Every finding on record at Martha T Berry MCF

Based on observation, interview, and record review, the facility failed to provide a homelike environment including the availability of warm/hot water, for nine residents (R36, R81, R82, R85, R87, R89, R123, R136, and R160). Findings include:R36 On 3/31/26 at 9:45 AM, R36 was observed lying in bed watching television. R36 pointed to the foot of the bed and stated, Those holes bother me. I don't like that and I wish it was fixed. The footboard at the end of the bed was noted to have two large open areas where the laminate on the footboard was missing and loose. Further observation revealed, in the wall behind the bed was a large hole about 6 inches long and 3 inches wide. A record review revealed R36 was admitted on [DATE] with the following medical diagnoses of Hypertension and Anxiety Disorder. R36's Brief Interview of Mental Status assessment score was 15/15 indicating intact cognition. On 4/01/26 at 10:30 AM, a tour of R36's room was conducted with the Housekeeping Director J and acknowledged the previously noted areas were in need of repair. On 4/02/26 at 10:08 AM, an interview occurred with the Maintenance Director K discussing the areas of concern and confirmed the areas were in need of repair and all rooms should be in good repair and comfortable for all residents. A review of the facility's policy titled Homelike Environment policy documented in part, .the facility provides a personalized, homelike environment that recognizes the individuality and autonomy of our residents to provide an opportunity for self-expression and encourage links with the past, family members and friends. On 3/31/26 at 3:55 PM, a family member of Resident #87 reported that Resident #87 told her the water in the shower room often runs cold. On 04/01/2026 between 10:00 AM-10:30 AM, the following hot water temperatures were measured (the hot water was running for 3 minutes): Rm 2174/2176 (Resident 87,160): 80 degrees Fahrenheit Rm 2170/2172 (Resident #81, 85): 99 degrees Fahrenheit Rm 2130/2132 (Resident #82, 89): 77 degrees Fahrenheit Rm 2126/2128 (Resident #123, 136): 86 degrees Fahrenheit. When queried at that time about the hot water temperature in their bathroom, Resident 136 stated It's cold! Resident 136 further stated that the water starts out warm, but that it is cold by the end of the shower. Review of the facility's hot water temperature logs revealed that the hot water temperatures in the above-mentioned rooms had last been measured on 3/8/26. Review of the facility policy Room Environment Safety revised 3/9/26 noted: Each resident has the right to be treated with respect and dignity, which includes a safe, clean, comfortable and homelike environment .8. To assure comfortable and safe temperature levels are maintained .Water temperatures are maintained between 105 and 115.

Based on observation, interview, and record review the facility failed to provide timely repositioning and transfer assistance for two dependent residents (R85, R160) of three observed for quality of care. Findings include: R85On 03/31/2026 at 12:10 PM, 12:31 PM, 12:40 PM, and 1:17 PM, R85 was observed in the alcove dining area along with eight other residents. R85 was in a 'Broda' style wheelchair (designed for safer positioning and fall prevention). R85 was leaning toward the left side of the chair with the left shoulder lower toward the armrest. At 1:17 PM, R85's head was on the left side bolster, and the torso was leaned over to the left and scrunched down slightly. R85 did not respond to queries. At 1:36 PM, the left elbow was sticking out the back side of the wheelchair between the back support and side of the wheelchair. R85 moved their left leg up and down as it hung over the left arm of the wheelchair. At 2:08 PM, the chair had been leaned back to around 30-45 degrees. At 2:53 PM, R85 was observed in the wheelchair. R85 was observed leaning toward the left side of the chair with their arm hanging out the back side of the chair. The head of the chair was up around 30-45 degrees. On 04/01/2026 at 8:11 AM and 9:02 AM, R85 was in bed lying on their left side, facing the left side of the bed, dressed in a hospital style gown. A foam wedge was on the floor at the left side of the bed. At 9:40 AM, R85 was sitting up with the head of the bed around 30-45 degrees. At 10:00 AM, R85 was in bed as before. At 11:32 AM, R85 was in bed with the head up around 30-45 degrees with the foam wedge at left edge of bed. At 2:00 PM, R85 was in the 'Broda' wheelchair in the alcove dining area. R85's arm was through the opening at the back of the chair and R85 intermittently grabbed the lower frame of the 'Broda' wheelchair. Staff walked over to R85 as the surveyor entered and encouraged R85 to change position but did not change the position of R85.A review of the facility records for R85 revealed R85 was admitted into the facility on [DATE]. Diagnoses included Paralysis of the Right Side, Malnutrition, and Dementia. The care plan high risk for falls revised 03/19/26 documented, Offer assistance if I adjust myself in the wheelchair due to poor trunk control . wedge cushions for pressure relief removed from skin care plan . The active care plan further documented, .need staff to anticipate my care needs . The Minimum Data Set (MDS) assessment dated [DATE] documented severely impaired cognition and the need for substantial/maximal assistance to roll left and right in bed and dependent on staff for dressing, eating, toileting, hygiene, transfer and ambulation.On 04/02/2026 at 11:43 AM, Registered Nurse (RN) E reported the care plan for R85 was appropriate. R160A review of the facility records for R160 revealed R160 was admitted into the facility on [DATE]. Diagnoses included Chronic Ulcer of Left Heel, Malnutrition, and Dementia. The care plan risk for falls revised 03/24/26 documented, .care plan has been developed, reviewed or revised . Report any significant changes . The active care plan further documented, .have a diabetic ulcer to left heel . The self-care performance deficit care plan documented, .out of bed and ready for visits around 11 AM (initiated 01/16/25, revised 03/27/26) . even when I am sitting and visiting with family, interrupt me and make sure I do not have soiled briefs (initiated 05/07/24, revised 03/27/26) . The Minimum Data Set (MDS) assessment dated [DATE] documented severely impaired cognition and dependence on staff to roll left and right in bed, and for dressing, toileting, hygiene, transfer and ambulation. On 04/01/2026 at 8:37 AM, R160 was observed on their back in bed, dressed on the upper body only. At 9:06 AM, R160 remained on their back in bed with the head up around 30-45 degrees. At 10:00 AM, R160 was in bed as before. At 11:32 AM, R160 continued in bed as before, glasses on, eyes closed, the head of the bed up around 30-45 degrees. R160's head was tilted down slightly and over to the right shoulder. At 11:49 AM, a family member came to visit and R160 was in bed as before. At 12:17 PM, R160 was dressed and seated in a wheelchair in the main dining room with the family member (one hour and 17 minutes after care planned time of 11:00 AM).On 04/02/2026 at 8:06 AM, R160 was on their back in bed, with the head of the bed up around 30-45 degrees. At 9:28 AM, R160 was in bed, the head of the bed was up around 45-60 degrees, and a staff member was assisting R160 to eat. At 12:04 PM, R160 was on their back in bed, with the head up around 30-45 degrees and had a family member in the room and not up in their wheelchair and ready to go to the main dining room for lunch. On 04/02/2026 9:33 AM, Certified Nursing Assistant (CNA) G reported R160 required total care and may help with their arms but was not likely to initiate activity. A review of the facility policy titled, Repositioning Policy last dated 01/06/26, revealed, Purpose: To provide guidelines for safe repositioning of residents, to relieve pressure on bony prominences, increase circulation, and provide comfort. Policy: It is the policy of (the facility) to ensure that residents who are unable to change position without assistance are repositioned appropriately . Residents will be maintained in correct body alignment to the extent possible, knowing the resident may be able to make smaller shifts in position between the time staff have provided repositioning for the resident, and the residents physical condition allows (such as contractures/deformities).

Based on interview and record review, the facility failed to ensure the invitation and inclusion in care conferences (participation in planning their own care) of one resident (R103) of two reviewed for care planning. Findings include: On 3/31/26 at 10:27 AM, R103 was asked about their satisfaction with the care and services they were receiving at the facility. R103 stated, I want to get out of here. R103 was asked if they had discussed this issue in their care conference meetings. R103 indicated that they had never attended a care conference meeting and didn't know anything about them. R103 expressed a desire to attend their care conferences. A record review of R103's electronic medical record (EMR) revealed documentation of care conferences being conducted regarding R103 on 11/5/25 and 2/11/26. There was no documentation which indicated the residents' invitation to the conference, attendance, refusal, or a reason why the resident was not in attendance at either care conference. Further review of R103's EMR revealed that R103 was admitted to the facility on [DATE] with diagnoses that included, Dementia and Type 2 diabetes. R103's most recent quarterly minimum data set assessment (MDS) dated [DATE] revealed that R103 had a moderately impaired cognition and required setup and cleanup help with oral hygiene and eating. On 4/2/26 at 10:25 AM, Social Worker (SW) H was interviewed about R103's participation in their care conferences on 11/5/25 and 2/11/26. SW H indicated they had not invited and included the resident in their care conferences due to concerns related to behavioral issues by the resident towards their family. SW H was asked if they had documented these concerns and reasons anywhere in the resident's record to which she responded, No. SW H indicated they should have included the resident in the care planning process. On 4/2/26 at 1:30 PM, the Director of Nursing (DON) was interviewed and asked the standard for who should be invited to resident care conferences. The DON indicated the resident and responsible party should be invited, and the care conference is usually conducted by the social worker. A facility policy titled Baseline/Comprehensive Care Plan Reviewed September 19, 2025 stated the following: Comprehensive Care Plans: 1. The comprehensive care plan will be developed .with input from the resident .d. Include resident preference, potential for future discharge and discharge plan as appropriate. 2. The IDT (Interdisciplinary Team) will discuss the plan of care with the resident .at regularly scheduled care plan conferences. 4. If the resident .is unable to participate in the scheduled care plan conference an explanation will be documented in the medical record.

Based on observation, interview, and record review, the facility failed to apply protective heel boots (footwear used to relieve pressure on the heel) for one resident (R147) out of five reviewed for skin conditions. Findings include:A review of the Electronic Medical Record (EMR) for R147 revealed a physician's order last revised 8/28/2024 for R147 to have protective boots while in bed.Further review of the EMR revealed R147 was admitted to the facility 5/24/2022 with diagnoses of peripheral vascular disease, contracture of right and left knees, chronic pain syndrome, and type two diabetes. Review of R147's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out 15, indicating fully intact cognition. Section M (Skin Conditions) revealed that the resident is at risk of developing pressure ulcers/injuries.On 03/31/2026 at 10:30 AM and 1:15 PM, R147 was observed lying in bed with no protective heel boots in place.On 04/01/2026 at 11:29 AM and 2:08 PM, R147 was observed lying in bed with no protective heel boots in place.On 04/02/2026 at 2:06 PM, R147 was observed lying in bed with no protective heel boots in place. R147 was asked if they refused to wear protective heel boots, and their response was not understandable. A pair of protective heel boots were observed sitting on a wheelchair outside of R147's room.On 04/02/2026 at 2:10 PM, an interview was conducted with Licensed Practical Nurse (LPN) D. They stated they float in different areas and only work on that floor about once a month, but they weren't aware of R147 refusing to wear protective heel boots and said R147 would probably agree to put them on if asked. LPN D said that a Certified Nurse Aide (CNA) may have taken off the protective heel boots to provide care but wasn't sure. After LPN D reviewed R147's EMR, they stated that R147 should have protective heel boots on.On 04/02/2026 at 4:09 PM, an interview was conducted with the Director of Nursing (DON), Assistant Director of Nursing) (ADON) F, and Registered Nurse (RN) Unit Manager E. The DON stated when there is an order for protective heel boots, they should be applied. If a resident refuses, that should be documented in their Treatment Administration Record (TAR). ADON F stated when a resident refuses, staff should attempt to reapproach the resident in an hour to encourage them again. If they continue to refuse, staff should attempt to use a pillow or other intervention the resident will be willing to use and inform management about the resident's repeated refusal. RN E said R147 is known to them to sometimes they are willing to wear protective heel boots and sometimes refuse them.A review of the care plan for R147 (last review completed 2/17/2026) revealed I am at risk for impaired skin integrity related to impaired mobility, contractures, medication use, incontinence, weakness, and recurring diabetic ulcers to my feet. I am known to refuse care and refuse to get out of bed. Interventions in the care plan included Heel protector boots on bilateral feet and/or float my heels with a pillow while in bed.A review of R147's March and April 2026 TARs did not reveal documented refusals for protective heel boot applications. A review of a policy titled Pressure Injury Prevention and Management last reviewed 12/19/2025 revealed .Evidenced-based interventions for prevention will be implemented for residents who are assessed at risk or who have a pressure injury present.

Based on interview and record review the facility failed to ensure appropriate interventions were implemented to prevent a fall with injury for one resident (R901) of three reviewed for falls. Findings include:This citation pertains to Intake 2661503.A review of a progress note by Licensed Practical Nurse (LPN) A dated 10/05/25 at 12:38 PM, documented, Resident was observed lying in the hallway face down in a pile of blood. Writer (LPN A) assisted resident to (their) back then into wheelchair. Writer applied pressure to laceration on (right) R side of forehead and to bridge of nose . Writer asked resident what happened, and (they) began to cry stating that (their) head hurts. Writer applied pressure to bleeding areas until the ambulance arrived. Ambulance arrived and took resident to (hospital). Review of a post fall assessment by LPN A documented, .Post Fall Evaluation Late Entry: Fall Details: Date/Time of Fall: 10/05/2025 11:30 AM. Fall occurred in the hallway. Activity at the time of fall: Ambulating. Reason for the fall was evident. Reason for fall: Ambulating. Did an injury occur as a result of the fall: Yes. Injury details: Hematoma (collection of blood or bruise) in center of forehead, Laceration above R (right) eye . A review of the clinical record for R901 revealed, R901 was admitted into facility on 09/01/2023. Diagnoses included: Dementia with Psychotic Disturbance, Syncope (fainting) and Collapse, and Difficulty Walking. Upon return from the hospital on [DATE] diagnoses included: Zygomatic (cheek bone) fracture, Maxilla (upper jaw) fracture, Le Fort Fracture two and three, (Le Fort indicates a facial fracture and the amount of the face involved. Level one is just the maxilla, two involves in addition the nasal area, and three in addition involves the cheekbones to the level of the eyes.) A Left radius (low arm bone) fracture and contusions to the eyeball and orbital tissues. A review of the hospital discharge notes dated 10/09/25 revealed a physician note dated 10/08/25 which documented, .significant facial swelling . restless . appears uncomfortable . The note also documented admission to the Intensive care unit, opioids for pain and sedatives for the resident's comfort. A review of the Brief Interview for Mental Status (BIMS) scores for R901 dated 08/23/25 documented a score of 3/15 which indicated R901 had a severe cognitive impairment. A review of a care plan dated 9/5/23 for R901 revealed: I am at risk for falls r/t (related to) impaired cognition, impaired mobility, poor safety awareness, incontinence, previous falls, high risk anti-hypertensive & anti-depressant medication use. A care plan intervention added on 9/22/23 documented, Assure elder has assistive device (walker) in reach at bedside and encourage use prior to ambulating. A review of a care plan dated 9/14/24 for R901 revealed: I am at risk for wandering (related to) r/t Cognitive Impairment.A review of the care plan dated 10/3/23 for R901 revealed: I have a potential for decline in ambulation r/t Muscle weakness. Restorative- Ambulate 50 feet with (rolling walker) RW (standby assist) SBA as tolerated.A review of the fall risk evaluations dated 06/07/2025 and 08/30/2025 documented R901 at a 13, with a number greater than ten is considered a high fall risk.On 11/10/25 at 11:29 AM and 12:19 PM, the Director of Nursing (DON) was queried about fall protocol and falls at the facility. The DON reported recent education was provided for activity aide (AA C). AA C had intercepted a resident (R901) walking down the hallway holding onto a bedside table. AA C took the tray table from R901 and instructed R901 to grab the handrail and to stay there. When AA C turned away to return the tray table to the resident's room, R901 walked away from the handrail. The resident then fell. The DON further reported the education to AA C included, you can never tell a demented person to stay and expect them to remember a moment later. On 11/10/25 at 12:41 PM, AA C reported they had known R901 for around two years. AA C recounted the incident with R901 and reported they had been on their way to dietary when they observed R901 coming up the hall to the nurse's station pushing a bedside tray table. AA C met up with R901 in the hallway around twenty feet or so from the resident's room. AA C felt R901 was in danger while using the bedside table and instructed R901 to hold onto the handrail while they went and retrieved the resident's walker. AA C returned the bedside table to the room and before they retrieved the walker they heard a loud noise. AA C exited R901's room to find that R901 had fallen. AA C acknowledged they received education after the incident, to never leave the resident. On 11/10/25 at 3:10 PM, Unit Manager UM D was asked about R901's fall and reported R901 would frequently walk away from their walker and need redirection due to poor safety awareness. UM D recounted the fall and reported staff AA C was seen walking from the nurse station while R901was walking up the hallway from their room. AA C had R901 stand at the railing and holding on. AA C then went to R901's room and as AA C walked away, R901 turned and walked approximately 10-15 steps caught their foot and fell. UM D reported they provided education to AA C which included any resident seen walking without their device should be secured with a gait belt and assisted to a seated position. UM D reported It was the wrong decision. You cannot leave a dementia resident alone.On 11/10/25 at 5:15 PM, the Administrator acknowledged AA C had the opportunity to intervene appropriately and did not. A review of the facility policy titled, Falls - Clinical Protocol with approved date of 07/09/25 revealed, Purpose: To ensure that residents at risk for fall events are identified and that appropriate interventions are put in place to minimize their risk for falling and risk for injury . 3. Residents who score a 10 or higher on the Nursing Advantage Fall Risk Evaluation will be considered a high risk for falls . 8. Supervision is an intervention and a means of mitigating the risk of an accident. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision is based on the individual residents assessed needs and identified hazards in the resident environment. Adequate supervision may vary from resident to resident and from time to time for the same resident .

This citation pertains to Intakes MI00149363 and MI00149481. Based on observation, interview, and record review, the facility failed to implement a dental care plan for one resident (R110) out of one reviewed for comprehensive care plans. Findings include: On 01/27/25 at 10:00 AM R110 was observed laying in bed watching television. R110 was asked about dental care and stated they wanted teeth pulled at a dentist office, not the facility. A review of the medical record revealed R110 admitted into the facility on [DATE] with the following diagnoses, Dysphagia, Malnutrition, Adult Personality Disorders, and Adjusment Disorder. A review of the Minimum Data Set (MDS) assessment on 1/9/25 revealed a Brief Interview for Mental Status (BIMS) score of 9/15 indicating moderately impaired cognition. Further review of of R110's medical record revealed dental consultions and issues with they're teeth. There was no comprehensive dental care plan with interventions noted in the medical record. On 01/29/2025 at 1:00 PM, an interview was conducted with Social Worker A regarding R110's dental care plan to which they responded, they had to go ask the other social worker and try to find care plan. At 2:15 PM, Social Worker A confrimed R110 did need a care plan and there was not one in the current medical record. On 01/29/2025 at 3:15 PM, an interview was conducted with the Director of Nursing (DON) regarding R110's dental care plan to which they replied their expectation is that care plans are completed accurately and timely for each resident. On 01/29/2025 at 2:09 PM, a request was made for the care plan policy and was not recieved by the end of the survey.

Based on observation, interview and record review, the facility failed to implement interventions to prevent the development of a deep tissue injury and subsequent stage 3 pressure ulcer ( full-thickness skin loss) for one resident (R49), of three residents reviewed for pressure ulcers. Findings include: On 1/28/25 at 8:21 AM, R49 was observed in bed eating breakfast, heels flat on the bed. Attempts to interview the resident were to no avail as the resident was pleasantly confused. A review of R49's medical record revealed they were admitted into the facility on [DATE] with diagnoses that included Dementia, Muscle Weakness, and Psychotic Disorder. Further review of R49's medical record revealed they were significantly cognitively impaired, and was dependent for bed mobility per their care plan initiated on 12/13/23. Further review of R49's medical record revealed they sustained a fall on 8/6/24 resulting in a left hip fracture. Further review of R49's medical record revealed the following progress notes: 8/9/2024 18:41 (6:41pm) IDT (interdisciplinary team) Progress Note .Elder continues on IDT for falls. Elder had a fall on 8/6/24 at 18:15 (6:15pm) during a shower the elder had a witnessed fall. The elder was sent to the hospital and was noted to have a left hip fx (fracture). Elder had surgical repair and returned to facility WBAT L/LE (weight bearing as tolerated, left lower extremity) .Elder has hip precautions in place until surgical intervention is clarified with medical records and/or ortho (orthopedics) . 8/10/2024 17:59 (5:59pm) .Braden Scale for Predicting Pressure Ulcer Risk Evaluation Braden Evaluation: Sensory Perception: Slightly limited. Moisture: Rarely moist. Activity: Chairfast. Resident is Very Limited: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. Nutrition: Adequate. Friction and shear: Potential problem BRADEN Score: 16.0 (at risk) . 8/12/2024 11:28 (11:28am) Skin/Wound Note .Elder was readmitted to the facility on [DATE]. During the assessment, the following observations were made regarding the elder's skin: - 20 staples on the left hip - [NAME] and purple bruising on the left hip and left knee - [NAME] bruising on the right knee - Scattered skin tags and age spots on the upper and lower back - Dime-sized abrasion on the left buttock with slow blanching redness, no drainage, no pain, and no odor noted -bilateral feet, dry skin . 9/1/2024 08:03 (8:03am) General Nursing Note .CNA (certified nursing assistant) informed nurse of new skin condition observed on resident bilateral heels. Nurse observed discoloration of Left heel, soft tissue, nonbankable (non-blanchable), and black in color. Right heel exhibited redness slow (blood) return when blanching . 9/1/2024 14:39 (2:39pm) General Nursing Note .Writer alerted of skin concern to residents left heel. Writer assessed resident and noted the following; Darkened areas to left heel, irregular edges noted, surrounding skin normal in color. Heel cool to touch. Orders updated in [medical record]; interventions placed to aide in healing process. Wound care team to follow up. 10/2/2024 16:17 (4:17pm) Skin/Wound Note .Resident seen today by [nurse practitioner]. [R49] is being seen for left heel DTI (deep tissue injury) which is now a stage 3 pressure injury. Wound measures 1cm (centimeter) x 0.8cm x 0.2cm. Scant amount of serous drainage noted. Wound bed has 76-100% slough. The wound is stable. Peri-wound skin texture is normal . 10/4/2024 11:16 (11:16am) IDT Progress Note .[R49] is being brought to IDT for [their] left heel in house stage 3 pressure injury. This wound was previously dx (diagnosed ) as DTI .[R49] is incontinent of bowel and bladder and needs two-person assistance with the gait belt for transfers. Staff assistance is required for bed mobility and turning . Further review of R49's medical record revealed upon the resident returning to the facility on [DATE] following their fracture, they did not have any new orders or care plan interventions to prevent the development of a pressure ulcer to the resident's heels due to their new limited mobility and at risk Braden Score. On 1/29/25 at 12:36 PM, Wound Care Nurse (WCN D) was interviewed regarding R49's pressure ulcer, and confirmed the resident sustained a fall in August and did have a reduction in mobility. WCN D explained interventions implemented once the DTI was identified, but was unable to provide an explanation as to why the resident didn't have interventions in place prior to the discovery of the DTI. On 1/29/25 02:23 PM, an interview was completed with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) regarding R49's pressure ulcer on their left heel. They both acknowledged there were no interventions put into place prior to the development of the DTI, aside from a specialty mattress R49 was on prior to the fracture and all residents receive upon admission into the facility. A review of the facility's Pressure Injury Prevention and Management policy revealed the following, 4. Interventions for Prevention and to Promote Healing a. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). b. Evidenced-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but not limited to: o Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.); o Minimize exposure to moisture and keep skin clean, especially of fecal contamination; o Provide appropriate, pressure-redistributing, support surfaces; o Maintain or improve nutrition and hydration status, where feasible .

Based on observation, interview, and record review, the facility failed ensure a medication error rate not greater than 5%, for one resident (R181) out of four residents observed during medication pass, resulting in a medication error rate of 7.4%. Findings include: On 1/28/25 at 8:16 AM, Licensed Practical Nurse (LPN) B prepared medications for R181 which included Diltiazem (to treat high blood pressure) ER (extended release) and Methenamine Hippurate (to prevent urinary tract infections). After placing all medication tablets in a medication cup, LPN B stated oh the other nurse told me that they need to be crushed. LPN B explained there is a standing order that states medications can be crushed if needed. LPN B explained they had a reference book indicating medications could and could not be crushed. LPN B was then observed to reference the medication book and stated, I don't see them in here. LPN 'B then crushed all the medications, mixed them with pudding, and administered them to R181. LPN B was asked if they could call the pharmacy to ask if a medication should be crushed if it was not in the book. LPN B replied yes. A review of R181's medical record revealed they were admitted to the facility on [DATE] with a diagnosis of Unspecified Dementia, Arthritis, and other specified disorders of bladder. Further record review revealed a Brief Interview for Mental Status score of 3, indicating significant cognitive impairment. Further review of R181's medical record revealed the following active medication orders: Methenamine Hippurate oral tablet 1 GM (gram). Give 1 tablet by mouth two times a day for UTI (urinary tract infection) prevention; Diltiazem HCL (hydrochloride) ER (extended release) oral tablet extended release 24-hour 240 mg (milligrams) Give 240mg by mouth one time a day for HTN (high blood pressure). On 1/28/25 at 3:23PM, Unit Manager (UM A) explained any extended-release medication should not be crushed, and that LPN B should have called the pharmacy if they were not sure. At this time a phone interview was conducted with Pharmacist C. Pharmacist C explained that Diltiazem ER is an extended-release medication and should not be crushed and explained that if Diltiazem ER is crushed the resident would get the whole dose of medication all at once instead of a continuous extended release which could cause their blood pressure to drop. Pharmacist C explained that Methenamine Hippurate should not be crushed because it has an enteric coating on it and if it were crushed it would irritate the resident's stomach and also since it is a antimicrobial the protein can break down in the stomach acid rendering the medication less effective. On 1/29/25 at 10:11 AM, the Director of Nursing (DON) explained if a medication is not listed in the reference book the nurse should call the pharmacy for clarification. A review of the facility's policy titled Crushed Medications revealed the following: Policy: It is the policy of (facility) to ensure medications administered crushed will be administered according to standards of practice for safety and accuracy in medication administration and free of significant medication errors. Procedure: 1. Medication shall be crushed according to physician orders .3. The pharmacist will review medications to be crushed for safety and stability .

Based on observation, interview, and record review, the facility failed to administer a pain patch for one sampled resident (R28) of one review for medication administration. Findings include: On 1/27/25 at 1:36 PM, R28 was asked about the care at the facility and stated, Yesterday they didn't give me my pain patch. R28 reported this happens often. A review of R28's medical record revealed, R28 was admitted to the facility on [DATE] with diagnosis of Chronic Obstructive Pulmonary Disease (COPD). A review of R28's Minimum Data Set (MDS) assessment dated [DATE], noted R28 with an intact cognition and requires staff assistance to complete activities of daily living (ADLs). A review of the Medication Administration Record (MAR) for December 2024 revealed, Lidocaine Patch 4 % Apply to the painful area topically one time a day for Musculoskeletal pain. Apply to the affected areas/painful region -Start Date 06/17/2023. On December 20th the MAR was marked with a 9 indicated see nurses notes (for reason why not administered). A review of the cooresponding nursing noted did not document the reason the Lidocaine Patch medication was not administered. A review of R28's MAR for January 2025 revealed, Lidocaine Patch 4 % Apply to the painful area topically one time a day for Musculoskeletal pain. Apply to the affected areas/painful region. On January 24th the MAR was marked with a 9 indicated see nurses notes. A review of the cooresponding nursing noted did not document the reason the Lidocaine Patch medication was not administered. On 1/29/25 at 9:53 AM, Unit Manager A was asked about the number code 9 and the expectation for that code. Unit Manager A explained the nurse should put in a note to explain the reason whay a medicaiton is not given. Unit Manager A was asked if the Lidocain patch was a medication the facility had in their storage/backup box and later confirmed the facility does have that medication on hand and available for administration without waiting for the refill. A review of R28's care plan revealed, Focus: I am at risk for pain related to/resident has chronic pain related to Pressure points, Reduced mobility Date Initiated: 02/19/2021. Goal: If my pain exceeds what I deem as comfortable, my medication will be effective (reduce and/or relieve) within one hour of administration through next review date. Date Initiated: 02/19/2021. Interventions: Monitor my pain level for effectiveness of analgesic within one hour after administration. Date Initiated: 02/19/2021. Nursing and Therapy staff will confer with my physician if I display signs of pain or verbalizations of pain to determine if a medication adjustment is appropriate. Date Initiated: 02/19/2021. On 1/29/25 at 3:08 PM, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were asked about the medication not being available. The ADON explained the facility has the Lidocain patch on hand and is available for the residents. The DON explained there should be documentation when number code 9 is documented on the MAR. A review of the facility's policy titled, POLICY: MEDICATION - NOT READILY AVAILABLE dated 07/20/2024 noted, PURPOSE: There may be occurrences when resident medications are not readily available. The facility provides pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs/biologicals to meet the needs of each resident. This policy provides guidelines for licensed nursing staff if a medication(s) is not readily available. POLICY: It is the policy of [name of facility] that the facility accurately and safely provides and/or obtains pharmaceutical services, including the provision of routine and emergency medications/biologicals to enable continuity of care for current residents and an anticipated admission or transfer of resident from acute care or other institutional setting. PROCEDURE: 1. The facility will utilize a systematic approach to provide or obtained routine and/or emergency medications and biologicals in order to meet the needs of each resident. 2. Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner. 3. Each time that a nurse is administering medications he/she will observe the current availability of medications and re-order medication in a timely manner. 4. A STAT supply of commonly used medications is maintained in-house for timely initiation of medications. This would be through emergency medication boxes or Pyxis machine use, (if available). 5. In the event of a new order the facility is allowed 24-hours to begin a medication unless otherwise specified by the physician.

Based on observation, interview and record review, the facility failed to implement adequate supervision, and effective fall interventions for one sampled resident (R117) of four residents reviewed for falls, resulting in multiple falls, and a hospitalization . Findings include: On 1/28/25 at 8:28 AM, R117 was observed in bed on their back, floor mats observed on both sides of the bed. Attempts to interview the resident was to no avail due to their cognition. A review of R117's medical record revealed they were admitted into the facility on [DATE] with diagnoses that included Dementia, Hypertension, and Muscle Weakness. Further review revealed the resident was severely cognitively impaired with a brief interview for mental status score of 3/15, had a language barrier, and was dependent on staff for all activities of daily living. Further review of the resident's medical record revealed the following progress notes related to unwitnessed falls: 9/17/2024 13:22 (1:22pm) Incident Note .Resident observed kneeling on [their] knees next to the bed on the floor mat by the activities lady. Resident was asked if [they were] okay, and the resident replied 'yes' 9/25/2024 16:45 (4:45pm) Incident Note .Observed on the floor in the dining room door entrance sitting sloughed (slouched) against the wall with wheelchair unlocked slightly near the resident . 9/30/2024 19:46 (7:46pm) General Nursing Note .Approx (approximately) 11:45 writer observed resident on footrests of w/c (wheelchair) leaning on left side of body. 10/9/2024 20:35 (8:35pm) General Nursing Note .Writer was informed by CENA (certified nursing assistant) elder was on the floor. Upon arrival elder was sitting on buttock, elder has floor mats which were in place. Elder was facing the hallway with feet pointed out towards the hallway pulling on [their] peg tube (feeding tube) . 11/1/2024 03:45 (3:45am) General Nursing Note .The resident was found on the floor in the hallway after an unwitnessed fall . 11/1/2024 16:20 (4:20pm) Incident Note .Writer received in report elder had an unwitnessed fall during night shift. during day shift while doing care CENA report elder in moderate pain, writer went into elder room elder shows s/o (signs of) pain guarding right hip, facial grimacing, limited ROM (range of motion) . 11/2/2024 07:30 (7:30am) General Nursing Note [Physician] was notified of elder Xray results. Right femoral neck fracture (upper leg bone), order was given to send elder to hospital . 1/9/2025 10:44 (10:44am) Incident Note .Writer called into room by therapist because resident was halfway out of bed, upon arrival [R117] was on the floor sitting with [their] back against the bed, legs on the floor. Pt (patient) reported not knowing how [they] got on the floor . A review of R117's fall care plan revealed the following: Focus: I am at risk for falls r/t (related to) cognitive impairment, decreased mobility 2/2 right hip fracture and Parkinson's disease, and poor safety awareness. Date Initiated: 04/06/2023 Interventions: -Frequent rounding for safety Date Initiated: 04/27/2023 -I have a preference and safety need to not go to bed until after 8pm unless requested by elder Date Initiated: 10/10/2024 -I need constant reminders not to get up out of bed on my own. Date Initiated: 08/11/2023 -I need to be offered time to stretch my legs with assistance after sitting for long periods Date Initiated: 05/06/2024 -I will attempt to pick stuff up off the floor after I eat. Please clean the floor around me after I eat for safety Date Initiated: 06/24/2024 -I am incontinent, and I will attempt to self-transfer, please offer frequent checks for improved safety and comfort. Date Initiated: 01/16/2024 -If you see that I am restless please offer to get me up into my w/c and offer engaging activity Date Initiated: 08/14/2023 -Mediation review. Date Initiated: 01/09/2025 -Offer to assist me to bed for a nap after meals. Date Initiated: 04/14/2024 -Place me in common area anytime I'm awake to prevent me from falling. Date Initiated: 04/20/2023 Please bring me to the dining room prior to AM meal as tolerated Date Initiated: 01/23/2024 -Please get me up for activities daily Date Initiated: 11/05/2023 -Please have dycem in my W/C to help prevent me from sliding. Date Initiated: 04/24/2023 - Please have non-skid socks on while in bed, non-skid footwear out of bed Date Initiated: 04/24/2024 -Please toilet me before and after meals Date Initiated: 06/21/2024 -Reinforce need to call for assistance. Date Initiated: 04/07/2023 -Sometimes I enjoy breakfast in bed, when I am done eating, please offer to get me I will use bilateral floor mats at bedside for increased safety r/t impaired safety awareness -When I go down for bed, ensure I have a night snack. Date Initiated: 04/25/2024 - When in D/R (dining room) please have me seated at the table nearest the TV as I require closer supervision and have a preference for this table Date Initiated: 06/14/2024 -while placed in the common while awake I will be provided engaging activity to assist with maintaining safety. Date Initiated: 01/09/2025 On 1/29/25 at 11:51 AM, R117's falls and interventions following the falls were reviewed with the Risk Investigation Manager (RIM), and noted the following: -Regarding the 9/17/24 fall, the intervention was for the resident to be offered to get into their wheelchair and to an activity. -Regarding the 9/25/24 fall, the intervention was for a medication review however, prior to the review, the resident sustained another fall. The RIM acknowledged upon reviewing that fall, the resident did not have a dycem (non-slip material used for stabilization) in their wheelchair which had been care planned and was not being implemented. There were also no additional fall interventions following this fall. -Regarding the 10/9/24 fall, the intervention was for the resident to not go back to bed until 8pm unless requested by the elder. The RIM was asked about the resident's language barrier and explained the resident can shake their head for yes or no when answering questions. -Regarding the 10/31/24 fall, the resident was transferred to the hospital after sustaining a fracture however, upon the resident's return, the RIM acknowledged there were no interventions put into place. The RIM was asked about the process for assessing care planned interventions to ensure they are effective, and explained that falls are assessed for 72 hours following a fall in which the interdisciplinary team reviews the intervention and revise as needed. On 1/29/25 at 2:33 PM, an interview was completed with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) regarding R117's falls and effective interventions not being in place. The DON acknowledged the interventions should be in place, and efforts have been put into place to decrease falls within the facility. A review of the facility's Falls-Clinical Protocol revealed the following, 6. A comprehensive care plan will be completed and will address risk factors identified during the fall risk assessment. Interventions will be implemented accordingly. 7. Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision is based on the individual residents assessed needs and identified hazards in the resident environment .

Based on interview and record review, the facility failed to ensure an update for a preadmission screening (PAS) and resident review (ARR) /Hospital Exempted Discharge for a Level II evaluation was completed for one resident (R187) of three residents reviewed for PASARR. Findings include: A review of the medical record revealed that R187 admitted into the facility on [DATE] with the following diagnoses of paranoid schizophrenia, post traumatic stress diorder and dissociative identity disorder. A review of the most recent Minimum Data Set assessment dated [DATE] was completed with a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. A review of the medical record revealed a Preadmission Screening with a hospital exemption dated on 9/18/24. There was no change in condition for hospital discharge within 30 days and the PASSAR had not been updated. There was no additional PASARR forms nor was a Level II screening requested due to R187 having mental illness diagnoses. On 01/28/2025 at 10:57 AM, an interview was conducted with Social Worker A regarding R187's level II screening not being completed. Social Worker A stated were not aware or who had been completing the 3877/3878 forms. On 01/29/2025 at 3:15 PM, an interview was conducted with the Director of Nursing (DON) regarding R187's level II screening not being completed. The DON said her expectation is the PASARR's and level II for each resident are completed accurately and timely per the policy. A review of a facility policy titled, RESIDENT ASSESSMENT- COORDINATION WITH PASARR PROGRAM revealed the following: 3. Individuals admitted under a Hospital Exempted Discharge and remains in the facility longer than the 30 days, must be screened by an authorized facility designee using the State's Level I screening process via Form DCH 3877 and the designee must refer any resident who has or may have MD, ID or a related condition to the appropriate state-designated authority for Level II PASARR evaluation and determination.

Based on observation, interview, and record review, the facility failed to implement skin interventions and date skin care treatments, for one sampled resident (R153) of three reviewed for skin. Findings include: On 1/27/25 at 1:34 PM, R153 was observed in their room sitting in a wheelchair. R153 was asked about the care at the facility and mentioned they need a new bandage strip. R153's right elbow was observed with a brown bandage on it without a date and intial, R153's right upper thigh was observed with a brown bandage on it without a date, and R153's right leg was observed with a discolored area that was not covered. R153 explained the facility has not followed up and changed the bandages for a few days. On 1/29/25 at 9:42 AM, R153's skin on the left leg was observed with a large red area that had a large blister that was not covered. R153 reported it was not covered on 1/28/25 and the bandage on their right elbow needed to be replaced because it fell off. On 1/29/25 at 9:45 AM, Unit Manager A was asked to observe R153's skin. Unit Manager A reported R153 should have a bandage on the left leg and when skin treatments are completed the nurse is required to date and initial the bandage. On 1/29/25 at 10:51 AM, the Wound Nurse was asked the facility's expectations regarding wound treatments. The Wound Nurse reported, R153's treatments are completed on the night shift and the nurse should've dated and signed the bandage. A review of R153's medical record revealed two physian's orders: -Cleanse left anterior thigh with normal saline pat dry apply xeroform and cover with dry dressing every night shift and as needed for abrasion. Start 12/11/24 - end date: Indefinite. -Cleanse left and right legs with normal saline, pat dry, apply xeroform (gauze dressing) to open areas and cysts cover with ABD (dressing used to cover and protect wounds or incisions) and wrap lightly with kerlix. every night shift for wound care and as needed for wound care. Start 1/14/25 - end date: Indefinite. A review of R153's Treatment Administration Record (TAR) noted on 1/23/25, the order to cleanse left and right legs with normal saline, pat dry, apply xeroform to open areas and cysts cover with ABD and wrap lightly with kerlix every night shift for wound care, treatment box was without documentation the treatment was completed. Further review of R153's medical record revealed R153 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Acute Respiratory failure. A review of R153's quarterly Minimum Data Set (MDS) assessment, dated 10/22/14 noted R153 with an intact cognition and they required staff for activities of daily living. A review of R153's care plan revealed, I am at risk for impaired skin integrity r/t (related to) impaired mobility. Date Initiated: 01/13/2023. Goal: My skin will remain intact through the review date. Date Initiated: 01/13/2023. Interventions: Skin assessment weekly per protocol. Interventions to be implemented as needed based on findings. Date Initiated: 08/05/2024. Focus: I am at risk for complications r/t abrasion on L (left) thigh. Date Initiated: 12/13/2024. Goal: My skin abrasion will be healed by review date. Date Initiated: 12/13/2024. Interventions: Monitor/document location, size and treatment of skin abrasion. Report abnormalities, failure to heal, s/sx (signs and symptoms) of infection, maceration etc. to MD (medical doctor). Date Initiated: 12/13/2024. On 1/29/25 at 3:07 PM, the Director of Nursing (DON) was asked the facility's expectation regarding documentation of treatments. The DON reported the treatments should be dated and initialed when completed. A review of the facility's policy titled Wound Care and Treatment Standard Operating Procedures dated 04/10/19 noted, PURPOSE The purpose of this Standard Operating Procedure is to ensure the clinical team treats resident wounds as part of the skin integrity program . 4. PROCEDURES This procedure is to be performed when it has been determined by the wound care nurse or physician or wound care specialist that a wound treatment is required and ordered: . 14.Dress wound. [NAME] dressing with initials, time, and date and apply to dressing .

This citation pertains to Intake: MI00146692 Based on interview, and record review, the facility failed to ensure protection from misappropriation of property for one resident (R700) out of one resident reviewed for abuse . Findings include: Reviewof a facility reported incident documented, A resident's (R700) debit card ws obtained and used by an employee without the permissionof the resident or their responsible party. The suspected employee was brought in for interviewing and confessed to using the card without permission . On 9/17/24 at 10:45 AM, R700 was observed in they're room laying in bed. R700 unable to recall the incident. A review of R700's clinical record revealed R700 was admitted into the facility on [DATE] with diagnoses that included: chronic Obstructive Pulmonary Disease, Psychotic disorder with Hallucinations. A review of R700's Minimum Data Set (MDS) assessment dated [DATE] revealed R700 had a Brief Interview of Mental Status (BIMS) assessment score of 6 indicating severe cognitive impairment. On 9/17/24 at 1:25 PM a phone interview was held with 700's daughter regarding the alleged incident. R700's family member stated, I gave my mother the purse with the wallet in it about six months ago because those items helped her feel independent. I had no idea this would happen until we noticed the charges on the card. It never crossed my mind that this would happen. There was cash and the card in the wallet. I quickly reported it to the police and the facility who conducted an investigation. An interview occurred on 9/17/24 at 2:04 PM, with the Risk Investigation Manager (Nurse A) who conducted a facility investigation stated ,Once the family notified our social worker charges had been made on the card, the facility reported the incident to the State Agency, the (name of local sheriff's office) and started our investigation. Once the vending machinnes confirmed the charges were made in the facility, we were able to coordinate the times of the transactions at the vending machine with the facility camera's to determine an alleged suspect. Upon identifying the perpatrator and interviewing them, perpetrator admitted the crime and was terminated. On 9/17/24 at 1:35 PM, an attempt to reach the perpetrator occurred but there was no answer and a message was left. A review of the facility's investigation revealed the following conclusion, the facility has substantiated that abuse occurred in the form of misappropriation of a resident's property. A resident's debit card ws obtained and used by an employeewithout the permissionof the resident or their responsible party. The suspected employee was brought in for interviewing and confessed to using the card without permission. Video footage confirmed the employee's whereabouts during the time the care was used. The resident's responsible party was reimbursed . A review of the policy entitled, Resident Abuse, Neglect and Exploitation Program revealed the following : Residents have the right to be free from abuse, neglect, exploitation and misappropriation of property. It is our responsibility to protect these rights with a program that detects, monitors and trains staff on the signs of abuse, neglect, exploitation and misappropriation of property and screens out individuals that may pose a threat to our residents, thoroughly investigate allegations and suspicions of these actions, and report to the proper agencies in a way that meets state and federal requirements. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included: 1. The identification of like residents and their responsible parties who had credit or debit cards in their possession. 2. Audit like residents to ensure no one else had unauthorized charges on their card. 3. Interview self responsible residents to verify their accountsand unauthorized charges. Measures systemic changes made to ensure that deficient practice will not occur and affect others 1. All staff were re-educated on following about misappropriation of resident's property. 2. All staff were re-educated on the abuse policy How facility monitors its corrective actions to ensure same deficiient practice is corrected and will not recur. 1. The social Work department / designee will interview residents/ responsible parties duringresident care conferences regarding unusual transactions of residents personal funds weekly for four weeks, the monthly for four months and quarterly until compliance is met. 2. The Social Worker / Unit Manager will query employees about misappropriation weekly for weeks and then monthly untils compliance is met. Date of compliance 9/3/24. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to Intake M100139900. Based on observation, interview and record review, the facility failed to ensure that call lights remained within reach for six (R30, R62, R83, R110, R131, R136) of 13 sampled residents, resulting in resident and family member dissatisfaction with care and the potential for delayed or unmet care needs. Findings include: R83 Review of the medical record facesheet for R83 revealed an admitted [DATE] with diagnoses that included Dementia, Anxiety Disorder and Muscle Weakness. The Minimum Data Set (MDS) assessment dated [DATE] indicated R83 required primarily total (Dependent) assistance for activities of daily living (ADLs). The Brief Interview for Mental Status (BIMS) score of 10/15 indicated moderate cognitive impairment. On 11/13/23 at 2:56 PM, R83 was observed laying in bed. R83's call light was observed on top of the tall wardrobe storage cabinet adjacent to the head of the bed out of the resident's reach. Review of R83's Care Plan dated 08/09/23 revealed a Focus area identifying R83's need for ADL assistance due to impaired mobility. This Focus area included the following Intervention statement: I move my call light by unclipping it from linens to adjust myself in and around the bed. Please check my call light frequently that I can reach it. On 11/15/23 at 1:36 PM, R83 was observed laying in bed. The call light was observed hanging through the hole in the headboard and to the floor, out of the resident's reach. It was noted that although the facility had identified the resident's history of removing the call light, observations revealed the call light was placed in a manner and location that was highly unlikely to have been placed by the resident. On 11/15/23 at 1:39 PM, R83's family member was visiting and was interviewed regarding the concerns expressed in the Intake called into the State Agency. The family member reported that during daily visits they continue to regularly find the resident's call light placed out of reach. R62 Review of the medical record facesheet for R62 revealed an admitted [DATE] with diagnoses that included Dementia, Anxiety Disorder and Rheumatoid Arthritis. The MDS assessment dated [DATE] indicated R62 required primarily moderate/maximum assistance for ADLs. The BIMS score of 3/15 indicated severe cognitive impairment. Further review of R62's record revealed a history of multiple falls. R62's Care Plan dated 08/16/23 included a Focus area addressing the resident's fall history that included the Goal area of keeping the resident free of falls. This Goal area included the following Intervention: I will stay in bed when the lights are out at night and I will use my call light to ask for assistance to get up. On 11/15/23 at 9:11 AM, R62 was observed laying in bed. The call light was observed laying on the floor above the head of the bed near the wall, out of the resident's reach. R30 Review of the medical record facesheet for R30 revealed an admitted [DATE] with diagnoses that included Acute Respiratory Failure, Vascular Dementia and Cerebral Infarction. The MDS assessment dated [DATE] indicated R30 required primarily maximum assistance for ADLs. The BIMS score of 4/15 indicated severe cognitive impairment. On 11/14/23 at 9:48 AM, R30 was observed laying in bed and the call light was observed laying on the floor out of the resident's reach. R110 Review of the medical record facesheet for R110 revealed an admitted [DATE] with diagnoses that included Neurocognitive Disorder with Lewy Bodies, Parkinson's Disease and Anxiety Disorder. The MDS assessment dated [DATE] indicated R110 required primarily total assistance for ADLs. The BIMS score of 0/15 indicated severe cognitive impairment. On 11/14/23 at 9:49 AM, R110 was observed sitting up in the chair near the foot of the bed facing the door. The call light was observed hanging over the head of the bed behind the resident and out of reach. On 11/15/23 at 10:02 AM, the facility's Director of Nursing (DON) reported that the expectation regarding call lights is that resident's call light always be placed so that the resident can easily access it. 32220 R136 On 11/13/23 at 10:15 AM, R136 was observed to be on their back in bed holding an apple in their left hand. R136 was dressed in a hospital style gown. A pillow was under the knees and lower legs and the heels rested on the bed. The head of the bed was up 30 to 45 degrees, a body wedge was on a chair away from the bed and the call light button was hanging down below the bed frame on the (the resident's left) left side and visible from the doorway. On 11/13/23 at 4:33 PM, R136 was observed to be in bed on their back with the head of the bed up around 30 to 45 degrees. R136 held their head over toward their right shoulder. The call light button was hanging down below the bed frame on the left side. On 11/14/23 at 7:53 AM, R136 continued in bed with a pillow under their knees and their heels on the bed. The head of the bed was up around 30-45 degrees, an apple was on the tray table and R136 was on their back, dressed in a hospital style gown, with their head over to the right shoulder. The call light button was hanging down below the bed frame on the left side. On 11/14/23 at 8:32 AM and 9:17 AM, R136 was observed to be in bed on their back, with the head of the bed lower but raised slightly around 20 to 30 degrees. R136 was covered to the shoulders with a sheet. The call light button was hanging down below the bed frame on the left side. On 11/14/23 at 11:38 AM, R136 was observed to be on their back in bed as before. R136 appeared asleep in bed. R136 had a pillow or other device on the right side. The call light button was hanging down below the bed frame on the left side. On 11/14/23 at 1:14 PM, staff exited the room of R136 with their meal tray. R136 was sitting more upright in bed, with the head up around 45-60 degrees and appeared asleep with their head over toward the right shoulder. A sandwich and danish were on the tray table over the bed. R136 attempted to answer queries but fell back to sleep mid sentence. The call light button remained below bed frame at the head of bed. On 11/14/23 at 4:46 PM, R136 was on their back in bed with the call light at their waist. Their head was over toward the right shoulder and a towel had been placed for the head to rest upon. A half sandwich and an apple were on the tray table. The head of the bed was up around 20 to 30 degrees and R136 appeared asleep. A review of the medical record facesheet for R136 revealed, R136 was admitted into the facility on [DATE]. Diagnoses included Low back back, Reflux Disease and High Blood Pressure. Care plan interventions included keep the wedge positioned under my right side while in bed to prevent/reduce me from leaning over. Date initiated 06/15/23 .heel protector boots on bilateral feet or float my heels with a pillow wihile in bed. Date initiated 05/15/23 .Bed Mobility: I require pertial physical assist with one staff. Date initiated 05/12/23 . The Minimum Data Set (MDS) assessment dated [DATE] indicated intact cognition with a 13/15 Brief Interview for Mental Status score and was dependant on staff for personal and toilet hygiene. The ability to roll left and right was not defined. The 08/08/23 MDS indicated the ability to roll left and right was dependant. R131 On 11/15/23 at 9:25 AM, R131 was on their back in bed, dressed in a hospital style gown, the head of the bed elevated to around 20 to 30 degrees and a towel over their chest. The call light button was hanging down at left side of bed below frame and touched the floor. On 11/15/23 at 10:51 AM, R131 was on their back in bed, dressed in a hospital style gown, with the head of the bed elevated to around 20 to 30 degrees. The call light button was hanging down at left side of bed below frame and touched the floor. On 11/15/23 at 11:01 AM, R131 had been turned toward and onto their right side with a wedge behind their back. The head of the bed appeared slightly lower. The call light button was hanging down at left side of bed below frame and touched the floor. A clip was in place on the call button end. A review of the medical record facesheet for R131 revealed, R131 was admitted into the facility on [DATE]. Diagnoses included Dementia and Parkinson's. The MDS dated [DATE] indicated impaired cognition with a 7/15 Brief Interview for Mental Status score and R131 was dependant for eating, oral hygiene and toilet needs. The ability to roll left and right was not defined. The 07/14/23 MDS indicated the ability to roll left and right was dependant. A wound note dated 11/15/23 documented a pressure ulcer to the sacral/tailbone region. Review of the facility policy titled Answering Call Lights dated 11/08/23 revealed the Purpose statement: Residents admitted to (name of) Medical Care Facility can expect their needs/requests to met in a timely manner. It is our responsibility to ensure the resident's call light is available, within reach, functioning properly and answered promptly. The Procedure section of this policy included the following entries: 1. Facility staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light .5. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room.

Based on observation, interview and record review, the facility failed to provide a privacy bag for a urinary drainage bag for one resident (R79) out of two reviewed for catheters, resulting in loss of privacy and dignity. Findings Include: On 11/13/2023 at 11:05 AM, R79 was observed in the dining area sitting in their wheelchair. R79 was observed to have a catheter, with no privacy bag on the urinary drainage bag. R79 was queried as to if they prefer not to have a privacy bag. R79 stated that they prefer to have a privacy bag on, and that they thought they had the drainage bag with the blue cover on it. A review of the medical record revealed that R79 admitted into the facility on [DATE] with the following diagnoses, Obstructive and Reflux Uropathy, Dysphagia, and Major Depressive Disorder. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental status score of 15/15 indicating an intact cognition. R79 also required extensive two person assist with transfers and bed mobility. On 11/13/2023 at 11:10 AM, Nurse H was informed that R79 did not have a privacy bag for their urinary drainage bag and would like it changed. Nurse H states that they don't know why they had that bag on and would change it. Nurse H then proceeded to take R79 to their room and change the urinary drainage bag to one with a privacy cover. On 11/13/2023 at 11:21 AM, R79 was brought back to the dining area with a privacy bag on their urinary drainage bag. R79 stated that they felt better with the privacy cover on there since they would be going to activities later. On 11/15/2023 at 1:50PM, an interview was conducted with the Director of Nursing (DON) regarding privacy bags and dignity in the facility. The DON stated that I expect that we have a privacy bag for all urinary drainage bags for dignity. The DON stated that usually all the bags have the blue cover, but when residents go out to the hospital or for an appointment and come back then they have a different bag. The DON stated that if this happens, then the bag should be changed immediately. A review of a facility policy titled, Catheter Care, Urinary noted the following, .11. The drainage bag will be stored in a fig leaf drainage bag/dignity/privacy bag to enhance the residents dignity while catheter is in use.

