Every finding on record at Manistee County Medical Care Facility

Based on interview and record review, the facility failed to ensure one Resident (#31) of five residents reviewed for eligible immunizations was offered a pneumococcal vaccine as recommended by the Centers for Disease Control and Prevention (CDC).Findings Include:Resident #31 (R31)Review of the electronic medical record (EMR) for R31, revealed initial admission to the facility on 7/19/16 with diagnoses including multiple sclerosis, dementia, and failure to thrive. The most recent pneumococcal immunization for R31 was administered on 6/27/17. The status of the next pneumococcal immunization read, refused.Review of R31's vaccination history on the Michigan Care Improvement Registry (MCIR), revealed the recommended date for the PCV20/PCV21(Pneumococcal 20-valent Conjugate/Pneumococcal 21-valent conjugate) vaccine was 6/27/22.No education regarding the benefits and risks of the immunization or declination of a pneumococcal immunization being offering could be located in R31's EMR.On 12/3/25 at 12:48 PM, an interview was conducted with Infection Preventionist (IP) B regarding R31's vaccination status. IP B confirmed R31 was eligible for a pneumococcal vaccine but the physician [Medical Doctor (MD) C] chose not to offer it to R31.Review of an Infection/Antibiotic Progress Note written on 10/9/24 at 10:28 AM by IP B read, [R31's] immunization status reviewed with [MD C] regarding shared clinical decision to consider PVC 20 vaccination. [R31] received pneumococcal 23 and Prevnar 13 in the past. The physician does not wish to order PCV at this time. On 12/3/25 at 8:10 PM, an interview was conducted with R31's Durable Power of Attorney (DPOA) B regarding R31's vaccination status. DPOA B stated she was not offered the option for the pneumococcal vaccination, explained its purpose, or educated on the risks or benefits of receiving the immunization. DPOA B indicated she would have liked R31 to receive the immunization.Review of a document titled, Shared Clinical Decision-Making: PVC20 or PCV21 Vaccination for Adults 65 Years or Older released by the National Center for Immunization and Respiratory Diseases on 9/11/24, read, in part: .The determination to administer PCV20 or PCV21 is based on a shared clinical decision-making (SCDM) process between a patient and their health care provider. Increased risk of exposure to PCV20 or PCV21 serotypes may occur among people who are living in: Nursing homes or other long-term care facilities.Review of the facility policy titled, Pneumonia Vaccine for Residents, reviewed 2/27/25, read, in part: .All residents of [Facility Name] will be offered the eligible pneumonia vaccine upon admission, if no allergies or have already met the eligibility requirement stated in this policy . PROCEDURE: Determine eligibility of the resident per physician order/immunization status. Provide residents with important information statement related to pneumonia vaccine.Consent to treat form will be signed by resident or guardian.

Based on interview and record review, the facility failed to ensure the provision of dignified care and services for five Confidential Residents (C1, C2, C3, C4, and C5)) out of 13 residents reviewed for dgnity. This deficient practice resulted in feelings of intimidation, frustration, and fear of retaliation from facility staff. Findings include: Confidential Resident C2 Review of C2's Minimum Data Set (MDS) assessment, dated 9/23/24, revealed a Brief Interview for Mental Status (BIMS) score of 13 of 15, reflective of intact cognition. During an interview on 10/07/24 at 12:29 p.m., Confidential Resident C2 was asked about the provision of dignified and respectful care and services by facility staff. C2 initially spoke in a whisper and said she did not want to discuss it, but then motioned this Surveyor closer and said there was one staff member that did not like her and did not treat her properly. When asked who the staff member was, C2 noted it was Staff T, who had refused to clean up a beverage C2 had spilled at lunch. C2 said she had spilled a lunch beverage, and it was all over the floor. Staff T entered the room and did not clean/pick up the spilled beverage. C2 said they had yelled for Staff T to come back, but Staff T never returned to the room, and the beverage remained on the floor for approximately an hour. During an interview on 10/7/24 at approximately 12:35 p.m., Staff U entered C2's room, and C2 asked Staff U to confirmed what they had just reported to this Surveyor. Staff U said they had heard C2 yelling for Staff T and came to the room to investigate what was going on. Staff U confirmed C2 had a beverage spilled on the floor and it had not been cleaned up by Staff T. Staff U said they had come into C2's room and had to finish cleaning up the floor. Staff U said the spilled had remained on C2's floor for over an hour. Staff U said she was aware of resident complaints regarding how Staff T treated some of the residents. Review of Staff T's personnel file on 10/08/24 at 12:10 p.m., revealed no disciplinary action present in their personnel file for the last year. Confidential Resident C4 Review of C4's Minimum Data Set (MDS) assessment, dated 8/5/24, revealed a Brief Interview for Mental Status (BIMS) score of 12 of 15, reflective of moderate cognitive impairment. During an interview on 10/07/24 at 2:34 p.m., Confidential Resident C4 was asked if they had any concerns related to respectful and dignified care. C4 said that Staff V had taken them to the bathroom and had not adequately cleaned up the feces that was present in her perineal area. C4 said Staff T had found the feces and showed her the amount of stool that was left in and on her body. C4 stated, I went to the office, and I told the office staff about it. I got really sick. When she (Staff V) come in here and [they] work on you, you have to take [them] if there is nobody else . C4 said the office staff were supposed to talk to Staff V about the lack of care and said she did not want Staff V caring for her any more. During an interview on 10/08/24 at 10:47 a.m., the Director of Nursing (DON) was asked if there was an investigation file for allegations made by C4 that Staff V did not provide toileting hygiene properly for the Resident. The DON stated, I don't have anything on [C4]. I know [they] did not like [Staff V]. When asked if Staff V was able to provide care for C4 currently, the DON stated, I don't have [Staff V] in that section. No, I don't. I can't have continuity all the time. I don't want [Staff V] in that section. When asked if other Residents had complained about [Staff V's] undignified and disrespectful treatment, the DON stated, Yes, other residents like C1. When asked if C1 was the only one to complain about Staff V, the DON stated, No, C5 also complained about [Staff V]. When asked if there was any other resident, the DON stated, C3 on 8/12/24. When asked documentation of the Confidential Resident complaints about Staff V's care would be found in their personnel file, the DON acknowledged that no written documentation of those resident allegations/complaints would be found in Staff V's personnel file. The DON said she had completed interviews with Staff V, but they were not documented as evidence of the allegations. The DON confirmed that Staff V had been re-assigned to a different area with different residents. The DON acknowledged [Staff V] did have a pattern of behavior and people were feeling a little uneasy around her. When asked if they have received staff reports that Staff V was not performing her duties properly, the DON stated, I get multiple complaints a day from staff - some I take to heart, some I don't. I have received a complaint from one of my complainers . I do agree that I have heard [Staff W] curse before. Do I know that Staff W swore at C5? I believe C5 (that Staff W swore at him). The DON acknowledged she had previously heard Staff W swear while working in the facility. Review of C5's Minimum Data Set (MDS) assessment, dated 8/5/24, revealed a Brief Interview for Mental Status (BIMS) score of 13 of 15, reflective of intact cognition. Confidential Resident C3 Review of C3s Minimum Data Set (MDS) assessment, dated 9/16/24, revealed a Brief Interview for Mental Status (BIMS) score of 12 of 15, moderate cognitive impairment. During an interview on 10/08/24 at 9:12 a.m., Confident Resident C3 was asked if she had ever been treated in an undignified or disrespectful manner by facility staff. C3 said she was in the facility for a short time period and had a couple of disagreements with facility staff. C3 said she had brought it up to the DON, and everything was settled, and the Staff member in question no longer provided care to her. C3 said she did not remember the Staff members name, but when several names were mentioned, C3 confirmed it was Staff V. C3 stated, The first time, before [they] did anything else, [they] would walk over to my window and shut my blinds. I told [them] to open the blinds. I told them I was the patient, and you are going to open those blinds, and [they] left (without opening the blinds). I guess they (administration) gave her hell. [Staff V] got hall bent out of shape. I didn't want Staff V here. [Staff V] doesn't come and take care of me anymore. Confident Resident C1 Review of C21s Minimum Data Set (MDS) assessment, dated 9/23/24, revealed a Brief Interview for Mental Status (BIMS) score of 15 of 15, reflective of intact cognition. During an interview on 10/08/24 at 3:11 p.m., C1 stated, [Staff V] was very disrespectful to both myself, and my wife. How was she disrespectful? If I couldn't turn on my side, she would yell at me and say, 'You can do it', and she would not turn me . Staff V would leave me on urine stained, wet pads . I complained to [The DON] about it. I probably (first) complained about three to four months (ago). When asked what the DON did in response to the complaints, C1 stated, I am not sure what [the DON] did, because nothing changed. [The DON] did not give me any feedback. I told [the DON] the same things I told you . [Staff V's] lack of hygienic care for me was the most troublesome to me . I was laying in my own pee. [Staff V] had an air of superiority, like [they were] better than me. That is how I felt anyway. I would say about a month after the initial complaint about [Staff V] I complained to [the DON] again. I told her the same issues were going on. She says, 'That it is hard to hire good people.' [The DON] said she would take care of it. She initially banned [Staff V] from the hallway, but now she is allowed in my room if she has at least one aide with her. I am still not comfortable with having Staff V in my room. I agreed to it because they are short-staffed, but I don't feel comfortable about it . I think administration has not dealt with these individuals appropriately, and I think people are afraid to speak up. Staff are very intimidated here . During a telephone interview on 10/08/24 at 3:46 p.m., Family Member (FM) F of C1 was asked about the provision of respectful and dignified care by facility staff. FM F stated, One day the green (privacy) curtain was shut, and I arrived earlier than expected. I waited to tell [Staff V] that I was here. I heard her say, to C1, 'I don't care what you want. I am going to do what I want to do.' C1 wanted the nurse to come and look at his bottom before [Staff V] covered it up . I told [Staff V] that was so inappropriate. I asked [them] why [they] didn't get the nurse. [Staff V] said I will get her when I want to. I [FM F] went and got the nurse and she acted like I was the problem. I said to [Staff V], why do I have problems with you, when I have no problems with anyone else here. [Staff V] rolled her eyes and made an obvious smirk to the nurse. The nurse was saying it needed to be treated right away. [Staff V] wanted to get c1 dressed right away - and what [Staff V] was doing was ripping the skin and it was bleeding. Even though [C1] was repeated saying 'Please, please get the nurse before you put anything on me, because there is something wrong, it is hurting so bad.' [Staff V] said 'You are not in charge here'. During a continued telephone interview on 10/08/24 at 3:51 p.m., FM F stated, Another time I had trouble, C1 was saying [Staff V] was leaving wet (urine soaked) pads on [their] bed. I put my hand under the blanket, and the mat was soaked. It was wet . I told the nurse I was going to make C1's bed. The nurse took everything off the bed and remade the bed. The nurse told [Staff V] what was going on and [Staff V] started acting like she was going to make the bed. After the nurse left, [Staff V] turned and said, 'it is all taken care of now isn't it. Now you don't have anything to say about it' . When [Staff V] was by themselves, they were ornery. I stayed away from [them] as much as I could . C1 just reported it to [the DON]. I thought everything would be taken care of because [Staff V] seemed to be having trouble with other people at the same time. It is up to the facility to take care of this. We are not in charge of anything here. Review of the Resident Rights Policy, reviewed 07/24, revealed the following, in part: .The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility . The resident has a right to be treated with respect and dignity .

Based on observation, interview, and record review, the facility failed to ensure all medications and biologicals were stored in locked compartments accessible only by authorized personnel in one medication room, of one medication storage room reviewed during the medication storage task. This deficient practice resulted in the potential for medication diversion when the medication room door was propped open without supervision and the medication refrigerator was unlocked and utilized for staff food items. Findings include: During an observation on 10/09/24 at 7:27 a.m. the second floor medication storage room was found propped wide open and unattended by any facility staff. This Surveyor walked into the medication storage room without supervision. Registered Nurse (RN) S, upon seeing this Surveyor walked into the second floor medication room. RN S acknowledged the medication room door was not supposed to be left open, unattended, and stated, I already shut this door once. When the unlocked, medication refrigerator was opened, three small plastic, storage containers with food, an aluminum foiled wrapped sandwicn, and a protein drink were observed in the medication refrigerator with the back-up resident medication requiring refrigeration. RN S stated, That is not supposed to be here. I will get that out of here right now. RN S removed all of the food items from the medication storage room refrigerator and placed them on top of her purse/bag on the medication storage room counter next to the refrigerator. RN S closed the medication room door upon exit from the medication storage room with this Surveyor. During an observation on 10/09/24 at 7:55 a.m., the medication room door was found again propped open and unsupervised to the second floor medication room. This Surveyor entered the second floor medication room, unsupervised through the open, unsecured door. Unlocked, unsecured medication observed included discarded medication for Resident (R199) found in a carboard box with one pharmacy prepared packed of medications. All medication stored in the medication refrigerator was unlocked and unsecured. During an interview on 10/09/24 at 7:58 a.m., the Director of Nursing (DON) was asked to observed the second floor medication room door that was propped open with no staff supervision. The DON said the nurse around the corner was supervising the open medication room. When the DON looked for the nurse and confirmed the nurse was not within view of the open medication room door, the DON confirmed the medication room door should not be left open unattended. The DON shut the second floor medication room door on 10/09/24 at 8::00 a.m. During an interview on 10/9/24 at 8:00 a.m., when asked if it was acceptable for staff to place their lunch food items in the medication room refrigerator for storage, the DON looked at this Surveyor in apparent disbelief and stated, No, it is not acceptable for staff to put their lunch in the medication refrigerator. Review of the Medication and Nursig Storage Rooms policy, on 10/9/24 at 10:00 a.m., revealed the following, in part: : .It is the policy of [Facility Name] to ensure medications housed on our premises will be stored in the medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, security and expiration . 1. General Guidelines: a. Drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. b. Only authorized personnel will have access to the keys to locked compartments. c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart .

This deficiency pertains to Intake MI00147245 and MI147343 Based on interview and record review, the facility failed to notify the state agency timely of reportable occurrences for one Residents (R199) of two residents reviewed for abuse. Findings include: Resident #199 On 9/26/24 at 1:00 a.m., Resident #199 (R199) was found unresponsive in his wheelchair. A nurse's progress note dated 9/26/24 at 1:44 a.m. documented R199 had been resting in his wheelchair until 1:00 a.m. when staff approached R199 about going to bed. Documentation in nurse progress notes indicate R199's arms and legs were flaccid, and the resident had a blank gaze when staff performed sternal rubbing. R199 was transferred to the Emergency Department (ED) on 9/26/24 at 1:35 a.m. where a urine drug screen (UDS) was performed. The results of the UDS were positive for cocaine. The ED physician documented, in part: .I reviewed the nursing home note and also his medication list. Nothing can account for the cocaine in his urine .A confirmation test quantitatively was sent out . In a hospital Discharge Summary dated 9/27/24, the physician documented the UDS was repeated and returned positive results for the presence of cocaine. The Discharge Summary documented pharmacy involvement to verify potential cross-reactions with medications, but there were none found. R199 returned to the facility on [DATE]. On 10/2/24, R199's attending physician documented, in part: . I am aware of the call that they made last week that he was obtunded [diminished response to stimuli, often due to a state of reduced consciousness]. He was sent to the hospital and this is attending I followed this case there [sic]. It was found that his urine tested positive in the preliminary testing for cocaine. I spoke with the hospitalist and [R199] had been rechecked and again tested positive. Just now we found out that the confirmatory test was positive for the metabolite of cocaine benzoylecgonine which in my research is the main metabolite for cocaine, can persist in the urine for 5 days and is usually how ingestion is diagnosed , he has very few if any false positives, but I did read where he [sic]could be from some sort of teas from Latin America. Cocaine must have been ingested somehow. In my clinical practice we find this fairly commonly due to adulterated marijuana . During a phone interview with the Durable Power of Attorney (DPOA) and Family Member (FM) N on 10/7/24 at 2:13 p.m., FM N said she was notified by the hospital about the cocaine identified in R199's UDS. FM N conveyed R199 had never used illicit drugs. The Director of Nursing (DON) was interviewed on 10/8/24 at 8:45 a.m. The DON said she and the Administrator (NHA) were made aware R199 tested positive for cocaine when R199 was readmitted to the facility on [DATE]. The DON confirmed a facility-reported incident was not filed with the state agency until 10/2/24.

Based on interview and record review, the facility failed to ensure invasive blood sugar (glucometer) testing and insulin injections were administered by licensed nursing staff for one Resident (R19) out of 13 residents reviewed for qualified staffing. This deficient practice resulted in Certified Nurse Aide (CNA) B providing care outside the scope of practice when they administered insulin via injection and completed invasive blood glucose monitoring for R19. Findings include: During an interview on 10/08/24 at 9:22 a.m., R19 said [CNA B] came into their room and gave them two insulin shots. R19 stated, [CNA B] gave me the insulin . [CNA B] came in and gave it (insulin) to me on one side . and then came in later and gave it to me on the other side. This happened in May or June. It is almost like a bad dream . I knew it wasn't right . Review of R19's Physician Order Summary, as of 10/9/24, revealed the following orders to be administered by licensed nursing staff, in part: Humalog Injection Solution 100 Unit/ML (milliliter) (Insulin Lispro) Inject as per sliding scale; if 0-100 = 0 units; 101-150 = 5 units; 151-400 = 10 units, subcutaneously three times a day for DM (diabetes mellitus). Lantus Subcutaneous Solution 100 Unit/ML (Insulin Glargine) Inject 20 unit subcutaneously one time a day for DM. Review or R19's Care Plan Interventions revealed the following, in part: Accu-Chek's and insulin as ordered by physician. Date Initiated: 02/02/2024 . Administer medications as ordered by physician . Date Initiated: 02/02/2024. During an interview on 10/08/24 at 9:56 a.m., the Director of Nursing (DON) reported, The Date of Infraction was 8/12/24. This is the RN's (RN A's) corrective action. He received a written warning. It is pretty severe to have a CNA giving medication (insulin). The DON confirmed [CNA B] was spoken to about the administration of insulin to [R19]. Discipline documentation for both CNA B and RN A were requested at that time from the DON. The DON said they would have to look in CNA B's personnel file. Review of RN A's personnel filed on 10/08/24 at 11:36 a.m., revealed the following, in part: 1. 8/12/24 Corrective Action Notice, with all duplicate pages attached, received directly from the DON was not found in RN A's personnel file. Review of the Corrective Action Notice, dated 8/12/24 for [RN A], revealed the following Section 2: [RN A] gave insulin to [CNA B] to give to Resident in room (Room Number). Work Rules #1 - Conduct harmful to the reputation and purpose of [Facility Name]. #9 - Unprofessional conduct while in the workplace or while on [Facility Name] work. Review of CNA B's Disciplinary Action in Personnel File revealed only one disciplinary action documentation found in CNA B's personnel file. No documentation was present regarding administration of insulin, or completion of an invasive blood sugar (glucometer) check by CNA B without a nursing license. During a telephone interview on 10/9/24 at 4:50 a.m., RN A acknowledged he had given CNA B the tasks of blood sugar monitoring, and insulin injection for R19. RN A stated, I didn't pressure her (CNA B), I asked her, and it was completely 100% my idea . [CNA B] did the [blood glucose monitoring] reading . [The DON] took my statement. It was my final written warning . RN A said it (CNA B giving insulin and blood sugar test) happened on a weekend: a Saturday. [RN A] . asked [CNA B] to perform the [blood sugar monitoring] and administer insulin two times to R19. RN A said he knew it was a mistake, and they should have asked another nurse in the building to perform those tasks if [RN A] was not going to enter R19's room. RN A confirmed they had documented on the Medication Administration Record (MAR), that [RN A] had administered the insulin two times on that Saturday. RN A stated, I knew it was wrong. I thought to myself, 'What was I thinking.' I should not have asked CNA B to do that.

Based on observation, interview, and record review, the facility failed to provide the necessary standards of care and services for diabetes management in one Resident (Resident #37) of one resident reviewed for diabetic management. This deficient practice resulted in the potential for diabetic related complications including organ damage, stroke, and death. Findings include: Resident #37 (R37) Review of R37's electronic medical record (EMR) revealed admission to the facility on [DATE] with diagnoses including Type 2 diabetes mellitus. R37's 8/19/24 Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 2, indicative of severe cognitive impairment. R37 was also noted to have received seven insulin injections in Section N of the 8/19/24 MDS assessment. Review of R37's Medication Administration Record (MAR) revealed the following: Basaglar Tempo Pen Subcutaneous Solution Pen-injector 100 Unit/ML (milliliters) (Insulin Glargine) Inject 20 unit subcutaneously one time a day for DM (diabetes mellitus) HumaLOG Injection Solution 100 UNIT/ML (Insulin Lispro) Inject 5 unit subcutaneously with meals related to type 2 diabetes mellitus without complications plus sliding scale insulin HumaLOG Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 150-200 = 2 units; 201-250 = 4 units; 251-300 = 6 units; 301-350 = 8 units; 351-400 = 10 units; 401-500 = call DR (doctor); subcutaneously three times a day for DM Review of R37's MAR revealed no orders, including frequency or method, to monitor blood glucose levels or an order for Glucagon Emergency Kit. Review of R37's Blood Sugar Summary from 7/1/24 through 10/8/24 revealed R37 was being monitored for blood sugar values three times a day and ranging from 63-334. An interview was conducted with Registered Nurse (RN) L on 10/9/24 at 9:40 a.m. RN L confirmed R37 was diagnosed with type 2 diabetes with orders for insulin. RN L stated that the Glucagon Emergency Kit was a standing order and would notify the physician after the event if Glucagon was used for R37. Review of R37's Standing Orders dated 2/14/24 revealed no order for the use of Glucagon. An interview was conducted with the Director of Nursing (DON) on 10/9/24 at 9:55 a.m. The DON confirmed that R37 did not have physician orders for blood glucose monitoring despite being tested daily. The DON also confirmed that Glucagon is not part of the facility's standing order and R37 should have access to Glucagon if needed. Review of the facility's Hypoglycemia Management policy dated 9/24 revealed, .Compliance Guidelines .Diabetic residents will have their blood sugar tested per the physician's orders and at the residents' request .If the blood glucose reading is 70 mg/dL or below, the nurse will utilize the '15'15 Rule' per the American Diabetes Association. The 15-15 rule: The nurse will provide 15 grams of carbohydrate to resident to raise blood glucose and complete a follow up blood glucose test in 15 minutes .Per American Diabetes Association examples of 15 grams of carbohydrates may be: 4 ounces of juice or regular soda, 1 tablespoon of sugar, honey, or corn syrup, Glucose tablets, Gel tube . The facility's policy did not indicate the use of Glucagon.

Based on observation, interview, and record review, the facility failed to provide appropriate support surfaces for residents with wounds, develop care plan interventions for pressure-reducing support surfaces, accurately document the stage of a pressure injury, and provide ongoing weekly skin assessments for one (Residents R43) of four residents reviewed for pressure injury, resulting in the potential for worsening pressure ulcers. Findings include: Resident #43 On 10/7/24 at 12:20 p.m., Resident #43 (R43) said she hurt, and indicated the pain was in her gluteal area. R43 was sitting in a recliner with no visible chair cushion on the recliner. The mattress on R43's bed was a standard facility mattress. R43 was unable to answer questions regarding potential skin impairment. R43 had a quarterly Minimum Data Set (MDS) assessment completed on 7/22/24. The MDS documented R43 was dependent on staff for Activities of Daily Living (ADL), including dependence on staff for bed mobility, turning and repositioning. Physician's orders for R43 included treatment orders for a Stage 4 (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) pressure injury to the sacrum. Progress notes in the medical record dated 9/14/24, 9/23/24, 9/27/24, 9/28/24, 9/29/24, and 9/30/24 documented a Stage 4 pressure injury to R43's sacrum. Wound Evaluation Forms dated 9/10/24 and 10/7/24 documented the pressure injury on the sacrum as a Stage 3 (Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue with the presence of slough and/or eschar that does not obscure the depth of tissue loss). The wound evaluation forms documented the pressure injury as developing in the facility. Skin assessment records revealed no documented skin assessments for R43 from 9/4/24 to 10/2/24. The skin assessment of 9/4/24 reflected no skin impairment. The skin assessment of 10/2/24 documented, in part: .[R43] is frequently offered fluids and assisted with position changes when [R43] allows, however [R43] frequently refuses these position changes. Interventions remain in place to mitigate these risks and are reflected in her plan of care. These interventions include pressure reducing devices to [R43] bed and chair as well as frequent rounding to include assisting and offering position changes . A review of R43's care plan did not reveal interventions for pressure reducing devices to the bed or chair. The care plan did not document refusals of position changes or contain interventions to alleviate pressure if R43 refused to be turned or repositioned. The Director of Nursing (DON) was interviewed on 10/8/24 at 2:00 p.m. The DON confirmed there were no skin assessments completed for R43 between 9/4/24 and 10/2/24. The DON said skin assessments are expected to be completed at least weekly. The DON reviewed the care plan and confirmed there were no care plan interventions for support surfaces. When asked why R43 did not have a therapeutic support surface such as a low air loss mattress on the bed, the DON replied, She should have one. The policy Skin Assessments dated 7/2024 read, in part: .A full body, or head to toe skin assessment will be completed by the licensed nurse and documented in the electronic health record (EHR) on admission/readmission and weekly thereafter . The policy Standards of Care dated 7/2024 read, in part: .It is the policy of (name of facility) to use facility standards of care in developing resident-directed, individualized care plans .with resident-specific approaches .Standards of care promote consistent quality and the provision of clear, concise direction for staff providing care .

