Every finding on record at Marvin & Betty Danto Health Care Center

Based on observation, interview and record review, the facility failed to ensure an appropriate call button was provided for use and placed within reach of one resident (R74) of one resident reviewed for accommodation of needsFindings include:On 3/16/2026 at approximately 8:42 a.m., R74 was observed in their room, laying in their bed. R74 was asked if they had any concerns with the care and they reported they wanted their bed raised up. R74 was asked if they could use the call button to call for help and they reported they could not find it. R74's call button was observed to be unclipped and hanging off the site of the bed on the floor. R74 was asked if they had the ability to use the call button and they reported they did not think so because they had trouble with their hands. R74 was asked how they get help from staff and they reported the did not know. On 3/16/26 at approximately 3:11 p.m., R74 was observed in their room, laying in their bed. R74 was queried if they had the ability to use their call button and they reported they did not. R74 was queried how they call for assistance from facility staff, and they indicated they have to yell out for help, but sometimes nobody will hear them if they are not walking by. On 3/17/26 at approximately 1:07 p.m., R74 was observed in their room, sitting in their wheelchair. R74 was asked if they knew where their call button was located and they indicated they did not as they do not see well. R74 was queried if they could reach their call light and they indicated they could not. R74's call light was observed on their bed, out of reach and inaccessible to R74. On 3/18/26 at approximately 8:50 a.m., R74 was observed in their room, lying in their bed. R74's call light was observed to be up on the side of the bed located up by R74's neck out of reach of R74's hands/arms. R74 was queried if they could reach their call button and they indicated they could not. R74 was queried if they could use their call button if they had it by pressing down on it and they indicated they could not because they have a problem with their hands. R74 was asked if they felt they could use a touch pad that only required laying their hand on the pad, instead of wrapping their hand around it and pressing down and they indicated it would be better for them. On 3/16/26 the medical record for R74 was reviewed and revealed the following: R74 was initially admitted to the facility on [DATE] and had diagnoses including osteoarthritis and quadriplegic cerebral palsy. A review of R74's MDS (minimum data set) with an ARD (assessment reference date) of 2/9/26 revealed R46 was dependent on staff with most of their activities of daily living. A review of R74's care plan revealed the following: I have an ADL (activities of daily living) self-care performance deficit related to weakness, CP (Cerebral Palsy) with quadriplegia and OP (osteoporosis). Date Initiated: 02/03/2026 On 3/18/26 at approximately 9:05 a.m., Nurse Manager U (NM U) was observed assessing R74's ability to use their call button. R74 reported they were not able to use it and was unsuccessful in demonstrating their ability to press the button to call for assistance. NM U reported they would provide R74 a touch pad to call for assistance that did not require R74's hands to wrap around and press down. NM U reported that a bell may also work, but R74 was unable to use the current call button. NM U was queried if the call button should be place within the reach of residents for use and they indicated that it should be. NM U was queried how staff assess for ability to use the light and they reported that it was an observation made by CNA's and Nurses if they could use it or not. On 3/18/26 a facility document titled Call Light as reviewed and revealed the following: PROCEDURE PURPOSE: To respond promptly to resident's call for assistance .To assure call system is in proper working order. PROCEDURE DETAILS: 1. Facility personnel must be aware of call lights. 2. Answer call lights in a prompt, calm, courteous manner. 3. You must turn the call light off at the point of origin; this is accomplished by pushing the switch or by depressing the ring around the button that activates the call light. 4. When providing care to residents be sure to position the call light conveniently for the resident to use. Tell the resident where the call light is and show him/her how to use the call light. 5. Orient new residents to the call light system. 6. Notify the maintenance department and enter defective call light location(s) in the TELS system. 7. Place call light on the bed or preferred location stated by the resident prior to leaving the room .

Based on observation, interview and record review, the facility failed to ensure a safe, homelike environment for one (R71) of four residents reviewed for the environment. Findings include:On 3/16/26 at 8:56 AM, R71 was observed lying in bed. R71 was asked if she had any concerns about the facility. R71 explained she was worried that the [NAME] attached above the dresser was going to fall and break all her items on the shelves. Observation of the shelves of the [NAME] revealed the pegs, that normally connect the shelf to the upright support, were completely visible and not attached to the upright support on the right side of the [NAME]. The back of the [NAME] was also not connected to the upright support and a gap of approximately 1 1/2 inches was observed on the bottom right-hand corner. Observation of the items on the shelves revealed various personal and decorative items, many would be broken if the [NAME] fell apart. R71 was asked if she had talked to anyone about the condition of the [NAME]. R71 explained she had talked to Maintenance approximately three weeks prior and was told it would be removed, but she had not heard anything else about it, and it was still there.Review of the clinical record revealed R71 was admitted into the facility on 3/21/24 with diagnoses that included: diabetes, heart disease and anxiety disorder. According to the Minimum Data Set [MDS] assessment dated [DATE], R71 had moderately impaired cognition.On 3/17/26 at 11:08 AM, the Maintenance Director [Staff 'A'] was interviewed and asked if he was aware of any concern with R71's [NAME] on the dresser. Staff 'A' explained he was not. Upon observation of the [NAME] with Staff 'A', Staff 'A' explained he would remove the [NAME] immediately. When asked how the shelves in the [NAME] were being supported, Staff 'A' explained there was a band behind the back, but the [NAME] needed to be taken down. Staff 'A' was asked if the condition of the [NAME] was something that he expected staff to report to him. Staff 'A' explained he would have expected staff to report something in that condition.On 3/17/26 at 12:32 PM, the Administrator and Director of Nursing [DON] were interviewed together. Both were asked who at the facility could report things that needed to be repaired to the Maintenance Department. The DON explained all staff members could report to the Maintenance Department. Review of a facility policy titled, Homelike Environment revised 5/2025 read in part, .Residents are provided with a safe, clean, comfortable and homelike environment.

Based on observation, interview and record review the facility failed to ensure one Resident (R8) of one resident reviewed for restraints had appropriate clinical justification/assessments for the use of a seatbelt. Findings include:On 3/17/26 at 2:56 PM, R8 was observed in the dining room sitting in their wheelchair playing bingo with other residents. After bingo was completed, R8 was asked about their seat belt and if they were able to unlatch it by themselves. R8 reported that they could not remove the belt themselves and when they were asked if they knew why they had the seat belt in place R8 replied with a gesture of a shoulder shrug.A review of the record revealed that R8 was admitted to the facility on [DATE] with the admitting diagnosis of Muscular dystrophy, Friedreich Ataxia and Mood disorder due to known physiological condition with depressive features. R8 has a Brief interview for [NAME] status score of 15 which indicated no cognitive impairment.On 3/17/26 at 9:37 AM, an interview was conducted with the Director of Nursing (DON) who was asked about the seat belt restraint for R8 and if their were consents, physician orders and appropriate documentation for the use of the seat belt. The DON reported that they did not have a consent because the mother of R8 requested that they use the seat belt for safety and poor trunk control. The DON was then asked if R8 required a seat belt? The DON reported that she knew that her seat belt broke but that would be a question for the Unit Manager.On 3/17/26 at 10:43 AM, Certified Nursing assistant (CNA) W was interviewed and reported that they were familiar with R8's care and had taken care of them before. CNA W was asked if R8 required a seat belt while up in the wheelchair. CNA W reported that R8 did require the use of a seatbelt only when they were in the wheelchair.A review of the medical record revealed that a medical order was placed on 3/17/26 which read . Seat belt released per facility policy. And a progress note written by the DON on 3/17/26 which read in part, Spoke to resident mother/legal guardian with unit manager regarding seatbelt in w/c (wheelchair) and she states she is fine with it and gives permission to use as she is the one that wanted seatbelt as her daughter has no trunk control and slides from chair and this is what keeps her safe.On 3/18/26 and interview with Unit Manager (UM) V was conducted. They were asked to provide the physician orders for the seat belt restraint prior to 3/17/26. UM V reported that they did not have an order, but they could show the point of care charting that the CNAs completed on the seatbelt. UM V was asked if there had been any training to the staff on how to use the seatbelt, the clinical justification for the device and what alternatives were tried before this device was put into place. UM V reported that they could not answer those questions because the seat belt was already in place when they began employment at the facility.On 3/18/26 at 9:23 AM, an interview with the DON was conducted. The DON was asked was the seatbelt for R8 considered a restraint. The DON reported that they did not consider the seatbelt a restraint if it was used for positioning since R8 doesn't have any trunk control and cannot control their movements and it (the seatbelt) was not affecting their daily life. The DON was asked what was the medical reasoning and the physician oversite on the use of the restraint. The DON reported that the seat belt was used for positioning and safety due to muscular dystrophy, she reported that she would have to look for physician documentation because it was applied two years ago. The DON was asked how often should R8 be reassessed for the use the restraint. The DON is reported annually and when there is a change in condition. The DON was asked about the last assessment in the medical record that was completed on 12/18/24 and the DON reported there were two assessments completed in the that same year. A review of the medical record revealed that the assessment tool completed on 12/18/24 read in part If resident has issues with balance while sitting and cannot recover balance under their own power, may want to consider a restraint if all other alternatives have been attempted. There was no additional information provided by the exit of the survey.

Based on observation, interview and record review, the facility failed to ensure enteral feeding was documented correctly and administered according to the Physician's order for one resident (R3) of one resident reviewed for enteral feeding. Findings include:On 3/16/26 at approximately 9:57 a.m., R3 was observed in their room, lying in bed. R3 was observed to have enteral formula infusing via their J-tube (jejunostomy) at 45 ml (milliliters) an hour. R3's Bottle of formula that was hanging on the pole contained no information on it including the name, rate and date/time bottle was hung. All of the documentation fields were observed to be blank. On 3/16/26 at approximately 3:23 p.m., R3 was observed in their room, laying in their bed. R3 was observed to have enteral formula infusing at 45 ml and hour with a total feed of 2293 indicated on the pump. R3's bottle of formula was observed with the 'rate field left blank. On 3/16/26 the medical record for R3 was reviewed and revealed the following: R3 was initially admitted to the facility on [DATE] and had diagnoses including Disorders of Bilirubin metabolism and Severe protein-calorie malnutrition. A review of R3's MDS (minimum data set) with an ARD (assessment reference date) of 2/27/26 revealed R3 needed assistance from facility staff with their activities of daily living. Section K indicated R3 had a feeding tube. A review of R3's care plans revealed the following Focus-I require a tube feeding Digestive Pancreatic Cancer: Gastric Outlet Obstruction Date Initiated: 02/11/2026 .Interventions-TF (tube feeding) per orders Date Initiated: 03/09/2026 . A Physician's order dated 3/6/26 revealed the following: two times a day Verify placement. Flush with 30mL of water. Start Pivot 1.5 at 1400/ 2 PM @ 40 ml/hr (hour) & continue until 800 mL/1200 kcal (kilocalories) have infused AND two times a day Use JT port for TF. Flush with_50___mLs water every _1_hours during pump infusion total 1000 ml. AND every night shift Ensure TF running during shift A Nutritional evaluation dated 3/6/26 revealed the following: Pivot 1.5 40 ml/hr (hour) x 20 hrs (hours) = 800 ml/1200 kcal, 75 g pro, 600 ml H2O (water) . On 3/16/26 at approximately 3:25 p.m., R3's enteral feeding order was reviewed in the EMR (electronic medical record) with Nurse X. Nurse X indicated they were unaware the order had been changed earlier the previous week and that they would go change the setting on the pump to the current active order of 40 ml's an hour. On 3/18/26 at approximately 9:40 a.m., Nurse Manager U (NM U) was queried regarding the multiple observations of R3's enteral feeding infusing at 45 ml outside of the Physician's orders and they indicated that R3's goal was to get to 45 ml's and hour but that the Nurse should be following the Physician's order. NM U was queried regarding the standard of practice regarding the documentation requirements for the bottle of formula that was hung on the pole and they indicated that the name, room number, date and rate should be on the bottle that was being used for the infusion. On 3/18/26 a facility document titled Enteral Nutrition was reviewed and revealed the following: Policy Statement-Adequate nutritional support through enteral nutrition is provided to residents as ordered.Policy Interpretation and Implementation1.The interdisciplinary team, including the dietitian, conducts a full nutritional assessment within current initial assessment timeframes to determine the clinical necessity of enteral feedings. The assessment includes: Evaluation of the resident's current clinical and nutritional status; Relevant functional and psychosocial factors; and A review of interventions to maintain oral intake prior to the use of a feeding tube and the resident's response to them. 2. The recommendation to initiate the use of enteral nutrition is based on the results of the comprehensive nutritional assessment, and is consistent with current standards of practice, the resident's advance directives, treatment goals and facility policies. 3. The dietitian, with input from the provider and nurse: Estimates calorie, protein, nutrient and fluid needs; Determines whether the resident's current intake is adequate to meet his or her nutritional needs; Recommends special food formulations; and Calculates fluids to be provided (beyond free fluids in formula).4. Enteral nutrition is ordered by the provider based on the recommendations of the dietitian. If a feeding tube is ordered, the provider and interdisciplinary team document why enteral nutrition is medically necessary.5. Some examples of potential benefits of using a feeding tube include: Addressing malnutrition and dehydration; Promoting wound healing; and/or Allowing a resident to gain strength that may allow him or her to return to oral nutrition. 6.If the resident has a feeding tube placed prior to admission or returning to the facility, the provider and the interdisciplinary team will review the rationale for the placement of the feeding tube, the resident's current clinical and nutritional status, and the treatment goals and wishes of the resident.7.The decision to continue or discontinue the use of the feeding tube is made through collaboration between the interdisciplinary team, the provider and the resident. 8.The dietitian monitors residents who are receiving enteral nutrition, and makes appropriate recommendations for interventions to enhance tolerance and nutritional adequacy of enteral feedings.9. The nursing staff and provider monitor the resident for signs and symptoms of inadequate nutrition, altered hydration, hypo- or hyperglycemia, and altered electrolytes. The nursing staff and provider also monitor the resident for worsening of conditions that place the resident at risk for the above.10. Enteral feedings are scheduled to try to optimize resident independence whenever possible (e.g., at night or during hours that do not interfere with the resident's ability to participate in facility activities).11.Complete orders include:The enteral nutrition product; Delivery site (tip placement);The specific enteral access device (nasogastric, gastric, jejunostomy tube, etc.; Administration method (continuous, bolus, intermittent); Volume and rate of administration; The volume/rate goals and recommendations for advancement toward these; and Instructions for flushing (volume, frequency, timing and 24-hour volume).12.The provider will consider the need for supplemental orders, including: Confirmation of tube placement; Laboratory monitoring;Instructions for EN preparation.Nutritional consultation; Head of bed elevation; Oral care; and Checks for gastric residual volume (GRV). 13. Staff caring for residents with feeding tubes are trained on potential adverse effects of tube feeding, such as: Reduced opportunity for socialization;Diminished sensory experience; and Restriction of movement.14. Staff caring for residents with feeding tubes are trained on how to recognize and report complications associated with the insertion and/or use of a feeding tube, such as:Aspiration;Tube misplacement or migration; Skin breakdown around insertion site; Perforation of the stomach or small intestine leading to peritonitis; Esophageal swelling, strictures, fistulas; and Clogging of the tube.15.Staff caring for residents with feeding tubes are trained on how to recognize and report complications relating to the administration of enteral nutrition products, such as:Nausea, vomiting, diarrhea and abdominal cramping; Inadequate nutrition; Metabolic abnormalities; Interactions between feeding formula and medications; and Aspiration.16. Risk of aspiration is assessed by the nurse and provider and addressed in the individual care plan. Risk of aspiration may be affected by: Diminished level of consciousness; Moderate to severe swallowing difficulties; Improper positioning of the resident during feeding; and Failure to confirm placement of the feeding tube prior to initiating the feeding.17. Residents receiving enteral nutrition are periodically reassessed for the continued appropriateness and necessity of the feeding tube. Results of these assessments are documented, and any changes are made to the care plan. Input from the resident or legal representative is included in the assessment.18. Central supply is responsible for ordering all tube feeding supplies. The staff may use products from a basic formulary until any specialized products can be delivered .

Based on observation, interview and record review, the facility failed to ensure resident care equipment was in safe operating condition for one (R116) of four residents reviewed for environment concerns. Findings include:Multiple observations of R116's room were conducted from 3/16/26 - 3/17/26 which identified the following concerns:On 3/16/26 at 8:28 AM, 9:16 AM, 9:34 AM, 12:24 PM, and 3/17/26 at 7:55 AM and 11:10 AM, R116's footboard appeared to be broken and was tilted sideways and leaned down on the left side). Additionally, the low air mattress electrical panel which was secured to the footboard had a continuous flashing red light for the indicator labelled Power Fail.On 3/17/26 at 11:10 AM, the Maintenance Director (Staff 'A') was asked to observe R116's room. Upon entering the room, Nurse 'E' was standing next to the resident who was seated in a gerichair recliner obtaining vitals. The same flashing red light was observed on the air mattress unit and the footboard remained leaning down on the right side. When asked about the air mattress unit, Staff 'A' pressed a button on the unit and stated sometimes the unit had to be reset and they had power surges at times. When Nurse 'E' was asked if they had identified any concerns with the air mattress unit and footboard, they reported they did not but acknowledged the flashing light and leaning footboard.When asked if anyone had reported any similar concerns about that, Staff 'A' reported there were none. They further reported the facility utilized an electronic reporting system that all staff had access to, but there were none reported about R116's concerns with the air mattress or footboard. When informed of the multiple observations from 3/16 - 3/17/26 of the same flashing indicator and leaning footboard, Staff 'A' reported the expectation is that those should've been identified by staff and reported so they could've addressed it sooner. Staff 'A' proceeded to remove the footboard and reported the screws were broken and needed to be replaced.On 3/17/26 at 12:00 PM, an interview was conducted with the Administrator and Director of Nursing. At that time, they were informed of the observations and interview with staff regarding R116's air mattress unit and footboard. The Administrator reported staff had been in-serviced multiple times about reporting concerns when identified and would have to follow-up.According to the facility's policy titled, Quality of Life - Homelike Environment dated May 2017:Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible .According to the facility's policy titled, 'Maintenance Service dated Revised 2009: .The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.