This citation pertains to Intake MI00139900. Based on observation, interview and record review the facility failed to ensure staff cleaned rooms daily for two room areas 2131 and 3133, resulting in the potential for dissatisfaction with room conditions and the accumulation of debris. Findings include: On 11/13/23 at 10:32 AM, 12:42 PM and 4:45 PM, in room [ROOM NUMBER]: The resident was observed to be in bed. A tube feed pump was active and attached to a pole with four legs/feet. On the flat surface of two of the four feet were two [NAME] size areas of what looked like dried tube feeding. Observed under the head of the bed on the floor were: a small wedge (ankle/foot orthotic boot), a call light cord clip and two caps for the tube feeding line (these are removed when the tube feeding is connected to the resident). In room [ROOM NUMBER]: a tube feed pump was active and attached to a pole with four legs/feet. On the flat surface of one of the four feet was a dime size and smaller areas of what looked like dried tube feeding. Observed under the feet of the pole were three caps for tube feeding line. On 11/13/23 at 10:59 AM, Housekeeper J reported that staffing for housekeeping department was good. On 11/14/23 at 7:58 AM, 9:17 AM, 11:42 AM, 1:20 PM and 4:48 PM, in room [ROOM NUMBER]: The resident was observed to be in bed. A tube feed pump was actively infusing and attached to a pole with four legs/feet. On the flat surface of two of the four feet were the same two [NAME] size areas of dried tube feeding. Observed under the head of the bed on the floor was the same: small wedge boot, call light cord clip and two caps for the tube feeding line. In room [ROOM NUMBER]: The resident was observed to be in bed. A tube feed pump was active and attached to a pole with four legs/feet. On the flat of one of the four feet had the same dime size and smaller areas of dried tube feeding. Observed under the feet of the pole were three caps for tube feeding line. At 8:07 AM and 4:48 PM a staff member was observed in the residents room. On 11/15/23 at 10:52 AM, Housekeeper I was asked about the process used to clean the rooms and went through their routine which included wiping door knobs, and light switches, cleaning the bathroom and mopping the floor. On 11/15/23 at 9:27 AM and 10:59 AM, in room [ROOM NUMBER]: The resident was observed to be in bed. The tube feed pump was active and attached to a pole with four legs/feet. On the flat surface of two of the four feet were the same two [NAME] size areas of dried tube feeding. Observed under the head of the bed on the floor was the same: small wedge boot, the call light cord clip and two caps for the tube feeding lines. In room [ROOM NUMBER]: a tube feed pump was active and attached to a pole with four legs/feet. On the flat surface of one of the four feet were the same dime size and smaller areas of dried tube feeding. Observed under the feet of the pole were three caps for tube feeding line. Housekeeping and nursing staff were observed in and out of the rooms multiple times during the survey. A review of the facility policy titled. Routine Cleaning review dated 06/28/23 revealed: Routine Cleaning and Disinfecting Purpose: To ensure proper routine cleaning and disinfection to minimize the risk of spreading infections and communicable diseases. Policy: It is the policy of (name of) Care Facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible . 2. Cleaning considerations include, but not limited to, the following: a. Dry cleaning procedures will be conducted before wet procedures. b. Clean from areas that are visibly clean and least likely to be contaminated to areas usually visibly dirty. c. Clean from top to bottom (bring dirt from high levels down to floor levels). d. Clean from back to front areas. 3. Consistent surface cleaning and disinfection will be conducted with a detailed focus on high touch areas to include, but not limited to: a. Toilet flush handles b. Bed rails c.Tray tables d. Call buttons e. TV remote f. Telephones g. Toilet seats h. Monitor control panels, touch screens and cables i. Resident chairs j. IV poles . 11.Horizontal surfaces with infrequent hand contact (windowsills and hard surface flooring) in routine resident-care areas should be cleaned: a. On a regular basis b. When soiling and spills occur c. When a resident is discharged from the facility .

This citation pertains to Intake MI00139058. Based on interview and record review, the facility failed to protect a vulnerable resident (R84) from unconsentual inappropriate touching by a resident (R166) who had documented sexual behaviors of out of seven residents reviewed for abuse, resulting in emotional distress. Findings include: Review of the facility Five Day Investigation Report submitted to the State Agency revealed that R84 reported to a staff member on 07/09/23 that while in a common activity area they had been touched in a sexually inappropriate manner by R166 and that they found it upsetting. This report indicated that a second staff member reported observing R84 being tearful and expressing emotional distress shortly following the alleged incident. The report indicated that during follow-up facility interviews, R84's responses fluctuated between acknowledging that the incident occurred and either denying or not recalling that the incident occurred. Facility interviews with R166 indicated that they did not recall the alleged behavior taking place. The facility report indicated that review of video surveillance of the incident revealed that R166 had touched R84's breast and had not touched R84's groin area. Review of the medical record facesheet for R84 revealed an admitted [DATE] with diagnoses that included Epilepsy, Traumatic Brain Injury related to gun shot wound to the head (at age 15) and Mild Intellectual Disabilities. The Minimum Data Set (MDS) assessment dated [DATE] indicated R84 required primarily moderate assistance for activities of daily living (ADLs). The Brief Interview for Mental Status (BIMS) score of 9/15 indicated moderate cognitive impairment. Review of R84's Care Plan dated 07/05/22 revealed the Focus area statement Due to my impaired cognition, I am at risk of making decisions that could jeopardize my safety. Per my mother/guardian, I have a history of partaking in activities at the command of males. My mother/guardian has requested for me not to be in the room of male [residents]. The Interventions associated with this Focus area included the following entry: Please offer increased supervision when I am with male residents. Review of the facility medical recordfacesheet for R166 revealed an admitted [DATE] with diagnoses that included Cerebral Infarction, Left (non-dominant) Hemiplegia, Epilepsy and Vascular Dementia. The MDS assessment dated [DATE] indicated R166 required primarily maximum assistance for ADLs. The BIMS assessment score of 15/15 indicated intact cognition. Review of R166's Care Plan dated 06/14/23 included a Focus area that included the following statement: I have a history of making sexually inappropriate comments toward staff. I will also sometimes request staff to provide care to my genital area that may not be clinically necessary and may moan during routine personal care. I often view these behavioral expressions as playful flirtation and not inappropriate The Interventions associated with this Focus area included: - If I moan or make inappropriate statements during care provided to my genital area please explain that you are only completing clinically necessary personal care and that it is not appropriate to make this process appear sexual in nature. - Keep a straight face and avoid displaying an emotional reaction to my inappropriate sexual comments as I may be wanting to get a rise out of you. Provide firm and consistent education that you are here to provide care to me and to please refrain from asking me personal questions or discussing other relationships. - Please provide me with a male CNA (certified nursing assistants) if possible or two female CNAs with care as I am known to make sexually inappropriate comments toward staff. On 11/14/23 at 8:50 AM, R84 was asked about the reported incident involving another resident touching them inappropriately and if they could recall or talk about what happened. R84 stated No way [NAME]. When asked if this was a situation that was difficult to talk about R84 stated No, (name of R166) never touched me anyway. On 11/14/23 at 9:13 AM, R166 was asked if they could recall or talk about an incident involving them touching another resident inappropriately. R166 reported that they and [R84] used to sit together and have sex talk. R166 reported that on the reported occasion they did touch R84 stating I grabbed her breast. I asked her to lift her arm up and then I grabbed her. I can tell you that I regret it now . I don't even like [R84]. I have a new girlfriend now. On 11/14/23, Risk Manager/Registered Nurse (RN) D was interviewed regarding the availability of the video that was referred to in the facility investigation and reported that the video was no longer available in the system and that it had not been saved outside of the automated expiration time. On 11/15/23 at 8:50 AM, Activity Aide K was interviewed and reported that they did recall the reported incident. Activity Aide K stated that they approached R84 following an activity because they appeared upset. When they asked R84 what was wrong R84 reported that R166 had grabbed her breast and her groin and that they did not like it. Activity Aide K reported that they returned R84 to their room, notified the nurse on the resident's unit and called the facility Administrator (NHA) to report the incident. On 11/15/23 at 9:36 AM, CENA L was interviewed and reported that they did recall the reported incident and that shortly after R84 returned to their room they spoke with R84. CENA L reported that R84 was visibly upset and crying and reported that R166 had grabbed their breast and that they did not want R166 to do that and they were upset about it. CENA L reported that they attempted to console and redirect R84. On 11/15/23 at 9:59 AM, the facility Director of Nursing (DON) reported that the facility expectation is that a resident should never be exposed to being touched in an inappropriate or unwanted manner. Review of the facility policy titled Resident Abuse, Neglect and Exploitation dated 04/03/23 includes the Purpose statement: Residents have the right to be free from abuse, neglect, exploitation and misappropriation of property. It is our responsibility to protect these rights with a program that detects, monitors and trains staff on the signs of abuse, neglect, exploitation and misappropriation of property and screens out individuals that may pose a threat to our residents, .Definitions section which includes the following entry: 3. c. Sexual Abuse: Is non-consensual contact of any type with a resident. It includes but is not limited to unwanted intimate touching of any kind, especially breasts or perineal area; .

This citation pertains to Intake MI00135255. Based on observation, interview, and record review the facility failed to provide timely activities of daily living (ADLs) for one dependent sampled resident (R801), resulting in waiting in a soil brief for over an hour. Findings include: On 5/3/23 at 10:16 AM, when entering R801's room it was observed with a strong odor of feces. R801 was asked if they were waiting to be changed and stated, Yes. R801 was asked if they pressed the call light and stated, Yes. R801 was asked how long ago they pressed the light and was observed to look at the clock and stated, about 15 minutes ago. I was told I had to wait. On 5/3/23 at 10:29 AM, Certified Nurse Assistant (CNA) A was observed to go in the room of R801 and talk to them. CNA A was observed to leave out of the room at 10:30 AM. As CNA A walked out R801 was heard to ask in a loud voice, Can you clean me up. CNA A was heard to say Yea. as they walked down the hallway. R801 was observed to yell for CNA A by name (CNA A) multiple times, CNA A did not return to R801. At 10:31 AM, R801 was heard to call out for CNA A again. Other staff was observed to walk by R801's room during this time and was not observed to enter R801's room. At 10:41 AM, R801 was heard to call out for CNA A. At 10:56 AM, R801's call light was observed to be on. Staff was observed to go into the room at 10:57 AM. The staff person was heard to introduce themselves as the Nurse Practitioner (NP). R801 was heard to tell the NP that they needed to be cleaned up. The NP stated that they will get the girls (CNA's) to come and clean them (R801) up. The NP was observed to leave R801's room at 10:59 AM, the call light stayed on. At 11:00 AM, an unidentified staff person was observed to walk in R801's room and out at 11:01 AM, the call light was observed to be off. At 11:17 AM, R801 was asked if the staff had come back to clean them up. R801 stated, No. At 11:22 AM, CNA B was observed to walk down the hallway of R801's room and was asked if they were assigned to R801. CNA B stated, No. CNA B asked if there was something wrong, CNA B was explained that R801 needed some assistance with a brief change. CNA B explained that they will find the aide for R801. During that time the assigned CNA C was observed to come out of another resident's room. CNA B was observed to speak with CNA C about R801. CNA C was observed to enter R801's room at 11:24 AM to provide care. A review of R801's medical record revealed R801 was admitted to the facility on [DATE], with diagnosis of Hemiplegia affecting left nondominant side. A review of R801's Minimum Data Set (MDS) assessment dated [DATE], revealed R801 with an intact cognition and to require extensive assistance with Activities of Daily Living (ADL's). Bed mobility Extensive assistance with two+ (more) persons physical assist, transfer status total dependence, and toilet use extensive assistance with one-person physical assist. Further record review revealed, Skin assessment dated [DATE], noted, Resident's skin is clear. Mild redness on buttocks - treatment in place. Right ankle mild redness noted - treatment in place. A review of R801's care plan noted, Focus: I am at risk for impaired skin integrity r/t (related to) incontinence, medication use, and decreased mobility. I am known to refuse my showers and refuse to allow staff to comb my hair; which puts me at risk for tangles in my hair. If I refuse a shower, offer me a bed bath as an alternative. Date Initiated: 05/29/2021. Goal: My skin will remain intact through the review date. Date Initiated: 05/29/2021. Interventions: Skin assessment weekly per protocol. Interventions to be implemented as needed based on findings. Date Initiated: 05/29/2021. Focus: I require assistance in ADLs R/T impaired mobility . Date Initiated: 08/27/2020 Goal: o My needs will be anticipated and met by staff daily. Date Initiated: 08/27/2020. Interventions: I am Incontinent of bowel and bladder when in bed, I wear an XL (extra large) brief for dignity and comfort. When up in chair I am able to let staff know I need to use the restroom Date Initiated: 08/27/2020. I need 2 person to be present in my room when giving me adl care during showers and transfers. Date Initiated: 12/16/2020. On 5/3/23 at 2:26 AM, the Director of Nursing (DON) was asked the facility's expectations for answering call lights and providing ADL care timely and responded if the light is on and you can address and to leave the light on until the concern is taken care of. A review of the facility's policy titled, Answering Call Light, dated May 3, 2023 noted, PURPOSE: Residents admitted to (Nursing Facility) can expect their needs/requests to be met in a timely manner. It is our responsibility to ensure the residents call light is available, within reach, functioning properly and answered promptly. POLICY: It is the policy of (Nursing Facility) to ensure that each resident who is continent of bladder and bowel receives the necessary services and assistance to maintain continence, unless it is clinically not possible; and a resident who is incontinent of bladder and bowel is identified, assessed and provided appropriate treatment and services to achieve or maintain as much normal bladder function as possible and restore as much normal bowel function as possible .

Based on observation, interview, and record review, the facility failed to 1.) ensure signage for identifying isolation room/personal protective equipment (PPE) was placed for three (3) Residents (R5, R168, and R174), of three residents reviewed for COVID-19 isolation rooms and 2.) appropriate PPE use in the facility, resulting in the potential of spreading a communicable respiratory disease in a vulnerable population of 184 residents. Findings include: During an observation on 8/22/2022 at 11:00 AM, upon entering the facility's main lobby, writing on a white board alerted those entering the facility that, 3 Residents COVID-19 Positive. During the entrance conference, Nursing Home Administrator (NHA) A confirmed positive cases of COVID-19 in the facility. Resident #5 (R5) According to the Minimum Data Set (MDS) assessment dated [DATE], R5 scored 00/15 indicating she was unable to complete her BIMS (Brief Interview for Mental Status) had unclear speech having to be prompted to make needs known due to language barrier; comprehending most conversations with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R5's Progress Note dated 8/17/2022 15:07 (3:07 PM) reported resident tested Rapid/PCR positive Covid-19 and was transferred to the 2D isolation unit. Review of R5's Order Summary dated 8/19/2022 reported COVID: Contact and Droplet Precautions every shift for Covid until 8/27/2022 23:59 (11:59 PM). It was noted isolation precautions were not ordered for two days after resident had been diagnosed . Review of R5's Care Plan dated 8/17/2022 focused on resident testing positive for COVID-19 r/t (related to) positive PCR. Goal for the resident was to remain free of symptoms of COVID-19 with interventions that included, to be on droplet isolation precautions. Resident #168 (R168) According to the MDS dated [DATE], R168 was not given a BIMS (Brief Interview for Mental Status) due to not being able to communicate with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R168's Test Report 8/17/2022 08:46:33 (8:46:33 AM) reported Assay Information Test Result: [CONDITION(S)]-CoV-2 POSITIVE. Review of R168's Order Summary 8/19/2022 reported COVID: Contact and Droplet Precautions every shift for Covid until 8/27/2022 23:59 (11:59 PM). It was noted isolation precautions were not ordered for two days after resident had been diagnosed . Review of R168's Care Plan dated 8/17/2022 focused on resident testing positive for COVID-19 r/t positive PCR. Goal for the resident was to remain free of symptoms of COVID-19 with interventions that included to be on droplet isolation precautions. Review of R168's Progress Note 8/17/2022 13:34 (1:34 PM) reported the resident tested Rapid/PCR positive for Covid-19 and was transferred to 2D isolation unit. Resident #174 (174) According to the MDS dated [DATE], R174 scored 1/15 (severely cognitively impaired) on her BIMS (Brief Interview for Mental Status), had clear speech making her needs known, understood others, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R174's Progress Note 8/17/2022 13:56 (1:56 PM) reported the resident tested Rapid/PCR positive for Covid 19 and transferred to the 2D isolation unit. Review of R174's Order Summary 8/19/2022 reported COVID: Contact and Droplet Precautions every shift for Covid until 8/27/2022 23:59. It was noted isolation precautions were not ordered for two days after resident had been diagnosed . Review of R174's Care Plan dated 8/17/2022 focused on resident testing positive for COVID-19 r/t positive PCR. Goal for the resident was to remain free of symptoms of COVID-19 with interventions that included to be on droplet isolation precautions. Observed on 8/22/2022 at 12:15 PM on unit 2D, the facility had dedicated a COVID-19 isolation area. rooms [ROOM NUMBERS] were occupied by R5, R168, and R174. It was noted, R5 and R168 shared a room. There was no signage on the doors indicating they were contact/droplet isolation and/or transmission-based precautions rooms, or the types of PPE equipment necessary to enter. An isolation cart was positioned in the hall outside of the rooms with boxes of various PPE equipment. No signage was visible indicating the PPE was to be worn when entering the rooms. Observed on 8/23/22 at 4:31 PM in the designated COVID-19 isolation area, no isolation transmission-based precautions signage was on the doors of R5, R168, and R174. It was noted, R5 and R168 shared a room. Both doors were wide open. During an observation and interview on 8/23/2022 at 4:35 PM, in the designated COVID-19 isolation area, no isolation transmission-based precautions signage was on the doors of R5, R168, and R174. It was noted, R5 and R168 shared a room. Both doors were wide open. Certified Nursing Assistant (CNA) E stated, I work this unit often and I just know what PPE to wear. There are no signs on the doors. Observed on 8/23/22 at 4:39 PM in the designated COVID-19 isolation area, no isolation transmission-based precautions signage was on the doors for R5, R168, and R174. It was noted, R5 and R168 shared a room. Both doors were wide open. Observed on 8/23/22 at 4:42 PM Family Member (FM) L visiting R168. No isolation transmission-based precautions signage was on the doors for R5, R168, and R174. It was noted, R5 and R168 shared a room. Both doors were wide open. Observed on 8/24/22 at 7:36 AM in the designated COVID-19 isolation area, no isolation transmission-based precautions signage was on the doors for R5, R168, and R174. It was noted, R5 and R168 shared a room Both doors were wide open. During an interview and observation on 8/24/2022 at 7:45 AM MDS Coordinator F stated, I am the nurse working on the Enhanced Area with the positive COVID-19 residents today. There are no signs on those resident doors because this is not a COVID-19 unit. Staff just know what to wear because there were COVID-19 positive residents a month or so ago. Observed on 8/24/22 at 08:19 AM in the designated COVID-19 isolation area, no isolation transmission-based precautions signage was on the doors for R5, R168, and R174. It was noted, R5 and R168 shared a room Both doors were wide open. Observed on 8/24/22 at 09:32 AM on Unit 2B, Certified Nursing Assistant (CNA) G was passing trays to residents in the dining area and rooms [ROOM NUMBERS]. CNA G was wearing a blue surgical mask under her nose. Observed on 8/24/2022 at 9:32 AM Activities R was wearing blue surgical mask under nose while assisting residents with breakfast in Unit 2B's dining area. Observed on 8/24/2022 at 9:35 AM one of the double doors to the entrance of the designated Covid-19 isolation area was open with no signage alerting those that entered the areas designation. During an interview on 8/24/2022 at 2:46 PM Infection Control Preventionist (IP) D stated, The rooms where the Covid-19 positive residents are is not a Covid unit. Currently there are three (3) positive residents, and the facility is treating the rooms just as isolation rooms. The whole unit is in isolation, so the signage is on the doors going into the area not on the COVID-19 positive resident room doors. It is considered an Enhanced PPE Area. Face shields are not used because they are causing problems during treatments, causing accidents, and fogging up. The Administrator made the decision the facility did not have to use face shields, anywhere. The facility is not following CDC guidelines as we are not using eye protection/face shields with Covid-19 positive residents. I do not see any reason why to keep the doors closed, they are to provide a homelike environment and the residents may not want them closed. It was noted staff assigned to the COVID-19 area wore face shields while performing direct care to the identified positive residents. During an interview and record review on 8/24/22 at 3:52 PM, Nursing Home Administrator (NHA) A stated, The facility does not have a Covid unit. The facility calls the Covid-19 positive rooms the Enhanced Area. I put out a MEMO in June (2022) that staff in non-isolation areas did not have to wear face shields. Review of facility MEMO dated 6/1/2022 revealed . Eye protection is still required in the isolation area only . During an interview on 8/24/2022 at 4:15 PM NHA A stated, I do not want staff to read CDC guidelines in a policy; they are always changing. I just want what staff must know to be plain and simple. CDC guidelines have changed so many times that it gets confusing. The area the positive Covid-19 residents are in is not a designated Covid-19 unit. The facility calls it an Enhanced Area because therapy takes residents through there and staff walks there to other parts of the building. That way staff does not have to wear full PPE when going by there. There is no signage on doors because they are not isolation rooms. They are Enhanced Areas. During an interview on 8/25/22 at 10:34 AM IP C stated, PPE requirements for COVID-19 positive residents are N95 mask, face shield, gowns, gloves, and hairnet. Staff would know what to wear by the signs on top of the isolation carts that state Stop See Nurse. The facility follows CDC guidelines. COVID-19 positive residents are to be placed on Droplet precautions and those isolation precautions dictate what staff need to wear when entering a COVID-19 positive room. IP B stated, I posted signage on the doors today, 8/25/2022. I made a mistake by not posting signage of the COVID-19 positive rooms when the residents were placed in the rooms. IP C and IP B stated, A mask, any mask, is to be worn over the nose. It is for infection control prevention. Review of facility policy NOVEL CORONAVIRUS PREVENTION AND RESPONSE reviewed March 9, 2022, revealed, PURPOSE: The Infection Prevention Program has been established to maintain an infection prevention and control program that is designed to provide a safe, sanitary, and comfortable environment for our residents and staff as well as to prevent development and transmission of communicable diseases and infections. POLICY: It is the policy of (name of facility) promptly respond to suspicion of illness associated with a novel coronavirus in efforts to identify, treat and prevent the spread of the virus. 5. Interventions to prevent the spread of respiratory germs within the facility .d. Educate staff on proper use of personal protective equipment and application of standard, contact, droplet, and airborne precautions, including eye protection. e. Promote easy and correct use of personal protective equipment (PPE) by: i. Posting signs on the door or wall outside of the resident room that clearly describe the type of precautions needed and required PPE . Review of facility policy ISOLATION PRECAUTIONS, reviewed April 23, 2022, revealed, PURPOSE: Our residents have significant risk of acquiring infections due to their compromised health, and or lack of awareness of preventive health techniques. To provide guidelines for appropriate precautions including isolation to prevent the spread of infections, this policy specifies the different types of precautions, including when and how isolation should be used for a resident. POLICY: It is the policy of (name of facility) to take appropriate precautions, including isolation, to prevent transmission of infectious agents. Precautions will be initiated when there is a reason to believe that a resident has a communicable infection. PROCEDURE: DEFINITIONS Standard precautions (formerly Universal Precautions) refers to infection prevention practices that apply to all residents, regardless of suspected or confirmed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .k.a. Isolation Precautions) refers to the actions (precautions) implemented, in addition to standard precautions, that are based upon the means of transmission ( . contact, and droplet) in order to prevent or control infections . Contact precautions are measures that are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the resident or the resident's environment. Droplet precautions refers to actions designed to reduce/prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions . Isolation refers to the practices employed to reduce the spread of an infectious agent and/or minimize the transmission of infection . 2 .Nursing staff will apply Transmission-Based Precautions, with a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The nursing staff will use standard approaches, as defined by the CDC, for transmission-based precautions .contact and droplet precautions. The category of transmission-based precautions will determine the type of PPE to be used . 7. Information regarding the particular type of precaution to be utilized will be communicated through . signage .8. The Infection Preventionist will serve as a consultant to facility staff on infectious diseases and the implementation of isolation precautions . Dedicated COVID 19 Isolation Unit: The facility may establish a dedicated COVID 19 isolation unit to provide care in a safe environment with appropriate precautions initiated. 1. The dedicated COVID 19 isolation unit will follow isolation precautions with appropriate transmission-based precautions . .The fit of the medical device used to cover the wearer's mouth and nose is a critical factor in the level of source control (preventing exposure of others) and level of the wearer's exposure to infectious particles . https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html According to CDC.gov/coronavirus, Core Principles of COVID-19 Infection Prevention .Face covering or mask (covering mouth and nose) .in accordance with CDC guidance .

Based on observation, interview and record review, the facility failed to ensure residents were repositioned timely for four sampled Residents (R58, R103, R110, R127) and one non sampled resident (R85) of five whose positioning was reviewed, resulting in the potential for skin breakdown, discomfort and unmet care needs. Findings include: Resident #58 (R58) On 08/23/22 at 12:23 PM, R58 was observed to be in bed with their oxygen on. The call light at the right side, was outside the assist bar. A heels up cushion was under R58's lower legs and their heels appeared down over the rear edge and on the bed. On 08/23/22 at 4:26 PM, R58 was on their back in a low bed, and provided confused answers to queries. The lower legs were on a heels up cushion and the heels were on the bed. On 08/24/22 at 7:37 AM, R58 was observed to be on their back in bed, with the head of the bed up 20-30 degrees, oxygen on and a heels up cushion in place with heels slightly off the bed. A low air loss (LAL) style mattress was active. Staff was with the resident. On 08/24/22 at 10:56 AM, R58 was observed to be on their back in bed dressed in a hospital style gown, with the head of the bed (HOB) up around 30-45 degrees. On 08/24/22 at 12:01 PM, R58's lunch tray was brought into the room. R58 was in a similar position on their backside in bed with a clothing protector in place. At 12:05 PM staff entered the room to assist resident to eat. Ow Ow was heard when head of bed was raised. On 08/24/22 at 1:13 PM, R58 continued on their back in bed, dressed in a hospital style gown, leaning slightly off center to their right. The head of the bed was up around 45-60 degrees. Oxygen delivery via nasal cannula was observed in place under their nose. R58 talked out with various words related to cats. A stuffed cat was observed on the tray table. R58 converted to say Help me. Help me. Staff were observed to be briefly in and out of the room. The heels up cushion was under the lower legs and R58 was observed to bounce their feet up and down. On 08/24/22 at 3:30 PM, the condition of R58 was reviewed with the Therapy Director who reported increased confusion, a significant physical decline and the R58 was unable to roll unassisted. On 08/24/22 at 4:32 PM, R58 continued in bed at as 1:13 PM. The HOB was up 45-60 degrees, R58 leaning toward right of center of bed, oxygen on, cat on lap now and in a teal blue gown. The lower legs on the heels up cushion with the heels down toward the bed. On 08/25/22 at 6:20 AM and 7:52 AM, R58 was observed to be in bed dressed in a teal blue hospital style gown. The TV was on. The HOB was up 30-45 degrees. The oxygen was worn. R58 had their head over to the right slightly and the heels on the bed. On 08/25/22 at 9:50 AM, R58 continued in bed as at 6:20. The HOB was up 30-45 degrees with their heels on the bed and a cushion under the lower legs. The top sheet was away from the feet and revealed no footwear. The feet appeared swollen. R58 called out help at times. A brief, blue pad and plastic bag were at the foot of bed left of R58's feet. On 08/25/22 at 10:53 AM, the Social Work Director reported that post R58's hospital stay, R58 was significantly less mellow and less conversant. A review of the facility record for R58 revealed R58 was admitted into the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] indicated severe cognitive impairment and the need for extensive to total assist of one or two persons for bed mobility, transfer, locomotion, toilet use, dressing and personal hygiene. The MDS further indicated the resident was at risk for development of pressure ulcers. The nursing care plan revised 06/30/22 documented R58 to be .at risk for pain related to muscle weakness with impaired mobility . and to be at risk for impaired skin integrity related to incontinence and impaired mobility . Interventions included .Assist me with frequent repositioning while in bed . Resident #103 (R103) On 08/23/22 at 11:26 AM, R103 was observed to be on their back in bed with the head of the bed (HOB) up 30-45 degrees and dressed in a hospital style gown. R103 had their mouth open (appeared asleep) and their right hand in a fist on their chest. A low air loss mattress was active and a pad style call light was visible. The lower legs of R103 were up on a cushion with the heels down and resting on the bed. A stuffed bear was next to their left foot. On 08/23/22 at 2:07 PM, R103 was observed to be on their back in bed with the head of the bed (HOB) up 30-45 degrees and dressed in a hospital style gown. Lunch was partially eaten at bedside and a sippy style cup laid on it's side on the tray. R103 appeared asleep with the stuffed bear at the left side of their head. On 08/24/22 at 7:41 AM and 9:29 AM, R103 was observed to be on their back in bed with the head of the bed (HOB) up 30-45 degrees and dressed in a hospital style gown. The head leaned left slightly toward the stuffed bear at the side of R103's head. On 08/24/22 at 1:19 PM, R103 remained on their back in bed with the head of the bed up 45-60 degrees. The sheet was off the lower legs and feet. No foot wear was observed on the feet. An IV drip was running. A device behind the torso of the resident to turn them and off load pressure was not observed. On 08/24/22 at 2:28 PM, R103 was observed to be on partially on their back in bed with the head of the bed (HOB) up 30-45 degrees and dressed in a t shirt. R103 was observed to face left with a foam wedge behind the right torso. On 08/24/22 at 4:38 PM, the covers were off the upper body and the bear was at the left shoulder of R103. R103 was on their back in bed dressed in a hospital style gown. The head of the bed was up 20-30 degrees and the IV fluids were running. R103 moved their hands around spontaneously and their eyes remained closed. On 08/25/22 at 6:26 AM, 7:57 AM, R103 was observed to be on their back in bed with the head of the bed (HOB) up 20-30 degrees and dressed in a hospital style gown. A foam wedge was not observed. A review of the facility record for R103 revealed R103 was admitted into the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] indicated impaired cognition and the need for extensive or total assistance of one person for bed mobility, transfers, personal hygiene, toilet use and bathing. Range of motion was impaired to at least one side for the upper and lower extremities. The MDS further indicated the resident was at risk for development of pressure ulcers. The nursing care plan revised 05/03/22 documented, .an alteration in (Activities of Daily Living) ADLs, related to generalized weakness, hallucinations, decreased mobility and impaired cognition . Interventions included, .Check and change me frequently . The nursing care plan revised 07/26/22, documented, .(R103) at risk for impaired skin integrity .assist with frequent repositioning while in bed . float my heels with a pillow while in bed . A review of the point of care nurse aide documentation for August 2022 revealed shaving was not documented as done or refused on 08/05, 08/15 and 08/22. A shower/bath was not documented as done or refused on 08/05. Resident #110 (R110) On 08/24/22 At 7:47 AM, R110 was observed to be on their back in a low bed with the head of the bed flat and dressed in a hospital style gown. R110's head rested on two pillows. On 08/24/22 at 12:45 PM, R110 was observed to be on their back in bed in a low bed. Their legs were crossed left over right and R110's head was over to the right shoulder. The call light rested on the bed just above the left shoulder. On 08/24/22 at 1:31 PM and 1:50 PM, R110 was observed to be on their back in bed in a low bed. Their legs were at the right side edge of the bed. R110's head was over to the right shoulder. Two pillows were behind the head. The call light rested on the bed just above the left shoulder. On 08/24/22 at 2:37 PM, R110 was observed to be on their back in bed, dressed in a hospital style gown. R110's head was on two pillows and tilted toward the right. The knees were flexed up. The call light rested on the bed just above the left shoulder. On 08/24/22 at 4:42 PM, R110 was observed to be on their back in bed, dressed in a hospital style gown. R110's head was on two pillows and tilted toward the right. The bed cover was down slightly off the left shoulder. The knees were flexed up. The call light rested on the bed just above the left shoulder. On 8/25/22 at 6:31 AM and 8:00 AM, R110 was observed to be on their back in bed with the head of the bed flat and dressed in a hospital style gown. R110's head was on two pillows and tilted toward the right. The bed cover was down slightly off the left shoulder. The knees were flexed up. On 08/25/22 at 9:56 AM, R110 was observed to be on their back in bed with the left shoulder up slightly. R110 made some nonsense verbalizations which had become progressively louder then stopped. The head of the bed was up 45-60 degree. A review of the facility record for R110 revealed R110 was admitted into the facility on [DATE]. A review of the MDS dated [DATE] indicated impaired cognition and the need for extensive assistance of two persons for bed mobility, transfers, dressing, toilet use and personal hygiene and total assistance for bathing. The MDS further indicated the resident was at risk for development of pressure ulcers. The nursing care plan revised 07/20/22 documented, (R110) require(s) assistance with all activities of daily living due to being confused at all times . am at risk for falls . Elevate bilateral lower extremities while in be to reduce dependant [CONDITION(S)] (swelling) . Please make sure I am centered in the bed during rounds . when in bed I need to be rounded on frequently to assess needs . Resident #127 (R127) and Resident #85 (R85) On 08/23/22 at 9:32 AM, 10:52 AM, R127 was observed to be seated in a geri-chair (medical recliner) in the dining area. The back of the the chair was upright around 60 degrees. A lift sling was under the resident. The backside of the chair was toward the window, the table was at the left side. On 08/23/22 at 2:30 PM, R127 was seated in the recliner seated in wheelchair as before and appeared asleep. R85 was seated at the table with R127. R85 was dressed and seated in a wheelchair. A lift sling was in the wheelchair behind the back of R85. On 08/23/22 at 3:23 PM, R127 was observed to be seated in the recliner as before, the fingers of their hands were laced together and rested on the abdomen. R85 continued at the same table seated in their wheelchair. Staff was passing out chips and beverages. On 08/24/22 at 12:49 PM, R127 was observed to be dressed and seated in a geri-chair/recliner. R127 had a tray table over their lap and was eating lunch. R127 was in the day room located left of the table as the day before. R127 faced out toward the doorway. On 08/24/22 at 1:28 PM, R127 was observed to be seated in the recliner and faced toward the doorway of the day room. A tray table was over the recliner. R85 was seated in their wheelchair at the same table. A lift sling behind their back in the wheelchair. On 08/24/22 at 1:45 PM, R127 and R85 were in position as at 1:28 PM. R85 moved their hands up and down and appeared to interact with R127. On 08/24/22 at 2:39 PM, R127 and R85 were observed to be seated in positions at the table as at 1:45 PM. R85 had coffee and chips. R85 had a pillow behind their back. On 08/24/22 at 3:15 PM, R127 was observed to be seated in their recliner and R85 was observed to be seated in their wheelchair at the same table as before. The sling in the wheelchair was behind R85. On 08/24/22 at 4:45 PM, R85 appeared at the same table as before with R127. R85 continued up in their wheelchair. R127 was in a similar position as before with a tray table over their lap from the right side and their left side to the table. A review of the facility record for R85 revealed R85 was admitted into the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment date 06/15/22 indicated severely impaired cognition and the need for extensive assistance of one person for bed mobility, locomotion, dressing, toilet use and personal hygiene. Transfer required total assistance. A review of the facility record for R127 revealed R127 was admitted into the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment date 07/13/22 indicated severely impaired cognition and the need for extensive assistance of one or two persons for bed mobility, transfer, dressing, toilet use and personal hygiene. Locomotion and bathing required total assistance. On 08/25/22 at 1:05 PM, the Director of Quality Control Staff DD was asked about repositioning of dependant residents and reported residents should be repositioned approximately every 2 hours and staff conduct rounding to monitor this. A review of the facility policy titled, Repositioning Residents last reviewed 01/28/22 revealed, Purpose: To provide guidelines for safe repositioning of residents, to relieve pressure on bony prominences, increase circulation, and provide comfort. Policy: It is the policy of [NAME] T. Berry Medical Care Facility to ensure that residents who are unable to change position without assistance are repositioned appropriately .

This citation pertains to intake: MI 217. Based on observation, interview, and record review, the facility failed to prevent physical abuse from a staff person, for one sampled Resident 45 (R45) of four sampled residents reviewed for abuse, resulting in physical abuse and psychosocial distress using the reasonable person concept. Findings include: On 5/10/21 at 10:12 AM, R45 was observed in their room pulling sheets on a bed that was already made. An attempt to interview R45 was made, but not successful due to R45's impaired cognition. On 5/11/21 at 8:30 AM, R45 was observed in their bed under a blanket and was asked how they were doing and stated, I'm going crazy. A review of the intake incident summary noted, It was reported by Licensed Practical Nurse I (LPN I) that she observed Certified Nursing Assistant J (CNA J) push [R45] into [R45's] recliner chair in [R45's] room. She stated that [R45] became combative and was kicking and hitting at [CNA J.] She states she observed [CNA J] grab [R45] by [R45's] arms. [LPN I] stated she immediately intervened and told [CNA J] to leave the room . On 5/11/21 at 4:26 PM, during an interview via phone, LPN I was asked about the incident that occurred on 1/6/21 with R45 being pushed. LPN I explained, it was around 9:00 PM or 10:00 PM at night. R45 was in one of R45's moods and was walking around banging and pushing on the locked doors. LPN I continued and stated, When [R45] was banging on the door [CNA J] was in another residents room making a bed. [CNA J] came out and grabbed [R45] to redirect [R45]. [R45] was walking backwards and once [CNA J] got [R45] in the room, I came in to give [R45's] roommate their meds, I heard some noise, looked over and I saw [CNA J] push [R45] into the chair. That is when [R45] became combative and started to hit and kick [CNA J]. [CNA J] grabbed [R45's] wrist to get [R45] to stop hitting her. I told [CNA J] to get out and I grabbed her hands because she was holding [R45's] hands. LPN I was asked when the incident was reported and stated, I reported Immediately. I found the acting supervisor (Nurse Manager K) we went to the desk and called the DON (Director of Nursing) and were told to walk [CNA J] out of the building. On 5/12/21 at 12:14 PM, during an interview via phone CNA J was asked about the incident that occurred with R45 and stated, [R45] was having a outburst and was following me around, knocking on doors, and messing with doorknobs. I was changing sheets in a room. [R45] kept coming in rooms after me and I kept redirecting and [R45] would come back every time. The Nurse (LPN I) had words with [R45], I took [R45] and redirected him into another room. [R45] don't like you telling him what to do. I just told [R45] to come to the room. As we got in the room I told [R45] 'You are being rude', but that may not have been the word I used. That is when [R45] started getting upset. [R45] was pushing back to leave the room. I blocked [R45] so [R45] would not get out the room. Now [R45] is cussing and the nurse (LPN I) is in the room to give the roommate meds. Nurse (LPN I) said 'Well just let [R45] be.' I said to [LPN I] I deal with [R45] I know how to calm [R45] down. Then LPN I left the room. CNA J was asked if at any point did, she push R45 down into the chair and stated, No. I was left in the room with [R45]. No. If I pushed him in the chair why didn't [LPN I] stop me before she walked out. I was later told by [Nurse K] I had to leave the building. A review of CNA J's clocked timed for 1/6/21 reflected, CNA J punched in at 3:06 PM - punched out at 8:22 PM. A review of R45's medical record noted, R45 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R45's Quarterly Minimum Data Set assessment dated [DATE], noted R45 with a severely impaired cognition and required limited assistance with some activities of daily living. A review of R45's care plan noted, Focus: I have impaired cognition r/t (related to) Dx (diagnosis) of [CONDITION(S)] and Anxiety Disorder. My short and long-term memory is impaired my confusion anxiety worsens in the evening I sometimes seek my wife and try to leave the unit at times. Date Initiated: 4/17/2019. Goal: I will continue to recognize staff as familiar faces and be able to locate my room independently until the next review date. Date initiated: 04/17/2019. Interventions: approach me in a calm reassuring manner and refer to me by name, as if we have known each other for many years. Date Initiated: 4/17/2019. Further review of R45's medical record progress notes revealed, 1/6/2021 19:11 (7:11 PM) General Nursing Note Text: Writer with assistance from staff attempted to administer [MEDICATION(S)] injection to Resident in [R45] room. Resident began impulsively pulling down [R45] pants without a request from Writer or CNA and while monitoring Resident, due to past inappropriate behaviors, Writer accidentally dropped the vial on the floor and it shattered . 1/7/2021 09:31 (AM) Social Service Note Text: SW (Social work) met with resident this morning to complete wellness check to eval (evaluation) for any emotional distress following issues that were reported last night. Resident was observed standing near [R45's] garbage can masturbating. SW asked resident if [R45] could stop so we could talk but resident was unable to be re-directed and continued to moan. SW asked resident if [R45] could go to [R45's] side of the room out of view of [R45's] roommate to allow privacy for both. Resident sat down in [R45's] chair. SW closed resident's curtain and door for privacy. SW will continue to follow as needed. On 5/12/21 at 2:47 PM, the Director of Quality and Compliance and the Risk Management Manager were interviewed regarding the facility's investigation for the incident with CNA J and R45. They explained that CNA J was placed on leave and the facility started the investigation and education for abuse. The Risk Manager provided the written statements from the investigation. Statement #1 On 1/6/21 I was passing medication on the [unit]. The CNA [CNA J] was in [another resident's room] changing [their] bedding when [R45] began trying to get out of the door of the [unit]. She (CNA J) stopped doing what she was doing and came and got [R45] and began to walk [R45] to [R45's] room. [R45] said do you have to grab my arm like that. I looked up from what I was doing when I heard that. I did not observe any roughness so I kept on preparing medications for the [resident]. I went into the room preparing to give [resident their] meds but I heard shuffling noises so I looked up and saw her (CNA J) grabbing and pulling patient (R45) into the room by the patients arms. There were no bruises. Once they were in the room all the way I witnessed [CNA J] roughly push [R45] down into [R45's] chair. She (CNA J) pushed [R45] hard enough to scoot the chair back and [R45] fell into the chair from the force of the push. [R45] began kicking and hitting her (CNA J) because of what she did and she began grabbing [R45's] arms very roughly. I immediately stopped what I was doing and walked over. I told her (CNA J) to leave [R45] alone I got it. She said No I got this. I will use reverse psychology on [R45] 'Oh you're hurting me, ow [R45] that hurts.' I told her (CNA J) to leave [R45's] room and I asked [another nurse] I just reviewed if this classified as abuse. She (the other nurse) confirmed my thoughts. I called [Nurse Manager K] to tell her what happened and asked who do I call since [the administrator] is on vacation and what's the number. I called [the DON]. I explained the situation, [Nurse Manager K] told [CNA J] she is on administrative leave and [the DON] would be calling her to investigate. Signed: LPN I 1/7/21. Statement #2 1/6/21 I received a call from [LPN I] stating CNA [CNA J] was holding a residents hand with force and [CNA J] she believed had pushed the resident [R45] into [R45's] recliner causing the resident to kick and try to hit CNA. Also res (resident) was stating 'Why would you do that.' I immediately went to [the unit] where [LPN I] was at desk and stated she was going to call [the administrator] but as he was out she did phone the DON. I stated I was going to walk [CNA J] out which I did. [CNA J] asked why she had to leave. I explained she was being put on administrative leave for alleged abuse. She then asked which resident. I told her I did not have all the info and that [the DON] and or HR (human resources) would be in touch with her. She then stated, 'Oh you mean [R45], I had to hold [R45's] hands down so [R45] wouldn't hit me.' I again told her HR and or [the DON] would be in touch with her and walked her to the lobby. Signed: Nurse Manager K. A review of CNA J's personnel file noted a document titled Personnel Action Form noted, Nurse reported to DON that CNA (CNA J) was observed using more force than physically necessary or appropriate with elder during care . CNA J was termed from employment on 1/26/21 immediately for grossly poor nursing care, which is failure to give adequate and appropriate care to a resident. On 5/12/21 at 3:00 PM, the Social worker was asked about their involvement with the incident and stated, I saw [R45] the morning after. [R45] was very confused which was [R45's] baseline and did not remember anything about the incident. I saw [R45] after for wellness visits for three days and we had psych come in. On 5/12/21 at 3:17 PM, an interview was attempted with Nurse Manager K via phone, voice mail was left. Nurse Manager K did not return a call by the end of the survey. On 5/12/21 at 3:34 PM, the new DON (not the DON that was here at the time of the incident) was asked if they were familiar with this incident and stated, No. The DON was asked the facility's expectation for a resident that may be combative and if it was ok to hold their arms or push them down into a chair and stated, No. A review of the facility's policy titled, Resident Abuse, Neglect and Exploitation Program dated, 1/21/20, revealed, PURPOSE: Residents have the right to be free from abuse, neglect, exploitation and misappropriation of property . POLICY: It is the policy of [Facility] to maintain a program that protects our residents' rights to be free of abuse, neglect, exploitation of and misappropriation of property. GUIDELINES 1. Residents should not be subjected to abuse, neglect, exploitation or misappropriation of personal property .

This citation pertains to Intake number MI 858. Based on observation, interview, and record review the facility failed to perform a transfer with two people and a Hoyer lift from a wheelchair to a shower bench affecting one resident (R905) as care planned of four residents reviewed for falls resulting in a fall with injury and persistent pain. Findings include: On 10/06/20 at 8:49 AM, R905 was observed and interviewed regarding falling at the facility and stated, I fell three weeks ago in the bathroom for my shower. R905 was asked if any staff were helping in the bathroom and stated, They were trying to put me in the shower but I just kept sliding. R905 was asked how many staff members were helping and stated, One aide, a new one. R905 was asked if there was anything that could have been done to have prevented the fall and stated, (The aide) should have asked the nurse for help. R905 was asked if there should two aides to assist in the bathroom and stated. Yes, but they don't always have two. R905 was asked if anything was injured and stated, I hurt my tailbone and back. I didn't hit my head, but my tailbone and back still hurt. Record Review of R905's Electronic Health Record (EHR) revealed R905 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment dated , 09/17/2020 revealed R905 had a Brief Interview for Mental Status (BIMS) score of eight out of 15 indicating a moderately impaired cognition and needed extensive assistance of two people for transfers. Review of the facility's Incident and Accident (I&A) Summary revealed that On 9/24/2020, (Certified Nurses Aide (CNAB)) was transferring resident from the shower bench to the wheelchair without a hoyer lift when resident slipped and fell causing 4 skin tears on bilateral arms (2 on each arm). Resident complained of neck and back pain immediately after the incident. On 10/06/20 at 12:20, CNAC was asked about transferring R905 and stated, (R905) has always been a Hoyer lift and two people have to be there when they're being lifted. Once (R905) is in the shower only one person needs to be there, but she would have to have two when we get her off the shower chair. I personally would never use the shower bench. The only people that use the bench are the people that can walk like you and me. You are supposed to use the Kardex, the Kardex would let you know all that. (R905 used to use the 'Sit-to-Stand Lift but now She's a Hoyer lift, and any mechanical lift needs two people to transfer a resident. On 10/06/20 at 12:27, Nurse Dwas asked about R905's pain and stated, The only pain she complained of prior to the fall was in the knees. I was not here the day she fell but heard about it in report. R905 was always a two person assist. Record review of R905's Care Plan revealed. Focus' I have had an actual fall and am at risk for falls r/t (related to) muscle weakness, [MEDICAL CONDITION] and [MEDICAL CONDITION] (Weakness and paralysis) of the left side, orthostatic bp (changes in blood pressure with movement), dementia, pain, and past falls. Initiated 12/10/2019, Revised 10/06/2020. Intervention, I only use the proper shower chair for my bathing needs. Focus, I will need assistance with my ADLs (Activities of Daily Living) r/t impaired mobility and left sided weakness. Initiated 01/09/2020, Revised 10/06/2020. Intervention, Transfer: I need 2-person hoyer lift. Initiated 01/09/2020, Revised 10/06/2020. On 10/06/2020 at 4:26 PM, the Director of Nursing was off during the survey. The Assistant Director of Nursing (ADON) was asked about the facility's policy and procedure regarding fall prevention and stated, They have to follow the care plan, they have to read the Kardex and follow the instructions. (CNA B) was educated, then all of the CNAs were re-educated and we had a disciplinary hearing in Human Resources. Review of the facility's policy and procedure titled, POLICY: Falls - Clinical Protocol dated, Reviewed: August 20, 2020 revealed, 5. A comprehensive care plan will be completed and will address risk factors identified during the fall risk assessment. Interventions will be implemented accordingly.

This citation pertains to intake 1. Based on interview and record review, the facility failed to ensure proper indwelling Foley catheter placement, affecting one sampled resident (R#702) of three reviewed, resulting in urethral trauma, bleeding, and a visit to the Emergency Department (ED). Findings include: A review of intake 1 revealed the following: (R#702) is unable to speak, has a history of Stroke, Dementia, and Cerebral Vascular Disease. On 02/26/20, (R#702's) urinary catheter was pulled out and inflated with saline. The next nurse on shift discovered that (R#702) had quite a bit of bleeding in (their) vaginal area and the doctor ordered (the resident) to be sent to the hospital. (R#702's) arm and legs are contracted and it's not likely that (they) pulled it out. A review of R#702's record revealed the following: A progress note dated 2/26/2020 at 19:18 (7:18 PM) written by Registered Nurse (RN) C Note Text: Resident had urine soaked brief x 2 during shift, SN changed Foley catheter, resident tolerated well. A progress note dated 2/26/2020 at 20:15 (8:15 PM) written by Licensed Practical Nurse (LPN) A: Resident Foley was removed while the balloon was still inflated, resident was experiencing vaginal bleeding, RN team lead cleaned resident up and reinserted catheter, bleeding did not stop .after hours doctor called and informed (ambulance) called and resident sent out for excessive vaginal bleeding, (family) called and informed of .situation and was told where (they were) being transferred to, acting shift supervisor notified, vital taken before resident was sent out were 154/78 (blood pressure), 93 pulse, 93 o2 (oxygen), 98.4 temperature . A progress note dated 2/27/2020 03:10 (3:10 AM): Note Text: resident received from (hospital) at 0310, resident has a urinary tract infection [MEDICAL CONDITION], and a new order for [MEDICATION NAME] (antibiotic) 100 mg (milligrams), vital signs upon arrival were, 136/89 (blood pressure), 67 pulse, 97 o2, 98.4 temperature, catheter was changed at hospital, external bleeding stopped . A progress note dated 2/27/2020 23:54 (11:54 PM): Late Entry: Note Text: Resident c/o (complained of) pain (throbbing) from (their) vagina. Upon assessment writer noted no redness, slight swelling of outer lips. Resident has a UTI, declined pain pills . On 6/30/20 at 10:17 AM, LPN A was interviewed via phone regarding their progress note for R#702 on 2/26/20. LPN A was read the note and then stated, That was the RN improperly placing the catheter. The resident ended up having to go out for that. You just jogged my memory. LPN A continued and stated, I was doing my rounds, it was the beginning of the shift. (R#702), something looked funny or off with (them). I looked in to check and see what was going on. (They) normally had issues with the catheter. I got in report that it had been changed. I wanted to make sure there was return. I looked and the bag had nothing but blood. I got the team lead (RN). I opened the brief because sometimes (R#702) would have urine leakage. I opened the brief and the balloon was still inflated and it was sitting in the brief. The resident didn't appear in any pain. I don't know how long it was like that. I went and got the nurse I was relieving and got the team lead, went and got supplies to clean (them) up. After that I was no longer in the room because the team lead was finishing everything .and then judging by that (R#702) got sent out. When asked if an incident/accident (I/A) report was filled out for that situation, LPN A indicated if there was it would be the team lead/RN's job to fill it out, and was not sure if one was completed or not. LPN A stated that RN C no longer worked for the facility. On 6/30/20 at 10:30 AM, the facility was asked to provide any I/A's for R#702 from 2020. The facility provided one I/A dated 1/14/20 that was unrelated to the resident's catheter. A review of R#702's medical record revealed a hospital document dated 2/26/20 titled, ED After Visit Summary, with the following: Diagnoses: [REDACTED]. -Trauma of urethra, initial encounter Done Today: -Bladder scan -Foley/urology care Your medications have changed. Start taking: -[MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) ([MEDICATION NAME]) (antibiotic to treat/prevent urinary tract infections). On 6/30/20 at 11:00 AM, 1:25 PM, and 2:40 PM, attempts were made to contact former facility employee RN C via phone. The mailbox was full and a message was not able to be left for callback each time. A call back was not received prior to survey exit. On 6/30/20 at 1:07 PM, the Director of Nursing (DON) was queried if there were any additional I/A's for R#702 other than the one from January 2020. The DON indicated there wasn't. The DON was then queried regarding the incident with the resident's catheter on 2/26/20. The DON stated she would have to look it up and would be back to discuss the incident. On 6/30/20 at 1:57 PM, the DON was again interviewed and stated the following in regard to R#702 and the incident with (their) catheter on 2/26/20: The Foley catheter was leaking at 7:20 PM. The nurse went in and the bed was wet with urine. They changed the catheter. At 8:15 PM, a nurse went back and there was some bleeding and the catheter was out. (DON indicated the resident had a stent placed at this time that was calcified). No one was in the room caring for (them) between that time so there's no knowledge of how the catheter came out. Because there was bleeding, it appeared to be from the vagina. I looked at the hospital documentation, it doesn't say what it's from, there was just an ED visit. The DON was then asked if she saw there was urethra trauma on the hospital discharge documentation. The DON stated, No, I didn't see that. That would explain it with the balloon coming out. The DON then stated, (LPN A and RN C) were the nurses at the time. When asked who placed the catheter, the DON stated, I believe the RN, who doesn't work here anymore. On 6/30/20 at 3:21 PM, the DON was queried regarding any procedures/policies/guidance the facility had for when to fill out I/A reports. The DON indicated the facility has no written process for incidents and accidents. The DON stated, We use (the electronic medical record) for I/A's. There is a risk management tab. I don't believe that the RN should have filled out an I/A for that incident because it was obviously the catheter and the bleeding. We don't typically fill out reports for when catheters are out, it's not our standard of practice. When queried regarding RN C's note that stated, SN changed Foley catheter, the DON stated, SN probably meant RN. She was the RN on duty. The DON indicated she could confidently say SN was a typographical error that was supposed to say RN. The DON continued and stated, It looks like something went wrong with the catheter placement, and indicated that the outcome with R#702 was not ideal and not the expectation of care. A review of R#702's medical record and Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was admitted into the facility on [DATE] and most recently re-admitted on [DATE] with medical [DIAGNOSES REDACTED]. Further review revealed at the time of the MDS assessment the resident was cognitively intact, had range of motion impairments on both upper and lower extremities, and required extensive to total assistance from staff for activities of daily living (ADLs). A review of the facility's policy titled, Catheter Care, Urinary, reviewed July 9, 2019, revealed, Purpose: Our residents with catheters are at greater risk of infection and need to receive catheter care to help prevent catheter associated infections. Policy: It is the policy of (facility) to provide catheter care reduce the risk of catheter associated urinary tract infections .Procedure: .2. The licensed nurse to change indwelling catheters and drainage bags per physician orders [REDACTED].

