Every finding on record at Marshall Nursing and Rehabilitation Community

Based on observation, interview and record review the facility failed to ensure that grievances were promptly investigated and resolved for Residents that participate in Resident Council meetings. Findings include:Review of the Resident Council Meeting minutes dated 2/17/26, 3/10/26, 4/21/26, 6/16/26 and 7/21/26 reflected residents voiced concerns regarding staffing levels/call light response time. Grievance/concern forms dated 3/30/26 was in response to the 2/17 Resident Council meeting and reflected education would was done to correct the problem. The same response with the same date was given for the 3/10/26 meeting. There was no evidence provided that a grievance/concern form was filed for the 4/21/26 meeting. Grievance/concern response to the 6/19/26 Resident Council Meeting minutes was also dated 6/19/26 education and discipline for lack of standards of care. The grievance/concern form from the Resident Council meeting dated 7/21/26 was dated 7/22/26 and reflected response was call light audits were ongoing and education would be done. On 08/05/2026 at 3:00 PM, during the confidential group meeting held with 4 residents that routinely attend the facility monthly Resident Council meetings, 4 of the 4 participants reported call light response time was still at unacceptable levels of 30 to 40 minutes. One of the participants reported having to occasionally leave her room and physically track staff down to get help for her roommate after waiting 45 minutes. When quired the response received from Management as this had been a chronic problem, the group participants reported the response is staff are busy. On 08/06/2026 at 1:55 PM during an interview with the Director of Nursing (DON) B on the ongoing complaint of call light response time brought forth by members of the facility resident council member, DON B stated he did education. Documentation was requested at this time that the education had been done, it was also requested to review the call light audits that were done per the completed grievance document. DON B stated he did not have a sign in sheet or evidence this was done. I just talk to the staff. A second request for call light audits were made at this time and DON B stated he had just started his first audit on call light response time two days prior. On 08/06/2026 2:17 PM, DON B provided an attendance sheet related to education on call light response time. The staff signatures were all dated 8/5 and 8/6/26. On 08/06/26 during an interview with Nursing home Administrator (NHA) A, regarding the chronic complaint of call light response time and lack of evidence that the facility attempted to resolve the issue. NHA A stated call light audits were in place and ongoing. By the end of the survey, call light audits for the month of April were provided along with one additional audit dated 8/6/26.

Based on observation, interview, and record review the facility failed to provide food preferences for 4 Residents (#6,#9, #19, #27) of 4 resident reviewed for food preferences and four of four resident in a confidential resident council meeting.Findings Included: Resident #19(R19)Review of the Face Sheet and Minimum Data Set (MDS) with Assessment Reference date (ARD) 6/19/26, reflected R19 was a [AGE] year-old female with diagnoses that included hypertension (high blood pressure, heart arrythmia, and gastroesophageal reflux disease. The MDS reflected R419 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she was dependent on staff for transfers, dressing and toileting. The MDS reflected R19 did not have any behaviors and received insulin. During an observation and interview and record review on 8/04/2026 at 9:00 AM, R19 was lying in bed and appeared to be able to answer questions without difficulty. R19 reported does not eat pork and they are aware of that and often has to eat hamburgers daily and reported was unhappy that only cold sandwiches available for evening meal 7 days a week. During an interview on 8/06/2026 at 8:18 AM, R27 and R9 reported dinner last night was terrible. reported uncooked rice and chicken so dry you could hurt with someone if tossed. R27 reported was served peas and 1 slice of white bread on Sunday dinner 2 weeks prior and another evening baloney sandwich which does not seem very nutritionally appropriate for residents with rehab goals. Both R9 and R27 reported evening meals were cold sandwiches 7 days per week and had been complaining to staff for months they were unhappy with options. On 08/05/2026 at 3:00 PM, during the confidential group meeting held with 4 residents that routinely attend the facility monthly Resident Council meetings, 4 of the 4 participants reported they receive cold sandwiches for dinner every day. One group participant reported I am so darned tired of having a cold sandwich for dinner, it's ridiculous! Another group participant stated they often request a hot meal for dinner, but the only hot item is a hamburger or hotdog which reverts back to a sandwich/handheld type of meal. Another resident stated the facility used to offer a chef or taco salads in lieu of a sandwich for dinner but despite asking for this it hasn't been offered in about a year. On 08/06/2026 at 8:45 AM, during an interview with Kitchen Manager I she reported being well aware that the residents complain of getting sandwiches for dinner too frequently. When queried what was in place to ensure preferences were being met, Kitchen manager I stated she told the facility cook that they could make hot meal alternatives. When queried if she followed up on that, to ensure resident preferences were met, Kitchen Manager I reported no. Resident #6 (R6) Review of the medical record revealed R6 was admitted [DATE] with diagnoses that included urinary tract infection, hypertension, type 2 diabetes, hypothyroidism (low thyroid hormone), depression, anxiety, hyperlipidemia, and after care following surgery on the genitourinary system. Review of R6's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 0 6/20/2026, revealed a Brief Interview for Mental Status (BIMS) of 13 (cognitively intact) out of 15. During observation and interview on 08/04/2026 at 01:27 p.m. R6 was observed lying in bed. R6 explained that she had a concern that she was receiving cold sandwiches for dinner almost every night. R6 explained that when she would ask for an alternative, she would only be offered sandwiches or a hamburger. R6 explained that she has asked for a hot meal at dinner time but continues to have sandwiches. R6 explained that it occurs so frequently that her husband is bringing her dinner now. Review of the four week facility menus revealed the following: Week 1- Three dinners were sandwiches Week 2- Two dinners were sandwiches Week 3- Four nights were sandwiches Week 4- Three nights were sandwiches Review of facility alternate menu revealed the following options: Chicken noodle soup Sandwich of choice: a. Deli meat and cheese b. grilled cheese c. peanut butter and jelly d. egg salad e. fried egg sandwich - Hamburger - Cheeseburger - Hot dog Review of the facility Food Council Minutes, dated 6/16/2026, revealed To many sandwiches in the evening. The same document did not reveal any response to the council's concern. Review of the facility Resident Council Concern Form, dated 7/21/2026, revealed To many sandwiches on menu. The same document revealed Department Heads Plan of Action- RD (Registered Dietician) (her name) reviewed menu for sandwiches to be decreased. During an interview on 08/06/2026 at 08:25 a.m. Dietary Manager (DM) I explained she had been the Dietary Manager since June of 2026. DM I explained she was aware that some residents had an issue with sandwiches served for the dinner meals. DM I explained that the Corporate Registered Dietician (RD) was in the process of changing the facility menu. DM I explained that those changes had to be enacted and could not explain what the change in menu would include.

This citation pertains to intake 3104012Based on observation, interview, and record review the facility failed to meet professional standards for mediation administration for two residents (#21, #42) of four residents review for medication administration.Findings Included: Resident #42(R42) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R42 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included non-Alzheimer dementia, diabetes, anxiety and depression. The MDS reflected R42 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she required minimal assist with some activities of daily living tasks. During an observation and interview on 8/04/2026 at 11:40 AM, R42 was observed ambulating independently in room. R42 appeared calm and well-groomed and able to answer questions without difficulty. R42 reported receiving an injectable medication weekly that had a couple occasions of missed doses in past two months. Review of R42 Medication Administration Record (MAR), dated 7/1/26 through 7/31/26, reflected a hole on the MAR for 7/18/26 (no documentation as given) for weekly Ozempic injection. During an interview on 8/06/2026 at 2:04 PM, Director of Nursing (DON) B verified R42 had a missed dose of physician ordered Ozempic on 7/18/26. DON B reported would expect staff to notify physician and DON if medication was available to give and pharmacy could have provided within 24 hours. DON B verified was unable to locate evidence staff notified physician or documented in R42 medical record. Resident #21 (R21) Review of the medical record revealed R21 was admitted [DATE] with diagnoses that included Parkinson's Disease (brain cells stop making dopamine), hypertension, bipolar disorder, mild cognitive impairment, osteoarthritis (cushion between bone wears away and causes arthritis), and reduced mobility. Review of R21's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/24/2026, revealed a Brief Interview for Mental Status (BIMS) of 12 (moderate cognitive impairment) out of 15. During observation and interview on 08/04/2026 at 10:58 a.m. R21 was observed sitting in wheelchair in the activity room. R21 wheeled herself to her room for interview. R21 explained that she had completed a concern form because she had not been receiving her Parkinson medication timely. Review of R21's medical record revealed a physician order for carbidopa-levaopa (medication used for the treatment of Parkinson's Disease) tablet- extended release- 25-200 mg (milligrams), give one table by mouth 4 times per day. Review of R21's medication administration record, month of July, revealed the medication was to be given the following times: 08:00 a.m., 12:00 p.m., 04:00 p.m., and 08:00 p.m. Review of R21's Medication Administration Record (MAR) for a single month was reviewed. The month of July, 2026 alone revealed the following dates and times that carbidopa-levaopa had been given late: -07/02/2026-08:00 a.m. dose: 09:25 a.m. – documented Late Administration: Administered Late -07/03/2026-08:00 a.m. dose: 09:12 a.m. – documented Late Administration: Administered Late -07/03/2026 -08:00 p.m. dose : 02:13 a.m.- documented Late Administration: Administered Late -07/04/2026-08:00 p.m. dose: 09:17 p.m. – documented Late Administration: Charted Late -07/05/2026- 08:00 a.m. dose: 09:07 a.m.- documented Late Administration: Administered Late -07/05/2026- 08:00 p.m. dose: 10:02 p.m. documented Late Administration: Administered Late -07/08/2026-08:00 p.m. dose: 09:10 p.m.-documented Late Administration: Charted Late -07/16/2026-08:00 a.m. dose: 09:09 a.m.- documented Late Administration: Charted Late -07/16/2026-12:00 p.m. dose: 01:12 p.m.-documented Late Administration: Charted Late -07/17/2026-04:00 p.m. dose: 05:12 p.m. – documented Late Administration: other -07/17/2026-8:00 p.m. dose: 09:41 p.m.- documented Late Administration: other -07/18/2026-08:00 a.m. dose: 09:15 a.m.- documented Late Administration: Charted Late -07/19/2026-08:00 a.m. dose: 09:19 a.m.- documented Late Administration: other -07/20/2026-08:00 a.m. dose: 09:19 a.m.- documented Late Administration: Charted Late -07/20/2026- 08:00 p.m. dose: 09:17 p.m.- documented Late Administration: Charted Late -07/22/2026- 08:00 a.m. dose: 09:25 a.m. - documented Late Administration: Charted Late -07/22/2026-08:00 p.m. dose: 09:18 p.m.- documented Late Administration: Charted Late - 07/23/2026- 04:00 p.m. dose: 05:22 p.m. - documented Late Administration: Charted Late - 07/23/2026- 08:00 p.m. dose: 10:17 p.m. - documented Late Administration: Charted Late -07/26/2026-08:00 a.m. dose: 09:02 a.m.- documented Late Administration: Charted Late -07/28/2026-08:00 p.m. dose: 09:27 p.m. - documented Late Administration: Charted Late -07/31/2026-08:00 p.m. dose: 09:19 p.m. documented Late Administration: Charted Late During an interview on 08/05/2026 at 01:12 p.m. Director of Nursing (DON) B explained that it was his expectation that Licensed Nursing Staff follow acceptable professional standards when administering resident medication. DON B explained that those standards would include following the physician orders. DON B explained that the Licensed Nursing Staff have one hour before and one hour after the scheduled administration time to provide the resident the medication. DON B explained that if the medication was administered outside of those parameters then the medication would be late. DON B explained that the facility computerized medication administration record system requires the nurse to document the reason the medication has been given outside the ordered time parameters. DON B explained that it was a professional standard to chart the medication as given at the time that the medication was actually given. DON B explained that it was not appropriate to chart the medication as given at a later time. DON B reviewed R21's Medication Administration Record (MAR) for July 2026. DON B confirmed that R21 had received her carbidopa-levaopa outside of her ordered timed parameters 22 times during the one month of July that was reviewed. DON B could not explain why R21's carbidopa-levaopa had been administered late 22 times in one month.

Based on interview and record review, the facility failed to ensure that the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) was provided for one resident (Resident #20) of three residents reviewed for beneficiary notices. Findings include: Review the clinical record, included the Minimum Data Set (MDS) dated [DATE] revealed R20 was admitted to the facility on [DATE] with a diagnosis of hemiplegia and chronic kidney disease. R20 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). During review of the SNF (Skilled Nursing Facility) Beneficiary Notification Review (completed by the facility) revealed R20's Medicare coverage for skilled nursing services would end on 7/24/26. However, the facility failed to provide R20 with a Notice of Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN). On 08/06/26 at 10:10am during an interview with the Nursing Home Administrator (NHA) A, it was requested to provide documentation that the SNFABN for R20 be provided. NHA A stated that was the responsibility of the MDS coordinator, not the responsibility of NHA A. On 08/06/2026 10:16 AM, during an interview with MDS coordinator C she reported that she was responsible for issuing notices of non-coverage related to Medicare but was not aware, until today when she was informed by the facility that she was also responsible for SNF/ABN as well. This lack of communication as to the responsibility of resident notification had resulted in R20 never being issued the SNF/ABN.

Based on observation, interview and record review the facility failed to maintain oral care needs for 1 of 1 dependent residents (Resident #12) reviewed for oral care, resulting in moderate plaque buildup on teeth and increased likelihood of compromised dignity and gum disease. Findings include:Resident #12(R12)Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R12 was a [AGE] year-old male originally admitted to the facility on [DATE], with diagnoses that included traumatic spinal cord dysfunction with quadriplegia, seizure disorder and depression. The MDS reflected R12 ability to make daily decisions was severely impaired, and he was dependent on staff for hygiene, oral hygiene, transfers, dressing, and bathing. During an observation and interview on 8/04/2026 at 10:51 AM, R12 was observed in bed, able to answer simple questions without difficulty. Observed teeth to have heavy plaque buildup and gums that appeared inflamed. R12 reported staff do not assist him with mouth care and unable to recall last time teeth were brushed or seen by dentist.During an observation on 8/6/26 at approximately 11:50 a.m., R12 was in bed with continued heavy plaque buildup on teeth.Review of R12 Dental Care Plan, dated 8/8/22, reflected, Provide oral care q[every] shift and PRN [as needed]. Moisturize lips PRN. May need to re approach if [named R12] is resistive to oral care.Review of most recent R12 Dental Consult, dated 2/18/26, reflected, He has heavy plaque and tartar lower lingual.Oral Hygiene instructions were provided.recommend Resident be brought to the dental clinic at their next visit.During an observation and interview on 8/06/2026 at 11:54 AM, Certified Nurse Aid (CNA) P reported staff know how to care for residents by following the Care Plans. CNA P reported R12 required assistance with several Activities of Daily Living including oral care in morning. CNA P reported staff document in Point of Care charting under AM care when morning care is completed including check and change, hygiene care and dressing and reported was responsible for caring for R12 that day and completed AM care. This surveyor requested CNA P to locate R12's oral care supplies. CNA P entered R12 room and started looking in R12 bedside nightstand top drawer, then bottom drawer and was unable to locate. CNA P was observed looking through R12 closet. Observed R12 in bed and appeared alert and awake. R12 was asked if staff assisted him brush his teeth that morning and R12 stated, no. R12 reported was unable to recall last time staff brushed his teeth. CNA P then reported she did not brush R12 that morning because, it got crazy.During an interview on 8/06/2026 at 2:20 PM Director of Nursing (DON) B reported expected staff to follow resident Care Plans including R12 care plan for oral care. DON B reported AM Care, documented by staff, included oral care and if R12 refused staff are expected to document on behavior log as refusal. Review of R12 Behavior Log, dated June 2026 through current, reflected no oral care refusals.

Based on interview and record review the facility failed to accurately record grievances for one resident (#21) out of one residents reviewed for grievancesFindings Included:Resident #21 (R21)Review of the medical record revealed R21 was admitted [DATE] with diagnoses that included Parkinson's Disease (brain cells stop making dopamine), hypertension, bipolar disorder, mild cognitive impairment, osteoarthritis (cushion between bone wears away and causes arthritis), and reduced mobility. Review of R21's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/24/2026, revealed a Brief Interview for Mental Status (BIMS) of 12 (moderate cognitive impairment) out of 15.During observation and interview on 08/04/2026 at 10:58 a.m. R21 was observed sitting in wheelchair in the activity room. R21 wheeled herself to her room for interview. R21 proceed to explain that she had filed several grievances regarding issues with the care at the facility. R21 explained that she was missing a tie dye shirt, a pair of capri pants that were [NAME] egg blue, and shirt with a cat on the front of it. R21 explained that she had also completed a concern form because she had not been receiving her Parkinson medication timely. R21 explained that the missing items had not been found or replaced to her satisfaction.Review of facility documents entitled Grievance/Complain Form, completed on behalf of R21, revealed the following:- Grievance/Complaint Form-Date submitted 6/29/26. Persons submitted (name of R21), no resident information completed. Stated baby blue pants missing, [NAME] (sp)dyed shirt, dog night gown *missing items*. Corrective action: Found dog nightgown. [NAME] (sp) dyed shift replaced. Blue pants daughter agreed to replace and facility to reimburse. No date listed when daughter notified, no date of when resident was notified. The document does-not have that the resident was provide a copy of the completed grievance documentation.Review of the grievance log for the last six months did not list R21's concerns dated 06/29/2026. The grievance log did not list any concern regarding R21's issue with not receiving Parkinson's Disease medication timely.During an interview on 08/05/2026 at 02:31 p.m. Nursing Home Administrator (NHA) A explained that residents have the right to voice grievances to the facility. NHA A explained that resident could complete a Grievance/Complaint Form themselves or staff could assist the resident to complete. NHA A explained that all concern forms are record on the facility grievance log so that they be tracked. NHA A explained the grievance log would allow the facility to track and trend concerns. NHA A explained that it was her expectation that all resident concerns are record on a Grievance/Complaint Form. NHA A explained that it was her expectation that documents be completed in its entirety and that the resident/responsible person be provided a copy of the concern form. NHA A reviewed the facility grievance tracking log and confirmed that R21's Grievance/Complaint Form, dated 06/29/2026, was not on the facility grievance log. NHA A could not explain why R21's Grievance/Complaint Form, dated 06/29/2026, had not been completed on the log. NHA A confirmed that the facility had not completed a Grievance/Complaint Form for R21, regarding the concern with not receiving Parkinson's Disease Medication timely.NHA A confirmed that the facility had not completed R21's Grievance/Complaint Form, dated 06/29/2026, in its entirety and they could not demonstrate that R21's concerns were resolved to her satisfaction or that R21 had been provided a copy of the document.

Based on observation, interview, and record review the facility failed to implement comprehensive resident-centered care plans for one out of 13 residents (Resident #12) reviewed for care plans, resulting in R12 oral care needs not being met. Findings: Resident #12(R12)Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R12 was a [AGE] year-old male originally admitted to the facility on [DATE], with diagnoses that included traumatic spinal cord dysfunction with quadriplegia, seizure disorder and depression. The MDS reflected R12 ability to make daily decisions was severely impaired, and he was dependent on staff for hygiene, oral hygiene, transfers, dressing, and bathing. During an observation and interview on 8/04/2026 at 10:51 AM, R12 was observed in bed, able to answer simple questions without difficulty. Observed teeth to have heavy plaque buildup and gums that appeared inflamed. R12 reported staff do not assist him with mouth care and unable to recall last time teeth were brushed or seen by dentist.During an observation on 8/6/26 at approximately 11:50 a.m., R12 was in bed with continued heavy plaque buildup on teeth.Review of R12 Dental Care Plan, dated 8/8/22, reflected, Provide oral care q[every] shift and PRN [as needed]. Moisturize lips PRN. May need to re approach if [named R12] is resistive to oral care.Review of most recent R12 Dental Consult, dated 2/18/26, reflected, He has heavy plaque and tartar lower lingual.Oral Hygiene instructions were provided.recommend Resident be brought to the dental clinic at their next visit.During an observation and interview on 8/06/2026 at 11:54 AM, Certified Nurse Aid (CNA) P reported staff know how to care for residents by following the Care Plans. CNA P reported R12 required assistance with several Activities of Daily Living including oral care in morning. CNA P reported staff document in Point of Care charting under AM care when morning care is completed including check and change, hygiene care and dressing and reported was responsible for caring for R12 that day and completed AM care. This surveyor requested CNA P to locate R12's oral care supplies. CNA P entered R12 room and started looking in R12 bedside nightstand top drawer, then bottom drawer and was unable to locate any oral care supplies. CNA P was observed looking through R12s closet. Observed R12 in bed and appeared alert and awake. R12 was asked if staff assisted him to brush his teeth that morning and R12 stated, no. R12 reported was unable to recall last time staff brushed his teeth. CNA P then reported she did not brush R12 that morning because, it got crazy.During an interview on 8/06/2026 at 2:20 PM Director of Nursing (DON) B reported expected staff to follow resident Care Plans including R12 care plan for oral care. DON B reported AM Care, documented by staff, included oral care and if R12 refused staff are expected to document on behavior log as refusal.

Based on observation, interview and record review, the facility failed to ensure vision services were provided for one resident (R26) of one resident reviewed for vision services resulting in missed physician ordered urgent ophthalmology consult related to acute retinal detachment of right eye and lost vision in the right eye with prior left eye vision loss. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) with Assessment Reference date of 7/5/26, reflected R26 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included acute right eye retinal detachment with vision loss, hypertension, diabetes, glaucoma, anxiety, and depression. The MDS reflected R26 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she required partial to moderate physical staff assist with transfer, dressing, hygiene, bathing, and toileting. Continued review of R26 MDS reflected vision, severely impaired-no vision or sees only light, colors or shapes; eyes do not appear to follow objects. The MDS reflected R26 had a mood interview score of 15 that reflected moderately severe depression (worsened since admission assessment, dated 1/2/26, that reflected mild depressing with score of 7.)During an observation and interview on 8/04/2026 at 2:28 PM, R26 was lying in bed with lights off and appeared able to answer questions without difficulty. R26 appeared ungroomed, disheveled, quiet and alert but sleepy. R26 reported was admitted to the facility from the hospital at the end of December 2025 after right eye retinal detachment that caused her to be blind. R26 reported had prior vision loss in left eye related to glaucoma so after right eye vision loss could only see black. R26 reported had requested facility staff several times to be seen by ophthalmologist and had not yet been seen. R26 reported was scared and sad that sudden vision loss was now going to be permanent and appeared to become emotional.Review of R26 Hospital Discharge summary, dated [DATE], reflected R26 was admitted [DATE] and discharged [DATE]. The document included, She presents to the emergency department for vision loss in right eye. Patient is blind in her left eye as well due to glaucoma.Summary of Hospitalization: [AGE] year old, vision loss right eye. Was previously blind in left.Neuro reviewed recommended continuing ASA [aspirin] and adding Plavix x 3 weeks. Sent to SNF [skilled nursing facility], urgent referral provided for ophthalmology.Special Instructions: Follow up with ophthalmology and neurology.Review of R26 Progress Note, dated 1/6/26, reflected, Appointment made with [named local] Ophthalmology 1/9/26 at 9:35am Your Way to pick up at 8:45am.Review of R26 Progress Note, dated 1/7/26, reflected, Spoke with guardian, [named]and she plans to attend appointment on Friday 1/9/26 with resident.Review of Progress Note, dated 1/13/26, reflected, Message left with guardian, [named] toconfirm ophthalmology appointment on 1/16/26 or if she had located closer provider.Review of R26 Electronic Medical Record dated 12/30/25 through 8/5/26 reflected no evidence that R26 was seen for urgent ophthalmology consult.During an interview on 8/05/2026 at 1:32 PM, Unit Manager (UM) Q reported had worked at the facility for about one year. UM Q reported was responsible for outside consults including R26 ophthalmology consult. UM Q reported R26 had a court appointed guardian service and was not seen for physician ordered urgent opthamology consult. UM Q reported placed call to R26 guardian and did not hear back from her in between January and current time (8/5/26). UM Q verified was unable to locate any follow up with R26 guardian between January and now in R26 EMR and apologized and stated, actually that is unacceptable, that was my fault. UM Q reported planned to follow up with R26 guardian service and schedule ophthalmology appointment as soon as possible. During an interview on 8/05/2026 at 3:08 PM, Nursing Home Administrator(NHA) A reported would expect staff to follow up on and facilitate consult appointments including R26 urgent ophthalmology consult.

This citation pertains to intake 3104012Based on observation, interview, and record review the facility failed to ensure that three residents (#13, #15, #21) were treated with dignity and care in manner that promotes maintenance or enhancement of their quality of life out of three residents reviewed for dignity.Findings Included: Resident #13 (R13)Review of the medical record revealed R13 was admitted [DATE] with diagnoses that included Alzheimer's Disease, muscle weakness, depression, type 2 diabetes, anxiety, and cardiomyopathy (enlarged/thickening of heart muscle). Review of R13's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/27/2026, revealed a Brief Interview for Mental Status (BIMS) of 4 (severely impaired cognition) out of 15.During observation on 08/04/2026 at 01:41 p.m. R13 was not observed in his room. 13's room was observed not to have a curtain between his bed and his roommate's (R15) bed. During observation and attempted interview on 08/04/2026 at 01:45 p.m. R13 was observed sitting up in the activity room. R13 could not answer interview questions.Resident #15 (R15)Review of the medical record revealed R15 was admitted [DATE] with diagnoses that included Alzheimer's disease, congestive heart failure (CHF), atrial fibrillation, hypothyroidism (low thyroid hormone), psychotic disorder with delusions (a fixed belief that is not grounded in reality) depression, epilepsy (brain disorder that causes seizures), neuromuscular dysfunction of the bladder (nerve damage to the bladder that does not allow holding of urine or total empty of bladder), chronic kidney disease, and dysphagia (difficulty swallowing). Review of R15's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/20/2026, revealed a Brief Interview for Mental Status (BIMS) of 4 (severely impaired cognition) out of 15.During observation and attempted interview on 08/04/2026 at 01:38 p.m. R15 was observer lying in bed. No curtain was observed present on the curtain track around R15's bed and no curtain was present between R15's bed and his roommate's(R13). R15 was unable to answer interview questions.During an interview on 08/05/2026 at 03:16 p.m. Certified Nursing Aide (CNA) L explained that all residents were to have privacy curtains in their room. CNA L explained that privacy curtains were between resident's beds and had to be pulled to maintain a resident's dignity and privacy during person care. At the conclusion of this interview CNA L was asked to observe R13's and R15's room. CNA L confirmed that R13 did not have a privacy curtain between R13's bed and R15's bed. CNA L confirmed that R15 did not have privacy curtain between the bed and the door. CNA L could not explain how long R13 and R15 had been without a curtain. CNA L denied that she had notified anyone for the need of a privacy curtain.During an interview on 08/05/2026 at 03:24 p.m. Director of Nursing (DON) B explained that it was the expectation of the facility that all residents' rooms had a privacy curtain to maintain resident dignity and privacy. DON B explained that privacy curtains were removed for cleaning purposes. DON B could not answer if other privacy curtains were applied while the resident curtains were being cleaned. At the conclusion of this interview DON B was asked to observe R13's and R15's room. DON B confirmed that both R13 and R15 did not have privacy curtains in the room. DON B confirmed that the curtain tacks were empty. DON B could not explain why privacy curtains were not present and could not explain the duration of time that R13 and R15 had not had privacy curtains present.Resident #21 (R21)Review of the medical record revealed R21 was admitted [DATE] with diagnoses that included Parkinson's Disease (brain cells stop making dopamine), hypertension, bipolar disorder, mild cognitive impairment, osteoarthritis (cushion between bone wears away and causes arthritis), and reduced mobility. Review of R21's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/24/2026, revealed a Brief Interview for Mental Status (BIMS) of 12 (moderate cognitive impairment) out of 15.During observation and interview on 08/04/2026 at 10:58 a.m. R21 was observed sitting in wheelchair in the activity room. R21 wheeled herself to her room for interview. R21 explained that she was upset because the facility was not providing her Parkinson medication on time. R21 explained that when she had explained the concern to the nursing staff (an agency nurse no longer at facility). R21 explained that the nurse made her feel insignificant and made her feel that the nurse was better and smarter than herself. R21 explained that she held an accounting degree and that her degree was higher than most of the nursing staff in the building. R21 was visibly upset during the interview. R21 explained that she did not feel that the staff had treated her with dignity and respect regarding her concerns.During an interview on 08/05/2026 at 03:04 p.m. Nursing Home Administrator A denied that she had any knowledge that R21 had the feeling that the staff had not treated her with dignity and respect when she had voiced a concern regarding her medication administration.

Based on observation and interview, the facility failed to ensure that multi-dose vials of tuberculin were dated upon opening for one of one medication room and medications were labeled in one of two medication carts reviewed for labeling, dating and expiration of medications, resulting in the potential for medications given to residents to have decreased potency, reduced strength and effect. Findings include:Medication vials should always be discarded whenever sterility is compromised or questionable. In addition, the United States Pharmacopeia (USP) General Chapter 797 [16] recommends the following for multi-dose vials of sterile pharmaceuticals: If a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. If a multi-dose vial has not been opened or accessed (e.g., needle-punctured), it should be discarded according to the manufacturer ' s expiration date. The manufacturer ' s expiration date refers to the date after which an unopened multi-dose vial should not be used. The beyond-use-date refers to the date after which an opened multi-dose vial should not be used. The beyond-use-date should never exceed the manufacturer ' s original expiration date. Retrieved from http://www.cdc.gov/injectionsafety/providers/provider_faqs_multivials.htmlDuring an observation and interview on 8/04/2026 at 9:51 AM, Licensed Practical Nurse (LPN) R unlocked [NAME] Hall cart 2. Observed unlabeled, undated Ozempic pen. LPN R reported was not aware of any residents on hall that use Ozempic and verified pen did not have name or open date on it.During an interview on 8/06/2026 at 2:04 PM, Director of Nursing (DON) B verified unlabeled Ozempic pen belonged to R42 and should have been labeled with resident name and open date and had been discarded.During an observation and interview on 8/06/2026 at 3:08 PM, Unit Manager (UM) Q unlock medication room. Observed one open, undated multi use vial of Tuberculin inside the refrigerator. UM Q verified the vial was open and had no open date and should and reported plan to discard.

