or refused, the physician is notified .

Based on interview and record review the facility failed to ensure timely vital signs were documented prior to dialysis and documented post dialysis in the clinical record for one resident (R121) of two residents whose dialysis communications were reviewed resulting in the potential for inadequate data for assessment of the resident's status. Findings include: On 06/27/23 at 7:56 AM Licensed Practical Nurse (LPN) Q was asked about R121 and reported R121 had dialysis three times a week and had heard R121 went to dialysis then came back not feeling well, and was sent out to the hospital. A review of the nurse's note dated 05/20/23 at 4:47 PM by LPN L documented R121 returned from dialysis around 12:15 PM and at 12:30 PM R121 resident was found slumped in their chair with a faint pulse and EMS was called. The progress notes further indicated R121 was treated for ongoing and intermittent abdominal pain, nausea and vomiting since 05/12/23. A review of the Dialysis Communication form completed by LPN S dated 05/20/23 at 6:22 AM documented vitals from 05/19/23 at 10:38 PM. The blood pressure (BP) was 128/76 and a heart rate of 72. No information from the dialysis center was documented. A review of the dialysis communication forms dated 05/16/23 and 05/18/23 (BP before dialysis was 135/65 BP post dialysis 119/48) indicated the blood pressure and heart rate documented on 05/19/23 were within normal limits for R121. A blood pressure just prior to leaving for dialysis on 05/20/23 was not documented. A review of the dialysis center information received via fax at the facility on 06/28/23 at 1:09 PM revealed the initial blood pressure for R121 at the dialysis center timed at 7 AM was documented as 93/46. Ten to twenty points lower than that documented on the dialysis communication forms. A blood pressure timed at 10 AM documented a blood pressure of 83/38. The session finished at 11:07 AM. An 11:07 AM blood pressure was not documented. No unusual occurrences was documented by the dialysis center and R121 was returned to the facility. A review of the nurse notes dated 05/20/23 at 6:33 AM, documented, New orders in place Fluids to be ran at 60 milliliters (ml) an hour for one day .Resident complained of not feeling well. Emesis (vomiting) throughout the night. (Intramuscularly) IM Phenergan (anti nausea/emetic medication) administered Resident agreed to go to dialysis this morning, stated didn't want to go then quickly changes mind .out to dialysis at 6:30 AM . On 06/28/23 at 8:48 AM and at 1:18 PM, the Director of Nursing (DON) was asked about the R121's incident and 05/20/23 dialysis communication form and reported that the morning vitals should be taken and documented on the form. The DON acknowledged the lower BP on the dialysis center notes and reported that the dialysis center was not consistent in returning the communication form sent with the patient. On 06/28/23 at 1:55 PM, LPN S was interviewed via phone and reported that they had been in contact with the physician the night before. LPN S reported that the resident made the decision to go out to dialysis and did not recall what the vital signs (BP) were but the normal procedure would be to take vitals in the morning. A review of the facility policy Dialysis, Hemodialysis with last revised date of 09/23/19, documented, Purpose: Proper Assessment and care of residents receiving Hemodialysis. Procedure: 1. Complete Pre-Dialysis information and send Dialysis Communication form with resident .3. Obtain vital signs on return from center . 5. If notes are absent upon resident's return charge nurse is to call dialysis center for report . The policy did not indicate the timing of the pre-dialysis vital signs.

Based on observation, interview, and record review the facility failed to ensure that assistive communication devices were provided to one resident (R85) with a communication impairment, of one resident reviewed for communication, resulting in the likelihood of miscommunication between the resident and staff and the potential for unmet care needs. Findings include: On 6/26/23 at 9:49 AM, during an initial tour of the facility on the B unit, Licensed Practical Nurse (LPN) C informed the surveyor that R85 was unable to speak or hear. LPN C was interviewed regarding how they communicate with R85. LPN C stated, (R85) gestures sometimes. LPN C was also asked if any communication devices such as a communication board were provided to R85 and kept in their room to assist staff/resident communication, to which she stated, No. R85's electronic medical record (EMR) was reviewed and revealed that R85 was most recently admitted to the facility on [DATE] with diagnoses that included Dementia and Respiratory failure. R85's most recent quarterly minimum data set assessment (MDS) dated [DATE] revealed that R85 had a moderately impaired cognition, highly impaired hearing and unclear speech, and required supervision to limited assistance of one person for all activities of daily living (ADLs) other than eating. On 6/26/23 at 9:53 AM, R85 was met in their room for observation and interview. R85's room was observed to be dark, all lights were off in their room, and R85 was sitting on their bed with a hooded sweat shirt on with the hood of their sweat shirt covering their head. An inspection R85's room revealed no communication board, paper, and/or any other assistive communication devices being present in the room. R85 did not respond to any questions. On 6/27/23 at 10:02 AM, R85 was observed in their room with the lights off. R85 did not respond to any questions and made utterances/sounds. No communication assistive devices were observed in R85's room. On 6/27/23 at 10:13 AM, Certified Nursing Assistant (CNA) E was interviewed about how they communicate with R85. CNA E stated They gesture. CNA E was asked if they had ever observed/utilized any type of communication device to communicate with R85 such as a communication board. CNA E stated, No and indicated that R85 did not have a communication board. On 6/27/23 at 1:38 PM, an observation was made of R85 in their room, lying on their bed with the room light on. No communication board and/or any other communication devices were observed in R85's room. On 6/27/23 at 1:57 PM an interview was conducted with Social Services Director (SSD) D regarding communication related to R85. SSD D indicated that R85 had a notebook that they write in when meeting with SSD D and communicating with them. SSD D was further interviewed and asked about other communication assistive devices utilized and provided to R85 to assist them with their communication with staff. SSD D indicated that according to R85's care plan, (R85) should be provided with paper and a communication board to assist them with communication. SSD D indicated that the activities department was responsible for providing residents with communication boards as needed. On 6/27/23 at 2:29 PM, Activity Director (AD) F was interviewed regarding communication involving R85. AD F indicated that they were working on providing communication boards to all residents in the facility who had communication challenges. AD F stated, I am going to put a communication board and note pad by (R85's) bed so they will be able to better communicate with staff. On 6/28/23 at 9:21 AM, an observation was made of no communication board, paper, and or any other communication assistive devices being present in R85's room. On 6/28/23 at 9:45 AM, a review of R85's Communication/Activities care plan revealed the following interventions, Provide me with [a] picture communication board so that I can make my needs known. Date Initiated: 06/21/2023 Revision on: 06/21/2023. Provide me with paper and something to write with during conversations so that I can read what you have to say, and also write down my responses. Date Initiated: 07/31/2020 Revision on: 12/16/2022. Use pictures for cues as needed as this may help communicate better to you my wants/needs. Date Initiated: 07/31/2020 Revision on: 12/16/2022. On 6/28/23 at 11:23 AM, the Director of Nursing (DON) was interviewed regarding expectations for staff implementing and following activity/communication interventions listed on R85's care plan. The DON stated, Of course the interventions should be followed. On 6/28/23 at 3:07 PM, a facility policy titled Activities of Daily Living (ADL) (Daily Life Functions) Origination Date: July 1, 2008 was reviewed and stated the following, Purpose: 1. To assist resident in achieving maximum functional ability with dignity and self esteem. 2. To provide assistance to residents as necessary. 5. To teach resident use of assistive devices to maintain optimum ADL function. 6. To improve quality of life. Equipment: 3. Appropriate assistive devices. 12. Use adaptive equipment as directed .

Based on observation, interview, and record review, the facility failed to ensure call light accessibility for one resident (R29) reviewed for accommodation of needs resulting in the potential for unmet care needs. Findings include: On 6/26/23 at 8:30 AM and 2:40 PM, R29 was observed in bed asleep. Their call light was observed wrapped around a wall hook out of reach of the resident. In order for the resident to obtain access to the light, they would have to get out of bed, reach up and unravel it from around the hook. A review of R29's medical record revealed that they were admitted into the facility with diagnoses that include Alzheimer's Disease, Unspecified Convulsions, and a history of falling. Further review revealed that the resident was severely cognitively impaired and requited limited to total dependence for Activities of Daily Living. On 6/27/23 at 7:54 AM , 12:13 PM, and 4:09 PM, the resident's call light remained out of reach and wrapped around their wall hook. On 6/28/23 at 7:59 AM, R29's called light was observed out of reach and wrapped around their wall hook out. A review of R29's care plan revealed the following, Goal: Safety/Falls: I am at risk for falls due to hx (history) of falls, use of psychotropic medication and confusion Date Initiated: 03/29/2017. Revision on: 03/29/2023. Interventions: Make sure my call light is within reach when I'm in my room, and remind me to use it. I prefer it be draped over my light at the head of my bed. Date Initiated: 03/29/2017. Revision on: 10/24/2017 . On 6/28/23 at 11:54 AM, the Director of Nursing (DON) was asked for her expectation related to call light accessibility. The DON explained that every call light has a clip and should clipped to their bedding or in them while in their wheelchair. She further explained that it should be accessible for residents to reach. A review of the facility's Call Light policy revealed the following, PROCEDURE: 1. Call lights will be placed within reach of the resident .

This citation refers to Intake number MI00132714. Based on interview and record review the facility failed to ensure a resident did not develop a pressure ulcer for one sampled resident (R905) of three resident reviewed for skin management, resulting in the development of a pressure ulcer and subsequent infection of the pressure ulcer and hospitalization . Findings include: On 12/28/22 at 09:25 AM, Family Member A was called to discuss the complaint related to their family member. Family Member A said that they visited R#905 on September 4, 2022, and that the nurse said R#905 had a bad wound infection. Family Member A stated they didn't know about the wound. A review of the electronic medical record noted R#905 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of Heart Failure, Dementia, Cardiomyopathy, Osteoarthritis, and Stroke. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed R#905 was Moderate cognitively impaired and required extensive assistance to perform Activities of Daily Living (ADLs). A medical record review of the Skin & Wound - Total Body Skin Assessment noted 6/11/22 zero new wounds. A medical record review of the Skin & Wound - Total Body Skin Assessment noted 6/25/22 zero new wounds. A medical record review of the Skin & Wound - Total Body Skin Assessment noted 7/2/22 zero new wounds. A medical record review of the Skin & Wound - Total Body Skin Assessment noted 7/9/22 zero new wounds. A medical record review of the Skin & Wound - Total Body Skin Assessment noted 7/16/22 zero new wounds. A medical record review of the Skin & Wound - Total Body Skin Assessment noted 7/23/22 zero new wounds. A medical record review of the Skin & Wound - Total Body Skin Assessment noted 7/30/22 zero new wounds. A medical record review of the Skin & Wound - Total Body Skin Assessment noted 8/6/22 zero new wounds. A medical record review of the Skin & Wound - Total Body Skin Assessment noted 8/13/22 zero new wounds. A medical record review of the Skin & Wound - Total Body Skin Assessment noted 8/20/22 zero new wounds. A medical record review of the Skin & Wound - Total Body Skin Assessment noted 8/27/22 zero new wounds. A medical record review of the Skin & Wound - Total Body Skin Assessment noted 9/3/22 zero new wounds. A review of the medical record progress notes noted the following: -8/26/2022 23:30 (11:30 PM) . Nurses Note: CNA (Certified Nurse Aide) reported to nurse regarding a wound to residents (R#905) left side of (their) left foot. Observed round wound with redness and whitish and dark center. Cleansed with saf cleanse and applied aquacel foam dressing. Ordered wound consult. Placed in communications. Message in doctor's book. Report to oncoming nurse. Resident resting in bed. No c/o (complaint of) pain. Scheduled pain meds effective. -9/1/2022 12:56 (12:56 PM) .Nurses Note: Writer noted decline in resident condition, also wound to left foot has slight green discharge. Writer call MD (medical doctor) and log it in Dr (doctor) book. -9/2/2022 12:05 (12:05 PM) .Lab Results Note Text: Results reviewed with physician, new orders in place. Physician spoke with family, all parties agreeable to plan of care. -9/4/2022 15:33 (3:33 PM) .Nurses Note: (R#905) intake has decreased .Pt (patient) has had no urine this shift. It looks like she just had 1L 0.9 NS (1 Liter of Normal Saline intravenous-IV-solution) . -9/7/2022 09:03 (9:03 AM) Lab Results Note Text: Physician made aware of lab results. Upon physical exam resident was noted to be short of breath and hypoxic. VO (Verbal Order) to send (R#905) to (emergency room ) for further evaluation and treatment . -9/7/2022 09:08 Nurses Note: Upon doing rounds writer noted resident had gurgling cough, rapid breathing and complaints of SOB (short of breath) .911 was initiated and resident was sent to hospital for further evaluation . -9/7/2022 18:56 (6:56 PM) Physician's Note Text: Transfer to hospital (R#905) secondary to hypoxia, sepsis . Patient started on antibiotics and IV (intravenous) fluid last week secondary to wound infection with dehydration. Noted to have very poor urine output. Order written to insert indwelling catheter and continue IV fluid, labs ordered. 9/1/2022 WBC (White Blood Count) 17 (The normal number of WBCs in the blood is 4,500 to 11,000). Chest x-ray was ordered due to hypoxia however breathing became labored and mentation worsened. Transferred to acute care hospital for evaluation, likely sepsis . -9/6/22, Lab Results Report noted WBC of 20. A review of the Braden Scale for Predicting Pressure Sore Risk dated 8/14/22 indicated a score of 14 (Moderate risk for skin breakdown). A review of the hospital notes dated 9/8/22 01:28 PM, noted the following: .Pressure ulcer noted on the left lateral foot with purulent discharge and surrounding erythema (redness and swelling) .Wound Care Progress Note Service Date/Time: 9/8/2022 10:06 (AM), Wound care consulted. Stg 4 PI (stage 4 pressure injury/ulcer-deep wound reaching into muscle and bone) to the left lateral foot . Stg 2 PI (Stage 2 pressure injury/ulcer-outer surface of the skin damaged) to the spine . On 12/28/22 at 2:28 PM, Wound Care Nurse E was interviewed and asked about R#905 wound, staging, and skin assessments. Wound Care Nurse E stated, I was off on a medical leave .the Director of Nursing (DON) is not hear .I'll get the Nurse Manager (Nurse Manger F). On 12/28/22 at 2:35 PM, Nurse Manager F was interviewed and queried about R#905's wound that was documented on 8/26/22 in the progress note. Nurse Manager F said that it was not documented in the wound assessment because they discussed it during the facility's morning meeting. On 12/28/22 at 4:37 PM, an interview was completed with the NHA (Nursing Home Administrator) and Corporate Nurse (covering for the DON) were queried in regards to the wounds for R#905. The Corporate Nurse stated, The wound care assessments should be completed. The Administrator did not provide and explanation in regard to R#905's wounds. Requested Total Body Skin Assessment from 6/1/22 to discharge (9/7/22) via email on 12/28/2022 2:52 PM, did not receive any staging of the foot wound or wound documentation related to the spine pressure ulcer. A review of the facility's wound care policy Wound Managment Program dated revised on 8/17/2017 noted the following: Complete the following documentation weekly, as applicable to type of wound/skin condition: Weekly Pressure Ulcer .Wound Documentation and picture.in wound rounds Weekly Non-Pressure Wound Documentation and picture in wound rounds Print off weekly documentation from wound rounds and scan it into (name of electronic medical record system.