This citation pertains to intake 3. Based on interview and record review, the facility failed to adequately monitor hydration status, food, and supplement intake and ensure/provide hydration for one sampled resident (R501) of four reviewed, resulting in dehydration and hospitalization . Findings include: On 5/12/20 at 9:40 AM, an interview was conducted with Confidential Witness Z (CW Z) about R501. CW Z reported R501 had been at the facility since April of 2019 and that they would visit R501 every day, but had been unable to visit (on-site) with R501 because of the COVID-19 (Coronavirus 2019) guidelines. CW Z stated when they were at the facility, there were times they would have to get R501 water and that R501 required the water to be handed to them. CW Z reported that since the visitation restrictions for COVID were implemented, they were not allowed to visit and spoke with R501 once a week on the phone and March 24, 2020 was the last time they were able to speak with R501. CW Z reported when they called on March 31, 2020, R501 was unable to speak. R501 was sent to the hospital on April 1, 2020 because staff believed R501 was dehydrated. CW Z indicated R501 passed away on April 10, 2020. CW Z reported being told by the hospital doctors that the cause of death was severe dehydration and that R501 had not had any food or water in 5-7 days. CW Z further stated that a doctor from the facility had told them in February R501 was dehydrated and other visitors were concerned about residents getting enough to drink. CW Z was concerned that the facility failed to give R501 food or water for an extended period and did not send them to the hospital early enough resulting in severe dehydration. A review of R501's acute care hospital documents revealed the resident's initial encounter at the hospital was on 4/1/20, and the resident was placed on hospice after admission to the hospital. The documents revealed R501 passed away while on hospice on 4/10/20. R501's final [DIAGNOSES REDACTED]. 2. Severe dehydration with acute renal (kidney) failure, present on admission . Further review revealed, Hospital Course: .(patient) came in with severe confusion and dehydration with [MEDICAL CONDITION] .admitted here for inpatient hospice, and passed away here. A review of R501's facility medical record revealed the following: A quarterly Registered Dietician (RD) note dated 12/23/19 which noted, Spoke with nursing in AM (morning) states ate good for breakfast. Water within reach. States resident only drinks sips of medpass but does well with breeze (medpass and breeze are nutritional supplements). Also notes res (resident) will eat more if fed. (Spouse) feeds res at dinner. Progress notes which noted, intake 25% or less of 2 or more meals in a day dated in January 2020 on 1/25, 1/27, 1/30; February 2020 on 2/3, 2/4, 2/6, 2/8, 2/13, 2/16, 2/19, 2/26; March 2020 on 3/4, 3/14, 3/18, 3/19, 3/23, 3/29, 3/31. Additional progress notes indicated intake 25% or less of 2 or more meals in a day back to August of 2019. A review of R501's Nutritional Full Assessment completed by the Registered Dietician (RD) dated 3/21/20 revealed: Supplements/Planned Extras: Breeze TID (three times a day) 591ml (milliliters), Medpass 120ml TID, w/ (with) 8oz (ounces) of additional fluid added (267ml). ProMod Liquid 30ml daily . CW (current weight) 133.8# (pounds), BMI (body mass index) 21 underweight for age. Free of sig. (significant) wt (weight) changes x 30/90/180 days. Usual body weight 155-160#. General appearance: thin .Estimated fluid requirement 1800ml (per day) .Estimated Nutrients Provided at Meals: Fluid (ml): [PHONE NUMBER]. Estimated Nutrients Provided by Supplement, Planned Extras, or Tube Feeding: Fluid (ml): 858. Per food record, average meal acceptance 26-75%. Resident accepting snacks. Supplement intake varies. Res likely meeting needs AEB (as evidenced by) wt stable . Comments: 2/26 labs: BUN/Crt ratio (BUN/Creatinine ratio - helpful in diagnosing kidney disease) 26.67 H (high), total protein 4.9 L (low) however increased from 12/11 labs, [MEDICATION NAME] 3.2 L (low). 12/11 BUN 29 H (high), BUN/Crt ratio 36 H, total protein 4.7 L, [MEDICATION NAME] 3.2 L, hgb (hemoglobin) 10.8 L, hct (hematocrit) 34.4 L likely r/t (related to) advanced age . K. Hydration Risk: ***REFER TO HYDRATION ASSESSMENT*** comments: At risk for dehydration related to Alzheimer's, and use of laxatives/[MEDICAL CONDITION] agents. Skips meals? Yes. Does refuse some meals. Advanced Directive for Tube Feeding? Yes. Nutrition Assessment Summary: .Resident receives (supplements) for wt loss Assistance w/ eating ranges from independent to total assistance. Average meal acceptance 25-75% .Physician note 3/4 according the patient's family (R501) is more sleepy and is skipping meals and is losing weight. Patient was started on appetite stimulant 10 days ago .According to bedside sitter, (R501) did decline breakfast . Further review of R501's medical record was conducted for the mentioned hydration assessment, however, one was not found. Progress notes which indicated No BM (bowel movement) times three days dated 12/26/19, 1/20/20, and 3/4/20 (constipation can be a result of lack of fluid intake). A review of R501's Medication Administration Record [REDACTED] For order Add 8 ounces of fluid to med pass every 8 hours for wt loss, R501 was charted as sleeping (code 7) and was not administered the order at 0600 on 3/3, 3/9, 3/10, 3/11, 3/13, 3/14, 3/16, 3/21 (8 oz fluid = 236 ml of fluid). There was also no charting present on 3/26 at 0600 for this order. No accompanying progress notes were observed in the record for the dates it was not given. For order Breeze three times a day for Weight loss, R501 was charted as sleeping and not administered the order at 0600 on 3/3, 3/9, 3/10, 3/11, 3/12, 3/13, 3/14, 3/21, and 3/23. No administration of the order was charted at 0600 on 3/26, and an X was present for percent taken in at 0600 on 3/1, 3/2, 3/5, 3/7, and 3/31; at 1400 on 3/14 and 3/15; and at 2100 on 3/4. For order, Med pass supplement three times a day for 120 ml TID for poor PO <50%, R501 was charted as sleeping and not administered the order at 0600 on 3/3, 3/9, 3/10, 3/11, 3/12, 3/13, 3/14, 3/16, 3/21, and 3/23. No administration of the order was charted at 0600 on 3/26, and an X was present for percent taken in at 0600 on 3/1, 3/2, 3/5, 3/7, and 3/31; at 1400 on 3/14, 3/15 and 3/20; and at 2100 on 3/1, 3/4, and 3/6. On 5/13/20 at 2:47 PM, the Director of Nursing (DON) was queried what an X for percentage taken in on the MAR indicated [REDACTED]. The DON responded, I spoke with a nurse who was a nurse who actually placed an X on the %. She stated she places an X because she is unsure of the amount of supplement (Breeze in this case) that the resident drank because (R501) did not drink it all at once. Review of R501's Documentation Survey Report, for assigned tasks revealed that Amount Eaten was not documented for R501 on on the following shifts: 0900 (9am) and 1300 (1pm): 1/4, 1/5, 1/6, 1/8, 1/9, 1/12, 1/18, 1/19, 1/24, 2/14, 2/15, 2/17, 3/20, 3/8 (1300 only), 3/9, 3/14 (1300 only), 3/15, 3/20 (1300 only), 3/22, 3/24, 3/26, and 3/27. 1800 (6pm): 1/3, 1/7, 1/12, 1/15, 1/18, 1/19, 1/22, 1/25, 1/27, 1/29, 1/30, 2/3, 2/7, 2/8, 2/9, 2/10, 3/3, 3/13, and 3/28. 2000 (8pm) snacks were not marked as given to the resident on the following dates: 1/3, 1/7, 1/15, 1/18, 1/19, 1/22, 1/23, 1/24, 1/26, 1/27, 1/29, 1/30, 2/1, 2/3, 2/6 through 2/10, 2/15, 2/18, 2/20, 2/22, 2/23, 3/3, 3/12 through 3/14, 3/28, and 3/29. R501 also had a Magic cup ordered TID which was not documented as given on 0900 shift on 3/1, 3/9, 3/15, 3/22, 3/24, 3/26, 3/27; 1300 shift on 3/1, 3/8, 3/9, 3/14, 3/15, 3/20, 3/22, 3/24, 3/26, and 3/27; and 1800 shift on 3/3, 3/13, and 3/28. A progress noted dated 3/4/20 revealed: (spouse) requested cup holder on wheelchair. A progress note by Nurse Practitioner (NP) D on 3/25/20 revealed: Follow-up anorexia and weight loss. History Of Present Illness: Patient is seen and examined in the room. (R501) awakened resting in bed. According to the bedside sitter patient did consume breakfast this morning. (R501) is noted with within normal vital signs, review of labs indicate positive weight gain. Patient noted with improved appetite with use of [MEDICATION NAME]. Hydration or potential for dehydration for R501 was not mentioned. A progress note on 3/31/20 at 1:55 PM revealed: (R501) was lethargic during phone scheduled time. Family was notified and will try again later on. A review of a change in condition transfer form dated 4/1/20 at 3:30 PM revealed: The change in condition, symptoms, or signs observed and evaluated is/are: Functional decline (worsening function and/or mobility) .BP (blood pressure) 101/57 .Decreased level of consciousness (sleepy, lethargic), decreased mobility, Needs more assistance with ADLs, swallowing difficulty, weakness (general), Decreased urine output .Primary Care Clinician Notified: 4/1/20 3:35 PM .Recommendation of Primary Clinicians: Send to ER (emergency room ) . R501's labwork from 4/1/20 revealed a BUN of 149 mg/dl (normal 7-20), creatinine of 4.470 mg/dl (normal 0.550-1.300), Sodium of 162 (normal 135-147), and BUN/Crt ratio of 33.33 (normal 12-20). On 5/12/20 at 10:55 AM, Licensed Practical Nurse (LPN) A was asked about R501 and reported about a week before R501 left that the resident had been refusing food and drink more than normal and staff could not get R501 to drink. Nurse A reported R501 was total care for daily needs like drinking fluids and prior to the shutdown for COVID-19, R501 would be in the dining room most days. On 5/13/20 at 11:34 AM, Certified Nursing Assistant (CNA) B was interviewed regarding caring for R501. CNA B indicated that the resident's spouse normally came to visit and helped the resident. CNA B stated R501 did, pretty good with liquids, and if they were sitting up in a chair (they) could hold a water, but indicated the resident did need help. A progress note for R501 written by LPN C revealed the following: 3/31/2020 17:34 (5:34) Nutrition Note Note Text: 25% or less of 2 or more meals in a day Resident 1:1 aid alerted nurse resident food intake was less than 25%, writer encouraged fluids and nutritional supplements. On 5/13/20 at 12:06 PM, LPN C was interviewed and queried about working with R501 and the resident's intake. LPN C stated, I know I worked with (them) in March. They were saying (R501) was eating just not as much, it was right before the visiting restrictions. (R501) liked the Breeze drinks. It always took (them) longer to finish but (R501) would eventually take those. When asked if the resident required assistance for drinking, LPN C stated, I'm not for sure if it was documented but (R501) wouldn't just grab at something and drink it, no. (R501)'s spouse recommended we hold it for (them) because (R501) would hold the cups too hard and they would break. When asked if she recalled reviewing any labwork for the resident, LPN C stated, No. When asked what type of interventions they expect to see for monitoring eating and drinking, LPN C stated, Well, there are the supplements. The next thing is, if no one is eating or drinking anything we would need to contact the physician or NP (nurse practitioner). Next step, IV (intravenous) protocols, we would need to get fluids and hydration in them, get labwork. When asked if she observed any of that in R501 while working with the resident, LPN C stated, No, I was just told it would take (them) a little longer to eat and drink. LPN C indicated the resident had a 1:1 safety sitter at all times due to history of falls, and indicated that the safety sitter would have been responsible for assisting the resident with eating and drinking, and paying attention to water intake and encouraging drinking. LPN C stated further, We all noticed a difference in all of the residents once the lockdown happened. They couldn't see their families, it was just a very hard time for everyone. (R501)'s spouse would literally come every day. It wasn't their norm anymore. On 5/13/20 at 12:47 PM, NP D was interviewed and queried regarding caring for R501. NP D indicated they remembered the resident somewhat and stated, I believe that resident was in acute [MEDICAL CONDITION] when they were sent out. When queried regarding the BUN/Crt ratio being 26.67 H (high) on 2/26, NP D stated, The BUN and creatinine were normal individually so I was not thinking to give IV fluids then. I was thinking about (R501)'s labs though and the resident did receive [MEDICATION NAME] (medication given [MEDICATION NAME] or when sick with the flu) in March. I was also not sure if that caused any renal damage. I know the resident was not very verbal and needed a lot of help, and needed assistance with feeding. I don't recall anyone reporting to me that (R501) was not eating or drinking. When queried if she was informed about the resident becoming lethargic, NP D stated, I was not told about anything significant changing except for the day when I ordered the STAT labs. When queried regarding the resident's hydration status, NP D stated, There was always someone 1:1 with (them). I can't tell you if (R501) was dehydrated from not being fed. The last time I had seen (them), (R501) didn't look significantly different. When the STAT labs came back it was too late for doing IV fluids so the best thing was to send (them) out. When queried regarding the STAT lab results on 4/1/20, NP D stated, To be honest, I don't know if [MEDICATION NAME] would cause that but I have no idea if (R501) stopped eating and drinking, I wasn't told about that. On 5/13/20 at 1:11 PM, the RD was interviewed and queried regarding monitoring R501's nutrition and hydration status. The RD indicated the resident was on multiple supplements and that she had added 8 ounces of water to the resident's regimen every 8 hours to increase fluid intake. When queried regarding R501's labwork that came back on 4/1/20, the RD indicated she did not review those labs, but she had reviewed the labwork prior to that and noted it during her annual assessment on 3/21/20. When queried what intervention was put into place, the RD stated, We had to increase fluids, and had someone with (them) for 1:1. When I did the annual I went in and talked with the aide. They were to be providing fluids throughout the shift. When queried if she was informed in March if the resident was becoming more lethargic and not wanting to eat or drink, the RD stated, I think I noted that in my assessment. That the family said (R501) was more sleepy and losing weight. But we were taking (R501)'s weight and it was stable. (R501) was on an appetite stimulant that started 10 days prior. We were hoping (R501) would gain weight, but then shortly after was sent out to the hospital. When queried regarding the documentation for the supplement administration on R501's MAR, the RD indicated she reviewed them when she did her assessment but did not have an answer as to why an X was present in the charting. The RD stated, I do know that's why (R501) was getting supplements multiple times a day, because the intake did vary. The RD was then asked about R501's resulted labwork on 4/1/20 and stated, I wasn't notified there were labs taken but was notified (R501) was sent out to the hospital. Looking at the BUN I would assume it was likely from dehydration. When queried regarding IV fluids, the RD indicated those would be ordered by the NP and nursing. When queried regarding logged fluid intake, the RD indicated fluid intake was not documented individually, but was included in overall amount eaten that was documented in the medical record. The RD indicated that maintaining hydration is a question for nursing and stated, The resident did have a 1:1, so each nurse or aide would be able to speak more to that. On 5/13/20 at 1:39 PM, LPN E was interviewed regarding caring for R501. LPN E was noted to have charted R501 as sleeping at 0600 on the MAR indicated [REDACTED]. Even though (R501) was 1:1, when I took (them) Breeze and med pass, I would try for (them) to drink but I would only document what I saw (R501) take. Even though I left it in the room with the 1:1, (R501) was only drinking about 25% of it. LPN E further indicated, (R501) had been declining on (their) intake. I would only document what I actually saw was administered. Sometimes the resident would drink it and sometimes not. The resident was sleepy often in the mornings. They had me giving (supplements) to (them) at 6 AM and I didn't understand why I would wake somebody up that early, because (R501) wouldn't drink it. At night I could get it to (them) before (R501) laid down, though. I personally would tell the 1:1's to make sure (R501) was drinking. When queried if R501 had a decline in wanting to drink, and if it was difficult to get the resident to drink in the morning, LPN E stated, I think I documented it and I think I placed something in the doctor's log about it that (R501) wasn't wanting to drink in the morning. I know I passed it on shift to shift. On 5/13/20 at 2:25 PM, CNA F was called and queried regarding caring for R501. When asked about providing assistance to R501, CNA F stated she remembered the resident's spouse being around often, and stated, We chart the food intake and changing and daily care. Fluid intake is included under food intake. When queried further regarding R501's needs for eating and drinking, CNA F stated, I know (R501) needed a cup for (their) wheelchair and I got that for (them). Sometimes (R501) would drink on (their) own but the majority of the time you needed to do it because (R501) would squeeze the cup too hard. We had to hold the regular cup for (them). Staff was responsible for doing that. When asked if the resident would tell staff if they were thirsty or hungry, CNA F stated, No. (R501) didn't talk much. We needed to help (them) regularly. On 5/13/20 at 4:38 PM, the DON was interviewed. When queried regarding expectation for interventions for residents with poor fluid and food intake the DON stated, If someone is not eating, we obviously encourage and offer substitutions. If it's an ongoing issue, we notify the family and involve them. We talk with physician and talk with the dietician for input. When queried regarding X marked for percentage of intake of supplements on R501's MAR, the DON stated I would expect them (nurses) to put the actual amount given. That didn't make sense to me. I asked her (nurse) specifically about it - she is someone who's initials appeared with an 'X.' She stated (R501) would not drink (their) whole Breeze, so she put an 'X' because she didn't know the exact amount (R501) drank. So, I would expect if that was the case, that there would be documentation that says (R501) accepted the Breeze, however, the amount is unknown. My expectation is that would be communicated. I can't say it wasn't, but can't say it was. When queried regarding the supplements not given because the resident was charted as sleeping, the DON stated, I don't think it would be unreasonable not to wake someone up who is sleeping. But, I expect them to come back when they're not sleeping and offer it. When asked if that would be documented in the record if staff came back with the supplement, the DON stated, That would be a good nursing practice to document if they came back. The DON was then asked if she could clarify where the hydration assessment for R501 was that was referenced in the RD's assessment done on 3/21. The DON stated, I didn't look for that one. Let me see if there was one. The DON paused and then stated, I do not see one in (R501)'s chart, so I can't say what she was referring to. When asked if nursing addresses resident hydration status in their assessments or documentation, the DON stated, If it's obvious if someone is not drinking or has a significant change in condition, they would chart by exception. If there is that exception, I would expect to see it charted. The DON was queried regarding R501's labwork from 4/1/20 and asked if she would consider them to be an indication of dehydration. The DON stated, I would. When queried if there was anything in the physician log books regarding R501 and their hydration status or decline in intake, since NP D stated she was not made aware of it, the DON stated she had looked but could not find anything. The DON continued and stated, I cannot speak to what she (NP) says. I can't say the nurses did or didn't and can't say if she did or didn't get called. When queried regarding having knowledge of R501's condition, the DON stated, When families stopped visiting, we were keeping an eye on the residents in general overall. We knew that was difficult. (R501)'s spouse visited (them) routinely. I was aware (R501) was not eating well and they encouraged, but that happened before when (the spouse) was coming here as well. When asked if 1:1 staff was responsible for assisting residents with eating and drinking, the DON stated, That would be one person that would do it. Supplements would've come from the nurse and charted in the MAR. The nurse would be responsible, but 1:1 staff could give (them) drinks of water. A review of R501's care plan revealed: NUTRITION: I have potential risk for dehydration and alt. (alteration) in Nutrition Status because I: -Fluctuating PO (oral) intake -use [MEDICAL CONDITION] agents -use laxatives -Dx (diagnoses): [MEDICAL CONDITION], Alzheimer's Wt. Status: My BMI is underweight for age Significant wt loss in 2019. Date Initiated: 04/11/2019 Created on: 04/11/2019 Revision on: 04/01/2020. Interventions: Supplements as RX (prescribed): Medpass 120ml TID Breeze 240ml TID Magic cup BID Promod 30 ml BID Date Initiated: 04/15/2019 Created on: 04/15/2019, Revision on: 04/01/2020. Feeding status: extensive assist to total dependence, 1:1 supervision, Date Initiated: 04/11/2019, Created on: 04/11/2019, Revision on: 04/01/2020. Adaptive feeding device (s) as per RX 2 handled cup with spill proof lid, with straw, Date Initiated: 03/19/2020, Created on: 03/19/2020, Revision on: 03/19/2020. A review of R501's Minimum Data Set assessment dated [DATE] revealed the resident was most recently admitted into the facility on [DATE] and had medical [DIAGNOSES REDACTED]. Further review revealed the resident was severely cognitively impaired and required extensive assistance from staff for activities of daily living such as eating, dressing, hygiene, bed mobility, and toilet use. A review of the facility's policy titled, Change in Resident Condition, reviewed 2/28/20, revealed, The licensed nurse will be made aware of a change in a resident's condition by his/her own observation, CNA observation, or during physician/designee visit or by any facility staff or family/visitors. 2. Then the licensed nurse will assess the resident ' s condition by using the SBAR tool. 3. If the resident ' s condition requires immediate notification, the licensed nurse will contact the physician/designee and notify the physician/designee of the resident ' s assessment findings and obtain any new orders from the physician/designee and carry out those orders. The nurse will document all orders and communication with physician/designee in the EMAR. 4. The licensed nurse will notify the resident/responsible party of assessment findings, and physician orders. 5. If the resident ' s condition does not require immediate notification of the physician/designee, the licensed nurse will place in doctor ' s log and notify resident/responsible party. A review of the facility's policy titled, Nutrition/Hydration Status Maintenance, reviewed 3/1/20, revealed, 1. The facility/staff will: a. Provide nutritional and hydration care and services to each resident, consistent with the resident ' s comprehensive assessment; b. Recognize, evaluate, and address the needs of every resident, including but not limited to, the resident at risk or already experiencing impaired nutrition and/or hydration status; c. Provide a therapeutic diet that takes into account the resident ' s clinical condition, and preferences, when there is a nutritional indication and the health care provider orders a therapeutic diet; and d. Maintains acceptable parameters of nutritional and status, such as usual body weight or desirable body weight range and electrolyte balance, unless the residents clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. e. Offer sufficient fluid intake to maintain proper hydration and health, including nasogastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids. f. Provide nourishing alternative meals and snacks for resident who want to eat at non-traditional times or outside of scheduled meal service time. g. Offer a nourishing snack at bedtime. 1. A comprehensive nutritional assessment will be completed by the Nutrition Services designee on any resident identified as being at risk for unplanned weight loss/gain and/or compromised nutritional status. 2. Licensed Nurse/designee will establish a consistent method of weighing a resident. 3. Information gathered from the nutritional assessment will be used to develop an individualized care plan to address the resident ' s specific nutritional concerns. 4. Care plan interventions must be re-evaluated by Nursing and Nutrition Services designees for effectiveness and modified as appropriate. 5. The physician will be informed of nutritional status/dehydration concerns and may order interventions as appropriate. 6. Intake and output will be documented in the EHR as indicated. 7. The registered dietitian or dietary manager may be consulted to assist with interventions. 8. Observations pertinent to the resident ' s hydration status should be recorded in the EHR as appropriate. 9. The interdisciplinary plan of care will communicate care instructions to staff.

This Citation Pertains to Intake MI 792. Based on observation, interview and record review, the facility failed to prevent an unauthorized exit for one (#701) of 8 sampled resident with a known elopement risk who ambulates with a walker, passed an unattended Receptionist's desk, out the front door, and exited the building unbeknownst to staff for approximately 1.5 hours on [DATE]. The last known observation of resident # 701 was at 5:00 PM. The Resident was found by a visitor near a busy highway at approximately 6:30 PM on [DATE]. The Immediate Jeopardy (IJ) started on [DATE] and was identified on [DATE]. The Administrator was notified of the Immediate Jeopardy on [DATE] and was asked for a plan to remove the immediacy. The IJ was removed on [DATE] based on the implementation of the removal plan as verified onsite on [DATE]. Although the immediacy was removed the facility's deficient practice was not corrected and remained isolated with actual harm that is not immediate jeopardy. Findings include: Review of intake information revealed, Confidential Employee A contacted the State Agency and reported, (Resident #701) eloped on (MONTH) 14th (2019) . A family member of another Resident saw (Resident #701) on crossing streets (major intersections with multiple lanes of traffic) . The intake information further indicated a Facility Reported Incident (FRI) had not been reported to the State Agency. On [DATE] at 10:00 AM, Resident #701 was observed sitting in a chair with a four wheeled rolling walker positioned next to the chair. A black colored band was noted on the Resident's wrist. The resident was interviewed and was pleasant during conversation, but displayed scattered thought processes. When queried if they had exited the building, Resident #701 stated, Yeah, the person across the hall died and I wanted to go outside. When asked how they got outside, Resident #701 replied, I went out the front door. When queried if there was anyone at the front desk of the facility when they went out the front door, Resident #701 replied, No. I think they must have been in the bathroom. There was somebody going out and I went with them. When asked who else was going out, Resident #701 indicated they did not know. When asked if facility staff were aware they were leaving the building, Resident #701 indicated they did not. With further inquiry regarding where they were going and what occurred next, Resident #701 stated, One person, another Resident's (spouse) was chasing me in their car. I was in the parking lot. When queried where they were in the parking lot, Resident #701 indicated they were walking through the connected parking lots of other businesses to the east of the facility building towards the road. When queried regarding the reason they had been admitted to the facility, Resident #701 stated, They said I wandered off. I went for a walk and I guess I got tired and didn't know. I slipped and fell and then somebody called EMS. I had to be in the hospital for quite a while. When queried regarding their injuries from the incident, Resident #701 replied, I can't remember all, but I know I hurt my back. With further inquiry regarding where they had lived prior to being admitted to the facility, Resident #701 indicated they had lived with family and in multiple different long term and assisted living facilities. When queried if they wanted to exit the facility at this time, Resident #701 indicated they wanted to get out of the facility and stated, I don't want to be confined. I want to get out and get fresh air. I get tired of smelling the odors in here. When queried regarding facility activities including organized trips outside of the facility and ability to go outside to get fresh air in enclosed facility courtyards, Resident #701 replied, They have activities, but not enough for me. I don't like being confined like I am in here. I like to go out. Resident #701 then pointed at the black colored band on their right wrist and stated, They put this on me now so I can't get out. It's a tether. On [DATE] at 10:40 AM, Nursing Assistant B was interviewed regarding Resident #701 eloping from the facility on [DATE], Nursing Assistant B stated, It was like (Resident #701) had been plotting it for a while because they sat down there (front door area) and waited for the (front desk) person to go to the bathroom. With further inquiry, Nursing Assistant B stated, (Resident #701) sits down there. (The Resident) has never really been happy here. Maybe (Resident #701) wanted to go outside to smoke. (Resident #701) is a smoker, they have been caught smoking in their room before. Record review revealed Resident #701 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) revealed the Resident was cognitively intact and required supervision to perform some Activities of Daily Living (ADLs), utilized a walker for ambulation and was not steady on their feet. Additional review of Resident #701's medical record revealed the Resident had a legal guardian since [DATE] and their legal guardian made decisions pertaining to their care due to being deemed incompetent. Further review of Resident #701's medical record revealed an Incident Note, authored by Nurse D and dated [DATE] at 7:04 PM which detailed, (Resident #701) was seen by a family member walking up the driveway towards (road). Family member contacted security to let security know pt. (patient) was out of the building. Security contacted shift supervisor and shift supervisor alerted writer that patient was out of the building. Code grey was called. Writer immediately left the building to look for patient. Writer found pt. at the end of the driveway walking with walker and with coat on. Family member encouraged pt. to turn around. Writer assist patient back to the building. Writer asked patient where they were going and patient stated they were walking to meet their granddaughter's grandmother, stated they were picking them up. Pt. walked back with writer with no resistance . No further progress note documentation pertaining to the elopement was present in Resident #701's medical record. Review of Resident #701's assessment documentation revealed the following assessments: -[DATE]: Wandering Risk Assessment . Moderate Risk for Wandering . Known wanderer/hx (history) of wandering . -[DATE] at 9:34 PM: Wandering Risk Assessment . Moderate Risk for Wandering . Diagnosis: [REDACTED]. Review of Resident #701's care plans revealed the following care plan, Alteration in ADLs R/T (related to) impaired mobility I usually get around independently with supervision with my walker. I require assistance with my ADL due to my [DIAGNOSES REDACTED]. I am at risk for elopement because I tried to go outside to smoke (Initiated: [DATE]; Revised: [DATE]). Care plan interventions included: -Ambulates with hand held assist x 1 person assistance (Initiated: [DATE]; Revised: [DATE]) -Use a Rolling walker for functional mobility (Initiated: [DATE]; Revised: [DATE]) -Transfers: I need supervision with transfers (Initiated: [DATE]; Revised: [DATE]) -Ask me for my preferences and allow me to make choices with regards to ADLs/schedules (Initiated: [DATE]; Revised: [DATE]) Another care plan was implemented following the Resident's elopement on [DATE]. The care plan indicated, I am at risk for elopement related to my cognition and my attempt at eloping (Created and Initiated: [DATE]). Care plan interventions included: -I am on elopement safety checks until otherwise determined by the (Interdisciplinary Team) IDT (Created and Initiated: [DATE]) -I am placed on increased supervision for my safety (Created and Initiated: [DATE]) -I have a wander watch on my wrist (Created and Initiated: [DATE]) -My picture is located at the nursing stations around the building and at the front desk (Created and Initiated: [DATE]) An interview was conducted with Nurse D on [DATE] at 12:10 PM. When queried regarding Resident #701's elopement from the facility on [DATE], Nurse D stated, All I know is that I was up on the floor and my supervisor got a call that (Resident #701) was outside. I ran out there (outside) and (Resident #701) said they were going to meet their granddaughter's grandmother. I asked (Resident #701) how they got out. (The Resident) said they just walked out. When asked if facility staff were aware the Resident had exited the building and grounds, Nurse D acknowledged staff were not aware. When asked if the Resident was allowed to leave the facility alone without staff knowledge, Nurse D revealed they were not. With further inquiry regarding Resident #701's elopement, Nurse D stated, It was another Resident's family member who notified my supervisor. They (family member) were still there when I got out there. When queried where the Resident was when they found them outside, Nurse D stated, To the left of the building, in parking lot. With further inquiry regarding how far to the left of the building, Nurse D did not provide an explanation. When queried who the visitor was that had identified the Resident and notified the facility, Nurse D replied, I don't remember right off hand. When asked the last time they had seen the Resident, Nurse D stated, About 5:00 PM-5:30 PM at dinner. When asked what time the Resident was found outside, Nurse D replied, About 6:30 PM. When queried regarding facility policy/procedures pertaining to interventions for Residents with an identified moderate risk for elopement, Nurse D indicated there are no specific interventions unless an elopement had occurred and stated, If elopement has never happened before there isn't. Everyone is at risk for elopement when they can walk around. We don't just say low, high, or medium unless something happens because you can't just predict. When queried regarding the Resident's facility wandering/elopement assessment indicating the Resident was a Moderate Risk for elopement, Nurse D stated, I think everybody is a moderate risk. Like I said if elopement has never happened before then there isn't. When queried if they were assigned to care for the Resident(s) in the room across the hall from Resident #701's room on [DATE], Nurse D indicated their assignment included all the Residents in the rooms surrounding Resident #701's room. When queried if another Resident had passed away that day/evening, Nurse D replied, No, not that day. The (Resident) across the hall was on Hospice, but they didn't pass that night. When queried if Resident #701 had a history of [REDACTED]. With inquiry regarding what occurred following Resident #701's return to the facility, Nurse D stated, Went in and assessed (Resident #701). The Resident was okay. The maintenance guy came and put a wander guard on (Resident #701) and that was pretty much it. When queried if Resident #701's care plan was updated, Nurse D replied, I think I put one in. On [DATE] at 12:30 PM, an interview was conducted with front desk Staff E. When queried regarding facility policy/procedure pertaining to staff at the front desk/entry door of the facility, Staff [NAME] stated, There is someone seven days a week from 7:00 AM to 8:00 PM. There are always two people and lunch breaks are covered by the second (staff). When asked what their role was, Staff [NAME] replied, Keep an eye on Residents, get up and engage those residents at risk for exiting, help with what they need, watch cameras, and check visitors in and out. When asked how they are aware of which Residents are elopement risks, Staff [NAME] indicated they are informed of these Residents and indicated there was a book. When asked if they were familiar with the Resident who eloped, Staff [NAME] stated, Yes, (Resident #701) was one of the ones who would come down and would just get up and walk around. I would engage (Resident #701) and they would usually go back upstairs. When asked if they had ever had to redirect Resident #701 from the exit, Staff [NAME] replied, Yes. An interview was conducted with facility visitor Witness I on [DATE] at 12:40 PM. When queried regarding Resident #701 on [DATE], Witness I stated, I was in the parking lot when I saw a Resident outside of the facility. I went back in and told (Staff H) that I didn't think (Resident #701) should be out there. When asked, Witness I stated, (Resident #701) was walking towards Groesbeck Highway. With further inquiry, Witness I revealed, When I first saw (Resident #701), they were kinda by the Health Department. When I came back out (after telling Staff H), (Resident #701) was closer to the road. (Resident #701) must have been a pretty good walker. When asked if the Resident was wearing a coat, Witness I stated, (Resident #701) had a hoodie on, not a winter coat, with the hood up. On [DATE] at 1:00 PM, the video footage of the incdient was requested from the Administrator, but was not provided by the end of the survey. Review of facility provided Incident Report, dated [DATE], for Resident #701 revealed, Elopement . Pt. (Patient) was spotted by one of the family members walking up towards (Road) with walker. Pt. was last seen in the dining room eating dinner around 5 PM. Writer last seen pt. around 4:,[DATE]:45 PM in their room . Resident Description: Pt stated they were going to meet their nieces grandmother stated they were picking them up . Immediate Action Taken: Writer ran down to the end of the driveway to get pt. Family member had pt. walk back towards the building. Writer meet pt. at the end of the driveway . On [DATE] at 1:15 PM, an interview was conducted with the facility Administrator. When queried regarding Resident #701's elopement from the facility on [DATE], the Administrator indicated the incident was initially reported by staff to the Assistant Director of Nursing (ADON) who was the acting Director of Nursing (DON) at the time of the incident. The Administrator stated, (Resident #701) was allowed to go out (outside of the facility) prior to this. After this, (Resident #701) was reassessed. When asked what interventions were in place to ensure adequate supervision and safety for Resident #701 due to the Resident's assessed risk and history of wandering/elopement, the Administrator stated, Any Resident can go out if not care planned for elopement. When queried why the Resident was allowed to go outside when they had a care plan in place pertaining to their risk for elopement, the Administrator replied, My philosophy is the Eden Alternative, risk vs benefit. We decided this was not an elopement as (Resident #701) wanders and goes outside. We do not put a wander guard on someone if they don't exhibit behaviors. When queried regarding facility investigation of the incident in addition to the Incident and Accident Report, the Administrator revealed an investigation was not completed by the facility as the facility determined Resident #701's exit from the facility was wandering and not an elopement. An interview was conducted with the Assistant Director of Nursing (ADON) on [DATE] at 1:35 PM. When queried regarding Resident #701's elopement from the facility on [DATE], the ADON stated, I received a phone call that (Resident #701) was outside and then I called the (Administrator). I also looked in (Resident #701's) chart and saw that they had a guardian, but did have a (Brief Interview for Mental Status) BIMS of 15. When asked what actions and steps were taken following the elopement, the ADON stated, We determined that (Resident #701) wandered, went outside and decided to let the family/guardian know. We talked about the wander guard system. The ADON then stated, (Resident #701's child/guardian) had no concerns. When asked about Resident #701's cognition and level of confusion evidenced by inconsistent documentation within the medical record and Resident statements including the Incident Note indicating the Resident had stated they were going outside to meet their granddaughter's grandmother, the Facility Incident and Accident Report indicating they were going to meet their niece's grandmother, and the Resident stating they wanted to go outside because another Resident had passed away when Nurse D revealed no Resident deaths occurred near Resident #701's room on the day of the elopement, the ADON did not provide an explanation. When queried regarding facility policy/procedure pertaining to supervision of Residents at the front entrance of the facility, the ADON stated, I was told there was one person (staff member) there (front entrance) who had went to the bathroom. When asked if the front entrance door is supposed to be locked per facility policy/procedure when there is no staff in attendance, the ADON replied, Yes. When asked if the Resident exited the facility unsupervised and in an unenclosed area by themselves often, the ADON stated, I'm not sure. I know (Resident #701) has been out there with their family. It is elder (resident) specific where they go outside. When asked if there should be a care plan in place for Residents who leave the facility unsupervised in unenclosed areas, the ADON did not provide a response. When queried regarding Resident #701 being identified as a Moderate Risk for elopement/wandering upon admission, having a care plan indicating they were at risk for elopement, and the Resident's history of elopement prior to admission to the facility, the ADON indicated the Resident was an elopement risk related to wanting to go outside to smoke and stated, (Resident #701) wandered, not eloped. We determined it was not an elopement. With further inquiry regarding the Resident's history of wandering, the ADON indicated they were unaware of the Resident's history prior to admission to the facility. When asked what the definition of an elopement was, per facility policy/procedure, the ADON indicated they would need to review the policy. Facility policy entitled, Elopement (Approved [DATE]) was reviewed with the ADON at this time. The policy revealed, Elopement occurs when a Resident leaves the premises or a safe area without authorization (i.e., an order for [REDACTED].#701 walking, unsupervised in the parking lot, towards the road, without staff knowledge was considered a safe area per facility policy, the ADON replied, I walk in the parking lot. No further explanation was provided. An interview was completed with facility front desk Staff [NAME] on [DATE] at 2:00 PM. When queried how often Resident #701 left the facility to go outside without supervision, through the front entry door, Staff [NAME] stated, (Resident #701) never goes outside without their family. With further inquiry regarding their interactions with Resident #701, Staff [NAME] revealed the Resident frequently sits in the front lobby area of the facility. When queried regarding facility policy/procedure pertaining to Residents exiting the facility, Staff [NAME] replied, If someone tries to get out, we call the floor and make sure it was an approved LOA (Leave of Absence). If not, we redirect (the Resident). When asked about facility policy/procedure pertaining to staff presence at the front entry door, Staff [NAME] stated, If there is only one (staff) for some reason, the protocol is to call maintenance or lock the door as a last resort (if need to leave desk). At 2:40 PM on [DATE], an interview was completed with Maintenance Director F. When queried if the buildings and parking area of the businesses next to the facility, including the health department, were considered part of the facility campus, Maintenance Director F stated, No. On [DATE] at 2:45 PM, an interview was conducted with the facility Administrator, DON, and ADON. When queried regarding Resident #701's care plan pertaining to elopement initiated on [DATE], the Administrator stated, The care plan is solely related to smoking. When queried why the care plan did not include interventions related to smoking and/or smoking cessation if the care plan was related solely to smoking, the Administrator stated to the DON, Why would it not be in the Care Plan? At this time the DON indicated the Resident had previously been on a smoking cessation patch. When queried regarding documentation of interventions, the DON stated, No, we do not have documentation of that. The only documentation we have is of the medication being completed. With further inquiry regarding Resident #701 being identified as an elopement risk and interventions in place prior to the Resident's elopement, the Administrator indicated the facility determined the incident was not an elopement and stated, (Resident #701's) guardian told us it was okay. When queried why facility staff state they redirect Resident #701 when they attempt to leave the facility unattended and unsupervised if they are not going on an approved LOA, the Administrator stated, We have not completely adopted the Eden Perspective. When queried regarding documentation in the medical record of communication with Resident #701's legal guardian, the ADON stated, No. I did not document that. An interview was conducted with Resident #701's family member and Legal Guardian Witness G on [DATE] at 3:10 PM. When queried regarding Resident #701, Witness G revealed the Resident was not able to live independently and that they were their legal guardian. When asked if they were aware Resident #701 had left the facility unsupervised by facility staff, Witness G stated, I got a phone call that (Resident #701) tried to leave the facility. (Resident #701) used to wander and that is why they are there now. Witness G then stated, I was like, (Resident #701) was outside and they (facility staff) didn't know? With further inquiry, Witness G stated, I believe (Resident #701) was trying to be slick and get some smokes (cigarettes). (The Resident) called me first, before the facility did and told me I was gonna get a call because they tried to run away. When asked if they were aware the Resident was found outside by a facility visitor, Witness G replied, No. They (facility staff) just told me (the Resident) got out but was back and everything was okay. When queried regarding facility staff statements indicating the Resident was able to exit the building in unenclosed areas, unsupervised by facility staff, Witness G stated, No, I did not give permission for (Resident #701) to go out front. No, that is a lie. I only know about (Resident #701) going outside on the second floor (enclosed, outdoor sitting area of the facility). I was under the impression that they (facility Residents) were always supervised when outside. When asked if they would expect facility staff to redirect Resident #701 if they attempt to exit the building, Witness G replied, Yeah. When asked, Witness G revealed they had not received any further communication from facility staff regarding Resident #701's elopement. On [DATE] at 4:15 PM, the DON provided a General Progress Note dated [DATE] at 3:56 PM and authored by the ADON. The progress note indicated facility staff contacted Witness G at this date/time. The note detailed, Spoke to Resident's guardian/child (Witness G) . reviewed prior conversation that was had on [DATE] regarding Resident's choice to go outside . We discussed that Resident is allowed to go outside, with permission from (Witness G). (Witness G) wanted to have the wander guard in place . On [DATE] at 5:15 PM, an interview was conducted with Facility Front Desk Staff H. When queried if they were working at the front desk/entrance door of the facility on [DATE] when Resident #701 eloped from the facility, Staff H revealed they were. When asked what occurred, Staff H stated, I went to the bathroom and came back. Then (Witness I) then came down the elevator. I talked to (Witness I) for a few minutes and then they left. (Witness I) came back a few minutes later and said there was a Resident outside. I asked them who it was and what they looked like. I figured out it was (Resident #701). Then I called the House Supervisor. With further inquiry, Staff H revealed Witness I had driven their car back to the facility. When asked, Staff H indicated Witness I informed them Resident #701 was east of the facility, but they were unable to see the Resident. When queried regarding facility policy/procedure related to leaving the front desk/entry door to the facility unattended, Staff H replied, Supposed to call the House Supervisor to cover. When asked if they called the House Supervisor prior to leaving the desk and door unattended, Staff H stated, No. On [DATE] at 1:08 PM, the video footage of the incdient was requested from the Director of Nursing ( DON), but was not provided by the end of the survey. Record review of facility policy/procedure entitled, Elopement (Approved [DATE]) revealed, It is the policy of . to ensure the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision . to prevent avoidable accidents. Procedure . 1. Wandering is random or repetitive locomotion that may be goal directed (e.g. the person appears to be searching for something such as an exit) or non-goal directed or aimless. 2. Elopement occurs when a Resident leaves the premises or a safe area without authorization (i.e., an order for [REDACTED]. Safe areas include all areas on the second floor and third floor . and the front sidewalk next to the building up to the last bench on either side of the entry . 6. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering . a. Residents will be assessed for Risk for Elopement or Unsafe Wandering upon admission . b. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan . d. Adequate supervision will be provided . to help prevent accidents or elopements . Review of facility policy/procedure entitled, Care Plans (Reviewed [DATE]) revealed, The facility will develop and implement a comprehensive care plan for each Resident that included measurable goals and includes the instructions needed to provide effective and person-centered care . Comprehensive Care Plans . f. Include interventions to address the current needs of the Resident . Plan of removal : On (MONTH) 16, 2019 the Director of Human Resources educated the receptionist present at the front desk on the evening of (MONTH) 14, 2019 regarding front door security. Resident #701 continues to reside safely at the facility. A wandering assessment and Brief Interview of Mental Status (BIMS) assessment were completed on (MONTH) 9, 2020. Resident #701 received a score of 4 on the wandering assessment indicating low risk of wandering. Resident # 701 received a score of 15 on the BIMS assessment which indicates the resident is cognitively intact. A review of the medical record shows that resident # 701 has not gone outside of the facility since the event of (MONTH) 14, 2019. A care plan review was completed on (MONTH) 9, 2020. The care plan was updated to reflect the individuality of resident # 701. A wander guard band was placed on her walker per resident #701 preference. Resident #701 is identified in the wandering/elopement risk book which is located at the front desk, at each nursing station, in the Director of Nursing office and the Executive Director office. On (MONTH) 9, 2020, the ADON spoke with daughter/guardian of resident #701. The daughter/guardian indicated she has given permission for resident #701 to go outside. She stated she wanted the wander guard in place to ensure staff are aware of resident #701 desire to go outside and she wants resident #701 to have a voice in decisions and maintain as much independence as possible. On (MONTH) 9, 2020 the Executive Director immediately implemented a Standard Operating Procedure for Front Door Security to ensure residents are kept in a safe environment. During open hours the door will be attended, if need arises for the door to be left unattended it will be locked. The reception staff on duty have been educated by the Executive Assistant on the Standard Operating Procedure. The reception staff on duty after this date will be educated prior to the start of their shift. On (MONTH) 9, 2020 assessment of current facility resident was initiated for wandering risk utilizing the Wandering Risk Assessment and assessed for cognitive status utilizing the Brief Interview Mental Assessment. Wandering risk care plans were reviewed and revised as need was identified. The initiative will be completed on (MONTH) 10, 2020. The assessments were completed by the clinical staff and the social services staff. On (MONTH) 9, 2020 education was initiated for Wandering and Elopement, emergency preparedness-elopement, locating a missing resident SOP, and front door security. The current percentage of employees educated is 59% as of receipt of this plan of removal. Additional education has been scheduled in Healthcare Academy. The current percentage of employees completing Healthcare Academy education is 23% as of receipt of this plan of removal. Facility staff who have not received education will be educated prior to the start of their next scheduled shift. The education was completed by the staff development department, clinical managers, environmental services and safety services supervisor, environmental services and safety services manager and the nutritional services manager. On (MONTH) 9, 2020 the Elopement policy was reviewed by the Director of Nursing and revised to include wandering risk and elopement risk. Beginning (MONTH) 10, 2020, the environmental and safety services manager or designee will conduct front door lock audits 3 times weekly during the hours of 7:00am and 8:00pm. An Ad-Hoc QAPI Committee meeting will be held on (MONTH) 10, 2020 at 1:00pm to discuss resident safety, front door security, wandering risk and elopement risk assessment, identified risk interventions and documentation.

Citation pertains to MI 232 Based on interview and record review, the facility failed to ensure that frozen food brought into the facility was served in a manner that was palatable (preferable temperature) for 1 (#501) of 3 residents reviewed for food palatability, resulting in a first degree burn to their tongue. Findings include: On 7/6/18 at 9:00 a.m., the clinical record for resident #501 revealed that the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 6/21/18, indicated an intact cognition and that R#501 required extensive physical assistance of one person for eating. On 7/6/18 at 9:15 a.m., a review of the resident's Activity of Daily Living (ADL) Care plan indicated the following: Focus: I have ADLs self care performance deficit and requires assistance with ADLs . Date Initiated: 3/27/18. Goal: I will maintain my current level of function in .eating .Interventions: I require assistance with eating for all meals. Date Initiated: 3/28/18. On 7/6/18 at 9:30 a.m., a review of the resident's Kardex indicated the following: I need total assistance w/feeding to ensure adequate intake. I require assistance with eating for all meals. On 7/6/18 at 9:37 a.m., review of a progress note dated 6/19/18 at 12:28 a.m., indicated the following: (R#501) informed writer that during lunch time on 6/18/18, the daytime Certified Nursing Assistant (CNA) fed her a microwave TV dinner that was brought in by family. The food was too hot and it burned right side of resident tongue . On 7/6/18 at 9:45 a.m., review of a progress note dated 6/19/18 at 2:51 p.m., indicated the following: Met with resident related to event of 6/18/18. Resident stated their food was hot and burned their tongue. Assessment of their tongue indicated a pink tongue with a slight reddened area on the right edge . On 7/6/18 at 9:52 a.m., review of a physician progress notes [REDACTED]. On 7/6/18 at 10:00 a.m., a 1:1 inservice training document dated 6/26/18, and signed by CNA A was reviewed and indicated the following: Program Title: Warming Up Food And Resident Observation Regarding Food Temperature. Objective: Provide Education R/T Warming Up Resident Food Temperature Guidelines And Resident Observation. What To Do If Temperature Too Hot Or Cold. On 7/6/18 at 10:10 a.m., resident 501 was interviewed regarding the incident which occurred involving her frozen food on 6/18/18 and stated that CNA A heated up frozen lasagna brought to her by her family for lunch. R#501 stated, It burned my tongue, first degree, it was painful. It is healed now. On 7/6/18 at 10:20 a.m., CNA A was interviewed regarding the incident which occurred involving R#501 on 6/18/18. CNA A stated, The resident asked me to heat up their frozen lasagna for lunch. I followed the directions on the the box for heating it up and letting it cool. I gave the resident a small bite and they ate it, I gave them a second bite and they ate that too. When I gave the resident a third bite, they said that it was too hot and told me to throw the food away. The resident never told me that they burned their tongue. CNA A was queried on if she tested the lasagna before serving it to R#501. CNA A stated, Test it, how? On 7/6/18 at 1:03 p.m. Nurse B was interviewed regarding the incident which occurred involving R#501 on 6/18/18. Nurse B stated, I examined (R#501's) tongue on 6/18/18 in the evening and noticed a white patch on the right side of their tongue. It looked like it had a small burn on it. On 7/6/18 at 1:15 p.m., the facility investigation involving R#501 and the incident which occurred on 6/18/18, was reviewed with the Director of Nursing (DON). The DON stated, CNA A served food to R#501 that was too hot which caused a first degree burn to the resident's tongue. CNA A was provided 1:1 education on heating food. On 7/6/18 at 1:30 p.m., the DON was requested to provide one of R#501's frozen lasagna meals to allow for review of the Manufacture's recommendations for heating and cooling of the lasagna. The DON indicated that R#501 currently had no frozen meals present at the facility. On 7/6/18 at 1:40 p.m., review of the facility policy titled Food Items-Brought In By Family And Visitors Revised (MONTH) 9, (YEAR). was reviewed and indicated the following: 7. Food items needing heating/re-heating will be heated/re-heated according to facility guidelines. Hot food temperatures must be checked before the cooking process has ended. On 7/6/18, the facility provided documentation to address the incident which occurred on 6/18/18. A summary of this plan indicated the following: June 28, (YEAR) : Past Non-Compliance Resident continues to reside in the facility. She continues a regular diet and requires total assistance with meals. She was diagnosed with [REDACTED]. She has had no further negative outcome from the event. On 6/19/18 the facility identified residents who request heated/re-heated food items. They were assessed and there is no evidence of negative outcomes. On 6/19/18 care plan/Kardex review was initiated to ensure identification of risk factors related heating/re-heating food items. The care plan/Kardex was updated by 7/6/18. On 6/19/18 a facility audit was completed by the Nutritional Services Manager to ensure thermometers are available in each area that has a microwave oven. All areas have a thermometer available. The dietary department has implemented a scheduled audit to ensure the presence of a thermometer in all areas containing a microwave oven. This is an on-going audit. On 6/19/18 Heating/Re-Heating food education was initiated for clinical staff. Education will continue until 100% of staff are educated. On 6/19/18 competency validation for heating/re-heating food items was initiated for staff. Return demonstration of heating/re-heating food items will continue until 100% of clinical staff are validated. On 6/25/18 CNA received 1:1 education provided by Staff Development Manager. CNA will participate in facility wide education through the Town Hall Meetings scheduled for 7/11/18. On 6/29/18 licensed nursing staff were assigned to observe and document the heating/re-heating of food items prior to the food item being served to the resident. This is an ongoing audit. The Director of Nursing is responsible for sustained compliance.

