Every finding on record at Lapeer County Medical Care Facility

Based on observation, interview and record review, the facility failed to prevent two unstageable pressure ulcers (a severe wound with full-thickness tissue loss, fully covered by slough or eschar, making its true depth hidden) for one resident (Resident #164) of three residents reviewed for pressure ulcers, resulting in bilateral heel pressure ulcers. Findings include.Resident #164:On 3/30/2026, at 10:45 AM, Resident #164 was propelling in the hallway in their wheelchair. There were no wheelchair pedals and the residents' heels were slightly dragging on the floor while they propelled. Resident #164 had on socks. On 3/31/2026, at 9:51 AM, a record review of Resident #164's electronic medical record revealed an admission on [DATE] with diagnoses that included neurocognitive disorder with Lewy bodies, Alzheimer's disease and Psychotic disorder. Resident #164 had severely impaired cognition and required assistance with all Activities of Daily Living. A review of the progress notes revealed 1/30/2026 14:36 (2:36 PM) . Skin Issues: #001 . Left heel . new wound . Unstageable pressure injuries presenting as deep tissue injury. Wound acquired in-house. Wound is new . Length (cm) (centimeters) 0.92 Width (cm): 1.21 Depth )cm): 0 . #002 . Right heel . Unstageable pressure injuries presenting as deep tissue injury. Wound acquired in-house. Wound is new . Length 1.92 Width 1.1 Depth 0 . 2/5/2026 10:00 IDT discussed new wounds noted last week. IDT discussed that (resident) was in bed more than usual due to influenza infection. IDT discussed that foam boots, turn schedule, and liquid protein were ordered. IDT discussed that order for multivitamin would benefit healing. IDT discussed that (resident) has been up in her wheelchair like normal this week and that alternating pressure mattress is not needed due to her return to baseline with mobility and orders for turn schedule and boots. No other changes in plan of care are needed at this time. IDT is in agreement with current plan of care. A review of the Task List Report revealed the following interventions: Hold on shoes Date Initiated 02/19/2026 Low Air Loss Alternating Pressure mattress, settings: Comfort Level: (3), Firmness: (Alternating) Date Initiated 03/13/2026 A review of the Pressure ulcer/Injury notes labeled Rt. (right) Heel revealed the following: 2/9/2026 Length (cm) 2.1 Width (cm) 2.53 Depth 0 2/16/2026 Length (cm) 3.4 Width (cm) 2,74 Depth 0 2/26/2026 Length (cm) 2.19 Width (cm) 3.12 Depth 0 3/17/2026 Length (cm) 2.51 Width (cm) 3.01 Depth 0 3/30/2026 Length (cm) 2.11 Width (cm) 2.65 Depth 0 A review of the Pressure ulcer/Injury notes labeled left heel revealed the following: 2/9/2026 Length (cm) 0.99 Width (cm) 1.64 Depth 0 2/16/2026 Length (cm) 1.56 Width (cm) 2.03 Depth 0 2/26/2026 Length (cm) 1.55 Width (cm) 1.78 Depth 0 3/9/2026 Length (cm) 1.52 Width (cm) 1.8 Depth 0 3/17/2026 Length (cm) 1.18 Width (cm) 1.17 Depth 0 3/24/2026 Length (cm) 2.64 Width (cm) 1.89 Depth 0 3/30/2026 Length (cm) 1.62 Width (cm) 1.97 Depth 0 A review of the INTEGUMENTARY FOCUS: (the resident) has the potential for impairment in skin integrity related to poor safety awareness, frail skin, side effects of medications, and incontinence. Geri gloves were trialed in [DATE], and she refused about half of the time. Staff are to anticipate resident may obtain skin injuries, like bruising and skin tears, easily. (the resident) has a history of MRSA, infection to skin. Hx of removing Geri Gloves after they are applied. Date Initiated: 06/27/2024 Revision on: 12/01/2025 ,,, Interventions/Tasks . Encourage resident to wear Prevolon boots to bilateral feet while in bed Date Initiated: 03/06/2026 Revision on: 03/06/2026 A review of the care plan WOUND CARE FOCUS (the resident) has BILATERAL HEEL PRESSURE ulcer on bilateral heels, R/t pressure, Staff encourage boot in and out of bed prevalon and prafo. Date Initiated: 03/06/2026 Revision on: 03/06/2026 . Interventions/Tasks Give meds as ordered . Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations Date Initiated: 03/06/2026 On 4/01/2026, at 10:48, Nurse M was interviewed regarding Resident #164's heel pressure ulcers. Nurse M was asked if the pressure ulcers were avoidable or unavoidable and Nurse M stated, avoidable. Nurse M was asked to provide weekly wound measurements. On 4/01/2026, at 11:10 AM, the Director of Nursing (DON) was asked how Resident #164's pressure ulcers developed and the DON offered, they would follow up. On 4/01/2026, at 11:30 AM, the DON provided that Resident #164 had influenza was in bed for a week and had decreased food/fluid intake. The DON was asked what interventions they placed for Resident #164 and the DON offered, we placed the boots but then she kept rubbing her heels inside the boots so the boots were discontinued. The DON also stated that the facility tried different boots because when the resident propels in the wheelchair she at times uses her heels to assist in propelling. The DON offered, the resident is active and doesn't always want to rest in bed to elevate her heels.

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents who consume food from the kitchen. Findings include:On 03/30/2026 at 9:36am, during the initial kitchen tour, observed can opener visibly soiled. During this observation, Culinary Supervisor A was queried on how often the can openers are cleaned and stated it's cleaned daily. On 03/30/2026 at 9:37am observed a chemical feed downstream of an atmospheric vacuum breaker in the dishwashing area. One wasting tee was observed lying inside the sink basin and another wasting tee sitting above the sink in a bin. According to the State of Michigan's 2008 Cross Connection Manual on atmospheric vacuum breakers, AVBs shall not be installed where they will be under continuous pressure for more than 12 hours (i.e. no downstream shutoff valve).According to the State of Michigan's 2008 Cross Connection Manual on chemical feeder backflow prevention, Another concern with a hose being run from a faucet to the dispenser is that many times a valve is installed on the hose downstream of an AVB, which is not allowed since AVBs cannot be subject to continuous pressure.On 03/30/2026 at 9:43am Everwipe Chem-ready sanitizer bucket was tested, and the result was zero with the prepared date as 2-16-26 and use by date of 3-16-26. During this observation, Culinary Supervisor A was interviewed on what range the sanitizer solution should be kept at, and she stated 150-200 and that the buckets are supposed to be good for a month. According to the FDA 2022 Food Code, 3-304.14 Wiping Cloths, Use Limitation, Cloths in-use for wiping counters and other equipment surfaces shall be .Held between uses in a chemical sanitizer solution at a concentration specified under S 4-501.114 and The sanitizing solution must be changed as needed to minimize the accumulation of organic material and sustain proper concentration. Proper sanitizer concentration should be ensured by checking the solution periodically with an appropriate chemical test kit.According to the facility's policy on sanitizer buckets, Sanitizer concentration should be read between 200-400ppm or manufacturer's recommendation. In addition, Everwipe buckets tested at least once a day and replace every thirty days unless wipes run out sooner.On 03/30/2026 at 9:46am observed mixer visibly soiled. During this observation, Culinary Supervisor A was interviewed on how often it's cleaned, and she stated it's cleaned after every use. On 03/30/2026 at 9:52am observed shredded lettuce with a best by date of 3/29 in fridge located in the cafeteria. During this observation, Culinary Supervisor A was asked what they do when food is past it's best by date, she stated it's thrown out and proceeded to throw away the chopped lettuce. On 03/30/2026 at 9:57am observed interior walls of microwave visibly soiled in the pantry room on the first floor. During this observation, Assistant Food Service Director B was interviewed on how often the microwave is cleaned and he answered it's cleaned daily. On 03/30/2026 at 10:00am observed a fan with accumulated dust on the surface blowing directly at the three-compartment sink in one east pod kitchen. During this observation, Assistant Food Service Director B was interviewed on how often the fan is cleaned, and he stated it's cleaned once a week or as needed. On 03/30/2026 at 10:18am observed a steady stream of water leaking underneath the hand sink in one west pod kitchen. According to the FDA 2022 Food Code, 5-205.15 System Maintained in Good Repair, A plumbing system shall be: repaired according to law.and maintained in good repair.On 03/30/2026 at 10:19am observed cooked mushrooms with a discard date of 3/28 in fridge in the one west pod kitchen. On 03/30/2026 at 10:22am observed milk in a cup with a lid without datemarking in fridge in one west dining area. On 03/30/2026 at 10:25am observed interior walls of microwave visibly soiled in pantry room located on two south. According to the 2022 Food Code, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, Ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.According to the facility's policy on date marking, The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. and the marking system shall consist of a label, the day/date of opening, and the day/date item must be consumed or discarded. On 03/30/2026 at 10:38am observed brownish residue on the interior of a cup on the clean dish rack in two south east pod kitchen. According to the 2022 Food Code, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, Equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations, nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the facility's policy on cleaning and sanitizing food contact surfaces, During all hours of operation, visually and physically inspect food contact surfaces of equipment and utensils to ensure that the surfaces are clean. On 03/30/2026 at 12:29pm observed [NAME] C touch face with bare hand and then proceeded to use clean utensils to tray food at two north non pod tray line. According to the FDA 2022 Food Code, 2-301.14 When to Wash, Food employees shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and .After engaging in other activities that contaminate the hands. According to the facility's policy on handwashing for dietary employees, Wash hands: after touching hair, face, or body.

Based on observation, interview and record review, the facility failed to 1) Follow care-planned interventions for one resident (Resident #12) , 2) Ensure supervision for one resident (Resident #164), and 3) Ensure safety with hot liquids for one resident (Resident #91) out of five residents sampled for safety, resulting in blisters from a hot liquid and the inability to propel freely. Finding include:Resident 91 (R91): 03/30/2026 4:20 PM, an observation was made of R91 in her room sitting in their wheelchair. The Resident was observed to not be sitting upright but was slouched in the wheelchair. The Resident was working on activities on her overbed table. The Resident was interviewed but was unreliable with answers and did not engage in conversation. An observation was made of limited mobility of her arms. A review of Resident 91's medical record revealed an admission into the facility on 7/10/20 with diagnoses that included Parkinson's Disease, scoliosis, dementia and osteoarthritis. A review of R91's Minimum Data Set assessment revealed a Brief Interview of Mental Status score of 3/15 that indicated severely impaired cognition and the Resident needed set up assistance with eating, partial/moderate assistance with oral hygiene and upper body dressing and the Resident had bilateral impairment of the upper and lower extremities. A review of R91's care plan revealed a Nutrition/Hydration Focus with an intervention dated initiated on 3/4/35 Diet-Hot liquids: Resident to use cup with lid. Resident to wear clothing protector/lap protector, Resident encouraged to be seated at lowered table/tray surface for optimal positioning, revision on 12/1/25 revealed, Diet-Hot liquids: Resident to use cup with lid, Resident to wear clothing protector/lap protector. A review of the Facility Reported Incident, Resident 91 was given hot cocoa with lid and straw. Resident was drinking cocoa but dropped the cup when trying to replace it to the dining room table. It fell in her lap, causing 1 blister to her right leg and 2 blisters to her left leg. Resident was removed to her room and treated for pain/burning . The Investigation Summary was reviewed and revealed the incident occurred on 11/30/25 at 4:00 pm, .It was observed via video footage (no witnesses) that the resident attempted to place the cup back on the table after taking a drink and it didn't make it securely back on top of the table. Upon review of practices within the facility the IDT (Interdisciplinary team) determined that the temperature log that the kitchen is utilizing to log the temperatures of hot liquids being served to residents is within range and appropriate. However, the log does not show a time at which the temperatures are being recorded. The log is updated with a time column to log. Further, the CNA (certified nursing assistant) who served the resident her hot chocolate did not provide the resident with a clothing/lap protector. She was issued an education for safety. On 3/31/26 at 4:06 PM, an interview was conducted with the Director of Nursing (DON) regarding Resident 91 spilling hot chocolate on her legs causing blisters to form. The DON reported that the Resident had missed the edge of the table when she went to put the cup back on the tabletop. Staff were right around the corner, and they had removed her clothing right away. When asked where the CNA got the hot water from, the DON explained that the staff had reached over and grabbed it out of the kitchen window, it had not been temped by the cook yet and the hot water carafe had not been cooled yet. The DON explained that the dietary staff was around the back and not right there. The DON reported that the Resident had not been given a shirt protector or lap protector. The DON indicated education given to the CNA but was unsure if all staff had an inservice. The DON was asked if they did any audits to monitor for compliance and reported they did not do any audits. The DON reported that the blisters healed and there had not been any issues with infection. A review of the facility policy titled, Safe Serving Temperatures for Hot Liquids, revealed, Policy Statement, It is the policy of this facility to provide residents their desired drink preferences with respect given to the safe temperature at which hot liquids should be served. This policy is aimed at the served temperature of hot liquids and not the temperature for which they are brewed or derived. Policy Explanation and Compliance Guidelines: 2.Dietary staff, hold and monitor all hot liquids within the kitchen until safe serving temps are reached and recorded. Once safe serving temperatures are reached, dietary staff make the drinks available for other floor staff to assist in serving residents. 5. Hot liquids/drinks prepared outside of dietary kitchens, such as the unit pantries, shall be temperature checked by the person serving the drink and within the safe serving temperature range (120 (degrees) – 140 (degrees)) before serving to the resident. 6. If poured coffee or hot liquid exceeds 140 (degrees), the drink/carafe shall endure a cooling period, within the kitchen or pantry, until temperatures are within range for safe serving. 8. All residents are assessed for their ability to handle containers and consume liquids. Residents with difficulties will receive appropriate supervision and use of assistive devices in order to consume liquids. Residents with difficulties will receive appropriate supervision and use of assistive devices in order to consume hot liquids. Interventions will be individualized and noted on the resident's plan of care. Interventions include, but are not limited to: .d. Clothing protector/Neck napkin. Resident #12: On 3/30/2026, at 10:43 AM, Resident #12 was in their wheelchair. They were pounding their right hand on their wheelchair arm hard. On 3/30/2026, at 11:44 AM, a record review of Resident #12's electronic medical record revealed an admission on [DATE] with diagnoses that included Dystonia (neurological movement disorder), schizoaffective disorder and Dementia. Resident #12 had severely impaired cognition and required extensive assistance with Activities of Daily Living. A review of the INTEGUMENTARY FOCUS: . Per POA (power of attorney) resident bruises easily, and due to her dystonia resident has increased potential for bruising and skin tears . A review of the care plans revealed no intervention for their potential bruising. A review of the Physician orders revealed . Positioning/supportive Device: arm rolls to wheelchair arm rests No directions specified . Active Revision Date 3/9/2026 A review of the Kardex revealed . Supportive/Adaptive Equipment: arm rolls to wheelchair arm rests . A review of the progress notes revealed 3/7/2026 17:45 (5:45 PM) Incident Note Note Text: CNA brought to writer's attention that resident had some bruising to her arm. Writer assessed resident and noted two bruised to the upper right bicep area. One bruise approximately 2cm (centimeters) in diameter and the other approximately 1.5 cm in diameter. Bruising bluish/purple in color. Resident denied and pain to the area. Resident unable to give description of how bruises were obtained. Writer noted the placement of the bruises. No catastrophic reactions were noted when writer identified the bruises. Resident is very active in her wheelchair all day long. An effect of resident's demeaner is to periodically pound on wheelchair heavily. Writer called POA to notify them of the bruising. Writer placed on physician's board for notification. On 3/30/2026, at 1:31 PM, Resident #12 was in their wheelchair. There was no padding to their bilateral wheelchair arms. Resident #12 was pounding on their wheelchair arms. On 3/31/2026, at 10:49 AM, Resident #12 was in their wheelchair. There was no padding to their bilateral wheelchair arms. On 3/31/2026, at 2:14 PM, Unit Manager (UM) P was interviewed regarding Resident #12's intervention of arm rests to their wheelchair. Unit Manger P was asked why for two days the padded arm rests were not available to Resident #12 and UM P provided they would look into it. On 3/31/2026, at 2:27 PM, a record review of Resident #12's electronic medical record along with UM P revealed the arm rests were added as an intervention for their previously noted arm bruising on March 7. UM P offered, that the resident may have removed the arm rests and will follow up. On 3/31/2026, at 3:31 PM, UM P offered, the arm rests pads were not found because the resident is all over the building. UM P was asked how they would ensure the arm rests pads were available for Resident #12 and UM P offered, she did have them on early this morning but they were not located. On 4/01/2026, at 8:21 AM, the DON was interviewed regarding the lack of arm rests noted to Resident #12's wheelchair for their bruising and the DON offered, she takes them off. On 4/01/2026, at 8:42 AM, Resident #12 was in their wheelchair and there was an arm rest pad noted to their right side only. The left side of the wheelchair did not have a pad placed. The resident was observed pounding on the attached wheelchair pad with their right hand. On 4/01/2026, at 8:50 AM, Resident #12 was observed pounding hard to left wheelchair armrest. Resident #164: On 3/30/2026, at 10:50 AM, Resident #164 propelled in their wheelchair into room [ROOM NUMBER] (not their room). Resident #164 propelled to the foot of the bed and appeared to get their wheelchair stuck on the foot board. Resident #164 was mumbling and was unable to answer any questions. There was a nurse in the hallway near a medication cart near room [ROOM NUMBER]. There was another staff member that exited room [ROOM NUMBER] and walked towards the day room. On 3/30/2026, at 10:55 AM, Two staff members were observed across the hallway near room [ROOM NUMBER] and walked in the opposite direction of room [ROOM NUMBER]. On 3/30/2026, at 11:02 AM, Nurse L remained in the hallway near room [ROOM NUMBER]. Resident #164 remained in room [ROOM NUMBER] and was unable to move their wheelchair forward or backwards. Resident #164 was mumbling while attempting to move their wheels with a scowl to their face. On 3/30/2026, at 11:04 AM, two staff members (hospitality aides) walked to the end of the hall to the window and did not notice Resident #164 stuck in room [ROOM NUMBER]. On 3/30/2026, at 11:08 AM, Hospitality aide N walked toward room [ROOM NUMBER] turned and noticed Resident #164 stuck in room [ROOM NUMBER]. Hospitality aide N assisted Resident #164 out of the room and into the hallway. On 3/31/2026, at 9:51 AM, a record review of Resident #164's electronic medical record revealed an admission on [DATE] with diagnoses that included neurocognitive disorder with Lewy bodies, Alzheimer's disease and Psychotic disorder. Resident #164 had severely impaired cognition and required assistance with all Activities of Daily Living. On 3/31/2026, at 10:52 AM, CNA O was asked where Resident #164 was and CNA O offered, most likely down on the southside (the south end of the building).

Based on observation, interview, and record review, the facility failed to eliminate dead end plumbing and ensure appropriate backflow prevention was installed at plumbing fixtures, resulting in the potential for contamination to the water supply, affecting all residents. Findings include: On 03/31/2026 at 9:48am observed a dead end water line in the one east pod kitchen area. During this observation, Maintenance and Housekeeping Manager D was interviewed on what the water line was used for, and she stated the line used to feed into an old juice machine, but it was removed about a month ago and that the unused water line needed to be removed. On 03/31/2026 at 10:16am observed dead end water line that was plumbed through the wall near the hand sink in the soiled utility room on two west. During this observation, Maintenance and Housekeeping Manager D was asked what the water line was used for and she stated she wasn't sure. According to the Centers for Disease Control and Prevention, Controlling Legionella in Potable Water Systems dated January 3rd, 2025, Eliminate dead legs, which are sections of no- or low-water flow. On 03/31/2026 at 10:44am observed outside spigot with spray nozzle downstream of hose bib vacuum breaker in one south west courtyard. On 03/31/2026 at 10:47am observed outside spigot with spray nozzle downstream of hose bib vacuum breaker in west courtyard. On 03/31/2026 at 10:50am observed outside spigot with spray nozzle downstream of hose bib vacuum breaker in east courtyard. On 03/31/2026 at 11:00am observed outside spigot with spray nozzle downstream of hose bib vacuum breaker at front entrance. According to the State of Michigan's 2008 Cross Connection Manual on atmospheric vacuum breakers, AVBs shall not be installed where they will be under continuous pressure for more than 12 hours (i.e. no downstream shutoff valve).

Based on observation, interview and record review, the facility failed to ensure that residents were treated in a respectful and dignified manner to ensure toileting assistance for one resident (Resident #162), and provide dining assistance in the 1-South dining room, resulting in Residents having soiled briefs due to call lights not being answered timely, the potential for weight loss, and residents' feelings of frustration. Dining Observation: Residents in the 1st Floor South Dining Room On 3/30/2026 at 12:09 PM, during an observation in the 1st floor South dining room, a group of 10 residents were observed sitting in the dining room, for the lunch meal. Per Nurse Q, the meal usually started at 12:00 PM. Two Nurse Aides R and S were delivering the drinks to the residents. The aides were asked how many staff were usually assigned to assist the residents with their meals in the dining room and hallways and they said Two. The meal was served beginning at 12:10 PM.-The two aides assisted in passing trays to the residents and then assisted the residents with eating. There were 3 residents who sat without eating, while one resident received assistance. Their food was left uncovered. It had been left sitting open and untouched for greater than 10 minutes. Then 1 aide went to the hall to pass trays, and 1 aide was left to assist the residents in the dining room. She started to feed 2 residents at once, then rose and took a resident down the hall to go to the restroom. On 3/30/2026 at 12:33 PM, during the 1st floor South dining room observation, no staff were in the dining room observing, monitoring or assisting the 10 residents. The [NAME] was in the kitchen. 1 resident had his head down near his meal tray. Two additional residents sat without touching their trays or receiving assistance; their meal trays remained open throughout. The [NAME] came out of the kitchen to try to assist one of the residents. On 3/30/2026 at 12:37 PM, Nurse Q entered the dining room, sat between two residents and began feeding them at the same time. For some of the residents their food had been sitting out for almost 30 minutes. The aides were in the halls assisting other residents. On 3/31/2026 at 12:35 PM, the lunch meal was observed. There was a Charge Nurse, and 3 nurses aides present in the dining room, to assist the residents. On 3/31/2026 at 1:45 PM, the dining observations were reviewed with the Director of Nursing. Discussed with her the number of residents sitting without assistance or monitoring in the 1st Floor South dining room on 3/30/2026 during the lunch meal. She said there should have been staff present in the dining room. Resident #162: R162 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include hemiplegia and hemiparesis following cerebral infarction that affects the full right dominant side, hypertensive heart disease and chronic kidney disease. On 03/30/2026 at 10:20AM, an interview was conducted with R162. R162 was asked if the facility answers her call light in a timely manner. R162 stated, it takes a long time to get the call light answered and I only turn it on if I truly need something. R162 stated, the regular aides see my light and they come down quickly. The newer aides see my call light on and they take forever to get here. The other day an aide came into my room and was trying to get the bucket on my commode but couldn't. The aide then threw the bucket down and left the room frustrated. I really had to go to the bathroom, I thought the aide was going to come back and help me and they didn't and consequently I messed my pants. I started to cry, I was very upset and eventually a staff member came by to change my brief and clean me up. I told someone about it but never got an apology at all. On 04/01/2026 at 10:48AM, an interview was conducted with the Director of Nursing (DON). The DON was asked if they were aware of the concern that R162 had. The DON stated, I know this happened on second shift. R162 turned on her call light, the aide entered the room and then left without completing the care. I was told that the aide left the call light on for the other aide to come down and help. However, no one came back. On 04/01/2026 at 11:39AM, the DON indicated the facility investigated the situation. The DON stated that on 03/192026, R162's aide was giving a shower to another resident, the Assistant Director of Nursing (ADON) asked the hall partner to go help R162 and she went and answered the call light, but by that time R162 was upset and didn't want to be touched. The nurse on the floor went in at that time and was able to complete the care. R162 stated to social worker and unit manager that her call light was on for over 45 minutes while she waited to be toileted and then she just eventually went in her pants and then began yelling for help. R162 was noted to be very tearful at the time. On 04/01/2026 at 11:48AM, a review of the call light log from 03/19/2026 revealed that R162's call light was on for 42 minutes at 4:26PM and then for 28 minutes at 5:15PM On 04/01/2026 12:09 PM Interview with [NAME], LPN. Her aide was giving someone a shower, I know she was embarrassed and tearful that she went in her pants. Another aide went down to help but R162 didn't want her help. I have a good rapport with her and was able to clean her up. I know this happened sometime between 4:30-6:30pm. I don't know how long her call light was on but she was incontinent of stool and tearful.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive care plan for one resident (Resident (#56) of 1 resident reviewed for smoking, resulting in Resident #56 lacking a care plan to identify where to store the resident's smoking materials including a lighter. Findings Include: Resident #56:Smoking A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #56 was admitted to the facility on [DATE] with diagnoses: History of a stroke, left sided weakness, history of traumatic brain injury, COPD, Nicotine dependence, with withdrawal. Anxiety, Depression, peripheral vascular disease, chronic pain syndrome. The MDS assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status/BIMS score of 15/15, needed some assistance with care and used a motorized wheelchair. On 3/30/2026 at 9:30 AM, during the Entrance Conference with the Administrator and Director of Nursing/DON, the Administrator said the facility was a Non-Smoking Campus, but Resident #56 left the campus to smoke. When asked where he went, the Administrator said he had an electric wheelchair and left the premises in his wheelchair and went down the road. When asked who was responsible for the resident's smoking materials, cigarettes and lighter, the Administrator said sometimes his family brought the resident cigarettes, but the facility did not keep them for the resident. The Administrator said he did not know if the resident had a lighter or how he lit the cigarettes. On 3/31/2026 at 11:30 AM, Resident #56 was interviewed in his room. He was lying in bed watching TV. His electric wheelchair was in his room next to the bed. The resident was asked about his wheelchair, and he said he used his wheelchair inside and outside of the facility. The resident was asked if his wheelchair ever ran out of power and he said it had. He said someone would stop on the road to help him, a passerby would either bring him back or notify the facility and they would send a truck to pick him up and the wheelchair. The resident was asked if he was able to call for assistance and he said he no longer had a phone. During the interview with Resident #56 on 3/31/2026 at 11:30 AM, the resident was asked about smoking, and he said he smoked but he would go off the facility property to smoke. When asked where he kept his cigarettes, he said he didn't currently have any. The resident was asked how he lit his cigarette and he stated, With a lighter. The resident was asked where he kept his lighter and he looked at his bedside dresser. The lighter was lying on top of the dresser. A review of the Care Plans for Resident #56 indicated the following: Mood/Behavior: (Resident #56) is at risk for depression r/t (related to) rules and policies of facility. He has times of smoking at entrances and in building with education. date initiated 6/4/2024 and revised 1/27/2026 with Interventions including: When observed smoking, remind him this is a non-smoking facility/campus. Smoking is to be off campus, date initiated 1/27/2026. There was no mention of the resident carrying cigarettes or a lighter in the facility. (Resident #56) has Emphysema/COPD related to smoking, was active smoker on admission. Continues to smoke on grounds despite education of no smoking policy, date initiated 9/10/2024 and revised 1/22/2026. The interventions did not mention the resident smoking or that he had cigarettes and a lighter. The Care Plans did not address the resident having smoking materials in his possession in the building. On 3/31/2026 at 4:32 PM, the DON was interviewed about the resident having a lighter on his countertop in his room. She said he had a lock box in his room and was supposed to use it for the lighter when he was not in his room. Reviewed the resident was sleeping soundly earlier and did not stir when the door was opened and his name was called on two separate instances. It was observed during the survey that several residents were observed wandering in the hallways and into other residents rooms in the facility Also reviewed the care plan did not mention anything related to storing the residents lighter in a lock box. On 4/1/2026 at 10:33 AM, the Administrator was interviewed about Resident #56 smoking and having smoking materials in his possession. He said the facility did not manage the resident's cigarettes or lighter. Reviewed with the Administrator the lighter was not secured in the resident's room and could be accessible to other residents, who might be confused. He said the resident had been observed smoking on facility grounds and in the building and they had been working with the resident and educating him about the smoking policy. Reviewed there was no Care Plan that addressed the safety involved with storing the resident's cigarettes and lighter. A review of the facility policy titled, Smoking Policy, date updated 9/4/13 and reviewed 9/23/2025 provided, Policy Statement: To provide an environment that promotes good health, wellness and prevention, to recognized the harmful effects associated with smoking. It is the policy of (the facility) that all tobacco related products are prohibited in all buildings and on all grounds owned, operated or under agreement with (the facility). The only exception is: smoking is allowed in the personal vehicles. Individuals covered by this policy include, but are not limited to, Employees, Residents Visitors. Violation of this policy will lead to corrective action up to and including discharge. The policy did not address where the resident would safely store his cigarettes or lighter.

Based on interview and record review, the facility failed to revise care plans for psychotropic medications for one resident (R2) of five residents reviewed for psychotropic medications resulting in an inaccurate care plan. Findings include: Resident #2 (R2):R2 is 90yrs old and originally admitted to the facility on [DATE] with diagnoses that include dementia, major depressive disorder, anxiety disorder and chronic kidney disease.On 04/01/2026 at 8:56AM, a medication regimen review (MRR) was conducted in the electronic medical record (EMR).On 04/01/2026 at 9:00AM, record review of the physician's orders revealed that R2 is prescribed, Seroquel 25mg, one tablet by mouth at bedtime, dated 2/12/26 and Remeron 15mg, once daily, with a dose change noted on 6/11/25.On 04/01/2026 at 9:05AM, record review revealed a care plan is present for psychoactive medication, initiated on 03/13/2024, last revised on 04/15/2025. The care plan references Remeron and that a Gradual Dose Reduction (GDR) was attempted on 4/7/25. The care plan does not reference the use of Seroquel. The care plan has not been updated since 4/15/25.On 04/01/2026 at 10:34AM, an interview was conducted with the Social Worker (SW) E. SW E was asked who is responsible for updating care plans for psychotropic meds. SW E stated, the nurses, the other social workers and I can update the care plans. SW E was asked when care plans are updated for psychotropic meds. SW E stated that we updated them quarterly and as needed. SW E stated, as needed includes GDR's, dose changes and medication changes. SW E was asked if the care plan should have been updated with the change in dosage and new medication. SW E stated that it should have been updated for the Seroquel at minimum.On 04/01/2026 at 10:54AM, an interview was conducted with the Director of Nursing (DON) The DON was made aware that the care plan had not been updated. The DON stated that the care plan should have been updated with the new medication that was added. Review of the policy titled, Interdisciplinary Care Plan, revealed,Policy Interpretation and Implementation3. The Unit manager will review the information found in each care plan section looking at the care that has been provided related to physician orders, labs, diagnostic testing, current medical status, etc. in order to assure continuity of care. Any issues found will be discussed with the appropriate interdisciplinary care plan team member and if necessary, taken to the physician and resident/family seeking direction for future plan of care. 4. For quarterly/annual/CIS care plan updates, the Interdisciplinary care plan team will review their goals and approaches for appropriateness and request any necessary changes by notifying the Floor Coordinator. The Unit manager will discuss the goals/approaches with the physician and make any necessary changes in the electronic care plan.

Based on interview and record review the facility failed to ensure that professional standards of practice were followed with the assessment, monitoring, documentation and timely physician notification of a medication error for one resident (Resident 131) who had been administered in error a Norco 5mg/325 mg (an opioid pain medication of a combination of acetaminophen and hydrocodone), of one resident reviewed for a change in condition. Findings include:Resident #131 (R131):On 3/30/26 at 9:46 AM, an observation was made of Resident 131 lying in bed. The Resident aroused to a knock on her doorway. The Resident was asked questions but did not answer questions reliably and did not engage in conversation. A review of Resident 131's (R131) medical record revealed an admission into the facility on 5/23/18 with diagnoses that included Alzheimer's disease, and dementia. A review of the Minimum Data Set assessment revealed a Brief Interview of Mental Status score of 4/15 that indicated severely impaired cognition. A review of the Resident's allergies revealed an allergy to codeine and sulfa antibiotics. Further review of the medical record revealed progress notes of medication error that included:-1/31/26 at 11:57 PM, Writer attempted to call both POAs (power of attorney). No response.-2/1/26 at 9:02 AM, Attempted to call POA in regard to medication error, no answer.-2/1/26 at 4:44 PM, Writer contacted POA (Name). Writer notified POA of situation and actions taken. POA with no questions or concerns and thanked writer for the call.-2/1/26 at 6:04 PM, PA notified. No new orders at this time.A review of the Medication Administration Record (MAR) revealed no documentation of the medication that had been administered. On 3/31/26 at 3:55 PM, an interview was conducted with the Director of Nursing (DON) of the medication error with Resident 131. The DON was asked what the medication error was and reported the Nurse had given Norco (narcotic pain medication that contained acetaminophen and hydrocodone) that was supposed to be given to another resident. Resident 131 had an allergy to codeine. The medical record was reviewed with the DON. The review revealed a lack of documentation about what medication was given. The MAR and progress notes lacked documentation of the medication that was administered to the Resident. The DON indicated that the medication should be documented if it had been given. The PA (physicians assistant) was documented as notified on 2/1/26 at 6:04 PM in the progress notes and the DON indicated it was not timely and was unsure, looking at the documentation, if the practitioner was notified of the medication error prior to the next day at 6 pm. The documentation monitoring for signs and symptoms of allergic reaction was reviewed, but the documentation lack assessment of receiving the narcotic medication like lethargy. The DON reported they should be monitoring side effects of narcotic medication as well as monitoring for allergic reactions.

Based on observation, interview and record review, the facility failed to ensure that an Enteral nutrition (tube feeding/nutrition through a feeding tube into the stomach or intestines) formula was identified when ordered for one resident (Resident #23) of 1 resident reviewed for enteral nutrition, resulting in the potential for Resident #23 to not receive the appropriate Enteral formula.Findings Include: Tube Feeding Resident #23: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #23 was admitted to the facility on [DATE] with diagnoses: history of a traumatic brain injury, epilepsy, quadriplegia, dysphagia (difficulty swallowing), gastrostomy tube (feeding tube into the stomach), and hearing loss. The MDS assessment dated [DATE] revealed the resident had a memory problem and needed assistance with all care. Section K Swallowing/Nutritional Status from the MDS assessment indicated the resident had a feeding tube and received his nutrition and fluids via the feeding tube. On 3/30/2026 at 11:37 AM, Resident #23 was observed sitting in a Broda chair. A tube feeding pump and syringe were in the room; the pump was not on. The resident was not receiving any enteral/tube feeding at that time. The resident was alert, but unable to answer questions. A review of the physician orders for Resident #23 identified the following: Enteral Feed Order two times a day Enteral feeding formula 1.5 cal per cc, 4 cans to equal 948cc, Give 948cc at 79cc/hr via Kangaroo E pump. Flush bag 565cc water at 48cc/hr. Feed time-ON at 6 pm off at 6 am- 12 hours- or until completion, start date 10/21/2025 at 1800 (6:00 PM). A review of the March 2026 Medication Administration Record/Treatment Administration Records (MAR/TARs) for Resident #23 revealed the following: Enteral Feed Order two times a day Enteral feeding formula 1.5 cal per cc, 4 cans to equal 948cc, Give 948cc at 79cc/hr via Kangaroo E pump. Flush bag 565cc water at 48cc/hr. Feed time-ON at 6 pm off at 6 am- 12 hours- or until completion, start date 10/21/2025 at 1800 (6:00 PM). Enteral Feed Order in the afternoon Give 1 unit Enteral feeding formula 1.5 cal per cc 237 cc via G-tube one time a day to equal 237cc for nutrition. Give 1 237 cc can bolus via G-tube, Give 100 cc total free water flush: 50cc before and after bolus feed at 2pm, start date 12/14/2025. There were also several additional orders for water administration via the feeding tube on the MAR/TAR for March 2026. A review of the Kardex for Resident #23 provided the following: Eating/Nutrition: Diet-Feed with license staff only (Nurse only to feed tube feeding). Diet Enteral feeding formula 1.5 cal per cc, 4 cans to equal 948cc at 79cc/hr. Give 1 unit Enteral feeding formula 1.5 cal per cc 237 cc via G-tube one time a day. A review of the Care Plans for Resident #23 identified the following: Enteral Feed- (Resident #23) requires tube feeding related to diagnosis of Dysphagia and history of (TBI) traumatic brain injury, date initiated 10/13/2025 and revised 3/27/2026 with Interventions including: Enteral feeding formula 1.5 cal per cc, 4 cans to equal 948cc. undated; Give 1 unit Enteral feeding formula 1.5 cal per cc 237 cc. date initiated and revised 12/14/2025. During a review of the physician orders, MAR/TARs for March 2026, Kardex and Care Plans for Resident #23, there was no identification of the type or brand of enteral nutrition the resident was to receive. A review of the Nutrition Risk Assessment dated locked 3/26/2026 for Resident #23, identified . Tube feeding can be a risk to the resident as there is potential for aspiration, infection at tube site, intolerance to tube feeding or formula, fluid imbalance. Enteral feeding formula 1.5 cal per cc. There was no mention of the specific enteral feeding formula the resident was to receive. On 3/31/2026 at 11:45 AM, Nurses G and H were interviewed about Resident #23's enteral feeding formula. Nurse H went to a cupboard at the nurses' station and removed a container of Jevity 1.5 enteral nutrition 237 cc per carton. She said that it was the formula that Resident #23 received. Next to the box with the Jevity 1.5 was another box with a different brand of enteral feeding formula. During the interview with Nurses G and H, Nurse G showed the physician order for enteral nutrition for Resident #23. It did not say what Brand of formula was to be used; it said enteral tube feeding 1.5. Nurse H showed the Medication Administration Record/MAR for Resident #23 for March 2026 and it said the same thing. There was no mention of the specific formula or therapeutic substitution to provide to the resident. On 3/31/2026 at 12:02 PM Nurse Manager I was interviewed about the enteral nutrition order for Resident #23. She said at one point Jevity was in short supply and they had to substitute with other brands and stated, So we bought other brands. We've had Jevity for a while now and we haven't changed the order back. The Nurse Manager I said the dietary department helped with the orders and no specific brand was ordered. She said Resident #23 received the containers of 237 ml Jevity 1.5. On 3/31/2026 at 1:30 PM, the Director of Nursing was interviewed and said she was working with the nurses to ensure a physician order was in place for the specific enteral nutrition Resident #23 was to receive. A review of the facility policy titled, Tube Feeding Administration, updated 3/14/2022 and reviewed 9/15/2025 provided, Policy Statement: To provide a concise approach for administering and documenting tube feedings. 1. Read tube feeding orders and gather appropriate equipment. If using an E-Pump Set or E-Pump Set with flush bag, nurse will prepare this using the prescribed amount and type of tube feeding solution. Label the tube feeding bag with the resident's name, date, time, feeding instructions (includes name and strength of formula and water amount.)

Based on observation, interview and record review, the facility failed to ensure that an oxygen administration and care plan was updated for one resident (Resident #1) of one resident reviewed for oxygen administration, resulting in an empty oxygen tank and low oxygen saturations. Findings include. Resident #1: On 3/30/2026, at 9:55 AM, Resident #1 was sitting in their wheelchair with their overbed table in front of them. Resident #1 appeared anxious and was crying. Resident #1 had oxygen on via nasal canula that was set to 2 liters via the wall oxygen. On 3/30/2026, at 11:30 AM, a record review of Resident #1's electronic medical record revealed a readmission on [DATE] with diagnoses that included Congestive Heart Failure, Dementia and heart arrythmia. Resident #1 had severely impaired cognition and required assistance with all Activities of Daily Living. A review of Physician orders revealed . Administer Oxygen @ 3 Liter/min Via Nasal Canula with humidification on (24 hrs/day) . Start Date 3/21/2026 . A review of the CARDIOVASCULAR FOCUS care plan revealed . OXGYEN SETTINGS: O2 via nasal prongs @ 2liters On at BED (HS) off in AM/Apply if resident is napping. Humidified Continuous. Date Initiated: 03/15/2023 Revision on: 03/15/2023 . A review of O2 Sats Summary revealed . 3/21/2026 14:41 (2:41 PM) 79.0 % Method Room Air . On 3/30/2026, at 1:55 PM, Resident #1 was sitting in their wheelchair in their room. They were hooked to the oxygen tank that was hanging on their wheelchair. The oxygen dial was noted to be in the red zone. Resident #1 appeared anxious and short of breath. On 3/30/2026, at 1:57 PM, an observation along with Nurse K of Resident #1's oxygen saturation was conducted. Resident #1's oxygen saturation was 79%. Nurse K placed the oximeter onto another finger and the saturation rate was 80%. Nurse K hooked Resident #1 to the wall unit and turned the oxygen rate up to 3 liters. Resident #1's oxygen saturation rose to 92%. On 3/30/2026, at 4:11 PM, Resident #1 was resting in their recliner. Their nasal canula was off and resting on their lap. Their call light was on. Nurse J entered and was asked to obtain an oxygen saturation. The result was 86%. Nurse J placed Resident #1 on the oxygen tank. CNA O assisted the resident to the bathroom. Resident #1 appeared anxious. On 3/31/2026, at 10:35 AM, Resident #1 was sitting in their wheelchair. Their oxygen was supplied by the wall unit at 3 liters. Resident #1 appeared calm and smiled. On 3/31/2026, at 1:13 PM, Nurse J was asked if Resident #1 removes their oxygen and Nurse J stated, she took it off three times during lunch. On 4/01/2026, at 8:28 AM, The Director of Nursing (DON) was asked how they ensure Resident #1 has their oxygen on and the DON offered, we put it on when we notice it's off. The DON was alerted the oxygen tank was empty and Resident #1's oxygen saturation was at 79% and the DON offered, that shouldn't have happened.