This citation has two deficient practices, A. and B.: A. Based on observation, interview, and record review, the facility failed to: 1. Maintain an accurate and ongoing monthly infection tracking and monitoring system; 2. Follow established COVID-19 testing guidelines per facility policy for Residents and Staff; 3. Notify the health department of new COVID-19 cases; 4. Investigate and surveil new cases of COVID-19 in Staff; 5. Screen vendors/visitors for COVID-19 symptoms; and 6. Practice hand hygiene during resident care to prevent the spread of infection. This deficient practice was identified as an Immediate Jeopardy (IJ) due to the facility failing to have any monthly Resident surveillance for April or [DATE], during which time four staff tested positive for COVID-19, with the likelihood to result in further infections outbreaks for all Residents and Staff. The IJ began on [DATE], when a second facility staff member tested positive for COVID-19, no contract tracing was done, and Resident testing and monitoring of infections was not initiated. The IJ notification was communicated verbally to the Administrator on [DATE] at 12:49 p.m. and was followed with an email copy with request for an abatement plan. The deficient practice continued at a pattern level of potential for more than minimal harm until onsite review and confirmation of the completion of the full plan of correction. Findings include: On [DATE] at 2:00 p.m., the facility surveyors entered the facility. On the outside door of the facility, a signed noted that the last positive case of COVID-19 was on [DATE] for a staff member. On [DATE] at 2:55 p.m., during the entrance conference with the Administrator and the Director of Nursing (DON), all of the Infection Control documentation, including line listings, summaries, mapping, testing, policies, and vaccination up to the current day was requested. The DON reported that there was a new Infection Preventionist (IP B) who was in training, but that she (the DON) was helping to finish train her. The DON was asked to confirm that per the sign on the door there was only one positive staff case of COVID-19 from [DATE]. The DON reported that just as the surveyors had entered the building an activities aide had tested positive during their twice-a-week testing due to being in outbreak mode. On [DATE] at 4:39 p.m., three infection surveillance binders were provided. A review of these binders revealed the following: The [DATE] Infection Report revealed no documentation regarding a COVID-19 outbreak. Per a breakdown for types of facility acquired infection by unit revealed no respiratory infections on any of the three units. A review of the resident Line Listing revealed no COVID-19 infections. There were two maps Labeled Resident COVID-19 2021 Mapping- [DATE]. The first map had 11 rooms highlighted in pink and yellow, with no indication if these were positive residents or which date they were positive. The second map contained 7 highlighted Xs on 6 Resident rooms and highlighted dates written beside the Social Work office, Therapy Gym, and the Front entrance. A list was written in the middle of the map which contained 12 names, 4 of which were designated as staff, 6 designated as residents, and two names with no designation. There was no outbreak summary or line listing for this outbreak. The [DATE] Infection Report revealed only 1 respiratory illness. The [DATE] COVID-19 Mapping revealed eight resident rooms highlighted with dates written beside them. There was a list of 8 names written on top of this mapping and were all noted to be staff. There was no line listing for the COVID-19 infections in the Residents nor any names attached to the rooms. The [DATE] Infection Control Report Analysis revealed there were 2 positive staff for COVID-19. This summery noted that there were zero Resident COVID-19 infections, but did not include any information on Resident testing or any outbreak investigation. The [DATE] tab revealed only an Interdepartmental Infection Control Rounds audit dated April. There was no summary, line listing, or mapping. The [DATE] tab was empty and contained no infection tracking at all. These binders contained no information related to COVID-19 outbreaks other than the maps, and the monthly summaries revealed no indication of the outbreak. No testing, screening, or vaccination data was provided. On [DATE] at approximately 5:00 p.m., Corporate Registered Nurse (RN) Z asked if there was any documentation she could provide the survey team. The remainder of the Infection Surveillance as well as all of the COVID-19 surveillance was requested from Corporate RN Z as it had not been provided yet. On [DATE] at 4:20 p.m., Corporate Nurse/Registered Nurse (RN Y) verified that there was no infection tracking, surveillance, or mapping for [DATE] and [DATE]. Corporate RN Y also reported that the DON had reported she had given all of the infection data to the survey team already, despite no COVID-19 surveillance being provided. Corporate RN Y was asked who was officially in charge of the Infection Control Program and reported it was the DON, as IP B was in training. On [DATE] at 5:50 p.m., an interview was conducted with the DON, who reported that another staff had tested positive on [DATE] in the evening. The DON was asked to confirm that there was no COVID-19 Infection Surveillance, who then reported that she did have a binder of it. The DON could not answer why it had not been provided on [DATE] when requested, or why she had told Corporate RN Y to tell the survey team that there was no COVID-19 Infection Surveillance. The DON reported that they were testing the unvaccinated and unboosted staff once per week through April, and were now doing outbreak testing of all staff twice per week. The DON was asked to provide the COVID-19 staff and resident testing logs. The DON reported that IP B had the logs and called her to come to the office. At approximately 6:08 p.m., IP B arrived and reported that the log was in the DON's office the entire time. A review of the testing log revealed that Dietary Aide P who tested positive on [DATE] had been scratched off the log. IP B reported she did this because she . wanted to keep it (the staffs test result) private . Further review of this log revealed that Dietary Aide J who tested positive on [DATE] was not on the log at all. IPB could not explain why the data was not on the log other than that she did not have time to write it in. IP B then reported that Dietary Aide J tested himself and was positive. IP B confirmed that some staff were testing themselves and leaving the test kits in the education room for someone to review at a later time. The DON was asked when Activities Aide N had worked in the past 72 hours and reported she had just clocked in when she tested and she hadn't worked since the previous week. The DON reported that Dietary Aide J had not worked at all as he was just starting work again after not working for a year or so. At 6:21 p.m., the punch cards for Dietary Aide P, Activities Aide P, and Dietary Aide J were requested for the two weeks prior to their positive tests. Review of the COVID-19 binder provided on [DATE] at 5:50 p.m. revealed the following: A Resident COVID-19 2021 Mapping for [DATE] that did not match the one that was found in the Infection Control Binders. This map had 17 names on it and did not delineate which were residents and staff. A Resident COVID-19 2021 Mapping for [DATE] which listed five names. There was no indication if these were staff or residents. A Resident COVID-19 2022 Mapping for [DATE] with one name (Certified Occupational Therapy Aide COTA CC). An email was found in plastic sheath behind this map that was sent to the health department form the DON on [DATE] which revealed Nurse Aide (NA) Q tested positive on that morning, despite her name not being listed on the months Mapping. A contact tracing form was found for NA Q but not for COTA CC. A review of the Contact Tracing form for NA Q revealed, .Room Number/location or Assignment worked of Resident/employee for the last 48 hours prior to test collection date: C wing . Can Positive Resident/Staff identify close contacts . yes .If yes, list identified residents affected that will require quarantine/TBP .(section not filled out . If Yes, test all staff (regardless of vaccination status) that had a high risk exposure with a COVID-19 positive individual AND test all residents (regardless of vaccination status, that had close contact with a COVID-19 positive individual . Initiate Outbreak Testing for vaccinated and unvaccinated residents and staff identified on page one . Testing dates of scheduled testing for next two weeks: (written in) [DATE], [DATE], [DATE], [DATE] . A review of a Line listing with no Monthly date revealed one staff listing for NA Q which revealed her symptoms of cough, malaise, headache, and chills started on [DATE] and tested positive. A review of a COVID 19 Contact Tracing Questionnaire Tool - Staff Member for NA Q dated [DATE] filled out by IP B revealed it was blank and had not been completed. Further review of the binder revealed a Contract Tracing forms for Dietary Aide P who tested positive on [DATE], but no Contact tracing forms were completed for Activities Assistant N or Dietary Aide J. On [DATE] at 8:45 a.m., an interview was conducted with the DON, Corporate RN Y, the Vice President of Clinical Operations (VP BB), and the Administrator. When asked if the health department had been notified of the ,d+[DATE], ,d+[DATE], and ,d+[DATE] staff cases of COVID, VP RN BB reported that the DON had reported them just then (the morning of [DATE]). When asked if the Residents had been tested since Activities Aide N had been in the building, VP RN BB reported that Activities Aide N had tested at the start of her shift and was immediately sent home. VP RN BB was informed that per the timesheet for Activities Aide N, she was clocked in for two hours on [DATE], and was either in the building after she tested positive or had not tested at the start of her shift. VP RN BB was informed that per the interview with the DON on the previous day ([DATE]) the DON had not completed the contact tracing for Activities Aide N or Dietary Aide J. The DON was then asked why the monthly summaries for November and [DATE] did not indicate anywhere that there had been a COVID-19 outbreak in the staff nor any line listings of the infections. The DON stated, I can't give you a good answer right now. When asked about Resident #168, the DON reported that the Resident had been sent out to the hospital and died later. On [DATE] at 9:18 a.m., an interview was conducted with Nurse Aide (NA) Q. When asked about her day on [DATE] when she tested positive, NA Q reported she just had symptoms on that day and few days later. NA Q reported she had a sore throat and didn't think anything of it until later she was changing a patient and she felt lightheaded, so the nurse tested her and she was positive. NA Q reported that she had screened in and had told the receptionist she had a sore throat which was audibly notable because of her raspy voice. NA Q reported she could not remember the patient she had been working with. NA Q also reported that many staff did not screen in, and some had even walked in that morning ([DATE]) and had not screened in. On [DATE] at 9:31 a.m., IP B was asked to provide a Resident COVID-19 testing log. IP B reported that they did not have a log, but that each individual Resident should have an order and a test result for each test that they received. IP B was asked if she recalled Residents being tested for COVID-19 in [DATE] and reported that she couldn't remember as she was still in training. A review of Sampled Residents #115, #72, and #34 (who resided on C-Wing in March of 2022) revealed no orders for COVID-19 tests, no test results, and no progress notes about testing or new quarantine/monitoring orders for [DATE]. On [DATE] at 9:41 a.m., Certified Occupational Therapy Assistant (COTA) CC was asked about her testing positive on [DATE]. COTA CC reported she tested on home that day because her son had tested positive a few days prior. COTA CC reported that she did not have any symptoms until Tuesday ([DATE]) and that she returned to work on [DATE]. When asked why she came back so soon, COTA CC reported she asked the DON if she could come back and she (the DON) told her (COTA CC) that she could. On [DATE] at 10:02 p.m., VP RN BB, the DON, and Corporate RN Y were interviewed. VP RN BB reported that he had called Activities Aide N who had reported she had never been within 6 feet of a Resident for more than 15 minutes. When asked which Residents and Staff she had had contact with, VP RN BB reported that Activities Aide N was unable to state. On [DATE] at 10:45 a.m., the DON was asked to provide the documentation log of all the Residents with their COVID-19 vaccination status and consents. The DON reported she did not have a binder or system to keep them all together, but she had the documents that she had sent to the Pharmacy. The DON reported that .some . of the consents were attached to the documents. Resident #168 A review of the list of names from the [DATE] COVID-19 Mapping revealed Resident #168 was listed as testing positive on [DATE]. A review of her medical record revealed she admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of her [DATE] Minimum Data Set (MDS) assessment revealed she scored ,d+[DATE] on the Brief Interview for Mental Status (BIMS) assessment, indicating intact cognition. A review of Resident #168's Immunization Tab in her Electronic Medical Record (EMR) revealed no indication of whether she had received, accepted, or refused COVID-19 Vaccination. Further review of the Physicians orders revealed no order to give any COVID-19 vaccination. Review of her documents revealed no consent or declination for the vaccine. On [DATE] at 9:45 a.m., VP RN BB and Corporate RN Y were asked to provide the COVID-19 Vaccination consent form for Resident #168, as it was not in her clinical record. The Administrator reported that it may take a while to find as the DON's filing system was putting things (documents and records) in cardboard boxes. When asked if it was appropriate to store resident medical records, especially those that had not yet been scanned into the medical record, to be stored in cardboard boxes, the Administrator reported that it was not. Corporate RN Y reported that the DON had told her that she had found a bag of documents and that it was possibly in the bag. The DON reported that the Unit Manager might have vaccination consent forms. On [DATE] at 10:40 a.m., Unit Manger/LPN G was asked about the Vaccination consent for #168 and reported that she would have to dig through a box of stuff that hadn't yet been scanned in. LPN G was notified that Resident #168 had nothing in her immunizations tab about being vaccinated and LPN G reported that if Resident #168 had previously been vaccinated they would have taken the info from her Mikker. On [DATE] at 11:14 a.m., Corporate RN Y reported that she had found the Vaccination Consent form for Resident #168 in the cloth bag. The document was reviewed with Corporate RN Y and revealed Resident #168 had consent to receive the [NAME] COVID-19 vaccination on [DATE]. The second page of the two page document that documented that she had received the vaccination had not been filled out. Corporate RN Y reported she would look to see if there was any evidence that Resident #168 had received the vaccination. On [DATE] at 11:49 a.m., Corporate RN Y reported she was unable to find any evidence to show Resident #168 received the vaccination that she had consented for. On [DATE] at 3:41 p.m. the following was observed in the main C dining room: There was a party in progress with a steam table set up with hot dogs and a counter with ice cream buckets sitting on the counter, not refrigerated, and many toppings/condiments. There was no clear delineation of food serving areas, and staff and residents were walking/wheeling around and through the area and self-serving from the ice cream counter. Staff E was observed serving ice cream, with long hair past the waist, without a hairnet in place to contain the hair. Staff C was sitting at a table at the end of the steam table, eating a hotdog. Staff C then continued to chew, pulled up the mask over the face, and began clearing plates from residents who were sitting at tables. Staff C touched dirty plates with bare hands, then returned to the original table where she was eating and continued to eat the hot dog without performing hand hygiene before or after clearing the plates and eating. Several staff came into the room and self-served ice cream with no hair nets in place or observed hand hygiene. Staff D was observed to go behind the steam table with no hand hygiene, and serve a resident a hot dog, with long hair down the back and no hair net in place and no hand hygiene before or after the service. When asked about the steam table service without a hair net or hand hygiene, Staff D agreed she did not wear a hair net. Staff D said she was on her way to the hand washing sink on the other side of the room, when this Surveyor stopped her for questions, but was observed to pause after coming out from the steam table, not proceeding to the sink. When asked about eating, then clearing plates without hand hygiene, Staff C confirmed she did not perform hand hygiene and stated, We know better. On [DATE] at 8:00 a.m., PEG (Percutaneous Endoscopic Gastrostomy) tube medication administration was observed performed by Licensed Practical Nurse (LPN) FF for Resident #32. LPN FF prepared each medication by placing a ungloved finger inside each of the plastic envelopes used to crush medications in order to open them to place the pill inside for crushing. LPN FF then crushed the medications one by one and again inserted an ungloved finger into the crushing envelope to open it up before emptying crushed contents into a medication cup. 5. Failure to screen vendors/visitors for COVID-19 symptoms On [DATE] at 12:24 PM, a Transport Vendor (SS) entered the facility through the main front door pushing a wheelchair. He proceeded to the end of the hallway. Receptionist (Staff TT) said the vendor was in the building to pick up a resident who was being discharged , and the vendor had not been screened. Staff TT said, They (vendors) usually don't go down the hall, but he did. Vendor SS was asked if he had been screened or had his body temperature checked and replied, They did not ask me any questions. He said his temperature had not been taken. When asked if he had been vaccinated, Vendor SS stated, Sure. The facility policy titled Pandemic Response Plan dated [DATE], read in part: Visitation can be conducted through different means based on facility's structure and resident's needs. Regardless of how visits are conducted, there are certain core principles and best practices that reduce the risk of COVID-19 transmission . 1. Screening of all who enter the facility for signs and symptoms of COVID-19 (e.g., temperature checks, questions about and observations of signs or symptoms), and denial of entry of those with positive [CONDITION(S)] test for COVID-19, symptoms of COVID-19, or currently meeting the criteria for quarantine. 6. Failure to practice hand hygiene to prevent the spread of infection: On [DATE] at 8:36 AM, LPN FF was observed administering medication to Resident #32. LPN FF was at the bedside of Resident #32 and had to return to his medication cart in the hallway to obtain cups. He took off his gloves, returned to the room and put on new gloves. He changed his gloves again during the procedure. When asked about infection control and gloving, LPN FF stated, I didn't sanitize my hands. Generally, I would do that, I am just being honest. I did not wash my hands after changing my gloves. During a telephone interview on [DATE], at 7:55 AM, the DON stated her expectations would be hand hygiene should be performed before putting on and after taking off gloves. The facility policy titled, Hand Washing and Hand Hygiene dated [DATE] read in part: To protect our residents, visitors, and staff, each facility will promote hand hygiene practices during all care activities and working in locations within the facility. Conditions which may require hand hygiene include but not limited to: Before and After applying gloves . B. Based on interview and record review, the facility failed to have an active 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 water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among the 123 residents in the facility. Findings include: On [DATE] at 9:45 AM, the building water management policy and procedure was requested from the facility Administrator. The Administrator stated that it was in the survey binder. Upon review of the survey binder, there was no policy and procedures regarding the building water management plan in the survey binder. On [DATE] at 10:00 AM, when informed that the building water management plan was not in the survey binder, the Administrator stated that he would have the Maintenance Director come and speak with me. On [DATE] at 10:15 AM, Maintenance Director I was queried about the facility's water management plan. Maintenance Director I stated that the only measure currently being implemented to reduce the risk and growth of Legionella in the building water system, was the chlorination of shower heads and aerators throughout the building. When asked if there was a facility risk assessment that had been performed to identify where Legionella and other OPPP could grow and spread, Maintenance Director I stated he was not aware of any. When asked if the facility had a written water management policy and procedure that incorporated the CDC tool-kit and the ASHRAE guidelines, Maintenance Director I stated they did not. On [DATE] at 10:30 AM, the Director of Nursing (DON) and the newly appointed Infection Preventionist B were queried as to their involvement in the facility's building water management program, and the DON stated, The Maintenance Director mainly handles that. The facility Abatement plan was accepted, and facility implementation began as follows to remove Immediacy: The activity aide was re-educated regarding COVID testing and Signs and symptoms (s/sx) on [DATE] by the ICP (Infection Control Practitioner). The infection control program was updated for April & May on [DATE]. A 1x audit was started on [DATE] to ensure that all staff had a COVID test completed. All residents in the building will be swabbed on [DATE] to ensure they were all negative. A one-time review of nurse's notes was completed on [DATE] for the last 14 days to ensure that no resident presented with any signs and symptoms of COVID that would need further testing. COVID-19 contact tracing was performed on [DATE] for two identified positive staff members who had not been contact traced. Re-education of all staff was started on [DATE] and will be completed on [DATE] on the importance of routine staff screening upon entry to the facility and the importance of vendor screening before allowing admittance to the facility. COVID testing at the beginning of the shift as indicated. Current staff who have not signed for education prior to date of compliance will not be allowed to work until education is received and will sign for receipt of education prior to working next assigned shift. The Infection Control Practitioner (ICP) and the Director of Nursing (DON) were re-educated on COVID contact tracing, infection control surveillance by the Regional Director of Operations on [DATE]. DON and Executive Director reviewed the Infection Control policy on [DATE] and found them to be appropriate. Beginning on [DATE] staff will be tested 2x/week at the beginning of their shift and they will not go to their work area until testing is completed. Beginning on [DATE] the following System Change was implemented: Infection Control Practitioner (ICP) /designee will complete 5 chart reviews weekly x 12 weeks to ensure that no residents presented with signs and symptoms (s/sx) of COVID without completing a rapid Point of Care (PoC) test. This will continue until the Quality Assurance (QA) committee has determined compliance. 100% of all staff received education in person or mobile text on [DATE]. For those who received initial re-education via mobile text will be provided with the mandatory plan of removal education in-person prior to the start of their next scheduled shift to ensure in-person receipt and understanding. Beginning on ,d+[DATE] the Infection Control Practitioner (ICP) will take the monthly Infection Control surveillance to the Quality Assurance (QA) meeting monthly to ensure completeness and accuracy. DON or designee will audit weekly to assure that accurately tracking and contact tracing for COVID positive staff is being completed, COVID testing for staff and residents are being completed timely, Infection Control program and documentation is up to date, and health department is notified timely for COVID cases. Audits to be completed as stated above weekly x 12 weeks to assure ongoing compliance. Concerns identified will be corrected at the time of observation. Results of audits will be reported to QAPI monthly x3 and PRN as needed. The DON is responsible for Ongoing compliance.

Based on observation, interview, and record review the facility failed to assess and supervise one resident's ability to safely smoke outside (Resident #22) and failed to investigate resident falls to prevent further falls for two residents (#22, #86) out of three residents with a high risk for falls reviewed. This deficient practice resulted in four unwitnessed falls for Resident #22 (one with a hematoma or bruising to the forehead), and potential for further falls due to lack of investigation (#22, #86). Findings include: Resident #22 Resident #22's Electronic Medical Record (EMR) revealed an admitted [DATE] with medical diagnoses including repeated falls, stroke, [CONDITION(S)], major depressive disorder, and [CONDITION(S)] disorder. The Minimum Data Set (MDS) assessment for Resident #86 dated 2/17/22 contained a Brief Interview of Mental Status (BIMS) score of 9/15 indicating moderate cognitive impairment. This MDS also indicated Resident #22 had multiple falls with and without injury in the past 3 months. During a confidential group interview on 5/10/22 at 11:15 AM, the group stated they found Resident (#22) on the ground alone outside in the smoking area having a [CONDITION(S)]. The group explained the smoking area was open from 7 AM until 11 PM. Any resident who could push the door open and self-propel into the smoking area could go out during that time frame. No one could assist others to go out the door. The area was unsupervised. On 5/10/22 at 4:22 PM, the Director of Nursing (DON) presented the accident/incident reports for Resident #22's falls. These reports included four falls which had occurred outside on the smoking patio in winter months. - 11/16/21: Resident observed on the smoking patio on her back having [CONDITION(S)], legs and arms shaking. Verbally responsive when talked to. Helmet off head on the ground. Denies pain. Resident unable to give description. Intervention: care plan followed. Fall is result of [CONDITION(S)]. No further intervention at this time. - 11/24/21: (Resident #22) was observed on the patio having a [CONDITION(S)] .Resident unable to give description. - 1/6/22: resident went out to smoke observed on ground with no helmet, hematoma to forehead, alert and conscious .Intervention: care plan reviewed and was followed. No further intervention at this time. - 3/3/22: Resident sitting on the ground outside, smoking patio, with helmet on. Resident stated lost balance while taking cigarette from locker outside patio and fell on buttocks. During an interview on 5/12/22 at 5:12 PM, Director of Social Work (Social Worker K) reviewed the medical record and said the last safe smoking assessment for Resident #22 was on 11/8/21. There were 17 falls since the last safe smoking assessment including four which occurred outside in the unsupervised smoking patio. During an interview on 5/11/22 at 3:44 PM, the DON was asked to provide further investigation (such as interviews, diagrams, and root cause analysis) for the accident/incident reports for the falls of Resident #22. No further information was provided. The smoking area and smoking activity for facility residents were discussed. The DON stated smoking was not a supervised activity, and she said, It is an independent activity. The DON said Resident #22 has had a ton of seizures. For the fall on 1/6/22, Resident #22 fell outside on the smoking patio found on ground with no helmet, and a resulting hematoma on her forehead and was sent to the hospital. The DON responded, They (the nursing staff) get scared and call 911 right away and she (Resident #22) has gone to the hospital and had every test imaginable at the hospital. The DON said the 1/6/22 fall outside happened at 7:00 at night resulting in a hematoma because Resident #22 will not wear the strap for the helmet. The DON said Resident #22's helmet will sometimes fall off and occasionally she will get a little bump on the head. The DON concluded, We do the best we can to avoid it with her. When asked about the lack of new interventions and lack of complete investigation to prevent further falls and injuries, the DON said, There is not a new intervention every time (Resident #22) has a [CONDITION(S)] which are several times a week, even several times a day sometimes. When asked about the risk of injury due to the unsupervised smoking area being open every day from 7:00 AM to 11:00 PM throughout the year, the DON agreed there is a risk for injury. The DON said, It is not a supervised activity. It is not at my decision-making level. During an interview on 5/11/22 at 4:20 PM, the Corporate Clinical Registered Nurse (RN) Y, confirmed there was not a safe smoking assessment in the past quarter, since 11/8/21. The care plan for Resident #22 included a focus of SMOKING/BEHAVIORS with a goal including: .I will be assessed for my safety awareness by next review to see if I am able to participate in this activity Date Initiated: 3/12/21 and Revision on: 5/11/21. One intervention included: Resident will be assessed upon admission and periodically to determine they are able to smoke safely Date Initiated: 3/12/21 and Revision on: 5/11/21. The Safe Smoking List (as of 4/1/2022) included Resident #22. The facility policy titled: SAFE SMOKING dated as revised 2/4/2014 read in part, PURPOSE: To promote the safety of residents who smoke by assessing and managing their smoking capabilities, thereby minimizing risk for injury or harm to self and others . PROCESS/PROCEDURE: 1. Assess the resident's ability to smoke safely . 2.complet the Safe Smoking Assessment. 3. Review and update assessment quarterly and at any time a change in status occurs. Resident #86 Resident #86's EMR revealed an admitted [DATE] with medical diagnoses including [CONDITION(S)], dementia, and major depressive disorder. The MDS assessment for Resident #86 dated 4/4/22 contained a BIMS score of 99 indicating the interview was not able to be completed due to cognitive impairment. On 5/10/22 at 10:52, Resident #86 was observed with an reddened healing injury on her forehead. Licensed Practical Nurse (LPN) FF stated Resident #86 had a recent fall on 4/24/22. The EMR for Resident #86 revealed a nurse progress notes for the fall with injury: - 4/24/2022 Note Text: CNA (Certified Nurse Aide) brought it to my attention that a resident was on the floor. Observed resident laying on her Left side bleeding from her head. I alerted another nurse to helped with resident and call for ambulance and MD . - 4/25/2022 Note Text: CNA (CNA OO) wrote a statement stating on paper, I was pushing the dinner cart down the hall. I noticed (Resident #86) was in front of cart. I tried to grab her chair but before I could grab her she was already falling I'm guessing she was sitting on the edge of chair. And initial nurse progress note, on return from the hospital five days following the fall: - 4/29/2022 Nurses Note DOCUMENT RELEVANT INFORMATION ABOUT THE RESIDENT: Received (Resident #86) with a dx (diagnosis) of subarachnoid hemorrhage (head injury) admitted to facility via stretcher . On 5/10/22 at 4:22 PM, the DON presented an accident/incident report for Resident #86's 4/24/22 fall. It read in part: CNA brought it to my attention that a resident was on the floor. Observed resident laying on her Left side bleeding from her head. I alerted another nurse to helped with resident and call for ambulance and MD. (This statement was identical to the 4/24/22 EMR progress note.) The report stated the intervention for the fall: Transfer to hospital. Intervention on return to have PT/OT follow up and tx (treat). There were no staff interviews, diagram of fall, or further details (on which floor, how did the fall occur, were other residents or staff involved etc) included with the investigation. During an interview on 5/10/22 at 5:30 PM, the DON stated she was not able to find any further investigation. She stated she had no other interviews, root cause analysis, or other findings needed interventions to prevent further falls. The DON stated, That is all I have for that investigation. I had a call into an agency nurse to interview her but that might be at home. The progress notes indicated CNA OO witnessed the fall of Resident #86 on 4/24/22. On 5/11/22 at 10:13 AM, RN Y looked at the facility records and no one with the name of CNA OO was employed at the facility. Therefore, CNA OO was determined to be a contracted staff. RN Y did find CNA OO worked with Resident #86 on 4/24/22 but said CNA OO could not be contacted due to her contracted status. During an interview on 5/11/122 at 10:30 AM, the DON stated the investigation could have been more complete. The DON stated, That should be here. We know her practice and that doesn't translate into the report. The investigation is incomplete. 05/11/22 04:45 PM DON That is all I have for that investigation. I had a call into an agency nurse to interview her but that might be at home. The facility policy titled: Falls Reduction Program dated as last revised 9/25/2016 read in part, Purpose: To provide a safe environment for residents, modify risk factors and reduce risk of fall-related injury . 3. If fall occurs Charge Nurse to complete the following: Physical assessment of resident and observation of environment, Immediate interventions as identified by physical assessment and environmental observation, Incident report .