Based on observation and interview, the facility failed to maintain a sanitary healthcare environment amongst residential common areas including a shared shower room, flooring, training bathroom and rehabilitation equipment, and shared Hoyer lift (lift device used to transfer residents). This deficient practice has potential to affect all residents that utilize these areas and equipment. Findings include: On 4/3/25 at 8:46 AM, entrance into a shared shower room located on the 600 hallway revealed a four sectioned area that contained two shower rooms, one tub room, and one private toileting room. Upon entrance, an odor of sewage was identified. Observation in the tub room revealed an uncovered floor drain, and the sewage smell was greater the closer contact with inspecting the drain. Adhered to the floor were two exposed metal sharp fasteners. The corner baseboard was observed with a broken aqua green colored corner tile lying on the floor surrounded by dry wall debris. The central tub identified as a Carousel Tub was observed storing a bedside commode and a floor mat. The tub drain was dirty with a thick ring of brown colored discoloration. A black and red electric wheelchair was noted in the room with one wheelchair footrest on the chair. The shower bed was on the opposite wall and the blue colored foam padding was cracked exposing the foam interior. Black hairs were observed on the headrest of the pad. The two shower rooms were observed containing used wet towels and washcloths on the floor. The shower room on the right was observed with bulked up wet washcloths lying on a shower chair and black colored hairs were noted on the bench and floor. Puddled water and soap residue was noted in front of the shower chair. Wet towels and washcloths were on lying on the floor within the shower and flooring of the entire room. The shower room to the left was observed having used towels bagged in the corner and wet wash cloths lying on the floor in the shower, outside the shower area, and in the sink. The private toilet room door was observed locked. On 4/3/25 at 8:57 AM, a hoyer lift was observed in front of room [ROOM NUMBER] with a moderate amount of crushed food crumbs on the rolling base of the machine. On 4/3/25 at 9:05 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) were brought down the 600 hallway and acknowledged the Hoyer lift was soiled with crumbled food matter and was not sanitary. The shared shower room on the 600 hallway was opened and the NHA commented that there were soiled towels on the floor and this was not acceptable. The tub room was confirmed by the DON and NHA that it was currently used as a storage room. The DON and NHA were not aware of the open floor drain and identified there was an odor. It was confirmed the shower bed was currently used for residents and noted the padding was damaged, and the black hairs were not sanitary. When questioned why the toilet room was locked, the DON said it should not be locked and access to the key to unlock was outside of the locked shower room. Both agreed having the door locked was not safe or sanitary in case a resident needed to use the facility pre or post their shower and there was no easy way to open the door. On 4/3/25 at 9:35 AM, the Rehabilitation (Rehab) Training Bathroom was observed storing three bottles of opened, partially used peri care spray, one container of multiuse sanitation wipes, and a large spray bottle containing an unidentified blue liquid on the top of the toilet tank. The perimeter of the rehabilitation area was observed storing multi use rehab equipment and the floor was observed dusty, and dirty. The window towards the back right corner of the room stored three potted plants with dead leaves and soil on the windowsill, and on floor next to the rehab equipment. On 4/3/25 at 9:45 AM, The Director of Rehab Services (DRS) E was shown the top of the toilet tank storing bottles of opened, partially used peri care spray and agreed that was not sanitary. DRS E was informed the sanitizing wipes previously observed had since been removed, but the spray bottle containing the blue liquid had remained and DRS E remarked they had no idea what it was. DRS E acknowledged the equipment stored against the perimeter of the room on the floor was currently used by the residents and acknowledged the floors were unkempt and needed a deep clean.

This citation pertains to Intake MI00149648. Based on observation, interview and record review, the facility failed to obtain consent to search personal belongings from one resident (R801) of one resident reviewed for Rights to Privacy and Confidentiality. Findings include: A complaint was filed with the State Agency that alleged the facility was going through residents personal possessions without permission. Clinical record review revealed R801 was admitted to the facility on [DATE] and resided as a long-term resident related to chronic pain to the right hip joint as a result from a complicated history involving multiple surgeries. R801's Brief Interview for Mental Status (BIMS) assessed on 3/24/25 scored 15/15 which indicated no cognitive impairment. On 4/3/25 at 11:00 AM, an interview was conducted in R801's room and inquired why they alleged the facility was going through their personal belongings. R801 said just before Christmas 2024, a friend of theirs was observed by staff talking to them through the window in their room. R801 said the staff notified the Nursing Home Administrator (NHA) and suspected they were hoarding their Oxycodone (narcotic, opioid, used to treat pain) and selling it out their window. R801 said a few days after the situation, they returned from Bingo and another resident of the facility (requested to remain anonymous) said they witnessed the NHA going through R801's belongings and told R801, the NHA tore your stuff up! R801 remarked they knew their belongings were tampered with because the bottom third drawer of their nightstand stored their mail, paperwork, and personal letters. R801 had them in a specific order, and when they went into that drawer, all the paperwork was messed up. R801 then pointed to a free standing safe located against the wall under the window, and said once that incident occurred, they had to purchase a safe and they cannot trust the facility. R801 confirmed they were never approached by the NHA to search their room and were not provided consent to do so. On 4/3/25 at 3:32 PM, an interview with the NHA and the Director of Nursing (DON) acknowledged residents' rooms can be searched when there is suspicion of illegal activity or display of suspicious behaviors. When asked if the facility obtains consent, they confirmed they obtain verbal consent only. When inquired if R801's room was searched, the NHA confirmed they searched their room without consent. When asked why they searched their room, the NHA replied they heard a rumor and would not further comment what the rumor was, but they did in fact go through their belongings. The NHA was also asked if there was suspicion of illegal activity, why were the local authorities not contacted. The NHA had no further comments. Review of the facility policy titled; Residents Rights dated 11/24 documented: .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's rights to: privacy and confidentiality .

This citation pertains to Intake Number(s): MI00150488. Based on observation, interview, and record review, the facility failed to provide assistance with dressing and getting out of bed in a timely manner to one (R806) of three residents reviewed for activities of daily living. Findings include: On 4/3/25 at approximately 9:20 AM, R806 was observed lying in bed wearing a hospital gown. R806 reported she wanted to get dressed and get out of bed. R806 reported she liked to pick out her own outfit from the closet and match her shoes to it. R806 explained she notified the Certified Nursing Assistant (CNA) approximately five minutes prior that she would like to get dressed and get out of bed. On 4/3/25 at 9:55 AM, CNA 'D' was observed exiting R806's room. R806 remained in bed wearing a hospital gown. CNA 'D' reported he changed R806's brief and put pants on her. On 4/3/25 at 10:15 AM, R806 remained in bed wearing a hospital gown. CNA 'D' brought a mechanical lift into R806's room at that time. On 4/3/25 at approximately 10:20 AM, R806 remained in bed wearing a hospital gown. R806 seemed slightly confused and reported she was waiting for staff to clean her wheelchair and then they would assist her out of bed. A wheelchair was observed in R806's room at that time. At 10:25 AM, an interview was conducted with CNA 'F' who reported he planned to get R806 dressed and out of bed, but needed help from another CNA and the one assigned to that unit was busy with another resident. On 4/3/25, at 11:00 AM, approximately one hour and 45 minutes after R806 initially asked to get out of bed, R806 was observed up in her wheelchair, dressed, and in the activity room. A review of R806's clinical record revealed R806 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: vascular dementia. A review of a Minimum Data Set (MDS) assessment dated [DATE], R806 had moderately impaired cognition, no behaviors, and was dependent on staff for upper body dressing and transfers. A review of R806's active care plans revealed R806 required assistance with dressing and required a mechanical lift with assistance of two people for transfers. On 4/3/25 at 2:30 PM, an interview was conducted with the Director of Nursing (DON). When queried about staffing on R806's unit, the DON reported there were typically two CNAs assigned to that unit giving each CNA approximately 10 residents to care for. When queried about who was permitted to assist with resident care, including mechanical lift transfers, the DON reported the CNAs and nurses, including any nurse managers, could assist. The above observations of R806 waiting approximately one hour and 45 minutes to be dressed and transferred to the wheelchair was discussed with the DON. The DON reported that was a long time to wait if the resident requested to get up and the CNA could have requested assistance from the nurse, unit manager, or DON.

This citation pertains to Intake Number(s): MI00149894. Based on observation, interview, and record review, the facility failed to promptly identify a new skin impairment and implement interventions to prevent reoccurrence for one (R806) of two residents reviewed for pressure ulcers. Findings include: On 4/3/25 at approximately 9:20 AM, R806 was observed lying in bed. An indwelling urinary catheter drainage bag was observed attached to the side of the bed. R806 reported she was waiting to get assistance with getting dressed and getting out of bed. A review of R806's clinical record revealed R806 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: vascular dementia. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R806 had moderately impaired cognition, no behaviors, required substantial/maximal assistance for rolling left and right, had an indwelling catheter, was at risk of developing pressure ulcers, and did not have any pressure ulcers or other skin impairments. A review of R806's Physician's Orders revealed an order dated 3/27/25 for Wound care right lateral thigh .apply betadine, leave open to air q (every) shift . On 4/3/25 at 9:55 AM, CNA 'D' pulled down R806's right pant leg to expose the right lateral (outside) thigh. A flat black area that appeared to be approximately the size of a dime was observed. On the top of R806's thigh an adhesive dressing was observed anchoring the urinary catheter tubing to her leg. When queried about how she got the wound on the outside of her thigh, R806 said, I have a catheter and they stuck that on there with glue. A review of R806's progress notes revealed the a Nursing/Clinical note dated 3/20/25 that read, The afternoon aide informed writer that there was a change in skin on resident. Assessed resident and came across a skin tear on the side of the right thigh . On 4/3/25 at 1:30 PM, all incident reports with associated investigations for R806 since March 2025 were requested from the Administrator and Director of Nursing (DON). A review of an incident report for R806 dated 3/20/25 revealed, While resident was being changed, daughter and aide observed a skin tear on the side of the right thigh .Resident unable to give description . In addition, the facility provided a pain assessment dated [DATE] and a copy of the progress note mentioned above. A review of R806's Treatment Administration Record (TAR) for March 2025 revealed an order for Body audit - daily every day shift for skin observation 0-no skin breakdown, 1-Previously identified wound/breakdown, 2-Newly identified wound/breakdown - describe in progress note. On 3/19/25, 1 was documented which indicated R806 had a previously identified skin impairment. On 3/20/25, 2 was documented which indicated R806 had a newly identified skin impairment. A review of a Wound Evaluation dated 3/21/25 revealed R806 had an in-house acquired blister (a small pocket of body fluid within the upper layers of the skin) to the right lateral thigh that measured 1.16 centimeters (cm) in length and 0.78 cm in width. No further description of the wound was documented. The photo taken at the time of the evaluation showed a irregular shaped small black area. It was not documented that a medical provider was notified. It should be noted that the wound in the photo appeared flat and did not appear raised and fluid filled). A review of a Wound Evaluation dated 3/27/25 revealed R806 had an in-house acquired blister to the right lateral thigh that measured 1.86 cm in length and 1.31 cm in width. The photo taken at the time of the evaluation showed a flat black area that did not resemble a fluid filled pocket (blister). On 4/3/25 at 1:54 PM, an interview was conducted with the wound nurse, Registered Nurse (RN) 'A'. When queried about the facility's process when a new skin impairment was identified, RN 'A' reported he was notified by the nurse. RN 'A' assessed all wounds and the Nurse Practitioner (NP) (either the facility's NP or the wound clinic's NP) would diagnose the wound and ensure the correct treatment was in place. When queried about R806's skin impairment to the lateral right thigh, RN 'A' reported he first assessed the wound on 3/21/25 and at that time it was scabbed over. When queried about whether a scab meant it was in a stage of healing, RN 'A' reported it did. When queried about how R806 obtained the wound on the thigh, RN 'A' reported he did not know and stated, Maybe the wheelchair rubbed on it but said he only assessed the wounds and did not determine the cause. On 4/3/25 at 2:30 PM, an interview was conducted with the DON. When queried about what was done to determine the cause of the skin impairment to R806's right lateral thigh, the DON reported she did not know, but that it was possibly caused from friction and rubbing or maybe the wheelchair or the (mechanical lift). When queried about what was implemented to prevent further occurrences of the same kind, the DON stated, You can't prevent friction from happening. When queried about whether the wound was identified timely when it was first identified as a black scabbed area, the DON reported she felt it was identified timely because she was notified on 3/20/25 and it was assessed on 3/21/25 and it likely scabbed in that time frame. A review of a facility policy titled, Skin Management Guidelines . dated 11/2024, revealed, in part, the following: .Inspect the skin on a daily basis when performing or assisting with personal care or ADLs .Review the interventions and strategies for effectiveness on an ongoing basis .

This citation pertains to Intake MI00149894 Based on observation, interview and record review, the facility failed to prevent pressure ulcer formation and ensure accurate skin assessments for one (R807) of two residents reviewed for pressure ulcers resulting in R807 developing a Deep Tissue Injury (DTI - persistent non-blanchable deep red, maroon or purple discoloration) to the left medial (inside) heel . Findings include: On 4/3/25 at 11:23 AM, R807 was observed sitting in a wheelchair in the therapy room. At that time, R807 walked with a four-wheeled-walker from the therapy room to their room with a Physical Therapist walking behind with their wheelchair. R807 was observed walking at a brisk pace. R807 explained their heel felt better since they had put a dressing on it. R807 was observed wearing gripper socks and their left heel had a dressing under the sock. After sitting in a recliner in their room, R807 was asked about the wound on their heel. R807 explained the facility told them they developed their wound because they were rubbing their heel on the bed, but they did not remember doing that. A pair of foam boots were observed laying in another chair in the room, R807 was asked if the staff put the foam boots on them when they were in bed. R807 explained they did now. When asked if they put them on before there was a wound, R807 said no. R807 was asked if they could turn (or reposition) themselves. R807 explained it was very difficult. R807 was asked if staff came in and turned them routinely when they were in bed. R807 explained only if they asked to be turned would the staff turn them, but at night they could not get anyone to come into their room when they put the light on. Review of the clinical record revealed R807 was admitted into the facility on [DATE] with diagnoses that included: aftercare following joint replacement surgery, macular degeneration and rotator cuff tear or rupture of right shoulder. According to the Minimum Data Set (MDS) assessment dated [DATE], R807 was cognitively intact and was dependent on staff for activities of daily living (ADL's). Review of R807's ADL care plan revealed interventions revised 3/5/25 that read, BED MOBILITY: I require assistance by (ext {extensive} x 1) staff to turn and reposition in bed. Review of R807's skin integrity care plan revealed an intervention initiated 3/4/25 that read, . Prqafo [sic] (Pressure Relief Ankle Foot Orthosis) boots WIB (while in bed) as tolerated . Turn and reposition q2h (every two hours). Review of a Nursing Assessment Admission/Readmission for R807 dated 3/4/25 revealed no documentation of any issue with R807's left heel in Section K. Skin. Review of R807's progress notes revealed a nursing note dated 3/4/25 at 2:54 PM read in part, 2nd skin assessment completed . Heels intact . Review of Braden Scale for Predicting Pressure Sore Risk assessments for R807 revealed: 3/4/25 scored 15, indicating AT RISK 15-18 3/12/25 scored 17 3/20/25 scored 20, indicating above the risk scale 3/26/25 scored 19 Review of R807's 30 day Look Back for Reposition every 2 hours when in bed/chair revealed no documentation on the midnight shift on: 3/5/25, 3/8/25, 3/9/25, 3/12/25, 3/20/25, 3/25/25, 3/26/25, 3/28/25, and 3/31/25. On 3/19/25 the documentation was marked No at 12:14 AM. Review of a late entry Wound Practitioner Progress note for R807 dated 3/20/25 at 1:48 PM read in part, .was found today to have a deep tissue injury to the left heel with reports of heel pain. Staff report that (they) often refuses to wear (their) heel boots . 4.4cm (centimeters) x 3.7cm x 0.1cm . Purple - 100% . Boggy . On 4/3/25 at 2:01 PM, Registered Nurse (RN) A, who served as the Wound Care Nurse, was interviewed and asked how R807 acquired a DTI on their left heel. RN A explained R807 might have been rubbing their foot on the bed when they were lying on it. RN A was asked how likely it would be that R807 would be raising and lowering their knee to rub that foot as it was on the same side as their hip replacement they were admitted for . RN A explained that was not likely, but as R807 was always lying on their right side, the medial aspect of the left heel would be against the mattress, and had been told R807 did not like to wear their foam boots. RN A was asked why there was no documentation of R807 refusing to wear foam boots until after the DTI was acquired. RN A had no answer. Review of R807's March 2025 Treatment Administration Record revealed an order with a start date of 3/7/25 for, Body audit - daily every day shift for Skin observation 0-No skin breakdown, 1-Previously identified wound/breakdown 2-Newly identified wound/breakdown- describe in progress note. The body audit was marked as 1 every day except on 3/19/25 when a second body audit on the same day was marked as 2. The associated progress note dated 3/19/25 at 1:49 PM documented on a sacral wound R807 was admitted with. Review of R807's assessments revealed a Skilled Daily: Medically Complex form. There was a section of the form for documentation of skin, .B. Skin . 6. Skin items noted: (Check all that apply) 1. Surgical 2. Pressure 3. Other 4. None; 6a. Describe skin conditions; 6b. Are treatments or daily monitoring needed related to wounds? 1. Yes 2. No . In the 30 days R807 had been in the facility the daily assessment form had only been completed 10 times. Of the 10 assessments completed, eight documented 4. None for skin items noted and five of the 10 assessments marked 2. No for treatments or daily monitoring needed. It should be noted R807 was admitted with a surgical wound and a pressure injury to the sacrum, both had daily wound treatments. On 4/3/25 at 2:44 PM, the Director of Nursing (DON) was interviewed and asked how R807 acquired the DTI to their left heel. The DON explained it was possible the DTI was present on admission. The DON was asked if it had been present on admission why was there no documentation on it for over two weeks after R807's admission. The DON explained it might not have been noticed until it was a blister. When asked if the nurses should have noticed a discoloration or a boggy heel in their daily body audit, the DON had no answer. The DON was asked how often the Skilled Daily: Medically Complex assessment should be completed. The DON explained it should be done daily. When informed of 20 days with no assessment, the DON explained she was more concerned if the skin assessments were accurate. When informed of the mostly inaccurate skin assessments of the completed Skilled Daily assessments, the DON had no answer. The DON was asked why there was no documentation of R807 refusing the foam heel boots until after acquiring the left heel DTI. The DON explained she had talked to R807 who told her they did not like the boots. The DON was asked if it should be documented if a resident did not like to wear the boots, or took them off. The DON agreed it should be documented. Review of a facility policy titled, Skin Management Guidelines Prevention of Pressure Ulcers/Injuries revised 1/2023 read in part, .Skin is assessed on admission to the facility and at least weekly to identify alterations in skin, and any wound assessment should be documented in the medical record . 3. Inspect the skin on a daily basis when performing or assisting with personal care or ADLs. a. Identify any signs of developing pressure injuries (i.e., nonblanchable erythema) . b. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.) . e. Reposition resident as indicated on the care plan .