Based on observation, interview and record review, the facility failed to operationalize care-planned interventions for behaviors for one resident (Resident #74) who wandered through the unit propelling their wheelchair, going into other residents' rooms, and displacing items of other residents, of one resident reviewed for mood/behaviors. Findings include:Resident 74 (R74):On 3/30/26 at 10:23 AM, observations were made on the dementia unit of the facility. An observation was made of R74 in a wheelchair, propelling herself at a fast pace, up and down the hallway. R74 was observed going in and out of resident rooms, going from one room and going across the hall to another room and proceeded to go in multiple rooms. R74 was observed to be going into other rooms where other residents were in. At one point, a resident was walking out of her room and R74 was going into the room, the other resident was able to sidestep fast enough not to collide with R74 in their wheelchair. Staff were in the area but did not intervene with the Resident going in and out of other resident rooms. At one point, the Resident was seen picking up items on a tray that was next to a resident sleeping in bed. A Staff, talking to a resident in the hallway, was alerted to R74 rearranging items on the meal tray of the other resident. R74 continued to wheel up and down the hall and in and out of other rooms. Another observation was made of a resident talking to staff in the hallway with her back turned to where R74 was propelling herself. R74 propelled up to the Resident standing and staff were able to stop the wheelchair before it came into contact with the other resident. The staff turned around R74 and R74 proceeded to propel up and down the hallway and in and out of rooms. The Resident was not observed to be redirected by staff to attend the activities in the common area. On 3/31/26 at 11:50 AM, an observation was made on the dementia unit of R74 propelling herself in the hallway and in and out of other resident rooms. R74 was observed to take a covered plate from room [ROOM NUMBER]-2 where a resident was in bed. R74 took the covered plate across the hall to room [ROOM NUMBER] and placed it on the bed. Staff were in the area and took the covered plate out of room [ROOM NUMBER] and were informed by the surveyor that it came from 174. The staff did not redirect R74. R74 did not have a busy apron or activity mat in her room, in the hallway, in the common area or with her. The Resident was not offered a tactile or soft item to hold or redirected to activities going on in the common area. A review of Resident 74's medical record revealed an admission into the facility on 3/2/22 with diagnoses that included Alzheimer's disease, dementia, anxiety disorder, and mood disorder. A review of the resident's Minimum Data Set assessment revealed the resident was moderately impaired for cognitive skills for daily decision making, was dependent on a helper for activities of daily living and used a wheelchair that was used manually by the resident. A review of R74's Kardex revealed: Intervention and Behavior Plan: Encourage [NAME] to have busy apron when up in wheelchair. When observed entering other resident rooms- re-direct to her room or common area and distract with activity, offer tactile and soft items for resident to hold. A review of R74's care plan revealed:-Safety Focus: . (R74's name) has been noted to propel herself in wheelchair with feet and she utilizes her trunk to get momentum by flinging her chest forward. Revision on 5/30/25. The care plan lacked interventions on safety for the resident or other residents in regards to potential accidents with other residents/staff or items in the hallway.-Behavior/Mood: (Residents name) wanders/enters other rooms and has rare occasion of refusing care r/t (related to) Dementia, psychotic disorder, mood disorder, and anxiety disorder, with an intervention When observed entering other resident rooms- redirect to her room or common area and distract with activity, offer tactile and soft items for resident to hold.-ADL (activities of daily living) Focus, with interventions that included, Intervention and Behavior Plan: Encourage (R74) to have busy apron when up in wheelchair, revision on 1/29/25.-Activities Focus: (R74) is dependent on staff for activities, cognitive stimulation, and social interaction d/t (due to) Alzheimer's disease, dementia with psychotic disturbance, anxiety, and hearing loss. Interventions included, (R74) needs assistance/escort to activity functions, revision on 1/12/24; Encourage involvement in activities. (R74) activities of past interest are: spiritual activities, pet/dog visits, intergenerational activities, caring for baby dolls, flower activities, simple jigsaw or word puzzles, games, looking at catalogs or shopping at the General Store, time outdoors in nice weather, watching TV, food events, beauty and grooming activities, revision on 11/14/25; Offer tactile and soft items for resident to hold, revision on 2/10/23. A review of R74's Task: Behavior Monitoring and Interventions revealed the following:Dated 3/30/26 the area No Behaviors Observed was marked at 06:59, 14:59 and 22:12. Dated 3/31/26 the area No Behaviors Observed was marked at 06:59, 14:59 and 21:23.There was a behavior of Entering Other Resident's Room/Personal Space available in the documentation to monitor for but was not identified as a behavior that was identified on 3/30 and 3/31. On 3/31/26 at 1:30 PM, an interview was conducted with Activities U regarding R74's care planned interventions. When asked about the busy apron, the Activities staff reported the resident has two activity blankets that they use with her. When asked where they were, they stated, They are not out right now. The Activities staff went to a storage area off the hallway. The room had many activity supplies stored. The Activity staff got a bin down and stated, When they come back form laundry, they put them in there. When asked how long they have been stored in the bin, the Activity staff was unsure when they were out last for R74. On 3/31/26 at 2:11 PM, an interview was conducted with the Unit Manager, Nurse (UM) T regarding Resident 74's behaviors and care planned interventions. The safety of residents was asked about with the behavior of R74 propelling at a fast pace through the unit and reviewed the observations made. The UM reported that the Resident should be redirected by staff and that there has not been any accidents that she was aware of. The Unit Manager reported they had tried to use the yellow banners that go across the room doors but that did not stop the resident due to her being able to take them off the doorways. The UM reported that staff should be redirecting when they notice it. The UM indicated that touching other residents' food was an issue and stated, They should be encouraging her not to touch other peoples' foods. When asked about the busy apron and activity blankets, the UM indicated they should be out for the Resident to use and redirected to activities when activities are going on. A review of facility policy titled, Managing Resident with Anxiety/Aggression, revealed, .Policy Interpretation and Implementation: .8. Offer music, TV, video, exercise, card playing, busy box or any activity of enjoyment that you may be able to engage resident in. 10. If resident is independently mobile, either ambulating or propelling w/c (wheelchair), and remains in anxious state, provide one on one intervention until resident has calmed down. Follow behind them (sometimes being in their view continues to cause distress) and make sure they remain safe and others are out of harms way.

This Citation Pertains to Intake Number 2661843. Based on observation, interview and record review, the facility failed to ensure supervision was provided during mealtime for two residents (#1 and 2), who had safe swallow instructions during meals, of four Residents reviewed for dining and assistance with meals. Findings include:On 11/13/25 at 12:15 PM, an observation was made of the dining room on the second floor during the lunchtime meal. The following observations were made:-Resident 1 (R1) was sitting in a Broda chair. The Broda chair is slightly reclined. There were two men working on the construction near the cabinets with yellow caution tape blocking the area. Resident 1 is positioned facing the construction area. -Resident 2 (R2) was positioned at a table with two other residents with her back towards the construction area and facing the outer wall. -At 12:32 PM, lunch trays are passed on the 2nd floor dining area. The hot food is served onto plates on the other side of the kitchenette area and not in vision of the Residents on the other side of the kitchenette/counter area. Staff come around from the other side where the hot food was located and delivered Residents' food. They set the Resident's food down on the table and then left the area to get another Resident their food. Most Residents had their food.-Resident 1 is seated in her Broda chair, reclined slightly, has shirt protector on and eating her food. Staff have left the dining area-At 12:33 PM, Resident 2 was given her meal and staff left the Resident with out directive or encouragement to eat. Resident 2 did not have a shirt protector on. All food items on ticket were received. R2 picked up a fork and pushed the cooked broccoli around on her plate. Meat was received cut into bite size pieces. The Resident did not eat any food but had taken some sips of V8 juice. Staff left the area after the food was given to R2.-At 12:48 PM, an observation was made of staff not in the dining area consistently while Residents are eating. R1 was eating without being monitored for safety. R2 has not eaten a single bite of food. No staff in area other than the staff working on construction who are not attentive to Residents eating and have their backs turned towards the Residents and not in visual sight of R2. Activity staff came and removed the folded linen from R2 that she had accomplished prior to getting her meal. The Activity staff did not assist or encourage the R2 to eat and left the area after briefly talking to another Resident, leaving no staff in the dining area. -At 12:51 PM, no staff in the dining area where R1 and R2 were seated. R1 was eating her meal, not seen to be alternating sips with food. R2 has not eaten any bites of food but drank some V8 juice. -At 12:56 PM, Staff came into the area and removed the plate from a Resident who left the dining area and was seated at R2's table. The Staff did not assist or encourage R1 or R2 and the staff left the area.-At 12:57 PM, Staff came into the area and removed plates where a resident had finished the meal and left the area. The Staff did not encourage or assist R1 or R2. -At 12:58 PM, Staff in the area cleaned a table of Residents that were done with meal. Did not come to R2 to assist or encourage meal. Resident had not eaten except some sips of V8 juice.-At 1:00 PM, a CNA asked R2 if she was hungry, R2 gave an unheard response and was not assisted with a bite of food. The CNA left and the Resident put her head down and closed her eyes after the CNA left.-At 1:01 PM, a Nurse comes to R1 and asked if she was done eating and said she saw she was sleeping. The Nurse leaves and R1 started to eat again. No assistance was given to R2. No staff in the area.-At 1:03 PM, staff came into the area and woke up R2 and asked if she was going to eat. The Staff put a fork into the Resident's hand and leaves the area. The Resident takes her first bite of food after the staff leaves the area.-At 1:05 PM, staff came in and took R1 from the dining area. There were no staff in the area after R1 was taken out. Maintenance staff were working on the counter and in and out of the area, backs to the dining area and not in visual sight of R2. R2 was eating.-At 1:10 PM, R2 continued eating. R4 had Visitor C seated at the same table with R2. The Visitor had left the area. R2 and R4 were the only Residents in the room eating. R2 ate a good portion of spaghetti and piled some of the spaghetti onto the cut-up strawberries. R2 had eaten one piece of meat, some spaghetti and half of the cup of V8 juice. There were no staff in the area.-At 1:17 PM, R4's Visitor returned to the dining area. There were no staff in the area while R2 ate her lunch.-At 1:23 PM, R2 had stopped eating at 1:21 PM and had her head down. Staff came in, woke the Resident, assisted with a sip of V8 juice, put meat on the fork and fed the Resident the meat. The Staff puts another piece of meat on the fork, encouraged the Resident with another bite and lets the Resident know she will be back. The staff leave the area. -At 1:27 PM, the staff that was in at 1:23 returns, assisted R2 by putting another bite of meat on the fork and gave the Resident the bite. R2 takes the meat readily. The Staff then left the area after giving the Resident the bite of food.-At 1:28 PM, R2 took the fork and started to eat the meat on her own. There were no staff in the area.-At 1:31 PM, Staff came by and asked the Resident how she was doing, the Resident replied Good. The Staff encourage the Resident to eat and then leaves the dining area while the Resident continues to eat.-At 1:32 PM, R2 continues to eat and tried to pick out the strawberries from under the piled-on spaghetti. There were no staff in the dining area in view of the Resident.-At 1:33 PM, Staff came by R2, saw the Resident eating and said to the Resident that she would be back.-At 1:38 PM, Visitor with R4 left the dining area. R2 was interviewed and answered simple questions. The Resident reported the food was good. She was observed to be brushing off food from her lap. When asked if she was offered a shirt protector, she reported that sometimes she gets one and sometimes she doesn't and stated, didn't today. There were no staff in the dining area. R2 continued to eat.-At 1:44 PM, Activity staff came into the dining area, assisted a resident out and left the area. No other staff were present in the dining area where R2 continued to eat and had consumed strawberries with spaghetti. -At 1:49 PM, CNA D comes into the dining area, asked R2 if she was completed with her meal, removes the food portion, leaves the liquids with the Resident and leaves the area. At 1:54 PM, Resident 2 remains in the dining area with her liquids at the table. Resident 1A review of Resident 1's medical record revealed an admission into the facility on [DATE] with diagnoses that included Multiple Sclerosis, hemiplegia affecting left side, Alzheimer's disease, and dysphagia. A review of the Minimum Data Set (MDS) assessment revealed a Brief Interview of Mental Status (BIMS) score of 11/15 that indicated moderate cognitive impairment and the Resident needed set up or clean up assistance with eating and dependent on helper for other activities of daily living, mobility and transfer. A review of R1's meal ticket revealed the following:-Safe Swallow: Sit upright for all po (oral) intake, small bites, slow rate, alternate bites/sips 1: (to)1, report coughing to nursing staff. A review of Resident 2's medical record revealed an admission into the facility on 1/13/23 with diagnoses that included Alzheimer's disease, diabetes, dementia, and dysphagia. A review of the MDS revealed a BIMS score of 3/15 that indicated severe cognitive impairment and needed setup or clean up assistance with eating and dependent on helper for most other activities of daily living. A review of R2's meal ticket revealed the following:-Meal Note: courage meals in dining room/offer cues/encouragement-Daily Note: Cut everything into bite size pieces.-Profile Note: Diet: Regular diet, regular texture. Regular/thin consistency *Meat cut up into bite size pieces. Meat cut up into bite sized pieces, per POA cut everything into bite sized pieces, no sweets, offer fruit or diet Jello.-Safe Swallow Instructions: close supervision at meals and encouragement for po (oral) intake, instruction for small bites/sips, alternating solids/liquids, slow rate. On 11/13/25 at 2:45 PM, an interview was conducted with the Administrator (NHA) of the dining observations with lack of staff in the area, lack of assistance and encouragement with meals and a review of Resident 2's meal ticket with safe swallow instructions. The NHA indicated that by the time the Resident was assisted with food, her meal would have been cold. A review of the weights for Resident 2 revealed the Resident was approximately 125 pounds about a year ago, 121 pounds three months ago, and recent weight was 116 pounds, revealing R2 had weight loss. On 11/13/25 at 3:15 PM, an interview was conducted with Unit Manager (UM), Nurse E regarding the dining observation made on the second-floor dining area for R2. The UM reported that there should be staff during dining to monitor and assist as needed. On 11/14/25 at 1:56 PM, an interview was continued from the prior day with the Umit Manager. The UM reported that the Safe Swallow Instructions meant that Speech Therapy had seen the resident and set up guidelines for safe swallow instructions, both R1 and R2 were on swallow precautions and both Residents needed supervision/monitoring in the dining area while eating. R1 should have her Broda chair at a 90-degree angle and a review of the recline of the Resident during the lunchtime meal observation on 11/13/25 was discussed. The UM was unsure what the 1:1 meant and indicated she would get clarification from speech therapy on that. The UM indicated that staff should encourage bites with sips for R1 and that staff should be monitoring the Resident while eating to keep an eye on her. The Speech Therapy recommendations for R1 and R2 were requested.A review of R1's Speech Therapy SLP Evaluation and Plan of Treatment, dated 5/29/25 revealed a referral evaluation for occasional oral pocketing during meals when tired. Assessment of overall abilities include Set-up and Supervision; Assessment Summary included, .Pt (patient) appears to be tolerating current diet at this time. SLP (speech language pathologist) did provide education to DNA/nurse on safe swallowing/compensatory strategies. R1's Kardex (patient care guide) revealed, Diet-Safe Swallow Instructions: Sit upright for all po (oral) intake, small bites, slow rate, alternate bites/sips 1:1, report coughing to nursing staff. A review of R2's Speech therapy SLP Evaluation and Plan of treatment, dated 9/19/25 revealed the Potential for achieving goals: Guarded due to decreased alertness and cognition. Recommendations included Supervision for oral intake=close supervision and Strategies included Swallow Strategies/Positions: to facility safety and efficiency, it is recommended the patient use the following strategies and/or maneuvers during oral intake: bolus size modifications, lingual sweep/reswallow and alternation of liquids/solids; and Reason for Skilled Service: To assess safest and least restrictive diet to ensure maintenance of nutrition via oral intake with no evidence of airway compromise. R2's Kardex revealed, Diet-Safe Swallow Instructions: close supervision at meals and encouragement for po intake, instruction for small bites/sips, alternating solids/liquids, slow rate. A review of facility document titled, Standard Policy and Procedure, revealed, Subject: Any safe swallow suggestions will be included on each meal ticket for use by CNA (Certified Nursing Assistant), Purpose: to ensure proper feeding techniques. Procedure: 1. Safe swallow suggestions will be written by speech therapist and placed into (electronic medical record) care plan and (dietary system) for Dietary to print onto tickets. 2. Dietary will add a copy of safe swallow suggestions on each meal ticket. A review of facility policy titled, Feeding a resident, revealed, .1. Check residents meal ticket for current diet orders or safe swallowing instructions. 10. Encourage the resident to hold his glass, bread, finger foods and participate in meal as able. 11. Allow him time to chew and swallow. Follow any speech therapy orders/safe swallow instruction on the resident's meal ticket.

Based on observation, interview and record review the facility failed to ensure call lights were within reach and responded to in a timely manner for 11 residents (R3, R16, R22, R36, R46, R52, R61, R63, R80, R116, R138) and a confidential group of residents, resulting in long call light wait times, delayed assistance and call lights not being accessible. Findings include: Resident #16 R16 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include hypertension, gastro-esophageal reflux disease and atherosclerotic heart disease. R16 has a brief interview for mental status (BIMS) score of 15, indicating they are cognitively intact. On 02/19/25 at 10:16AM, an interview was conducted with R16. R16 was asked if the facility staff answers her call light in a timely manner. R16 stated the staff can be slow to answer call lights, it's especially slow during meal pass times and when they are picking up trays. R16 stated that she has waited 3hrs one time. R16 was asked if they have ever had any issues with incontinence due to long wait times. R16 stated they have had several accidents (incontinence) due to long call light waits. R16 stated they had to self-transfer at one point to get to the bathroom because they couldn't wait, R16 stated they have observed the staff walking by her door and not answering her call light. Record review of call light times revealed that on 2/17/25 at 3:10PM the call light was on for 1 hour and 23 minutes, on 2/15/25 at 6:51PM the call light was on for 1 hours 50 minutes on 2/15/25 at 10:03AM the call light was on for 1 hour and 4 minutes and on 2/12/25 at 5:47PM the call light was on for 1 hour and 26 minutes. Resident #36 R36 is [AGE] years old and most recently admitted to the facility on [DATE], with diagnoses that include neurogenic bladder, hypertension and multiple sclerosis. On 02/18/25 at 11:37AM, an interview was conducted with R36. R36 was asked if the facility staff answers his call light in a timely manner to meet his needs. R36 stated no they don't and that the staff takes on average 15-20 minutes to answer the call light and sometimes it is longer. R36 was asked if that wait time is good for him. R36 stated that at times it can be too long, luckily for me I have a catheter and a colostomy otherwise it would be way too long of a time to wait if I had to go to the bathroom. Record review of recent call light times revealed that on 2/19/25 the call light was on for 35:27, on 2/18/25 the call light was on for 31:39, on 2/15/25 the call light was on for 1 hour and 10 minutes, on 2/12/25 the call light was on for 36:09 and on 2/8/25 the call light was on for 43:49. Resident #52 R52 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include hemiplegia and hemiparesis following cerebral infarction, panic disorder, overactive bladder and anxiety disorder. R52 has a BIMS score of 14 indicating they are cognitively intact. On 02/18/25 at 12:45PM, an interview was conducted with R52. R52 was asked if the staff answers her call light in a timely manner. R52 stated it takes the staff a long time to answer the call light because they have to check a screen at the nurses desk to see who has their light on. R52 stated staff said that is the only way they know which call lights are on. R52 was asked how long they have waited to receive help. R52 stated I have waited up to 45 minutes before to get help and when they do, they only 'half-help. Record review of recent call light times revealed that on 2/18/25 at 7:13PM the call light was on for 48:35, on 2/6/25 at 1:45PM the call light was on for 1 hour and 7 minutes and on 2/6/25 at 1:02PM the call light was on for 33:18. Resident #61 R61 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include chronic respiratory failure, end stage renal disease with dependence on renal dialysis, hypertension and anemia. R61 has a BIMS score of 14 indicating that they are cognitively intact. On 02/19/25 at 09:11AM, an interview was conducted with R61. R61 was asked if the staff answers his call light in a timely manner. R61 said that it takes long time to get call light answered, I had at least a 90 minute wait just yesterday. R61 was asked if there are specific shifts or times of the day that the responses are slower. R61 stated that all shifts struggle to answer call lights timely, there is no specific time of the day. Record review of recent call light times revealed that on 2/18/25 at 7:15PM the call light was on for 1 hour and 17 minutes, on 2/17/25 at 7:35PM the call light was on for 1 hour and 21 minutes and on 2/12/25 at 11:20PM the call light was on for 44:58. 22348 Facility Resident Council: 02/19/25 02:45 PM, the surveyor reviewed the Resident Council Meeting Minutes submitted by the facility dated from July 2024 up to January 2025. The contents did not reflect the staffing shortage and delayed call light response discussed. The Activities Director was absent during the Resident Council meeting held on 2/20/25 at 3:00 PM. Six confidential residents attended the Resident Council Meeting. On 2/19/25 at 3:00 PM, during the Resident Council Meeting, six confidential groups of residents complained about delayed call light response time in an average wait time of an hour up to 2 to 3 hours sometimes. Confidential Resident #6 indicated that the call lights were not within reach, or they turned the call lights off when they came to your room and then left, and it took 4- 6 hours before staff returned. Confidential Resident #6 stated, Some staff turn the call light off and don't return. Showers are done but at the staff's convenience. There's not enough help with feeding. I have to wait a while for someone to come and feed me. After the meeting on 02/19/25 at 03:58 PM, the Administrator was made aware of the Resident Council's concerns. Resident #3 (R3) During the resident interview on 02/19/25 at 10:21 AM, R3 was found groaning in pain while in bed, positioned almost sitting upright in (high-fowlers) when the surveyor asked how he was. R3 indicated that he was uncomfortable and his head and neck were hurting. He further described that he sat up to eat breakfast and stated, No one came back since, and his neck really hurts. It was observed that dried blood stains were found on the pillowcase. CNA T, who responded from the call light, was queried and stated that she was unsure where the blood came from, but she thought it was coming from the lesion on his head. Further reply from CNA T explained that she was not assigned to the hall but happened to be walking by and thought help was needed. The surveyor confirmed with CNA T that there was no call light sounding, and no light was visual to alert staff even if the R3 had activated his call light. R3 was [AGE] years old and admitted on [DATE] with a diagnosis of Chronic Kidney Disease Stage 3, Squamous Cell Carcinoma of the scalp and neck, and Dementia, in addition to other diagnoses. His Brief Interview for Mental Status (BIMS) score, dated 12/4/2024, was 08/15, which indicated a moderate cognitive impairment. This means that the person may need extra help with daily activities. A review of R3's Minimum Data Set (MDS) GG section, dated 12/4/24, revealed that he depended on most ADLs, such as upper and lower body dressing, showers, and toilet use. He was assessed as frequently incontinent with a bladder elimination pattern and occasionally with a bowel elimination pattern. CNA T repositioned R3, and the pillow case was changed. Resident #116 (R116) On 02/18/25 at 11:38 AM, R116 was observed resting in his room while lying in bed. R116's wife was sitting at the bedside (at R116's left side). R116 call light was found on the floor, which was inaccessible and away from R116 reach. R116's wife confirmed that the call button was found on the floor on the resident's right side. It was not anchored or did not dangle for the resident to access when needed. R116's wife explained that R116 had used his call light made his needs known when he was hungry or in pain. The wife stated that they must know I was here, that is probably why they did not place the call light where he could reach them. R116's wife said, It has happened before. A review of R116's Electronic Medical Record on 2/19/2025 at 1:30 PM revealed R116 was [AGE] years old and admitted to the facility on [DATE] with a diagnosis of Seizure Disorder, Dementia, and cerebrovascular accident (CVA) with 1-sided upper and lower extremity impairment in addition to other diagnoses. R116 BIMS Score was 07/15 assessment date of 1/22/2025. A BIMS Score of 0-7 means severe cognitive impairment. R116, on the assessment date of 1/22/2025, was dependent on all daily activities such as eating, toileting, and showers and was always incontinent with both bowel and bladder elimination patterns. Resident #80 (R80) On 02/19/25 at 11:16 AM, R80 discussed issues with staff call light response. Sometimes it takes a little while. Sometimes, 1 hour and could take more than 2 hours before they return. The request varies from a cold pack to food and nursing care-related needs. R80 explained, I am transferred using a Hoyer lift, so it is quite a wait to get the lift and have the staff put me in it. All I can do is wait. I get hot at times due to my medical condition, and I get the shakes if I don't have an ice pack resting on my chest. Sometimes, it takes over 2 hours just to get the ice pack. I live in my chair practically, so I need assistance most of the time, especially when going to the toilet. A review of Electronic Medical Records on 2/20/25 at 2:00 PM revealed that R80 was [AGE] years old and admitted to the facility on ,d+[DATE]/ 2023 with the following diagnosis: Multiple Sclerosis, Type 2 Diabetes, and Paraplegia in addition to other diagnoses. R80 has a BIMS Score of 15/15. The date of assessment was 12/23/24. A BIMS score of 15 indicates that R80 has intact cognitive functioning. The Minimum Data Set Section GG assessed on 1/2/2025 revealed that the resident had no impairment in the upper extremities but impaired both sides of the lower extremities. R80 depended on most activities of daily living, including upper and lower body dressing, toileting, and maximum assistance with his personal hygiene. R80 is transferred via the mechanical lift. R80 was always continent with a bladder elimination pattern, although he was always incontinent with bowel movements. On 2/21/25 at 3:00 PM, The Facility's Resident's Rights and Call Light Policies were reviewed. 37771 Resident #22 A review of Resident #22's medical record revealed an admission on 3/5/24 with diagnoses that included dementia, heart disease, anxiety, and fall. A review of the Minimum Data Set (MDS) assessment revealed a BIMS (brief interview of mental status) score of 10/15 that indicated moderately impaired cognition, and the Resident needed, and the Resident needed partial/moderate assistance with toileting hygiene and most mobility and transfers and substantial/maximal assistance with dressing. On 2/18/25 at 1:15 PM, an observation was made of Resident #22's room. The Resident was not in the room at that time. The Resident's bed was positioned up against the wall and the call light cord hung down between the wall and the bed and the push mechanism was on the floor. The call light cord was towards the foot of the bed. The call light was not in reach for the Resident. On 2/19/25 at 8:56 AM, an observation was made of the Resident in the dining room eating, seated in her wheelchair. The Resident's room had the call light cord hanging between the wall and the bed and the push mechanism was on the floor. The Resident was observed in their room after breakfast seated in their wheelchair. The call light remained on the floor and not in reach for the resident. On 2/20/25 at 9:15 AM, an observation was made of Resident #22 in bed with her eyes closed. The Resident's call light was positioned on the floor and not within reach for the Resident. On 2/21/25 at 9:38 AM, an observation was made of Resident #22 laying in bed. There was a breakfast tray on the overbed table that was partially eaten. The call light was observed to be hanging from the wall and positioned between the wall and the bed with the push apparatus on the floor and not within reach for the Resident. On 2/21/25 at 11:08 AM, an observation was made with Unit Manager, Nurse Q of Resident #22 sleeping in her bed. An observation was made of the Resident's call light cord hanging down the wall past the mattress and laying on the floor. The call light was not in reach for the Resident. The Unit Manager retrieved the call light off the floor and positioned it within reach for the Resident. The Unit manager indicated that the call lights should be within reach for the Residents. Resident #46 A review of Resident #46's medical record revealed a readmission into the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, quadriplegia, heart disease, and contracture of unspecified joint. A review of the MDS assessment revealed the Resident had intact cognition and was dependent on staff for activities of daily living, mobility and transfers. On 2/19/25 at 12:18 PM, an interview was conducted with Resident #46 who answered questions and engaged in conversation. The Resident was asked if they had concerns regarding their care. The Resident reported that the call light could take 30 minutes to an hour to answer and stated, I have to yell out to get help. The Resident reported the staff do not have the pagers anymore, there is no light above the door and the staff had to look at a screen at the nurses' station or on tablets and the screen does not work. The Resident voiced frustration that the CNAs do not answer call lights timely. Resident #63 A review of Resident #63's medical record revealed an admission into the facility on [DATE] with diagnoses that included neurocognitive disorder with Lewy Bodies, Parkinson's disease, diabetes, obstructive sleep apnea, and anxiety disorder. A review of the MDS revealed the Resident had intact cognition and was dependent on helper for most activities of daily living, mobility and transfers. On 2/19/25 at 2:11 PM, an interview was conducted with Resident #63 who answered questions and engaged in conversation. The Resident was up in her wheelchair seated next to the bed. An observation was made of a call light that was upside down V shape. The Resident reported she could not use the push button call light. When asked about any concerns she had regarding her care, the Resident reported long call light wait times and that staff will shut it off, say they will be back and then they don't come back. The Resident expressed having to wait up to four hours to be changed due to having incontinence. When asked if they do a check and change every, two hours, the Resident expressed frustration and stated, They don't come every 2 hours to check on us, not enough people (staff). The Resident reported that staff have left the room without making sure the call light is in reach or hide it under the covers and I can't find it. The Resident reported not having her oxygen on during the night and went several hours without the oxygen and stated, It gives you a sick feeling to have that light on and no one comes to find out why it is on. Resident #138 A review of Resident #138's medical record revealed an admission into the facility on [DATE] with diagnoses that included arthritis, dementia and anxiety disorder. On 2/19/25 at 10:01 AM, an observation was made of Resident #138 sitting in her wheelchair in their room. The Resident was yelling out to staff that passed by her room. The Resident was interviewed, did not answer questions appropriately, but engaged in random conversation. The Resident was asked about her call light but did not know where it was and asked if it was on. The call light was not on. An observation was made of the call light at the top of the bed and positioned underneath the pillow. The Resident was seated next to the bed in front of the bedside table and was not in reach of the call light.

Based on observation, interview and record review the facility failed to update and reviews care plans for psychotropic meds, pain, skin care and respiratory care for 4 Residents (R#3, R#32, R#47, & R#90) of 5 sampled residents reviewed for care plans. Findings include: Resident #3 (R3) General According to the Electronic Medical Record reviewed on 2/19/2025 at 2:00 PM, R3 was [AGE] years old who was admitted to the facility on [DATE] with a diagnosis of Alzeihmers Disease (late onset), Carcinoma of the situ of skin and scalp, and neck, Squamous cell cardinoma of the skin of scalp and neck and Chronic Kidney Disease Stage 3 in addition to other diagnoses. R3 has a Brief Interview of Mental Status (BIMS) Score of 08/15 assessed on 12/4/2024. A Score of 08-12 on the BIMS indicates moderate cognition impairment. A score of 0-7 points suggests severe cognitive impairment and a scor of 13-15bpoints suggests that cognition is intact. R3, according to the Minimum Data Set (MDS) assessment dated [DATE] is dependent with staff in all Activities of Daily Living and Personal Hygiene except for Eating where he needed set up and clean up assistance. R3 is always incontinent with Bladder elimination pattern but occassionally incontinent with bowel elimination pattern. During the R3 interview conducted on 02/21/25 at 11:20 AM, after the scalp dressing was applied to R3, R3 was asked of his level of pain from 1-10, with 10 being the most pain). R3 responded, Pain is 100. R3 complained of pain and requested for pain relief. R3 further described the location by stating, my neck hurts from the position I was in. R3's gown had some blood stain on his right side of the shoulder that looks like a dried blood stain. Registered Nurse (RN H) was ask where the blood was coming from. RN H indicated that she was unsure where it was coming from but she assumed that R3 scratches a lot and have skin lesions all over his body. RN Hrevealed that R3 receives a daily treatment applied to his skin. She stated, Some type of cream. On 2/21/25 at 11:00 am, RN H was observed during wound care and dressing change. There was a scant drainage noted on the dressing that was removed. The wound area measured 2 centimeter (cm) wide by 1.5 cm length with width open area at the scalp area. Although R3 was grimacing and complained of pain during dressing change, RN H stated that R3 did not have any complaints of pain earlier this morning upon administering his routine aspirin (ASA) 1 mg at around 9:30 AM. On 2/21/25 at 11:30 AM, R3 was queried about the blood stains on nis gown. R3 indicated that he was unaware where it came from or when his gown was last changed. Pain Management: On 02/19/25 at 10:21 AM, R3 complained he is uncomfortable. R3 was observed sitting upright in bed and complained of extreme head and neck pain, grimacing and moaning. Pain scale level of 10/10 revealed by R3 during an interview on 02/19/25 10:21 AM witnessed by staff. Staff CNA T stated that she was getting the nurse. CNA T Lowered the head of the bed and repositioned him in bed. CNA J stated, we got him comfortable and got his head down. R3's pillow case had dried blood stain noted. After confirming the observation with CNA T, she revealed that it was the nurses that did the wound dressing changes daily. CNA T stated that the blood must have been from his head lesion. CNA T further stated that sometimes the dressing come off from his scalp. It was observed by CNA T and the surveyor that R3 did not have a dressing on his scalp during this observation and was in extreme pain. A review of the Medication Administration Record (MAR) for R3 dated February 2025 revealed only 2 medications for pain relief: Pain orders in the February 2025 MAR were: Aspirin 81 mg 1 tab P. O. in AM and Acetamenophen 325 mg 2 tablets for PRN. The February 2025 MAR (from February 1 through February 20) showed R3 had zero pain daily assessed and recorded. There were no PRN Tylenol administered for relief of pain. R3's February 2025 MAR revealed no pain relief was given despite R3 was observed and verbally complained of extreme head and neck pain, grimacing and moaning, Pain scale level of 10 per R3 during an interview on 02/19/25 10:21 AM to staff. The next pain relief received was on 2/10/25, the following day of ASA 81 mg 1 tablet routinely administered daily. Upon review of the Electronic Record Review for R3's Care Plan on 2/21/25 at 12: 00 PM, It revealed: 1. Pain care plan was initiated on 8/28/23 and date of Revision was 09/07/2023. The most recent intervention update was dated 3/6/24, which indicated to: Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria. nausea, vomiting, dizzyness and falls. Report occurrences to the physician. Date initiated 03/06/2024. No other revisions of the care plan for pain was noted after 03/06/2024. 2. Wound/Skin Care Plan was initiated on 08/28/2023, Last revised on 08/01/2024 Skin lesions that were found and observed all over his body with blood stains on his linens were not updated in his wound/skin care plan. No new interventions and update were entered despite new treatment orders, new monitoring and assessment orders and update in R3 wound condition and specialist consultation and recommendations. Resident #47 (R47) Advanced Directive Care Plan On 02/19/25 at 12:47 PM, R47's Advanced Directives in her clinical file was dated 11/1/2023. R47's care plan on Advanced Directives were last revised on 11/7/2023. According to the review of Electronic Medical Records conducted on 2/20/25 at 2:45 PM, R47 was [AGE] years old and admitted to the facility on [DATE] with the diagnosis of Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left dominant side, vascular dementia with mood disturbances, and peripheral vascular disease in addition to other diagnoses. R47's son was the Durable Power of Attorney (DPOA) and emergency contact. R47's Brief Interview of Mental Status (BIMS), which was assessed on 12/25/24, revealed a score of 09/15. A score of 9 indicates moderate cognitive impairment. A score of 0-7 represents severe cognitive impairment, and 13-15 signifies intact cognitive function. R47 Care Plan on Advanced Directives was reviewed and revised on 11/07/2023. Upon interview with the Social Worker (SW) on 02/21/25 at 10:11 AM, the SW indicated that they reviewed the resident's Advanced Directives with the staff every quarterly, during care conferences, and annually. The surveyor and SW reviewed the care conference notes and the SW progress notes. The SW revealed she cannot find the notes for now and will ask the unit manager to help find any notes on R47 Advanced Directives. The SW also confirmed that R47's care plan for Do-Not-Resuscitate was last updated in 2023. R47's BIMS Score was 9/15, and she has a Durable Power of Attorney (DPOA). The SW stated, Sometimes, the family may have difficulty coming in to sign. The SW confirmed that she could not find any progress notes regarding discussing the Advanced Directive with the family/DPOA and updating the care plan. On 02/21/25 at 10:20 AM, The Unit Manager confirmed that she could not find any progress notes or care conference notes indicating that the Advanced Directive has been reviewed since 2023. A facility policy entitled Advanced Directives, last updated on 2/14/2024 was reviewed on 2/21/25 at 10:30 AM. The Policy Statement: To provide the resident, guardian, medical durable power of attorney, and /or resident advocate an opportunity to make their wishes known prior to a life-threatening incident occurring. It should be understood that any decision that is made is not binding and can be revoked at any time by the above listed parties . .7. If at any time the resident/responsible parties decide on changing the current advance directives the nurse will follow the above policy. Quarterly with MDS/care plan reviews the Floor Coordinator will review current Advance Directives with appropriate parties (if in attendance) and answer any questions or make any necessary changes. The Facility's Interdisciplinary Care Planning Policy, updated on 1/12/2024, was reviewed on 2/21/25 at 3:00 PM, indicated: Policy Statement: To provide a system to ensure all resident's care plans are developed and updated. This facility utilizes an electronic charting system. The resident care plan is created and stored via orders and entries into the electronic charting system. Note: The electronic version of the care plan is considered the current care plan. .Policy Interpretation and Implementation: 1. Upon admission, resident status is assessed by the Interdisciplinary Team members (Dietary, AT, SW, Nursing, Restorative Nurse R.N., Skilled Therapies) using a combination of assessment tools including the MDS/CAA's. Care plans are developed on a timely basis, according to the RAI process. 2. Each discipline, based on their admission assessment, submits care plan information (i.e.: problems, goals, approaches) to the appropriate Unit manager. Unit managers will compile all assessment information to create an individualized computer care plan. Cardiovascular Respiratory Neuromuscular/ Skeletal Psychosocial/Orientation (includes Discharge Plan) Integumentary Nutrition Gastrointestinal Genitourinary Endocrine/ Metabolic Sensory ADL/ Safety Miscellaneous 3. The Unit manager will review the information found in each care plan section looking at the care that has been provided related to physician orders, labs, diagnostic testing, current medical status, etc. in order to assure continuity of care. Any issues found will be discussed with the appropriate interdisciplinary care plan team member and if necessary taken to the physician and resident/family seeking direction for future plan of care. 4. For quarterly/annual/CIS care plan updates, the Interdisciplinary care plan team will review their goals and approaches for appropriateness and request any necessary changes by notifying the Floor Coordinator. The Unit manager will discuss the goals/approaches with the physician and make any necessary changes in the electronic care plan. 5. After review of the care plan by the interdisciplinary care plan team member, a quarterly progress note is made to reflect the review. 6. Interdisciplinary Care Plan meetings (clinicals) are conducted by the RN Unit manager and attended by Dietary, AT, SW, Restorative Nurse R.N., if requested by family. Resident (if desires) and resident's representative also attend. Other disciplines, when applicable, also attend meeting. (Restorative Nurse R.N., OT, PT, ST, Charge Nurse, CMH, Hospice, etc.) Also note that a phone conference may be done if representative is unable to attend meeting. 7. During the meeting, the Unit manager reviews and discusses any adjustments, clarifications, etc. to the plan of care. A review of current Advance Directives will also be discussed. Any concerns requiring physician evaluation are compiled by the Charge Nurse or Unit manager and placed on physician board after meeting. 8. The Unit manager will document a brief summary of the Care Plan meeting in the EMAR. 9. Updating of the CNA Bedside Kardex is completed once the pertinent order is saved in the computer and the LPN copies off the new CNA Bedside Kardex as indicated in the Noting Orders Policy. This incorporates approaches that are the responsibility of the CNA. 10. The MAR's and TAR's and shift charting tasks are updated the moment the order is saved in the computer. This completes the requirement for licensed nurse to follow the physician orders/plan of care. 37666 Pressure Ulcer/Injury Resident #90 A record review of the Face sheet and Minimum Data Set/MDS assessment for Resident #90 indicated an admitted [DATE] with diagnoses: Alzheimer's dementia, depression, arthritis, hypertension, heart disease, and anxiety. An unstageable pressure ulcer on the right heel was identified on 1/13/2025. The MDS assessment dated [DATE] identified the resident had severe cognitive loss with a Brief Interview for Mental Status/BIMS score of 5/15 and the resident needed assistance with all care. An MDS significant change assessment dated [DATE] revealed the resident was dependent with care needs and her condition and declined. A review of the 11/13/2024 MDS assessment revealed the resident did not have any pressure ulcers or other type of skin ulcers. A 2/5/2025 MDS significant change assessment indicated the resident had 2 unstageable pressure ulcers. A review of the assessments for Resident #90 revealed the resident had an unstageable pressure ulcer to the right heel 1/13/2025 and also an unstageable pressure ulcer on the outer base/hallux of her right great toe dated 12/17/2024. On 2/21/2025 at 8:45 AM, wound care for Resident #90 was observed with Nurse B. The resident was observed sitting in a Broda chair. Nurse B washed her hands and applied gloves, then opened the dressing to show 3 wounds on Resident #90's right foot: 1. right great toe outside edge about 0.25 cm x 0.25 cm blackened area, 2. outer right foot near base of great toe ~1.5 x 1.5 cm wound black around and pink in the middle and 3. a black scabbed area ~ 1 x 1 cm on the right heel. The Nurse did not know how long the resident had the wounds and said they were facility acquired. A review of the Care Plans for Resident #90 identified the following: Pressure Injury Focus: (Resident #90) has an unstageable pressure injury to her right hallux (base of right great toe). She has a history of cellulitis to this area. She has an unstageable pressure injury to her right heel, date initiated 12/202024 and revised 1/20/2025 with 3 interventions: Administer treatments as ordered and monitor for effectiveness, date initiated 12/20/2024; Assess/record/monitor wound healing weekly date initiated and revised 12/20/2024; Monitor/document/report (as needed) any changes in skin status . date initiated 12/20/2024. There were no preventive measures identified before or after the pressure ulcers were identified. Integumentary Focus: (Resident #90) is at risk for potential impairment to skin and feet integrity related to the aging process with potential for increased dryness, fragility, incontinence, need for assistance with care as her Alzheimer's Dementia progresses ., date initiated 2/14/2023 and revised 5/14/2023 with Interventions including: Roho: Check Proper inflation cushion Thursday, date initiated 12/27/2024 and revised 1/30/2025. There were no Care Plan interventions specific to the resident right foot pressure ulcers. The Care Plans did not include measures to prevent skin breakdown on the resident's feet. 49944 Resident #32 R32 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include, dementia, major depressive disorder, dysphagia and atrial fibrillation. R32 has a brief interview for mental status (BIMS) score of 3 indicating severe cognitive impairment. On 02/20/25 at 09:57AM, record review revealed R32 has physician's orders for Rexulti 1mg initiated 02/18/25 and Pristiq 100mg initiated 01/28/25, both medications are for depression On 02/20/25 at 11:31AM, record review revealed that R32 has a care plan in place for Effexor for depression, however, Effexor was discontinued on 01/05/25. The psychotherapeutic medications care plan was initiated and last updated on 12/6/24. The care plan does not reference that R32 is on Rexulti 1mg initiated 02/18/25 and Pristiq 100mg initiated 01/28/25, both medications are for depression On 02/20/25 at 11:53AM, an interview was conducted with Unit Manager (UM) D. UM D was asked who is responsible for implementing and updating care plans for psychotherapeutic medications. UM D stated that, Usually it is social work that does that (implements and updates care plans) but the Minimum Data Set (MDS) nurse or me will do it if it needs to be done. This surveyor verified with UM D that the care plan for psychotherapeutic medication was initiated and updated on 12/6/24. UM D was asked if the care plan should have been initiated sooner when R32 started on psychotherapeutic medication. UM D stated, Yes, the care plan should have been implemented at that time and updated with changes in medication. It was just missed; I don't really know why it wasn't implemented or updated. Record review of the policy titled, Interdisciplinary Care Plan, reviewed 01/12/24, revealed: 4. For quarterly/annual/CIS care plan updates, the Interdisciplinary care plan team will review their goals and approaches for appropriateness and request any necessary changes by notifying the Floor Coordinator. The Unit manager will discuss the goals/approaches with the physician and make any necessary changes in the electronic care plan. 5. After review of the care plan by the interdisciplinary care plan team member, a quarterly progress note is made to reflect the review. 6. Interdisciplinary Care Plan meetings (clinicals) are conducted by the RN Unit manager and attended by Dietary, AT, SW, Restorative Nurse R.N., if requested by family. Resident (if desires) and resident's representative also attend. Other disciplines, when applicable, also attend meeting. (Restorative Nurse R.N., OT, PT, ST, Charge Nurse, CMH, Hospice, etc.) Also note that a phone conference may be done if representative is unable to attend meeting. 7. During the meeting, the Unit manager reviews and discusses any adjustments, clarifications, etc. to the plan of care. A review of current Advance Directives will also be discussed. Any concerns requiring physician evaluation are compiled by the Charge Nurse or Unit manager and placed on physician board after meeting.