This deficient practice has two parts, A. and B.: A. Based on interview and record review, the facility failed to ensure emergency care was provided timely for one Resident (#88) of 22 residents reviewed for quality of care. This deficient practice led to Acute Kidney Injury (AKI) and [CONDITION(S)]. Findings include: On 5/10/22 at 10:36 a.m., a review of the EMR showed Resident #88 admitted to the facility on [DATE]. A review of the census tab in the EMR revealed a Discharge stop billing entry on 3/26/22. A review of the progress notes for Resident #88 read in part: 3/23/2022 (4:39 p.m.) . Physician's Note . (Resident #88) . . This is an [AGE] year-old . with past history of [CONDITION(S)] (Stroke) with [CONDITION(S)] (inability to speak), dysphagia (difficulty swallowing) with history of PEG (Percutaneous Endoscopic Gastrostomy) tube placement and left [CONDITION(S)] (one sided paralysis). Positive for history of diabetes, DVT ([CONDITION(S)]) right upper extremity . (Resident #88) was previously residing at (another facility) and was transferred to (the facility) for long-term care. On admission patient is nonverbal able to follow some commands Patient is awake, nonverbal and confused at baseline . . Code Status: Full code . . Vitals: Blood pressure 145/72 pulse 79 respiratory rate 20 temperature 97.9 oxygen saturation 93% . Cardiovascular: RRR, nml S1 and S2, no rubs, murmurs or [NAME], no [CONDITION(S)], no cyanosis; . Gastrointestinal: Abdomen soft, NT(non-tender), ND(non-distended), no masses, normal bowel sounds; PEG tube Neurological: Awake and alert with [CONDITION(S)], left sided deficits, does not follow commands . left [CONDITION(S)] with contracture of left upper extremity . . Type 2 diabetes mellitus . . Blood sugars have been elevated . . Electronically signed By: (NP V) 3/26/2022 (10:59 p.m.) . Nurses Note . received resident 330pm (3:30 p.m.), report from am (morning) nurse stated resident noted with increased respirations (32) , O2 (oxygen) placed 3l (liters) via n/c (nasal cannula). states on call informed, order for neb (nebulizer) tx (treatment) one time & stat (immediate) cxr (chest x-ray) as resident had emesis yesterday .nurse states slight improvement with tx & 02. writer observed resident (#88) in bed . face flushed, skin clammy. resp (respirations) 34 & labored. spo2 (oxygen saturation) 88% with 02 (oxygen) . abd (abdomen) slightly distended with hardened area to left side . hr (heart rate) 87, b/p (blood pressure) 113/54 t (temp) 97.4. blood sugar 380 (mg/dl). abnormal labs noted in computer , am nurse notified on call of labs who stated to send to ER. am nurse informed DON who stated to call medical director. am nurse called medical director who gave orders for xtra (extra) fluids & repeat labs in am. daughter in to visit, am nurse answered questions & POC (Plan of Care) explained. daughter stated resident has been like this before when [CONDITION(S)] (urinary tract infection) present. am nurse stated she messaged MD (Physician). approx (approximately) hour later, daughter requested resident (#88) to be transferred to hospital. DON informed, spoke with medical director who states it will be considered AMA (Against Medical Advice). Daughter informed, verbalized understanding & still wants resident transferred to (Local Hospital). (Ambulance Service) called for transport. AMA paperwork filled out & signed . vitals upon discharge t 97.5, p87, r 34 & labored, b/p 107/52, spo2 97 % with o2 3l via n/c (Licensed Practical Nurse (LPN) AA) 4/1/2022 (2:56 p.m.) . Physician's Note . (Resident #88) . . Encounter Date: 04-01-2022 Chief Complaint: Readmission status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient admitted to acute care hospital March 26 through March 31, 2022 due to acute kidney injury, [CONDITION(S)] with [CONDITION(S)]. readmitted to Lake Pointe for further care . . Code Status: Full code . . Vitals: Blood pressure 124/68 pulse 70 respiratory rate 18 temperature 97.4 oxygen saturation 98% . . Assessments/Plans: Acute kidney injury Patient with acute kidney injury status post [MEDICAL RECORD OR PHYSICIAN ORDER] . [CONDITION(S)] Patient completed antibiotic therapy. treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . . Electronically signed By: (NP V) A review of the CBC (complete blood count) w (with)/differential and Basic Metabolic Panel, with collection date of 3/26/22 at 9:05 a.m., revealed the following: WBC (White Blood Cells) 18.0 Range 4.00 - 11.00 H (high) RBC (Red Blood Cells) 5.81 Range 3.80 - 5.50 H Platelet Count 529 Range 130 - 400 H Neutrophil# (specialized WBC) 12.9 Range 1.7 - 7.7 H Sodium 162 Range 136 - 145 HH (Critical High) Potassium 5.4 Range 3.5 - 5.3 H Chloride 118 Range 98 - 110 H Glucose 161 Range 74 - 109 H BUN 135 Range 7 - 25 HH Creatinine 1.45 Range 0.60 - 1.30 H GFR (Kidney Function) 42 Range >60ml/min L (Low) (milliliters/minute) A review of the Acute Care Hospital documents revealed the following: ED (Emerency Department) Provider Notes (dated 3/26/22) Chief Complaint (Resident #88) presents with Blood Infection Possible [CONDITION(S)] .presents for evaluation of fever. (Resident #88) comes from (the facility) . Daughter states that some blood work was done earlier today which showed elevated white blood cell count and potassium and creatinine and Blood Urea Nitrogen (BUN). (Resident #88) has a PEG tube in as well there is a concern she may have aspirated . .Code [CONDITION(S)] activated on initial encounter due to fever and suspicion for [CONDITION(S)] . [MEDICATION(S)] (IV antibiotic) and [MEDICATION(S)] (IV antibiotic) ordered . . Final Impression Severe [CONDITION(S)] . Urinary tract infection . [CONDITION(S)] Elevated BUN Elevated troponin (enzyme level for muscle damage) . Nephrology (Kidney Physician) Consultation (dated 3/27/22): Primary reason for Consultation: Acute kidney injury . . HPI: (History of Present Illness) . presented to the hospital with fever. (Resident #88) was also noted to have elevated white cell count. (Resident #88) was also noted to have acute kidney injury and [CONDITION(S)] (high blood potassium [sic]-[CONDITION(S)] [low blood potassium]) . (Resident #88) did have a few episodes of [CONDITION(S)] . . Diagnosis . Severe [CONDITION(S)] . . AKI . . [CONDITION(S)] . . Leukocytosis . On 5/11/22 at 3:45 p.m., a call was placed to the attending physician for Resident #88 and a message was left to return call to discuss the hospitalization of Resident #88. No return call was received by the end of the survey. On 5/11/22 at 4:01 p.m., during an interview, when asked why the physician would have sent Resident #88 to the hospital AMA, LPN G stated The physician sometimes will try to have residents treated here and sometimes we have residents wanting to go out for reasons that are not emergent and I think the physician uses it as a deterrent to go to the hospital when they can be treated in the facility. On 5/11/22 at 4:30 p.m., during an interview with the DON and Nursing Home Administrator (NHA), the NHA stated the Physician wants AMA documented when he feels like it's against his medical advice. The NHA stated it does not prevent the facility from allowing the resident or the resident's RP (Responsible Party) from exercising their right to go out to the hospital anyways. This Surveyor expressed concerns with using the terminology of AMA to deter the family in any way from seeking medical care for their family member. The NHA acknowledged the concern expressed but offered no possible change in the facility practice. On 5/12/22 at 11:48 a.m., during an interview, Registered Nurse (RN) L stated the bed hold process would not have been initiated as Resident #88 was discharged AMA. RN DD stated Resident #88 was not able to make her own decisions because she was completely non-verbal. When asked what impact the AMA process could have on a resident, RN L stated So when they go out we can take them back but we don't have to take them back. We can refuse to accept them back. RN L confirmed the family's input should have been considered when making care decisions. RN L acknowledged the discharge AMA process could have potentially deterred the family member in making important life decisions for Resident #88. The facility failed to recognize Resident #88 was exhibiting beginning signs of [CONDITION(S)] and failed to ensure Resident #88 received timely intervention at a higher level of care. The hospital documents show Resident #88 suffered severe [CONDITION(S)] and AKI. A review of the Discharge or Transfer of Resident, with a revised date of 8/5/21, read in part: Key Terms . Emergency Transfer /Discharge: for medical reasons, or the immediate safety and welfare of a resident, initiated by the facility. Discharge Against Medical Advice: When the resident or resident's family wishes to take the resident home and the attending physician cannot be reached or physician indicates discharge would be medically contraindicated. Purpose: To provide safe departure from the Center, and provide sufficient information for after care of the resident. To provide guidelines to ensure the proper steps are taken should a resident or their guardian or family member(s) request to be discharged from the Center against medical advice (AMA). . Discharge Against Medical Advice 1. The resident /guest and family legal representative should be informed of the risk involved, the benefits of staying at the facility and alternatives to do both. The MD (Physician) should be notified and encouraged to speak with the resident/guest. . 5. If a patient leaves against Medical Advice the facility does not have to let the patient return to the facility in the future. B. Based on interview and record review, the facility failed to ensure adequate monitoring and control of blood sugars for one Resident (#13) of 22 residents reviewed for quality of care. This deficient practice led to the potential for increased risk of diabetic related complications. Findings include: On 5/10/22 at 10:54 a.m., during an interview, Resident #13 stated he was concerned about his blood sugars being high and attributed his high blood sugars to his diet. A review of the May 2022 electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 5:00 p.m. 401 mg/dl on 5/4/22 9:00 p.m. 407 mg/dl on 5/7/22 422 mg/dl on 5/9/22 There were 10 additional blood sugars between 300 mg/dl and 400 mg/dl from 41 total possible blood sugars taken for Resident #13. A review of the April 2022 eMAR for Resident #13 revealed the following blood sugars greater than 400 mg (milligrams)/dl (deciliter): 8:00 a.m. 497 mg/dl on 4/13/22 12:00 p.m. 421 mg/dl on 4/13/22 5:00 p.m. 402 mg/dl on 4/13/22 488 mg/dl on 4/22/22 412 mg/dl on 4/30/22 9:00 p.m. 455 mg/dl on 4/1/22 402 mg/dl on 4/13/22 435 mg/dl on 4/14/22 513 mg/dl on 4/17/22 477 mg/dl on 4/25/22 548 mg/dl on 4/27/22 499 mg/dl on 4/29/22 There were 35 additional blood sugars between 300 mg/dl and 400 mg/dl from 120 total possible blood sugars taken for Resident #13. A review of the March 2022 eMAR for Resident #13 revealed the following blood sugars greater than 400 mg (milligrams)/dl (deciliter): 8:00 a.m. 404 mg/dl on 3/2/22 459 mg/dl on 3/11/22 5:00 p.m. 443 mg/dl on 3/8/22 406 mg/dl on 3/14/22 402 mg/dl on 3/28/22 9:00 p.m. 465 mg/dl on 3/9/22 406 mg/dl on 3/14/22 417 mg/dl on 3/16/22 420 mg/dl on 3/23/22 441 mg/dl on 3/28/22 484 mg/dl on 3/29/22 There were 44 additional blood sugars between 300 mg/dl and 400 mg/dl from 124 total possible blood sugars taken for Resident #13. A review of the February 2022 eMAR for Resident #13 revealed the following blood sugars greater than 400 mg (milligrams)/dl (deciliter): 8:00 a.m. 458 mg/dl on 2/1/22 420 mg/dl on 2/9/22 12:00 p.m. 428 mg/dl on 2/21/22 5:00 p.m. 420 mg/dl on 2/16/22 9:00 p.m. 448 mg/dl on 2/12/22 438 mg/dl on 2/14/22 420 mg/dl on 2/16/22 412 mg/dl on 2/27/22 There were 43 additional blood sugars between 300 mg/dl and 400 mg/dl from 112 total possible blood sugars taken for Resident #13. A review of the Diabetic Care Plan in the Electronic Medical Record (EMR) accessed on 5/12/22 lacked any direction on when to report abnormal blood sugars to the physician. A review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] 4/13/2022 (6:51 p.m.) . Physician's Note . Late Entry . (Resident #13) . . Past Medical History: Type 2 diabetes . . Other [CONDITION(S)] [MEDICATION(S)] eye disease . (Resident #13) remains on [MEDICATION(S)] (steroid eye medication), [MEDICATION(S)] (antiviral medication) daily . . Type 2 diabetes mellitus without complications . Continue [MEDICATION(S)] (insulin) and mealtime insulin. Carb controlled diabetic diet. Monitor hemoglobin A1c ( blood sugar test to determine 3 month average) and Accu-Cheks (blood sugar testing) Blood sugars are generally well controlled . . Electronically signed By: (Nurse Practitioner [NP] V) . 3/11/2022 ( 4:50 p.m.) . Physician's Note . Late Entry: . (Resident #13) . . Past Medical History: Type 2 diabetes . . [MEDICATION(S)] eyedrops to twice daily until follow-up with (consultant physician) . . Type 2 diabetes mellitus without complications . Continue [MEDICATION(S)] and mealtime insulin. Carb controlled diabetic diet. Monitor hemoglobin A1c and Accu-Cheks Blood sugars are generally well controlled . . Electronically signed By: (NP V) . A review of the order section of the EMR for Resident #13 revealed the following insulin orders: [MEDICATION(S)] Solution 100 UNIT/ML (Insulin Detemir) Inject 38 unit subcutaneously two times a day for Diabetes II -Start Date- 09/09/2021 (9:00 p.m.) [MEDICATION(S)] Solution (Insulin [MEDICATION(S)]) Inject 10 unit subcutaneously before meals for Diabetes Mellitus Type 2 Hold is (sic) resident does not eat a snack -Start Date- 08/03/2021 (5:00 p.m.) There were no parameters present in the order section to direct nursing staff on when to call the physician for high or low blood sugars. A review of the Progress Notes section of the EMR for Resident #13 read in part: 4/17/2022 (11:36 p.m.) Nurses Note . BS (blood sugar) 513 (mg/dl) this evening . New one time insulin order obtained and given . There were no additional progress notes from 2/1/22 forward to show any other elevated blood sugars were addressed with the physician providers. On 5/12/22 at 11:14 a.m., during an interview, when asked about how blood sugars are supposed to be addressed, Licensed Practical Nurse (LPN) W stated there should be parameters in place for all diabetics. LPN W confirmed there were no parameters in place for Resident #13. On 5/12/22 at 11:16 a.m., during an interview, Registered Nurse (RN) X called NP V to ask about adding an insulin sliding scale coverage order for Resident #13 due to his frequently high blood sugars. Following that phone conversation with NP V, RN X confirmed NP V allowed a standard sliding scale to be added to the orders for Resident #13, along with addition of parameters to follow a hypoglycemic (low blood sugar) protocol when blood sugars are less than 70 mg/dl and call the physician for further direction for blood sugars over 400 mg/dl. On 5/12/22 at 11:20 a.m., during an interview, when asked how blood sugar levels were evaluated for stability, NP V stated she usually looked at the vital sign section of the EMR to get an idea of blood sugar trending for residents. NP V stated she had not been contacted by staff regarding any blood sugars being over 400 mg/dl. NP V stated she just had the staff start a sliding scale for him and stated she would have to keep a closer eye on blood sugars for Resident #13. On 5/12/22 at 11:35 a.m., during an interview, the Director of Nursing (DON) confirmed nursing staff should be calling physicians when a resident's blood sugar is greater than 400 mg/dl. A review of the facility policy [CONDITION(S)] (Diabetic Coma), with a revised date of 11/12/2014 read in part: Purpose Residents will be monitored for signs and symptoms of [CONDITION(S)] which if not treated can result in diabetic coma. . 3. If result are above 400 (mg/dl) or greater that physician guidance for resident the physician will be IMMEDIATELY contacted. a. If Physician orders coverage, please recheck blood sugars in 1 hour and contact physician for further direction . . 5. Document care and treatment provided to resident in nurses notes.

This citation pertains to MI 100, MI 837, and MI 948 Based on observation, interview, and record review, the facility failed administer ordered medications to ensure adequate pain management for two Residents (#107 & #34) of four residents reviewed for pain management. This deficient practice resulted in severe pain and poor quality of life. Findings include: Resident #107 On 5/10/22 at 9:58 a.m., during an interview, Resident #107 stated they ran out of her pain medication for almost a week. Resident #107 stated she was prescribed a sustained release [MEDICATION(S)] (opioid pain analgesic for severe pain) for chronic pain and stated someone forgot to make sure it was ordered. Resident #107 stated the facility was giving her a [MEDICATION(S)] (opioid pain analgesic for moderate pain) but it was not working to relieve her pain. Resident #107 stated, I was really pissed off about that one. I told them this was really killing me. I couldn't get up to go to the bathroom. I couldn't get up to do anything. When asked approximately when this occurred, Resident #107 stated it was about two weeks ago when this happened. Resident #107 stated, They just kept saying to me it's on order. Resident #107 stated a nurse on nights was the one who told Resident #107 the issue was it never got ordered. Resident #107 stated the medication came back in about a week ago and her pain is much better now. A review of the Electronic Medical Record (EMR) revealed admission to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the April 2022 electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] Capsule 35 mg Give 1 capsule by mouth two times a day for oa ([CONDITION(S)]) Start Date 4/18/22 (8:00 p.m.) [MEDICATION(S)] Sodium Cream 2.5% Apply to both knees topically two times a day related to polyosteoarthritis Start Date 4/19/22 (8:00 p.m.) D/C (Discontinue) Date 4/28/22 (12:49 p.m.) [MEDICATION(S)] Sodium Gel 1% Apply to affected area topically four times a day for pain. Start Date 4/8/22 (9:00 a.m.) [MEDICATION(S)] Capsule 150 mg Give 1 capsule by mouth two times a day related to polyneuropathy (nerve pain) Start Date 4/7/22 (8:00 p.m.) D/C Date 4/8/22 (10 :30 a.m.) [MEDICATION(S)] Capsule 75 mg (milligram) Give 1 (one) capsule by mouth in the morning for nerve pain. Start Date 4/8/22 (9:00 a.m.) D/C Date 4/8/22 (10:26 a.m.) [MEDICATION(S)] Capsule 75 mg Give 75 mg by mouth two times a day for pain hold for sedation Start Date 4/8/22 (8:00 p.m.) D/C Date 4/14/22 (6:51 a.m.) [MEDICATION(S)] Capsule 150 mg Give 150 mg by mouth two times a day for [CONDITION(S)] Start Date 4/13/22 (8:00 p.m.) [MEDICATION(S)] ER (Extended Release) Tablet 30 mg Give 15 mg by mouth two times a day related to other chronic pain Start Date 4/7/22 (8:00 p.m.) D/C Date 4/8/22 (10:39 a.m.) [MEDICATION(S)] ER Tablet 15 mg Give 15 mg by mouth two times a day for pain hold for sedation Start Date 4/8/22 (8:00 p.m.) [MEDICATION(S)]-Acetaminophen ([MEDICATION(S)]) Tablet 10/325 mg Give 1 tablet by mouth every 6 hours as needed for severe pain Start Date 4/7/22 (11:15 p.m.) Pain Assessment Every shift for assessment Start Date: 4/28/22 (7:00 a.m.) A review of the Individual Resident 's Controlled Substance Record for [MEDICATION(S)] ER 15 mg tablets with a deliver date of 4/8/22 for a quantity of 4 tablets was dispensed to Resident #107 per order and ran out on 4/10/22. A review of the Individual Resident 's Controlled Substance Record for [MEDICATION(S)] ER 15 mg tablets with a delivery date of 4/10/22 for a quantity of 30 tablets was dispensed per order and ran out after the dose delivered on 4/25/22 at 9:00 p.m. A review of the Individual Resident 's Controlled Substance Record for [MEDICATION(S)] ER 15 mg tablets with a delivery date of 4/29/22 for a quantity of 28 tablets was dispensed per order starting on 4/29/22 at 10:00 p.m. and ran out after the dose delivered on 5/11/22 at 9:00 p.m. Review of the medication delivery receipts revealed Resident #107 had gone without [MEDICATION(S)] ER 15 mg twice daily for a total of 7 doses starting on 4/26/22 for the a.m. dose, though the 4/29/22 a.m. dose before receiving her medication as ordered again on 4/29/22 at 10:00 p.m. A review of the eMAR for April 2022 revealed Resident #107's pain was not routinely being assessed until 4/28/22. During the same time period when Resident #107's pain medication ran out, an increase in [MEDICATION(S)] was observed in the eMAR with 6 doses administered over the three-day time period. Pain ratings obtained during administration of [MEDICATION(S)] were done and Resident [NAME] her pain at a 0 prior to running out of the [MEDICATION(S)] 15 mg tablets. Subsequent doses of [MEDICATION(S)] on 4/26/22 and 4/27/22 were accompanied by pain ratings of 3, 4, 6, and two 7's (scale 0-10) indicating Resident was increasingly experiencing moderate to severe pain. A review of the May 2022 eMAR revealed Resident #107 rated their pain anywhere from a 0 - 4 (mild) on average and only one time was their pain higher at 5 (moderate). On 5/12/22 at 1:13 p.m., during an interview, Licensed Practical Nurse (LPN) G stated taht they were unaware of the pain medication not being available for Resident #107. On 5/12/22 at 1:15 p.m., during a follow-up interview, Resident #107 was asked what effect the missing pain medication had on her stay at the facility. Resident #107 stated she couldn't get up to do anything and couldn't even participate in therapy the pain was so bad. Resident # 107 stated when the facility was giving her the [MEDICATION(S)] for the time she was missing the sustained release [MEDICATION(S)] tablets the pain was .completely debilitating. A review of the facility provided pharmacy back up medications inventory list revealed [MEDICATION(S)] ER 15 mg tablets was available in the back up inventory. No facility effort was documented in an attempt to secure medication required to treat Resident #107's pain emergently. Resident #107 ended up waiting until the next scheduled delivery made by the pharmacy provider. Resident #34 On 5/10/22 at 9:59 a.m., Resident #34 was observed in bed with a breakfast tray on her overbed table. Resident #34's eyes were rolling around and she was grimacing. When asked how the breakfast was, Resident #34 moaned that she was in too much pain to eat. Resident #34 was asked if the nurse had provided her pain medication and she responded she gave her something but that it wasn't working. On 5/10/22 at 10:00 a.m., RN M was asked about Resident #34's pain. RN M reported that the Resident had received a scheduled and an as needed (PRN) pain medication. RN M reported that the resident had told her she used to get a medicated pain rub (topical cream) and that she would call the doctor about it. RN M reported this a normal level of pain for Resident #34. A review of Resident #34's May 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . RN M rated Resident #34's pain as a 1 out of 10 when she dispensed Resident #34's [MEDICATION(S)] 5-325 (a narcotic pain medication) mg at 9:25 a.m, 25 minutes later. A review of resident #34's progress note for medication administration on 5/10/22 at 3:27 p.m. revealed, refused (medication) stated she hurts to (sic) bad. No as needed pain medications were signed out as dispensed. On 5/11/22 at 8:57 a.m., Resident #34 was observed sitting up in bed with Certified Nurse Aide (CNA) S beside her encouraging her to eat her breakfast. Resident #34 stated to this surveyor, I need my medicine, my back hurts so bad. Please. Resident #34 was moaning in pain. CNA S reported that she had already told the nurse, and that the Resident wouldn't eat because she was in too much pain. On 5/11/22 at 9:01 a.m., RN M was asked about Resident #34's pain while at the medication cart outside her room. RN M reported she would check to see if Resident #34 could receive anything for pain. RN M asked if the Resident had recently received a pain medication and RN M reported that she had received a PRN pain medication from the midnight nurse. RN M also reported that Resident #34 was only receiving Biofreeze (a topical cream with menthol) and no other medicated pain rub. RN M reported she would give the Resident a sticky note to remind her when she could have another pain pill, because otherwise the resident is .constantly ringing us (using the call light). A review of Resident #34's medical record revealed she admitted to the facility on originally on 8/29/19 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the 2/22/22 Minimum Data Set Assessment revealed she scored 14/15 on the BIMS assessment, indicating intact cognition and had an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident #34's Care plan for Pain revised 3/2/22 revealed, Pain Management I have c/o (complaints of) pain r/t (related to) b/l (bilateral) shoulder, left ankle, low back, muscle spasms and knee pain. I have diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Assess for verbal and non-verbal s/sx (signs and symptoms) of distress or pain unrelieved by ordered meds (9/16/19) . Review of this care plan revealed no new or revised interventions for her pain since 2019. A review of Resident #34's Hospital Stay Details dated 5/2/22 revealed, Your medications have changed: Start taking: . [MEDICATION(S)] ([MEDICATION(S)] - a medicated gel for pain), [MEDICATION(S)] Stop Taking: biofreeze (menthol) .[MEDICATION(S)] (a muscle relaxer) . [MEDICATION(S)]-acetaminophen 5-325 mg tablet (a narcotic pain medication) .[MEDICATION(S)] 5% . [MEDICATION(S)] 15 mg (milligrams) 12 hr (hour) tablet . replaced by a similar medication . Your diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Your diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a 5/6/22 physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Chronic pain syndrome. [MEDICATION(S)], will restart [MEDICATION(S)] every 12 hours. Patient would benefit from evaluation in pain clinic . On 5/12/22 at 11:59 a.m., RN L was asked about Resident #34's pain and reported that she had chronic pain and used to go to a pain clinic prior to admission. RN L also reported that Resident #34 had recently returned from the hospital and reported her current pain regimen wasn't always working. RN L was asked about the physician discussing the benefits of a pain clinic referral, and reported she did not know anything about it. On 5/12/22 at 12:10 p.m., Resident #34 was observed being weighed by CNA T and CNA U with RN L. Resident #34 was whimpering in pain as they raised her up in the sling. A review of the facility policy titled, Pain Management revised 8/17/17 revealed, Policy: improve the quality of life for our residents by ensuring timely pain identification and interventions Process: . 4. Initiate immediate interventions to promote comfort, considering non-pharmacological and pharmacological interventions. Evaluate for effectiveness with resident observation and interview. If interventions are not effective notify physician. 5. Develop a Care Plan/Kardex which incorporates the assessment and interventions identified on the Pain Assessment .