Based on observation, interview, and record review, the facility failed to ensure a clean, comfortable, homelike environment for for five residents, (R#'s 105, 46, 16, 17, 58, 84, and 30) of five residents reviewed for a homelike environment, and for 11 residents (who wished to remain anonymous) from the group meeting, resulting in verbalized complaints regarding the environment, housekeeping, and laundry services. Findings include: On 1/7/25 at 9:40 AM, the tube feeding pole in room [ROOM NUMBER] was observed to have dried up tube feeding formula staining the length of the pole and on the braces holding the wheels. On 1/7/25 at 9:55 AM the wall behind R16's bed was observed with a large area of missing paint and numerous long and deep gouges in the drywall. On 1/7/25 at 10:05 AM, room [ROOM NUMBER]-W (bed at the window side of room) was observed to have dirty clothing, crumbs, empty food and beverage packaging, food and paper debris, and empty pistachio shells strewn about the floor. It was further observed a large, five pound tub of raw honey with sticky, soiled debris on the jar and lid of the jar. On 1/7/25 at 10:28 AM an interview with R105 was conducted regarding housekeeping and said sometimes they services was okay and sometimes it wasn't. They said often times the floors needed to be swept and mopped and it didn't get done. On 1/7/25 at 10:31 AM, R46's floor very soiled with what appeared to be sticky food substances on the left side of the bed. R46 said the facility frequently provided no housekeeping services on the weekends. They were asked the last time the floor had been swept and mopped and said it had been a few days. On 1/7/25 at 10:36 AM, R58's room was observed to have three open translucent garbage bags on the floor. Two bags were observed to contain linens (unclear if clean or dirty), and one bag appeared to have trash contained in it. On 1/7/25 at 10:40 AM, R17 was observed up in their wheelchair. There were no linens on the bed and multiple towels and a gown were observed to be tossed under the bed. On 1/7/25 at 11:07 AM, R84 said the facility had a difficult time providing clean linens on the nights and weekends. They further reported there were no housekeeping staff on the weekends. On 1/8/25 at 2:29 PM, and 1/9/24 at 8:16 AM, room [ROOM NUMBER]'s bathroom was observed to contain a bedside commode with multiple articles of clothing not stored in a bag piled on top of it. On 1/9/24 at 8:10 AM, room [ROOM NUMBER]'s floor was observed to be littered with paper and food/crumb debris. The bathroom floor had a black sticky substance with crumbs and paper debris sticking to the floor. In the corner of the bathroom an open translucent garbage bag was observed on the floor with clothing spilling from the top of the bag. On 1/9/24 at 8:14 AM, room [ROOM NUMBER]'s bathroom floor was observed with four open translucent trash bags containing a mix of clothing and linens. On 1/9/24 at 8:16 AM, room [ROOM NUMBER]'s bathroom was observed with wadded up clothing not contained in a bag piled in the seat of a wheelchair. Resident Council On 1/8/25 at 11:00 AM, a Resident Council meeting was conducted with 11 residents who requested to remain anonymous. During the meeting, the residents who were cognitively intact, were asked questions regarding care and life at the facility. The residents expressed numerous concerns about the facility's failure to keep a clean, comfortable and homelike environment. One resident noted that they had concerns regarding linen and towels. The resident noted there have been times when their linen is wet, and they ask staff to change it. Staff will tell them that they do not have any and will place several towels over the wet linen. Another resident reported the same concerns. They noted that they believe that some of the staff hoard linen and makes it difficult for other staff to find proper linen. Another resident noted that staff often try to obtain linen but often do not have keys to unlock them from storage. Further concerns centered around ensuring housekeeping was routinely done. One resident reported that housekeeping was very limited over the weekends and often their room was not properly cleaned. Another resident noted that often housekeeping is not timely picking up garbage off the floor, leaving pill cups on their bedside tables and leaving dirty used tissues in residents' rooms. A third concern centered around laundry. The residents reported that in the past the facility left bins in the residents' bathrooms. Dirty laundry would be placed in the bins and staff would pick up laundry from the bins and they believed that system worked best. Another resident stated that in October 2024 the facility changed the way dirty clothes were taken down to the laundry room They noted that staff now pick up dirty laundry, put them in plastic bags and then it is sent to laundry. One resident explained that they did not believe the bags are labeled with their names or room number and they often do not get their clothes back. Another resident had a concern that staff often mixed dirty linen with dirty clothes and they thought that was an infection control concern. A third resident stated that there was only one person who was doing laundry and that made things difficult to get their clean laundry back timely. R30 On 1/7/25 at approximately 10:30 AM, R30 was observed sitting in their room. The resident was alert but had difficulty answering all questions asked. A piece of paper was observed on the closet door that noted their family was responsible for doing the resident's laundry. A review of R30's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included type II diabetes, Encephalopathy and dementia. The resident's daughter was noted to be their active DPOA (durable power of attorney). On 1/7/25 at approximately 12:51 PM a phone interview was conducted with the resident's DPOA. They reported that many times the resident's clothes go missing and they believe staff is sending their clothes to the laundry. On 1/7/25 at approximately 1:45 PM, Laundry Staff (LS) I was observed returning laundry to R30's room. When asked why they were bringing back clothes as there was a note in the resident's room that indicated the resident's family was to do their laundry, LS I stated that things have been very difficult for them and other staff since the facility changed the way laundry was to be removed form residents' rooms. On 1/9/25 at approximately 9:03 AM, an interview was conducted with the Administrator. The concerns brought up at the Resident Council meeting and concerns pertaining to R30 were discussed. The Administrator reported that they were aware of the concerns regarding linen and noted that staff had been educated to not hoard linen. They also noted that change in laundry was done with an effort to try to get clothes back to residents timely. 34275 38271 On 01/07/25 at approximately 9:52 a.m., During the environmental rounds, a review of the facility was conducted with Maintenance Director R (MD R) and the following was observed: At approximately 10:03 a.m., room [ROOM NUMBER] had a nebulizer respiratory machine plugged into an standard extension cord. MD R was queried regarding the medical device being plugged into the extension cord and they reported that was not allowed and that the nebulizer should be plugged into an outlet. At approximately 10:15 a.m., room [ROOM NUMBER]-D had large gouges in the wall of their room consisting of approximately three feet up and down. MD R was queried regarding the gouges and reported that they had not been made aware of them. MD R was asked what the process was for notifying maintenance staff for needed repairs and they indicated the facility has a reporting system called TELS (a system used to communicate work order with maintenance) that staff can use to create a work order that notify's maintenance of needed repairs. MD R was asked if any work orders were in TELS for the drywall repair and they indicated that none were made. At approximately 3:03 p.m., an inspection of the facility laundry room was conducted and the following was observed: Collected-layered dust was observed behind the washing machines and the Clean linen racks were observed in the dirty washing section with the flaps up exposing the clean linens to potential contaminants in the room. A facility document titled Quality of life: Homelike Environment was reviewed and revealed the following: Policy Statement: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible .

Based on observation, interview, and record review, the facility failed to ensure medication were administered and documented per professional standards for two residents, (R#'s 47 and 104) of five residents reviewed for professional standards with medication administration and documentation resulting in verbalized complaints of not receiving as needed pain medications on time and inaccurate medical record keeping. Findings include: R47 On 1/7/25 at 10:47 AM, an interview was conducted with R47. They said they did not believe the nursing staff were accurately recording the times they received their as needed narcotic pain medication resulting in them experiencing a delay of receiving their next as needed doses. On 1/8/25 at 2:23 PM, a review of R47's clinical record revealed they admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses that included: heart failure, diabetes, and chronic kidney disease. R47's most recently completed Minimum Data Set assessment revealed R47 had intact cognition. A review of R47's physician's orders was conducted and revealed an order for oxycodone 5 milligrams, give two tablets every six hours as needed. A review of R47's CONTROLLED SUBSTANCE RECORD (a form used to document the proof of use and reconciliation of controlled substances) and Medication Administration Record (MAR) was conducted and revealed the following: oxycodone signed out on the CONTROLLED SUBSTANCE RECORD on 1/3/25 by Nurse 'A' at 9AM, no documentation on the MAR the medication had been given. oxycodone signed out on the CONTROLLED SUBSTANCE RECORD on 1/5/25 by Nurse 'J' at 5:30 AM, no documentation on the MAR the medication had been given. oxycodone signed out on the CONTROLLED SUBSTANCE RECORD on 1/5/25 by Nurse 'A' at 1 PM, no documentation on the MAR the medication had been given. oxycodone signed out on the CONTROLLED SUBSTANCE RECORD on 1/5/25 by Nurse 'A' at 7 PM, no documentation on the MAR the medication had been given. oxycodone signed out on the CONTROLLED SUBSTANCE RECORD on 1/6/25 by Nurse 'K' at 6:10 PM, no documentation on the MAR the medication had been given. On 1/8/25 at 1:20 PM, an interview was conducted with Nurse 'A' regarding administration and documentation of R47's oxycodone. They were asked why they did not document the administrations of the medications on the MAR and offered no response, only saying it was, habit to check the CONTROLLED SUBSTANCE RECORDS for the timing and administration of the medication. On 1/8/24 at 1:58 PM, an interview was conducted with the facility's Director of Nursing regarding the documentation of medications on the MAR and said all medications given should be documented at the time they were given on the MAR. A review of a facility provided policy titled, Medication Administration was conducted and read, Medications are administered in a safe and timely manner, and as prescribed .23. 23. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. The date and time the medication was administered; b. The dosage; c. The route of administration; d. The injection site (if applicable); e. Any complaints or symptoms for which the drug was administered; f. Any results achieved and when those results were observed; and g. The signature and title of the person administering the drug . 49083 Resident 104 Clinical record review revealed R104 was admitted to the facility on [DATE] with medical diagnoses including hypertension, heart failure, prostate cancer, thyroid disorder, and renal Insufficiency. A Brief Interview of Mental status (BIMS) score 15/15 indicating R104 was cognitively intact. On 1/8/25, at 10:34 AM, Licensed Practical Nurse (LPN) A was observed administering medications to R104. On 1/8/25 at 11:50 AM, A medication reconciliation record review was attempted of the Medication Administration Record (MAR) and revealed no medications that were observed administered to R104 were documented as given. On 1/8/25 at 1:37 PM, A medication reconciliation record review was attempted of the MAR and revealed no medications that were observed administered to R104 were documented as given. On 1/8/25 at 2:09 PM, A medication reconciliation record review was attempted of the MAR and revealed no medications that were observed for medication administration were documented as given to R104. The Director of Nursing (DON) was informed the medication administration survey could not be completed because LPN A had not documented administration of R104's medications from the morning observation. When questioned when Nursing is to document medication administration, the DON confirmed Nursing documents medications given at the time they are administered. Review of the facilities policy titled; Medication Administration dated 4/2019 documented: .The individual administering the medication initials the resident's EMAR <sic> after giving each medication .

Based on observation, interview, and record review, the facility failed to ensure Hospice services were provided per plan of care for one resident, (R4) of one resident reviewed for Hospice, resulting in R4 not receiving Hospice services per the provisions. Findings include: On 1/7/25 at 10:25 AM and 1:05 PM, R4 was observed in their bed asleep. On 1/8/25 at 11:25 AM, a review of of R4's clinical record revealed they admitted to the facility on [DATE], and most recently readmitted on [DATE] with diagnoses that included: multiple sclerosis, pressure ulcers, osteomyelitis (bone infection, anxiety disorder, dementia, and contractures. R4's most recent Minimum Data Set assessment revealed R4 had moderately impaired cognition and required assistance from staff for activities of daily living. On 1/7/25 at 12:54 PM, continued review of R4's record revealed they signed on for Hospice services on 10/14/24. A review of the Hospice plan of care and orders for the benefit period of 10/14/24 thru 1/11/25 was conducted and indicated R4 was to receive skilled nursing visits twice a week and as needed, and nurse aide visits twice a week and as needed. A review of hospice staff notes revealed their first skilled nursing visit occurred on 10/30/24, two weeks after they signed on for services. Continued review of the notes revealed skilled nursing visits on the following dates: 11/5/24, 11/14/24, 11/20/24, 11/26/24, 12/12/24, 12/13/24, 12/19/24, 12/27/24, and 1/2/25. It was noted the skilled nursing progress notes did not indicate R2 receive the the plan of care skilled nursing visits twice per week. It was further discovered R2 had no documented visits from a Hospice nurse aide. On 1/8/25 at 11:08 AM, an interview was conducted with the facility's Director of Nursing (DON) they were asked who in the facility followed up to ensure the Hospice company was conducting visits per their plan of care and said they did not know if anyone followed up to ensure Hospice staff were completing the visits. They were then asked about the particular Hospice company R4 had signed up with and said they thought R4 was to receive skilled nursing visits one time per week and nurse aide visits twice per week. At that time R4's Hospice plan of care was brought to their attention with the outlined provisions of visits from the nurse and aide being scheduled twice per week. They indicated they would follow-up with the Hospice company for clarification. At 11:21 PM, the DON followed-up and agreed the services had not been provided per plan of care. A review of a facility provided policy titled, Hospice Program was conducted and read, .5. Hospice providers who contract with this facility: a. must have a written agreement with the facility outlining (in detail) the responsibilities of the facility and the hospice agency; and b. are held responsible for meeting the same professional standards and timeliness of service as any contracted individual or agency associated with the facility .12. Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility (including the responsible provider and discipline assigned to specific tasks) in order to maintain the resident's highest practicable physical, mental, and psychosocial well-being .

Based on observation and interview, the facility failed to ensure proper storage of medications for four of four medication carts reviewed for medication storage. Findings include: On 1/8/2024 at 8:52 AM, an observation of the 700-1 Medication Cart was conducted with Licensed Practical Nurse (LPN) B. The following medications were observed throughout the cart unpackaged and without patient identifiers. 1 WHITE ROUND TAB 1 1/4 TAB 1 WHITE OVAL 1 SMALL WHITE ROUND 1/Z 1 ROUND WHITE R/196 1 WHITE ROUND 1 PEACH ROUND EP102 2 OBLONG YELLOW NVR/17 3 PINK OBLONG 894/5 1 PEACH EP102 Insulin Pen (Humalog) observed with no patient identifier, only room [ROOM NUMBER] D written in black marker. On 1/8/2024 at 9:18 AM, an observation of the 600 Medication Cart was conducted with LPN C. The following medications were observed throughout the cart unpackaged and without patient identifiers. 1/2 WHITE TAB 3 PEACH ROUND EP102 1 WHITE ROUND AC41 2 ROUND WHITE EP116 1 OBLONG GREEN 45E1 1 WHITE ROUND 128C 3 YELLOW OBLONG 88H 1 WHITE ROUND G10 1 WHITE ROUND AC41 1 SMALL WHITE ROUND P5 1 ORANGE ROUND B302 1 HEXAGON BLUE 77 2 PINK 30LPIN 1 ORANGE OVAL B85 1 ROUND 196 1 ROUND 61 1 GREEN OBLONG 1 WHITE ROUND P20 On 1/8/25 at 9:18 AM, An observation of the 500 Medication Cart was conducted with LPN A. A total of nine medications were observed throughout the second drawer of the cart unpackaged and without patient identifiers. On 1/8/25 at 1:59 PM, The Director of Nursing (DON) was informed of the medication cart observations and acknowledged medications should not be stored without secured packaging and without patient identifiers. 38271 On 1/07/25 at approximately 10:44 a.m., a Medication Cart located next to room [ROOM NUMBER] was observed unlocked and unattended by any Nursing staff. On 1/7/25 at approximately 10:48 a.m., Nurse S was observed coming down the hall out of a residents room with a vital monitoring machine. Nurse S was queried if the medication cart should be locked and they indicated it should be and was observed locking it. A Review of the facility's policy titled; Storage of Medications dated 4/2019 documented the following: The facility stores all drugs and biological's in a safe, secure, and orderly manner .Drugs are stored in the packaging, containers in which they are received .

Based on observation, interview and record review the facility failed to obtain an assessment and physician's order for self-administration of medications for one (R98) of one resident reviewed for self-administration of medication/treatments. Findings include: On 1/7/25 at approximately 10:20 AM, R98 was observed lying in bed. The resident was alert and able to answer questions asked. During the interview, several medical ointments/treatments were observed on the resident's shelf and on their tray table next to their bed. Observations included the following: Hydrocortisone 1%, Antibiotic creams, Icy hot and Bio freeze. When asked about the medications, R98 reported that they can put some of them on themselves or staff can put them on as well. On 1/8/25 at approximately 11:50 AM, R98's room was observed. The medications remained in the room on the resident's shelf. At approximately 12:00 PM, Nurse 'D who was assigned to the hall where R98 resided,entered the room with the Surveyor and noted the medications observed should not be in open areas in the resident's room. Nurse D noted that the resident did not have an order to self-administer medications. Nurse D removed the medications from R98's room and brought them to Unit Manager (UM) E. On 1/8/25 at approximately 12:15 PM, UM E was interviewed regarding the facility protocol on self-administration of medications and/or leaving medications unlocked in a resident's room. UM E reported that residents who want to self-administer medications must have an order. In addition, if they do have an order, the medications should be locked up when not in use. UM E noted that R98 did not have an order to self-administer medications. On 1/8/24 at approximately 2:09 PM, an interview was conducted with the Director of Nursing (DON). The DON was asked as to the facility policy pertaining to self-administration of medication and medication storage, the DON reported that residents must have an order to self-administer medications, and those medications should be locked up when not in use. With respect to R98, the DON noted that they believed the residents significant other was bringing in the medications. A review of R98's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: cerebral infarction, type II diabetes and pain in shoulder and hips.A review of the resident's Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 11/15 (moderately cognitively impaired). The facility policy titled, Self-Administration of Medications was reviewed and documented, Policy. In order to maintain the residents' high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility .Procedures .For those residents who self-administer, the interdisciplinary team verifies the residents ability to self-administer .if the resident demonstrates the ability to safely self-administer medications, a further assessment of the safety of bedside medication storage is conducted .