This citation pertains to intake 3104012.Based on observation, interview, and record review the facility failed to ensure palatable and appetizing food was served to 2 (Resident #19 and #21) of 2 residents reviewed for receiving palatable and appetizing food, resulting in potential for decreased oral intake.Findings include: Resident #19(R19)Review of the Face Sheet and Minimum Data Set (MDS) with Assessment Reference date (ARD) 6/19/26, reflected R19 was a [AGE] year-old female with diagnoses that included hypertension (high blood pressure, heart arrythmia, and gastroesophageal reflux disease. The MDS reflected R419 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she was dependent on staff for transfers, dressing and toileting. The MDS reflected R19 did not have any behaviors and received insulin. During an observation and interview and record review on 8/04/2026 at 9:00 AM, R19 was lying in bed and appeared to be able to answer questions without difficulty. R19 reported does not eat pork and they are aware of that and often has to eat hamburgers daily and reported was unhappy that only cold sandwiches available for evening meal 7 days a week. Resident #21 (R21) Review of the medical record revealed R21 was admitted [DATE] with diagnoses that included Parkinson's Disease (brain cells stop making dopamine), hypertension, bipolar disorder, mild cognitive impairment, osteoarthritis (cushion between bone wears away and causes arthritis), and reduced mobility. Review of R21's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/24/2026, revealed a Brief Interview for Mental Status (BIMS) of 12 (moderate cognitive impairment) out of 15. During observation and interview on 08/04/2026 at 10:58 a.m. R21 was observed sitting in wheelchair in the activity room. R21 wheeled herself to her room for interview. R21 explained that her meals are frequently cold. R21 also explained that she has asked for an alternative when she does not like the food on the menu but one night they did not bring her the alternative she asked for.

Based on observation, interview, and record review, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 (Resident #19) of 13 reviewed for MDS assessments, resulting in the potential for inaccurate care plans and unmet care needs. Findings Include: Resident #19 (R19)Review of the Face Sheet and Minimum Data Set (MDS) with Assessment Reference date (ARD) 6/19/26, reflected R19 was a [AGE] year-old female with diagnoses that included hypertension (high blood pressure, heart arrythmia, and gastroesophageal reflux disease. The MDS reflected R19 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she was dependent on staff for transfers, dressing and toileting. The MDS reflected R19 did not have any behaviors and received insulin. During an observation and interview and record review on 8/04/2026 at 9:00 AM, R19 was lying in bed and appeared to be able to answer questions without difficulty. R19 had MDS indicators in system that indicated R19 received insulin. R19 denied have diagnosis of diabetes and reported had never used insulin. Review of R19 Electronic Medical Record on 8/06/2026 at 10:09 AM, including Physician Orders, Hospital discharge documents and Medication Administration Record, reflected no evidence that R19 had ever received insulin.During an interview on 8/06/2026 at 10:35 AM, Director of Nursing (DON) B, verified R19's admission MDS with ARD of 6/19/26 reflected R19 was on insulin and then stated R19 was not on insulin and confirmed R19 MDS assessment was not accurate. DON B reported would expect MDS data to be accurate.

This citation pertains to Intake 3000710.Based on interview and record review, the facility failed to ensure five of five licensed nurses had the necessary competency evaluations as identified in the facility assessment. Findings include:Review of the Facility Assessment Tool initiated 12/18/27, updated 1/15/26, and reviewed with the QAA/QAPI committee on 2/26/26 revealed the facility had an average number of residents with the following condition/need: Wounds-5Wound vacuum-1tracheostomy-1catheters-3enteral nutrition-3ostomy-2The Facility Assessment Tool included a section for Staff training/education and competencies which revealed A facility must develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles. A facility must determine the amount and types of training necessary based on a facility assessment. The listed training included a number of topics with an online training platform being used as the preferred training method. The training section of the Facility Assessment Tool also included a list of annual competencies which included, but not limited to, areas such as: person-centered care, activities of daily living, disaster planning and procedures, infection control, medication administration, measurements (i.e. vital signs), resident assessment and examination, caring for persons with Alzheimer's/dementia, specialized care (catheterization insertion/care, colostomy care, diabetic blood glucose testing, oxygen administration, suctioning, pre-op and post-op care, tracheostomy care/suctioning, ventilator care, tube feedings, wound care/dressings, dialysis care), and caring for residents with mental and psychosocial disorders. According to the facility's CMS 802 provided 5/12/26, the facility's census included nine residents with indwelling catheters, one resident with a tracheostomy, three residents receiving enteral nutrition, and one resident receiving parenteral nutrition. On 5/13/26 at 8:24 AM, annual competency evaluations for Licensed Practical Nurse (LPN) H, LPN I, LPN K, LPN L, and Registered Nurse (RN) N were requested from Nursing Home Administrator (NHA) A. The document provided was a tracheostomy care Education/In-Service Record dated 5/12/26 for LPN H and LPN I. In an interview on 5/13/26 at 10:33 AM, Director of Nursing (DON) B reported the facility had previously identified that skills competencies were missing and had scheduled a skills fair for next week. When asked how the facility verified competency of agency staff, DON B reported agency staff signed an attestation. In an interview on 5/14/26 at 3:53 PM, NHA A reported the facility had identified they had not completed annual competency evaluations; therefore they scheduled a skills fair for next week. NHA A reported they were able to locate an older competency evaluation for one of the staff that was requested. NHA A was asked to provide any documents the facility had regarding the requested licensed nurse competency evaluations. Review of the provided documents revealed LPN L's Licensed Nursing Skills Competency Checklist was completed on 6/5/24. RN N signed a nurse education acknowledgement on 6/14/25 for another facility.

Based on interview and record review, the facility failed to protect the resident's right to be free from of physical abuse by a staff member. Findings include: Per the facility face sheet Resident #1 (R1) was an [AGE] year-old who was originally admitted to the facility on [DATE] with a return to the facility date of [DATE]. Diagnosis included Alzheimer's disease, bipolar disorder, dementia, and anxiety. Review of a Physician's progress note dated [DATE] revealed R1 expired and had a time of death of 3:34 PM (actual time was 2:34 PM) on [DATE]. Review of a progress note dated [DATE] revealed a phone call was made to R1's guardian at approximately 2:20 PM to discuss R1's change in condition and the assessment made by Medical Director (MD) C. The notes revealed that while the Assistant Director of Nursing (ADON) D was on the phone with R1's guardian two Certified Nurse Aids (CNA's) approached ADON D and informed her that they believed R1 had passed away and requesting a nursing assessment. The note revealed ADON D assessed R1 and found R1 to be unresponsive in bed with eyes fixed, no visible breathing, and no lung sounds present. ADON D had listened for an apical pulse (heartbeat) for full 60 seconds and no pulse was noted. The note revealed MD C assessed R1 and called official time of death at 2:34 PM. In an interview on [DATE] at 9:31 AM, R1's Guardian E stated she was made aware on [DATE] that R1 had been hostile when receiving a shower, and that she had kicked a bar on the wall in the shower room. Guardian E said it was reported to her that R1 was having a behavior and was combative during the shower. Guardian E said she received the call on the 18th of March that R1 had a bruise on her leg and then she received a call that R1 had passed away. Guardian E said it was a shock to her that R1 passed away. Guardian E said R1 was doing fine and in her normal state prior to that day and stated she had not received any phone calls about her having a change in her condition.Review of a progress note made by Director of Nursing (DON) B revealed Guardian E was notified regarding a bruise to R1's right shin. The note revealed that during the shower R1 began to be aggressive with staff and hit her leg on the shower chair which caused a bruise. An X-ray was ordered. In an interview on [DATE] at 2:08 PM, CNA F stated that she was terminated from her employment at the facility on [DATE]. CNA F said her and CNA G went into R1's room with the mechanical lift and the shower chair and said when they put the sling under R1 she became combative and was yelling that we were was not supposed to give her a shower. CNA G said R1 was digging, kicking, and hitting. CNA F said R1 was transferred to the shower chair in her room but never stopped hitting digging into her skin. CNA F said she shampooed R1's hair and CNA G washed her body all while R1 continued to dig into their skin and hit them. CNA F said she gave R1 the shower because she was told she had to by Registered Nurse (RN) H or she would get written up. Review of an Employee Memorandum dated [DATE] revealed CNA F was terminated from her employment at the facility for violation of resident rights amongst other reasons.CNA F continued to state that there were bars on the wall in the shower area, and R1 kicked the bar on the wall with her right leg. CNA F said she held R1's arms down while CNA G washed R1. CNA F stated that right from the beginning R1 said she did not want to take a shower and said R1 made the statement more than once. CNA F said she told R1 she was asked to give her a shower, and R1 said no then she got combative. CNA F said RN H told her that no matter what R1 was going to get a shower and told us that we had to shower her. CNA F said on [DATE] she was notified by the facility that she was suspended and then fired.CNA F further stated that it was a surprise to her that R1 died. CNA F said R1 was in her normal state up until the day she passed. CNA F said R1 was not actively declining in health prior to her death. In an interview on [DATE] at 8:20 AM, RN H stated R1 was scheduled for a shower. RN H said the CNAs reported to her that in the shower, when they transferred R1 from to the shower chair, she hit her leg on the mechanical lift bar. RN H said she was surprised R1 had passed away, and she did not make a connection between the bruising on R1's right shin and her death. RN H said R1 never complained of any pain.Review of a statement that RN H wrote post the incident dated [DATE] revealed, R1 had bruising, swelling, and an abrasion to her right shin area after hitting her leg on the mechanical lift bar. The statement revealed that the lower leg showed bruising and swelling that was not present earlier in the night. The swelling extended from the knee to the ankle. The statement revealed R1 yelled out loudly and pulled away from direct touch to the swollen area, R1 refused to allow ROM of the knee when attempted; R1 guarded the leg and yelled out. In an interview on [DATE] at 8:38 AM, CNA G stated that CNA F had approached her and asked her if she would help with showering R1. CNA G said R1 was very irate and was kicking, while in the shower room she was kicking again and she ended up kicking the shower bar, which resulted in a bruise. CNA G said R1 was being combative because she did not want to take a shower. CNA G said CNA F was told by RN H that she needed to give R1 a shower. CNA G said she visibly saw CNA F holding R1's down by her wrists so R1 did not hit her, and the whole time R1 was saying she did not want to shower. CNA G further stated that the shower should not have been given with R1 not wanting it and should have told RN H that R1 was absolutely refusing and we were going against R1's rights. CNA G said R1 was complaining about her knee hurting. CNA G stated that she did consider this to be abuse; stating that CNA F holding R1's wrists down was abuse, and she should have told CNA F to release her grip and reported the abuse to RN H. CNA G also stated that forcing R1 to take a shower was abuse.Review of a shower sheet dated [DATE], revealed documentation that R1 had bruising form kicking and did not want the shower. This was documented by CNA F and G. Review of a statement written by CNA F dated [DATE] revealed R1 was kicking and kicked the mechanical lift bar and the shower room bar. The statement revealed R1 was very combative and had fingertip bruising on her arms from keeping her form digging on and biting CNA F and G.Review of a statement written by CNA G revealed that once getting R1 into the mechanical lift R1 was so angry she was trying to kick CNA F. The statement revealed that once getting R1 to the shower she ended up kicking the shower bar that was on the wall. Review of an X-ray result dated [DATE] revealed R1 had an acute transverse fibular neck fracture (fracture of the lower leg).

Based on interview and record review the facility failed to report to investigate abuse against one out of three residents (R1). Per the facility face sheet Resident #1 (R1) was an [AGE] year-old who was originally admitted to the facility on [DATE] with a return to the facility date of [DATE]. Diagnosis included Alzheimer's disease, bipolar disorder, dementia, and anxiety. Review of a Physician's progress note dated [DATE] revealed R1 expired and had a time of death of 3:34 PM (actual time was 2:34 PM) on [DATE]. Review of a progress note made by Director of Nursing (DON) B revealed Guardian E was notified regarding a bruise to R1's right shin. The note revealed that during the shower R1 began to be aggressive with staff and hit her leg on the shower chair which caused a bruise. An X-ray was ordered. In an interview on [DATE] at 2:08 PM, CNA F stated that she was terminated from her employment at the facility on [DATE]. CNA F said her and CNA G went into R1's room with the mechanical lift and the shower chair and said when they put the sling under R1 she became combative and was yelling that we were was not supposed to give her a shower. CNA G said R1 was digging, kicking, and hitting. CNA F said R1 was transferred to the shower chair in her room but never stopped hitting digging into her skin. CNA F said she shampooed R1's hair and CNA G washed her body all while R1 continued to dig into their skin and hit them. CNA F said she gave R1 the shower because she was told she had to by Registered Nurse (RN) H or she would get written up. CNA F continued to state that there were bars on the wall in the shower area, and R1 kicked the bar on the wall with her right leg. CNA F said she held R1's arms down while CNA G washed R1. CNA F stated that right from the beginning R1 said she did not want to take a shower and said R1 made the statement more than once. CNA F said she told R1 she was asked to give her a shower, and R1 said no then she got combative. CNA F said RN H told her that no matter what R1 was going to get a shower and told us that we had to shower her. CNA F said on [DATE] she was notified by the facility that she was suspended and then fired.Review of a statement that RN H wrote post the incident dated [DATE] revealed, R1 had bruising, swelling, and an abrasion to her right shin area after hitting her leg on the mechanical lift bar. The statement revealed that the lower leg showed bruising and swelling that was not present earlier in the night. The swelling extended from the knee to the ankle. The statement revealed R1 yelled out loudly and pulled away from direct touch to the swollen area, R1 refused to allow ROM of the knee when attempted; R1 guarded the leg and yelled out. In an interview on [DATE] at 8:38 AM, CNA G stated that CNA F had approached her and asked her if she would help with showering R1. CNA G said R1 was very irate and was kicking, while in the shower room she was kicking again and she ended up kicking the shower bar, which resulted in a bruise. CNA G said R1 was being combative because she did not want to take a shower. CNA G said CNA F was told by RN H that she needed to give R1 a shower. CNA G said she visibly saw CNA F holding R1's down by her wrists so R1 did not hit her, and the whole time R1 was saying she did not want to shower. CNA G further stated that the shower should not have been given with R1 not wanting it and should have told RN H that R1 was absolutely refusing and we were going against R1's rights. CNA G said R1 was complaining about her knee hurting. CNA G stated that she did consider this to be abuse; stating that CNA F holding R1's wrists down was abuse, and she should have told CNA F to release her grip and reported the abuse to RN H. CNA G also stated that forcing R1 to take a shower was abuse.Review of a shower sheet dated [DATE], revealed documentation that R1 had bruising form kicking and did not want the shower. This was documented by CNA F and G. Review of a statement written by CNA F dated [DATE] revealed R1 was kicking and kicked the mechanical lift bar and the shower room bar. The statement revealed R1 was very combative and had fingertip bruising on her arms from keeping her form digging on and biting CNA F and G.Review of a statement written by CNA G revealed that once getting R1 into the mechanical lift R1 was so angry she was trying to kick CNA F. The statement revealed that once getting R1 to the shower she ended up kicking the shower bar that was on the wall. Review of an X-ray result dated [DATE] revealed R1 had an acute transverse fibular neck fracture (fracture of the lower leg).It was requested on [DATE] at 3:00 PM and again at 3:25 PM the facility incident report, and the facility's thorough investigation. The incident report and investigation were never received. The facility did not perform an investigation regarding the incident.

Based on interview and record review the facility failed to report to the state agency abuse against one out of three residents (R1). Per the facility face sheet Resident #1 (R1) was an [AGE] year-old who was originally admitted to the facility on [DATE] with a return to the facility date of [DATE]. Diagnosis included Alzheimer's disease, bipolar disorder, dementia, and anxiety. Review of a Physician's progress note dated [DATE] revealed R1 expired and had a time of death of 3:34 PM (actual time was 2:34 PM) on [DATE]. Review of a progress note dated [DATE] revealed a phone call was made to R1's guardian at approximately 2:20 PM to discuss R1's change in condition and the assessment made by Medical Director (MD) C. The notes revealed that while the Assistant Director of Nursing (ADON) D was on the phone with R1's guardian two Certified Nurse Aids (CNA's) approached ADON D and informed her that they believed R1 had passed away and requesting a nursing assessment. The note revealed ADON D assessed R1 and found R1 to be unresponsive in bed with eyes fixed, no visible breathing, and no lung sounds present. ADON D had listened for an apical pulse (heartbeat) for full 60 seconds and no pulse was noted. The note revealed MD C assessed R1 and called official time of death at 2:34 PM. In an interview on [DATE] at 9:31 AM, R1's Guardian E stated she was made aware on [DATE] that R1 had been hostile when receiving a shower, and that she had kicked a bar on the wall in the shower room. Guardian E said it was reported to her that R1 was having a behavior and was combative during the shower. Guardian E said she received the call on the 18th of March that R1 had a bruise on her leg and then she received a call that R1 had passed away. Guardian E said it was a shock to her that R1 passed away. Guardian E said R1 was doing fine and in her normal state prior to that day and stated she had not received any phone calls about her having a change in her condition.Review of a progress note made by Director of Nursing (DON) B revealed Guardian E was notified regarding a bruise to R1's right shin. The note revealed that during the shower R1 began to be aggressive with staff and hit her leg on the shower chair which caused a bruise. An X-ray was ordered. In an interview on [DATE] at 2:08 PM, CNA F stated that she was terminated from her employment at the facility on [DATE]. CNA F said her and CNA G went into R1's room with the mechanical lift and the shower chair and said when they put the sling under R1 she became combative and was yelling that we were was not supposed to give her a shower. CNA G said R1 was digging, kicking, and hitting. CNA F said R1 was transferred to the shower chair in her room but never stopped hitting digging into her skin. CNA F said she shampooed R1's hair and CNA G washed her body all while R1 continued to dig into their skin and hit them. CNA F said she gave R1 the shower because she was told she had to by Registered Nurse (RN) H or she would get written up. CNA F continued to state that there were bars on the wall in the shower area, and R1 kicked the bar on the wall with her right leg. CNA F said she held R1's arms down while CNA G washed R1. CNA F stated that right from the beginning R1 said she did not want to take a shower and said R1 made the statement more than once. CNA F said she told R1 she was asked to give her a shower, and R1 said no then she got combative. CNA F said RN H told her that no matter what R1 was going to get a shower and told us that we had to shower her. CNA F said on [DATE] she was notified by the facility that she was suspended and then fired.In an interview on [DATE] at 8:20 AM, RN H stated R1 was scheduled for a shower. RN H said the CNAs reported to her that in the shower, when they transferred R1 from to the shower chair, she hit her leg on the mechanical lift bar. RN H said she was surprised R1 had passed away, and she did not make a connection between the bruising on R1's right shin and her death. RN H said R1 never complained of any pain.Review of a statement that RN H wrote post the incident dated [DATE] revealed, R1 had bruising, swelling, and an abrasion to her right shin area after hitting her leg on the mechanical lift bar. The statement revealed that the lower leg showed bruising and swelling that was not present earlier in the night. The swelling extended from the knee to the ankle. The statement revealed R1 yelled out loudly and pulled away from direct touch to the swollen area, R1 refused to allow ROM of the knee when attempted; R1 guarded the leg and yelled out. In an interview on [DATE] at 8:38 AM, CNA G stated that CNA F had approached her and asked her if she would help with showering R1. CNA G said R1 was very irate and was kicking, while in the shower room she was kicking again and she ended up kicking the shower bar, which resulted in a bruise. CNA G said R1 was being combative because she did not want to take a shower. CNA G said CNA F was told by RN H that she needed to give R1 a shower. CNA G said she visibly saw CNA F holding R1's down by her wrists so R1 did not hit her, and the whole time R1 was saying she did not want to shower. CNA G further stated that the shower should not have been given with R1 not wanting it and should have told RN H that R1 was absolutely refusing and we were going against R1's rights. CNA G said R1 was complaining about her knee hurting. CNA G stated that she did consider this to be abuse; stating that CNA F holding R1's wrists down was abuse, and she should have told CNA F to release her grip and reported the abuse to RN H. CNA G also stated that forcing R1 to take a shower was abuse.Review of a shower sheet dated [DATE], revealed documentation that R1 had bruising form kicking and did not want the shower. This was documented by CNA F and G. Review of a statement written by CNA F dated [DATE] revealed R1 was kicking and kicked the mechanical lift bar and the shower room wall bar. The statement revealed R1 was very combative and had fingertip bruising on her arms from keeping her form digging on and biting CNA F and G.Review of a statement written by CNA G revealed that once getting R1 into the mechanical lift R1 was so angry she was trying to kick CNA F. The statement revealed that once getting R1 to the shower she ended up kicking the shower bar that was on the wall. Review of an X-ray result dated [DATE] revealed R1 had an acute transverse fibular neck fracture (fracture of the lower leg).In an interview on [DATE] at 11:33 AM, Administrator A stated that she was not able to substantiate abuse (despite CNA F's written statement) so the incident was not reportable. The incident was not reported to the state agency.

Based on observation, interview, and record review the facility failed to ensure food brought in by outside family and/or visitors that was stored in the resident refrigerators were labeled and dated,Findings Included: This citation pertains to intake number 2747062.During an observation on 3/3/2026 at 3:30 PM, with Director of Nursing (DON) B of the refrigerator on [NAME] south revealed a large and small box of outside delivery pizza that had no labeling, no date, no expiration date, and no resident name, On the [NAME] hall it was observed in the refrigerator a bag of tacos from an outside restaurant that had a date on the receipt as received on 2/27/2026, which was past the expiration date; a salad was noted with no date and no resident name, n blood orange Liter bottle of soda, a grape 2L soda, and another 2L bottle soda were observed in the refrigerator opened with no dates and no resident's names. DON B agreed that the food must be labeled, dated and have the resident's name on it. Review of the facility's policy and procedure titled FOODS BROUGHT IN TO RESIDENT EDUCATION MATERIAL revealed, Refrigerated Cooked Food items will automatically be disposed after 3 days (counting day of food brought in, as day #1) for UNOPENED packaged foods manufacturer's use by date will be applicable. For all opened packages, use FOOD STORAGE CHART for date marking. Allopened packages must have open date & use by date clearly marked. Frozen items can be held until manufacturer's Use By Date Frozen items can be held until manufacturer's Use ByDate .Foods found without dates will be also discarded .

Based on observation and interview the facility failed to ensure infection control practices were maintained for two out of three (Resident 7 and 9) catheter bags. Findings Included:This citation pertains to intake number 2787832.Resident #7 (R7):In an observation on 3/3/2026 at 9:47 AM R7 was observed lying in bed asleep. R107 had a catheter bag which was on the side of the bed next to window. The catheter bag was laying 100% on the floor and was not attached to the bed.Review of R7's care plans revealed a care plan was in place for Indwelling Catheter. The care plan had an intervention dated 9/11/2025 of, Do not allow tubing or any part of the drainage system to touch the floor.Resident #9 (R9):On 3/3/2026 at 9:44 AM, R9 was observed in bed, and also observed to have a catheter bag hanging on the side of the bed with bottom of bag laying on the floor.On 3/3/2026 at 2:43 PM, observation of catheter bag revealed that the bag had been moved to the end of the bed; was attached to the bed, however the bottom bag was still lying on the floor.On 3/4/2026 at 8:19 AM R9 was observed lying in bed with the catheter bag hanging on the bed and the bottom of the bad resting on the floor.In an interview on 3/4/2026 at 2:25 PM, Infection Control Preventionist (ICP) C stated that catheter bags should always hang on the side of the bed, not touching the ground, and below the resident. ICP C said the bags definitely should not be touching the floor.In an interview on 3/4/2026 at 2:50 PM, Director of Nursing (DON B stated that his expectation was that catheter bags were not on the floor or hanging on the floor. DON B stated that was an infection control concern.

This citation pertains to intake 2685929.Based on interview and record review, the facility failed to implement care plan interventions for one (R2) of three reviewed.Findings include:Review of the medical record revealed R2 was admitted to the facility on [DATE] with diagnoses that included overactive bladder and intellectual disabilities. The Discharge Minimum Data Set (MDS) dated [DATE] revealed R2 was severely cognitively impaired and had an indwelling urinary catheter. R2 had an unplanned discharge to the hospital on [DATE] and did not return to the facility. Review of R2's Catheter/Ostomy care plan dated 10/9/25 revealed an intervention to document output. Review of R2's output record revealed four documented urine outputs:10/12/25 at 6:07 AM Urine: large10/14/25 at 5:21 AM Urine: large10/16/25 at 5:18 AM Urine: 750 milliliters (mL)10/17/25 at 5:43 AM Urine: 900 mLReview of the Nursing Note dated 10/18/25 revealed Resident's catheter not draining. Attempted to flush with sterile water. Unable to flush. Removed foley and replaced .Catheter immediately drained 500 [mL] of dark yellow urine with sediment.In an interview on 2/5/26 at 9:15 AM, Certified Nursing Assistant (CNA) D reported catheter bags were emptied a couple times per day and as needed. CNA D reported the amount emptied was supposed to be documented under urine output. In an interview on 2/5/26 at 9:44 AM, Director of Nursing (DON) B reported urinary catheter output should be documented minimally every shift (three times per day). DON B agreed R2 only had four documentations of output throughout their nine-day admission.

Based on observation, interview and record review the facility failed to maintain best practices in accordance with professional standards of food service safety. The deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen.Findings include: 09/02/2025 at 9:27AM, observation of a beverage pitcher found brown and white dried liquids on it. The pitcher was stored with other pitchers and storage containers on a shelf under the prep table. Certified Food Manager (CFM) BB confirmed that this area was where cleaned ready to use containers were stored. On 9/2/25 at 10:33 AM, observation of the kitchen ice scoop holder found an increased accumulation of white and brown crusted debris at the bottom inside of the holder. On 9/2/25 at 12:22 PM, observation of the meat slicer found an increased amount of dried meat debris on the back blade and back top portion of the unit. An interview at this time with CFM BB found that staff don't use the slicer and to her knowledge it hasn't been used in a couple of weeks. Upon showing CFM BB the slicer, she stated they would remove it from the kitchen. On 9/2/25 at 12:27 PM, observation of the clean mechanical scoop drawer found excess crumb debris lined up in the back corners of the drawer. Further review found that the drawer only opens halfway, making it hard for staff to clean effectively or know when excess debris may accumulate. On 9/3/25 at 7:55 AM, observation of the two door Horizon cooler found increased accumulation of debris on the top side of the door gaskets. According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 09/02/2025 at 9:40AM, observation of the drain line for the hand sink found that it was the same drain line for the ice machine. Following the drain line from the hand sink, it was observed that little to no slope was evident, allowing the potential for regular discharge from the hand sink to make its way to the ice machine. These lines should be separated. According to the 2022 FDA Food Code section 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. On 9/2/25 at 10:37 AM, observation of the Forest Unit water pass station found that the cooler containing ice for hydration pass was not fitted with the means to self-drain, allowing the ice for consumption to comingle with the melted ice water in the cooler. On 9/2/25 at 10:47 AM, observation of the [NAME] Unit water pass station found the cooler containing ice for hydration pass was not fitted with the means to self-drain, allowing the ice for consumption to comingle with the melted ice water in the cooler. At this time, it was observed that the contents of the cooler were half water and half was ice. On 9/2/25 at 12:30 PM, An interview with CFM BB found that Certified Nursing Assistants (CNA's) take care of the hydration pass and ice chests on the units. When asked who cleans the coolers, CFM BB stated that third shift staff clean and sanitize the units. According to the 2022 FDA Food Code section 3-303.12 Storage or Display of Food in Contact with Water or Ice.(B) Except as specified in ¶¶ (C) and (D) of this section, unPACKAGED FOOD may not be stored in direct contact with undrained ice. On 9/3/25 at 8:02 AM, observation of the kitchen cutting boards found the white cutting board was stained with orange and brown debris while having some deep cut marks on the board. When asked about using the cutting board, CFM BB stated it should be re-surfaced or not used. When asked if there were other pieces of equipment that need repair in the kitchen, CFM BB stated that the plate warmer only has one side that works and that staff must work off the one side and place the plates back and forth and keep a cover on the side that doesn't work in order to keep the plates hot. On 9/3/25 at 2:00 PM, observation of the Freezer #3 found that both doors of the unit had gasket seals that were ripped and torn in the middle of the doors. According to the 2022 FDA Food Code section 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2.