Based on interview and record review, the facility failed to ensure that a COVID-19 vaccination was given as requested and consent for one Resident (#168) and failed to maintain COVID-19 vaccination consents/declinations and immunizations in a organized and safe manner with the potential to affect all 123 Residents. This deficient practice resulted in Resident #168 not receiving the COVID-19 vaccination and contracting COVID-19 in the building on [DATE] and being sent to the hospital on [DATE] where she expired seven days later. Findings include: A review of the list of names from the [DATE] COVID-19 Mapping revealed Resident #168 was listed as testing positive on [DATE]. A review of her medical record revealed she admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of her [DATE] Minimum Data Set (MDS) assessment revealed she scored ,d+[DATE] on the Brief Interview for Mental Status (BIMS) assessment, indicating intact cognition. A review of Resident #168's Immunization Tab in her Electronic Medical Record (EMR) revealed no indication of whether she had received, accepted, or refused COVID-19 Vaccination. Further review of the Physicians orders revealed no order to give any COVID-19 vaccination. Review of her documents revealed no consent or declination for the vaccine. A review of a progress note dated [DATE] revealed, . At approx. (approximately) 9:28 am Resident (#168) was yelling out to nurse w/ (with) complaints of not being able to breathe. Writer checked nasal canula, assisted resident into upright position and administered rescue inhaler. Residents O2 (oxygen) saturation was non-readable. Writer performed CPR (cardiopulmonary resuscitation) until other nursing staff arrived. Writer called EMT (Emergency Medical Transport) @ (at) approx. 9:31am. EMT arrived approx. 9:38am and took over. There were no updates on the outcome of Resident #168's transfer hospital and she did not readmit to the facility. A review of a Hospital Discharge Summary dated [DATE] revealed the following, (Name of Resident #168) was brought to the emergency department after cardiopulmonary arrest at her assisted living. She was diagnosed approximately 1 week prior with COVID on a routine testing through her assisted living. She had an approximate 13 minute down time (time without a pulse or respiration). She was admitted to the ICU (Intensive Care Unit) and supported with nephrology, critical care, neuro ICU and ID (Infectious Disease) following. She was noted to be seizing and was diagnosed with an [CONDITION(S)] [CONDITION(S)] ([CONDITION(S)] from a lack of oxygen for the brain). Unfortunately, she coded again in the ICU . She continued to code and was eventually pronounced dead. On [DATE] at 9:45 a.m., VP RN BB and Corporate RN Y were asked to provide the COVID-19 Vaccination consent form for Resident #168, as it was not in her clinical record. The Administrator reported that it may take a while to find as the DON's filing system was putting things (documents and records) in cardboard boxes. When asked if it was appropriate to store resident medical records, especially those that had not yet been scanned into the medical record, to be stored in cardboard boxes, the Administrator reported that it was not. Corporate RN Y reported that the DON had told her that she had found a bag of documents and that the consent was possibly in that bag. The DON reported that the Unit Manager might have vaccination consent forms. The DON reported she did not have a system to maintain and organize the COVID-19 vaccination consent/declination forms, and that some were in boxes waiting to be scanned in her office and on the units. On [DATE] at 10:40 a.m., Unit Manger/LPN G was asked about the Vaccination consent for #168 and reported that she would have to dig through a box of stuff that hadn't yet been scanned in to the medical record. When notified that Resident #168 had nothing in her immunizations tab about being vaccinated, LPN G reported that if Resident #168 had previously been vaccinated they would have taken the information from her (State Immunization Record). On [DATE] at 11:14 a.m., Corporate RN Y reported she had found the Vaccination Consent form for Resident #168 in the cloth bag. The document was reviewed with Corporate RN Y and revealed Resident #168 had consented to receive the [NAME] COVID-19 vaccination on [DATE]. The second page of the two-page form which documented that she had received the vaccination had not been filled out. Corporate RN Y reported she would look to see if there was any evidence that Resident #168 had received the vaccination. On [DATE] at 11:49 a.m., Corporate RN Y reported she was unable to find any evidence to show Resident #168 received the vaccination that she had consented for. Corporate RN Y also reported she did not have any information to provide as to why the vaccination was not given. A review of the COVID-19 Weekly Vaccine Orders revealed the following: [DATE]- 1 dose of Moderna was requested and 2 doses of [NAME]. [DATE]- 2 doses of Moderna, 2 boosters of Moderna, and 2 [NAME]. [DATE]- 7 doses of Moderna, 11 boosters of Moderna, and 2 doses of [NAME]. [DATE]- 8 doses of Moderna, 12 boosters of Moderna, and 2 [NAME]. [DATE]- 8 doses of Moderna, 25 boosters of Moderna, and 1 [NAME]. [DATE]- 12 doses of Moderna and 16 boosters of Moderna. A review of the facility policy titled, Vaccine-Policy-Procedure dated [DATE] revealed, . COVID-19 vaccinations will be offered to all staff and residents (or their representative if they cannot make health care decisions) per CDC (centers for disease control) and/or FDA (food and drug administration) guidelines unless such immunization is medically contraindicated, the individual has already been immunized during this time period or the individual refuses to receive the vaccine . The facility will maintain documentation for all residents and staff on COVID-19 vaccination . for Residents, the information will be documented in their medical record. The information to be documented includes: The staff person, resident or representative was provided education regarding the benefits and potential risks associated with the COVID-19 vaccine. Whether the staff person, resident/representative consented to the vaccine. IF yes: Which vaccine was administered. Which dose was administered. Date of vaccination. If no, reason for refusal: Contraindication. Refusal. For staff or residents who refuse, the facility will ask that individual to sign a COVID-19 vaccine declination form and maintain a copy of the form.

This citation pertains to intake # MI 898 and MI 348. Based on observation, interview and record review, the facility 1) Failed to maintain an adequate amount of emergency medicine for one resident (Resident #705) of two residents reviewed for diabetic management, resulting in a need for emergency medical care, including hospitalization . Findings include: Resident #705 On 02/23/2022 at 10:34 AM, Confidential Witness E was called and interviewed by phone in regard to Resident #705's stay at the facility. Confidential Witness E explained that Resident #705 was diabetic and had fluctuating blood sugar levels that were not being monitored closely by the facility. On 02/23/2022 at 11:05 AM, Confidential Witness D was interviewed via telephone in regard to Resident #705's stay within the facility. Confidential Witness D revealed, (Resident #705) has not been the same since this, (Resident #705) is more out of it. They (the facility) are supposed to review their medications Friday. Confidential Witness D explained that the facility did not have the medications to treat a low blood sugar and Resident #705 had to go to the hospital on 01/07/2022. On 02/23/2022 at 11:15 AM, Resident #705 was observed awake in bed. Resident #705 was asked if they recalled the incident in which they had to go to the hospital as a result of low blood sugar. Resident #705 stated, It has been good here but I have been so sleepy. Resident #705 was not able to elaborate and appeared drowsy. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #705 was readmitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #705 had a Brief Interview for Mental Status (BIMS) score of 09 (previous MDS BIMS score 15, indicating an intact cognition), indicating impaired cognition and needed extensive assistance with most care needs. A review of the Progress Notes for Resident #705 revealed the following: 01/5/2022 17:48 (05:48 PM) Nurses Note .After resident ingested supplements and supper blood sugar rechecked 137. 1/7/2022 06:48 (AM) Nurses Note .Writer called to room by nurse. Assigned nurse stated while rounding, resident was unresponsive when name was called and sternum rub preformed. Nurse assessed VS (vital signs). BP (blood pressure)-128/70, Resp (respirations)-12 (below normal), Temp (temperature)-97.0, Pulse-79, SpO2 (pulse oxe 70%, normal is 90-100%) on 4L/min (liters of oxygen per minute) via NC (nasal cannula), BS 25 .(normal is 70-100) Non rebreather mask applied while administering high flow O2 (oxygen) at 15 L/min. Writer informed assigned nurse that resident's code status is DNR (do not resuscitate). 911 called. Upon EMS (emergency medical services) arrival, technicians administered emergency [MEDICATION(S)] (used to increase blood sugar levels instantly) in attempts to elevated (sic) levels and were unsuccessful. Resident transferred to .Emergency Department. Primary physician called and notified of resident's change in condition and transfer to hospital. Resident's mother .called and notified of resident's change in condition and transfer to hospital as well. Resident's face sheet, active order list, notice of transfer and bed hold policy sent with resident. 2/4/2022 16:39 (04:39 PM) Physician's Note .Review Of Systems: Patient is poor historian, awake alert and confused. Positive episodes of agitation and yelling out .Continue supportive care, attempt reassurance and redirection Staff reports family is noncompliant with recommended dietary restrictions. Patient positive for episodes of diarrhea at times which is chronic in nature. Attempt to reeducate family and patient .Type 2 diabetes mellitus without complications .Currently on .sliding scale insulin. Continue to monitor avoid a tight control to avoid episodes of [CONDITION(S)]. Blood sugars remain frequently elevated likely secondary to dietary intake. Continue to attempt education of patient and family regarding dietary intake . A record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .(Insulin [MEDICATION(S)]) Inject as per sliding scale: if .70 (blood sugar reading) and lower notify MD (Medical Doctor) .related to TYPE 1 DIABETES MELLITUS [MEDICATION(S)] Emergency Kit .Inject 1 mg (milligram) intramuscularly every 24 hours as needed for [CONDITION(S)] May give [MEDICATION(S)] PRN (as needed) if blood sugar < 70 and PT (patient) is unresponsive or unable to take PO (by mouth) meds. Recheck blood glucose in 15 min (minutes). Start Date-12/27/2021. Glucose Gel 40 % (Dextrose) (Diabetic Use) Give 15 gram by mouth every 24 hours as needed for [CONDITION(S)] If glucose <70& res (resident). Is conscious give [MEDICATION(S)] gel by mouth. Notify md for further orders. Recheck blood glucose in 15 min. Continue monitoring good glucose until over 70 and symptoms subside. Start Date-12/27/2021. On 01/05/2022 at 05:00 PM, Resident #705's blood sugar was 30, and on 01/07/2022 at 06:48 AM the blood sugar was 25. There was no documentation to support use of [MEDICATION(S)] or Glucose Gel administration to Resident #705, for either of the low blood glucose readings as per order on the MAR. A review of the hospital notes from Resident #705's emergency room admitted d 01/07/2022 revealed the following: [Resident #705] was sent for mental status changes per EMS .blood sugars were noted to be low in the 20s .blood sugars were improved but .mental status did not improve .was also noted to be hypoxic therefore .was intubated for airway protection .[Resident #705] is seen sedated on the ventilator in the ER (emergency room ) . On 02/23/2022 at 01:30 PM, an interview was attempted with the Nursing Home Administrator (NHA) in regard to emergency glucose supplies being available for use and stated, I would need to review that with a clinician. The NHA did not provide any further explanation. On 02/23/2022 at 01:44 PM, the Director of Nursing (DON) was interviewed in regard to Resident #705's having severely low blood sugar levels on 01/05/2022 and 01/07/2022 and not getting emergency glucose/[MEDICATION(S)] as per order. The DON explained that the facility had given all the [MEDICATION(S)] that was in the building and that Resident #705 was not alert enough to take anything oral. The DON was asked for documentation of the back up glucose and [MEDICATION(S)] use during that timeframe from pharmacy, however the facility did not provide the requested information prior to survey exit. On 02/23/2022 at 02:41 PM, Nurse Supervisor F was interviewed via telephone in regard to Resident #705 not receiving emergency [MEDICATION(S)] on 01/07/2022 and stated, There was no more IM (intramuscular) [MEDICATION(S)] in the building, it had been utilized for another patient. I called the Doctor and they said to send the resident out. The Nurse Supervisor F was asked when EMS arrived to the facility and stated, I think between five to fifteen minutes later. A review of the policy titled [CONDITION(S)] Insulin Shock dated 07/01/2008) revealed the following: Diabetic residents will be monitored for [CONDITION(S)] (insulin shock). This is a condition when resident has too much insulin. Causes of too much insulin or anti diabetes medication may include: medications, inconsistent food intake, physical activity or medical conditions. Usually onset is sudden. The following symptoms should be reported and acted upon immediately: 1. Symptoms of [CONDITION(S)] (insulin reaction): Altered behavior of mental function, Confusion or disorientation, Lethargy/weakness, Hallucinations, Irritability, Pale, cool skin, Poor concentration or coordination, Perspiring, Slurred speech, Stupor, unconsciousness and/or convulsions Coma. NOTE: IF RESIDENT IS UN RESPONSIVE, CONVULSING OR IN A COMA THIS IS A LIFE-THREATENING EMERGENCY PROCEDURE: 1. A random accu-check will be done if resident exhibits any of the above signs/symptoms. The accu-check would reveal a low blood sugar - usually below 70 or per medical director guidance. 2. If resident is unconscious/unresponsive/or in a coma. (Usually blood glucose level is below 40.) Give [MEDICATION(S)] by injection. If no immediate improvement to [MEDICATION(S)], call 911 and transfer to hospital Notify Physician. If improvement noted re check blood glucose in 15 minutes and giving .glucose or fast acting carbohydrate if needed. Continue monitoring blood glucose until over 70 and symptoms subside .8. Document care and treatment provided in nurses notes.

This citation pertains to intakes: 9 and 7 Based on observation, interview and record review, the facility failed to prevent non-consensual sexual contact, and monitor a male resident (R904-BIMS of 9) with a known history of inappropriate flirtatious behaviors, resulting in R904 performing a sex act with a female resident (R903-BIMS of 3) on 8/2/2020 at approximately 4:20pm. R904 closed and blocked R903's room door with a heavy chair, causing the Certified Nursing Assistant (CNA) to forcibly open the door. R904 was found in R903's bed sitting between her legs. Her gown was pulled up, her brief was undone, and R904 was touching her vagina. This resulted in an Immediate Jeopardy (IJ) and the likelihood for serious physical and/or psychosocial harm, injury, impairment, or death. The Immediate Jeopardy (IJ) started on 8/2/2020 and was identified on 8/5/2020. The Administrator was notified of the Immediate Jeopardy on 8/5/2020 and was asked for a plan to remove the immediacy. The IJ was removed on 8/6/2020, based on the facility's implementation of the removal plan as verified onsite on 8/6/2020. Although the immediacy was removed, the facility's deficient practice was not corrected and remained isolated with actual harm that is not immediate jeopardy. Findings Include: A review of the complaint information revealed the following: On 08/02/2020 between 3:50 pm and 4:10 pm, while the aides were doing their rounds, (R903's) room was barricaded shut. When staff was able to enter, there was a male resident with his hand over (R903's) vagina and had her nightgown pulled up under her breast. (R903) wears adult briefs and those were ripped off. The male resident told staff to get out as they were making love . On 8/5/2020 at 9:00AM, the NHA (Nursing Home Administrator) was briefly interviewed about the incident and explained that the investigation had not yet been completed, and that R903 was assessed by the facility following the incident, and that they showed, No signs of psychosocial harm. A review of R903's medical record revealed that they were initially admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A review of R903's Minimum Data Set Assessment (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 3/15 indicating a Severely Impaired Cognition. R903 also required extensive assistance with Activities of Daily Living (ADLs). Further review of R903's medical record indicated that the resident had not returned to the facility from the hospital, after being sent on 8/2/2020. On 8/5/2020 at 9:20AM, R904 was observed in their room laying in bed. Upon entering the resident's room, they were alert and oriented and answered questions regarding their life without any issues. R904 was asked about the incident in which they went into R903's room. R904 stated, I went in the room to help her get into bed. When R904 was asked to expound on what occurred after he entered her room, R904 stated, I don't remember. R904 was asked if he touched R903, and stated, I can't remember. When asked if he had closed the door when in R903's room, he stated, No. On 8/5/2020 at 9:25AM, a Confidential Resident (CR#1) was interviewed as to whether or not they had seen or heard anything related to the incident regarding R903 and R904. CR#1 stated, R904 told me that he stuck three fingers inside of her .(R904) is a sex offender, and has no respect for women. CR#1 stated, He talks to all the women around here in a disrespectful way. A review of R904's medical record revealed that they were admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A review of R904's MDS dated [DATE] noted a BIMS score of 9/15 indicating a moderately impaired cognition. The MDS also noted that R904 was independent for ADLs. Further review of R904's medical record revealed the following progress notes: 10/29/2019 10:14 (10:14am) Social Service Note. Status reviewed for Quarterly MDS assessment. Resident has a [DIAGNOSES REDACTED]. He has impaired cognitive skills. He reports no s/s (signs and symptoms) of depression. He wanders throughout the building, looking to go outside. He also has been known to make inappropriate comments towards women. He was last seen by psych on 8-1-19 . 1/28/2020 16:07 (4:07pm) Social Service Note. Status reviewed for Quarterly MDS assessment. Resident has impaired cognitive skills due to his [DIAGNOSES REDACTED]. He also has a [DIAGNOSES REDACTED]. He has a history of making inappropriate comments to/requests of others. He was last seen by psych on 11-16-19 and receives [MEDICATION NAME] and [MEDICATION NAME] . 2/3/2020 08:14 (8:14am) Life Enrichment Note. Quarterly Review: Life Enrichment care plan has been reviewed and updated. (R904) is up daily in his wheelchair propelling throughout the facility interacting with peers and staff. (R904) does like to ask the ladies for a kiss but he is easily redirected when this happens . 5/4/2020 11:09 (11:09AM) Life Enrichment Note. Quarterly Note: Life Enrichment care plan has been reviewed and updated. (R904) is alert and able to make his daily needs known . (R904) enjoys socializing and interacting with staff and his peers but due to social distancing he is unable to do so. (R904) does like to ask the ladies for a kiss but he is easily redirected when this happens . 5/8/2020 14:46 (2:46PM) Psych Note Late Entry: Complaint: History of Sexually Inappropriate Behavior, Cognitive Impairment . Medical records and documentation were reviewed by remote access, and discussed with team, along with any changes to medication to be made .He has a history of sexually inappropriate behaviors with no recent concerns. Some yelling out. Assessment & Plan: Adjustment disorder with disturbance of conduct (unchanged). Plan: Behavioral log reviewed- 1 instance of sexually inappropriate behavior documented by staff over last 30 days. Continue with [MEDICATION NAME] medication without GDR (gradual dose reduction). 5/26/2020 15:16 (3:16PM) Alert Note Note Text: Resident Kicking/Hitting Resident leaving wing, refusing to come back, resident arguing with staff and trying to hit them when attempting to redirect resident back to unit. Resident's family member called and asked them to call and have a talk with him, social work made aware of incident. 6/30/2020 11:40 (11:40am) Alert Note Note Text: Resident Sexually Inappropriate. Writer spoke with resident about inappropriate behavior. Resident stated he will stop. 8/2/2020 19:25 (7:25pm) Incident Note Note Text: When CNA's was doing rounds they came to the lady residents room door and it was closed. When CNA's tried to opened up the door and the door was barricaded with a heavy chair. CNA's had to force the door open when they observed resident sitting on a lady residents bed in between her legs. Resident was touching her vagina, with his head down in between her legs. Witness' immediately stopped the resident from touching the lady resident, one cna stayed in the room with residents and the other CNA got the writer. Writer asked the resident what was he doing, and resident stated 'What are ya'll doing in my room?!' Writer informed resident that he was not in his room and resident stated 'We was about to make love!' Resident was immediately taken out of the room. Resident assessed and no trauma on resident. Hands assessed, no blood or trauma on his hands. Abuse coordinator contacted and informed. Doctor Informed. Emergency contact contacted. 8/3/2020 15:41 (3:41pm) Nurses Note. Document relevant information about the resident: Resident is on Q15 (every 15 minutes checks). Resident spent most of the day in room. Resident had to be redirected not to roam the halls and directed back to his room. Resident Continues to say inappropriate sexual language to staff. Resident is his own guardian. Oncoming nurse informed of 15 minute checks. On 8/5/2020 at 11:37AM, Social Worker A was interviewed regarding the incident between R903 and R904 and stated, (R904) is oblivious to the situation and doesn't remember the incident. Social Worker A explained that R904 has never had any physical interaction with any other residents. Social Worker A explained that R904 does have Dementia, and their cognition fluctuates, but that (R904) was Educated on not touching other residents, keeping their hands to themselves, and to not enter someone else's room. Social Worker A indicated that R904 has, Always been flirty and would ask for a hug or a kiss, and would also ask the staff if they were married because he would pay for their divorce. On 8/5/2020 at 3:40PM, R904 was observed sitting in the doorway of their room, and upon approach stated, Hey my sugar. On 8/5/2020 at 3:53PM, an interview was completed with CNA B about the incident with R903 and R904. CNA B stated, We were doing our rounds, and were wondering why the door was shut, so me and the other aide pushed the door and it was hard to open; We really had to push it in. Once we got into the room, we found that there was a chair behind the door, and we saw (R904) in the (R903's) bed. CNA B was asked how R904 was positioned in the bed, and stated, (R904) was sitting between (R903's) legs with his head leaning toward (R903's) private area (vagina). When we asked (R904) what they were doing, (R904) said,'This is my room', and we tried to explain that it couldn't be because it was a lady's room. CNA B explained that the other CNA on duty went to go get the nurse while she stayed in the room. CNA B was asked what R904 was wearing, and stated, He usually wears an undershirt, and a long sleeve shirt on over it, but the long sleeve shirt was hanging on his wheelchair. CNA B was asked what R903 was wearing and stated, (R904) was wearing a gown and it was pulled up to her breasts. CNA B was asked if they saw anything else, and stated, One side of (R903's) brief was unlatched. CNA B was asked if (R903) said anything, and stated, (R903) was just laying there and just looking at us. CNA B was asked if R904 usually gets out of their wheelchair, and stated, Yes. They were asked about R904's behaviors and stated, Everytime you pass by (R904's) room, they ask if you can give them a kiss or a hug. CNA B was asked what happened next and stated, The nurse came and did an assessment, and then we moved (R903) to another unit, and (R904) was taken to his room. CNA B was asked if they knew the amount of time R904 was in R903's room and stated, The nurse saw him at 3:30pm, and we found him in the room at 4pm. A review of CNA E's telephone interview conducted with the NHA on 8/2/2020 at 5:30pm stated the following: CNA E: I was doing my rounds with (CNA B) at around 4pm. We went to (R903's) room and the door was closed. It was hard to open because there was a chair behind it. NHA: A wheelchair? CNA E: No. The visitor's chair. We pushed the door and I saw (R904) sitting on the bed and (R903) had one leg on his lap and one leg behind him. NHA: What was he doing? CNA E: It looked like he was moving his hands in the private area. NHA: Could you see any private parts? CNA E: No of (R904), but I could see some of (R903). NHA: What could you see? CNA E: I saw the brief was unhooked on one side and the gown was up. It looked like he had his hand in her private area. NHA: What happened next? CNAE: I went to get the nurse (Nurse D). She came and we removed (R904) from the room. We made sure (R903) was ok, and (CNA B) was with her . On 8/6/2020 at 10:52AM, Nurse D was interviewed about the incident between R903 and R904 and stated, I was doing a catheter change and when I came out of the room, the aide flagged me down, so when I went in there (R903's room). He (R904) was sitting on the bed. (R903's) brief was unfastened on both sides. I asked him what he was doing, in her room, and he sad, 'We about to make love', and he was told she is not alert to tell you to make love. Nurse D stated, We got him in his chair, and he started saying, Who are you, where's my room'. Once he was back into his room, I called, (NHA). We moved (R903) to A wing because there are more men over here (B wing). 15 minute checks were completed and he was kept in the room all night. Nurse D was asked if R903 had a roommate, and explained that R903 had a private room at the end of the hall. R904's room was observed in the middle of the unit. Nurse D was asked how R904 was dressed and explained that he was fully dressed while R903's gown was above her waist side because they could see that her brief was unfastened. Nurse D was asked what time this incident occurred, and stated, Between 4:10pm and 4:20pm. Nurse D was asked about R904's behaviors and stated, He flirts a lot and will act like he will grab you but won't do it. He will also ask for kisses. Nurse D was asked about R904's cognition and stated, For the most part, he is alert and orientated with times of confusion. Nurse D also indicated that they attempted to ask R903 if R904 had hurt her, or if she was scared, and she didn't say anything. A review of R903's physical from the hospital was reviewed and revealed the following, There was no further report of penile penetration as it was noted the patient had his hand in her groin standing above her. It was also noted later on in the patient's stay that police had been called, but nursing staff at (Nursing Home) did report that patient had a large bowel immediately after the assault and staff did completely clean her and wipe her vagina and urethra area likely removing any evidence of sexual assault. On 8/6/2020 at 12:42PM, an interview was completed with the NHA in regards to the incident, and explained that the incident was not predicted, R904 was flirtatious, and that they are currently looking at an alternative all male placement for him. On 8/6/2020 at 2:59PM, the interim Director of Nursing as of 8/5/2020 was asked about the incident, and indicated that they did not work on that unit at the time of the incident. The DON was asked about interventions that are being put into place and explained that R904 has been put on a 1:1, and will be provided supervision frequently. They are also seeing a nursing home which is all male. The DON further explained once R903 returns to the facility, her psychosocial well-being will be monitored by social work and following by psych services. A review of the facility's Abuse, Neglect and/or Misappropriation of Resident Funds or Property revised 12/10/18 outlined the following, Policy Statement. (Corporation name) will not tolerate verbal, sexual, physical or mental abuse, involuntary seclusion and/or neglect of its residents or misappropriation of resident ' s funds or property by anyone .Purpose: To assure each resident in the center is free from abuse, neglect and exploitation. 1. Procedure. a) Definitions. viii) Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion or sexual assault and includes non-consensual sexual contact of any type with a resident. Facility Abatement Plan: Element #1 Resident #904 was re-assessed on 8/5/20 by the IDT and the care plan was updated. Resident #904 was placed 1:1 on 8/5/20. Resident #904 will remain on 1:1 for a period of seven (7) days. Resident #904 will then be evaluated by the IDT and will offer alternate placements if needed. Behavior Management meeting will take place 8/6/2020 for resident #904. The female resident was moved to a different hallway prior to her going to the hospital on [DATE]. Upon her return to the facility she will provided psychosocial visits daily for three (days) and then as needed. All other residents in the building have the potential for non-consensual sexual contact. The female resident mentioned was transferred to the hospital for further medical evaluation. Physician and legal guardian were notified. Element #2 A one-time audit was completed on 8/5/20 of all residents currently residing at the facility for history of inappropriate flirtatious behaviors or suspicious nonconsensual sexual contact. No issues were noted. An interview was conducted with all interviewable residents to ensure that no sexual abuse or nonconsensual sexual contact has been made since residing at the facility and no issues were noted. A one-audit was completed on 8/5/20 of all current residents' nurses notes for the last 14 days to ensure that no patterns of sexual abuse or nonconsensual sexual contact has occurred and no issues noted. A one-time audit was completed of the last 30-days of incident reports to rule out any patterns of abuse, suspicious behavior or non-consensual sexual contact by the Regional Nurse Consultant on 8/5/20 and no issues were noted. Staff were re-educated on the abuse policy including sexual abuse and non-consensual sexual content. Education was initiated on 8/5/20 with staff who were working at 3pm on 8/5/20 verbal education was completed by the Nurse Managers/designee(s). Staff will be educated by the Nurse Managers/designee(s) continuing on 8/5/20 prior to working their next scheduled shift to ensure that staff are re-educated on the abuse policy. Element #3 The facility policy for abuse was reviewed by the NHA and DON on 8/5/20 and no changes were needed. System change to include: The Nurse Managers will review the 24-hour reports Monday through Friday and notify the IDT of any inappropriate flirtatious behaviors or history of sexual behaviors. These residents will be reviewed by the IDT and Care plans will be updated and interventions will be updated as needed. Element #4 Beginning 8/6/20, the Executive Director or designee(s) will randomly interview five (5) residents weekly for 12 weeks to ensure that any type of abuse is not occurring. Results of the audits will be taken to the QA committee. The result of all monitoring will be reported to the facility's QA Committee monthly for further recommendations. The Executive Director is responsible for ongoing compliance.