This citation pertains to intake MI 061 Based on interview and record review, the facility failed to provide consistent and adequate supervision for the prevention of aspiration for one (Resident #901) who was accessed as one person assist during meals, of three residents reviewed for supervision, when multiple confused residents were left without assigned supervision, resulting in Resident #901 consuming a peanut butter and jelly snack that caused aspiration, cardiovascular arrest, death, and an Immediate Jeopardy (IJ) to the residents health and safety. Findings include: The Immediate Jeopardy (IJ) started on [DATE]. The IJ was identified on [DATE] at 11:30 a.m. The Administrator was notified of the Immediate Jeopardy on [DATE] at 1:25 p.m. A plan to remove the immediacy was requested. The IJ was removed on [DATE] based on the provider's implementation of the plan of removal and verified onsite on [DATE]. Although the immediacy was removed the facility's deficient practice was not corrected and remained isolated with actual harm that is not immediate jeopardy. On [DATE] at 10:00 a.m., record review of Resident #901's medical records revealed the following: The face sheet revealed an admission into the facility on [DATE] and a re-admission on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated a severely impaired cognition, the requirement for extensive assistance with the help of one person for eating, and the requirement of extensive to total assistance with all other activities of daily living (ADLs). Review of the doctor's orders revealed an order, dated [DATE], for Regular diet Pureed texture, Nectar consistency. The ambulance run sheet, dated [DATE], revealed the following documentation: An 87 y/o (year old) female [MEDICAL CONDITION] .Pt (patient) found in bed with staff performing chest compressions. Staff stated that pt. possibly choked on a peanut butter sandwich. They've been doing chest compressions and ventilations for approx. (approximately) 8 minutes. Pads attached to monitor and showed asystole (absence of heart activity) .Pt's airway was frequently suctioned, with copious amounts of emesis removed from the airway .Lung sounds revealed rales, with evidence of possible aspiration. The hospital's emergency room record, dated [DATE], revealed the following documentation: Chief Complaint, provided via EMS, who states that the patient arrested. History of Present Illness: The patient presents as an [AGE] year old female from assisted living (long term care) where she was eating a peanut butter and jelly sandwich today. Per staff report to EMS, the patient was seen to be choking and arrested. The patient was down for roughly 8 minutes prior to EMS arrival with active CPR (cardiopulmonary resuscitation). EMS tried an additional 15 minutes of CPR en route where the patient remained asystolic. The facility's investigation conclusion of the incident, dated [DATE], included the following documentation: . Resident #901 was in the 3rd floor dining room attending a pre-lunch movie watching activity with several other residents. Resident #901 was provided a peanut butter and jelly sandwich by another resident (#902). Resident #902 would have no knowledge of Resident #901's diet .Resident #901 accepted and consumed a portion of the sandwich . On [DATE] at 10:33 a.m., the Director of Nursing (DON) and the Executive Assistant (Staff A) were interviewed regarding Resident 901's incident. The DON stated, She was up that morning at the regular time. She was put in the dining room for 'movie time.' The tables were sat up in a row in front of the TV to watch the movie. Resident #902 (resident identified as providing the snack to Resident #901) was independent and moved her wheelchair around. She (#902) was given a peanut butter and jelly prepackaged sandwich. She was sitting next to Resident #901. When asked if there was supervision in the TV area where the residents were watching the movie, the DON stated, We really don't have a good time frame. Multiple staff were in and out of the dining room attending to their (residents' needs). It was about 12:30 pm when the CNA (Certified Nursing Assistant B) started applying clothing protectors for lunch. She came to Resident #901. She had left sided [MEDICAL CONDITION] (due to history of a stroke). She frequently napped in her wheelchair. The CNA (B) then realized she (#901) was unresponsive. Another CNA (C) also assisted her to her room. CPR was initiated. Before suctioning, they found a food product in her (#901's) mouth, suctioned food product. EMS (Emergency Medical Services) arrived in about 7 minutes. The hospital indicated she had cardiopulmonary arrest. The residents were in a structured activity. It was set up by activities. They put a movie in before lunch. The peanut butter and jelly sandwich was given to Resident #902 at 11:10 a.m. Snacks usually come out at about 10 a.m. Resident #901 would not have gotten snacks. She is on a pureed diet. CNA D passed out the snacks at around 11:10 am. He gave Resident #902 her snack around this time. CNA D did not give Resident #901 a snack. The two residents (#s 901 & 902) were sitting next each other. Resident #902 did not have a history of food sharing ever before. Resident #901 never seeked food or scavenged for food. The name of the Activity personal (staff) who started the activity for the movie was requested for interview. In the meantime, the DON was queried as to when the movie started. The DON was queried as to when Resident #901 was discovered unresponsive. The DON answered, Resident #901 was found unresponsive at 12:30 p.m. by CNA 'B.' The CNA who assisted her was CNA 'C.' They were both in the dining room. When asked what other staff were in the dining room during the time Resident #901 was found unresponsive, the DON reported not being sure of who else was in the dining room at the time Resident #901 was found unresponsive. When asked how many residents were in the dining room at the time of the incident, the DON stated, About eight residents were in there watching the movie. Again, the Activity person (staff) that initiated the movie activity was requested for questions. The DON went on to state, Nurse E reported that when she responded to the 'code blue' and arrived to the room, she said there was a chunk of something and smelled peanut butter. CNA B said there was a peanut butter and jelly wrapper on the table and noted she (#901) had some food on her shirt and it smelled like peanut butter. CNA C also stated there was something chewed up on her shirt and it smelled like peanut butter. Nurse F did a mouth sweep and smelled peanut butter. He suctioned her and some debris was brought up. Nurse G was the nurse assigned to her. She (Nurse G) was at lunch during the code, but when she arrived she noted a thick brown content in her (#901's) mouth, but no bread. She also smelled peanut butter. The staff reported to EMS that she possibly choked on a peanut butter sandwich. They got food out of her airway by suctioning. That was the report by EMS. The DON was queried whether Resident #902 had a history of [REDACTED]. The DON reported that there were no prior incidents and stated, After this incident, Resident #902 tried to give someone her food. There was one occurrence. She is now on restorative dining. On [DATE] at 10:32 a.m., the Activity Director (Staff K) was queried regarding what type of movie was playing for the residents in the dining room at the time of the incident and how many residents were included in the activity. Staff K stated, It was on one of the movie channels, classic movies on television. Not sure how many residents were there. Staff K then reported that Activity Aide (H) had started the movie/activity. On [DATE] at 10:40 a.m., Activity Aide H was interviewed regarding the day of the incident, [DATE]. Activity Aide H stated, I'm not sure of a movie being set up. Usually, the TV is just on. My shift starts at 8 a.m. At that time around 8:30 a.m., the TV/movie was already turned on. There were residents in the dining room at the time. The other Activity Staff on duty on that Saturday was staff I. She worked on the second floor. It is usually three of us, but only two of us, (activity aides) were working that day. I usually go to 3 B. We were the only two (activity aides) working that morning from 8 a.m. until 12 p.m. Activity Aide H worked the 3rd floor. That was not a structured activity. Sometimes they put residents in there (the dining room) to relax them. On the weekend, normally one of us are assigned on the morning. Two are assigned to go on the second floor. Since I am a floater, I usually go on the third floor. It's just myself until the 12 o'clock person comes in. So, I automatically assist with feeding on the 3 B side because they have so many feeders. That day,on Saturday ([DATE]), there was no assigned CNA or Activity Aide for a movie (Activity). I just saw the residents in the room watching TV. The Third floor does not have an Activity Aide until 12 p.m. That's why they just put on regular TV that day. Both the DON and the Activity Aide H agreed that this was not a structured activity on the morning of [DATE]. Both reported that approximately eight to 10 residents were positioned in front of the TV that morning that included Resident #s 901 and 902. At this time, the DON went on to say the following: She (#901) was on the 3rd floor (3000 dining room). My understanding is that I thought it was a structured activity. Based on the information I got from activities, I considered that a structured activity. Based on what Activity Aide 'H' is telling you, it does not sound like a structured activity. The CNAs are assigned to the dining rooms during meal times, not during the day. That was prior to meal time so they were not in there; at the time they were watching the movie. There would not have been a CNA assigned to the dining room. hey are only scheduled to be there for meals. There was no consistent monitoring the dining room during the time of the incident/movie. I would have to ask why the third activity aide came in late that day. Not sure if this was her assigned area. Per Activity Aide 'H,' she normally goes to that area to work. Record review of the facility's investigation did not include any written statements/interviews that were conducted with the Activity staff. The DON provided no explanation for the omission. On [DATE] at 11:35 a.m., the Activity Director (Staff K) stated, We do sometimes on the weekend have someone in the dining room. We don't necessarily assign a specific person. They are to know to go to the floor. Activity Aide 'H' was assigned to that floor for that day for 11:30 a.m. to 1:00 p.m. She should have been there during that time for the 3000-dining room. On [DATE] at 11:46 a.m., Activity Aide H stated, I was not assigned to the 3000-dining room. Now, after the incident (on [DATE]) they want us in there from 11:30 am until 1 p.m. On the weekends I have been assisting with feeding because it is a lot of feeders on 3 B. If I was assigned to be in that area that is where I would have been. I was never told to be there in that dining room during that time period prior to the incident. On [DATE] at 12:10 p.m., review of written statements from the staff regarding the incident revealed the following: Nurse G's statement, dated [DATE], revealed that Nurse G was identified as being Resident #901's primary nurse at the time of the incident. The statement revealed the following documentation: Nurse G stated that at 11:00 a.m. snacks were sitting at the desk and she asked CNA D to pass them out. Nurse G stated that Resident #901 was talking to other residents while snacks were passed. She stated she observed Resident #902 at 11:10 in the dining room and she had a peanut butter and jelly sandwich. Nurse G returned from lunch at 12:38 p.m. and the code was going on. Nurse G stated Resident #901 smelled of peanut butter. She stated there was light brown thick content in her mouth but no bread in her mouth . CNA D's statement, dated [DATE], revealed the following documentation: He (CNA D) stated he was aware that she (#901) was on a puree (pureed) diet. CNA D stated that at approximately 11:10 a.m., he gave a peanut butter and jelly sandwich to Resident #902. He did not give one to Resident #901. Per this statement CNA D was identified as being Resident #901's primary CNA during the time of the incident. Nurse E'sstatement, dated [DATE], indicated that she was serving in the role of shift supervisor. The statement revealed: She (Nurse E) stated she was made aware of the occurrence when she heard a 'code blue' called. She stated when she entered the room she could smell peanut butter .Nurse E stated she could see a chunk of something in Resident #901's mouth, so she did a mouth sweep .Nurse E stated that after Resident #901 was transferred to the hospital she returned to the dining room and observed peanut butter and jelly 'smeared' on the table where Resident #901 was sitting .Nurse E stated she started performing breathing assistance with an Ambu bag while Resident #901 was still in the wheelchair. Nurse E stated she saw 'beige stuff' in Resident #901's oral cavity and her tongue was white. She stated she removed a 'quarter size chunk of dough.' Nurse E stated she continued to provide respiratory assistance and that CPR was initiated. She stated that when she returned to the dining room she noted a cellophane package on the table near where Resident #901 was sitting. Nurse F's statement, dated [DATE], included the the following documentation: Nurse F stated he did a mouth sweep with no results but that he smelled peanut butter. He stated he initiated suctioning her (#901) and stated, 'some debris was brought up.' He stated he 'got food out of her throat with the suction . On [DATE] at 4:30 p.m., the Administrator reported on working on a plan of correction and reported that the facility takes responsibility for the incident. The facility submitted the following Plan of Removal: [DATE], (YEAR) Plan of Removal Resident #901 no longer resides in the facility. On [DATE] the Smuckers Uncrustable sandwiches were removed as a snack item for residents. On [DATE] the facility identified residents who receive a pureed diet. No other negative outcomes have occurred. On [DATE] Residents receiving pureed diets are seated together. On [DATE] the facility identified current residents who are food sharers and/or scavengers. On [DATE] the facility began resident observation by licensed nurses for safe consumption of peanut butter and jelly sandwiches by residents. On [DATE] Resident engagement education was initiated. Education will continue until 100% of staff are educated. Staff will be educated on resident engagement before the start of their next scheduled shift. On [DATE] the Licensed nursing staff were assigned to observe and assist with meal service in each dining room for meals Sunday through Monday. On [DATE] the Certified Nursing Assistants were assigned consistent dining room supervision times for all assignment sets Sunday through Monday. On [DATE] the Activity Aides assignment was reviewed and adjusted to include a specific schedule/assignment Sunday through Monday which includes a consistent assignment in the 2000 and 3000 dining room for Lunch from 11:30am - 1:00pm. On [DATE] the activity schedule was reviewed and adjusted to include structured activities including activities in the 2000 and 3000 dining room Sunday through Monday from 10:30am to 11:30am. On [DATE] choking risk education was initiated for staff. Education will continue until 100% of staff are educated. Staff will be educated on resident engagement before the start of their next scheduled shift. On [DATE] administrative staff support is provided during the lunch meal Monday through Friday to assist with resident engagement and supervision. On [DATE] it was determined that in the absence of the day shift weekend House Manager, a nursing manager is scheduled on Saturday and/or Sunday and conducts facility rounds in resident common areas to ensure residents are receiving appropriate supervision. On [DATE] all nurse managers began a scheduled rounding program in 2000 and 3000 dining rooms to assure compliance with staff engagement and assuring appropriate resident supervision.

Pertains to Intakes MI 524,MI 430,MI 391 and MI 607 Based on observation, interview and record review the facility failed to Ensure proper body alignment when repositioning Resident #501 (R#501) and failed to use a hoyer lift when transferring 2 (#'s 507 and 501) sampled residents from 3 residents reviewed for accidents, resulting in fractures. Findings include: Resident #507 On 5/23/18, record review revealed that resident #507 was admitted into the facility on [DATE] which [DIAGNOSES REDACTED]. According to Minimum Data Set ((MDS) dated [DATE], R#507 had intact cognition with extensive assist with most Activities of Daily Living (ADLs) and total dependence with transfers. On 5/23/18 at 11:00 a.m., resident 507, was asked about how she received fractures to her hip and ankle, the resident stated, Well, on Mothers Day (5/13/18) I wanted to get up and go to the activity they (facility) was having. I asked Certified Nursing Assistant (CNA) A to get me up. CNA A went to get a hoyer and returned and said he couldn't find one. CNA A told me I could be picked up. CNA A picked me up with my legs between his/hers and turned and threw me in the chair. When asked how long has the facility been using the hoyer lift for transfers, R#507 stated, About two years. I think if the hoyer would have been used, I would be ok. On 5/23/18, review of 5 Day Investigation implemented by facility reveals .CNAB was interviewed a second time, at 2:59 p.m. on (MONTH) 14. (YEAR) by Risk Investigation Manager (RIM) and Director of Nursing (DON). CNA B was asked how she and CNA A transferred R#507 to the chair CNA B stated that they used a two person assist .CNA B was asked if she was aware of the transfer status of R#507, CNA B stated No. CNA B was asked where she would find that information and CNA B stated In the kardex. . CNA B was interviewed a third time , on (MONTH) 17, (YEAR), at 205 p.m. CNA B stated that in (MONTH) 13 (YEAR), he/she was aware that R#507 used a Hoyer lift to transfer but denied this during her/his first interview because she was nervous. On 5/23/28, continued review of 5 Day Investigation. .CNA A was interviewed by RIM and DON at 3:04 p.m., via phone. CNA A was asked if he/she participated in the transfer of R#507 on Sunday (MONTH) 13 (YEAR), he stated Yes. CNA A stated that he put R#507 hands around his shoulder and he/she put is arms around her waist. He/she grabbed onto her pants and lifted her from the bed to the wheel chair about 3 steps away. CNA A was asked of CNA B assisted him/her with the transfer, CNAA stated No she was making a bed or something. CNA A was interviewed again on (MONTH) 17 (YEAR), CNA Astated He/she did not do a transfer of R#507 by himself/herself. CNA A stated, that they did a two person transfer. On 5/23/18, review of 5 Day Investigation- Summary Conclusion documents, . However, it was most likely that R#507 sustained the fracture to his/her right femur and left ankle during during the manual transfer on 5/13/18. On 5/23/18 at 11:30 a.m., Phone interview with CNA A, when asked if a hoyer lift was used to transfer R#507 on 5/13/18, CNA A stated, No. When asked if he/she had been aware that a hoyer was ordered for all transfers of R#507, CNA A stated Yes. On 5/23/18 at 11:40 a.m., Phone interview with CNA A, when asked if a hoyer lift was used to transfer R#507 on 5/13/18, CNA A stated, No. When asked if he/she had been aware that a hoyer was ordered for all transfers of R#507, CNA A stated Yes. On 5/23/18 at 2:00 p.m., Interview with RIM, when asked if R#507 was to be transferred with a hoyer lift, RIM stated Yes. When asked where staff would get information regarding a residents transfer, Rim stated in the Kardex. On 5/23/18 at 2:15 p.m., Interview with DON,when asked if R#507 was to be transferred with a hoyer lift, DON stated Yes. On 5/23/18, record review of policy Patient Lifts- Standard Operating Procedures- 3. Responsibilities- Certified Nursing Assistants : The certified nursing assistant is responsible to identify the resident transfer status as documented on the resident Kardex (CNA care plan)and transfer the resident accordingly. 4. Procedures- A. Hoyer Lift/ Maxi Lift- Bed to chair. 2. The staff member initiating the transfer will review the residents care plan or Kardex to determine the residents transfer status. On 5/23/18, record review of Fall Care Plan for R#507 Kardex- Transferring- I am a Hoyer Lift with 2 pa (person assist) for transfers. Review of Care Plan-Falls- Intervention- I am a Hoyer lift with 2 pa for transfers- date initiated 12/6/17. On 5/23/18, review of radiograph (X-rays) taken on 5/13/18 at 18:49 at hospital reveals 1.Impression- Suspicion of a minimally displaced medial and posterior maileoli fracture. 2. Impression-Distal right femoral fracture . Resident #501 On 5/23/18 at 10:15 a.m. the clinical record for Resident #501 was reviewed and revealed that the resident was originally admitted into the facility on [DATE] and readmitted into the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 10/5/17, indicated a severely impaired cognition and extensive assistance required for all activities of daily living (ADLs). On 5/23/18 at 10:30 a.m., review of an incident report dated 1/3/18, at 4:25 p.m. indicated the following, Incident Description: CNA reported reddened red 5th finger, discolored 4th finger on right hand around 12:00 on 1/3/18. 5th finger red, [MEDICAL CONDITION] noted, discoloration noted. Injuries observed at time of incident: Injury Type: Bruise. Injury Location: Right hand (back). Immediate Action Taken: Area observed, no pain noted at this time, no facial grimacing when area was touched. Physician notified, new order for X-ray of right hand. On 5/23/18 at 10:45 p.m., a review of Resident #501's X-ray results dated 1/3/18, indicated the following, Impressions, Age indeterminate comminuted fracture at the base of the proximal phalanx of the thumb. [MEDICAL CONDITION] and [MEDICAL CONDITION] with erosive component. Associated soft-tissue swelling. Mild [DIAGNOSES REDACTED]. Prominent vascular calcifications. Further review of documentation in Resident #501's record indicated that the resident was transferred to the hospital emergency room for evaluation of the fracture on 1/4/18, and returned to the facility on [DATE], with the additional [DIAGNOSES REDACTED]. On 5/23/18 at 11:00 a.m., a review of 1:1 in-service training dated 1/8/18 titled, Safe transfers and repositioning involving CNA staff C and CNA staff D indicated the following, Staff must visualize all extremities prior to transferring or repositioning the resident. If you cannot visualize any extremity you must call for the nurses assistance prior to repositioning. On 5/23/18 at 12:05 p.m., Resident #501 was observed in their room, in bed, asleep. Resident #501 was observed to have a Cardiac Chair in their room which had a velcro strap on it holding a cushion in place on the chair. On 5/23/18 at 2:22 pm an interview was conducted with CNA staff C regarding the incident which occurred involving Resident #501 on 1/3/18. CNA staff C stated, Myself and CNA staff D were attempting to re-position Resident #501 in their chair, the resident would not move up in their chair and we didn't know why, I looked underneath the resident's chair and noticed that their pinky finger was stuck in the ribbon that holds the cushion in place at the bottom of the chair, I removed their finger and we repositioned the resident. CNA C was queried on if she would normally observe the location of a resident's hands and and arms before positioning them. CNA C stated, Yes. On 5/23/18 at 2:47 p.m. an interview was conducted with CNA staff D regarding the incident which occurred involving Resident #501 on 1/3/18. CNA staff D stated, Myself and CNA staff C were repositioning the resident in his chair, I was on the left side and the other CNA was on the right side, I crossed the resident's arm across his stomach before repositioning him, I don't know what the other CNA did, obviously she didn't do this with the resident's right arm. On 5/23/18 at 3:06 p.m. an interview was conducted with the Risk Investigation Manager (RIM) regarding the incident which occurred involving Resident #501 on 1/3/18. The RIM indicated that she had investigated this incident and determined that CNA staff C and CNA staff D were attempting to reposition the resident in their Cardiac Chair and the resident got his right hand stuck between the cushion on the chair and the velcro strap holding the cushion in place. Following the occurrence of this incident the resident's right hand was swollen. X-rays to the resident's hand revealed that he had a fracture to the base of his thumb and right small finger. The RIM stated, Education was done with both CNAs regarding positioning. The CNAs know better than that. Both hands should be in sight when positioning a resident. On 5/23/18 at 3:30 p.m. the Director of Nursing (DON) was asked for the facility's policy and procedure on appropriate positioning of residents and provided a document titled Positioning of Residents updated 5/12/16. Review of the document revealed the following, Objective: To provide guidelines for positioning residents to relieve pressure on bony prominence's, increase circulation, and provide comfort. Policy: Residents will maintain correct body alignment .Resident's body parts must never be pulled, grabbed, or jerked at any time while positioning.

Based on observation, interview and record review, the facility failed to operationalize policies/procedures to recognize, assess, monitor, evaluate, and document pain for two (#'s 6 and 139) of five Residents reviewed for pain, of a total sample of 35, resulting in inconsistent pain assessment methods for non-verbal Residents and lack of effective pain management for non-verbal Residents expressing signs of pain and discomfort. Findings include: Resident #6 Record review on 2/6/18 at 5:10 PM revealed Resident # 6 was most recently admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was rarely/never understood, severely cognitively impaired, and required extensive assistance to perform Activities of Daily Living (ADL's). Review further revealed the Resident was admitted to Hospice care on 7/10/17, did not communicate verbally, and had a facility acquired pressure ulcer (wound caused by pressure). On 2/8/18 at 11:06 AM, observation of Resident #6's pressure ulcer wound care treatment occurred with Nurse X and Nursing Assistant T. Resident #6 was placed on their left side with their face towards Nursing Assistant T for the wound care treatment. During the treatment, Resident #6 was observed moving their legs restlessly, attempting to reach behind them towards the wound and grabbing Nursing Assistant Ts arms. The Resident also displayed facial grimacing during the wound care treatment. When queried regarding Resident #6's pain, Nurse X stated, They got [MEDICATION NAME] at 9:52 (AM). With further inquiry regarding the effectiveness of the pain medication and the Resident's non-verbal signs/symptoms of pain, Nurse X did not provide further explanation. On 2/8/18 at 12:30 PM, Resident #6's medical record was reviewed. Review revealed the following: A care plan entitled, I am at risk for pain r/t (related to): [MEDICAL CONDITION] muscle weakness impaired cognition (Initiated: 5/23/17; Created 5/9/17). The following interventions were included in the care plan: -Administer [MEDICATION NAME] ([MEDICATION NAME]) as per orders. Give 1/2 hour before treatment or care (Initiated: 1/31/18) -Anticipate my need for pain relief and respond immediately to any complaint or nonverbal (moans, labored breathing, restlessness, clenched teeth, grimacing, etc.) signs of pain (Initiated: 1/31/18) -Currently I am on scheduled and prn dosages of the [MEDICATION NAME] Solution as well as prn (as needed) [MEDICATION NAME] 5-325 mg (milligrams); which are effective at this time (Initiated: 12/6/17) -I am not able to verbalize when I am in pain, but if I become restless that is one of the ways I express my pain (Initiated: 5/23/17; Created 5/9/17) -If I seem uncomfortable or in any pain, rubbing my back, repositioning me, pushing me around the unit, and giving me a shower always helps to keep me relaxed and comfortable; reducing my pain (Initiated: 12/6/17) -Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, nausea; vomiting; dizziness, and falls. Report occurrences to the physician (Initiated: 1/31/18) Review of Resident #6's healthcare provider orders and Medication Administration Record (MAR) at this time revealed the Resident had been receiving [MEDICATION NAME] Solution (Liquid narcotic pain medication - 5 mg by mouth every 6 hours) at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM for pain since 11/10/17. Resident #6 also had the following active as needed pain medication orders: -[MEDICATION NAME] Tablet 5-325 mg (narcotic pain medication); One tablet every 6 hours as needed -[MEDICATION NAME] Solution (Liquid narcotic pain medication); 5 mg by mouth every 4 hours as needed During the month of February 2018, Resident #6 had not received any [MEDICATION NAME] and had received two doses of as needed [MEDICATION NAME] on 2/2/18 at 2:32 PM and on 2/8/18 at 9:52 AM. Resident # 6's Pain Level Summary documentation in the medical record revealed the scale utilized for pain assessment included Numerical and PAINAD (Pain Assessment IN Advanced Dementia- nonverbal pain assessment tool). For the month of February 2018, Numerical assessment was completed 47 times and the PAINAD assessment was completed four times. Resident # 6's documentation indicated the Resident had no pain on 2/8/18 at 12:49 AM, 6:00 AM, 9:52 AM, 11:39 AM, and 1:30 PM. Resident # 139 On 2/6/18 at 11:27 AM, Resident #139 was observed in their room in the facility. The Resident was positioned on their back. The Resident made brief eye contact but did not respond verbally when spoken to. Record review on 2/6/18 at 4:55 PM revealed Resident #139 was most recently readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired, rarely/never understands others, is rarely never understood, and was totally dependent upon others for completion of all Activities of Daily Living (ADL's). On 2/7/18 at 12:08 PM, Resident #139 was heard yelling and moaning from the hall of the facility. Upon entering the Resident's room, the Resident was observed lying in their bed positioned on their back. The head of the Resident's bed was elevated approximately 15 degrees. Resident #139 was yelling loudly and making moaning sounds. The Resident was observed pulling their knees toward their chest and moving restlessly in their bed while displaying facial grimacing. Facility staff were observed entering the Residents room at 12:25 PM. On 2/7/18 at 12:35 PM, record review of Resident #139's care plans revealed a care plan entitled, Risk for pain r/t Muscle weakness with impaired mobility, Contractures, Hx (History) [MEDICAL CONDITION](stroke) with hemi (paralysis) and other multiple comorbidities. Please note: (Resident #139) is not able to verbalize needs and is not able to use call light. Monitor for non verbal S/S (signs/symptoms) of Pain (Initiated: 1/24/18). The following interventions were included in the care plan: -Monitor/record/report to Nurse any s/sx (signs/symptoms) of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing) (Initiated: 1/24/18) -Administer [MEDICATION NAME] (Tylenol) as per orders. Give 1/2 hour before treatments or care (Initiated: 1/24/18) -Anticipate the resident's need for pain relief and respond immediately to any S/S of pain (Initiated: 1/24/18) -Evaluate the effectiveness of pain interventions within one hour after administration. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition (Initiated: 1/24/18) -Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician (Initiated: 1/24/18) -Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain (Initiated: 1/24/18) -Resident's pain is also managed by repositioning, placing by the bird cage and music therapy all help to reduce pain levels and keep resident comfortable (Initiated: 1/24/18) At this time, pain assessment documentation on the Medication Administration Record (MAR) was reviewed. Documentation indicated Resident #139's pain level was 0 (zero) for both day shift and night shift during the month of February 2018. Review of pain assessment documentation on the MAR for the month of January 2018 revealed documentation of Resident #139 having a pain level of 5 (five) on 1/21/18 during the day shift. All other documentation for day and night shift during the month of January 2018 indicated a pain level of 0 (zero). Additional review of the resident's medical record revealed [REDACTED].Treatment 1. Abdominal pain Notes: unclear etiology. Rule out small bowel obstruction and constipation. We will order x-ray of the abdomen and we will continue to follow . Follow Up 2 - 3 Days. No further physician notes were noted in the Resident's medical record. The last nurses note within Resident #139's medical record was dated 1/29/18 at 11:51 PM and did not address the Resident's pain. On 2/7/18 at 1:28 PM, Resident #139 was observed yelling out and moaning in their room. The Resident was moving restlessly in their bed. On 2/8/18 at 6:20 AM, Resident #139 was heard yelling out and moaning from the hall of the facility. When the Resident's room was approached, the room curtain was observed to be pulled across the door area of the room with the room door open. Upon entering the room, Resident #139 was observed lying crossways on their bed. The Resident was squirming and appeared restless with their head and feet off of the bed. The Resident was coughing and facial grimacing was observed. On 2/8/18 at 6:27 AM, observation of the Resident's position in their bed occurred with Nurse O. The Resident was in the same position as previously described. When queried regarding the Resident's position in bed, yelling out, and moaning, Nurse O stated, That's normal. No further explanation was provided. An interview was completed with Nursing Assistant S on 2/8/18 at 6:50 AM. When queried regarding staff communication with Resident # 139, Nursing Assistant S indicated the Resident does not communicate and stated, I just talk them through tasks. When queried regarding Resident #138 yelling out and moaning, Nursing Assistant S stated, (Resident #138) is like that throughout the night. When asked if the Resident has pain, Nursing Assistant S stated, I don't know. I think the way (the Resident) positions themselves is uncomfortable. On 2/8/18 at 6:54 AM, Resident #139 was heard yelling out and moaning from the hall of the facility. Upon entering the room, the Resident was moving around in their bed. Facial grimacing was observed. Nurse O, Nursing Assistant S, and Nursing Assistant U were observed in the hall of the facility but did not respond to the Resident. On 2/8/18 at 7:10 AM, Nurse Q was observed entering Resident #139's room. After Nurse Q exited the Resident's room, an interview was completed. When queried, Nurse Q stated, (Resident #139) was wet. When asked about pain management for Resident #139, Nurse Q indicated the Resident receives medication. No further explanation was provided. On 2/8/18 at 1:45 PM, record review of documentation within the medical record revealed Resident #139 received Tylenol 800 mg (milligrams) every eight hours for pain (order dated 8/2/17). Further review a General Nursing Note, dated 2/8/18 at 7:10 AM which stated, Resident noted turned sideways in bed and making noises, brief checked noted wet, tf (tube feed) running w/o (without) difficulty, brief changed and resident repositioned and hob (head of bed) elevated to semi fowlers. Resident tolerates well. An interview was completed with the Director of Nursing (DON) and Nurse F on 2/8/18 at 2:00 PM. Review of Resident #139's pain assessment documentation under Pain Level Summary and assessment sections of the medical record was completed with the DON at this time. Per facility documentation, the scale utilized for pain documentation was primarily Numerical. When asked if the Verbal pain scale indicated Resident's rated their pain level on a scale from zero to ten, the DON responded, Yes. When queried if Resident #139 was able to rate their pain on a scale of zero to ten, the DON indicated the Resident was not able to rate their pain. With further inquiry regarding Resident #139's pain including assessment and documentation, the DON did not provide an explanation. When queried regarding the frequency that Residents pain should be assessed and documented, the DON stated, I will have to check the policy. When queried regarding facility policy/procedure for pain assessment of non-verbal Residents, the DON indicated they were unsure. Nurse F then stated, We use the Abbey scale. Record review of facility policy entitled, Pain Assessment and Management (Updated 5/17/16) on 2/8/18 at 6:00 PM revealed, Staff will assess pain using a 0-10 verbal pain scale or a 1-10 Faces pain scale with cognitive or verbal impairment .monitoring will be individualized, including reassessment of the Residents response to the intervention outlined in the plan care. This will ensure that once a plan of care is formulated, there is ongoing assessment of whether pain management is achieving the Resident's specific goals. The Resident's complaint of pain and/or signs and symptoms (increased agitation. mood and behavior problems, and decline in functional status) expressed by Resident are valid measurements of pain. Nurse will assess and/or inquire if Resident is experiencing pain/discomfort every shift, and document as indicated. Pain management program will be documented on the Medication Administration Record (MAR) .Weekly/monthly as needed documentation included location of pain, medication/treatment administered, relief of pain/effectiveness of treatment, and side effects. Review and revise care plans, as indicated . The policy further revealed, Procedure: . 2. Pain scale is used to assess intensity of pain and relief of pain. Pain level will be documented by using one of the following methods: numeric scale; Wong face scale; Non-communicative Residents are assessed by observation of nonverbal behavior (i.e., moaning, facial grimacing, yelling out) . Onset of Pain . 3. Document pain on the MAR as follows: Date and time; Intensity; Nonverbal signs of pain; pain location; Non-medication interventions . Documentation: Interdisciplinary Progress Notes . Care Plan . MAR .

This Citation Pertains to Intake Number MI 148. Based on observation, interview, and record review, the facility failed to implement and operationalize fall prevention interventions including the provision of adequate supervision to prevent falls and failed to complete thorough assessment following falls for two (#'s 701 and 702) of three Residents reviewed for falls, of a total sample of three, resulting in lack of implementation of planned interventions to prevent falls, inadequate staff supervision, and a Resident fall which resulted in Resident #701 suffering a laceration to their head and fractured facial bones. Findings include: Resident #701 Record review on 1/23/18 at 9:00 AM revealed Resident #701 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required extensive assistance to perform Activities of Daily Living (ADL's). Additional review at this time revealed the Resident was transferred from the facility to the hospital on [DATE] due to injuries associated with a fall and readmitted on [DATE]. On 1/23/18 at 10:25 AM, Resident #701 was observed in their room. The Resident was lying in their bed, positioned on their back. The Resident had a towel over their chest that was covered with yellow pieces of food which appeared to be chunks of eggs. The Resident's call light was observed hanging off of the left side of their bed and not within their reach. The Resident's overbed table was positioned near the foot of the bed and not within their reach. A pad bed alarm was noted on the Resident's bed. Four containers of unopened pre-thickened, flavored water were observed on the table. Three of the containers were labeled as Honey- like consistency and one container was labeled as Nectar-like consistency. The Resident was observed rolling their tongue in their mouth to push out pieces of egg like substance. No teeth or dentures were observed. Resident #701 was pleasantly confused. When spoke to and asked questions, the Resident made eye contact but did not provide meaningful or purposeful answers to questions. An interview was completed with Nurse A on 1/23/18 at 10:30 AM. When queried regarding Resident # 701, Nurse A stated, (The Resident) needs help with eating. They need assist (to eat). Nurse A then stated, (Resident #701) is a regular, mechanical soft diet and honey consistency (thickened) liquids. When asked about the Resident's fall in the facility on 12/17/17, Nurse A indicated they were not working at that time. On 1/23/18 at 10:35 AM, an interview was completed with Nursing Assistant B. When queried regarding Resident #701, Nursing Assistant B stated, (Resident #701) needs assistance eating. When queried regarding Resident #701 having a towel over their chest with food on it, Nursing Assistant B replied, I fed (the Resident) breakfast this morning. I meant to grab it but I forgot. When queried regarding Resident #701's fall within the facility, Nursing Assistant B stated, I was off work for three weeks. I came back to work at the end of December and I could tell (Resident #701) had declined. With additional inquiry, Nursing Assistant B stated, (Resident #701) could still stand but they are not the same as before I left. On 1/23/18 at 10:45 AM, observation of Resident #701 transpired. The Resident remained in the same position in their bed with a towel over their chest covered with yellow pieces of food which appeared to be chunks of eggs. The Residents call light remained out of their reach, hanging off of the left side of their bed. A pad bed alarm was noted on the Resident's bed. The overbed table was positioned near the foot of the Resident's bed and not within their reach. Three of the containers were labeled as Honey- like consistency and one container was labeled as Nectar-like consistency. One of the Honey- like consistency containers was observed to be opened with a straw in it. Record review of Resident #701's medical record on 1/23/18 at 11:10 AM revealed the following documentation: -12/17/17 at 6:54 PM, Incident Note authored by Nurse F: Resident was observed on the floor in the dining room at 1115 (11:15 AM). Resident was face down and was mumbling. Resident's pants clothing protector and bottom of shoes had thickened coffee on them. Resident hit the left side of face on the floor causing a small hematoma and opening, Resident's chair was locked and Resident has antitippers on wheelchair, Resident's foot print was on the floor where the thickened coffee was spilled. Resident was assisted off the floor, ROM (Range Of Motion) was performed and VS (Vital Signs) were assessed . Writer applied steri-strips to opening on the left side of face/eye area and applied ice for swelling. Resident's NP (Nurse Practitioner) . was here and was able to assess Resident as well and make order to be sent out to Hospital for evaluation and observation . -12/17/17 at 6:59 PM, physician progress notes [REDACTED]. Per nursing, patient has unwitnessed fall from wheelchair. Floor was wet with thick liquid coffee. Patient became sleepy, would not follow commands, or speak. On exam patient is sleepy, uncooperative with exam. Patient is unable to follow an ROS (Review of Systems) due to confusion at baseline . (Family) agreeable to send patient out for further evaluation due to potentially unstable with mental status changes . Examination: General Appearance: sleepy. HEENT (Head, Eyes, Ears, Nose, and Throat): Left forehead contusion with laceration, gross bleeding, swelling . Assessments: 1/ Traumatic injury of head . 2. Confusion and disorientation, 3. Fall . 4. Laceration of forehead . 5. Contusion of forehead . Treatment: 1. Traumatic injury of head . Change of mental status s/p (status [REDACTED]. 3. Fall . fell from wheelchair unwitnessed with trauma to head, unknown loss of consciousness, send for urgent evaluation . -CT (CAT) scan, dated 12/17/17: Findings: Multiple facial fractures are noted. For example mildly displaced fracture involved the left anterior wall of the maxillary sinus, displaced [MEDICAL CONDITION] lateral wall of the maxillary sinus. Comminuted [MEDICAL CONDITION] lateral orbital wall. Floor of the left orbital wall appears irregular and mildly depressed, very suspicious for displaced fracture. Small amount of subcutaneous [MEDICAL CONDITION] and mild adjacent soft tissue swelling is noted adjacent to the lateral wall of the left lateral maxillary sinus. Again noted is mild asymmetric pre-septal soft tissue swelling and small hematoma lateral to the left globe .Nasal septum is deviated to the right of the midline . Impressions: Mildly displaced fracture involving the anterior wall of the left maxillary sinus, displaced [MEDICAL CONDITION] lateral wall of the maxillary sinus. Comminuted [MEDICAL CONDITION] lateral orbital wall. Displaced fracture involving the anterior inferior left orbital rim. Floor of the left orbital wall appears irregular and mildly depressed, very suspicious for displaced fracture . Review of Resident #701's care plans at this time revealed the following care plans: I have a risk for falls r/t (related to) my hx of falls, poor safety awareness and memory loss (Initiated: 5/27/17, Revised: 11/27/17). This care plan included the following interventions: -I am a Falling Star which means I require frequent checks (Initiated: 5/27/17, Revised: 11/27/17) -I have a anti-Thrust Seat Cushion on w/c (wheelchair) (Initiated: 6/21/17) -I have anti-tip and anti-rollback to my wheelchair (Initiated: 6/21/17) -I like to self transfer due to me forgetting to ask for assist (Initiated: 5/27/17) (Resident #701) presents as A&O (Alert and Orientated) x person with STM (Short Term Memory) and LTM (Long Term Memory) impairment and severely impaired decision making. (Resident #701) has a history of exhibiting fluctuations in inattention & disorganized thinking/rambling from subject to subject. Staff are anticipating needs . (Initiated: 1/6/16, Revised: 7/13/16) An interview was completed with Unit Manager Nurse C on 1/23/18 at 3:35 PM. When queried regarding Resident #701's fall within the facility, Nurse C stated, I remember this day really well. (Resident #701) was sitting in their wheelchair in the little dining room. I went in there and (Resident #701) was face down on the floor. The floor was wet and you could see (the Resident's) foot print in the liquid. When asked what interventions were in place to prevent the Resident from falling, Nurse C replied, Anti-roll backs and dysem on their wheelchair. When asked if the Resident was alone in the dining room when the fall occurred, Nurse C replied, There was no staff in the dining room. When queried there was supposed to be staff in the dining room, Nurse C replied, Yes, always. When asked if facility policy/procedure to always have staff in the dining room, Nurse C stated, Yes because of all the confused Residents we have. With further inquiry regarding why no staff were present in the dining room, Nurse C stated, We usually have five aides (nursing assistants) but we only had four that day. They (staff) used an assignment sheet for nights because it has the sets broke up into four sections instead of five. That sheet doesn't have the dining assignments on it. It got missed. Nurse C further stated, One of the aides normally works nights. They stayed over to help and they didn't know. With further inquiry, Nurse C stated, No one called in, we were scheduled one CNA short. When asked if Resident #701 was able to eat and drink unattended, Nurse C replied, (Resident #701) needs assistance. (Resident #701) was not supposed to be left alone in the dining room. When asked about a facility policy/procedure pertaining to staff in the dining room, Nurse C stated, I know they (facility leadership) were working on it. I will check and get it to you. On 1/23/18 at 4:10 PM, an interview was completed with Nurse C. At this time, Nurse C indicated the facility did not have a policy pertaining to staff in facility dining rooms. On 1/23/18 at 4:55 PM, an interview was completed with the Director of Nursing (DON). When queried regarding Resident #701's fall and facility policy/procedure regarding staff monitoring in the dining room of the facility, the DON stated, If (Unit Manager Nurse C) told you there is always supposed to be a staff member in the dining room then that is what they said. When asked if the fall could have been prevented if a staff member would have been present in the dining room providing Resident supervision, the DON did not provide further explanation. Resident #702 Record review on 1/23/18 at 9:20 AM revealed Resident #702 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required limited to extensive assistance to perform Activities of Daily Living (ADL's). On 1/23/18 at 9:40 AM, observation occurred of Resident #702's room. The Resident was not present in their room at this time. A falling star was noted next to the Resident's name located at the door of the room. The Resident's room was observed to have minimal personal items with the exception of two pairs of slippers and one pair of shoes sitting on the floor next to the head of the bed. There were no fall/floor mats observed in the room. On 1/23/18 at 10:05 AM, Resident #702 was observed sitting in a common area of the facility in a wheelchair. There were no staff members present in the area. The Resident's wheelchair was noted to have bilateral leg/foot rests in place. The Resident's feet were observed to be on the floor and not positioned on the leg/foot rests. The Resident was not wearing eye glasses. The Resident was observed leaning forward in their wheelchair and grabbing the front wheel of the chair. An interview was completed with Resident #702 at this time. When queried what they were reaching for, Resident #702 stated, I'm trying to get my shoes on. The Resident was pleasantly confused and unable to meaningfully answer questions. Record review on 1/23/18 at 11:00 AM revealed the Resident had fell twice within the facility. Documentation pertaining to the fall that occurred on 12/6/17 revealed: -Fall Incident Report, dated 12/6/17 at 12:00 AM: This nurse was notified by CNA that Resident was on the floor in bathroom crawling. This nurse and two CNAs assisted Resident in to wheelchair . Resident stated they were trying to fix the toilet. The toilet was leaking and they were trying to turn the water off to fix the toilet . No injuries observed post incident. -Incident Note, dated 12/6/17 at 12:35 AM: This nurse was notified by CNA that Resident was on the floor in bathroom crawling. This nurse and two CNAs assisted Resident in to wheelchair . Documentation pertaining to the fall that occurred on 12/16/17 revealed: -Fall Incident Report, dated 12/16/17 at 3:32 AM: Resident observed on floor near curtain, lying on right side. Resident stated they were trying to get out of bed . No injuries observed post incident. -Activity Note on 12/16/17 at 3:38 AM: Resident observed on floor near curtain, lying on right side. Resident stated they were trying to get out of bed . Review of Resident #702's care plans at this time revealed an active care entitled, I am at risk for falls r/t general weakness, impaired vision, use of [MEDICAL CONDITION] medications and Hx (history) of falls (Initiated: 10/19/17, Revised: 12/5/17). The following interventions were included in the care plan: -I would like to have b/l (bilateral) floor mats to be at my bed side whenever I am in bed for my safety (Initiated: 12/16/17; Created: 12/18/17) -Make sure I have my glasses on during waking hours and they are clean and in good repair (Initiated: 10/31/17) An interview was completed with Unit Manager Nurse G on 1/23/18 at 1:10 PM. When queried regarding Resident #702, Nurse G stated, (Resident #702) was moved to my unit and started acting out. We reached out to (the Resident's) family member and got psych services to eval them. When queried regarding the Resident's falls in the facility on 12/6/17 and 12/16/17, interventions in place to prevent falls and observations of the Resident, Nurse G stated, We put fall mats and (Resident #702) is always supposed to wear their glasses. Nurse G indicated the Resident had very poor eyesight. When queried if there should be fall mats in the Resident's room, Nurse G stated, Yes, they should be in there. When asked why the Resident was not wearing glasses when observed in the common area on the facility at 10:05 AM, Nurse G was unable to provide an explanation. On 1/23/18 at 1:30 PM, an observation of Resident #702's room was completed with Unit Manager Nurse G. Upon entering the Resident's room with Nurse G, Nurse G looked around the room and stated, No, they're (fall mats) are not here. Nurse G then indicated the fall mats may have been removed for cleaning. An interview was completed with Unit Manager Nurse G and Housekeeping Staff H. Nurse G asked Housekeeping Staff H if they removed the fall mats from Resident #702's room for cleaning and Staff H replied, No. When queried, Nurse G stated, That is the only thing that I could think would happen to them (fall mats). No one else would move them. When queried, Nurse G indicated there are spare fall mats within the facility that should be utilized if a Resident's fall mats were soiled or had to be removed from the room. On 1/23/18 at 4:55 PM, an interview was completed with the Director of Nursing (DON). When queried regarding Resident #702's fall mats and eyeglasses, the DON was unable to provide an explanation. Review of facility policy entitled, Falls- Clinical Protocol (Dated 9/1/17) on 1/23/18 at 6:00 PM revealed, Purpose: To ensure that Residents at high risk for fall are identified and that appropriate interventions are put in place to minimize their risks for falling . 7. If the individual continues to fall, the licensed nurse and physician will re-evaluate the situation and consider other possible reasons for the Resident's falling(besides those that have already been identified) and will re-evaluate the continued relevance of current interventions. 8. When a Resident has a witnessed fall where the Resident hits his/her head, or when the Resident has unwitnessed fall, the licensed nurse will initiate neuro checks .