Based on observation, interview, and record review the facility failed to ensure pain medications were given as ordered for one (resident #26) of two reviewed for pain, resulting in resident experiencing harm with uncontrolled pain. Findings include: Resident 26 (R26) A review of the medical record indicated that R26 was admitted to the facility on [DATE] with diagnoses including sepsis, osteomyelitis, a Stage 4 sacral pressure ulcer (full thickness skin loss that extends into muscle, bone or supporting structures) , muscle weakness, and type 2 diabetes. The Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 8/16/24, reflected that R26 scored 8 out of 15 on the Brief Interview for Mental Status (BIMS), indicating cognitive impairment. On 9/18/24 at 9:18 AM, R26 was observed lying in bed on a pressure-reducing air mattress, dressed in a gown. R26 was positioned flat on the mattress, without pillows to offload pressure or elevate (float) his heels. R26 was conversant, understood questions clearly, and responded appropriately. He reported being admitted with one pressure ulcer on his sacrum and had developed additional ulcers after admission. He stated that a wound vac (negative pressure wound therapy) was applied to the sacral ulcer, and described experiencing severe pain from the pressure ulcers, which prevented him from wanting to be moved in bed. R26 stated that the pain is excruciating during wound care, rating his pain at a 9 to a ten during and after wound care. A review of R26's Care Plan for Pressure Ulcer Care, initiated on 8/12/24, indicated that R26 had a Stage 4 pressure ulcer (penetrating all three layers of skin) on his sacrum at the time of admission. The same care plan was revised on 9/17/24 to include a facility-acquired Stage 4 ulcer on his left heel and a facility-acquired Stage 3 ulcer (full-thickness skin loss with damage to subcutaneous tissue) on his left lower buttock. The care plan included an intervention to treating pain prior to wound care. A review of the same Care Plan revealed a focus are for pain, which stated, R26 has the potential for pain related to: osteomyelitis, stage 4 sacral wound, recent left fibula fracture, and left knee pain and swelling. Interventions included to administer pain medication as ordered. A review of R26's Physician Orders revealed an order initiated on 8/15/24 and discontinued on 8/19/24 for Oxycodone (pain relieving medication) 5 milligrams (mg) every four hours as needed. Instructions on the order stated give in addition to schedule [oxycodone] dose before dressing changes. The Oxycodone was not administered 8/15/24-8/19/24. A review of R26's Physician Orders revealed an active order initiated on 8/19/24 for Oxycodone 10 mg as needed every 6 hours for severe pain and before dressing changes. May give long acting [oxycodone] and short acting together. Review of the Physician Order's revealed daily wound care for R26's sacral wound. The as needed and before dressing changes Oxycodone 10 mg was only administered on the following dates/times: 8/22/24 one dose at 6:27 pm 8/23/24 one dose at 5:26 pm 8/28/24 one dose at 7:51 am 8/29/24 one dose at 3:31 pm 9/1/24 one dose at 4:55 pm 9/14/24 one dose at 10:02 am 9/15/24 one dose at 7:55 am 9/19/14 one dose at 9:58 am Review of the Physician Order revealed two orders were initiated on 9/17/24 daily wound care for R26's left heel and left buttock wound. Review of a Physician Note dated 8/26/24 reflected R26 was seen by the nurse practitioner for follow up to pain for sacral wound and anxiety R26's pain regimen was adjusted to long acting 12hr Oxycodone . He tells me his pain is better than previously noted. He still has increased pain with wound care and is fearful and reluctant to turn in bed, creating increased anxiety that he will become dizzy to the point where he refuses incontinence care and wound care . Review of a Physician Note dated 9/4/24 reflected R26 was seen for follow up to pain for sacral wound and anxiety .Pain regimen was adjusted to long acting 12hr Oxy [oxycodone]. He tells me his pain is better than previously noted but with increased pain with wound care . On 09/19/24 at 12:12 PM, Registered Nurse (RN) H reported that R26 refuses wound care and turning and repositioning due to pain. On 09/19/24 at 3:15 PM. Licensed Practical Nurse (LPN) AA reported that R26 will often refuse wound care and turning and repositioning due to pain. In an interview on 9/19/24 at 12:24 PM, Certified Nursing Assistant (CNA) F PM indicated that she was familiar with R26 and his care needs. CNA F reported that R26 often refused repositioning due to pain and fear of falling. On 9/20/24 at 12:49 PM, Registered Nurse (RN) D was in R26's room and reported that he was finishing up R26's care and getting R26 ready for the wound care observation. RN D closed R26's door. R26 was heard crying out during care. On 9/20/24 at 12:53 PM, during the wound treatment observation, R26 cried out several times during both left heel and left buttock dressing changes. Review of the medical record revealed that no as needed pain medication was administered prior to the dressing changes. On 9/20/24 at 1:33 PM R26 was heard stating ow from outside of his room. After entering R26's room, R26 stated that he was sore after the wound dressing change and that he felt pain about an hour after each wound care dressing change. R26 stated that his current pain level was a 9, and the pain worsens with movement which keeps him from wanting to turn and reposition. R26 reported that he knows that he needs the wound dressing changes for the wounds to successfully heal, however he dreads the wound dressing changes due to the amount of pain that occurs during and after. When asked of the as needed pain medication helps with the pain, R26 stated that he can ask for Tylenol for pain but was completely unaware of any other pain medication order. R26 stated that staff did not regularly as him about his pain level or offer any as needed pain medication before or after wound care. Record Review revealed pain assessments were being completed but were not consistent with what R26 was reporting. In an interview on 9/20/24 at 2:11 PM, RN D verified that R26 did not receive any as needed pain medication prior to the wound dressing changes. After reviewing the as needed pain medication Physician order, RN D stated that it would have been appropriate to offer pain medication prior to the dressing change.

Based on observation, interview, and record review, the facility failed to prevent the development of pressure injuries, including a medical device-related pressure injury, for one resident (Resident #26) out of 4 reviewed for pressure injuries. This deficient practice resulted in resident experiencing harm due to facility-acquired pressure injuries. Findings include: Resident 26 (R26) A review of the medical record indicated that R26 was admitted to the facility on [DATE] with diagnoses including sepsis, osteomyelitis, a sacral pressure ulcer, muscle weakness, and type 2 diabetes. The Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 8/16/24, reflected that R26 scored 8 out of 15 on the Brief Interview for Mental Status (BIMS), indicating cognitive impairment. On 9/18/24 at 9:18 AM, R26 was observed lying in bed on a pressure-reducing air mattress, dressed in a gown. R26 was positioned flat on the mattress, without pillows to offload pressure or elevate (float) his heels. R26 was conversant, understood questions clearly, and responded appropriately. He reported being admitted with one pressure ulcer on his sacrum and had developed additional ulcers after admission. He stated that a wound vac (negative pressure wound therapy) was applied to the sacral ulcer, and described experiencing severe pain from the pressure ulcers, which prevented him from moving in bed. When asked if staff assisted with repositioning or used pillows to float his heels, R26 said staff did not offer assistance and that he would comply with interventions with assistance and if his pain was properly managed. A single pillow, used to elevate his head, was observed in the room. On 9/18/34 at 11:45 AM, R26 was again observed lying in bed in the same position without pillows to offload pressure or float his heels. A review of his electronic medical record revealed no documented refusals for turning, repositioning, or floating his heels. In an interview at 2:14 PM, Certified Nursing Assistant (CNA) V stated that R26 did not have pillows, wedges, or boots to float his heels. A review of R26's Care Plan for Pressure Ulcer Care, initiated on 8/12/24, indicated that R26 had a Stage 4 pressure ulcer (penetrating all three layers of skin) on his sacrum at the time of admission. The same care plan was revised on 9/17/24 to include a facility-acquired Stage 4 pressure ulcer on his left heel and a facility-acquired Stage 3 pressure ulcer (full-thickness skin loss with damage to subcutaneous tissue) on his left lower buttock. The care plan included interventions such as weekly skin assessments, elevating heels when in bed as the resident allowed, encouraging repositioning every two hours, using a pressure-reducing mattress, treating pain prior to wound care, and using blankets or pillows to cushion bony prominence's. A review of R26's Physician Orders revealed an order initiated on 8/19/24 for oxycodone 10 milligrams for severe pain, especially before dressing changes. Another order, initiated on 9/17/24, instructed staff to offer to elevate R26's heels while in bed and to document any refusals. R26's Weekly Skin Assessment documentation showed that the last skin assessment was completed on 8/17/24, with the next one not performed until 9/2/24, meaning more than two weeks had passed without a documented skin assessment. A 9/13/24 skin assessment identified a Stage 3 pressure ulcer on the left heel and another on the left ischium (lower buttock). A Wound Assessment on the same date recorded that the left heel pressure ulcer, first noted on 9/11/24, measured 2.3 cm in length, 3.4 cm in width, and 0.1 cm in depth. Another Wound Assessment on 9/17/24 revealed a left buttock pressure ulcer, first noted on 9/17/24, measuring 2.3 cm in length, 1.2 cm in width, and 0.1 cm in depth. On 9/19/24, a Nurse Practitioner evaluated R26's wounds. The left ischium pressure ulcer was documented as Stage 3, measuring 1.5 cm by 1.0 cm, with moderate serous drainage (clear, watery fluid) and a wound bed consisting of 50% granulation tissue (red tissue) and 50% slough (necrotic tissue). The left heel ulcer was documented as unstageable, measuring 1.2 cm by 2.0 cm with moderate serous drainage, 20% granulation tissue, and 80% slough tissue. On 9/19/24 at 10:56 AM, R26 presented in the same position. R26's pressure-reducing air mattress was observed unplugged. On 9/19/24 at 12:22 PM, R26 presented in the same position. R26's pressure-reducing air mattress remained unplugged. In an interview on 9/19/24 at 12:24 PM, Certified Nursing Assistant (CNA) F PM indicated that she was familiar with R26 and his care needs. CNA F reported that R26 often refused repositioning due to pain and fear of falling, but staff had noticed the lack of repositioning and recently talked about obtaining pillows from laundry to assist. On 9/19/24 at 3:02 PM, R26's pressure-reducing air mattress remained unplugged. R26's heels were floated with the use of a pillow. On 9/20/24 at 12:53 PM, RN D during changing the wound dressing on R26's left buttock wound, another wound was identified by surveyor and RN D. The new would presented as a line and contained areas of slough, The newly identified wound appeared to have occurred from the tubing on the wound vac, which was positioned directly underneath R26 and pressed into the skin underneath the newly identified wound. When asked to describe the newly identified wound, RN D stated that the wound presents as a stage one, possibly a stage two in some spots with areas of slough. When asked how this wound occurred, RN D verified that it appears to have occurred from the wound vac tubing and RN D would classify it as a medical device related pressure injury. During the wound treatment observation, R26 cried out several times during both dressing changes. Review of the medical record revealed that no as needed pain medication was administered prior to the dressing changes. On 9/20/24 at 1:33 PM R26 was heard stating ow from outside of his room. Upon entering R26's room, R26 stated that he was sore after the wound dressing change and that he felt pain about an hour after each wound care dressing change. R26 stated that his current pain level was a 9, and the pain worsens with movement which keeps him from wanting to turn and reposition. R26 reported that he knows that he needs the wound dressing changes for the wounds to successfully heal, however he dreads the wound dressing changes due to the amount of pain that occurs during and after. When asked of the as needed pain medication helps with the pain, R26 stated that he can ask for Tylenol for pain but was completely unaware of any other pain medication order. R26 stated that staff did not regularly ask him about his pain level or offer any as needed pain medication before or after wound care. In an interview on 9/20/24 at 2:11 PM, RN D verified that R26 did not receive any as needed pain medication prior to the wound dressing changes. After reviewing the as needed pain medication Physician order, RN D stated that it would have been appropriate to offer pain medication prior to the dressing change. When asked about R26's reluctance to turn and reposition, RN D stated that in addition to pain, R26 was afraid of falling, therefore, will clutch to the side of the bed. When asked if any anxiety relieving methods were discussed with the Physician or care team, RN D stated that it may have been but could not find any evidence of any intervention or conversation. When asked about the pressure relieving mattress being unplugged, RN D confirmed that it was brought to his attention and that the mattress should be plugged in, as well as a Physician order to verify that the mattress is functioning.

This citation pertains to intake MI00137735 and MI00137656 Based on interview and record review, the facility failed to 1) ensure the emergency Ambu-bag was at the bedside 2) failed to provide timely cardio-pulmonary resuscitation (CPR) according to standards of practice for one (Resident #3) of one reviewed for emergency resuscitation, resulting in an Immediate Jeopardy when R3 was discovered unresponsive without pulse or respirations with a full 3 minute delay prior to the initiation of CPR resulting in death and 3) failed to ensure current Cardio-pulmonary Resuscitation (CPR) certification for 3 licensed nursing staff (received online training only) resulting in the potential for the 32 facility residents who are Full-Code to not being resuscitated during a cardiopulmonary arrest. Findings include: Resident #3 (R3) was initially admitted to facility on [DATE] and readmitted on [DATE] with diagnoses including anoxic brain injury (damage due to a loss of oxygen flow to the brain), tracheostomy status, (an opening that surgeons make through the front of the neck and into the windpipe for breathing purposes), muscle weakness, and history of pneumonia. Review of the Progress Notes revealed that R3 had a guardian but was able to make needs known through the nodding of his head or use of a tablet. Review of a Minimum Data Set (MDS) dated [DATE] reflected that R3 deceased while at the facility. Review of R3's medical record completed with the following findings noted: Order dated [DATE] stated, CODE STATUS: Full Code/Give CPR. Review of a Progress Note dated [DATE] at 2:53 AM revealed R3 was discovered unresponsive at 12:49 AM. The note revealed the following timeline of events: 0049 (12:49 PM) PT (patient) found unresponsive 0050 (12:50 PM) writer notified, crash cart arrived, AED (Automated External Defibrillator) arrived 0051 (12:51 AM) 911 called 0057 (12:57 AM) EMS (Emergency Medical Services) arrived on scene 0102 (1:02 AM) [Local EMS Service] took over compressions (chest compressions) . Review of an Emergency Report Report dated [DATE] revealed the following information: On [DATE] at 12:49 AM, R3 was discovered with the status check marked as unconscious, not breathing, no pulse, cardiopulmonary arrest. The code was paged overhead by Licensed Practical Nurse (LPN) D. At 12:50 AM, the crash cart arrived. At 12:50 AM the AED arrived. At 12:52 AM, CPR was initiated. EMS arrived at 12:57 AM. Under the Staff present at event section of the form listed the captain as LPN D. Compressions LPN D. Airway Certified Nursing Assistant (CNA) C. AED LPN D. Runner Certified Nursing Assistant (CNA) K and recorder Certified Nursing Assistant (CNA) L. Review of an Event Report with a date of [DATE] at 2:03 AM revealed that R3 was found unresponsive on [DATE] at 12:50 AM by Certified Nursing Assistant L in a pulseless state. The same report reflected that compressions were started at 12:52 AM. Review of the Medical Certificate of Death indicated R3 was pronounced dead on [DATE] at 1:23 AM. The Cause of Death was listed as Respiratory Failure during sleep and Hypoglycemia. In a telephone interview on [DATE] at 2:01 PM, Certified Nursing Assistant C confirmed that she was present when R3 was discovered unresponsive and had to assist in the resuscitation efforts. CNA C stated on that night, she heard Licensed Practical Nurse (LPN) D yell for her. CNA C proceeded to run to the room of R3 while another CNA grabbed the crash cart and AED device. CNA C denied seeing any cart with supplies outside of the room or an Ambu-bag in the room. When queried why the crash cart was needed and what items were used from the cart, CNA C reported that the bagger used for breathing (Ambu-bag) was retrieved from the crash cart. CNA C stated that LPN D assessed R3, applied the AED and then performed chest compressions while CNA C managed the airway on R3. CNA C reported that LPN D and herself were the only two that actively participated in the code and that the other CNA'S did not feel comfortable assisting. CNA C stated that she had her CPR certification for Healthcare Providers. The facility was unable to provide the CPR verification upon request. In a telephone interview on [DATE] at 2:35 PM, LPN D reported that CNA L discovered R3 in his bed, unresponsive. LPN D instructed CNA L to obtain the crash cart and the AED device, which were located in the dining room. LPN D called for help which prompted a response from CNA C and CNA K. When asked what was obtained from the crash cart, LPN D stated that the Ambu-bag and extra suction were located in the crash cart. LPN D reported that she applied the AED on R3 when CNA K delivered it. When asked if the Ambu-bag used during the code was retrieved from the crash cart, LPN D reported that Ambu-bag was in the bottom drawer of the crash cart. LPN D reported that CNA C used the Ambu-bag to assist with R3's airway but wasn't doing breaths in the correct sequence so LPN D had to perform both chest compressions and airway during the code. When asked how much time passed between CNA L notifying you about R3 and when compressions started, LPN D stated it had only been a few minutes . the look on her face said it all. I turned tube feed off, wait for a couple minutes, and said get the crash cart which was in dining room . I turned the tube feed off. It was paused because if paused too long, it will scream at me. When asked who had paused it, LPN D reported I would assume the aide (CNA) paused it because she was just going in to provide care for him, to reposition and turn him. In a telephone interview on [DATE] at 11:58 AM, CNA K confirmed that she was present at the time R3 was discovered unresponsive. CNA K heard the staff calling for help and observed the code. CNA K reported that LPN D was doing chest compressions and CNA B was using the air pump thing (Ambu-bag) to deliver breaths to R3. When asked what items were retrieved from the crash cart, CNA K stated that CNA L grabbed the air pump (Ambu-bag) from the crash cart. Multiple unsuccessful telephone interview attempts were made in an effort to contact Certified Nursing Assistant L. According to the American Heart Association, Summary of High-Quality CPR Components for BLS Providers .make sure the environment is safe for rescuers and victims, check for responsiveness .no definite pulse within 10 seconds (breathing and pulse can be check simultaneously in less than 10 seconds) .send someone for help and being CPR immediately . Advanced Life Support Manual, American Heart Association, Page 80.) According to the Mayo Clinic, .Trained and ready to go. If you're well-trained and confident in your ability, check to see if there is a pulse and breathing. If there is no pulse or breathing within 10 seconds, begin chest compressions. Start CPR with 30 chest compressions before giving two rescue breaths . (https://www.mayoclinic.org/first-aid/first-aid-cpr/basics/art-20056600) Review of the facility policy titled Cardiopulmonary Resuscitation with a ,d+[DATE] reviewed/revised date stated, Purpose: The purpose of this policy and procedure is to ensure the facility is able to and does provide emergency basic life support immediately when needed, including cardiopulmonary resuscitation (CPR), to any resident requiring such care prior to the arrival of emergency medical personnel in accordance with resident's physician orders, such as DN/Full Code, and the resident's advance directives. The facility will provide consistent and appropriate response to emergency situations, to provide basic life support (BLS) that is consistent with acceptable practice standards held by the American Heart Association (AHA . Licensed Nurses providing direct resident care including supervision and/or delegation responsibilities will have a current and valid CPR certification from American Heart Association for healthcare providers upon hire. The facility will track and monitor licensed nurse CPR certification annually with nurse licensure tracking. There is no grace period for expired CPR certification; nurses will be removed from the schedule until they obtain a current healthcare provider CPR certification. Atrium communities will consistently follow the American Heart Association (AHA) guidelines for Basic Life Support (BLS) or follow Emergency Cardiac Care (ECC). These guidelines reflect global resuscitation science and treatment recommendations. On [DATE] 9:43 AM the facility provided the CPR certifications on hand for staff members. It was discovered that several CPR certifications were missing for nurses and of those provided, Licensed Practical Nurses (LPN) E, F and I had received online training only for their CPR certification. Additionally, LPN F had a certification date of [DATE]. In an interview on [DATE] at 9:57 AM, LPN F verified that she had completed the online only certification of her CPR training earlier that day. LPN F verified that it was online only and required no return demonstration. LPN F stated that her previous CPR certification expired back in May however, was not removed from the schedule and continued to work shifts with an expired CPR certification. In a telephone interview on [DATE] 12:24 PM, Licensed Practical Nurse (LPN) E reported that she provided proof of her CPR certification to the facility last night. When asked where she received her CPR certification, LPN E stated it was online and she had for years. When queried if there was any return demonstration completed, LPN E stated it was all online. Review of the Certificate of Completion dated [DATE], revealed LPN E completed her CPR training through an online course. In a telephone interview on [DATE] at 1:40 PM, Licensed Practical Nurse (LPN) I reported if a resident coded, she would need a Certified Nursing Assistant (CNA) to assist with CPR, but she was not sure who was certified. LPN I reported she assisted another nurse with CPR at shift change within the last year. Review of the Certificate of Completion dated [DATE], revealed LPN I completed her CPR training through an online course. In an interview on [DATE] at 10:59 AM, Nursing Home Administrator A revealed that the facility used to have a CPR card binder and was waiting for a couple of staff members CPR cards. NHA A reported that the facility used to obtain copies of CPR certifications but realized that the copies were not being obtained and stored in the binder. The Immediate Jeopardy began on [DATE] when the facility failed to provide timely cardiopulmonary resuscitation according to standards of practice and have an emergency Ambu-bag at the bedside for a tracheostomy resident. Nursing Home Administrator (NHA) A was notified of the Immediate Jeopardy on [DATE] at 11:15 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on [DATE] but noncompliance remains at a scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance that has not been verified by the State Agency. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy: 1. Staff educated on timeline for initiating CPR, by beginning of shift for each nurse or staff member who holds a CPR certification 2. A staff member with a current valid CPR will be scheduled 24 hours a day with responsibility for performing CPR 3. Ambu-bag audit completed to ensure at bedside for tracheostomy residents

Based on observation, interview and record review, the facility failed to provide quality of care for 6 of 8 residents (#10, 15, 35, 46, 51 and 302), resulting in lack of wound assessments for Resident #302, failure to identify residents during medication administration (R10, 15, 35 and 46) and failure to monitor, assess, treat, hospitalize and provide comfort measures resulting in death for Resident #51. Findings include: Resident #51 According to the clinical records, including the Minimum Data Set (MDS) dated [DATE], Resident 51 (R51) was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Brief Interview for Mental Status (BIMS) reflected R51 scored 15 out of 15 (cognitively intact). Record review revealed the facility form titled Medical Treatment Decisions of Resident reflected R51 did not want cardiopulmonary resuscitation (CPR), but did want to be hospitalized , wanted artificial hydration, and wanted IV antibiotics and medication. The facility form was signed by the physician and R51 on [DATE]. However, the physician order dated [DATE] reflected R51 full code/ give CPR. R51 went into respiratory distress on [DATE] at 7:50 PM, progress notes reflected (oxygen at 4 liters per minute, SpO2(peripheral capillary oxygen saturation; the percentage of oxygenated hemoglobin in the blood) at 54%, weak and thready pulse using accessory muscles to[sic] breath, cool and clammy skin and skin tone faded and cold to touch) there was no documentation that the physician was notified. There was no documentation to reflect that hospitalization , or any other type of treatment were discussed, offered or tried on R51's behalf. The Nurses progress note dated [DATE] at 8:05 PM reflected absence of breath and heartbeat for 5 minutes. On [DATE] at 09:41 AM, during a phone interview with the nurse assigned to R51 on [DATE], Licensed Practical Nurse (LPN) K stated R51 was a DNR (Do Not Resucutate) and the paperwork was in her hard chart. As far as she could recall, R51 did not want anything [additional treatment]. She stated she called R51's family to verify [treatment/R51's wishes] and he did not want to go against what she had wanted. LPN K stated as far as she knew R51 did not want to go to the hospital. When asked who she informed that R51's wishes were to not go to the hospital, LPN K stated she told that to R51's family. LPN K further reported R51 did not want to go to the hospital as far as she knew and stated that was through the Advance Directive. When asked what documents to review to verify that information, LPN K stated there were two forms: One is an actual DNR, the other has boxes they check and go over with the physician. LPN K stated she called the family, reviewed the form [Medical Treatment Decisions of Resident] and the family did not want to go against R51's wishes. When asked what the form said, LPN K stated it was 2 months ago, and did not recall what specifically was on that paper. LPN K stated she had the form for Medical Treatment Decisions of Resident form in front of her [when she spoke to R51's family]. LPN K stated she called Physician Q and the Assistant Director of Nursing (ADON) C before calling the family. LPN K stated she explained to Physician Q and ADON C that R51 was a DNR. LPN K stated she was told to make R51 comfortable. When asked if that conversation was documented anywhere, LPN K stated it should be in her notes that she had spoken to both of them. When queried what Physician Q directed her to do to keep R51 comfortable, LPN K reported she did not recall. When asked if she asked Physician Q about increasing R51's oxygen or starting R51 on a rebreather mask, LPN K stated Physician Q did not direct her to turn up the oxygen or use a rebreather. LPN K reported she did not recall being told to do that or for her asking for those things. Nor did she recall asking if she could give more [MEDICATION(S)]. LPN K stated she had been in contact with Physician Q that day starting at about 2:00 or 3:00 PM, she had called Physician Q regarding another resident but stated she did recall telling him that R51 was lethargic. LPN K could not account for why she did not document any of the conversations she reportedly had with Physician Q or ADON C, but it had been a hectic day as the afternoon shift nurse called in and she had to work a double shift. On [DATE] at 02:23 PM, during an interview, ADON C reported LPN K did call her at home on the morning of [DATE] stating that R51 was sleeping a lot. ADON C stated I was the nurse on call. ADON C stated she had not heard from LPN K again until that night after R51 expired. ADON C stated she received a frantic phone call from LPN K who stated over and over Oh my God. Oh My God and explained R51 coded and died . ADON C stated We did not expect that. On [DATE] at 03:35 PM, a phone call was made in an attempt to interview Physician Q. Physician Q declined to be interviewed. During an interview with Administrator A on [DATE] at 01:35 PM, Administrator A was insistant LPN K notified Physician Q just ask her though did not offer any explanation why there were no nursing progress notes to reflect this. There was no documentation in the electronic medical record or the hard paper medical record that Physician Q was notified of R51's decline, the need for hospitalization , increased monitoring, comfort measures, medication changes or alternative breathing equipment/masks. Administrator A was informed if there was evidence of this a copy will be requested. There was no additional documentation provided by Administrator A by the survey exit date of [DATE]. Resident #10 (R10): During a medical administration observation on [DATE], at 7:31 AM, Registered Nurse (RN) N was observed to administered R10 four medications. RN N did not ask R10 his name, nor was observed to use any other identifying measure to confirm R10 was receiving the right medication. Resident #35 (R35): During the medication administration observation on [DATE], at 7:42 AM, RN N was observed to administer R35 two medications. RN N did not ask R35 his name, nor was observed to use any other identifying measure to confirm R35 was receiving the right medication. Resident #46 (R46): During the same medication administration observation, [DATE], 7:46 AM, RN N was observed to administer R46 seven medications. RN N did not ask R46 his name nor was observed to use any other identifying measure to confirm R46 was receiving the right medication. Resident #15 (R15): RN N was further observed on [DATE], at 7:53 AM, to administer R15 18 medications. RN N did not ask R15 his name, nor was observed to use any other identifying measure to confirm R15 was receiving the right medication. Immediately following R15's medication administration on [DATE], RN N stated she had only worked at the facility for two weeks. RN N was asked how she identified residents to assure that she was giving the correct medications to the correct residents. RN N stated some residents had pictures in the medication binder (a binder that contained all the resident medication administration records (MARs)), but stated that some do not, and the pictures were what the nurses used to identify residents. RN N stated she was trained to use the pictures in the medication administration book for identifying residents. Review of the medication administration binder that RN N used to administer medications was conducted during the interview with RN N. It was observed that R10, R15, R35, and R46 did not have a picture in the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on [DATE], at 9:13 AM, Director of Nursing (DON) B stated there were photos in the medication administration binder with each resident's MARs. DON B stated the resident's names were outside of the resident's room door on the name plate, and the nurses were familiar with the residents. DON B stated the nurses were to use two ways to identify residents. Record review of the facility policy and procedure titled, General Dose Preparation and Medication Administration., dated with an effective date of [DATE], revealed on the first page #4, Prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: under 4.1.1 Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, and the correct rate, at the correct time, for the correct resident . Resident #302 (R302): Review of the medical record reflected R302 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R302's Admission Minimum Data Set (MDS) was In process but reflected a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 15 out of 15 (cognitively intact). On [DATE] at 3:20 PM, R302 was observed in bed. Two bandages were observed on their left lower leg. R302 reported they had wounds and a prior [CONDITION(S)] infection for which they had been on antibiotics. R302 reported their dressings were last changed the night prior. R302's Physician's Orders, reviewed on [DATE] at 8:57 AM, reflected, Cleanse with normal saline, pat dry. Apply Xeroform and cover with a [MEDICATION(S)] border Special Instructions: Left posterior calf change dressing 3 times a week and PRN [as needed] Once A Day on Tue [Tuesday], Thu [Thursday], Sat [Saturday] . The order start date was [DATE]. R302's Skin/Body Assessment, dated [DATE], reflected, .Describe Skin Impairment, if necessary . There was documentation of a left leg wound but no other descriptive or assessment information pertaining to the wound. R302's Care Plans, dated [DATE], reflected they were at risk for skin breakdown. During an interview on [DATE] at 2:42 PM, Registered Nurse (RN) G reported R302 had a major wound on the left lower extremity (left leg), calf area. RN G then stated it was not a major wound but needed some attention. RN G stated it was a venous stasis ulcer. RN G reported DON B or ADON C did wound rounds and progress of the wounds weekly. When asked if that was on a paper form or in the Electronic Medical Record [EMR], RN G stated they had seen it in the Progress Notes [in EMR]. RN G stated there were times there was not a Progress Note. RN G stated they may have last personally seen R302's wound the previous Friday [[DATE]]. According to RN G there were a couple small, open spots that were producing scant amounts of serosanguinous drainage. On [DATE] at 3:15 PM, wound documentation was not observed in R302's Progress Notes (eight days after their admission to the facility). On [DATE] at 3:19 PM, an email was sent to Administrator A to request R302's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . An email was received from DON B on [DATE] at 4:45 PM, which included a note, authored by DON B on [DATE] at 4:01 PM. [R302] admitted from [Hospital Name] on [DATE] for short term rehabilitation, new hemodialysis, and left posterior calf venous stasis wound care. Prior to admission to the hospital for profound weakness and [CONDITION(S)] requiring IV antibiotics . Admitting measurements of left posterior calf venous stasis wounds: 3 cm [centimeters] round area that is 0.1cm in depth [sic] An irregular shaped wound that is 5 cm x [by] 6 cm x 0.1 cm [sic] Current treatment plan includes clean with NS [normal saline] and pat dry, apply Xeroform dressing and cover with [MEDICATION(S)] Tuesday, Thursday, and Saturday and PRN .Guidelines for ulcer/wound care are implemented. During an interview on [DATE] at 9:31 AM, DON B reported they assessed and documented on wounds weekly. When asked where wounds were typically documented, DON B reported the observations section of the EMR, Progress Notes, and here [a clipboard they were holding]. DON B reported R302 had a stasis ulcer of the left posterior (back) calf. When asked what prompted their Progress Note at 4:01 PM on [DATE], which included assessment of R302's wound, [CONDITION(S)] fistula, limb alert bracelet and peritoneal [CONDITION(S)] catheter, DON B reported they did a note like that, a comprehensive note, weekly. When asked when R302's wound was assessed, DON B reported yesterday [[DATE]], when R302 returned from [CONDITION(S)]. When asked where the documentation of R302's wound was prior to [DATE], DON B stated the wound orders and the TAR. Regarding where the wound assessment was on admission, DON B stated it was in the admission skin assessment under the Observations section of the EMR. The Surveyor went to that section of the EMR, in the presence of the DON. DON B showed the assessment to click on, which was titled, Skin - Skin Body Assessment. The section Describe Skin Impairment, if necessary reflected, .Left leg wound. There was no additional descriptive or assessment information pertaining to R302's wound until [DATE] (eight days after their admission to the facility).