Based on observation, interview and record review, the facility failed to provide a safe and monitored environment to prevent falls and injuries for 4 Residents (# 21, #103, #126, #127) of 13 residents reviewed for falls, resulting in residents having multiple falls and Resident's #'s 126 and #127 sustaining large bruises on their faces. Findings Include: Resident #21 Accidents A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #21 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Alzheimer's dementia, History of a stroke, heart disease, hypertension, , orthostatic hypotension, history of repeated falls, anxiety, kidney disease, and arthritis. The MDS assessment dated [DATE] revealed the resident had severe cognitive loss with a Brief Interview for Mental Status/BIMS score of 3/15 and the resident was dependent for most care. On 2/18/2025 at 11:18 AM, Resident #21 was observed sitting in the day room for an activity. A record review of the notes from the medical record revealed the resident had encountered multiple falls on the unit. A review of the Incident and Accident Reports indicated Resident #21 had 11 falls over the past year. Three of the fall incidents identified there was no nurse on the unit at the time of the fall; including the most recent fall on 2/14/2025. A record review of the Care Plans revealed the following: Falls/Safety Focus: (Resident #21) is at High risk for falls related to Confusion, Gait/balance problems, psychoactive drug use, Alzheimer's disease, and dementia with potential for decreased safety awareness as the dementia process progresses, date initiated 11/17/2022 and revision on 5/8/2024. The last updated intervention was 11/13/2024, Encourage gripper socks at all times. Resident #103 Accidents A record review of the Face sheet and MDS assessment indicated Resident #103 was admitted to the facility on [DATE] with diagnoses: Alzheimer's disease, history of seizures, history of a stroke, heart disease, peripheral vascular disease, arthritis, anxiety and cochlear implants. The MDS assessment dated [DATE] revealed the resident had a severe memory problem and was dependent with care. On 2/18/2025 at 11:47 AM, Resident #103 was observed in the day room, sitting in a wheelchair with an activity blanket on her lap. The Activity aide P said the resident wanders in around the unit in her wheelchair; wherever she wants to go. The unit is a locked dementia unit. A review of the medical record for Resident #103 revealed she had several recent falls including 2/6/2025 and 2/8/2025 and on 2/13/2025 a new bruise on the resident's left chin was identified. Per a nurses note on 2/13/2025 Nurse noted a bruise to the left chin- while the bruise to the left eye was already charted and noted . Writer saw resident yesterday, and bruise to left lower chin was not there . A review of the Incident and Accident reports for Resident #103 identified 13 falls from 3/31/2024- 2/8/2025. Of the 13 falls for Resident #103, 6 Incident Reports said there was no nurse on the unit at the time of the fall. A record review of the Care Plans identified the following: Safety Focus: (Resident #103 is at high risk for falls related to diagnosis of dementia, seizures, . (Resident #103) is high fall risk due to inability to process surroundings due to sensory impairments and dementia. (Resident #103) has poor safety awareness and is unable to understand physical limitations . date initiated 4/17/2023 and revised 4/3/2024. The last updated intervention was 9/6/2024. The resident continued to fall. Resident #126 Accidents A record review of the Face sheet and MDS assessment indicated Resident #126 was admitted to the facility on [DATE] with diagnoses: Alzheimer's disease, history of a stroke, anxiety, hypothyroidism, history of urinary tract infection, and hearing loss. The MDS assessment dated [DATE] revealed the resident had a BIMS score of 2/15 with severe cognitive loss and needed some assistance with care. On 2/18/2025 at 11:31 AM, Resident #126 was observed lying in bed with a large purple bruise under her right eye. She said she had had it awhile and said she didn't know how she got it. A review of the incident and accident reports for Resident #126 indicated the resident was noted to have bruising on her left hand 1/30/2025. On 1/31/2025 a nurses note identified the resident had a bruise under her right eye, from a nurse aide bumping her head on the resident's eye during care and the resident had bruising under her left breast. A record review of the Care Plans for Resident #126 identified the following: Safety Focus: [NAME] is at high risk for falls related to diagnosis of dementia. Resident with potential for increased risk for falls related to inability to recognize physical limitations and poor safety awareness. History of fall with forehead laceration and hospital stay for brain hemorrhage, date initiated 3/28/2023 and revised 11/1/2024, with Interventions including: Follow facility fall protocol, date initiated and revised 3/28/2023 and Gripper straps at/to in front of toilet and sink in bathroom, dated initiated 3/17/2023 and revised 9/6/2024. The last time the Safety Care Plan was updated was 9/6/2024. A review of the Skin Care Plan for Resident #126 did not mention bruising on her right eye, left hand or left breast. Resident #127 Accidents A record review of the Face sheet and MDS assessment indicated Resident #127 was admitted to the facility on [DATE] with diagnoses: Alzheimer's dementia, anxiety, hypertension, hypothyroidism, back pain, depression and a history of kidney stones. The MDS assessment dated [DATE] revealed the resident had severe cognitive loss with a BIMS score of 4/15 and the resident was independent with most care. On 2/18/2025 at 11:55 AM, Resident #127 was observed walking in the hall. She had a large dark purple bruise under her right eye. When asked about it the resident said she did not know how it happened. A record review of the progress notes revealed the following: A Fall Risk Evaluation dated 2/18/2025: The resident had 3 or more falls in the past 3 months. On 2/17/2025 at 5:00 PM, the resident was found on the floor in the hallway. On 2/14/2025 at 3:00 AM, the resident was found on the floor near her bathroom door. A review of an Incident and Accident report for Resident #127 revealed there was no nurse on the unit at the time of the fall. A review of the nurses notes indicated the resident had said she felt dizzy on several occasions prior to lowering herself to the floor or being assisted to the floor. A record review of the Care Plans for Resident #127 identified the following: Safety Focus: (Resident #127) is at high risk for falls due to history of falls prior to admission, decreased mobility, poor safety awareness, HTN (hypertension), and lumbar disc degeneration, date initiated 9/26/2024 and revised 10/1/2024 with Interventions including: Follow facility fall protocol, date initiated and revised 9/26/2024; Place Resident into the Fall prevention Program, date initiated 10/10/2024. The most recent intervention was dated 2/14/2025, Encourage gripper socks when not wearing shoes, date initiated and revised 2/14/2025. There was no updated intervention after the resident fell on [DATE] and no mention of her facial injury/bruising. Residents #21, #103, #126 and #127 all resided on the locked Dementia Unit. The Dementia Unit consisted of 2 separate locked halls on the 1st floor, with a total census of approximately 29 residents. On 2/20/2025 at 9:40 AM, the call light notification pad, situated on a wheeling stand in the hallway of the Dementia unit, had a blank screen. Nurse I said the pad was like a tablet and was used for call light notifications. She said the pad screen would show which call lights were on so the staff could answer them. When asked why it was not on, she said it wasn't working. Nurse Aide GG was in the hall and said if you wanted to know which lights were on, you had to leave the locked unit and go outside the doors where another screen was located. The nurse and nurse aide were asked how they would know if someone needed help if they weren't aware of the call lights being on and they said they wouldn't know unless they left the locked hallway. On 2/20/2025 at 1:23 PM, Unit Manager Q and Quality Assurance/QA Nurse R were interviewed about the frequent falls of the residents on the Dementia unit. The QA Nurse R said the facility had a Fall prevention program that residents at risk for falls are placed in. The QA Nurse was asked what the program included and she said that residents who had more than 1 fall per quarter were considered a candidate for the program and an order would be written for the program. She said the residents' Kardex and Care Plan would say the resident was in the Fall prevention program. The program included adding an orange tag on the residents' wheelchairs and walker if they used one. The didn't receive an orange tag if they walked themselves without a walker. She said the residents were revaluated every quarter for continued need. If the resident went 2 quarters without a fall the program was discontinued. During the interview on 2/20/2025 at 1:23 PM, Nurses Q and R were asked if the Fall prevention program included any additional measures to aid in preventing falls and said the staff performed Purposeful rounding. Nurse R said Purposeful rounding was to encourage staff to be more aware of what was occurring on the unit and she also said the facility had added additional activities to the Dementia unit. A review of the facility's staff schedules for Nurse and Nurse Aides, indicated there wasn't always a Nurse specifically assigned for the Dementia unit on the night shift. During the survey the resident census was 29 on the Dementia unit. There were usually 2-3 nurse aides divided between the 2 locked hallways. On 2/21/2025 at 3:30 PM, the Director of Nursing/DON was interviewed related to staffing. The DON said on the night shift/11:00 PM-7:00 AM, one nurse was assigned to cover both the 2nd floor north area and 1st floor north area. A nurse was not assigned specifically to the 1st Floor locked Dementia unit. The DON was asked if that meant a nurse might not be on the Dementia unit but actually be upstairs on another unit and she said that was how they were staffed. Reviewed with the DON that the schedule indicated there were at times only 2 Nurse Aides assigned to the Dementia unit (one on each locked hall) and she said sometimes there were 3. During the interview with the Director of Nursing on 2/21/2025 at 3:30 PM, reviewed with the DON that some of the residents had repeatedly fallen and some with serious injuries. The DON said the residents were placed in the Fall prevention program: she said that included Purposeful rounding and the orange stickers if the resident was in a wheelchair or used a walker. There was no sticker if they walked on their own. The DON was asked if the program was effective because the residents continued to fall and she said she thought it might be. The DON was asked if the facility had looked at staffing on night shift on the Dementia unit to ensure there were enough staff to supervise the residents, as most of the falls were in the evening and at night. 11 of the falls did not have a nurse present on the unit when the resident fell . She said the facility had not planned to have a nurse specifically assigned to the Dementia unit on night shift: of 35 falls reviewed, 20 were on the night shift. On 2/21/2025 at 3:45 PM, during the interview with the DON, she was asked about the call light system as it was not working consistently on the halls of the Dementia unit and she said the staff could install an app on their personal phones that would notify them when a call light was on; the DON said not all staff had the app on their phones as it was an option for them to do this. A review of the Facility assessment dated [DATE] provided, . Nursing: Staffing Plan- The facility bases its nursing staffing patterns to provide nursing and related services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident as determined by resident centered assessments and individualized plans of care . On 2/25/2025 at 9:30 AM, the call light pads on the 2 halls of the Dementia unit were not working. A review of the facility policies identified the following: Fall Prevention and Identification Program: To provide all staff a means to identify and assist residents who have identified as frequent fallers The policy discussed the orange tags, obtaining an order for the Fall prevention program and adding the information to the resident's Kardex. The policy does not identify additional interventions. There was no intervention listed for a resident who did not use a wheelchair or walker.

Based on observation, interview and record review, the facility failed to maintain a consistently operational call light system affecting three residents (Resident #46, Resident #63 and Resident #74) and a resident census of 158, resulting in extended call light times, unmet needs, and inconsistent tablet operability. Finding include: FACILITY On 02/19/25 at 02:18PM, an interview was conducted with Certified Nursing Assistant (CNA) E. CNA E was asked how they know if there is a resident call light on. CNA E stated they have tablets in the halls that will show call lights that are on. CNA E was asked how reliable the tablets are. CNA E stated, sometimes the tablets will crash and I will reboot it. Sometimes it works and sometimes it doesn't. We have an app for our phones as well, but it drains my battery so I don't use it. There is a computer in the nurses station that has every call light that is on in the building. On 02/19/25 at 2:24PM, an interview was conducted with CNA F. CNA F was asked if there was any other way besides the tablets and the main computer at the nurses station to know if a call light is on. CNA F responded, No, there are no lights above the doors and no sounds. So if the tablets aren't functioning we have to go the main computer at the desk.: On 02/20/25 at 09:03AM, observation revealed the call light tablet screen outside of room [ROOM NUMBER] reads Vision Link II Mobile voice isn't responding. The device is not currently functioning. On 02/20/25 at 09:26AM, observation revealed the call light tablet at the 2nd Floor East Nurses station is not functioning. On 02/20/25 at 09:29AM, observation revealed the call light tablet by the Grand View Blvd. Sign is not on. On 02/20/25 at 09:30AM, on 2 North: observation revealed a call light tablet with the message on the screen reading, Not responding. This was verified with Registered Nurse RN H. On 02/21/25 at 09:42AM, an interview was conducted with CNA G. CNA G was asked if they ever have any issues with the tablets used for call lights. CNA G stated, Sometimes they don't connect and we have to reconnect them and get them going. We still have the monitor at the nurses station and some people have the app on their phone. CNA G was asked how often do the tablets disconnect daily? CNA G stated, I believe a lot, I mostly bypass them and go straight to the nurses station because I know it will be working. CNA G was asked if they have ever had any complaints of long call light times from the residents and have any residents been incontinent due to a long wait time. CNA G stated, Yes, I have had complaints and had to clean residents up after a long wait. On 02/21/25 at 09:47AM, observation revealed a tablet used for call lights by the Grand View Blvd. sign on the 2nd floor is not turned on and is plugged in to the wall. On 02/21/25 at 12:44PM, observation revealed a tablet used for call lights outside of room [ROOM NUMBER], it was not functioning. This surveyor turned on the call light in room [ROOM NUMBER], went back to the tablet and the tablet would not display that the call light was on. Review of the Policy titled, Vision Link II Call System with Mobile Application, revised 7/23/24 revealed: 2. All direct care staff (CNA's, RN's, LPN's, Hospitality Aides, and Housekeepers) will be required to utilize the nursing call system via the mobile app throughout the duration of their assigned shift. It is encouraged that all non-direct care facility employees log into the Mobile app as a means of communication with fell ow employees and for general call light oversight 37666 On 2/20/2025 at 9:40 AM, the call light notification pad, situated on a wheeling stand in the hallway of the Dementia unit, had a blank screen. Nurse I said the pad was like a tablet and was used for call light notifications. She said the pad screen would show which call lights were on so the staff could answer them. When asked why it was not on, she said it wasn't working. Nurse Aide GG was in the hall and said if you wanted to know which lights were on, you had to leave the locked unit and go outside the doors where another screen was located. The nurse and nurse aide were asked how they would know if someone needed help if they weren't aware of the call lights being on and they said they wouldn't know unless they left the locked hallway. On 2/21/2025 at 3:45 PM, during the interview with the DON, she was asked about the call light system as it was not working consistently on the halls of the Dementia unit and she said the staff could install an app on their personal phones that would notify them when a call light was on; the DON said not all staff had the app on their phones as it was an option for them to do this. On 2/25/2025 at 9:30 AM, the call light pads on the 2 halls of the Dementia unit were not working. 37771 Resident #46: A review of Resident #46's medical record revealed a readmission into the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, quadriplegia, heart disease, and contracture of unspecified joint. A review of the MDS assessment revealed the Resident had intact cognition and was dependent on staff for activities of daily living, mobility and transfers. On 2/19/25 at 12:18 PM, an interview was conducted with Resident #46 who answered questions and engaged in conversation. The Resident was asked if they had concerns regarding their care. The Resident reported that the call light could take 30 minutes to an hour to answer and stated, I have to yell out to get help. The Resident reported the staff do not have the pagers anymore, there is no light above the door and the staff had to look at a screen at the nurses' station or on tablets and the screen does not work. The Resident voiced frustration that the CNA's do not answer call lights timely. Resident #63: A review of Resident #63's medical record revealed an admission into the facility on [DATE] with diagnoses that included neurocognitive disorder with Lewy Bodies, Parkinson's disease, diabetes, obstructive sleep apnea, and anxiety disorder. A review of the MDS revealed the Resident had intact cognition and was dependent on helper for most activities of daily living, mobility and transfers. On 2/19/25 at 2:11 PM, an interview was conducted with Resident #63 who answered questions and engaged in conversation. The Resident was up in her wheelchair seated next to the bed. An observation was made of a call light that was upside down V shape. The Resident reported she could not use the push button call light. When asked about any concerns she had regarding her care, the Resident reported long call light wait times and that staff will shut it off, say they will be back and then they don't come back. The Resident expressed having to wait up to four hours to be changed due to having incontinence. When asked if they do a check and change every, two hours, the Resident expressed frustration and stated, They don't come every 2 hours to check on us, not enough people (staff). The Resident reported that staff have left the room without making sure the call light is in reach or hide it under the covers and I can't find it. The Resident reported not having her oxygen on during the night and went several hours without the oxygen and stated, It gives you a sick feeling to have that light on and no one comes to find out why it is on. Resident #74: A review of Resident #74's medical record revealed an admission into the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, emphysema, dementia, heart failure and anxiety disorder. A review of the MDS revealed the Resident had intact cognition, was independent with ambulation, mobility and needed partial/moderate assistance with shower/bathing. On 2/19/25 at 9:16 AM, an interview was conducted with Resident #74. When asked about any issues or concerns they had about their care at the facility, the Resident reported extended call light wait times. The Resident was asked how long they have had to wait for staff response when using the call light. The Resident stated, Can take 30 minutes, sometimes an hour. The Resident responded that she has called for her breathing treatment, needing her inhaler and stated, then have to wait for someone to answer the light. On 2/21/25 at 10:21 AM, an observation was made at the nurses' station 2nd floor south with a call light tablet that indicated on the screen Communication Error. Failed to communicate with server: unauthorized. There was no staff in the area at that time. On 2/21/25 at 10:24 AM, CNA FF was asked about the call light tablet at the nurse's station. The CNA tried to reset the tablet, but it would not resent. When asked how the staff was notified of call lights, the CNA reported the computer screen inside the nurses' station and stated, We can have it on our phone as well. When asked if they had it on their phone, the CNA stated, No not right now it's not up, and reported the app was not available on their phone at this time. The CNA was asked how they would get the tablet to work again, and they reported they would have to put a work order in to let them know it was not working.

Based on observation, interview, and record review, the facility failed to validate and update the care plan for DNR status for one resident (R#47) of 3 residents reviewed for advanced directives. Findings include: Resident #47 Advance Directives On 02/19/25 at 12:47 PM, R47's Advanced Directives in her clinical file was dated 11/1/2023. Resident #47 (R47) According to the review of Electronic Medical Records conducted on 2/20/25 at 2:45 PM, R47 was [AGE] years old and admitted to the facility on [DATE] with the diagnosis of Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left dominant side, vascular dementia with mood disturbances, and peripheral vascular disease in addition to other diagnoses. R47's son was the Durable Power of Attorney (DPOA) and emergency contact. R47's Brief Interview of Mental Status (BIMS), which was assessed on 12/25/24, revealed a score of 09/15. A score of 9 indicates moderate cognitive impairment. A score of 0-7 represents severe cognitive impairment, and 13-15 signifies intact cognitive function. R47 Care Plan on Advanced Directives was reviewed and revised on 11/07/2023. Upon interview with the Social Worker (SWS) on 02/21/25 at 10:11 AM, the SW indicated that they reviewed the resident's Advanced Directives with the staff every quarterly, during care conferences, and annually. The surveyor and SW reviewed the care conference notes and the social worker's progress notes. The SW S revealed she cannot find the notes for now and will ask the unit manager to help find any notes on R47 Advanced Directives. The SW S also confirmed that R47's care plan for Do-Not-Resuscitate was last updated in 2023. R47's BIMS Score was 9/15, and she has a Durable Power of Attorney (DPOA). The SW stated, Sometimes, the family may have difficulty coming in to sign. The SW S confirmed that she could not find any progress notes regarding discussing the Advanced Directive with the family/DPOA and updating the care plan. On 02/21/25 at 10:20 AM, The Unit Manager (UMK) confirmed that she could not find any progress notes or care conference notes indicating that the Advanced Directive has been reviewed since 2023. A facility policy entitled Advanced Directives, last updated on 2/14/2024 was reviewed on 2/21/25 at 10:30 AM. The Policy Statement: To provide the resident, guardian, medical durable power of attorney (DPOA), and /or resident advocate an opportunity to make their wishes known prior to a life-threatening incident occurring. It should be understood that any decision that is made is not binding and can be revoked at any time by the above listed parties . .7. If at any time the resident/responsible parties decide on changing the current advance directives the nurse will follow the above policy. Quarterly with MDS/care plan reviews the Floor Coordinator will review current Advance Directives with appropriate parties (if in attendance) and answer any questions or make any necessary changes.

Based on interview and record review the facility failed to complete a comprehensive care plan for one resident (R32) of four residents reviewed for unnecessary medications. Findings include: Resident #32 R32 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include, dementia, major depressive disorder, dysphagia and atrial fibrillation. R32 has a brief interview for mental status (BIMS) score of 3 indicating severe cognitive impairment. On 02/20/25 at 09:57AM, record review revealed that R32 admitted to the facility on [DATE] and there is a physician's order dated 09/10/24 for Venlafaxine (Effexor) HCl ER Tablet 150mg, give one tablet by mouth one time a day for depression. On 02/20/25 at 11:31AM, record review revealed that R32 has a care plan in place for Effexor for depression, however, Effexor was discontinued on 01/05/25. The psychotherapeutic medications care plan was initiated on 12/6/24, psychotherapeutic medication (Effexor) was initiated on 09/10/24. On 02/20/25 at 11:53AM, an interview was conducted with Unit Manager (UM) D. UM D was asked who is responsible for implementing and updating care plans for psychotherapeutic medications. UM D stated that, Usually it is social work that does that (implements and updates care plans) but the Minimum Data Set (MDS) nurse or me will do it if it needs to be done. This surveyor verified with UM D that the care plan for psychotherapeutic medication was initiated and updated on 12/6/24. UM D was asked if the care plan should have been initiated sooner when R32 started on psychotherapeutic medication. UM D stated, Yes, the care plan should have been implemented at that time and updated with changes in medication. It was just missed, I don't really know why it wasn't implemented or updated. Record review of the policy titled, Interdisciplinary Care Plan, reviewed 01/12/24, revealed: Policy Interpretation and Implementation: 1. Upon admission, resident status is assessed by the Interdisciplinary Team members (Dietary, AT, SW, Nursing, Restorative Nurse R.N., Skilled Therapies) using a combination of assessment tools including the MDS/CAA's. Care plans are developed on a timely basis, according to the RAI process. 2. Each discipline, based on their admission assessment, submits care plan information (i.e.: problems, goals, approaches) to the appropriate Unit manager. Unit managers will compile all assessment information to create an individualized computer care plan. Cardiovascular Respiratory Neuromuscular/ Skeletal Psychosocial/Orientation (includes Discharge Plan) Integumentary Nutrition Gastrointestinal Genitourinary Endocrine/ Metabolic Sensory ADL/ Safety Miscellaneous 3. The Unit manager will review the information found in each care plan section looking at the care that has been provided related to physician orders, labs, diagnostic testing, current medical status, etc. in order to assure continuity of care. Any issues found will be discussed with the appropriate interdisciplinary care plan team member and if necessary, taken to the physician and resident/family seeking direction for future plan of care.

Based on observation, interview and record review, the facility failed to ensure nail care was provided for two residents (#46 and #78) of five residents reviewed for Activities of Daily Living (ADL). Findings include: Resident #46: A review of Resident #46's medical record revealed a readmission into the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, quadriplegia, heart disease, and contracture of unspecified joint. A review of the Minimum Data Set (MDS)assessment revealed the Resident had intact cognition and was dependent on staff for activities of daily living, mobility and transfers. On 2/18/25 at 12:27 PM, an interview was conducted with Resident #46 who answered questions and engaged in conversation. The Resident was observed to have limited mobility of her hands. The Resident's fingernails were long and there were a couple nails that had nail polish that was chipped or worn off from most of the nails. The Resident was asked about her fingernails, and she responded that activities would do them sometimes and stated, They are supposed to ask when I get my shower, but they don't, and expressed that the fingernails were longer than she liked. Resident #78: A review of Resident #78's medical record revealed an admission into the facility on [DATE] with diagnoses that included cerebral palsy, aphasia, severe intellectual disabilities and abnormal involuntary movements. A review of the MDS assessment revealed the Resident had severely impaired cognition and was dependent on a helper for activities of daily living, mobility and transfers. On 2/18/25 at 12:07 PM, an observation was made of Resident #78 sitting up in a chair in their room. The Resident was not able to be interviewed and did not engage in conversation. The Resident was observed to have jerking motions of his arms and hands had limited mobility and contractures. The Residents nails were observed to be long, and a couple of the nails were jagged. The Resident occasionally got his hands to his face and made contact with his eyes and nose with non-purposeful jerking movements. On 2/20/25 at 12:30 PM, an observation was made of Resident #78 sitting up in his wheelchair. The Resident's nails remained long, and a couple were jagged. A scratch mark was observed on the Resident's right cheek area. The Resident was observed to flail his arms around. On 2/20/25 at 1:40 PM, Resident #78's tube feeding was administered by Nurse AA. The Resident was observed to flail his arms around. The scratch on the Resident's right cheek was observed. The Nurse was asked about the Resident's bathing schedule and reported the Resident would get a bed bath twice a week. When asked about nail care, the Nurse indicated they don't look like they had recent attention. A review of Resident #78's medical record revealed a progress note titled Incident Note, dated 5/9/24 at 1:00 AM, Nurse and aid were boosting resident when a scratch on the resident forehead and nose was observed. Red scratch on bridge of the nose measure approximately 0.6 cm. Dry open to air. Scratch to the forehead is red and dry measures approximately 1.2 cm. Superficial scratch on the forehead measures at 5 cm. Fingernails trimmed. A review of Resident #78's care plan revealed an integumentary focus (Resident name) is at risk for potential skin and feet integrity secondary to cerebral palsy, total assist with cares, involuntary movement ., and an intervention of Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short, with initiation on 1/24/23. On 2/21/25 at 11:08 AM, an interview was conducted with Unit Manager, Nurse Q regarding fingernail care. The Unit Manager was asked about facility policy regarding nail care. The Unit Manager indicated nail care was to be performed on shower or bathing days and as needed. When review of Resident #46, the Unit Manager indicated that her showers were weekly and more if requested or needed. When asked if Resident #46 refused nail care, the Unit Manager reported that if she refused, the nurse would be notified and put a note in the medical record. A review of the medical record did not reveal documentation of refusals for nail care. An observation was made with the Unit Manager of Resident #78's fingernails long and not trimmed. A review of Resident #78's medical record revealed the Resident had bathing activities the prior night but there was no documentation that the Resident had refused nail care. The Unit Manager indicated Resident #46 did not refuse nail care. The Unit Manager reported that when the CNA signs for the bathing activity it includes clipping and cleaning fingernails. A review of facility policy titled, Nail Care, updated 10/11/24, revealed, Policy Statement: To provide staff guidelines on how to care for residents fingernails/toenails on bath day and PRN (as needed) .

Based on observation, interview and record review, the facility failed to 1). Ensure coordination of Hospice Services for one resident (#151) reviewed for Hospice service. Findings Include: Resident #151: Hospice and End of Life A review of the Face sheet and MDS/Minimum Data Set assessment indicated Resident #151 was admitted to the facility on [DATE] with diagnoses: Seizures, history of falls with fractures: fourth cervical vertebra, nasal bones, maxilla, Dementia, anxiety, depression and hypertension. The resident wore a neck brace for the cervical fracture. A review of the physician orders indicated the resident was admitted to Hospice services on 1/21/2025 on admission. On 2/18/2025 at 12:17 PM, Resident #151 was observed sitting in a chair in his room watching TV. He was talkative and tried to answer question. He said he did not think he was receiving Hospice services. A review of the Care Plans identified a Hospice Care Plan dated initiated 2/3/2025 and revised 2/4/2025 with an intervention: Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met, dated 2/20/25 and Work with nursing staff to provide maximum comfort for the resident, date initiated 2/3/2025. On 2/21/2025 at 1:00 PM, during an interview with Nurse I she was asked where the Hospice notes for Resident #151 were located, as they were not in the electronic medical record. Nurse I said she did not know where the hospice notes were. Nurse I asked the Charge nurse and said she was told they were in the electronic medical record. Reviewed the notes were not in the electronic medical record. On 2/21/25 at 1:14 PM, Nurse Manager K brought a Hospice binder from the 1st floor North hall. It was a Hospice book for Resident #151. There was one Hospice nurses note dated 1/21/2025, the day of Resident #151's admission. There was also a Social Worker's note was 1/24/2025. The Unit Manager K confirmed there were no additional Hospice notes for the resident. She said she would try to find them. A review of the Hospice Care Plan for Resident #151 was started on 2/3/2025; it was not initiated on admission. It was started almost 2 weeks after the resident was admitted with Hospice care. On 2/21/2025 at 1:34 PM, Unit Manager K said the Hospice care notes for Resident #151 were not in the resident's chart or at the facility. She said she called Residential Hospice to request the documents. Nurse Manager K was asked who was to place the Hospice Notes in the resident's Hospice binder and she said another nurse manager had a code to view the Hospice documentation system and retrieve the documents, but that nurse was not working that day. Nurse K said she did not have a code to retrieve the Hospice documents. Resident #151 did not have evidence of coordination of Hospice Care. There was no documentation of Hospice clinical care provided to the resident in the medical record or at the facility. On 2/25/2025 at 12:30 PM, the Director of Nursing was asked if there was a policy for Hospice care. She said it would be included in the Hospice contract. A review of the facility policy titled, Hospice Program, dated November 2017, provided When a resident chooses to receive hospice care and service, the facility will coordinate and provide care in cooperation with hospice staff in order to promote the residents' highest practicable physical, mental, and psychosocial well-being . The facility maintains written agreements with hospice providers that specify the care and services to be provided and the process for hospice and nursing home communication of necessary information regarding the patient's care . The plan of care will identify the care and service that each entity will provide in order to meet the needs of the resident . Hospice staff will document progress notes and any new recommendations upon each visit. This documentation will be kept in a binder labeled for the appropriate hospice agency .

Based on observation, interview and record review, the facility failed to ensure appropriate interventions were in place and supervision was provided to prevent a fall with injury for one resident (Resident # 401) of 6 residents reviewed for accidents and falls, resulting in Resident #401 experiencing multiple falls and sustaining several fractures. Findings Include: Resident #401: Accidents: A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #401 was admitted to the facility on [DATE] with diagnoses: Alzheimer's Dementia, anxiety, depression, arthritis, and history of urinary tract infections. The MDS assessment dated [DATE] revealed the resident had severe cognitive decline with a Brief Interview for Mental Status (BIMS) score of 3/15 and Resident #401 needed assistance with all care. On 12/12/23 at 12:30 PM, Resident #401 was observed lying in bed awake visiting with a family member. The resident smiled but did not answer or respond to questions. The family member, said the resident had encountered several falls at the facility that resulted in multiple fractures. The visitor said the resident now had a mat on the floor beside the bed after the most recent fall with fracture. On 12/14/2023 during a review of five Incident and Accident/I&A reports for Resident #401 the following was identified: 5 reports for falls dated 9/12/23, 10/16/23, 11/3/23, 11/25/23, and 11/26/23. On 9/12/2023 and 11/26/2023 the resident sustained fractures due to the falls: 9/12/2023 2 fractures of the pubic rami and 11/26/2023 a fracture of the right trochanter/hip. The falls are summarized as follows: On 9/12/23 at 1930/7:30 PM: Resident #401 had a fall; found on floor in hallway, head against the wall- complained of/(c/o) left hip pain- resident with multiple c/o hip and knee pain. Resident #401 was yelling out and repeatedly complaining of pain. The staff documented the behaviors of yelling and an order was given for an anti-anxiety medication/Ativan. A CT scan was ordered on 9/18/2023 and was not performed until 9/26/2023 the results were charted on 10/2/2023 and identified 2 pubic rami (pelvic) fractures. A review of a progress note dated 9/13/2023 at 5:03 AM: Complaint of pain in pelvic region . A Fall Risk Evaluation dated 9/13/2023 at 8:12 AM . 1-2 falls in past 3 months . Fall risk score: 12.0. Actioned clinical suggestions: . This was left blank. 9/13/2023 at 10:30 AM, a progress note: Resident noted to be restless, anxious, tearful and yelling out . It hurts . 9/17/2023 at 2:01 PM, a progress note: . resident hollering out in pain . 9/18/2023 at 2:03 PM, a physician progress note: . (patient) still suffer from pain, will check ct of the pelvis and left hip . 9/18/2023 at 3:32 PM, a progress note, . new order for CT scan . 9/20/2023 at 2:07 PM, a physician progress note, (patient) is still in pain . 9/22/2023 at 1:26 PM, a therapy note, . delay in treatment by PT until after CT scan on 9/26/2023 . 9/28/2023 at 7:10 PM, a behavior note, Resident noted to be yelling out and shows increased anxiety . received telephone order to give Ativan . 10/2/2023 at 3:19 PM, a therapy progress note, . received CT scan results of pelvis today . there is two nondisplaced pelvic fractures noted on CT scan . contacted (doctor) . 10/3/2023 at 2:22 PM, a physician progress note, (patient) suffers pelvic fractures, also developed fungal rash on her abdomen . Resident #401 fell on [DATE] a CT scan was ordered on 9/18/2023 and was completed on 9/26/2023. There was no clinical documentation of the results until a therapist documented on 10/2/2023 and contacted the physician. The resident was identified to have 2 pelvic fractures. The resident had been yelling out in pain for 3 weeks and was given Ativan for yelling. On 10/16/2023 at 3:35 PM: Resident #401 had a fall -found on floor in room, lying flat on her back next to a bedside table; an aide heard the resident hollering out. A note on the I&A report revealed, . Writer received order for routine pain medications as pain could be cause of fall, dated 10/17/2023. A review of the physician orders indicated the new order was for a muscle relaxer/Robaxin. The order was initiated greater than 30 days after the resident previously fell and sustained 2 pelvic fractures. The resident had an order for Tylenol 325 mg tablet, Give 2 tablets by mouth two times a day for pain, start date 9/15/2023, but continued to yell out in pain. On 11/3/23 at 12:00 PM: Resident #401 had a fall. The I&A report said the resident was observed on floor near room doorway; I'm hurting. An intervention was enacted: park w/c next to right side of bed. A review of a progress note dated 11/3/2023 at 1:41 PM provided, . resident observed on floor. resident sitting on buttocks with feet out in front and hands behind, near doorway . Resident states, I'm hurting . On 11/25/23 at 10:52 PM: Resident #401 had a fall-on floor next to bed unwitnessed. No new interventions were added until 11/27/2023 (concave mattress)- (the resident fell again on 11/26/2023 and fractured her right hip.) A review of a progress note dated 11/25/2023 at 10:55 PM: Resident observed on floor on right side of bed . has redness on right side of face and above right eyebrow and c/o (complains of) headache . There was no mention of additional interventions to aid in prevention of future falls. On 11/26/23 at 8:00 AM: Resident #401 had a fall out of bed - . resident had fallen out of bed. (Nurse aide) initially heard a loud noise from resident's room and went to check on what had happened. (Nurse aide) reports observing resident to be laying on their right side on the floor in front of wheelchair next to right side of bed. When writer went to see resident, resident was positioned back in bed lying on their back . unwitnessed fall . Resident given routine medications for pain once in bed . 'Tylenol . Ativan . Methocarbamol (Robaxin),' . x-ray is placed for pelvis area. Nursing will continue to follow POC. A review of Resident #401's Medication Administration Record (MAR) for November 2023 indicated the resident was receiving a sedating anti-anxiety medication/Ativan 0.5 mg routinely 4 times a day as well as Robaxin, a sedating medication once a day. From November 1st 2023 to November 18th, 2023 the resident also had an order for diphenhydramine/Benadryl, for itching related to an ongoing rash. The resident had received the medication twice on 11/2/2023 and fell on [DATE]. In all the resident had 6 documented doses of the medication, which can also cause sedation/drowsiness and confusion in elderly persons. A review of the progress notes for Resident #401 revealed the following: 11/26/2023 at 8:52 AM: . (Nurse aide) initially heard a loud noise from resident's room and went to check on what had happened. (Nurse aide) reports observing resident to be laying on their right side on the floor in front of wheelchair . Nursing will continue to follow POC. 11/26/2023 at 9:50 AM: . Resident to be repeating pain in right hip . Writer to place stat x-ray order for pelvis . 11/26/2023 at 2:55 PM: Writer called 911 to report resident needing transportation to hospital for radiology report showing right hip fracture . 11/29/2023 at 2:54 PM: . report from (hospital). Resident had a right hip fracture and (surgical repair) on the 26th . she will come back with a script for Norco (narcotic pain medication) and muscle relaxers . Nurse states she recommended hospice to family . 11/29/2023 at 3:32 PM: . Family inquired about what we would do with resident and current condition . discussed with them how we would monitor her closely . placed a concave mattress to help her with feeling the edge of the bed . A review of the Care Plans for Resident #401 indicated a Safety Care Plan: (Resident #401) is at high risk for falls secondary to her history of a fall x 1 prior to admission (6/29/2023) decreased safety awareness secondary to Dementia, anxiety, and potential side effects of medications. (Resident) has had falls since admission, and she is currently utilizing a concave mattress to find the edges of the bed, date initiated 6/29/2023 and revised 12/12/2023 to include the concave mattress. There were 4 interventions with the most recent dated 7/21/2023. A review of the Kardex for Resident #401 on 12/14/2023 identified fall mats beside the bed and a concave mattress. There were no dates when enacted. Place resident in Fall prevention program was also undated. During an interview with the Director of Nursing/DON, on 12/15/2023 at 3:20 PM, she was asked about Resident #401's 5 falls. She said the resident had fallen and also sustained several fractures. The DON was asked about the Resident's fall on 9/12/2023, order for a CT scan on 9/18/2023 that was not completed until 9/26/2023 and the lack of clinical documentation of the CT scan results until 10/2/2023, when the therapist documented the results. She said she was aware. Also reviewed that the resident had been yelling out, saying she was in pain and staff were documenting behaviors and the resident was given Ativan. The resident continued to have 4 more falls and suffered another fracture on the last fall 11/26/2023. She was hospitalized and had surgical repair of the fracture. There was not consistent documentation that the resident was being monitored or that additional interventions were enacted to try and prevent continued falls with injury. The DON was asked about the Fall prevention program, and she said it was a policy. A review of the facility policy titled, Fall Prevention and Identification Program, dated reviewed 9/22/2014 revealed, To provide all staff a means to identify and assist residents who have been identifies as frequent fallers. Residents who have been deemed a frequent faller (more than 1 fall in a quarter) by the Interdisciplinary Team, will be place in a Fall Prevention Program . Residents who are in this program will be evaluated for appropriateness every quarter with are conferences, on re-admission and with significant change in status assessments . The policy said the resident would receive an orange dot on their wheelchair and identification bracelet and physician order to identify they are a fall risk. It did not identify interventions to aid in prevention of falls. All residents at the facility are evaluated for falls each quarter with the MDS assessment process, on re-admission and with significant changes.