This Citation Pertains to Intake Number MI 677. Based on interview and record review, the facility failed to ensure planned interventions and ordered levels of care and timely assessment and monitoring for one (#701) of two Residents reviewed for appropriate care, assessment and monitoring, of a total sample of three, resulting in a Resident experiencing a displaced fracture of their right femur (right thigh bone broken and not aligned), pain, and a delay in emergency medical treatment. Findings include: Record review on [DATE] at 8:30 AM revealed Resident #701 was originally admitted to the facility on [DATE] and most recently admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required extensive to total assistance to perform activities of daily living. Review further revealed the Resident was receiving Hospice services and was discharged from the facility on [DATE]. On [DATE] at 9:00 AM, an interview was conducted with Confidential Witness A. When queried regarding Resident #701, Witness A stated, It happened Sunday night. They (staff) weren't doing anything but putting an ice pack on it. Witness A further stated, I came in on Monday to see (the Resident) and the Hospice nurse was there. They (Hospice Nurse B and Hospice Nursing Assistant C) said (Resident #701) should go to the ER (emergency room ). The nurse at the facility told me they thought it was a ruptured muscle. They did an x-ray at the ER and (Resident #701) had a broken femur. (Resident #701) had to have surgery on Tuesday. The surgery was too much for (the Resident) and they had a stroke on Friday. (The Resident) died on [DATE]nd. Witness A further stated, (Resident #701) was at the facility a long time but when they were in the hospital, they said 'I can't go back there, they are killing me.' Then when (the Resident) was in the hospital, one of the hospital administrators asked us if they (the hospital) could send the x-ray report of (the Resident's) broken femur to the facility because they needed the report to do an investigation for the state because of the fall. We said no. No one at the facility ever said anything to us about (the Resident) falling. Review of Resident #701's medical record documentation on [DATE] at 9:30 AM revealed the following documentation: -[DATE] at 3:24 AM, General Nursing Note: Patient was yelling out I popped my knee, writer observed a hard knot on patient right thigh and it is warm to touch. No redness noted. Dr notified and a new order for bio freeze (topical over-the-counter pain relief gel) will start 4 x a day for 2 weeks on right thigh. Pain med given. Will continue to monitor. [DATE], Hospice Nursing Note: Patient wake in bed. C/O (complain of) high pain right hip/thigh. Rates ,[DATE]. Pt screams in pain with any movement or touching of area. High right thigh with bulge measuring 4 inches by 5 inches. Patient received [MEDICATION NAME] prior to visit with minimal relief . Verbal order received . to send patient . to ER for eval. Report given to ER. Facility Unit Manager (Nurse D) aware of situation as well as nurse caring for patient. Patient medicated with [MEDICATION NAME] 5 mg (milligrams) prior to transport to ER . Review of Resident #701's care plans at this time revealed a care plan entitled, I require extensive to total assist with my ADL's . (Initiated: [DATE], Revised [DATE]). This care plan included the intervention, I require 2 PA (Person Assist) for all transfers) On [DATE] at 11:30 AM, an interview was conducted with the Assistant Director of Nursing (ADON). When queried, the ADON stated, There are no Incident and Accident (I & A) reports for (Resident #701). An interview was completed with Hospice Nurse B on [DATE] at 2:20 PM. When queried regarding Resident #701, Hospice Nurse B stated, (Hospice Nursing Assistant C) called me and said (Resident #701) was in a lot of pain and their leg looked abnormal, I measured it. Hospice Nurse B stated, When I got there (Resident #701's) right thigh was bulging. Their thigh appeared pushed out and their knee was inward. With further inquiry, Hospice Nurse B stated, It was a 100% change in (the Resident's) condition. Their leg did not look like that before. Hospice Nurse B specified, (Resident #701) had complained of pain before but always mild. (The Resident) only ever wanted [MEDICATION NAME] (oral medication for pain), they never wanted [MEDICATION NAME] before but they requested it. I knew that meant (Resident #701) was in a lot of pain. When asked what time the Resident was assessed and the transferred, Hospice Nurse B replied, I had them (facility staff) give (Resident #701) [MEDICATION NAME] before they were transferred so (the Resident) left the facility shortly after that. Hospice Nurse B then stated, (Resident #701) was discharged to a different facility when they got out of the hospital. They did not want to go back there. Review of Resident #701 Medication Administration Record [REDACTED]. Additional review of the MAR indicated [REDACTED]. An interview was conducted with Unit Manager Nurse D on [DATE] at 2:40 PM. When queried regarding Resident #701, Nurse D stated, (Hospice Nurse B) came and got me. (Resident #701's) knee was turned inward. When queried why there was not a facility Incident and Accident for Resident #701, Nurse D stated, Didn't do one because they told me to keep a soft file on it. On [DATE] at 2:50 PM, record review of soft file pertaining to Resident #701 was reviewed with Nurse D. Soft file contained an Incident Investigation form including statements from Nurse E and Nursing Assistant F, and an incident summary authored by Nurse D. The Incident Investigation included the following documentation regarding the incident: -What Happened: Initially I was doing my rounds- when I got in (Resident #701's) room- Resident stated their leg was hurting and asked me to lay them flat, but I went and got all their supplies . then I laid (Resident #701) flat and I told (the Resident) when I go to turn them grab the pad and they said be gentle. I grabbed the pad and I I went to turn (the Resident), they said my leg snapped and that's when I stopped and got the nurse. The nurse and I then gave care together . -Why did this occur: The Resident stated the CENA (Nursing Assistant F) grabbed their leg directly and turned their leg and did not use a pad but moved them in the bed by grabbing directly on their skin instead of the pad. -How did this occur: The Resident is care planned for two pa (person assist) at all times while doing care and the CENA (Nursing Assistant) initially went in and provided care to the Resident alone and then got the nurse after the Resident stated their leg had popped. The incident summary, authored by Nurse D (no date) revealed, The Hospice nurse came and got me stating the Resident c/o pain when touch right upper leg and (Resident #701) is saying their leg is broken. Nurse gave the Resident [MEDICATION NAME] while the Hospice nurse and writer assessed the Resident's leg. Writer asked the Resident what happened and per the Resident the midnight shift CENA (nursing assistant) was giving care and while moving them in bed pulled directly on the Resident's leg instead of using the pad or an extra person. Resident stated they told the CENA they head a pop sound in their leg and the CENA stopping giving care and went to get the nurse. The Resident denied anyone actually beating them up or hitting them but they did say the CENA (Nursing Assistant) was rough while giving care and the CENA (Nursing Assistant) pulled on their leg directly. The Resident was sent out to check for possible fracture or dislocation in hip. There was no redness noted but there was a bulge sticking out on the Residents right upper hip . The Resident's family; was present so they already knew what was going on . When queried, Nurse D stated, (Nursing Assistant F) should not have been providing care to (Resident #701) by themselves. When queried if Resident #701's family had been notified of incident prior to arriving at the facility, Nurse D did not provide a response. Documentation of family notification including time of notification, was not noted within Resident #701's medical record. Review of documentation from the ER for Resident #701 at this time revealed an X-Ray of the Resident's right hip and pelvis, dated [DATE] at 3:19 PM, which indicated, Acute displaced [MEDICAL CONDITION] right femoral diaphysis. On [DATE] at 3:05 PM, an interview as conducted with Nurse E. When queried regarding Resident #701, Nurse E stated, (Nursing Assistant F) came out (of the Resident's room) and told me they were trying to change (the Resident) alone. With further inquiry, Nurse E stated, (Resident #701) had like a big knot on their right hip, it looked like it was swelled up. It looked different that the other (hip) did. Nurse E then stated, I felt it, it was hard. (The Resident) Didn't want me to turn them or nothing. (The Resident) just kept screaming I pulled my leg. It (Resident #701's leg) didn't look right. When asked, Nurse E stated, I never saw a broken hip before so I asked another nurse to look. They (other nurse) didn't say they thought it was broke. I called the doctor and they ordered Biofreeze. I felt like it needed something more than just Biofreeze. When queried if they assessed Resident again during their shift, Nurse E replied, I put on the Biofreeze. Record review on [DATE] at 3:15 PM of Resident #701's Treatment Administration Record (TAR) revealed documentation of Biofreeze application by Nurse E at 5:10 AM on [DATE]. An interview was completed with Nursing Assistant F on [DATE] at 4:20 PM. When queried regarding Resident #701, Nursing Assistant F stated, We were getting our assignments, we were working short. I remember because I had 18 people that night. When I went in to check on (Resident #701), they asked me to lay them flat. I should have known something was wrong right then. (Resident #701) never wanted to be flat, they would get upset if you put the bed flat any other time. Nursing Assistant F then stated, I laid (the Resident) flat. (Resident #701) was a two person (required assistance of two staff members) but there was no body available to help. With further inquiry, Nursing Assistant F stated, (Resident #701) told me their leg was hurting even before I turned them, when I was turning the Resident in bed, they started yelling, My leg, my leg, my leg. Nursing Assistant F then indicated they got (Nurse E) to assist them to change Resident #701. When queried what time the incident occurred, Nursing Assistant F replied, I don't know for sure. Our assignment changed like three times that shift because of staffing. When asked about work start and shift times, Nursing Assistant F replied, 7:00 PM, we work eight hour shifts. With further inquiry, Nursing Assistant F indicated the incident probably occurred after midnight but stated, I really can't be sure about the time. On [DATE] at 4:35 PM, an interview was conducted with the Director of Nursing (DON). When queried regarding Resident #701, the DON replied, We sent (the Resident) to the hospital and they did not come back (to the facility. When queried further regarding the fracture to the Resident's femur and being turned with by only one staff member, the DON indicated the Nursing Assistant had been educated. When queried regarding the facility not having an incident report but had a soft file pertaining to the incident, the DON did not provide an explanation. When queried why the Resident was not transferred to the emergency department sooner when the Resident was experiencing pain, had a 4 inch by 5 inch raised area on their hip, and Nurse E statement that they did not feel the treatment ordered by the physician was sufficient, the DON replied, (The Resident) should have been sent to the ER if that was what the nurse thought. The nurse didn't tell us that. That would have changed the situation. Record review on [DATE] at 5:30 PM of facility policy entitled, Occurrence Reporting- Residents (Updated [DATE]) revealed, An Unusual Occurrence Report will be completed if a Resident has an unusual incidence . Record review of facility policy entitled, Change in Resident Condition (Updated [DATE]) on [DATE] at 5:35 PM revealed, The Residents will be assessed on a continuous basis. Care will be provided according to the standard of care. The shift supervisor, physician, and responsible party will be notified of the Resident's change in condition, as soon as possible. Record review on [DATE] at 5:40 PM of facility policy entitled, Notification of Changes (Approved [DATE]) revealed, It is the policy of (facility) that the Resident, the Resident's physician, and /or Resident's family member or legal representative, consistent with his or her authority be notified when there are certain changes of a Resident's condition. Changes that would require notification include: 1. Accidents: a. Resulting in injury, b. Potential to require physician intervention or hospitalization ; 2. Significant change in the Resident's physical, mental or psychosocial condition such as deterioration in health .

This citation pertains to MI 096 Based on observation, interview and record review, the facility neglected to assess the appropriateness, obtain a physician's orders [REDACTED].#901) of 3 residents, from a total of three sampled for Leave of Absences when the resident left the faciity on [DATE] via public transportation during the morning hours and went to a local department store 2 - 3 miles away from the facility. An Immediate Jeopardy (IJ) arose when the facility identified Resident #901 with multiple comorbidities; Mental Illness/[MEDICAL CONDITION], High risk for falls, [MEDICAL CONDITION] disorders, Generalized Weakness and noted behavior problems, but was allowed to leave the facility unaccompanied, resulting in the potential for serious harm, injury, or death. The Immediate Jeopardy was identified on 6/19/17 at 11:00 AM. The Administrator was notified of the Immediate Jeopardy on 6/19/17 at 1:50 p.m. A plan to remove the immediacy was requested. The immediacy was removed on 6/19/17 based on the facility's implementation of the removal plan as verified onsite. Although the IJ was removed, the facility's deficient practice was not corrected and remained as isolated. No actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings Include: On 6/19/17 at 9:22 a.m., an anonymous complainant was interviewed via phone. The complainant reported that Resident #901 went to a local department store unaccompanied via public transportation. The complainant stated, She (#901) said she wheeled all around the parking lot of the store and the store. After I found out, I texted her (#901's) public guardian. I also told the facility's social worker (SW B). Resident #901 said the nurse told her that she could go. There was no doctor's order. They have not followed up on it. Shortly, after that on another occasion, the Guardian witnessed her at the main door entrance waiting for public transportation. She (#901) was stopped by the Guardian, then she (#901) became very upset. The Unit Manager (Nurse C) allowed Resident #901 to leave the facility. On 6/19/17 at 9:29 a.m., the facility's Activity Supervisor (Employee D) was queried regarding the procedures for scheduled day trips (outings) for the residents. Employee D reported that residents are accompanied and/or supervised by staff. Employee D stated, If residents have guardians we call them first for authorization. The Activities staff call for the guardians for approval. On 6/19/17 at 9:50 a.m., the Director of Nursing (DON) was interviewed regarding the procedure for Leave of Absences (LOAs). The DON stated, We have standing orders for LOA unless the doctor says otherwise. They (Activities Department) have not had any outings for the month of June. On 6/19/17 at 10:04 a.m., Employee D was interviewed again regarding recent day trips/outings for the residents. Employee D stated, There have been no outings via the Activity's Department. We have had no trips to any local stores. There are some residents who go out independently on the bus to local stores. A list of those residents was requested at this time. On 6/19/17 at 10:24 a.m., Resident #901 was interviewed regarding the outing to a local department store. Resident #901 stated, Around 10 days ago I had permission from Nurse C to go out. I was gone for about two hours. No one went with me. No one ever told me that I couldn't go out alone. I went out just that one time. I called public transportation from my cell phone. I left out the front door. I did not sign a form. I didn't think I was sneaking or doing anything wrong. When asked if she accepted any money from anyone, Resident #901 stated, One woman paid my bus fare on the way back. Resident #901 was queried if she left the facility since then. Resident #901 stated, I was at the front door waiting for a ride when my guardian saw me. She stopped me. Nobody told me to sign out first. I thought my doctor had approved for me to go out. On 6/19/17 at 10:44 a.m., the Unit Manager (Nurse C) was interviewed regarding the incident. Nurse C stated, She (#901) had an incident where she went out by herself. She wanted to go LOA on her own. I told the Social Worker to get the OK. Last week she tried to go and we stopped her. She never had an order for [REDACTED]. I told her I would get it (approval) for her. She wanted to go to the store alone. Nurse C was asked if the incident where Resident #901 to the store alone was documented, Nurse C reported that it was not documented. Review of the nurses' notes with Nurse C revealed no documentation of the incident. Nurse C was then asked if there was an incident report completed. Nurse C answered, No. There was no incident report completed for Resident #901's unaccompanied trip to the local store. Nurse C further stated, The nurse didn't know that she (#901) could not go LOA and she did not complete an incident report. I am not sure of the exact date it happened. I believe this happened a week ago. On 6/19/17 at 10:59 a.m., during an interview regarding Resident #901's LOA, the DON stated, I am not aware of the incident. I know she is alert. She has a guardian. I should have been informed. On 6/19/17 at 11:08 a.m., the Social Worker (SW B) was interviewed regarding the incident. SW B stated, I heard about it second hand from her (#901's) OBRA worker. She reported the incident that she (#901) went to a local department store. I contacted the guardian. Resident #901 is [MEDICAL CONDITION]. She has some mental illness. I set up a meeting after I heard about the incident. When asked if an incident report was completed and if there were any corrective measures put into place after the incident, SW B stated, No. On 6/19/17 at 11:22 a.m., the DON and the Unit Manager (Nurse C) were both interviewed together. Again, the DON reported not knowing about the incident. Nurse C stated, She (#901) does not have an order for [REDACTED]. The resident now fully knows that she can't go LOA. The DON stated, An Incident and Accident (I/A) report should have been completed. Nurse C stated, We don't know which nurse let her go LOA. I never gave her permission. I know last Wednesday she became upset when I would not let her go out the second time. Her guardian was here at that time. On 6/19/17 at 11:56 a.m., the DON stated, She (#901) does not have an order for [REDACTED]. When asked if the Administrator was informed of the incident, the DON stated, He was not informed. On 6/19/17 at 12:05 p.m., record review of the following revealed: Resident #901's face sheet indicated an original admission into the facility on [DATE] and a re-admission on 3/20/17 with [DIAGNOSES REDACTED]. Resident #901 was identified for at risk for falls per the most current fall risk assessment. The most current quarterly Minimum Data Set (MDS) assessment, dated 5/4/17, indicated that Resident #901 had an intact cognition and limited assistance with the physical support of one person was required with the assistance for transfers, ambulation, toilet use, and personal hygiene. Review of the doctor's orders did not reveal an order for [REDACTED].#901. The nurses' notes for the months of May and June 2017 did not reveal any documentation of LOA's. The facility's policy titled Abuse Prevention and Investigation, last reviewed 6/14/17 and last revised 6/1917, revealed the following documentation: It is the policy of the facility to maintain a program that protects our residents' rights to be free from abuse and neglect .Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . The facility's policy entitled Leave of Absence, updated 5/12/16, revealed the following documentation: Resident may request a Leave of Absence (LOA), preferably 48 hours in advance of LOA or as soon as possible. Residents are assessed upon admission/re-admission or change in condition ability to go LOA. LOA's will be logged in the resident LOA binder, located on the unit. If resident does not have a standing order for an LOA, then the Nurse will obtain physician order [REDACTED]. Unit Clerk/nurse will complete Resident Leave of Absence Log form. Nurse/Unit Clerk will call down to front desk to notify Security/Designee that resident is leaving LOA. Security Guard/Designee will then allow resident to exit the facility. Upon return of the Nurse/Unit Clerk party will sign resident back in on the unit in the LOA binder . On 6/20/17 at 1:05 p.m., during a phone interview, the complainant reported the unaccompanied LOA incident occurred on 6/1/17 during the day. The complainant further stated, I told the social worker (B), also another social worker was sitting in the office when I told her. On 6/20/17 at 1:55 p.m., Resident #901's guardian was interviewed via phone. The guardian stated, I never gave the facility consent for her (#901) to go on LOA unaccompanied. They didn't even call me when it happened. I found out a week later by someone who does not work there. They set it up. She (#901) went to the business office and took money out of her account for shopping. I was even there visiting last week at the facility when I noticed her at the front door waiting to be picked up by the bus again. I told the facility that she was not to go out. They told me to go over there and tell her. I told them to do it. They were the ones who told her that she could go out. When they did, she (#901) became very upset with me. She kept yelling, The unit manager (Nurse C) set it up. The facility submitted the following plan of correction to remove the immediacy: ELEMENT 1 Resident #901 residents in the facility and appears calm and in no acute distress. Resident #901 has had no further LOAs since 6/01/2017. On 6/19/2017, at 3:00 p.m. resident had a skin assessment and pain assessment completed licensed nurse with no negative findings. On 6/19/2017 at 3:40 p.m. resident was assessed by Dr. Iskander with no negative findings. Progress note available. On 6/19/2017 at 3:20 p.m. resident #901 had a cognitive assessment done using the BIMS assessment with a score of 15 out of 15. Resident #901 was educated that she much be accompanied by facility staff when leaving the building and approval from guardian is necessary. Resident #901 care plan and Kardex was updated to include the need for staff assistance when leaving the facility. Resident #901 was also educated that she has a guardian and she must have guardian approval along with physician approval to have a LOA. Guardian and physician was notified of the incident and documentation has been provided in the resident's record. ELEMENT 2 Residents in the facility that have not been assessed for appropriateness of LOA have the potential to be affected by the deficient practice. All residents in the facility will be re-assessed using the MTB LOA Assessment Summary Sheet by licensed nurses. Residents that have not been assessed will not be allowed to leave the facility unattended until new assessment completed. All residents will be assessed by 5:30 p.m. on 6/20/2017. Orders will be written upon physician's permission once assessments are complete. Resident's care plans in Kardexs will be updated as necessary. LOA books have been placed at each nurses station for residents, families and guardians to sign residents out prior to leaving the facility. Telephone calls were made to family members and guardians by social workers to sign residents out in LOA book at each nurses station. Family members and guardians also reminded to always notify the nurse before taking the resident out of the facility. Administration and DON are in agreement with this process. Residents who are self responsible have been notified on 06/19/2017 of this process. ELEMENT 3 At 2:30 p.m. IDT met and was educated by administrator that residents without a LOA order from the physician that states resident is able to leave the facility unattended may not leave the facility. Education was provided to nursing managers and social workers to check LOA orders and to notify guardian when necessary. Nursing and social work staff will be re-educated on current LOA policy. The LOA policy was reviewed and updated by the administrator at 3:45 p.m. on 6/19/2017. Education was started immediately for the staff nurses and managers present in the building on afternoon shift on 6/19/2017. Education will be completed by 5:30 p.m. on 6/20/2017, any nursing and social work staff that have not been educated by 5:30 p.m. on 6/20/2017 will be removed from the schedule until education is completed. ELEMENT 4 Residents in the facility that do not have assessment completed at this time 3:50 p.m. on 6/19/2017 will not be allowed to leave the facility unattended. The DON and administrator or designee will visually audit LOA assessment sheets for completion daily times two weeks then weekly thereafter. Findings will be reported to QAPI and QAPI will make further recommendations. Administrator is responsible for ongoing compliance. ELEMENT 5 Completion by 6/20/2017.

This Citation Pertains to Intake MI 904. Based on observation, interview, and record review, the facility failed to provide monitoring and supervision to prevent the elopement from the facility of one (#701) of three Residents reviewed for elopement risk, out of a total sample of three Residents. An Immediate Jeopardy (IJ) arose when the facility identified the Resident as a risk for elopement, but failed to develop and implement effective interventions and monitoring to prevent actual elopement from the facility and facility staff were unaware of the Resident's whereabouts resulting in the potential for serious harm, injury, or death. The Immediate Jeopardy was identified on 6/5/17 at approximately 8:15 PM. The administrator was notified of the IJ on 6/7/17 at 3:00 PM. A plan to remove the immediacy was requested. The IJ was removed on 6/8/17 based on the facility's implementation of the plan removal as verified onsite. Although the IJ was removed, the facility's deficient practice remains at isolated. No actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: Record review on 6/7/17 at 8:45 AM revealed Resident #701 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Resident's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident had severe cognitive impairment and required supervision to limited assistance to perform Activities of Daily Living (ADL's). Additional record review of Resident #701's medical record at this time revealed a Progress Note authored by Nurse A with the following documentation, Staff responded to a call from security/Front desk at 8:18 PM stating that Resident was observed by a Police officer outside in the parking lot and given directions to retrieve Resident from Police department next door to the facility. Staff walked over to retrieve Resident and was back on the unit at 8:41 PM. Doors leading out to the Garden (Courtyard) are locked. Resident Alert to person with confusion noted. Educated resident on boundaries in the facility and when to call for a Nurses or an Aids (nursing aides) assistance . Denies any pain at this time. Skin is clear and intact. Unit manager and Director of Nursing (DON) aware of situation. Residents (family member) notified. Physician C notified. An interview was conducted with the Director of Nursing (DON) on 6/7/17 at 8:45 AM. When queried how Residents within the facility are evaluated for risk of wondering and elopement, the DON indicated that an assessment was completed upon admission to the facility, quarterly, and if there is a significant change in the Residents condition. When queried how many Residents within the facility are currently considered to be at risk for elopement, the DON replied, I have a list. When queried how the facility ensures safety of Residents at risk for elopement, the DON replied, We are working to get a different system that will enable us to use wander guards. Our current system won't support it. Facility policies/procedures pertaining to elopement of Residents was requested. On 6/7/17 at 8:50 AM, list entitled Residents at Risk for Elopement was received from the DON. Record review of f provided list revealed six Residents, including Resident #701, were evaluated by the facility and considered to be at risk for elopement. An interview was conducted with Maintenance Director B on 6/7/17 at 9:00 AM. When queried regarding the courtyard and Resident #701's elopement from the facility, Maintenance Director B stated, (Resident #701) got out and walked across the parking lot. All we could come up with was the gate was left open by the Landscapers. When queried further regarding the Landscapers, Maintenance Director B replied, We hire a company that comes in to mow and work on the flowerbeds. They use the gates to bring their equipment into the courtyard area. A tour of the second floor facility courtyard was completed with Maintenance Director B on 6/7/17 at 9:05 AM. The walk through tour of the courtyard revealed one entrance to the courtyard from the building that was accessible to Residents and two gates with keypad code access that allowed access into the courtyard from outside of the facility. When queried regarding the number of facility vendors that had the keypad access code to the gates to enter the facility courtyard, Maintenance Director B replied, None now but I couldn't tell you who all had the code before. Landscapers, electricians, and other contractors would have had it. We didn't keep track. When queried further, Maintenance Director B stated, The code was changed after (Resident #701) got out. The only people who know the code now are the maintenance staff. Upon request, Maintenance Director B demonstrated the method in which the gate was able to be opened and closed. Upon closing the gate, Maintenance Director B stated, The Gate has to be really slammed to be closed. I think it didn't get shut hard enough. When asked who left the gate open, Maintenance Director B stated, Not able to tell. There is a camera out here but it is obscured by trees. They weren't thinking about the trees growing when they put it in. Can't see the gate at all. When asked if Residents are supervised when they are outside in the courtyard area, Maintenance Director B replied, No but it (courtyard) is locked at night. When queried who locks the courtyard entrance so that Residents are not able to enter the courtyard at night, Maintenance Director B replied, Nursing. When queried what time the courtyard door is locked, Maintenance Director B responded, When it starts to get dark out. When asked if records of locking the courtyard entrance are documented and maintained, Maintenance Director B stated, I don't think that there are any (records) but I think it is something that we should start to do. Record review on 6/7/17 at 9:15 AM of facility provided Incident and Accident Report for Resident # 701 revealed the following documentation: The Sheriff's department called the facility at approximately 8:15 PM saying that they had the Resident in their lobby . Facility staff went and got the resident immediately and noted that the resident exited the gate that was left open by the Landscapers. Resident was back in the facility approximately 8:30 PM . An interview was conducted with the Director of Nursing (DON) and Maintenance Director B regarding Resident #701's elopement from the facility on 6/7/17 at 10:30 AM. When queried regarding who contacted the facility the Police Department to notify staff that the Resident was at the Police Department, the DON stated, We went to the Sheriff's Department yesterday and tried to find out who called here but we were told there was no record of that information. When questioned where Resident was located within the Sheriff's Department, the DON replied, (Resident #701) was in the lobby I think. With further inquiry, the DON indicated that facility staff were unaware of what doors the Resident utilized to enter the Sheriff's Department lobby and/or which way the Resident walked to the doors. When queried how the facility came to the conclusion that an individual from the Landscaping Company left the courtyard gate unlocked, Maintenance Director B replied, It (courtyard gate) has been left open before. They (Landscapers) have left it (the gate) open when they are working out there. When queried what staff were responsible for locking the courtyard entrance door that Residents utilize to enter the courtyard area at night, the DON indicated that they were unaware of who was responsible when elopement occurred. The DON then stated, Maintenance Director B will lock from now on. When queried regarding the courtyard gate being unlocked on 6/5/17, Maintenance Director B stated, Yes, I came in (to work) and locked it. Review on 6/7/17 at 10:50 AM of Resident #701's electronic medical record revealed one Wandering Risk Assessment completed on 6/6/17 at 5:07 PM by Nurse G which classified the Resident as High Risk for Wandering. Review of Section E of the MDS assessment dated [DATE] indicated Resident #701 did not exhibit wandering behaviors. Additional review revealed a Progress Note-Social Work dated 8/23/16 at 4:23 PM that indicated, (Resident #701) is noted to wander daily, but is redirected by staff. Review of the Resident's care plans at this time revealed the following resolved and active wandering/elopement care plans: I prefer to wander as evidenced by as I am disoriented to place, I have a history of attempting to leave facility unattended and impaired safety. I can be redirected by staff. I am followed by psych services as needed. (Date Initiated: 7/28/16; Resolved Date: 6/6/2017) (Resident #701) is an elopement risk/wanderer as evidenced by disorientated to place, history of attempts to leave facility unattended, impaired safety awareness, and significantly intrudes on the privacy of others. (Resident) is redirected by staff. Followed by psych services as needed. (Resident) has a [DIAGNOSES REDACTED]. I prefer to wander as evidenced by as I am disoriented to place, I have a history of attempting to leave facility unattended and impaired safety. I have a wander assessment score of 11 (high risk)(Date Initiated: 06/06/2017) On 6/7/17 at 11:15 AM, an interview was completed with MDS Nurse F. When queried regarding Resident #701's MDS assessment related to wandering behaviors and care plan for wandering not matching, Nurse F stated, The MDS goes off of the look back period so if the person that completed that section of the MDS did not see those behaviors (wandering) it would not be marked (on MDS assessment). Nurse F further stated, I did not complete that part of the (MDS) assessment. With additional inquiry regarding the Resident having a care plan for wandering and recent elopement from the facility, Nurse F stated, If you are asking me if (Resident #701)wonders, my answer is yes. On 6/7/17 at 12:00 PM, an observation of Resident #701's room occurred. The door to the Residents room was located across the hall from the entrance door to the facility courtyard. The distance from the door of Resident #701's room to the facility courtyard entrance was approximately 12 feet. An interview was conducted with Nurse D on 6/7/17 at 12:10 PM. When queried regarding Resident #701, Nurse D stated, I am always trying to redirect (Resident #701) because they are always trying to get out. With further inquiry, Nurse D stated, (Resident #701) was at a different facility before, got out, and hitchhiked all the way back to their old house. (Resident #701) always has memories of going home. On 6/7/17 at 12:20 PM, Resident #701 was observed in the main second floor dining room area of the facility. The Resident was confused, alert and oriented to self only, and possessed a pleasant demeanor. On 6/7/17 at 12:15 PM, an interview was conducted with Nursing Assistant F. When queried regarding staff supervision of Residents in the courtyard, Nursing Assistant F replied, Residents can go out by themselves.When asked about Resident #701, Nursing Assistant F stated, I haven't seen (Resident #701) outside on their own much. I try to redirect (Resident #701) before they go outside because they are confused. On 6/7/17 at 1:50 PM, Resident #701 was observed sitting outside on a bench in the second floor courtyard area of the facility. Record review on 6/7/17 at 2:00 PM revealed a General Nursing Note dated 6/5/17 at 4:36 PM written by Staff H that indicated, Resident alert with some confusion resident was found outside in the garden area wondering around lost and confused an officer escorted the resident back inside of the facility Director of Nursing aware of clinical situation . Resident is known for wandering around the facility will continue to monitor resident and perform hourly rounds on resident safety maintained. On 6/7/17 at 2:10 PM, an interview was completed with the DON and Maintenance Director B. When queried regarding documentation in Resident #701's medical record dated 6/5/17 at 4:36 PM that indicated the Resident was found outside in the garden area (court yard) wondering around lost and confused and assisted by a Police Officer, Maintenance Director B replied, (Resident #701) was still inside the court yard. They were sitting on the seat of their walker down by the fence talking to a Police Officer. When queried where Resident #701 was sitting in relationship to the courtyard gate, Maintenance Director B replied, Right down from it, closer to the storage shed. When queried if the courtyard gate was locked at that time, Maintenance Director B replied, Yes. The DON then stated, I went out to check on the Resident then too. (Resident #701) was still inside the courtyard. When questioned if additional safety monitoring was implemented following this incident, the DON responded, (Resident #701) was taken back in the facility. The Resident didn't leave the facility. On 6/8/17 at 7:45 AM, an interview was conducted with the DON. When queried regarding the second floor courtyard, the DON replied, We are just going to close it down for now. On 6/8/17 at 9:20 AM, an interview was completed with Maintenance Director B. When queried regarding the second floor court yard, Maintenance Director B stated, No Residents are allowed outside at this time. We have it locked until we figure out what we are going to do. When queried regarding the time the courtyard gate was unlocked on 6/5/17 when Resident #701 exited the facility premises, Maintenance Director B replied, I'm not sure what time the Landscapers left but they were here when I left for the day. When queried what time they left for the day, Maintenance Director B replied, I don't know probably around 4:00 PM or 5:00 PM. On 6/8/17 at 9:30 AM, the second floor courtyard entrance from the facility to the courtyard was observed to be locked. On 6/8/17 at 8:47 AM, an interview was completed with Nurse I. When queried regarding Resident #701 leaving the facility on 6/5/17, Nurse I stated, I was getting ready to go home and one of the aides (nursing assistants) said I've got to go get the Resident. They were walking around in the parking lot. We walked out the front (of the facility) and through the parking lot but didn't see the Resident. We went into the Sheriff's Office lobby and (Resident #701) was sitting there talking to a lady in the lobby. (Resident #701) had snacks rolled up in clothes in the basket on their walker, like how they do on TV with the sticks on the old shows. When I asked (the Resident) where they were going, (Resident #701) told me to St. Clair Shores. I didn't see any injuries and walked the Resident back to the facility to their Nurse. When queried if they were aware of how the Resident exited the facility, Nurse I replied, I believe the gate was open. When queried if they saw the gate open, Nurse I replied, I don't know. When queried if the Resident made previous attempts to leave the facility unattended, Nurse I replied, (Resident #701) is always walking around. At 8:55 AM on 6/8/17, an interview was conducted with Nurse A. When queried regarding Resident #701 on 6/5/17, Nurse A stated, I was (the Resident's) nurse. I got to work at 7:00 PM and didn't get done counting until around 7:30 PM. When asked if they saw Resident #701, Nurse A replied, Yeah, they were walking around as usual. I probably got on my cart at 8:00 PM. I saw (Resident #701) wrapping something up, that was probably a bit before 8:00 PM. Upon inquiry of what the Resident was wrapping up, Nurse A replied, Snacks from the snack cart. It was all stuff (the Resident) could have. Nurse A then stated, Got a call between 8:15 PM and 8:20 PM saying (Resident #701) was in the parking lot outside. I sent the nurse aide out to get them. When queried if the resident had a history of [REDACTED]. (Resident #701) is pretty free. On 6/8/17 at 1:45 PM, an interview was conducted with facility Contractor J. When queried regarding landscaping crew size at the facility on 6/5/17, Contractor J stated, We send three guys. When queried regarding the time frame the landscaping crew was at the facility on 6/5/17, Contractor J replied, Started in the morning and left in the morning. They were there from 9:20 AM to 11:00 AM on 6/5/17. When asked what services were performed, Contractor J stated, Cut the grass, lawn maintenance is every Monday. An interview was completed with the DON on 6/8/17 at 2:30 PM. When queried, the DON stated, We are doing elopement assessments on all Residents in the facility. We have identified 22 Residents that are elopement risks. Record review on 6/8/17 at 3:00 PM of facility provided policy entitled Elopement Assessment (Updated 5/16) revealed, All Residents will be assessed for risk of wandering/elopement during the referral process, on admission, readmission, quarterly, or with a significant change of condition. The policy further identified, The facility will identify Residents with any history, past or present, of wandering/elopement, or confusion and The staff assigned to care for the Resident will frequently observe the whereabouts of each identified Resident. The facility submitted the following plan of correction: Element 1 Resident #701 was returned to the facility and was assessed and there were no signs and symptoms of injuries noted. Resident #701 care plan and Kardex have been updated to include elopement risk and every three hour safety checks. Resident #701 has been placed on frequent safety rounds to be conducted hourly by nursing staff starting 06/07/2017 at 4:00 p.m. Prior to 06/07/2017, resident was being monitored every three hours by nursing staff from 6/5/2017 at 9:00 p.m. until 06/07/2017 to 4:00 p.m. Resident will be reassessed after 72 hours by the IDT to determine the need for further hourly checks or discontinuation of hourly checks. Resident #701 physician and family members have been notified regarding elopement as of 06/07/2017. No further elopement attempts have been observed by resident #701. The perimeter locking codes were changed at 10:35 p.m. on June 5, 2017, and inspection of the gates to assure they remained locked. Courtyard on the 2nd floor has been closed for resident use until new monitoring system is in place. Residents have no exit access to this courtyard. Resident council informed of immediate change. Safety rounds will be completed for residents identified to be high risk for elopement every two hours by nursing staff and will continue until 6/13/2017. Element 2 Residents in the facility that were already observed to be elopement risks were reassessed via MTB wandering risk assessment on 06/06/2017. At present census is 200, nursing staff has started new MTB wandering assessments with an expected completion date of 6/8/2017 at 6:00 p.m. for all residents. Care plans and Kardexs are being updated as necessary related to assessments being completed by nursing staff. Pictures and elopement books are located at each nurses station and the reception lobby desk and were reviewed and updated as necessary on 6/6/2017 and will be updated again as the MTB wandering risk assessments are completed and new residents are identified. A memo has been placed on the courtyard door to notify residents that the courtyard is closed. Resident council members were notified by DON and Deputy Director of the immediate closure of the 2nd floor courtyard. Doors are locked and residents have no way to exit out of the doors. Element 3 At 8:05 a.m. on 06/06/2017, maintenance staff was in-serviced on the new process that includes: a. Maintenance to both courtyards will be scheduled, and the courtyards secured during maintenance. Maintenance will secure the courtyard and assure there are no residents in the courtyard prior to letting the vendor in. b. The vendor will be let into the area after the area is secured and it is assured there are no residents in the area. c. After the vendor is done, the Maintenance crew member will visually inspect each perimeter gate to assure each lock is reengaged, log the date, time and individual checking the perimeter, then unlock the doors to the resident areas for resident to re-enter the courtyards. d. The courtyards perimeter will be checked once daily, seven days a week during late Spring, Summer, Fall and weather permitting. If weather is bad the maintenance team will assure the doors leading to the courtyards are locked, and will document that on the log. At 3:00 p.m. on 6/7/2017, Maintenance Director educated to close 2nd floor courtyard and to check locked gates and shed door twice daily between 9:00 and 10:00 a.m. and between 4:00 and 5:00 p.m. daily until new monitoring system has been purchased. All facility staff present on the afternoon shift on the date of 06/07/2017 were educated to the location of the elopement books, which is each nurses station and the reception desk in lobby. They were also educated of the closure of the 2nd floor courtyard. Nursing staff present on afternoon shift of 06/07/2017 was educated additionally to make frequent rounds on resident #701. New education will be starting on midnight shift to include review of elopement protocol, location of elopement books, closure of the courtyard and frequent safety rounds for residents identified to be at risk for elopement. All staff members that are not present will be educated via electronic education using the OnShift informational program by the staff development coordinator. Information will be sent out on 06/07/2017 by 9:00 p.m. Ongoing education will be scheduled every shift times five days. All staff members without education by 06/12/2017 will not be allowed to return to work until education completed. Facility elopement policy has been reviewed and deemed appropriate by the Director of Nursing on 06/07/2017. The maintenance staff will be educated by the Maintenance Director started on 06/07/2017 to 06/08/2017 to check courtyard locks to the gates and locks to the shed twice daily and to ensure that the courtyard doors are locked from the inside. The information will be logged for administrative review daily. Facility staff educated of the closure for the 2nd floor courtyard and to make frequent rounds for residents C.P. Each nurse station staff educated to include elopement books of residents who are risk for elopement. Element 4 The courtyard access doors are locked and are checked by maintenance twice daily in the a.m. between 9:00 and 10:00 a.m. and in the afternoon between 4:00 and 5:00 p.m. The courtyard perimeter will be checked twice daily and shed lockage will be checked daily between the same times, seven days a week until new monitoring system is in place. The facility administrator has been working with representatives from Compass and Night Watch for implementation of new safety and monitoring systems. The safety and monitoring project is ongoing and the courtyard will be closed until project is complete. Maintenance Director will visually audit for locked access doors to the courtyard, locked perimeter gates and locked shed. DON or designee will visually monitor for frequent safety checks to be completed three times a week times two weeks and weekly times four weeks until compliance is met. Audit findings will be reported to QAPI committee. QAPI committee will makes recommendations for further auditing. Element 5 The Administrator or designee is responsible for ongoing compliance. Element 6 Compliance date is 06/12/2017.

Based on observation, interview and record review, the facility failed to ensure that 1 (# 701) of 5 Residents reviewed for pressure ulcers (wounds caused by pressure), from a total sample of 31, received appropriate assessment, monitoring, hygiene care, and documentation to prevent the development of avoidable, re-occurring pressure ulcers, resulting in pain, inaccurate monitoring, delayed healing, and the potential for delayed treatment and increased risk of infection. Findings include: On 5/15/17 at 2:00 PM, record review revealed that Resident #701 was originally admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #701 was cognitively intact and required extensive to total assistance to complete Activities of Daily Living (ADL's). On 5/15/17 at 4:00 PM, Resident #701 was observed in the hallway outside of their room sitting in an electric wheelchair. An interview was conducted with the Resident at this time. When queried, Resident #701 stated, I have a sore on my left butt that they are putting something on. When queried if the sore caused pain, the Resident stated, Yeah, they give me stuff for it. Record review of Resident #701's medical record on 5/15/17 at 4:30 PM revealed Vascular and Wound Consultation documentation dated 5/11/17 that indicated the Resident was being treated for [REDACTED]. Pressure ulcer, stage three (III), left buttocks Abscess left hip On 5/16/17 from 9:35 AM to 10:40 AM, wound care observation for Resident #701 was completed with Wound Care Nurse I and Nurse N. When queried regarding the Resident's wounds, Nurse I was unable to provide the date that the pressure ulcer was first observed but stated, The pressure ulcer is facility acquired. (Resident #701) has reoccurring ulcers. Resident #701 was observed lying on the bed in their room. The bed had an alternating air mattress overlay that was not connected to the mattress and moved freely on top of the mattress. The air mattress appeared to be partially deflated and the Resident appeared to be sunk into the overlay. The skin surrounding the wound was observed to be bright red in color. When queried regarding the bright red color of the skin, Nurse I stated, it doesn't feel hot to me. Nurse N removed the dressing from Resident #701's left hip abscess. A small amount of yellow and white colored drainage was noted on the removed dressing. Warm compresses were applied to the wound bed area by Nurse N and Nurse I. During the time that the compresses were being applied, white and yellow colored drainage that appeared thick in consistency was observed actively draining from the Resident's left hip abscess. When questioned if the drainage had been cultured for infection, Nurse I replied, I just took over the first of April and I was told it is a reoccurring area. When inquired further, Nurse I stated, No, it hasn't been cultured. After a dressing was applied to the Resident's left hip abscess, Resident #701 was turned on their right side to complete the dressing the dressing change to the left buttocks pressure ulcer. When the Resident was turned onto their side by Nurse I and Nurse N, a moderate amount of stool was observed in the Residents perineal and rectal area. The dressing to the Resident's left buttocks pressure ulcer fell off the Resident when they were being turned and was saturated with red/yellow colored drainage. The dressing that fell off of the Resident's left buttocks pressure ulcer was an ABD pad (large dressing) and a 4 X 4 gauze pad. When queried regarding the order for the wound dressing, Nurse I stated, It is supposed to be an Allevyn Adhesive dressing (foam dressing for wounds with adhesive), somebody must have changed it and put that on it. The draw pad under the Resident was visibly soiled with stool and light red and yellow colored drainage. The wound bed was open and beefy red in color. Nurse N cleansed the wound with normal saline and covered with an Allevyn Adhesive dressing. On the back of Resident #701's left thigh/lower buttocks area, an open wound was observed. When queried regarding the wound, Nurse I stated, That's a new one. When queried if the wound was a pressure ulcer, Nurse I stated, Yes. Nurse N proceeded to cleanse the wound with normal saline and applied an Allevyn Adhesive dressing. Nurse I and Nurse N then repositioned the Resident and exited the room at 10:40 AM. An interview was conducted with Nurse I and Nurse N at this time. When queried regarding how the air mattress overlay is attached to Resident #701's bed and if the mattress was deflated, Nurse I stated, I don't really know anything about them. Maintenance does that. When queried further, Nurse I stated, I think they lose air. When queried regarding facility policy pertaining to the observation of new pressure ulcers and measurements of wounds, Nurse I stated, The wound care Doctor comes in and does the measurements. I just keep it clean and covered until then. When queried regarding why they did not provide care to the Resident by cleaning the observed stool, Nurse I replied, I didn't see it. Nurse N stated, I thought it was a scab. When queried further, Nurse N stated, I will put on the call light so the nurse aide can come and clean (the Resident). When queried regarding the role of ensuring adequate hygiene care and wound healing, a response was not received. On 5/17/17 at 11:50 AM, an interview was conducted with Nurse M. When queried regarding Resident #701's pressure ulcers and incontinence care, Nurse M stated, That shouldn't happen. That isn't what we do here. On 5/17/17 at 12:15 PM, an interview was conducted with Resident #701. When queried regarding pressure ulcers and treatment, Resident #701 stated, I don't really know what they (staff) do with them but I know that they are there. When queried regarding pain, Resident #701 replied, My butt does hurt. I can't move myself so when I'm in my chair and it starts to hurt, I ask to go back to bed. Sometimes it takes quite a while for them to get to me, especially on the weekends. When queried regarding pain during wound care, Resident #701 replied, Sometimes the nurse gives me something before, that makes it okay. When queried how often they receive pain medication prior to wound care, Resident #701 replied, I did yesterday (the Resident laughed). I couldn't tell you for sure but it can really hurt if I don't get it. When queried if staff assist the Resident to be repositioned frequently in bed, Resident #701 replied, They are to busy. When queried further, Resident #701 stated, No, not really. They told me that is why I got that mattress thing. When queried regarding refusal of care and repositioning, Resident #701 stated, I have a couple times before when I wasn't feeling good but that was all. On 5/17/17 at 3:00 PM, an interview was conducted with the Director of Nursing (DON). When queried regarding the lack of care to restore Resident #701's hygiene and the new facility acquired pressure ulcer discovered 5/16/17, the DON replied, All I can say is that is not acceptable. When queried if the Resident not having stool cleaned from their skin in a timely manner would contribute to discomfort, infection, and development of new pressure ulcers, the DON stated, Yes, I really can't say anything. Record review of Resident #701's Care Plans entitled (Resident #701) has actual impairment to skin integrity r/t fragile skin, incontinent of bowel and bladder . (Date Initiated: 11/17/2016, Revised: 03/09/2017) and Resident has impaired skin integrity- an Cutaneous abscess to left groin. (Resident) is at risk for further breakdown related to incontinence, has actual risk for pressure ulcers, hx of being noncompliant with repositioning in bed, refusing showers and staying up in chair too long, as well as impaired mobility. (Date Initiated: 08/10/2012, Revised: 5/15/17) on 5/17/17 at 3:35 PM revealed the following interventions: Frequent Reposition, Keep skin clean and dry. Use lotion on dry skin, Encourage and assist in slight position changes while in chair, Documentation per facility protocol. On 5/17/17 at 4:00 PM, Nursing Skin/Wound Note documentation of Resident #701's wounds were reviewed. A note authored by Nurse I and dated 5/16/17 at 6:53 PM revealed the following documentation Resident noted to have an open area on his left lower buttocks. Wound bed is clean, 1.2 centimeters (cm) by 1.3 cm. Dry dressing applied and will be evaluated by wound care team on Thursday. An interview was conducted with Nurse I and the Director of Nursing (DON) on 5/17/17 at 4:10 PM. When queried if wound care for Resident #701 was completed 5/16/17 after wound care had been completed and dressing applied at 10:40 AM, Nurse I replied, No. When queried how wound size measurements were documented for the new pressure ulcer observed on Resident #701's left upper thigh/lower buttocks when no measurements were obtained during the observed dressing change, Nurse I stated, I eyeballed it. When queried how they were able to accurately document wound measurements when measurements were not actually obtained, Nurse I replied, I guess I should have put approximately. The wound care Doctor will measure when they see the Resident. When asked if documenting wound measurements that were obtained by eyeballing the wound was facility policy or procedure, Nurse I stated, I'm sure it's not. When queried if wound measurements for other Residents within the facility were actual measurements, Nurse I looked down at the table and did not provide a response. When queried how the validity of wound care measurements and documentation for all Residents that they (Nurse I) have provided wound care treatments for within the facility, Nurse I replied, I guess you can't. An interview was conducted with the DON on 5/17/17 at 4:20 PM. When queried regarding documentation and statements by Nurse I, the DON replied, All I can say is that is not acceptable. When queried the number of Residents that have wound measurements and treatments provided by Nurse I, the DON replied, I will find out. When queried how the documentation of wound measurements and wound care for all other Residents within the facility that receive wound treatment by Nurse I is reliable and accurate, the DON replied, All I can say is that is not okay and not professional. On 5/17/17 at 4:30 PM an interview was conducted with the DON. When queried regarding what Residents are seen by the wound care doctor, the DON replied, Anybody with a stage three or four or pressure ulcer that is not healing, and initial pressure ulcers. When queried if a Resident with stage two pressure ulcer is continued to be seen by the wound care Doctor after being evaluated or treated by Wound Nurse I, the DON stated, I don't know. When queried what the standard procedure is within the facility for new facility acquired pressure ulcers, the DON replied, Supposed to fill out an incident report and if Nurse I is here, they are supposed to measure the wound. When queried if consult order is entered in the medical record for a Resident to see the wound care Doctor, the DON stated, I think so but Nurse I might just let them (wound care Doctor) know when they come in to do rounds. Record review on 5/17/17 at 5:00 PM of facility provided documentation from the DON entitled Wound Care List revealed 17 Residents within the facility were receiving wound care treatments by Nurse I. Record review of facility policy entitled Wound Care: Level III (Revised 5/10/17) on 5/17/17 at 5:05 PM revealed Documentation of wound care or treatment in the medical record should include the following: 1. The type of wound care given. 2. The date and time the wound care was given. 3. The position in which the resident was placed. 4. The name and title of the individual performing the wound care. 5. Any change in the resident's condition. 6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. 7. How the resident tolerated the procedure. 8. Any problems or complaints made by the resident related to the procedure. 9. If the resident refused the treatment and the reason(s) why. 10. The signature and title of the person recording the data.

This Citation Pertains To MI 680 Based on observation, interview and record review, the facility failed to provide adequate supervision and interventions to prevent falls for 2 (#'s 708 and 712) of 7 residents that were reviewed for falls from a total sample of 30, resulting in an orbital fracture and sutures to the forehead for Resident#708. Findings include: A review of the electronic medical record (emr) on 7-12-2016 at 2:00 p.m. reflected Resident #708 was an [AGE] year old female admitted into the facility on [DATE] and readmitted on 0 6-25-2016 with [DIAGNOSES REDACTED]. A review of the emr further reflected a fall risk evaluation dated 8-15-2015 that identified Resident #708 as high risk for falling. The Minimum Data Set ((MDS) dated [DATE] reflected that resident 708 was unable to ambulate and required the assistance of 2 persons for transfers, had long and short term memory impairment and severely impaired cognitive skills for daily decision making. A review of the facility form titled Unusual Occurrence Report dated 6-24-2016 reflected 2 Certified Nurse Aides (CNA's) had taken Resident #708 to the bathroom to get changed and cleaned up. CNA C had left the bathroom to get supplies, CNA D had stayed with Resident #708, who was in her wheelchair. CNA D's written statement reflected she occasionally cared for Resident #708 whom was trying to reach for the garbage can .I was prepping for care and when I turned back around she was falling . The unusual occurrence report reflected that the sensor pad in the wheelchair was functioning properly. Resident #708 was sent to the hospital and received sutures above her right eye and diagnosed with [REDACTED]. The fall care plan that was in place at the time of the fall (6-24-2016) for Resident #708 created on 10-09-2012 reflected she was at risk for falls due to psychotropic medications, impaired balance, weakness, decreased mobility, poor safety awareness, cognitive impairment and a history of falling. Interventions included sensor alarm in bed and wheelchair, therapy screens and evaluations as needed and redirection. Contact guard (direct contact with patient for safety) when toileting was added to the care plan on 7-06-2016. Resident #708's kardex ( a tool used for cna's which identifies specific needs for each individual resident) which was reviewed on 7-14-2016 did not include contact guard during toileting. On 7-14-2016 at 12:45 p.m. during an interview with the Director of Nursing and Unit Manager B they reported that Resident #708 required 2 staff persons to help get her cleaned up and that CNA C left the room to get supplies and CNA D was left alone with Resident #708 in the bathroom. When queried for clarification how CNA D was present in a small bathroom alone with Resident #708 and a functioning alarm how a fall could occur? Unit Manager B reported that Resident #708 has a tendency to lean forward and she kept trying to reach for the trash can. The DON replied she (cna) turned her back for a minute to turn the water on. When queried if CNA D should have waited for CNA C to return before turning the water on and prepping for care, given the fact that Resident #708 kept reaching for the trash can and had a tendency to lean forward, there was no response. On 7-14-2016 neither CNA Cor CNA D were working. An attempt to interview both CNA's were made via telephone at 1:00 p.m. Neither CNA answered, voice mails were left on both numbers that were provided by the facility with contact information. Neither CNA C or CNA D returned phone call. On 7-14-2016 at 1:30 p.m. an observation of Resident #708's bathroom was observed to be approximately 4 feet by 4 feet. The toilet was observed directly next to the sink. On 7-14-2016, a review of the facility's fall policy titled Falls-Clinical Protocol with a revision date of June 2016 did not address residents who were identified as high risk for falls and their toileting or supervision needs. ( ) Resident # 712 On 7/13/16 at 7:40 a.m., review of the face sheet for Resident #712 revealed that the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ( MDS) assessment dated [DATE] revealed that Resident #712 needed extensive assistance with transfers, eating, bathing and toileting. The MDS also revealed that Resident #712 was severely cognitively impaired and incontinent of bowel and bladder. On 7/14/16 at 2:00 p.m., review of the Falls Morse Scale dated 6/3/16 revealed that Resident #712 scored a 75 which represents a High Risk for falls. On 7/14/16 at 2:30 p.m., review of accident reports for Resident #712 revealed that the resident had falls on 1/10/16 (fell out of bed), on 1/22/16 (fell out of wheelchair) and on 5/1/16 (fell out of wheelchair-hit head). On 7/14/16 at 3:00 p.m. review of the physician orders [REDACTED].#712 has a sensor alarm to the bed, an alarming seatbelt to the wheelchair and a wheelchair pad alarm, and all were to be checked for placement and functioning QS (every shift). On 7/14/16 at 11:00 a.m., Nurse Unit Manager K, was interviewed regarding the alarms for Resident #712. Nurse K stated, We review falls with the fall committee and determine the interventions to put in place. When an alarm is ordered, we write the order and then write to check for the placement and functioning of alarms. When further queried as to the reasoning for alarm orders to be written with check placement and functioning of the device, Nurse K stated, She (Resident #712) had fallen and it was discovered her alarm was not on, so the Certified Nurses Aide (CNA) and the nurses are now responsible to check the alarms at the beginning of their shift to make sure they are on and working. Nurse K further explained that the nurses document that the alarms are present and functioning in the Treatment Administration Record (TAR). On 7/14/16 at 3:15 p.m., review of the TAR for Resident #712 revealed that the alarms were not checked for functioning and placement for a shift on each of the following days: 7/5/16, 7/6/16, 7/8/16 and 7/9/16. On 7/14/16 at 3:30 p.m., the Administrator was interviewed regarding the missing documentation for the alarm checks for Resident #712 on the TAR. The Administrator looked at the TAR and stated, I don't even know why this (the check functioning and placement order) is on here. On 7/14/16 at 3:30 p.m., the Director of Nursing( DON) was interviewed regarding the missing documentation for Resident #712 on the TAR, the DON offered no verbal explanation. On 7/14/16 at 3:40 p.m., review of the facility's policy, titled, Safety Device-Wheelchair/Chair Alarm Pad revised 5/23/16, and policy, titled. Bed/Chair Alarms revised 5/5/16 did not specify what exactly to document. Both policies stated under Documentation to document in the Daily Care Record. ( )