Based on observation, interview, and record review, the facility failed to provide the highest practicable care and services for 1 of 3 residents reviewed for care of residents with dementia and severe cognitive impairment (Resident #2), from a total of 5 sampled residents, resulting in loss of function, and based on the reasonable person standard: increased pain and potential psychological trauma related to a fractured elbow. Findings include: According to RN Journal 2017, Nursing assessment is an important but often lacking piece of the puzzle when managing falls, since rapid and appropriate nursing assessment, including physical assessment and communication of findings to other professionals, aids optimal and timely management of the patient. <2000-2017 RN-Journal.com // Times Publishing, LLC> According to the MDS/Minimum Data Set, dated dated [DATE], Resident #2 was a [AGE] year old, admitted to the facility on [DATE], who had severe cognitive impairment, was totally dependent for staff (2+ person assist) with bed mobility, transfers, dressing, and bathing, and had [DIAGNOSES REDACTED]. A facility 5 Day Follow Up Investigation of (Resident #2) Incident/Injury revealed, On 7/26/17 facility staff noted that (Resident #2) had mild swelling, warmth and discoloration to her right arm .(Resident #2) was interviewed and reported that she hurt her arm during a fall .[MEDICAL CONDITION] joint .She exhibited no signs or symptoms of any pain outside of her normal pain levels which are related to her arthritis and the routine pain medications that were given as prescribed by her attending physician provided effective pain management . However, an imaging report, dated 7/26/17 at 6:48 PM, revealed Resident #2 did not have arthritis, .Marked osteopenia (moderate weak bone). Shoulder and wrist articulations (joints) are intact without arthritis or acute (new) process. Impression: complete fractures about the elbow . And, review of Resident #2's Care Plans revealed Resident #2 had pain from a right elbow fracture, Category: Pain. 7/26/17 - R (right) ulna (elbow) fracture . And, according to Resident #2's physician progress notes [REDACTED]. discontinued. Review of Resident #2's Care Plans revealed, 2/23/13: At risk for falls and subsequent injury related to: History of falls, advanced dementia, weakness, impaired safety awareness .(added/not dated): (Resident #2) intentionally lowers herself from her low bed to sleep .7/26/17: R (right) ulna (long bone in forearm) fracture, surgical repair 8/3/17 . On 9/11/17 at 8:25 AM, Resident #2 was observed with her eyes closed (asleep) in bed laying on her left side at the edge of the bed, with her legs hanging over. There was a mattress on the floor at her bedside, that was approximately 12 inches below the mattress she was laying on. The other side of the bed was flush against the wall, and there was a thin fall mat up against that wall that was secured in place by the bed. The mat extended approximately 10-12 inches above the surface of the bed. The call light was attached to the large wooden headboard. In an interview, on 9/12/17 at 10:02 AM, Nurse Aide P said, Prior to the injury, (Resident #2) could grab a cup and try to feed herself with her right hand . In an interview, on 9/12/17 at 10:38 AM, Nurse Aide Z said she worked Forest Hall (the Unit where Resident #2 resided) but was not assigned to Resident #2 on 7/23/27, 7/25/17 and 7/26/17 reported, (Resident #2) doesn't talk .very infrequently can she tell us if she is in pain or where . Nurse Aide Z said Resident #2 was .not using her right arm lately. A Witness Statement, signed by Nurse Aide O and dated 7/27/17, revealed, .I came in Monday (7/24/17) morning, (Resident #2's) bed was I (sic) low position, the mattress was on the floor next to the bed .when I went to take her right arm out of the gown she said Owwwwwww. (Resident #2's) right hand was limp .there was no swelling or bruising .I used the Hoyer to get (Resident #2) up .I took her to the dining area .she used her left hand to hold her cup and drink .I noticed the bruise on Tuesday (7/25/27) when I gave her a shower at about 3 something, (Nurse Aide P) helped me get her into the shower chair with the Hoyer .After the shower I told the nurse about the bruise and she said she thought she laid on it or it was arthritis. In an interview, on 9/13/17 at 9:07 AM, Nurse Aide O reported said, On Monday (7/24/17) Resident #2's right arm was limp; she screamed when I moved it. It was abnormal and I noticed. I conveyed that to (LPN H who was assigned to Resident #2 the day shift on 7/24/17 and 7/26/17); he was getting report, he told me to get her dressed and get her up (with the Hoyer). I got (Resident #2) dressed by myself .On Wednesday (7/26/17), as I was filling out the shower sheet, I asked (LPN S) if she knew about Resident #2's arm, and she said she already knew about the bruise and not to write it on the shower sheet. I said, 'Have you seen her arm? It's pretty bruised. And (LPN S) said, 'Ya, we think its from her arthritis. In an interview, on 9/13/17 at 8:55 AM, Nurse Aide T (who worked day shift on Forest Unit on 7/24/17 and 7/25/17) reported, On Monday (7/24/17), (Nurse Aide O) and I got (Resident #2) up in her chair (with the Hoyer/mechanical lift) and took her to the dining room. If you picked her arm up, (Resident #2) hollered .When lifted, she yelled 'Ow, that hurt'. When I pressed on her arm like this (she pressed a couple of fingers onto her own forearm) it didn't bother her, but if lifted just a little, it really hurt. It was totally different than usual. In an interview, on 9/13/17 at 9:22 AM, LPN H said, I learned about it (pain and limpness in Resident #2's arm) the morning just after it happened. They told me when (Nurse Aide O) was getting her up in the morning . LPN H reported he looked at Resident #2 after she was up in her wheelchair and seated in the Dining Room, and when he performed Range of Motion on her right arm, she winced when he moved her shoulder, elbow, hands and fingers. LPN H said he was only able to move Resident #2's bent arm a little away from her body due to pain. When asked if he obtained Resident #2's vital signs or documented his findings, LPN H said, I don't think I did .because I had Unit Manager (Q) look at it (Resident #2's right arm). LPN H reported he had not been given any information regarding Resident #2's arm in report that morning (Monday, 7/24/17), had not charted in the Progress Notes or on the 24 hour report board, did not call the physician or write it in the physician's book, and did not notify Resident #2's Guardian JJ. LPN H reported Resident #2 was started on scheduled [MEDICATION NAME] (narcotic pain medication) 3 times a day after she had surgery on her elbow to repair the fracture, and was still receiving that dosage. LPN H said he was not given individualized education nor disciplined regarding Resident #2's injury because he was not required to fill out an SBAR about (Resident #2's) right arm pain. LPN H said, I've never seen signs of pain with (Resident #2). When interviewed as to why he was still administering [MEDICATION NAME] 3 times a day to Resident #2, he said, Because it's ordered. According to an Orthopedic Specialist Encounter Note, dated 8/09/17, (Resident #2) states .pain is improved. She is taking [MEDICATION NAME] for pain . According to an Orthopedic Specialist Encounter Note, dated 9/07/17, (Resident #2) .Pain is resolved. Swelling is resolved. She is wearing a splint today . In an interview, on 9/12/17 at 10:02 AM, Nurse Aide P reported, Prior to the injury, (Resident #2) could grab a cup and try to feed herself with her right hand .I don't think she could have hurt her arm from falling from her bed to the mat .(Resident #2) doesn't talk .very infrequently can she tell us if she is in pain or where . According to a hand written undated statement, Nurse Aide U (who no longer worked at the facility) documented, On the morning of 7/26/17 I observed a bruise on (Resident #2's) forearm on the top of her forearm. A typed Witness Statement, dated 7/28/17 and signed by Nurse Aide L, revealed, .I (Nurse Aide L) worked Wednesday (7/26/17), (Nurse Aide N) and I went in to get (Resident #2) up together .we noticed her right arm was swollen and there was a bruise purple from elbow to the wrist, we went and got the nurse .(Nurse Aide N) and I laid (Resident #2) down after supper, we used the Hoyer lift, this was about 7 pm. (Resident #2) said her arm was sore . In an interview, on 9/12/17 at 2:25 PM, LPN K stated she heard nothing about Resident #2's arm when she received report at the beginning of second shift on Wednesday, 7/26/17. LPN K stated, When I just looked at it, I knew right away it was broken. I touched it. She said Ow. DON (B) agreed it was broken . Although LPN K stated she realized Resident #2's elbow was fractured, she still had the Nurse Aides move her with the Hoyer. In an interview, on 9/12/17 at 2:03 PM, Nurse Aide N reported, Me and (Nurse Aide L) found it (bruising) on Wednesday (7/26/17) at around 4:30 PM. It looked like a day old - blue black. I said, this didn't just happen. The bruising was from her wrist to above her elbow. None of her skin on top or below was a normal skin color. (LPN K) didn't know. I picked it up and (Resident #2) said that hurt. (LPN K and DON B) came in the room and looked at it. LPN K told us to put (Resident in the chair - with the Hoyer). Later, they came for an x-ray. She's a feeder anyway, but she's been using her left hand. We (Me/Nurse Aide N, and Nurse Aides LL and Y) found her face down on the mat Sunday night. No, we don't have to do an Incident Report because it's Care Planned. Usually, we don't tell the nurse she rolled out of bed. We get her back into bed with the Hoyer. In an interview, on 9/12/17 at 3:00 PM, DON/Director of Nursing B reported she assessed Resident #2's right arm on 7/26/17, but did not write a Progress Note about it. DON B stated the her root cause analysis revealed Resident #2 likely sustained a fractured right elbow second shift on Sunday evening (7/23/17) when she rolled out of bed (unwitnessed). DON B reported there was no Incident/Accident Report related to the incident because, I would not document it because she's Care Planned that she places herself on the floor. DON B reported Nurse Aide P saw bruising on Resident #2's right arm on Tuesday, (7/25/27), at around 3:30 PM and reported it to LPN S . (LPN S) got disciplined for not filling out the SBAR (Situation, Background, Assessment, Recommendation; a form/process to facilitate prompt and appropriate communication) second shift on 7/25/17. DON B said, (Nurse Aide U) and Nurse Aide X (both worked midnight shift on 7/25/17) knew about the bruising and did not report to the nurse on duty (LPN R). In an interview, on 9/13/17 at 10:48 AM, Unit Manager Q confirmed, Monday (7/24/17), (LPN H) came to me. Said girls said (Resident #2) was complaining her arm was hurting. I looked at it. I moved her arm and fingers. I assumed she laid on it. Said we will just monitor. Yes, (Resident #2) winced when her arm was lifted .I didn't see it Wednesday. Wednesday morning, (Nurse Aide O) told me she found the bruise on Tuesday, when she gave the shower. I saw it and said, 'Holy Mackerel'. I don't know if anyone measured it. I can't tell you why there are no Progress Notes about it. There should have been. I can't remember if I wrote a witness statement or not. I didn't document my assessment. I assumed (LPN H) would document. When asked if Nurse Aides were documenting each time Resident #2 was found on the bedside mattress, Unit Manager Q said, I'm not sure if there is a behavior log for (Resident #2). It's Care Planned, so they don't have to document. According to Resident #2's August 2017 Treatment Record, Start date 8/11/17 - end date 8/30/17, skin prep to outer left ankle BID (twice a day) . In an interview, on 9/13/17 at 3:30 PM, Unit Manager Q reported Resident #2 developed unblanchable redness on her outer left ankle from laying on her left side after her right elbow was fractured. In an interview, on 9/13/17 at 1:59 PM, OT/Occupational Therapist KK reported Resident #2 was normally right handed, and since her return from the hospital, her right arm had been wrapped with an elastic bandage, splinted, and she had orders to have her right arm immobilized with a sling. OT KK said due to these factors along with the fact she had a fractured elbow, she had lost full mobility of her arm (even though it may have been temporary and she had been removing the splint and moving her right arm). In a telephone interview, on 9/13/17 at 2:46 PM, Resident #2's Guardian JJ reported he was not made aware that Resident #2 was experiencing pain, limpness, loss of range of motion, or bruising in her right arm until 7/26/17, when they sent her out to the hospital. Guardian JJ said when he last visited Resident #2 she was in quite a bit of pain .winces when you touch her arm .she doesn't want you to touch her arm, she strikes at staff when they are attempting to work with the arm. Guardian JJ said he was unaware that Resident #2 fell out of bed frequently, and he was not notified she was found on the bedside mat the evening of 7/23/17.

This citation pertains to MI 740. Based on observation, interview and record review, the facility failed to prevent falls for 1 of 3 residents reviewed for falls (Resident #2), from a total of 5 sampled residents, resulting in a fall with injury (fractured elbow), the potential for worsening of the injury due to repeatedly moving (dressing, showering, and transferring with a Hoyer lift, etc.) Resident #2 (who had an unsecured broken elbow), and continued falls with the potential for injury, and the potential for psychological harm. Findings include: According to the MDS/Minimum Data Set, dated dated [DATE], Resident #2 was a [AGE] year old, admitted to the facility on [DATE], who had severe cognitive impairment, was totally dependent for staff (2+ person assist) with bed mobility, transfers, dressing, and bathing, and had [DIAGNOSES REDACTED]. Review of Resident #2's Care Plans revealed, 2/23/13: At risk for falls and subsequent injury related to: History of falls, advanced dementia, weakness, impaired safety awareness .(added/not dated): (Resident #2) intentionally lowers herself from her low bed to sleep .7/26/17: R (right) ulna (long bone in forearm) fracture, surgical repair 8/3/17 . Review of Resident #2's Electronic Medical Record/EMR revealed no Nursing Progress Notes between 7/01/17 - 7/25/17. According to an Orthopedic Specialist Encounter Note, dated 7/28/17, (Resident #2) reports falling, though she is unable to describe the circumstances of her fall .she presents wearing right elbow splint On 9/11/17 at 8:25 AM, Resident #2 was observed with her eyes closed (asleep) in bed laying at the edge of the bed, with her legs hanging over. There was a mattress on the floor at her bedside, that was approximately 12 inches below the mattress she was laying on. The other side of the bed was flush against the wall, and there was a thin fall mat up against that wall that was secured in place by the bed. The mat extended approximately 10-12 inches above the surface of the bed. The call light was attached to the large wooden headboard. According to an Incident/Accident Report, Date of incident/accident: (Wednesday) 7/26/17 at 5:00 PM .Resident's condition before incident/accident - Normal .Aides observed Rt (right) arm swollen bruised, and hurts upon movement . physician notified .5:20 PM .resident representative notified: 5:20 PM .X-ray ordered - Fx (fracture) Report .taken to hospital .7/26/17 8:30 PM . This report was signed, but not dated when signed, by RN/Registered Nurse K, DON/Director of Nursing B, Administrator A, and Medical Director II. The facility 5 Day Follow Up Investigation of (Resident #2) Incident/Injury revealed, On 7/26/17 facility staff noted that (Resident #2) had mild swelling, warmth and discoloration to her right arm .(Resident #2) was interviewed and reported that she hurt her arm during a fall .fracture of the elbow joint .Staff interviews confirmed that there were no falls noted .She exhibited no signs or symptoms of any pain outside of her normal pain levels which are related to her arthritis and the routine pain medications that were given as prescribed by her attending physician provided effective pain management . An imaging report, dated 7/26/17 at 6:48 PM, revealed, Acute complete mildly proximally distracted base of olecranon process (end of the long bone of the lower arm) of proximal ulna. There is either a smaller acute avulsion (forceful tearing away) fracture involving the coronoid process (lower portion of the joint) of the proximal ulna (top of the bone) or the adjacent radial head (bottom of the upper arm bone). Joint effusion (fluid) and surrounding soft tissue swelling. No dislocation. Marked osteopenia (moderate weak bone). Shoulder and wrist articulations (joints) are intact without arthritis or acute (new) process. Impression: complete fractures about the elbow . According to Radiopaedia (an online x-ray dictionary), 2017, Complete fractures are fractures where the parts of the bone that have been fractured are completely separated from each other. <https://radiopaedia.org/articles/complete-fracture> According to The American Journal of Orthopedics, 2017, Fractures of the olecranon are classically the result of fall on the elbow .Olecranon fractures are sustained secondary to a fall, usually on a flexed elbow; while proximal ulna fractures result from high-energy injuries including motor vehicle accidents or fall from height . <http://www.mdedge.com/amjorthopedics/dsm/ /orthopedics/fractures-olecranon-and-proximal-ulna> A Witness Statement, signed by Nurse Aide O and dated 7/27/17, revealed, .I came in Monday (7/24/17) morning, (Resident #2's) bed was I (sic) low position, the mattress was on the floor next to the bed .when I went to take her right arm out of the gown she said Owwwwwww. (Resident #2's) right hand was limp .there was no swelling or bruising .I used the Hoyer to get (Resident #2) up .I took her to the dining area .she used her left hand to hold her cup and drink .I have seen (Resident #5) .pushing (Resident #2) around in the wheelchair and she has bumped her arm on the railing and it looked like it has gotten caught in the railing. This was a while ago .I noticed the bruise on Tuesday (7/25/27) when I gave her a shower at about 3 something, (Nurse Aide P) helped me get her into the shower chair with the Hoyer .After the shower I told the nurse about the bruise and she said she thought she laid on it or it was arthritis. A typed Witness Statement, signed by Nurse Aide M dated 7/27/17, revealed, I worked Forest Hall (the unit where Resident #2 resided). (Nurse Aide L) and I got her up with the Hoyer lift .I have seen (Resident) #2) lean on the wall in her room with her right arm, she also hits the wall with her entire arm over and over . In an interview, on 9/12/17 at 10:02 AM, Nurse Aide P (who worked first shift and second shift - until 6:00 PM on Tuesday, 7/25/17) reported she noticed purple bruising on Resident #2's right elbow area on Tuesday, 7/25/17 on the day shift, and reported it to the 2nd shift nurse, LPN/Licensed Practical Nurse S. Nurse Aide P said, Prior to the injury, (Resident #2) could grab a cup and try to feed herself with her right hand .I wouldn't think she could have hurt her arm from falling from her bed to the mat . In an interview, on 9/12/17 at 10:38 AM, Nurse Aide Z said she worked Forest Hall (the Unit where Resident #2 resided) but was not assigned to Resident #2 on 7/23/27, 7/25/17 and 7/26/17 reported, (Resident #2) doesn't talk .very infrequently can she tell us if she is in pain or where .(Nurse Aide U) was the 3rd shift Aide before my shift (Tuesday, 7/25/17). Nurse Aide P said she thought Resident #2 sustained the elbow fracture from hitting it on the wall while in bed because, she flails her arms .right after this happened they put the pad against the wall. Nurse Aide Z said Resident #2 was .not using her right arm lately. In an interview, on 9/12/17 at 2:03 PM, Nurse Aide N reported, Me and (Nurse Aide L) found it (bruising) on Wednesday (7/26/17) at around 4:30 PM. It looked like a day old - blue black. I said, this didn't just happen. The bruising was from her wrist to above her elbow. None of her skin on top or below was a normal skin color. (LPN K) didn't know. I picked it up and (Resident #2) said that hurt. (LPN K and DON B) came in the room and looked at it. LPN K told us to put (Resident in the chair - with the Hoyer). Later, they came for an x-ray. She's a feeder anyway, but she's been using her left hand. We (Me/Nurse Aide N, and Nurse Aides LL and Y) found her face down on the mat Sunday night. No, we don't have to do an Incident Report because it's Care Planned. Usually, we don't tell the nurse she rolled out of bed. We get her back into bed with the Hoyer. In an interview, on 9/12/17 at 2:25 PM, LPN K stated she heard nothing about Resident #2's arm when she received report at the beginning of second shift on Wednesday, 7/26/17. LPN K stated, When I just looked at it, I knew right away it was broken. I touched it. She said Ow. DON (B) agreed it was broken. LPN K added, when Resident #2 grabs staff, not other residents. It's hard to break free from her. In an interview, on 9/12/17 at 3:00 PM, DON/Director of Nursing B reported she did not write a Progress Note after assessing Resident #2's arm on 7/26/17. DON B stated her root cause analysis revealed Resident #2 likely sustained a fractured right elbow second shift on Sunday evening (7/23/17) when she rolled out of bed (unwitnessed). DON B reported there was no Incident/Accident Report related to the incident because, I would not document it because she's Care Planned that she places herself on the floor. DON B reported Nurse Aide P saw bruising on Resident #2's right arm on Tuesday, (7/25/27), at around 3:30 PM and reported it to LPN S . (LPN S) got disciplined for not filling out the SBAR (Situation, Background, Assessment, Recommendation; a form/process to facilitate prompt and appropriate communication). DON B said, (Nurse Aide U) got disciplined for not reporting, and Nurse Aide X (both worked midnight shift on 7/25/17) knew about the bruising and did not report to the nurse on duty (LPN R) either. In an interview, on 9/13/17 at 8:55 AM, Nurse Aide T (who worked day shift on Forest Unit on 7/24/17 and 7/25/17) reported, On Monday (7/24/17), (Nurse Aide O) and I got (Resident #2) up in her chair (with the Hoyer/mechanical lift) and took her to the dining room. If you picked her arm up, (Resident #2) hollered .When lifted, she yelled 'Ow, that hurt'. When I pressed on her arm like this (she pressed a couple of fingers onto her own forearm) it didn't bother her, but if lifted just a little, it really hurt. It was totally different than usual. Nurse Aide T reported she thought Resident #2 probably sustained the fracture hitting her elbow during a transfer with the Hoyer lift. In an interview, on 9/13/17 at 9:07 AM, Nurse Aide O reported said, On Monday (7/24/17) Resident #2's right arm was limp; she screamed when I moved it. It was abnormal and I noticed. I conveyed that to (LPN H who was assigned to Resident #2 the day shift on 7/24/17 and 7/26/17); he was getting report, he told me to get her dressed and get her up (with the Hoyer). I got (Resident #2) dressed by myself .On Wednesday (7/26/17), as I was filling out the shower sheet, I asked (LPN S) if she knew about Resident #2's arm, and she said she already knew about the bruise and not to write it on the shower sheet. I said, 'Have you seen her arm? It's pretty bruised. And (LPN S) said, 'Ya, we think its from her arthritis. In an interview, on 9/13/17 at 9:22 AM, LPN H said, I learned about it (pain and limpness in Resident #2's arm) the morning just after it happened. They told me when (Nurse Aide O) was getting her up in the morning . LPN H reported he looked at Resident #2 after she was up in her wheelchair and seated in the Dining Room, and when he performed Range of Motion on her right arm, she winced when he moved her shoulder, elbow, hands and fingers. LPN H said he was only able to move Resident #2's bent arm a little away from her body due to pain. When asked if he obtained Resident #2's vital signs or documented his findings, LPN H said, I don't think I did .because I had Unit Manager (Q) look at it (Resident #2's right arm). LPN H reported he had not been given any information regarding Resident #2's arm in report that morning (Monday, 7/24/17), had not charted in the Progress Notes or on the 24 hour report board, did not call the physician or write it in the physician's book, and did not notify Resident #2's Guardian JJ. LPN H said he was not given individualized education nor disciplined regarding Resident #2's injury because he was not required to fill out an SBAR about (Resident #2's) right arm pain. LPN H said, I've never seen signs of pain with (Resident #2). LPN H reported he was present (did not remember the day) when Social Worker interviewed Resident #2 about how the incident occurred, and heard Resident #2 say on the wood .Her headboard is made of wood. In an interview, on 9/13/17 at 10:48 AM, Unit Manager Q confirmed, Monday (7/24/17), (LPN H) came to me. Said girls said (Resident #2) was complaining her arm was hurting. I looked at it. I moved her arm and fingers. I assumed she laid on it. Said we will just monitor. Yes, (Resident #2) winced when her arm was lifted .I didn't see it Wednesday. Wednesday morning, (Nurse Aide O) told me she found the bruise on Tuesday, when she gave the shower. I saw it and said, 'Holy Mackerel'. I don't know if anyone measured it. I can't tell you why there are no Progress Notes about it. There should have been. I can't remember if I wrote a witness statement or not. I didn't document my assessment. I assumed (LPN H) would document. When asked if a perimeter mattress had ever been used on Resident #2's bed, Unit Manager Q replied, No because it might remind her not to get out of bed. When asked if Nurse Aides were documenting each time Resident #2 was found on the bedside mattress, Unit Manager Q said, I'm not sure if there is a behavior log for (Resident #2). It's Care Planned, so they don't have to document. On 9/13/17 at 10:50 AM, Resident #2 was observed with her eyes closed (asleep) laying at the edge of her low bed on her left side; the head of the bed elevated approximately 40 degrees and there was a mattress on the floor at her bedside and the fall mat was against the wall, secured in place by the bed. According to a typed witness statement, signed and dated on 7/27/17 (not timed) by LPN S, I worked Forest Hall .on Monday (7/24/17). (LPN H - day shift nurse) mentioned to me he felt (Resident #2's) arm was stiff .I assessed her arm .I also worked Forest Hall on Tuesday (7/25/27) .(Resident #2) had her shower that afternoon; the (Nurse Aide) asked me if I knew that her arm hurt. I told her that yes, I was informed . In an interview, on 9/13/17 at 2:07 PM, LPN S reported Resident #2 continued to be found on the floor mat since 7/23/17: They find (Resident #2) on the floor mat frequently, but not every day, but they (the Nurse Aides) are not required to tell me when it happens, so I might not know about all of the times it happens. When interviewed as to the definition of a fall, LPN S said, A fall is when a person goes from one level and ends up on a different level. Yes, she goes from one level to another, but I've been told it doesn't qualify as a fall because it's Care Planned; LPN S said she didn't think it was in the facility policies, but she learned it from other nurses. Review of the facility's Fall Prevention and management Program Policy, dated 6/2016, revealed, A fall is defined as unintentionally coming to rest on the ground, floor or other lower level .Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred .Immediately upon discovery of a fall event a License (sic) Nurse will be summoned to the resident's aid. The resident is not to be moved if at all possible prior to the completion of the nurse' initial assessment for potential injuries .The nurse will complete an assessment to identify any injuries immediately .The nurse will complete a series of post fall assessments, interviews and investigative reports .Documents include: Post Fall Assessment .Fall SBAR .Skin Assessment .