Based on observation, interview and record review the facility failed to ensure timely and accurate advanced directives information was in place and ensure resident wishes were timely implemented for two R66 and R2 out of four residents reviewed for Advanced Directives. Findings include: R66 On [DATE] at approximately 10:30 AM, R66 was observed lying in bed. The resident was alert, but not able to answer any questions asked. A review of R66's clinical record noted the resident was initially admitted to the facility on [DATE] with diagnoses that included: dementia, chronic kidney disease and anxiety. A review of the resident's Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was severely cognitively impaired. The top of the resident's electronic face sheet indicated the resident was a FULL CODE. Continued review of R66's clinical record noted a form titled, Advance Directives/Medical Treatment Decisions ([DATE]) that documented: This is to acknowledge that I have been informed in writing in a language that I understand of my right and all rules and regulations to make decisions concerning medical care, including the right to issue Advance Directives to be followed should I become incapacitated .I have chosen to formulate and issue the following Advance Directives .Do Not Resuscitate(DNR) (an X was checked in the box). The form was signed by the resident and another signature noted as Legal Representative on [DATE]. On [DATE] at approximately 9:17 AM, an interview was conducted with Social Worker (SW) G. SW G was asked as to the facility protocol regarding Advanced Directives/Code Status. SW G noted that when residents enter the facility, they receive admission paperwork and are asked to determine if they want to be FULL CODE or DNR. They are also asked to provide or complete Advanced Directive Forms. When asked about R66's record that noted the resident was a FULL CODE but had a form completed that noted their wish was DNR, SW G reported that there appeared to be a discrepancy between the two that needed to be corrected. On [DATE] at approximately 10:48 AM, an interview was conducted with Social Worker (SW) F. SW F reported that they were assigned to R66. SW F was asked why R66's wishes to be a DNR was not properly entered in the resident's clinical record. SW F noted that the form Advance Directives/Medical Treatment Decisions completed by the resident and resident's family was not considered effective until a physician discussed the wishes with the resident and/or the resident's responsible party. SW F also reported that they recall talking with the resident who decided they wanted FULL CODE. They further reported that there were notes in the resident's record that indicated they changed their wishes to remain FULL CODE. SW F was asked to provide supporting documents. *It should be noted that no documents indicating the resident's choice to be FULL CODE was provided prior to the end of the survey. Continued review of R66's clinical record was conducted. An attempt to locate SW F's notes regarding the R66's wishes was made. No notes were found. However, a hospital record dated [DATE] documented, in part: I discussed CODE STATUS .patient did not want CPR or intubation .Will continue as DO NOT RESUSCITATE . A Durable Power of Attorney (DPOA)for Health Form (dated [DATE]) was located in the resident's record. A second interview was conducted with SW F. SW F was asked if the resident had been deemed incompetent. SW F reported that they had been but noted the document needed to be placed in the resident's record. SW F was then asked if there had been any discussion with the DPOA (Durable Power Of Attorney) or family member. SW F reported that they had not talked with the family member. R2 On [DATE] at approximately 9:20 AM, R2 was observed lying in bed. The resident was alert and able to answer most questions asked. During the interview the resident reported that they were not happy at the facility and wished they could return to their prior home. A review of R2's clinical record noted the resident was initially admitted to the facility on [DATE] with diagnoses that include: paranoid schizophrenia, post-traumatic stress disorder, and type II diabetes. A review of the resident's Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of ,d+[DATE] (cognitively intact cognition). The resident was noted as a FULL CODE. Continued review of R2's clinical record revealed, in part, the following: [DATE] -Social Services: .Resident's son is activated DPOA as her DPOA paperwork is activated as her DPOA paperwork is not dependent on her ability to make decisions . A document titled; General Durable Power of Attorney was reviewed. The form documented in part: I R2 .appoint my son (name redacted) as my Agent with full power, unless I direct otherwise, to conduct all of my affairs .My Agent is authorized .with respect to any of my property and interests in property as follows .Manage assets .Debts .Deposits .Checks .Borrowing .Collection [NAME] .Securities and investments .Litigation .Insurance .Taxes .Services .Support .Benefits .Vehicles .Powers related .POWERS RELATED TO MY PERSONAL CARE Establish residency .Care contracts .Medical and personal records . *It should be noted the form did not authorize R2's son to make decisions as to code status, medication/treatments etc. Further there were no notes located in the resident's record that indicated discussion were made regarding R2's wishes. Consent forms for the following medications were signed by the R2's son: Xanax ([DATE]), Trazadone ([DATE]), Lexapro ([DATE]). [DATE]: Infection Control Information Consent Forms: No was checked for: Influenza (Flu), Pneumonia, COVID booster, Shingrix (Shingles), Respiratory Syncytial Virus (RSV) the form was signed by R2's son. On [DATE] at approximately 4:55 PM, an interview was conducted with SW F. SW F was asked if R2 had been deemed incompetent. They reported that they had not. When asked why R2's son was making medical decisions for the resident and if end of life wishes had been discussed with R2. SW F noted that R2 had an unusual DPOA that indicated the resident did not have to be deemed incompetent to allow their son to make health care decisions. The DPOA document was reviewed with SW F and a discussion as to the limitations on medical treatment/end of life decisions was discussed. On [DATE] at approximately 9:06 AM, a discussion about R66 and R2 lack of proper DPOA documents was conducted. The Administrator noted the discrepancies. The facility policy titled, Advance Directives/Advance Care Planning was reviewed and documented, in part: Policy Statement: Advance directives will be respected in accordance with state law and facility policy .Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance if he or she chooses to do so .prior to or upon admission of a resident, the Social Service Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advanced directives .information about whether or not the resident has executed an advance directive shall be displayed promptly in the medical record .The Attending Physician will provide information to the resident and legal representative regarding the resident's health status, treatment options .Durable Power of Attorney for Health Care .a document delegating authority to a legal representative to make health decisions in case the individual delegating that authority subsequently become incapacitated .

Based on observation, interview, and record review, the facility failed to assess a resident for alternative or augmentative communication methods to ensure functional communication for one Resident (R91) of one resident reviewed for activities of daily living. Findings include: Review of the Minimum Data Set (MDS) assessment, dated 9/26/24, revealed R91 was admitted to the facility on [DATE], with diagnoses including stroke, aphasia (difficulty speaking), hemiplegia or hemiparesis (paralyzed or weak limbs), seizure disorder, and depression. The sensory assessment revealed R91 had adequate hearing and vision, was non-verbal, and showed they could rarely communicate their needs. The Brief Interview for Mental Status (BIMS) assessment revealed R91 could not participate. The activities of daily living assessment showed R91 could eat independently without set-up. On 1/07/25 at 12:10 p.m., R91 was observed in their bed eating their lunch. R91 pointed angrily at their meal card ticket with their left hand and held it up for the Surveyor to see. R91 next pointed to their plate of food, and then to their mouth and shook their head 'no'. R91 then picked up his small juice drinks and shook his head 'no'. R91 appeared distressed with their face frowning and furrowing of their eyebrows. R91 then pointed to their mouth and opened it. Surveyor observed a small sore on the top of R91's upper mouth, with no obvious teeth. R91 was asked if they had pain and nodded 'yes'. Surveyor was unable to understand what R91 did not like about their food. Surveyor next asked yes and no questions and by a process of elimination learned R91 did not like their modified diet of soft food and thickened liquids and wanted regular food. Surveyor asked R91 if they could write. R91 shook their head 'no' and showed Surveyor their right hand, which was tightly clenched in a fist. When asked if they were right-handed, R91 shook their head, 'yes'. There was no rolled washcloth, palm protector, or splint in their hand. R91 continued to point at their right hand. When asked if they wanted something to open their hand, R91 nodded 'yes'. R91 then pointed to their right foot, which was directly on their mattress, pointed down, and to their closet. A foot brace was observed and R91 pointed to the brace, an ankle foot orthosis, and then pointed to their right foot. R91 was asked if they wanted the brace on their foot, and R91 nodded 'yes'. Surveyor let R91 know they would follow up with staff. On 1/07/25 at approximately 12:15 p.m., R91 appeared distressed during the interview with difficulty communicating their needs and nodded 'yes' they felt frustrated with their communication. R91 then gestured again to Surveyor and Surveyor was unable to understand what they were trying to say. R91 was asked if they wanted a way to better communicate their needs and nodded 'yes'. When asked how this made them feel, R91 showed surveyor a sad face, by showing tears below their eyes and squinting their eyes. Surveyor looked for an augmentative or alternate communication device or a communication board in R91's room to assist them to express their needs and none was found. R91 was asked if they had any device to assist with communication, they shook their head, No. On 1/07/25 at 12:18 p.m., review of R91's meal ticket showed they were on a mechanical soft, thickened liquid diet. On 1/07/25 at approximately 12:20 p.m., R91's aide, Certified Nursing Assistant (CNA) L, was asked how they communicated with R91 and if there was any assistive devices or alternate means of communication, given R91's extensive efforts, extra time, and expressed frustration communicating their needs. CNA L reported there was no communication board and R91 could not write. When asked how they communicated with R91, CNA L responded R91 pointed at objects in their room to communicate some of their needs, although they could not communicate all their needs this way. When asked about R91's concerns, CNA L reported the staff were working on R91's teeth and dentures, and confirmed R91 did not like their soft modified diet, and they had no hand splint, or treatment for their right hand. On 1/07/25 at approximately 12:25 p.m., the Unit Manager, Registered Nurse F, was asked how R91 communicated with staff. RN F reported they communicated by pointing to show what they needed. Surveyor asked RN F if they had any assistive, alternate, or augmentative communication devices to express all their needs. RN F responded, No. RN F was notified about R91 pointing to their mouth and reporting pain, and how they pointed to their right hand being closed and pointed to their meal ticket and expressed being frustrated with their diet. RN F reported would they follow up. RN F reported R91 could read when asked if they could read their meal ticket, since R91 showed it to Surveyor. Surveyor shared R91 reported feeling sad. Review of R91's nursing progress note, dated 1/07/25 at 1:59 p.m., confirmed R91 communication with nursing staff showed they did not want their mechanical soft diet, and complained of pain in their hand and mouth pain. The note also showed R91 was sad and depressed. This confirmed Surveyor communication with R91 and showed potential for improved communication with augmentative communication, sign language (left hand) or other mediums of functional communication. On 1/08/25 at 9:18 a.m., CNA M was asked about R91's communication, and stated R91 should have a communication board in their room, since they did a lot of pointing for their basic needs but wanted to communicate more than they could do by pointing. CNA M reported R91 could point when they needed to use the urinal and could read their activities and their chronicle (newsletter) daily. CNA M stated, We try to guess (at their gestures) and see if we can be accurate .I think speech therapy should work more on (their) speech, as it's not all coming out (their needs). CNA M reported they had not referred R91 to speech therapy. CNA M saw R91 did not have a communication board in their room, and said they would get them one from the facility social worker, who supplied them. On 1/08/25 at 10:11 a.m., the Director of Rehabilitation, Certified Occupational Therapist Assistant (COTA) N, confirmed the social workers in the facility distributed the communication boards. COTA N was asked if speech therapy was addressing communication and facility communication boards, as they had evaluated R91 on 1/07/25 and had only addressed their swallowing. COTA N planned to clarify this. Surveyor requested R91's speech therapy records. Review of R91's speech therapy records confirmed speech therapy had seen R91 for dysphagia only on 1/07/25, not for communication. Communication was added to a revised 1/08/25 speech therapy assessment, with the diagnosis of aphasia (difficulty speaking), dated 1/08/25. Further record review revealed R91 was seen for speech therapy for another episode beginning 5/29/2024, for dysphagia only. Review of R91's Care Plan revealed, Difficulty communicating as evidenced by (R91 was) nonverbal related to aphasia. Able to communicate by using hand gestures and nods head for 'no' and 'yes' answers. Able to follow commands. Date initiated: 11/15/2022. Revision on 3/30/2024 . There were no alternate types of functional communication systems noted, such as communication boards, tablets, computers, sign language or otherwise, given R91 was observed and staff reported they could point for some but not all of their needs. Review of R91's therapy notes requested from the facility revealed speech therapy records only, and no occupational or physical therapy records, which COTA N confirmed. Review of R91's updated speech therapy evaluation, dated 1/08/25 at 3:15 p.m., revealed R91 was evaluated for dysphagia and swallowing therapy on 1/07/25 and on 1/08/24 for functional communication (at 1:54 p.m.), after discussing R91's functional communication with COTA N. On 1/08/25 at 12:04 p.m., Registered Dietician, RD Q, confirmed R91 was unhappy with their modified texture diet after meeting with them. RD Q shared R91 was holding up their beverages cups in the air and slamming them down. RD Q reported they were able to understand R91's likes and dislikes from yes and no questions, showing R91's potential to communicate their needs. Review of R91's activity note, dated 12/23/24, revealed R91 was alert and oriented times 2-3 spheres, was able to make some (not all) of their needs known by nod/shaking their head or gestures. On 1/09/25 at approximately 9:25 a.m., COTA N accompanied Surveyor to R91's room where a laminated, four-page communication board was observed on R91's bulletin board in their room, out of reach. Each page had anywhere from 14 to 20 pictures to communicate both basic and more specific needs, including pain, medications, washing hair, and thirsty and some items which did not relate to R91's care, including suctioning, crutches, intravenous feeding, and oxygen. R91 held the pages up with their left hand and squinted with one eye, held the board up to one side, and pointed at the pictures. R91 was successfully able to point to the pain and the medication pictures, and then pointed to their head. COTA N asked R91 if they wanted pain medication and they nodded 'yes'. R91 then pointed to the shoe picture and their brace in their room and showed COTA N they wanted their foot brace on. COTA N stated they would ask speech therapy to provide a communication board with less boxes, since they had evaluated R91 for use of a more basic communication board on 1/08/25. When COTA N went to reattach the communication board back onto R91's bulletin board in their room on their right (impaired side), R91 waived their arms no and pointed to their bedside table on their left side. COTA N placed the laminated communication board pages on their bedside table, per R91's wishes. R91 pointed to the picture of dentures (mouth) and then picked up their juice cups and slammed them on the bedside table. When asked, R91 showed they did not want them and appeared agitated. Review of R91's Speech therapy evaluation, updated to include functional communication on 1/08/25, showed speech therapy services evaluated and planned to provide training in augmentative communication with a communication board to R91. This showed some functional potential for R91 to use adaptive and or augmentative communication, given this goal by the evaluating speech therapist. Further review of the speech therapy evaluation showed for reading comprehension, R91 was able to comprehend basic sight words or phrases in everyday context 26-49% of the time, participate in communication exchanges without additional assistance 26-49% of the time, participate in multi-modality communication (different modes of communication) to convey simple meaningful messages related to routine daily activities in low-demand situations 26-49% of the time, and participate in short, structured meaningful conversations in low-demand situations 26 to 49% of the time. The assessment showed R91 demonstrated the rehabilitation potential to communicate functionally, and speech therapy would be exploring various alternate means of communication, including the use of a communication board, and other communication training, strategies, and mediums. On 1/09/25 at 12:43 p.m., the Activity Director, Staff H, was asked about R91's communication and reading ability during activities. Staff H confirmed R91 received the daily new chronicles and they believed they could likely read it, or at least some of the pictures. Regarding yes/no questions, Staff H reported R91 seemed to be accurate in their responses, and they could follow one-step directions. On 1/09/25 at approximately 2:00 p.m., the concerns related to R91's functional communication were shared with the Director of Nursing (DON) and the Nursing Home Administrator (NHA). The DON expressed they believed R91 pointing at objects in their room was functional communication, and the NHA had no additional comment. A policy titled, Assistive Devices and Equipment was received, however did not address functional communication or adaptive or augmentative communication devices. The facility was asked for a resident communication policy; none was provided by the end of the survey.

Based on observation, interview, and record review the facility failed to ensure an order for supplemental oxygen for one resident (R17) of one resident reviewed for oxygen. Findings include: On 1/7/25 at 10:40 AM, R17 was observed up in their wheelchair. An oxygen concentrator powered on was observed at the the bedside with the nasal cannula tubing draped over the top of the concentrator. It was observed the concentrator delivery rate was set at two liters. An interview was attempted, however; R17 was did not respond to attempts at verbal communication. During the observation, staff were observed to enter the room and place the nasal cannula delivering oxygen on R17. On 1/7/24 at approximately 12:50 PM and 2:35 PM, R17 was observed up in their wheelchair at the bedside with two liters of oxygen being delivered via nasal cannula from the concentrator. On 1/8/25 at 9:00 AM, 11:04 AM and 1:06 PM, R17 was observed in their bed with two Liters of oxygen being delivered via nasal cannula from the concentrator. On 1/8/25 at 2:18 PM, a review of R17's clinical record revealed they admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses that included: spastic hemiplegic cerebral palsy, adjustment disorder, dysphagia, high blood pressure, and chronic pain. A review of R17's physician's orders was conducted and did not reveal an order for supplemental oxygen On 1/8/25 at 1:58 PM, an interview was conducted with the facility's Director of Nursing and it was indicated there should have been an order for supplemental oxygen. A review of a facility provided policy titled, Oxygen Administration was conducted and read, The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation 1. Verify that there is a physician's order for this procedure .