This citation pertains to intake number MI 618. Based on observation, interview and record review, the facility failed to provide adequate supervision and follow transfer orders for 1 (# 702) of 3 residents reviewed for falls, out of a total sample of 3 residents, resulting in resident 702 being left alone and unassisted in bathroom and falling to hard-tiled floor incurring a 3-4 centimeter abrasion to forehead with heavy bleeding and a 1 centimeter abrasion to right leg with subsequent pain requiring emergent medical intervention at local hospital. Findings include: Review of the clinical record and facility investigation reports on 04/06/16 at 10:30 am and 1:10 PM revealed the following: Facility unusual occurrence report dated 03/27/16 and last signed by administrator on 03/28/16 indicated, on 03/27/16 at 4:10 PM inside room [ROOM NUMBER] bathroom, resident 702 fell and had a 3.5 centimeter ( cm) abrasion to head and 1 centimeter abrasion to leg. This report indicated resident 702 was observed on bathroom floor with injury to head and right leg and attempted to self-ambulate during toileting. This report indicated resident 702 was sent to the hospital. Occurrence investigation report employee statement dated 03/27/16 that indicated, under summary section, CNA 'A' was out of the restroom to get a towel off her (702's) bed. When I went back in the restroom she was on the floor with a bleeding head. Pain assessment dated [DATE] that indicated resident 702 had back pain, joint pain, cut on head, and cut on R (right) leg. This assessment indicated resident 702 stated, It hurts and had a pain rating of 8 out of 10 indicating it hurts whole lot based on the scale illustration. Physician order [REDACTED]. The electronic medical record (EMR) census report indicated resident 702 was readmitted back to the facility on [DATE]. During an observation on 04/06/16 at 9:55 am, the bathroom inside room [ROOM NUMBER] was observed containing a hard tiled floor. During an observation on 04/06/16 at 10:00 am, resident 702 was observed sitting up in a geriatric chair inside the facility day room with other residents. Resident 702 was observed having a healing abrasion with dried blood approximately 5 centimeters in length located to the upper left side of forehead with faint bruising around the area. Attempts to interview resident 702 at this time were unsuccessful due to significant cognitive deficits. During an interview with certified nurse aide (CNA) 'A' on 04/06/16 at 11:00 am, CNA 'A' said, on 03/27/16 at approximately 4:00 PM, she was toileting resident 702 alone and unassisted inside the bathroom in room [ROOM NUMBER] (resident 702's room). CNA 'A' said, while transferring resident 702 alone and unassisted from the geriatric chair to the toilet, resident 702 became uncooperative, started fidgeting and placed her hands inside the soiled brief. CNA 'A' said she had resident 702 stand up over the toilet while holding the wall rail next to the toilet, proceeded to clean the resident, change the soiled brief, and when finished, pulled up resident 702's pants. CNA 'A' said, after cleaning and changing resident 702's brief, she noticed the wall railing next to the toilet had a small amount of boo-boo (fecal remnants) on the surface. CNA 'A' said she wanted to clean the soiled railing but could not because she had used all the readily available cleaning towels. CNA 'A' said, while resident 702 was still standing over the toilet, she left resident 702 alone and unassisted in the bathroom for a brief moment to obtain additional cleaning towels outside the bathroom approximately 8-10 feet away. CNA 'A' said, as her back was turned, she heard the sound of resident 702's body strike the bathroom floor. CNA 'A' said she called for help which came in a few minutes. CNA 'A' said resident 702 had a cut on the forehead with blood everywhere. CNA 'A' said, at the time of the fall, she believed resident 702's transfer orders were for one person assistance only. CNA 'A' said she did not have a gait belt. During an interview with licensed practical nurse (LPN) 'B' on 04/06/16 at 11:30 am, LPN 'B' said she did not witness resident 702's fall that occurred on 03/27/16 at approximately 4:00 PM. LPN 'B' said she became aware of the fall while returning from her break. LPN 'B' said when she entered the bathroom inside room [ROOM NUMBER], she observed three persons inside the bathroom assisting resident 702, including CNA 'A' and LPN 'C'. LPN 'B' said she observed resident 702 on the bathroom floor with pants pulled-up, having heavy bleeding from the forehead and a small abrasion/skin tear to the right leg. LPN 'B' said as staff attempted to apply pressure to the forehead wound, resident 702 kept saying, ouch! and get me up. LPN 'B' said resident 702 required emergent medical care and was transferred to the hospital on [DATE] and later returned to the facility on [DATE]. LPN 'B' said she did not visualize a gait belt on the resident. LPN 'B' said the geriatric chair was located outside the bathroom. LPN 'B' said CNA's and other staff can easily reference resident care information, including transfer and toileting orders, in the DCR book (summarization of resident care information, similar to a Kardex) located at each nursing station. During an interview with licensed practical nurse (LPN) 'C' on 04/06/16 at 12:05 PM, LPN 'C' said she did not witness resident 702's fall that occurred on 03/27/16 at approximately 4:00 PM. LPN 'C' said she became aware of the fall when she heard assistance was needed in room [ROOM NUMBER]. LPN 'C' said she was one of the first responders to the scene. LPN 'C' said when she entered the bathroom inside room [ROOM NUMBER], she observed CNA 'A' in the bathroom with resident 702. LPN 'C' said resident 702 was on the floor fully dressed with pants pulled up and bleeding heavily from a [MEDICAL CONDITION]. LPN 'C' said a geriatric chair was located just outside the bathroom door. LPN 'C' said there was no evidence of a gait belt on the resident. LPN 'C' said a small blood stain was observed on resident 702's right pant leg and, upon further assessment, a small skin tear approximately 2 centimeters in length was observed to the right shin area. LPN 'C' said resident 702 was confused and uncooperative with medical care and kept trying to remove medical dressings put in place to stop the bleeding. Further review of the record, facility investigation reports, and policies/procedures on 04/06/16 at 10:30 am and 1:10 PM revealed the following: Face sheet dated 08/19/15 that indicated resident 702 was an [AGE] year old female with [DIAGNOSES REDACTED]. Minimum (MDS) data set [DATE] that indicated resident 702 had a brief interview for mental status (BIMS) score of 2 (severely impaired cognition) and required extensive assistance with one person physical assistance for transferring and toilet use. This assessment also indicated, under balance during transitions and walking section, the resident was not steady and only able to stabilize with staff assistance for moving from a seated to standing position and moving on and off toilet. Also, resident 702 had a care plan generated for ADL's related to generalized weakness, impaired mobility and impaired cognition (initiated 05/29/15) and a care plan for fall risk related to impaired cognition (initiated on 05/27/15). Physician order [REDACTED]. DCR information dated 02/29/16 indicated resident 702 was confused, was a high fall risk, and under transferring section, PA x 1 with all transfers (one person assist with all transfers). The DCR did not indicate the need for a gait belt. Physician order [REDACTED]. These orders, as written, were: (1.) 2 PA T/F (two person assist with transfers). (2.) 1 PA T/F W/gait belt (one person assist for transfer with gait belt). (3.) T/F W/gait belt (transfer with gait belt). Physician order [REDACTED]. During interviews with the director of nursing (DON) on 04/06/16 at 11:55 am and 1:00 PM, when asked to clarify the multiple transfer orders in place for resident 702, the DON said resident 702's transfer order at the time of the fall was 1 person with gait belt assist. The DON said, due to a variety of factors including being a high fall risk and confusion, it was not appropriate clinical practice to leave resident 702 alone and unassisted during toileting or transferring. The DON said CNA's are expected to have appropriate supplies available when providing care and should notify other staff if assistance was needed. The DON had no answer when asked why the transfer orders for resident 702 were documented differently in the DCR and physician orders. Review of facility's Policy titled, Safe Lifting and Movement of Residents dated (revision) 02/16/16 indicated, under policy statement section, For purposes of safety, gait belts will be used with residents that cannot independently ambulate or transfer. and, under policy interpretation and implementation section, 8. It will be the responsibility of each employee to ensure they have it (gait belt) available for use at all times when at work. The surveyor requested additional policies and/or procedures regarding toileting and transfer specifics. As of the exit date the facility did not provide any further policy or procedure relevant to such. ( )

This citation pertains to intake #MI 551 Based on observation, interview, and record review, the facility failed to ensure tab alarm was properly functioning and operational, for one cognitively impaired Resident (#601), who had a known history of falls, out of three Residents reviewed for falls, from a total sample of three, resulting in the Resident (#601) experiencing a fall, sustaining a fractured clavicle and requiring emergency medical care. Findings include: Findings include: Review of the record revealed an Unusual Occurrence report dated 01/22/16 that indicated on 01/22/16 at 1:00 p.m., unwitnessed fall resident up in front dining room waiting to eat lunch and staff brought her back saying she fell out of w/c (wheelchair). Everyone was busy passing trays and then seen resident on the floor. In the Occurrence Investigation report dated 1/22/16 indicated in the summary a statement from the Certifed Nursing Assisant (CNA) assigned to Resident #601 at the time of the fall, noted that Resident was in front dining area waiting to eat lunch and staff member's discovered, resident on the floor and notified the nurse of incident. Resident was crying holding left shoulder. The resident statement noted Resident #601 said my arm hurts, Resident verbalized asked resident what happened and no responds just kept holding on her left shoulder. The 5 day report revealed upon assessment resident was holding and guarding the left shoulder and crying. Resident also had a left knee skin tear .X-ray results returned at 1800 as positive for fracture at the mid and distal third of the clavicle with overriding of fracture fragments ., Physician ordered the resident to be sent out to an Acute Care Facility on 11/22/2016 and returned to the facility on [DATE]. This report also noted upon further investigation, that the resident's wheelchair tab alarm did not sound when the resident fell ., The alarm was not turned on . Further review of the report mention that the staff noticed the resident was observed away from her wheelchair suggesting that the resident unlocked her wheelchair and scooted herself to the edge of her chair and fell . Review of the record revealed a face sheet dated 1/22/16, Resident #601 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., [DIAGNOSES REDACTED], Vitamin D deficiency, [DIAGNOSES REDACTED], Dementia with behavioral disturbances, Psychosis, and Malaise. Resident #601 care plan indicated: Risk for falls related to use of psychotropic medications, unsteady gait, incontinence, hx of falls, cognitive impairment, impaired mobility, with a date of initiation of 10/01/13 revision date of 12/09/15. Interventions: Safety measures as ordered. (bilateral floor pads, sensor alarm in bed, tab alarm in w/c, geowing mattress). According to the Treatment sheet noted order for placement/function sensor alarm on w/c every shift (qshift) January 1, 2016 through January 31, 2016 revealed: 7 a.m.-7 p.m. on the 2nd, 15th, 24th , 31st, and 7 p.m.-7 a.m. 3rd, 6th, 10th, 24th, 29th ,31st were left without initialing that the alarm was checked. During an interview with the Director of Nursing (DON) on 2/16/16 at 4:00 p.m., the DON said that the wheelchair alarm was not turned on during the time of the incident and could not explain why it was not on. An interview with the Nurse and the CNA was attempted by phone. Policy titled Accident and Supervision with a revised date of November 23, 2015, noted 3. Implementation of Intervention-using specific interventions to try to reduce a resident ' s risks from hazards in the environment. The process includes a-i; e. Ensuring that the interventions are put into action. 4. Monitoring and Modification . a. Ensuring that interventions are implemented correctly and consistently. ( )

This citation refers to MI 173. Based on observation, interview and record review, the facility failed to provide adequate supervision for one (#701) resident of three sampled residents reviewed for high risk for falls with injuries, resulting in an avoidable fall and hip fracture which required hospitalization and hip surgery. Findings include: On 11/12/15 at 10:00 am, a review of the five day facility investigation of a Facility Reported incident, 11/9/15, for Resident #701 , revealed the following. The Unusual Occurrence Report, dated 11/4/15, 10:00 pm, reflected Resident #701 had .gotten up out of her gerichair, started walking and lost balance and fell to the floor, moaning with left leg.The summary of the incident, dated 11/5/15, reflected Resident lying on floor in dining room on right side, moved extremities, no bleeding observed, moaning on left side when moved. Assisted off floor, put in geri chair .Dr ordered stat xray of bilateral hip . The x-ray report dated 11/5/15, 3:30 am, reflected the following: LEFT HIP: Examination reveals an impacted transcervical fracture of the neck of the left femur . The clinical progress notes, dated 11/5/15 reflected Resident had bilateral stat x-ray of hip done at 2:20 am, 11/5/15, 5:45 am, Dr. order to send her out (to hospital) .family member notified. The hospital records, dated 11/5/15, reflected Resident #701 was scheduled for surgery for [REDACTED]. An Employee Interaction (employee discipline record), dated 11/5/15, for Nurse 'B', written by the Assistant Director of Nursing (ADON) 'A' reflected, On 11/5/15 during the 7p-7a shift, Nurse 'B' who was the responsible nurse, asked CENA (certified nursing assistant) who was monitoring the resident (#701) to leave out of the dining area to provide her with assistance. CENA informed the nurse that resident #701 had been actively trying to get out of her chair. Nurse instructed CENA to come with her, leaving the resident unattended in the dining room. As a result of poor judgement by Nurse 'B' the resident sustained [REDACTED]. (signed by ADON). Resident #701 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/12/15, at 1:00 pm, review of the quarterly minimum data set resident assessment for resident #701, dated 8/4/15, revealed Resident #701 had severe cognitive impairment, and was totally dependant on staff assistance for bed mobility, transfer and ambulation (not steady, only able to stabilize with staff assistance), dressing, eating, hygiene and bathing. The fall risk assessment, dated 9/10/1,5 reflected Resident #701 was a high risk for falls. The care plan for fall risk, dated 5/27/15, included an intervention to encourage resident to be up in common areas when up in geri-chair. On 11/12/15 at 12:30 pm, Resident #701 was observed in her room, seated in a geri-chair. Resident #701 moaned when the back of gerrichair was slightly reclined by the daughter/responsible party. During an interview at that time Resident #701's daughter/responsible party, stated the facility had notified her on 11/04/15 at midnight that Resident #701 had a fall, moaned, and x-rays were ordered. On 11/5/15, at 5:45 am, the facility notified her that Resident #701 had a hip fracture and was sent to the hospital. The daughter further stated: .when I arrived at the hospital, I was told her (Resident #701) hip was broken and she needed surgery . During a telephone interview on 11/12/15 at 2:00 pm, Nurse 'B' stated that she was the responsible nurse on the 7pm-7am shift. Nurse 'B' stated that she ask CENA 'C' to leave the dining room to assist her with another resident. There was one other resident in the dining room with Resident #701. CENA 'C' was the only nursing assistant in the dining room monitoring residents. Nurse 'B' stated, .I thought Resident #701 could be left alone because her geri-chair was reclined . During a telephone interview on 11/12/15 at 2:30 pm, CENA 'C' stated that on 11/04/15 around 10:00 pm, Nurse ' B' .came into the dining room and asked me to assist her with another resident. I told her I didn't want to leave Resident #701 in the dining room, because I was afraid she would fall .she kept trying to get out of the geri-chair .Nurse 'B' insisted that I could leave her alone to assist her with another resident. I was afraid that she would fall. No one else was in the dining room to watch the residents .a few moments after I left, CENA 'D' called for assistance with Resident #701 .CENA 'D' had found her (#701) on the floor in the dining room . CENA 'B' further explained that when she was summoned back to the dining room by CENA 'D', she saw Resident #701 lying on a blanket and she assisted CENA 'D' to transfer Resident #701 to the geri-chair. During an interview on 11/12/15 at 3:00 pm, ADON 'A' stated, .The dining room/common area on unit 3B1 was covered at all times . ADON 'A' further explained that the Daily CENAs assignment sheets reflected scheduled times to monitor the 3B1 dining room/common area to ensure it is monitored at all times and the Daily CENA Assignment Sheet, dated 11/4/15 reflected that CENA 'C' was assigned to the 3B1 dining room on the afternoon shift. Additionally ADON 'A', stated, .all nurses are aware that the 3B1 dining room must be supervised and all times and that residents can not be left unattended in that room . During an interview on 11/12/15 at 3:15 pm, the Director of Nursing stated the facility did not have a policy related to supervision of residents while in the 3B1 dining room, .however it was a facility standard of practice .residents should not be left unattended in the 3B1 dining room .the residents need supervision to limit the potential for accidents and injuries. ( )

This citation pertains to intake number MI 032 Based on interview and record review the facility failed to prevent a fall for one (#501) of three residents reviewed for fractures from a total sample of three, resulting in fractures of the left and right femur and right knee requiring surgical intervention. Findings Include: On 5/21/14 at 1:50 p.m., Resident #501 was observed up in a wheelchair with a tab alarm in place, bilateral leg braces with sheep skin lining raised slightly on wheelchair leg supports, in the entrance to the third floor dining room with several staff present. When queried about having a fall, Resident #501 said she did not recall having a fall or hurting her legs. On 5/21/14 at 12:50 p.m., a review of Resident #501's clinical record revealed she was originally admitted to the facility in 2003 with readmission's on 9/30/11 and 2/26/14. [DIAGNOSES REDACTED]. Further review of the clinical record revealed a Fall Risk assessment dated [DATE] with a score of 21 and a 12/6/13 Fall Risk Assessment with a score of 15 (high risk is a score of greater than 10). Per the 12/6/13 Fall Risk Assessment , Resident #501's risk factors included: Intermittent confusion, frequently incontinent, balance problems while rising from a chair, standing, and during transfers, decreased muscular coordination, poor safety skills (impulsive), medications including, anti-seizure, hypoglycemics, psychotropics, antidepressants and cathartics (assists in defecation), and [DIAGNOSES REDACTED]. Review of the February 2014 Physician order sheet and Care Plan titled "High Fall Risk" revealed safety interventions that included: Floor pad (mat) to left side of bed, keep bed in lowest position and non-slip mat in wheelchair. Review of the facility's physician progress notes [REDACTED].#501 for a follow up for recent fall with bilateral femur fractures, and right total knee replacement and left gamma nail surgical repairs. A hospital Physician integrated progress record dated 2/25/14 at 6:00 a.m., documented "left subtrochanteric fracture, Gamma nail (implant or fixation device specifically designed for the treatment of [REDACTED]." On 5/21/14 at 1:30 p.m., review of the facility investigation file revealed an "Incident and Accident" report dated 2/23/14 at 2:00 p.m., that documented, Resident #501 was observed by CNA (Certified Nursing Assistant) (Staff "C") sitting on floor with legs out in front. Resident attempted self transfer from wheelchair to bed. Abrasion on left side of back. Alert with confusion no complaints of pain. Resident (#501) wanted to go to bed. Footwear "splint/brace/AFO/boot". A Nurse's note dated 2/23/14 at 2:00 p.m., documented the Nurse was called to (Resident #501's) room by CNA ("C"). Resident observed on floor next to bed with buttocks on floor. Resident attempted to self transfer from wheelchair to bed. Vital signs with in normal, no complaints of pain or distress. Small abrasion on left side of back. Resident is alert with confusion, able to make needs known. Resident is impulsive. A Nurse's note dated 2/23/14 at 3-11 p.m. shift, documented that, (Nurse Staff "B") went to Resident's (#501) room with CNA's to obtain urine specimen. Nurse "B" pulled back covers and observed "right knee and leg from hip to knee swollen and right leg shorter than left. As (Nurse "B") lowered head of bed to assess right leg better, Resident (#501) began yelling /screaming. . . Doctor notified, Resident to be sent out to (name of acute care hospital)." On 5/21/14 at 2:00 p.m., Unit Manager Licensed Practical Nurse/LPN (Staff "D"), said that Resident #501 wanted to lay down after lunch (on 2/23/14) and the Certified Nursing Assistant/CNA (Staff "C") took her to her room, then left her while she went out of the room to get linens. Resident #501 stood (from her wheelchair) and fell . CNA "C" found her on the floor, notified the Nurse who assessed her. The CNA "C" changed (brief), Resident #501 who had no complaints of pain. On 5/21/14 at 2:35 p.m., LPN (Staff "A") stated "It was after lunch, 2:00 p.m., when the CNA ("C") called me to the room stating she (Resident #501) was on the floor. I assessed her and she had no pain, she has limited range of motion and it had not changed. I did a skin assessment and found a small abrasion on her back. Her vital signs were stable, she was alert with confusion, able to make her needs known, and can say if she has pain." LPN "A" said (Resident #501 ) was more upset about having had a bowel movement. Staff "A" said that she had checked Resident #501 after the CNA cleaned her up and she had no complaints of pain. When queried Nurse "A" said she never saw Resident #501 attempting to self transfer, however she had observed Resident #501 "putting her hands on the wheelchair arms like she would try to get up, but didn't just readjusted." On 5/21/14 at 3:40 p.m., CNA "C" was interviewed per phone regarding Resident #501. CNA "C" stated "Resident ("C") had tried to get out of bed that morning, which was unusual. She had no alarm at that time, it was discontinued a few months before. I never saw her try to stand up out of the wheelchair before, until the day before (the fall), when she tried to pull herself up on the rail in the hall.. The Nurse's (Nurse "A") and everyone (CNA "E") new about it. She (Resident #501) was not acting herself. . . On that day she started acting not like herself and calling out, saying she would stand and walk and that she was going to get out of here and take care of herself. I told (LPN "A") and she said she would document it and put it in the Doctor's log. She (Resident #501) had been that way for two days (not acting herself). I had her on both days Saturday, and Sunday when she fell . I asked the Nurse ("A") about alarms, because she was trying to get up, and she said no that she didn't need them. I always keep her (Resident #501) in the dining room because she needs extra supervision. . . On Sunday (2/23/14) she (Resident #501) wanted to go back to bed after lunch about 1:00 p.m., so I took her in her wheelchair into her room. I realized she didn't have a blanket and I left her in her wheelchair in the room and went to get it. I was out less than 2 minutes. When I got back she was on the floor. The wheelchair was locked, she was sitting on her bottom on the floor 'laughing'." I asked her what happened and she said she was trying to get in bed. I called a Housekeeper who got the Nurse. Resident (#501) denied pain, said 'no pain', she just wanted to get in bed." CNA "C" said the Nurse assessed the Resident who denied pain. CNA "C" said "I went in and checked her before I left about 2-3:00 p.m., and she was on her right side asleep. I came in the next day and was told she (#501) had fractured her hips and knee." When queried as to why she left Resident #501 alone in her room if she was attempting to stand, CNA "C" stated "She was calm and just sitting there, she was a different person. I knew I would be right back 1-2 minutes. I thought the Nurse had given her meds (medications) or something that calmed her." On 5/22/14 at 10:35 a.m., LPN "A" was queried regarding whether CNA "C" told her Resident #501 had attempted to stand by holding on to the hand rails in the hall and attempted self transfer several times on 2/23/14 prior to the fall. LPN "A" said I thought it was like more aggressive, wanting not to leave dining room or yelling for crackers. I did not see her attempt to stand. I do know she had a behavior log at the time related to behaviors. . . I don't know what happened to her behavior logs. . . Maybe she (CNA "C") did report she (Resident #501) was attempting to get up, but I took it as more aggressive with her behaviors." On 5/22/14 at 10:55 a.m., Registered Nurse/RN afternoon Supervisor Staff "F", said she had been informed on 2/23/14 at the start of the afternoon shift, that Resident (#501) had fallen at approximately 2:00 p.m. and that she had been very "agitated and abusing staff", and can shout and be mean". Staff Supervisor "F" said later that evening Nurse "B" attempted to obtain a urine specimen and "(Resident #501) was reaching for her leg and saying ouch and rubbing her knee". Her legs were observed to be uneven, she was very agitated and she was transferred to the hospital. On 5/22/14 at 11:15 a.m., CNA Staff "F" was queried per phone regarding Resident #501's behaviors and fall on 2/23/14. CNA "F" stated, "I remember her in the hall pulling at the railing trying to get up. When asked what she (Resident #501) was doing she said 'trying to get up' . . . I have seen her trying to get out of bed. I wasn't the only one who saw her trying to stand. That was not normal for her, so I would have told the Nurse. . .I haven't seen a behavior sheet in a while. Everyone new she would try to get up, that's why she is in the wheelchair. We never leave her in her room alone (in the wheelchair). The way she is, I wouldn't leave her alone. I would never leave her alone in her room in her chair. Her attempts to stand was reported to the Nurse, don't recall who (which Nurse)." On 5/22/14 at 9:50 a.m., CNA "C" stated "I documented she was distressed, tearful and attempting to stand on the behavior log (provided a blank copy titled "Behavior/intervention monitoring"), but I don't know where it is. It should be in the chart." On 5/22/14 at 9:25 a.m., Unit Manager, LPN "D" was asked to provide a copy of Resident #501's behavior/intervention monitoring log for 2/2014. LPN "D" stated she "was unable to find the behavior log. It should be here in the record, I know she had one." On 5/22/14 at 12:35 p.m., Resident #501's son and DPOA (Durable Power of Attorney) was interviewed per phone. He stated he had "never seen his mother attempt to self transfer, but she can get combative and doesn't listen, refuses medications. It wouldn't surprise me if she tried to get up. " He said he was notified of the fall from the wheelchair and told she had self transferred. He was told she only had an abrasion at first and later informed she was at the hospital and broke both femurs and blew out her knee. . . She has a plastic knee now and rods in both legs from hips to knees." A review of the facility's policy titled "Fall Risk Assessment" undated revealed: "Assessment data shall be used to identify underlying medical conditions that may increase the risk of injury from falls (such as osteoporosis). . The staff, with the support of the Attending Physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, Activities of Daily Living capabilities, activity tolerance, continence, and cognition. . . . will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable." Further review of the facility policy titled "Falls and Fall Risk, Managing" undated, revealed: "The staff, with the input of the attending Physician, will identify appropriate interventions to reduce the risk of falls. . . As needed, the Attending Physician will help the staff reconsider possible causes that may not previously have been identified. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls." ( )

SEE INTAKE NUMBERS MI 692, MI 808, MI 859, MI 879, MI 991, MI 205, MI 302. THIS CITATION HAS MULTIPLE DEFICIENT PRACTICE STATEMENTS (A AND B). A.) BASED ON INTERVIEW, RECORD REVIEW, THE FACILITY FAILED TO PROVIDE SUFFICIENT NURSING STAFF TO ATTAIN OR MAINTAIN THE HIGHEST PRACTICABLE PHYSICAL, MENTAL AND PSYCHOSOCIAL WELL-BEING OF EACH RESIDENT IN ACCORDANCE WITH PHYSICIANS' ORDERS AND PLANS OF CARE IN 49 RESIDENTS ON NURSING UNIT 2-A, WHO WERE WITHOUT THE SERVICES OF A LICENSED NURSE ON TWO SEPARATE DATES RESULTING IN AN IMMEDIATE JEOPARDY WHEN, 1.) FROM 11:00 P.M. ON [DATE] UNTIL 5:30 A.M. ON [DATE], 11 MEDICATIONS WERE NOT ADMINISTERED (INCLUDING PAIN MEDICATIONS, INHALERS, A MUSCLE RELAXANT AND [MEDICAL CONDITION] REPLACEMENT MEDICATIONS) AND FIFTEEN MEDICAL TREATMENTS WERE NOT COMPLETED (INCLUDING WOUND AND SKIN TREATMENTS, treatment of [REDACTED]. IN ADDITION, 4 MEDICATIONS WERE NOT ADMINISTERED DURING THE MIDNIGHT SHIFT ON NURSING UNIT 3-A (INCLUDING [MEDICAL CONDITION] REPLACEMENT MEDICATION, PAIN MEDICATION, MEDICATION FOR ACID REFLUX DISEASE, AND A POSSIBLE DOSE OF INSULIN), AND 2.) FOR RESIDENTS OF NURSING UNIT 2-A DURING THE 3:00 P.M. TO 11:00 P.M. SHIFT ON [DATE], WHEN ONE OF TWO LICENSED NURSING STAFF ASSIGNED TO THE UNIT LEFT, AT 6:00 P.M. AND WAS NOT REPLACED, RESULTING IN 43 MEDICATION ERRORS FOR APPROXIMATELY 49 RESIDENTS WHO RESIDED ON NURSING UNIT 2-A. THIS DEFICIENT PRACTICE PLACED ALL FACILITY RESIDENTS, WHO RECEIVE CARE AND SERVICES PER PHYSICIANS' ORDERS AND PLANS OF CARE, AT RISK FOR SERIOUS HARM AND/OR DEATH. FINDINGS INCLUDE: STAFFING INCIDENT ON [DATE]-[DATE]: ACCORDING TO THE PERSONNEL FILE, LICENSED PRACTICAL NURSE (LPN) #9 WAS HIRED BY THE FACILITY ON [DATE] AS A CONTINGENT NURSE (A NURSE WHO IS EMPLOYED TO BE AVAILABLE IF REGULAR STAFF ARE NOT AVAILABLE TO WORK). IN AN INTERVIEW ON [DATE] AT 9:00 A.M., LPN #9 SAID SHE DID NOT ARRIVE AT THE FACILITY UNTIL 6:15 P.M. ON [DATE] BECAUSE SHE WAS UNAWARE THAT SHE HAD BEEN SCHEDULED FOR THE 3:00 P.M.-11 P.M. SHIFT UNTIL SHE WAS CALLED BY THE STAFFING COORDINATOR. LPN #9 SAID SHE WAS TOLD BY A CO-WORKER THAT SHE (LPN #9) WAS THE SHIFT SUPERVISOR, RESPONSIBLE FOR REPLACING STAFF MEMBERS WHO CALLED IN TO REPORT THEY WOULD NOT BE WORKING THE UPCOMING MIDNIGHT SHIFT (11:00 P.M.-7:00 A.M.). LPN #9 STATED THAT A NURSE CALLED IN SICK AT 7:00 P.M. AND THAT REGISTERED NURSE (R.N.) #4, WHO WAS WORKING THE AFTERNOON SHIFT VOLUNTEERED TO WORK A DOUBLE SHIFT TO COVER THE NURSE WHO "CALLED IN". LPN #9 STATED THAT A SECOND LICENSED NURSE CALL-IN OCCURRED AT 9:56 P.M. AND THAT SHE ATTEMPTED TO FIND A REPLACEMENT BY CALLING TWO MANAGERS AND "A COUPLE NURSES" BUT WAS UNSUCCESSFUL. ONE MANAGER DID NOT ANSWER HIS PHONE AND THE SECOND MANAGER SAID SHE HAD JUST TAKEN A SLEEPING PILL. LPN #9 SAID IT WAS HER UNDERSTANDING THAT SHE WAS TO CALL THE STAFFING COORDINATOR IF SHE HAD TROUBLE FINDING STAFF REPLACEMENTS. LPN #9 SAID THE STAFFING COORDINATOR SAID, "I DON'T KNOW WHAT TO TELL YOU." ACCORDING TO LPN #9, THE STAFFING COORDINATOR DID NOT TELL HER TO CALL THE DON (DIRECTOR OF NURSING) #1. LPN #9 SAID HER LATE ARRIVAL FOR DUTY ON [DATE] PLACED HER BEHIND SCHEDULE FROM THE TIME SHE ARRIVED, MAKING IT MORE DIFFICULT TO PERFORM DUTIES OF A SHIFT SUPERVISOR. LPN #9 SAID WHEN SHE ARRIVED ON THE UNIT AT 6:15 P.M. ANOTHER NURSE, WORKING ON THE SAME UNIT, GAVE HER THE NARCOTIC KEYS BUT DID NOT COUNT THE NARCOTICS WITH HER. LPN #9 SAID SHE GOT NO REPORT ABOUT HER 26 ASSIGNED RESIDENTS. LPN #9 SAID SHE WAS LATE PASSING MEDICATIONS SCHEDULED FOR 5:30 P.M. AND 6 P.M., AND SOME MEDICATIONS DID NOT GET PASSED BECAUSE IT TOO LATE. LPN #9 SAID SHE DID NOT START A TUBE FEEDING SCHEDULED AT 4 P.M. UNTIL 7:15 P.M. AND HAD NOT BEEN AWARE, UNTIL 5:30 P.M., THAT RESIDENT #516 HAD RETURNED TO THE FACILITY AT 2:35 P.M. FROM THE HOSPITAL. IN AN INTERVIEW ON [DATE] AT 6:30 P.M., R.N. #4 STATED THAT ON [DATE], THREE NURSES WERE PRESENT TO WORK THE 11:00 P.M.-7:00 A.M. SHIFT. FACILITY STAFFING SCHEDULES AND A CENSUS REPORT FOR [DATE] INDICATED THAT LPN #3 WORKED ON NURSING UNIT 3-B ON THE 3:00 P.M.-11:00 P.M. SHIFT AND CONTINUED ON THE SAME UNIT FOR THE 11:00 P.M.-7:00 A.M. SHIFT, RESPONSIBLE FOR 54 RESIDENTS. LPN #5 WORKED ON NURSING UNIT 2-B ON THE 11:00 P.M.-7:00 A.M. SHIFT WITH RESPONSIBILITY FOR 53 RESIDENTS. R.N. #4 WORKED ON NURSING UNIT 2-B ON THE 3:00 P.M.-11:00 P.M. SHIFT AND CONTINUED A DOUBLE SHIFT ON NURSING UNIT 3-A WITH RESPONSIBILITY FOR 54 RESIDENTS. NO NURSE WAS AVAILABLE TO WORK ON UNIT 2-A, WHICH HAD 49 RESIDENTS. NURSE #3, INTERVIEWED ON [DATE] AT 2:50 P.M., SAID SHE HAD BEEN SCHEDULED TO WORK A DOUBLE SHIFT. IN AN INTERVIEW ON [DATE] AT 6:30 P.M., R.N. #4 STATED THAT STAFFING WAS NOT ADEQUATE ON [DATE] ON THE 11:00 P.M.-7:00 A.M. SHIFT, AND THERE WAS NO PLAN IN PLACE TO MEET THE THE NEEDS OF THE RESIDENTS ON NURSING UNIT 2-A. R.N. #4 SAID SHE COUNTED NARCOTICS ON THE 2 MEDICATION CARTS ON 3-A AND THE 2 MEDICATION CARTS ON 3-B (TOTAL OF 4 MEDICATION CARTS). RN #4 SAID SHE ALSO COUNTED NARCOTICS ON THE TWO MEDICATION CARTS ON 2-A AND PUT THE 2-A MEDICATION (AND NARCOTIC) KEYS IN ONE OF THE MEDICATION CARTS ON 2-B, EVEN THOUGH NURSE #3 SAID SHE DID NOT WANT THE KEYS. R.N. #4 SAID SHE CHECKED THE MEDICATION BOOKS ON 2-A TO SEE WHAT NEEDED TO BE GIVEN DURING THE SHIFT. RN #4 SAID SHE GAVE TWO MEDICATIONS TO RESIDENTS ON 2-A DURING THE NIGHT, AN ANTIANXIETY MEDICATION AND A PAIN MEDICATION. SHE SAID SHE WAS UNABLE TO ADMINISTER ANYMORE MEDICATIONS FOR THAT UNIT BECAUSE SHE HAD TOO MUCH TO DO ON 3-A. RN #3 SAID SHE COUNTED NARCOTICS ON HER TWO MEDICATION CARTS ON UNIT 3-A AT 6:30 A.M. WITH THE MIDNIGHT NURSE WORKING ON 3-B, AND THEN SHE COUNTED NARCOTICS ON THE TWO MEDICATION CARTS FOR 2-A WITH NURSE MANAGER #13, WHO HAD ARRIVED AT 5:30 A.M. RN #4 SAID NEITHER THE ADMINISTRATOR OR THE DON TALKED TO HER DURING THE NIGHT TO SEE HOW THINGS WERE GOING. RN #4 SAID SHE SAID SHE COULD ONLY WORK UNTIL 6 A.M. ON [DATE] WHEN SHE AGREED TO DO A DOUBLE SHIFT; BUT WHEN SHE FOUND OUT THERE WAS NO NURSE ON UNIT 2-A, SHE AGREED TO STAY UNTIL 7 A.M. RN #4 SAID SHE LEFT THE FACILITY AT 7:05 A.M. ACCORDING TO THE PERSONNEL FILE, LPN #5 WAS HIRED BY THE FACILITY ON [DATE]. IN AN INTERVIEW ON [DATE] AT 8:11 A.M., LPN #5 STATED THAT SHE WAS NEWLY HIRED AND HAD SPENT ONE WEEK IN THE CLASSROOM, AND ON [DATE] WAS IN HER SECOND WEEK ON A CLINICAL UNIT. LPN #5 SAID SHE DID NOT GET A REPORT FROM THE 3:00 P.M.-11:00 P.M. NURSE UNTIL 11:30 P.M. LPN #5 SAID SHE REFUSED TO COUNT NARCOTICS WITH THE 3:00 P.M.-11:00 P.M. NURSE ON UNIT 2-A AND TOLD EVERYONE THAT SHE COULD NOT BE RESPONSIBLE FOR 100 RESIDENTS AND WAS NOT ACCEPTING THE MEDICATION AND NARCOTIC KEYS FOR THE 2-A UNIT. LPN #5 SAID RN #4 TEXTED THE ASSISTANT DIRECTOR OF NURSING (ADON) #7 AT 11:10 P.M., BUT RECEIVED NO MESSAGE BACK FROM HER. LPN #5 SAID RN #4 TEXTED NURSE MANAGER #6 ABOUT 11:40 P.M. OR 11:50 P.M. AND GOT NO MESSAGE IN RETURN. AT APPROXIMATELY MIDNIGHT, CALLS WERE MADE TO NURSE MANAGER #13 AND THE DON AND A SECOND CALL WAS MADE TO THE DON, PER LPN #5, WITHOUT A RESPONSE. BETWEEN 12:30 A.M. AND 12:45 A.M. LPN #5 SAID SHE CALLED THE ADMINISTRATOR. THE ADMINISTRATOR, PER LPN #5, SAID SHE WOULD CALL HER MANAGERS. AT 1:30 A.M., PER LPN #5, SHE RECEIVED A TELEPHONE CALL FROM NURSE MANAGER #13 WHO SAID SOMEONE WOULD BE IN AT 3 A.M. AND STATED "DON'T WORRY", AND THAT A DAY SHIFT NURSE WILL BE COMING IN ALSO. LPN #5 SAID SHE ALSO RECEIVED A TELEPHONE CALL FROM THE DON WHO SAID SOMEONE WOULD BE IN AT 3 A.M. AND THE DAY NURSE WOULD BE COMING IN EARLY. AT 4:30 A.M., PER LPN #5, MANAGER #13 CALLED AND ASKED IF ANYONE HAD ARRIVED. LPN #5 SAID MANAGER #13 SAID SHE WOULD COME SINCE NO ONE ELSE HAD ARRIVED. PER LPN #5, MANAGER #13 ARRIVED BETWEEN 5:00 A.M. AND 5:30 A.M. LPN #5 SAID SHE PASSED ALL HER MEDICATIONS FOR RESIDENTS ON 2-B AND DID ALL HER TREATMENTS FOR THE RESIDENTS ON 2-B. IN AN INTERVIEW ON [DATE] AT 2:50 P.M., LPN #3 SAID THE MIDNIGHT STAFFING ON [DATE] WAS "OVERWHELMING". LPN #3 SAID CNA'S ON UNIT 2-A DID NOT CALL HER DURING THE SHIFT, AND SHE DID NOT GO TO THE 2-A UNIT. LPN #3 SAID SHE HAD NO INSTRUCTIONS ABOUT MEDICATION ADMINISTRATION OR COVERING EMERGENCY SITUATIONS ON 2-A IF SOMETHING SHOULD HAPPEN. AT 6 A.M., PER LPN #3, RN #4 ASKED HER TO COUNT NARCOTICS FOR THE TWO MEDICATION CARTS ON 3-A SO SHE (RN #4) COULD LEAVE THE FACILITY. LPN #3 SAID, "I WAS TAKING KEYS FOR 4 MEDICATION CARTS." LPN #3 SAID RN #4 SAID MAR (MEDICATION ADMINISTRATION RECORD) TABS WERE PULLED FOR RESIDENTS ON UNIT 3-A WHO STILL HAD MEDICATIONS TO BE ADMINISTERED ON THE 11:00 P.M.-7:00 A.M. SHIFT, AND SHE WAS LEAVING THEM FOR THE DAY SHIFT TO COMPLETE. LPN #3 SAID RN #4 SAID SHE "WROTE OUT A REPORT" FOR THE DAY SHIFT. MANAGER #13, INTERVIEWED ON [DATE] AT APPROXIMATELY 11 A.M., SAID SHE ARRIVED IN THE FACILITY THAT MORNING AT 5:30 A.M. MANAGER #13 SAID SHE BEGAN PASSING MEDICATIONS ON UNIT 2-A AS SOON AS SHE ARRIVED ALTHOUGH SHE HAD NOT DOCUMENTED ON THE MAR WHICH MEDICATIONS HAD BEEN GIVEN. ACCORDING TO THE MAR'S, AND BASED ON THE VERBAL REPORTS OF NURSE MANAGER #13, INTERVIEWED ON [DATE] AT APPROXIMATELY 11 A.M., THE FOLLOWING MEDICATIONS HAD NOT BEEN ADMINISTERED DURING THE MIDNIGHT SHIFT OF [DATE]: 1) RESIDENT #504 DID NOT RECEIVE A DOSE OF A SCHEDULED INHALER AT 6:00 A.M. 2) NON-SAMPLED RESIDENT #012 DID NOT RECEIVE 1 SCHEDULED INHALER AT 12:00 A.M. AND DID NOT RECEIVE 2 SCHEDULED INHALERS AT 6:00 A.M. AND A DOSE OF "MUCUS RELIEF" AT 6:00 A.M. 3) RESIDENT #508 DID NOT RECEIVE A 6:00 A.M. DOSE OF A SKELETAL MUSCLE RELAXANT. 4) NON-SAMPLED RESIDENT #099 DID NOT RECEIVE A 6 A.M. SCHEDULED DOSE OF A PAIN MEDICATION. 5) RESIDENT #513 DID NOT RECEIVE A 6:00 A.M. DOSE OF [MEDICAL CONDITION] REPLACEMENT MEDICATION. 6) NON-SAMPLED RESIDENT #091 DID NOT RECEIVE A 12:30 A.M. DOSE OF A SCHEDULED PAIN MEDICATION. 7) NON-SAMPLED RESIDENT #064 DID NOT RECEIVE A OPIOID NARCOTIC SCHEDULED AT 2:30 A.M. 8) NON-SAMPLED RESIDENT #064 DID NOT RECEIVE A 3:00 A.M. SCHEDULED [MEDICATION NAME]. BASED ON TREATMENT RECORDS FOR [DATE] AND [DATE], FIFTEEN MEDICAL TREATMENTS WERE NOT COMPLETED ON UNIT 2-A WHICH INCLUDED WOUND AND SKIN TREATMENTS, treatment of [REDACTED]. ACCORDING TO THE 3-A MAR, REVIEWED WITH MANAGER #6 ON [DATE] AT 5:15 P.M., 4 MEDICATIONS WERE NOT ADMINISTERED: 1) NON-SAMPLED RESIDENT #128 MISSED A DOSE OF [MEDICAL CONDITION] MEDICATION AT 6:30 A.M. AND MISSED A DOSE OF A MEDICATION TO REDUCE [MEDICAL CONDITION] REFLUX AT 6:00 A.M. RESIDENT #128 DID NOT HAVE HER BLOOD SUGAR tested AT 6:30 A.M. POTENTIALLY MISSING A DOSE OF INSULIN. 2) NON-SAMPLED RESIDENT #159 MISSED A DOSE OF A [MEDICAL CONDITION] MEDICATION AT 6:00 A.M. 3) NON-SAMPLED RESIDENT #033 MISSED A DOSE OF AN OPIOID (PAIN MEDICATION) [MEDICATION NAME] AT 1:00 A.M. BASED ON TREATMENT RECORDS FOR [DATE] AND [DATE], 7 WOUND AND SKIN CARE TREATMENTS WERE NOT COMPLETED ON UNIT 3-A. IN AN INTERVIEW ON [DATE] AT 1:15 P.M., DON #1 SAID ADMINISTRATOR #1 CALLED HER AT 1:00 A.M. ON [DATE]. DON #1 STATED, "SOMETIMES WE ONLY HAVE THREE NURSES ON THE MIDNIGHT SHIFT - NOT TOO MUCH IS GOING ON." DON #1 SAID SHE DIDN'T REALIZE THAT MEDICATIONS HAD BEEN MISSED. IN AN INTERVIEW ON [DATE] AT 5:00 P.M., ADMINISTRATOR #1 SAID SHE BELIEVED THERE WAS ENOUGH STAFF ON THE 11:00 P.M.-7:00 A.M. SHIFT ON [DATE] FOR THE CENSUS THAT NIGHT. ADMINISTRATOR #1 FURTHER STATED, "IF MEDICATIONS DIDN'T GET PASSED, THE PHYSICIAN WAS NOTIFIED AND THE PROCEDURE WAS FOLLOWED FOR MEDICATION ERRORS." STAFFING INCIDENT ON [DATE]: LPN #11 WAS INTERVIEWED ON [DATE] AT 4:30 P.M. REGARDING A NURSING STAFF SHORTAGE THAT OCCURRED ON NURSING UNIT 2-A ON [DATE] DURING THE 3:00 P.M.-11 P.M. SHIFT. LPN #11 STATED THAT HE WAS RESPONSIBLE FOR ALL 49 RESIDENTS ON THE UNIT AFTER 6:00 P.M., WHEN A NURSE LEFT THE FACILITY AND WAS NOT REPLACED. LPN #11 STATED THE UNIT REQUIRED THE SERVICES OF TWO NURSES ON THE AFTERNOON SHIFT. HE SAID HE COULD NOT PASS MEDICATIONS TO ALL RESIDENTS DURING THE SHIFT. ACCORDING TO STAFFING RECORDS FOR [DATE], R.N. #18 WORKED THE DAY SHIFT ON UNIT 2-A. ON THE 3:00 P.M.-11:00 P.M. STAFFING RECORDS, NURSE #18'S NAME WAS WRITTEN IN "TIL 6 PM" ON UNIT 2-A. NO ADDITIONAL STAFFING WAS SPECIFIED AFTER 6 P.M. R.N. #18 WAS INTERVIEWED ON [DATE] AT 11:45 A.M. R.N. #18 SAID SHE WORKED THE DAY SHIFT, 7:00 A.M.-3:00 P.M. ON [DATE] AND SAID SHE WAS "MANDATED" TO WORK A DOUBLE SHIFT BY THE "ON-CALL SUPERVISOR". RN #18 SAID SHE TOLD THE SUPERVISOR THAT SHE COULD NOT STAY BEYOND 6 P.M. BECAUSE SHE HAD A CHILD WHO COULD NOT BE LEFT ALONE. THE SUPERVISOR AGAIN TOLD HER THAT SHE WAS MANDATED TO STAY UNTIL 11 P.M. RN #18 SAID SHE TOLD THE ON-CALL SUPERVISOR AT LEAST THREE TIMES THAT SHE COULD NOT STAY LATER THAN 6 P.M. RN #18 SAID SHE ALSO TOLD ANOTHER SUPERVISOR SHE COULD NOT STAY PAST 6 P.M. RN #18 SAID LPN #11 TOLD HER SHE COULD LEAVE AND ACCEPTED HER MEDICATION KEYS. RN #18 SAID SHE FELT TERRIBLE WHEN SHE LEFT, BUT SHE COULD NOT LEAVE HER CHILD ALONE. IN AN INTERVIEW ON [DATE] AT APPROXIMATELY 11 A.M., NURSING MANAGER #13, WHO HAD RESPONSIBILITY FOR UNIT 2-A, SAID SHE DID NOT FIND OUT ABOUT THE [DATE] STAFFING PROBLEM UNTIL THE NEXT DAY. MANAGER #13 SAID SHE HEARD THAT ONLY 3 NURSES WERE LEFT ON THE SECOND FLOOR. THEY WERE TOLD BY SOMEONE TO SPLIT THE MEDICATION CART WHICH WAS NO LONGER ASSIGNED TO A NURSE, BUT THEY REFUSED TO DO SO. SHE DID NOT KNOW WHO SHARED THAT INFORMATION WITH HER. MAR'S FOR MEDICATIONS SCHEDULED TO BE ADMINISTERED DURING THE 3:00 P.M.-11:00 P.M. SHIFT ON [DATE] FOR ALL RESIDENTS ON UNIT 2-A WERE REVIEWED. A TOTAL OF 43 MEDICATIONS FOR 14 RESIDENTS WERE NOT ADMINISTERED. THE MEDICATIONS INCLUDED THE FOLLOWING: ANTIDEPRESSANT, ANTIHYPERTENSIVES, INSULIN, ORAL DIABETES MEDICATIONS, DEMENTIA MEDICATIONS, OPIOID AND NON-OPIOID [MEDICATION NAME], STOOL SOFTENERS, EYE MEDICATIONS, ANTIPSYCHOTICS, DIURETICS, ANTI-ASTHMA MEDICATIONS, PARKINSON MEDICATION, MEDICATION FOR NERVE PAIN, A MEDICATION TO TREAT URINE FLOW IN MEN WITH PROSTATE DISEASE, AND AN ANTI-CHOLESTEROL MEDICATION. THE ADMINISTRATOR WAS INFORMED ON [DATE] AT 1:42 P.M. OF THE IMMEDIATE JEOPARDY THAT BEGAN ON [DATE] AT 6 P.M. DUE TO THE FAILURE TO PROVIDE SUFFICIENT NURSING STAFF TO ATTAIN OR MAINTAIN THE HIGHEST PRACTICABLE PHYSICAL, MENTAL AND PSYCHOSOCIAL WELL-BEING OF EACH RESIDENT IN ACCORDANCE WITH PHYSICIANS' ORDERS AND PLANS OF CARE FOR 49 RESIDENTS, WHO WERE WITHOUT THE SERVICES OF A LICENSED NURSE. ON [DATE] AT 4:50 P.M. THE SURVEYOR CONFIRMED THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY. 1. BEGINNING ON [DATE], RESIDENTS WHO DID NOT RECEIVE THEIR MEDICATIONS ON NURSING UNIT 2-A DURING THE [DATE] WERE assessed with [REDACTED]. THE MEDICATION ERROR REPORTS HAVE NOT YET BEEN SIGNED BY THE PHYSICIAN AND ADMINISTRATOR. 2. ON [DATE], THE NURSING STAFF SCHEDULER WAS PLACED ON ADMINISTRATIVE LEAVE. 3. ON [DATE], A TEMPORARY CLERICAL PERSON WAS ASSIGNED TO ASSIST WITH SCHEDULING LICENSED NURSES. THIS PERSON WILL BE AVAILABLE MONDAY THROUGH FRIDAY FROM 9:00 A.M. TO 5:00 P.M. TO WORK WITH THE DIRECTOR OF NURSING AND NURSE MANAGERS TO ENSURE ADEQUATE COVERAGE OF LICENSED NURSING PERSONNEL ON EACH SHIFT. 4. ON [DATE], RESIDENTS WHO DID NOT RECEIVE THEIR MEDICATIONS OR TREATMENTS ON NURSING UNIT 2-A AND 3-A DURING THE 11:00 P.M. TO 7:00 A.M. SHIFT ON [DATE] WERE assessed with [REDACTED]. SIXTEEN OF THE TWENTY MEDICATION ERROR REPORTS HAVE NOT YET BEEN SIGNED BY THE PHYSICIAN AND ADMINISTRATOR. 5. ON [DATE] AT 6 P.M., THE ADMINISTRATOR IN-SERVICED NURSING MANAGEMENT REGARDING APPROPRIATE LICENSED NURSING COVERAGE ON ALL SHIFTS, INCLUDING THEIR RESPONSIBILITY TO COVER IF REQUIRED AND FAILURE TO COME IN AS REQUIRED WILL RESULT IN APPROPRIATE DISCIPLINARY ACTION IF ADEQUATE COVERAGE IS NOT ACQUIRED. THE FOLLOWING STAFF WERE INCLUDED IN THE IN-SERVICE: DIRECTOR OF NURSING, ASSISTANT DIRECTOR OF NURSING #1, ASSISTANT DIRECTOR OF NURSING #2, NURSE MANAGER #1, NURSE MANAGER #2, NURSE MANAGER #3. 6. ON [DATE] AT APPROXIMATELY 6:30 P.M., AN IMMEDIATE ASSESSMENT OF STAFFING NUMBERS FOR CURRENT AND UPCOMING SHIFTS WITH ADJUSTMENTS TO ENSURE THAT ADEQUATE LICENSED STAFF WERE SCHEDULED ON EACH UNIT WAS COMPLETED BY CLERICAL STAFF AND NURSE MANAGERS. THE ASSESSMENT FOUND THAT THERE WERE SHIFT VACANCIES WHICH WERE FLAGGED TO BE FILLED BY LICENSED NURSING PERSONNEL. THE DON SAID THE FACILITY WAS USING AGENCY STAFF TO FILL VACANCIES. 7. BEGINNING ON [DATE], THE DESIGNATED ON-CALL NURSE MANAGER WILL ARRIVE AT THE FACILITY WITHIN ONE HOUR OF BEING CONTACTED BY THE SHIFT SUPERVISOR OR DESIGNEE FOR ANY CALL-IN THAT IS NOT REPLACED. THEY ARE TO ENSURE THERE ARE FOUR NURSES ON THE SECOND FLOOR AND FOUR NURSES ON THE THIRD FLOOR FOR DAY SHIFT FOR A TOTAL OF EIGHT NURSES. THEY ARE ALSO TO ENSURE THERE ARE FOUR NURSES ON THE SECOND FLOOR AND FOUR NURSES ON THE THIRD FLOOR FOR THE AFTERNOON SHIFT FOR A TOTAL OF EIGHT NURSES. ADDITIONALLY, THERE ARE TO BE TWO NURSES ON THE SECOND FLOOR AND TWO NURSES ON THE THIRD FLOOR FOR THE MIDNIGHT SHIFT FOR A TOTAL OF FOUR NURSES ON THE MIDNIGHT SHIFT. THE DIRECTOR OF NURSING, ASSISTANT DIRECTORS OF NURSING AND NURSE MANAGERS ARE AWARE THAT THEY ARE RESPONSIBLE FOR FULFILLING THIS DUTY. THIS IS A REVISION TO FACILITY PRACTICE. A POLICY/PROTOCOL WAS WRITTEN FOR THIS REVISED FACILITY PRACTICE. A POLICY WAS DEVELOPED FOR NURSE MANAGEMENT COVERAGE FOR WHICH TRAINING BEGAN ON [DATE] FOR LICENSED NURSES HAVING THE POTENTIAL TO SERVE IN THE SHIFT SUPERVISOR POSITION. 8. ON [DATE], THE NURSES WHO FAILED TO ADMINISTER MEDICATIONS AND/OR TREATMENTS ON [DATE] AND [DATE] FOR ANY RESIDENT WERE PLACED ON LEAVE WITH CORRESPONDING DISCIPLINARY OR EDUCATIONAL REMEDIES AS DEEMED APPROPRIATE. 9. ON [DATE], MAR AUDITS WERE COMPLETED BY NURSE MANAGERS AND SHIFT SUPERVISORS TO ENSURE THERE WERE NO MISSED MEDICATIONS AND THERE WAS APPROPRIATE DOCUMENTATION. BEGINNING ON [DATE], ON-GOING MAR AUDITS WILL BE COMPLETED BY NURSE MANAGERS/SHIFT SUPERVISORS DAILY TO ENSURE NO MISSED MEDICATION FOR RESIDENTS COVERING ALL SHIFTS. ANY VARIANCES WILL BE ADDRESSED IMMEDIATELY PER FACILITY POLICY. 10. BEGINNING ON THE [DATE], THE SHIFT SUPERVISOR/NURSE MANAGER WILL CALL THE ADMINISTRATOR TO REPORT LICENSED NURSING STAFFING TO ENSURE ADEQUATE LICENSED STAFF COVERAGE. 11. A POLICY WAS DEVELOPED FOR NURSE MANAGEMENT COVERAGE FOR WHICH TRAINING BEGAN ON [DATE] FOR LICENSED NURSES HAVING THE POTENTIAL TO SERVE IN THE SHIFT SUPERVISOR POSITION. BEGINNING ON [DATE] ALL LICENSED NURSES DESIGNATED TO ACT AS SHIFT SUPERVISORS DURING THE EVENING AND WEEKENDS WILL HAVE TRAINING DOCUMENTED TO ENSURE COMPETENCY PRIOR TO ACTING AS SHIFT SUPERVISOR. THE DON WILL ASSURE THAT THE DESIGNATED LICENSED NURSE WHO IS APPOINTED SHIFT SUPERVISOR WILL HAVE COMPLETED TRAINING AND CAN VERBALIZE UNDERSTANDING OF POSITION RESPONSIBILITIES. NO ONE WILL ACT AS SUPERVISOR WITHOUT HAVING THIS TRAINING FIRST. NINE OUT OF FIFTEEN NURSES THAT HAVE THE POTENTIAL TO ACT AS SHIFT SUPERVISOR HAVE BEEN TRAINED ACCORDINGLY. 12. ON [DATE], NURSING ADMINISTRATION BEGAN TO CONDUCT IN-SERVICE TRAINING FOR ALL LICENSED NURSES REGARDING THE SHIFT REPORT (TRANSFERENCE OF MED CART AND NURSING COVERAGE FOR RESIDENTS) FROM ONE NURSE TO ANOTHER TO ENSURE ADEQUATE COVERAGE IS AVAILABLE TO RESIDENTS. 30 OF 47 NURSES HAVE BEEN IN SERVICED. ALL NURSES WILL GET THIS IN-SERVICE PRIOR TO WORKING THEIR NEXT SHIFT. WHILE THE IMMEDIATE JEOPARDY WAS REMOVED ON [DATE], THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF PATTERN AND SEVERITY OF NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT AN IMMEDIATE JEOPARDY DUE TO SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY. ( ) B.) BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY: 1.) FAILED TO PROVIDE SUFFICIENT QUALIFIED LICENSED NURSES TO ADMINISTER MEDICATIONS TO 44 OF APPROXIMATELY 217 RESIDENTS IN THE FACILITY ON [DATE] IN A TIMELY MANNER AND 1 (#504) OF APPROXIMATELY 49 RESIDENTS ON NURSING UNIT 2-A ON [DATE] PLACING THEM AT RISK FOR DECLINE IN MEDICAL CONDITION, AND 2.) FAILED TO HAVE QUALIFIED LICENSED NURSING STAFF AVAILABLE TO MONITOR THE CHANGING CONDITION IN 1 OF 54 RESIDENTS (#515) ON NURSING UNIT 2-B ON [DATE], RESULTING IN THE POTENTIAL FOR DECREASED STAFFING TO HAVE CONTRIBUTED TO A DECLINE IN HER MEDICAL CONDITION AND SUBSEQUENT DEATH. FINDINGS INCLUDE: ACCORDING TO FACILITY POLICY FOR "ADMINISTERING MEDICATIONS", DATED DECEMBER 2012, "MEDICATIONS MUST BE ADMINISTERED WITHIN ONE HOUR OF THEIR PRESCRIBED TIME, UNLESS OTHERWISE SPECIFIED (FOR EXAMPLE, BEFORE AND AFTER MEAL ORDERS)." ON [DATE] NURSES WERE OBSERVED ADMINISTERING 9 A.M. MEDICATIONS PAST THE TIME ALLOWED PER THE MEDICATION ADMINISTRATION POLICY. MEDICATION ADMINISTRATION WOULD BE APPROPRIATE BETWEEN 8:00 A.M. AND 10:00 A.M., ACCORDING TO THE FACILITY POLICY. LPN #30, INTERVIEWED AT 10:25 A.M. ON [DATE], SAID SHE HAD TO PASS MEDICATIONS TO TWO MORE RESIDENTS. LPN #30 EXPLAINED THAT MEDICATIONS WERE LATE BECAUSE SHE WAS WORKING WITH A "TRAINEE" WHO WAS HAVING DIFFICULTY PASSING MEDICATIONS WITHIN THE ALLOTTED TIME FRAME. LPN #30 SAID SHE DECIDED THAT SHE NEEDED TO TAKE OVER MEDICATION ADMINISTRATION FOR THE TRAINEE. LPN #30 SAID SHE USUALLY PASSED HER MEDICATIONS ON TIME ACCORDING TO FACILITY POLICY. LPN #33, INTERVIEWED AT 10:30 A.M. ON [DATE], SAID SHE HAD 18 MORE RESIDENTS WHO HAD NOT RECEIVED THEIR 9 A.M. MEDICATIONS. LPN #33 SAID SHE WAS A NEW NURSE AND WAS HAVING TROUBLE GETTING EVERYTHING DONE ON TIME. LPN #31, INTERVIEWED AT 10:35 A.M. ON [DATE], SAID SHE HAD 12 MORE RESIDENTS WHO HAD NOT RECEIVED THEIR 9 A.M. MEDICATIONS. LPN #11, INTERVIEWED AT 10:45 A.M. ON [DATE], SAID HE WAS PASSING HIS LAST 9:00 A.M. MEDICATION AT 10:45 A.M. LPN #11 SAID HE HAD BEEN EMPLOYED BY THE FACILITY FOR [AGE] years. R.N. #18, INTERVIEWED AT 10:40 A.M. ON [DATE], SAID SHE HAD 2 MORE RESIDENTS WHO HAD NOT RECEIVED 9:00 A.M. MEDICATIONS. LPN #32, INTERVIEWED AT 10:05 A.M., SAID SHE HAD 9 RESIDENTS WHO HAD NOT RECEIVED THEIR 9 A.M. MEDICATIONS. ( ) RESIDENT #504 RESIDENT #504, ACCORDING TO A [DATE] SOCIAL SERVICE PROGRESS NOTE, WAS COGNITIVELY INTACT AND DISPLAYED NO BEHAVIORAL SYMPTOMS. IN AN INTERVIEW ON [DATE] AT 1:50 P.M., RESIDENT #504 EXPLAINED IN DETAIL HER MEDICATION SCHEDULE AND STATED THAT TWO WEEKS AGO SHE DID NOT RECEIVE HER 9 A.M. MEDICATIONS UNTIL 1 P.M. ACCORDING TO THE ,[DATE] MAR, IT WAS DOCUMENTED THAT RESIDENT #504 REFUSED HER INHALER ON [DATE] BECAUSE IT WAS "TOO LATE". ( ) RESIDENT #515 ACCORDING TO A STAFFING ASSIGNMENT SHEET, DATED [DATE], LPN #34 WAS SCHEDULED TO WORK ON NURSING UNIT 2-B FOR 4 HOURS, FROM 11:00 P.M. ([DATE])-3:00 A.M. ([DATE]). LPN #35 WAS SCHEDULED TO WORK 8 HOURS ON UNIT 2-A, 11:00 P.M.-7:00 A.M. THE STAFFING ASSIGNMENT SHEET INDICATED THAT LPN #35 WAS ALSO SCHEDULED TO COVER UNIT 2-B FROM 3:00 A.M.-5:30 A.M. ON [DATE]. THE STAFFING ASSIGNMENT SHEET INDICATED THAT LPN #12 WAS SCHEDULED TO WORK FROM 5:30 A.M.-7:00 A.M. RESIDENT #515 WAS admitted to the facility on [DATE], PER THE ADMISSION RECORD. A [DATE] SOCIAL SERVICE PROGRESS NOTE, DATED [DATE], INDICATED THAT RESIDENT #515 WAS admitted TO THE FACILITY FOR SHORT TERM SKILLED REHABILITATION FOLLOWING A hospitalization FOR [MEDICAL CONDITIONS], ACCELERATED HYPERTENSION, AND OTHER MEDICAL CONDITIONS. RESIDENT #515 HAD NO COGNITIVE/MEMORY IMPAIRMENT, PER THE BIMS (BRIEF INTERVIEW OF MENTAL STATUS).. REVIEW OF A [DATE] PHYSICIAN'S HISTORY & PHYSICAL REPORT INDICATED THAT RESIDENT #515 had a history of [REDACTED]. REVIEW OF A NURSING NOTE ON [DATE] DOCUMENTED RESIDENT #515 HAD A BLOOD PRESSURE OF ,[DATE], PULSE OF 84, AND RESPIRATORY RATE OF 18, WITHOUT ANY SIGNS OF RESPIRATORY DISTRESS. REVIEW OF A physician progress notes [REDACTED]. LABORATORY TESTS WERE ORDERED ([DATE]) WHICH SHOWED NORMAL SERUM ELECTROLYTE VALUES, BUT A LOW HEMOGLOBIN AND HEMATOCRIT (INDICATING A PRESENCE OF [MEDICAL CONDITION]). A [DATE] NURSING PROGRESS NOTE INDICATED THAT RESIDENT #515'S SON REPORTED THAT RESIDENT #515 EXPERIENCED AN "EPISODE" DURING A LEAVE OF ABSENCE THAT DAY WHEN SHE BECAME "FAINT FOR ABOUT 2 MIN (MINUTES)". VITAL SIGNS WERE DOCUMENTED. NO OTHER NURSING ASSESSMENTS WERE DOCUMENTED. A [DATE] NURSING PROGRESS NOTE ON [DATE] DOCUMENTED RESIDENT #515'S WEIGHT AS 197 ,[DATE] POUNDS. A PREVIOUS WEIGHT ON A NUTRITIONAL ASSESSMENT ON [DATE] WAS 181.2 (RESIDENT HEIGHT WAS 62 INCHES). ON [DATE] THE NURSE INDICATED THAT THE RESIDENT'S LOWER LEGS WERE TAUT BUT NOT [MEDICAL CONDITION]. NO OTHER PHYSICAL ASSESSMENTS WERE DOCUMENTED. ON [DATE] THE ONLY NURSING PROGRESS NOTE FOR RESIDENT #515 STATED THAT A STOOL SAMPLE WAS OBTAINED. ON [DATE] THE PHYSICIAN'S PROGRESS NOTE FOR RESIDENT #515 DOCUMENTED SOME BILATERAL LOWER EXTREMITY [MEDICAL CONDITION], DIMINISHED BREATH SOUNDS, AND BILATERAL RHONCHI (OBSTRUCTION OF AIR IN [MEDICATION NAME] TUBES) . THE NOTE INDICATED THE PHYSICIAN ORDERED AN IMMEDIATE CHEST X-RAY, RESPIRATORY INHALERS, COUGH MEDICINE, AND OXYGEN. THE [DIAGNOSES REDACTED]. REVIEW OF A NURSING PROGRESS NOTE DATED [DATE], (NO TIME SPECIFIED BUT WRITTEN PRIOR TO A 4 P.M. NURSING PROGRESS NOTE) DOCUMENTED THAT RESIDENT #515 WAS UPSET, COMPLAINED OF SHORTNESS OF BREATH, AND SAID SHE "FELT FUNNY". THE NOTE INDICATED RESIDENT #515'S OXYGEN SATURATION WAS 88% (NORMAL 95 TO 100 PERCENT). NO FURTHER NURSING ASSESSMENTS WERE DOCUMENTED FOR RESIDENT #515 ON [DATE]. NO VITAL SIGNS WERE DOCUMENTED. THERE WAS NO OTHER OXYGEN SATURATION DOCUMENTED. IT WAS NOT DOCUMENTED WHETHER THE RESIDENT CONTINUED TO USE OXYGEN. REVIEW OF THE NURSING PROGRESS NOTE DATED [DATE] REVEALED THAT RESIDENT #515'S CHEST X-RAY WAS DONE AT 4:00 P.M., AND THE RESULTS WERE CALLED TO THE PHYSICIAN AT 7:30 P.M. THE CHEST X-RAY, DATED [DATE], DOCUMENTED, "MILD CENTRAL VASCULAR CONGESTION WHICH MAY REPRESENT MILD OR EARLY [MEDICAL CONDITION]". IN AN INTERVIEWED ON [DATE] AT 3:50 P.M., LPN #34 SAID SHE AGREED TO WORK THE FIRST FOUR HOURS OF THE MIDNIGHT SHIFT ON [DATE], 11:00 P.M.-3:00 A.M. LPN #34 SAID SHE WORKED THE PREVIOUS 3:00 P.M.-11:00 P.M.. SHIFT ON UNIT 3-A, AND THEN AGREED TO WORK THE MIDNIGHT SHIFT ON NURSING UNIT 2-B. LPN #34 SAID SHE HAD WALKED THE HALLWAYS OF UNIT 2-B AND HAD NO REASON TO AWAKEN RESIDENT #515. IN AN INTERVIEW ON [DATE] AT 1:45 P.M., CNA #36 STATED THAT SHE CARED FOR RESIDENT #515 DURING THE MIDNIGHT SHIFT ON [DATE]. CNA #36 SAID SHE DID NOT KNOW THAT RESIDENT #515 HAD MEDICAL SYMPTOMS DURING THE DAY SHIFT. CNA #36 SAID THERE WAS NO REGULARLY SCHEDULED NURSE ON THE UNIT THAT NIGHT. CNA #36 SAID THERE WAS NO NURSE ON THE UNIT WHEN SHE ENTERED RESIDENT #515'S ROOM SHORTLY BEFORE 5 A.M. AND FOUND HER UNRESPONSIVE AND NOT BREATHING. CNA #36 SAID SHE LEFT RESIDENT #515'S ROOM TO FIND LPN #35 ON THE OTHER SECOND FLOOR UNIT AT THAT TIME SHE SAW LPN #37 COMING ON DUTY. CNA #36 SAID SHE WAS SHOCKED TO FIND THAT RESIDENT #515 HAD EXPIRED BECAUSE SHE WAS SCHEDULED FOR DISCHARGE SOON. CNA #36 SAID IT WAS DIFFICULT WORKING WITHOUT A NURSE ON THEIR UNIT AND THAT LPN #35 WAS BUSY ON HER UNIT AND DID NOT HAVE TIME TO CHECK THE CNA'S ON NURSING UNIT 2-B DURING THE MIDNIGHT SHIFT ON [DATE]. CNA #36 SAID SOMETIMES THEY HAD TO "BEG" ANOTHER NURSE TO COME TO THEIR UNIT WHEN THEY WORKED WITHOUT A LICENSED NURSE. LPN #37, INTERVIEWED ON [DATE] AT 3:30 P.M., SAID SHE SAW CNA #36 "WAVING FRANTICALLY" AS SHE CAME ON DUTY. LPN #37 SAID SHE DID NOT KNOW HOW LONG RESIDENT #515 HAD BEEN DEAD. IN AN INTERVIEW ON [DATE] AT 1:30 P.M., LPN #35 SAID SHE WORKED THE MIDNIGHT SHIFT ON [DATE], (11:00 P.M. ON [DATE]-7:00 A.M. ON [DATE]) ON NURSING UNIT 2-A AND HAD NOT KNOWN ABOUT THE NURSING SCHEDULE ON 2-B UNTIL NURSE #34 ASKED HER TO COUNT NARCOTICS WITH HER AT 3 A.M. JUST BEFORE LEAVING THE FACILITY. LPN #35 SAID LPN #12, ASSIGNED TO NURSING UNIT #2-B ON [DATE], ARRIVED AT 5:30 A.M. LPN #35 SAID SHE WAS WALKING WITH LPN #12 TO THE MEDICATION ROOM ON 2-B TO GET THE MEDICATION KEYS AND NARCOTIC KEYS FOR LPN #12 WHEN CNA #36 "PEEKED OUT OF THE DOOR OF A RESIDENT'S ROOM AND SAID SHE HAD A RESIDENT WHO WOULDN'T WAKE UP." LPN #35 SAID SHE WENT INTO RESIDENT #515'S ROOM AND FOUND THE RESIDENT WITHOUT A PULSE. LPN #35 SAID SHE FOUND A BLOOD PRESSURE CUFF, AND RESIDENT #515 HAD NO BLOOD PRESSURE. LPN #35 SAID NEITHER SHE NOR LPN #12 KNEW ANYTHING ABOUT THE RESIDENT. WHEN LPN #12 GOT THE RESIDENT'S CHART, THEY FOUND THAT THE RESIDENT WAS A "NO CODE". LPN #35 SAID SHE ADON #7 AND DON #1 AFTER THE DEATH OF RESIDENT #515, AND THERE WAS NO ANSWER FROM EITHER PERSON. LPN #35 SAID AT THE BEGINNING OF THE SHIFT SOMEONE TOLD HER SHE WAS SHIFT SUPERVISOR. LPN #35 SAID SHE REFUSED TO BE SHIFT SUPERVISOR AND HAD NO TRAINING TO BE A SHIFT SUPERVISOR. ( )