This citation has two Deficient Practice Statements (DPS A and DPS B). DPS A. Based on interview and record review, the facility failed to assess, monitor, and appropriately/adequately intervene for 1 of 3 residents reviewed for quality of care (Resident #1), from a total of 6 sampled residents, when she was found to have a high fever, decreased mental status, and low oxygen saturation levels on [DATE] at approximately 2:30 AM, which likely caused serious psychological trauma, and, due to lack of all appropriate interventions, led to her death, and placed all 52 facility residents, who may experience similar declines in physical condition, at high risk for serious injury, harm and/or death. Findings include: According to the Minimum Data Set, dated dated [DATE], Resident #1 was a [AGE] year old woman, admitted to the facility on [DATE], scored 15 out of 15 (indicating she had no cognitive impairment), needed extensive assistance with transfers, had no falls, received Insulin, did not use supplemental oxygen, and had [DIAGNOSES REDACTED]. The Face Sheet, on [DATE], revealed Resident #1 appointed Contact H as her first Emergency contact. And, the Medical Record revealed Resident #1 was Full Code status. An Incident/Accident Report, dated [DATE] at 6:00 AM, revealed Resident #1 was lowered to the floor by Nurse Aide M during a transfer with a slide board from her bed to wheelchair. In a telephone interview, on [DATE] at 2:24 PM, an anonymous complainant X reported, Resident #1's Emergency Contact H was not notified of a fall she sustained on [DATE], and not notified of a significant change of condition (that began on [DATE] at approximately 2:30 AM), until a few minutes before she expired on [DATE] at 11:34 PM. The anonymous complainant X also said she had spoken to Medical Director C after Resident #1 expired, and he told her he was not notified Resident #1 had a change of condition until around 11:00 PM on [DATE]. Review of Resident #1's Physician Orders revealed the order for a chest x-ray revealed it was written on [DATE] at 8:08 AM, but the time the order was received from the physician was not documented. And, review of a Radiology confirmation fax report from the facility to Radiology services, revealed the order for Resident #1's chest x-ray arrived at the Radiology services at 2:28 AM on [DATE]. No order for a urinalysis was found. According to a Nursing Progress Note, dated [DATE] at 7:25 AM, documented by LPN/Licensed Practical Nurse D, Resident (#1) lethargic. Noted elevated temp of 102. Tylenol given .Lung sounds diminished bilaterally Noted intermittent dry cough. SpO2 (oxygen level in the blood) 74% on room air. O2 applied at 3 liters. SPoO2 @ 93%. (Medical Director C) notified. Orders obtained for CR (chest x-ray) and UA (urinalysis). CXR ordered. Medical Diagnostics aware (sic). The time Resident #1 was found lethargic, temp of 102, etc. was not documented, and there was no mention of Resident #1's Emergency Contact being notified of her significant change of status. Review of an Employee Memorandum, dated [DATE], revealed DON B disciplined LPN D for: 2nd and Final written warning .Failure to follow companies (sic) standards & expectations .not appropriately ass (assessing) and follow through with assessment. Residents' SpO2 at ,[DATE] %. did not recheck SpO2 for an hour at that time SpO2 78% . The next Nursing Progress Note for Resident #1 was dated [DATE] at 3:45 PM by LPN E, and revealed, .Tylenol given in am for temp of 99.6 . No other vital signs or lung sounds were recorded, and the Note revealed the chest x-ray and urinalysis had not yet been obtained, and again, there was no mention that Resident #1's Emergency Contact was notified. Review of a One-On-One Record, dated [DATE], revealed LPN E received education from DON B regarding: 1. Organization; 2. Documentation, must document on all findings - observations - LOC (level of consciousness) and follow up on all diagnostics. The next Nursing Progress Note for Resident #1 was dated [DATE] at 11:00 PM by RN/Registered Nurse F, and revealed no evidence that vital signs, or lung sounds had been monitored, nor whether Resident #1 had been using oxygen during the second shift. According to the note, .at the end of this shift, (Resident #1) having respiratory difficulties and pulse was weak .Medical Director C) notified .(Daughter-in-Law O) was called to notify her of residents condition. The phone number was a non working number. Next person called was (Emergency Contact G) .(Resident #1) had expired . Review of the Electronic Medical Vital Signs Records revealed the last documented set of vital signs on that system was [DATE]. In an interview, on [DATE] at 10:35 AM, DON/Director of Nursing B reported she thought she had done a complete investigation that was achieved by talking to staff, and she concluded the X-ray had not been obtained before Resident #1 expired because the Medical Director did not order it to be done STAT (immediately). However, there was no recorded timeline or documentation of the Cardiopulmonary Resuscitation of Resident #1 other than a brief Nursing Progress note(a person is typically assigned as the Recorder during a CPR event to capture the timeline and the actions of the persons present). DON B, LPN D and RN F did not initiate Investigative tools (such as Incident/Accident Report an Unusual Occurrence Report/these documents prompt staff to call the Emergency Contact when an occurrence or change of status occur) to record or analyze Resident #1's death. And, LPN D, LPN E, and RN F did not use an SBAR (an acronym for Situation, Background, Assessment, Recommendation; a technique that can be used to facilitate prompt and appropriate communication and intervention), or the facility's Care Path Tool (see below) for Resident #1 on [DATE]. When asked if she found any fault with the facility's action regarding the demise of Resident #1, DON B said, No, and when asked what her thoughts were on why Resident #1 expired, she replied, She had a lot of co-morbidities like diabetes and [MEDICAL CONDITION]. She had one leg amputated. She had to die of something, sometime. On [DATE] at 12:00 PM, presented a short written summary of her timeline of events between [DATE] - [DATE], and witness statements from LPN E, dated [DATE], and LPN D, not dated. According to the facility Notification of Change Policy and Procedure, dated ,[DATE], The Residents physician and responsible party must be notified when an event involving the resident occurs or when the resident experiences a change in condition, potential discharge, room transfer or death .(The facility) has adopted the current INTERACT Tool Change in Condition .NOTIFICATION: Call the physician and document time on SBAR Communication Form and Progress Note . The facility's Resident Care documents included Care Path Decision Tools, all dated 2014, for the following change of conditions: Potential for Dehydration, Symptoms of Shortness of Breath, Symptoms of Lower Respiratory Infection, Symptoms of [MEDICAL CONDITION], Fever, Gastrointestinal Symptoms, Symptoms of Urinary Tract Infection, Symptoms of Acute Mental Status Change, and Change in Behavior. According to the one of the facility's Care Path Decision Tools,Care Path: Fever - .Notify (physician) . Monitor vital signs, fluid intake/urine output every ,[DATE] hrs (hours) for ,[DATE] hrs. Do not give [MEDICATION NAME] (Tylenol) unless necessary for comfort - it can mask fever, or until source of fever known. If on diuretic, consider holding. Oral, IV or subcutaneous fluids if needed for hydration. Update advance care plan and directives if appropriate. According to another of the facility's Care Path Decision Tools: Symptoms of Shortness of Breath - .Notify (physician) .Monitor vial signs and urine output every ,[DATE] hours, O2 supplementation as indicated, Consider initiating or modifying dose of medication (e.g. diuretics, steroids, nebulizers, etc .), Respiratory therapy (if available), Ensure influenza and pneumococcal immunizations are up to date . And according to a third Care Path Decision Tool: Change in Behavior - . Notify (physician) .Consider IV or subcutaneous fluids if needed for hydration; Evaluate for unmet needs, environmental factors, and other non-medical causes, Consider non-pharmacologic interventions (e.g. sensory environmental, exercise, others that have been effective for this resident in the past) . According to Resident #1's MAR/Medication Administration Record, [REDACTED]. And although no administration of [MEDICATION NAME]/Tylenol was recorded on Resident #1's MAR, Nursing Progress Notes revealed she was administered [MEDICATION NAME] at least twice after she was found to have a fever from an unknown source. And, there was no discussion with Resident #1 regarding her Code Status by any staff member. In an interview, on [DATE] at 12:50 PM, LPN D reported she called and got orders from Medical Director C between 4:00 AM - 4:30 AM on [DATE] (but did not say if she attempted to notify Resident #1's Emergency Contact) because Resident #1 Nurse Aide K reported to her that Resident #1's 'wasn't acting right' and had 'a temperature of 101 (degrees Fahrenheit) or 102 somewhere between 3:30 AM - 4:00 AM .a change of condition. LPN D said O2 sats (oxygen in the blood) were down, so we applied oxygen, and she took Resident #1 'some Tylenol. LPN D said Resident #1 told her she had not felt well on [DATE], and added that she had to keep reminding Resident #1 to keep the oxygen on, since she was repeatedly taking it off. In a telephone interview, on [DATE] at 1:30 PM, Resident #1's 1st Emergency Contact H immediately answered the phone and reported she was not called about Resident #1's change of status until 11:21 PM on [DATE], and denied that any phone messages were left regarding Resident #1. Emergency contact H said, Resident #1's second Emergency contact (O) was a pastor at the church she and Resident #1 attended, and it was difficult to contact O via phone because they are so busy .I am always available by phone. Day and night. In an interview, on [DATE] at 1:48 PM, LPN E, the licensed nurse assigned to Resident #1 on [DATE] on the day shift, reported he did not document any vital signs in Resident #1's Medical Record on [DATE]. When asked if nursing staff had any documents/forms to help them manage a change in status, and if he used any form, on [DATE] to manage Resident #1's change of status, LPN E said, No, like what kind of form? Surveyor stated, Such as SBAR, and LPN E said he didn't know what that was. When asked if he was familiar with Care Paths, LPN E said he heard of them, thought they were in a folder at the desk, but he had not seen them since his orientation. In an interview, on [DATE] at 2:05 PM, Nurse Aide I reported during the shift change report at 6:00 AM on [DATE], the midnight Nurse Aide K reported to her that during the night Resident #1 was not acting herself and, at one point, they could not get her Oxygen level up over 80%. Nurse Aide I said Nurse Aide K told her LPN D gave Resident #1 some medication to take her fever away. Nurse Aide I reported that prior to Resident #1's fall on [DATE], (could not remember exactly when what day) Resident #1 had no strength in her upper body, so she began using the mechanical body lift to transfer her. Nurse Aide I stated she reported this to the Therapy Department. Nurse Aide I reported that at approximately 2:00 PM on [DATE], Resident #1 requested to use the commode to have a bowel movement, and was placed on the commode, but could not keep herself upright, and could not stay seated without Nurse Aide I physically holding her in place. Nurse Aide I said Resident #1 was throwing body and her arms backwards, which was very unusual behavior. Resident #1 was transferred to bed before she had fully completed her bowel movement and placed on a bedpan. According to Nurse Aide I, Resident #1 began yelling, which was not typical for her either. Nurse Aide I said, I did not take vital signs for her that day, but (LPN E) did and said her oxygen level was down around 85 or so. In an interview, on [DATE] at 2:25 PM, Nurse Aide J reported she did not take vital signs on Resident #1 during the second shift on [DATE], and was not instructed to do so. Nurse Aide J said Resident #1 was confused on second shift, kind of like she had a UTI/urinary tract infection, and said she reported the confusion to RN F around 8:30 PM. Nurse Aide J said, I don't remember if O2 was on (Resident #1). In an interview, on [DATE] at 2:45 PM, RN F reported she was assigned to Resident #1 on second shift on [DATE], but did not assess or monitor Resident #1's vital signs or oxygen on between 2:00 PM - 10:00 PM, and could not recall Resident #1 wearing oxygen. RN F stated it was her responsibility to have monitored Resident #1's vital signs, but she did not obtain vital signs other than her blood sugar at around 5:00 PM, which was 131. RN F said she should have monitored Resident #1, but she did not check the clip board to see who needed vital signs, and said, That is on me. RN F also reported the Chest X-Ray had not been obtained before Resident #1 expired. RN F reported she called Resident #1's daughter (Daughter-in-Law O) after 11:00 PM that night rather than first Emergency Contact H because, I felt family should know first. According to the Certificate of Death, signed by Medical Director C on [DATE], Resident #1 died on [DATE] at at 11:34 PM from Left sided [MEDICAL CONDITION] - Approximate Interval Between Onset and Death: several months. In an interview, on [DATE] at 3:35 PM, Medical Director C (Resident #1's physician) reported he did not recall anyone calling and telling him Resident #1's temperature was 102 degrees and her oxygen levels were in the 70's on [DATE]. Medical Director C said the only thing he remembered, and he said he remembered it clearly, was getting a call after 11:00 PM on [DATE] and being told they needed to ship Resident #1 to the hospital because she wasn't looking good, and then another call shortly after telling him she had arrested, CPR/Cardiopulmonary resuscitation was performed, 911 was called, arrived, continued CPR, and Resident #1 died . Medical Director C reported the occurrence had not been investigated, but needed to be because the facility did not have a policy or procedure to document and analyze the death of a facility resident that had a Full Code status. Medical Director C stated he had not been aware of Resident #1's decreased strength, altered mental status, low oxygen levels, and that now with that knowledge, believed Resident #1's [MEDICAL CONDITION] was due to low oxygen, and because of the temperature of 102 degrees Fahrenheit, Resident #1 likely had pneumonia or a urinary tract infection. Medical Director C said often Incident/Accident Reports are faxed to him, and sit there for awhile until he gets to them, and thus, he may have not seen the report for the fall on [DATE]. Medical Director C said if he had known of Resident #1's altered physical and mental status, he would have been at the facility immediately to examine her. Medical Director C stated he had approved the use of Care Path and Nursing Staff should have followed it. The facility Resident Incident/Accident Reporting Protocol, dated ,[DATE], regarding incident or accidents on our premises stated, Falls, Skin Injury injury of unknown, and potential abuse situations will be investigated per this policy, but the policy did not mention how to report, investigate, or analyze Unusual Occurrences (such as the death of a resident with a full code status). In an interview, on [DATE] at approximately 4:30 PM, DON/Director of Nursing B reported Resident #1's Granddaughter L complained on [DATE] about the poor care Resident #1 was receiving that day, but said the family harassed her staff, and told Surveyor, If they didn't think we were doing a good job, they should have taken (Resident #1) home. DON B said she had analyzed the unusual occurrence of the death of Resident #1 by interviewing staff, and stated she found no fault with the facility's actions surrounding Resident #1's death. When asked what she thought was the reason Resident #1 expired, DON B replied, She had a lot of co-morbidities like diabetes and kidney failure .she had to die of something sometime. When asked about the facility's Notification of Change (Change of Status) Policy and Procedure, dated ,[DATE], DON B also stated Nursing Staff were supposed to use SBAR (an acronym for Situation, Background, Assessment, Recommendation; a technique that can be used to facilitate prompt and appropriate communication), which was the INTERACT Tool Change in Condition form, mentioned in the policy. However, as Surveyor waited for her to search the EMAR (electronic medical record), and watch DON B file through the closed paper record, she was unable to provide evidence that SBAR had been done. DON B said, Maybe it wasn't done. Of note, the next day, on [DATE] at 1:05 PM, DON B and Consultant N, presented a CNA (Nurse Aide) Assignment Sheet, and an SBAR as evidence the facility's policy had been followed by the Nurses involved (LPN D, E, and RN F). DON said the SBAR was on her desk yesterday. Review of the SBAR form revealed it was signed, but not dated, by LPN E. With another Surveyor present, this Surveyor located LPN E in the facility and asked him if he had completed the SBAR on [DATE] (the date of Resident of Concern's death). LPN E hesitantly replied, No. When asked when he did complete the form, he hesitated and then said, .It must have been the day after she died . DON B and Consultant N also presented a CNA Assignment Sheet, dated [DATE] that revealed Resident #1's name but there was no evidence who documented the vital signs or when they were obtained. DON B stated, We had students in the building that night. In an interview during the survey with a confidential staff member W , W confirmed when SBAR's are completed and stated that Management is now requiring SBARs be completed after the fact .they are supposed to be done when a change of condition occurs to help guide the process, not days afterwards, and it was well known that nursing staff administer Stock [MEDICATION NAME] without documenting it on the MAR, and this increased the chance that an overdose of [MEDICATION NAME] could occur. W also reported that Nurse Aides had not been using the Stop and Watch tool to report changes to licensed nurses. Early Warning Tool, dated 2014, If you have identified a change while caring for or observing a resident please circle the change and notify a nurse. Either give the nurse a copy of this tool or review it with her/him as soon as you can: Seems different than usual; Talks or communicates less; Overall needs more help; Pain - new or worsening; Participated less in activities; Ate less; No bowel movement in 3 days; or diarrhea; Drank less; Weight change; Agitated or nervous more than usual; Tired, weak, confused, or drowsy; Change in skin color or condition; Help with walking, transferring, toileting more than usual . Administrator A was presented with Immediate Jeopardy Notification on [DATE] at 12:50 PM due to the facility's failure to assess, monitor, and appropriately/adequately intervene for Resident #1, when she was found to have a high fever, decreased mental status, and low oxygen saturation levels on [DATE] at approximately 2:30 AM. Resident # 1 subsequently died on [DATE] at 11:34 PM. These deficient practices place all facility residents, who experience similar declines in physical condition, at high risk for serious injury, harm and/or death. Immediate Jeopardy was removed on [DATE] when the facility had the following in place: On [DATE], all 52 facility residents were reviewed for change of status, and for those that required intervention, the physician was notified, orders received, and care plans were updated. As of [DATE], 12 of 12 facility licensed nurses had been educated on: 1. Notification of Change Policy and Procedure, dated ,[DATE]; 2. Notification to family members/guardians of change in condition; 3. Assessment protocols for Change of Condition/what type of vital signs need to be assessed; 4. Critical Thinking Skills/when to call the physician and what information to have ready; 4. Timely follow-up on diagnostics; 5. When to call 911; 6. Complete documentation of change of condition; 7. When to call the DON regarding change of status; 8. Change of Shift assessment and reporting requirements of resident with a change of status. As of [DATE], 26 of 29 facility Nurse Aides had been educated on the use of Interact: Stop and Watch form and when vital signs are to be taken. The remaining Nurse Aides will not be allowed to work until they have received the education. As of [DATE], review of all residents with a change of status, 24 hour report board, and all new orders began at Morning Meeting, 5 days a week. On [DATE], the Quality Assurance Committee met to assure proper ongoing assessment of residents, proper notifications, and post Cardiopulmonary Resuscitation analysis measures were in place. Although the immediate jeopardy was removed on [DATE], the facility remained out of compliance with a scope and severity of isolated actual harm that is not immediate jeopardy, due to sustained compliance could not be verified by the state agency. DPS B. Based on interview and record review, the facility failed to provide Cardiopulmonary Resuscitation (CPR) for 1 (Resident #3) of 5 reviewed for quality of care, from a total sample of 6, resulting in Resident #3 being found gray, cold, and without a pulse and not receiving CPR per his signed advance directive. Findings include: Review of the facility's Cardiopulmonary Resuscitation Care Standards revised ,[DATE], revealed Cardiopulmonary Resuscitation (CPR): CPR is artificially maintaining breathing and heart beat for those in cardiac or respiratory arrest until additional help arrives. Please note: Once CPR is initiated, it must continue until the patient recovers or a Physician/Nurse Practitioner provides the pronouncement of death .Do Not Resuscitate (DNR): DNR is a legal order provided by physicians to not provide CPR and/or other measures to prolong life in the event of loss of cardiac functioning. Families and friends may not initiate a DNR order verbally. In the absence of a legally executed DNR order, CPR will be initiated and [DATE] called . Residents will be provided a preference/choice/option upon admission to this facility to decide what response and care they prefer in the event their heart should stop beating and/or respirations cease. 1. This choice may be designated in the form of an Advanced Directive or DNR/Full Code order 2. In the absence of a DNR or Advance Directive, a full code will be initiated in the event of a medical emergency a) Once CPR is initiated, it must continue until the patient recovers or a Physician/Nurse Practitioner pronounces death b) Families/friends may not override this decision without a physician's order 3. The choice is to assure that the resident is provided patient centered care including CPR if requested 4. This choice includes assurance that appropriately trained staff is available to provide CPR to those residents that: a) Request CPR in their Advance Directive b) Have not formulated an Advance Directive c) Do not have a valid Do Not Resuscitate (DNR) order d) Do not show signs of clinical death as defined by the AHA Guidelines for CPR and Emergency Cardiovascular Care (ECC). Please note: Signs of clinical death may include rigor mortis, dependent lividity (pooling of blood in body after heart has stopped noted by bluish discoloration in dependent body parts of feet, hands), decapitation, transection, or decomposition) are present . (name of the corporation) communities will consistently follow the American Heart Association (AHA) guidelines for Basic Life Support (BLS) or follow Emergency Critical Care (ECC) guidelines to determine brain death. 1. Calling [DATE] is a part of this emergency response but is not the only action the facility will provide 2. Nurses will initiate CPR in the absence of a DNR/Advance Directive . Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #3 was a [AGE] year old male, admitted to the facility on [DATE] and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS revealed Resident #3 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). The Face Sheet revealed There are no Advanced Directives selected for this resident and Resident #3 expired on [DATE]. Review of the Determination of Inability to Participate in Medical Treatment Decisions, revealed the form was signed by a physician on [DATE] and a second form signed by the physician on [DATE], both indicating Resident #3 was capable of signing documents. Review of the Medical Treatment Decisions signed by Resident #3 and a witness on [DATE] and signed by the physician on [DATE], revealed Resident #3 wished to have CPR and hospitalization . The form was reviewed on [DATE] and again signed by Resident #3. Review of the Care Conference note dated [DATE], revealed CPR status was reviewed with Resident #3 and no changes were made. The Care Conference note revealed Resident #3 wishes for CPR. Review of Resident #3's medical record, revealed he was hospitalized from [DATE] until [DATE]. Review of the hospital History and Physical Reports dated [DATE], revealed He is a DO NOT RESUSCITATE . Review of Resident #3's Physician's Order Report dated [DATE] through [DATE], revealed an order for [REDACTED].#3 was readmitted to the facility after hospitalization from [DATE] through [DATE]). There was no further physician's order for a code status. Review of the entire medical record revealed no physician's order for DNR. Review of the Nursing Note dated [DATE] and written by Licensed Practical Nurse (LPN) Q, revealed .CENA (Certified Nursing Assistant) called nurse to room @ 0110 (1:10am) resident gray, cold, and no pulse-Dr. (name of doctor) called with return call from on call (name of doctor) orders to release remains to (name of funeral home) . There was no documentation that CPR was attempted. Review of the Record of Death revealed Resident #3 died on [DATE] at 1:10 am. The surveyor attempted to contact LPN Q via telephone on [DATE] at 9:48 am and [DATE] at 12:36 pm. A voicemail was left each time, requesting a return call. No return call was received prior to the exit of the survey. In an interview on [DATE] at 10:08 am, Social Services (SS) G reported that according to Resident #3's medical record, he was a full code (do CPR) because the most recent document signed in 2012, indicated Resident #3 wanted CPR. In an interview on [DATE] at 11:11 am, Director of Nursing (DON) B reported the night Resident #3 died , the electronic medical record was down, therefore staff was using the paper medical record. DON B reported if there is no code status or staff cannot locate the code status, then a full code (CPR) should be initiated. DON B stated that's standard across the board. DON B confirmed that Resident #3 did not receive CPR. DON B reviewed Resident #3's medical record and was not able to locate any code status document after the one signed by Resident #3 in 2011, indicating he wanted CPR. DON B stated the facility can't just go by hospital paperwork. Sometimes they (residents) change their mind when they get here . When asked if Resident #3 should have received CPR, DON B stated per our policy he was a full code.

This citation pertains to MI 510 Based on observation, interview and record review the facility failed to provide pain management assessment/interventions for a non-speaking resident for 1 of 3 sampled residents (#101) evaluated for pain management, from a total sample of 3 residents, resulting in the potential for unmet physical and psychological needs. Findings include: Resident #101 was admitted to the facility on [DATE] with a medical history according to the face sheet which included pneumonitis due to inhalation of food or vomit, [MEDICAL CONDITION] and [MEDICAL CONDITION] following a stroke (one side affected and unable to move that side) [MEDICAL CONDITION], high blood pressure, [MEDICAL CONDITION]-calorie malnutrition, alcohol dependence, unspecified alcohol-induced dementia, [MEDICAL CONDITION] (unable to speak) dysphasia (unable to swallow) and urinary incontinence. Review of the medical record revealed Resident #101 was admitted to the facility on [DATE] transferred to the hospital on 11/22 readmitted to the facility on ,[DATE], transferred to the hospital on 12/4 readmitted to the facility on ,[DATE], sent to the emergency roiagnom on ,[DATE] returned to the facility on ,[DATE]. Review of the MDS (minimum data set an assessment tool) dated 11/9/15 revealed Resident #101 was rarely able to express his own wants, sometimes understood others, was severely impaired for daily decision making skills, displayed physical behaviors directed toward others, was totally dependent on staff to move from side-side in bed, transfer, dress, toilet, bath and required extensive one person assistance with eating and personal hygiene, upper and lower extremity impairment on one side of the body and was incontinent of both bowel and bladder. Resident #101 was observed on 12/9/15 at 10:15 AM in his room in bed and was heard by this surveyor from the hallway to be grinding his teeth. Resident #101 was noted to be not moving his right arm which was lying on his chest without any support from pillows or blankets, his right foot was lying on the mattress without being raised off the mattress. Resident #101 continually rubbed/moved his left leg with his left hand sliding his left foot across the mattress in a back and forth motion. Review of the Nursing Care Plans titled Pain dated 8/4/15 the Problem as at risk for actual pain related to stroke right sided weakness and decreased mobility. Goal: Free from pain. Interventions: Administer medications as ordered, monitor effectiveness. Assess effects of pain on resident sleep, activities, self care, appetite, psychosocial, relationship disturbance. Evaluate effectiveness of pain management, monitor and record complaints of pain, monitor and record any non-verbal signs of pain, restlessness, grimacing, guarding, moaning, position for comfort with physical support, use measures such as distraction, imagery, relaxation, heat/cold, massage. Review of the Initial 21 Day Care Plan dated 12/7/15 for Resident #101 upon readmission Section titled Pain Goal: Experience less pain Med's: See MAR and Monitor pain QS (every shift) were checked. Review of MAR dated 11/1/15 to 11/30/15 for the 10 PM-6 AM shift documentation for Pain Assessment from 11/7 to 11/22/15 revealed no documentation was present related to pain assessment for Resident #101. Review of Wound Clinic Physician orders [REDACTED]. Review of the MAR (Medication Administration Record) dated 11/18/15 to 12/18/15 revealed 7 doses of Tylenol had been given to Resident #101 on 11/19, 20, 21 and one dose on 11/22. Resident #101 was admitted to the hospital on [DATE] and readmitted on ,[DATE]. No documentation upon re-admission to the facility was present for the Tylenol previously ordered by the wound clinic on 11/18/15. Review of Wound Clinic Progress Note dated 11/11/15 revealed: Plan: #6 I placed a call to the DON (director of nurses) regarding concerns over the care that he has received there. I expressed concerns of reports orders from us have been questioned and the dressings have not been applied as directed. Review of the Wound Clinic Progress Note dated 11/18 revealed I prescribed Tylenol 325 to be given to the patient twice a day to help control pain. Review of the MAR dated 12/7/15 to 1/6/16 no documentation was present for pain assessment nor indicating that pain assessments had been completed upon readmission to the facility on [DATE]. During an interview on 12/9/15 at 2:10 PM, Certified Nurse Aide (CNA) H reported that Resident #101 Seemed to grind his teeth more when he was turned. That's when it's really noticeable. Review of the medical record revealed Resident #101 had a Stage 4 pressure ulcer for which he received treatment both at the facility and Wound Clinic with wound cleaning, wound packing and dressing placement. (Stage 4 wound is open wound showing muscle with tunnel to the inside). According to the National Pressure Ulcer Advisory Panel: Stage IV (pressure ulcer) is defined as: Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Further description: Stage IV ulcers can extend into muscle and/or supporting structures (for example, fascia, tendon, or joint capsule) making osteo[DIAGNOSES REDACTED] possible. Exposed bone/tendon is visible or directly palpable. According to Ostomy and Wound Management (2/2009) Pressure Ulcer Pain: A Systematic Literature Review and National Pressure Ulcer Advisory Panel White Paper: Pressure ulcer pain may be caused by tissue trauma from sustained loads, inflammation, damaged nerve endings, infection, dressing changes, debridement, operative procedures, and other treatments. The skin has more sensory nerves than any other body organ. As the pressure ulcer cellular damage expands, chemicals are released that irritate nociceptive nerve terminals. Nociceptive pain is an appropriate physiological response to a painful stimulus and involves acute or chronic inflammation. Pain, particularly acute pain, is also a stimulus to the stress response; thus, at the cellular level, [MEDICAL CONDITION] may develop because of limited painful breathing and peripheral [MEDICATION NAME] and impede wound healing.8 Pain also may diminish appetite and decrease nutritional status. The single most reliable indicator of the existence and intensity of pain and any resultant distress is the patient ' s self-report through the use of established reporting instruments. The NPUAP is an advocacy organization that believes that all pressure ulcers cause pain. Healthcare providers report that dressing change and wound treatment are among the most painful times for an individual with a pressure ulcer. Review of the Physician orders [REDACTED]. In the Nursing Care Plan dated 8/4/15 and updated 10/3/15 no intervention of pre-medication with any pain medication was documented prior to wound clinic appointments or facility wound care dressing changes. During a dressing change observation for Resident #101 in his room on 12/9/15 at 2:20 PM with Registered Nurse (RN) P no [MEDICATION NAME] Gel was applied prior to the dressing change. While observing the wound dressing change to the right ischium, Resident #101 was turned onto his left side as RN P cleaned the area and then with a sterile Q-tip packed approximately 4 inches of gauze into the wound tunneled area. As RN P was packing the wound, Resident #101 was observed to be squirming his body toward the edge of the bed as if to try and get away. Due to [MEDICAL CONDITION], Resident #101 was unable to verbally indicate his pain level. During an interview with RN P on 12/9/15 at 2:20 PM when asked how she assessed Resident #101 for pain she replied I have not given him Tylenol today and did not pre-medicate him prior to the dressing change. Review of the Medication Administration Records (MAR) dated 12/7/15 through 12/11/15 revealed no documentation related to the application of [MEDICATION NAME] Gel prior to dressing changes. Review of the facility Care Standard titled Pain Management revised 4/12 revealed: Policy: It is the policy to respect and support the resident's rights to optimal pain management. Procedure: 1. It is the responsibility of all clinical staff to assess and periodically reassess the resident for pain and appropriate intervention to relieve pain. #1 a: At time of admission to our facility resident will be interviewed regarding pain during initial nursing assessment using 1-10 faces scale or FLACC table for residents with cognitive or communication problems. #6 Non-Communication Assessment Tool (Total FLACC Columns) Face, Legs, Activity, Cry, Consolability (FLACC an objective visual tool developed for staff to observe each area and rate 0-2 total scores 0-9 to indicate pain for resident's unable to tell staff their pain level). No documentation was present in the medical record regarding the use of the FLACC scale to assess for pain in the non-communication assessment for Resident #101. Given the National Pressure Ulcer Advisory Panel's definition of a Stage VI pressure ulcer and likelihood of pain associated with Resident #101's stage 4 pressure ulcer, his inability to verbalize pain, the facility's lack of pain assessments and not following physician's orders [REDACTED]. ( )