Based on interview and record review, the facility failed to provide appropriate interventions to prevent triggers for one Resident (R8) of one resident reviewed for trauma-informed care and Post Traumatic Stress Disorder (PTSD). Findings include: Review of R8's Minimum Data Set (MDS) assessment, dated 9/27/24, revealed R8 was admitted to the facility on [DATE], with current diagnoses including heart failure, depression, anxiety, and PTSD (Post Traumatic Stress Disorder). R8 had no physical, verbal, or other behaviors towards others. R8 required supervision or touching assistance with bed mobility and transfers, and minimal assistance for toileting. The depression assessment (PHQ-9) showed a score of 19/27, which revealed moderately severe depression. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 15/15, showing R8 was cognitively intact. On 1/08/25 at 11:24 a.m., R8 was observed in their bariatric hospital bed. R8 reported they were struggling to adjust to being a long-term care resident at the facility, given their younger age, but understood they needed significant care. R8 shared they had a diagnosis of PTSD, however, did not share their triggers or what would help, and was not asked. R8 reported they did not like their current psychological provider and this was why they refused the visits, as the provider reflected what they said back to them and did not offer strategies or solutions for their adjustment concerns. R8 shared they had told social services and nursing staff they wanted another care provider, or for the social worker to assist them, but nothing had changed. R8 stated they still wanted additional social services support in house, and another care outside psych care provider. Review of R8's facility diagnosis list in the Electronic Medical Record (EMR) revealed a diagnosis of PTSD, dated 8/29/24. Review of R8's physician orders revealed they were prescribed a medication for PTSD, Prazosin, on 8/29/24, and remained on this medication as of 1/09/25. Review of R8's physician provider notes revealed they were diagnosed with PTSD, Chronic, and were noted as taking Prazosin for PTSD during January 2025 (noted on 1/03/25), December, 2024, November, 2024, October, 2024, and August, 2024 (initiated 8/28/24). Review of R8's Care Plan, accessed 1/08/25, revealed no Care Plan for trauma-informed care (PTSD), trauma, or for triggers for their PTSD diagnosis. Further review of R8's Insomnia (lack of sleeping well) Care Plan, accessed 1/08/25, dated 10/01/24, revealed a diagnosis of insomnia due to medical condition, PTSD, anxiety, and depression, with interventions, Establish a HS (nighttime) routine with Resident (80), maintain consistent schedule with daily routine, and monitor for factors that may contribute to poor sleeping. There was no mention of any trauma triggers. Review of R8's Behavioral Care Plan, accessed 1/08/25, revealed, At Risk for behavioral symptoms r/t (related to) agitation and hallucinations . This included Complaints regarding room and facility but chooses not to move rooms or have referrals made to other facilities, accusations, calling 911 reporting (they) just wanted someone to come to (their) room, yelling out, making accusatory statements r/t staff not providing care and nobody assisting ADLs (activities of daily living care needs), while multiple staff in (their) room, .falsifying health conditions and exacerbating symptoms, appears fine before staff walks into room; when staff walk into room (R8) states (they) can't breathe, shaking, calls 911 (emergency services number) despite physician recommending (they) go to hospital. Date initiated 2/28/22. Revision on 12/03/24 . PTSD was not noted on the behavioral care plan, or any triggers identified. Review of R8's Treatment Care Plan, accessed 1/08/24, revealed R8 was non-compliant with care and treatments which included declining medications, declining showers, declining nail care, choosing not to move rooms, declining meals, declining supplements, declining use of light, declining to get out of bed, not wanting to be changed when soiled, declining diet downgrade, declining to see dentist, taking off their oxygen, declining therapy evaluations and sessions, declining to get back in bed when asking to be put back, declining to have a wound picture taken, declining to go to scheduled appointments, and declining leg ACE wraps. PTSD was not noted on this Care Plan, or any triggers. Review of R8's psych progress note, dated 8/14/24, revealed, (R8) shared with this social worker that it's hard to accept that (they) will be living in a nursing home for the rest of (their) life . There was no documented follow-up regarding this concern. Review of R8's psychiatry assessment provider note, dated 8/16/24, revealed R8 reported night terrors and only being able to sleep 10 to 20 minutes at time. R8 reported during the assessment they had observed verbal abuse towards a family member and had to take on a role of trying to save their other family member. Review of R8's psych progress note, dated 8/27/24, revealed, (R8) is complaining of Terrible night terrors. (They) said, I try to avoid going to sleep because they are so bad . Review of R8's psychiatry progress note, dated 8/28/24, revealed their night terrors were so bad, they were trying to avoid going to sleep. The note stated, (R8) talks about her 'night terror' and reports being r/t (related to) h/o (history of) trauma, with their (family member) and watching them abuse (family member) in addition to dealing with emotional and verbal abuse (themselves) . Their diagnoses on this report included major depressive disorder, generalized anxiety disorder, and Post Traumatic Stress Disorder (PTSD), chronic. There is a notation in parentheses which said rule out. The report further revealed, Plan: r/t h/o verbal and emotional abuse by (family member) and nightmares. Start Prazosin (a medication for PTSD and nightmares). The report confirmed R8 was a recipient of repetitive traumatic experiences in their family, and the provider deemed medication was needed to address the concerns. Review of R8's psych progress note, dated 9/12/24, revealed R8 reported they were continuing to struggle with their past family trauma, and they were having nightmares. Review of the EMR showed R8 declined five psychological provider visits on: 10/02/24, 10/10/24,10/23/24, 12/04/24, and 12/11/24, with none since 12/11/24. Review of R8's EMR showed they refused their medications on 1/09/25, they refused their soup (which was their preference) on 1/08/25, showing care refusals in the past week. Review of R8's updated Care Plan, accessed 1/09/25 (date of survey exit), revealed, Post Trauma Symptoms as evidenced by resident report R/T (related to) distressing event outside the range of usual human experience. Will demonstrate ability to deal with emotional reactions as evidenced by verbalization of feelings of adjustment to LTC (Long Term Care Facility) setting, comorbidities. Date initiated 1/09/25 . Interventions included identifying coping strategies, talking about at own pace, providing reassurance of safety, and psychology follow-up as needed. No triggers were identified at that time. Review of R8's Social Services notes and assessments in the EMR (reviewed from 8/28/24 through 1/08/25) showed there were no supportive visits provided to address R8's PTSD/trauma, triggers, or interventions. Social Services did not address R8's many behavioral and care rejection concerns, given their refusals to participate with outside psychological services providers and ongoing signs and symptoms of psychosocial distress, behaviors, and adjustment concerns. On 1/08/25 at 1:04 p.m., Social Worker (SW) F was asked about R8's PTSD diagnosis and reviewed the EMR with Surveyor. Surveyor showed SW F their diagnosis list included a diagnosis of PTSD, and the MDS triggered for a PTSD diagnosis. SW F reported they did not know R8 had a PTSD diagnosis. SW F was asked if they had provided any supportive visits to R8 related to their depression and behaviors and responded they had not. SW F acknowledged they were R8's social worker, and this was within their scope of practice to provide supportive visits, and acknowledged after review of R8's Care Plan and documentation they should have provided supportive visits, given R8's provider refusals and their ongoing behaviors and reported distress. SW F acknowledged there was no formal trauma assessment for R8, however trauma was reflected in their assessments, and had been marked No for 12/2024. SW F acknowledged the PTSD diagnosis should have been on R8's Care Plan separately, and stated, We have no way to know triggers and interventions. I am going to see (R8) and see if (they) will accept supportive visits from myself, and if (they) want to try psychology again, and I will update the Care Plan . SW F reported R8 did better working with females (providers and staff) but did not disclose why. On 1/08/25 at 10:20 a.m., the Rehabilitation Director, Certified Occupational Therapist (COTA) N, confirmed R8 was not participating in therapy services in the facility. COTA N reported they would evaluate R8, who would say they would participate, and then there were many refusals. COTA N did not know why they refused so often. Review of R8's Social Services (SS) Assessment, dated 9/27/24, revealed they had a history of trauma, which manifested in nightmares and feelings of guilt, with no triggers identified. On 1/09/25 at 12:11 p.m., Social Worker (SW) G (the other facility social worker) was asked about R8's Care Plan not designating a trauma or PTSD Care Plan, with triggers identified, given the 9/27/24 SS assessment and notation of trauma and identified concerns. Surveyor reviewed there was no progress note regarding a social services follow-up visit, and no SS supportive visits when R8 declined the outside providers. SW G reviewed the EMR and reported they understood the concerns. SW G reported the process when a resident had a PTSD diagnosis was they would ask them about trauma, complete a PTSD Care Plan, and identify triggers and respective interventions. SW G stated they would then provide supportive Social Services visits. SW G reviewed the 9/27/24 SS assessment, which showed a score of 2 concerns identified. SW F reported they would do a separate trauma assessment with a score of 3 concerns of more. Given R8 reported during the assessment they had nightmares and feelings of guilt about past family trauma, SW G was asked if a separate trauma assessment would have been appropriate. SW G declined to respond. On 1/09/25 at 12:48 p.m., Activity Director (AD) H was asked about R8's participation in facility activities. AD H reported R8 would show an interest in their programs and activities, and then would refuse to participate. AD H explained R8 would say, I want to come to the program; let me know when they are going on, and then would refuse to come. Surveyor asked if R8 had a problem sitting up in their wheelchair and confirmed they had never observed or heard of a problem there, and R8 had not reported pain as a reason. AD H was asked if they were aware R8 had a PTSD diagnosis. AD H reported they had not been made aware. When asked if that would change their approach to R8's activities, AD H stated, Yes, if we knew there was a (trauma) trigger it may change how we would provide something (an activity). I will talk with (R8) and we will go over the programs (to encourage their participation) . On 1/09/25 at 3:20 p.m., Surveyor shared the concerns related to R8's PTSD diagnosis, with self-reported adjustment concerns, limited care planning, no identification of triggers, and limited social services follow-up with the Director of Nursing (DON), with the Nursing Home Administrator (NHA) present. The DON reported in August (2024) the psychiatry provider had acknowledged R8 had nightmares which they addressed, and this was not a confirmed diagnosis, and provided documentation of the provider's 8/2024 visit. Surveyor explained on R8's MDS assessment and on their EMR diagnosis page PTSD was a diagnosis, and R8 themselves had confirmed they had a PTSD, however had not been asked triggers so the facility could follow-up. The DON denied a full PTSD diagnosis for R8 and said it had not been fully clarified and handed the surveyor the psych provider's 8/2024 visit. The NHA supported the DON's conclusions. Review of the policy, Trauma Informed and Culturally Competent Care, Level III, reviewed 8/2024, revealed, Purpose: To guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice. To address the needs of trauma survivors by minimizing triggers and/or re-traumatization .Trauma results from events, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being .Trigger is a psychological stimulus that prompts recall of a previous traumatic event, even if the stimulus itself is not traumatic or frightening .Traumatic events which may affect residents during their lifetime include: a. physical, sexual, and emotional abuse .For trauma survivors, the transition to living in an institutional setting (and the associated loss of independence) can trigger profound re-traumatization .Triggers are highly individualized. Some common triggers may include: .j. Experiencing a lack of privacy or confinement in a crowded or small space; k. exposure to loud noises, or bright/flashing lights. l certain sights, such as objects and/or m. sounds, smells, and physical touch .12. Select screening and assessment tools in collaboration with the QAPI (Quality Assurance and Performance Committee) .15. Establish an environment of physical and emotional safety for residents and staff .27. Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate .28. Identify and decrease exposure to triggers that may re-traumatize the resident. 29. Recognize the relationship between past trauma and current health concerns, e.g. substance abuse, eating disorders, anxiety, and depression) .Resident Care Strategies. 31 .Safety. Ensure the residents have a sense of psychological, social, cultural, moral, and physical safety. Practice active listening without judgement .Recognize trust is earned over time. Individuals may not disclose information until a relationship has been established .Empowerment: Ensure the residents choices and preferences are honored and that residents are empowered to be active participants in their care . Review of the policy, Social Services, dated 9/2024, revealed, Our facility provides Social Services to assure each resident can attain or maintain his/her highest practicable physical, mental, or psychosocial well-being. Policy Interpretation and Implementation: The Director of Social Services is a qualified social worker and is responsible for: .b. providing for the social and emotional needs of the resident and family .meeting or assisting with the medically-related social service needs of residents .y. Providing or arranging for mental and psychosocial counseling services, as needed . 5. Not all medically-related social services are provided by a qualified social worker. However, the facility is responsible for ensuring that all residents are provided these services whether by a staff member or through referrals to an outside agency .

Based on observation, interview, and record review the facility failed to ensure a medication error rate less than five percent when three medication errors were identified from a total of 41 opportunities for one resident (R104) of five residents observed during medication administration, resulting in a medication error rate of 7.32%. Findings include: Clinical record review revealed R104 was admitted to the facility on [DATE] with medical diagnoses including hypertension, heart failure, prostate cancer, thyroid disorder, and renal Insufficiency. Brief Interview of Mental Status (BIMS) scored 15/15 indicating R104 was cognitively intact. On 1/8/25, at 10:34 AM, Licensed Practical Nurse (LPN) A was reviewed for medication administration and was observed inaccurately measuring ordered 17 grams MiraLAX (a laxative medication) resulting in R104 receiving a lesser dose than ordered. On 1/8/25 at 4:12 PM, A medication reconciliation was conducted for R104 and revealed LPN A administered Metoprolol (heart failure, hypertension medication) 50 milligrams (mg) and failed to hold the medication based on ordered parameters to not administer if heartrate is less than 60 beats per minute. LPN 'A administered the medication with a documented heartrate of 57 beats per minute. During record review, R104 order for Flonase (allergy relief medication) one spray per each nostril was documented as administered at time of medication observation and the medication was not administered during this observation. On 1/8/25 at 2:16 PM, The Director of Nursing (DON) was informed of the above findings. The DON was shown the measuring cap of bottle of MiraLAX, and acknowledged the medication was not measured correctly resulting in R104 received a lower dose than what was ordered. The DON was informed R104's medication Flonase was not observed as given and documented by LPN A as administered. The DON further acknowledged R104's ordered Metoprolol parameters were not followed and the medication should not have been administered.

This citation pertains to intake #MI00134966 and MI00141309. This citation has two deficient practices. Deficient Practice #1 Based on interviews and record reviews the facility failed to implement an order to obtain daily blood sugar (BS) levels upon admission, failed to identify and report to the physician abnormal lab results, and failed to timely report to the physician a change of condition for one (R104) of one resident reviewed for an expired closed record sample, resulting in a delay of care and services and the prompt intervention to transfer the resident to a higher level of care. Findings include: Review of the medical record revealed R104 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] and expired fifteen days later. R104 was admitted with diagnoses that included: dementia, type 2 diabetes mellitus, long term use of insulin, and hypertension. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 1 (which indicated severely impaired cognition) and required staff assistance for all Activities of Daily Living (ADLs). Review of the hospital documentation provided to the facility upon R104's admission documented the following in part . Problem List . Colitis, Fecal impaction . Medication List . BD SINGLE USE SWABS REGULAR Pads USE ONCE daily . Embrace Lancets Ultra Thin 30G . USE ONCE daily . The swabs are alcohol pads, and the lancets are used to test blood sugar levels daily as documented in the hospital discharge paperwork. Review of the physician orders revealed the resident was receiving Insulin Glargine daily for diabetes mellitus. Further review of the hospital discharge papers documented in part . Additional Insulin Admin (administration) Instructions . Insulin glargine (LANTUS) . Do not mix with other insulins . Notify physician if Blood Glucose less than 70 mg/dl or greater than 349 mg/dl (milligrams per deciliter) . Review of the medical record revealed the facility did not implement the order to utilize the lancets daily to obtain R104's blood sugars until [DATE], two weeks after admitting into the facility. Further review of the medical record revealed no documentation on why the order was not implemented upon admission and implemented two weeks later. Review of the medical record revealed R104 had an unwitnessed fall at the facility on [DATE], that resulted in a transfer to the hospital and documented injury on around his right eye . Area around the right eye cleansed and steri-stripped and revealed a R (right) proximal humerus fracture. Review of the physician orders revealed a Basic Metabolic Profile (BMP) and Complete Blood Count (CBC) ordered on [DATE]. Review of a CMP (Complete Metabolic Profile) and CBC reported to the facility on [DATE] at 1:46 PM, documented multiple abnormal labs as follows: Glucose 352 H (High) - (,d+[DATE] normal range) BUN 41 H (,d+[DATE] normal range) Creatinine 1.35 H (0.60 -1.30 normal range) B/C Ration 30.37 H (8.0 - 25.0 normal range) AST (SGOT) 11 L (Low) (,d+[DATE] normal range) Alkaline Phosphatase 134 H (34 - 104 normal range) GFR Caucasian 51 L (> 60 normal range) RBC 3.75 L (4.10 - 6.20 normal range) Hemoglobin 11.7 L (13.5 - 17.5 normal range) Hematocrit 34.8 L (41XXX,d+[DATE].0 normal range) Neutrophil 78.6 H (40.0 - 74.0 normal range) Lymphocyte 13.1 L (19.0 - 48.0 normal range) Review of the medical record and physician consultations revealed no identification of the review and/or reporting to the physician the abnormal labs. Review of a facility policy titled Lab and Diagnostic Test Results . (Reviewed ,d+[DATE]) documented in part . When test results are reported to the facility, a nurse will first review the results . The nurse will identify the urgency of communicating with the Attending Physician based on physician request, the seriousness of any abnormality . Review of two Orders- Administration Note dated [DATE], both at 5:48 AM documented pt (patient) can not swallow for their morning Tylenol medication and pt failed to swallow for their morning Omeprazole medication. This note was documented by Licensed Practical Nurse (LPN) M. Review of the Medication Administration Record (MAR) and medical record revealed the resident had no documented issues with swallowing noted and had taken all previous medications with no swallowing concerns identified. Review of a Nursing note dated [DATE] (more than an hour later at 6:58 AM) documented in part . pt is lethargic, cannot [NAME] (swallow) and nonverbal through out night shift. Blood sugar went up, call np (nurse practitioner) and ordered 2 unit of lispo. This note was documented by LPN M. Review of the medical record revealed multiple nursing and physician notes that documented the resident to have been alert and able to communicate their basic needs to staff (resident primary language was Russian) until the date of [DATE] at 6:58 AM, when the nurse documented the resident was lethargic and nonverbal through out night shift. This indicated a change of condition from the resident's baseline. Review of the medical record revealed no documentation of the physician or np to have been notified of the identified change of condition with R104 at that time. Further review of the record revealed no documented vitals or assessments throughout the night shift, after the change of condition was identified, with the exception of the 7 AM vitals obtained. Review of a Nursing note dated [DATE] at 8:14 AM, documented in part . pt. observed lethargic at 7:00 am during change of shift report, vital signs Bp (blood pressure) ,d+[DATE], hr (heart rate) 103, resp (respirations) 22 . md (medical doctor) notified . Md order to transfer pt to (hospital name) via 911 . This note was also documented by LPN M. This indicated a delay with informing the physician of the change of condition with R104. The nurse documented on [DATE] at 6:58 AM, of the resident to have been lethargic, unable to swallow and nonverbal throughout night shift. At 5:48 AM, it was documented that the resident could not swallow their morning medications, However the physician was not notified until 7:00 per the nurses note on [DATE] at 8:14 AM. Review of a Nursing note dated [DATE] at 9:23 AM, documented in part . family states patient passed away at 11 am on 10.23.23 . On [DATE] at 3:18 PM, a telephone interview was conducted with LPN M and LPN M was asked if R104 was observed lethargic throughout their shift on [DATE] nightshift (going into the morning of [DATE]) and LPN M confirmed R104 was lethargic throughout the night and when asked why they did not inform the change of condition to the physician, LPN M stated they were informed by the off going nurse that they took report from that R104 was a hospice resident. LPN M stated they were to monitor R104 until they passed and then inform the hospice group. LPN M stated in part . it was not my normal unit. It was the first day I worked with the resident and she (previous nurse) told me he was hospice and my mistake is I didn't look into his chart to see if he was hospice or not . LPN M was asked if they informed the NP of R104's change of condition when they reported the elevated BS level and LPN M stated they had not, they only reported the elevated BS level because they thought R104 was on hospice. LPN M was asked when they realized that R104 was not a hospice resident and LPN M replied, . when I was giving report (to the incoming morning nurse) she said No, he is not hospice (R104's name) is a full code and he has to be monitored and has to go out like a full code . At that time LPN M stated they went to obtain R104's vitals, called the physician and transferred the resident out via 911 was the physician directed. LPN M stated the problem was that they were busy throughout the night and didn't read R104's chart. LPN M stated they know now to check the chart. LPN M denied any of the Administration staff to have followed up with them regarding this incident. On [DATE] at 9:35 AM, the Director of Nursing (DON) was interviewed and asked about the delay in LPN M to have informed a physician of the change of condition identified with R104, which resulted in a delay in transferring the resident to a higher level of care, and the DON stated they reviewed what happened and did not identify any concerns at the time. The DON stated LPN M identified a change of condition at shift change, notified the physician and sent them to the hospital where they died . The DON was asked about LPN M progress note that documented the resident to have been lethargic and nonverbal through out the night shift and unable to swallow their morning medications at 5:48 AM, however the physician to not have been notified until the change of shift when the incoming nurse informed LPN M that R104 was not a hospice resident and had to be monitored and sent to the hospital as a full code resident and the DON stated they were unaware that LPN M thought R104 was a hospice resident and the assessment and notification to the physician regarding R104's change of condition was conducted after the oncoming nurse informed LPN M that R104 was not on hospice. The DON was then asked why the facility failed to implement blood sugar testing upon admission for the resident and the DON stated they reviewed the discharge list from the hospital, but it did not document for the facility to obtain the BS levels. The Lancet order was reviewed with the DON, which documented to be used daily. The DON was asked what lancets are used for and the DON replied to obtain blood sugar levels. The DON was asked why an order to obtain the BS levels was eventually ordered two weeks into R104's stay at the facility and the DON did not have a response. The DON was asked why there was no documentation of the abnormal labs reported to the facility on [DATE] to have been reported to the physician or reviewed by the physician and the DON stated they would look into it and follow back up. No further explanation or documentation was received by the end of the survey. Review of a facility policy titled Change in a Resident's Condition or Status (no date documented on policy) documented in part . Our facility shall promptly notify the . Attending Physician . of changes in the resident's medical/mental condition and/or status . Deficient Practice #2 Based on observations, interviews, and record reviews the facility failed to consistently administer a pain medication (Morphine) timely to manage the pain for one (R64) of one resident reviewed for pain medication administrations, resulting in verbalized frustration and severe pain for the resident. Findings include: On [DATE] at 9:40 AM, R64 was observed lying on their back in bed. When asked if they had concern or issues with their care at the facility, R64 stated sometimes they get their pain medication almost two hours late and it .kills me . R64 explained that they had been diagnosed with Parkinson's disease and when they do not receive their scheduled pain medication on time, their pain is unbearable. R64 stated they have verbalized their concern to multiple facility nurses. Review of the physician orders revealed the following scheduled pain medications: Pregabalin 50 MG (milligram) oral capsule, every eight hours for pain. Tramadol HCl 50 MG tablet by mouth every eight hours for pain. Morphine Sulfate 0.25 ml (milliters) solution by mouth every 4 hours for pain/SOB (shortness of breath). Review of a medication audit documented consistent late administrations of R64's Morphine medication for [DATE] as follows: [DATE] - 9 AM Morphine given at 12:48 PM. [DATE] - 9 AM Morphine given at 10:21 AM. [DATE] - 9 AM Morphine given at 10:44 AM. [DATE] - 5 PM Morphine given at 6:15 PM. [DATE] - 9 AM Morphine given at 2:40 PM. [DATE] - 1 PM Morphine given at 2:41 PM. [DATE] - 1 PM Morphine given at 2:42 PM. [DATE] - 5 PM Morphine given at 6:16 PM. [DATE] - 1 PM Morphine given at 2:29 PM. Review of the medical record revealed no documentation on why the Morphine was administered late. Review of a facility policy titled Medication Administration reviewed ,d+[DATE] documented in part . Medications are administered in a safe and timely manner, and as prescribed . Medications are administered, in accordance with prescriber orders, including any required time frame . Medication administration times are determined by resident need and benefit, not staff convenience . Mediations are administered within one (1) hour of their prescribed time . On [DATE] at 9:22 AM, the Director of Nursing (DON) was interviewed and informed of R64's verbalized complaints of their pain medications consistently being given late and causing the resident to have severe pain. The DON stated they were unaware of the pain medications to have been administered late and could not speak on the behalf of the nurse's that administered the multiple late doses of the pain medication. No further explanation or documentation was provided by the end of the survey.