This Citation Pertains to Intake Number MI00133837. Based on interview and record review, the facility failed to assess and monitor a resident with a wound infection, urinary tract infection and elevated temperatures for one resident (Resident #1) of three residents reviewed for changes in condition, resulting in hospitalization , wound infection, sepsis, deterioration of health status and wellbeing and subsequent death. Findings include: Resident #1: A review of Resident #1's medical record revealed an admission into the facility on [DATE], readmission on 7/22/22 and transferred to the hospital on 11/1/22. The Resident had diagnoses that included cerebral infarction (stroke), depression, diabetes, history of falling, anxiety disorder, Alzheimer's disease, difficulty in walking, dysphagia, encephalopathy, gastrostomy status, and pressure ulcer of sacral region. A review of the Minimum Data Set (MDS) assessment, dated 8/18/22, revealed the Resident had severely impaired cognitive skills for daily decision making and was total dependent on staff for bed mobility, dressing, eating, toilet use and personal hygiene. Further review of the MDS revealed the Resident was at risk of pressure ulcers and did not have a pressure ulcer on readmission into the facility. A review of Resident #1's Temperature Summary in the medical record revealed the Resident had a temperature recorded on 10/29/22 at 1:11 PM of 100.5 degrees Fahrenheit; 10/31/22 at 2:32 PM of 99.4 degrees Fahrenheit; 10/31/22 at 5:17 AM of 100.9 degrees Fahrenheit; and 11/1/22 at 12:19 AM of 103.1 degrees Fahrenheit. A review of the Progress Notes revealed no documentation regarding interventions or vital signs with the documented temperature of 100.5 degrees Fahrenheit on 10/29/22 and the next temperature documented on 10/30/22 at 1:01 AM. The Blood Pressure Summary had two listed blood pressures documented on 10/27/22 at 2:59 PM of 132/84 and on 11/1/22 at 12:19 AM of 111/55. The Pulse Summary had two listed pressures documented on 10/27/22 at 2:59 PM of 68 bpm (beats per minute) and on 11/1/22 at 12:19 AM of 100 bpm. A review of the progress notes, dated 11/1/22 at 12:10 AM, revealed the Resident received Tylenol via PEG-Tube (percutaneous endoscopic gastrostomy tube) and dated 11/1/22 at 1:41 AM, temp re check - 99.1 v/s (vital signs) 128/68, P (pulse) 93, 98% (O2 saturation) resp 22, resident had elevated temp 103.1 Rapid Covid test negative at this time. Resident appears to have increase edema. Writer called DTR (daughter) r/t (related to) change dtr requesting resident to be sent to (name of hospital) . Progress note dated 11/1/22 at 1:59 AM, communication with physician, revealed, Situation: elevated temp; Background : possible septic; Assessment (RN)/Appearance (LPN): wound infection completed ABT (antibiotic therapy); Recommendations: Send to (Name of hospital) per DTR request. A review of Resident #1's Medication Administration Record (MAR) revealed an order for Weekly Skin Checks and weekly vital to be completed today every day shift every Thru (Thursday). Completed weekly skin check today and assure that weekly vitals are completed today, with a start date on 10/6/22 and discontinued on 11/8/22. On 10/6/22 and 10/20/22, the MAR was checked as completed but there were no vital signs documented in the vital sign summary or progress notes. On 10/13/22 there was no documentation of completion on the MAR and no vitals noted in the progress notes or on the vital sign summary. A review of Resident #1's wound assessment, completed on 10/24/22 revealed, . Wound measures 4 cm (centimeters) x (by) 5cm x2cm depth. Wound has thick gray slough in the center, with small amount of purulent drainage. Wound base is grey. Periwound is intact with irregular borders and is erythematous. Wound has a strong odor. Dressing performed as ordered. Will continue current treatment as currently ordered. A review of Resident #1's culture and sensitivity for the wound on the coccyx revealed the following: -Gram Stain Many Gram Positive CoccI, Multiple Morphologies Present, Moderate Gram Positive Bacilli, Moderate Gram Negative Bacilli -Isolate 1 few Escherichia coli -Isolate 2 Many Proteus mirabilis -Culture, Anaerobic ***Canceled*** The Resident was started on Ceftriaxone on 10/17/22 to 10/26/22. The progress note on 10/24/22, documented the wound assessment with signs and symptoms of continued infection, .Wound has thick gray slough in the center, with small amount of purulent drainage. Wound base is grey. Periwound is intact with irregular borders and is erythematous. Wound has a strong odor . There was a lack of further evaluation of the wound from 10/24/22 until transfer to the hospital on 11/1/22. A review of Resident #1's urinalysis, culture and sensitivity for urine, revealed the following: -Date collected, 10/19/22, date reported 10/21/22. -Urinalysis, with out-of-range test results, included: color dark yellow; appearance turbid; blood-trace; protein present; leukocytes esterase large; and microscopic results with +3 bacteria. -Culture Isolate 1 revealed, greater than 100,000 CFU/NL of Pseudomonas aeruginosa. The document had a handwritten note that stated, Already being Tx (treated) with Ceftriaxone for 10 day for wound infection, was not dated or signed. The sensitivity did not list Ceftriaxone in the list of antibiotics to determine susceptibility to the antibiotic. Further review of the medical record revealed a lack of progress notes indicating assessment of the urinary tract infection development or progress. On 10/21/22 at 7:39 PM, an Alert Note, revealed, Resident ua/cs with culture is completed CrCL (creatinine clearance) 106.0 resident is currently being with ceftazidime which is supectible (susceptible) to infection place on DR board. The Resident was not prescribed ceftazidime. A review of Resident #1's hospital records revealed the following: -Emergency Documentation dated 11/1/22, revealed, .Assessment/Plan 1. Sacral decubitus ulcer, 2. Sepsis, 3. Hyperglycemia, 4. Cellulitis of buttock . History of Present Illness: . Blood sugar noted to be above 600 per EMS (ambulance) .sacral decubitus ulcer with significant surrounding erythema, wound containing apparent necrotic tissue, fetid smell and drainage. Wound is noted to be emanating bubbles of gas upon palpitation . significantly dehydrated and hyperglycemic . -CT Chest/abdomen/pelvis without contrast, dated 11/1/22, Impression: 1. Sacral decubitus ulcer with soft tissue air tracking along the right gluteal musculature and right pelvic floor musculature. Additionally there is osseous demineralization and or erosive change of the underlying sacrum which could relate to osteomyelitis . -Consultation Notes, dated 11/2/22, revealed, .Evaluation of sacral wound on arrival reveals an approximate 15 cm x 20 cm and the sacral bone is visible at the base of the ulcer with necrotic skin subcutaneous tissue and muscle at the edges smelling sacral decubitus ulcer with significant surrounding erythema, wound containing apparent necrotic tissue, fetid smell and drainage -Consultation Notes, date 11/2/22, Addendum, revealed, .size of the decubitus ulcer and the depth making it a stage IV decubitus ulcer 15 x 20 before any debridement and that it will need at least 1 surgical debridement prolonged wound dressing changes eventually the patient will need either a surgical flap done by plastic surgeon or a skin graft and there is a very good chance that the patient might require a diverting loop ileostomy as the patient had a stroke and is not mobile and unable to control her bowel function the diverting stoma is to help with wound care management. The daughter decided to make her mom comfort measures only she stopped the IV antibiotics stop tube feeds and no surgical intervention . On 2/17/23 at 10:05 AM, an interview was conducted with the Director of Nursing (DON) regarding Resident #1's facility acquired pressure ulcer and elevated temperatures. A review of vital signs revealed no other vital signs documented on 10/29/22 with the elevated temperature of 100.5 degrees Fahrenheit. When asked about the facility policy with elevated temperatures for a Resident, the DON indicated that the Resident should be rechecked for anything abnormal, recheck temperatures, get a full set of vital signs, contact the Physician and start standing orders for room restrictions, Covid, RSV, Flu A and B testing and reported a lack of documentation that the interventions and assessments had been completed. The DON indicated that there had been a Covid outbreak in the facility and that Covid testing had been done on the 10/27/22 and on 10/31/22, but the Nursing staff should have tested the Resident with the spike in temperature on 10/29/22. When queried regarding the pressure ulcer, the Resident on antibiotics with expected improvement within 72 hours of antibiotic therapy, further review of the medical record revealed a lack of assessment. The DON stated, I am not seeing assessment until the 103 temperature, with mention of wound infection and a set of vital signs prior to transfer to the hospital. On 2/17/23 at 3:35 PM, an interview was conducted with the Infection Control Preventionist (ICP), Nurse H regarding Resident #1's wound and urine cultures and sensitivities and elevated temperatures. When asked about doing wound cultures, the ICP indicated that for a wound culture, usually an aerobic and anaerobic cultures were done and was unsure why the anaerobic culture had been canceled. The ICP indicated that another wound culture would be sent right away. The urinalysis, culture and sensitivity, collected on 10/19 and reported on 10/21/22, and the antibiotic not listed on the sensitivity was reviewed with the ICP. The ICP reported she was out of the building at that time and was unsure what the physician had seen to indicate the Ceftriaxone was appropriate for the urinary tract infection (UTI) and indicated the Unit Manager or the Nurses should be checking with the physician. When asked about ongoing assessments, the ICP indicated Nursing staff should assess and monitor for sepsis with wound infection and UTI. When asked about Resident #1's elevated temperature on 10/29/22, the ICP indicated that usually 100.4 and over an assessment was to be completed to monitor for urinary tract infection by completing a UA (urinary analysis), Covid testing, and assess the wound knowing antibiotics were finished. The ICP indicated that monitoring improvement of infections and reactions to antibiotic use would include documentation of the assessment of the wound, appearance, and drainage, every time they look at the wound. On 2/17/23 at 4:00 PM, an interview was conducted with Unit Manager J regarding Resident #1's pressure ulcer and elevated temperatures. When asked about the elevated temperature on 10/29/22 and assessments, the Unit Manager indicated that the Nurse would treat with Tylenol as needed and continue to monitor, inform the charge nurse, and continue with assessment. When asked about facility protocol for monitoring vital signs, the Unit Manager indicated that vital signs were to be assessed weekly unless otherwise ordered, unless signs and symptoms of anything else as an elevated temperature, wound infection and monitor for more if further issues with the vital signs. The vital signs and wound assessments were reviewed with the Unit Manager. The Unit Manager indicated she was aware there were holes in the weekly assessments that were not done and a lack of wound assessment after the completion of antibiotic to determine change and/or worsening of the wound. A facility policy was requested for Changes in Condition, policy of Vital Sign Monitoring and Sepsis/Infection, but were not received prior to exit. A review of the facility policy titled, Infection Prevention and Control Program Outline, revealed, .1. Surveillance: The RN's and LPN's participate in surveillance through assessment of residents and reporting changes in condition to the resident's physicians and floor coordinators for notification of changes and inhouse reporting of communicable diseases and infections. Daily Surveillance: . Daily updates on antibiotic therapy, room restrictions, skin and wound documentation .

This Citation Pertains to Intake Number MI00133837. Based on interview and record review, the facility failed to prevent, monitor and treat a facility-acquired pressure ulcer for one resident (Resident #1) of three residents reviewed for pressure ulcers, resulting in the worsening of the pressure ulcer to a Stage IV, infection, sepsis, a deterioration of health and wellbeing and subsequent death. Findings include: Resident #1: A review of Resident #1's medical record revealed an admission into the facility on [DATE], readmission on 7/22/22 and transferred to the hospital on 11/1/22. The Resident had diagnoses that included cerebral infarction (stroke), depression, diabetes, history of falling, anxiety disorder, Alzheimer's disease, difficulty in walking, dysphagia, encephalopathy, gastrostomy status, and pressure ulcer of sacral region. A review of the Minimum Data Set (MDS) assessment, dated 8/18/22, revealed the Resident had severely impaired cognitive skills for daily decision making and was total dependent on staff for bed mobility, dressing, eating, toilet use and personal hygiene. Further review of the MDS revealed the Resident was at risk of pressure ulcers and did not have a pressure ulcer on readmission into the facility. A review of Resident medical record of EzGraphs (facility documentation for assessment and measurement of wounds) and Progress Notes regarding wound assessments revealed the following: -Dated 9/12/22, Skin/Wound Note, Writer into resident room and noted on mid lower back 3 cm x 2 cm bruised area with small opening. Writer applied betadine wipe and will place order for betadine wipe for 7 days. Will continue to monitor with daily cares. -Dated 9/14/22, Skin/Wound Note, Writer into resident's room and noted open area on left buttock 1 cm x 2 cm. No drainage or bleeding noted. Writer will place order for z guard to buttock for 7 days. Will continue to monitor with daily cares. -Dated 9/19/22, Skin/Wound Note, CNA (certified nursing assistant) notified writer that resident with an open area to coccyx. Writer in to resident's room to assess. Resident with an open area to coccyx measuring approx. 1.5 cm x 0.5 cm. Wound base is red, peri-wound is erythematous and edematous with blanchable redness and purple discoloration present . Writer did a Ez graph and place on physician board for eval d/t (due to) possible pressure ulcer to coccyx. Nursing will continue to monitor with daily cares. -Dated 10/13/22, Skin/Wound Note, Resident coccyx area Ez graph done. 7 x 12 x 3 cm, [7 cm of eschar tissue with tunneling at noon, 3, & 6] peri wound base is bright red non blanchable. At 6 pm 1.5 slough area, with a foul odor coming from wound/referring to DR (doctor) treatment is Not effective at this time, Will obtain clarification on turn schedule. Possible get OOB (out of bed) schedule. -Dated 10/14/22, Orders-Administration Note, .Writer obtained wound culture from coccyx. Tan colored drainage and strong odor noted Writer sent specimen with maintenance. -Dated 10/17/22, Skin/Wound Note, Wound on coccyx has opened up. Writer noted 5.5 cm x 3 cm x 1 cm. Wound has increased odor. Writer noted yellow drainage. Will refer to physician. Nursing will continue to monitor with daily cares. -Dated 10/17/22, Skin/Wound Note, EZ to coccyx. Writer in to assess. Coccyx wound measures 5.5 cm x 5 cm x 1 cm in depth. Undermining measuring approx., 2 cm noted to 7 -9 O clock, and 4 and 5 O clock. Wound base with moderate amount of tan slough, and soft brownish slough toward the coccyx crest. Pink coloration noted undermining edges. Blanchable erythematous and edematous noted to peri wound. Small amount of tan colored drainage to old dressing with strong odor. Resident with no c/o (complaints of) pain or discomfort during treatment. Writer will refer to physician for possible new treatment to area. Wound culture was obtained and result placed on physician board for eval. EZ refer to physician. -Dated 10/24/22, Skin/Wound Note, Writer in to resident's room to assess coccyx wound. Wound measures 4 cm x 5cm x2cm depth. Wound has thick gray slough in the center, with small amount of purulent drainage. Wound base is grey. Periwound is intact with irregular borders and is erythematous. Wound has a strong odor. Dressing performed as ordered. Will continue current treatment as currently ordered. -A review of the Treatment Administration Record (TAR) revealed an order to Perform EZ graph: Coccyx q (every) Monday, every day shift every Mon for Wound, Perform E-Z graph, eval tx (treatment) with a start date on 9/26/22. The EZ graph was not documented as completed on 9/26/22, 10/3/22 or 10/10/22. A review of the TAR of wound treatments for Resident #1's wound revealed the following: -Start Date on 9/12/22 and discontinued on 9/19/22 to apply betadine wipe to lower back open area once daily describe site. In the morning for cleanse mid lower back with betadine wipe once daily. Not documented as completed on 9/12/22 or 9/13/22. Review of the progress notes revealed a lack of daily monitoring documented. The wound description did not indicate the wound was on the coccyx and no EZ graph was found in the medical record. -Start date 9/14/22 and discontinued on 9/14/22, Place z guard on open area on eft buttock twice daily after soap and water wash. Two times a day . Completed on 9/14/22 at 9:00 AM. -Start date on 9/20/22 and discontinued on 9/22/22, Providone Iodine wipe to coccyx [open area] after Saline wipe wash AM [Pressure Ulcer Stage II] every day shift for Wound. Documented as completed on 9/20/22 and 9/21/22 and not documented as completed on 9/22/22. -Start date on 9/23/22 and discontinued on 10/13/22, Providone Iodine wipe to coccyx [open area] after Saline wipe wash cover with 3 x 3 hydrocellular dressing AM [Pressure Ulcer Stage II] every day shift for Wound. Documented as not completed on 9/24, 9/26, 10/3, 10/9, and 10/13. -Start date 10/14/22 and discontinued on 10/18/22, Providone Iodine wipe to coccyx [open area] flush open area with saline, pat dry with gauze, cover with 4 x 4 hydrocellular dressing apply bards wipe at the outer edge of wound bed, AM non stageable every day shift for Wound. Documented as not completed on 10/15 and 10/18. -Start date 10/19/22 and discontinued on 10/20/22, Flush open area on coccyx with Saline then dry thoroughly, cleanse with Betadine Wipe, apply bards wipe at the outer edge of wound bed then cover with 4 x 4 hydrocellular dressing every day shift for Wound, and ordered as needed. -Start date 10/21/22 and discontinued on 10/24/22, Calcium Alginate (opiticel) to fit inside coccyx wound, apply hydrogel, apply protective barrier wipe to peri wound, cover with 6 x 6 hydrocellular dressing every day shift every other day for wound. Not documented as completed on 10/21/22. -Start date 10/25/22, Calcium Alginate (opiticel) to fit inside coccyx wound, apply hydrogel, apply protective barrier wipe to peri wound, cover with 6 x 6 hydrocellular dressing every day shift every other day for wound, and ordered as needed. A review of Resident #1's culture and sensitivity for the wound on the coccyx revealed the following: -Gram Stain Many Gram Positive CoccI, Multiple Morphologies Present, Moderate Gram Positive Bacilli, Moderate Gram Negative Bacilli -Isolate 1 few Escherichia coli -Isolate 2 Many Proteus mirabilis -Culture, Anaerobic ***Canceled*** The Resident was started on Ceftriaxone on 10/17/22 to 10/26/22. The progress note on 10/24/22, documented the wound assessment with signs and symptoms of continued infection, .Wound has thick gray slough in the center, with small amount of purulent drainage. Wound base is grey. Periwound is intact with irregular borders and is erythematous. Wound has a strong odor . There was a lack of further evaluation of the wound from 10/24/22 until transfer to the hospital on 11/1/22. A review of Resident #1's Temperature Summary in the medical record revealed the Resident had a temperature recorded on 10/29/22 at 1:11 PM of 100.5 degrees Fahrenheit; 10/31/22 at 2:32 PM of 99.4 degrees Fahrenheit; 10/31/22 at 5:17 AM of 100.9 degrees Fahrenheit; and 11/1/22 at 12:19 AM of 103.1 degrees Fahrenheit. Further review of Resident #1's Progress Notes revealed the following: -Dated 11/1/22 at 1:41 AM, Temp re check - 99.1 v/s 128/68, P (pulse) 93, 98% resp 22, resident had elevated temp 103.1 Rapid Covid test negative at this time. Resident appears to have increase edema. Writer called DTR (daughter) r/t (related to) change dtr requesting resident to be sent to (hospital name) . -Dated 11/1/22 at 1:59 AM, Communication - with Physician, Situation: elevated temp; Background: possible septic; Assessment (RN)/Appearance (LPN): wound infection completed ABT (antibiotics); Recommendations: Send to (hospital name) per DTR request. A review of Resident #1's hospital records revealed the following: -Emergency Documentation dated 11/1/22, revealed, .Assessment/Plan 1. Sacral decubitus ulcer, 2. Sepsis, 3. Hyperglycemia, 4. Cellulitis of buttock . History of Present Illness: . Blood sugar noted to be above 600 per EMS (ambulance) .sacral decubitus ulcer with significant surrounding erythema, wound containing apparent necrotic tissue, fetid smell and drainage. Wound is noted to be emanating bubbles of gas upon palpitation . significantly dehydrated and hyperglycemic . -CT Chest/abdomen/pelvis without contrast, dated 11/1/22, Impression: 1. Sacral decubitus ulcer with soft tissue air tracking along the right gluteal musculature and right pelvic floor musculature. Additionally there is osseous demineralization and or erosive change of the underlying sacrum which could relate to osteomyelitis . -Consultation Notes, dated 11/2/22, revealed, .Evaluation of sacral wound on arrival reveals an approximate 15 cm (centimeter) x 20 cm and the sacral bone is visible at the base of the ulcer with necrotic skin subcutaneous tissue and muscle at the edges smelling sacral decubitus ulcer with significant surrounding erythema, wound containing apparent necrotic tissue, fetid smell and drainage -Consultation Notes, date 11/2/22, Addendum, revealed, .size of the decubitus ulcer and the depth making it a stage IV decubitus ulcer 15 x 20 before any debridement and that it will need at least 1 surgical debridement prolonged wound dressing changes eventually the patient will need either a surgical flap done by plastic surgeon or a skin graft and there is a very good chance that the patient might require a diverting loop ileostomy as the patient had a stroke and is not mobile and unable to control her bowel function the diverting stoma is to help with wound care management. The daughter decided to make her mom comfort measures only she stopped the IV antibiotics stop tube feeds and no surgical intervention . On 2/17/23 at 10:05 AM, an interview was conducted with the Director of Nursing (DON) regarding Resident #1's facility acquired pressure ulcer. A review of Resident #1's medical record with the DON revealed question as to the origination of the pressure ulcer with the documentation on 9/12/22 of mid lower back 3 cm x 2 cm bruised area with small opening or on 9/14/22 of open area on left buttock 1 cm x 2 cm and no Ez graph completed with further location and description. When asked if the Resident had multiple wounds, the DON was unsure. When asked about the order, dated 9/12/22, to monitor site daily, the DON, after review of the medical record, indicated a lack of assessments and EZ graphs. Treatment changes and treatments documented as not completed were reviewed with the DON. When asked about the change in the dressing on 10/21/22 of Calcium Alginate, hydrogel, barrier wipe and cover with 6 x 6 and the assessment of the wound to signifying the need to change the dressing, the DON stated, I don't see anything but on 10/17 for the physician to review. The wound culture was reviewed with the DON. The culture documented results reported on 10/16/22 at 10:30 AM, but the physician had not ordered the antibiotic until 10/17/22. When asked if the physician had been contacted on 10/16/22 of the culture results, the DON indicated that staff would have to log into the lab portal to get the results and did not know why the physician had not been called on 10/16/22. The DON was queried regarding the infected pressure ulcer, the Resident on antibiotics with expected improvement within 72 hours of antibiotic therapy, and further review of the medical record revealed a lack of assessment after the completion of the antibiotic therapy. The DON stated, I am not seeing assessment until (11/1/22) the 103 temperature, with mention of wound infection and a set of vital signs prior to transfer to the hospital. On 2/17/23 at 3:35 PM, an interview was conducted with the Infection Control Preventionist (ICP), Nurse H regarding Resident #1's facility acquired pressure ulcer. When asked about doing wound cultures, the ICP indicated that for a wound culture, an aerobic and anaerobic cultures were done and was unsure why the anaerobic culture had been canceled. The ICP indicated that another wound culture should be sent right away. The ICP Nurse indicated she was not made aware that the Anaerobic culture had been canceled. When asked about ongoing assessments, the ICP indicated Nursing staff should assess and monitor for sepsis with wound infection. When asked about Resident #1's elevated temperature on 10/29/22, the ICP indicated that usually 100.4 and over an assessment was to be completed to monitor for urinary tract infection by completing a UA (urinary analysis), Covid testing, and assess the wound knowing antibiotics were finished. The ICP indicated that monitoring improvement of infections and reactions to antibiotic use would include documentation of the assessment of the wound, appearance, and drainage, every time they look at the wound. On 2/17/23 at 4:00 PM, an interview was conducted with Unit Manager J regarding Resident #1's pressure ulcer and elevated temperatures. The Unit Manager indicated she was aware there were holes in the weekly assessments that were not done and a lack of wound assessment after the completion of antibiotic to determine change and/or worsening of the wound. A review of the facility policy titled Pressure Ulcer Monitoring Protocol, revealed, . 4. Weekly the Charge nurse will assess the pressure ulcer by measuring it using the clear size graph which is part of the 2 part EZ graph system. Once the wound is traced on the graph and assessed, the plastic backing will be peeled off the back of the graph and then placed onto the paper part of the EZ graph. The nurse will complete the wound assessment sheet in its entirety by filling out the EZ graph paper part of the system . 6. ICN (Infection Control Nurse) compiles a list of all residents with current pressure ulcers and distributes this list weekly to the interdisciplinary team. Each team member will review the resident's current pan of care as it relates to their specialty and make any necessary changes. 7. Monitoring of progress: A clean pressure ulcer with adequate intervention and blood supply should show evidence of some healing within 2-4 weeks. If no progress can be demonstrated, the physician should reevaluate the adequacy of the overall treatment plan as well as staff and resident adherence to this plan .

Based on observation, interview and record review, the facility failed to ensure physical restraints were not utilized for staff convenience and to unnecessarily inhibit freedom of movement for one resident (Resident #85) of two residents reviewed, resulting in failure to comprehensively assess, classify, and document restraint use, application and utilization of a restraint for a cognitively and physically impaired resident, lack of informed consent, and the likelihood for knowledge deficiency related to risks, physical discomfort and psychosocial distress utilizing the reasonable person concept. Findings include: Resident #85: Record review revealed Resident #85 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was rarely/never understood, displayed no behaviors, and required limited to total assistance to perform Activities of Daily Living (ADLs) with the exception of being independent with eating. The MDS assessment further revealed the Resident had two falls, one without injury and one with injury, and bed and chair alarms were utilized daily but did not have a restraint. During entrance conference with the facility Administrator on 9/19/22 at 10:59 AM, State survey staff were notified the facility had transitioned to a new Electronic Medical Record (EMR) system on 9/1/22 and resident medical records were located in both the prior and new EMR systems. On 9/19/22 at 12:24 PM, Resident #85 was observed sitting in their wheelchair at a table in the dining room area of the unit. Multiple residents were in the area waiting for lunch service. A chair alarm and lap buddy (firm foam device attached to the wheelchair and positioned in front of the abdomen and over the legs) were noted on the wheelchair. A soft cervical collar brace was present on the Resident's neck. While the Resident was sitting at the table, Licensed Practical Nurse (LPN) O was observed administering the Resident's medications but did not assess the lap buddy. After passing medications, LPN O exited the locked facility unit leaving one staff member (Certified Nursing Assistant [CNA] P) on the unit. At 2:23 PM on 9/19/22, Resident #85 was observed sitting in their wheelchair in the same position, with the chair alarm and lap buddy in place, at the table in the dining room. The Resident had a soft cervical collar brace in place. An interview was completed with Certified Nursing Assistant (CNA) P at this time. When queried regarding Resident #85's soft cervical brace, CNA P revealed (Resident #85) fell and broke their neck. When queried why the Resident had the lap buddy on their wheelchair, CNA P replied, So they won't get up. CNA P was then asked if the Resident was able to remove the lap buddy independently, CNA P replied, (Resident #85) won't. They are 104 (years old). On 9/20/22 at 8:00 AM, Resident #85 was observed in their room in bed. The Resident was positioned on their right side with their eyes closed. Their soft cervical brace was visibly soiled and sitting on the windowsill in the room. Resident #85's wheelchair was sitting in the room and was observed to have a pommel cushion (cushion with a square, raised wedge in the front keeping legs separating and limiting forwarding motion) on the seat. The lap buddy was next to the wheelchair. A paper Kardex (bedside care guide), toileting schedule, and turning schedule were present on the end of the Resident's bed. Review of the bedside Kardex revealed the following: - Safety: Lap Buddy; release, toilet, shift position/ROM (Range of Motion) every two hours (specify) [sic] - Orthotic to: May remove soft C-Collar (cervical brace) for bathing, eating, or laying still in bed. Must wear if up walking - Pommel cushion to wc (wheelchair) with posey grip (anti-slip material) above and below cushion The bedside turning schedule did not include documentation of repositioning/ROM and/or releasing the lap buddy when the Resident was up and not in bed. Review of the bedside toileting schedule for Resident #85 detailed: - 9/14/22: 9:30 AM- Dry - 9/15/22: 12:00 AM- Void, 2:00 AM: Void, 4:00 AM: Dry, 6:00 AM: Dry, 9:00 AM: Dry/BM - 9/16/22: 6:30 PM- Dry/BM/Bathroom, 9:30 PM- Dry/Bathroom - 9/17/22: 12:00 AM- Incontinent/Void, 2:00 AM: Incontinent/Void, 9:30 AM- Dry - 9/18/22: 4:00 AM- Incontinent/Void, 9:45 AM: Incontinent/Void/BM, 9:30 PM- Incontinent/Void - 9/19/22: 4:00 AM: Incontinent/Void At 9:07 AM on 9/20/22, a care observation for Resident #85 occurred. CNA R was assisting the Resident to sit up in bed and ambulate with their walker at this time. CNA R did not place the cervical collar on the Resident prior to assisting them to sit up. CNA R asked the Resident to reach for and hold the walker handles and to stand without the cervical collar in place. At this time, CNA R was stopped and queried regarding the Resident's level of assistance required and required assistive devices including the soft cervical collar. CNA R indicated they were attempting to get the Resident situated prior to putting the collar on. CNA R proceeded to look in the Resident's drawers before locating the cervical brace on the windowsill. CNA R then placed the cervical collar on the Resident. CNA R was asked why the Resident had both a pommel cushion and a lap buddy. CNA R revealed Resident #85 had the pommel (called saddle) cushion on their wheelchair for a while, but the lap buddy was new. When queried how the lap buddy worked, CNA R revealed the device was not easy to place as the foam on the edges had to be fit in between the metal sides/arm rests of the wheelchair. When asked why Resident #85 had the lap buddy, CNA R indicated the Resident tries to get up by themselves and the lap buddy stops them. When asked if Resident #85 was able to ambulate, CNA R revealed the Resident was able to ambulate with a walker and one assist. CNA R was then asked if the Resident was receiving therapy and/or restorative services and revealed they were unsure. Review of Resident #85's current care plan in the new EMR system revealed the Resident did not have a care plan in place related to use of a lap buddy. A care plan entitled, Care Tasks (Initiated: 8/5/22) was present in the EMR. This care plan included the following interventions: - Ambulate: One assist with gait belt and Four wheeled walker (Initiated: 8/5/22) - Anti roll back device to W/C (Wheelchair) (Initiated: 8/5/22) - Anti tip bars to W/C (Initiated: 8/5/22) - Concave mattress to bed for positioning (Initiated and Revised: 8/5/22) - Gripper socks: On when in bed, shoes on when up (Initiated and Revised: 8/5/22) - Gripper strips at/to: Right side of bed, middle of bed. Bathroom in front of sink, toilet and shower (Initiated and Revised: 8/5/22) - Please keep closet door locked with child lock at all times (Initiated and Revised: 8/5/22) - Pommel cushion to w/c with posey grip above and below cushion (Initiated and Revised: 8/5/22) - Speak loudly and clearly to residents' ear as is hard of hearing (Initiated and Revised: 8/5/22) - Toilet seat with bilateral arms (Initiated: 8/5/22) - Transfer bar to right side of HOB (Head of Bed) (Initiated: 8/5/22) - Transfer: One assist with gait belt with two wheeled walker (Initiated and Revised: 8/5/22) Review of Resident #85's ADL / Safety Care Plan in the prior EMR included the following approaches/ interventions and dates: - Toilet seat with bil. (bilateral) arms for support (11/3/14) - Gripper Socks on when in bed , shoes on when up (6/6/16) - Gripper Strips at/to: Right side of bed, middle of bed and in bathroom in front of sink, toilet and shower (3/21/18) - Chair Alarm to all chairs with posey grip above and below pad Change pad annually and prn (as needed) (4/15/19) - Anti tip bars to w/c (wheelchair) (3/5/21) - Anti roll back device (3/11/21) - Bed Alarm set @ 1 second interval Change pad annually and prn (5/26/21) Review of Resident #85's Progress Notes in the EMR's revealed the following: - 3/20/22 at 10:02 AM: FAMILY/RESPONSIBLE PARTY notified . of 2nd fall last night, (family) asked writer why resident would keep falling from wheelchair and if they had been restless, writer notified (family) that although writer was not here at the time of the incident it is noted resident was restless and attempting to stand up, (family) asked the writer 'since (Resident #85) is so confused, for their safety, is there any way you can kind of strap them into it?' Writer educated (family) on the inability to strap (resident) in d/t (due to) that being considered a restraint which we cannot do, writer did educate (family) on the option of a lap buddy or an alarming Velcro seatbelt for which resident has an eval in place for from therapy to eval if that is appropriate for the resident, (family) said would discuss it further with (Resident son) later this afternoon. Writer notified (family) that we would be completing a UA (urinalysis) as well to r/o (rule out) infectious process as a cause for restlessness . - 8/8/22 at 9:44 AM: Interdisciplinary Care Conference Review . Reviewed plan of care . Resident is . alert, confused . Resident is a participant in some unit activities, is cooperative and pleasant . requiring extensive to total assist with ADL functions, transfers and ambulates with 1 assist, gait belt and 2 wheeled walker . also has a w/c for long distances had a fall on 7/8/22 no apparent injury reported, has a bed alarm and chair alarm in place due to attempts to get up on own and falls . - 9/9/22 at 9:00 PM: Health Status Note: Resident returned to facility from visit post fall. Resident noted to have order for c collar to be in place at all times and off only to wash No further nurses' notes in either EMR systems addressed the lap buddy. The EMR did not include any nursing assessments related to implementation, utilization, and/or assessment of the lap buddy. Further review of Resident #85's EMR's revealed no documentation of consent for lap buddy/restraint use and/or advance directives/legal representative. Review of Resident #85's Health Care Provider Orders revealed the active orders in the new EMR system, Renew any previously signed restraint orders which have not been discontinued (7/8/22) Review of Resident #85's CNA POC (Point of Care) Response History documentation for the past 30 days revealed the task, Lap Buddy; release, toilet, shift position/R.O.M. every 2 hours (Specify) (sic). The task began on 9/12/22. Detailed review revealed the following documentation of completion: - 9/12/22 at 6:42 PM - 9/13/22 at 2:30 PM, and 7:23 PM - 9/14/22 at 2:52 AM, 2:19 PM, and 9:44 PM - 9/15/22 at 12:50 AM, 2:22 PM, and 6:25 PM - 9/16/22 at 11:52 AM and 9:30 PM - 9/17/22 at 1:07 AM, 11:44 AM, and 8:38 PM - 9/18/22 at 12:20 AM, 10:51 AM, and 8:20 PM - 9/19/22 at 5:47 AM, 1:46 PM, and 8:55 PM - 9/20/22 at 12:49 PM An interview was conducted with Social Services Director U on 9/21/22 at 9:44 AM. When queried regarding Resident #85's cognition and advance directives, Social Services Director U revealed they had worked at the facility less than two weeks and would need to review the EMR. Director U stated they would follow up with requested information. On 9/21/22 at 10:50 AM, Resident #85 was observed in the TV room of the unit. The Resident was sitting in their wheelchair with the soft neck brace in place and the lap buddy restraint in place in their wheelchair. An overbed table was in front of the Resident and they were eating ice cream. No staff were present in the area. When asked questions, Resident #85 made eye contact but did not provide appropriate and/or related responses. At 11:05 AM on 9/21/22, an observation of Resident #85 occurred in the TV/Dining room area of the unit. The Resident was sitting in their wheelchair with the lap buddy and chair alarm in place. There were no staff visible in the area. Resident #85 was pleasantly confused when asked questions. When asked if they could remove the lap buddy on their wheelchair, Resident #85 responded Yes but did not remove the lap buddy. This Surveyor then pointed to the lap buddy and asked Resident #85 if they would remove it, Resident #85 replied, Yes and began touching the lap buddy. The Resident proceeded to touch the lap buddy. The Resident brushed food crumbs off the top and then reached to the zipper on the edge and unsuccessfully attempted to unzip the waterproof nylon style cover. Resident #85 then began pulling at the sides and pulling up on the lap buddy but was unable to remove the restraint. An interview was completed with Therapy Director X on 9/21/22 at 12:14 PM. When queried if Therapy services typically evaluate use of assistive devices including pommel cushions and lap buddies, Director X replied, Yes. When queried regarding Resident #85's pommel cushion, Director X reviewed the EMR and stated, Recommended on 5/31/22. When queried regarding the reason for the pommel cushion, Therapy Director X indicated it was recommended due to positioning. When queried regarding Resident #85's lap buddy, Director X revealed Therapy had not evaluated the Resident for the appropriateness of a lap buddy and stated, Not referred to us (therapy). When queried why Therapy would not evaluate for appropriateness, Director X was unable to provide an explanation. With further inquiry regarding Resident #85's lap buddy, Director X stated, We should not use them (lap buddy) as restraint. On 9/21/22 at 3:37 PM, a second interview was completed with Social Services Director U. When asked about Resident #85, Social Services Director U stated, (Resident #85) has not had a legal decision maker in place since admission. Director U was asked to clarify if they were saying the Resident had not had any type of legal representation for medical decisions in place since their initial admitted in 2013, Director U verbalized confirmation. When asked if the Resident was cognitively intact when they were originally admitted to the facility, Director U revealed the Resident had been severely cognitively impaired since admission in 2013. When queried, Director U indicated the Resident was unable to make their own medical decision. When asked who was making medical decisions for the Residents as they had a DNR (Do Not Resuscitate) order in place, Director U revealed facility staff had been contacting one of the Resident's children who was listed as an emergency contact. Director U revealed they contacted one of Resident #85's emergency contacts (one of their children) to inform them that legal representation needed to be established and that the Resident's code status had been changed to a full code. An interview was conducted with the facility Administrator and Director of Nursing (DON) on 9/21/22 at 4:39 PM. When queried if Resident #85 would be able to remove the lap buddy due to their cognitive status, both the DON and Administrator stated the Resident would not. When asked if the lap buddy was a restraint, the DON and Administrator both confirmed the device was a restraint. The Administrator stated, (Resident #85) does not have the (cognitive) capacity to remove (the lap buddy). When queried regarding facility policy/procedure related to consent for restraint use and legal representation for residents who are unable to make their own medical decisions, the Administrator verified Resident #85 should have a consent but did not. The Administrator stated, Does not have a consent and did not have a legal guardian (representative) to sign one. The Administrator revealed the situation would be corrected but were unable to provide further explanation. An interview and record review were conducted with the Director of Nursing (DON) on 9/22/22 at 8:46 AM. When queried regarding the reason Resident #85 had the lap buddy implemented and lack of actual order in the EMR, the DON reviewed the EMR and Incident and Accident Reports for the Resident. The DON stated the lap buddy was implemented on 9/12/22 following the Resident's fall with cervical spinal fracture (neck). An interview was completed with Registered Nurse (RN) T on 9/22/22 at 8:46 AM. When queried regarding Resident #85, RN T revealed they had been working when the Resident fell and suffered a fracture. When asked, RN T revealed Resident #85 was a high risk for falls. RN T was queried regarding interventions in place to prevent falls. RN T revealed the Resident had alarms in place and stated, (Resident #85) also had the pummel cushion to stop them from getting up. When asked about the lap buddy, RN T revealed that was implemented after the fall to stop the Resident from getting up by themselves. A facility policy/procedure related to restraints was requested from the facility Administrator on 9/20/22 at 4:29 PM but not received by the conclusion of the survey. Review of facility provided policy/procedure entitled, Resident Rights & Responsibilities (Revised 1/20/19) revealed, Policy . 5. Respect and dignity. The resident has a right to be treated with respect and dignity, including a. The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms .

Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures to ensure adequate staffing levels and appropriate assessment and monitoring per professional standards of practice to prevent and mitigate falls including falls with injury, appropriate transfers, and ensure implementation of interventions to prevent skin tears for four residents (Resident #47, Resident #85, Resident #113, and Resident #121) of six residents reviewed, resulting in a lack of adequate supervision to prevent falls, lack of assessment and monitoring following falls, lack of investigation and documentation of falls with injury, Resident #113 suffering a [CONDITION(S)], Resident #85 experiencing a fractured cervical spine, and Resident #27 suffering a [CONDITION(S)], unnecessary pain, and the likelihood for decline in overall health status. Finding include: Resident #85: Record review revealed Resident #85 was originally admitted to the facility on [DATE] and most recently returned on 9/9/22 with diagnoses which included anxiety, hearing loss, repeated falls, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was rarely/never understood, displayed no behaviors, and required limited to total assistance to perform Activities of Daily Living (ADLs) with the exception of being independent with eating. The MDS assessment further revealed the Resident had two falls, one without injury and one with injury, and bed and chair alarms were utilized daily but did not have a restraint. On 9/19/22 at 12:24 PM, Resident #85 was observed sitting in their wheelchair at a table in the dining room area of the unit. Multiple residents were in the area waiting for lunch service. A chair alarm and lap buddy (firm foam device attached to the wheelchair and positioned in front of the abdomen and over the legs) were noted on the wheelchair. A soft cervical collar brace was present on the Resident's neck. At 2:23 PM on 9/19/22, Resident #85 was observed sitting in their wheelchair in the same position, with the chair alarm and lap buddy in place, at the table in the dining room. The Resident had a soft cervical collar brace in place. An interview was completed with Certified Nursing Assistant (CNA) P at this time. When queried regarding Resident #85's soft cervical brace, CNA P revealed (Resident #85) fell and broke their neck. When queried why the Resident had the lap buddy on their wheelchair, CNA P replied, So they won't get up. On 9/20/22 at 8:00 AM, Resident #85 was observed in their room in bed. The Resident was positioned on their right side with their eyes closed. Their soft cervical brace was visibly soiled and sitting on the windowsill in the room. Resident #85's wheelchair was sitting in the room and was observed to have a pommel cushion (cushion with a square, raised wedge in the front keeping legs separating and limiting forwarding motion) on the seat. The lap buddy was next to the wheelchair. A two wheeled walker was also present in the room. A paper Kardex (bedside care guide), toileting schedule, and turning schedule were present on the end of the Resident's bed. Review of the bedside Kardex revealed the following: - Safety: Lap Buddy; release, toilet, shift position/ROM (Range of Motion) every two hours (specify) [sic] - Orthotic to: May remove soft C-Collar (cervical brace) for bathing, eating, or laying still in bed. Must wear if up walking - Pommel cushion to wc (wheelchair) with posey grip (anti-slip material) above and below cushion - Anti-roll back device to wc - Anti-tip bars to w/c - Concave mattress to bed for positioning - Gripper socks: On when in bed, shoes on when up - Ambulate: One assist with gait belt and four wheeled walker - Transfer: One assist with gait belt and two wheeled walker At 9:07 AM on 9/20/22, a care observation for Resident #85 occurred. CNA R was assisting the Resident to sit up in bed and ambulate with their walker. CNA R did not place the cervical collar on the Resident prior to assisting them to sit up. CNA R asked the Resident to reach for and hold the two wheeled walker handles and to stand without the cervical collar in place. At this time, CNA R was stopped and queried regarding the Resident's level of assistance required and required assistive devices including the soft cervical collar. When asked why the Resident had both a pommel cushion and a lap buddy, CNA R revealed Resident #85 had the pommel (called saddle) cushion on their wheelchair for a while, but the lap buddy was new and indicated they were to prevent the Resident from getting up so they would not fall. CNA R revealed the Resident tries to get up by themselves and the lap buddy stops them. When asked if Resident #85 was able to ambulate, CNA R revealed the Resident was able to ambulate with a walker and one assist. When asked if the Resident was supposed to have a two wheeled or four wheeled walker, CNA R gestured towards the walker in the room and indicated that was the only walker they were aware of the Resident using. CNA R was then asked if the Resident was receiving therapy and/or restorative services and revealed they were unsure. Review of Resident #85's current care plan in the new EMR system revealed the Resident did not have a care plan specifically related to falls and/or safety. A care plan entitled, Care Tasks . To remain at my highest functional ability as possible and to continue with my plan of care in the safest manor (sic) possible (Initiated: 8/5/22) was noted. This care plan included the interventions: - Ambulate: One assist with gait belt and Four wheeled walker (Initiated: 8/5/22) - Anti roll back device to W/C (Wheelchair) (Initiated: 8/5/22) - Anti tip bars to W/C (Initiated: 8/5/22) - Concave mattress to bed for positioning (Initiated and Revised: 8/5/22) - Gripper socks: On when in bed, shoes on when up (Initiated and Revised: 8/5/22) - Gripper strips at/to: Right side of bed, middle of bed. Bathroom in front of sink, toilet and shower (Initiated and Revised: 8/5/22) - Please keep closet door locked with child lock at all times (Initiated and Revised: 8/5/22) - Pommel cushion to w/c with posey grip above and below cushion (Initiated and Revised: 8/5/22) - Speak loudly and clearly to residents' ear as is hard of hearing (Initiated and Revised: 8/5/22) - Toilet seat with bilateral arms (Initiated: 8/5/22) - Transfer bar to right side of HOB (Head of Bed) (Initiated: 8/5/22) - Transfer: One assist with gait belt with two wheeled walker (Initiated and Revised: 8/5/22) Review of Resident #85's Progress Notes in the EMR's revealed the following: - 2/23/22 at 10:47 PM: Incident . Type of Event: Observed on Floor . Writer was in the hallway with back turned to the resident caring for another resident. Writer heard thump and turned around to observe resident laying on the floor next to wheelchair by the couch in the front of the hallway . lying on her left side in the fetal position. Writer got help and immediately got resident back into chair. Proceeded to do vitals and neuro checks. Contacted nurse supervisor who came and assisted in cleaning and applying steri strips to the wound on the back of the left hand about 5.5 cm across the back of hand. Skin was approximated into place with steri strips and covered. Head was looked at and no bumps or bruises were noted. Injury: skin tear Range of motion check: moves all extremities no c/o (complaints of) pain Neuro checks . - 2/26/22 at 1:52 AM: Follow up . Injury noted from fall . fall from 2/23 . Writer noted 4 cm (centimeter) x 6 cm bruise to middle of resident's forehead. Writer noted all of resident's neuro checks have all been WNL (Within Normal Limits) . also noted 7 cm x 8 cm bruise to top of resident's left hand. Steri-strips covering 6 cm skin tear to top of left hand . - 3/19/22 at 7:28 PM: Incident . fall . Writer was sitting in hallway with residents, resident was self-propelling self in wheelchair in hallway and stating wanted to go home. Resident wheeling self around, then resident abruptly leaned forward in wheelchair in attempt to stand but went forward instead, appearing to land on knees and then land on left shoulder. Resident did not hit head. Chair alarm did sound. ROM and neuro's normal. Resident yelling out Get me up! Get me up! Hospitality aide informed CNA to come down hall and assisted writer to help resident into wheelchair . no apparent injury . - 3/19/22 at 9:48 PM: Incident . fall . Writer notified by CNA that resident was on the floor. Writer down hall and notes resident in hallway, laying on left side near back door of hallway. Resident had been sitting near back door asking for it to be opened, resident appeared to have attempted to stand from wheelchair and fell . CNA was answering other alarm in room, and other CNA was in hallway with other residents. Resident with other fall just 2 hours prior, resident propelling self in w/c and stating needs to go home. Resident not agitated but very set on opening the door. Resident denies pain and denies hitting head, writer notes no redness to head. Left shoulder with some redness, left elbow with a red/light purple bruise starting to form 3 cm x 4 cm. Small abrasion noted to left hip 1 cm x 0.2 cm. Some redness to outer left calf noted . ROM and neuro checks normal. Injury: bruising scrape . - 3/20/22 at 3:25 AM: Skin Comments . Writer notes that left outer elbow with a bump formed and bruise darkened since several hours prior d/t fall, resident with pain on touch but not with ROM (Range of Motion) . - 3/20/22 at 10:02 AM: FAMILY/RESPONSIBLE PARTY notified . of 2nd fall last night, (family) asked writer why resident would keep falling from wheelchair and if they had been restless, writer notified (family) that although writer was not here at the time of the incident it is noted resident was restless and attempting to stand up, (family) asked the writer 'since (Resident #85) is so confused, for their safety, is there any way you can kind of strap them into it?' Writer educated (family) on the inability to strap (resident) in d/t (due to) that being considered a restraint which we cannot do, writer did educate (family) on the option of a lap buddy or an alarming Velcro seatbelt for which resident has an eval in place for from therapy to eval if that is appropriate for the resident, (family) said would discuss it further with (Resident son) later this afternoon. Writer notified (family) that we would be completing a UA (urinalysis) as well to r/o (rule out) infectious process as a cause for restlessness . - 5/8/22 at 5:40 PM . Incident . fall . Writer was on north hall in the dayroom and heard chair alarm start to go off on east hall, looked through partially opened divider to see resident in process of falling from slight standing position to floor. Resident landed on left hip and left elbow. Resident was just trying to stand from wheelchair. Resident did not hit head . redness to left hip, and redness to left elbow. Resident has minor bleeding from under fingernail of right middle finger. Resident denies pain. When asked what was trying to do stated I was trying to fix my pants. Injury: scrape, just redness on left elbow and left hip Range of motion check: moves all extremities . - 5/10/22 at 7:11 PM: BEHAVIOR: Writer notified that resident becoming agitated after dinner, resident stating needs to go home, attempting to stand from wheelchair multiple times. Resident raising voice at staff, attempting to hit at staff. Staff attempting food/fluids, toileting and redirection. Resident attempting to go to doors and yelling I gotta go home!. Writer spoke with (family) and asked about residents nighttime [MEDICATION(S)] (anti-anxiety medication) being given, resident then did receive this and (family) stated Geri chair (wheeled reclining chair) could be used to prevent fall as resident trying to stand repeatedly . stating if [MEDICATION(S)] not successful then she is fine with [MEDICATION(S)] (antianxiety medication) SO (standing order) being used . - 7/8/22 at 11:02 PM: Incident . fall . Writer responded to chair alarm just in time to witness go from standing to falling on left side . did not hit head . states was trying to go home . - 8/2/22 at 9:44 AM: Interdisciplinary Care Conference Review . Reviewed plan of care . Resident is . alert, confused . Resident is a participant in some unit activities, is cooperative and pleasant . requiring extensive to total assist with ADL functions, transfers and ambulates with 1 assist, gait belt and 2 wheeled walker . also has a w/c for long distances had a fall on 7/8/22 no apparent injury reported, has a bed alarm and chair alarm in place due to attempts to get up on own and falls . - 9/9/22 at 9:00 PM: Health Status Note: Resident returned to facility from visit post fall. Resident noted to have order for c collar to be in place at all times and off only to wash Note: There was no assessment and/or progress note in the EMR indicating the Resident had fell . - 9/14/22 at 6:59 PM: Orders - Administration Note . Perform Weekly Skin Assessment . Resident with greenish/yellow bruising to middle of forehead. Resident with an recent fall and skin injuries already reported . - 9/18/22 at 2:12 AM: Skin/Wound Note . CNA called down writer to check out resident's scab . has a scab from a fall noted earlier in the week, scab has redness surrounding the entire area about 2 cm out from the scabbing . Review of Resident #85's health care provider orders did not include an order for transfer to the hospital following their fall on 9/9/22 nor were any hospital records from the transfer noted in the EMR. Review of Resident #85's clinical census documentation did not indicate the Resident left the facility. On 9/21/22 at 10:50 AM, Resident #85 was observed in the TV room of the unit. The Resident was sitting in their wheelchair with the soft neck brace in place and the lap buddy restraint in place in their wheelchair. An overbed table was in front of the Resident and they were eating ice cream. No staff were present in the area. When asked questions, Resident #85 made eye contact but did not provide appropriate and/or related responses. At 11:05 AM on 9/21/22, an observation of Resident #85 occurred in the TV/Dining room area of the unit. The Resident was sitting in their wheelchair with the lap buddy and chair alarm in place. There were no staff visible in the area. Resident #85 was pleasantly confused when asked questions. Resident #85's facility provided fall Incident and Accident (I and A) reports revealed the forms completed prior to September 2022 included the nurses note present in the EMR but did not incorporate an analysis of the fall nor did they detail interventions implemented to prevent future falls. Review of the I and A's for September 2022 revealed the following: - 9/9/22 at 2:50 PM: Un-witnessed Fall . Resident's room . Description: CNA notified writer that resident found on the floor. Writer into resident's room to assess. Resident lying on the floor on left side, fetus (sic) position. Resident is alert, awake, confused and agitated . bruises to left knee, posterior left shoulder, two skin tears to left hand measuring approx. 0.3 cm. Writer cleaned area . applied 7 small steri-strips . no bumps noted to head . CNA informed writer than resident with increased agitation attempting to get out unit, then resident went back to room and stated 'I am going to fall' . Predisposing Environmental Factors . None . Predisposing Physiological Factors . Impaired Memory . Predisposing Situational Factors . None . - 9/9/22 at 4:10 PM: Witnessed Fall . Resident's Room . Description: CNA notified writer that resident was leaving forward to left side while sitting in w/c by the time can attempted to assist resident, resident felt (sic) into the floor . left side by CNA report . Writer into resident's room to assess. Resident lying on the floor on left side . stated 'ouch my leg hurt' . moderate pain to right inner lower leg. Resident is alert and confused . did not move resident . Resident sent to ER for eval d/t (due to) c/o (complaints of) pain to left leg and unable to move leg . Injury Type: No injuries observed at time of incident . Mobility: Wheelchair bound . Predisposing Environmental Factors . None . Predisposing Physiological Factors . Impaired Memory . An interview and review of Resident #85's I and A reports was completed with the Director of Nursing (DON) on 9/22/22 at 8:46 AM. When queried what interventions were implemented following the Resident's fall on 2/23/22, the DON stated, No interventions were implemented. When asked questions regarding analysis of the fall including the Resident's status prior to and following the fall including continence, activity, pain level, location, etc , the DON revealed an investigation had not been completed and were unable to provide a response. When asked why interventions were not evaluated for appropriateness/effectiveness and/or why none were added, the DON was unable to provide an explanation. The DON stated the facility recently identified the lack of analysis following incidents and were going to have a consultant come to the facility to assist them. The DON was then asked about the Resident's fall on 3/19/22 and revealed the facility completed a therapy evaluation following the fall but did not elaborate further. When queried regarding analysis and interventions following Resident #85's fall on 5/8/22, the DON replied, Gait belt added. When asked how that addressed the root cause of the fall, the DON replied, I don't think it does. The DON was they asked why no staff were present in the day/dining/common rooms of the locked dementia care unit and replied, Should be. When queried regarding observations of lack of staff supervision in the common areas of the unit during the survey, the DON did not provide further explanation. When asked about the Resident's fall on 7/8/22, the DON stated there were no new interventions. When queried if the planned interventions were in place at the time of the above-mentioned falls, the DON revealed they were unable to say as the information was not documented. When queried regarding Resident #85's fall on 9/9/22 at 2:50 PM including where their location and activity at the time of the fall, the DON stated, I don't know. When asked if there was any other documentation and/or follow-up related to the fall, the DON revealed there was not. The DON was asked what interventions were following the fall and revealed a lap buddy was implemented on 9/12/22. When queried regarding Resident #85's second fall on 9/9/22 at 4:10 PM, the DON revealed they were unable to provide any additional information due to lack of documentation and investigation. On 9/22/22 at 9:30 AM, an interview was conducted with Registered Nurse (RN) T and the DON. When asked, RN T revealed they were Resident #85's assigned nurse on 9/9/22. RN T was queried regarding the Resident's falls and revealed the first fall was unwitnessed and occurred in the Resident's room. When asked where the Resident was in their room when they fell , RN T replied, In the wheelchair, the girls (CNA staff) told me. RN T elaborated the first fall was unwitnessed. When queried if they were present on the unit when Resident #85 fell , RN T replied, No, I was passing meds and indicated they were on a different unit. RN T was then asked if the Resident's planned interventions related to falls were in place at the time of the fall, including the alarm on their wheelchair. RN T indicated it was and stated, That is why (the CNA) went in there. RN T continued, (Resident #85) also had the pommel cushion to stop them from getting up. When asked if the pommel cushion was being used to ensure the Resident was positioned appropriately in the wheelchair or if it was used to prevent the Resident from getting up, RN T reiterated the pommel cushion was supposed to stop the Resident from getting up. With further inquiry, RN T revealed Resident #85 was antsy and staff had put them in their room in the wheelchair. RN T was asked why the staff left Resident #85 alone in their room if they were agitated and stated, I don't know. RN T revealed they told the girls (CNA staff) to monitor (Resident #85) after the first fall. When queried regarding interventions implemented to calm and/or reduce the Resident's agitation, RN T replied, I think they took (Resident #85) to the bathroom. RN T was then asked about the second fall on the same day and stated, Second fall was in (the Resident's) room. RN T stated, (Resident #85) was sitting in the wheelchair and leaning forward. The CNA was in the hall, by the time they went in, it was to late. RN T specified the Resident was sent to the ER following the second fall. When queried regarding the Resident's cervical spinal fracture, assessment completed and abnormal findings, RN T stated, We were more concerned about (the Resident's) leg. RN T disclosed Resident #85 returned to the facility with a C-collar and a diagnosis of a cervical spinal fracture. When queried if they had completed and documented a transfer and/or other additional assessment findings, RN T revealed there was no additional documentation. After RN T exited the room, the DON was asked if it was appropriate to leave Resident #85 alone when they were antsy and stated, No. Review of Resident #85's Hospital Medical Records dated 9/9/22 detailed, emergency room . Reason for Visit: Multiple falls; Pain on RT (right) leg and hand . Final Diagnosis: C1 (Top Cervical Vertebra closest to the skull); Contusion of left hand; Knee contusion, Thoracic (middle section of the spine) compression fracture (fractures caused by sudden, forceful impacts where the head moves forward and places pressure on the middle section of the spine) . Resident #121: A review of Resident #121's medical record revealed an admission into the facility on [DATE] with diagnoses that included cerebral atherosclerosis, fracture of left femur, cerebral atherosclerosis, dementia, anxiety disorder, depression, pain in left hip, retention of urine, constipation, low vision right eye, [CONDITION(S)] left eye and history of falling. A review of the Minimum Data Set assessment, dated 8/17/22, revealed, the Resident had severely impaired cognition and needed extensive assistance with activities of daily living that included bed mobility, transfers, dressing, and personal hygiene and needed two-person physical assist with extensive assistance for toilet use. On 9/19/22 at 12:52 PM, an observation was made of Resident #121 sitting in her wheelchair in the dining area. When asked questions, the Resident did not answer questions well and did not converse in appropriate conversation. A review of Resident #121's progress notes, the Resident had a fall on 9/4/22, was found in the bathroom and the Resident had reported to staff that she had crawled there. On 9/21/22 at 4:39 PM, an interview was conducted with Unit Manager, Nurse A regarding Resident #121's falls. The Unit Manager reviewed the fall and indicated she had the fall on 9/4/22 and that the Resident was found in the bathroom by staff, it was unwitnessed, the Resident had an alarm that was sounding that alerted staff to the room and reported there were no injuries documented. The Unit Manager was asked if neurological checks were to be completed. The Unit Manager reviewed the medical record and reported that it was an unwitnessed fall and indicated neurological checks were to be performed with an unwitnessed fall for a disoriented Resident, with neurological checks starting with every 15 minutes for the first hour and initiated right after the occurrence of the fall. The Unit Manager was unable to find the neuro checks in the medical record for 9/4/22 and reported an order to start on 9/7/22. The Unit Manager indicated he was off and did not come back until 9/6/22 and upon review, the neuro checks had not been ordered. When asked if the care plan had been updated, the Unit Manager indicated that the care plan had not been pulled over from the old system and that nothing in the old system would have been put into place after 9/1/22. The Unit Manager reviewed the medical record and indicated there was not a care plan for falls in the new charting system. Resident #47: On 9/21/22, at 8:50 AM, Resident #47 was sitting in the dining room eating breakfast. Resident #47 had numerous dry scabbed skin tears to their bilateral hands. Resident #47 lifted their sleeve and stated, I did have a real big one up here and then pulled their sleeve down trying to cover the skin tears on their right hand. On 9/21, at 1:30 PM, a record review of Resident #47's electronic medical record revealed an admission on 03/28/2022 with diagnoses that include Dementia with behavioral disturbances, [CONDITION(S)], and [CONDITION(S)]. Resident #47 has severely impaired cognition and required extensive assistance with Activities of Daily Living. A review of the incident and accident reports, physician orders and progress notes provided by the facility revealed the following: 05/10/2022 Type of Event: skin tear laceration . 08/10/2022 . skin tear . 08/17/2022 . noted resident propelling w/c (wheelchair) and getting stuck between peer w/c . 08/29/2022 . skin tear right forearm and top of right hand . 08/31/2022 . abrasion left wrist . A review of both electronic medical record care plans for falls/injuries revealed the following: PROBLEMS/STRENGTHS Potential for falls or injuries secondary to ANXIETY DISORDER, [CONDITION(S)] DISORDER, [CONDITION(S)], [CONDITION(S)], DORSAGLIA, DEMENTIA WITH POTENTIAL COGNITIVE DECLINES CAUSING DECREASED SAFETY AWARENESS. GOAL (S): Will not experience serious injury from fall . APPROACHES Monitor for changes in transfer ability which may indicate either more independence or more support from staff . Keep call light within easy reach for resident . Focus Care Task Date Initiated: 08/08/2022 Goal To remain at my highest functional ability as possible and to continue with my plan of care in the safest manor possible Date Initiated: 08/08/2022 Target Date: 09/14/2022 Interventions . Transfer: Two assist standup lift Date Initiated: 08/08/2022 . There were no interventions initiated to aide or protect in residents hands and arms from the skin tears and abrasions. On 9/22/22, at 09:26 AM, an observation of CNA Y assisting Resident #47 with toileting was conducted. CNA Y propelled Resident #47 into the bathroom in their wheelchair then stopped and read the bedside care plan. CNA Y then left out of the room and returned with an easy lift and commode. CNA Y hurriedly assisted Resident #47 into the easy lift sling and moved the easy lift machine into place in front of the resident. CNA Y removed the Velcro seat belt and began to lift the resident while the resident had a hold of their wheelchair wheels. Resident #47 began yelling STOP! STOP! You're breaking my arms. CNA Y stopped the lift and assessed the sling placement, seat belt and motioned that they were going to begin lifting the resident again. CNA Y was asked to stop as the resident was still holding onto the wheels. CNA Y then placed Resident #47's bilateral hands on the grab bars on the easy lift, lifted the resident onto the commode. Once the resident was sitting on the commode, CNA H entered and offered their assistance. CNA H assisted CNA Y with placing Resident #47 back into their wheelchair. CNA H was asked if Resident #47 required one or two persons assist with the easy lift and CNA H stated, she tends to get agitated so two people are required. CNA Y was asked why they used the easy lift alone and CNA Y stated, that the resident was new to them. On 9/22/22, at 12:28 PM, the Director of Nursing (DON) was interviewed regarding Resident #47's incident and accident reports. The DON was asked if they implemented any intervention to aide in the decrease of the amount of skin tears Resident #47 had sustained and the DON stated, she has lotion ordered for her skin. The DON was asked if they had ever considered protecting her hands with gloves or having her wear longer sleeved clothing and the DON stated, maybe she would do good with geri-sleeves (protect the upper extremities from abrasions, bruises, snags and tears throughout the day) or derma sleeves (protects fragile skin and reduces shear) . The DON stated, they would implement the intervention and place the order. The DON was alerted of the easy lift transfer with CNA Y and was asked regarding the transfer status and the DON offered that we have people that are a 2 assist transfer to protect them. The DON further offered the CNA Y needs to be reeducated. A review of the Stand up Lift Use Policy Revised: 12/04/2019 revealed . Explain the procedure to the resident . Have the resident hold the lift handles . Resident #113: On 09/19/22 at 10:35 AM Resident #113 was observed in her room sleeping in bed. Nasal cannula was noted on resident's face. Room was clean, no excess clutter or furniture was noted. 09/20/22 at 09:45 AM Resident #113 was observed in her room sleeping in bed, positioned flat on her back. Call light in reach. A record review of the Face Sheet and MDS assessment indicated the Resident #113 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Cerebral infarction (stroke), Dysphasia (difficulty swallowing) following cerebral infarction, Hypertension, Asthma, Type 2 Diabetes Mellitus, [CONDITION(S)], [CONDITION(S)], Acute [CONDITION(S)] with [CONDITION(S)], gastrotomy status, History of falling, Alzheimer's disease, Muscle weakness, Convulsions, presence of cardiac pacemaker. The MDS admission assessment dated [DATE] indicated Resident #113 had severely impaired cognitive abilities, with BIMS score 3/15, and needed assistance with daily care, transfers, and toileting. On 09/21/22 at 11:23 AM during interview with Unit Manager, Registered Nurse L, she was asked about Resident #113 and her stay in a facility. Nurse L stated that resident had a change in condition on 07/19/22 after she suffered a fall from a wheelchair. Resident had to be hospitalized . After resident returned from hospital on 07/22/22, she had to be hospitalized again on 07/23/22 with a diagnosis of stroke. Resident #113 returned to facility on 08/10/22 with a significant decline in condition. Resident is staying in bed all the time and is hard to arouse. She is totally dependent on staff assistance for moving and repositioning. Review of Resident #113's record revealed the following documentation: Nursing note dated 06/11/2022- Type of Event: fall. Description of event: Writer called to Northeast Hall from North Hall. Observed resident on floor, in front of couch, legs out in front or resident, back partially against couch, no c/o (complaints of) pain, no injury noted, resident was attempting to sit on couch, slipped, hit back of head on a table, and fell to the floor. Injury: no apparent injury. Range of motion check: moves all extremities, no c/o pain. Neuro checks: (immediately after) Bilateral hand grasp firm, due to light unable to assess pupil dilation, checked in 10 minutes with position change, PERL, Neuro's remained WNL (within normal limits), remained of shift. Care Given/ First Aide Given: Ice offered; resident refused. Vitals: Immediately After: Blood Pressure 184/98 Pulse 85 Respirations 18 Temperature 98.5 SPO2 99 % Via RA Blood Sugar 143. 3 minutes after: Blood Pressure 158/76 Pulse 95 Respirations 20 Temperature 98.5. 10 minutes after: Blood Pressure 128/80 Pulse 80 Respirations 18 Temperature 98.5 Nursing note dated 07 [TRUNCATED]

This Citation pertains to Intake Number MI 260. Based on interview and record review, the facility 1) Failed to obtain ordered lab work in a timely manner, 2) Notify the physician of foul smelling vaginal discharge, and 3) Assess for dehydration timely for one resident (Resident #1) of three residents reviewed for changes in condition, resulting in hospitalization for septic shock due to an acute Urinary Tract Infection ([CONDITION(S)]), dehydration, severe [CONDITION(S)] (high blood sodium), acute [CONDITION(S)] and ultimately death. Findings include. On 1/20/22, at 11:00 AM, the Director of Nursing (DON) was asked if the facility offers intravenous hydration and/or subcutaneous hydration and the DON stated that the facility does so with a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #1: On 1/20/22, at 1:00 PM, a record review of Resident #1's electronic medical record revealed an admission on 9/13/2018 with a readmission on 1/27/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 required extensive assistance with all Activities of Daily Living (ADL). A review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 12/17/2021 11:35 AM Insert straight catheter q.d.(every day) p.r.n.(as needed) /LPN (to obtain UA) 12/17/2021 12:04 PM LPN CHARTING: [CONDITION(S)] Signs and symptoms for q (every) shift x(times) 3 days 12/17/2021 12:04 PM RN EVAL: [CONDITION(S)] signs and symptoms 12/20/2021 12/20/2021 0630 PM LPN CHARTING: [CONDITION(S)] Signs and symptoms q shift x 3 days 12/20/2021 0630 PM RN EVAL: [CONDITION(S)] Signs and symptoms 12/23/2021 12/20/2021 0631 PM RN EVAL: Other: 12/21/2021 other charting to be evaluated UA to be obtained today 12/22/2021 0501 PM RN EVAL: Other:12/24/2021 other charting to be evaluated check for urine culture from UA sent on 12/21 A review of the progress notes revealed the following: 12/17/2021 12:03 PM Charge Nurse discussion with family/responsible party: Writer called down to residents visit by (family member.) (Family member) has concerns regarding residents increased fatigue . has concerns regarding her hydration or a possible [CONDITION(S)] . Writer notified residents (family member) that we could complete a UA . Writer notified (family member) that although hydration may play a part in this that the resident does not want to drink and is resistant at times to this . will continue to monitor the resident with all cares . 12/20/2021 06:32 AM . no temp. noted no flank pain noted, no complaints of burning with urination Resident does have vaginal discharge with foul odor. URINARY PROCEDURE DONE: Writer with help of CNA staff attempted to get UA via straight cath. Resident did not tolerate and repeatedly put hands down there and made it difficult to get specimen without being contaminated. Unable to get this shift. There was no note that the physician was notified of the vaginal discharge or the inability to obtain the urine specimen. 12/21/2021 10:44 AM URINARY PROCEDURE DONE: Foley catheter straight cathed as ordered to obtain specimen for UA/C&S (culture and sensitivity). Urine amber, cloudy, and odorous. Resident tolerated procedure well . 12/22/2021 05:01 PM RECEIVED LAB WORK: Will refer to physician for eval. URINALYSIS 12/21/2021 Color = YELLOW = TURBID (cloudy or foamy urine typically comes from either pus or blood in the urinary tract) . Bacteria 2+ URINE CULTURE 12/21/2021 PENDING The progress note did not detail if the physician was notified of the abnormal UA result. 12/22/2021 05:05 PM RECEIVED LAB WORK: . CMP (complete metabolic panel) 12/21/2021 unable to process CMP testing results were questionable. Please redraw specimen. 12/23/2021 06:53 PM LAB COMMENTS: Writer into room to obtain STAT labs writer was unsuccessful to posterior left hand x 1 and successful to posterior left hand x 1 . 12/24/2021 12:21 AM Late Entry for: 12/23/2021 LAB COMMENTS: Writer received call from lab at approx. 6pm with critical sodium 174 and chloride 140 . notified (physician) of critical labs via phone. (physician) gave orders for Sodium to be redrawn . Writer went to pt room to perform redraw. Attempts X 2 in right hand and left wrist. Writer called lab at 6:30pm to notify them of STAT lab draw . 12/24/2021 12:23 AM TRANSFERRED TO: (local hospital) by ambulance NOTIFICATION: Writer called (family member) r/t (related to) lab value, writer informed (family member) labs were still elevated . (family member) did state to send . to (local hospital) . A review of the Urinalysis/UA lab result Dated 12/21/2021 revealed UA Appearance Abnormal Turbid . UA Hyaline Casts (clusters of urinary sediment that contain red blood cells, white blood cells and fat bodies) Abnormal 50-100 . UA Bacteria Abnormal 2+ . A review of the hospital records revealed the following: Patient (Resident #1) Date of Admit: 12/24/2021 . This is an 88 y/o lady who presented to the hospital with abnormal lab values. She resides at (the facility) and (family member) notes that she had increased lethargy for the past week. Labs were drawn and showed increased sodium and kidney levels, thus patient was sent to the ER. In the ER, patient was found to have acute [CONDITION(S)] and a sodium level of 175. Lactic Acid was 2.5 and improved to 1.4 with IV fluids. Patient was also hypothermic. She was started on IV [MEDICATION(S)] for [CONDITION(S)]. UA positive for [CONDITION(S)] (urinary tract infection) . Plan of Care Assessment 1. Septic shock due to [CONDITION(S)] 2. Acute urinary tract infection 3. Dehydration 4. Severe [CONDITION(S)] 5. Acute [CONDITION(S)] 6. Vascular Dementia . Plan: Admit to ICU (intensive care unit) . A review of the death certificate revealed PRONOUNCED DEAD ON December 30,2021 . CAUSE OF DEATH a. [CONDITION(S)] b. Dehydration c. Acute [CONDITION(S)] . On 1/24/22, at 9:20 AM, the DON was interviewed regarding Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON was asked when the UA was ordered by the physician and the DON stated, that the labs were ordered on 12/17/21 and there was one attempt on the 20th to obtain the urine specimen but that was unsuccessful. The DON was asked why it took so long to obtain the UA and the DON stated, I would have tried to get it the day it was ordered and that it is not normal to wait 3 days to get a UA lab completed. On 1/24/22, at 9:45 AM, a record review of Resident #1's progress notes was conducted with the Assistant Director of Nursing (ADON). The ADON was asked to show documentation that the physician was notified of the delay in obtaining the UA and the noted vaginal discharge. The ADON stated that they didn't see any such documentation. A record review of the PHYSICIANS'S PROBLEM LIST along with the ADON revealed that Resident #1 was not listed for the delay in obtaining the UA and the vaginal discharge.

This Citation pertains to Intake Number MI 714 Based on observation, interview, and record review the facility failed to develop and implement comprehensive policies and procedures for serving hot liquids to facility residents, resulting in one resident (Resident #20) sustaining 2nd degree [CONDITION(S)] on her right abdomen and upper thigh areas causing extreme pain, and undue suffering, with the potential to affect all facility residents receiving hot liquids from the kitchen. Findings Include: On 1/20/22 at approximately 1:45 PM, an interview was conducted with ADON (Assistant Director of Nursing) regarding Resident #20 spilling hot water on herself. The ADON reported she was not in the building when the incident occurred and upon her return assisted with the initial assessment of the resident. The ADON explained Resident #20 had [CONDITION(S)] under her breast line, along her abdomen and it wrapped to the right side and some spots on her right hip. She also observed a few blisters on her lower abdomen. Upon Resident #20's readmission to the facility they updated her care plan to reflect that Resident #20 must have a cup with a lid, has to up in a chair in her room or in the dining area when she has hot tea. The ADON reported Resident #20 is legally blind and likes her tray to be set up a particular way and most aides are aware of this. The ADON reported Resident #20 has always been served hot tea with her tray and had never had any spills prior to this incident. The ADON reported currently they take the temperature of the hot water in the kitchen and right before it is served to the residents. On 1/20/22 at approximately 2:00 PM, an interview was conducted with Care Coordinator B regarding Resident #20. Coordinator B stated the resident has appointments every two weeks with the burn clinic and the [CONDITION(S)] are healing well. The Care Coordinator observed the [CONDITION(S)], and they were from below her breast on the right side, all the way down to the top of the right thigh. Coordinator B reported Resident #20 was able to tell her that she spilled hot tea on herself which caused the [CONDITION(S)]. On 1/20/22 at 2:30 PM, an interview was conducted with Occupational Therapist C, regarding Resident #20. Occupational Therapist C was asked if they routinely complete hot liquids assessments for facility residents. It was explained there is not currently a formal process in place for hot liquid assessments but if a therapist feels a resident is unsafe in handling hot liquids, they will address it with an assessment and provide their recommendations. Occupational Therapist C reported she was directed by the Rehab Director to complete a hot liquids assessment on Resident #20 once she was readmitted back to the facility. Therapist C further explained Resident #20 has a vision deficit and is systemic in how her meal tray is set up. Resident #20 always had hot tea with her meals for many without incident. Therapist C stated Resident #20 explained that her hot tea was placed behind a bowl versus next to it. The resident was sitting in her bed with the head of bed elevated, instead of on the side of the bed. Resident #20's sleeve got caught on the straw of the hot tea and splashed all over her. Occupational Therapist C stated she made the recommendation the hot tea is served to Resident #20 in a coffee mug with a stir stick instead of a straw. A review was completed of the Hot Liquid Risk Assessment completed with Resident #20 on 12/1/2021 at 2:38 PM by Occupational Therapist C. The assessment stated, Hot liquid risk assessment with patient demonstrating good safety awareness. Patient was able to recall and describe in depth the situation surrounding the hot tea spill. Patient states that her tray was brought to her and positioning of items was relayed. Patient stated that her cookies were placed above her food, which they normally placed to her far left, and her silverware/napkin roll was placed behind her drinks. Patient states that she was feeling her tray and placement of items when she reached behind her tea for her napkin. When she brought her hand back, she caught the straw of the hot tea causing the drink to spill toward her .Patient states in the past she has been given tea that is too hot to drink and has opened water to scoop ice cubes out to place in tea. Given the detailed account of incident along with ability to problem solve solutions, patient demonstrates good safety awareness and low risk for spill if tray is set up in proper position with given instruct of where items are located . It can be noted this was the first Hot Liquids safety assessment that was completed on Resident #20. On 1/24/2022 at approximately 9:30 AM, a review was completed of Resident #20's medical records and it revealed the resident was admitted to the facility on [DATE] with diagnoses that included: [CONDITION(S)], [CONDITION(S)] and Mood Disorder. Resident #20 is cognitively intact and able to make her needs known and does require assistance with daily cares. Further review was completed and there was no hot liquids safety assessment or other documentation regarding safe handling, tray set up or how the hot liquids should be served to Resident #20 located in the residents' medical records. On 1/25/22 at approximately 9:30 AM, an interview was conducted with Food Services Director F regarding their process for temping hot liquids before serving to residents. Director F explained Resident #20 always had hot water on her tray and she prefers to dip her own tea bag in the cup. Director F stated dietary staff dispense the hot liquids (water and coffee) from their coffee brewer (has spigots for hot water and coffee) in the kitchen into crafts (insulated pitchers). Director F stated they put ice in the bottom of the crafts and temp them prior to taking them upstairs. Before serving residents, they complete a test cup on the coffee and hot water to ensure the temperature is not over 140 degrees. Director F was queried if this was the process when Resident #20 had the spill. Director F reported prior to the spill there was no process in place for cooling or temping hot liquids being served to residents. Director F explained dietary staff would temp the water and coffee when they dispensed it into the crafts but there were no attempts at cooling the liquids. Director F was queried if there were temperature logs from that day that showed the temperature of the water. Director F reported dietary staff were temping the water and coffee, but it was documented. On 1/24/22 at 11:02 AM an interview was conducted with CNA (Certified Nursing Assistant) E regarding the incident with Resident #20. CNA E reported she was in the dining area and heard a scream for help and when she entered Resident #20's room she was lying flat on her back with her nightgown pulled out and a Styrofoam cup (with the lid a couple of inches away) was next to her. CNA E reported the resident is legally blind but routinely has hot tea with all her meals and has never had an incident. CNA E explained Resident #20 was trying to take her clothes off as she had her nightgown pulled up and her brief pulled away from her body. She reported the [CONDITION(S)] spanned from her abdomen (on the right side) to her hips and there were blisters. On 1/25/22 at 10:05 AM, an interview was conducted with Nurse D regarding Resident #20's hot tea spill. Nurse D stated she was passing medications in the dining room area and overhead a resident scream. She observed a CNA walking into Resident #20's room and she walked in after her. Nurse D observed Resident #20 sitting in bed and her shirt was off. When asked what occurred Resident #20 reported she spilled her tea and burned herself. Nurse D reported they soaked towels in cold water and placed them on the resident burn areas which were on her chest, abdomen, thigh, and right hip. Nurse D stated the resident normally has hot tea served with her meals and there has never been an issue. Nurse D stated they sent the resident out to the hospital for assessment. On 1/25/22 at 11:40 AM, this writer observed the new process for hot liquids in the kitchen. Director F also dispensed hot water from the brewer into a cup and the temperature was 180 degrees. On 1/26/2022 at 11:40 AM, Resident #20 was laying in bed after facility staff provided care for her. Resident #20 was asked if she remembered when her hot tea spilled on her, and she stated she did. She reported she was lying in bed and the staff delivered her tray. Resident #20 explained the head of her bed was elevated as she was having lunch while still in bed. She unwrapped her silverware and decided she did not need it so she put it back on her tray. As she was bringing her arm forward from putting the silverware back her sleeve caught the top of the straw on her tea, and it splashed all over on her. Resident #20 pointed to an area on her abdomen that was bandaged. She continued many residents had complained regarding the temperature of the hot water and she believes the facility should not have served water of that high temperature to residents. Resident #20 reported staff were quick to respond once she spilled the water and added now the temperature of her water is much cooler and they don't serve it in such a large cup. Resident #20 explained since her admission at the facility, she has always received hot water with her meals and never incurred an issue until now. Review was completed of emergency room records for Resident #20. The records stated, .Noted the right side of her abdomen as well as anterior thighs region of [CONDITION(S)] consistent with splash type burn from hot liquid. She has a scattered areas of second-degree burn with intact blisters with the central portion of burn .Approximate area of second-degree burn is less than 3-4% second-degree burn at this time .Thermal burn partial thickness right side of abdomen and anterior hip/less than 2-3% thermal second degree burn right lateral abdomen and anterior hip . Resident #20 was transferred from local emergency room to an acute care hospital that specializes in burn. A review was completed of their records and the following was revealed, .Per report she lives at a (facility) and accidentally spilled hot tea water onto herself, localized to her right abdomen and upper thigh .Abdomen: + superficial partial thickness burn to tight lateral abdomen with 3 small blisters present, no drainage, tender to palpation .Extremities: + small area of superficial partial thickness burn to right upper thigh .Active Problems: Second degree burn of multiple sites of trunk burn of right thigh, second degree. Partial thickness burn of left thigh, partial thickness burn of right thigh . Review was completed of the FRI (Facility Reported incident) investigation completed by the facility regarding Resident #20's hot tea spill. The investigation indicated the following: .Resident was in bed and had hot tea with her meal. Hot water cup spilled onto resident. Redness noted to chest, abdomen, right upper lateral leg/hip and gluteal fold, Resident spilled water on herself. Resident stated, the water spilled stupid. Blister noted to right hip and abdomen. Resident c/o pain and burning .Wet was cloth applied to reddened areas On 1/25/22 at 2:30 PM, the DON (Director of Nursing) reported prior to Resident #20 tea spill, there was not a policy that addressed appropriate temperatures to serve residents liquids and a cooling process. The DON verified with Facility Educator G there was no training provided to staff prior to the incident in November 2021 regarding serving hot liquids to residents. On 1/27/2022 at 9:15 AM, an interview was conducted with the Administrator regarding the incident with Resident #20. The Administrator expressed Resident #20 is very particular regarding her meal trays and how they are set up in a linear fashion. He continued after the incident they completed education and a process change with the facility staff as it was found there were no processes in place for serving, cooling, and temping hot liquids prior to serving to residents. The Administrator reported the facility completed hot liquid assessment as needed for residents and not at a specific frequency as other assessments.

This citation pertains to Intake Number MI 556. Based on observation, interview, and record review, the facility failed to maintain safety by following care planned safety interventions for one resident (Resident #200) out of 4 residents reviewed for safety, resulting in Resident #200 sustaining a Left Humeral (upper arm/shoulder) fracture, pain and suffering. Findings include: On 12/26/19, Review was done of Resident #200's medical record and it revealed the following. Resident #200 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to Minimum Data Set ((MDS) dated [DATE], Resident #200 scored 7 for Cognition Assessment (Moderate impairment) and required two person assist with Activities of Daily Living (ADL) care and for transfers with mechanical lift. Review of Resident #200's Care plans dated 11/22/19, for Transfers documented 'Stand up Lift Two Assist, Place AFO (Ankle Foot Orthosis to correct weakness and for positioning) to be on left foot. Make sure to stabilize the knees, at the knee support.' Review of the bedside Care plan dated 11/01/19, through 12/27/19, transfer 'Stand up lift, with 2 assist, to guide left foot, make sure left foot is down.' Review was done on 12/26/19, of a Facility Reported Incidence, submitted to the State Agency related to Resident #200, by the Director of Nursing documenting On (MONTH) 1st @ 1:30 PM, I was contacted by nurse from the facility related to X-ray findings for Resident #200, due to verbal complaints from Resident #200 of pain to left arm from the morning hours of 11/30/19. The X- Ray results confirmed an acute [MEDICAL CONDITION] Humerus with displacement. The Doctor was notified and indicated to send Resident #200 to the emergency room for evaluation. The report also indicated that Resident #200's arm fell to her side during a transfer with the Stand up Lift during the afternoon hours on 11/30/19. The DON documented he came to the facility at 2:30 PM on 12/1/19, and started an investigation, and that Resident #200 was at the hospital upon his arrival. The report indicated all staff that were present and assigned to the hall/unit and directly to care for Resident #200 were questioned and statements were taken. The report documented that the DON obtained assignment sheets for the previous shift when Resident #200 voiced verbal complaints that her left arm was hurting. The report indicated the DON interviewed Certified Nursing Assistant C on 12/1/19, who was assigned to care for Resident #200 on afternoon shift 11/30/19, if anything occurred on her shift. CNA C indicated she came on shift on 11/30/19, and observed Resident #200 on the bedside commode. CNA C indicated she came onto shift behind CNA A and got report from CNA A that Resident #200 was on the commode and CNA A would finish Resident #200's care before leaving her shift on 11/30/19. CNA C reported that when she went to check on Resident #200, she was sitting back in her wheel chair and off the commode. CNA C was suspended pending further investigation according to the report. The report indicated the DON interviewed CNA D and asked if she had any involvement with Resident #200 during the afternoon hours of 11/30/19. CNA D verbalized she had assisted CNA C with transfers on the afternoon shift of 11/30/19. The reported indicated Resident #200 returned to the facility on [DATE], around 6:15 PM, with a left arm immobilizer on, due to fractured left arm and need for ortho consult. The report documented a conversation with Resident #200 and the DON upon her return from the hospital. It was documented that Resident #200 said I just returned from the hospital because I have a fracture, and the girls were transferring me with a standup lift and my arm fell to the side and started hurting with pain. The report documented Resident #200 had a previous stroke that resulted in left sided [MEDICAL CONDITION] (weakness) and complete flaccidity to her left arm and hand. The report documented orders, charting, and initiated vital signs, pain management, and the previous transfer status was changed from a 2 person sit to stand lift to electric lift 2 assist. Review of 5 day report documented additional staff interviewed, and CNA C was re- interviewed on 12/2/19, and indicated that report was given to her by CNA A before going off shift, and Resident #200 had been toileted by CNA A before leaving first shift on 11/30/19, and when CNA C looked in the room Resident #200 was on the commode. CNA C indicated she went to check on other residents and get report. CNA C indicated that when she checked on Resident #200 later that day, Resident #200 was complaining of left arm pain. The report indicated a phone call was made to CNA A on 12/2/19, to get information on what happened on 11/30/19. The report documented that CNA A got resident #200 up for breakfast that day, performed ADL care with the assistance of CNA B, and toileted Resident #200 before attending an activity. The DON interviewed CNA B on 12/2/19, who indicated she did not assist with any transfers or toileting for Resident #200 with CNA A and the report indicated CNA B also told the DON that CNA A approached her on 12/1/19, and said if they come asking you if you helped me, tell them you did. The report documented that thru the interviews it was concluded that CNA A did not follow the Facility Policy and Procedure for Stand up mechanical Lift during her shift on 11/30/19, and was terminated on 12/4/19, for violating facility Policy and Procedures , and disregarding a transfer status order and safety interventions. Review was done of Facility Policy 'Stand up Lift Use' dated 4/28/14, documented To provide means for staff to Transfer a resident who has some torso control and fair to poor leg strength. Explain procedure to the resident. Provide privacy. Assist resident to sitting position. Place sling around the resident's waist fasten strap. Place lift in front of resident. Lock the lift. Place resident feet on platform. Attach sling to lifting arms of lift using second loop. Have resident hold lift handles. Use lift controller and spread lift legs for positioning. Tell resident you are performing transfer, unlock breaks, perform transfer. Lift resident using control panel. transfer resident to bed or chair The DON was interviewed on 12/26/19, related to this investigation and indicated he viewed video footage for the day 11/30/19, and seen CNA A obtain the mechanical lift and take it to Resident #200's room two times on her shift, and stayed approximately 20 minutes each time with no other staff observed to enter or exit the room on both events. The DON was asked what the second person was supposed to be doing during the sit to stand lift transfer and indicated the 2nd person was supposed to support the left arm for Resident #200 due to weakness, and assist with safety. The DON indicated CNA A performed an illegal transfer not in accordance the safety bed side care plan interventions or their Policy for Lifts and they Terminated her for it. The DON indicated during the interview with CNA B it was reported that CNA B never laid hands on Resident #200 as CNA A indicated and was asked to cover it up that she transferred Resident #200 by herself. The DON said that the sling goes up under the arms and without the additional support, and weak legs, the sling must have caused the fracture to Resident #200 if she slumped at all. The DON also indicated that a Write-ups were given to CNA C and Dwho also performed a transfer on 11/30/19, 2nd shift, and informed that Resident #200's arm was not supported during a transfer and fell to her side, causing additional pain and discomfort. The DON provided this Surveyor the Write up for CNA C, but was not able to provide the Write Up for CNA D. The DON was asked if the Surveyor could view the video footage and indicated he did not have it anymore and it was only available for 14 days. Review of Radiology Report dated 12/1/19, and electronically signed 12:13 PM, by the Medical Director documented results of Fracture involving Humeral head with displacement. Conclusion: Acute proximal left fracture as described. Review of Consultation report from an Ortho Consult dated 12/5/19, documented under Diagnosis: [REDACTED]. No transfers, or handling left upper extremity. Return in 6 weeks on 1/16/20. Phone interview was done with CNA A on 12/26/19, 9:51 AM, related to the incident with Resident #200. CNA A was asked if she transferred Resident #200 according to bed side care plan, and said Yes with the help of CNA B. CNA A was informed that video footage revealed her going into the room with the sit to stand lift two times on her shift and no other staff were observed to enter or exit the room. CNA A reiterated she did transfer Resident #200 both times with the help of CNA B. CNA A indicated that the DON showed her the video footage and she could not explain why the video showed no other staff entering or exiting the room. CNA A said that they transferred Resident #200 to her chair. CNA A said they got her up for breakfast and again before her shift was over. CNA A was asked if she was still worked at the facility and said No, I was terminated on 12/4/19, by the DON for not using two person assist with the Sit to Stand Mechanical Lift. Interview was conducted on 12/26/19, at 3:52 PM, with CNA C who indicated she came on shift behind CNA A on 11/30/19, 2nd shift. CNA A indicated she observed Resident #200 at the start of her shift on the bedside commode. CNA C verbalized any transfers for Resident #200 require a Sit to Stand Lift to transfer Resident #200 out of bed, to commode, to her chair, and back to bed, with assistance from another staff member. CNA C said that when she went back to check on Resident #200, Resident was back in her chair off the commode before CNA A left for the day. CNA C indicated she performed a transfer later that day with the help of CNA D to get resident back in bed. CNA C said at that time, she could not remember the staff member that help her perform the transfer, and then indicated it was CNA D. CNA C said that Resident #200 was complaining of pain once she was back in the bed, and would not let her remove clothing off from the waist up, and that Resident #200 was complaining that her left arm hurt real bad. CNA C was asked if she informed the nurse about the pain and said No. CNA C was asked why and said she must have forgot to. CNA C verbalized the next day she was pulled out of report and asked to give a statement to the DON and sent home. CNA C indicated that she received a discipline a few days later because during one of the transfers, Resident #200's left arm was not supported during the transfer and fell to Resident #200's left side during the transfer. Interview was conducted with CNA D on 12/26/19 at 4:35 PM related to transfer on 11/30/19, with CNA C. CNA D also verbalized she couldn't remember the staff that was helping perform the transfer and then indicated it was CNA C. CNA D was asked if anyone supported Resident #200's left arm during the transfer and indicated No. CNA D verbalized that while the lift was going up, Resident #200's arm fell to her side. CNA D was asked if Resident #200 expressed any pain and said no, and reiterated that no staff was supporting the left arm during the transfer. A phone Interview with CNA B was conducted on 12/27/19, @ 11:25 AM, related to the incident with Resident #200. CNA B verbalized she had came to work on 12/1/19, and was informed of an X-Ray taken for Resident #200 that indicated a Left shoulder fracture. I was interviewed by DON related to my assignment and hall partner for 11/30/19, with CNA [NAME] CNA B verbalized that CNA A came to her and said that she transferred Resident #200 by herself times two on 11/30/19, and that if anyone comes to ask me if I helped, say I did. CNA B said she nodded her head yes and went to work. CNA B verbalized when the DON questioned her, she told the truth. CNA B said, I did not lay hands on Resident #200 at all on 11/30/19. CNA B also said that CNA A never came and asked her to help because she would have. CNA B said that CNA A did the transfers by herself. An interview was conducted with Resident #200 on 12/27/19, 12:00 PM. Resident #200 was able to tell Surveyor what day, year, who the president was, and how long she had been at the facility. Resident #200 was asked how she received a broken left shoulder and said Two girls did it. Two girls I have never seen before, and haven't' seen since. I hope I don't either. They did not know what they were doing and did a transfer, and they twisted my left arm behind me and I felt pressure and a pop. I demanded to get an X-ray the next day because the pain got so bad later on. That was my paralyzed arm that was caused from a stroke many years ago. I told the girls You better stop during the transfer, but they didn't stop. I told the girls they are hurting me. The next day on Sunday 12/1/19, the pain was so bad, I couldn't stand it. The nurse came in to see me on Sunday 12/1/19. and tried to move my arm, but couldn't. I couldn't do anything with it. I went to the hospital and they gave me [MEDICATION NAME] for the pain. They put the Girdle on my arm. That was what they called it in the hospital, a girdle (Immobilizer). I used to get up and use the bedside commode before, now when I don't want to get up, I use the bed pan. The pain was terrible and I hope no one ever goes thru this. It is real bad. Review of Physical Therapy evaluation and plan of treatment dated 11/22/19, documented for Transfer Status: Stand up Lift with twp person assist with all transfers with left AFO on and with stabilization left (UE) upper extremity, and left knee to be supported by the knee pads while standing in the stand up lift. The DON was interviewed again on 12/27/19, regarding the fracture on Resident #200, and indicated that the single person transfer injured the left shoulder and then when the arm was not supported during the next transfer, it made it worse and that was how Resident #200 received a Left Humeral Fracture.