Based on observation, interview and record review, the facility failed to provide the proper care and treatment for 2 of 4 residents (#1, 5) and 1 of 2 extended survey resident (#15) reviewed for pressure ulcers from a total sample of 14 residents, resulting in Resident #1 being placed in immediate jeopardy to her health and safety on 4/16/14 when a stage 4 (full thickness of skin and subcutaneous tissue loss, exposing muscle or bone) left buttock pressure ulcer that was found to have acquired at the facility for resident #1. Resident #1 was hospitalized briefly and was being treated for [REDACTED].#5 developed a facility acquired stage 4 sacral pressure ulcer and Resident #15 with a newly acquired stage 2 (partial thickness of skin loss) left heel pressure ulcer. Findings include: According to the "physician's orders [REDACTED].#1 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The "Resident Progress Notes" dated 8/10/13 through 4/15/14 reflected Resident #1 developed a stage 2 pressure ulcer on her right buttock on 12/02/13 that was healed on 1/13/14. On 1/27/14 Resident #1 developed a stage 2 pressure ulcer on her left buttock. This pressure ulcer was now a stage 4 with measurement of 6 cm x 6 cm x 7 cm, causing permanent tissue damage with the complication of osteo[DIAGNOSES REDACTED] (infection in bone). The facility was placed in Immediate Jeopardy as a result of the facility's failure to provide repositioning and proper treatment to prevent development of pressure ulcer for Resident #1 who was care planned to inspect skin weekly and provide pressure relieving surface. On 4/15/14 at 1:00 p.m., Resident #1 was observed lying on her left side (where the ulcer is) in bed. On 4/16/14 at 9:00 a.m., Director of Nursing (Staff "B") stated Resident #1 was usually up from breakfast until dinner (8-10 hours). On 3/27/14 The Weekly Pressure Ulcer Progress Report indicated Resident #1's left buttock wound increased in size to 6.0 cm long, 6.0 cm wide and 7.0 cm deep. On 4/17/14 at 10:30 a.m., the Nursing Home Administrator was notified of the Immediate Jeopardy that was identified on 4/16/14, due to the facility's failure to prevent Resident #1 from acquiring a stage 4 pressure ulcer development and the potential for pressure ulcer development for all other residents residing in the facility at risk for pressure ulcer development. A request for a written plan of removal was requested at that time. On 4/18/14 at 9:00 a.m., the surveyor verified that the facility had done the following to remove the Immediate Jeopardy for Resident #1: 1) Completion of new "Braden" assessment 2) Completion of body assessment 3) Speciality air loss mattress ordered 4) Completion of new dietary intervention 5) Order for wound clinic obtained 6) Order to turn resident every one hour obtained 7) Revising nursing care plan 8) Establish weekly skin assessment schedule 9) Designation of wound nurse 10) Establish training regarding pressure ulcer prevention and treatment 11) Direct care staff inservice regarding turning and repositioning 12) Infection control related to dressing change Although the Immediate Jeopardy was removed on 4/18/14, the facility remained out of compliance with a scope of pattern and severity of "Actual harm that is not immediate jeopardy" due to sustained compliance having not been verified by the State Agency. Findings include: According to the Pressure Ulcer Care Area Assessment (CAA) dated 9/10/13 reflected Resident #1 was a [AGE] year old female admitted with fractured right wrist post fall at home. Resident #1 had a history of [REDACTED]. Resident #1 required assist for all activities of daily living (ADL) and extensive assist for bathing. Resident #1 was in wheelchair most of the time but could ambulate with arm support walker. Resident #1 did not exhibit any behaviors with the Alzheimer's dementia. Resident #1 was easily redirected and had minimal memory impairment. Resident #1 had a history of [REDACTED]. Resident #1 had BIMS (brief interview for mental status) score of 4 out of possible 15 points, indicating she had severe cognition. Nursing cares were provided with toileting and proper hygiene. Weekly skin assessments were performed by CENA (certified evaluated nursing aide)'s and licensed nursing. The "Skin Check" dated 8/10/13 (admitted ) reflected Resident #1 had no skin breakdown on her back side of body. However, the first "Head to Toe Weekly Skin Body Assessment" with body figure dated 12/2/13 reflected Resident #1 had 0.5 cm (length) x 0.5 cm (width) x 0.01 cm (depth) open area on her right buttock. The "Weekly Pressure Ulcer Profree Report" dated 1/13/14 indicated this right buttock stage 2 pressure ulcer was healed. There were no weekly skin assessments done before 12/2/13 (nearly 4 months). The "Resident Progress Notes," utilized by all interdisciplinary team, dated 1/27/14 reflected Resident #1 had an "open area noted left buttock. Measures 2 cm by 2 cm by 0.01 cm. Draining small amount of sero-sanguinous drainage. Thin [MEDICATION NAME] dressing ordered and applied to area." The "Weekly Skin Assessment" identified this wound as present on 1/26/14. The next skin assessment was done on 2/17/14 (21 days later). Subsequent skin assessment was dated 2/26/14 (10 days later), 3/21/14 (23 days later), 3/26/14, 4/1/14, 4/8/14 and 4/15/14. There were no weekly skin assessments done before 12/2/13 (nearly 4 months). The "Weekly Pressure Ulcer Progress Report" for left buttock dated 1/27/14 through 4/10/14 reflected Resident #1 was having progressively worsening pressure ulcer in terms of size and characteristics as follows: 01/27/14 stage 2 2.0 x 2.0 x 0.1 (in centimeters) 02/03/14 stage 2 3.0 x 2.5 x 0.01 02/10/14 stage 2 5.0 x 8.0 x 0.01 02/17/14 stage 2 5.0 x 5.5 x dark center 02/26/14 unstageable 4.0 x 6.0 x loose black tissue 03/03/14 stage 2 6.0 x 8.0 x 1.5, tunneling (back staging) 03/06/14 stage 2 6.0 x 8.0 x 5.5, culture obtained 03/20/14 stage 3 6.0 x 6.0 x 6.0 (incorrect staging) 03/27/14 stage 3 6.0 x 6.0 x 7.0 04/03/14 stage 3 6.0 x 6.0 x 7.0 04/10/14 stage 3 5.5 x 5.5 x 7.0 The "Physician's Progress" dated 2/11/14 reflected Resident #1 "...developed a stage 2 decubitus ulcer on her left buttock. It measures about 3-4 cm across. It has some adherent yellowish material..."Resident #1 was admitted to the hospital on [DATE]. The "History and Physical" written by Resident #1's attending physician at the hospital reflected, "...three or four weeks ago she started developing a small decubitus ulceration on her right buttock (incorrect). Then became deeper and about a week ago was noted to be extremely malodorous and deep. A wound VAC was placed and the patient was then reevaluated today. The wound is about 4-5 cm across and very deep. I can reach all the way to the sacrum...the culture report few multiple bacteria, one of which [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant staphylococcus aureus)...since the wound is progressing despite therapy at the nursing home with a wound VAC, I decided that she needed to be admitted for debridement in the operating room..." The "consultation notes" by the hospital surgeon dated 3/11/14 reflected the wound is a "grade 4 left buttock decubitus." I do think this clearly involves the bone, and she likely has some underlying osteo[DIAGNOSES REDACTED]...The wound, however, does not show acute signs of infections that require surgical debridement." On 4/16/14 at 9:00 a.m., Director of Nursing, (staff "B") was asked what risks led to the development of Resident #1's recurrent development of avoidable pressure ulcers. Staff "B" stated resident #1 had dementia, not remembering she needed to shift her body while she was sitting in her wheelchair. Staff "B" was asked how long resident #1 stayed in her chair. Staff "B" stated resident #1 usually stayed up from breakfast until dinner. Staff "B" added that Resident #1 had always been continent of urine with occasional dribbling. Staff "B" was asked whether the facility had a wound care nurse or if resident #1 was seen by a wound doctor. Staff "B" stated the facility did not have a wound care nurse and resident #1 was being cared by her attending physician only. Staff "B" was asked what interventions would be needed to promote healing of buttock pressure ulcers. Staff "B" stated resident #1 would prefer sitting up rather than lying down, and she would not be able to lie down on her own. Staff "B" added that Resident #1 was usually pleasant and cooperative. Staff "B" was asked what type of mattress and cushion resident #1 had. Staff "B" stated resident #1 had a standard pressure relieving mattress. On 4/15/14 at 1:00 p.m., Resident #1 was observed lying on her left side (where the ulcer is) in bed. On 4/16/14 at 9:30 a.m., the nurse aide, (staff "C") stated she had put Resident #1 up in her chair at 7:15 a.m. this morning. Staff "C" stated she planned on laying the resident down after lunch today. At 12:00 p.m., ( 5 hours later) Resident #1 was observed lying in bed and was up at 2:15 p.m. The CNA care plan, updated 3/21/14 reflected "encourage resident to lie down between meals. Lay on right or left side. walk to dine and to bathroom with walker and gait belt." Staff "C" stated Resident #1 had not been walked for some time and the staff just pushed her to dining room or bathroom. The nursing care plan related to skin breakdown dated 8/10/13 reflected Resident #1 was at risk due to a history of fall with wrist fracture, diuretic therapy, [MEDICAL CONDITIONS], dementia and depression. The interventions included 1) assess risk factors, 2) skin inspection weekly, 3) encourage good nutrition, 4) pressure reduction cushion and mattress, 5) reposition every 2 hours and as needed, 6) report any signs of skin breakdown. The facility "Licensed Nurse Skin/Body Assessment" policy, revised 1/08 reflected 1) Licensed nurse will assess the resident for any skin regulates such as bruising, redness, swelling, blisters, open areas such as cuts, lacerations , or broken skin, soreness or pain, unusually cold or hot spots and unusually hard or soft spots. 2) Weekly "Head to Toe Skin Body Assessment" will be performed on all residents in addition to Certified Nurse Assistance Skin Check form. 3) At the time of discovery, the licensed nurse will notify the resident, physician and responsible party, initiate treatment in accordance with facility protocols, standing orders or physician direction, take appropriate action to assure that, as appropriate, the skin irregularis is measured and staged, document findings and notifications in the medical record. ( ) On 4/17/14 at 10:35 am, in discussion with resident #1's Attending physician "M", physician "M" stated, "the resident has dementia, moves where she wants, do you expect the staff to move her every 5 minutes." Attending physician "M" reported Resident #1 was seen by the wound clinic nurse, the family refused to have her seen at the clinic and the facility was able to provide treatment and care and reported he had documented on 3/18/14, 3/25/14 and 4/18/14. Attending physician #1 was asked if he had documented the above information in his progress note and responded, "no not outlining what I told you I was there yesterday and dictated that information." On 4/17/14 at 10:45 am, Resident #1 was observed for a dressing change to her stage 3 sacrum pressure ulcer with a [DEVICE], with Licensed Practical Nurse (LPN) "F" and Assistant Director of Nursing "G" assisting. LPN "F" was observed to place the saline container to clean the pressure ulcer on the window sill without a barrier. LPN "F" removed Resident's soiled dressing wearing gloves. The wound measured 5.6 centimeters width x 5.4 cm length x 5.5 cm deep at 11 o'clock and 3.4 cm deep at 3 o'clock, there was minimal drainage, the wound was a beefy red with irregular edges. The surrounding left buttock area was observed to have been reddened. The clear wound measuring device was placed on the towel next to the treatment supplies. The area was Wearing the same gloves, LPN "F" used her pen to write down the measurements and laid the pen on the 4 x 4 that was then used to clean the wound, with the saline from the window sill. Wearing the same soiled gloves, LPN "F" picked up the clean foam dressing to place over the wound. LPN "F" was requested to stop the treatment and obtain new supplies and clean the wound. LPN "G" placed the soiled pen on the tray table. LPN "F" cleaned the wound a second time and proceeded to pick up the foam again. LPN "G" reminded LPN "F" to change her gloves and wash her hands. LPN "F" was observed to change the wound vac which was almost full of reddish/tan drainage, without the use of any gloves and placed in the waste basket at the bedside. LPN "F" and LPN "G" both stated gloves should be worn when handling any body fluids and the container should go in a hazard container in the soiled utility room. ( ) According to the Physician order [REDACTED].#15 was an [AGE] year old female admitted to the facility 4/14/14 with [DIAGNOSES REDACTED]. The page "Skin Assessment" including the diagrams under the "Admission Nursing Assessment" dated 4/14/14 for Resident #15 was blank. On 4/18/14 at 9:15a.m., Director of Nursing, (staff "B") was asked whether she could locate the admission skin assessment. Staff "B" was not able to locate one. On 4/18/14 at 10:25 a.m., Resident #15 was observed having her left lower leg wound dressing changed in her room by the Licensed Practical Nurse (LPN), (staff "F") assisted by the Assistant Director of Nursing, (staff "G"). Staff "F" first removed "Prafo" boot and the sock from Resident #15's left leg. The old dressing on her left lateral lower leg had the date written 4/16/14 as last change. As Staff "F" removed the old dressing, it had moderate amount of sero-sanguneous drainage. The wound measured approximately 10 cm long, 8 cm wide and 2.5 cm deep. Staff "F" applied wet-to dry dressing before covering the wound with adhesive cover dressing. Staff "F" was ready to put Resident #15's sock and the boot. Staff "F" stated the sock was wet and was going to change to the new one. Resident #15 left heel was observed dribbling with red blood on the bed linen. There was a red blister measured approximately 3.5 cm long and 5 cm wide that had just opened up. Staff "F" stated she was not aware that the resident had a blister. ( ) Resident #5 According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #5 was an [AGE] year old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Brief Interview for Mental Status (BIMS) score of 1 out of 15, reflecting severe cognitive impairment. Review of the Treatment record revealed Resident #5 had no open areas on 9/2/13. On 11/12/13 resident #5 was documented to have and open area on the coccyx "3 cm x 0.5 cm x .1 cm." (Stage 2: Partial thickness skin loss). Review of the "Determination of Unavoidable Pressure Wound," form completed and signed by the physician on 11/30/13 had recommendations that listed "prevention and treatment implemented despite unavoidable criteria "turn and reposition every 2 hours and PRN, Nutritional supplements, pressure reducing mattress, roho cushion in wheel chair, skin barrier ointment, wound clinic center intervention." On the bottom of the page hand written in was the information "Air mattress ordered and rec'd 1/22/14." On 4/16/14 Review of Resident #5's clinical record did not reveal any progress notes from the wound clinic. The Director of Nursing (DON) reported she would have to request them from the wound clinic. Records were received on 4/17/14. Review of Wound clinic Progress notes reflected: According to the wound clinic history and physical dated 12/5/13, "sacral stage III pressure ulcer that measures 5.0 x 6.0 x 0.2 cm. (Stage 3: Full thickness skin loss, exposing subcutaneous tissue). There is a moderate amount of serosanguineous drainage. No four odor. Small amount of granulation. Large amount of necrosis with yellow [MEDICATION NAME] and slough." Wound clinic note dated 12/12/13 stated, "Wound #1 sacral stage III, 4.5 x 6.0 x 0.2 cm. There is no undermining or tunneling. slough and [MEDICATION NAME]. The periwound shows some maceration." Wound clinic note dated 12/19/13, stated, "Wound #1 sacral stage III, 3.2 x 5.7 x. 02 cm large amount of [MEDICATION NAME] and slough. There is exposed muscle. There is no significant granulation. A large amount of serosanguineous drainage. Wound #2 Left buttock is new. Stage 2 pressure ulcer measure 1.3 x 0.5 x 0.3 there is moderate amount of serosanguineous drainage." Wound clinic note dated 12/26/13 stated, "Wound #1 sacral stage III, 3.8 x 3.3 x 0.2 moderate amount of serosanguineous drainage and moderate amount of [MEDICATION NAME] and slough. maceration was decreased. Wound #2 healed." Wound clinic note dated 1/8/14 stated, "Wound #1 3.8 x 5.0 x 0.2 cm. There is some new granulation tissue. There is Small amount of adherent slough. Surrounding skin is thickened. There is moderate amount of serosanguineous drainage." Wound clinic note dated 1/16/14 stated, "Wound #1 A the sacrum measures 4 x 3.5 x 0.2 cm in depth There is a moderate amount of serosanguineous drainage and moderate amount of adherent slough. Wound #1 A, the left sacrum is newly divided off from this wound. It measures 0.8 x 0.5 x 0.2 There is a moderate amount of serosanguineous drainage, a small amount of adherent slough. Some evidence of shear force." Wound clinic note dated 1/22/14 stated, "Wound #1 A has merged with #1. the sacrum measures 4.7 x 4.2 x 0.1 Upon further evaluation of this wound the center of the wound has new necrosis. There is a foul odor. There is a moderate amount of greenish drainage from the wound. It is friable. It is covered with some eschar and adherent slough. There is fascia exposed. Assessment A stage 3 ulcer of the sacrum, now worse with new deep tissue injury. Mostly likely will be a stage 4." Wound clinic noted dated 2/13/14 stated, "hospitalized shortly after last visit for a fever, a urinary tract infection, and wound infection. Culture from January 14, 2014, grew out 3 + e. coli and 2 + [MEDICATION NAME]. Patient was admitted to the hospital on [DATE], and was given a 2 week course of IV [MEDICATION NAME] and a 1 week course of IV [MEDICATION NAME] for her UTI." Wound #1 sacrum is stage 4 pressure ulcer to the sacrum." (Stage 4: Full thickness skin loss, exposing muscle or bone). Wound clinic noted dated 2/20/14 stated, "Wound #1 is now bridged off to wounds #1 a and #1 b. The wound s improved in appearance. Wound #1, sacrum, measures 2.5 x 3.5 x 0.6 cm. ...Wound #1 a measures 0.8 x 0.5 x 0.1 cm. A small amount of slough. Wound #1 b, distal sacrum, measures 0.3 x 0.5 x 0.1 cm A small amount of slough...Stage 4 pressure ulcer to the sacrum" Wound clinic noted dated 2/27/14 stated, "Wound #1 the sacrum measures 2.3 x 3.2 x 0.5 in depth there is a small amount of slough. Wound #1 a proximal and wound #1 b distal sacrum are healed. Assessment: Stage 4 pressure ulcer to the sacrum, improving... Plan of care: Continue with pressure-relieving mattress. She is up in her chair for 1 1/2 hours 3 times a day for meals then back in bed." According to Resident #5's CNA Resident info sheet, Resident #5 was "Please have attend activities & lay down for approximately 1 hr. 1-2 daily... Float heels in bed. Lay on her left side. Ensure w/c is reclined when in her room." According to the Pressure Ulcer care plan with a start date of 12/3/13, revealed an intervention written in dated 12/4/13 "family education on risks of being up too much without off loading body." All other interventions were dated 12/2/14. (Pressure ulcer was reported to have developed on 10/30/14). 1/22/14 an intervention of alternating air loss bed implemented. There have been no other interventions to the care plan in the last 3 months. There was no weekly monitoring in Resident #5's clinical record from 1/22/14 through 4/16/14. Resident #5's wound documentation provided measurements of the wound. There was no other descriptions of Resident #5's wound documented. On 4/15/14 at 9:30 am, during the initial tour Resident #5 was observed lying in bed on her back. On 4/15/14 at 2:40 pm, resident was again observed lying on her back. On 4/16/14 at 8:30 am, and at 4:05 pm, Resident #5 observed lying on her back. On 4/17/14 at 1:30 pm,was observed for a dressing change to her stage 4 sacrum pressure ulcer, with Licensed Practical Nurse (LPN) "F" and Certified Nurse Assistant "K" assisting. Resident #5's brief was observed to have been soiled with urine and was left in place during the dressing change. LPM "F" measured the wound then placed the clear wound measuring device on the bedside tray on top of Resident #5's plate of cookies and remote control. LPN "F" cleaned the wound bed, left the resident to wash her hands and change her gloves. CNA "K" allowed Resident #5's cleaned wound to lay back on to the soiled urine soaked brief. LPN "F" returned, Resident #5 was repositioned and LPN "F" preceded to apply the clean dressing to the site. LPN "F" was requested to stop, clean the wound again, and reapply a clean dressing. Following the dressing being reapplied, with the same gloves on, LPN "F" removed the soiled brief, picked up the remaining treatment supplies and placed them in the bag and sat them on the bedside table, next to Resident #5's cookies, with her soiled gloves. LPN "F" then removed her gloves and picked up the contaminated supplies. LPN "F" was asked what she was going to do with the supplies and responded, "return them to the treatment cart." On 4/17/14 at 2:15 pm, DON "B" and LPN "F" were interviewed, DON "B" reported facility expectations were for staff to follow facility policy for hand washing and following the facility policy for infection control practices for dressing changes. DON "B" was asked if she had monitored any staff dressing changes and infection control practices. DON "B" reported there was no documentation of any monitoring. On 4/18/14 at 10:45 am, Director of Nursing (DON) "B" reported the staff nurses completed the treatments for the pressure, the documentation was in the treatment records, and she kept a log of the weekly measurements in a document on her computer. DON "B" was questioned if the documentation included any information on the wound other than the measurements on a regular basis and her response was, "No." DON "B" was asked if anyone else had access such as the nurses or the physicians to the documentation on her computer and her response was "No." DON "B" had documentation that revealed she had been aware of Resident #5's wound 2 weeks earlier on 10/30/13. DON was requested to review MAR indicated [REDACTED]. and inquired if the monitoring was appropriate DON "B" responded, "No." According to the facility "Hand washing/Hand Hygiene," policy (no date), " Wash hands and other skin surfaces: 8. After immediate contamination with blood, other body fluids or potentially contaminated articles, 9. After removing gloves...11. Before and after nursing treatments or procedures (dressing changes...). A copy of the facility Licensed Nursing staff "Dressing Change Competency," was provided by DON "B" on 4/18/14 and included "use bedside table to assemble supplies...Establish a clean field: A barrier... is used. Assure that soiled supplies are not carried over the clean field. Wash hands. Don clean gloves..." ( )

Based on observation, interview, and record review, the facility failed to consistently provide services and implement interventions to address pressure relief in 1 (Resident #1) of 2 residents reviewed for pressure ulcers, from a total sample of 6 residents, resulting in the potential for non-healing or worsening pressure ulcer. Findings Include: According to the "Resident Admission Record" dated 3/14/14 Resident #1 was a [AGE] year old female re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Pressure Ulcer Care Area Assessment (CAA) dated 4/23/14 reflected Resident #1 required assistance for all activities of daily living (ADL) and extensive assist for bathing. Resident #1 currently had a Stage 4 pressure ulcer, required a special mattress to reduce or relieve pressure, required regular schedule of turning, had cognitive loss, had poor nutrition and was at risk for skin breakdown related to multiple risk factors including diabetes, [MEDICAL CONDITIONS] and kidney disease. The CAA also revealed nursing monitors would healing, assist resident with transfers, mobility, toileting and showers. On 6/12/14 at 9:20 a.m., in the presence of Assistant Director of Nursing (ADON) "C" and Certified Nursing Assistant (CNA) "K", Resident #1's pressure ulcer was observed. The pressure ulcer appeared to be a stage IV that measured approximately 1.5 cm in diameter and was approximately 3.5 cm deep, the skin around the wound slightly reddened. Review of the nursing care plan related to pressure ulcers dated 3/14/14, reflected Resident #1 had a stage IV pressure ulcer. The interventions included alternating pressure low air loss with safety parameters to bed. On 6/11/14 at 9:45 a.m., Resident #1 was observed in her bed lying on her back and appeared to be sleeping. Resident #1 was lying on a speciality mattress, a SB3000 low air loss mattress with selectable alternating pressure function. Resident #1's speciality air mattress was on, however the "alternating pressure" function was not selected as on. On 6/12/14 at 9:00 a.m., Resident #1 was observed lying in her bed, the specialty air mattress was on, however the "alternating pressure" function was not selected as on. On 6/12/14 at 1:15 p.m., Resident # 1 was observed lying in her bed, again, the specialty air mattress was on, however the "alternating pressure" function was not selected as on. During an interview on 6/12/14 at 3:09, Regional Consultant "L" stated, "(Resident #1's) mattress should be on alternating pressure, unless they are moving the resident or getting the resident out of bed". ( )

Based on observation, interview, and record review, 1) the facility failed to identify a practice that led to a fracture for 1 (#10) of 2 residents reviewed for decline in Activities of Daily Living, and failed to prevent a fall for 1 (#1) of 5 residents reviewed for falls out of 14 sampled residents, resulting in a fracture for resident #10 and a serious skin injury for resident #1; and the facility failed to lock 1 of 2 treatment carts at all times resulting in the potential for not less than 10 residents to have access to toxic chemicals. Findings include: According to the face sheet in the medical record, resident #10 was a [AGE] year old female with [DIAGNOSES REDACTED]. She had been admitted to the facility on [DATE]. According to the facility "Investigation Summary" dated 12/05/13, resident #10, "has been a 2 person assist with a sit to stand lift for a significant portion of her stay." A review of resident #10's medical record revealed an undated "SBAR (Situation, Background, Assessment or Appearance, Request) Communication and Progress Note". In the "Situation" section of the SBAR form, the nurse documented that the resident complained of pain in the right leg/hip/knee and the pain had started on 11/06/13. The severity of pain was rated 6 of 10 (0 being no pain and 10 being the worst pain). The "Progress Note" section of the SBAR form continued to document the nursing exam: "CNA reported resident pain to charge nurse. Charge nurse not familiar with resident and asked DON (Director of Nursing) to accompany her for assessment of pain. Charge nurse observed right knee, thigh, and lower leg. No redness, swelling or bruising noted. Resident was seated in wheelchair and able to lift upper leg off seat of wheelchair and extend leg at knee. Resident denied falling. Resident was observed rubbing her leg/thigh and along the outer aspect of her knee. During palpation of knee during extension and flexion resident denied any pain in that region. She was not able to identify specifically the location of pain, only stated 'it just hurts'." A review of the resident's medical record also revealed a pain assessment dated [DATE]. The assessment documented the pain as "Severe, 7-8 (on a scale of 0 to 10 with 10 being the worst), hurts bad." A review of the "Resident Progress Notes" for November 2013 revealed that documentation by nursing staff regarding complaints of pain in the resident's right leg began on 11/08/13. The progress note prior to 11/08/13, dated 11/04/13, had been made by the dietary manager. There was no nursing note between 11/04/13 and 11/08/13. According to subsequent nursing notes, the resident's knee became swollen and discolored. X-rays of the hip and knee were negative for trauma to the bone, soft tissue, and prosthesis. According to the hospital report, the CT scan done on 11/26/13 revealed "Findings: There is an acute impacted fracture of the distal right femur just proximal to the femoral component of a right knee replacement. The fracture line extends to the femoral component of the arthroplasty." The facility conducted an investigation to determine the cause of the fracture. According to the "Investigation Summary" dated 12/05/13, the transfer mode was changed from a Sit-To-Stand lift to a Hoyer lift on 11/08/13. The facility provided the statements given by caregivers. Statements included: "When we transfer her on the Sit-to-Stand we have to remind her to straighten her R foot, keep a firm hold on the bars, and to stand up straight as possible. But sometimes her knees buckle and she drops her grip, then her knees fall against the knee pad on the lift. This tend to happen often - the need to remind her - it is not a new issue." "When we transfer (Resident #10) on the Sit-to-Stand we have to tell her to stand up straight and keep her right foot on the platform. The last time, 11/4/13 (sic), I was involved in a transfer with (Resident #10) on the sit to stand she lifted her R foot off the platform and her R knee may have landed on top/against the knee pad on the sit to stand. I'm not 100% sure if it did or not." "The first time I noticed the resident was in pain was on 11/6/13 (sic). Her knee appeared swollen also. When we went to transfer her with the Sit-to-Stand we noticed that the knee pad on the lift had been raised a couple inches higher than normal. The knee pad still supported her legs and the top of the knee pad positioned below her knee." The last paragraph of the "Investigation Summary" dated 12/05/13 and started 11/26/13, while not designated a conclusion, stated: "Staff members who worked directly with (Resident #10) demonstrated for investigators the manner in which (Resident #10) transferred on the sit to stand lift. During the demonstrations, the staff consistently conveyed that (Resident #10) frequently would loosen her grip on the grab bars of the lift and drop her weight into the lift sling resulting in her knees hitting the top of the knee support pad of the lift. Staff members who worked directly with (Resident #10) indicated that she required frequent cueing to maintain posture and upper arm tension. One nursing aide also conveyed that on 11/5/13 (sic), during a transfer, (Resident #10) slid or lifted her right foot off the foot platform resulting in her, (Resident #10), upper body to shift forward and her knee coming into direct contact with the top of the knee support pad on the lift." The facility was aware that resident #10 would loosen her grip and hit her knees on the lift support pad and continued to transfer the resident with the Sit-To-Stand until 11/08/14 when the resident experienced severe pain and was subsequently transferred with a Hoyer lift and diagnosed with [REDACTED]. ( ) According to the Minimum Data Set (MDS) dated ,[DATE] Resident #1 was a [AGE] year old female admitted to the facility on [DATE] with fractured right wrist post fall at home. Resident #1 had a history of [REDACTED]. Resident #1 required assist for all activities of daily living (ADL) and extensive assist for bathing. Resident #1 was in a wheelchair most of the time but could ambulate with arm support walker. Resident #1's BIMS (brief interview for mental status) score was 4 out of possible 15 points, reflecting she had a considerably severe degree of cognitive impairment. Resident #1 had 5 falls (8/15/13, 9/5/13, 12/23/13, 3/11/14, 4/9/14) since her admission. The Falls care plan dated 8/10/13 reflected Resident #1 was at risk for falls and subsequent injury related to a fall at home, dementia, diuretic therapy and anti-depressant therapy. The approaches included 1) Assess medications, 2) Call light within reach, 3) Encourage use of hand rails or hand grips, 4) foot rest while in wheelchair, 5) bed in lowest position, 6) keep bathroom and hallway clutter free, 7) Lock wheelchair brakes when transferring, 8) physical and occupational therapy referral, 9) non skid shoes/socks. Handwritten additional approaches included discontinue wheelchair pedals dated 9/6/13 and toilet before and after meals and bedtime dated 4/10/14. The Incident/Accident Report dated 8/15/13 reflected Resident #1 "got up alone, wheelchair not locked, resident slid to floor." The steps taken to prevent recurrence included to educate resident about using call light. The Incident/Accident Report dated 9/5/13 reflected Resident #1 was "unable to state how slipped-denies hitting head, call light was not on." The steps taken to prevent recurrence included to initiate wheelchair alarm, toilet after meals and discontinue foot pedals on wheelchair. The investigation concluded the resident made contact with the foot pedal during her self-transfer and stumbled resulting in the fall. The Incident/Accident Report dated 12/23/13 reflected Resident #1 was "discovered lying on bathroom floor, resident states she doesn't know what happened. Large hematoma on right forehead and swelling on right hand near thumb region." The steps taken to prevent recurrence included placing sensor pad and tab alarm, magnetic key alarm and placing connector cord out of reach. The investigation reflected the resident tried to stand up from the toilet, bent down to pull up her pants, then hit her head on the sink. The resident's fall alarm was found unclipped from her shirt and placed in the wheelchair. The statement from the Licensed Practical Nurse described the resident as having a "baseball" sized hematoma on her right temporal region, bruising/swelling on right hand near thumb. On 4/16/14 at 12:00 p.m., Resident #1 was observed with extensive fading bruises on both sides of her face and both forearms. The nurse aides, (staff "O") and (staff "C") who were assisting the resident for toileting in the shower room stated the resident got these bruises when she had fallen fours months ago before Christmas. On 4/18/14 at 11:30 a.m., the Administrator (staff "A") was asked about the lack of an X-ray. Staff "A" stated the resident had no signs and symptoms of neurological deficit. On 4/18/14 in a.m., the Director of Nursing, (Staff "B") was asked why it took so long for staff to reach Resident #1 who had gotten herself to bathroom from her bed. Staff "B" stated there were 3 aides working, 2 were providing care for another resident and 1 aide was on a break. The Incident/Accident Report dated 3/11/14 reflected Resident #1 "ambulating to beauty shop to be weighed, assist of walker and 1 staff at door patient's knees folded and resident fell slowly to floor sitting on her bottom when nurses arrived." The steps taken to prevent recurrence included keeping wheelchair with resident when walking stand by assist with walker more than 50 feet. The Incident/Accident Report dated 4/9/14 reflected Resident #1 was "found sitting on floor in front of wheelchair without wheels locked in front of open bathroom door. The steps taken to prevent recurrence included providing consistent reminder to use call light and toilet after meals. On 4/18/14 in a.m., the Director of Nursing, (staff "B") was asked about the effectiveness to educate residents with severe cognitive impairment for use of call lights and locking wheelchairs. Staff "B" had no response. ( ) During the initial tour on 4/15/14 at approximately 9:30 am, the treatment cart was observed in the dining room on the 200 hall wing, unlock and was observed to have been unlocked until approximately 11:00 am with approximately 10 residents observed in the dining room area. There were approximately 25 prescribed and over the counter treatments (topicals) observed in the treatment cart. On 4/17/14 at 1:30 pm, the treatment cart was observed to have been unlocked. Two residents were observed sitting in the dining room area, Licensed Practical Nurse (LPN) "F" Was asked what the concern would be if residents were to get into the cart as it was unattended and responded, " Residents could have an allergic reaction, ingest types of topicals they should not and have to go out (to the hospital). " ( )