This citation pertians to MI 541 and MI 569 Based on interview and record review, the facility failed to ensure that 1 ( #702) of 4 residents reviewed for falls, from a total sample of 4, was transferred with a mechanically lift and with the assistance of 2 staff members, resulting in the resident sustaining a fall with a hip fracture, hospitalization and surgery. Findings include: On 12/28/16 at 11:00 am record review revealed that resident #702 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data set assessment (MDS) showed a Brief Interview for Mental Status (BIMS) score of 7 out of 15 indicating cognitive impairment and the need for extensive assistance with 2 persons for transfer, toileting and bathing. On 12/28/16 at 11:20 am review of the Activities of Living ( ADL) care plan indicated that the resident requires extensive assistance with ADLs, is incontinent of bowel and bladder related to spinal stenosis and requires extensive assist of 2 staff members and mechanical stand lift for all transfers. On 12/28/16 at 1:00 PM review of an incident and accident report dated 9/23/16 at 7:30 PM and revised on 11/1/16 at 10:05 am, by Licensed Practical Nurse (LPN) A reveals, CNA (certified nursing assistant) reported observed resident (#702) on floor. Resident assessed and provided pain medication. Called MD (medical doctor) and family. X-ray ordered, sent to hospital. He stated he fell . A review of the facility investigation of the incident, on 12/28/16 at 3:00 PM indicates the Director of Nursing (DON) concluded an investigation of the 9/23/16 incident on 10/3/16. Two CNA's B and C and 1 confidential resident D were interviewed. CNA B was interviewed by facility staff on 9/26/16 and stated, I was in another resident's room and I heard a bang. I went into room and I seen (Resident #702) on his side. He asked me to help him up, so I assisted him to bed. I went to (LPN A) and told him (the resident) fell and (LPN A) went to check on him for pain. CNA C was interviewed on 9/26/16 and stated, Prior to going to break, (Resident #702) was sitting in his wheel chair with call light in reach. Upon return to the unit I was told by the nurse (LPN A) that (the resident) fell . I entered the room and (the resident) said he fell and was transferred wrong but didn't know if it was from floor or wheel chair. (CNA B) told me he heard a boom in room . and went in the room to find (the resident) on the floor. Confidential resident D was interviewed by the facility staff about the evening of 9/23/16, (Confidential resident D) stated that he was sleeping when he was awoken by a crash went over to (Resident #702) who was in his bed and asked him if he was okay. (Resident #702) .stated he didn't handle me the way the others do. A review on 12/28/16 at 12:00 am, of the nurses progress notes reveals the following: An entry written by LPN A and dated 9/23/16 at 9:32 PM, describing the incident with Resident #702 on 9/23/16. The following entry was written and then crossed out. It reads, Cena (certified nursing assistant) came to me asked for a pain pill, when asked why he was in pain and where, he told me the resident fell . Resident was already back in bed when I entered the room. Resident guarding his right hip and right knee looks swollen, DR (medical doctor) wants STAT( right now) Xray done. When I asked the Cena he says he found him like that, on the floor. When asked the resident he and (the confidential resident D) said that Cena dropped him, trying to transfer without machine. I wasn't notified or called when he was on the floor. Cena told me that they told him to go lay him down because he was ready to go to bed, and 15-20 mins (minutes) later, is when he seek my help. A nurses note by LPN A on 9/23/16 at 10:28 PM reads, resident pain level is now a 5 instead of a 10. Tramadol seems to be effective .Waiting on Xray to come, STAT. A nurses note on 9/24/16 at 6:18 am reads, Ultram tablet 50 milligrams ( mg), give 1 tablet by mouth every 6 hours as needed for pain, c/o (complains of) right sided leg pain, written by RN E. A nurses note on 9/24/16 at 7:15 am, written by RN E reveals, the Xray report was received at around 3:00 am, the resident was unable to move his right leg and it was swollen and slightly internally rotated. The nurse contacted the resident's family and was unable to contact the physician. The DON was contacted and gave approval for Resident #702 to be transferred to the hospital. Report was provided to the ambulance officers. An interview with the Director of Nursing ( DON) and Administrator on 12/28/16 at 3:10 PM revealed, the administrator was not working at the facility at the time of the incident, but had access to past incident reports and the investigation. The DON was asked how Resident #702 fell and obtained a fracture of the right hip. The DON stated, The CNA did not check the Kardex (a document with information used to care for the resident) for the Plan of Care and transferred the resident inappropriately. On 12/28/16 at 1:55 PM the facility's policy, titled, Mechanical Lit Transfer dated 7/1/08 states, Mechanical lifts are used to safety transfer a resident unable to transfer in any other manner. On 12/28/16 at 2:00 PM review of The Falls Reduction Program dated 7/1/08 and revised 9/25/16 reveals: Purpose: To provide a safe environment for residents, modify risk factors and reduce risk of fall-related injury.Implement and indicate individualized interventions on Care Plan/Kardex. The resident was transported to the hospital on [DATE] by ambulance, underwent right hip surgery and did not return to the facility. ( )

This citation pertains to intake #MI 302. Based on observation, interview and record review, the facility failed to ensure a Resident's hand was free from the spokes of a wheelchair prior to movement of the Resident for one (#701) of three sampled residents reviewed for abuse/neglect, from a total sample of three, resulting in Resident #701's hand being caught in the spokes of the wheelchair during movement of the resident and subsequent acute fracture of the base of the first metacarpal bone (thumb) with mild displacement . Findings include: On 3/11/15 at 9:20 a.m., Resident #701 was observed lying in bed, asleep. A purple cast was observed on the resident's right hand/wrist. On 3/11/15 at 12:20 p.m., Resident #701 was observed seated in a high backed wheelchair in the A dining room. At that time, staff were observed attempting to encourage Resident #701 to eat her lunch (which was untouched). While facial grimacing was observed, Resident #701 stated, "Oh I'm in so much pain. Oh my back hurts so bad I just wanna lay down." On 3/11/15 at 2:30 p.m., Resident #701 was observed seated in the "A" dining room with Licensed Practical Nurse (LPN "G"). At that time when queried if she could recall what happened to her hand, Resident #701 pointed to her right thumb with her left hand and stated, "First they twisted and pulled." When queried if she had any pain, Resident #701 became tearful and stated, "Yes, my back is the worst though. It's very heavy. It's not so much pain (pointed to right thumb) it's the weight, its heavy. Look at this thing." Resident #701 was unable to recall or provide any specific details of the alleged incident on 2/8/15. On 3/11/15 at 11:25 a.m., the Administrator was interviewed, about the facility's reported incident with Resident #701, the Administrator reported that Resident #701 had alleged that a nurse (LPN "C") had hurt her. The facility had obtained an x-ray which revealed she was positive for an acute fracture of the thumb. Review of the facility's investigation reflected, "...based on staff interviews on 2/8/15 after dinner between the hours 6:30 p.m. - 7:30 p.m., Certified Nursing Assistant (CNA "F") observed LPN "C" attempt to redirect Resident #701 as she was near (Supplemental Resident #1), As LPN "C" turned Resident #701 around in the wheelchair her right hand got caught in the wheelchair. At 8:00 p.m. Resident #701's right hand began to swell and bruise. Resident was complaining of pain, Tylenol 3 was administered to resident. The bruising increased and the hand became edematous, stat x-ray was ordered. X-ray results were received on 2/9/15 at 7:30 a.m., indicating an acute fracture of the base of the first metacarpal bone with mild displacement...Resident was transferred to (name of local hospital) for treatment, received a cast and returned to facility..." Review of the facility's interviews with staff reflected: Interview with LPN "A" - "approximately 7 pm approached nursing station and Resident #701 was in hallway and mentioned her hand hurt her. LPN "C" was at the desk and was asked by LPN "A" regarding hand and LPN "C" said "She's okay". Upon return to desk observed CNAs and LPN "B" listening to resident who was upset and talking about her hand. LPN "B" was wrapping it with gauze - briefly overheard CNAs saying "the nurse did it". I assumed LPN "B" got report, and after med pass, LPN "B" went to C wing. Resident's right hand appeared bruised and swelling. I heard him (LPN "B") say to LPN "E" that he was ordering an xray for resident. LPN "B" said he heard CNAs also saying "the nurse did it". Interview with LPN "B" - "noted he arrived 2/8/15 at 7 pm and counted narcotics with LPN "C". No mention in report came up with Resident #701. After LPN "C" left it was noticed that she (Resident #701) had some bruising on her right hand. I gave her some Tylenol #3 and she told me it hurt. It was reported to me by a CNA that her hand had gotten caught in her w/c when LPN "C" was pushing her. At approximately 12 am got a call from LPN "E" (A wing nurse) and informed that Resident #701's hand had become edematous. Called physician and voicemail directed to call nurse practitioner. She ordered a stat x-ray." Interview #1 with LPN "C" - 2/9/15 "resident agitated yelling, throwing items...refused to be toileted, refused lunch, telling other residents not to eat and that I put poison in her food. She was accusing staff of hitting her. No hitting or any abuse noted or witnessed." Interview #2 with LPN "C" - 2/16/15 "around 4 pm resident refused to take meds...Around 6:40 pm I was charting on the computer and I noticed that resident is not at front of nurse's station, she was sitting in front of room #1. Resident #701 brought back to front of nurse's station, not complaining of hurting or pain. At 7 pm resident was complaining saying CNAs and LPN "B" that I did something to her finger. There was nothing on her finger or hand, and I did not do anything to resident." Interview with CNA "D" - 2/12/15 "...At 6:30 pm LPN "C" tried to put Resident #701 to bed. Resident stated "get her out of here". LPN "C" left and I put her to bed. She wanted to get right back up so I got her up. About 10-15 minutes later I saw Resident #701...at the desk...and stated, "...she hurt my hand, she twisted it. (Resident demonstrated twisting action with hands). Her right hand was discolored. It was not swollen. LPN "C" was standing behind me at desk LPN "C" said something like she always says that." Interview with LPN "E" - 2/12/15 "reported at 11 pm - made round with back A wing nurse and was waiting for LPN "B" to come back from B wing he gave me report. He also said the aid told him LPN "C" was hitting Resident #701 or something. He said he knows it's not true. He told me Resident #701 had bruise to right hand. I asked where the incident report, he said they already know. I said are you sure he said yes. I said what did the Dr say, he said he didn't call the Dr it's just a bruise. I told him we should call the Dr get x-ray or something..." Interview with CNA "F" - 2/11/15 "on [DATE] I came in at 3 pm. At approximately 6:30/7 pm I observed the nurse (LPN "C") grab Resident #701 from behind and turn her around. She was trying to separate her from another resident. I saw Resident #701's right hand get caught in wheelchair. Resident #701 stated, "She twisted it, it's broke!" It started to get swollen. The nurse did not do anything. The resident wanted to call her daughter so I dialed the phone for her. I heard her say "that nurse twisted it. It's broke". LPN "C" stated she does that all the time referring to the resident crying I told her no she doesn't. I told the nurse (LPN "B") I think LPN "C" did something to Resident #701's hand. LPN "B" stated to the resident "Don't worry I'll take care of you." LPN "B" wrapped her hand. At around 9:30 pm her alarm was sounding she was yelling my name. I noticed the wrap had come off and that her hand was now purple. In informed the nurse LPN "B"." Review of the clinical record revealed Resident #701 was initially admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #701 was severely cognitively impaired (scored 6/15 on mental status exam), had almost constant pain, and had received only as needed pain medication during this assessment period. Review of the radiology report dated "2/9/15 07:27", read "Conclusion: Acute Fracture of the base of the first metacarpal bone with mild displacement..." Review of the interdisciplinary progress notes from 2/5/15 - 3/10/15 (most recent) revealed there was no documentation on 2/8/15 regarding Resident #701's behaviors, complaints of pain, or allegations of abuse. On 3/11/15 at 11:10 a.m., an interview was conducted with CNA "F" by phone. When queried about Resident #701's concerns, CNA "F" stated, "I was there when it happened. The nurse (LPN "C") went to go turn her around and she didn't check to make sure her arm wasn't in the way, she was in a hurry and turned her around and her hand was caught in it. After that happened she (Resident #701) was crying. When queried about whether this had been reported to Administration, CNA "F" stated, "It was end of shift so I let the nurse caring for her know, it was LPN "B"." On 3/11/15 at 11:41 a.m., an interview was conducted with LPN "B" by phone (who was confirmed by the Director of Nursing as the nurse who was on duty with Resident #701 on 2/8/15 beginning at 7:00 p.m.). When queried about the alleged incident on 2/8/15, LPN "B" reported that he usually worked 7 pm to 7 am and worked with Resident #701 for four hours that day until 11 pm. LPN "B" reported that he had received report at shift change from LPN "C" and stated, "She (LPN "C") didn't report that anything occurred." LPN "B" further reported, "Resident #701 complained her hand hurt. It was swollen. I gave pain meds. It must've just happened. Later on I was called and at that point I ordered a stat x-ray." When queried whether the Administrator or Director of Nursing (DON) had been notified of the resident's abuse allegation, LPN "B" stated, "I didn't know any results, I wanted to wait until I had something to give them." When queried about what the facility's policy was for reporting allegations of abuse, and or changes in condition, LPN "B" stated, "To let the Administrator know immediately." On 3/11/15 at 11:48 a.m., an interview was conducted with LPN "C" (alleged perpetrator) by phone. At that time, LPN "C" was queried regarding the alleged incident and stated, "I worked it was Sunday, after that I was called by the DON and she said I did something to the resident. She (Resident #701) was confused, acting up and I didn't see anything happen." When queried if Resident #701 had verbalized any concern on 2/8/15 regarding her hand, LPN "C" stated, "I didn't hear anything. It was about 6:40 when I brought her to the nurse's desk. I thought maybe I did but I didn't notice anything. She said her hand hurts and I was leaving and I was with the nurse (LPN "A" who was identified as the other nurse working A hall that day with LPN "C") and she said she told him LPN "B" as he came in." On 3/11/15 at 2:40 p.m., an interview was conducted with LPN "A" by phone. At that time, LPN "A" was queried regarding the alleged incident on 2/8/15 and stated, "I was working the back of A hall. I didn't see anything but I heard her say something like see what she did to my hand. The nurse was taking over for her (LPN "C") I seen Resident #701 at front desk and LPN "B" was taking care of her. When queried if she had reported the abuse allegation to Administration, LPN "A" stated, "I didn't because I saw he was taking care of it. I worked days and afternoon shift that day." When asked what time Resident #701 had verbalized the concern, LPN "A" stated, "She started complaining at the end of day time shift and it was the nurse's time to go.(LPN "C")" ( )