Based on observation, interview, and record review, the facility failed to implement interventions to address range of motion (ROM) for one resident (Resident #11) of two residents reviewed for limited range of motion. This deficient practice resulted in the potential for extreme pain, discomfort, and worsening of positions. Findings include: Review of R11's Electronic Medical Record (EMR) revealed an admitted [DATE] and diagnoses including cerebral palsy, epilepsy, anoxic brain damage, and anxiety disorder. Review of R11's 8/19/24 Quarterly Minimum Data Set (MDS) assessment revealed they were unable to complete the Brief Interview for Mental Status (BIMS) score and was marked with severely impaired cognition. In Section O of the 8/19/24 MDS, R11 was noted to have received zero days of treatment for therapy services and restorative nursing program services. On 10/7/24 at approximately 3:00 p.m., R11 was observed sitting in her bed watching television. R11's bed was noted to be elevated at the head. R11 was nonverbal during this interaction but was observed with her head leaning down and towards the right with her right ear resting on her shoulders. There were no assistive devices in place. On 10/8/24 at 9:53 a.m., R11 was observed sleeping in her bed. The head of R11's bed was elevated with her head slumped down onto her right shoulder. On 10/8/24 at 10:17 a.m., R11 was observed after being changed by two staff members. R11 was placed in the same position, with the head of her bed elevated and her head slumped down onto her right shoulder. An interview was conducted with Certified Nurse Aide (CNA) P who stated that R11's head positioning had been this way for quite some time. CNA P stated that R11's neck will become excoriated and red due to the position of her head on her shoulder. An observation was made of R11's neck which showed a pinkish red excoriation mark starting underneath R11's chin and ending at the base of her neck on the right side. CNA P stated that nursing will put cream on her neck to help with pain and healing. CNA P confirmed that after changing R11 she did not turn or reposition her into a new position. On 10/8/24 at approximately 10:40 a.m., an interview was conducted with Director of Rehabilitation (DOR) Q in R11's room. DOR Q observed R11's head positioning and confirmed that R11's head going down and touching her right shoulder has gotten significantly worse since admission. DOR Q confirmed that R11 had not been screened by therapy for her positioning and was not made aware of the excoriation on her neck. Review of R11's Care Plan revealed the following, .(R11) is at risk for skin breakdown related to incontinence and contractures, need for total care from staff for transfers/skincare/repositioning, incontinence, and history of skin issues .Interventions: Assist with repositioning and incontinence care at least every two hours. Reposition side-to-side . An interview was conducted with the Director of Nursing on 10/9/24 at 10:16 a.m. The DON confirmed that R11's head positioning has gotten worse and confirmed that a therapy screen should have been conducted. Review of the facility's Standards of Care policy reviewed 7/24 revealed the following, .A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene .CNA - Standards of Care: .Turn/reposition residents who cannot turn/reposition themselves, every two (2) hours and as needed. Support body alignment with pillows, wedges, ordered splints, etc. Chair bound residents, once (1x) every hour .Stop and watch tool will be utilized to communicate changes in condition of residents to the nurses .If the concern is not addressed by the nurse and the problem persists then report this finding to DON/ADON (Assistant Director of Nursing) .Responding to decline in ADL (activities of daily living) skills as a change in medical condition, Evaluating reasons for decline in ADL skills .

Based on observation, interview and record review, the facility failed to adhere to Enhanced Barrier Precautions and follow infection control standards of practice in 2 of 2 residents (Resident #43 and Resident #12) review for infection control, resulting in the potential for the spread of infection. Findings include: Resident #43 Signage was posted outside the door to R43's room that read, in part, .Enhanced Barrier Precautions [EBP] . Put on PPE [Personal Protective Equipment] before entering for high contact care: 1. Hand Hygiene 2. Gown 3. Gloves . On 10/9/24 at 9:50 a.m., the Wound Nurse (Registered Nurse (RN) M) was observed completing treatments and dressing changes to R43's pressure injuries. The sacral wound was observed to be a Stage 3 pressure injury without a dressing. A stage 2 pressure injury was observed on the right buttock lateral to the superior gluteal fold. RN M wore gloves but did not wear a gown throughout the dressing change procedure in accordance with EBP instructions. Resident #12 Resident #12 (R12) had a stage 3 pressure injury on the right gluteus. EBP signage posted outside the door to R12's room instructed staff to wear gowns and gloves for high-contact care. On 10/9/24 at 10:17 a.m., RN M was observed completing a dressing change to R12's pressure injury. RN M did not wear a gown throughout the dressing change procedure. RN M was interviewed on 10/9/24 at 10:38 a.m. RN M was asked regarding EBP. RN M said Enhanced Barrier Precautions are for catheters, wounds, or the immunocompromised. RN M said EBP consists of wearing gowns and gloves, and confirmed dressing changes were considered high contact care. When asked why a gown was not worn during treatments and dressing change procedures, RN M said, I know should have had a gown on. I thought about that when I was done. The policy Enhanced Barrier Precautions dated 3/28/24 read, in part: .'Enhanced barrier precautions' refer to the use of gown and gloves for use during high-contact resident care activities .4. High-contact resident care activities include .h. Wound care .

Based on interview and record review, the facility failed to complete, post, and retain the required daily nurse staffing information. This deficient practice resulted in the inability of residents and visitors to determine the number of staff available to provide resident care and had the potential to affect all 45 residents in the facility. Findings include: A review of the Daily Nursing Staff sheets from July - August, provided by the Director of Nursing (DON), revealed no postings were completed for the following dates: July (2024) 1, 3-7, 9, 11-14, 16-21, 23-25, 27-29, 31; and August (2024) 2-19, 21, 22, 24-26, 28, 31; and September (2024) 1, 2, 6-8, 10-16, 18, 19, 21-30. It was noted staffing sheets were not completed, posted, or retained on 73 of 92 days reviewed. On 10/9/24 at 10:37 AM, an interview was conducted with Nursing Administrative Assistant/Scheduler R who verified she was in responsible for completing and retaining the daily nursing staff postings. Scheduler R stated she worked on a part-time basis and only completes the required daily nurse staffing information on the days she works. When asked if the task was delegated to a different employee on the days she was not scheduled to work, Scheduler R verified it was not. On 10/9/24 at 10:53 AM, an interview was conducted with the DON regarding her expectations related to completion and retention of daily nurse staffing information. The DON stated, My expectation is that they should be completed daily. It's a regulation.

Based on observation, interview, and record review, the facility failed to prevent proper supervision of coffee carts for three of four hallways during an observation of the lunch service meal. This deficient practice resulted in the potential for residents who were deemed unsafe to handle hot liquids independently, to subsequently suffer burns and burn related medical complications. Findings include: An observation was made of the lunch meal service on 11/14/23 at 11:50 a.m. During this time, carts were being delivered to their designated hallways. Observation of the first cart for rooms 101-116 with three staff members assisting in passing the hallway meals. It was observed that Registered Nurse (RN) D prepared coffee from a separate coffee cart, placing the coffee cups without lids on top of the trays, and then allowing the trays to go into resident rooms. After all meals were delivered, the coffee cart was left unattended in the hallway. An observation was made of the second hallway cart for rooms 117-131 on 11/1/243 at 12:00 p.m. RN D was again assisting in pouring coffee into a cup, placing on the trays uncovered, and assisting with the other two staff members in delivering the trays to the correct rooms. Once all meals were delivered, the coffee cart was left unattended in the hallway. An observation was made of the third hallway cart for rooms 203-213 on 11/14/23 at 12:15 p.m. The meals had already been delivered to the residents with the coffee cart left unattended in the hallway. An interview was conducted with the Nursing Home Administrator (NHA) and Dietary Manager (DM) F who both stated the facility implemented the separate coffee carts during COVID-19 restrictions. Both the NHA and DM F agreed the coffee should have been supervised or removed from the hallways when completed with passing meals. Review of the temperature log for the lunch meal with Dietary Manager F revealed the coffee had a temperature of 139 degrees Fahrenheit when leaving the kitchen. Review of the facility's Hot Beverage policy revised on 1/6/20 and reviewed on 11/14/23 read, in part, Purpose: To ensure safety while allowing residents to enjoy hot beverages. Background: To allow the residents of [facility name] to safely consume hot beverages safely while maintaining their dignity while maintaining safety. Educate staff members regarding serving hot beverages to residents .

Based on observation, interview, and record review, the facility failed to securely store medications, for Resident #6 (R6), two of two medication rooms and one of two medication carts reviewed. This deficient practice resulted in the potential for expired medication use and misappropriation of Resident property. Findings include: On 11/14/23 at 12:35 PM, an observation was made of Resident #6 (R6) in her room. R6 was sitting up in her wheelchair and watching television. R6 had a dresser just to the right of her doorway and on top of the dresser was a plastic container with various items inside. Inside R6's plastic container on her dresser, two tubes of diphenhydramine cream and one tube of hydrocortisone cream were observed. R6 was asked why she had the creams in her room and replied, I use them for itching and for the rash on my back, and the Certified Nurse Aides will rub it on my back. On 11/15/23 at 7:50 AM, an observation was made of R6's room, and the three tubes of cream remained on top of her dresser inside the plastic container. A review of R6's care plan, physician orders, and assessments all lacked any documentation, orders, or safe assessment for self-administration of medications. A review of R6's Minimum Data Set (MDS), section C for cognition, revealed a BIMS (brief interview for mental status) score of 11, which indicated R6 had moderately impaired cognition. On 11/15/23 at 8:45 AM, an observation was made of the first-floor medication cart which was found to have 36 packets of triple antibiotic ointment 0.03 ounces in the top drawer, with lot number 1327, and expiration date 08/23. On 11/15/23 at 8:55 AM, an observation was made of the first-floor medication room which was found to have one box of [Name Brand] fiber thins, 12 count, with unknown lot number (nurse grabbed and threw it in the trash), and expiration date 09/22. Other items found to be expired were one box of ostomy supplies, and one box of 100 count hemoccult testing cards and solution. On 11/15/23 at 8:15 AM, an observation was made of the second-floor medication room which was found to have two [Name Brand] rapid test for influenza, covid, and other respiratory infections, with lot number 2035380, and expiration date 02/06/2023, 7 individual universal catheterization trays with lot number 2132135264, and expiration date 07/26/2023, and one box of ostomy supplies which the nurse threw out before this Surveyor could verify the expiration date. On 11/15/23 at 9:15 AM, after reviewing the first floor medication room with the Director of Nursing (DON) there were expired supplies and some ointment. The DON, Infection Preventionist/Registered Nurse (RN) B and both nurses confirmed no medications were to be stored in the residents' room and there should not be any medications of any type in their rooms. The DON and RN B also confirmed no expired medications or biologicals should be in the medication rooms. On 11/15/23 at 11:20 AM, RN B brought in a piece of paper titled, Weekly Rounds - Night Shift (Sunday into Monday), and read in part, .Check med-room for expired medications . RN B confirmed these are routinely checked on night shift Sunday into Monday both floors. In review of the routine check paper from the second-floor revealed that a check was completed for the night shift on 11/13/23. No routine check list was provided to this Surveyor for the first-floor medication room to ensure no expired medications and or biologicals. On 11/15/23 at 3:15 PM, in an interview and observation, the DON was brought to R6's room and showed the three tubes of medication on top of her dresser in a plastic container. The DON asked R6 where she had gotten the medication from and R6 replied, Family had brought it in from home. The DON also confirmed the three tubes of medication should not be in R6's room and indicated R6 lacked an assessment for safe self-administration of medications, physicians order, and care plan to do so. Review of facility policy, Self-Administration of Medications, dated 9/19/23, read in part, Policy: Each resident who wishes to self-administer medication and for their ability to safely do so. Guideline: 1. If a resident requests to self-administer medications, the Nurse will determine if it is safe to do so before the resident can exercise that right by completing an assessment in .[the electronic medical record Name Brand]. 2. An order will be obtained from the physician for self-administration by the Nurse. 3. A self-administration of medication care plan will be developed by the Nurse, for the resident who is deemed capable and will include which medications and routes of administration this applies to. The care plan will also address storage and documentation of administration of medications as well as the location of medication administration .5. Those residents who have medications at their bedside and can properly administer them will be provided with a tackle box or a locking bag with a padlock and/or key. One key will be provided to the resident and the matching key by the licensed nurse. 6. The nurse will ask every shift for the usage of medication and document in the MAR (medication administration record). Review of the facility policy, Storing Medications, undated, read in part, Policy: Medications and biologicals will be stored in a safe, secure and orderly manner, at proper temperatures and accessible only to licensed nursing and pharmacy personnel or others authorized by law to administer medications. Procedure: .14. Any outdated, contaminated or deteriorated medication, or those in containers which are cracked, soiled, or without secure closures must be removed from stock and destroyed according to procedures for medication destruction .