Based on interview and closed record review, the facility failed to transfer 1 of 4 insulin dependent diabetic residents (#104) to the hospital in a timely manner from a total of 14 insulin dependent diabetic residents in the facility, resulting in a neglect of appropriate care, severe low blood sugar levels leading to insulin shock. Resident #104 was admitted to the intensive care unit and died on [DATE], less than [AGE] years later in the hospital. Findings include: The Facility Resident Admission Record dated [DATE] revealed that resident #104 was a [AGE] year old male with [DIAGNOSES REDACTED]. The "Medical Treatment Decisions" form dated [DATE] reflected directives of resident #104 included yes to cardiopulmonary resuscitation (CPR), hospitalization , [MEDICAL TREATMENT], artificial hydration, medication for comfort and intravenous antibiotics and medications. The Care A rea Assessment (CAA) related to nutritional status dated [DATE] reflected resident #104 was an obese individual with BMI (body mass index; measure of body fat based on height and weight) score of 33.5 (score of over 30 is considered obese) and received a therapeutic diet related to [DIAGNOSES REDACTED]. The nutritional care plan dated [DATE] reflected resident #104 was receiving a regular diet with no added salt diet. However, the admission orders [REDACTED]. On [DATE] at 9:45 a.m., the dietary manager, (staff "B") stated she made a recommendation to change resident #104's diet to be liberalized diet. Staff "B" added she usually gave the recommendation form to the nursing staff. Staff "B" stated resident #104 was a large person (214.2 pounds) and she felt he needed more calories ( ,[DATE] calories) than 1800 calorie. Staff "B" added that the resident was hungry and he was asking for double portions, thus she honored his wishes. Staff "B" could not explain a lack of a recommendation form or the physician's orders [REDACTED]. The physician's orders [REDACTED]. insulin, 80 units at bed time and "[MEDICATION NAME]," a short-acting insulin, dosages according to sliding scale as follows: blood sugar levels less than 150 mg/dl no insulin blood sugar levels ,[DATE] 2 units blood sugar levels ,[DATE] 4 units blood sugar levels ,[DATE] 6 units if blood sugar levels >301, give 8 units and call physician. The blood sugar (mg/dl) flow sheet dated [DATE] reflected resident #104 had a wide fluctuations at various times on various dates: Dates ,[DATE] ,[DATE] ,[DATE] ,[DATE] ,[DATE] Times 6:30 A 222 221 245 366 71 11:00 A 357 400 530 176 4:30 P >600 323 460 307 117 8:00 P 344 367 208 349 308 Dates ,[DATE] ,[DATE] ,[DATE] ,[DATE] Times 6:30 A 184 215 74 95 11:00 A 240 73 132 80 4:30 P 432 155 102 84 8:00 P 206 298 243 52 The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"[MEDICATION NAME]" insulin coverage reflected resident #104 was administered 8 units for blood sugar levels greater than 301 14 times, but the physician was notified only once ([DATE] at 4:30 p.m.) despite the ordered instruction. The "Resident Progress Notes" dated [DATE] at 10:40 a.m., reflected, "went in resident room to attempt medication administration, PTA (physical therapy assistant) in room states that resident does not appear to be himself and is acting as though he is sick. resident assessed by this nurse and found to be disoriented, complained of feeling 'sick,' skin cool and clammy and diaphoretic-blood sugar checked and found to be 53 mg/dl. 120 ml orange juice and 240 ml of milk accepted immediately, refused food. After short period blood sugar remains 53, assessed again after 30 minutes and found to be unchanged-full tube of "Insta-glucose" 30 grams given, blood sugar 80 mg/dl after 5 minutes. physician notified." At 1:00 p.m. on same day and entered as a late entry ([DATE]) The "Resident Progress Notes" reflected, "resident given can of coke for sugar level of 51 mg/dl (200 ml)...blood sugar found to be 75 mg/dl after short period." At 2:15 p.m. an order to decrease "[MEDICATION NAME]" to 40 units daily in AM and give "[MEDICATION NAME]" one time if blood sugar was below 60 mg/dl after alternative measures failed." The subsequent progress notes dated [DATE] from 2:34 p.m. to 10:22 p.m. were documented as a late entries by a afternoon shift registered nurse, (staff "A"). The notes reflected, At 2:34 p.m. on [DATE] resident #104's blood sugar 97, moaning, eyes open and answers questions. At 4:30 p.m., resident #104 had a large emesis of liquid and undigested food and incontinent of soft brown stool, resident has not voided this shift. At 5:30 p.m., Doctor (doctor's name) office updated with resident's current blood sugar and resident's inability to void. At 6:00 p.m., blood sugar 74, resident moaning while mouth breathing. At 6:45 p.m., resident not swallowing saliva, mouth manually cleared of white phlegm. resident will not open his eyes when spoken to, groans when touched. At 7:30 p.m., attempted to arouse resident...resident mouth breathing. At 7:45 p.m., resident blood sugar 52, diaphoretic, cool and clammy skin. At 8:00 p.m., blood sugar recheck following [MEDICATION NAME] injection is 79, resident continues to have copious amounts of white phlegm, mouth cleared manually, breathing more labored at this time. resident does not respond to voice or touch. At 9:45 p.m., resident blood sugar is 47. respirations becoming more labored, resident is positioned tilted on his side, oxygen on per nasal cannula at 2 liters/min." The "Resident Progress Notes" dated [DATE] at 10:47 p.m., nearly 12 hours after he was first assessed to be having hypoglycemic/ low blood sugar episode, reflected resident #104 was transferred to the local hospital after the on-call physician was contacted by a midnight shift nurse. On [DATE] at 2:30 p.m., the second shift nurse/registered nurse, (staff "A") was interviewed over the phone. Staff "A" stated she had worked at the facility for 6 years and was familiar with resident #104. Staff "A" stated she was informed by a day shift nurse that the resident was not doing well on [DATE]. Staff "A" stated she was aware the resident was a "Full" code, meaning that all life saving measures should be implemented at the event of emergency. Staff "A" was asked whether she felt at any point that the resident should have been transferred to a hospital because his clinical condition was not improving with the interventions including "[MEDICATION NAME]" injection rendered to him or not. The "Diabetes Care Guide" American College of Physicians, 2007, p. 106 states that the effects of [MEDICATION NAME] lasts only ,[DATE] minutes, so if the patient does not respond to [MEDICATION NAME] within 15 minutes, emergency assistance is needed. Staff "A" stated she wanted to ask the doctor for transfers several times, because no matter what she did the resident was not responding to her interventions. However, she was never able to talk to him directly and remembered about other similar incidents where she was discouraged by the management for contacting physicians for transfers. Staff "A" added that she had resigned from the facility since this incident. The ambulance report dated [DATE] reflected resident #104 was found unresponsive and his blood sugar was 21 mg/dl at the scene, thus he was intubated. The emergency room physician report dated [DATE] revealed resident #104 "...had an aspiration event at about 4:00 p.m...he was having difficulty breathing but was not brought in at that time...subsequently he was found down later tonight...therefore he was intubated and transported to our facility...his blood pressure was ,[DATE] and x-ray showed right lower lobe infiltrate... when "Foley" catheter was placed, obtained 1800 ml tea-colored urine...will admit to the intensive care unit..." Resident #104 passed away on [DATE]. On [DATE] at 10:30 a.m., the Director of Nursing, (staff "C") was interviewed at the facility conference room. Staff "C" stated resident #104 was non-compliant with his diet, his family would bring junk food, and his blood sugars were very difficult to control. Staff "C" stated she was informed about resident #104's low blood sugar problems at between shift (1st and 2nd shift) report and his scheduled long-acting day time insulin was being held on [DATE] even though his finger prick blood sugar level was 95 mg/dl at 6:00 a.m. In fact resident #104's fasting blood sugar level (drawn at 6:07 a.m) on [DATE] was 50 mg/dl. There was no evidence that the nursing staff was aware of the result. There was no documentation as to why the long-acting morning insulin was being held. Director of Nursing, (staff "C") added that she left the facility at 5:30 p.m. and asked the second shift nurse, (staff "B") to call her at home if resident #104's condition did not improve. Staff "C" stated she did not hear from her at all. The facility protocols for transfer to acute care revised [DATE] reflected the immediate transfer is required 1) [MEDICAL CONDITION] or unresolved chest pain, 2) [MEDICAL CONDITION]/arrest unresolved by interventions, 3) confirmed fracture or injury required sutures, 4) sustained change in level of consciousness unresolved by interventions, 5) peripherally inserted central line/arterial line removal, and 6) hemorraghic. On [DATE] at 10:30 a.m.,The Director of Nursing, (staff "C") confirmed that she would have transferred resident #104 at earlier time if she had been adequately informed by the staff. ( )

Based on interview and closed record review, the facility failed to identify and quickly intervene to correct the signs and symptoms of low blood sugar for 1 of 4 insulin dependent diabetic residents (#104) from a total of 14 insulin dependent diabetic residents in the facility, resulting in an insulin shock and an irreversable clinical outcome. Resident #104 was subsequently admitted to the intensive care unit and died on [DATE], less than 48 hours later in the hospital. Findings include: The Facility Resident Admission Record dated [DATE] revealed that resident #104 was a [AGE] year old male with [DIAGNOSES REDACTED]. The "Medical Treatment Decisions" form dated [DATE] reflected directives of resident #104 included yes to cardiopulmonary resuscitation (CPR), hospitalization , [MEDICAL TREATMENT], artificial hydration, medication for comfort and intravenous antibiotics and medications. The Care Area Assessment (CAA) related to nutritional status dated [DATE] reflected resident #104 was an obese individual with BMI (body mass index; measure of body fat based on height and weight) score of 33.5 (score of over 30 is considered obese) and received a therapeutic diet related to [DIAGNOSES REDACTED]. The nutritional care plan dated [DATE] reflected resident #104 was receiving a regular diet with no added salt diet. However, the admission orders [REDACTED]. On [DATE] at 9:45 a.m., the dietary manager, (staff "B") stated she made a recommendation to change resident #104's diet to be liberalized diet. Staff "B" added she usually gave the recommendation form to the nursing staff. Staff "B" stated resident #104 was a large person (214.2 pounds) and she felt he needed more calories ( ,[DATE] calories) than 1800 calorie. Staff "B" added that the resident was hungry and he was asking for double portions, thus she honored his wishes. Staff "B" could not explain a lack of a recommendation form or the physician's orders [REDACTED]. The physician's orders [REDACTED]. insulin, 80 units at bed time and "[MEDICATION NAME]," a short-acting insulin, dosages according to sliding scale as follows: blood sugar levels less than 150 mg/dl no insulin blood sugar levels ,[DATE] 2 units blood sugar levels ,[DATE] 4 units blood sugar levels ,[DATE] 6 units if blood sugar levels >301, give 8 units and call physician. The blood sugar (mg/dl) flow sheet dated [DATE] reflected resident #104 had a wide fluctuations at various times on various dates: Dates ,[DATE] ,[DATE] ,[DATE] ,[DATE] ,[DATE] Times 6:30 A 222 221 245 366 71 11:00 A 357 400 530 176 4:30 P >600 323 460 307 117 8:00 P 344 367 208 349 308 Dates ,[DATE] ,[DATE] ,[DATE] ,[DATE] Times 6:30 A 184 215 74 95 11:00 A 240 73 132 80 4:30 P 432 155 102 84 8:00 P 206 298 243 52 The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"[MEDICATION NAME]" insulin coverage reflected resident #104 was administered 8 units for blood sugar levels greater than 301 14 times, but the physician was notified only once ([DATE] at 4:30 p.m.) despite the ordered instruction. The "Resident Progress Notes" dated [DATE] at 10:40 a.m., reflected, "went in resident room to attempt medication administration, PTA (physical therapy assistant) in room states that resident does not appear to be himself and is acting as though he is sick. resident assessed by this nurse and found to be disoriented, complained of feeling 'sick,' skin cool and clammy and diaphoretic-blood sugar checked and found to be 53 mg/dl. 120 ml orange juice and 240 ml of milk accepted immediately, refused food. After short period blood sugar remains 53, assessed again after 30 minutes and found to be unchanged-full tube of "Insta-glucose" 30 grams given, blood sugar 80 mg/dl after 5 minutes. physician notified." At 1:00 p.m. on same day and entered as a late entry ([DATE]) The "Resident Progress Notes" reflected, "resident given can of coke for sugar level of 51 mg/dl (200 ml)...blood sugar found to be 75 mg/dl after short period." At 2:15 p.m. an order to decrease "[MEDICATION NAME]" to 40 units daily in AM and give "[MEDICATION NAME]" one time if blood sugar was below 60 mg/dl after alternative measures failed." The subsequent progress notes dated [DATE] from 2:34 p.m. to 10:22 p.m. were documented as a late entries by a afternoon shift registered nurse, (staff "A"). The notes reflected, At 2:34 p.m. on [DATE] resident #104's blood sugar 97, moaning, eyes open and answers questions. At 4:30 p.m., resident #104 had a large emesis of liquid and undigested food and incontinent of soft brown stool, resident has not voided this shift. At 5:30 p.m., Doctor (doctor's name) office updated with resident's current blood sugar and resident's inability to void. At 6:00 p.m., blood sugar 74, resident moaning while mouth breathing. At 6:45 p.m., resident not swallowing saliva, mouth manually cleared of white phlegm. resident will not open his eyes when spoken to, groans when touched. At 7:30 p.m., attempted to arouse resident...resident mouth breathing. At 7:45 p.m., resident blood sugar 52, diaphoretic, cool and clammy skin. At 8:00 p.m., blood sugar recheck following [MEDICATION NAME] injection is 79, resident continues to have copious amounts of white phlegm, mouth cleared manually, breathing more labored at this time. resident does not respond to voice or touch. At 9:45 p.m., resident blood sugar is 47. respirations becoming more labored, resident is positioned tilted on his side, oxygen on per nasal cannula at 2 liters/min." The "Resident Progress Notes" dated [DATE] at 10:47 p.m., nearly 12 hours after he was first assessed to be having hypoglycemic/ low blood sugar episode, reflected resident #104 was transferred to the local hospital after the on-call physician was contacted by a midnight shift nurse. On [DATE] at 2:30 p.m., the second shift nurse/registered nurse, (staff "A") was interviewed over the phone. Staff "A" stated she had worked at the facility for 6 years and was familiar with resident #104. Staff "A" stated she was informed by a day shift nurse that the resident was not doing well on [DATE]. Staff "A" stated she was aware the resident was a "Full" code, meaning that all life saving measures should be implemented at the event of emergency. Staff "A" was asked whether she felt at any point that the resident should have been transferred to a hospital because his clinical condition was not improving with the interventions including "[MEDICATION NAME]" injection rendered to him or not. The "Diabetes Care Guide" American College of Physicians, 2007, p. 106 states that the effects of [MEDICATION NAME] lasts only ,[DATE] minutes, so if the patient does not respond to [MEDICATION NAME] within 15 minutes, emergency assistance is needed. Staff "A" stated she wanted to ask the doctor for transfers several times, because no matter what she did the resident was not responding to her interventions. However, she was never able to talk to him directly and remembered about other similar incidents where she was discouraged by the management for contacting physicians for transfers. Staff "A" added that she had resigned from the facility since this incident. The ambulance report dated [DATE] reflected resident #104 was found unresponsive and his blood sugar was 21 mg/dl at the scene, thus he was intubated. The emergency room physician report dated [DATE] revealed resident #104 "...had an aspiration event at about 4:00 p.m...he was having difficulty breathing but was not brought in at that time...subsequently he was found down later tonight...therefore he was intubated and transported to our facility...his blood pressure was ,[DATE] and x-ray showed right lower lobe infiltrate... when "Foley" catheter was placed, obtained 1800 ml tea-colored urine...will admit to the intensive care unit..." Resident #104 passed away on [DATE]. On [DATE] at 10:30 a.m., the Director of Nursing, (staff "C") was interviewed at the facility conference room. Staff "C" stated resident #104 was non-compliant with his diet, his family would bring junk food, and his blood sugars were very difficult to control. Staff "C" stated she was informed about resident #104's low blood sugar problems at between shift (1st and 2nd shift) report and his scheduled long-acting day time insulin was being held on [DATE] even though his finger prick blood sugar level was 95 mg/dl at 6:00 a.m. In fact resident #104's fasting blood sugar level (drawn at 6:07 a.m) on [DATE] was 50 mg/dl. There was no evidence that the nursing staff was aware of the result. There was no documentation as to why the long-acting morning insulin was being held. Director of Nursing, (staff "C") added that she left the facility at 5:30 p.m. and asked the second shift nurse, (staff "B") to call her at home if resident #104's condition did not improve. Staff "C" stated she did not hear from her at all. The facility protocols for transfer to acute care revised [DATE] reflected the immediate transfer is required 1) [MEDICAL CONDITION] or unresolved chest pain, 2) [MEDICAL CONDITION]/arrest unresolved by interventions, 3) confirmed fracture or injury required sutures, 4) sustained change in level of consciousness unresolved by interventions, 5) peripherally inserted central line/arterial line removal, and 6) hemorraghic. On [DATE] at 10:30 a.m.,The Director of Nursing, (staff "C") confirmed that she would have transferred resident #104 at earlier time if she had been adequately informed by the staff. ( )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW THE FACILITY FAILED TO ENSURE RESIDENTS WHO ENTER THE FACILITY WITHOUT PRESSURE SORES DID NOT DEVELOP PRESSURE SORES FOR 2 (#3, #8) OF 4 TOTAL SAMPLED RESIDENTS OBSERVED FOR PRESSURE SORES RESULTING IN A STAGE III PRESSURE ULCER FOR RESIDENT #3 AND AN UNSTAGEABLE PRESSURE ULCER FOR RESIDENT#8 AND LIMITING THE ABILITY FOR RESIDENT #3 AND #8 TO ATTAIN THEIR HIGHEST PRACTICABLE WELL-BEING. FINDINGS INCLUDE: RESIDENT #3 IS AN [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED].D.) OF DEMENTIA WITH BEHAVIORAL DISTURBANCE, [MEDICAL CONDITIONS], HYPERCALCEMIA, HYPERTENSION, ISCHEMIC [MEDICAL CONDITION], DIABETES MELLITIS TYPE II, CARDIOMEGALY, AND CERVICAL SPONDYLOSIS. ON 10/11/2011 AT 3:55 P.M. RESIDENT #3'S DAUGHTER WAS INTERVIEWED IN RESIDENT #3'S ROOM. RESIDENT #3'S DAUGHTER BECAME TEARFUL AND EXPRESSED CONCERN AND WORRY WITH FACIAL EXPRESSIONS REGARDING HER MOTHER'S CARE. RESIDENT #3'S DAUGHTER EXPRESSED CONCERN ABOUT THE WOUND TO THE SURVEYOR BY STATING "TWO WEEKS AGO HER SORE WAS THE SIZE OF A PENNY, SHE WOULD COMPLAIN TO US AND EVERYONE ELSE ABOUT PAIN ON HER BUTT, NOW IT'S HUGE, STINKS, AND IS BLEEDING. MY SISTER'S SAW IT ON SUNDAY." RESIDENT #3'S MEDICAL RECORD DOCUMENT TITLED "RESIDENT PROGRESS NOTES:" REFLECTED AN ENTRY DATE OF 9/28/2011 THAT STATED "RESIDENT HAS A 1 CM X 1 CM OPEN AREA ON HER RIGHT LOWER BUTTOCK. THE CARE PLAN PROBLEM DATED 9/28/2011 LISTED "RESIDENT HAS A PRESSURE ULCER R/T (RELATED TO) INCONTINENCE, DECREASED MOBILITY, STAGE: 2, LOCATION: RIGHT BUTTOCKS" AND THE APPROACHES WERE LISTED AS "CONDUCT A SKIN INSPECTION LICENSED NURSE TO DO WEEKLY SKIN INSPECTIONS AND CNAS (CERTIFIED NURSES ASSISTANTS) INSPECT SKIN BREAKDOWN (SORE, TENDER, RED, OR BROKEN AREAS)". IN ARRANGING FOR THE OBSERVATION OF RESIDENT #3'S RIGHT ISCHIAL WOUND ON 10/11/11 AT 5:45 P.M. WITH THE DIRECTOR OF NURSING (DON), THE DON STATED THE FACILITY DID NOT HAVE A DEDICATED WOUND NURSE. THE DON CONVEYED THAT ALL THE NURSES ARE RESPONSIBLE FOR THE WOUND TREATMENTS IN THE AREA THE NURSES ARE ASSIGNED. THE LAST SKIN ASSESSMENT FOR RESIDENT #3 WAS NOTED ON THE DOCUMENT TITLED "HEAD TO TOE WEEKLY SKIN BODY ASSESSMENT", NOT DATED. A REVIEW ON 10/11/2011 OF THE DOCUMENT TITLED "HEAD TO TOE WEEKLY SKIN BODY ASSESSMENT" REFLECTED THE LAST ENTRY WAS DOCUMENTED ON 10/2/11 9 DAYS PREVIOUSLY WITH DOCUMENTATION ON THE SKIN GRID WHICH STATED "FRAGILE WITH SMALL SPOTS, OPEN, 1 1/2 X 3 CM WITH FIRM TISSUE SURROUNDING WITH LINES DRAWN TO THE DOTS DRAWN ON THE BUTTOCK AREA OF THE BODY DIAGRAM. NO OTHER SKIN ASSESSMENT WAS NOTED IN RESIDENT #3'S MEDICAL RECORD ABOUT THE WOUND. IN THE DOCUMENT TITLED "RESIDENT PROGRESS NOTES" WITH ENTRY DATE OF 10/10/2011 IT IS WRITTEN, "THE DOCTORS OFFICE WAS CALLED TO SEE IF A REFERRAL COULD BE MADE FOR THE WOUND CLINIC..." ON 10/12/2011 AT 12:38 P.M. AN OBSERVATION OF RESIDENT #3'S DRESSING CHANGE TO HER RIGHT ISCHIAL (BUTTOCKS) WOUND WAS COMPLETED IN THE RESIDENT'S ROOM. LICENSED PRACTICAL NURSE (LPN), STAFF "V", UPON HAVING RESIDENT #3 POSITIONED TO VIEW THE WOUND, STATED "THIS IS MUCH WORSE". STAFF "V" WAS THEN ASKED BY THE SURVEYOR TO MEASURE THE WOUND AND AFTER MEASURING THE WOUND, STATED "IT IS 4 CM X 7 CM AND IS MALODOROUS". UPON VIEWING THE RIGHT ISCHIAL (BUTTOCKS AREA) WOUND, IT WAS NOTED TO APPEAR AS A DEEP CRATER WITH A SOUR ODOR; DRAINAGE FROM THE WOUND THAT APPEARED ON THE DRESSING BEING REMOVED WAS NOTED TO BE SEROSANGUINOUS (PUS AND BLOOD) AND THE WOUND WAS NOTED TO BE A STAGE III ULCER. A STAGE III PRESSURE ULCER ACCORDING TO PERRY AND POTTER, CLINICAL NURSING SKILLS AND TECHNIQUES, 6TH EDITION IS DESCRIBED AS A WOUND OF " FULL-THICKNESS SKIN LOSS INVOLVING DAMAGE TO, OR NECROSIS OF SUBCUTANEOUS TISSUE THAT MAY EXTEND DOWN TO, BUT NOT THROUGH, UNDERLYING FASCIA. THE ULCER PRESENTS CLINICALLY AS A DEEP CRATER WITH OR WITHOUT UNDERMINING OF ADJACENT TISSUE. " ALTHOUGH RESIDENT #3 WAS ADMINISTERED A PAIN MEDICATION AN HOUR PRIOR TO THE START OF THE DRESSING CHANGE,RESIDENT #3 WOULD PULL AWAY HIPS, JUMP, AND CRY OUT, AS IF IN PAIN, EVERY TIME THE WOUND WAS TOUCHED. ON 10/14/2011 AT 12:50 P.M. AN INTERVIEW WITH CERTIFIED NURSE ASSISTANT STAFF "E" WAS CONDUCTED IN THE HALLWAY OUTSIDE OF THE SHOWER/TUB ROOM ON THE FOREST UNIT. STAFF "E" WAS ASKED ABOUT RESIDENT #3'S ROUTINE AND IF RESIDENT #3 WAS REPOSITIONED EVERY 2 HOURS PRIOR TO ACQUIRING THE PRESSURE ULCER AND STAFF "E" STATED "WELL, WE (THE CERTIFIED NURSE ASSISTANTS) WOULD GET HER UP FOR BREAKFAST AND SHE WOULD STAY UP FOR A WHILE AFTER LUNCH, AFTER BREAKFAST THERE WAS ONLY AN HOUR AND A HALF BEFORE WE WOULD HAVE TO GET HER BACK UP FOR LUNCH , SO WE HAD HER STAY UP, THEN IT TAKES A WHILE TO GET HER INTO BED BECAUSE IT TAKES TWO OF US TO ASSIST HER SO SHE (RESIDENT #3) SITS IN HER CHAIR FOR QUITE A WHILE, A LONG TIME." THEN STAFF "E" WAS ASKED TO DESCRIBE A "LONG TIME" AND RESPONDED BY STATING "5-7 HOURS." ON 10/14/2011 AN INTERVIEW THAT BEGAN AT 8:15 A.M. WITH THE DIRECTOR OF NURSING (DON) WAS CONDUCTED IN THE CONFERENCE ROOM. THE DON WAS ASKED IF RESIDENT #3'S PRESSURE ULCER WAS AVOIDABLE AND THE DON REPLIED BY STATING, "PROBABLY" THEN THE DON WAS ASKED WERE ALL OF THE 6 PRESSURE ULCERS THAT WERE ACQUIRED IN THE FACILITY AVOIDABLE, AND THE DON REPLIED WITH HESITANCE AND STATED "YES, PROBABLY". THE FACILITY WAS UNABLE TO PROVIDE DOCUMENTATION THAT RELATED TO RESIDENT #3'S RISK PRIOR TO ACQUIRING THE PRESSURE ULCER AND FAILED TO IMPLEMENT A COMPREHENSIVE REVIEW OF INTERVENTIONS AFTER THE IDENTIFICATION OF RESIDENT #3 ACQUIRING THE PRESSURE ULCER. ON 10/14/2011 AT APPROXIMATELY 9:00 A.M. THE DON APPROACHED THIS SURVEYOR IN THE HALL OUTSIDE OF THE SERVICE ENTRANCE DOOR AND ASKED IF SHE COULD SPEAK WITH THIS SURVEYOR. UPON WALKING INTO THE SERVICE ENTRANCE HALLWAY THE DON STATED "WHEN I STARTED HERE I NOTICED THAT WE HAD SOME MAJOR ISSUES WITH SKIN CARE, I HAVE STARTED WORKING ON IT BUT, I CAN'T CHANGE THINGS IN 3 MONTHS." AND "I CAN'T FIX THE PROBLEMS LIKE RESIDENT #3'S WOUND UNLESS MY STAFF TELLS ME ABOUT IT." ON 10/14/2011 UPON RESIDENT #3'S RETURN FROM AN INITIAL VISIT TO THE WOUND CLINIC, THE PHYSICIAN ORDERS/PATIENT INSTRUCTIONS DOCUMENT DATED 10/14/2011 WAS REVIEWED AND THE [DIAGNOSES REDACTED]. ISCHIUM (BUTTOCKS AREA) POSS. (POSSIBLE) OSTEO[DIAGNOSES REDACTED] (INFECTION REACHING THE BONE). ( ) ACCORDING TO PHYSICIAN ORDERS [REDACTED]. RESIDENT (#8) WAS diagnosed with [REDACTED]. NURSE "I" WAS OBSERVED ON 10/13/11 AT 10:15 A.M., AS THE DRESSING WAS CHANGED TO THE ACHILLES TENDON AREA OF THE POSTERIOR RIGHT LEG. RESIDENT (#8) WAS OBSERVED AS THE DRESSING WAS REMOVED AND AREA CLEANSED. RESIDENT (#8) WAS THEN OBSERVED AS SHE REPLACED HER LEG ONTO A BLUE PLASTIC FOOT ELEVATION DEVICE AS NO SUPPORT TO THE FOOT SUSPENDED INTO AIR HAD BEEN PROVIDED. THE PLASTIC DEVICE HAD NOT BEEN OBSERVED TO BE DISINFECTED BY NURSE "I". THE OPEN WOUND RESTED UPON THE EDGE OF THE FOOT ELEVATION DEVICE WHICH FACILITATED PRESSURE RELIEF TO THE HEEL AREA ONLY. THE DRESSING CHANGE WAS COMPLETED BY NURSE "I" AND AN IDENTIFIED PROVOLON BOOT WAS APPLIED TO THE RIGHT LEG TO FACILITATE HEEL RELIEF. THE PROVOLON SPLINT WAS OBSERVED ON 10/14/11 AT 3:20 P.M. IT WAS ABLE TO BE DETERMINED NOT TO CONTAIN A METAL STAY. THE INNER BOOT WAS FIRM WITH AN AIR FILLED PLASTIC FOR THE FOOT TO REST UPON. PRESENT WAS NURSE "A". NURSE "A' WAS IN AGREEMENT PRESSURE WAS PRESENT TO THE ACHILLES AREA WITH RELIEF TO THE HEEL, EVEN WITH THE PROVOLON BOOT APPLIED. NURSE "A" WAS INTERVIEWED ON 10/14/11 AT 3:20 P.M. IT WAS STATED THE PROVOLON SPLINT HAD BEEN ORDERED BY THE WOUND CLINIC. NURSE "A" STATED, "I ADDED TO THE CARE PLAN AND THE CARE GUIDE WHICH STAFF CARRIED ON 10/13/11, THE WORDS, FLOAT HEELS AT ALL TIMES ON HEELS UP CUSHION, BEING SURE TO KEEP PRESSURE OFF OF RIGHT ACHILLES AREA." NURSE "A" STATED, " I HAVE REPRINTED A COPY FOR YOU, BECAUSE IT WAS DISCOVERED THE NOTATION WAS NOT ON THE CARE GUIDE INSTRUCTION SHEET FOR THE AIDES. NOW IT IS THERE." NURSE "A" WAS MADE AWARE THE CARE PLAN HAD ONLY ADDRESSED HEEL ELEVATION. NURSE "A" WAS MADE AWARE THE USE OF PILLOW/BLANKETS HAD NO SPECIFICS LISTED. DIRECTOR OF NURSING WAS INTERVIEWED ON 10/14 /11 AT 3:30 P.M. SHE STATED, "I SPOKE WITH ALL OF THE STAFF LAST NIGHT AND PLACED A CALL TO THE WOUND NURSE AT THE WOUND CLINIC AND DID NOT DOCUMENT." IT WAS INDICATED STAFF WILL MAINTAIN PRESSURE RELIEF TO THE RIGHT LOWER LEG. WHEN QUESTIONED IF EDUCATION HAD BEEN PROVIDED FOR IMMOBILIZER TECHNIQUE CARE, THE DIRECTOR OF NURSING WAS UNABLE TO BE SPECIFIC. RECORD REVIEW OF THE RESIDENT PROGRESS NOTES DATED 4/26/11-4/28/11 WERE REVIEWED ON 10/14/11 AND REFLECTED DRESSINGS HAD BEEN PLACED TO THE TOP OF THE RIGHT LEG IMMOBILIZER AND TO THE BOTTOM OF THE RIGHT LEG IMMOBILIZER DUE TO A 2.O CENTIMETER OPENED AREA AT THE EDGE OF THE LEG IMMOBILIZER. RECORD REVIEW OF THE CARE PLAN FOR RESIDENT (#8) WAS REVIEWED ON 10/14/11. IT REFLECTED THE START DATE OF AN UNSTAGEABLE PRESSURE ULCER TO THE RIGHT ACHILLES AREA WAS 6/3/11. IT REFLECTED THE HEELS WERE TO BE ELEVATED. THE WOUND CLINIC WAS INITIATED ON 7/27/11. RECORD REVIEW OF RESIDENT (#8'S) WEEKLY HEAD TO TOE SKIN BODY ASSESSMENT SHEET WAS REVIEWED ON 10/14/11. THE FOLLOWING WAS REFLECTED: 1. ON 5/14/11, AN OPEN AREA WAS CIRCLED BY A CHARGE NURSE. 2. NO HEAD TO TOE WEEKLY SKIN BODY ASSESSMENT SHEET WAS PROVIDED BY THE FACILITY FOR THE ENTIRE MONTH OF JUNE. 3. OPEN AREAS WERE REFLECTED TO THE RIGHT ACHILLES TENDON AREA ON 7/4/11, 7/11/11,7/18/11 AND REFLECTED THEN ON A WEEKLY BASIS. RECORD REVIEW OF RESIDENT (#8'S) WEEKLY PRESSURE ULCER PROGRESS REPORT WERE REVIEWED ON 10/14/11 AND REFLECTED THE FOLLOWING: 1. 6/3/11-6/30/11, REFLECTED COLOR TO BE BLACK. REFLECTED, UNSTAGEABLE. REFLECTED NO DEPTH. REFLECTED MEASUREMENTS TO PROGRESS FROM 7.0 CENTIMETERS IN LENGTH BY 2.0 CENTIMETERS (CM) IN WIDTH - 6.0 (CM) - 4.0 (CM). DEPTH , NONE - 0.3 (CM). 2. THE MONTH OF 7/2011 REFLECTED ONLY THE DATE OF 7/20/11. THE WOUND WAS STAGED AS UNSTAGEABLE. MEASURED, 5.0 (CM) IN LENGTH BY 2.5 (CM) IM WIDTH BY 0.3 (CM) IN DEPTH. IT REFLECTED THE COLOR TO BE BLACK WITH YELLOW PRESENT. DRAINAGE WAS REFLECTED AS CLEAR AND RED. 3. THE DOCUMENT REFLECTED THE NEXT DATES TO BE 8/4/11-10/7/11. A. MEASUREMENTS PROGRESSED FROM 5.0 (CM) -5.0 (CM) IN LENGTH. B. MEASUREMENTS PROGRESSED FROM 4.0 (CM)-3.0 (CM) IN WIDTH. C. MEASUREMENTS PROGRESSED FROM 0.3 (CM)-0.2 (CM) IN DEPTH. D. DRAINAGE PROGRESSED FROM RED AND CLEAR - SCANT AMOUNT. E. COLOR PROGRESSED FROM BLACK-YELLOW. THE DIRECTOR OF NURSING WAS INTERVIEWED ON 10/14/11 AT 4:30 P.M. THE FOLLOWING WAS ABLE TO BE VERIFIED: 1. THE WOUND CLINIC WAS CONSULTED BY THE FACILITY FOR THE HEALING PROCESS IN JULY. 2. THE WOUND TO THE ACHILLES TENDON AREA, CONTINUED TO EXPERIENCE MINIMAL PRESSURE RELIEF AND TOTAL PRESSURE RELIEF HAD NOT YET BEEN ACCOMPLISHED. 3. THE WOUND WAS LOCATED AT THE BASE OF THE RIGHT LEG IMMOBILIZER. 4. NO DOCUMENTATION WAS ABLE TO BE LOCATED IN THE PROGRESS NOTES OF NURSING, WHICH SUPPORTED THE FACT, STAFF WERE KNOWLEDGEABLE OF LEG ELEVATION OF AN AFFECTED EXTREMITY. 5. NO DOCUMENTATION/INSTRUCTION WAS ABLE TO BE LOCATED IN THE CARE PLANS OR CARE GUIDES WHICH SUPPORTED STAFF WERE KNOWLEDGEABLE ABOUT CARE OF A LEG IMMOBILIZER. ( )