SEE INTAKE MI 692. BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, FACILITY STAFF FAILED TO ATTAIN OR MAINTAIN THE HIGHEST PRACTICABLE PHYSICAL WELL-BEING (IMPLEMENT INTERVENTIONS IN ACCORDANCE WITH THE RESIDENT NEEDS AND STANDARDS OF CARE) IN 3 OF 4 SAMPLED RESIDENTS (#516, #506, AND #517), IN A TOTAL OF 23 SAMPLED RESIDENTS, RESULTING IN RESIDENT #516'S TRANSFER TO THE HOSPITAL IN DIABETIC KETOACIDOSIS, RESIDENT #506'S CONTINUED URINARY CATHETER LEAKAGE WITH RESULTANT SCROTAL AND PENIS SWELLING, REDNESS, AND PAIN AND POTENTIAL DETERIORATION OF PRESSURE SORES, AND PLACING RESIDENT #517 AT RISK FOR INFECTION. FINDINGS INCLUDE: AN ANA (AMERICAN NURSING ASSOCIATION) STANDARD OF CARE FOR MEDICAL SURGICAL NURSING IN CREIGHTON'S "LAW EVERY NURSE SHOULD KNOW", 5TH EDITION, STATES THAT THE COLLECTION OF DATA ABOUT THE HEALTH STATUS OF A PATIENT IS SYSTEMATIC AND CONTINUOUS. THE DATA MUST BE COMMUNICATED TO THE APPROPRIATE PERSONS, RECORDED, AND STORED IN A RETRIEVABLE AND ACCESSIBLE SYSTEM. (P. 13) IN "LEGAL AND ETHICAL ISSUES IN NURSING" BY G. GUIDO (2001), IT STATES THAT "DOCUMENTATION MUST SHOW CONTINUITY OF CARE, INTERVENTIONS THAT WERE USED, AND PATIENT RESPONSES TO THE THERAPIES IMPLEMENTED. NURSE'S NOTES ARE TO BE CONCISE, CLEAR, TIMELY, AND COMPLETE." (P. 171) IT STATES THAT A JURY CAN INFER THAT NO OBSERVATION OF THE PATIENT WAS CONDUCTED IF THERE IS NO MENTION OF A CHANGE IN THE CONDITION OF THE PATIENT." RESIDENT #516 PER THE ADMISSION RECORD, RESIDENT #516 WAS [AGE] years OLD AND ORIGINALLY admitted to the facility on [DATE]. REVIEW OF THE NURSING PROGRESS NOTES INDICATED THAT RESIDENT #516 HAD BEEN TRANSFERRED TO THE hospital on [DATE] WITH A BLOOD SUGAR OF 592 MG/DL. HER RETURN TO THE FACILITY (NURSING UNIT 3-A) WAS ON 3/4/13, PER PHYSICIAN admission orders [REDACTED] IN AN INTERVIEW ON 3/12/13 AT 1:30 P.M., PHYSICIAN #17 STATED RESIDENT #516 HAD VERY UNSTABLE BLOOD SUGARS AND COULD GO FROM A BLOOD SUGAR OF 40 MG/DL TO 500 MG/DL IN HOURS. PHYSICIAN #17 STATED, "SHE COULD CRASH IN MINUTES OR TWO HOURS." PHYSICIAN #17 SAID THEY HAD NEVER BEEN ABLE TO CONTROL RESIDENT #516'S BLOOD SUGAR AT THE FACILITY AND HAD SENT HER TO AN ENDOCRINOLOGIST WHO WAS REGULATING RESIDENT #516'S INSULIN REGIMEN. IN AN INTERVIEW ON 3/12/13 AT 12:40 P.M., LICENSED PRACTICAL NURSE (LPN) #16, SAID SHE WORKED 7:00 A.M.-3:00 P.M. ON 3/4/13, AND LEFT AT THE END OF HER SHIFT BEFORE LPN #9 ARRIVED ON DUTY. LPN #16 SAID SHE DID AN ASSESSMENT OF RESIDENT #516'S VITAL SIGNS AND BLOOD SUGAR AND DOCUMENTED THEM IN A NURSING PROGRESS NOTE BEFORE SHE LEFT THE UNIT THAT DAY. REVIEW OF THE NURSES NOTE REVEALED THE BLOOD SUGAR DOCUMENTED ON THE NURSING PROGRESS NOTE ON 3/4/13 AT 2:35 P.M. WAS 151 MG/DL. (NORMAL BLOOD SUGAR 2 HOURS AFTER EATING: LESS THAN 140 MG/DL). IN AN INTERVIEW ON 3/11/13 AT 2:30 P.M., L.P.N. #15, STATED THAT L.P.N. #9 WAS NOT COMING ON DUTY FOR THE 3:00 P.M.-11 P.M. SHIFT ON 3/4/13 UNTIL 6 P.M., SO SHE (L.P.N. #15) WAS HELPING PROVIDE NURSING COVERAGE ON UNIT 2-B UNTIL LPN #9 ARRIVED. LPN #15 SAID SHE TRANSFERRED THE HOSPITAL ORDERS FROM THE HOSPITAL TRANSFER FORM, DATED 3/4/13, TO THE FACILITY admission orders [REDACTED]. LPN #15 SAID SHE PARTIALLY WROTE THE SLIDING SCALE INSULIN ORDER ON THE physician's orders [REDACTED]. LPN #15 SAID THE PHYSICIAN NEEDED TO BE CALLED TO CLARIFY THE ORDER. LPN #15 SAID SHE LEFT THE FACILITY AT 6 P.M. BEFORE LPN #9 ARRIVED, BUT SHE GAVE THE MESSAGE ABOUT THE INCOMPLETE INSULIN ORDER TO L.P.N. #20. IN AN INTERVIEW ON 3/6/13 AT 8:30 A.M., L.P.N. #9 SAID SHE DID NOT GET ANY REPORT ABOUT HER 26 RESIDENTS WHEN SHE ARRIVED ON DUTY 3/4/13 AT 6:15 P.M. LPN #9 SAID SHE DID NOT KNOW ABOUT RESIDENT #516'S ADMISSION UNTIL LATER IN THE SHIFT. REVIEW OF THE CLINICAL RECORD REVEALED THERE WERE NO MEDICATIONS DOCUMENTED AS GIVEN ON RESIDENT #516'S MAR (MEDICATION ADMINISTRATION RECORD) FOR THE 3:00 P.M.-11:00 P.M. SHIFT OR THE 11:00 P.M.-7:00 A.M. SHIFT ON 3/4/13. NO BLOOD SUGARS WERE DOCUMENTED ON THE MAR OR IN THE NURSING PROGRESS NOTES OTHER THAN THE BLOOD SUGAR DOCUMENTED BY L.P.N. #16 AT 2:35 P.M. THERE WERE MEDICATIONS ORDERED AT 5 P.M. AND 9 P.M. THE SLIDING SCALE INSULIN ORDER ON THE MAR INDICATED THAT A BLOOD SUGAR WAS TO BE DONE BEFORE MEALS AND AT BEDTIME AND THERE WAS AN INSULIN SCALE INDICATED THE AMOUNT OF INSULIN TO BE ADMINISTERED . THERE WERE NO ENTRIES ON THE MAR TO SHOW THAT BLOOD SUGARS HAD BEEN DONE OR INSULIN HAD BEEN ADMINISTERED. ON 3/12/13 AT 2:10 P.M., L.P.N. #6, UNIT MANAGER FOR THE 3RD FLOOR, PROVIDED THE SURVEYOR WITH A NURSE'S SHIFT REPORT, UNDATED, WHICH INDICATED THAT RESIDENT #516 HAD RETURNED FROM THE HOSPITAL. ON THE FORM, THERE WAS A BLOOD SUGAR OF 172 DOCUMENTED NEAR RESIDENT #516'S NAME. IT DID NOT INDICATE A TIME OR DATE THAT THE BLOOD SUGAR WAS DONE. IN AN INTERVIEW ON 3/5/13 AT 6:30 P.M., REGISTERED NURSE (RN) #4 SAID SHE HAD WORKED ON 3/4/13 ON UNIT 2-B DURING THE 3:00 P.M.-11:00 P.M. SHIFT AND HAD AGREED TO DO A DOUBLE SHIFT, WORKING 11:00 P.M.-7:00 A.M. ON UNIT 3-A. RN #4 SAID SHE HAD ASSUMED SOME RESPONSIBILITIES ON NURSING UNIT 2-A DURING THE MIDNIGHT SHIFT BECAUSE THERE WAS NO NURSE ASSIGNED TO THAT UNIT. RN #4 SAID SHE ALSO SPENT TIME TRYING TO FIND A NURSE WHO WOULD COME IN TO WORK UNIT 2-A. NURSE #4 SAID SHE LEFT THE FACILITY AT 7:05 A.M. IN AN INTERVIEW ON 3/12/13 AT 12:40 P.M., L.P.N. #16, SAID SHE STARTED WORK ON UNIT 3-A AT 7:00 A.M. ON 3/5/13 AND DID NOT GET ANY REPORT ABOUT RESIDENT #516'S BLOOD SUGARS. LPN #16 SAID SHE WAS MAKING CNA (CERTIFIED NURSING ASSISTANT) ASSIGNMENTS WHEN A RESTORATIVE AIDE TOLD HER THAT SOMEONE NEEDED TO CHECK RESIDENT #516. L.P.N. #16 SAID RESIDENT #516 WAS PALE, DIAPHORETIC, NON-RESPONSIVE, HAD NO BLOOD PRESSURE AND HER BLOOD SUGAR WAS TOO HIGH FOR THE GLUCOMETER TO READ. LPN #16 SAID RESIDENT #516 WAS TRANSFERRED TO THE HOSPITAL AND LEFT THE FACILITY IMMEDIATELY WITH "LIGHTS AND SIRENS" . IN AN INTERVIEW ON 3/12/13 AT 12:30 P.M., PHYSICIAN #17 SAID RESIDENT #516'S CONDITION WAS CRITICAL AND LIFE-THREATENING WHEN SHE left the faciity on [DATE] AND THAT RESIDENT #516 WAS IN DIABETIC KETOACIDOSIS (A CONDITION THAT OCCURS WHEN THE BODY DOES NOT HAVE ENOUGH INSULIN TO USE SUGAR WHICH CAN LEAD TO COMA AND DEATH.) ( ) RESIDENT #506 PER THE ADMISSION RECORD, RESIDENT #506 WAS [AGE] years OLD AND WAS REadmitted to the facility on [DATE], . ACCORDING TO A WOUND CARE SERVICES PROGRESS NOTE, DATED 12/20/12, RESIDENT #506 HAD A PAST MEDICAL HISTORY WHICH INCLUDED [MEDICAL CONDITIONS], DEMENTIA, AND PRESSURE SORES. REVIEW OF A 2/7/13 SOCIAL SERVICE PROGRESS NOTE INDICATED THAT RESIDENT #506 WAS ALERT AND ORIENTED, SCORING 11/15 ON THE BIMS (MENTAL STATUS ASSESSMENT TOOL) AND WAS ABLE TO COMMUNICATE HIS NEEDS TO THE STAFF. RESIDENT #506 ENJOYED ATTENDING ACTIVITIES AND INTERACTING WITH OTHER RESIDENTS, PER THE NOTE. REVIEW OF A 2/21/13 PHYSICIAN'S PROGRESS NOTE DOCUMENTED THAT RESIDENT #506 WAS BEING treated for [REDACTED]. THE NOTED INDICATED RESIDENT #506 HAD A SUPRAPUBIC CATHETER (SURGICALLY CREATED CONNECTION BETWEEN THE URINARY BLADDER AND THE SKIN) IN PLACE WHICH WAS LEAKING. REVIEW OF A 2/25/12 PHYSICIAN'S PROGRESS NOTE DOCUMENTED THAT RESIDENT #506 HAD URETHRITIS (INFECTION OF THE TUBE WHICH CARRIES URINE FROM THE BODY) AND HAD CONTINUED LEAKING FROM THE SUPRAPUBIC CATHETER. ON 3/4/13, PER A PHYSICIAN'S PROGRESS NOTE, A URINE CULTURE FOR RESIDENT #506, OBTAINED BY THE LABORATORY ON 2/27/13 SHOWED A UTI [MEDICAL CONDITIONS]. (MRSA IS A BACTERIUM RESPONSIBLE FOR DIFFICULT TO TREAT INFECTIONS IN HUMANS). THE NOTE INDICATED RESIDENT #506 WAS PLACED ON A NEW ANTIBIOTIC FOR 14 DAYS AND PLACED IN CONTACT ISOLATION. IN A TELEPHONE INTERVIEW ON 3/4/13 AT 4:20 P.M., CERTIFIED NURSE AIDE (CNA) #39 SAID THERE WAS NO URINE IN RESIDENT #506'S DRAINAGE BAG, USED WITH THE SUPRAPUBIC CATHETER, WHEN HE CAME ON DUTY 3/3/13 AT 3 P.M. CNA #39 SAID HE THOUGHT SOMEONE HAD EMPTIED THE DRAINAGE BAG AT THE END OF DAY SHIFT ALTHOUGH URINE WAS COMING OUT AROUND THE SUPRAPUBIC CATHETER. CNA #39 SAID HE WAS TOLD BY OTHER CNA'S NOT TO PUT BRIEFS ON RESIDENT #506. CNA #39 SAID HE CHANGED THE LINEN TWICE DURING HIS SHIFT, THE FIRST TIME THE DRAW SHEET WAS WET AND THE LAST TIME HE CHANGED RESIDENT #506 ON HIS SHIFT, THE DRAW SHEET AND THE BOTTOM SHEET WERE BOTH WET. CNA#39 SAID HE HAD NO CONVERSATION WITH THE NURSE ABOUT THE SUPRAPUBIC CATHETER LEAKING. CNA #42 WAS INTERVIEWED ON 3/4/13 AT 5 P.M. SHE SAID SHE HAD PROVIDED CARE FOR RESIDENT #506 DURING THE MIDNIGHT SHIFT BEGINNING AT 11:00 P.M. ON 3/3/13. SHE SAID URINE WAS DRAINING OUT AROUND THE SUPRAPUBIC CATHETER ON HER SHIFT. NO URINE CAME THROUGH THE CATHETER. CNA #42 SAID IT HAD BEEN LIKE THAT THE LAST TWO NIGHTS. SHE SAID RESIDENT #506 WAS CONSTANTLY WET, AND SHE HAD TO CHANGE ALL THE BEDDING EVERY TWO HOURS. CNA #42 SAID A COUPLE NIGHTS AGO, RESIDENT #506 WAS LEAKING URINE THROUGH HIS PENIS, BUT LAST NIGHT SHE COULDN'T TELL IF ANY URINE WAS COMING THROUGH THE PENIS. CNA #42 SAID SHE HAD BEEN TELLING THE NURSES. CNA #42 SAID THE NURSES TRIED FLUSHING THE CATHETER, BUT NOTHING SEEMED TO WORK. RESIDENT #506 WAS OBSERVED ON 3/4/13 AT 8:45 A.M. IN HIS BED AND IT WAS NOTED HIS SUPRAPUBIC CATHETER WAS LEAKING. RESIDENT #506 DID NOT HAVE A BRIEF IN PLACE. UNDER THE RESIDENT WAS A URINE SOAKED CLOTH DRAWSHEET. THERE WAS A URINE SOILED SHEET UNDERNEATH THE DRAWSHEET. THERE WAS A SMELL OF URINE IN THE ROOM. THREE OPEN WOUNDS WERE OBSERVED ON RESIDENT #506 ON 3/4/13 AT 8:45 A.M., TWO LEFT BUTTOCKS WOUNDS AND ONE LEFT ISCHIAL WOUND. THERE WAS RED GRANULATION TISSUE IN ALL THREE WOUNDS. ACCORDING TO A WOUND CARE SERVICES NOTE ON 1/24/13 THE LEFT BUTTOCK WOUND WAS A STAGE II PRESSURE ULCER, 4.1 CM X 1 CM. THE SECOND LEFT BUTTOCK WOUND WAS NOT IDENTIFIED ON THE WOUND CARE SERVICES NOTE. THE LEFT ISCHIAL WOUND WAS A STAGE II PRESSURE ULCER, 2.2 CM X 2.6 CM. BOTH WOUNDS WERE 76%-100% RED GRANULATION TISSUE ON 1/24/13. IN AN INTERVIEW ON 3/4/13 AT 8:45 A.M., CNA #38, SAID THAT NO BRIEFS WERE TO BE USED ON RESIDENT #506 WHILE IN BED. SHE SAID TOWELS WERE BEING PLACED AROUND THE SUPRAPUBIC CATHETER IN AN ATTEMPT TO PROTECT THE RESIDENT'S SKIN FROM URINE. THE JANUARY, 2013 DAILY CARE RECORD OFFERED NO GUIDANCE FOR THE CNA'S REGARDING THE LEAKING SUPRAPUBIC CATHETER AND PROTECTION OF THE SKIN. SKIN MANAGEMENT INTERVENTIONS INCLUDED; FLOAT HEELS, PRESSURE RELIEVING DEVICES IN THE CHAIR AND BED, SPECIALTY BED, TURN & REPOSITION RESIDENT, AND ENCOURAGE FLUIDS. CNA #38 SAID, "IT WOULD BE A SHAME TO LET HIM LIE IN URINE BECAUSE HIS BOTTOM IS DOING SO GOOD." CNA #38, INTERVIEWED ON 3/4/13 AT 3 P.M., SAID THAT RESIDENT #506 HAD QUITE A LOT OF URINE OUTPUT DURING HER SHIFT ON 3/4/13, BUT THERE WAS NO URINE IN THE SUPRAPUBIC DRAINAGE BAG. L.P.N. #41 SAID SHE CARED FOR RESIDENT #506 ON 3/4/13 DURING THE 7:00 A.M.-3:00 P.M. SHIFT. SHE SAID THE RESIDENT HAD SOME URINE LEAKING OUT OF HIS PENIS AND SOME OUT OF THE SUPRAPUBIC TUBE. SHE DID NOT KNOW WHEN THE NURSING STAFF HAD IRRIGATED THE CATHETER OR CHANGED THE CATHETER. SHE SAID THERE HAD BEEN 30-50 CC OF URINE IN THE DRAINAGE BAG. (CONTRADICTORY TO CNA #38'S STATEMENT ABOUT NO URINE IN THE SUPRAPUBIC DRAINAGE BAG.) ON 3/5/13, ACCORDING TO THE STAFFING SCHEDULE FOR DAY SHIFT, 7:00 A.M.-3:30 P.M., CNA #40 WAS ASSIGNED TO CARE FOR RESIDENT #506. CNA #40, IN AN INTERVIEW ON 3/5/13 AT 9:30 A.M., SAID SHE JUST FOUND OUT SHE WAS CARING FOR RESIDENT #506 DURING THE SHIFT. SHE DID NOT KNOW THAT THE SUPRAPUBIC CATHETER WAS LEAKING. THE BED BATH FOR RESIDENT #506, GIVEN BY CNA'S #38 AND #40, WAS OBSERVED ON 3/5/13 AT 9:30 A.M. NO URINE WAS PRESENT IN THE SUPRAPUBIC DRAINAGE BAG. THERE WAS URINE LEAKING AROUND THE SUPRAPUBIC CATHETER, AND THERE WAS SOME THICK DRAINAGE FROM THE PENIS. THE RESIDENT'S SCROTUM AND PENIS WERE RED AND SWOLLEN, MORE SWOLLEN AND RED THAN ON 3/4/13, PER CNA #38. THERE WAS SLIGHT REDNESS OF THE SKIN AROUND THE SUPRAPUBIC CATHETER ENTRY SITE. THE RESIDENT DID NOT HAVE A BRIEF IN PLACE. THE CLOTH DRAW SHEET WAS WET, BUT THE REGULAR SHEET UNDER THE DRAWSHEET WAS ONLY SLIGHTLY WET. THE RESIDENT CRIED OUT IN PAIN WHEN HIS SCROTUM AND PENIS WERE BEING CLEANED. THE PRESSURE SORES APPEARED UNCHANGED FROM 3/4/13. RESIDENT #506 HAD A NURSING PROGRESS NOTE ON 2/11/13 DOCUMENTING THE FOLLOWING; A URINE SPECIMEN AND URETHRAL CULTURE WAS SENT TO THE LABORATORY FOR CULTURE AND SENSITIVITY. THE RESIDENT COMPLAINED OF BACK AND BLADDER PAIN. THE URINE WAS BROWN. THE RESIDENT HAD A NEW ANTIBIOTIC ORDER, PER THE NOTE. ON 2/12/13 AT 7:30 A.M. THERE WAS A NURSING PROGRESS NOTE FOR RESIDENT #506 DOCUMENTING THAT HIS SUPRAPUBIC CATHETER WAS LEAKING AND THE SCROTUM WAS REDDENED. "CREAM APPLIED." THE PHYSICIAN WAS INFORMED, PER THE NOTE. THE NOTE STATED THAT THE NURSE ON THE MIDNIGHT SHIFT CHANGED THE SUPRAPUBIC CATHETER. THERE WAS NO DOCUMENTATION TO INDICATE WHETHER THE NEW SUPRAPUBIC CATHETER WAS EFFECTIVE IN ELIMINATING LEAKAGE. ON 2/15/13, 2/16/13, 2/17/13, 2/18/13 NURSING PROGRESS NOTES DOCUMENTED THAT RESIDENT #506 WAS RECEIVING AN ANTIBIOTIC FOR URETHRITIS. THERE WAS A NOTE ON 2/17/13 INDICATING THAT HIS COGNITION HAD DECREASED AND COULD NOT REMEMBER HIS ROOM LOCATION. NO PHYSICAL ASSESSMENTS WERE COMPLETED. THERE WAS NO DESCRIPTION OF THE URINE. THERE WAS NO DOCUMENTATION WHETHER URINE CONTINUED TO LEAK. THERE WAS NO DOCUMENTATION ABOUT THE REDDENED SCROTUM. ON 2/20/13 THERE WAS A NURSING PROGRESS NOTE FOR RESIDENT #506 THAT INDICATED THE ANTIBIOTIC WOULD BE CONTINUED, THAT RESIDENT #506 COMPLAINED OF NO PAIN, AND WAS VOIDING DARK YELLOW URINE WITHOUT HEMATURIA (URINE WITH BLOOD). ON 2/21/13 THERE WAS A NURSING PROGRESS NOTE FOR RESIDENT #506 THAT INDICATED THE SUPRAPUBIC CATHETER WAS CHANGED WITH AN AMBER URINE RETURN AFTER PLACEMENT. THERE WAS NO REASON IDENTIFIED FOR THE CATHETER CHANGE. ON 2/26/13 A NURSING PROGRESS NOTE INDICATED THAT RESIDENT #506 CONTINUED ON AN ANTIBIOTIC, NO PAIN PRESENT, SOME BLOOD TINGED URINE. THE NOTE STATED THAT A URINALYSIS WAS ORDERED DUE TO CATHETER LEAKAGE, AND THE SUPRAPUBIC CATHETER WAS TO BE FLUSHED WITH 300 CC NORMAL SALINE AFTER THE URINE SPECIMEN WAS OBTAINED. THERE WAS NO DOCUMENTATION AS TO THE EFFECTIVENESS OF THE CATHETER FLUSH. ON 2/27/13 A NURSING PROGRESS NOTE FOR RESIDENT #506 DOCUMENTED CONTINUED HEMATURIA, AND THE SUPRAPUBIC CATHETER WAS FLUSHED WITH 200 CC NORMAL SALINE. THE AMOUNT OF HEMATURIA WAS NOT DOCUMENTED. THE REASON FOR FLUSHING THE SUPRAPUBIC CATHETER WAS NOT IDENTIFIED, NOR ITS EFFECTIVENESS. ON 3/3/13 A PROGRESS NOTE AT 5 A.M. DOCUMENTED THAT RESIDENT #506 WAS WITHOUT PAIN AND RESTING COMFORTABLY IN BED, "VOIDING (?UNABLE TO READ WORDS) YELLOW URINE, NO HEMATURIA, POLYURIA (LARGE AMOUNT OF URINE), OR DYSURIA (PAINFUL URINATION)". THERE WAS NO DOCUMENTATION IN THE MEDICAL RECORD THAT THE RESIDENT'S SUPRAPUBIC CATHETER HAD EVER BEEN REMOVED, AND THE RESIDENT WAS ABLE TO URINATE NORMALLY. THERE WAS NO NURSING DOCUMENTATION FOR RESIDENT #506 AFTER 5 A.M. ON 3/3/13 OR ON 3/4/13 ABOUT THE ABSENCE OF URINE OUTPUT THROUGH THE SUPRAPUBIC CATHETER, LEAKAGE OF URINE AROUND THE SUPRAPUBIC CATHETER, DRAINAGE FROM THE PENIS, SWOLLEN AND REDDENED SCROTUM AND PENIS. THERE WAS NO PLAN OF CARE FOUND WHICH ADDRESSED THE PROBLEMS. THE DON (DIRECTOR OF NURSING) WAS INFORMED OF THESE OBSERVATIONS AT APPROXIMATELY 4 P.M. ON 3/5/13. ( ) THE DAILY CARE RECORD, DATED JANUARY, 2013, WHICH PROVIDED GUIDANCE FOR CNA CARE, INDICATED RESIDENT #506 HAD A SUPRAPUBIC CATHETER AND WAS INCONTINENT (CONTRADICTORY WITH SUPRAPUBIC CATHETER). THERE WERE NO GUIDELINES FOR A LEAKING CATHETER, RED, SWOLLEN, AND PAINFUL SCROTUM AND PENIS, AND POTENTIAL CONTAMINATION OF PRESSURE SORES WITH URINE [MEDICAL CONDITION]. A 2/11/13 CARE PLAN FOR A URINARY TRACT INFECTION AND CATHETER PLACEMENT FOR RESIDENT #506 DID NOT ADDRESS A LEAKING CATHETER, THE RED, SWOLLEN, AND PAINFUL SCROTUM AND PENIS, AND POTENTIAL CONTAMINATION OF PRESSURE SORES [MEDICAL CONDITION]. ( ) RESIDENT #517 RESIDENT #517 WAS REadmitted to the facility on [DATE], PER THE ADMISSIONS RECORD. IN AN INTERVIEW ON 3/12/13 AT 2:25 P.M., L.P.N. #15 STATED THAT RESIDENT #517 WAS FOUND THAT DAY WITH A SUTURE AT THE SITE OF THE 4TH TOE ON THE RIGHT FOOT. L.P.N. #15 SAID SHE HAD REMOVED THE SUTURE PER A physician's orders [REDACTED]. L.P.N. #15 SAID SHE DID NOT REMEMBER THE RESIDENT EVER RECEIVING WOUND CARE. L.P.N. #16 WAS INTERVIEWED ON 3/12/13 AT 2:20 P.M. SHE SAID SHE WAS ASSIGNED TO CARE FOR RESIDENT #517 DURING THE DAY SHIFT ON 3/12/13. SHE SAID SHE DID NOT REMEMBER RESIDENT #517 HAVING ANY SURGERY INVOLVING THE 4TH TOE ON THE RIGHT FOOT. PHYSICIAN #17 WAS INTERVIEWED ON 3/12/13 AT 1:30 P.M. THE PHYSICIAN SAID THE RESIDENT DID NOT HAVE ANY SURGERY RECENTLY AND HAD NOT BEEN OUT OF THE FACILITY IN THREE YEARS. THE PHYSICIAN DOCUMENTED IN A 3/12/13 PROGRESS NOTE THAT "(R) FOOT EXAMINED. 4TH TOE AMPUTATED 2010-? SUTURE STILL IN PLACE." RESIDENT #517, PER PHYSICIAN'S NOTE WAS CONFUSED AND UNABLE TO PROVIDE ANY HISTORY. ( )

REFER TO INTAKES MI 819, MI 106 AND MI 610. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE AND APPROPRIATE ASSISTANCE TO PREVENT FALLS FOR 2 (#103 AND #104) OF 7 SAMPLED RESIDENTS ALL REVIEWED FOR FALLS FROM A TOTAL SAMPLE OF 7 WHEN INTERVENTIONS TO PREVENT FALLS WERE REMOVED FOR RESIDENT #104 AND WHEN RESIDENT #103 WAS TRANSFERRED VIA MECHANICAL LIFT WITH ONLY 1-PERSON ASSISTANCE, RESULTING IN FALLS WITH INJURY. FINDINGS INCLUDE: RESIDENT #104: ACCORDING TO THE FACILITY'S INCIDENT REPORT DATED 10/16/12, AT 10:50 PM, RESIDENT #104 WAS "OBSERVED LAYING FACE DOWN IN THE DOORWAY ALARM SOUNDING WITH SIGNIFICANT BLOOD LOSS NOTED FROM LACERATIONS AND CONTUSIONS TO NOSE, FOREHEAD, AND TEMPORAL AREA ... ASSESSED FURTHER NOTED BED IN HIGH POSITION AND HEEL PROTECTORS WERE ON AT THE TIME OF FALL. TRANSFERRED TO HOSPITAL FOR EVALUATION AND TREATMENT. " HOSPITAL RECORDS DATED 10/17/12, DOCUMENTED THAT "PATIENT IS A [AGE] year OLD FEMALE WHO WAS PRESENTED TO THE ER (emergency room ) ON 10/17/12, SECONDARY TO A FALL OUT OF BED AT ECF (EXTENDED CARE FACILITY). IMPRESSION: CERVICAL 2 VERTEBRAL BODY FRACTURE AND RIGHT NONDISPLACED SMALL SUPERIOR LATERAL PATELLA FRACTURE SECONDARY TO UNWITNESSED FALL. ACCORDING TO THE HISTORY AND PHYSICAL DATED 10/11/12, RESIDENT #104 WAS admitted to the facility on [DATE] AND [DIAGNOSES REDACTED]. ACCORDING TO THE FALL RISK assessment dated [DATE], RESIDENT #104 WAS AT RISK FOR FALLS. THE CARE MANAGEMENT SUMMARY DATED 9/11/12, NOTED NO FALLS AT THAT TIME, BUT INTERVENTIONS THAT INCLUDED A LOW BED, AND A NON-SLIP MAT TO WHEELCHAIR. physician's orders [REDACTED]. ACCORDING TO PHYSICAL THERAPIST (PT) #10, INTERVIEWED ON 10/18/12, AT 10 A.M., A PT EVALUATION COMPLETED FOR RESIDENT #104 DUE TO A DECLINE IN HER AMBULATION ABILITY. RESIDENT #104 COULD NOT INDEPENDENTLY AND SAFELY AMBULATE. THE EXTENSION IN BOTH KNEES WAS LAGGING, MEANING THAT SHE COULD NOT STRAIGHTEN HER KNEES. HER SAFETY AWARENESS WAS NOT GOOD. SHE WAS AT RISK FOR FALLS BECAUSE SHE REQUIRED CONSTANT REMINDER AND VERBAL CUEING AND NEEDED SEQUENCING REMINDERS. ACCORDING TO THE NURSE AIDE (CNA) #7 ON 10/18/12 AT 10:30 AM, SHE (#7) TOOK CARE OF RESIDENT #104 EVERYDAY SHE WORKED. RESIDENT #104 RELIED ON THE CNA'S CARE AND DID NOT USE THE CALL LIGHT. CNA #7 PUT RESIDENT #104 TO BED AT 8:30 PM, ON 10/16/12. ACCORDING TO CNA #7, RESIDENT #104'S BED WAS IN A HIGH POSITION, RESIDENT #104 HAD HEEL PROTECTORS APPLIED TO BOTH FEET ON AND SHE WAS NOT ON A WEDGED MATTRESS. RESIDENT #104 fell THAT NIGHT. CNA #7 EXPLAINED THAT RESIDENT #104 HAD THE ABILITY TO ROLL FROM SIDE TO SIDE IN BED, USING THE GRAB BARS WITH NO ASSISTANCE REQUIRED BUT COULD NOT GET UP AND OUT OF BED ON HER OWN. CNA #7 COULD NOT TELL HOW SHE GOT OUT OF BED WITHOUT ASSISTANCE. RESIDENT #104 COULD NOT AMBULATE WITHOUT SOMEONE HOLDING HER WITH A GAIT BELT AND USING A ROLLING WALKER. CNA #7 STATED SHE DID NOT PUT THE BED TO ITS LOWEST POSITION BECAUSE THE BED MOVES WHEN YOU PUT IT ALL THE WAY DOWN. NURSE AIDE # 7 CLARIFIED THAT RESIDENT # 104'S BED HAD AN ON-GOING PROBLEM WITH THE LOCKING DEVICE ON THE BED. SHE (#7) DID NOT TELL THE NURSE OR REPORT THIS PROBLEM TO THE MAINTENANCE DEPARTMENT. WHEN NURSE AIDE #9 WAS INTERVIEWED ON 10/18/12 AT 3:15 PM, SHE STATED THAT AT AROUND 10:45 PM ON 10/16/12, SHE HEARD THE ALARM GOING OFF FAINTLY. SHE FOLLOWED WHERE THE SOUND WAS COMING FROM AND WHEN SHE OPENED RESIDENT #104'S DOOR, SHE FOUND THE RESIDENT ON THE FLOOR WITH HER FACE DOWN ON A POOL OF BLOOD. "IT WAS VERY BLOODY, BLOOD WAS ALL OVER HER FACE AND HER GOWN." NURSE AIDE #9 NOTICED THAT THE BED WAS IN A HIGH POSITION. SHE CALLED CNA #8 AND THE CHARGE NURSE IMMEDIATELY FOR HELP. SHE DENIED WITNESSING THE FALL. ACCORDING TO THE UNIT 2 NURSE MANAGER #7, INTERVIEWED ON 10/18/12 AT 12:00 PM, THE SAFETY TEAM DECIDED TO DISCONTINUE THE GEO WING (WEDGE CUSHION) ON 10/15/12 BECAUSE RESIDENT #104 HAD NOT HAD ANY RECENT FALL. RESIDENT #104 WAS ABLE TO GET UP ON HER OWN AND WAS AMBULATORY. ON 10/16/12, RESIDENT #104 WAS FOUND ON THE FLOOR FACE DOWN WITH BLOOD ON THE FLOOR. UNIT 2 MANAGER#7 INSISTED THAT RESIDENT #104 GOT UP AND OUT OF BED UNASSISTED. UNIT 2 MANAGER #7 STATED THAT RESIDENT COULD AMBULATE INDEPENDENTLY IN HER ROOM AND TO THE BATHROOM. NO SAFETY TEAM NOTES FOR THE DATE 10/15/12 WERE NOTED IN THE REVIEW OF THE CLINICAL RECORD. THERE WERE NO CHANGE/UPDATES IN THE RESIDENT #104'S CARE PLAN INDICATING THAT WING-TYPE MATTRESS WAS DISCONTINUED. THERE WERE NO PHYSICIAN'S PROGRESS NOTE RECOMMENDING THE DISCONTINUANCE OF THE WEDGED CUSHION. RESIDENT #103: THE FACILITY UNUSUAL OCCURRENCE REPORT DATED 9/5/12, DESCRIBED AT 1:40 PM, "CENA (CNA) #1 PUT RESIDENT (#103) ON HOYER (MECHANICAL LIFT) SLING. CENA #1 ATTEMPTED TO TF (TRANSFER) RESIDENT #103 FROM WHEELCHAIR TO BED AND SLING GOT BROKEN. RESIDENT #103 fell on THE FLOOR." THE INTERIM DON (DIRECTOR OF NURSING) INTERVIEWED ON 10/17/12 AT 11:15 AM, STATED THAT THE NURSE AIDE #1 DID NOT FOLLOW PROCEDURE AND TRANSFERRED RESIDENT #103 USING A HOYER (MECHANICAL) LIFT WITHOUT AN ASSISTANCE OF ANOTHER NURSE AIDE OR NURSE IN THE ROOM. ACCORDING TO THE DON, IT IS THE FACILITY'S POLICY AND PROCEDURE THAT ALL LIFTS MUST BE OPERATED WITH 2 NURSING PERSONNEL. THE DON WENT ON TO SAY THAT NURSE AIDE #1 NO LONGER WORKED AT THE FACILITY. RESIDENT #103 SUSTAINED A RIGHT HIP FRACTURE DUE TO THE FALL THAT OCCURRED DURING THE TRANSFER AND WAS SENT TO THE HOSPITAL. X-RAY RESULTS DATED 8/21/12 RECEIVED AT 2100 (9:00 PM), REVEALED: RECENT DISPLACED SUBTROCHANTERIC FRACTURE EXTENDING INTO THE PROXIMAL SHAFT OF THE FEMUR. HOSPITAL RECORD DATED 9/5/12, DOCUMENTED THAT RESIDENT #103 ARRIVED AT THE HOSPITAL AT 11:00 PM ON 9/5/12 BY AMBULANCE WITH A CHIEF COMPLAINT: "fell FROM HOYER LIFT AT ECF (EXTENDED CARE FACILITY) 7 HOURS AGO, + SHORT/ROTATED XRAY RIGHT PELVIC FRACTURE." REVIEW OF THE CLINICAL RECORD REVEALED THAT RESIDENT #103 WAS [AGE] years OLD, ALERT AND ORIENTED TO SELF ONLY. THE HISTORY AND PHYSICAL FORM DATED 1/23/12, DOCUMENTED A HISTORY OF CONGESTIVE HEART FAILURE EXACERBATION, CHRONIC OBSTRUCTIVE PULMONARY DISEASE EXACERBATION, DEMENTIA AND GAIT ABNORMALITY IN ADDITION TO OTHER DIAGNOSES. THE MINIMUM DATA SET assessment dated [DATE], DOCUMENTED THAT RESIDENT #103 WAS TOTALLY DEPENDENT ON STAFF FOR TRANSFERS AND ACTIVITIES OF DAILY LIVING (ALDS). SHE WAS INCONTINENT OF BOWEL AND BLADDER. DAILY CARE RECORD (DCR) DATED AUGUST 2012 AND SEPTEMBER 2012, NOTED THAT RESIDENT #103 REQUIRED 2 PERSON ASSISTANCE DURING TRANSFER USING A MAXI (MECHANICAL) LIFT. DURING AN INTERVIEW WITH NURSE AIDE #3 ON 10/16/12 AT 3:20 PM, SHE STATED THAT NURSE AIDE # 1 TOLD HER (#3) THAT SHE (#1) THAT NEEDED HELP WITH HOYER LIFT TRANSFER. ACCORDING TO NURSE AIDE #3, SHE (#3) REPLIED, "LET ME (#3) FINISH UP WITH THIS RESIDENT AND I WILL BE RIGHT THERE." AS SHE (#3) ENTERED RESIDENT #103'S ROOM, SHE SAW RESIDENT #103 UP ON THE LIFT (UP HIGHER THAN RESIDENT'S BED) AND SAW THE LEFT SIDE OF THE SLING SNAP OPEN AND RESIDENT #103 fell RIGHT OUT OF THE SLING TO THE FLOOR. RESIDENT #103 COMPLAINED OF PAIN ON THE LEFT HIP AT FIRST AND LATER ON THE RIGHT SIDE. NURSE AIDE #3 PUT A PILLOW UNDER HER HEAD AND CALLED FOR THE NURSE. NURSE AIDE #3 WAS UNSURE IF THE SLING WAS IMPROPERLY HOOKED, BECAUSE SHE WAS NOT THERE WHEN NURSE AIDE #1 ATTACHED THE SLING ON THE LIFT. AN UNSUCCESSFUL ATTEMPT TO INTERVIEW NURSE AIDE #1 BY TELEPHONE WAS MADE ON 10/16/12 AT 3:15 PM. THE SURVEYOR LEFT A MESSAGE IN THE VOICEMAIL BUT NURSE AIDE #1 DID NOT RETURN THE CALL. ACCORDING TO THE NURSE MANAGER #4 AT 10/17/12 AT 12:30 PM, SHE RESPONDED IMMEDIATELY AFTER THE FALL. NURSE MANAGER #4 INSPECTED THE INTEGRITY OF THE SLING AND THERE WAS A LITTLE RIP (ABOUT 2 INCHES IN LENGTH) FOUND BUT IT WOULD NOT HAVE CAUSED THE FALL. DURING FURTHER INVESTIGATION, NURSE AIDE #3 REVEALED THAT THAT SHE WAS NOT THERE WHEN RESIDENT #103 WAS HOOKED UP TO THE HOYER LIFT. NURSE AIDE #3 CAME INTO THE ROOM AT THE TIME WHEN RESIDENT #103 WAS SUSPENDED IN THE AIR AND SAW RESIDENT #103 fell RIGHT OUT OF THE SLING. NURSE MANAGER #4 STATED, "IT IS OUR THE FACILITY'S POLICY TO OPERATE SLINGS WITH 2 PERSON WHETHER IT IS THE MAXI LIFT OR THE SIT TO STAND LIFT FOR SAFETY. (NURSE AIDE #1) DID NOT FOLLOW THE FACILITY'S POLICY ON OPERATING LIFTS AND NO ONE CAN TELL IF SHE HOOKED THE SLINGS ACCORDINGLY BECAUSE THERE WAS NO OTHER PERSON TO VERIFY THAT. (RESIDENT #103) COMPLAINED OF PAIN ON THE LEFT HIP AND LATER ON THE RIGHT. AN X-RAY WAS DONE AND A FRACTURE WAS FOUND ON HER RIGHT HIP. (RESIDENT #103) WAS SENT TO THE HOSPITAL THAT NIGHT AND UNDERWENT HIP SURGERY." AT THE TIME OF THE INVESTIGATION ON COMPLETED ON 10/16/12 AND 10/18/12, RESIDENT #103 HAD NOT RETURNED TO THE FACILITY. ( )