REFER TO INTAKES # MI 218 AND MI 350. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION AND APPROPRIATE ASSISTANCE TO MAINTAIN SAFETY AND PREVENT FALL FOR ONE (#101) OF 4 SAMPLED RESIDENTS REVIEWED FOR ACCIDENTS FROM A TOTAL SAMPLE OF 4, RESULTING IN A FALL WITH INJURY REQUIRING SURGICAL INTERVENTION. FINDINGS INCLUDE: RESIDENT #101, A FEMALE RESIDENT, WAS admitted INto the facility on [DATE]. ACCORDING TO THE history and physical examination [REDACTED]'S AND DEMENTIA. ADDITIONALLY, RESIDENT #101 WAS DESCRIBED AS BEING ALERT WITH CONFUSION AND WAS AT HIGH RISK FOR FALLS. THE ADMISSION CARE PLAN DATED 4/15/13, SPECIFIED THAT RESIDENT #101 REQUIRED 1-PERSON ASSISTANCE WITH TRANSFERS, TOILET USE AND USED A WHEELCHAIR FOR HER MODE OF LOCOMOTION. RESIDENT #101 HAD BOTH CHAIR AND BED ALARMS TO ADDRESS HER FALL RISK. ACCORDING TO THE FACILITY REPORTED INCIDENT REPORT, DATED 4/25/13, "ON 4/21/12 AT 11:40 AM, RESIDENT (#101) WAS OBSERVED ON THE FLOOR IN FRONT OF THE NURSES' STATION BY REGISTERED NURSE (#3), WITH WHEELCHAIR ON TOP OF HER. . . RESIDENT #101 LATER COMPLAINED OF HIP PAIN. THE FALL WAS UNWITNESSED; THEREFORE THE FACILITY IS UNABLE TO DETERMINE WHAT CAUSED RESIDENT (#101) TO FALL." ACCORDING TO THE X-RAY RESULTS RECEIVED ON 4/21/13 AT 3:01 PM, RESIDENT #101 HAD SUSTAINED AN ACUTE IMPACTED LEFT FEMORAL FRACTURE FROM THIS FALL. THE HOSPITAL RECORDS DATED 4/21/13, NOTED A PRIMARY [DIAGNOSES REDACTED]. RESIDENT #101 UNDERWENT A SURGICAL PROCEDURE ON 4/22/13. RESIDENT#101 WAS discharged AND RETURNED AT THE FACILITY ON 4/24/13. AN INTERVIEW WITH REGISTERED NURSE (RN) #3 WAS CONDUCTED ON 5/7/13 AT 10:15 AM. RN #3 RECALLED GOING IN ANOTHER RESIDENT'S ROOM TO DO treatment for [REDACTED].#101 ON THE FLOOR, ON HER BELLY, WITH THE WHEELCHAIR COMPLETELY ON TOP OF HER. RN #3 RECALLED CALLING FOR HELP FROM STAFF, BUT NO ONE CAME AT FIRST. EVENTUALLY, A NURSE FROM ANOTHER UNIT CAME IN RESPONSE TO AN OVERHEAD PAGE. CERTIFIED NURSING ASSISTANT (CNA) #5 CAME OUT OF ANOTHER RESIDENT'S ROOM, AND HELPED TRANSFER RESIDENT #101 FROM THE FLOOR TO THE WHEELCHAIR. RESIDENT #101 WAS ALERT BUT WITH CONFUSION. SHE COULD NOT STATE WHAT HAD HAPPENED AND HOW SHE fell . AT FIRST, RESIDENT #101 DENIED PAIN, BUT LATER, RESIDENT #101 ASKED TO GO BACK TO BED AND STATED "HURT," WHILE POINTING TO HER BILATERAL HIPS. RN #3 CALLED FOR AN IMMEDIATE (STAT) X-RAY AND THE RESULTS SHOWED FRACTURE OF THE HIPS. THE PHYSICIAN ORDERED RESIDENT #101 SENT TO AN ACUTE CARE HOSPITAL AFTER 3:20 PM ON 4/21/13. RN #3 FURTHER RECALLED THAT CNA #4, AFTER BREAKFAST ON 4/21/13, HAD ASKED IF SHE (CNA #4) COULD BRING RESIDENT #101 INTO THE HALLWAY, BECAUSE OF RESTLESSNESS, SO THAT "WE CAN ALL KEEP AN EYE ON HER (RESIDENT #101)." RN #3 RECALLED THAT RESIDENT #101 WAS RESTLESS THE DAY BEFORE AND AN URINALYSIS HAD COME BACK POSITIVE FOR INFECTION. RESIDENT #101 HAD JUST STARTED ON ANTIBIOTICS THE DAY OF THE FALL. ON 5/7/13 AT 12:30 PM, DURING A TELEPHONE INTERVIEW, VISITOR #6 STATED THAT SHE WAS VISITING A FAMILY MEMBER WHO RESIDED AT THE FACILITY ON 4/21/13 WHEN SHE (VISITOR #6) OVERHEARD A LADY (RESIDENT #101) YELLING FOR HELP. IT WAS A CONSTANT YELL THAT LASTED ABOUT 10 TO15 MINUTES. WHEN VISITOR #6 WENT OUT OF THE ROOM TO INQUIRE WHAT WAS HAPPENING, VISITOR #6 AND HER DAUGHTER SAW RESIDENT #101 ON THE FLOOR, WITH A WHEELCHAIR ON TOP OF HER. VISITOR #6 STATED, "THERE WAS NO ONE THERE. NO NURSES RESPONDED TO THE LADY YELLING FOR HELP." VISITOR #6 SAID THAT SHE STARTED TO WONDER WHERE ALL THE STAFF MEMBERS WERE. A STAFF MEMBER (RN #3) IN A SCRUBS UNIFORM CAME BUT DID NOT TOUCH, ASSIST OR DID ANYTHING TO HELP THE RESIDENT (#101) ON THE FLOOR. RN #3 WAITED FOR A WHILE (MORE THAN 5 MINUTES) FOR ANOTHER STAFF MEMBER TO ARRIVE. VISITOR #6 RECALLED THAT THE STAFF MEMBER (RN #3) YELLED OUT FOR HELP, BUT NO ONE CAME. THEN, (RN #3) DECIDED TO CALL USING THE PAGING SYSTEM, AND, THEN ANOTHER NURSE (RN #5) CAME BUT THEY STILL DID NOT GET RESIDENT #101 UP OFF THE FLOOR UNTIL A THIRD STAFF MEMBER CAME. VISITOR #6 WENT ON TO SAY THAT THEY (THE STAFF MEMBERS) PUT THE RESIDENT (#101) BACK INTO THE WHEELCHAIR AND LEFT HER THERE TO EAT LUNCH, WITHOUT FURTHER EXAMINING HER NOR HAVE A DOCTOR SEE HER AFTER THE FALL. INTERVIEW WITH ASSIGNED NURSE AIDE (CNA #4) WAS CONDUCTED ON 5/7/13 AT 11:30 AM. CNA #4 STATED THAT SHE WAS AT LUNCH WHEN THE FALL OCCURRED. SHE RECALLED ASKING THE NURSE (RN #3) IF IT WAS OK TO PUT RESIDENT #101 IN THE HALLWAY BECAUSE SHE ATTEMPTED TO GET OUT OF BED UNASSISTED TWICE BEFORE 10:00 AM. CNA #4 STATED THAT RN #3 TOLD HER, "IT'S OK, SO STAFF CAN KEEP AN EYE ON HER AT ALL TIMES." CNA #4 WENT ON TO SAY THAT RESIDENT #101 WAS ACTING UNUSUAL THE DAY BEFORE, AS SHE (#101) HAD TRIED TO GET OUT OF BED A FEW TIMES. THE NURSE (RN #3) HAD TAKEN A URINE SAMPLE AND RESIDENT #101 HAD tested POSITIVE FOR A URINARY TRACT INFECTION. RN #3 TOLD CNA #4 THAT MORNING (4/21/13) THAT RESIDENT #101 HAD STARTED ANTIBIOTICS THAT DAY (4/21/13). CNA #4 RECALLED GOING ON BREAK AT 11:00 AM, AND STATED THAT SHE DID NOT WITNESS THE INCIDENT AND WAS ONLY TOLD OF WHAT HAPPENED WHEN SHE RETURNED FROM BREAK. INTERVIEW WITH CNA #7 WAS CONDUCTED ON 5/7/13 AT 11:05 AM. CNA #7 EXPLAINED THAT CNA #4 BROUGHT RESIDENT #101 INTO THE HALLWAY BY THE NURSES' STATION IN THE MORNING SOMETIME AFTER BREAKFAST, BECAUSE RESIDENT #101 WAS RESTLESS. CNA #7 DESCRIBED RESIDENT #101 AS BEING "UP AND DOWN AND MOVING AROUND." CNA #7 EXPLAINED THAT THEY (STAFF MEMBERS) WERE NOT SUPPOSED TO LEAVE RESIDENT #101 IN THE HALLWAY, BUT "THERE'S NOT MUCH WE CAN DO" BECAUSE SHE (#101) WAS "RESTLESS AND GETTING UP ON HER OWN." CNA #7 RECALLED GOING TO ANOTHER RESIDENT'S ROOM WHO HAD A COLOSTOMY EXPLOSION. CNA #7 SAID THAT THERE WAS ONE NURSE AND ANOTHER CNA IN THE ROOM WITH HER. THE DOOR WAS CLOSED DURING CARE, AND THEY DID NOT HEAR RESIDENT #101 YELL FOR HELP; DID NOT HEAR ANY ALARM SOUNDING OFF AND DID NOT HEAR RN #3 ASKING FOR HELP USING THE OVERHEAD PAGE. THEY DID NOT HEAR ANYTHING. CNA #7 ADDED, "IT IS HARD TO KEEP AN EYE ON A RESIDENT YET YOU HAVE TO PROVIDE CARE FOR OTHER RESIDENTS." CNA #7 STATED THAT SHE GOT OUT OF THE ROOM TO GET SUPPLIES, SHE SAW RESIDENT #101 ON THE FLOOR. CNA #7 STATED THAT THE TWO NURSES WHO WERE AT THE NURSE STATION ASKED HER (CNA #7) TO HELP THEM GET RESIDENT (#101) BACK TO HER WHEELCHAIR. AN INTERVIEW WITH RN #5 WAS CONDUCTED ON 5/7/13 AT 3:11 PM. RN #5 RECALLED THAT SHE WAS WORKING AT ON ANOTHER UNIT AND DID NOT WITNESS RESIDENT #101'S FALL, BUT HEARD "NURSES TO B-WING STAT" VIA THE OVERHEAD PAGE. RN #5 SAID THAT SHE IMMEDIATELY RAN TO RESPOND AND SAW RESIDENT #101 ON THE FLOOR WITH ONLY THE NURSE (RN #3) THERE. RESIDENT #101 WAS CONFUSED AND DENIED PAIN UPON IMMEDIATE ASSESSMENT. A VISITOR (VISITOR #6) WHO WAS THERE HAD ALERTED THE NURSE. RN #5 SAID THAT RN #3, CNA # 4 AND HERSELF (RN #5) HAD TRANSFERRED RESIDENT #101 FROM FLOOR TO WHEELCHAIR. RN #5 RECALLED LEAVING AFTER THE TRANSFER AND RETURNING TO HER ASSIGNED UNIT. ( )

THIS CITATION REFERS TO INTAKE NUMBERS MI 018 AND MI 030 AND INCLUDES MULTIPLE DEFICIENT PRACTICE STATEMENTS. BASED ON INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE CLOSED (INLINE) [MEDICAL CONDITION] SUCTIONING FOR ONE (RESIDENT #102) OF ONE SAMPLED RESIDENT WITH TRACHEOSTOMIES FROM A TOTAL SAMPLE OF 9 RESIDENTS, RESULTING IN IMMEDIATE JEOPARDY WHEN A FACILITY NURSE PROVIDED [MEDICAL CONDITION] CARE TO RESIDENT #102, AND LEFT THE SUCTION CATHETER TUBE LODGED 4 INCHES DOWN RESIDENT #102'S WINDPIPE. RESIDENT #102 SUBSEQUENTLY died . THIS DEFICIENT PRACTICE PLACES ANY RESIDENT OF THE FACILITY, WHO REQUIRES [MEDICAL CONDITION] CARE AND [MEDICAL CONDITION] SUCTIONING, AT HIGH RISK FOR PHYSICAL HARM, INJURY AND/OR DEATH. FINDINGS INCLUDE: RESIDENT #102: RESIDENT #102 WAS AN [AGE] year-OLD FEMALE, WHO WAS REadmitted to the facility on [DATE] AT 4:45 A.M., AFTER RECEIVING treatment for [REDACTED]. RESIDENT #102 WAS DEPENDENT ON STAFF FOR ALL ACTIVITIES OF DAILY LIVING (ADLS) AND HER MINIMUM DATA SET (MDS) ASSESSMENT, DATED [DATE], DOCUMENTED THAT RESIDENT #102 HAD SEVERELY IMPAIRED COGNITION. RESIDENT #102 HAD A LEGAL GUARDIAN AND HAD BEEN CLASSIFIED AS A "NO CODE" (NO CARDIO-PULMONARY RESUSCITATION/CPR) ON [DATE]. RESIDENT #102 HAD A [MEDICAL CONDITION], A FEEDING TUBE AND AN INTRAVENOUS (IV)/PERIPHERALLY INSERTED CENTRAL CATHETER (PICC) LINE ACCESS FOR ANTIBIOTIC ADMINISTRATION, DUE TO A [MEDICAL CONDITION] (MRSA) INFECTION AT THE [MEDICAL CONDITION] SITE. ACCORDING TO PHYSICIAN ORDERS, DATED [DATE], RESIDENT #102 WAS TO HAVE "TRACH ([MEDICAL CONDITION]) CARE DAILY AND PRN (AS NEEDED)." REVIEW OF RESIDENT #102'S CLINICAL RECORD REVEALED THAT RESIDENT #102 HAD NO CARE PLAN FOR RESPIRATORY/[MEDICAL CONDITION] CARE. ACCORDING TO NURSE'S NOTES, DATED [DATE], AT 1:00 AM, "CENA (CERTIFIED NURSE AIDE/CNA) OBSERVED RESIDENT HAS NO RESP (RESPIRATIONS). CALLED NURSE TO ROOM. NO VS (VITAL SIGNS) @ (AT) THIS TIME." RESIDENT #102 HAD EXPIRED. CERTIFIED NURSE AIDE (CNA) #8 WAS INTERVIEWED ON [DATE] AT 3:00 PM. CNA #8 STATED THAT SHE HAD BEEN ASSIGNED TO PROVIDE CARE TO RESIDENT #102 ON THE AFTERNOON SHIFT ON [DATE], AFTER RESIDENT #102 WAS RETURNED TO THE FACILITY FROM THE emergency room AT THE LOCAL ACUTE CARE HOSPITAL. ACCORDING TO CNA #8, THERE WAS SOMETHING DIFFERENT ABOUT RESIDENT #102'S [MEDICAL CONDITION], AND IT WAS SOMETHING CNA #8 WAS NOT FAMILIAR WITH FROM WORKING IN NURSING HOMES. THE REGISTERED NURSE (RN), WHO HAD BEEN THE DIRECTOR OF NURSING (DON) WHEN RESIDENT #102 EXPIRED, DON #3, WAS INTERVIEWED ON [DATE] AT 1:03 PM. DON #3 STATED RESIDENT #102 UTILIZED A "CLOSED [MEDICAL CONDITION] SYSTEM." A CLOSED TRACHEOTOMY SUCTION CATHETER ENABLES CLINICIANS TO CLEAR UNWANTED MUCUS BUILD-UP FROM THE AIRWAYS OF VENTILATED OR [MEDICAL CONDITION] PATIENTS WITHOUT THE NEED TO DISCONNECT THE PATIENT FROM THE VENTILATOR OR AEROSOL SOURCE. THE CATHETER IS PROTECTED INSIDE A SLEEVE AND IS USUALLY CHANGED ONLY ONCE A DAY TO IMPROVE PATIENT AND CAREGIVER SAFETY DURING ROUTINE SUCTIONING AND CATHETER CLEANING. ACCORDING TO DON #3, RESIDENT #102 HAD BEEN PROVIDED THIS TYPE OF [MEDICAL CONDITION] BY HER PHYSICIANS DURING HER hospitalization TO CONTAIN [MEDICAL CONDITION] INFECTION, AND THAT SHE (#102) WAS THE ONLY RESIDENT WHO HAD UTILIZED THIS TYPE OF [MEDICAL CONDITION] IN THE FACILITY. WHEN DON #3 WAS ASKED IF FACILITY NURSES HAD BEEN TRAINED IN THE APPROPRIATE USE OF A CLOSED [MEDICAL CONDITION] SUCTION SYSTEM, DON #3 STATED THAT THEY HAD ALL ATTENDED IN-SERVICE TRAINING ON THE DEVICE, BUT WAS NOT ABLE TO RECALL WHEN THE TRAINING TOOK PLACE AND WAS NOT ABLE TO PRODUCE A SIGN-IN SHEET OR AN OUTLINE OF THE TRAINING. DON #3 WAS NOT ABLE TO PROVIDE THE LITERATURE/MANUAL/PROCEDURE ON "CLOSED SUCTION" THAT WAS USED TO IN-SERVICE THE STAFF. THREE (3) MIDNIGHT (MN) NURSING STAFF MEMBERS WERE INTERVIEWED REGARDING THE CARE PROVIDED TO RESIDENT #102: CERTIFIED NURSE AIDE (CNA) #5 WAS INTERVIEWED ON [DATE] AT 1:28 PM; LICENSED PRACTICAL NURSE (LPN) #6 WAS INTERVIEWED ON [DATE] AT 3:30 PM; AND, LPN #7 WAS INTERVIEWED ON [DATE] AT 2:55 PM. ACCORDING TO EACH INTERVIEWEE, THEY WERE PRESENT IN THE ROOM DURING THE TIME THAT RESIDENT #102 WAS PROVIDED POST-MORTEM CARE, SHORTLY AFTER SHE (#102) HAD EXPIRED. EACH OF THESE NURSING STAFF MEMBERS STATED THAT THEY HAD OBSERVED THE EXTRACATION OF A SUCTION CATHETER TUBE, WHICH HAD BEEN LEFT, APPROXIMATELY FOUR INCHES DOWN, IN RESIDENT #102'S THROAT. IN AN INTERVIEW ON [DATE] AT 1:28 PM, CNA #5 STATED THAT RESIDENT #102 WAS FINE AT THE BEGINNING OF HER SHIFT (11:00 P.M. ON [DATE]). ACCORDING TO CNA #5, SHE (#5) TOOK RESIDENT 102'S VITAL SIGNS (BLOOD PRESSURE, PULSE RATE AND TEMPERATURE) AND THERE WAS "NOTHING OUT OF THE ORDINARY." CNA #5 WENT ON TO SAY THAT ON [DATE], AFTER THE AFTERNOON (PM) NURSE, REGISTERED NURSE (RN) #4 COMPLETED [MEDICAL CONDITION] CARE AT 12:30 A.M., SHE (CNA #5) WENT TO RESIDENT #102'S ROOM, AT APPROXIMATELY 12:45 A.M. ACCORDING TO CNA #5, RESIDENT #102 WAS "GASPING FOR BREATH AND WAS HAVING A HARD TIME BREATHING." CNA #5 WENT TO THE NURSE'S STATION AND FOUND RN #4 AT THE DESK AND TOLD HER THAT RESIDENT #102 "IS NOT BREATHING RIGHT!" CNA #5 REPORTED THAT RN #4 REPLIED, "I'M OFF THE CLOCK, GO GET YOUR MIDNIGHT NURSE (#6)." CNA #5 SAID THAT SHE (#5) FOUND LPN #6 IN ANOTHER RESIDENT'S ROOM, BUT LPN #6 TOLD HER (#5) THAT SHE (LPN #6) WAS BUSY AND THAT SHE (CNA #5) SHOULD GET RN #4 TO RESPOND. ACCORDING TO CNA #5, WHEN SHE AND RN #4 GOT BACK TO RESIDENT #102'S ROOM (AT APPROX. 