Based on observation, interview, and record review the facility failed to identify defective equipment for 1 of 5 sampled residents (Resident #101) resulting in Immediate Jeopardy when Resident #101 fell out of a mechanical Hoyer lift sling that broke while Resident #101 was suspended four feet off the floor and landed on her back onto the one inch wide, metal leg of a mechanical Hoyer lift, which measured six inches off the floor, resulting in 3 fracture ribs, increased pain, and the high risk for serious harm, injury, or death and placing six additional residents who require use of a mechanical Hoyer lift at risk for serious harm, injury, and/or death. Findings include: Review of the face sheet and the Minimal Data Sheet ((MDS) dated [DATE], reflected that Resident #101 was a [AGE] year old woman admitted to the facility on [DATE]. Resident #101 required extensive physical assist of two+ persons for transfers (moves between surfaces) and toilet use. Resident #101's functional limitation in range of motion (ROM) was documented as impairment to the upper and lower extremities of one side of her body. Resident #101's pain assessment reflected that she almost constantly had pain. Resident #101's height is documented as 71 inches and her weight is documented as 288 pounds. Resident #101's goal is documented as "expects to be discharged to the community". Resident #101's [DIAGNOSES REDACTED]. Review of the Care Area Assessment (CAA) dated 11/28/10, reflected Resident #101 Activities of Daily Living (ADL) Function Status/Rehabilitation Potential reported that Resident #101 needed a Hoyer lift, and assistance with ADL's. Review of the care plan dated 11/29/10, reflected the documented problem for Resident #101 as "is limited in ability to maintain grooming, personal hygiene, dressing, toileting, eating and mobility related to" Cardio Vascular Accident (stroke), left sided effect, depression and Heart Disease. The care plan approach for this problem was documented as "Physical Therapy/Occupational Therapy evaluation and treatment as indicated and ordered...". Review of the Incident/Accident (I/A) Report dated 2/1/11 at 8:45 a.m., reflected that Staff x 2 to get resident (#101) up. Resident (#101) using Hoyer lift for transfer when moving resident (#101) in Hoyer strap broke, resident (#101) landed on her back on floor. The I/A Report documented injury as redness and bruising to right side of back, right arm and the back side of the right knee, a hematoma (collection of blood) on the back right arm between the shoulder and elbow, and a small skin tear on the elbow of the right arm. The I/A Report documented that the physician was notified at 10:30 a.m., but did not see Resident #101. The I/A Report documented extremity strength and movement as moves extremities of right side with no problem, and had a history of [REDACTED]. In an interview on 3/9/11 at 7:50 a.m., Certified Nurse Aide (CNA) #2 reported that she and CNA #1 were getting Resident #101 up on 2/1/11 to weigh her. CNA #2 reported that on 2/1/11 at around 8:30 a.m., she got Resident #101's extra large green sling out of her closet. CNA #2 reported that the sling had frayed edges on the loops that attach to the lift. CNA #2 reported that Resident #101 was placed in the sling and that she did not recall which loops were attached to the Hoyer lift bar. CNA #2 reported that she and CNA #1 then lifted Resident #101 up off the bed about 4 feet in the air with the Hoyer lift to get Resident #101's bottom off the bed. CNA #2 reported that CNA #1 backed the Hoyer lift away from the bed and one of the leg straps (can't recall which one) broke and Resident #101 fell to the floor in "the blink of an eye it was very fast". Resident #101 landed on her back on the left leg of the Hoyer lift. CNA #2 reported she told Resident #101 not to move, but Resident #101 insisted she was in pain and moved herself off the leg of the Hoyer to between the legs of the Hoyer lift and she and CNA #1 put a pillow under Resident #101's head. CNA #2 reported that Resident #101 moved before Licensed Practical Nurse (LPN) #1 came into the room, then the DON came to the room. CNA #2 reported that she did not pay any attention to what LPN #1 and the DON were doing until she and CNA #1 were asked to roll Resident #101 and put a different sling under her. CNA #2 reported that she was not sure if anyone looked over the new sling to check for wear and frayed edges prior to the sling was being put under Resident #101 and attached to the Hoyer when Resident #101 was put back to bed. In an interview on 3/8/11 at 12:50 p.m., CNA #1 reported that on 2/1/11 at 8:30 a.m. the sling used to lift Resident #101 was already in her room and that she did not recall the size of the sling or what the sling looked like, because she was just helping CNA #2. CNA #1 reported that the sling had leg straps that go behind and between the legs then cross to attach to the sling bar. CNA #1 reported lifting Resident #101 off her bed and backing the Hoyer away from the bed, Resident #101 was about chest height from the ground on her (CNA #1 stated her height is 5'6"), one of the leg straps broke, and Resident #101 fell to the floor on her back onto the left leg of Hoyer lift. Review of the label on sling marked #8 documented "ALWAYS INSPECT SLING BEFORE EACH USE, DO NOT USE IF TORN OR DAMAGED OR HAS BEEN IN USE FOR MORE THAN 2 YEARS". In interviews on 3/8/11 at 12:50 and 3/9/11 at 8:35 a.m., the Director of Nursing (DON) reported that prior to Resident #101's fall on 2/1/11 the facility did not keep close tabs on the conditions of the slings used to lift residents with the Hoyer. The DON reported that on the day of the fall, 2/1/11, when the sling broke she heard a "holler" and went to Resident #101's room. Review of the Hospital X-ray dated 2/1/11 at 5:49 p.m., reflected that Resident #101's exam documented "There are at least 3 minimally displaced right rib fractures. The ribs involved include 8, 9, and 10". Observations by surveyor while on site between 3/8/11, 3/9/11 and 3/10/11 revealed CNA #1, CNA #2, CNA #5, and CNA #6 transfer different residents using the Hoyer lift. The surveyor did not observe CNA #1, CNA #2, CNA #5, and CNA #6 conduct a visual inspection of the sling per the facility Lift Sling Safety Inspection and Care dated 2/1/11. The Administrator was notified on 3/10/11 at 12:02 p.m. of the Immediate Jeopardy that began on 2/1/11 as a result of failure to maintain facility equipment when Resident #101 fell from a mechanical Hoyer lift sling broke during a transfer while Resident #101 was suspended four feet off the floor and landing on her back onto the one inch wide, metal leg of a mechanical Hoyer lift, which measured six inches off the floor. This deficient practice placed all residents who require the use of a mechanical Hoyer lift at high risk for possible physical harm, injury, and death. On 3/14/11, the Surveyor confirmed that the facility staff completed the following to remove Immediate Jeopardy: 1. On 2/1/11 all mechanical lift slings were inspected by the Director of Nursing to check the condition of the slings and the length of time the slings had been in use. Manufacturers guideline were obtained to ensure appropriate use. All residents using the mechanical lifts for transfers were identified on the Activity of Daily Living Guide, noting the size of the sling. 2. On 2/1/11 a new policy was developed for mechanical lift slings. 3. On 2/1/11, 48 of 48 nursing staff were in-service on appropriate mechanical lift transfers including assessing the integrity of the sling prior to use and washing and drying procedures for slings. No staff worked their next shift until the inservicing was completed. 4. On 2/1/11, 6 of 6 housekeeping and laundry staff have been inserviced regarding the correct washing and drying procedures and monitoring sling conditions. 5. Effective 2/1/11 the Director of Nursing/Designee began monitor slings bi-weekly. 6. Effective 2/1/11 the Director of Nursing or the Assistant Director of Nursing will observe mechanical lift transfers three times a week for one month, then one time a week for one month, then monthly thereafter. Results of the monitoring will be submitted to the Facility Continuous Quality Assurance Committee. The nursing staff have been competency tested . 7. Effective 2/1/11 the Maintenance Director was instructed to check mechanical lifts monthly to ensure that slings are in continual good working condition. Although the Immediate Jeopardy was removed on 3/10/11, the facility remained out of compliance at a scope and severity of isolated with actual harm that is not Immediate Jeopardy due to staff not complying with the new policy for mechanical slings, and sustained compliance had not be verified by the State Agency. ( )

Based on observation, interview, and record review the facility failed to provide the necessary care and services (adequate and appropriate emergency assessment and treatment) to maintain the highest practicable physical well-being, for 1 of 5 sampled residents (Resident #101) resulting in Immediate Jeopardy when Resident #101 fell out of a mechanical Hoyer lift sling while suspended four feet off the floor and landing on her back onto the one inch wide, metal leg of a mechanical Hoyer lift, which measured six inches off the floor at 8:45 a.m. then was transfer with a sling in a Hoyer lift back to bed and not sent to the Emergency Department for X-rays until 4:00 p.m. that day, resulting in high risk for serious harm, injury, or death and placing six additional residents who require use of a mechanical Hoyer lift at risk for serious harm, injury, and/or death. Findings include; "Spinal injuries include fractures, contusion, and compressions of the vertebral column, usually the result of trauma..The real danger lies in possible spinal cord damage...The primary treatment after spinal injury is immediate immobilization to stabilize the spine and prevent cord damage... Stabilization of the head and neck is done prior to moving the victim to prevent secondary injuries such as paralysis from destabilization of a cervical vertebrae fracture..." (Diseases: causes and [DIAGNOSES REDACTED].). Pennsylvania: Springhouse). "General Trauma Intervention: Keep the victim lying down or in the position in which he or she is found..." (Phipps, W. J., Monahan, F. D., Sands, J. K., Marek, J. F. & Neighbors, M. (2003). Medical-Surgical Nursing Health and Illness Perspectives (7th ed.). St. Louis: Mosby). According to the Nor-Cal EMS Spinal Immobilization Training Program (last revised March 1, 2004), "Even though the flexible C-spine is the most commonly injured component of the spine, it is not the only site that can be injured. Injuries can often co-exist in several regions of the spine. Until specific sites of injury can be accurately determined in the hospital setting,...Immobilizing just one area of the spine without protecting the entire spinal alignment is never appropriate..Spine pain is often poorly localized and might not be felt directly over the injury site. Therefore, pain in or around the spine should be treated as a "positive spine injury"..." Review of the face sheet of the clinical record and the Minimal Data Sheet ((MDS) dated [DATE], reflected that Resident #101 was a [AGE] year old woman admitted to the facility on [DATE]. Resident #101 required extensive physical assist of two+ persons for transfers (moves between surfaces) and toilet use. Resident #101's functional limitation in range of motion (ROM) was documented as impairment to the upper and lower extremities on one side of her body. Resident #101's height is documented as 71 inches and her weight is documented as 288 pounds. Resident #101's goal was to be discharged to the community. Resident #101's [DIAGNOSES REDACTED]. Review of the Care Area Assessment (CAA) dated 11/28/10, reflected Resident #101 Activities of Daily Living (ADL) Function Status/Rehabilitation Potential reported that Resident #101 was awaiting approval from insurance for therapy, needed a Hoyer lift, and assistance with ADL's. Review of the care plan dated 11/29/10, reflected the documented problem for Resident #101 was limited in the ability to maintain grooming, personal hygiene, dressing, toileting, eating and mobility related to Cardio Vascular Accident ([MEDICAL CONDITION]), left sided effect, depression and [MEDICAL CONDITION]. The care plan approach for this problem was documented as "Physical Therapy/Occupational Therapy evaluation and treatment as indicated and ordered...". Review of the Incident/Accident (I/A) Report dated 2/1/11 at 8:45 a.m., reflected that Staff x 2 to get resident (#101) up. Resident (#101) using Hoyer lift for transfer... when (staff CNA #1 & CNA #2) moving resident (#101) in Hoyer, the sling strap broke, resident (#101) landed on her back on floor. The I/A Report documented injury as redness and bruising to right side of back, right arm and the back side of the right knee, a hematoma (collection of blood) on the back right arm between the shoulder and elbow, and a small skin tear on the elbow of the right arm. The I/A Report documented that the physician was notified at 10:30 a.m., but did not see Resident #101. The I/A Report documented extremity strength and movement as moves extremities of right side with no problem, and had a history of [REDACTED]. In an interview on 3/9/11 at 7:50 a.m., Certified Nurse Aide (CNA) #2 reported that she and CNA #1 were getting Resident #101 up on 2/1/11 to weigh her. CNA #2 reported that on 2/1/11 at around 8:30 a.m., she got Resident #101's extra large green sling out of her closet. CNA #2 reported that the sling had frayed edges on the loops that attach to the lift. CNA #2 reported that Resident #101 was placed in the sling and that she did not recall which loops were attached to the Hoyer lift bar. CNA #2 reported that she and CNA #1 then lifted Resident #101 up off the bed about 4 feet in the air with the Hoyer lift to get Resident #101's bottom off the bed. CNA #2 reported that CNA #1 backed the Hoyer lift away from the bed and one of the leg straps (can't recall which one) broke and Resident #101 fell to the floor in "the blink of an eye it was very fast". Resident #101 landed on her back on the left leg of the Hoyer lift. CNA #2 reported she told Resident #101 not to move, but Resident #101 insisted she was in pain and moved herself off the leg of the Hoyer to between the legs of the Hoyer lift and she and CNA #1 put a pillow under Resident #101's head. CNA #2 reported that Resident #101 moved before LPN #1 came into the room, then the DON came to the room. CNA #2 reported that she did not pay any attention to what LPN #1 and the DON were doing until she and CNA #1 were asked to roll Resident #101 and put a different sling under her. CNA #2 reported that she was not sure if anyone looked over the new sling to check for wear and frayed edges prior to the sling was being put under Resident #101 and attached to the Hoyer when Resident #101 was put back to bed. Review of the label on sling marked #8 documented "ALWAYS INSPECT SLING BEFORE EACH USE, DO NOT USE IF TORN OR DAMAGED OR HAS BEEN IN USE FOR MORE THAN 2 YEARS". In interviews on 3/8/11 at 11:05, 3/9/11 at 4:30, and 3/10/11 at 10:40, Resident #101 reported that she has not been out of bed since 2/1/11, because she is afraid to of the Hoyer lift. Resident #101 reported that she had been very painful since the fall from the Hoyer lift 2/1/11 and has difficulty getting comfortable. Resident #101 reported falling from the Hoyer onto the leg of the Hoyer lift, the CNA put a pillow under her head, then Licensed Practical Nurse (LPN) #1 arrived in the room, but Resident #101 did not recall LPN #1 moving her arms, legs, shoulder, or hips before they put her back to bed using a Hoyer lift. Resident #101 reported that after she was back in bed it was hard to breath laying flat, so they raised her head up only a little, because they were not sure what was wrong with my back. Resident #101 reported that the pain in her back got worse so she went to the hospital. In an interview on 3/14/11 at 9:00 a.m., Resident #101 reported that no one has had her push her feet against their hands. In an interview on 3/8/11 at 12:50 p.m., CNA #1 reported that on 2/1/11 at 8:30 a.m. the sling used to lift Resident #101 was already in her room and that she did not recall the size of the sling or what the sling looked like, because she was just helping CNA #2. CNA #1 reported that the sling had leg straps that go behind and between the legs then cross to attach to the sling bar. CNA #1 reported lifting Resident #101 off her bed and backing the Hoyer away from the bed, Resident #101 was about chest height from the ground on her (CNA #1 stated her height is 5'6"), one of the leg straps broke, and Resident #101 fell to the floor on her back onto the left leg of Hoyer lift. CNA #1 reported that LPN #1 and the DON came to the room, but she could not recall if they moved Resident #101's arm, legs, shoulder, or any other body part to complete a ROM assessment, CNA #1 reported rolling Resident #101, without holding spinal column specifically aligned, putting a different sling under her, then lifted Resident #101 back to bed with the Hoyer in a slightly cradled position. No one held her neck aligned. CNA #1 reported that Resident #101 has not been out of bed since she returned from the hospital on [DATE]. In interviews on 3/8/11 at 12:50 and 3/9/11 at 8:35 a.m., the Director of Nursing (DON) reported that prior to Resident #101's fall on 2/1/11 the facility did not keep close tabs on the conditions of the slings used to lift residents with the Hoyer. The DON reported that on the day of the fall, 2/1/11, when the sling broke she heard a "holler" and went to Resident #101's room. The DON reported that Resident #101 was shook up, Resident #101 was not in greater pain than normal, the Hoyer was moved from under Resident #101, 2 CNA's rolled Resident #101 to put a different sling under her, and the Hoyer was used to lift Resident #101 back to bed from the floor. The DON reported that no C-spine protection was done and no one held Resident #101's neck, because Resident #101 was not complaining of increased pain. The DON reported that she did not do ROM on Resident #101, LPN #1 did. The DON was shown the Neurological assessment dated [DATE] at 8:47 a.m., signed by her at 9:02 a.m., 9:17 a.m., 9:32 a.m. 9:47 a.m., 10:47 a.m., 11:07 a.m., 11:37 a.m., 12:07 p.m., 1:07 p.m., 2:07 p.m., 3:07 p.m. 4:07 p.m. and 2/4/11 at 4:00 p.m., and asked why upper and lower extremities were not tested . the DON reported that they were "probably done" but she "just forgot to write them down". The DON reported that all the old slings had been replaced after Resident #101 fell on [DATE], because she was unable to determine how long the slings had been in use. In interviews on 3/8/11/ at 1:12 p.m. and 3/9/11/at 8:45 a.m., LPN #1 reported that CNA #1 called her to Resident #101's room and she found Resident #101 laying on her back between the legs of the Hoyer lift with her head at the pole between the legs. LPN #1 reported that she ask Resident #101 if she was hurting anywhere, LPN #1 touched under Resident #101's head to feel for bump and to check for blood. LPN #1 reported that she moved Resident #101's right arm (bent the arm at the elbow), touched the right hip but did not feel anything out of place, so then LPN #1 had Resident #101 lift her right leg then bend at the knee. LPN #1 reported that she did not move Resident #101's head, but Resident #101 was rolling her head side to side. LPN #1 reported that Resident #1 only complained of right back pain. LPN #1 stated that she had Resident #101 lift her left leg a little, but did not bend the left leg at the knee or hip, because Resident #101 probably couldn't have felt it anyhow since she had a stroke that had affected her left side. LPN #1 reported that CNA #1 and CNA #2 then rolled Resident #101 and LPN #1 examined Resident #101's back stating it was pinkish red with some bruising on the right side up and down where the leg of the Hoyer had been. LPN #1 reported that a different sling was placed under Resident #101 with no spinal precautions and a Hoyer was used to put her back to bed. LPN #1 reported that after Resident #101 was back to bed she gave her pain and anxiety medications at 9:00 a.m.. In an interview on 3/15/11 at 1:50 p.m., CNA #4 reported that after the fall from the Hoyer sling Resident #101 was very fearful to get up out of bed. In an interview on 3/15/11 at 3:55 p.m., LPN #2 reported that Resident #101 was not improving physically since coming to this facility. Review of the Emergency Department History and Physical dated 2/1/11 at 4:24 p.m. reflected Resident #101's weight as 290 pounds, ...a large bruise behind the left knee,...her left arm had quite a bit of contracture on that side already. Review of the Hospital X-ray dated 2/1/11 at 5:49 p.m., reflected that Resident #101's exam documented "There are at least 3 minimally displaced right rib fractures. The ribs involved include 8, 9, and 10". Observations by surveyor on 3/9/11 at 8:45 a.m. and 3/10/11 at 10:00 a.m. and 12:30 p.m. revealed CNA #1, CNA #2, CNA #5, and CNA #6 transfer different residents using the Hoyer lift. The surveyor did not observe CNA #1, CNA #2, CNA #5, and CNA #6 conduct a visual inspection of the sling per the facility guidelines documented in, Lift Sling Safety Inspection and Care dated 2/1/11. In an interview on 3/14/11 at 8:00 a.m., CNA #6 reported that the slings are "checked daily at the beginning of my shift". The Administrator was notified on 3/10/11 at 12:02 p.m. of the Immediate Jeopardy that began on 2/1/11 as a result of failure to provide adequate assessment and emergency treatment after a fall from a mechanical Hoyer lift sling while suspended four feet off the floor and landing on her back onto the one inch wide, metal leg of a mechanical Hoyer lift, which measured six inches off the floor, including not calling 911 and moving Resident #101 without adequate support. This deficient practice placed all residents who require the use of a mechanical Hoyer lift at high risk for possible physical harm, injury, and death. On 3/14/11, the Surveyor confirmed that the facility staff completed the following to remove Immediate Jeopardy: 1. On 3/10/11 the Policy and Procedures related to Range of Motion and Neurological Assessments related to a fall were reviewed. 2. On 3/10/11, 12 of the 14 licensed nurses received in-service training on the policy and procedures related to range of motion and neurological assessments at the time of a fall, as well as not to move the resident if there is any suspicion of spinal injury. The 2 nurses on vacation will receive in-service prior to their next scheduled shift. 3. On 3/10/11, 17 of 26 Certified Nursing Assistant's (CNA) were inserviced on fall protocol, including not to move resident and immediately notify charge nurse. The remaining CNA's will be inserviced prior to their next scheduled shift. 4. Beginning 3/10/11, the Falls Prevention Policy and Procedure will be included in the general orientation of all newly hired nurses. 5. As of 3/10/11, monitoring and return demonstration regarding Neurological Assessments and Range of Motion will begin, and be reviewed monthly with each nurse for 3 months. The Director of Nursing will be responsible to review the Neurological Assessments and Range of Motion demonstrations with the licensed nurses. 6. Beginning 3/10/11, the Director of Nursing will monitor five CNA's per week on various shifts to verify sustained compliance that a charge nurse is immediately notified after a fall and that the resident is not moved. Although the Immediate Jeopardy was removed on 3/10/11, the facility remained out of compliance at a scope and severity of isolated with actual harm that is not Immediate Jeopardy due to not all staff in-service training completed, and sustained compliance had not be verified by the State Agency. ( )