Based on observation, interview, and record review, the facility failed to maintain a medication administration error rate less than 5%, for 3 of 25 medication administrations. This deficient practice resulted in a medication administration error rate of 12.00%, with the potential for medical complications in resident treatment and conditions. Findings include: On 11/15/23 at 9:45 AM, an observation was made of Registered Nurse (RN) D preparing medication pass for Resident #15 (R15) in the medication storage room on the first floor. RN D grabbed a tray to place individual medication cups on, with one medication per cup, crushed, and dissolved in a small amount of water. RN D prepared three medications from a stock source including: aspirin, multivitamin, and vitamin D. RN D then grabbed a packet of medication pre-prepared by pharmacy which contained four medications. RN D opened the packet and dumped the medications in a cup and spilled three on the floor. RN D failed to notice she dropped three of the four medications on the floor. RN D dropped two white pills and one pink pill (identified on the floor where she stood at the medication cart as carbamazepine 200 mg, hydrocortisone 20 mg, and metoprolol tartrate 25 mg). RN D proceeded to crush and dissolve the one she had in the medication cup. RN D then grabbed the tray and placed it on the counter near the medication storage door. RN D grabbed her stethoscope and the tray and was proceeding to exit the medication storage room. This Surveyor stopped RN D and asked her in an interview, if she was going to replace the medications she had dropped on the floor and replied, What medications. This Surveyor pointed to the floor and RN D replied, I did not realize I dropped them. My eyesight is bad. I would not have noticed if you did not stop me and let me know I dropped them. On 11/15/23 at 9:55 AM, an observation was made of RN D accidentally signing out all the medications for R15 prior to dispensing them to R15 to ensure she took her medications. RN D stated, Oh no. I did not mean to do that. I just hit one to many buttons. RN D failed to do a double check on the medications she prepared for R15. Review of R15's Physician Orders on 11/15/23, revealed the following orders: aspirin 81 mg (milligram), hydrocortisone 20 mg, cholecalciferol 25 mcg, multiple vitamins with minerals, metoprolol tartrate 25 mg, sodium chloride 1 gm (gram), and carbamazepine 200 mg. Review of facility policy, Resident Medication Administration, dated 07/23, read in part, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: .10. Review MAR (Medication Administration Record) to identify medication to be administered. 11.) Compare medication source (bubble pack, vial, ect.) with MAR to verify resident name, medication name, form, dose, route, and time .17.) Sign MAR after administered .

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by: A. Dried food stores left open to air and uncovered. B. Spoiled and/or outdated foods left in the walk-in cooler. C. Food items stored in the walk-in cooler undated and unlabeled. This deficient practice has the potential to result in food borne illness among any, most, or all of the 42 residents who resided in the facility. Findings include: On 10/10/22 at approximately 10:26 a.m., during the initial tour of the kitchen, a container labeled instant potato granules was observed with the lid ajar and left an approximate 3 inch gap opening allowing for potential contamination. On 10/10/22 at approximately 10:58 a.m., during inspection of the left walk-in cooler, a container labeled diced chicken for pot pie was stored on one of the shelves and had no date. There was also a container of food located on one of the shelves which was undated and unlabeled and appeared to be some type of soup consistency product. On 10/10/22 at approximately 11:03 a.m., during inspection of the right walk-in cooler, a container with food product which appeared to be ham was observed on a rolling cart which was undated and unlabeled. There were two heads of cabbage located on one of the shelves sitting on a food delivery tray in proximity to other food items. Both heads of cabbage had observed black mold appearing spots on the surfaces. The tray had a label affixed which noted a date received of 8/31/22, a date washed of 9/22/22, and a used by date of 9/29/22. A tray of 9 single serve bowls of prepared sugar-free jello with a prepared date of 9/23/22 and an out date of 10/3/22 was also observed located on one of the storage shelves. There was an undated/unlabeled container of sliced product which appeared to be cucumbers located on a rolling cart. On 10/10/22 at approximately 11:05 a.m., these concerns were brought to Certified Dietary Manager (CDM) A who stated both heads of cabbage would be thrown in the garbage. CDM A acknowledged the outdated sugar-free jello products were kept beyond the discard date and threw them away. CDM A stated the cucumbers were cut that day and staff would label and date them. CDM A Acknowledged all food products stored in the walk in cooler should have been labeled and dated. On 10/11/22 at approximately 3:00 p.m., Cook B was asked what food product was located in the left walk-in cooler which remained undated and unlabeled. Cook Bstated it was potato soup which was pulled from the freezer some time earlier to thaw before use for the evening meal. Cook B was shown the product lacked a label or date. Cook B then labeled and dated the product and stated the label must have fallen off. On 10/12/22 at approximately 3:01 p.m., during an interview, CDM A was asked if dried stored foods should be covered when not in use. CDM A confirmed dried goods should be covered when not in use. CDM A was informed of the potato granules container cover being ajar leaving an opening to the environment with the potential for contamination. CDM A agreed the potato granules should have been covered with a lid if they were not in use and stated someone must have just been using them and forgot to close the lid. CDM A was then informed of the container of the unlabeled/undated food product, subsequently identified as potato soup. CDM Aagreed the potato soup should have been caught, labeled, and dated. 2013 FDA Food Code references: 3-307.11 Miscellaneous Sources of Contamination. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306 A review of the facility policy, Food Storage, with a revised date of 11/3/20, read in part: Policy: Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored, prepared and transported at an appropriate temperature and by methods designed to prevent contamination . 4. Plastic containers with tight fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables, and broken lots of bulk foods . 13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 2 days for dairy products, 5 days for all other foods or discarded . 15. Refrigeration: .e. All foods should be covered, labeled, and dated .

Based on observation, interview, and record review, the facility failed to ensure a medication error rate less than 5% for 2 of 4 residents (R28 and R37) reviewed during the medication pass. This deficient practice resulted in R28 and R37 receiving their medications crushed against the manufacture's guidance placing both residents at risk for additional side effects and a medication error rate of 16%. Findings include: During an observation on 10/11/22 at approximately 7:30 AM, Registered Nurse (RN) E prepared 8 medications which included one tablet of [MEDICATION(S)] 30 mg and placed them into a medication cup. RN E then placed the medications in a clear paper sleeve and crushed all of them together, poured them into a small cup with applesauce and administered them to R37. During an observation on 10/11/22 at approximately 7:40 AM, RN E prepared 7 medications which included one capsule of [MEDICATION(S)] 20 mg, one tablet of [MEDICATION(S)] (extended release) 30 mg, one tablet of Potassium Chloride ER 10 meq and placed them into medication cup. RN E then placed all the prepared medications in a plastic sleeve and crushed all of them together and poured the contents back into the medication cup with applesauce and administered them to R28. The facility provided a copy of Medications Not to Be Crushed form #MP5950 Rev 02/17 for review. The list reflected the following medications that should not be crushed: [MEDICATION(S)], [MEDICATION(S)], and Potassium chloride. Reasons listed at the bottom of the list reflected, 1. [MEDICATION(S)] coated formulation, 2. Time release formulation and 5. Capsule maybe opened, and contents removed for administration without crushing, chewing, or dissolving. During an interview on 10/11/22 at approximately 9:15 AM, the Director of Nursing (DON) was advised of this surveyor's observation of the 4 medications on the do not crush list that were crushed resulting in 4 errors in medication administration when medications were not provided according to the manufactures recommendations. There were no further documents provided for review prior to the exit of the survey.

Based on interview and record review, the facility failed to ensure that the responsible party was notified regarding the initiation of antiviral treatment for one Resident (#41) out of three residents reviewed for infection. This deficient practice resulted in unwanted treatment and the potential for adverse side effects. Findings include: A review of Resident #41 (R41's) medical record revealed she admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the 9/26/22 Minimum Data Set (MDS) assessment revealed she scored 13/15 on the Brief Interview for Mental Status. A review of a document in R41's medical record titled, Activation of Patient Advocate/DPOA revealed that she was deemed incompetent and her DPOA was activated on 7/15/22. A progress note for R41 dated 8/5/22 revealed she tested positive for COVID-19 infection. Further review of R41's progress notes revealed the following: 8/5/22 .Verbal order received: Paxlovid Tablet Therapy Pack 10 x 150 MG (milligrams) & 10 x 100MG (Nirmatrelvir & [MEDICATION(S)]) Give 2 capsule by mouth two times a day for Covid-19 . 8/5/22 Resident moved to Covid unit. Isolation precautions are in place. Daughter . called to check on resident, and she stated that she does not wish for her mother to receive Paxlovid, unless symptoms become more intense. Currently, resident seems asymptomatic, and denies coughing, sneezing, sniffling, headache. Will continue to monitor . 8/6/22 Received call from (Daughter of. She does not want (R41) to receive Paxlovid as long as she continues to be asymptomatic. (Daughter) is concerned about the possible cardiac s/e (side effects) of Paxlovid . Paxlovid is d/c'd (discontinued) for now. On 10/12/22 at 11:35 a.m., the Director of Nursing (DON) was asked to provide information on why the Pluvaxid was started for R41 before her DPOA could consent to the antiviral treatment. On 10/12/22 at 12:40 p.m., the DON provided a progress note for R41 dated 8/5/22 which revealed, Attempt to contact residents daughter . to update on positive rapid Covid results. No answer via home or cell phone. Left message for her to call facility. When asked if this meant that because DPOA did not immediately answer the phone, the treatment was started without first discussing it with her, the DON made no comment. A review of a progress note for R41 dated 8/17/22 revealed, During the month of August (name of R41) tested positive for Covid-19. She was transferred to the facilities Covid wing and placed under multi-route transmission precautions. She accepted a 1-day course of Paxlovid for the respiratory illness prior to family requesting it to be discontinued . A review of R41's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and record review, the facility failed to monitor blood glucose levels and vital signs for a neuro assessment for one Resident (#41) out of five residents reviewed for falls. This deficient practice resulted in the potential for falls and adverse outcomes related to elevated blood glucose levels. Findings include: Resident #41 A review of Resident #41 (R41's) medical record revealed she admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the 9/26/22 Minimum Data Set (MDS) assessment revealed she scored 13/15 on the Brief Interview for Mental Status. A review of a Fall report dated 6/25/22 revealed, Staff heard resident calling out for help. Upon entering residents room resident observed sitting on floor in front of wheelchair A Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R41's Fall report dated 7/1/22 revealed, Called to room per CENA (Certified Nurse Aide). Res sitting on floor, with her back against dresser . Res (resident) states she was sitting in her W/C (wheelchair), bent over to pick up a kleenex and fell forward. Res states, 'I hit my nose on dresser.' .Injury: Bruise Face . A Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R41's blood sugar log in the vitals tabs of her Electronic Medical Record (EMR) revealed the first blood sugar documented for 2022 was on 6/26/22 at 436 mg/dL. No blood glucose levels were check from 9/9/21 through 6/26/22 per the vitals tab. A review of R41's blood glucose log from 1/1/22 through 7/15/22 revealed the following: 6/26/22: 436.0 (mg/dL); 7/11/22: 499.0; 7/12/22 511.0; 7/12/22: 437.0; 7/12/22 437.0; 7/13/22 384.0; 7/13/22: 450.0; 7/13/22: 450.0; 7/14/22: 291.0; 7/14/22: 398.0; 7/15/22:214.0; These blood sugars would represent high blood sugar readings. A review of the labs for R41 in her electronic medical record (EMR) revealed hgbA1c's (test to indicate blood glucose control) revealed the following: 3/2/22 8.5% High (reference average is 4.0-5.6%) indicating poor control of blood glucose levels. 9/7/22 hgbA1c 7.8% (high). A review of R41's July 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Neuro Checks sheet dated 7/1/22-7/3/22 revealed no documentation of R41's vital signs (temperature, pulse, heart rate, or blood pressure). A review of the vital signs tabs revealed her blood pressure was taken twice on 7/1/22 post fall, but was only taken once per day on 7/2 and 7/3. R41's pulse was only taken once per day after the fall on 7/1/22, 7/2/22, and 7/3/22. On 10/12/22 at 11:13 a.m., the Director of Nursing (DON) was asked to provide the neurological assessment policy, but reported they did not have a policy specific to that. The DON provided the Incident/Accident Report policy with highlighted section on neuro checks. When asked about the missing vital signs, the DON reported it wasn't in their policy to include those. On 10/12/22 at 12:45 p.m., an interview was conducted with the DON who when asked why no blood sugars had been taken for the 7/1/22 fall assessment reported she could no answer why. When asked why if the 6/26/22 post fall blood sugar was extremely elevated was blood sugar not identified as a potential causative factor, the DON reported she didn't have an answer. The DON was asked if it was the facility policy or a standard of practice to not check blood sugars when diabetic residents were treated with oral medication or insulin and reported it was not. The DON was unable to comment on why the monitoring was missed. A review of the facility policy titled, Incident/Accident Reporting reviewed 9/24/20 revealed, Incident Reports: . Staff or visitor falls or injuries will be immediately reported to the nurse in charge. A written report will be made on the facilities incident report form . All head injuries will have PERRLA (pupils equal, round, react to light, accommodation). Neuro-checks will be done every fifteen (15) minutes for the first hour, then every hour for the next four (4) hours, then every shift for three (3 days) .