This citation pertains to Intake Numbers MI 872 and MI 836. Based on observation, interview and record review, the facility failed to prevent physical and verbal staff-to-resident abuse for two Residents (#1 and #4) of four residents reviewed for abuse resulting in Resident #1 experiencing their arm being restrained, verbal abuse and psychosocial distress (using the reasonable person concept) and Resident #4 being forced to shower after refusing, resulting in acquired bruises to the hand and wrist area, pain, frustration, fear and anxiety. Findings include: Resident #1: A review of Resident #1's medical record revealed an admission into the facility on [DATE] with a readmission on 4/11/19 and a discharge to the hospital on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set assessment revealed the resident had moderately impaired cognition and needed extensive assistance with dressing, personal hygiene and toilet use and was always incontinent of bowel and bladder. A review of the investigation report for an incident that occurred on 4/14/19, to Resident #1, signed by the Former Director of Nursing (Former DON) P, included the following: - On (MONTH) 14, 2019 at approximately 5:45 PM I (Former DON P) received a telephone call at my home from charge nurse (Nurse G) related to an incident with the resident (Resident #1) and (Certified Nursing Assistant (CNA) F). (CNA E) was in the room with (CNA F) providing care to (Resident #1) who had an incontinent bowel episode. It was reported that (CNAF) was assisting to turn (Resident #1) when he began to punch and knee at her calling her names and she proceeded to put her knee up next to his arm on the mattress to push his arm close to him and when he tried kneeing her she pushed his legs together as well. It was also reported that (CNA F) said to (the Resident) 'hit me again and it'll be the last time. 'Hit me again and see what happens next.' 'Hit me again and you'll lose the arm.' -CNA F was removed from resident care. The Former DON P arrived at the facility at approximately 6:05 PM. - . (CNA F) stated that, 'he was swearing and calling us (explicit language) and punching and kneeing at us, I told him to stop but I might been a little more aggressive than that.' He kept saying stop you (explicit language) to me and (CNA E). (CNA F) continued, 'I can't remember what I said because it was in the moment' 'to (CNA E's) ear it could've sounded like abuse.' I (Former DON) then asked her what she meant by to (CNA E's) ear and why she felt his ear would hear something different than what she heard. She stated, 'I was in the wrong and it wasn't good.' I asked her again if she could remember anything that was said and she said, 'I can't recall I was upset, and he did whatever he heard is probably right. I let it get the best of me. My personal stuff at home got the best of me. I'm having problems with my husband and I was in the wrong.' 'I'm 52 and I don't think I'm cut out for the CNA work anymore.' 'I'm too old.' I asked her again if she could recall any of these sentences that she said and she stated, (CNA E) was with me and he was the most accurate.' I asked her if the statement 'do that again and see what happens' is something close to what was said and she stated, 'yeah that might be pretty close.' I then asked her if she put her knee on the residents arm and she stated, 'I didn't put it on his arm but I did put it up next to his arm and pushed his arm up closer to his body by the mattress so that he wouldn't hit me anymore.' I asked her if her leg was next to his arm or on top of his arm and she stated, 'it was next to it kind of pushing it in close to his body so he wouldn't hit her anymore.' I could not get an accurate statement from her. I did reread her written statement that she had given the nursing staff which said, 'resident combative and verbally abusive towards AIDS and with all cares. Assisted other aid with getting dressed and changing pad which was soiled. Resident was heating (hitting) aid to which aide held his shirt and arm so resident wouldn't hit. Resident wouldn't cooperate with turning to get brief and pants on. Her statement was unsigned however she did confirm that was her writing and that was the statement that was written by her. I also reread my notes to her, and she stated they were accurate however she refused to sign my recount of our interview as well. She stated, 'if you have to fire me right now, I understand I was in the wrong and I don't blame you.' I informed her that the facility must complete and appropriate investigation and that we would most likely have to report this to the state agency, and it is likely if everything turns out as stated that she would be terminated . - . I (former DON) then spoke to (CNA E) who was the CNA in the room with (CNA F) during the time the statements were made. (CNA E) confirmed that they were trying to clean (Resident #1) up from a bowel movement incontinence episode. He said that (CNA F) did have her knee on the outside of the left arm pushing toward his body and into the mattress and he said the arm was not necessarily completely under her knee her knee was pushing it towards his body to keep him from hitting her. (CNA E) shared that (Resident #1) said to them, 'stop pulling on him and she pulled him like four times and (CNA E) saw his head tapping on the transfer bar which is padded and she looked at his head and body and he wasn't sure if she was doing that on purpose or not.' (CNA E) did state that (CNA F) made these three statements: 'hit me again and it'll be the last time.' 'Hit me again and see what happens next.' Hit me again and you'll lose the arm.' (CNA E) then stated the resident did try to knee her and she held his legs together as well. (CNA E) shared that they got (Resident #1) finished with care and up in the chair and he told (CNA Q) who then went and told the nurse which was approximately 5:30 PM or 5:45 PM. On 9/10/19 at 2:32 PM, an interview was conducted with CNA [NAME] regarding the incident on 4/14/19 with Resident #1 and CNA F. When queried regarding the events the CNA stated, We were getting him up for dinner. He was combative. He was weak on one side. She almost seemed like she was egging him on and said things like, hit me again and see what happens, hit me again and you will lose the arm. She was pinning his left arm down with her knee. She seemed like she was very upset with him doing that. We were trying to get him up for dinner. If you try to take his covers off, he would try to hit you. When queried if the resident had a history of [REDACTED]. He was grouchy and easily tested , you could say. If you tried to do any type of care or get him up for dinner, he was not happy with you but once he is up, he was fine. Later on, I learned how to redirect him or distract him. When this happened, we were still new and in training. We were waiting to take the testing (for CNA certification). He was incontinent both ways (urine and bowel movement) and we were cleaning him up for dinner. He just didn't like it being done. I tried to redirect but what she was yelling at him, it seemed like she was trying to agitate him more. I was froze. I just wanted to get him up and out of the situation. I should have said to her, 'Hey don't do that,' when she pinned his arm down. We were told to report that stuff when we see it. I was new and didn't know what to say at the time. I should have said to stop. In hindsight I should have said something, but I just froze up and didn't know what to do. We got him up as fast as we could and took him out. Our trainer was in the hallway and I went right to him and told him what she did, and he went to our charge nurse and team leader. They both came to ask what happened and what was said. The CNA indicated that the Nurse did not want CNA F around other Residents and had taken her out of direct care and had called the Director of Nursing. The CNA was queried why he didn't ask her to stop or call for assistance and stated, When she was pinning his arm down, I was going to say something, but we just got him up right away and into his chair. I know now we need to tell them not to do it. We were training with the same trainer and that was like our second or third day down that hallway. When queried why the trainer was not with them, the CNA indicated they were almost done with training and stated, He was training us to be on our own. We were doing things on our own because we were almost done with our training. She said she was a CNA for the last [AGE] years or so and she had moved up from Florida and had to take the class. When queried if the Resident had been injured the CNA indicated that he was not. When queried if the Resident showed any signs of fear, the CNA indicated the Resident did not and stated, He probably wouldn't remember if he was asked what had happened. On 9/10/19 at 4:09 PM, an interview was conducted with Charge Nurse G, regarding the incident on 4/14/19 with Resident #1 and CNA F. A review of the incident was conducted with the Nurse. The Nurse stated, (CNA E) reported it because the CNA (F) was too rough. When the Resident became combative, she held his arm down and he felt she was holding him down not like protecting herself. A review of what occurred after the CNA had reported it was conducted with the Nurse and stated, The CNA was in sight while it was discussed, and we called the DON. She was taken to get a written statement and the DON arrived and escorted her out of the building. The Nurse was queried regarding injury to the resident and the Nurse indicated that no physical injury was assessed on the Resident except for old bruising. On 9/10/19 at 4:46 PM, an interview was conducted with CNA F regarding the incident on 4/14/19 with Resident #1. The CNA explained that she had taken the CNA class at the facility and stated, I was a CNA in Florida and let it slide and I took the CNA class to get re-established to become a CNA again. When queried about the incident, the CNA stated, Yeah I remember it well. They asked me questions already. When I spoke with (Former DON) I told him I was done. Can you tell me what happened? The CNA stated, An aggressive resident was punching at me and kicking at me. I was protectively protecting myself when he has hitting me. The CNA was queried on how she protected herself but did not answer the question and stated, If I can't get a fell ow worker to help me when I am getting beat up then I am done. When queried if she had asked the other CNA for help, she replied, He was standing right there watching me get beat up and he just kept on wiping his bm (bowel movement). I have no other plans to be a caregiver in that field again. (CNA E) was cleaning up his bowel movement, he should have switched places with me. If there is a two team in there, if it's a male and female then the male CNA would be the one to take the hits. When queried regarding a situation with two female CNA's with an aggressive Resident, the CNA stated, If two females with an aggressive patient, we stop and walk away and get someone else in there. When queried if she had called for assistance or stopped and walked away, the CNA stated, I had my hands full. When queried if she had asked for CNA E's help or to switch with him, the CNA stated, He should have known what to do. He took the class. When queried if she had asked the other CNA for help or called for assistance, the CNA did not answer but stated, (CNA E) took the course, the teacher told us what to do in those situations. When queried what the teacher told you to do in those situations, the CNA paused then stated, I am trained in those situations. I know what I was to do. When queried what she had said to the Resident the CNA stated, This was back in (MONTH) and I told (the Former DON) that I was done. I admit I was wrong in the situation. I told (Former DON) that I was done and walked away from the situation. There was an investigation already. I told them about it. I don't need to be going over this again. The interview was then terminated shortly afterwards by the CN[NAME] On 9/12/19 at 8:50 AM, an interview was conducted with the Director of Nursing regarding Resident #1 and the incident that occurred on 4/14/19. The incident was reviewed with the DON. When queried what the facility policy was for providing care to a combative Resident, the DON stated, With a combative Resident, we ask that the staff member bring in a second CNA to deescalate any situation and to be there as a witness. With a combative Resident, they should stop what they are doing and grab another CNA to see if they get the same response. A review of the interview that was conducted with CNA F in which the CNA indicated the male CNA should have switched places with her because the Resident became combative, the DON stated, We don't expect the male CNA to take all the blows. When queried what should have been done in the situation, the DON stated, When he identified that the abuse was occurring, he should have stopped immediately and removed (CNA F). He should have protected the resident from (CNA F), stopped and removed her from the situation. On 9/12/19 at 11:53 AM, an interview with the Former Director of Nursing (FDON P) was conducted on the phone regarding the incident that occurred on 4/14/19 to Resident #1. The FDON stated, I got a call about dinner time. I was home and went in. (CNA [NAME] and CNA F) were taking care of (Resident #1). (The Resident) had a long history of being physical with staff. (CNA F) had said those things . (reviewed from the investigation report of the verbal abuse of the comments, 'hit me again and it'll be the last time. 'Hit me again and see what happens next.' 'Hit me again and you'll lose the arm'). The (CNA E) said she (CNA F) had put her knee on his (Resident #1's) arm and she said the knee was by his arm. I came in and assessed him, no bruising or redness that I seen and they (Nurses) looked him over also. When queried regarding an incident report, the FDON indicated he had not had completed one and stated, There was no injury, no outcome. The FDON indicated the Responsible Party was notified, the State Agency was notified and stated, I had (DON) flag her file so she was not a candidate for certification, she would not be able to test. The FDON indicated CNA F had come back in and he had interviewed her. The FDON indicated CNA F had tried to blame CNA [NAME] and stated, She said, My husband said why didn't he switch with me. When I asked if you asked him for help, she said 'no, I didn't.' When I asked (CNA E) he said he was in the middle of wiping the incontinent episode. It was finish and get done as soon as he could. Resident #4: A review of Resident #4's medical record revealed an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set assessment revealed the severely impaired cognition and needed assistance with transfers, dressing, personal hygiene, bathing and toilet use. A review of the investigation report for an incident that occurred on 7/2/19, to Resident #4, by the Director of Nursing (DON), included the following: - Day 1 Investigation Report (Resident #4) revealed, On (MONTH) 2, 2019 at 5:15 PM I (DON) was called at our facility by one of our charge nurses (Charge Nurse G) and made aware of a situation and potential abuse allegation against a resident (Resident #4) and suspected perpetrator CNA (CNA U) . Between the hours of 3:45 PM and 4:15 PM CNA (U) entered resident's private room (number) to begin giving her a scheduled PM shower. At 4:30 PM CNA (CNA M) reported that she received a nurse call page for resident room (number). Upon entering the private room if (of) (Resident #4), CNA (M) stated that CNA (U) appeared frustrated after she attempted to give (Resident #4) her shower. CNA (M) stated that she entered the resident's bathroom and saw resident sitting on the shower commode chair with her pants off and her sweater half off. CNA (M) stated that (Resident) appeared very upset and was complaining of pain to her left lower cheek, which resident had a skin tagged removed from that area previously that day. CNA (U) reported to CNA (M) that resident became very agitated and combative with her while preparing for her shower. CNA (M) stated that she tried to convince (Resident) to proceed with her shower and she simply stated 'no.' At that time (Resident's) assigned CNA (U) stated 'it's now or never.' At that point CNA (M) validated (Resident's) feelings and redirected her. CNA (M) assisted (Resident) with getting redressed and proceeded to push her to the dining room on the east hall pod dining room for dinner. CNA (M) noticed that (Resident) had some significant bruising to bilateral hands and wrist and when she questioned (Resident #4) about the bruising she became upset again and pointed at her CNA (U) and said 'she did it.' CNA (M) did say she heard (CNA U) sate the '(F-word)' a few times in front of (Resident ) but CNA (M) couldn't remember in what context the F word was used. CNA (M) . went immediately to her team leader (Nurse N) to report her concerns and findings . (Nurse N) reported that she assessed the bruising to bilateral hands, wrist, and forearms and noted the bruising to be consistent dark purple and appeared new. (Nurse N) reported that she reviewed the electronic charting system to see if there was any documentation to reflect the bruising. (Nurse N) stated that there was no documentation to reflect the significant bruising to bilateral hands, wrist, and forearms. (Nurse N) immediately reported the incident and suspected abuse allegation to her CN (Charge Nurse G) . CN (Charge Nurse G) reported that she immediately removed CNA (U) from the situation, placed her in the 2 south/east hall nurse charting area, had her write a statement, and then contacted me (DON) . At 6:15 PM, I approached (Resident #4) in the 2 south/east dining pod and asked her if I cold (could) wheel her back to her room so I could ask her a few questions. (Resident #4) nodded her head yes and so we proceeded back to her room in (number). After closing the door and getting down to (Resident's) eye level I noticed that she began to get tearful and started rubbing her wrist and hands. When I asked if she was okay she looked and me with fear and stated 'no, she did it! She grabbed me, she's not a very nice person.' I asked (Resident) if she was hit in anyway and she nodded her head no and began to rub her wrist and hands. (Resident) then pointed at the bathroom and started having difficulty getting her words out . (Resident #4) appeared to recall the event very vividly as evident in her body language. I made (Resident) aware that we would be contacting her POA (power of attorney) and also the local law enforcement to report the allegation of mistreatment. (Resident) immediately broke out in tears and nodded her head yes. I validated her fears and concerns told her that we are here to protect her and keep her safe. -Police Incident Report, dated 7/2/19, revealed, Interview Victim: On (MONTH) 2, 2019, at approximately 1927 hrs. (7:27 PM), I interviewed (Resident #4) regarding the incident. (Resident) was very upset about the incident and had a difficult time discussing the incident. When asked about the bruises, she stated 'that girl did it.' She said the girl grabbed her when she was in the bathroom and sitting. (Resident) was unable to give a name for the employee who did it. She explained the girl as tall with dark hair. She was unable to provide an other information as she was upset. Injuries: (Resident) had visible bruises on both of her hands and wrists. The nursing home RN medically checked and cleared her. -Written statement, dated 7/2/19, signed by CNA U, revealed, Resident was being very combative with cares. CNA tried to give resident a shower and resident yelled, hit, and punched CNA multiple times. CNA only touched residents arm to get her to stop punching CN[NAME] Resident was on commode in bathroom. Resident initially agreed to shower but once CNA got her in bathroom resident became very combative. CNA called for assistance and another CNA came in to help resolve issue. Resident was pulling on her own sweater very hard during procedure. After other CNA came in, we got resident dressed again and took resident down to dining room to cool down. The shower was refused, but a different CNA would be retrying shower with resident later that evening. -Written statement, dated 7/2/19, signed by CNA M, revealed, Answered call light-(CNA U) said, she won't get in shower. (Resident) was sitting on commode, pants off, sweater was half off. (Resident) was very upset, saying her left lower cheek hurt and pointed to it. I didn't see anything. I tried to convince (Resident) to shower, she insisted-no! I said, we can try after dinner, (CNA U) said, 'it's now or never.' (Resident) did not receive a shower. Seen the bruises on (Resident's) hands, reported it to nurse. (Resident) said, she did it and pointed to (CNA U). (CNA U) did say the 'F' word in front of resident. -Nursing note, dated 7/2/19 at 8:10 PM, revealed, Type of Event: bruise, Description of event: CNA responded to resident call light, upon entering resident bathroom(resident sitting on commode; agitated) noted bruising to resident right forearm, right and left hand. Peer CNA with resident reports resident combative behavior with attempt to provide scheduled shower. Injury: bruising right anterior forearm deep purple bruise with irregular margins 10 cm (centimeters) x (by) 3 cm; 1.8 cm x 2 cm, dorsal right hand near base of thumb 3 cm x 2 cm and base of 4th digit 2 cm x 2.8 cm. Left dorsal hand deep purple bruising; 5.2 cm x 3.8 cm; anterior left wrist 3.2 cm x 1 cm. Range of motion check: moves all extremities per baseline; no fc/O pain . -Psych physicians group visit, dated 7/3/19, revealed, Complaint: distress, anxiety, c/o (complaints of) bruised and rough handled during shower . Disposition: .with a hx (history) of major neurocognitive impairments, a hx of Alzh. (Alzheimer) Disease in her medical hx, a hx of [MEDICAL CONDITION], recurrent, unspecified, and Pt. (patient) with significant [MEDICAL CONDITION], able to convey her needs and some of her ideas if given ample time to process and organize her thoughts or when assisted to fill gaps. Pt. continues with anxiety and rumination about getting mistreated by an aid when she refused a shower. Those thoughts are triggered by cues and bruising on the right wrist . On 9/10/19 at 1:48 PM, an observation was made of Resident #4 lying in bed, awake. An interview was conducted with Resident #4. The Resident answered simple questions with one to three word sentences. When queried if anyone had hurt her, the Resident stated, They better not! Resident is pleasant, smiles and engaging in conversation. Dark, old appearing bruising noted to left wrist area and no bruising noted to right wrist area. No bruising noted to the Resident's face, fingers or lower part of the arms that were exposed from the sleeve of her shirt. On 9/10/19 at 3:31 PM, an interview was conducted with CNA M, regarding the incident on 7/2/19 that involved Resident #4. When queried regarding the incident the CNA stated, (CNA U) was trying to get her (Resident #4's) shower done before dinner. I seen the light was on, and that is when I found out she wanted to give her a shower. When I came in, I seen (Resident #4) was upset and (CNA U) was upset and she said she wanted to get her shower. (Resident #4) was very upset, this was not usual for her. Where was the Resident and the CNA? The CNA stated, (The Resident) was seated on the shower chair. She said she didn't want a shower. She had a cardigan sweater and that was half off. How long was the light going off? The CNA stated, I don't know, not too long. Did you hear anything before arriving in the bathroom? The CNA stated, I could hear that (the Resident) was upset. (Resident) made it clear to me she did not want a shower. I tried to convince her and she still didn't so I said we are not going to give you a shower right now and (CNA U) said 'its now or never'. When queried regarding how the Resident was acting, the CNA stated, She was really upset. When queried if she had seen the CNA hurt the Resident, the CNA stated, I didn't see anything physical. I think she said that the resident was hitting her. (Resident #4) don't hit. If she was doing something then it was probably pushing her away. When queried regarding behaviors that the Resident displays, the CNA stated, She doesn't have any behaviors. I have never had her with behaviors. Never seen her lash out. When queried regarding a history of the Resident refusing care, the CNA stated, I had never had her refuse care with me or seen her refuse before with other staff except one time when she didn't want her hair washed. When queried regarding what occurred next, the CNA stated, I finished getting her clothes on and (CNA U) stayed to help get her clothes on but (Resident) didn't want her to. It was obvious that (the Resident) was upset with her about getting her in the shower forcefully. The CNA was queried if the Resident was a one person or two person assist and stated, She is a one person assist. When queried why she let CNA U stay and help get her dressed when the Resident was upset with her, the CNA stated, I don't know, she just started putting her shoe on. After that I took her down to the dining room in her wheelchair. She was rubbing her hand. Got to the table and said let me see. It was the top of her fight hand, a big bruise, dark black, purplish. She pointed to her other hand and that was around her wrist. It was bruising. If I remember right, it was getting worse. Did you ask her what happened? The CNA state, I did and she would say, 'That girl'. I took her to the Nurse (Nurse N). (Nurse N) went to (Nurse G). When queried regarding CNA U, she stated, At that point we were serving dinner. (CNA U) was in the dining room and we were getting ready for dinner, she wasn't there for long before they removed her. The CNA was queried why she let CNA U continue with her care when the Resident showed distress over the CNA there and stated, I should have told her to go since the Resident was upset with her. I didn't realize she had the marks on her until after taking her down (to the dining room). On 9/10/19 at 3:00 PM, CNA U was called on the phone, but there was not an answer and a message was left. There was no return phone call prior to the exit of the survey. On 9/12/19 at 10:57 AM an interview with CNA CC was conducted regarding behaviors of Resident #4. The CNA was assigned care of Resident #4. When queried how the Resident communicates, the CNA stated, She gets her needs known by speaking, talks to you. Sometimes there is a delay but if you sit and listen she will tell you what she wants. When queried if the Resident could get her point across, the CNA stated, I would say so yes. When queried regarding showering the Resident, the CNA stated, Showers are on afternoons. When queried if she had refusal of showers, the CNA stated, I have given her a shower. She requested not to have her hair washed. She has the right to refuse. We don't push, let the nurse know. When queried regarding Resident #4 having combative behaviors with care, the CNA stated, No, never had her combative with me in anyway. Usually just explain to her then she is compliant. Just explain it to her and she usually lets you. On 9/12/19 at 9:50 AM, an interview was conducted with the Director of Nursing regarding the incident on 4/14/19 with Resident #1 when CNA F, while providing care to the Resident with CNA E, and CNA F had blocked the Resident's arm and verbalized, 'hit me again and it'll be the last time. 'Hit me again and see what happens next.' 'Hit me again and you'll lose the arm', and regarding the incident on 7/2/19 with Resident #4 developed bruising to the wrist and hand area after a shower had been attempted to be given by CNA U, with the Resident refusing the shower. When queried regarding Resident refusals of showers, the DON stated, If there are refusals, any kind of refusals, we attempt three times and then they would notify the charge nurse. We provide the Resident with education after they refuse. We tell our CNA's that with refusals they attempt 3 times with a different approach. When queried if CNA U had followed the facility policy, the DON stated, When (Resident #4) was displaying behaviors, no. At that time (the Resident) was pretty upset and not having any part of it. The Resident agreed to the shower but once she got into there, she refused to proceed with the shower. At that point the CNA should have got the Resident redressed and into the wheelchair and visited the shower at another time or see if another CNA could do the shower. When (CNA M) came in she noticed (the Resident) was upset. (CNA M) helped to get her redressed after she continued to refuse. When queried what CNA M could have done when realizing the Resident was upset with CNA U, the DON stated, If (Resident #4) was upset with the CNA, then (CNA M) should have asked her to leave, remove her from the situation. She could have asked what had happened and removed the CN[NAME] In both situations (incident with Resident #1 and incident with Resident #4) both staff had identified that there was something wrong, abuse or a situation that involved possible harm to the resident. Instead of completing the task they should have stopped and removed the person from the situation and reported it. They needed to act to ensure the safety of the resident immediately instead of continuing with the task. A review of the facility policy entitled, Abuse Prevention Program, with a reviewed date on 4/5/19, revealed, Policy Statement. Our residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Policy Interpretation and Implementation. 1. Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants . A review of the facility document entitled, Resident Abuse, Prevention and reporting, Elder Justice Act, revealed, Elder abuse is a term referring to any knowing, intentional,, or negligent act by a caregiver, family member or any other person that causes harm or a serious risk of harm to older people . Physical Abuse Is not limited to hitting, slapping, pinching, and kicking. Also includes controlling behavior through corporal punishment, including injuries of unknown etiology when it is suspicious, due to extent of injury or location of injury as is injury is located in an area not normally susceptible to injury . Verbal Abuse The use of oral, written or gestured language that willfully includes disparaging and derogatory terms to resident or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again. Examples: Verbal, Assault (verbal threat, no contact), Insults, Threats, Intimidation, Humiliation, Harassment . Abuse Prevention What can we do to STOP, PREVENT, and raise awareness about abuse . Stop-can you interrupt the chain o

Based on observation, interview and record review, the facility failed to provide two assist with ambulation as assessed, failed to have a call light within reach and a working safety alarm, and failed to follow an out of bed schedule for three residents (#'s 920, 924, 925) out of 21 residents reviewed for falls in a total sample of 30, resulting in a falls, a fall with injury, and the potential for further falls. Findings include: Resident #920: Review of Resident #920's clinical record, conducted on 5/26/16 at 9:00 a.m., revealed the following documentation: The most recent Minimum Data Set Assessment ((MDS) dated [DATE] documented that Resident #920 was originally admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #920's transfer and ambulation status was assessed as extensive assist of two staff for transfers and ambulation in the hallways. The MDS dated [DATE] assessed Resident #920's ambulatory status as limited assist of two staff for ambulating in the hallways. A Brief Interview of Mental Status (BIMS) assessment score of 4 out of 15 which indicated impaired cognition on both the 2/26/16 and 4/22/16 MDS's. The 2/26/16 MDS assessed Resident #920's pain level as no pain. The 4/22/16 MDS assessed Resident #920's pain as frequent with a score of 8 out of 10 with 10 being the worst. Review of the Certified Nursing Assistant (CNA) Kardex (care instructions), in place for Resident #920 at the time of the fall, was reviewed and revealed: 1. Ambulate with one assist with gait belt with rolling walker (in room for toileting). 2.Ambulate with nursing. Feet: 70 feet with one assist with rolling walker and one person to push wheelchair behind resident. A Facility Incident Report dated 3/31/16 at 4:50 p.m. was reviewed on 5/26/16 at 9:30 a.m. and revealed the following documentation: Type of event: fall. Description of event: CNA stated she was ambulate resident when resident stumbled on her own feet. CNA stated that she was able to guide resident to floor on to her right side without resident hitting her head .Resident C/O (complain of) right hip pain with assessment .Resident able to perform ROM (range of motion) but states right hip is painful. Order obtained for stat (now) x-ray of her right hip. A review of the X-Ray Radiology report dated 3/31/16 at 7:08 p.m., reviewed on 5/26/16 at 1:50 p.m., revealed documentation, Fracture involving right femoral trochanters (right hip)with displacement. A nurse's progress note reviewed at this time revealed the following, 8:28 p.m. Late entry for 3/31/16 7:30 p.m Received x-ray of right hip with conclusion: right hip fracture .Dr suggests that resident be sent to ER (emergency room ) for evaluation. Further review of nurses's progress notes revealed the following documentation: 4/4/16 Floor coordinator discussion with hospital discharge planner update on (Resident #920) who had surgery 4/1/16 r/t (related to) right hip fracture with rodding (used to realign and stabilize the bone after a fracture) done at this time. 4/5/16 12:21 p.m. Admission note .report from nurse at (hospital name) .resident (#920) had surgery to right hip on Sunday 4/3/16 .WBAT (weight bearing as tolerated), resident has not been walking and was a three assist with transfer. 4/5/16 1:37 p.m. Progress note .informed resident (#920) that we were going to be assessing her ability to transfer. Resident stated, I don't want to fall. Resident was unable to bear weight and stated, My leg really hurts . 5/11/16 Physical Therapy (PT) note .Resident (#920) has anxiety with weight-bearing on the right side .states I broke that hip. 5/20/16 PT note .Resident (#920) continues to have anxiety with gait (movement of limbs) activities. On 5/26/16 at 9:50 a.m. CNA J, was interviewed and stated she was a full time employee and normally assigned to Resident #920's care. CNA J stated, She is now a stand up (mechanical) lift .she used to be a one assist with a gait belt to get up but now we use the lift .she has a lot of hip pain .she never c/o hip pain before the fall. CNA J was asked how she assisted Resident #920 to ambulate prior to the fall. CNA J stated, One person walked next to her with a gait belt and one person would push the wheelchair behind her. If she got weak, she'd stop and take a breath in her wheelchair. On 5/26/16 at 1:30 p.m. CNA G, who was caring for Resident #920 at the time of her fall, was interviewed over the phone. CNA G was no longer employed at the facility at this time. CNA G was queried regarding the fall in which Resident #920 fractured her hip. CNA G stated, I was in training and I didn't really know how to read the ambulation and transfer sheets I was walking next to her with a gait belt and pulling the wheelchair (w/c) behind her with one hand .she only made one step out of the room and she went down .I was in training and I made a mistake. When asked how Resident #920 was lowered to the floor, CNA G stated, Half of her body fell sideways to the right. I was able to lower the top half of her body so she didn't hit her head .she was a lot bigger than me so I couldn't catch her. At 2:40 p.m. on 5/26/16, Licensed Practical Nurse (LPN) H who was documented on the Incident Report as a witness to Resident #920's fall was queried and stated, CNA G only read a part of the Kardex and misunderstood what it instructed. LPN G further revealed that Resident #920's w/c was not near her at the time of the fall, stating, She (CNA G) did not have the w/c with her. The Director of Nursing (DON) was interviewed on 5/26/16 at approximately 2:15 p.m. regarding Resident #920's fall and hip fracture. The DON stated, CNA G read the kardex wrong .she only read the first half of the instructions .Resident #920 was able to ambulate with one person in the room for toileting .there was supposed to be two people for ambulating otherwise .one to walk next to Resident #920 and one to push the w/c behind her. A record review of the three fall policy's provided by the facility did not address implementing safety interventions. Resident #925: A review of Resident #925's clinical record conducted on 5/25/16 at 3:00 p.m. revealed the following documentation: The most recent Minimum Data Set (MDS) assessment, dated 3/28/16, documented Resident #925 was originally admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #925 was assessed as cognitively intact and required limited assist of one staff with transfers and ambulation. A review of facility Incident Reports for Resident #925 conducted at 12:55 p.m. on 5/26/16 revealed Resident #925 had 13 falls on the following dates: 11/28/15; 12/30/15; 1/12/16; 1/13/16; 2/3/16; 2/8/16; 3/28/16; 4/13/16; 4/29/16; 5/8/16; 5/10/16; 5/11/16; and 5/24/16. A review of the most recent Incident Report dated 5/24/16 at 10:15 p.m. revealed the following, Type of event: found on floor. Description of event: Writer heard CNA (Certified Nurse Assistant) yelling for help down the hallway. CNA found resident on the floor when she went in to answer the call light. Writer asked CNA if chair alarm was sounding and she said no Writer noted a large amount of blood on the floor next to the resident as well as on her hands and clothing .noting a large laceration on left index finger when call light was removed from her hand. Injury: laceration on bil (bilateral-both hands) fingers, abrasion on left side c/o (complain of) pain with ROM (range of motion). In the section titled Intervention the documentation stated, Resident sent to ER (emergency room )/unaware of extent of injury. A review of nurse's notes dated 5/25/16 at 6:02 a.m. revealed, Return to facility: contusion (bruise) to left flank and multiple skin tears to left hand 1st and 2nd digit .left flank with presence of light abrasion 5.5 cm (centimeters) in length by 3 cm in width .bruising present to left posterior hand base of 2nd and 3rd digit, base of left 1st digit, base of left thumb. A review of physician's orders [REDACTED]. A review of Skilled Therapy Progress Notes/post fall evaluation dated 5/25/16 at 12:20 p.m. revealed, Resident does have an out of bed (oob) schedule in place where in she has orders to be in bed at 9:30 p.m., the fall having occurred at 10:15 p.m the oob schedule is in place to help anticipate the resident's need for rest and to follow her normal pattern of activity and rest. On 5/26/16 at 3:00 p.m., CNA I, who was assigned to Resident #925's care on 5/24/16, the night of the most recent fall, was queried as to why Resident #925 was not in bed per the oob schedule. CNA I stated, She was tired that day so she had been in bed since I came on at 3 p.m. She had just gotten oob at 9 p.m. Resident #925's clinical record was reviewed with the Director of Nursing (DON) on 5/26/16 at approximately 2:20 p.m. and revealed no documentation of Resident #925 refusing to follow the oob schedule after being offered to get in to or out of bed per the oob schedule. The DON offered no explanation as to why Resident #925's oob schedule (the most recent post fall intervention) was not followed on the day of her fall. The facility policy titled Interdisciplinary Post Fall Assessment (Fall Huddle) revised 3/14/2016 was reviewed at 3:15 p.m. on 5/26/16 and revealed, 4. The purpose of the Fall huddle is to investigate .and to find a root cause of the fall .Interventions will be implemented that are aimed at the root cause in an attempt to prevent future fall events from occurring. ( ) On 5/26/16 at 10:05 a.m., Resident #924 was observed sitting in her wheelchair in the TV room with her nephew. She was also observed propelling herself. Automatic rear wheelchair locks were noted and a sensor pad alarm were noted on her chair. Resident #924's alarming seatbelt was not fastened at the time. She was alert but was not able to answer simple questions. When asked about falls regarding Resident #924, the nephew stated, She is fast. So far she has not hurt herself or broken anything. She has had a few falls here. That seatbelt is to help her from falling. It alarms when she takes it off. On 5/26/16 at 10:50 a.m., review of Resident #924's clinical record revealed the following: The face sheet indicated that Resident #924 was admitted into the facility on [DATE]. The admission Minimum Data Set (MDS) assessment, dated 4/4/16, indicated a severely impaired cognition and that she required limited to extensive assistance with all activities of daily living (ADLs). The MDS listed the following Diagnoses: [REDACTED]. The MDS indicated that Resident #924 had a fall while at the facility. Resident #924's Incident Reports indicated that she had a total of four falls while residing in the facility. One of the four falls indicated that interventions to prevent Resident #924's fall were not in place at the time of the fall on 5/22/16. Resident #924's Incident Report, dated 5/22/16 at 6:45 p.m., revealed the following documentation: Found on floor. Writer called down to resident's room by CNA (Certified Nursing Assistant). Writer went to resident's room to find resident sitting on the floor, back leaned against recliner, legs extended. CNA stated Resident had transferred herself from the recliner and was using bed to stabilize herself as she walked along it . The Incident report indicated prior to the fall, Resident #924 was in her bedroom, TV on, lights off, and the curtains were open. The Incident Report went on to indicate that the call light was not within reach for Resident #924, in addition to the alarm not working: Chair alarm not sounding, new chair alarm replaced .placed resident in recliner, did not double check to make sure call light within reach. On 5/26/16 at 2:00 p.m., the Director of Nursing (DON) was queried regarding Resident #924's fall incident on 5/22/16. The DON offered no explanation. On 5/26/16 at 3:50 p.m., review of the facility's titled Fall Prevention and Identification Program, revised 2/14/16, revealed the following documentation: Residents, who have been deemed a frequent faller (more than one fall in a quarter) by the Interdisciplinary Team, will be placed in a Fall Prevention Program. Residents with a fall history (such as on admission) may also be placed in the Fall Prevention Program per the Floor Coordinator. The facility did not include interventions to prevent falls. ( )

Based on interviews and record review, the facility failed to ensure supervision and prevent falls by providing a service necessary to avoid harm (appropriate utilization, by facility staff, of a wheelchair sensor alarm, as ordered by the attending physician) for 1 of 27 residents (Resident #309) reviewed for fall risk, from a total of 30 residents sampled, resulting in Resident #309 experiencing a fall from her wheelchair, sustaining a blow to the forehead with a concussion and a laceration requiring closure with 7 sutures, and pain. Findings include: Review of the Face Sheet revealed Resident #309 was a [AGE] year old woman who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Sets ((MDS) dated [DATE] and 4/24/2015, Resident #309 was severely cognitively impaired, required extensive assistance with activities of daily living (ADL's), and experienced both long- and short-term memory loss. Review of the Fall Risk Assessments dated 11/11/2014 and 1/27/2015, identified Resident #309 at high risk for falls. Review of the Physician Monthly Orders dated 10/29/2014 (untimed), and renewed/continued as an order on the Physician Monthly Order for February 2015, specified Resident #309 was to use a chair sensor alarm to her wheelchair, with placement above her wheelchair cushion; this device was to be changed annually. Review of the Neuromuscular/Skeletal Care Plan initiated 1/16/2015 (untimed), and reviewed 2/6/2015, revealed Resident #309 was identified at high risk for falls. Issues identified in the plan of care revealed several attempts at self transfer, likely for toileting. The care plan specified continues with chair alarm that is used after PT (physical therapy) assessment. Review of the CENA Bedside Care Plan dated 2/13/2015 (untimed), specified Resident #309 was to have a sensor alarm to her wheelchair. According to the Nurses Progress Notes dated 2/24/2015 at 4:30 PM and the Interdisciplinary Post-Fall assessment dated [DATE] at 4:30 PM, Resident #309 was observed on the first floor west hallway by a housekeeper, face down with her right arm straight out with head resting on arm, knees slightly bent and wheelchair sitting behind resident (Resident #309). Small pool of blood forming under the forehead and visible on the floor. Resident appeared to have 3 small gashes above right eye in a star shape. No alarm sounded. Resident #309 was documented to have been transferred to a local hospital for evaluation. According to the Discharge Summary of the local hospital dated 2/24/2015 at 6:30 PM, Resident #309 sustained a laceration of her forehead and a concussion as a result of her fall at the facility. Resident #309 was documented to have received 7 sutures to close her wound. According to the Nurses Progress Notes dated 2/25/2015 at 7:45 AM, Resident #309 continued to experience headaches, for which she received pain medication. During an interview on 6/4/2015 at 9:40 AM, Maintenance Director T said manufacturers of both wheelchair sensor alarms utilized by the facility specified the alarms be changed outevery 12 months. He said the maintenance department changes out the batteries as needed, however, the checks regarding function are performed by the facility's nursing staff. During an interview on 6/5/2015 at 9:10 AM, CNA M said, She (Resident #309) had alarms on her bed and wheelchair; she was at risk for falls. She resides on the east hall, but the fall happened on the west hall - she wanders. She was pretty well down the west hall. She was agitated; I just let her go down there. I told other CNA's on the west hall to keep an eye on her; I went to the east hall and charted. I couldn't hear if the alarm went off; I was too far away. Someone told me the alarm on the wheelchair didn't work. During an interview on 6/5/2015 at 9:35 AM, Housekeeper Q said, I didn't observe the fall. I was at the end of the west hallway. I saw her (Resident #309) in the west hallway; she lives on the east hallway; she wanders to different places. I'd been cleaning the employee bathroom, walked out of the room, and saw the Resident on the floor in front of her wheelchair. She was flat on her stomach. There was blood on the floor beneath her head; a good amount of blood. There were no alarms sounding. I could see the alarm on the wheelchair, but it wasn't alarming. I don't know why it wasn't working. During an interview on 6/5/2015 at 10:55 AM, RN O said, She (Resident #309) is confused. She's very impulsive. She made attempts to self transfer. She had a wheelchair alarm. She was at risk for falls; she'd had falls. She was on another hallway. I heard a housekeeper (identified as Housekeeper Q) yell out 'She fell ; she's on the floor.' I went down to see. The Resident was on the floor in front of her wheelchair. She was bleeding from her forehead, a lot. I put pressure on it. I asked her what happened; she didn't respond. I didn't hear an alarm go off when she fell . I was close enough to have heard it, if it was functioning. I didn't hear it. During an interview on 6/5/2015 at 11:30 AM, Housekeeper P said, I see her (Resident #309) in her wheelchair in the hallways all the time. She's all over the first floor, not just the east or west hallways. On the day she fell , she was quite a ways down the west hallway. She was a resident on the east hallway. I heard something hit the floor. I turned around and there she was on the floor. She was face down on the floor; she'd fallen forward out of her wheelchair. There were no alarms sounding. I started yelling for a nurse. The alarm box was on the back of the wheelchair; but I don't know if the function lights were flashing. I saw the pad for the alarm on the top of the wheelchair cushion, but more to the back of the wheelchair cushion. I was the first person at the wheelchair. I don't understand why her alarm didn't work when she fell . During an interview on 6/5/2015 at 12:00 PM, RN R said, I did the post fall investigation. The alarm was not sounding; it was referred to maintenance. I was not told what happened with the alarm. During an interview on 6/5/2015 at 12:30 PM, the Director of Nursing said he expected facility staff to follow prescribed orders, plans of care, and to adhere to facility policies and procedures.