12:55 A.M.), RESIDENT #102 WAS NO LONGER BREATHING. WHEN INTERVIEWED ON [DATE] AT 3:30 PM, LPN #6 REPORTED THAT ON [DATE], SHE (#6) DID NOT ASSESS RESIDENT #102 IMMEDIATELY UPON THE START OF HER SHIFT (AT 11:00 PM). LPN #6 STATED THAT SHE (#6) DID NOT KNOW THAT RESIDENT #102 HAD BEEN readmitted BACK INTO THE FACILITY FROM THE HOSPITAL EARLIER THAT DAY ([DATE]). SHE admitted GOING IN TO RESIDENT #102'S ROOM ONE TIME ONLY, TO DO A "HEAD CHECK" (VISUALIZING THE RESIDENT) AND DID NOT SEE THAT RESIDENT #102 WAS IN ANY PAIN OR DISTRESS. LPN #6 SAID THAT SHE (#6) DID NOT TAKE RESIDENT #102'S VITAL SIGNS AND DID NOT ASSESS THE [MEDICAL CONDITION] PLACEMENT OR THE AIRWAY PATENCY. SHE DID NOT PROVIDE ANY DIRECT CARE FOR RESIDENT #102 FROM THE BEGINNING OF HER SHIFT (AT 11:00 PM). SHE DID RECALL THAT CNA #5 CAME TO HER IN ANOTHER RESIDENT'S ROOM AND TOLD HER THAT RESIDENT #102 WAS HAVING A HARD TIME BREATHING. SHE DIRECTED CNA #5 TO GET THE AFTERNOON NURSE, RN #4 AS SHE (LPN #6) WAS PROVIDING WOUND CARE. LPN #6 SAID THAT SHE (#6) WENT TO RESIDENT #102'S AS SOON AS SHE FINISHED WITH THE WOUND CARE AND OBSERVED THAT RESIDENT #102 HAD NO PULSE AND WAS NOT BREATHING. RN #4 TOLD BOTH LPN #6 AND CNA #3 THAT RESIDENT #102 WAS A DNR (DO NOT RESUSCITATE). WHEN INTERVIEWED ON [DATE] AT 2:55 PM, LPN #7 admitted THAT ON [DATE], AT APPROXIMATELY 12:20 TO 12:30 AM, RN #4, ASKED HER (LPN #7) TO SHOW HER (RN #4) WHERE TO FIND SUPPLIES AND HELP HER (#4) WITH THE CLOSED SUCTIONING TECHNIQUE FOR RESIDENT #102'S [MEDICAL CONDITION]. LPN #7 SAID THAT SHE (#7) GAVE HER (RN #4) THE [MEDICAL CONDITION] KIT, BUT REFUSED TO ASSIST RN #4 AT THAT TIME. DURING RESIDENT #102'S POST MORTEM CARE, LPN #7 STATED THAT SHE (#7), ALONG WITH LPN #6 AND CNA #5 FOUND THAT THE SUCTION CATHETER TUBE HAD BEEN LEFT APPROXIMATELY 4 INCHES DOWN IN RESIDENT 102'S THROAT. RN #4 WAS INTERVIEWED ON [DATE] AT 1:20 P.M. RN #4 admitted THAT ALTHOUGH SHE (#4) WAS ASSIGNED TO THE AFTERNOON SHIFT (3 PM TO 11 PM), SHE (#4) WAS STILL AT THE FACILITY AT 12:30 AM ON [DATE] BECAUSE SHE (RN #4) NEEDED TO FINISH UP HER SHIFT DUTIES. RN #4 STATED THAT SHE (#4) HAD PERFORMED [MEDICAL CONDITION] CARE FOR RESIDENT #102, INCLUDING SUCTIONING AND A DRESSING CHANGE. ALTHOUGH RN #4 STATED THAT SHE HAD ASKED LPN #7 WHERE TO FIND THE SUPPLIES NEEDED TO PROVIDE SUCTIONING TO RESIDENT #102, SHE DID NOT SAY IF SHE (#4) FELT THAT SHE WAS COMPETENT GIVING RESIDENT #102 [MEDICAL CONDITION] CARE AND DID NOT CONFIRM THAT SHE HAD ASKED LPN #7 FOR HELP. RN #4 admitted SHE WAS OVERWHELMED WITH HER WORK LOAD AND WAS NOT SUPPOSED TO BE WORKING "OFF THE CLOCK." RN #4 admitted THAT WHEN CNA #5 CAME TO TELL HER THAT RESIDENT #102 WAS NOT ABLE TO BREATHE, SHE (#4) SAID TO CNA #5, "I'M PUNCHED OUT. GET (LPN #6)." ON [DATE] AT 1:03 PM., DURING AN INTERVIEW, DON #3 STATED THAT WHEN THE LICENSED STAFF WERE IN-SERVICED ON THE CLOSED [MEDICAL CONDITION] SUCTION SYSTEM, RN #4 WAS NOT OBSERVED TO COUNTER DEMONSTRATE (RETURN DEMO) THE CLOSED SUCTION PROCEDURE, BUT THAT RN #4 HAD ASSURED HER (DON #3) (OVER THE TELEPHONE) THAT SHE (RN #4) FELT COMFORTABLE PROVIDING [MEDICAL CONDITION] CARE TO RESIDENT #102. AN EMPLOYEE DISCIPLINARY RECORD, DATED [DATE], INDICATED THAT THE FACILITY HAD TERMINATED RN #4 FOR QUALITY OF CARE PERFORMANCE RELATED TO THE [DATE] INCIDENT AND OTHER CONDUCT ISSUES. ON [DATE], AT 3:00 PM, THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY THAT BEGAN ON [DATE] AT 12:30 AM, WHEN RN #4 PROVIDED [MEDICAL CONDITION] CARE TO RESIDENT #102, AND LEFT THE SUCTION CATHETER TUBE LODGED 4 INCHES DOWN RESIDENT #102'S WINDPIPE. THIS DEFICIENT PRACTICE PLACED ANY RESIDENT IN THE FACILITY, WHO REQUIRED [MEDICAL CONDITION] CARE AND [MEDICAL CONDITION] SUCTIONING AT HIGH RISK FOR PHYSICAL HARM, INJURY AND/OR DEATH. ON [DATE], THE SURVEYOR VERIFIED THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. ON [DATE], THE ADMINISTRATOR VERIFIED THAT THE FACILITY CURRENTLY HAS NO RESIDENTS RESIDING IN THE FACILITY WITH A [MEDICAL CONDITION]. THERE HAVE BEEN NO RESIDENTS WITH TRACHEOSTOMIES IN THE HOME FROM THAT DATE FORWARD. 2. ON [DATE], THE ADMINISTRATOR DETERMINED THAT THE FACILITY WILL NOT ADMIT ANY RESIDENT WITH A [MEDICAL CONDITION] UNTIL ALL LICENSED NURSES ARE RE-EDUCATED ON HOW TO CARE FOR A [MEDICAL CONDITION] TO INCLUDE: A. SUCTIONING WITH RETURN DEMONSTRATION; AND, B. [MEDICAL CONDITION] CARE WITH RETURN DEMONSTRATION. 3. ON [DATE], THE ADMINISTRATOR VERBALLY INFORMED THE STAFF RESPONSIBLE FOR SCREENING NEW ADMISSIONS AND THE DON OF THE DECISION NOT TO ADMIT ANY RESIDENTS WITH TRACHEOSTOMIES. 4. ON [DATE], THE ADMINISTRATOR VERIFIED THERE HAD BEEN NO RESIDENTS WITH TRACHEOSTOMIES admitted SINCE [DATE] AND PUT HER VERBAL DIRECTIVE INTO WRITTEN INSTRUCTIONS TO THE ADMITTING OFFICE AND DON NOT TO ADMIT [MEDICAL CONDITION] RESIDENTS UNTIL FURTHER NOTICE. 5. ON [DATE], THE DON REVIEWED THE POLICIES AND PROCEDURE FOR [MEDICAL CONDITION] CARE AND SUCTIONING AND VERIFIED THAT THESE MET THE CURRENT STANDARD OF PRACTICE. 6. BEGINNING ON [DATE] THROUGH [DATE], THE DIRECTOR OF THE CORPORATE TRAINING INSTITUTE WILL EDUCATE THE LICENSED NURSES ON THE CURRENT STANDARD OF PRACTICE FOR [MEDICAL CONDITION] CARE AND SUCTIONING. THE LICENSED NURSES WILL BE REQUIRED TO PROVIDE A RETURN DEMONSTRATION OF THE CARE. THE RN CONDUCTING THE EDUCATION WILL VERIFY THE NURSES' CORRECT RETURN DEMONSTRATION USING A CLASSROOM MANNEQUIN THAT HAS A [MEDICAL CONDITION]. FOR ANY NURSES EXCUSED FROM THE EDUCATION DUE TO LEAVE OF ABSENCE, THE DON/DESIGNEE WILL PROVIDE THE EDUCATION AND COMPETENCY EVALUATION DURING THE FIRST WEEK THE NURSE RETURNS TO DUTY, BUT BEFORE HE/SHE IS TO PROVIDE [MEDICAL CONDITION] CARE OR SUCTIONING TO ANY RESIDENT. 7. ON [DATE] THE ADMINISTRATOR ARRANGED FOR A LOCAL RESPIRATORY THERAPY COMPANY TO PROVIDE IN-SERVICES FOR THE LICENSED NURSES ON [MEDICAL CONDITION] CARE AND SUCTIONING. BEGINNING ON [DATE] THE RESPIRATORY THERAPY COMPANY CONTRACTED BY THE ADMINISTRATOR WILL EDUCATE THE LICENSED NURSES ON THE CURRENT STANDARD OF PRACTICE FOR [MEDICAL CONDITION] CARE AND SUCTIONING TO REINFORCE THE LEARNING OF THE PREVIOUS WEEK. AT EACH OF THE EDUCATION SESSIONS THE DON/DESIGNEE WILL EDUCATE THERE LICENSED NURSES ON THE FACILITY POLICIES AND PROCEDURES TO CARRY OUT THE STANDARDS OF PRACTICE. (FACILITY STAFF) PROJECT THIS TRAINING WILL BE COMPLETED ON [DATE]. 8. BEGINNING ON [DATE] THE DON REVIEWED AND UPDATED THE NEW HIRE ORIENTATION TO ASSURE THAT UPON HIRE ALL NURSES WILL RECEIVE [MEDICAL CONDITION] EDUCATION WITH DEMONSTRATION. THE NURSE WILL NOT PERFORM DUTIES UNTIL COMPETENCIES HAVE BEEN DEMONSTRATED IN A. SUCTIONING A [MEDICAL CONDITION]; AND, B. [MEDICAL CONDITION] CARE. 9. ON [DATE], THE DON REVIEWED THE EVALUATION POLICY TO STATE, AT A MINIMUM OF ANNUALLY, LICENSED NURSES WILL BE COMPETENCY EVALUATED ON A [MEDICAL CONDITION] CARE AND SUCTIONING. 10. THE ADMINISTRATOR ALONE RETAINS THE AUTHORITY TO DETERMINE THAT THE EDUCATION IS COMPLETE, THE LICENSED NURSES COMPETENT, SUPPLIES AVAILABLE, AND THE HOME (FACILITY) READY AND ABLE TO CARE FOR [MEDICAL CONDITION] RESIDENTS. SHE WILL RE-OPEN THE HOME (FACILITY) TO ADMISSION OF [MEDICAL CONDITION] RESIDENTS AT THAT TIME. THE IMMEDIATE JEOPARDY (IJ) WHICH BEGAN ON [DATE] WAS REMOVED ON [DATE]. THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF "ISOLATED" AND SEVERITY OF "NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY" UNTIL ALL FACILITY STAFF MEMBERS HAVE BEEN TRAINED AND SUSTAINED COMPLIANCE CAN BE VERIFIED BY THE STATE AGENCY. ( ) BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO MONITOR AND ADMINISTER OXYGEN TO ONE RESIDENT (RESIDENT #107) OF 5 SAMPLED RESIDENTS WITH RESPIRATORY CARE NEEDS, FROM A TOTAL SAMPLE OF 9 RESIDENTS, WHEN RESIDENT #107 WENT WITHOUT SUPPLEMENTAL OXYGEN, AS ORDERED BY HER PHYSICIAN, RESULTING IN A LOW OXYGEN SATURATION LEVEL OF 87% AND THE POTENTIAL FOR RESPIRATORY DISTRESS AND COMPLICATIONS. ON [DATE] AT 4:10 PM, OBSERVATION REVEALED THAT A CODE HAD BEEN ANNOUNCED FOR ROOM B-8, OCCUPIED BY RESIDENT #107. RESIDENT #107 WAS OBSERVED LYING ON THE FLOOR WITH NURSING STAFF SURROUNDING HER. EMERGENCY MEDICAL SERVICES WERE CALLED AND RESIDENT #107 LEFT THE FACILITY AT 4:35 PM FOR FURTHER EVALUATION AND TREATMENT AT A LOCAL HOSPITAL. RESIDENT #107 WAS admitted to the facility on [DATE]. ACCORDING TO THE HISTORY AND PHYSICAL, DATED [DATE], RESIDENT #107 HAD [DIAGNOSES REDACTED]. ACCORDING TO ADMISSION DATA COLLECTION, RESIDENT #107 WAS admitted WITH PHYSICIAN ORDERS [REDACTED]. ACCORDING TO THE physician's orders [REDACTED]. [MEDICATION NAME] 2.5 MG Q 4 (HOURS) X DAILY (ASTHMA)." A CARE PLAN FOR RESPIRATORY DISEASE WAS INITIATED ON [DATE]. REVIEW OF THE Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'S OXYGEN SATURATION (PULSE OX) EVERY SHIFT FOR 7 DAYS AS ORDERED. THE ORDER WAS NOT DISCONTINUED. NURSES' NOTES ALSO CONTAINED NO EVIDENCE THAT NURSES MONITORED AND DOCUMENTED RESIDENT #107'S PULSE OX EVERY SHIFT. ACCORDING TO REGISTERED NURSE (RN) #25, WHO WAS INTERVIEWED ON [DATE] AT 10:40 AM, ON [DATE], RESIDENT #107 WAS FOUND IN THE BATHROOM AT 4:05 PM, UNRESPONSIVE, LIMP AND WAS FOAMING FROM HER MOUTH. A CODE (FOR CARDIAC RESUSCITATION) WAS CALLED IMMEDIATELY AND STAFF RESPONDED. RN #25 SAID, "SHE (#107) WAS BREATHING. HER OXYGEN WAS PUT ON AT 3 LITERS PER MINUTE AND HER PULSE OX WAS 93%. SHE (#107) WAS A FULL CODE. THE AMBULANCE ARRIVED 15 MINUTES LATER AND TRANSFERRED HER (#107) TO THE emergency room ." RN #25 STATED THAT SHE (#25) HAD NOT CHECKED RESIDENT #107'S OXYGEN SATURATION LEVEL (PULSE OX) FROM THE START OF HER SHIFT AT 7:00 AM UNTIL 4:00 PM. RN #25 DID NOT PUT OXYGEN ON RESIDENT #107 IN THE MORNING. RN #25 STATED THAT SHE (#25) DID NOT KNOW THAT RESIDENT #107'S OXYGEN SATURATION LEVEL HAD BEEN CHECKED WHILE SHE (#107) WAS IN OCCUPATIONAL THERAPY, WHERE IT WAS FOUND TO BE 87%. RN #25 SAID THAT RESIDENT #107'S PHYSICIAN WAS NOT CALLED REGARDING HER LOW OXYGEN SATURATION LEVEL. CNA #26 WAS INTERVIEWED ON [DATE] AT 3:30 PM. ACCORDING TO CNA #26, ON [DATE], SHE (#26) WAS TOLD BY OCCUPATIONAL THERAPIST (OT) #28 THAT SHE (OT #28) HAD LEFT RESIDENT #107 ON THE TOILET, SOMETIME AT AROUND 3:30 PM. OT #28 TOLD CNA #26 THAT RESIDENT #107 WAS A LITTLE CONFUSED AND TO WATCH HER FOR SAFETY. OT #28 DID NOT MENTION ANYTHING ABOUT RESIDENT #107'S OXYGEN SATURATION LEVEL. CNA #26 STATED THAT RESIDENT #107 TOLD HER (#26) SAID SHE WAS "HAVING TROUBLE USING THE BATHROOM." CNA #26 THEN TOLD RESIDENT #107 TO "SIT THERE FOR A LITTLE BIT" AND STEPPED OUT OF THE BATHROOM TO GIVE THE RESIDENT PRIVACY. CNA #26 COULD NOT RECALL IF RESIDENT #107 HAD HER OXYGEN ON OR NOT. AT AROUND 4:00 PM, RESIDENT #107 WAS FOUND SLUMPED OVER, UNRESPONSIVE AND HER LIPS WERE PURPLE. OT # 28 WAS INTERVIEWED ON [DATE] AT 3:50 PM. OT #28 STATED THAT ON [DATE], SOMETIME AFTER LUNCH, RESIDENT #107 WAS CONFUSED BEFORE THERAPY TREATMENT AND HAD A PULSE OX OF 87%. SHE DID NOT HAVE HER OXYGEN ON HER. IN THE THERAPY ROOM, OXYGEN WAS APPLIED TO RESIDENT #107 AT 2 LITERS/MIN AS ORDERED. RESIDENT #107'S PULSE OX WAS RECHECKED DURING OT TREATMENT AND IT WAS 96% AND AFTER TREATMENT AT 97%. OT #28 STATED THAT SHE (OT #28) DID NOT TELL THE NURSE IN CHARGE THAT RESIDENT #107'S PULSE OX WAS 87%. OT #28 STATED THAT SHE DID NOT CALL THE PHYSICIAN REGARDING THE RESIDENT'S PULSE OX. SHE TOLD CNA #26 TO WATCH RESIDENT #107 FOR SAFETY/FALL ISSUES BUT DID NOT MENTION THE LOW OXYGEN SATURATION LEVEL. DURING A TELEPHONE INTERVIEW WITH FAMILY MEMBER #29 ON [DATE] AT 11:50 AM, FAMILY MEMBER #29 STATED THAT DURING HIS VISIT AT LUNCH HOUR, RESIDENT #107 DID NOT HAVE HER OXYGEN ON HER. FAMILY MEMBER #29 SAID THAT RESIDENT #107 WAS SUPPOSED TO HAVE AN OXYGEN TANK HOOKED AT THE BACK OF HER WHEELCHAIR BUT DID NOT HAVE IT ON HER THAT DAY. NO ONE HAD CHECKED HER TO DETERMINE IF SHE NEEDED OXYGEN. FAMILY MEMBER #29 STATED HE TOOK RESIDENT #107 TO THE THERAPY ROOM AND LEFT THE FACILITY. DURING A TELEPHONE INTERVIEW WITH RESIDENT #107 ON [DATE] AT 11:55 AM, SHE STATED THAT SHE WAS STILL IN THE HOSPITAL. ACCORDING TO RESIDENT #107, SHE (#107) DID NOT HAVE HER OXYGEN ON ALL DAY ON [DATE] UNTIL THEY PUT IT ON HER WHILE AT THERAPY. THE DIRECTOR OF NURSING (DON) #2 VERIFIED ON [DATE] AT 11:28 AM THAT THE physician's orders [REDACTED]. DON #2 STATED THAT THERE SHOULD HAVE BEEN AN ENTRY ON THE MAR indicated [REDACTED]. NURSES' NOTES DID NOT HAVE DOCUMENTATION OF THE PULSE OX EVERY SHIFT STARTING FROM THE DATE IT WAS ORDERED. ( )