Based on interview and record review, the facility failed to: 1. ensure the physician addressed pharmacy recommendations, 2. ensure the reviewed pharmacy consults are including in the medical record, and 3. ensure the facility has a policy in place for medication regimen reviews (MRR's) for one Resident (#28) out of five residents reviewed for MRR's. This deficient practice resulted in the potential for continued fall risk, unnecessary medications, and unmonitored conditions. Findings include: Resident #28 A review of Resident #28 (R28's) medical record revealed she admitted to the facility on [DATE] with diagnoses including dementia, [CONDITION(S)], and [CONDITION(S)]. A review of her 8/29/22 Minimum Data Set (MDS) assessment revealed she scored 3/15 on the Brief Interview for Mental Status (BIMS) assessment indicating severely impaired cognition. A review of R28's progress notes revealed that pharmacy recommendations based on the MRR's were made on 5/12/22, 6/16/22, 8/17/22, and 9/14/22. On 10/11/22 at 4:30 p.m., these recommendations were requested from the DON as they were not in R28's medical record. On 10/12/22 at 10:20 a.m., the DON reported that R28's 8/17/22 MRR was not found in her medical record and it was retrieved from the pharmacist. This 8/17/22 MRR recommendation was regarding a [CONDITION(S)] gradual dose reduction. This recommendation was not addressed or signed by the physician. On 10/12/22 at 12:55 p.m., the DON provided R28's missing 5/12/22 MRR recommendation report that she had received from pharmacy for a gradual dose reduction of an antidepressant medication. This recommendation was unsigned by the physician and was not a part of the medical record or onsite within the facility. When asked for the facilities process, the DON reported she received the recommendations from pharmacy, then she put them in the physicians chart to review, and then they were sent back to her or another nurse who signed the corner that they had completed the recommendation. Then they were sent to medical records to be scanned into the medical record. The DON was asked to provide the facility policy regarding the physician response to pharmacy recommendations or medication regimen reviews On 10/12/22 at 11:13 a.m., the DON reported that the facility did not have a policy on medication regimen reviews or pharmacy recommendations.

Based on observation, interview and record review, the facility failed to maintain oxygen equipment in a safe and hygienic manner for two Residents (#7 & #18) of two residents reviewed for respiratory care. This deficient practice resulted in the potential for respiratory illness and respiratory-associated complications. Findings include: Resident #7 On 10/10/22 at approximately 11:46 a.m., Resident #7 had an oxygen concentrator in use in the room. Resident #7 was not in the room at the time of the observation. The nasal cannula was observed resting on a material pad covering the surface of the recliner. The pad is designed to soak up excess urine and was being used to protect the sitting surface of the recliner. The humidification chamber filled with water was undated. On 10/10/22 at approximately 11:47 a.m., an unidentified staff member brought Resident #7 back to the room who immediately left for another task without placing Resident #7 back on any oxygen. On 10/10/22 at approximately 11:49 a.m., the facility hair dresser entered the room and brought back a portable oxygen tank and placed Resident #7 back on oxygen via the nasal cannula connected to the portable oxygen tank. The nasal cannula tubing connected to the tank was observed kinked and potentially restricting the flow of oxygen. The tank nasal cannula was also observed to be undated. On 10/10/22 at 11:51 a.m., Registered Nurse (RN D) entered the room and changed Resident #7 over to the contaminated nasal cannula connected to the oxygen concentrator located in the room and failed to replace the contaminated nasal cannula. On 10/12/22 at 12:47 p.m., the humidification chamber connected to the oxygen concentrator remained undated and was in use on Resident #7 at the time of the observation. A review of the Minimum Data Set (MDS) assessment for Resident #7, dated 7/18/22 revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #18 On 10/10/22 at 3:25 p.m., during an interview, Resident #18 was observed connected to the oxygen concentrator in the room by a nasal cannula. There was also a portable oxygen tank located on the back of Resident #18's wheelchair with another nasal cannula which was laying on the floor with the part which inserts into the nose in contact with the floor. The nasal cannula tubing connected to the portable oxygen tank was dated 9/16/22. On 10/11/22 at approximately 8:41 a.m., Resident #18 was observed in his room connected to the portable oxygen tank running and the tubing was kinked off near the regulator potentially restricting the flow of oxygen. The tubing was dated 9/16/22. On 10/11/22 at 8:48 a.m., during an interview, the Director of Nursing (DON) was asked how often disposable oxygen equipment should be changed. The DON stated she believed disposable oxygen equipment should be changed out weekly but wanted to check for sure. The DON acknowledged the nasal cannula tubing connected to the portable oxygen tank had been in place for Resident #18 for almost a month. On 10/11/22 at 8:50 a.m., during a follow-up interview, the DON confirmed disposable oxygen equipment should be changed out weekly. On 10/11/22 at approximately 8:58 a.m., during a subsequent observation, the nasal cannula tubing connected to the oxygen concentrator for use by Resident #18 was dated 8/27/22. On 10/12/22 at approximately 12:41 p.m., during an interview, Certified Nurse Aide (CNA) C stated Resident #18 required assistance with changing his oxygen source from the oxygen concentrator to a portable oxygen tank and back. CNA C stated Resident #18 did not historically take his own nasal cannula off. CNA C stated Resident #18 in fact always waited for staff to help him transfer from one oxygen source to another and would ring if no one came to change his oxygen over. A review of the MDS for Resident #18 dated 8/8/22 revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility policy, Oxygen Therapy Policy, with a reviewed date of 4/19/22, read in part: .Oxygen cannula's will be changed weekly and as needed by the night shift nurse and dated . .Oxygen cannula's when not in use will be placed in an oxygen bag. All oxygen administration procedures shall adhere to infection control policies and procedures .

Based on interview and record review, the facility failed to thoroughly complete fall investigations and implement interventions based on root cause analysis for one Resident (#41) out three residents reviewed for falls. This deficient practice resulted in repeated falls and the potential for further injury. Findings include: Resident #41 A review of Resident #41 (R41's) medical record revealed she admitted to the facility on [DATE] with diagnoses of dementia, diabetes type 2, [CONDITION(S)], [CONDITION(S)], and asthma. A review of the 9/26/22 Minimum Data Set (MDS) assessment revealed she scored 13/15 on the Brief Interview for Mental Status. A review of a Fall report dated 6/25/22 revealed, Staff heard resident calling out for help. Upon entering residents room resident observed sitting on floor in front of wheelchair A review of the Post Fall Evaluation dated 6/25/22 revealed no documentation on new interventions and no review of the Residents blood sugar when the fall occurred. A review of R41's Fall report dated 7/1/22 revealed, Called to room per CENA (Certified Nurse Aide). Res sitting on floor, with her back against dresser . Res (resident) states she was sitting in her W/C (wheelchair), bent over to pick up a kleenex and fell forward. Res states, 'I hit my nose on dresser.' .Injury: Bruise Face . A review of the Post Fall assessment dated [DATE] revealed no assessment of R41's blood glucose levels during the fall, but did not that her blood pressure was elevated at 170/86 mm/Hg. A review of the Neuro Check sheet for this fall revealed four missing sets of neurological checks. A review of R41's blood sugar log in the vitals tabs of her Electronic Medical Record (EMR) revealed the first blood sugar documented for 2022 was on 6/26/22 at 436 mg/dL. There were no blood sugars taken after this one until 7/11/22. On 10/12/22 at 12:45 p.m., an interview was conducted with the DON who when asked why no blood sugars had been taken for the 7/1/22 fall assessment reported she could no answer why. When asked why if the 6/26/22 post fall blood sugar was extremely elevated was blood sugar not identified as a potential causative factor, the DON reported she didn't have an answer. A review of the facility policy titled, Fall and Injury Prevention reviewed by the facility on 4/22 revealed, It is the policy and procedure of the (facility name) to continuously strive to maintain a safer and more secure environment; to prevent falls and injury, and for each resident to receive adequate supervision and assist devices to prevent falls . A review of the facility policy titled, Incident/Accident Reporting reviewed 9/24/20 revealed, Incident Reports: . Staff or visitor falls or injuries will be immediately reported to the nurse in charge. A written report will be made on the facilities incident report form . All head injuries will have PERRLA (pupils equal, round, react to light, accommodation). Neuro-checks will be done every fifteen (15) minutes for the first hour, then every hour for the next four (4) hours, then every shift for three (3 days) .

Based on observation, interview and record review, the facility failed to ensure appropriate assessment, interventions and supervision were in place to prevent hot liquid spills [MEDICAL CONDITION] one Resident (#900) out of 3 residents reviewed for supervision. This deficient practice resulted in Resident #900 receiving second [MEDICAL CONDITION] his left groin after spilling hot coffee on himself and the potential for [MEDICAL CONDITION] further assessments, interventions and supervision in place. Findings include: A review of Resident #900's medical record revealed an admission date of [DATE], readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the 10/9/19 significant change Minimum Data Set (MDS) assessment revealed a score of 1/15 on the Brief Interview for Mental Status (BIMS) indicating severed cognitive impairment. Resident #900 was noted to have fluctuating behaviors present for inattention and disorganized thinking. Resident #900 was noted to need supervision of one person for locomotion and eating. On 1/22/2020 at 8:10 a.m. Resident #900 was observed in the main dining room located on the first floor. When asked by this Surveyor if he had any accidents recently Resident #900 stated , I spilled coffee on my lap. See? Resident #900 began to pull his left short leg up which showed two red streaks going across his left groin area. A review of the incident and accident report for Resident #900 dated 12/23/19 and written by Registered Nurse (RN) C read, Date: 12/23/19 07:45 a.m .This nurse was told that (Resident #900) had spilled coffee on his lap in the dining room. This nurse went to (Resident #900's) room where he was in front of his sink, sitting in his wheelchair, in just his brief. There was redness on his abd (abdomen) and left side groin. Resident stated he was 'helping others to coffee, trying to do a nice thing' .(Resident #900) has been asked numerous times to not deliver hot coffee to other residents in the dining room. He is non-complaint with this request on a daily basis. Every morning he places cups of coffee on a tray to give to other residents and this morning he lost his balance and one cup tipped into his lap. A phone interview was attempted with RN C on 1/22/2020 at 11:00 a.m. No return call was received from RN C before the survey exit on 1/22/2020. Review of Resident #900's Progress Notes dated 12/24/19 read, .2 blisters to thigh, intact with no drainage . Review of Resident #900's Skin assessment dated [DATE] read, Burn - Second Degree; Body Location -Groin; In-house Acquired. Dimensions: Area: 2.36 cm² (centimeters squared); Length 2.65 cm; Width: 3.57 cm . An interview was conducted with the Director of Nursing (DON) on 1/22/2020 at approximately 12:45 p.m. The DON confirmed that it was not brought to her attention until after Resident #900's coffee spill on 12/23/19 that Resident #900 had a history of [REDACTED]. When asked if Resident #900 had an assessment completed prior to the coffee spill on 12/23/19 to assure he was safe to handle hot liquids, the DON stated, No. A review of Resident #900's medical record confirmed there was no hot liquid assessment completed until after 12/23/19. A review of Resident #900's care plan revealed no updated interventions or care plans regarding the Resident's safety with hot liquids or the increase in supervision when Resident #900 is attempting to assist other residents. Review of the facility's Hot Beverage policy revised on 1/6/2020 read, Occupational Therapy to screen for hot beverage safety on admit, quarterly, annually, and when there is a significant change in the resident's status .If residents are noted to have any signs that may put them at risk while handling hot beverages, staff members should contact the nurse for further evaluation, Residents who require adaptive equipment and are at risk for spilling hot beverages will have this information included in their care plan .