This citation pertains to intake number MI 163 Based on interview and record review, the facility failed to provide a safe "stress ball" to a cognitively impaired resident to manage nervous energy and loud outbursts for one (#501) of four sampled residents reviewed for neglect from a total sample of four, resulting in Resident #501 discovered 2.5 hours later, non-responsive, with the foam stress ball in his mouth. The resident was subsequently pronounced dead. Findings include: A Facility reported incident on file documented that Resident #501 was found with a heart-shaped stress ball (therapy sponge ball) in his mouth. Resident #501 expired on [DATE] at the facility. A review of the facility's Summary of Investigation report, (undated) revealed, "On [DATE] at approximately 9:17 a.m., I (Director of Nursing/DON) received a telephone call from the charge nurse and RN "C" stating that they had found Resident #501 expired in his bed with a piece of a foam stress exercise ball in his mouth and he was blue." A review of the clinical record revealed that Resident #501 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] revealed that Resident #501 had severely impaired cognitive skills for decision making and required extensive to total physical assistance of staff with all activities of daily living (ADLs) including, bed mobility, transfers, dressing, eating, hygiene, bathing and toileting. The MDS further revealed that Resident #501 was nonambulatory. A "Nurse's Progress Note" dated [DATE] documented, "9:07 a.m., CNA called writer down to Resident #501's room, writer observed Resident #501 unresponsive laying in bed with bilateral arms at sides partial red stress ball laying on chest, nail beds blue, skin cold to touch, writer obtained blood pressure cuff and stethoscope, went back into room and noted resident with absence of vital signs including blood pressure, apical pulse, respirations and reflexes. Doctor and DON notified. Detective arrived to facility and spoke with several staff members. Detective stated that Resident #501 would be transported to hospital and autopsy would be done. At 11:55 a.m., ambulance with three attendants arrived to facility and left facility with Resident #501 on stretcher at 12:05 p.m." On [DATE] at 10:48 a.m., during an interview, the DON was queried and reported the following, "Resident #501 had a loud voice so we would give him things to keep him occupied. Other residents would get upset with his loud voice. It wasn't uncommon to give him things to keep his mind occupied. Resident #501 had [MEDICAL CONDITIONS] as a diagnosis. There was one event where he was found with his call light in his mouth. This happened January of 2014. Resident #501 was on a pureed diet with thickened liquids and never had a problem consuming his meals. A Hospice company was in prior and they passed out promotional items. The sponge was the Hospice company. The third shift Certified Nursing Assistant (CNA "D") worked the midnight shift gave Resident #501 the red ball from his night stand. He initially dropped it so CNA "D" gave it back to him. CNA "D" then left the room. On [DATE] at 11:10 a.m., CNA "A" was interviewed and reported, "I worked with him several times on that hall. I took report at about 7:25 a.m.. CNA "D" said she had changed him already because he was incontinent. When I walked down the hall past his room, I could see his feet. His television was on so I continued to walk down the hall. I didn't go into his room because he has behaviors and I didn't want to get him started up". When asked if Resident #501's face was observed, CNA "A" reported, "Resident #501's curtain was closed where I couldn't see his face. I then went to check on my other residents and got them up. I was going to give Resident #501 breakfast, but I went to the dining room instead serving other residents. I didn't go into Resident #501's room because I just didn't want to provoke a behavior. Resident #501 couldn't walk or sit on the side of the bed and he wasn't able to feed himself. I realize now that I need to make eye to eye contact with all my residents." On [DATE] at 11:49 a.m., CNA "B" was interviewed and reported, "I wasn't Resident #501's CNA on the day he died ([DATE]) but I was the one that found him. At 8:30 a.m., I was in the dining room starting breakfast tickets. I then left to go start passing trays. Around 9:00 a.m., I opened Resident #501's door. there was a chair by the door so I sat his tray on the chair and I left the room. His privacy curtain was closed. An alarm was sounding so I went to assist another resident. I put the other resident's pants on and wheeled him to the dining room. By the time I got back to Resident #501, it was after 9:00 a.m. I went back into his room, picked up the tray and went behind the curtain. I saw something red in his mouth. I took it out of his mouth then I rubbed his chest and called out his name. Resident #501 was cold and he looked gray and there was no response. His eyes were closed. I had a gut feeling he was gone. He had a foam ball in his mouth. It was the whole ball. I ran and told the nurse who was passing medications then I told RN "C" and she went to the room. I heard them say, "we have to figure out his code status", then I went on my break." On [DATE] at 12:21 p.m., during a subsequent interview, the DON reported, "I spoke with CNA "A" and she informed me that she got report and walked down the hall and only saw Resident #501's feet and that the curtain blocked his face. CNA "A" did not see Resident #501's face. CNA "A" went about her day. She should have poked her head in and said hello. That's the purpose of having over lapping shifts. We call them "Room to Room" for a reason. You should do room to room checks to ensure safety." On [DATE] at 4:01 p.m., RN "C" was interviewed and reported, "I was Resident #501's assigned nurse on [DATE]. My shift starts at 7:00 a.m., but I didn't see Resident #501 until after 9:00 a.m. when the CNA called me to his room." When asked why she hadn't seen Resident #501 until two hours after the start of shift, RN "C" reported, "My CNA's are expected to do bed to bed checks. I do rounds but I don't necessarily visualize the residents. My expectation is that the CNA's will do their rounds and visualize the residents and come to me with any issues. CNA "B" came and told me to go to Resident #501's room. When I got there, I found him in bed not breathing. His skin was cold and his fingernails were blue. He was a "No Code". I went to get the blood pressure cuff. There was no blood pressure or apical pulse and he had no reflexes. I pronounced Resident #501 dead at 9:10 a.m. Resident #501's face was pale blue and the ball was on his chest. If I had to experience this again, I wouldn't have done anything differently." A written statement written by CNA "D" documented, "The last time I saw Resident #501 was around 6:40 a.m. I changed him. Resident #501 asked for his red ball. I handed him his red ball. He dropped it so I picked it up and handed it back to him. He was quiet the rest of the night." The facility's Administrative staff was unable to explain why facility staff failed to check on Resident #501 at least every two hours and why staff failed to enter Resident #501's room during rounds to ensure that safety and personal needs were met. On [DATE] at 1:37 p.m., A review of the facility's "Report Format" policy dated [DATE] revealed: "CNA's will proceed down the hallways and do room to room bed check with the outgoing CNA's." "The outgoing shift is not allowed to leave the floor until 25 minutes after the hour, provided your bed to bed check responsibilities are completed. On [DATE] at 2:00 p.m., the DON reported, "I know. We've looked at the policy and we're going to make some changes right away. The Nurses are expected to make rounds as well to ensure the safety of the residents.

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ASSESS, SUPERVISE AND IMPLEMENT IMMEDIATE INTERVENTIONS AFTER EACH CRISIS SITUATION, FALL AND CHANGE IN BEHAVIOR FOR ONE ( #405) OF 18 SAMPLED RESIDENTS REVIEWED FOR ACCIDENTS FROM A TOTAL OF 30 RESIDENTS, RESULTING IN AN IMMEDIATE JEOPARDY TO THE RESIDENT'S HEALTH AND SAFETY AS EVIDENCED BY MULTIPLE FALLS, INJURIES, BRUISES, AND NUMEROUS PSYCHOTIC EPISODES OF RESTLESSNESS, AGITATION AND EMOTIONAL DISTRESS. THE IMMEDIATE JEOPARDY (IJ) WAS IDENTIFIED ON 3/4/11 AT 11:00 AM. THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON 3/11/11 AT 8:50 A.M. THE IJ WAS REMOVED ON 3/15/11, BASED ON THE PROVIDER'S IMPLEMENTATION OF CORRECTIVE ACTIONS ON 3/15/11, AS VERIFIED ONSITE ON 3/21/11, DURING THE COMPLETION OF THE EXTENDED SURVEY. ALTHOUGH THE IJ WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE WAS NOT CORRECTED AND REMAINED AS ISOLATED. NO ACTUAL HARM WITH THE POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY. IN ADDITION, THE FACILITY FAILED TO IMPLEMENT SAFETY MEASURES TO PREVENT FALLS FOR ONE ( # 429) OF 18 RESIDENTS REVIEWED FOR ACCIDENTS FROM A TOTAL OF 30 SAMPLED RESIDENTS AND FAILED TO SECURE OXYGEN CYLINDERS, RESULTING IN THE POTENTIAL FOR EXPLOSION. FINDINGS INCLUDE: ON 3/4/11, THE CLINICAL RECORD AND INCIDENT/ACCIDENT (I/A) REPORTS FOR RESIDENT #405 WERE REVIEWED WITH NURSES 'D' AND 'E' AT 11 AM, WITH NURSE 'A' AT 11:45 AM, AND WITH THE DIRECTOR OF NURSING (DON) AND THE ASSISTANT DIRECTOR OF NURSING (ADON) AT 1:10 PM. PER THE ADMISSION FACE SHEET/[DIAGNOSES REDACTED]. THE RESIDENT ALSO had a history of [REDACTED]. ACCORDING TO MINIMUM DATA SETS ((MDS) dated [DATE] AND 2/10/11, THE RESIDENT HAD SEVERE COGNITIVE IMPAIRMENT, REQUIRED EXTENSIVE ASSISTANCE FROM STAFF FOR TRANSFERS AND MOBILITY, AND WAS NON-AMBULATORY. THE RESIDENT'S MOOD/BEHAVIORS INCLUDED: REPETITIVE PHYSICAL MOVEMENTS, WANDERING, AND VERBAL ABUSIVENESS. THE RESIDENT WAS PRESCRIBED 1 MG (MILLIGRAM) OF RISPERDAL (ANTIPSYCHOTIC) FOR A HISTORY OF INCREASED CONFUSION WITH VERBAL AGGRESSION AND REFUSAL OF CARE. ACCORDING TO NURSES NOTES, RESIDENT #405 WAS OBSERVED ON THE DAY OF ADMISSION MAKING MULTIPLE ATTEMPTS TO SELF-TRANSFER FROM HER BED AND WHEELCHAIR. SHE WAS NOTED TO HAVE POOR SAFETY AWARENESS. THE RESIDENT WAS PRESCRIBED A LAP BUDDY (A TRAY-TYPE DEVICE ACROSS THE TORSO AREA) FOR THE WHEELCHAIR, CHAIR AND BED ALARMS, A BED GUARD (A BOLSTER-TYPE DEVICE TO PREVENT ROLLING OUT OF BED), AND AN ALARMING WHEELCHAIR SEATBELT FOR SAFETY. PER NURSES NOTES DATED 5/27/10 THRU 6/8/10, RESIDENT #405 CONTINUED TO ATTEMPT NUMEROUS SELF TRANSFERS EACH DAY. SHE ALSO REMOVED THE LAP BUDDY, CLIMBED OVER THE BED GUARD, AND WANDERED IN AND OUT OF OTHER RESIDENT'S ROOMS IN THE WHEELCHAIR. SHE WAS NOTED TO RECEIVE NUMEROUS "NOW" DOSES OF ATIVAN (FOR ANXIETY) DUE TO ANXIETY, RESTLESSNESS, AND REPEATEDLY ASKING TO "GO HOME" OR "GO TO BED (WHILE SHE WAS IN BED)." THE RESIDENT'S BEHAVIOR WAS UNCONTROLLED PER NOTES. REVIEW OF PAIN ASSESSMENTS FROM 5/26/10 THRU 6/3/10 NOTED THAT THERE WERE NO SIGNS THAT THE RESIDENT EXPERIENCED PAIN. SHE HAD NOT BEEN PRESCRIBED ANY PAIN MEDICATION. ON 6/4/10, THE RESIDENT COMPLAINED OF PAIN IN HER FINGERS. STAFF ASKED THE RESIDENT'S DURABLE POWER OF ATTORNEY (DPOA) IF THE RESIDENT COULD RECEIVE PAIN MEDICATION BECAUSE OF THE [DIAGNOSES REDACTED]. THE DPOA SAID, "SHE DOES NOT EXPERIENCE PAIN. SHE DOES NOT NEED ANY MEDICATION" AND REFUSED TO ALLOW THE RESIDENT TO RECEIVE PAIN MEDICATION. FROM 6/4/10 THRU 6/9/10, THE BEHAVIORS CONTINUED. REVIEW OF 28 I/A REPORTS FOR RESIDENT #405 NOTED THE FOLLOWING: 1. ON 6/9/10 AT 11:55 PM,THE RESIDENT fell OUT OF BED ATTEMPTING A SELF TRANSFER. THERE WAS NO NOTED INJURY. THE RESIDENT ALSO TORE OFF HER INCONTINENT BRIEF AND LEFT IT ON THE FLOOR. FROM 6/9/10 THRU 6/11/10, BEHAVIORS CONTINUED. ON 6/11/10, THE DPOA AGREED TO ALLOW A PRESCRIPTION FOR TYLENOL 650 MG EVERY 12 HOURS FOR PAIN RELIEF. THE RESIDENT WAS hospitalized from [DATE] THRU 6/15/10 FOR A LUNG CONDITION (PULMONARY EMBOLISM). FROM 6/16/10 THRU 6/25/10, THE RESIDENT EXHIBITED THE FOLLOWING BEHAVIOR: ANXIETY, REPEATEDLY PULLED OFF HER OXYGEN TUBING, GRIMACING AND COMPLAINING OF "PAIN ALL OVER," CONSTANTLY BUMPING INTO OBJECTS, WALLS, AND OTHER RESIDENTS IN THE WHEELCHAIR IN A RAPID AND FORCEFUL MANNER, WHEELING BACKWARDS IN THE WHEELCHAIR, WANDERING NON-STOP, ATTEMPTING SELF TRANSFERS, AND REMOVING THE LAP BUDDY. SHE RECEIVED NUMEROUS DOSES OF TYLENOL AND XANAX (FOR ANXIETY) WITHOUT RESULTS. 2. ON 6/26/10 AT 8 PM, THE RESIDENT WAS FOUND ON THE FLOOR IN HER ROOM. THERE WAS NO NOTED INJURY. ON 6/27/10, THE RESIDENT WAS FOUND IN A CLOSED PANTRY NUDE FROM THE WAIST UP, WAS WANDERING BACKWARDS IN THE WHEELCHAIR, AND ATTEMPTING SELF-TRANSFERS. ON 6/28/10 AT 2:50 PM, THE RESIDENT PROPELLED HERSELF BACKWARD AND "KNOCKED DOWN THE FLOOR COORDINATOR," AND ATTEMPTED SELF-TRANSFERS. 3. ON 6/29/10 AT 7:05 PM, THE RESIDENT WAS ON THE FLOOR IN HER ROOM. THERE WAS NO NOTED INJURY. SHE WAS AGITATED, ANXIOUS, THROWING OBJECTS, GRABBING STAFF, AND PULLING HER SEATBELT. SHE RECEIVED MULTIPLE DOSES OF XANAX AND TYLENOL. 4. ON 6/30/10 AT 1:30 AM, THE RESIDENT fell OUT OF BED WITH NO NOTED INJURY. 5. ON 6/30/10 AT 2:10 AM, THE RESIDENT WAS ON THE FLOOR IN HER ROOM WITH NO NOTED INJURY. SHE WAS ANXIOUS, AGITATED, RESTLESS, REPEATEDLY ASKED TO GO TO BED, AND COMPLAINED OF BACK PAIN. SHE WAS DELUSIONAL, PARANOID, WHISPERING TO SELF, AND SAID, "GET THAT MAN OUT OF MY ASS." THE RESIDENT CONTINUED TO REMOVE HER SEATBELT AND CLOTHES, AND ATTEMPT SELF-TRANSFERS. SHE RECEIVED NUMEROUS DOSES OF XANAX AND TYLENOL WITHOUT RESULTS. THE RESIDENT WAS SEEN ON 6/30/10 BY THE PSYCHIATRIST WHO RECOMMENDED ADEQUATE PAIN CONTROL. 6. ON 7/1/10 AT 10:45 AM, THE RESIDENT WAS ON THE FLOOR IN HER ROOM WITH NO NOTED INJURY. SHE SUSTAINED A 6 X 5 CENTIMETER (CM) PURPLE BRUISE ON THE LEFT BUTTOCK AND A QUARTER SIZE BUMP ON THE BACK OF THE HEAD THAT SHE HIT ON "ON HER BEDSIDE TABLE." 7. ON 7/1/10 AT 2:30 PM, THE RESIDENT fell OUT OF BED IN HER ROOM WITH NO NOTED INJURY. THE RESIDENT'S BEHAVIORS CONTINUED. THE RISPERDAL DOSES WERE INCREASED AND KLONOPIN (FOR PANIC ATTACKS) WAS ADDED WITHOUT RESULTS. THE RESIDENT WAS WANDERING, RESTLESS, RUNNING INTO OBJECTS AND STAFF, ATTEMPTING SELF TRANSFERS, AGITATED, RESTLESS, AND SLEEPLESS ON 7/1/10 AND 7/2/10. ON 7/3/10 AT 10:14 PM, THE RESIDENT KNOCKED HER ROOMMATE'S TELEVISION OFF OF THE STAND AND BROKE IT, AND THREATENED TO CHOKE HER. THE ROOMMATE CALLED HER A "[***] " AND YELLED "GET THE HELL OUT OF HERE." THERE WAS AN ORDER ON 7/3/10 TO TRANSFER RESIDENT #405 TO ANOTHER ROOM TO PREVENT FURTHER ALTERCATIONS. HOWEVER, PER NURSES NOTES, THE RESIDENT WAS NOT MOVED TO THE OTHER ROOM UNTIL 7/5/10 AT 10:32 AM. ALTHOUGH THE FOLLOWING OCCURRED: THROUGHOUT 7/4/10 AND 7/5/10, RESIDENT #405 WAS RESTLESS, ANXIOUS, UNABLE TO SIT STILL, TWISTING AND TURNING SELF IN THE WHEELCHAIR, TRYING TO GET UP FROM THE BED AND WHEELCHAIR WITHOUT ASSISTANCE, AND REMOVING THE SEATBELT. SHE CONTINUED TO HAVE THE BRUISE ON HER LEFT BUTTOCK, AND COMPLAINED OF PAIN IN THE BACK AND HIPS. SHE RECEIVED MULTIPLE DOSES OF TYLENOL AND ATIVAN THAT WERE NOT EFFECTIVE. ON 7/5/10, THE DPOA "VOICED CONCERN THAT PAIN WAS NOT BEING ADDRESSED." ON 7/5/10, THE PAIN MEDICATION WAS CHANGED FROM TYLENOL TO LORTAB. PER NURSES NOTES ON 7/6/10 AT 8:22 AM, RESULTS OF X-RAYS DATED 7/1/10 AT 5:48 PM, WERE RECEIVED. THE X-RAYS WERE DONE ACCORDING TO NURSE 'A' BECAUSE OF THE BRUISING SUSTAINED FROM THE FALL ON 7/1/10. THE RESULTS: "TWO VIEWS OF THE LEFT HIP/LEFT FEMUR REVEAL ADVANCED DEGENERATIVE CHANGES....WITH ACETABULAR PROTRUSION. A PREVIOUS ACETABULAR FRACTURE CANNOT BE EXCLUDED." THERE WAS NO EXPLANATION WHY THE X-RAY RESULTS WERE NOT RECEIVED FOR FIVE DAYS. THERE WAS NO FOLLOW-UP X-RAY TO RULE OUT A FRACTURE. NURSE 'A,' WHO WAS RESPONSIBLE FOR COORDINATING CARE, THE DON, AND THE ADON WERE UNABLE TO EXPLAIN WHY. THE DON SAID, "SHE (RESIDENT) HAD A CAR ACCIDENT [AGE] years AGO THAT EFFECTED AMBULATION." THE DON WAS UNABLE TO VERIFY THAT THE ACCIDENT RESULTED IN A FRACTURE TO THE AREA. 8. ON 7/6/10 AT 8:30 AM, THE RESIDENT fell IN HER ROOM WITH NO NOTED INJURY. BEHAVIORS CONTINUED. PER NURSES NOTES, SHE RECEIVED NUMEROUS DOSES OF ATIVAN AND LORTAB. ON 7/7/10 AND 7/8/10, THE RESIDENT GRABBED STAFF, HAD SYMPTOMS OF PAIN (RESTLESSNESS, FACIAL GRIMACING, CLENCHING FISTS), WAS PROPELLING HERSELF BACKWARDS, RUNNING INTO WALLS AND OBJECTS, ATTEMPTING SELF TRANSFERS, WANDERING INTO OTHER RESIDENTS' ROOMS, AND PULLING AT THE SAFETY BELT. SHE COMPLAINED OF PAIN IN THE BUTTOCKS. 9. ON 7/8/10 AT 2:45 PM, RESIDENT #405 fell IN HER ROOM WITH NO NOTED INJURY. 10. ON 7/8/10 AT 8:30 PM, THE RESIDENT fell IN HER ROOM WITH NO NOTED INJURY. 11. ON 7/8/10 AT 11:15 PM, THE RESIDENT fell IN HER ROOM WITH NO NOTED INJURY. 12. ON 7/9/10 AT 9 AM, THE RESIDENT WAS OBSERVED SLIDING TO THE FLOOR IN HER ROOM AND HAD TO BE LOWERED TO THE FLOOR BY STAFF. THERE WAS NO NOTED INJURY. ON 7/9, 7/10, AND 7/11/10, THE RESIDENT WAS ANXIOUS, SHIFTING BACK AND FORTH, AND COMPLAINED OF PAIN. SHE BECAME COMBATIVE WITH STAFF, KICKING AND SWINGING, ATTEMPTING SELF TRANSFERS, REMOVING, PROPELLING HERSELF BACKWARDS FORCEFULLY, AND TIPPING AN OXYGEN TANK OVER, PULLING DECORATIONS OFF THE WALL, AND KNOCKING THE BLOOD PRESSURE MACHINE ON THE FLOOR. 13. ON 7/11/10 AT 1:03 AM, THE RESIDENT WEDGED HERSELF IN THE DOOR OF A UNIT BATHROOM. SHE SUSTAINED REDNESS TO THE ENTIRE RING AND MIDDLE FINGER OF THE LEFT HAND WITH BRUISING FROM THE KNUCKLES TO THE FIRST JOINTS OF EACH FINGER. SHE WAS ALSO NOTED TO PROPEL BACKWARDS INTO THE WALL AND STAFF, AND BANGING THE CALVES ON BOTH LEGS AND SHINS WITH THE BACK OF THE WHEELCHAIR LEG RESTS. SHE SUSTAINED BRUISING TO THE LOWER LEGS. 14. ON 7/12/10 AT 12:55 AM, THE RESIDENT WAS NUDE AND HAD FALLEN IN HER ROOM WITH NO NOTED INJURY. SHE CONTINUED TO WANDER, RECEIVE LORTAB AND ATIVAN, ATTEMPTED TO REMOVE THE LAP BUDDY, AND RESIST CARE. THE RESIDENT "ALMOST PULLED OVER ELECTRIC LIFT" AND COMPLAINED OF PAIN. THE DOSAGE OF LORTAB WAS INCREASED WITHOUT RESULTS. PER NURSES NOTES ON 7/13/10 AT 6:49 AM, THE RESIDENT'S HAND WAS REASSESSED FROM THE INJURY ON 7/11/10: "....REDDISH PURPLE BRUISING NOTED TO 2ND, 3RD, AND 4 TH FINGERS AND BACK OF HAND JUST UNDER KNUCKLES" CONTINUED. THERE WAS NO X-RAY DONE FOLLOWING THE INJURY. NURSE 'A' WAS UNABLE TO EXPLAIN WHY. 15. ON 7/13/10 AT 11:30 PM, THE RESIDENT WAS ON THE FLOOR IN HER ROOM WITH NO NOTED INJURY. SHE REMAINED RESTLESS AND COMPLAINED OF PAIN. 16. ON 7/14/10 AT 2:51 AM, THE RESIDENT WAS ON THE FLOOR IN HER ROOM WITH NO NOTED INJURY. THE RESIDENT HAD A URINE CULTURE THAT WAS POSITIVE FOR BACTERIA AND WAS PRESCRIBED ANTIBIOTICS FOR 7 DAYS. THE DPOA VOICED THAT A URINARY TRACT INFECTION MAY BE THE CAUSE OF SOME BEHAVIORS. ON 7/15/10, CONTINUED BEHAVIORS AND COMPLAINTS OF "PAIN ALL OVER." ON 7/16/10, THE RESIDENT WAS PULLING OFF CLOTHING, RAMMING WHEELCHAIR INTO THE MEDICATION ROOM DOOR JAM, BANGING ON THE NURSES STATION COUNTER, AND WHEELING BACKWARDS WITH A SHOW OF ANGER. 17. ON 7/16/10 AT 12 AM, THE RESIDENT WAS NOTED TO HAVE BRUISING TO FEET: "RIGHT FOOT HAS 3 1/2 INCH DARK PURPLE BRUISING INVOLVING GREAT TOE AND ACROSS THE BASE OF 2ND, 3RD, 4 TH TOE 2 INCHES WIDE. ALSO BRUISE EXTENDS LATERALLY FROM GREAT TOE DOWN TOWARDS THE HEEL 5 INCHES....LEFT FOOT HAS BRUISING LATERALLY EXTENDING 3 INCHES FROM BASE OF GREAT TOE TOWARDS HEEL. THIS IS ALSO PURPLISH/BLUE. RESIDENT STATED THAT SHE DOES HAVE PAIN WITH AREA...." THE RESIDENT CONTINUED ROLLING HER WHEELCHAIR INTO WALLS AND OTHER RESIDENTS. ATIVAN WAS GIVEN THROUGHOUT THE DAY WITH THE RESIDENT OCCASIONALLY SPITTING OUT THE PILLS. SHE WAS AGITATED ON 7/17/10. 18. ON 7/18/10 AT 1:45 AM, THE RESIDENT AS ON THE FLOOR IN HER ROOM WITH NO NOTED INJURY. HER FEET REMAINED BRUISED. THROUGHOUT THE DAY, SHE ATTEMPTED SELF TRANSFERS, WAS RESTLESS, CONSTANTLY MOVING, PULLING OFF SHIRT, REMOVING LAP BUDDY, AND COMPLAINING OF PAIN "ALL OVER." 19. ON 7/19/10 AT 3:30 AM, RESIDENT #405 WAS ON THE FLOOR IN HER ROOM WITH NO NOTED INJURY. SHE WAS RESTLESS AND AGITATED THROUGHOUT THE DAY WITH NUMEROUS ATTEMPTS TO SELF TRANSFER. SHE HAD SIGNS OF PAIN AND STATED THAT SHE WAS HURTING. THE PSYCHIATRIST SAW THE RESIDENT ON 7/19/10 AND RECOMMENDED LONG-ACTING PAIN CONTROL AND NOTED: "PATIENT MAY BE IN PAIN DUE TO CONSTANT RESTLESSNESS, DISCOMFORT, UNEASINESS, AND NEED TO BE IN MOTION." PER NURSES NOTES ON 7/20/10, THE PHYSICIAN SAW THE PSYCHIATRIST'S RECOMMENDATIONS AND "WANTS TO START RESIDENT ON A DURAGESIC (PAIN) PATCH...." ON 7/20/10 AT 5:02 AM, NURSES NOTED: "LEFT FOOT HAS A NARROW LINE OF DARK PURPLE BRUISING ACROSS 2 BASES OF TOES AND LATERALLY BACK TOWARD HEEL. THERE IS ALSO BRUISING JUST ABOVE THE ANKLE INWARD THAT IS DIFFUSED BRUISING....RIGHT FOOT THERE IS DARK PURPLISH BRUISING ACROSS ALL TOES AT THE BASE EXCEPT FOR PINKY TOE. BRUISE EXTENDS LATERAL TO BACK TOWARD THE HEEL." THERE WERE NO X-RAYS OF THE RESIDENT'S FEET BECAUSE, ACCORDING TO NURSE 'A,' "THE PHYSICIAN DIDN'T ORDER IT." NURSE 'A,' THE DON, AND THE ADON WERE UNABLE TO EXPLAIN WHY. THERE WAS NO DOCUMENTATION THAT NURSING STAFF MENTIONED OBTAINING AN X-RAY TO THE PHYSICIAN. ON 3/4/11 AT 1:35 PM, WHEN THE PHYSICIAN WAS ASKED ABOUT AN X-RAY BEING DONE, HE SAID, "IT WAS DONE. WE DID AN X-RAY." HE HAD NO EXPLANATION WHEN NURSE 'A' SHOOK HER HEAD INDICATING THAT IT HAD NOT BEEN DONE. ON 7/20/10, THE RESIDENT RECEIVED A DURAGESIC PATCH PRESCRIBED FOR EVERY 72 HOURS AND THE 7 DAY COURSE OF ANTIBIOTICS FOR A URINARY TRACT INFECTION WERE COMPLETED BUT BEHAVIORS CONTINUED. FROM 7/20/10 THRU 7/24/10, RESIDENT #405 WANDERED AROUND BACKWARDS KNOCKING A BOARD OFF THE WALL AND TIPPING OVER THE VITAL SIGN MACHINE. SHE WAS GRABBING THE STAFF'S CLOTHING, PULLING THEIR CHAIRS BACKWARDS, AND ALMOST RAN OVER OTHER RESIDENTS. SHE COMPLAINED OF PAIN AND LORTAB AND ATIVAN WERE INEFFECTIVE. ON 7/25/10, THE RESIDENT'S BEHAVIOR WAS UNCHANGED. SHE KICKED A DIETARY FOOD RACK AND KNOCKED IT TO THE FLOOR. SHE WAS IN CONSTANT MOTION AND COMPLAINING OF PAIN. LORTAB AND ATIVAN WERE GIVEN NUMEROUS TIMES. 20. ON 7/25/10 AT 7:20 PM, THE RESIDENT WAS ON THE FLOOR IN HER ROOM WITH NO NOTED INJURY. THE RESIDENT WAS SEEN BY THE PSYCHIATRIST ON 7/26/10 WHO AGAIN RECOMMENDED PAIN CONTROL. ON 7/26/10, BEHAVIORS CONTINUED. THE RESIDENT RECEIVED LORTAB AND ATIVAN. 21. ON 7/27/10 AT 1:45 AM, RESIDENT #405, THE RESIDENT WAS ON THE FLOOR IN HER ROOM WITH NO NOTED INJURY, CONTINUED AGITATION AND COMPLAINTS OF PAIN. 22. ON 7/28/10, THE RESIDENT WAS ON THE FLOOR IN HER ROOM WITH NO NOTED INJURY. AGITATION CONTINUED AND FACIAL GRIMACING WITH COMPLAINTS OF PAIN. SHE BUMPED HER WHEELCHAIR FAST AND HARD INTO ANOTHER RESIDENTS CHAIR AND "WAS TOO RESTLESS TO STAY IN BED." THE RESIDENT RECEIVED LORTAB, THE DURAGESIC PATCH, AND ATIVAN FOR PAIN "ALL OVER" AND RESTLESSNESS FROM 7/28/10 THRU 8/9/10. 23. ON 8/9/10 AT 6:55 AM, THE RESIDENT WAS FOUND ON THE FLOOR IN HER ROOM AS A STAFF MEMBER WAS PASSING ICE. THERE WAS NO NOTED INJURY. THE SAFETY ALARM DID NOT SOUND. THERE WAS NO DOCUMENTED REASON WHY. ON 8/11/10 AT 6:31 AM, THE RESIDENT WAS OBSERVED AMBULATING DOWN THE HALLWAY, HOLDING ON TO THE RAIL. THE ALARM DID NOT SOUND. THERE WAS NO DOCUMENTED REASON WHY. WHEN ASKED IF SHE HAD PAIN, THE RESIDENT STATED "YES" AND POINTED TO THE RIGHT LOWER LEG. NURSES NOTES DATED 8/12/10 FOR A FOLLOW-UP OF THE INCIDENT ON 8/9/10 NOTED: "FAINT PURPLE BRUISING NOTED TO LEFT BUTTOCK." THERE WAS NO X-RAY TAKEN OF THE AREA. 24. ON 8/30/10 AT 2:53 PM, THE RESIDENT fell FORWARD OUT OF THE WHEELCHAIR IN HER ROOM, LANDING ON HER KNEES IN THE PRESENCE OF A NURSE AIDE WHO WAS IN THE PROCESS OF "GETTING EVERYTHING PREPARED TO TRANSFER RESIDENT" PER NURSES NOTES. THE resident sustained [REDACTED]. SHE COMPLAINED OF PAIN "ALL OVER." THE POSSIBLE CAUSE OF THE INCIDENT: "SLID FROM CHAIR." THERE WAS NO MENTION OF A LACK OF PROPER SUPERVISION OR WHY THE SAFETY BELT WAS NOT IN PLACE. A 9/2/10 FOLLOW UP OF THE 8/30/10 INCIDENT NOTED: "RESIDENT HAS SPIDER VEIN-LIKE BRUISING TO RIGHT OUTER LATERAL LEG JUST ABOVE KNEE, ALSO BRUISING TO LEFT INNER, BELOW KNEE....RESIDENT ALSO HAS A 3 INCH BY 2 INCH BRUISE TO POSTERIOR RIGHT LOWER BACK BOTTOM RIB CAGE...." 25. ON 10/2/10 AT 4:50 AM, THE I/A REPORT NOTED THE RESIDENT TO HAVE A 1 INCH BY 1 INCH BRUISE TO THE LEFT INNER BUTTOCKS. THE POSSIBLE CAUSE: "SLID FROM CHAIR." THERE WAS NO DOCUMENTED EXPLANATION OF THE EVENT. 26. ON 10/26/10 AT 9:41 PM, THE RESIDENT HAD A 1 INCH BY 1 INCH DARK PURPLE BRUISE ON THE RIGHT INNER BUTTOCK PER THE I/A REPORT. POSSIBLE CAUSE: "INJURED DURING TRANSFER." THERE WAS NO DOCUMENTED EXPLANATION OF THE EVENT. 27. ON 11/26/10 AT 4:40 PM, THE RESIDENT fell OUT OF BED AND SUSTAINED A 10 X 4 CM BRUISE "IN SHADES OF PURPLE AND GREEN" ON THE ENTIRE OUTER SIDE OF THE RIGHT FOOT. PER NURSES NOTES ON 11/27/10, THE RIGHT LATERAL ANKLE AND 3RD TOE OF THE FOOT WERE SWOLLEN. ON 11/29/10, NURSES NOTED: "....ANKLE SLIGHTLY SWOLLEN AND BLUEISH/PURPLE BRUISING NOTED ON ANKLE DOWN THE OUTSIDE OF FOOT, ALONG THE SIDE. NURSE 'A' INSTRUCTED STAFF TO CALL THE PHYSICIAN FOR AN X-RAY ORDER. X-RAYS WERE DONE ON 11/29/10 AT 7:05 PM. THE RESULTS: "OLD HEALED FRACTURE OF THE DISTAL TIBIA" AND "THERE IS A PROBABLE OLD FRACTURE OF THE PROXIMAL PHALANX (TOE BONE) OF THE FOURTH DIGIT." THERE WAS NO FOLLOW-UP X-RAY TO CONFIRM A FRACTURE. NURSE 'A' WAS UNABLE TO EXPLAIN WHY SHE HAD STAFF TO CALL THE PHYSICIAN TO ORDER X-RAYS OF THE ANKLE BUT DID NOT REQUEST X-RAYS WHEN THE RESIDENT'S TOES WERE SEVERELY BRUISED ON 7/16/10. FROM 12/27/10 THRU 1/8/11, RESIDENT #405 COMPLAINED OF PAIN AND HAD AN INCREASE IN AGITATION, RESTLESSNESS, FACIAL GRIMACING, ANXIETY, AND WAS ROCKING BACK AND FORTH. ON 1/7/11, THE DOSAGE OF THE DURAGESIC PATCH WAS INCREASED. 28. ON 1/8/11 AT 5:50 AM, THE RESIDENT WAS ON THE FLOOR IN HER ROOM WITH NO NOTED INJURY. ON 1/13/11, THE RESIDENT WOULD NOT BEAR WEIGHT ON THE LEFT LEG PER NURSES NOTES. THE RESIDENT'S "LEFT LEG WAS GOING MEDIALLY AND ANY ATTEMPTS AT FORWARD MOTION RESIDENT COULD NOT MOVE FEET." THE RESIDENT WAS GRIMACING, VERY RESTLESS, AND SAID THAT SHE WAS IN PAIN THROUGHOUT THE DAY. ON 2/3/11, NURSES NOTES: "STAFF STATED THAT RESIDENT OCCASIONALLY COMPLAINED OF PAIN....PLAN OF CARE ADEQUATE TO ADDRESS RESIDENT'S NEEDS." THERE WERE NO FURTHER DOCUMENTED ADVERSE BEHAVIORS FOR RESIDENT #405. PER NURSES NOTES ON 2/8/11, THE RESIDENT WAS "NOT BEARING ON HER LEFT LEG. SHE IS LEANING HARD TO THE RIGHT AND APPEARS TO BE TURNING HER BODY LATERALLY IN SOME MANNER THAT APPEARS MAY HURT HER HIP OR KNEE." ON 2/9/11: "HIP AND KNEE OF LEFT LEG SLIGHTLY ROTATED INTERNALLY. ANKLE OF LEFT LEG ROLLING IN." ON 2/23/11: WHEN THE NURSE AIDE TRANSFERRED THE RESIDENT "SHE STOOD ONLY ON RIGHT LEG. DID NOT PLACE WEIGHT ON HER LEFT LEG." THERE WAS NO DOCUMENTATION THAT THE PHYSICIAN WAS MADE AWARE SO THAT THE RESIDENT COULD BE EVALUATED OR HAVE A FOLLOW UP X-RAY ORDERED, ESPECIALLY IN LIEU OF THE ABNORMAL X-RAY REPORTED OF THE LEFT HIP ON 7/6/10. NURSES NOTES, DOCUMENTED SINCE ADMISSION, THAT RESIDENT #405 WAS PERIODICALLY AND INCONSISTENTLY PROVIDED ONE TO ONE SUPERVISION, BUT WHEN THE 28 INCIDENTS OCCURRED, MAINLY DURING PERIODS OF EXTREME AGITATION, THE RESIDENT WAS NOT BEING SUPERVISED. THE RESIDENT WAS ALSO UNSUPERVISED AS EVIDENCED BY DISROBING IN THE PANTRY, BREAKING THE ROOMMATE'S TELEVISION, AND FORCEFULLY RUNNING INTO RESIDENTS AND KNOCKING A STAFF MEMBER DOWN. THE DON AND ADON WERE UNABLE TO EXPLAIN WHY THE RESIDENT WAS NOT ADEQUATELY PROVIDED ONE TO ONE SUPERVISION BY STAFF TO PREVENT THE REPEATED INCIDENTS WHEN BEHAVIOR AND PAIN WAS UNCONTROLLED. POLICIES REGARDING PAIN MANAGEMENT WERE REQUESTED BUT NOT PROVIDED BY THE END OF THE SURVEY. PER THE "MANAGING RESIDENT WITH ANXIETY/AGGRESSION" POLICY DATED 6/1/2009: "IF THE RESIDENT IS MOBILE BY PROPELLING A WHEELCHAIR AND REMAINS IN AN ANXIOUS STATE, PROVIDE ONE TO ONE INTERVENTION UNTIL THE RESIDENT HAS CALMED DOWN. FOLLOW BEHIND THEM AND MAKE SURE THEY REMAIN SAFE AND OTHERS ARE OUT OF HARMS WAY. SEPARATE AND KEEP SEPARATED THOSE RESIDENTS WITH KNOWN CONFLICTS. PROVIDE A CALM, QUIET ENVIRONMENT." THE IMMEDIATE JEOPARDY WAS REMOVED ON 3/15/11 AT 3:00 PM, WHEN THE FACILITY IMPLEMENTED THE FOLLOWING PLAN OF CORRECTION: "ELEMENT 1--THE ATTENDING PHYSICIAN FOR RESIDENT #405 HAS REVIEWED THE PLAN OF CARE FOR FALL PREVENTION, AND THE PSYCHIATRY SERVICE RECOMMENDATIONS AND BEHAVIORAL PLAN OF CARE WITH NO NEW INTERVENTIONS/ORDERS NEEDED AT THIS TIME. THE FACILITY HAD THE OCCUPATIONAL AND PHYSICAL THERAPIST REVIEW THE PLAN OF CARE FOR FALL PREVENTION AS WELL AS SAFETY DEVICES IN PLACE AND THEY FEEL THE CURRENT PLAN OF CARE IS APPROPRIATE AT THE PRESENT TIME. THE LAST FALL, AS WELL AS BEHAVIOR CHARTING, WAS REVIEWED AND INTERVENTIONS/RECOMMENDATIONS HAVE BEEN EFFECTIVE AS RESIDENT (#405) HAS NOT FALLEN OR HAD AN ACUTE BEHAVIORAL CRISIS SINCE THAT TIME. THE ATTENDING PHYSICIAN WANTS TO CONTINUE THE CURRENT PLAN OF CARE AS HE FEELS IT HAS AND IS EFFECTIVE FOR THE RESIDENT. ELEMENT 2--A MEETING WITH ALL FLOOR CARE COORDINATORS AND RESTORATIVE NURSING WAS HELD TO DISCUSS ANY BEHAVIORAL ISSUES/FALLS WITH THEIR CURRENT RESIDENTS ON THEIR FLOORS. THERE WERE NO RESIDENTS THAT REQUIRED FURTHER INTERVENTIONS FOR FALLS OR BEHAVIORS THAT WERE NOT ALREADY BEING ADDRESSED BY THE ATTENDING PHYSICIAN OR CONSULTANT PSYCHIATRY SERVICES. AUDITS OF BEHAVIORS/INTERVENTIONS AND FALLS WILL BE PERFORMED DAILY BY THE D.O.N. VIA THE ELECTRONIC CHARTING SYSTEM. ANY IRREGULARITIES WILL BE DISCUSSED WITH APPROPRIATE STAFF INVOLVED. ELEMENT 3--THE FACILITY PROCESS FOR FALLS AND FALL PREVENTION, AS WELL AS MANAGING RESIDENTS WITH ANXIETY/AGGRESSION, WAS REVIEWED WITH THE MEDICAL DIRECTOR ON MARCH 15, 2011. THE INTERDISCIPLINARY POST FALL ASSESSMENT POLICY WAS UPDATED TO MEMORIALIZE PREVIOUSLY UNWRITTEN BUT IMPLEMENTED FACILITY POLICY WHICH PROVIDES CLEARER DIRECTION TO FACILITY STAFF ON EXPECTATIONS RELATED TO PROPER TIMES TO REFER FALLS AND BEHAVIORS TO THE PHYSICAL THERAPIST, OCCUPATIONAL THERAPIST AND ATTENDING PHYSICIAN VIA THE FLOOR CARE COORDINATORS FOR FURTHER DIRECTION. ALL FLOOR COORDINATORS, AND RESTORATIVE NURSING SUPERVISOR AND ASSISTANT SUPERVISOR WILL RECEIVE AN INSERVICE ON THE POLICY UPDATE PRIOR TO WORKING ON THE FLOOR. THE DIRECTOR OF NURSING REVIEWED ALL OTHER POLICIES WITH THE FLOOR CARE COORDINATORS AND RESTORATIVE NURSING STAFF. THE MANAGING RESIDENTS WITH ANXIETY/AGGRESSION POLICY WAS UPDATED TO MEMORIALIZE PREVIOUSLY UNWRITTEN BUT IMPLEMENTED FACILITY POLICY WHICH PROVIDES CLEARER DIRECTION TO FACILITY STAFF ON EXPECTATIONS RELATED TO WHEN TO CALL THE SOCIAL WORKER AND/OR ATTENDING PHYSICIAN FOR FURTHER DIRECTION FOR RESIDENT BEHAVIORS, WHEN ALREADY ORDERED INTERVENTIONS ARE INEFFECTIVE. FURTHER DIRECTION MAY INCLUDE ONE TO ONE INTERVENTIONS AND/OR ACUTE CARE hospitalization IF DEEMED APPROPRIATE. ALL FACILITY STAFF AFFECTED BY THE POLICY ARE BEING INSERVICED TODAY (3/15/11). FUTURE SHIFTS AND AFFECTIVE STAFF WILL NOT WORK THE FLOOR UNTIL THEY HAVE RECEIVED INSERVICE RELATED TO POLICY CHANGE. ELEMENT 4--THE DIRECTOR OF NURSING WILL MONITOR ALL FALL EVENTS AND BEHAVIORS VIA THE ELECTRONIC MEDICAL RECORD DAILY MONDAY THROUGH FRIDAY. ANY FALL OR BEHAVIOR INTERVENTIONS IMPLEMENTED WILL BE REVIEWED ALSO. THIS WILL BE DONE DAILY FOR 2 MONTHS THEN WEEKLY FOR 1 MONTH. THE AUDIT WILL BE ADDRESSED AT THE QUARTERLY QUALITY ASSURANCE COMMITTEE MEETING BY THE NURSING DIRECTOR. IF THERE ARE NO ONGOING ISSUES, THE DIRECTOR OF NURSING WILL SEEK FURTHER DIRECTION FORM THE COMMITTEE RELATED TO NEED FOR CONTINUED AUDITING TO BE PERFORMED." ( , , , , , , , ) ON 3/4/11 AT 12:20 P.M., RECORD REVIEW OF RESIDENT #429'S CLOSED CLINICAL RECORD (FACE SHEET) REVEALED AN ADMISSION INto the facility on [DATE] AND A RE-ADMISSION ON 6/21/10 WITH [DIAGNOSES REDACTED]. RESIDENT #429'S ADMISSION MDS, dated [DATE], INDICATED A SEVERELY IMPAIRED COGNITION AND REQUIRED EXTENSIVE TO TOTAL ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING (ADL'S). THE MDS ALSO INDICATED THAT RESIDENT #429 HAD FALLS WITHIN THE PAST 30 DAYS AND WITHIN THE PAST 31 - 180 DAYS. ON 3/4/11 AT 1:20 P.M., RESIDENT #429'S FALLS WERE REVIEWED WITH THE FACILITY'S RESTORATIVE NURSE SUPERVISOR (NURSE "D"). REVIEW OF THE FACILITY'S "INTERDISCIPLINARY POST-FALL ASSESSMENTS" REVEALED THAT RESIDENT #429 HAD TWO FALLS SINCE SHE WAS RE-admitted on [DATE]: FALL #1 HAPPENED ON 6/27/10 AT 2:17 P.M. THE REPORT HAD THE FOLLOWING DOCUMENTATION: "CENA (CERTIFIED NURSING ASSISTANT) WALKING PAST ROOM NOTED DOOR PARTIALLY CLOSED AND HEARD RESIDENT TALKING, STOPPED AND LOOKED, FOUND RESIDENT LYING FLAT ON HER BACK ON THE FLOOR WITH RIGHT LEG PROPPED ON FOOT OF BED AND HOLDING CHAIR ALARM BOX IN LEFT HAND DETACHED FROM CHAIR. WHEELCHAIR FACING FOOT OF BED. TEAM LEADER NOTIFIED. DENIED HITTING HEAD, STATED RIGHT LEG AND BUTTOCKS HURT. PAIN LEVEL 4. NOTED LIGHT PURPLE BRUISE MEASURING APPROXIMATELY 1.2 CM (CENTIMETERS) IN DIAMETER TO INNER RIGHT LOWER LEG AND SECOND BRUISE PURPLE IN COLOR MEASURING APPROXIMATELY 2 CM IN LENGTH TO INNER ANKLE. SCRAPE TO RIGHT SHIN...BRUISE LIGHT PURPLE IN COLOR NOTED ON LEFT UPPER BUTTOCK MEASURING APPROXIMATELY 1.1 CM IN DIAMETER AND SECOND ON LOWER BACK LIGHT PURPLE IN COLOR MEASURING APPROXIMATELY 1 CM IN DIAMETER. INSTRUCTED RESIDENT TO USE CALL LIGHT FOR ASSISTANCE AND NOT TO ATTEMPT TO STAND ON OWN." REVIEW OF THE physician's orders [REDACTED]. 1. GRIPPER STRIPS AT/TO RIGHT SIDE OF BED, IN FRONT OF SINK AND TOILET IN BATHROOM, 2. TRANSFER BAR BILATERAL SIDES HEAD OF BED, 3. BED ALARM SET AT ONE SECOND INTERVAL, 4. CHAIR ALARM (CHANGE PAD ANNUALLY AND AS NECESSARY TO ALL CHAIRS), AND 5. VELCRO SEAT BELT A PHYSICIAN ORDER [REDACTED]. A physician's orders [REDACTED]. AT THE TIME OF THE FALL ON 6/27/10, THERE WAS NO MENTION OF THE USE OF THE LAP BUDDY FOR RESIDENT #429. ON 3/4/11 AT 1:30 P.M., NURSE "D" WAS QUERIED REGARDING POST FALL INTERVENTIONS. NURSE "D" REPORTED THAT THERE WERE NO POST FALL INTERVENTIONS AND SHE DECIDED TO CONTINUE WITH THE PLAN OF CARE. THE CHAIR ALARM THAT DID NOT SOUND AND THE FACT THAT THE RESIDENT WAS WITNESSED HOLDING THE ALARM BOX WERE NOT ADDRESSED. THE "INTERDISCIPLINARY POST - FALL ASSESSMENT" REPORT READ UNDER THE SUBTITLE "RECOMMENDATION," READ, "NONE AT THIS TIME. CONTINUE TO MONITOR." NURSE "D" STATED, "I WANTED TO CONTINUE WATCHING HER. SHE WAS ABLE TO REMOVE THE LAP BUDDY." FALL #2 HAPPENED ON 6/30/10 AT 8:38 P.M. REVIEW OF THE FACILITY'S "INTERDISCIPLINARY POST - FALL ASSESSMENT," DATED 6/30/10 AT 8:38 P.M., THREE DAYS AFTER THE FIRST FALL (FALL #2), REVEALED THE FOLLOWING DOCUMENTATION: "CNA ALERTED TO ROOM BY CHAIR ALARM SOUNDING. CNA ENTERED ROOM AND FOUND RESIDENT LAYING ON FLOOR AT FOOT OF BED ON RIGHT SIDE...NO APPARENT INJURY." NURSE "D" REPORTED THAT THE RESIDENT fell FROM HER CHAIR AGAIN. AN ALARMING VELCRO SEATBELT WAS ADDED AFTER THIS FALL. NURSE "D" PROVIDED NO FURTHER EXPLANATION FOR NOT ADDING ANY POST INTERVENTIONS AFTER FALL #1 FROM HER CHAIR. ( ) ON 3/1/11 AT 11:50 A.M., DURING THE INITIAL TOUR OF THE SECOND FLOOR SOUTH WING, IT WAS OBSERVED THAT AN UNSECURED OXYGEN CYLINDER WAS SITTING UPRIGHT IN THE OXYGEN STORAGE ROOM. THE OXYGEN CYLINDER WAS SITTING ADJACENT TO A STAND FOR SECURING CYLINDERS. UNIT MANAGER " I ' " WAS QUERIED AND SAID THAT SHOULD NOT BE THERE WITHOUT A STAND. ON 3/2/11 AT 9:18 A.M., DURING GENERAL OBSERVATIONS OF THE SECOND FLOOR SOUTH WING, IT WAS OBSERVED THAT AN UNSECURED OXYGEN CYLINDER WAS SITTING UPRIGHT IN THE OXYGEN STORAGE ROOM. THE OXYGEN CYLINDER WAS SITTING ADJACENT TO A STAND FOR SECURING CYLINDERS. UNIT NURSE " J " WAS QUERIED AND SAID THAT SHOULD BE IN A CART. ON 3/3/11 AT 1:45 P.M., THE FACILITY'S POLICY FOR " SECURING OXYGEN ADMINISTRATION, UNDATED DOCUMENTED "OXYGEN CYLINDERS SHOULD BE SECURED AT ALL TIMES." ( )