This citation pertains to intake #'s MI00138332 and MI00135446. Based on observations, interviews and record reviews the facility failed to implement adequate preventive interventions to prevent the development of pressure ulcers, failed to complete accurate skin assessments, failed to ensure implemented preventive interventions were consistently completed and treatment orders were consistently completed as ordered by the physician for two residents, (R's 44 & 27) of three residents reviewed for pressure ulcers, resulting in the development of a facility acquired unstageable pressure ulcer with slough identified to the right heel of R44 within five weeks after being admitted to the facility. Findings include: On 12/12/23 at 9:31 AM, R44 was observed lying on their back in bed. Oxygen was observed being administered via nasal cannula. The resident was snoring and would not awaken with verbal stimuli. Review of the medical record revealed R44 was admitted to the facility on [DATE] with diagnoses that included: acute and chronic combined systolic and diastolic congestive heart failure, pulmonary edema, cardiomegaly, and gout. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition and required staff assistance for all Activities of Daily Living (ADLs). Review of multiple Skilled Daily: Medically Complex assessments completed by the nursing staff revealed the resident was an Extensive Assist of 1 staff for Level of assistance needed to perform Bed Mobility activities (move about in bed, sit to lying, lying to sitting on side of bed). Review of a Skilled Daily: Medically Complex assessment dated [DATE] at 3:02 PM, documented in part . Ability to understand others - Usually . Level of assistance need to eat/consume meals . Limited Assist of 1 staff . Level of assistance needed to perform Bed Mobility activities . Extensive Assist of 1 staff . Level of assistance needed to perform Transfer activities (to and from bed to chair/wheelchair; sit to stand) . Extensive Assist of 2+ staff . Level of assistance needed to ambulate . Extensive Assist of 2+ staff . Skin . None . Describe skin conditions- intact . Review of a Skilled Daily: Medically Complex assessment dated [DATE] at 2:24 PM, documented in part . Level of assistance needed to perform Bed Mobility activities . Extensive Assist of 1 staff . Level of assistance needed to perform Transfer activities . Extensive Assist of 2+ staff . Level of assistance needed to ambulate . Extensive Assist of 2+ staff . Skin . None . Describe skin conditions- intact . Review of a Skilled Daily: Medically Complex assessment dated [DATE] at 2:11 AM, documented in part . Level of assistance needed to perform Bed Mobility activities . Extensive Assist of 1 staff . Level of assistance needed to perform Transfer activities . Extensive Assist of 2+ staff . Level of assistance needed to ambulate . Extensive Assist of 2+ staff . Skin . None . Describe skin conditions- intact . Review of a Nursing note dated 12/11/12 at 10:11 AM, documented in part . Nurse on duty reported that a skin alteration noted on resident's right heel. Writer observed open wound that measured 4.3cm (centimeters) x 4.7cm unstageable pressure ulcer as coded by NP (Nurse Practitioner), wound bed is 80 eschar, 10% slough, and 10% epithelial, resident c/o (complaints of) pain during wound care only, new order for treatment initiated, resident is notified, UM (unit manager) is aware. Heel float boots applied, resident tolerated. Care plan updated . Review of the care plans revealed a care plan titled At risk for alteration in skin integrity related to: impaired mobility, incontinence inability to change brief and transfer self . Initiated on 10/31/23, documented the following intervention in part . Heel float boots WIB (while in bed) . this intervention was implemented on 12/11/23, the day the right heel wound was identified. Further review of the care plan revealed the following interventions implemented prior to the identification of the right heel wound: Pressure redistributing device on bed/chair, Obtain Labs as ordered and report results to physician, Observe skin condition with ADL care daily; report abnormalities, Encourage to reposition as needed; use assistive devices as needed, and Encourage fluids. These interventions were not adequate to prevent a wound development to the resident heels, being that the resident spent most of the day in bed and required staff assistance for bed mobility. Review of the December 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) documented the following order: Body audit every day shift every Tue (Tuesday), Fri (Friday) for Skin observation 0- No skin breakdown, 1-Previously identified wound/breakdown 2-Newly identified wound/breakdown-describe in progress note. The order start date was 11/7/23. The order was signed off with a check mark on 12/1/23, 12/5/23 and 12/8/23, neither documentation contained the indicator numbers as identified in the order. The order was discontinued on 12/11/23. Review of a physician order and the December 2023 MAR and TAR documented the following order: For right heel care: 1. Cleanse with NS (normal saline) then pat dry 2. Apply Therahoney to wound bed 3. Cover with calcium alginate 4. Lightly wrap with Kerlix 5. Secure with tape every day shift for wound care The order had a start date of 12/12/23 at 7 AM and a discontinue date of 12/12/23 at 10:29 AM. The order was not signed as completed for the date of 12/12/23. Further review of the physician orders and December 2023 MAR and TAR documented the following order: For right heel care: 1. Cleanse with NS then pat dry 2. Apply Betadine 3. Leave open to air 4. Every day shift for wound care This order has a start date of 12/13/23 at 7 AM. On 12/13/23 at 1:56 PM, R44 was observed lying on their back in bed. Light blue colored inflated heel boots were observed on a chair next to their bed. The Administrator was observed in the hall and was asked to have Unit Manager (UM) F (the unit manager that was assigned to R44's unit) come to the room. At 1:59 PM, UM arrived to R44's room and was shown and asked if the light blue inflated boots next to R44's bed was supposed to be on the resident's feet while they are in bed and UM G stated they absolutely should be on the resident's feet while in bed. UM F was asked to show R44's right heel for an observation. UM F informed the resident of the observation and removed the sheets revealing the right heel to have a blue skid sock on and direct contact with the resident's mattress. UM F started to remove the blue skid sock and paused half way through due to some resistance cause by the sock to have been stuck to the right heel wound bed. UM F then pulled the rest of the sock off without moistening the sock for an easier removal. The wound was observed to be about a half dollar in size, dark maroon/purple in color and the wound bed could not be visualized. The surrounding skin was observed to be opened. This observation revealed the wound boots were not while in bed as documented in the resident's care plan and the wound was not left open to air as ordered by the physician. On 12/13/23 at 2:11 PM, an interview was conducted with the Director of Nursing (DON) and the DON was informed of the 12/13/23 observation with UM F and was asked how the facility staff failed to identify the right heel wound despite the assessments documented as completed and the DON stated they were unsure of why the assessments were not effective. The DON was asked why adequate preventive interventions were not implemented to prevent the wound on R44's right heel, considering the resident did not ambulate on their own and is in bed most of the day. The DON stated the resident did walk, and the DON was asked if they ever observed R44 ambulating and the DON replied . Personally, I haven't seen him walking . The DON then stated the resident is usually up due to R44's wife insisting that the resident get out of bed. The DON was informed R44 was in bed sleeping for all of the observations made of R44 throughout the survey. An additional review of the December 2023 MAR and TAR on 12/14/23 revealed the right heel treatment order was not signed as completed for the start date of 12/13/23. No further explanation or documentation was received by the end of the survey. 38271 R27 On 12/12/23 at approximately 11:27 a.m., R27 was observed in their room, laying in their bed. R27 was observed to have an air mattress with protective boots on both of their feet. On 12/12/23 at approximately 2:42 p.m., R27 was observed in their room, laying in their bed. R27's left lateral foot dressing was observed with Nurse B. R27's foot dressing for their pressure ulcer was dated 12/10/23 and was observed to have a dried fluid that had seeped through the dressing. Nurse B was queried if they could describe the dressing and they indicated that it was on the left foot and was dated for 12/10/23. On 12/12/23 the medical record for R27 was reviewed and revealed the following: R27 was initially admitted to the facility on [DATE] and had diagnoses including Multiple Sclerosis and Pressure Ulcer of Left Heel-Unstageable. A Physician's order with a start date of 10/25/23 revealed the following: Wound care left lateral foot: 1. Cleanse with dakins solution and pat dry. 2. Apply alginate 3. wrap with kerlix every day shift for wound A review of R27's December 2023 Treatment Administration Record (TAR) revealed R27's dressing was not completed as ordered on 12/11/23. A comparison of R27's wound evaluations on 12/6/23 and 12/13/23 revealed the following: 12/6/23-Length-1.36 cm, Width-0.39 cm, Area-0.46 cm(squared) .12-13-23-Length-0.97 cm, Width-1.7 cm, Area-1.03 cm(squared) .Further review of the two wound evaluations revealed the wound had increased in size. On 12/14/23 at approximately 12:44 p.m., during a conversation with Nurse Manager E (NM E), NM E was queried regarding the dressing change not being done on 12/11/23 and they reported that they were made aware of it on 12/12/23 when Nurse B had informed them of the observation that it was not done and was still dated for 12/10/23. NM E reported that they did the wound dressing with Nurse B on 12/12/23 and made a note that they notified the doctor of the missed wound treatment. Further review of the progress notes and the TAR revealed no documentation that R27 had refused their wound care on 12/11/23.

This citation has two deficient practices. Deficient Practice #1 This citation pertains to intake #MI00141309 Based on observation, interview, and record review the facility failed to ensure proper amount of staff were utilized for bed mobility for one resident (R75), of one resident reviewed for bed mobility, resulting in a fall with multiple fractures requiring a transfer to the emergency room . Findings include: On 12/12/23 at approximately 10:15 AM, R75 was observed in their bed with a sling on their right arm. They were asked about the sling but refused to answer any questions and said, I am tired of being asked about it, I don't want to talk about that!. A review of R75's clinical record revealed they admitted to the facility on [DATE] and readmitted on [DATE]. R75's diagnoses included: cerebrovascular disease, hemiplegia, hemiparesis, seizures, falls, displaced humerus fracture (added 11/28/23), and multiple rib fractures (added 11/28/23). A review of R75's care plan and Kardex (care guide) was conducted and revealed that at the time of the fall, R75 required assistance from two staff members for bed mobility and transferring. On 12/13/23 at 10:51 AM, a review of a progress note dated 11/21/23 was conducted and read, .Aide was giving a patient bed bath when fell . ROM (range of motion) was initiated, patient complained of pain in his right ribs, hoyer lift was used to put the patient back in bed . Continued review of R75's progress notes revealed the following: A note dated 11/24/23 that read, .Resident was went out to hospital .for a CT scan of right side to r/o (rule out) possible fracture . A note dated 11/28/23 that read, Resident arrived back to facility from hospital . A note dated 11/29/23 that read, .readmitted <sic> with primary diagnosis, Fx (fracture) ribs and right humerus fracture . A note dated 11/29/23 from the physician that read, .Re-admit .Admission records revealed the patient was admitted to (hospital name) on 11/24/23-11/28/23 .Chest CT showed mildly displace acute fracture of 6th-9th ribs .Xray of the right upper extremity shows minimally displaced supracondylar fracture of the right distal humeruswith <sic> elbow joint effusion . On 12/13/23 at 11:15 AM, a review of a facility provided incident/accident report for R75's fall on 11/21/23 was conducted and revealed R75 was a two person assist for bed mobility and on 11/21/23 Certified Nurse Aide (CNA) 'Z' was giving R75 a bed bath by themselves and R75 rolled out of the bed sustaining several fractures. ON 12/13/23 at 1:13 PM, an interview was conducted with CNA 'Z' and they indicated they did not check R75's kardex for his bed mobility status and when they performed a bed bath by themselves R75 fell out of the bed. On 12/14/23 at 8:10 AM, an interview was conducted with the facility's Director of Nursing (DON) and they acknowledged the accidental fall when CNA 'Z' was performed R75's bed bath by themselves. A review of a facility provided policy titled, Falls and Fall risk, Managing was conducted and read, .Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . 38271 Deficient Practice #2 Based on observation, interview and record review the facility failed to ensure an environment free from hazards for one resident (R69) of seven residents reviewed for accidents/hazards and multiple other residents residing on the Medbridge 3 hallway. Findings include: On 12/12/23 at approximately 10:06 a.m., R69 observed in their sitting in their wheelchair in therapy room. R69 was observed to have oxygen infusing via their nasal cannula. R69 was observed to have their portable oxygen tank (POT) unsecured in a free standing position next to them without any device preventing it from falling over. On 12/12/13 at approximately 10:11 .am., Physical Therapy Assistant Q (PTA Q) was shown the free standing portable oxygen tank infusing oxygen to R69 and was queried if it should be secured. PTA Q indicated that it should be secured and was observed putting it into an oxygen bag located on the back of R69's wheelchair. On 12/13/23 at approximately 8:35 A.m., Certified Nursing Assistant S (CNA S) was observed coming around the corner in the Medbridge 3 hallway. A free standing portable oxygen tank was observed in the hallway and CNA S then opened a door and put it in a secured room. On 12/13/23 at approximately 8:36 a.m., an used syringe was observed placed on top of an unused medication cart. At that time, Nurse O was shown the unused syringe on top of the cart and queried if it should be left unattended and they indicated that it should not, and was observed throwing it in the sharps box. On 12/14/23 at approximately 10:42 a.m. during a conversation with Nurse Manager E (NM E), NM E was queried if portable oxygen tanks should be secured and not left free standing and they reported they should be secured with a caddie or in a bag. NM E was informed of the syringe observation and they indicated that syringes should be discarded in the sharps box after use and should not be left unattended.

This citation pertains to Intake Number: MI00131453. Based on interviews and record review, the facility failed to protect one (R256) of five residents reviewed for abuse, from sexual abuse by another resident (R255), resulting in psychosocial harm of R256 using the reasonable person concept due to R256 being unable to consent to being touched sexually by R255. Findings include: Review of a Facility Reported Incident (FRI) submitted to the State Agency revealed R255 groped (R256) between the legs and on breasts and it was witnessed by staff. An unannounced, onsite investigation was conducted on 1/12/23 to investigate the allegation. Review of a facility policy titled, Patient Protection Abuse, Neglect, Mistreatment and Misappropriation Prevention revealed, in part, the following: .Sexual Abuse is non-consensual sexual contact of any type .The resident has the right to be free from abuse . Review of R255's clinical record revealed R255 was admitted into the facility on [DATE] and discharged on [DATE] with diagnoses that included: hemiplegia (paralysis of one side of the body), sarcopenia (skeletal muscle disorder), and bipolar disorder. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R255 had intact cognition, rejection of care behaviors, and no wandering behaviors. R255 required extensive physical assistance with bed mobility and transfers and was able to independently propel in a wheelchair in the facility. Review of R255's progress notes revealed the following: A Customer Service progress note dated 8/10/22 documented, On 08/09/2022 Administrator with Admission coordinator as witness, educated this resident concerning the most recent abuse allegation (R255) was involved in. (R255) has been educated to not enter another patients room without their consent and to not touch another resident in any way without their consent. (R255) has also been educated that they should not discuss their genitalia with other residents as this can be an uncomfortable topic for certain individuals. Resident verbally expressed understanding to all of these points. Resident is aware of the on going investigation and spoke to the police on 08/08/2022 concerning the allegation. That progress note was written by the former Administrator, Administrator 'T'. A Customer Service progress note dated 8/22/22 documented, At approximately 12:30 PM, admin (administrator) spoke with resident to remind them of the previous education they received about not touching another resident without consent, not entering another residents room without consent, and not discussing explicit topics with another resident without their consent. (R255) verbalized understanding again and recalled the first conversation as well. Writer informed them that we will remove the 1:1 (one to one) sitter at this time but if there are any further issues they would be addressed. Social work continues to search for alternative placement. A General Progress Note dated 9/5/22 documented, Resident witnessed touching another resident in an inappropriate manner. Administrator was contacted. On-call manager contacted. Administrator contacted the police authority to investigate. No injuries noted on patient and victim. CNA (certified nursing assistant) statement completed and turned into Administrator. Resident transferred out to (hospital) with police escort for further psychiatric evaluation. Review of incident reports for R255 revealed another resident touched R255 inappropriately while (R255) was sleeping on 7/4/22. On 8/9/22, another resident alleged R255 came into their room, touched their leg and talked about (R255)'s penis. At that time, R255 was placed on one to one supervision. On 9/5/22, a CNA witnessed R255 touching R256 inappropriately in the lounge. It was documented that the CNA reported she saw R255 touching R256's breast and rubbing under their gown and proceeded to rub R256's leg. Review of R256's clinical record revealed R256 was admitted into the facility on [DATE] and discharged on [DATE] with diagnoses that included: dementia. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R256 had a severely impaired cognition. Review of R256's progress notes revealed a progress note dated 9/5/22 that read, CNA staff member witnessed another patient touching resident in an inappropriate manner . Review of an investigation of the incident that occurred between R255 and R256 on 9/5/22 revealed the following: An undated, typed summary of the investigation documented, .On Monday, September 5, 2022 at around 9:45 AM (CNA 'C') witnessed (R255) and (R256) in the Internet Cafe together, (CNA 'C') felt like something was not quite right when she left the room and returned to watch through the door. (R255) reached their hands up between (R256's) legs as well as reach up around their breasts. (CNA 'C') immediately told him to stop and pulled (R256) away from .(Local police department) interviewed (R255) who did not deny the incident .recommended a psychological petition to remove .from the facility .Officers agreed to take the case to the prosecutor for review .Both residents are their own responsible parties (it should be noted that according to the clinical record, R256 had severely impaired cognition) .In conclusion, abuse was substantiated as it was witnessed . Review of a signed Witness Statement given by CNA 'C' on 9/5/22 at 1:30 PM, revealed the following documentation: They (R255 and R256) were both in the Internet Cafe together when I walked in. I asked (R255) what are you doing and I said (R256) isn't going to answer any of your questions as (R256) does not have their mind. So leave (R256) alone. I stepped out to check on a call light. then I went to sit at the nursing station and I looked over and I was like what is (R255) doing. (R255) leaned all the way down and pulled up (R256) gown up from their ankles and took their right hand right up (R256)'s gown along their inner left thigh all the way up to their groin area. (R255) took their hand out and (R256) sat up and (R255) went up from behind their gown and started groping their breasts and was starting to go down to their buttocks. This like happened in less than a minute. I yelled out and said what are you doing. (R255) denied doing anything and told me to (explicit language). I removed (R256) immediately and got another CNA to remove (R255) .(R255) seemed uncomfortable but I tried to soothe them and all they said is I need the bathroom . Review of a signed Witness Statement given by Nurse 'X' on 9/5/22 at 12:30 PM revealed the following documentation: A CNA staff member reported to me that (R255) .had touched another resident (R256) in an inappropriate manner .breast and low back, then (R255) proceeded to touch and rub their leg and .proceeded up their leg to their groin area .When questioned again (R255) admitted guilt and said they did touch (R256) .(R256) did not recall incident. On 1/12/23 at 2:35 PM, an interview was conducted with CNA 'C'. When queried about what she witnessed between R255 and R256 on 9/5/22, CNA 'C' reported she was not assigned to either resident that day, but was using the computer in the facility's Internet Cafe. CNA 'C explained R256 was seated in a wheelchair in the cafe and R255 self propelled in a wheelchair into the cafe and tried talking with R255. CNA 'C' reported she told R255 that R256 could not understand them and suggested that they leave (R256) alone. CNA 'C' then left the Internet cafe to answer a call light and sat at the nurses' station where they could see into the Internet Cafe. CNA 'C' explained they saw R255 going up (R256's) leg under their gown, then back and around to their breast. CNA 'C' explained R255's hands were underneath R256's clothing. CNA 'C' entered the cafe, told R255 to stop, and moved R256 away from R255. When queried about how R256 presented at that time, CNA 'C' stated, (R256) was really quiet and appeared shocked, but (R256) is so confused so (R256) did not express anything to me. When queried about whether R255 had ever exhibited any sexual behaviors in the past, CNA 'C reported (R255) would make sexual comments to her (CNA 'C') during care, particularly showers and brief changes. CNA 'C' reported she was unaware of previous sexual behaviors with other residents. On 1/12/23 at 2:45 PM, an interview was conducted with the Administrator, who was the facility's Abuse Coordinator. When queried about the sexual abuse that was witnessed between R255 and R256, the Administrator confirmed the abuse was substantiated. The Administrator reported, R256 did not have any family or legal representative on file (R256 had only been in the facility for three days at the time of the incident) and the Administrator requested to press charges on R256's behalf. The Administrator further reported R255 had since been arrested for criminal sexual conduct.