Based on observation, interview, and record review, the facility failed to complete assessments to determine need for bed rails for one Resident (#15), resulting in immediate jeopardy (IJ) due to a fall from bed (Resident #15) and the likelihood of entrapment and serious harm for 74 Residents occupying beds with bed rails out of 82 occupied beds in the facility. This deficient practice resulted in the likelihood of entrapment, serious injury or harm, and/or death for all facility residents using bed rails without assessment of safety and appropriateness for medical conditions. The immediate jeopardy began on 8/2/19 at 4:30 a.m. when Resident #15 sustained a fall from a bed with side rails resulting in serious bodily injury (inoperable left [MEDICAL CONDITION]). Immediate jeopardy was identified on 10/29/19 at 4:30 p.m. with notification to the Nursing Home Administrator (NHA) on 10/29/19 at 5:15 p.m. An abatement plan was requested from the facility at that time. The immediate jeopardy was removed on 10/29/19 at 6:50 p.m., when the facility began implementation of the accepted IJ abatement Plan for removal of the immediate jeopardy, that included: All residents that utilize bed rails will be assessed by 11/1/19. Residents not assessed for bed rails will have the rails removed until assessment is completed. The Bed Rail Policy will be reviewed and updated to include assessment of safe bed rail use, signed consents obtained, measurement of entrapment zones and physician orders [REDACTED]. Nursing staff educated on the updated Bed Rail Policy. Noncompliance remained at a widespread level of no actual harm with potential for more than minimal harm, until confirmation of completion of the abatement plan, and verification of the facility process to ensure resident assessment of bed rail need and safety have been completed. Findings include: Review of Resident #15's medical record revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #15 needed one person extensive assist for bed mobility and extensive two person assist for transfers per the 7/22/19 annual Minimum Data Set (MDS) assessment. Resident #15 was marked as having no impairment in bilateral upper or lower extremities for range of motion (ROM). Resident #15 scored a 7/15 on the Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment, and had an activated Power of Attorney - Health (POA-H K) for decision making. On 10/28/19 at 12:45 p.m. an observation of Resident #15 was made by this Surveyor. Resident #15 was in her bed visiting with her POA-H K. It was observed that Resident #15's bed had bilateral (left and right side) grab bars near the head of the bed. An interview was conducted with Resident #15's POA-H K in regards to the care being provided to Resident #15 in the facility. POA-H L stated, Everything is fine. She fell and fractured her left hip a while back and is still recovering from that . On 10/29/19 at 9:09 a.m. an observation was made of Resident #15. Resident #15 was observed in her bed with bilateral side rails near the head of her bed. Resident #15 was noted to be awake and had a brief conversation with this Surveyor. Review of an Incident/Accident Report dated 8/2/19, revealed Resident #15 Was seen on the floor next to her bed by CNA (Certified Nurse Aide). Bed was in middle position (height level of bed to floor). Resident stated that she did not hit her head, but was complaining of left hip pain. Resident was able to move all extremities. She had a new skin tear to her left knee .Resident Description: Resident response was I don't know. Had patient move all extremities with pain to the left hip. Resident was hoyered (mechanical lift) to bed. Physician was notified and received verbal order for hip x-ray. 911 was called. Son was notified. Resident taken to hospital: Y (yes). No witnesses found . Review of the hospital CT (computer tomography) Scan (dated 8/2/19 at 8:03 a.m.) read, .Acute nondisplaced impacted subcapital fracture involving the proximal left femur . Review of the hospital Discharge Summary, dated 8/3/19, read, .left subcapital [MEDICAL CONDITION], nonoperative management due to contractures of left leg .This patient was seen by (Medical Doctor L) of Orthopedic Surgery. It was felt initially that she (Resident #15) might be a candidate per the ER (emergency room ) for an operative reduction and internal fixation of her left hip. However, she was found to have chronic contractures of her left leg and is not a candidate for such procedure. Recommendation was that the patient be nonweightbearing on the left leg and allow this to heal conservatively over time. Review of Resident #15's Post Fall Evaluation dated 8/5/19 did not note the current use of side rails, or include any new intervention to have side rails up or down while Resident #15 was in bed. Resident #15's Post Fall Evaluation read, Fall Detail Notes: Resident thought she heard someone ask her to roll over or scoot over and she rolled out of bed . Conclusion: Did the Residents current medical condition contribute to the fall: yes. Current medical conditions note: Dementia, poor memory . An interview was conducted with the Director of Nursing (DON) on 10/29/19 at 9:20 a.m. When asked if Resident #15's fall was reported to the state agency the DON stated, No, we did not report it because we felt it didn't meet the parameters. This Surveyor requested the complete investigation file. The DON stated, We cannot find all the witness statements, we only have one which was not the CNA who found (Resident #15) on the floor. This Surveyor requested the name and phone of the CNA who found Resident #15 on the floor on 8/2/19, later identified as CNA M. A phone interview was conducted with CNA M on 10/29/19 at 3:32 p.m. When asked when the last time CNA M saw Resident #15 prior to the fall, CNA M stated, I can't remember the exact time, but it would have been during rounds which happen between 2-3 a.m. When asked how Resident #15's bed was set up prior to being found on the floor, CNA M stated, Her bed was lowered, but not all the way to the ground. I attached her call light to her grab bar so she knew where it was at. When asked what type of grab bar Resident #15 had, CNA M stated, Bilateral side rails/grab bars. I always attach her call to it, but she uses it (side rail) to help staff reposition her in bed. They (side rails) come up to her mid-arm level when the bed is flat. An interview was conducted with the DON on 10/29/19 at 4:25 p.m. When asked if Resident #15 had grab bars attached to the bed prior to the fall on 8/2/19, the DON stated yes, she (Resident #15) uses them for repositioning. When asked if Resident #15 was currently using the same bed used on 8/2/19, the DON stated, no, she is in a different bed. The DON was asked to show this Surveyor the bed that Resident #15 was using on the date of 8/2/19. The DON located a similar bed that Resident #15 was using on 8/2/19. It was noted that this type of bed had bilateral side rails that, when vertical, place the side rail in the mid-arm level near the head of the bed. When a red lever is pushed in, the grab bar turns horizontal into a side rail that is placed in the middle of the bed. When asked if Resident #15's side rails were placed in the vertical or horizontal position on 8/2/19, the DON stated, Vertical. When asked how Resident #15 could have fallen out of bed, the DON stated, She would either have had to scoot down the bed or climbed over the rail. The DON confirmed that Resident #15 had no assessment, consent, or physician order [REDACTED]. Review of the facility's Bed Rail Policy reviewed 10/22/18 read, every resident of the Facility has the right to request bedrails or other bed safety devices, and; actual use of bedrails or other bed safety devicesw ill be the result of a resident or their responsible party's signed bed rail consent, a physican's order for bedrails: a resident assessment and an equipment assessment and; bed rails and other bed safety devices will not be used in any circumstances where an unsafe situation exists or may exist .Interdisciplinary Team (IDT) will complete the MDS 3.0, Care Plan, ADL (activities of daily living) Care Plan, and summarize the safe use of bed rails in the Restraint Resident Assessment Protocol (RAP). The assessment process is ongoing, with at least quarterly written documentation on use of bed rails .

Based on observation, interview, and record review, the facility failed to provide adequate supervision to assure resident safety to prevent a fall for one Resident (#15) of five Residents reviewed for falls. This deficient practice resulted in Resident #15's fall from bed causing a left [MEDICAL CONDITION] and the potential for serious harm and/or death for other residents in the facility using side rails without proper assessments of beds and the need for side rails. Findings include: Review of Resident #15's medical record revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #15 was noted to need one person extensive assist for bed mobility and extensive two person assist for transfers on her 7/22/19 annual Minimum Data Set (MDS) assessment. Resident #15 was marked as having no impairment in bilateral upper or lower extremities for range of motion (ROM). Resident #17 scored a 7/15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment, and had an activated Power of Attorney - Health (POA-H K) for decision making. On 10/28/19 at 12:45 p.m. an observation of Resident #15 was made by this Surveyor. Resident #15 was noted to be in her bed visiting with her POA-H K. Resident #15's bed had bilateral (left and right side) grab bars near the head of the bed. An interview was conducted with Resident #15's POA-H K in regards to the care being provided to Resident #15 in the facility. POA-H L stated, Everything is fine. She fell and fractured her left hip a while back and is still recovering from that . On 10/29/19 at 9:09 a.m. an observation was made of Resident #15 who was in her bed with bilateral side rails near the head of her bed. Resident #15 was noted to be awake and had a brief conversation with this Surveyor. Review of the facility Incident/Accident Report, dated 8/2/19, revealed Resident #15 Was seen on the floor next to her bed by CNA (Certified Nurse Aide). Bed was in middle position (height level of bed to floor). Resident stated that she did not hit her head, but was complaining of left hip pain. Resident was able to move all extremities. She had a new skin tear to her left knee . Resident Description: Resident response was I don't know. Had patient move all extremities with pain to the left hip. Resident was hoyered (mechanical lift) to bed. Physician was notified and received verbal order for hip x-ray. 911 was called. Son was notified. Resident taken to hospital: Y (yes). No witnesses found . Review of the hospital CT (computed tomography) Scan (dated 8/2/19 at 8:03 a.m.) read, .Acute nondisplaced impacted subcapital fracture involving the proximal left femur . A review of Resident #15's Fall Risk Evaulation dated 7/23/19 gave Resident #15 a total score of 12 stating Resident #15 was At Risk for falls and read, If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. Prevention protocol should be initiated immediately and documented on the care plan . An interview was conducted with the Director of Nursing (DON) on 10/29/19 at 9:20 a.m. The DON stated, We cannot find all the witness statements, we only have one which was not the CNA who found (Resident #15) on the floor. This Surveyor requested the name and phone of the CNA who found Resident #15 on the floor on 8/2/19, later identified as CNA M A phone interview was conducted with CNA M on 10/29/19 at 3:32 p.m. When asked when the last time CNA M saw Resident #15 prior to the fall, CNA M stated, I can't remember the exact time, but it would have been during rounds which happen between 2-3 a.m. When asked how Resident #15's bed was set up prior to being found on the floor, CNA M stated, Her bed was lowered, but not all the way to the ground. I attached her call light to her grab bar so she knew where it was at. When asked what type of grab bar Resident #15 had, CNA M stated, bilateral side rails/grab bars. I always attach her call to it, but she uses it to help staff reposition her in bed. They come up to her mid-arm level when the bed is flat. An interview was conducted with the DON on 10/29/19 at 4:25 p.m. When asked if Resident #15 had grab bars attached to the bed prior to the fall on 8/2/19, the DON stated, Yes, she (Resident #15) uses them for repositioning. When asked if Resident #15 was currently using the same bed used on 8/2/19, the DON stated, No, she is in a different bed. The DON was asked to show this Surveyor the bed that Resident #15 was using on 8/2/19. The DON located a similar bed that Resident #15 was using on 8/2/19. It was noted that this type of bed had bilateral side rails that, when vertical, place the side rail in the mid-arm level near the head of the bed. When a red lever is pushed in, the grab bar turns horizontal into a side rail that is placed in the middle of the bed. When asked if Resident #15's side rails were placed in the vertical or horizontal position on 8/2/19, the DON stated, Vertical. When asked how Resident #15 could have fallen out of bed, the DON stated, She would either have had to scoot down the bed or climbed over the rail. The DON confirmed that Resident #15 had no bed or bed side rail assessments done prior to the fall on 8/2/19, or after changing to a new bed. Review of the facility's Bed Rail Policy (reviewed 10/22/19) read, .Assessment: The MDS 3.0, the nursing assessment, nurse's notes and nursing five (5) day bed rail monitoring, will be used in the evaluation process to determine the best device that the individual resident needs for bed mobility, transfers and safety. Professional Nurses will:1) Complete the initial information on the nursing five (5) day bed rail monitoring .2) Take Immediate Corrective Action if; a) the head circumference is less than 14.5 (> fourteen and one half inches), b) if any of the actual gap sizes are greater than the Allowed Gap size. All device measurements are taken with the resident in bed. 3) This assessment will be completed when there are any changes in mattress, bed or side rails. 4) The nurse will inform the resident that the assessment procedure for device measurements will be repeated each shift for five (5) days. Quarterly, the assessment will be completed by the MDS Coordinator and documented on the five (5) day Bed Rail Assessment, under the Quarterly Review Section .