BASED ON OBSERVATION, INTERVIEW, AND RECORD, THE FACILITY FAILED TO ASSESS PAIN AND CHANGE OF CONDITION FOR ONE (#405) OF 30 SAMPLED RESIDENTS, RESULTING IN MULTIPLE FALLS WITH INJURIES, COMPLAINTS OF PAIN AND THE RESIDENT EXPERIENCING EMOTIONAL DISTRESSING BEHAVIOR WITHOUT RELIEF. FINDINGS INCLUDE: ON 3/4/11, THE CLINICAL RECORD AND INCIDENT/ACCIDENT (I/A) REPORTS FOR RESIDENT #405 WERE REVIEWED WITH NURSES 'D' AND 'E' AT 11 AM, WITH NURSE 'A' AT 11:45 AM, AND WITH THE DIRECTOR OF NURSING (DON) AND THE ASSISTANT DIRECTOR OF NURSING (ADON) AT 1:10 PM. PER THE ADMISSION FACE SHEET/[DIAGNOSES REDACTED]. THE RESIDENT ALSO had a history of [REDACTED]. ACCORDING TO MINIMUM DATA SETS ((MDS) dated [DATE] AND 2/10/11, THE RESIDENT HAD SEVERE COGNITIVE IMPAIRMENT, REQUIRED EXTENSIVE ASSISTANCE FROM STAFF FOR TRANSFERS AND MOBILITY, AND WAS NON-AMBULATORY. THE RESIDENT'S MOOD/BEHAVIORS INCLUDED: REPETITIVE PHYSICAL MOVEMENTS, WANDERING, AND VERBAL ABUSIVENESS. THE RESIDENT WAS PRESCRIBED 1 MG (MILLIGRAM) OF [MEDICATION NAME] (ANTIPSYCHOTIC) FOR A HISTORY OF INCREASED CONFUSION WITH VERBAL AGGRESSION AND REFUSAL OF CARE. ACCORDING TO NURSES NOTES, RESIDENT #405 WAS OBSERVED ON THE DAY OF ADMISSION MAKING MULTIPLE ATTEMPTS TO SELF-TRANSFER FROM HER BED AND WHEELCHAIR. SHE WAS NOTED TO HAVE POOR SAFETY AWARENESS. THE RESIDENT WAS PRESCRIBED A LAP BUDDY (A TRAY-TYPE DEVICE ACROSS THE TORSO AREA) FOR THE WHEELCHAIR, CHAIR AND BED ALARMS, A BED GUARD (A BOLSTER-TYPE DEVICE TO PREVENT ROLLING OUT OF BED), AND AN ALARMING WHEELCHAIR SEATBELT FOR SAFETY. PER NURSES NOTES DATED 5/27/10 THRU 6/8/10, RESIDENT #405 CONTINUED TO ATTEMPT NUMEROUS SELF TRANSFERS EACH DAY. SHE ALSO REMOVED THE LAP BUDDY, CLIMBED OVER THE BED GUARD, AND WANDERED IN AND OUT OF OTHER RESIDENT'S ROOMS IN THE WHEELCHAIR. SHE WAS NOTED TO RECEIVE NUMEROUS "NOW" DOSES OF [MEDICATION NAME] (FOR ANXIETY) DUE TO ANXIETY, RESTLESSNESS, AND REPEATEDLY ASKING TO "GO HOME" OR "GO TO BED (WHILE SHE WAS IN BED)." THE RESIDENT'S BEHAVIOR WAS UNCONTROLLED PER NOTES. REVIEW OF PAIN ASSESSMENTS FROM 5/26/10 THRU 6/3/10 NOTED THAT THERE WERE NO SIGNS THAT THE RESIDENT EXPERIENCED PAIN. SHE HAD NOT BEEN PRESCRIBED ANY PAIN MEDICATION. ON 6/4/10, THE RESIDENT COMPLAINED OF PAIN IN HER FINGERS. STAFF ASKED THE RESIDENT'S DURABLE POWER OF ATTORNEY (DPOA) IF THE RESIDENT COULD RECEIVE PAIN MEDICATION BECAUSE OF THE [DIAGNOSES REDACTED]. THE DPOA SAID, "SHE DOES NOT EXPERIENCE PAIN. SHE DOES NOT NEED ANY MEDICATION" AND REFUSED TO ALLOW THE RESIDENT TO RECEIVE PAIN MEDICATION. FROM 6/4/10 THRU 6/9/10, THE BEHAVIORS CONTINUED. REVIEW OF 28 I/A REPORTS FOR RESIDENT #405 NOTED THE FOLLOWING: 1. ON 6/9/10 AT 11:55 PM,THE RESIDENT fell OUT OF BED ATTEMPTING A SELF TRANSFER. THERE WAS NO NOTED INJURY. THE RESIDENT ALSO TORE OFF HER INCONTINENT BRIEF AND LEFT IT ON THE FLOOR. FROM 6/9/10 THRU 6/11/10, BEHAVIORS CONTINUED. ON 6/11/10, THE DPOA AGREED TO ALLOW A PRESCRIPTION FOR TYLENOL 650 MG EVERY 12 HOURS FOR PAIN RELIEF. THE RESIDENT WAS hospitalized from [DATE] THRU 6/15/10 FOR A LUNG CONDITION (PULMONARY EMBOLISM). FROM 6/16/10 THRU 6/25/10, THE RESIDENT EXHIBITED THE FOLLOWING BEHAVIOR: ANXIETY, REPEATEDLY PULLED OFF HER OXYGEN TUBING, GRIMACING AND COMPLAINING OF "PAIN ALL OVER," CONSTANTLY BUMPING INTO OBJECTS, WALLS, AND OTHER RESIDENTS IN THE WHEELCHAIR IN A RAPID AND FORCEFUL MANNER, WHEELING BACKWARDS IN THE WHEELCHAIR, WANDERING NON-STOP, ATTEMPTING SELF TRANSFERS, AND REMOVING THE LAP BUDDY. SHE RECEIVED NUMEROUS DOSES OF TYLENOL AND [MEDICATION NAME] (FOR ANXIETY) WITHOUT RESULTS. 2. ON 6/26/10 AT 8 PM, THE RESIDENT WAS FOUND ON THE FLOOR IN HER ROOM. THERE WAS NO NOTED INJURY. ON 6/27/10, THE RESIDENT WAS FOUND IN A CLOSED PANTRY NUDE FROM THE WAIST UP, WAS WANDERING BACKWARDS IN THE WHEELCHAIR, AND ATTEMPTING SELF-TRANSFERS. ON 6/28/10 AT 2:50 PM, THE RESIDENT PROPELLED HERSELF BACKWARD AND "KNOCKED DOWN THE FLOOR COORDINATOR," AND ATTEMPTED SELF-TRANSFERS. 3. ON 6/29/10 AT 7:05 PM, THE RESIDENT WAS ON THE FLOOR IN HER ROOM. THERE WAS NO NOTED INJURY. SHE WAS AGITATED, ANXIOUS, THROWING OBJECTS, GRABBING STAFF, AND PULLING HER SEATBELT. SHE RECEIVED MULTIPLE DOSES OF [MEDICATION NAME] AND TYLENOL. 4. ON 6/30/10 AT 1:30 AM, THE RESIDENT fell OUT OF BED WITH NO NOTED INJURY. 5. ON 6/30/10 AT 2:10 AM, THE RESIDENT WAS ON THE FLOOR IN HER ROOM WITH NO NOTED INJURY. SHE WAS ANXIOUS, AGITATED, RESTLESS, REPEATEDLY ASKED TO GO TO BED, AND COMPLAINED OF BACK PAIN. SHE WAS DELUSIONAL, PARANOID, WHISPERING TO SELF, AND SAID, "GET THAT MAN OUT OF MY ASS." THE RESIDENT CONTINUED TO REMOVE HER SEATBELT AND CLOTHES, AND ATTEMPT SELF-TRANSFERS. SHE RECEIVED NUMEROUS DOSES OF [MEDICATION NAME] AND TYLENOL WITHOUT RESULTS. THE RESIDENT WAS SEEN ON 6/30/10 BY THE PSYCHIATRIST WHO RECOMMENDED ADEQUATE PAIN CONTROL. 6. ON 7/1/10 AT 10:45 AM, THE RESIDENT WAS ON THE FLOOR IN HER ROOM WITH NO NOTED INJURY. SHE SUSTAINED A 6 X 5 CENTIMETER (CM) PURPLE BRUISE ON THE LEFT BUTTOCK AND A QUARTER SIZE BUMP ON THE BACK OF THE HEAD THAT SHE HIT ON "ON HER BEDSIDE TABLE." 7. ON 7/1/10 AT 2:30 PM, THE RESIDENT fell OUT OF BED IN HER ROOM WITH NO NOTED INJURY. THE RESIDENT'S BEHAVIORS CONTINUED. THE [MEDICATION NAME] DOSES WERE INCREASED AND KLONOPIN (FOR PANIC ATTACKS) WAS ADDED WITHOUT RESULTS. THE RESIDENT WAS WANDERING, RESTLESS, RUNNING INTO OBJECTS AND STAFF, ATTEMPTING SELF TRANSFERS, AGITATED, RESTLESS, AND SLEEPLESS ON 7/1/10 AND 7/2/10. ON 7/3/10 AT 10:14 PM, THE RESIDENT KNOCKED HER ROOMMATE'S TELEVISION OFF OF THE STAND AND BROKE IT, AND THREATENED TO CHOKE HER. THE ROOMMATE CALLED HER A "[***] " AND YELLED "GET THE HELL OUT OF HERE." THERE WAS AN ORDER ON 7/3/10 TO TRANSFER RESIDENT #405 TO ANOTHER ROOM TO PREVENT FURTHER ALTERCATIONS. HOWEVER, PER NURSES NOTES, THE RESIDENT WAS NOT MOVED TO THE OTHER ROOM UNTIL 7/5/10 AT 10:32 AM. ALTHOUGH THE FOLLOWING OCCURRED: THROUGHOUT 7/4/10 AND 7/5/10, RESIDENT #405 WAS RESTLESS, ANXIOUS, UNABLE TO SIT STILL, TWISTING AND TURNING SELF IN THE WHEELCHAIR, TRYING TO GET UP FROM THE BED AND WHEELCHAIR WITHOUT ASSISTANCE, AND REMOVING THE SEATBELT. SHE CONTINUED TO HAVE THE BRUISE ON HER LEFT BUTTOCK, AND COMPLAINED OF PAIN IN THE BACK AND HIPS. SHE RECEIVED MULTIPLE DOSES OF TYLENOL AND [MEDICATION NAME] THAT WERE NOT EFFECTIVE. ON 7/5/10, THE DPOA "VOICED CONCERN THAT PAIN WAS NOT BEING ADDRESSED." ON 7/5/10, THE PAIN MEDICATION WAS CHANGED FROM TYLENOL TO [MEDICATION NAME]. PER NURSES NOTES ON 7/6/10 AT 8:22 AM, RESULTS OF X-RAYS DATED 7/1/10 AT 5:48 PM, WERE RECEIVED. THE X-RAYS WERE DONE ACCORDING TO NURSE 'A' BECAUSE OF THE BRUISING SUSTAINED FROM THE FALL ON 7/1/10. THE RESULTS: "TWO VIEWS OF THE LEFT HIP/LEFT FEMUR REVEAL ADVANCED [MEDICAL CONDITION] CHANGES....WITH ACETABULAR PROTRUSION. A PREVIOUS ACETABULAR FRACTURE CANNOT BE EXCLUDED." THERE WAS NO EXPLANATION WHY THE X-RAY RESULTS WERE NOT RECEIVED FOR FIVE DAYS. THERE WAS NO FOLLOW-UP X-RAY TO RULE OUT A FRACTURE. NURSE 'A,' WHO WAS RESPONSIBLE FOR COORDINATING CARE, THE DON, AND THE ADON WERE UNABLE TO EXPLAIN WHY. THE DON SAID, "SHE (RESIDENT) HAD A CAR ACCIDENT [AGE] years AGO THAT EFFECTED AMBULATION." THE DON WAS UNABLE TO VERIFY THAT THE ACCIDENT RESULTED IN A FRACTURE TO THE AREA. 8. ON 7/6/10 AT 8:30 AM, THE RESIDENT fell IN HER ROOM WITH NO NOTED INJURY. BEHAVIORS CONTINUED. PER NURSES NOTES, SHE RECEIVED NUMEROUS DOSES OF [MEDICATION NAME] AND [MEDICATION NAME]. ON 7/7/10 AND 7/8/10, THE RESIDENT GRABBED STAFF, HAD SYMPTOMS OF PAIN (RESTLESSNESS, FACIAL GRIMACING, CLENCHING FISTS), WAS PROPELLING HERSELF BACKWARDS, RUNNING INTO WALLS AND OBJECTS, ATTEMPTING SELF TRANSFERS, WANDERING INTO OTHER RESIDENTS' ROOMS, AND PULLING AT THE SAFETY BELT. SHE COMPLAINED OF PAIN IN THE BUTTOCKS. 9. ON 7/8/10 AT 2:45 PM, RESIDENT #405 fell IN HER ROOM WITH NO NOTED INJURY. 10. ON 7/8/10 AT 8:30 PM, THE RESIDENT fell IN HER ROOM WITH NO NOTED INJURY. 11. ON 7/8/10 AT 11:15 PM, THE RESIDENT fell IN HER ROOM WITH NO NOTED INJURY. 12. ON 7/9/10 AT 9 AM, THE RESIDENT WAS OBSERVED SLIDING TO THE FLOOR IN HER ROOM AND HAD TO BE LOWERED TO THE FLOOR BY STAFF. THERE WAS NO NOTED INJURY. ON 7/9, 7/10, AND 7/11/10, THE RESIDENT WAS ANXIOUS, SHIFTING BACK AND FORTH, AND COMPLAINED OF PAIN. SHE BECAME COMBATIVE WITH STAFF, KICKING AND SWINGING, ATTEMPTING SELF TRANSFERS, REMOVING, PROPELLING HERSELF BACKWARDS FORCEFULLY, AND TIPPING AN OXYGEN TANK OVER, PULLING DECORATIONS OFF THE WALL, AND KNOCKING THE BLOOD PRESSURE MACHINE ON THE FLOOR. 13. ON 7/11/10 AT 1:03 AM, THE RESIDENT WEDGED HERSELF IN THE DOOR OF A UNIT BATHROOM. SHE SUSTAINED REDNESS TO THE ENTIRE RING AND MIDDLE FINGER OF THE LEFT HAND WITH BRUISING FROM THE KNUCKLES TO THE FIRST JOINTS OF EACH FINGER. SHE WAS ALSO NOTED TO PROPEL BACKWARDS INTO THE WALL AND STAFF, AND BANGING THE CALVES ON BOTH LEGS AND SHINS WITH THE BACK OF THE WHEELCHAIR LEG RESTS. SHE SUSTAINED BRUISING TO THE LOWER LEGS. 14. ON 7/12/10 AT 12:55 AM, THE RESIDENT WAS NUDE AND HAD FALLEN IN HER ROOM WITH NO NOTED INJURY. SHE CONTINUED TO WANDER, RECEIVE [MEDICATION NAME] AND [MEDICATION NAME], ATTEMPTED TO REMOVE THE LAP BUDDY, AND RESIST CARE. THE RESIDENT "ALMOST PULLED OVER ELECTRIC LIFT" AND COMPLAINED OF PAIN. THE DOSAGE OF [MEDICATION NAME] WAS INCREASED WITHOUT RESULTS. PER NURSES NOTES ON 7/13/10 AT 6:49 AM, THE RESIDENT'S HAND WAS REASSESSED FROM THE INJURY ON 7/11/10: "....REDDISH PURPLE BRUISING NOTED TO 2ND, 3RD, AND 4TH FINGERS AND BACK OF HAND JUST UNDER KNUCKLES" CONTINUED. THERE WAS NO X-RAY DONE FOLLOWING THE INJURY. NURSE 'A' WAS UNABLE TO EXPLAIN WHY. 15. ON 7/13/10 AT 11:30 PM, THE RESIDENT WAS ON THE FLOOR IN HER ROOM WITH NO NOTED INJURY. SHE REMAINED RESTLESS AND COMPLAINED OF PAIN. 16. ON 7/14/10 AT 2:51 AM, THE RESIDENT WAS ON THE FLOOR IN HER ROOM WITH NO NOTED INJURY. THE RESIDENT HAD A URINE CULTURE THAT WAS POSITIVE FOR BACTERIA AND WAS PRESCRIBED ANTIBIOTICS FOR 7 DAYS. THE DPOA VOICED THAT A URINARY TRACT INFECTION MAY BE THE CAUSE OF SOME BEHAVIORS. ON 7/15/10, CONTINUED BEHAVIORS AND COMPLAINTS OF "PAIN ALL OVER." ON 7/16/10, THE RESIDENT WAS PULLING OFF CLOTHING, RAMMING WHEELCHAIR INTO THE MEDICATION ROOM DOOR JAM, BANGING ON THE NURSES STATION COUNTER, AND WHEELING BACKWARDS WITH A SHOW OF ANGER. 17. ON 7/16/10 AT 12 AM, THE RESIDENT WAS NOTED TO HAVE BRUISING TO FEET: "RIGHT FOOT HAS 3 1/2 INCH DARK PURPLE BRUISING INVOLVING GREAT TOE AND ACROSS THE BASE OF 2ND, 3RD, 4TH TOE 2 INCHES WIDE. ALSO BRUISE EXTENDS LATERALLY FROM GREAT TOE DOWN TOWARDS THE HEEL 5 INCHES....LEFT FOOT HAS BRUISING LATERALLY EXTENDING 3 INCHES FROM BASE OF GREAT TOE TOWARDS HEEL. THIS IS ALSO PURPLISH/BLUE. RESIDENT STATED THAT SHE DOES HAVE PAIN WITH AREA...." THE RESIDENT CONTINUED ROLLING HER WHEELCHAIR INTO WALLS AND OTHER RESIDENTS. [MEDICATION NAME] WAS GIVEN THROUGHOUT THE DAY WITH THE RESIDENT OCCASIONALLY SPITTING OUT THE PILLS. SHE WAS AGITATED ON 7/17/10. 18. ON 7/18/10 AT 1:45 AM, THE RESIDENT AS ON THE FLOOR IN HER ROOM WITH NO NOTED INJURY. HER FEET REMAINED BRUISED. THROUGHOUT THE DAY, SHE ATTEMPTED SELF TRANSFERS, WAS RESTLESS, CONSTANTLY MOVING, PULLING OFF SHIRT, REMOVING LAP BUDDY, AND COMPLAINING OF PAIN "ALL OVER." 19. ON 7/19/10 AT 3:30 AM, RESIDENT #405 WAS ON THE FLOOR IN HER ROOM WITH NO NOTED INJURY. SHE WAS RESTLESS AND AGITATED THROUGHOUT THE DAY WITH NUMEROUS ATTEMPTS TO SELF TRANSFER. SHE HAD SIGNS OF PAIN AND STATED THAT SHE WAS HURTING. THE PSYCHIATRIST SAW THE RESIDENT ON 7/19/10 AND RECOMMENDED LONG-ACTING PAIN CONTROL AND NOTED: "PATIENT MAY BE IN PAIN DUE TO CONSTANT RESTLESSNESS, DISCOMFORT, UNEASINESS, AND NEED TO BE IN MOTION." PER NURSES NOTES ON 7/20/10, THE PHYSICIAN SAW THE PSYCHIATRIST'S RECOMMENDATIONS AND "WANTS TO START RESIDENT ON A [MEDICATION NAME] (PAIN) PATCH...." ON 7/20/10 AT 5:02 AM, NURSES NOTED: "LEFT FOOT HAS A NARROW LINE OF DARK PURPLE BRUISING ACROSS 2 BASES OF TOES AND LATERALLY BACK TOWARD HEEL. THERE IS ALSO BRUISING JUST ABOVE THE ANKLE INWARD THAT IS DIFFUSED BRUISING....RIGHT FOOT THERE IS DARK PURPLISH BRUISING ACROSS ALL TOES AT THE BASE EXCEPT FOR PINKY TOE. BRUISE EXTENDS LATERAL TO BACK TOWARD THE HEEL." THERE WERE NO X-RAYS OF THE RESIDENT'S FEET BECAUSE, ACCORDING TO NURSE 'A,' "THE PHYSICIAN DIDN'T ORDER IT." NURSE 'A,' THE DON, AND THE ADON WERE UNABLE TO EXPLAIN WHY. THERE WAS NO DOCUMENTATION THAT NURSING STAFF MENTIONED OBTAINING AN X-RAY TO THE PHYSICIAN. ON 3/4/11 AT 1:35 PM, WHEN THE PHYSICIAN WAS ASKED ABOUT AN X-RAY BEING DONE, HE SAID, "IT WAS DONE. WE DID AN X-RAY." HE HAD NO EXPLANATION WHEN NURSE 'A' SHOOK HER HEAD INDICATING THAT IT HAD NOT BEEN DONE. ON 7/20/10, THE RESIDENT RECEIVED A [MEDICATION NAME] PATCH PRESCRIBED FOR EVERY 72 HOURS AND THE 7 DAY COURSE OF ANTIBIOTICS FOR A URINARY TRACT INFECTION WERE COMPLETED BUT BEHAVIORS CONTINUED. FROM 7/20/10 THRU 7/24/10, RESIDENT #405 WANDERED AROUND BACKWARDS KNOCKING A BOARD OFF THE WALL AND TIPPING OVER THE VITAL SIGN MACHINE. SHE WAS GRABBING THE STAFF'S CLOTHING, PULLING THEIR CHAIRS BACKWARDS, AND ALMOST RAN OVER OTHER RESIDENTS. SHE COMPLAINED OF PAIN AND [MEDICATION NAME] AND [MEDICATION NAME] WERE INEFFECTIVE. ON 7/25/10, THE RESIDENT'S BEHAVIOR WAS UNCHANGED. SHE KICKED A DIETARY FOOD RACK AND KNOCKED IT TO THE FLOOR. SHE WAS IN CONSTANT MOTION AND COMPLAINING OF PAIN. [MEDICATION NAME] AND [MEDICATION NAME] WERE GIVEN NUMEROUS TIMES. 20. ON 7/25/10 AT 7:20 PM, THE RESIDENT WAS ON THE FLOOR IN HER ROOM WITH NO NOTED INJURY. THE RESIDENT WAS SEEN BY THE PSYCHIATRIST ON 7/26/10 WHO AGAIN RECOMMENDED PAIN CONTROL. ON 7/26/10, BEHAVIORS CONTINUED. THE RESIDENT RECEIVED [MEDICATION NAME] AND [MEDICATION NAME]. 21. ON 7/27/10 AT 1:45 AM, RESIDENT #405, THE RESIDENT WAS ON THE FLOOR IN HER ROOM WITH NO NOTED INJURY, CONTINUED AGITATION AND COMPLAINTS OF PAIN. 22. ON 7/28/10, THE RESIDENT WAS ON THE FLOOR IN HER ROOM WITH NO NOTED INJURY. AGITATION CONTINUED AND FACIAL GRIMACING WITH COMPLAINTS OF PAIN. SHE BUMPED HER WHEELCHAIR FAST AND HARD INTO ANOTHER RESIDENTS CHAIR AND "WAS TOO RESTLESS TO STAY IN BED." THE RESIDENT RECEIVED [MEDICATION NAME], THE [MEDICATION NAME] PATCH, AND [MEDICATION NAME] FOR PAIN "ALL OVER" AND RESTLESSNESS FROM 7/28/10 THRU 8/9/10. 23. ON 8/9/10 AT 6:55 AM, THE RESIDENT WAS FOUND ON THE FLOOR IN HER ROOM AS A STAFF MEMBER WAS PASSING ICE. THERE WAS NO NOTED INJURY. THE SAFETY ALARM DID NOT SOUND. THERE WAS NO DOCUMENTED REASON WHY. ON 8/11/10 AT 6:31 AM, THE RESIDENT WAS OBSERVED AMBULATING DOWN THE HALLWAY, HOLDING ON TO THE RAIL. THE ALARM DID NOT SOUND. THERE WAS NO DOCUMENTED REASON WHY. WHEN ASKED IF SHE HAD PAIN, THE RESIDENT STATED "YES" AND POINTED TO THE RIGHT LOWER LEG. NURSES NOTES DATED 8/12/10 FOR A FOLLOW-UP OF THE INCIDENT ON 8/9/10 NOTED: "FAINT PURPLE BRUISING NOTED TO LEFT BUTTOCK." THERE WAS NO X-RAY TAKEN OF THE AREA. 24. ON 8/30/10 AT 2:53 PM, THE RESIDENT fell FORWARD OUT OF THE WHEELCHAIR IN HER ROOM, LANDING ON HER KNEES IN THE PRESENCE OF A NURSE AIDE WHO WAS IN THE PROCESS OF "GETTING EVERYTHING PREPARED TO TRANSFER RESIDENT" PER NURSES NOTES. THE resident sustained [REDACTED]. SHE COMPLAINED OF PAIN "ALL OVER." THE POSSIBLE CAUSE OF THE INCIDENT: "SLID FROM CHAIR." THERE WAS NO MENTION OF A LACK OF PROPER SUPERVISION OR WHY THE SAFETY BELT WAS NOT IN PLACE. A 9/2/10 FOLLOW UP OF THE 8/30/10 INCIDENT NOTED: "RESIDENT HAS SPIDER VEIN-LIKE BRUISING TO RIGHT OUTER LATERAL LEG JUST ABOVE KNEE, ALSO BRUISING TO LEFT INNER, BELOW KNEE....RESIDENT ALSO HAS A 3 INCH BY 2 INCH BRUISE TO POSTERIOR RIGHT LOWER BACK BOTTOM RIB CAGE...." 25. ON 10/2/10 AT 4:50 AM, THE I/A REPORT NOTED THE RESIDENT TO HAVE A 1 INCH BY 1 INCH BRUISE TO THE LEFT INNER BUTTOCKS. THE POSSIBLE CAUSE: "SLID FROM CHAIR." THERE WAS NO DOCUMENTED EXPLANATION OF THE EVENT. 26. ON 10/26/10 AT 9:41 PM, THE RESIDENT HAD A 1 INCH BY 1 INCH DARK PURPLE BRUISE ON THE RIGHT INNER BUTTOCK PER THE I/A REPORT. POSSIBLE CAUSE: "INJURED DURING TRANSFER." THERE WAS NO DOCUMENTED EXPLANATION OF THE EVENT. 27. ON 11/26/10 AT 4:40 PM, THE RESIDENT fell OUT OF BED AND SUSTAINED A 10 X 4 CM BRUISE "IN SHADES OF PURPLE AND GREEN" ON THE ENTIRE OUTER SIDE OF THE RIGHT FOOT. PER NURSES NOTES ON 11/27/10, THE RIGHT LATERAL ANKLE AND 3RD TOE OF THE FOOT WERE SWOLLEN. ON 11/29/10, NURSES NOTED: "....ANKLE SLIGHTLY SWOLLEN AND BLUISH/PURPLE BRUISING NOTED ON ANKLE DOWN THE OUTSIDE OF FOOT, ALONG THE SIDE. NURSE 'A' INSTRUCTED STAFF TO CALL THE PHYSICIAN FOR AN X-RAY ORDER. X-RAYS WERE DONE ON 11/29/10 AT 7:05 PM. THE RESULTS: "OLD HEALED [MEDICAL CONDITION] TIBIA" AND "THERE IS A PROBABLE OLD [MEDICAL CONDITION] PHALANX (TOE BONE) OF THE FOURTH DIGIT." THERE WAS NO FOLLOW-UP X-RAY TO CONFIRM A FRACTURE. NURSE 'A' WAS UNABLE TO EXPLAIN WHY SHE HAD STAFF TO CALL THE PHYSICIAN TO ORDER X-RAYS OF THE ANKLE BUT DID NOT REQUEST X-RAYS WHEN THE RESIDENT'S TOES WERE SEVERELY BRUISED ON 7/16/10. FROM 12/27/10 THRU 1/8/11, RESIDENT #405 COMPLAINED OF PAIN AND HAD AN INCREASE IN AGITATION, RESTLESSNESS, FACIAL GRIMACING, ANXIETY, AND WAS ROCKING BACK AND FORTH. ON 1/7/11, THE DOSAGE OF THE [MEDICATION NAME] PATCH WAS INCREASED. 28. ON 1/8/11 AT 5:50 AM, THE RESIDENT WAS ON THE FLOOR IN HER ROOM WITH NO NOTED INJURY. ON 1/13/11, THE RESIDENT WOULD NOT BEAR WEIGHT ON THE LEFT LEG PER NURSES NOTES. THE RESIDENT'S "LEFT LEG WAS GOING MEDIALLY AND ANY ATTEMPTS AT FORWARD MOTION RESIDENT COULD NOT MOVE FEET." THE RESIDENT WAS GRIMACING, VERY RESTLESS, AND SAID THAT SHE WAS IN PAIN THROUGHOUT THE DAY. ON 2/3/11, NURSES NOTES: "STAFF STATED THAT RESIDENT OCCASIONALLY COMPLAINED OF PAIN....PLAN OF CARE ADEQUATE TO ADDRESS RESIDENT'S NEEDS." THERE WERE NO FURTHER DOCUMENTED ADVERSE BEHAVIORS FOR RESIDENT #405. PER NURSES NOTES ON 2/8/11, THE RESIDENT WAS "NOT BEARING ON HER LEFT LEG. SHE IS LEANING HARD TO THE RIGHT AND APPEARS TO BE TURNING HER BODY LATERALLY IN SOME MANNER THAT APPEARS MAY HURT HER HIP OR KNEE." ON 2/9/11: "HIP AND KNEE OF LEFT LEG SLIGHTLY ROTATED INTERNALLY. ANKLE OF LEFT LEG ROLLING IN." ON 2/23/11: WHEN THE NURSE AIDE TRANSFERRED THE RESIDENT "SHE STOOD ONLY ON RIGHT LEG. DID NOT PLACE WEIGHT ON HER LEFT LEG." THERE WAS NO DOCUMENTATION THAT THE PHYSICIAN WAS MADE AWARE SO THAT THE RESIDENT COULD BE EVALUATED OR HAVE A FOLLOW UP X-RAY ORDERED, ESPECIALLY IN LIEU OF THE ABNORMAL X-RAY REPORTED OF THE LEFT HIP ON 7/6/10. NURSES NOTES, DOCUMENTED SINCE ADMISSION, THAT RESIDENT #405 WAS PERIODICALLY AND INCONSISTENTLY PROVIDED ONE TO ONE SUPERVISION, BUT WHEN THE 28 INCIDENTS OCCURRED, MAINLY DURING PERIODS OF EXTREME AGITATION, THE RESIDENT WAS NOT BEING SUPERVISED. THE RESIDENT WAS ALSO UNSUPERVISED AS EVIDENCED BY DISROBING IN THE PANTRY, BREAKING THE ROOMMATE'S TELEVISION, AND FORCEFULLY RUNNING INTO RESIDENTS AND KNOCKING A STAFF MEMBER DOWN. THE DON AND ADON WERE UNABLE TO EXPLAIN WHY THE RESIDENT WAS NOT ADEQUATELY PROVIDED ONE TO ONE SUPERVISION BY STAFF TO PREVENT THE REPEATED INCIDENTS WHEN BEHAVIOR AND PAIN WAS UNCONTROLLED. POLICIES REGARDING PAIN MANAGEMENT WERE REQUESTED BUT NOT PROVIDED BY THE END OF THE SURVEY. PER THE "MANAGING RESIDENT WITH ANXIETY/AGGRESSION" POLICY DATED 6/1/2009: "IF THE RESIDENT IS MOBILE BY PROPELLING A WHEELCHAIR AND REMAINS IN AN ANXIOUS STATE, PROVIDE ONE TO ONE INTERVENTION UNTIL THE RESIDENT HAS CALMED DOWN. FOLLOW BEHIND THEM AND MAKE SURE THEY REMAIN SAFE AND OTHERS ARE OUT OF HARMS WAY. SEPARATE AND KEEP SEPARATED THOSE RESIDENTS WITH KNOWN CONFLICTS. PROVIDE A CALM, QUIET ENVIRONMENT." ( )