THIS CITATION REFERS TO INTAKES MI 018 AND MI 030. BASED ON INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE THE NECESSARY CARE AND SERVICES TO ATTAIN OR MAINTAIN THE HIGHEST PRACTICABLE PHYSICAL WELL-BEING FOR 2 RESIDENTS (RESIDENT # 102 AND RESIDENT #106) OF 9 SAMPLED RESIDENTS, ALL REVIEWED FOR APPROPRIATE CARE, FROM A TOTAL SAMPLE OF 9 RESIDENTS, WHEN STAFF DELAYED THEIR RESPONSES TO EMERGENCY SITUATIONS. THIS DEFICIENT PRACTICE RESULTED IN IMMEDIATE JEOPARDY FOR RESIDENT #102, WHEN IT TOOK LICENSED STAFF 10 MINUTES TO RESPOND TO A CALL FOR ASSISTANCE FOR RESIDENT #102, WHO WAS OBSERVED GASPING FOR BREATH. RESIDENT #102 SUBSEQUENTLY died . THIS DEFICIENT PRACTICE ALSO AFFECTED RESIDENT #106, WHEN IT TOOK 5 MINUTES, AFTER STAFF FOUND RESIDENT #106 BLUE AND NOT BREATHING, TO BEGIN CARDIO-PULMONARY RESUSCITATION (CPR). RESIDENT #106 SUBSEQUENTLY died . THIS DEFICIENT PRACTICE PLACES ALL RESIDENTS IN THE FACILITY, WHO COULD NEED EMERGENT CARE, AT HIGH RISK FOR PHYSICAL HARM, INJURY AND/OR DEATH. FINDINGS INCLUDE: RESIDENT #102: RESIDENT #102 WAS AN [AGE] year-OLD FEMALE, WHO WAS REadmitted to the facility on [DATE] AT 4:45 A.M., AFTER RECEIVING treatment for [REDACTED]. RESIDENT #102 WAS DEPENDENT ON STAFF FOR ALL ACTIVITIES OF DAILY LIVING (ADLS) AND HER MINIMUM DATA SET (MDS) ASSESSMENT, DATED [DATE], DOCUMENTED THAT RESIDENT #102 HAD SEVERELY IMPAIRED COGNITION. RESIDENT #102 HAD A LEGAL GUARDIAN AND HAD BEEN CLASSIFIED AS A "NO CODE" (NO CARDIO-PULMONARY RESUSCITATION/CPR) ON [DATE]. RESIDENT #102 HAD A [MEDICAL CONDITION], A FEEDING TUBE AND AN INTRAVENOUS (IV)/PERIPHERALLY INSERTED CENTRAL CATHETER (PICC) LINE ACCESS FOR ANTIBIOTIC ADMINISTRATION, DUE TO A [MEDICAL CONDITION] (MRSA) INFECTION AT THE [MEDICAL CONDITION] SITE. ACCORDING TO PHYSICIAN ORDERS, DATED [DATE], RESIDENT #102 WAS TO HAVE "TRACH ([MEDICAL CONDITION]) CARE DAILY AND PRN (AS NEEDED)." REVIEW OF RESIDENT #102'S CLINICAL RECORD REVEALED THAT RESIDENT #102 HAD NO CARE PLAN FOR RESPIRATORY/[MEDICAL CONDITION] CARE. IN AN INTERVIEW ON [DATE] AT 1:28 PM, CERTIFIED NURSE AIDE (CNA) #5 STATED THAT RESIDENT #102 WAS FINE AT THE BEGINNING OF HER SHIFT (11:00 P.M. ON [DATE]). ACCORDING TO CNA #5, SHE (#5) TOOK RESIDENT 102'S VITAL SIGNS (BLOOD PRESSURE, PULSE RATE AND TEMPERATURE) AND THERE WAS "NOTHING OUT OF THE ORDINARY." CNA #5 WENT ON TO SAY THAT ON [DATE], AFTER THE AFTERNOON (PM) NURSE, REGISTERED NURSE (RN) #4 COMPLETED [MEDICAL CONDITION] CARE AT 12:30 A.M., SHE (CNA #5) WENT TO RESIDENT #102'S ROOM, AT APPROXIMATELY 12:45 A.M. ACCORDING TO CNA #5, RESIDENT #102 WAS "GASPING FOR BREATH AND WAS HAVING A HARD TIME BREATHING." CNA #5 WENT TO THE NURSE'S STATION AND FOUND RN #4 AT THE DESK AND TOLD HER THAT RESIDENT #102 "IS NOT BREATHING RIGHT!" CNA #5 REPORTED THAT RN #4 REPLIED, "I'M OFF THE CLOCK, GO GET YOUR MIDNIGHT NURSE (LICENSED PRACTICAL NURSE/LPN #6)." CNA #5 SAID THAT SHE (#5) FOUND LPN #6 IN ANOTHER RESIDENT'S ROOM, BUT LPN #6 TOLD HER (#5) THAT SHE (LPN #6) WAS BUSY DOING WOUND CARE ON THE OTHER RESIDENT AND THAT SHE (CNA #5) SHOULD GET RN #4 TO RESPOND. ACCORDING TO CNA #5, WHEN SHE AND RN #4 GOT BACK TO RESIDENT #102'S ROOM (AT APPROX. 12:55 AM), RESIDENT #102 WAS NO LONGER BREATHING. ACCORDING TO CNA #5, APPROXIMATELY 10 MINUTES HAD PASSED SINCE SHE (#5) HAD FIRST NOTICED THAT RESIDENT #102 WAS HAVING DIFFICULTY WITH HER BREATHING. CNA #5 WENT ON TO SAY THAT RN #4 TOOK NO FURTHER ACTIONS TO PROVIDE CARE FOR RESIDENT #102. RN #4 WAS INTERVIEWED ON [DATE] AT 1:20 P.M. RN #4 STATED THAT ALTHOUGH SHE (#4) WAS ASSIGNED TO THE AFTERNOON SHIFT (3 PM TO 11 PM), SHE WAS STILL AT THE FACILITY AT 12:30 AM ON [DATE] BECAUSE SHE (RN #4) NEEDED TO FINISH UP HER SHIFT DUTIES. RN #4 admitted SHE WAS OVERWHELMED WITH HER WORK LOAD AND WAS NOT SUPPOSED TO BE WORKING "OFF THE CLOCK." RN #4 admitted THAT WHEN CNA #3 CAME TO TELL HER THAT RESIDENT #102 WAS NOT ABLE TO BREATHE, SHE (#4) SAID TO CNA #3, "I'M PUNCHED OUT. GET (LPN #6)." RN #4 WENT ON TO SAY THAT WHEN CNA #5 CAME BACK AND TOLD HER (RN #4) THAT LPN #6 WAS BUSY COMPLETING WOUND CARE, SHE (RN #4) WENT TO RESIDENT #102'S ROOM WITH CNA #5. HOWEVER, BY THE TIME THAT THEY GOT THERE, RESIDENT #102 WAS NOT BREATHING AND HAD NO PULSE. ACCORDING TO RN #4, NO FURTHER ACTION WAS TAKEN, INCLUDING ANY EMERGENCY PROCEDURES. AN EMPLOYEE DISCIPLINARY RECORD, DATED [DATE], INDICATED THAT THE FACILITY HAD TERMINATED RN #4 FOR QUALITY OF CARE PERFORMANCE RELATED TO THE [DATE] INCIDENT AND OTHER CONDUCT ISSUES. WHEN INTERVIEWED ON [DATE] AT 3:30 PM, LPN #6 STATED THAT ON [DATE], SHE (#6) DID NOT ASSESS RESIDENT #102 IMMEDIATELY UPON THE START OF HER SHIFT (AT 11:00 PM). LPN #6 STATED THAT SHE (#6) DID NOT KNOW THAT RESIDENT #102 HAD BEEN readmitted BACK INTO THE FACILITY FROM THE HOSPITAL EARLIER THAT DAY ([DATE]). LPN #6 STATED THAT SHE WENT INTO RESIDENT #102'S ROOM ONE TIME ONLY, TO DO A "HEAD CHECK" (VISUALIZING THE RESIDENT) AND DID NOT SEE THAT RESIDENT #102 WAS IN ANY PAIN OR DISTRESS. LPN #6 SAID THAT SHE (#6) DID NOT TAKE RESIDENT #102'S VITAL SIGNS AND DID NOT ASSESS THE [MEDICAL CONDITION] PLACEMENT OR THE AIRWAY PATENCY. SHE DID NOT PROVIDE ANY DIRECT CARE FOR RESIDENT #102 FROM THE BEGINNING OF HER SHIFT (AT 11:00 PM). SHE DID RECALL THAT CNA #5 CAME TO HER IN ANOTHER RESIDENT'S ROOM AND TOLD HER THAT RESIDENT #102 WAS HAVING A HARD TIME BREATHING. SHE DIRECTED CNA #5 TO GET THE AFTERNOON NURSE, RN #4 AS SHE (LPN #6) WAS PROVIDING WOUND CARE. LPN #6 SAID THAT SHE (#6) WENT TO RESIDENT #102'S AS SOON AS SHE FINISHED WITH THE WOUND CARE AND OBSERVED THAT RESIDENT #102 HAD NO PULSE AND WAS NOT BREATHING. RN #4 TOLD BOTH LPN #6 AND CNA #3 THAT RESIDENT #102 WAS A DNR (DO NOT RESUSCITATE). ON [DATE], AT 3:00 PM, THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY THAT BEGAN ON [DATE] AT 12:45 AM, WHEN IT TOOK LICENSED STAFF 10 MINUTES TO RESPOND TO A CALL FOR ASSISTANCE FOR RESIDENT #102, WHO WAS OBSERVED GASPING FOR BREATH, ARRIVING IN THE ROOM AT 12:55 AM. RESIDENT #102 died . THIS DEFICIENT PRACTICE PLACED ALL RESIDENTS IN THE FACILITY, WHO COULD REQUIRE EMERGENT CARE, AT HIGH RISK FOR PHYSICAL HARM, INJURY AND/OR DEATH. ON [DATE], THE SURVEYOR VERIFIED THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. ON [DATE], THE ADMINISTRATOR TERMINATED THE EMPLOYMENT OF THE LICENSED NURSE (RN #4) PM SHIFT. 2. ON [DATE], THE ADMINISTRATOR SUSPENDED THE LICENSED NURSE (LPN #6) UNTIL SUCH TIME AS SHE COMPLETED EDUCATION AS TO THE FACILITY'S EXPECTATIONS. 3. ON [DATE], THE DON REVIEWED THE RECENT MEDICAL EMERGENCIES (E.G. CODES AND CHOKING EPISODES) AND DEATHS. THE DON DETERMINED THAT LICENSED NURSES SHOULD FOLLOW PROTOCOLS LISTED BELOW IN #5 IN ALL EVENTS. 4. ON [DATE], THE DON REVISED THE DAILY ROUTINE OF THE LICENSED NURSES TO INCLUDE: A. UPON ENTERING THE FACILITY, THE LICENSED NURSE WILL REPORT TO THEIR ASSIGNED UNIT; B. THE ONCOMING SHIFT WILL DO A WALKING ROUND OF THE UNIT WITH THE OFFGOING NURSE WITH THE 24 HOURS REPORT. THIS REPORT WILL BE GIVEN WHILE WALKING FROM ROOM TO ROOM. ALL PATIENTS/RESIDENTS WILL BE PHYSICALLY OBSERVED TO ENSURE THAT THERE IS NO DISTRESS PRESENT; AND, C. RESIDENTS/PATIENTS WILL BE PRIORITIZED BASED ON LEVEL OF CARE REQUIREMENTS. 5. ON [DATE], THE DON REVIEWED THE POLICIES AND PROCEDURES RELATED TO RESPONDING TO MEDICAL EMERGENCIES AND DEEMED IT APPROPRIATE AS IT INCLUDES THE RESPONSIBILITY OF THE LICENSED NURSES TO RESPOND IMMEDIATELY TO LIFE AND DEATH SITUATIONS. THIS INCLUDED THE ASSESSMENT OF A RESIDENT IN RESPIRATORY DISTRESS AND OR/CHOKING, THE [MEDICATION NAME] MANEUVER AND OTHER EMERGENCY RESPONSES TO CHOKING AND RESPIRATORY DISTRESS, CALLING 911 WHEN EMERGENCY PROCEDURES ARE INITIATED, AND INITIATING CPR IN THE EVENT OF A REVERSIBLE AND ACCIDENTAL INCIDENT (SUCH AS CHOKING). 6. BEGINNING ON [DATE], THE DON AND DESIGNEES WILL IN-SERVICE THE LICENSED NURSES TELLING THEM THAT AS A LICENSED PROFESSIONAL THEY ARE RESPONSIBLE TO RESPOND IMMEDIATELY TO ALL EMERGENCIES WHILE THEY ARE IN THE FACILITY. THIS INCLUDES THE ASSESSMENT OF A RESIDENT IN RESPIRATORY DISTRESS AND OR CHOKING, THE [MEDICATION NAME] MANEUVER AND OTHER EMERGENCY RESPONSES TO CHOKING AND RESPIRATORY DISTRESS, CALLING 911 WHEN EMERGENCY PROCEDURES ARE INITIATED, AND INITIATING CPR IN THE EVENT OF A REVERSIBLE AND ACCIDENTAL INCIDENT (SUCH AS CHOKING). 7. ALL LICENSED NURSES WILL BE EDUCATED PRIOR TO THE BEGINNING OF THEIR SHIFT EFFECTIVE [DATE] UNTIL COMPLETED. THIS INCLUDES THE ASSESSMENT OF A RESIDENT IN RESPIRATORY DISTRESS AND/OR CHOKING, THE [MEDICATION NAME] MANEUVER AND OTHER EMERGENCY RESPONSES TO CHOKING AND RESPIRATORY DISTRESS, CALLING 911 WHEN EMERGENCY PROCEDURES ARE INITIATED, AND INITIATING CPR IN THE EVENT OF REVERSIBLE AND ACCIDENTAL INCIDENT (SUCH AS CHOKING). THE HOME HAS 45 LICENSED NURSES ON STAFF. FOR ANY NURSES EXCUSED FROM THE EDUCATION DUE TO LEAVE OF ABSENCE, THE DON/DESIGNEE WILL PROVIDE THE EDUCATION AND COMPETENCY EVALUATION PRIOR TO REPORTING FOR DUTY ON HIS/HER FIRST SCHEDULED SHIFT AFTER THE LEAVE ENDS. 8. ON [DATE], THE DON REVISED THE ORIENTATION FOR LICENSED NURSES TO INCLUDE THE LICENSED NURSE'S RESPONSIBILITIES DURING EMERGENT MEDICAL CONDITIONS. THIS INCLUDES THE ASSESSMENT OF A RESIDENT IN RESPIRATORY DISTRESS AND /OR CHOKING, THE [MEDICATION NAME] MANEUVER AND OTHER EMERGENCY RESPONSES TO CHOKING AND RESPIRATORY DISTRESS, CALLING 911 WHEN EMERGENCY PROCEDURES ARE INITIATED, AND INITIATING CPR IN THE EVENT OF A REVERSIBLE AND ACCIDENTAL INCIDENT (SUCH AS CHOKING). THE IMMEDIATE JEOPARDY (IJ) WHICH BEGAN ON [DATE] WAS REMOVED ON [DATE]. THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF "ISOLATED" AND SEVERITY OF "NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY" UNTIL ALL FACILITY STAFF MEMBERS HAVE BEEN TRAINED AND SUSTAINED COMPLIANCE CAN BE VERIFIED BY THE STATE AGENCY. ( ) RESIDENT #106: RESIDENT #106 WAS admitted to the facility on [DATE]. ACCORDING TO THE HISTORY AND PHYSICAL, DATED [DATE], RESIDENT #106 HAD [DIAGNOSES REDACTED]. ACCORDING TO RESIDENT #106'S ADVANCE DIRECTIVES, DATED [DATE], SHE WAS A FULL CODE. REVIEW OF PHYSICIAN ORDERS [REDACTED].#106 WAS TO HAVE OXYGEN AT 2 LITERS PER MINUTE PER NASAL CANNULA FOR OXYGEN SATURATION LESS THAN 92%; AND [MEDICATION NAME] 0.83% 1 [MEDICATION NAME] VIA NEBULIZER EVERY SIX HOURS AS NEEDED. ACCORDING TO HER MDS ASSESSMENT, DATED [DATE], RESIDENT #106 REQUIRED EXTENSIVE ASSISTANCE WITH BED MOBILITY, TRANSFERS, TOILET USE AND PERSONAL HYGIENE. REVIEW OF THE CLINICAL RECORD REVEALED THAT RESIDENT #106 HAD NO CARE PLAN FOR RESPIRATORY FUNCTION. SPEECH THERAPY EVALUATION NOTES, DATED [DATE], INDICATED THAT RESIDENT #106 HAD OROPHARYNGEAL PHASE DYSPHAGIA WITH A HIGH RISK OF ASPIRATION. THE SPEECH THERAPIST DETERMINED THAT RESIDENT #106 REQUIRED SUPERVISION WITH HER MEALS DUE TO THE RISK OF ASPIRATION AND A PUREED DIET WITH NECTAR THICK LIQUIDS. ACCORDING TO NURSES' NOTES, DATED [DATE] AT 11:20 PM, "AFTER DINNER, RESIDENT (#106) WAS LEFT BY DAUGHTER IN THE DINING ROOM, RESIDENT (#106) WAS BROUGHT BACK BY NURSING STAFF BECAUSE OF UNCONTROLLED BEHAVIOR AND SCREAMING IN THE DINING ROOM. RESIDENT #106 WAS THEN NOTICED GARGLING AND OR SOUNDING LIKE SHE HAD FLUID IN HER THROAT OR CHEST. CHEST XRAY WAS ORDERED TO RULE OUT FLUID IN THE LUNGS AND/OR CONGESTION." IN AN INTERVIEW ON [DATE] AT 3:45 PM, CNA #23 STATED THAT ON [DATE], AT AROUND 5:00 PM, RESIDENT #106 WAS IN THE DINING ROOM. SHE ATE 15% OF HER PUREED FOOD AND DRANK THICKENED LIQUIDS (MILK). CNA #23 STATED THAT SHE NOTICED THAT SOMETHING WAS WRONG WITH RESIDENT #106. RESIDENT #106 WAS "GARGLING" AND THE SOUND WAS COMING FROM RESIDENT #106'S UPPER CHEST OR THROAT. NURSE (#21) TOOK HER OUT OF THE DINING ROOM BECAUSE OF THE "NOISE" WHICH WAS DISTRACTING OTHER RESIDENTS. RESIDENT #106 WAS TAKEN TO HER ROOM. LPN #20 WAS INTERVIEWED ON [DATE] AT 3:00 PM. LPN #20 REPORTED THAT RESIDENT #106 HAD BEEN TAKEN FROM THE DINING ROOM AREA AT AROUND 5:30 OR 6:00 PM BECAUSE SHE WAS VERY LOUD AND AGITATED. RESIDENT #106 WAS TAKEN IN HER WHEEL CHAIR TO THE NURSE'S STATION WHERE SHE WAS OBSERVED TO BE "GARGLY" AND "DID NOT SOUND RIGHT." LPN #20 TOOK HER VITALS AT THAT TIME AND CHECKED HER OXYGEN SATURATION, WHICH WAS FOUND TO BE 90%. LPN #20 SAID THAT SHE (#20) THEN ASKED CNA #23 TO PUT RESIDENT #106 IN BED. LPN #20 SAID THAT SHE DID NO FURTHER ASSESSMENT OF RESIDENT #106 AT THAT TIME. DURING THE INTERVIEW WITH CNA #23, SHE (#23) FURTHER REPORTED THAT ONCE RESIDENT #106 WAS IN HER ROOM, SHE (CNA #23) OBSERVED THAT RESIDENT #106 HAD SOMETHING IN HER MOUTH. CNA #23 REPORTED, "SHE (#106) WAS TALKING FUNNY AND HAD SOME FLUID IN HER MOUTH AND WAS TRYING TO KEEP IT IN (HER MOUTH)." CNA #23 REPORTED THAT LATER IN THE EVENING, AS SHE WAS PROVIDING INCONTINENCE CARE TO RESIDENT #106, SHE (#23) REALIZED THAT THERE WAS SOMETHING WRONG WITH RESIDENT #106'S BREATHING, SO CNA #23 GOT LPN #20 TO ASSESS THE RESIDENT. RESIDENT #106 LOOKED "BLUE, (HAD) NO PULSE, (HAD) NO RESPIRATION." CNA #23 CONFIRMED THAT LPN #20 DID NOT START CPR RIGHT AWAY BUT INSTEAD HAD CNA #22 GET LPN #21 (WHO WAS AT THE FRONT MAIN LOBBY WATCHING THE FRONT DOOR). WHEN LPN #21 AND CNA #22 CAME TO THE ROOM, LPN #21 ASKED WHAT RESIDENT #106'S CODE STATUS WAS. LPN #20 DID NOT KNOW, SO LPN #21 WENT TO THE NURSE STATION TO FIND OUT. CNA #23 REPORTED, "IT WAS MAYBE 5 MINUTES" FROM THE TIME RESIDENT #106 WAS FOUND BLUE AND NOT BREATHING UNTIL LPN #21 DETERMINED THAT RESIDENT #106 WAS A FULL CODE AND ANNOUNCED OVER THE FACILITY PUBLIC ADDRESS SYSTEM FOR "ALL STAFF TO ROOM C-11." LPN #21 STARTED CPR. DURING THE INTERVIEW WITH LPN #20, SHE (#20) REPORTED THAT AT AROUND 8:00 PM (ON [DATE]), SHE WAS SUMMONED BY CNA #23 TO RESIDENT #106'S ROOM AND FOUND RESIDENT #106 WITH NO PULSE AND NO RESPIRATIONS. ACCORDING TO LPN #20, SHE (#20) TOLD CNA #23 TO GET LPN # 21. LPN #21 ARRIVED TO THE ROOM AND ASKED LPN #20 IF RESIDENT #106 WAS A FULL CODE. LPN #20 DID NOT KNOW RESIDENT #106'S CODE STATUS AND DID NOT START CPR UNTIL LPN #21 VERIFIED THAT RESIDENT #106 WAS A FULL CODE. LPN #20 DID NOT ESTIMATE THE AMOUNT OF TIME IT TOOK NURSING STAFF TO BEGIN CPR. LPN #21 WAS INTERVIEWED ON [DATE] AT 4:15 PM. ACCORDING TO LPN #21, AT APPROXIMATELY 8:00 PM ON [DATE], SHE WAS AT THE FRONT DESK RELIEVING THE RECEPTIONIST WHEN CNA #22 SAID TO HER (#21) THAT LPN #20 NEEDED HER (#21) RIGHT AWAY. LPN #21 WENT ON TO SAY THAT WHEN SHE ARRIVED IN RESIDENT #106'S ROOM, RESIDENT #106 HAD NO PULSE AND WAS NOT BREATHING. LPN #21 SAID THAT SHE ASKED LPN #20 WHAT RESIDENT #106'S CODE STATUS WAS, BUT LPN #20 WAS NOT SURE. LPN #21 STATED THAT SHE (#21) RAN TO THE NURSE'S STATION TO OBTAIN THE CHART AND VALIDATED THAT RESIDENT #106 WAS A FULL CODE. LPN #21 USED THE PUBLIC ADDRESS SYSTEM TO PAGE ALL STAFF TO RESIDENT #106'S ROOM. BY THE TIME SHE (#21) GOT BACK TO RESIDENT #106'S ROOM, OTHER NURSES HAD ARRIVED WITH THE CRASH CART. NURSING STAFF BEGAN CPR. LPN #21 DID NOT ESTIMATE THE AMOUNT OF TIME IT TOOK NURSING STAFF TO DETERMINE RESIDENT #106'S CODE STATUS AND BEGIN CPR. ACCORDING TO NURSES' NOTES DATED [DATE] AT 9:00 PM, "RESIDENT (#106) WAS NORMAL AS USUAL SELF. RESIDENT (#106) DID HAVE SOME GARGLING IN THROAT OR MAYBE SOME KIND OF FLEM (SIC) MAYBE CAUGHT IN HER THROAT. RESIDENT (#106) WAS PUT ON LIST FOR CHEST XRAY TO RULE OUT CONGESTION OR FLUID IN HER LUNGS OR CHEST ...(NO TIME SPECIFIED) RESIDENT (#106) VITALS ARE B/P (BLOOD PRESSURE),[DATE], PULSE 83, RESPIRATION = 18, PULSE O2 (OXYGEN) = 90%...(NO TIME SPECIFIED) RESIDENT (#106) WAS NOT BREATHING AND CPR (CARDIOPULMONARY RESUSCITATION) WAS STARTED (NO TIME SPECIFIED) AND EMS (EMERGENCY MEDICAL SERVICES) TOOK OVER ABOUT 5 MINUTES LATER. DOCTOR WAS CALLED AND ADMINISTRATOR AND DON (DIRECTOR OF NURSING)." ( )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION TO PREVENT FALLS, FOR ONE (#719) OF EIGHT RESIDENTS REVIEWED FOR FALLS, OUT OF A TOTAL SAMPLE OF 24 RESIDENTS, RESULTING IN A FALL REQUIRING hospitalization FOR A CLOSED HEAD INJURY AND SCALP LACERATION. FINDINGS INCLUDE: ON 10/18/12 AT 10:30 A.M., RESIDENT #719 WAS OBSERVED UP IN A WHEELCHAIR IN THE DINING ROOM. UPON INTERVIEW, RESIDENT #719 WAS PLEASANTLY CONFUSED. ON 10/18/12 AT 3:30 P.M., RECORD REVIEW REVEALED THAT RESIDENT #719 WAS ORIGINALLY admitted INto the facility on [DATE], AND WAS RE-admitted on [DATE] WITH [DIAGNOSES REDACTED]. ACCORDING TO THE MOST RECENT QUARTERLY Minimum Data Set, dated dated [DATE], RESIDENT #719 HAD MODERATELY IMPAIRED COGNITION. REVIEW OF A FALLS CARE PLAN FOR RESIDENT #719, INITIATED ON 6/1/12, NOTED: "FOCUS: I HAVE A HISTORY OF FALLS. I RECEIVE MEDICATIONS THAT COULD INCREASE MY RISK FOR FALLS. I ATTEMPT TO GET UP FROM MY BED AND WHEELCHAIR WITHOUT HELP. I HAVE DEMENTIA, POOR STANDING BALANCE AND UNSTEADY GAIT. GOALS: MY RISK FACTORS AND INJURY POTENTIAL WILL BE MINIMIZED AS ABLE. INTERVENTIONS: PLEASE KEEP ME IN THE HALLWAY WHEN I AM NOT IN BED." REVIEW OF THE UNDATED "RESIDENT CARE GUIDE" FOR RESIDENT #719 NOTED UNDER THE SECTION "SPECIAL INSTRUCTIONS/PREFERENCES: HX (HISTORY) OF FREQUENT FALLS". UNDER THE SECTION "SAFETY INTERVENTIONS: PLEASE KEEP IN HALLWAY WHEN NOT IN BED". REVIEW OF THE "UNUSUAL OCCURRENCE" FORMS FOR RESIDENT #719 REVEALED THE FOLLOWING: 1. ON 3/9/12 AT 4:30 A.M., "OBSERVED ON KNEES ON FLOOR MAT NEXT TO BED". THE RESIDENT STATED, "IT WAS TIME FOR BREAKFAST". IN THE SECTION "OTHER INTERVENTIONS/PREVENTION MEASURES TAKEN", IT WAS NOTED, "DIETARY LEFT MESSAGE FOR HS (HOUR OF SLEEP) SNACKS". 2. ON 3/10/12 AT 12:55 A.M., "OBSERVED ON KNEES ON FLOOR MAT NEXT TO BED". IN THE SECTION "OTHER INTERVENTIONS/PREVENTION MEASURES TAKEN", IT WAS NOTED, "WILL CONTINUE TO MONITOR THROUGHOUT NIGHT". 3. ON 5/26/12 AT 1:45 P.M., "OBSERVED ON FLOOR IN BATHROOM". IN THE SECTION "OTHER INTERVENTIONS/PREVENTION MEASURES TAKEN", IT WAS NOTED, "KEEP IN HALLWAY". 4. ON 5/31/12 AT 5:15 P.M., "OBSERVED SITTING ON FLOOR NEXT TO HER W/C (WHEELCHAIR)" IN HER ROOM. IN THE SECTION "OTHER INTERVENTIONS/PREVENTION MEASURES TAKEN", IT WAS NOTED, "STAFF TO ANTICIPATE NEEDS". 5. ON 6/3/12 AT 7:20 A.M., "OBSERVED SITTING ON FLOOR NEXT TO HER W/C" IN HER ROOM. IN THE SECTION "PHYSICAL ASSESSMENT/ABNORMALITIES", IT WAS NOTED: "LACERATION, LEFT LOWER CHEEK". IN THE SECTION "OTHER INTERVENTIONS/PREVENTION MEASURES TAKEN", IT WAS NOTED, "STAFF TO ANTICIPATE NEEDS". 6. ON 6/27/12 AT 5:30 A.M., "OBSERVED ON FLOOR NEXT TO BED". IN THE SECTION "PHYSICAL ASSESSMENT/ABNORMALITIES", IT WAS NOTED: "SKIN TEAR, RIGHT FOREARM". IN THE SECTION "OTHER INTERVENTIONS/PREVENTION MEASURES TAKEN", IT WAS NOTED, " LOW BED, TREATMENT STARTED". 7. ON 7/13/12 AT 3:45 P.M., "SITTING TOO CLOSE TO EDGE OF SEAT AND SLID TO FLOOR ON KNEES". RESIDENT STATED, "I WAS TRYING TO GET UP AND WALK ACROSS THE ROOM AND GET INTO BED". IN THE SECTION "OTHER INTERVENTIONS/PREVENTION MEASURES TAKEN", IT WAS NOTED, "PAIN ASSESSMENT". 8. ON 8/4/12 AT 9:00 P.M., "ON FLOOR AT BEDSIDE". IN THE SECTION "PHYSICAL ASSESSMENT/ABNORMALITIES", IT WAS NOTED: "LACERATION LEFT SCALP AREA, HEMATOMA LEFT FOREHEAD". IN THE SECTION "OTHER INTERVENTIONS/PREVENTION MEASURES TAKEN", IT WAS NOTED, "TRANSFER TO HOSPITAL". REVIEW OF THE NURSE'S NOTES FOR RESIDENT #719 NOTED: 8/4/12 9:00 P.M. "ON FLOOR AT BEDSIDE LAYING ON LT (LEFT) SIDE OF BODY WITH APPROX (APPROXIMATE) 3 CM (CENTIMETER) LACERATION TO TOP OF HEAD AND LARGE HEMATOMA TO LT FOREHEAD AREA. REMAINS ALERT AND RESPONSIVE WITH CONFUSION...ORDER RECEIVED AND NOTED TO TRANSFER TO HOSPITAL.". A physician's orders [REDACTED]. REVIEW OF THE HOSPITAL PROGRESS NOTES FOR RESIDENT #719, DATED 8/6/12, NOTED: "FALL WITH BLUNT HEAD TRAUMA, CONCUSSION, SCALP LACERATION AND HEMATOMA, BIL (BILATERAL) PERIORBITAL ECCHYMOSIS (BRUISING), BIL KNEE CONTUSIONS". DURING AN INTERVIEW ON 10/19/12 AT 2:00 P.M., NURSE "A" WAS QUERIED REGARDING RESIDENT #719'S FALLS. NURSE "A" STATED THAT SHE WAS WORKING ON THE NIGHT OF 8/4/12, WHEN RESIDENT #719 HAD SUSTAINED A FALL WITH SCALP LACERATION AND FOREHEAD HEMATOMA. NURSE "A" STATED THAT SHE WAS NOTIFIED BY CERTIFIED NURSE ASSISTANT(CNA) "B", THAT RESIDENT #719 HAD BEEN FOUND ON THE FLOOR AND WAS BLEEDING FROM THE HEAD. NURSE "A" STATED THAT SHE WAS UNSURE OF WHY RESIDENT #719 HAD BEEN LEFT UP IN HER WHEELCHAIR IN HER ROOM, BECAUSE "SHE (RESIDENT #719) LIKES TO GO TO BED RIGHT AFTER DINNER". NO EXPLANATION WAS GIVEN AS TO WHY RESIDENT #719 HAD BEEN LEFT ALONE, UP IN A WHEELCHAIR IN HER ROOM, WHEN THE RESIDENT'S CARE PLAN NOTED TO KEEP THE RESIDENT IN THE HALLWAY WHEN NOT IN BED. ON 10/19/12 AT 2:20 P.M., CNA "B" WAS QUERIED REGARDING RESIDENT #719 AND STATED THAT ON THE NIGHT OF 8/4/12, SHE WAS GETTING READY TO LEAVE THE UNIT, WHEN SHE HEARD AN ALARM GOING OFF. CNA "B" STATED THAT SHE WALKED INTO THE ROOM OF RESIDENT #719, AND OBSERVED THE RESIDENT LYING ON THE FLOOR IN FRONT OF HER WHEELCHAIR. CNA "B" STATED THAT SHE BELIEVED RESIDENT #719 HAD BEEN GIVEN A SHOWER EARLIER, AND THAT WAS WHY SHE WAS STILL UP IN A WHEELCHAIR IN HER ROOM. ON 10/19/12 AT 3:30 P.M., THE ADMINISTRATOR WAS QUERIED REGARDING RESIDENT #719'S FALL THAT OCCURRED ON 8/4/12. THE ADMINISTRATOR WAS UNAWARE OF THE INCIDENT, BECAUSE IT "HAPPENED BEFORE I CAME TO THIS FACILITY". NO EXPLANATION WAS PROVIDED AS TO WHY STAFF DID NOT IMPLEMENT THE SAFETY INTERVENTIONS THAT WERE LISTED ON RESIDENT #719'S CARE PLAN AND CNA CARE GUIDE. REVIEW OF THE FACILITY'S POLICY, "FALLS REDUCTION PROGRAM", REVISED ON 3/16/12, NOTED: PURPOSE: "TO PROVIDE A SAFE ENVIRONMENT FOR RESIDENTS, MODIFY RISK FACTORS, AND REDUCE RISK OF FALL RELATED INJURY." PROCEDURE: "ANALYZE RESIDENT RISK FOR FALL...IF RISK IDENTIFIED...INITIATE SAFETY PROCEDURES. IDENTIFY INDIVIDUALIZED INTERVENTIONS ON PLAN OF CARE, IDENTIFY INDIVIDUALIZED INTERVENTIONS ON RESIDENT CARE GUIDE...". ( )