This citation has two parts: 1 and 2: 1. Based on interview and record review, the facility failed to implement the bowel protocol for for one Resident (#4) out of 23 residents reviewed for constipation. This deficient practice resulted in a hospitalization from urosepsis secondary to a bowel impaction. Findings include: A review of Resident #4's Electronic Medical Record (EMR) revealed a Plan of Care Note dated 10/24/2018 at (01:21 PM) Note Text: P (Physical): Lethargy, abd (abdominal) pain. A (Assessment):T (Temperature) 101.0 p (pulse) 85 r Respirations) 36 bp (blood pressure) 181/71. C/O (Complaint Of) severe pain to LLQ (Left Lower Quadrant (abdominal assessment is split into four areas or quadrants)), wincing with touch, guarding area, c/o pain. abdomen is soft, not distended, no masses palpated (observed by feeling). BS (Bowel Sounds) active x (times) 4 quads (Quadrants). (Resident #4) is more lethargic and confused than usual, did not wake for breakfast, glassy-eyed stare. L/s (Lung Sounds) clear. Call to (Physician A), received order to transport to (Hospital K) for evaluation. Call to (family) to inform, she is in agreement with plan and will try to go to ER (emergency room ) to see (Resident #4). Call to 911 for transport to hospital, report called to (Hospital K) ER . Transported at (12:00 PM). A review of the History and Physical (H & P) dated 10/24/18 from Hospital K revealed Resident # 4 had a recent hospital visit and was diagnosed with [REDACTED]. According to the Hospital K H & P, Resident #4 was a pleasantly confused [AGE] year old . presenting to (Hospital K) from the (facility) on 10/24/18 secondary to left lower quadrant abdominal pain. .[MEDICAL CONDITION], and is unable to provide any meaningful history. According to the chart, the patient has had the left lower quadrant abdominal pain for 2 days. The patient was noted to be more lethargic today .Urinalysis (Urine Testing) revealed leukocyte esterase (white blood cell enzyme in the urine indicating infection)and white blood cells consistent with urinary tract infection so she was started on IV (Intravenous) [MEDICATION NAME] (Antibiotic) per the emergency department .CT (Cat Scan) of the abdomen and pelvis was performed that reveals a fecal impaction. There is mild to moderate sigmoid [DIAGNOSES REDACTED] (large intestine pocketing)without evidence of diverticulitis (infection of large intestine pcketing) . She does meet SIRS (Systemic (Full Body) [MEDICAL CONDITION] Response Syndrome) criteria with a fever of 101 and leukocytosis (too many white blood cells)with a white count of 15.58 . The patient is being admitted secondary [MEDICAL CONDITION] (full body infection) due to urinary tract infection. A review of the Plan of Care Note revealed Note Text: admitted to (Hospital K). DX (Diagnosis) UTI (Urinary Tract Infection) [MEDICAL CONDITION]. A review of the bowel record for the date range of 10/1/18-10/31/18 provided by the facility shows Resident #4 had nine consecutive shifts with no BM (Bowel Movement) charted from 10/20/18 07:53 PM through 10/23/18 at 02:01 PM. Resident #4 then had a small formed stool on 10/23/18 at 07:56 PM, and then no BM again until 10/24/18 at 11:14 AM which was a large hard stool just prior to sending resident to Hospital K. A review of the EMR document section revealed the following: 10/26/18 (10:48 PM) physician progress notes [REDACTED].#4) but she had been transferred back to the medical care facility. As will be recalled she had become somewhat confused, hypoxic and febrile. She had been being treated for [REDACTED]. However she was switched to [MEDICATION NAME] (Antibiotic) rapidly improved and was transferred back . Again she seems to have some drawback to everything but she said there were some problems at the hospital . General: No acute distress, no obvious pain, appears stated age, confused .Assessment/plan: 1. UTI [MEDICAL CONDITION]- [MEDICATION NAME]([MEDICATION NAME]) again the patient responded very promptly 2. Marked dementia . On 11/15/18 at 01:00 PM an interview with the Director of Nursing (DON) regarding review of the Medication Administration Record [REDACTED]. The DON also confirmed nursing staff should have done bowel protocol intervention based on the standing orders for Physician A. A review of the standing orders for Physician A undated, revealed the following: . 2. Milk of Magnesia, 30 cc (cubic centimeter) PO (oral) PRN (as needed) no BM (Bowel Movement) x (times) 48 hours . . 5. [MEDICATION NAME] supp (suppository) (or generic equivalent) PR (per rectum) PRN no BM in 72 hours . . 6. Fleets Enema (or generic equivalent) PR PRN no BM in 96 hours. Notify physician if no result . A review of the policy and procedure Bowel Protocol with a review date of 10/22/18 revealed the following: 1. Day shift nurse will run a look back report daily in the morning (as close to noon as possible) to capture the last six shifts. Residents who have not had a bowel movement within those 6 shifts will be placed on the bowel program monitoring sheet. 2. Milk of Magnesia 30 cc's or [MEDICATION NAME] tabs (2) will be administered then with the 1200 (12:00 PM) medication pass. 3. If resident has not had a bowel movement by the 0600 (6:00 AM) medication pass then administration of [MEDICATION NAME] suppository (or equivalent) will be given. 4. If resident is still without having a bowel movement by at the 0600 (6 a.m.) medication pass then a [MEDICATION NAME] enema will be administered by the night shift nurse. 5. If there are still no results within 6 hours, the residents physician is to be called for further instructions . .All steps must be recorded on the Bowel Program Monitoring Sheet as well as documentation in the MAR. 2. Based on interview and record review, the facility failed to notify the physician timely of a change in condition for one (Resident #26) of one resident reviewed for a change in condition. This deficient practice resulted in delay in treatment for [REDACTED]. Findings include: On 11/13/18 at 02:57 PM an interview with Registered Nurse (RN) H revealed the following: (Resident # 26) had a recent fall last week. (Resident #26) hit his head, and (Resident #26) hasn't been the same since then. I know it happened on the 8th (November (YEAR)) because that is when they started the neuro's (neurological checks). This is (Resident #26's) statement, (Resident #26) stated he 'fell from a standing position', and (Resident #26) was speaking clearly and acting appropriate at the time of the fall per assessment. (Resident #26) stated he hit his head hard. Neuro (neurological) checks because of head pain. It was recorded at 06:53 AM. (Resident # 26) came down the hall accusing staff of not giving him his medication. (Resident #26) was making wild statements, and this is when he started becoming paranoid, according to the notes at 4:36 am, and this is also when he started complaining about a sore throat and that nobody was doing anything about it. (Resident #26) was given Tylenol, and a sandwich and some milk at that time. (Resident # 26) was also accusing staff of not feeding him. RN H was asked if the physician was notified of the mental status change and she replied No, I was waiting for him to come in and see what he wants to do, maybe order a U/A or maybe some blood work. I knew he was coming today otherwise I would have called. Resident # 26 was observed to be extremely agitated during this interview with staff, and had to be redirected by another staff member unknown. A review of the Fall incident report dated 11/08/18 revealed the following: (Resident #26) had fallen from a standing position while standing in his closet. (Resident #26) was able to pick himself up and notify the aide of his fall . (Resident #26) replied he was standing in front of his closet when he began to fall, he explained he reached down to catch himself on the arm chair of his WC (Wheel Chair) and the WC turned on it's side and he fell to the floor, hitting his head 'Very hard on the floor .' An order dated 11/13/18 at 1717- CT (Cat Scan) of head with no contrast. Dx (Diagnosis) Altered Mental status after a fall. had been entered into the Electronic Medical Record (EMR) orders. 11/15/18 01:30 PM interview with the DON when asked for the results of the ordered CT (scan stated the CT would not be done until 11/16/18 because the order was received after the imaging center had already closed (The Imaging Center closed at 05:00 PM), and the DON stated scheduling of the CT scan had to be addressed the following day. A review of the policy and procedure Notification of Change to Physician and Legal Representative or Interested Family Member with a reviewed date of 04/02/18 revealed the following: We recognize the facility has the responsibility to immediately inform the physician, legal representative or interested family member of a significant change in a resident's physical, mental, or psychosocial status. 1. Examples of condition changes that require notification; Deterioration of Condition .

Based on observation, interview, and record review, the facility failed to prevent accident hazards for three of three residents (#22, #42, #69) reviewed for safety issues when, A. Resident #22 sustained a [MEDICAL CONDITION] due to unlocked wheels on a bedside commode, B. Resident #42 was observed seated in a wheelchair with an alarm device, in use, which was detached from its power source, and C. Resident #69 was transferred using the wrong sized sling which resulted in a fall. These deficient practices resulted in Resident #22 experiencing harm: a [MEDICAL CONDITION] requiring surgical intervention, and the potential for falls with worsened medical condition for Residents #42 and #69. Findings include: Resident #22 Review of the medical facesheet revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident was documented to be in the care of hospice. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #22 was cognitively intact (BIM score 15/15) and required extensive assist from a facility staff member with activities of daily living (ADLs), including toileting (defined as the use of a bedside commode, including transfers on and off the commode). The Resident was identified with standing balance issues as documented on the Physical Therapy assessment dated [DATE] at 3:01 pm, which revealed a standing balance of 2/5, or poor plus. Therefore, the Resident was dependent on facility staff to remove waste accumulated in the collection basin of the bedside commode. Review of the care plan dated 4/30/2018 revealed Resident #22 required her call light to remain within reach at all times while in room. Transfers (movements from surface to surface) made to a bedside commode, were specified as standing pivot . ADLs may vary depending on level of confusion. Facility staff were to monitor for any changes in cognition or abilities related to safety issues and implement appropriate changes or safety interventions if/as warranted. Staff were to keep wanted/needed items within reach; such as a bedside commode. The Fall Risk assessment dated [DATE] at 8:23 am, identified Resident #22 at risk for falls due to administration of medications including diuretics, antihypertensives, and narcotics (all medications with the ability to effect mental status changes, confusion, and sedation). Review of the facility Fall Report (#1394) dated 6/13/2018 at 4:35 am, documented cries for help were heard coming from a room on floor. Found Resident (#22) sitting upright next to bedside commode. Resident #22 was reported to have said, 'I was getting out of bed to use commode and someone didn't lock the brakes. I slid out of the chair, landing on my butt.' Per the Fall Report, Resident #22 was assessed, then returned to bed. In addition to the brakes of the bedside commode being unlocked, other predisposing physiological factors to the fall were identified as drowsiness, weakness, and sedation. Review of the nurses notes dated 6/13/2018 at 3:19 am, revealed Resident #22 had received administration of [MEDICATION NAME] (pain medication), as ordered, for the relief of pain. The next entry in the nurses notes was on 6/13/2018 at 5:02 am, which documented: Resident (#22) found on the floor of room, next to bedside commode . she also states she slid off of commode as 'someone didn't lock the chair.' Review of the Radiology Report dated 6/15/2018 (untimed), revealed Resident #22 was diagnosed with [REDACTED]. Documentation of an orthopedic surgeon consultation dated 8/3/2018 (untimed), indicated Resident #22 initially did not receive surgical intervention of her fractured right hip and continued with presence of the right femoral neck fracture, one month old, . patient now wants to proceed with (surgical procedure). Resident #22 underwent surgical intervention, right hemiarthroplasty (surgical repair of an injured hip joint involving replacement with a prosthesis), on 8/16/2018. During an interview on 11/13/18 at 12:36 pm, Resident #22 said, I had a fall at this facility about 2 to 3 months ago. I got up to use my beside commode, and the commode moved out from under me 'cause the brakes weren't locked. The aide didn't put the brakes on the last time I'd used the commode and she dumped it out. I was independent at the time; I didn't need staff to help me up. I just need them to lock the brakes. During a phone interview on 11/15/18 at 10:43 am, Registered Nurse (RN) G said, I didn't observe the fall. I assessed the resident after the fall. She said she got out of bed to go to the commode and the commode slipped out from under her. A CNA summoned me. I came in and found (R#22) on the floor. The commode had wheels on it. I don't know if the wheels were locked on it. She shouldn't have been using the bedside commode because of her degree of grogginess due to pain medication. She was slow to answer my questions and slow to respond to me. During a phone interview on 11/15/18 at 11:05 am, Certified Nurse Aide (CNA) F said, I was her aide that night. I didn't see her fall. Her commode was at her bedside. She self-transferred to her commode. She told me the brakes on her commode weren't locked. I was in her room earlier to give her water. I looked in her commode . I didn't look to see if the brakes were locked on the commode at that time. Later, I found her on the floor; she yelled for help. She was next to her bed, but to the side of where she was. The brakes of her commode were not locked. She fell and broke her hip, but tried to scoot herself on the floor .To empty the commode, most people here roll the commode over to the bathroom, dump it (contents of the collection basin) into the toilet then return it. We're supposed to put the brakes back on . The call light was on her bed. She hollered for help; she was on the floor . She was independent in her room. She pivot-transferred from her bed to her commode. During an interview on 11/15/18 at 11:20 am, Resident #22 said, The commode I used at the time of my fall, had (4) wheels; the back (2) wheels could be locked . The aides mostly pulled the pot (bedside commode) or rolled the pot, over to the bathroom in my room, then dumped it . I knew after I sat down on it that someone forgot to lock the wheels. It was too late, I'd already sat down; I had to go . I couldn't reach my call light; it was up higher on my bed. I couldn't contact anyone. It rolled backwards as I pushed down to stand up. My commode had been placed on the lower left side of my bed. We had just had a care conference a few days before my fall. I wanted to be independent; I'm in hospice. All the staff knew I used the commode and that I got up by myself, but somebody forgot to lock my brakes after they dumped it out. During an interview on 11/15/18 at 10:55 am, the Director of Nursing (DON) said, This resident wasn't well; she was on hospice. We had a care conference just a few days prior. She (Resident #22) asked us for a bedside commode to maintain her independence. She was able to get up on her own, independently, and use the commode. On 6/13/2018, she used the commode; it tipped over. She wasn't really that safe to perform that task; getting up to use the commode. Resident #69 A review of Resident #69's medical record revealed he admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the 10/9/18 Minimum Data Set (MDS) assessment revealed a score of 2/15 on the Brief Interview of Mental Status (BIMS) assessment, indicating severely impaired cognition. A review of the 11/7/18 Incident and Accident report revealed that Resident #69 during a full body transfer with Certified Nurses Aides (CNAs) B and C, . dropped onto the bed with this head hitting the Bed's right side grab bar . A review of the Investigation report completed by the Director of Nursing (DON) for the 11/7/18 fall revealed, . (CNA B) had gotten his (Resident #69)'s sling underneath him and went to get (CNA C) to assist in getting him out of bed. They said that he began to slip and wasn't until at that point they realized he had the green sling instead of the yellow sling. The green sling was still hanging in his room with his name on it and that was the sling (CNA B) grabbed to place under him. I (DON) asked (CNA B) if she routinely checks the kardex before assisting resident and she said she usually does but she has cared for him several times and this us usually the section she works and wasn't aware a change was made . A review of the 11/7/18 progress note for Resident #69 revealed, .While transfer(ring) resident to bed using full body hoyer lift, resident right side slide out of sling and dropped onto the bed with his head hitting the bed's right side grab bar .Did state that his head was tender to touch. Resident repositioned in bed. Neuro(logical) checks started . On 11/15/18 at 11:35 a.m., an interview was conducted with CNA B and CNA C regarding Resident #69's fall. CNA C stated, (CNA B) went to lay him down, she asked me to help. She (CNA B) had the green sling under him, she didn't know that it had changed. But we went looking for a yellow sling and there were none. So we had to transfer him the safest way possible so we went ahead and used the green sling. First his stump slid out, as (CNA B) lifted him higher his whole body slid out (of the sling) and he fell on to the bed. He still hit his head on the rail. (The nurse) came in and asked him questions. We had told a couple of people about the missing yellow slings. I don't know where they keep going. We were telling everyone that because of his weight loss he needed the yellow sling now. That's what happened. A review of the current care plan for Resident #69 revealed, . Requires use of full body lift with transfers. Use medium yellow quick fit sling and 2 assist for transfers in and out of bed/WC .(revised on 11/2/18) . Resident #42 On 11/13/18 at 02:45 PM an interview was attempted with Resident # 42. Resident # 42 was unable to carry on any meaningful conversation with this Surveyor. At the time of this interview attempt Resident #42 was observed sitting in a wheelchair with a chair alarm pressure pad cord hanging out the back of the wheelchair. The tip of the cord for the chair alarm pressure pad was not plugged into the alarm box. No staff were observed in Resident #42's room or near the room at the time of this observation.