THIS CITATION PERTAINS TO INTAKE # MI 416 AND MI 728. BASED ON INTERVIEWS AND RECORDS REVIEW, THE FACILITY FAILED TO ENSURE SAFETY FOR 2 OF 4 (#103 AND #104) SAMPLED RESIDENTS REVIEWED FOR ADEQUATE SUPERVISION AND SAFETY DEVICES, FROM A TOTAL SAMPLE OF 4, RESULTING IN A FALL AND RIGHT HIP FRACTURE FOR RESIDENT #103 AND A FALL WITH LEFT HIP FRACTURE FOR RESIDENT #104. FINDINGS INCLUDE: RESIDENT #103 ACCORDING TO THE FACE SHEET DATED 7/31/2012, RESIDENT #103 WAS AN [AGE] year OLD MALE, INITIALLY admitted to the facility on [DATE], REadmitted [DATE], WITH [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM DATA SET (MDS) ASSESSMENT, DATED 8/07/2012, RESIDENT #201 HAD SEVERELY IMPAIRED COGNITION, LONG AND SHORT-TERM MEMORY LOSS, COULD NOT BALANCE WITH STAFF ASSISTANCE, DID NOT WALK AND REQUIRED MINIMALLY TWO STAFF MEMBERS FOR ALL TRANSFERS. A CARE PLAN INITIATED 1/31/2012 DOCUMENTED THAT RESIDENT #103 HAD BEHAVIORS THAT INCLUDED RESTLESSNESS, IMPULSIVE BEHAVIORS, WANDERING WITH NO SENSE OF SAFETY, MARKEDLY IMPAIRED JUDGMENT AND WAS TO BE MONITORED IN THE "GENTLEMEN'S LEAGUE (CLOSED MALE UNIT) FOR SAFETY." A physician's orders [REDACTED].#103 FOR PROPER TRANSFER TECHNIQUE. ON THE "REHAB SERVICES SCREENING FORM," DATED 6/25/2012, AN OCCUPATIONAL THERAPIST DOCUMENTED RESIDENT #103 WAS SCREENED FOR TRANSFERS AND CONTINUED TO REQUIRE TWO STAFF PROVIDING "...MAXIMUM ASSISTANCE ..." TO TRANSFER SAFELY. THE MONTHLY RENEWAL ORDER DATED 7/01/2012, REQUIRED RESIDENT #103 BE PLACED IN A CARDIAC CHAIR (CC) WITH A NON-SKID MAT, SEAT CUSHION, SENSOR ALARM AND, WHEN AGITATED OR COMBATIVE, A LOCKING LAP TRAY TO MAINTAIN HIS SAFETY. A DAILY CARE RECORD DATED 7/2012 REVEALED RESIDENT #103 REQUIRED MINIMALLY TWO STAFF MEMBERS TO TRANSFER SAFELY. A FALL RISK ASSESSMENT COMPLETED ON 7/17/2012 DOCUMENTED THAT RESIDENT #103 HAD CONFUSION, INCONTINENCE, BALANCE PROBLEMS WHEN RISING FROM CHAIRS OR WALKING, LOSS OF BALANCE SITTING, STANDING AND WITH TRANSFERS, REQUIRED WALKING ASSISTANCE, DOCUMENTED ASSISTIVE DEVICES, INSTABILITY WITH TURNS AND NEGOTIATING DOORWAYS, DECREASED MUSCULAR COORDINATION AND RANGE OF MOTION (ROM), POOR SAFETY SKILLS, MULTIPLE PRESCRIBED MEDICATIONS, PREDISPOSING DISEASES AND AN INABILITY TO USE THE CALL LIGHT FOR ASSISTANCE, WHICH LEFT HIM AT "HIGH RISK" FOR FALLS. THE physician progress notes [REDACTED]. AN "UNUSUAL OCCURRENCE REPORT," DATED 7/28/2012 AT 6:25 A.M., DOCUMENTED THAT RESIDENT #103 WAS LEFT UNSUPERVISED IN THE DINING ROOM. RESIDENT #103 WAS FOUND ON THE FLOOR BY STAFF AND REFERRED TO THE LOCAL HOSPITAL FOR A RIGHT HIP FRACTURE. DURING AN INTERVIEW ON 9/04/2012 AT 12:10 P.M., CERTIFIED NURSING ASSISTANT (CNA) #1 SAID RESIDENT #103 HAD A LONG HISTORY OF SELF-TRANSFER ATTEMPTS FROM HIS BED AND CARDIAC CHAIR. CNA #1 SAID THAT ON 7/28/2012, AT APPROXIMATELY 5:00 A.M., RESIDENT #103 WAS MOVED INTO HIS CARDIAC CHAIR IN THE "GENTLEMEN'S LEAGUE" UNIT DINING ROOM AFTER HE MADE SEVERAL ATTEMPTS TO SELF-TRANSFER FROM BED. CNA #1 SAID THAT IN THE DINING ROOM, RESIDENT #103 "DRIFTED IN AND OUT" AND MADE MULTIPLE ATTEMPTS TO SELF-TRANSFER FROM HIS CARDIAC CHAIR. CNA #1 SAID SHE SUPERVISED RESIDENT #103 UNTIL HE WAS ASLEEP AND THEN LEFT HIM UNATTENDED FOR AN EXTENDED PERIOD OF TIME, WITHOUT ANY ADDITIONAL ASSISTIVE DEVICES IMPLEMENTED TO ENSURE HIS SAFETY. CNA #1 SAID, "I WAS GONE LONGER THEN I WANTED TO BE." A NURSING NOTE DATED 7/28/2012 AT 7:30 P.M., DOCUMENTED THAT LICENSED PRACTICAL NURSE (LPN) #2 FOUND RESIDENT #103, ALONE, ON THE FLOOR, APPROXIMATELY 10 FEET FROM HIS CARDIAC CHAIR WHEN, SHE ENTERED THE UNIT THROUGH LOCKED HALLWAY DOORS. LPN #1 DOCUMENTED SHE ASKED RESIDENT #103 WHAT HAPPENED, AND HE STATED, "I WALK" IN BROKEN ENGLISH. A physician's orders [REDACTED].M., REQUIRED STAFF TO OBTAIN A RIGHT HIP X-RAY ON RESIDENT #103. A RADIOLOGY REPORT DATED 7/28/2012, REVEALED RESIDENT #103 HAD "...A RIGHT FEMORAL NECK FRACTURE WITH MINIMAL DISPLACEMENT." A "PATIENT TRANSFER FORM" DOCUMENTED THAT RESIDENT #103 WAS SENT TO THE LOCAL AREA HOSPITAL FOR FURTHER EVALUATION AND THE SURGICAL REPAIR OF HIS "ACUTE" RIGHT FEMORAL NECK FRACTURE. ON 8/30/2012 AT 12:30 P.M., DIRECTOR OF NURSING #1 (DON #1) SAID SHE INVESTIGATED THE INCIDENT AND DETERMINED RESIDENT #103 BROKE HIS RIGHT HIP WHEN CNA #1 LEFT HIM WITHOUT ADEQUATE SUPERVISION AND/OR NECESSARY ASSISTIVE DEVICES (LAP TRAY) REQUIRED TO MAINTAIN HIS SAFETY ON AROUND 6:30 A.M., ON 7/28/2012. DON #1 SAID THAT THE FACILITY "PRACTICE...REQUIRED" A STAFF MEMBER BE PRESENT TO SUPERVISE ANY MALE RESIDENTS LEFT IN THE "3B2" DINING ROOM. DON #1 SAID THAT "NO STAFF (WERE) PRESENT IN THE DINING ROOM" WHEN RESIDENT #103 SELF-TRANSFERRED FROM HIS CARDIAC CHAIR, SELF-AMBULATED AND fell on [DATE]. RESIDENT #104 ACCORDING TO THE FACE SHEET DATED 8/28/2012, RESIDENT #104 WAS AN [AGE] year OLD FEMALE, INITIALLY admitted TO THE FACILITY 4/19/2012, AND WAS REadmitted on [DATE], WITH [DIAGNOSES REDACTED]. ACCORDING TO THE MDS assessment dated [DATE], RESIDENT #104 HAD IMPAIRED COGNITION WITH SHORT TERM MEMORY LOSS, COULD NOT WALK AND REQUIRED MINIMALLY ON STAFF MEMBER TO PROVIDE ASSISTANCE WITH ALL TRANSFERS. A FALLS CARE PLAN, DATED 4/25/2012, DOCUMENTED THAT RESIDENT #104 HAD IMPAIRED MOBILITY, ALTERED BALANCE, GENERALIZED WEAKNESS, A HISTORY OF FALLS, POOR SAFETY AWARENESS AND NEEDED APPROPRIATE FOOTWEAR AND PROMPT RESPONSE TO ALL REQUESTS FOR ASSISTANCE. OCCUPATIONAL THERAPY NOTES DATED 5/24/2012, DOCUMENTED THAT RESIDENT #104 REQUIRED A STAFF MEMBER TO ASSIST WITH ALL TRANSFERS AND ALL TOILETING. PHYSICAL THERAPY NOTES DATED 7/30/2012, DOCUMENTED THAT RESIDENT #104 REQUIRED A ROLLING WALKER AND STAFF ASSISTANCE FOR SAFETY DURING SHORT DISTANCE AMBULATION. A FALL RISK assessment dated [DATE], DOCUMENTED THAT RESIDENT #104 SUFFERED WITH CONFUSION, REQUIRED ELIMINATION ASSISTANCE, HAD POOR VISION, HAD BALANCE PROBLEMS WHEN RISING FROM CHAIR, LOSS OF BALANCE STANDING AND WALKING, INSTABILITY WITH TURNS AND NAVIGATING DOORWAYS. THE MONTHLY RENEWAL ORDER DATED 8/2012, NOTED THAT RESIDENT #104 HAD "POOR SAFETY AWARENESS," REQUIRED A LOW BED, A BED SENSOR ALARM AND MINIMALLY ONE STAFF MEMBER TO ASSIST WITH ALL TRANSFERS. NURSING NOTES DATED 7/19/2012 AT 5:00 A.M., DOCUMENTED THAT RESIDENT #104 HAD CONFUSION, PROBLEMS RISING FROM CHAIRS, LOSS OF BALANCE STANDING AND WITH TRANSFERS, AN INABILITY TO AMBULATE, PRESCRIBED MEDICATIONS AND PREDISPOSING DISEASES THAT PLACED HER AT RISK FOR FALLS. AN "UNUSUAL OCCURRENCE REPORT," DATED 8/24/2012 AT 5:00 A.M., DOCUMENTED THAT RESIDENT #104 EXPERIENCED AN UNWITNESSED FALL AND "WAS OBSERVED TURNING TO SIT ON THE TOILET," WHEN SHE COMPLAINED OF LEFT HIP PAIN. A PHYSICIAN ORDER [REDACTED].#104. AN X-RAY REPORT DATED 8/24/2012 REVEALED RESIDENT #104 HAD "AN ACUTE COMPLETE (LEFT) FEMORAL NECK FRACTURE WITH PARTIAL DISPLACEMENT..." ON 9/04/2012 AT 1:00 P.M., RESIDENT #104 WAS UNABLE TO RECALL THE DATE, BUT SAID SHE fell IN HER ROOM BECAUSE STAFF DID NOT RESPOND FOR MORE THAN AN HOUR TO HER CALL LIGHT. RESIDENT #104 SAID SHE PRESSED THE CALL LIGHT BUTTON AND WAITED BUT "DIDN'T WANT TO GO (DEFECATE) ON MYSELF." AFTER WAITING FOR SO LONG, "I TRIED TO WALK WITHOUT ASSISTANCE." ON 9/05/2012 AT 4:40 P.M., CNA #2 SAID ON 8/24/2012 AT 5:00 A.M., RESIDENT #104 HAD NO STAFF ASSISTANCE WHEN SHE TRANSFERRED OUT OF HER BED, WITHOUT APPROPRIATE FOOTWEAR AND SOUNDED HER SENSOR ALARM. CNA #2 SAID BY THE TIME ANY STAFF MEMBERS RESPONDED TO THE ALARM, RESIDENT #104 HAD ENOUGH TIME TO WALK FROM HER BED INTO THE BATHROOM (APPROXIMATELY 30 FEET), FALL, EXPERIENCE LEFT HIP PAIN, GET BACK UP AND TOILET HERSELF. CNA #2 SAID SHE ARRIVED AFTER CARING FOR OTHER RESIDENTS AND FOUND NO ASSISTIVE DEVICES (ROLLING WALKER OR WHEELCHAIR) NECESSARY FOR A SAFE TRANSFER IN PLACE. DURING AN INTERVIEW ON 9/04/2012 AT 12:40 P.M., ASSISTANT DIRECTOR OF NURSING #1 (ADON #1) SAID SHE INVESTIGATED THE FALL ON 8/24/2012 AND DETERMINED CNA ASSIGNMENTS WERE NOT ORGANIZED TO SUPPORT TIMELY RESPONSES TO RESIDENT NEEDS.

THIS CITATION PERTAINS TO MI 294 & MI 184 BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION IN 1 OF 5 RESIDENTS (RESIDENT #501), IN A TOTAL SAMPLE OF 5 RESIDENTS, RESULTING IN RESIDENT #501 SUSTAINING A LACERATION TO HIS FOREHEAD AND A RIGHT NASAL BONE FRACTURE. FINDINGS INCLUDE: REVIEW OF A DEATH CERTIFICATE DATED [DATE] REVEALED RESIDENT #501 expired on [DATE] DUE TO NATURAL CAUSES. REVIEW OF THE FACE SHEET DATED [DATE] REVEALED RESIDENT #501 WAS A [AGE] year OLD MALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM DATA SET (MDS), dated [DATE], REVEALED RESIDENT #501 HAD SEVERE COGNITIVE IMPAIRMENTS AND REQUIRED LIMITED ASSISTANCE WITH ACTIVITIES OF DAILY LIVING. REVIEW OF A FALL RISK ASSESSMENT, DATED [DATE], REVEALED RESIDENT #501 HAD A SCORE OF 19. THE ASSESSMENT INDICATED A TOTAL SCORE OF 21 OR ABOVE REPRESENTED A HIGH RISK FOR FALLS. REVIEW OF A FALLS CARE PLAN, DATED [DATE], AND UPDATED ON [DATE] REVEALED RESIDENT #501 WAS AT RISK FOR FALLS RELATED TO UNSTEADY BALANCE, CONFUSION, POOR SAFETY AWARENESS, AND NON-COMPLIANCE. REVIEW OF A THERAPY POST FALL SAFETY SCREEN, DATED [DATE], REVEALED A TABLE TRAY WAS INSTALLED TO RESIDENT #501'S CARDIAC CHAIR TO DECREASE IMPULSIVE BEHAVIOR. REVIEW OF AN UNUSUAL OCCURRENCE REPORT, DATED [DATE], REVEALED RESIDENT #501 fell on [DATE] AT 7:55 AM. THE REPORT REVEALED RESIDENT #501 SUSTAINED LACERATIONS TO HIS FOREHEAD AND NOSE AND WAS TRANSFERRED TO THE HOSPITAL. REVIEW OF A HOSPITAL'S COMPUTED TOMOGRAPHY (CT) SCAN REVEALED RESIDENT #501 SUSTAINED A RIGHT NASAL BONE FRACTURE. REVIEW OF A WRITTEN STATEMENT BY CERTIFIED NURSING ASSISTANT (CNA) #5, DATED [DATE], REVEALED CNA #5 WAS PROPELLING RESIDENT #501 IN THE CARDIAC TO THE BATHROOM WHEN HE JUMPED OUT OF THE CARDIAC CHAIR AND CNA #5 TRIED TO HOLD RESIDENT #501 BACK BUT HE JERKED AWAY FROM HER AND fell fell FACE FIRST IN THE BATHROOM ENTRY WAY. THE STATEMENT REVEALED CNA #5 CALLED LICENSED PRACTICAL NURSE (LPN) #4 FOR ASSISTANCE. AN INTERVIEW ON [DATE] AT 11:35 AM, LPN #4 REPORTED RESIDENT #501 WAS ON THE FLOOR OUTSIDE OF THE BATHROOM WITH A BLOODY NOSE AND LACERATION TO HIS FOREHEAD. LPN #4 REPORTED SHE COMPLETED A SKIN AND NEUROLOGICAL ASSESSMENT AND ADMINISTERED FIRST AID FOR RESIDENT #501. LPN #4 REPORTED THE TABLE TRAY WAS NOT ON THE CARDIAC CHAIR AT THE TIME OF THE INCIDENT. REVIEW OF A NURSE'S NOTE DATED [DATE] REVEALED RESIDENT #501 HAD APPROXIMATELY 5 SUTURES (STITCHES) TO HIS FOREHEAD AND 4 SUTURES TO HIS NOSE. ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 973. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT 1 OF 4 (#101) RESIDENTS SAMPLED FOR SAFETY OUT OF A TOTAL SAMPLE OF 4 RECEIVED THE REQUIRED ASSISTANCE WITH AMBULATION RESULTING IN LEFT HIP FRACTURE WITH ASSOCIATED PAIN AND THE POTENTIAL FOR FUTURE INJURY. FINDINGS: RESIDENT #101: ACCORDING TO THE FACESHEET DATED 8/22/2011, RESIDENT #101 LIVED IN THE FACILITY SINCE 7/21/2011. THE MINIMUM (MDS) data set [DATE], INDICATED THAT RESIDENT #101 WAS AN [AGE] year OLD ALERT MALE WHO REQUIRED EXTENSIVE ASSISTANCE WITH TOILETING, BED MOBILITY, TRANSFERS AND AMBULATION. HE HAD SEVERAL [DIAGNOSES REDACTED]. ACCORDING TO THE NURSING KARDEX DATED JULY 2011, RESIDENT #101 SUFFERED FROM AN IMPAIRED MEMORY AND IMPAIRED DECISION MAKING. THE FACILITY IMPLEMENTED SEVERAL INTERVENTIONS TO HELP ENSURE RESIDENT #101'S SAFETY, INCLUDING A WEDGE CUSHION IN HIS WHEELCHAIR (W/C), BILATERAL ASSIST BARS ON HIS BED, BILATERAL BED BOLSTERS, BILATERAL FLOOR PADS, A SENSOR ALARM ON HIS BED AND WHEELCHAIR, AND A WATCHMATE. ACCORDING TO THE PHYSICIAN ORDERS [REDACTED]. ACCORDING TO THE PHYSICAL THERAPY PROGRESS NOTES DATED 8-12-2011 THROUGH 8-17-2011, RESIDENT #101 REQUIRED MODERATE ASSISTANCE FOR BED MOBILITY, MODERATE ASSISTANCE TO MAXIMUM ASSISTANCE WITH TRANSFERS, AND MODERATE ASSISTANCE WITH WALKING ONCE STANDING WITH THE USE OF A ROLLING WALKER. ACCORDING TO "INTRODUCTION TO PHYSICAL THERAPY FOR PHYSICAL THERAPIST ASSISTANTS" (BY OLGA DREEBEN PUBLISHED BY JONES & BARTLETT PUBLISHERS, 2006), MODERATE ASSISTANCE REQUIRES THE STAFF TO CONSISTENTLY PROVIDE ASSISTANCE TO THE RESIDENT IN THE FORM OF ASSISTANCE WITH BALANCE, MOVING EXTREMITIES OR ASSISTIVE DEVICES, PROVIDE ASSISTANCE WITH APPROXIMATELY 50% OF THE TOTAL WORK INCLUDING WEIGHT BEARING, AND GUARD THE RESIDENT FROM PROBABLE ACCIDENTS. MAXIMUM ASSISTANCE REQUIRES THE STAFF TO CONSISTENTLY PROVIDE ASSISTANCE TO THE RESIDENT IN THE FORM OF ASSISTANCE WITH BALANCE, MOVING EXTREMITIES OR ASSISTIVE DEVICES PROVIDE ASSISTANCE WITH APPROXIMATELY 75% OF THE TOTAL WORK INCLUDING WEIGHT BEARING, AND GUARD THE RESIDENT FROM PROBABLE ACCIDENTS. ACCORDING TO THE PSYCHOLOGICAL assessment dated [DATE], RESIDENT #101 WAS REFERRED FOR THERAPY DUE TO IMPULSIVITY AND BEHAVIORAL ISSUES AND A "...HISTORY OF ATTEMPTING TO AMBULATE WITHOUT ASSISTANCE...HAS POOR SAFETY AWARENESS..." NO EVIDENCE COULD BE FOUND IN RESIDENT #101'S CHART TO INDICATE ANY CHANGES IN SUPERVISION OR INTERVENTIONS TO PREVENT ACCIDENTS FOR RESIDENT #101. ACCORDING TO THE CLINICAL PROGRESS NOTES DATED 8-17-2011, AT 7:15 AM, THE FACILITY FAILED TO PROVIDE RESIDENT #101 WITH TRANSFER AND AMBULATION ASSISTANCE AND RESIDENT #101 fell . RESIDENT #101'S ALARM WAS SOUNDING AND THE CERTIFIED NURSE ASSISTANT (CNA) FOUND RESIDENT #101 ON THE FLOOR LYING ON THE LEFT SIDE IN FRONT OF THE BATHROOM. ACCORDING TO THE CLINICAL PROGRESS NOTES RESIDENT #101 POINTED TO THE BACK OF HIS HEAD AND WAS HOLDING HIS LEFT HIP WHEN ASKED IF HE WAS IN PAIN. THE PHYSICIAN WAS NOTIFIED AND X-RAYS WERE OBTAINED. ACCORDING TO THE RADIOLOGY REPORT DATED 8-17-2011 RESIDENT #101 SUFFERED FROM AN ACUTE LEFT INTERTROCANTERIC FEMORAL FRACTURE (BROKEN HIP). ON 9/14/2011 AT 10:45 AM CNA #1 WAS INTERVIEWED AND SAID THAT SHE WAS WORKING THE DAY RESIDENT #101 fell . CNA #1 SAID SHE WAS AT THE NURSING STATION WHEN SHE HEARD THE ALARM. CNA #1 SAID THAT AS SOON AS SHE HEARD THE ALARM SHE RAN TO THE ROOM. CNA #1 SAID THE ROOM WAS "...ONLY ABOUT AS FAR AS THE THIRD CHAIR AT THE TABLE ..." THE SURVEYOR MEASURED THE DISTANCE TO BE APPROXIMATELY 8 FEET. CNA #1 SAID THAT AS SHE WENT INTO THE ROOM, RESIDENT #101 HAD ALREADY FALLEN. CNA #1 SAID SHE BELIEVED THE SENSOR ALARM DID NOT ALARM RIGHT AWAY. CNA #1 SAID THE BED SENSOR ALARM WAS ALARMING, BUT RESIDENT #101 WAS ALL THE WAY TO THE BATHROOM. CNA #1 DESCRIBED THE DISTANCE AS FARTHER THAN THE DISTANCE THE CNA HAD TO TRAVEL TO GET TO THE ROOM. CNA #1 SAID "...HE DOES NOT MOVE THAT FAST...THERE IS NO WAY THE ALARM WENT OFF RIGHT AWAY..." ON 9/14/2011 AT 10:55 AM CNA #2 WAS INTERVIEWED AND SAID THAT SHE WAS WORKING THE DAY RESIDENT #101 fell . CNA #2 SAID SHE WAS WALKING DOWN THE HALL, AND HEARD A THUD. CNA #2 SAID THE ALARM WENT OFF AFTER SHE HEARD THE THUD AND SHE WENT INTO THE ROOM TO FIND THAT RESIDENT #101 HAD ALREADY FALLEN TO THE FLOOR. ON 9/9/2011 AT 10:45 AM, RESIDENT #101 WAS OBSERVED IN HIS ROOM SITTING IN A WHEELCHAIR WITH HIS WIFE. RESIDENT #101 WAS OBSERVED WITH A WEDGE CUSHION IN HIS WHEELCHAIR AND AN ALARM ON HIS BED. THERE WAS NO ALARM ON HIS CHAIR. ON 9-9-2011 AT 10:49 AM THE DIRECTOR OF NURSING (DON) SAID RESIDENT #101 SHOULD HAVE AN ALARM IN PLACE WHEN HE IS IN OR OUT OF BED. THE DON INSPECTED RESIDENT #101'S WHEELCHAIR AND WAS UNABLE TO FIND A CHAIR ALARM. THE ALARM WAS FOUND ON A CHAIR OUTSIDE RESIDENT #101'S ROOM BESIDE THE DOORWAY. THE DON SAID THAT THE CHAIR SENSOR ALARM WAS AN IMPORTANT PART OF HIS SAFETY PLAN AND MUST BE IN PLACE TO ENSUE RESIDENT #101 ' S SAFETY, BUT WAS NOT. ON 9-9-2011 AT 10:52 AM THE LICENSED PRACTICAL NURSE, LPN #1 SAID RESIDENT #101 HAD BEEN IN THE CHAIR FOR ABOUT 40 MINUTES WITHOUT HIS ALARM. LPN #1 WAS UNABLE TO EXPLAIN HOW THE FACILITY WAS ENSURING THE RESIDENT #101'S SAFETY FROM FALLS, OR HOW THE STAFF WOULD KNOW IF RESIDENT #101 ATTEMPTED TO AMBULATE WITHOUT ASSISTANCE WITHOUT THE SAFETY MEASURES IN PLACE. ( )

THIS CITATION PERTAINS TO INTAKE # MI 278 AND INTAKE # MI 527. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION, AND ASSISTIVE DEVICES TO PREVENT ACCIDENTS IN 2 OF 4 SAMPLED RESIDENTS (#101 AND #102) RESULTING IN REPEATED AVOIDABLE FALLS, RESIDENT #101'S LEFT HIP, AND ANKLE PAIN, BROKEN LEFT FEMUR, AND LEFT ELBOW SKIN TEAR; RESIDENT #102'S LACERATION ON THE FOREHEAD, LEFT SHOULDER PAIN AND A BROKEN LEFT ARM, AND THE POTENTIAL FOR FUTURE FALLS WITH INJURY. FINDINGS: RESIDENT # 101: ACCORDING TO THE FACE SHEET DATED 2/16/2011, RESIDENT # 101 HAS LIVED IN THE FACILITY SINCE AUGUST 2010. THE MINIMUM (MDS) data set [DATE], INDICATED THAT RESIDENT #101 WAS AN [AGE] year OLD MALE WITH IMPAIRED COGNITIVE ABILITIES. RESIDENT #101 REQUIRED SUPERVISION FOR ALL ACTIVITIES OF DAILY LIVING INCLUDING LOCOMOTION, WALKING, TOILETING AND TRANSFERS. RESIDENT #101 HAD SEVERAL [DIAGNOSES REDACTED]. THE CARE PLAN FOR RESIDENT #101 DATED 8/20/2010, IDENTIFIED THE POTENTIAL FOR FALLS AND IMPAIRED COGNITION AS AREAS FOR CONCERN AND IMPLEMENTED SEVERAL INTERVENTIONS INCLUDING SENSOR PAD ALARMS IN WHEELCHAIR AND BED, AMBULATION WITH SUPERVISION AND STAND BY ASSISTANCE, AND SUPERVISE WHILE IN GQ (GENTLEMEN'S QUARTERS) (A LOCKED ALL MALE UNIT DESIGNED TO HOUSE RESIDENTS WITH SIGNIFICANT BEHAVIORAL PROBLEMS WHERE RESIDENT #101 RESIDED). ON 3/2/2011 AT 11:30 AM THE DIRECTOR OF NURSING SAID RESIDENT # 101 IS TO BE UNDER OBSERVATION AT ALL TIMES. ACCORDING TO THE OCCURRENCE REPORT DATED 1/18/2011 FACILITY STAFF FAILED TO SUPERVISE OR PROVIDE AMBULATION ASSISTANCE FOR RESIDENT #101. RESIDENT #101 WAS FOUND ON THE FLOOR AT 8:15 AM BY A CERTIFIED NURSE ASSISTANT (CNA). ACCORDING TO THE OCCURRENCE REPORT NO ALARM WAS SOUNDING AND NO ONE HAD BEEN SUPERVISING RESIDENT #101. RESIDENT #101 SUFFERED NO APPARENT INJURY FROM THIS FALL. AS A RESULT OF THE INVESTIGATION THE FACILITY MODIFIED RESIDENT #101'S CARE PLAN TO INCLUDE RESIDENT #101 WAS TO BE IN A COMMON PLACE AREA WHILE AWAKE. NO EVIDENCE COULD BE FOUND TO INDICATE ANY CHANGES WERE MADE TO ENSURE RESIDENT #101 RECEIVED THE SUPERVISION REQUIRED. ACCORDING TO THE OCCURRENCE REPORT DATED 2/6/2011 FACILITY STAFF FAILED TO SUPERVISE OR PROVIDE AMBULATION ASSISTANCE FOR RESIDENT #101. RESIDENT #101 WAS FOUND ON THE FLOOR AT 3:20 PM BY A CNA. ACCORDING TO THE NURSE'S NOTES DATED 2/6/11 RESIDENT #101 COMPLAINED OF PAIN AT THE LEFT HIP, AND ANKLE. RESIDENT #101 WAS UNABLE TO BEAR WEIGHT ON THE LEFT SIDE AND RECEIVED A SKIN TEAR ON THE LEFT ELBOW. ACCORDING TO THE RADIOLOGY REPORT DATED 2/7/2011 RESIDENT #101 SUSTAINED A LEFT FEMUR FRACTURE AND WAS SENT TO THE HOSPITAL FOR FURTHER EVALUATION AND TREATMENT. ON 3/2/2011 AT 1:20 PM CNA #1 SAID THAT ON 2/6/2011 HE FOUND RESIDENT #101 ON THE FLOOR. CNA #1 SAID HE WAS IN ANOTHER ROOM GETTING ANOTHER RESIDENT OFF THE TOILET WHEN HE HEARD RESIDENT #101'S ALARM. CNA #1 SAID THAT RESIDENT #101'S MENTAL STATUS WAS DECLINING AND HIS GAIT WAS UNSTABLE. CNA #1 SAID RESIDENT #101 NEEDED A LOT OF HELP TO WALK AND GO TO THE BATHROOM BUT DID NOT GET ANY HELP OR SUPERVISION THAT DAY. ON 3/3/2011 AT 11:30 AM THE UNIT MANAGER SAID THAT SINCE 1/7/2011 RESIDENT #101 MUST BE SUPERVISED AT ALL TIMES WHILE IN GENTLEMEN'S QUARTERS. THE UNIT MANAGER REVIEWED RESIDENT #101'S CHART AND SAID THAT ON BOTH 1/18/2011 AND 2/6/2011 "...NO ONE WAS SUPERVISING..." ON 3/4/2011 AT 1:40 PM THE ADMINISTRATOR REVIEWED RESIDENT # 101'S CLINICAL RECORD. THE ADMINISTRATOR WAS NOT ABLE TO PROVIDE EVIDENCE THAT RESIDENT # 101 RECEIVED THE SUPERVISION RESIDENT #101 REQUIRED TO ENSURE HIS SAFETY. THE ADMINISTRATOR SAID RESIDENT # 101 REQUIRED SUPERVISION AND DIDN'T GET IT " ...WE OBVIOUSLY HAVE A SUPERVISION PROBLEM ... " RESIDENT # 102: ACCORDING TO THE FACE SHEET DATED 1/13/2011, RESIDENT #102 HAS LIVED IN THE FACILITY SINCE NOVEMBER 2010. THE MINIMUM (MDS) data set [DATE], INDICATED THAT RESIDENT #102 WAS A [AGE] year OLD ALERT FEMALE. RESIDENT #102 REQUIRED SUPERVISION FOR ALL ACTIVITIES OF DAILY LIVING INCLUDING LOCOMOTION, WALKING, TOILETING AND TRANSFERS. RESIDENT #102 HAD SEVERAL [DIAGNOSES REDACTED]. ACCORDING TO THE OCCURRENCE REPORT DATED 2/20/2011 FACILITY STAFF FAILED TO SUPERVISE OR PROVIDE TOILETING ASSISTANCE AND RESIDENT #102 WAS FOUND ON THE BATHROOM FLOOR AT 3:40 PM BY A CNA. RESIDENT #102 SUSTAINED A LACERATION TO HER FOREHEAD, HAD LEFT SHOULDER PAIN, AND A BROKEN LEFT HUMERUS (UPPER ARM). AS A RESULT OF THE INVESTIGATION THE FACILITY MODIFIED THE CARE PLAN TO INCLUDE NON SKID SOCKS AT ALL TIMES AND SENSOR ALARMS WHILE IN BED. ON 3/2/2011 AT 11:15 AM RESIDENT #102 WAS OBSERVED IN BED WITH NO NON SKID SOCKS ON. RESIDENT #102 WAS OBSERVED WITH SLICK SOLED SHOES WITHOUT TRACTION BARS OF ANY TYPE. NO ALARM WAS OBSERVED TO BE IN PLACE IN RESIDENT #102'S WHEELCHAIR OR BED. THERE WAS AN ALARM WITH THE SENSOR PAD ATTACHED HANGING AT RESIDENT # 102'S BEDSIDE, HANGING OVER THE SIDERAIL. THE ALARM SENSOR PAD WAS OBSERVED TO HAVE BEEN PLACED BETWEEN THE MATTRESS AND SIDE RAIL. ON 3/2/2011 AT 11:15 AM THE DIRECTOR OF NURSING (DON) WAS QUESTIONED ABOUT THE FUNCTIONALITY OF THE ALARM IN THE LOCATION IN WHICH IT WAS FOUND. THE DON DECLINED TO ANSWER AND ATTEMPTED TO PLACE THE SENSOR PAD UNDER RESIDENT #101. ON 3/2/2011 AT 11:2 AM CNA #1 SAID "...THIS ALARM CAN'T WORK...THE ALARM WON'T WORK UNLESS THE PAD IS ACTUALLY UNDER THE RESIDENT..." ON 3/2/2011 AT 11:40 AM CNA #2 SAID SHE KNEW NOTHING ABOUT THE ALARM, BUT SAID THAT RESIDENT #102 NEEDS NEW SHOES AND HAS FOR A WHILE. CNA #2 SAID RESIDENT #102 DOESN'T LIKE THE NON SKID SOCKS, AND COMPLAINS OFTEN THAT HER SHOES ARE SLIPPING. CNA #2 SAID SHE HAS TALKED TO THE NURSES AND ASKED FOR THE NURSES AND OTHER STAFF TO HELP GET RESIDENT #102 SAFE SHOES. CNA #2 SAID NO ONE HAS DONE ANYTHING TO HELP RESIDENT #102 GET SAFE SHOES. ( )

BASED ON OBSERVATIONS INTERVIEWS AND RECORDS REVIEW THE FACILITY FAILED TO ENSURE APPROPRIATE STAFF SUPERVISION AND ASSISTIVE DEVICES TO PREVENT ACCIDENTS IN 4 OF 4 SAMPLED RESIDENTS (#101, #102, #103, #104), RESULTING IN RESIDENT #101 FRACTURING HER NOSE AND BRUISING HER FACE AFTER A FALL, A POTENTIAL FOR FUTURE FALLS FOR RESIDENT #102, A LACK OF SUPERVISION FOR RESIDENT #103 RESULTING IN A DISLODGED FOLEY AND PENILE BLEEDING, AND A FALL FOR RESIDENT #104, WITH THE POTENTIAL FOR FUTURE FALLS. FINDINGS INCLUDE: RESIDENT #101 ACCORDING TO THE FACE SHEET DATED 04/05/2010 AT 7:16 A.M., RESIDENT #101 LIVED AT THE FACILITY SINCE 03/11/2010. HER [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM DATA SHEET DATED 10/07/2010, STAFF ASSESSED RESIDENT #101 TO HAVE SOME DIFFICULTY IN ORIENTATION AND RECALL. SHE REQUIRED MINIMALLY ONE STAFF MEMBER TO PROVIDE ASSISTANCE WITH TRANSFERS, AMBULATION, DRESSING, EATING, TOILET USE AND HYGIENE. RESIDENT #101 COULD NOT BALANCE WITHOUT HUMAN ASSISTANCE STABILIZING HER WHILE STANDING, WALKING, TURNING, TOILETING AND TRANSFERS BETWEEN SURFACES. SHE USED A WALKER AND WHEELCHAIR FOR MOBILITY. ACCORDING TO PHYSICAL THERAPY NOTES DATED 04/29/2010, THERAPY discharged RESIDENT #101 FROM THEIR PROGRAM ON 04/10/2010 REQUIRING STANDBY ASSISTANCE WITH A FOUR WHEELED WALKER FOR AMBULATION AND MODERATE INDEPENDENCE WITH TRANSFERS. ACCORDING TO PHYSICIAN ORDERS [REDACTED]. ACCORDING TO A FALL ASSESSMENT COMPLETED ON 12/10/2010, RESIDENT #101 HAD A "HIGH RISK" FOR FALLS. ACCORDING TO A CARE PLAN DATED 09/12/2010, STAFF ASSESSED RESIDENT #101 AND FOUND THAT SHE had a history of [REDACTED]. STAFF IMPLEMENTED MEASURES INCLUDING THE "CORRECT USE ...OF SEATING AND ASSISTIVE DEVICES AS EVALUATED AND ORDERED". ACCORDING TO THE "NURSING KARDEX" DATED 12/2010, RESIDENT #101 REQUIRED STAFF TO PROVIDE AT LEAST ONE PERSON, A GAIT BELT AND A WALKER TO ASSIST HER WITH AMBULATION. SHE NEEDED A TAB ALARM ON HER WHEELCHAIR TO ALERT STAFF TO HER FREQUENT SELF-TRANSFERS. ACCORDING TO NURSING NOTES DATED 10/06/2010 AT 6:00 A.M., RESIDENT #101 IS "CONFUSED (AND) TAKE(S) (HER) TAB ALARM OFF (TO) PUT IT IN HER RED PURSE AND HIDES PURSE UNDER HER PILLOW." ACCORDING TO EMPLOYEE "A", A NURSE ROUTINELY CARING FOR RESIDENT #101 BEFORE HER FALL, RESIDENT #101 OFTEN COMPLETED INDEPENDENT, SELF-DIRECTED TRANSFERS AND DUTIES IN HER BEDROOM/BATHROOM WITHOUT STAFF ASSISTANCE OR KNOWLEDGE BEFORE FALLING ON 12/10/2010. ACCORDING TO EMPLOYEE "A" THE FREQUENCY OF SELF-TRANSFERS AND SELF-AMBULATION DEPENDED ON THE RESIDENTS DRIVE TO COMPLETE A TASK. EMPLOYEE "A" SAID RESIDENT #101 KNEW HOW TO REMOVE HER OWN SAFETY DEVICES FOR MONTHS BUT DID NOT REMEMBER TO PUT ON HER CALL LIGHT FOR STAFF ASSISTANCE. ACCORDING TO EMPLOYEE "A", RESIDENT #101 SELF-TRANSFERRED AND AMBULATED AT LEAST WEEKLY, BUT OFTEN MORE THEN THAT. EMPLOYEE "A" SAID THE FACILITY DID NOT IMPLEMENT ANY INTERVENTIONS TO KEEP RESIDENT #101 SAFE AFTER ASSESSING HER TAB ALARM TO BE AN INEFFECTIVE SAFETY MEASURE. ACCORDING TO THE "FALLS OCCURRENCE INVESTIGATION TOOL" DATED 12/10/2010, STAFF FOUND RESIDENT #101 ON HER BEDROOM FLOOR WITH A LACERATION ON THE BRIDGE OF HER NOSE. HER REQUIRED TAB ALARM DID NOT SOUND. SHE HAD FALLEN TO HER BEDROOM FLOOR AND STAFF DOCUMENTED "RESIDENT REMOVED HER (OWN) TAB ALARM." ON 01/11/2010 AT 12:30 P.M., THE FACILITY ADMINISTRATOR AND DIRECTOR OF NURSING SAID THAT RESIDENT #101 HAD A LONG HISTORY OF REMOVING HER OWN WHEELCHAIR TAB ALARM BEFORE SHE fell on [DATE]. AFTER REVIEWING THE MEDICAL RECORD AND PERTINENT DOCUMENTS, THE ADMINISTRATOR AND DIRECTOR OF NURSING SAID REATTACHING THE TAB ALARM TO RESIDENT #101, KNOWING SHE INDEPENDENTLY REMOVES THE ALARM MAKES THE DEVICE INEFFECTIVE FOR SAFETY. BOTH SAID THE FACILITY FAILED TO IMPLEMENT ANY ADDITIONAL MEASURES TO KEEP RESIDENT #101 SAFE AFTER KNOWING SHE REMOVED HER OWN SAFETY ALARMS. ACCORDING TO A RADIOLOGY REPORTS FROM A LOCAL HOSPITAL DATED 12/10/2010, RESIDENT #101 HAD SUSTAINED A "MARKEDLY COMMINUTED NASAL BONE FRACTURE" WITH SOFT TISSUE SWELLING FROM THE FALL. RESIDENT #102 ACCORDING TO THE FACE SHEET DATED 12/13/2010 AT 2:03 P.M., RESIDENT #102 LIVED AT THE FACILITY SINCE 09/10/2009. HER [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM DATA SHEET 11/24/2010, STAFF ASSESSED RESIDENT #101 TO HAVE SOME DIFFICULTY WITH ORIENTATION AND RECALL OF EVENTS. SHE REQUIRED MINIMALLY ONE STAFF MEMBER TO PROVIDE ASSISTANCE WITH TRANSFERS, WALKING, DRESSING, EATING, TOILETING AND HYGIENE. SHE WAS NOT STEADY WHILE STANDING, WALKING, TURNING OR MOVING BETWEEN SURFACES. ACCORDING TO THE PHYSICIAN ORDERS [REDACTED]." ON 01/11/2011 AT 1:36 P.M., OBSERVATIONS MADE WITH EMPLOYEE "B" PRESENT, A REGISTERED NURSE, REVEALED RESIDENT #102 SITTING IN HER ROOM. RESIDENT #102 SAT IN A WHEELCHAIR, HOWEVER IT WAS NOT A HIGH BACK TILT WHEELCHAIR AND IT DID NOT HAVE A CUSHION OR NON-SKID MAT. EMPLOYEE "B" VERIFIED RESIDENT #102 DID NOT HAVE THESE CARE PLANNED MEASURES IN PLACE AND THEN SAID SHE WOULD HAVE SOMEONE APPLY THE CUSHION. ON 01/19/2011 AT 11:00 A.M., THE FACILITY ADMINISTRATOR AND DIRECTOR OF NURSING SAID THE FACILITY ' S FAILURE TO IMPLEMENT CARE PLANNED SAFETY MEASURES, ORDERED BY HER PHYSICIAN, INCLUDING A HIGH BACK TILT WHEELCHAIR, A WHEELCHAIR CUSHION AND A NON-SLIP MAT MEANT THE RESIDENT WAS AT RISK FOR FUTURE FALLS AND THE FACILITY HAD A DEFICIENT PRACTICE. RESIDENT #103 ACCORDING TO THE FACE SHEET DATED 12/13/2010 AT 2:11 P.M., RESIDENT #103 LIVED AT THE FACILITY SINCE 09/01/2010. HIS [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM (MDS) data set [DATE], STAFF ASSESSED RESIDENT #103 TO HAVE SIGNIFICANT COGNITIVE IMPAIRMENTS, DEMONSTRATING BOTH LONG AND SHORT-TERM MEMORY LOSS. HE REQUIRED MINIMALLY ONE STAFF MEMBER TO ASSIST WITH TRANSFERS, AMBULATION, EATING, DRESSING AND HYGIENE. ACCORDING TO A PHYSICAL THERAPY EVALUATION COMPLETED 9/04/2010, RESIDENT #103 REQUIRED A STAFF MEMBER TO PROVIDE CONTACT GUARD ASSISTANCE. ACCORDING TO THE BOOK "INTRODUCTION TO PHYSICAL THERAPY FOR PHYSICAL THERAPY ASSISTANTS" BY OLGA DREEBEN 2007, CONTACT GUARD ASSISTANCE MEANS THE RESIDENTS "CONSISTENTLY NEEDS PHYSICAL ASSISTANCE FOR GUIDANCE AND GUIDING." ACCORDING TO THE "QUALITY ASSESSMENT OCCURRENCE REPORT" DATED 09/02/2010 AT 8:15 P.M., RESIDENT #103 PULLED OUT HIS FOLEY CATHETER WITH THE BALLOON INTACT AFTER INDEPENDENTLY TRANSFERRING "TO (THE) BR (BATHROOM) AFTER (THE STAFF) 1:1 LEFT (HIM ALONE IN) THE ROOM". NURSING ASSESSED THE RESIDENT AND FOUND BLEEDING FROM HIS PENIS. ON 01/19/2011 AT 11:10 A.M., THE FACILITY ADMINISTRATOR AND DIRECTOR OF NURSING SAID THAT STAFF SHOULD NEVER LEAVE RESIDENTS REQUIRING 1:1 SUPERVISION ALONE. ACCORDING TO EACH OF THEM, THE FACILITY DID NOT MAINTAIN THE REQUIRED LEVEL OF SUPERVISION FOR RESIDENT #103 ' S ON 09/02/2010 AT 8:15 P.M., TO MAINTAIN HIS SAFETY. RESIDENT #104 ACCORDING TO THE FACE SHEET DATED 08/12/2008 AT 9:33 A.M., RESIDENT #104 LIVED AT THE FACILITY SINCE 10/11/1996. HER [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM (MDS) data set [DATE], STAFF ASSESSED RESIDENT #104 TO HAVE SOME DIFFICULTY WITH COGNITIVE FUNCTION. HE REQUIRED MINIMALLY ONE STAFF MEMBER TO PROVIDE ASSISTANCE WITH TRANSFERS. SHE COULD NOT WALK AND COULD NOT BALANCE. ACCORDING TO PHYSICIAN ORDERS [REDACTED]. ACCORDING TO THE "FALL RISK ASSESSMENT" DATED 10/05/2010, RESIDENT #104 HAD AN INCREASED RISK FOR FALLS RELATED TO HER INTERMITTENT CONFUSION, 1-2 FALLS IN THE PAST 3 MONTHS, FREQUENT INCONTINENCE, POOR VISION, BALANCE PROBLEMS SITTING, STANDING, WITH TRANSFERS, DECREASED MUSCULAR COORDINATION, DECREASED RANGE OF MOTION/CONTRACTURES/ POOR SAFETY SKILLS (IMPULSIVE), INABILITY TO AMBULATE, MEDICATIONS INCLUDING ANTI-SEIZURE, ANTI-PSYCHOTIC, ANTI-DEPRESSANTS AND HER diagnosed DEMENTIA AND STOKE. ACCORDING TO THE "QUALITY ASSESSMENT OCCURRENCE REPORT" DATED 10/31/2010 (NOT TIMED), STAFF FOUND RESIDENT #104 AFTER SHE SELF-TRANSFERRED FROM HER BED TO THE FLOOR. STAFF DOCUMENTED THE SAFETY MEASURES IN PLACE AT THE TIME OF THE INCIDENT. ON 01/19/2010 AT 11:20 A.M., THE ADMINISTRATOR AND DIRECTOR OF NURSING REVIEWED RESIDENT #104 ' S MEDICAL RECORD. THEY BOTH SAID THE FACILITY FAILED TO CHANGE THE LEVEL OF SUPERVISION AND/OR IMPLEMENT ANY NEW SAFETY MEASURES AFTER THEY FOUND RESIDENT #104 ON THE FLOOR, LEAVING HER AT RISK FOR FUTURE FALLS. ON 01/19/2011 AT 11:45 A.M., DURING A REVIEW OF SIX FALLS WITH THE ADMINISTRATOR SHE SAID, "WE ANTICIPATED THAT YOU WOULD FIND " BECAUSE THE FACILITY HAS FAILED TO REVIEW SOME OF THE FALLS AND THERE ARE PROBLEMS WITH THE ENTIRE PROGRAM. AFTER LOOKING AT THE DIRECTOR OF NURSING SHE SAID, " WE KNOW THE FALLS PROGRAM NEEDS TO BE FIXED " . THE DIRECTOR OF NURSING AGREED.