This citation pertains to Intake Number(s): MI00131690, MI00131961, and MI00131453. Based on observation, interview, and record review, the facility failed to ensure three (R42, R355, and R71) of 10 residents reviewed for accidents, were positioned, transferred, and supervised in a manner consistent with their plan of care, resulting in a fracture to R42's foot, a fracture to R355's left humerus (long bone in the arm that runs from the elbow to the shoulder), and loss of consciousness and vomiting of R71. Findings include: Review of a facility policy titled, Interdisciplinary Care Planning, revised 3/2018, revealed, in part, the following: .Once the care plan is developed, the staff must implement the interventions identified in the care plan . R42 Review of a complaint submitted to the State Agency revealed an allegation that R42 was dropped in the shower which resulted in injury. On 1/12/23 at 8:50 AM, R42 was observed seated in bed with a breakfast tray in front of her. At that time, R42 was interviewed and queried about any concerns regarding her care. R42 reported on 12/21/22, while in the shower room with Certified Nursing Assistant (CNA) 'B' and another CNA, CNA 'B' insisted that she stand. R42 reported she explained to CNA 'B that she could not stand or walk and CNA 'B' dragged me from the shower chair to the bathroom and I have had trouble with my left foot ever since. R42 explained she required a mechanical lift that utilized a body sling and suspended her in the air without standing, in order to transfer but the two aides did not utilize a mechanical lift that day. R42 stated, (CNA 'B') was very rude and did not believe that I could not stand. R42 reported she did not fall, but her left foot hurt since that day. R42 further reported an X-ray was completed which revealed an injury. R42 reported she told the assigned nurse once she was back in her room and discussed her concerns with the Director of Nursing (DON). R42 explained that she had an appointment with a foot doctor that day (1/12/23) and believed it was due to the injury she sustained on 12/21/22. When queried about the level of pain she experienced on a scale of one to 10 with 10 being the worse pain possible, R42 reported her pain was a 10. Review of R42's clinical record revealed R42 was admitted into the facility on [DATE], readmitted on [DATE], and had a transfer to the emergency roiagnom on [DATE] with diagnoses that included: spondylosis (osteoarthritis of the spine) with myelopathy (spinal cord compression) cervical (neck) region, adjustment disorder, low back pain, and type 2 diabetes. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R42 had intact cognition, no behaviors, was totally physically dependent on staff members for transfers and bathing. Review of R42's care plans revealed a care plan initiated on 5/16/19 and revised on 3/11/22 that documented, ADL (activities of daily living) Self care deficit as evidenced by immobility/balance, generalized weakness/debility. Documented interventions included the following that was initiated on 3/22/22: Transfer with mechanical lift with x 2 assist. Review of R42's progress notes revealed the following: A COVID-19 (Coronavirus Disease 2019) Surveillance progress notes dated 12/21/22 at 3:14 PM and 10:42 PM documented R42 was not experiencing nausea, vomiting, or diarrhea. There were no progress notes documented on 12/21/22 that referred to any injury or fall as reported by R42 and the complaint intake. A Skilled Nursing progress note dated 12/25/22 at 1:06 AM documented, .Pt (patient) C/O (complains of) left ankle painful to touch, MD (physician) notified place an order X-ray 2-view and venous doppler to Left lower extremity to Rule out DVT (deep vein thrombosis) . A General Progress Note dated 12/27/22 documented, Patient states on 12.21.22 patient was receiving a shower from 2 cenas. while patient was in shower she fell ill and began experiencing vomiting along with diarrhea. patient was taken out of shower station. in process of trying to rush patient back to room related to illness, patients left foot was bumped in shower station. Patient did not complain of pain during this time. swelling noted to area a few days later. orders for xray and doppler of foot to rule out dvt (deep vein thrombosis/blood clot). findings show fracture to left ankle. CT (computerized tomography) suggested. patient sent to hospital. resulting in ankle fracture and splint to area . A General Progress Note dated 12/27/22 documented, Resident transferred to hospital for transverse fracture (complete fractures that traverse the bone perpendicular to the axis of the bone) through the distal (away from the point of attachment - joint) tibia (shin bone)/medial malleolus (inner ankle) shown on xray . A NP (Nurse Practitioner) Progress Note dated 12/27/22 documented, Chief Complaint - swelling, weakness .Patient seen today, nurse reports swelling to the left lower extremity over 48 hours . On exam pt complains of pain to the foot area .D/w (discussed with) nurse, no report of any recent fall or trauma .12/25 xray showing 'Severe osteopenia. Acute nondisplaced transverse fracture through the distal tibia/medial malleolus. Possible nondisplaced distal fibular shaft fracture. Mild diffuse soft tissue swelling. Consider CT for further evaluation' . Diagnosis 1-acute left foot swelling with left foot pain .Diagnosis 1 Plan - d/w pt and unit manager, obtain CT scan pt has been mostly on bed past 3 days, continue to immobilize left foot until CT scan done, consider immobilizer consider opiate medication for when pain escalates . On 1/12/23 at 10:24 AM, an interview was conducted with CNA 'A' who was assigned to R42 on 12/21/22 during the day shift. When queried about how a resident's transfer status was determined, CNA 'A' reported staff were required to check the resident's Kardex. When queried about what happened with R42 on 12/21/22, CNA 'A' reported R42 originally did not want a shower, but eventually agreed to having one. CNA 'A' explained R42 was transferred from the bed to the shower chair with the assistance of CNA 'B'. When queried about how R42 was transferred, CNA 'A' stated, (CNA 'B') picked (R42) up and set her in the chair. I picked up her legs and he had her arms from behind and we picked her up and set her in the chair. CNA 'A' further reported they took R42 to the shower and proceeded to give a shower when R42 began throwing up and had a bowel movement in the shower. CNA 'A' further explained R42 was washed in the shower chair and then brought back to her room where CNA 'A and CNA 'B' picked R42 up by her arms and legs a second time and placed her in the bed. When queried about whether R42 complained of any pain, CNA 'A' reported R42 reported her leg hurt before, during, and after the shower. On 1/12/23 at 9:47 AM, the Administrator and DON were asked to provide any incident reports and associated investigations for R42. Review of an incident report for R42 revealed the following: Date of Incident: 12/27/22 .Location of incident: Shower Room .Description of incident: Patient received left lower foot xray related to pain and swelling. patient was assisted onto shower chair via 2 people. As aides held upper and lower extremities and placed onto shower chair. Resident began vomiting and diarrhea in shower. upon resident feeling sick, resident was being escorted by cena out of shower when her left foot was bumped while exiting. Cena attempted to rush patient back in room to give care as patient was actively vomiting. It should be noted that the incident occurred on 12/21/22 and there was no incident report completed on that day and no progress note documented in the electronic medical record until six days later on 12/27/22. Review of the facility's investigation revealed the following witness statements: A signed Witness Statement given by R42 on 12/30/22 documented, It was on Dec. (December) 21, (CNA 'A') was assigned to give me a shower. She asked the guy aide to help me. He went to get me up, I said that I don't stand. So they both tried to lift me up by my arms. I told them not to. So the guy aide stood in front of me. He stood me up and put me in the shower chair. I did not feel a crack at that time. My foot hurt a little when he stood me up. When I was in the shower room, I got sick and nauseous. They put me back in my room. They put me back in my room the same way . A signed Witness Statement given by CNA 'A' on 12/27/22 documented, On December 21 I was assigned to (R42) for a shower. Myself and another Cena picked her up from her bed and put her into the shower chair. I had her legs and the other cena held her arms. Her feed did not bump anything at this time. I then took her to the shower. While in the shower the patient starting vomiting and having diarrhea. The only time her foot got bumped was when I turned around in the shower chair and I was washing her up. This was to her left foot. I asked (CNA 'B') to help me in the shower because she started vomiting. Once we got back to the room, we used (brand name mechanical lift) back in bed . A signed Witness Statement given by CNA 'B' on 12/27/22 documented, On December 21 (CNA 'A') was assigned to give (R42) a shower. It was around 9 AM (CNA 'A') asked me to help her get into the shower chair. I held her arms and (CNA 'A') held her feet. I came back to help (CNA 'A') in the shower room because the patient was having diarrhea and vomiting. I remember only cleaning the shower room. I believe I heard her say 'ow!' when she took her out of the shower room. At that time I was at the nurses station looking up her Kardex on how to transfer since she was not my patient I wasn't sure when I was first asked to help. I saw that she was a (brand name mechanical lift) and helped (CNA 'A') put her back in bed via (brand name mechanical lift) this time. On 1/12/23 at 10:45 AM, an interview was conducted with the DON. When queried about whether CNA 'A' and CNA 'B' provided care to R42 on 12/21/22 according to her required plan of care, the DON reported they did not. The DON reported the CNAs should have checked the kardex before attempting to transfer R42. The DON further reported that residents should never be transferred by their arms and legs. The DON explained that both CNA 'A' and CNA 'B' received education on ensuring residents were properly transferred. 39592 R355 Review of a Facility Reported Incident (FRI) dated 11/24/22 read in part, Apparently after therapy Friday afternoon until sometime on Saturday morning at 10:00am, the resident had something happen to her arm . On the morning 11/19 around 10:00 a.m. (R355) nurse noticed significant rectal bleeding, While preparing (R355) to send to the hospital . (R355) was having arm pain . On Friday 11/18 from 12:50-2:00 p.,. (R355) participated fully in physical therapy . On Thursday 11/24 . referral from hospital indicating an x-ray which showed a left proximal humerus fracture . Review of the closed record revealed R355 was admitted into the facility on [DATE] with diagnoses that included: congestive heart failure, encephalopathy and depression. According to the MDS assessment dated [DATE], R355 had moderately impaired cognition and required the extensive assistance of staff for ADL's, including bed mobility. Review of R355's ADL care plan initiated 10/26/22 revealed an intervention that read, Transfer with ext (extensive) x2 (two people) assist with mechanical lift, Ext x2 assist with bed mobility. Further review of the FRI revealed hospital records that read in part, .(R355) was brought to the ED (Emergency Department) for eval (evaluation) of 'GI (gastrointestinal) bleed and left shoulder pain'. She apparently woke up yesterday am with left shoulder, humeral pain with significant bruising. Unsure of mechanism of injury to shoulder . Work up in the ED revealed multiple findings that include left proximal humerus fracture . Acute comminuted and displaced fracture of the proximal humerus, predominantly through the surgical neck. No suspicious osseous lesion to suggest pathologic fracture . Review of CNA documentation for R355 revealed on 11/18/22 at 3:25 PM and on 1/19/22 at 2:20 AM bed mobility was marked as 3 - EXTENSIVE ASSISTANCE and 2 - One person physical assist. On 1/11/23 at 11:03 AM, Registered Nurse (RN) H, R355's day shift nurse on 11/18/22 and 11/19/22, was interviewed by phone and asked about R355's arm. RN H explained R355 had not complained of pain before her shift ended on 11/18/22, 7:00 PM, but R355 did had some rectal bleeding . when she came back on 11/19/22, 7:00 AM, R355 was complaining about left arm pain . R355's was still having rectal bleeding so she called the doctor about the bleeding and the left arm pain . she put that R355 needed an x-ray of her left arm on the hospital transfer form and told EMS (emergency medical services) when they came to take R355 to the hospital. RN H was asked if R355 had told her what happened to her arm RN H explained R355 was confused and saying things that did not make sense. On 1/11/23 at 11:26 AM, Licensed Practical Nurse (LPN) L, R355's night shift nurse, was called and a message was left. On 1/11/23 at 1:42 PM, CNA I was interviewed by phone and asked about R355. CNA I explained he had worked the afternoon shift (2:00 PM-10:00 PM) and the midnight shift (10:00 PM-7:00 AM) . he was changing R355 around 7:00 PM when he noticed a little blood so he called for the nurse. CNA I was asked if he was by himself, and how he turned R355 in the bed to position or change her. CNA I explained he was by himself and used a draw sheet to turn her towards him because she was so small and frail. When asked if he knew R355's bed mobility status, CNA I explained she was an extensive two person. On 1/11/22 at 2:13 PM, the DON was interviewed and asked if a resident's Kardex said they were a 2 person extensive assist, could one CNA use a draw sheet to turn the resident. The DON explained if the Kardex said two person, then there needed to be two people to turn the resident. When asked if it was possible R355's arm could have been broken while being turned by one CNA using a draw sheet, the DON had no answer. On 1/12/23 at 9:46 AM, LPN L was interviewed by phone and asked about R355's arm. LPN L explained he was just walking down the hall to get report when CNA I called to him that he was in the middle of changing R355 and she was bleeding from the rectum . he and RN H went into R355's room . R355 did not complain of any pain . told CNA I to notify him immediately if R355 was bleeding during the night . in the morning, while passing medications, R355 said she was having pain, so he gave her some Tylenol. Review of a facility policy titled, Bed Positioning, undated, read in part, .1. Verify transfer assist needed per Kardex. Obtain additional assistance as indicated . 34275 R71 On 1/10/23 at approximately 10:22 AM, R71 was observed seated in their wheelchair outside of their room with a bedside table in front of them. The resident was alert, but not able to answer most questions asked. A review of R71's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included the following: dementia, adjustment disorder and psychotic disorder. A review of the residents MDS (10/6/22) noted the resident had a BIMS score of 5/15 (severely cognitively impaired) and required extensive one person assist for toileting. Continued review of the resident's clinical record documented, in part, the following: 11/10/2022 General Progress note (1:40PM): .at approximately 1330 patient presented position head on floor body over head near toilet unresponsive for 2 mins.Vomiting 3x, mental status change observed .right eye not reactive or responsive to light, patient was having medium sized hard bm .Patient sent to (name redacted) hospital . Care Plan: Focus: Urinary incontinence related to functional incontinence, impaired mobility (revision 4/6/2022) . Interventions: Provide assistance with toileting (date initiated 3/31/2022). Focus: At risk for falls due to unsteady gait, impaired mobility, dementia and behavioral disturbance (date initiated 3/30/2022) . Interventions: when transferring resident to restroom do not leave unattended (11/10/22) . An Incident/Accident report (I/A) dated 11/10/22 was reviewed and documented, in part: Patient's Name: R71 .Date of Incident 11/10/22 1:30 PM .Location of Incident: Patient's Room .Description of Incident: approximately 1330 patient presented position head on floor body over head near toilet, unresponsive for 2 mins Vomiting 3x mental status change .right eye not reactive to light. Patient was having medium sized hard bm at time of observed on floor .Was patient taken to hospital? Yes .Describe cause of incident, if known: Patient escorted to bathroom by therapy. Patient insisted to be in bathroom by herself. Therapy stepped out for privacy as patient frequently self-transfers to bathroom with out assistance .a few moments later therapy observed patient in laying position with head on floor body over head near toilet .unresponsive for 2 minutes .Corrective Action: neck stabilized with neck collar. Staff able to transfer patient to bed. Upon assessment right eye not reactive to light, along with multiple emesis episodes. 911 called . On 1/12/23 at approximately 9:35 AM, the Director of Nursing (DON) was asked if there were any further documents, including statements that would specify names of staff (therapy etc.) involved in the incident. The DON reported that all documents were attached to the IA and suggested talking with the Therapy Department. On 1/12/23 at approximately 11:10 AM, an interview was conducted with Physically Therapy Manager (PTM) W. PTM W was asked if she was familiar with the incident and who was therapy person noted in the I/A. PTM W reported she recalled the incident and that that the therapy person was Physical Therapy Assistant (PTA). PTM Wfurther reported that R71 had been evaluated to start PT again on 11/8/22 due to a decline in mobility. PTM Wprovide documentation pertaining to the assessment completed on 11/8/22 that documented, in part: has patient fallen in the past? Yes .Does patient feel unsteady when standing? Yes .Does patient worry about falling? Yes . On 1/12/23 at approximately 9:40 AM, PTA J was interviewed about the incident. When asked what occurred, PTA J noted that it was the first day R71 was to start PT. She went to the resident's room and the resident was confused and initially did not want to attend therapy. R71 then stated she would go but needed to go to the bathroom and wanted her privacy. PTA J further stated that she physically did not assist her to the toilet but witnessed that she was on the toilet and then left the room to get her some water and when she returned R71 was on the floor, and she contacted a nurse for assistance. On 1/12/23 at approximately 11:11 AM a second interview was conducted with the DON. Nurse Y was also present during the interview. When asked if R71, given her decline in functioning, history of falls and dementia should have been left alone in the bathroom, the DON reported that she might have given the resident privacy, but would not have left the room and would have remained outside of the bathroom door.