BASED ON RECORD REVIEW AND INTERVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION AND UTILIZE APPROPRIATE ASSISTIVE DEVICES (PROPER FITTING FOOTWEAR) FOR ONE RESIDENT (#1) IDENTIFIED IN A FACILITY REPORTED INCIDENT INVOLVING A FALL OUT OF FOUR SAMPLED RESIDENTS. THE FACILITY FAILURES IN THESE AREAS RESULTED IN RESIDENT #1 FALLING AND SUSTAINING A FRACTURE TO HER LEFT HUMERUS. FINDINGS INCLUDE: ON 5/3/11 AT APPROXIMATELY 11:30 A.M., A REVIEW OF RESIDENT #1'S MEDICAL RECORD REVEALS THIS [AGE] year OLD FEMALE RESIDENT HAS BEEN AT THE FACILITY SINCE 11/26/08. UPON REVIEW OF CURRENT physician's orders [REDACTED]. AN INTERVIEW WITH THE DIRECTOR OF NURSING (DON) ON 5/3/11 AT 11:45 A.M., REVEALED THAT RESIDENT #1 fell IN HER ROOM ON THE EVENING OF 4/15/11, WHILE BEING TRANSFERRED TO THE BATHROOM FROM HER WHEELCHAIR BY CERTIFIED NURSE AIDE (CNA) "A". THE DON STATED THAT A GAIT BELT HAD NOT BEEN USED BY CNA "A" DURING THE TRANSFER. THE DON INDICATED THAT IT IS A STANDARD OF PRACTICE FOR STAFF TO USE A GAIT BELT FOR RESIDENTS REQUIRING NON-MECHANICAL ASSISTANCE FOR TRANSFERS. THE DON FURTHER INDICATED THAT RESIDENT #1 HAD NO PRIOR FALL HISTORY AT THE FACILITY. ON 5/3/11 AT APPROXIMATELY 12:30 P.M., A REVIEW OF RESIDENT #1'S "ADL (ACTIVITY OF DAILY LIVING) PLAN OF CARE" EFFECTIVE MARCH OF 2011, REVEALS THAT RESIDENT #1 REQUIRES THE ASSISTANCE OF ONE PERSON FOR ALL TRANSFERS. ON 5/3/11 AT APPROXIMATELY 1 P.M., AN INCIDENT REPORT DATED 4/15/11 WAS REVIEWED. THE INCIDENT REPORT REVEALED THAT ON 4/15/11 AT APPROXIMATELY 10:05 P.M., CNA "D" REPORTED TO ON-DUTY CHARGE NURSE ("B"), THAT RESIDENT #1 HAD FALLEN IN HER ROOM. UPON EXAMINATION BY CHARGE NURSE "B", RESIDENT #1 WAS FOUND TO HAVE A 4 CENTIMETER IN DIAMETER BRUISE ON HER LEFT ELBOW AND A ONE AND A HALF MILLIMETER SKIN TEAR TO THE SAME ELBOW. THE INCIDENT REPORT INDICATED THAT THERE WERE NO FURTHER INJURIES NOTED. RESIDENT #1 WAS ASSISTED TO A SITTING POSITION AND THEN TRANSFERRED INTO HER BED. THE INCIDENT REPORT INCLUDED AN ENTRY FOR "CONDITION OF SHOES" TO BE COMPLETED BY STAFF. STAFF DOCUMENTED THAT HER SHOES WERE TOO BIG. THE INCIDENT REPORT DOCUMENTED THE REASON FOR THE INCIDENT AS RESIDENT #1 STATING THAT "THE FLOOR IS TOO SLIPPERY". INTERVENTIONS IDENTIFIED ON THE INCIDENT REPORT TO PREVENT REOCCURRENCE OF ANOTHER FALL DOCUMENTED THE FOLLOWING INTERVENTION, "TAKE THE SHOES AWAY FROM (RESIDENT #1). THEY ARE TOO LARGE AND SHE TRIPPED ON THEM. PT (PHYSICAL THERAPY) TO EVALUATE FOR SHOES." NURSING NOTES WERE REVIEWED ON 5/3/11 AT APPROXIMATELY 1:00 P.M. THESE NOTES REVEALED THAT FOLLOWING THE INCIDENT ON THE EVENING OF 4/15/11, RESIDENT #1 CONTINUED TO EXPERIENCE PAIN IN HER LEFT ELBOW AND WAS PROVIDED PAIN MEDICATION ON 4/16/11 AT 4:30 A.M. AND 6:30 A.M. AT APPROXIMATELY 8 A.M. ON 4/16/11, THE ATTENDING PHYSICIAN WAS NOTIFIED OF RESIDENT #1'S CONTINUED PAIN AND IT WAS ORDERED THAT SHE GO TO THE LOCAL MEDICAL CENTER FOR EVALUATION. RADIOLOGY RECORDS DATED 4/16/11, FOUND A DISPLACED CONDYLAR FRACTURE OF THE LEFT HUMERUS. A REVIEW OF HOSPITAL PROGRESS NOTES FOR 4/16/11 REVEAL THAT RESIDENT #1 WAS PROVIDED PAIN MEDICATION AND HER LEFT ARM WAS PLACED IN A SPLINT UNTIL SHE COULD HAVE IT SURGICALLY REPAIRED ON 4/18/11. AN INTERVIEW WAS CONDUCTED WITH CNA "A" ON 5/3/11 AT APPROXIMATELY 1:00 P.M. CNA "A" INDICATED THAT SHE WAS GETTING RESIDENT #1 READY FOR BED ON THE EVENING OF 4/15/11. SHE STATES THAT RESIDENT #1 WAS IN HER WHEELCHAIR JUST OUTSIDE HER ROOM. SHE REPORTEDLY BROUGHT RESIDENT #1 INTO THE ROOM, LOCKED THE BRAKES ON HER WHEELCHAIR, AND PROCEEDED TO TRANSFER HER FROM THE WHEELCHAIR TO AN UPRIGHT POSITION AND BEGAN TO WALK INTO THE BATHROOM. CNA "A" INDICATED THAT SHE DID NOT USE A GAIT BELT FOR THE TRANSFER. CNA "A" STATED THAT THE "BLACK SHOES" THAT RESIDENT #1'S FAMILY HAD REQUESTED TO BE ON WERE BEING WORN AT THE TIME OF THE TRANSFER. CNA "A" INDICATED THAT RESIDENT #1 WALKED SEVERAL STEPS AND THEN fell TO THE FLOOR, LANDING ON HER LEFT ELBOW. CNA "A" WAS UNABLE TO BREAK RESIDENT #1'S FALL. CNA "A" INDICATED THAT THIS WAS THE FIRST TIME SHE HAD SEEN THE BLACK SHOES BUT HAD BEEN TOLD THAT RESIDENT #1'S FAMILY WANTED HER TO WEAR THEM. CNA "D", THE CO-WORKER OF CNA "A" ON THE EVENING OF 4/15/11, WAS INTERVIEWED ON 5/3/11 AT APPROXIMATELY 2:10 P.M. CNA "D" INDICATES THAT SHE WAS IN THE ROOM OF RESIDENT #1 AT THE TIME OF THE FALL AND WAS ASSISTING RESIDENT #1'S ROOMMATE, RESIDENT #2, WITH EVENING CARES. CNA "D" STATED THAT SHE WITNESSED CNA "A" HELP RESIDENT #1 OUT OF THE WHEELCHAIR. SHE DID NOT SEE HER USE A GAIT BELT FOR THE TRANSFER. CNA "D" STATED THAT SHE HEARD RESIDENT #1'S SHOES MAKING A "KLOP, KLOP, KLOP" SOUND AND THEN WITNESSED RESIDENT #1 FALL TO THE FLOOR. CNA "D" STATED THAT CNA "A" TRIED TO HELP RESIDENT #1 BUT COULD NOT STOP THE FALL. CNA "D" STATED THAT SHE IMMEDIATELY WENT TO CHARGE NURSE "B" FOR ASSISTANCE. INTERVIEWS WITH ALL STAFF INVOLVED ON THE NIGHT OF RESIDENT #1'S FALL (CNA "A", CNA "D" AND CHARGE NURSE "B") COULD NOT CONFIRM THAT THERE WAS ANY WATER OR SLIPPERY FLOOR AT THE TIME OF THE ACCIDENT. A REVIEW OF THE FACILITY'S FIVE DAY INVESTIGATIVE SUMMARY FROM THIS INCIDENT, DATED 4/20/11, REVEALED THE FOLLOWING REFERENCES TO THE NEW SHOES WORN BY RESIDENT #1 PRIOR TO THE FALL, "THE SHOES ARE A TYPE OF SHOE THAT A PODIATRIST WOULD APPLY TO A PATIENT AFTER THEY HAD A PROCEDURE DONE ON THEIR FEET/TOES. THEY ARE OPEN TOE WITH VELCRO STRAPS" AND "IT IS REPORTED BY STAFF INVOLVED THAT THE SHOES FIT HER (RESIDENT #1) WIDTH WISE, BUT HER FOOT IS TOO SHORT FOR THE SHOE AND THERE IS A GAP AND (sic) THE TOE END OF THE SHOE WHEN SHE WAS WALKING. THE VELCRO STRAPS WERE TIGHTENED AS TIGHT AS THEY COULD GO BUT, WHEN SHE WAS AMBULATING, THAT GAP CAUSED HER FOOT TO PUSH FORWARD MAKING THE SHOE 'FLOPPY AND CLUNKY' AND CAUSED HER TO TRIP HERSELF DURING AMBULATION." ON 5/3/11 AT APPROXIMATELY 3:00 P.M., AN INTERVIEW WAS CONDUCTED WITH RESIDENT #1 IN HER ROOM. RESIDENT #1'S LEGAL GUARDIAN AND HIS WIFE WERE VISITING WITH RESIDENT #1 AT THE TIME. RESIDENT #1 WAS UNABLE TO EXPLAIN HOW SHE HAD INJURED HER ELBOW OTHER THAN SHE HAD FALLEN. SHE COULD NOT RECALL ANY PARTICULARS CONTRIBUTING TO THE FALL. RESIDENT #1'S GUARDIAN AND HIS SPOUSE INDICATED THEY HAD BROUGHT IN SPECIAL SHOES FOR RESIDENT #1 APPROXIMATELY 2 DAYS PRIOR TO THE ACCIDENT. THEY INDICATED THEY HAD PLACED THE SHOES ON RESIDENT #1'S FEET AND INSTRUCTED STAFF TO HAVE HER WEAR THEM. THE GUARDIAN AND HIS WIFE INDICATED THAT THE SHOES FIT HER PROPERLY AND HAD BEEN APPROVED BY RESIDENT #1'S PHYSICIAN. ( )