This citation pertains to intake: MI 995. Based on interview and record review the facility failed to prevent the development of an unstageable wound to the right clavicle/shoulder for one (R902) of two residents reviewed for pressure ulcers, resulting in pain and an infection to the wound. Findings include: On 5/23/22 at 10:57 AM, a telephone interview was conducted with the complainant. The complainant stated they had concerns regarding a pressure ulcer that developed on R902's neck. Review of the clinical record revealed R902 was admitted into the facility on [DATE] with a readmitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition and required staff assistance for all Activities of Daily Living (ADLs). Review of a General Progress Note dated 2/11/22 at 6:18 PM, documented in part . Nurse was informed by the Aide that Pt. (patient) had a open wound on the right shoulder. Nursed assessed the pt. to find that the pt. in fact had an open wound on the rt (right) shoulder. Nurse notified family, MD (Medical Doctor) and Unit Manager as well. MD instructed the Nurse to cleanse the area, apply A&D ointment and cover with gauze and ABD pad. Pt. complain <sic> of pain at the time of observation . Review of a daily body audit on the February Treatment Administration Record (TAR) revealed a daily body audits every day shift for skin order. The nurses signed the order every day (with the exception of 2/4/22) as completed. Prior to 2/11/22, the facility nurses failed to identify the skin changes to the resident's right shoulder/clavicle area. Review of a MP (Medical Practitioner) Wound Progress Note dated 2/15/22 at 12:23 PM, documented in part . initial wound assessment for a right clavicle/shoulder ulcer. Approx. onset 2/13/2022. Contributing factors . neck contracture . States she has pain all over during assessment . Location - right shoulder/clavicle . Non pressure wound . Unstageable . Length in cm (centimeters) 0.53. Width in cm 1.58 Depth in cm - UTD (unable to determine) . Granulation color % description - 70% . Slough color % description 30% . During an interview on 5/24/22 at 9:00 AM, the Director of Nursing (DON) confirmed that the wound on R902's neck was indeed a pressure ulcer stating that it was caused by the resident's headphones. Review of R902's medical record picture on the census report, reveals the resident neck contraction to the right side. Review of a care plan titled At risk for alteration in skin integrity related to Contractures . neck was initially implemented on 4/29/2018 and revised on the following dates: 8/12/2019, 6/17/2020, 12/7/20, 7/16/2021 and 3/22/2022 all noting the neck contracture. Further review of the care plan revealed the facility failed to implement an intervention to prevent any skin changes or wound development to the area of the neck contracture. Review of a facility policy titled Skin Management Guidelines (3/2022) documented in part, . Purpose: To describe the process steps required for identification of patients at risk for the development of skin alterations, identify prevention techniques and interventions to assist with the management of pressure injuries and skin alterations . On 5/24/22 at 9:00 AM, the Director of Nursing (DON) was interviewed and asked about the daily audits and where staff are supposed to document any abnormal findings if identified. The DON explained the nurses would check it off on the TAR and document any abnormal findings in the progress notes. When asked how was it that none of the nurses identified any changes to the resident neck/clavicle area until it was already an unstageable wound, the DON stated the nurses possibly didn't remove her pillow to look there. The DON stated the facility implemented a neck brace so that there would no longer be pressure to the right clavicle and shoulder area (this was implemented after the identification of the wound). The DON stated the wound was caused by the resident headphones that she wore all the time. The DON was then asked why the facility didn't pad the headphones or place a barrier to the area of the resident's right side neck contracture and the DON stated the resident was able to tell them if she felt pain or anything to that area. Further review of the medical record revealed the following: A NP Progress Note dated 3/7/22 at 3:54 PM, documented in part . seen today for right clavicular wound, on pt states . RIGT <sic> side is painful because of the wound . she has contracture deformity of the neck . RIGHT neck wound with discharge, yellowish . per sensitivity . pt need for oral abt (antibiotic) and IV (Intravenous) abt: [MEDICATION(S)] oral and [MEDICATION(S)] IV .

This citation pertains to intake(s): MI 995 & MI 952. Based on interview and record review the facility failed to prevent falls for two residents (R's 902 & 905) of three residents reviewed for falls, resulting in a subdural hematoma, subarachnoid hemorrhage, posterior scalp hematoma (R902), and closed displaced fracture of surgical neck of right humerus (R905). Findings include: R902 Review of the clinical record revealed R902 was admitted into the facility on [DATE] with a readmitted [DATE] and diagnoses that included: [CONDITION(S)], contractures of the right and left hands and wrists, and muscle wasting and atrophy. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition and required staff assistance for all Activities of Daily Living (ADLs). Review of a Nursing note dated 12/9/21 at 10:05 AM, documented in part . At approx 9:45 am, the cena (aide) rushed to the . nursing station and informed the nurse that the patient fell from the shower bed. The patient was observed on the floor with blood present. 911 and NP (Nurse Practitioner) notified. The patient BP (Blood Pressure) 161/108, p (pulse) 132, spo (oxygen saturation) 97, t (temperature) 98.4, r (respirations) 20. The patient was crying. The patient was not moved, repositioned or any extremities splinted per 911 recommendation. The family . notified of patients status and that patient is being transferred to (hospital name) . Review of a Nursing note dated 12/9/21 at 10:19 AM, documented in part . The patient has blood coming from head. The patient c/o (complaints of) back pain. The patient did not lose consciousness . Review of a NP (Nurse Practitioner) Progress Note dated 12/9/21 at 11:21 AM, documented in part . seen today in shower room crying and yelling out in pain 10/10 in neck. Pt (patient) seen with EMS (Emergency Medical Services) present, staff reports the pt had witnessed fall hitting her <sic>, no LOC (Loss Of Consciousness). Obvious bleeding from posterior head being wrapped by EMS. Nursing reports INR is 3.5 this am on [MEDICATION(S)] 4mg (milligram) PO (by mouth) QHS (every hour of sleep). She is A&OX3 (alert and oriented times three) and aware she is being transferred to ER (emergency room ) . moderate amount of blood loss . Review of a hospital Imaging Result dated 12/09/21 at 12:28 PM, documented in part . EXAMINATION: CT THORACOLUMBAR SPINE REFORMAT WO CONTRAST, CT HEAD AND CERVICAL SPINE WITHOUT CONTRAST . IMPRESSION . Small left focal tentorial subdural hematoma with largest portion measuring up to 8 mm (millimeters) in thickness . Scattered subarachnoid hemorrhage. Posterior scalp hematoma . Review of a facility Witness Statement dated 12/23/21 at 2:30 PM, with Registered Nurse (RN) A (the nurse that was washing the resident at the time of the fall) documented in part, . I was standing at the top of the shower gurney near her head. The head of the gurney was elevated to approx. 45 degrees . All of a sudden we heard a snap. It all happened so fast. The pad she was laying on was obviously wet. The head of the gurney went down all of a sudden. It was in the upright position and all of a sudden it collapsed. We had it elevated because she had an ear infection. For it to collapse the pin was not inserted appropriately. We did not check the pin or the clips. We didn't even think about checking it. This was my second time using this (shower gurney). I didn't check the pin or clips the first time either. If the pin was in <sic> correct position it's safe to say the head of the gurney would not have collapsed . On 5/23/22 at 1:43 PM, an interview was attempted via telephone with RN A, a message was left but a return phone call was not received by the end of survey. On 5/24/22 at 8:50 AM, the DON was interviewed and asked about the fall with R902 and stated they were in a morning meeting and staff came in to get her to tell her about the fall. They went to the shower room and R902 was on the floor bleeding from the head. When asked how that happened the DON stated in part, . The head part fell out (on the shower gurney), they (facility staff) didn't latch it properly . We were unaware that a new one (shower gurney) was in the facility . The DON continued to explain that the facility ordered two new shower gurneys and they were not the same shower gurneys that the facility had in stock. These were new gurneys that had pins and latches that you could operate on it. When asked, the DON stated the facility did not provide education to their staff regarding how to operate the new shower gurneys because they (administration staff) did not know that it was a different model than the one that they had in the facility. The DON then stated the new shower gurneys were immediately removed from the units. R905 Review of the clinical record revealed R905 was admitted into the facility on [DATE] with diagnoses that included: orthopedic aftercare, fracture of left femur, and history of falling. A MDS assessment dated [DATE] documented Severely impaired cognitive skills for daily decision making and required staff assistance for all ADLs. Review of R905's preadmission referral paperwork provided to the facility dated 1/19/22 at 11:00 AM, documented the following, . Primary Diagnosis: Facture of unspecified part of neck of left femur, initial encounter for closed fracture . Review of a hospital discharge After Visit Summary provided to the facility documented in part, . 1/13/22 9:04 AM, Left Hip Hemiarthroplasty . Fall resulting in femur fracture . Further review of the hospital discharge paperwork revealed a PT (Physical Therapy)/OT (Occupational Therapy) Note dated 1/17/22 at 11:41 AM, that documented in part . Alert, Follows . 1 step commands . Safety Judgement- Impaired; Slow Processing; Low Insight/Safety Awareness . Decreased awareness, Decreased awareness of deficits . Review of a Medical Practitioner Note dated 1/20/22 at 11:41 AM, documented in part . present from (hospital initials) after a fall . work up showed left femoral fx (fracture) s/p (status post) left hip hemiarthroplasty . here for rehab . Review of a General Progress Note dated 2/8/22 at 10:10 AM documented in part, . resident observed on the floor and lay <sic> down on her left side. Resident stated she was trying to transfer from the bed to the wheelchair then she fell . Resident did not use the call light for assistant <sic>. Pt. transferred via mechanical left <sic> to the bed and assistance of three staff. Resident state that she did not hit her head, no C/O pain . neuro check is initiated . Review of a Nursing note dated 2/9/22 at 11:21 AM, documented in part . IDT (Interdisciplinary team) Note s/p (status post) fall 2/8/22 10:00 AM. Resident observed on the floor and lay down on her left side. Resident verbalize she was trying to transfer from the bed to the wheelchair then she fell . Resident did not use the call light for assistant <sic>. Resident transferred via mechanical left <sic> to the bed and assistance of three staff . Intervention Offer to get up after breakfast . Review of a care plan titled At risk for fall due to left femur fx (fracture) . documented an intervention created on 2/9/2022 to offer to assist resident out of bed after breakfast. The resident required a two-person physical assistance for transfers and was assessed to have severely impaired cognition. Staff was already required to offer and assist the resident out of bed in the mornings. This intervention was not an effective intervention. Review of a Nursing note dated 2/15/22 at 8:57 AM, documented in part . Pt (patient) observed on floor after writer heard patient yelling out. Pt observed next to her bed lying on her back. Hoyer lifted backed into bed. Upon assessment writer observed R (right) shoulder looked like it was out of place or possible dislocated. Pt c/o (complaints of) severe pain in R shoulder. Pt is on [MEDICATION(S)] (anticoagulant) . Pt stated she was transferring w/o assistance from her chair to the bed. Dr/NP notified . Review an Incident Report dated 2/15/22 noted the second fall to happen at 9:40 AM. Further review of the Incident Report dated 2/8/22 noted the first fall to happen at 10 AM, noting both falls to have occurred around the same time of the morning. The resident cognition status was documented as severely impaired. The intervention implemented after the first fall offer to assist resident out of bed after breakfast confirmed to be an ineffective intervention. Review of a Nursing note dated 2/15/22 at 9:03 AM, documented in part . Pt sent to ER (emergency room ) visit by 911 no lights/sirens per request of patient . Review of a hospital ED (Emergency Department) After Visit Summary dated 2/15/2022, documented in part . Victim of trauma with multiple injuries, Injury of head, initial encounter, Acute pain of right shoulder, Closed displaced fracture of surgical neck of right humerus . Further review of the At risk for falls due to left femur FX revealed the care plan was modified to At risk for falls due to left femur FX, [CONDITION(S)], hx of falls, resident is noncompliant with asking for assistance revised on 2/18/22, that documented the following interventions: Derma with wings (implemented 2/15/22), Bed in low position (implemented on 2/17/22) and Low bed (implemented on 2/17/22). All of these interventions were implemented after the resident's second fall that resulted in injury while the resident was attempting to transfer from their bed. On 5/24/22 at 2:53 PM, the DON and Administrator was interviewed and asked why the following interventions for the bed in low position, low bed and derma with wings were not implemented for the resident initially after being admitted into the facility knowing the resident transferred to the facility due to a fall at home that required hip surgery and was assessed to have severely impaired cognition or at the minimal implemented after the first fall in the facility on 2/8/22 considering that both falls occurred due to the resident trying to transfer out of their bed in the morning around the same time. The DON stated there was an intervention to have the resident bed in low position. At this time the care plans were reviewed with DON, the DON stated they didn't understand why it was implemented on 2/17/22 and not earlier. The DON stated they would look further into it and follow up. At 4:17 PM, the DON returned and stated they believe the bed in low positioning was not implemented initially because having the bed in a low position would have popped her hip out of place s/p hip surgery. The DON was then asked then why the intervention was implemented on 2/17/22 if it wasn't an appropriate intervention s/p hip surgery and stated the resident was more than likely healed at that time. Review of a care plan titled ADL self-care deficit documented the following interventions Left hip precautions and Left hip precautions- No crossing legs. The was no further documentation of what hip precautions the nursing staff was supposed to follow. Review of a facility policy titled Falls Practice (12/2011) documented in part, . Upon admission, review hospital discharge records, transfer sheets or other data regarding the patient's history of, or risk factors for, experiencing a fall. Interview the patient and family . about the patient's history of falls, possible causes of those falls and interventions that did not work to prevent further falls . the patient's initial care plan is updated or a comprehensive care plan is developed to include individualized patient interventions that focus on the patient's risk factors .

This citation pertains to intake# MI 607. Based on interview and record review the facility failed to notify the physician and implement interventions and/or treatments for a pressure wound for one resident (R901) of two residents reviewed for pressure ulcers, resulting in the worsening of a pressure ulcer to a stage three pressure ulcer (a wound that involves the full thickness of the skin and may extend into the subcutaneous tissue layer). Findings include: On 6/17/21 a concern submitted to the state agency was reviewed which indicated R901 did not receive appropriate care to prevent pressure ulcers. On 6/17/21 the medical record for R901 was reviewed and revealed the following: R901 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R901's Minimum Data Set with an Assessment Reference Date of 3/8/21 revealed R901 needed extensive assistance from staff with most of their activities of daily living. R901's BIMS score (brief interview of mental status) was eight indicating moderately impaired cognition. Review of a Braden scale evaluation (a scale used to identify risk levels for pressure ulcer development) dated 3/5/21 revealed a score of 11 indicating R901 was a high risk for developing pressure ulcers. Review of an Admission/Re-Admission Evaluation note dated 3/5/21 revealed the following: Clinical Evaluation Integumentary (Skin)-Skin Integrity Issues Present: [Yes] .Description: bruise on LLQ, (lower left quadrant) discoloration on left groin, minor bruise on left upper arm. redness on left breast area. redness/self-scratches on left buttocks. minor skin issue on sacral area Further review of the note revealed no baseline careplan was initiated for the identified skin impairments. The baseline careplan for the skin section on the evaluation was blank and not filled out. Review of the Admit/Readmit note dated 3/5/21 revealed, 5:50 pm pt (patient) arrived via stretcher accompanied with 2 EMS (emergency medical services) personnel .skin assessment: skin warm and dry. bruise on LLQ. discoloration on left groin. redness/self-scratch on left buttock. minor skin redness/issue on sacral area Review of a general progress note dated 3/6/21 at 6:56 AM revealed the following: Pt (patient) has small bruises on her abdomen and a small open wound on her sacrum . Review of a skin progress note dated 3/8/21 revealed the following: Skin assessment completed. Resident has stage 3 Pressure ulcer at coccyx. Pink wound bed Review of a Medical Provider wound progress note dated 3/10/21 revealed the following: Skin abnormal finding -Wound Exam-Wound 1 Location - sacrum skin and wound at measurement 3/8, seen visually 3/10. Type -Pressure .Pressure Severity-Stage 3 .Diagnosis 1-acute sacral stage III pressure injury, initial- Diagnosis 1-Plan-Clean with NS (normal saline), pat dry 2. Apply triad to wound bed, 3. Cover with dry 4x4 and foam dressing daily and PRN(as needed). APM (alternating pressure) mattress Pressure reduction wheelchair cushion- has gel cushion Limit time up in chair to as each sitting session Elevate foot of bed when head of bed is up to reduce shearing RD (Registered Dietician) follows PRN Pro source no carb (carbohydrate) liquid nutritional supplement 30 mL (milliliters) by mouth daily assist with frequent turn and repositioning pillows for offloading . Review of R901's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R901's careplan revealed the following: At risk for alteration in skin integrity related to: impaired mobility .5/11/21 open area to sacral coccyx. Date Initiated-3/8/21. Revision on 5/11/21 . Further review of R901's skin integrity careplan revealed no interventions were initiated to address skin integrity concerns until 3/8/21. On 6/17/21 at approximately 2:50 p.m., R901's medical record was reviewed with the Director of Nursing (DON). The DON was queried regarding the implementation of treatments for R901's wound on their sacrum and they indicated that the baseline careplan should have been initiated for the skin breakdown that was identified on the admission nursing evaluation and when R901's wound was documented as having opened up on 3/6/21 the Physician should have been notified and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON was queried why no treatments were initiated until 3/8/21 for R901's wound and they indicated they were unsure but that R901 was admitted on a Friday, and they weren't aware of the wound until Monday 3/8/21 and at that time an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON was queried regarding the progression and worsening of R901's sacrum wound from the minor skin redness identified on 3/5 to the identification of the stage 3 pressure ulcer on 3/8 and they reported they would have to educate their nursing staff on ensuring treatments were put into place for wounds. On 6/18/20 a facility document titled Skin Practice Guide was reviewed and revealed the following: Phase 1:Assess (Cont) .(2) A patient having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing .

This citation pertains to intake #MI 607. Based on interview and record review the facility failed to ensure a safe transfer was completed for one resident (R901) of two residents reviewed for accidents, resulting in R901 sustaining a femoral fracture. Findings include: Review of a complaint submitted to the state agency on 6/10/21 revealed R901 sustained a fall with an injury. On 6/17/21 the medical record for R901 was reviewed and revealed the following: R901 was admitted to the facility on [DATE] and had diagnoses including [CONDITION(S)], Alzheimer's disease, and Cerebral Infarction (stroke). A review of R901's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/8/21 revealed R901 needed extensive assistance from staff with most of their activities of daily living. R901's BIMS score (brief interview of mental status) was eight indicating moderately impaired cognition. Review of a progress note dated 5/2/21 revealed the following: writer help pt (patient) with hygiene and dressed up. writer attempted to transfer from bed to wheelchair as per nurse and family request. writer used the EZ (mechanical sit to stand lift) as per transfer careplan. Writer requested nurse present during transfer, the sling slipping out. nurse called other staffs help, pt was assisted, lowered to the floor. pt transfer back to the floor with Hoyer lift use . A patient safety note dated 5/3/21 revealed the following: IDT (interdisciplinary) rounds s/p (status post) fall on 5/2/21 at 11:55 am. Resident was being transferred into chair from bed per family request and wanting resident to sit up so they could visit at window. Resident was being transferred with stand lift per kardex (a care guide for direct care staff) and could not hold balance and had to be lowered to floor by nursing staff. Resident had complaints of left knee pain, so an X-ray was ordered A NP progress note (Nurse Practitioner) dated 5/5/21 revealed the following: Chief Complaint -right knee fracture .HPI (History of presenting illness)-[R901 demographics] seen today s/p fall May 2, 2021 .on exam CENA (certified nursing assistant) at bedside for incontinent care, patient screaming and crying and stating it hurts holding the right thigh area. There is no bruising noted, noted swelling around knee area and right upper thigh muscles vastuslateralis tight. Patient screams of pain on patellar palpation ,only able to bend approx (approximately) 15 degrees and yells of pain 5/2 X-ray: right knee- fracture right medial femoral epicondyle with minimal callus and mild displacement. joint effusion. DJD ([CONDITION(S)] joint disease) . A radiology record dated 5/7/21 revealed the following: Impression-Comminuted minimally displaced distal femoral fracture with involvement of the media femoral condyle and intercondylar region . A NP progress note dated 5/10/21 revealed the following: Pt was sent to ER (emergency room ) 5/7 for CT (computed tomography) to r/o (rule out) fracture. Today pt denies any pain, noted right Lower ext (extremity) soft splint/knee immobilizer, edeam <sic> to the feet noted. CT scan done 5/7 showed osteopenic bones , mod (moderate) right hip [CONDITION(S)] changes ,comminuted minimally displaced distal femoral fx (fracture) with involvement of the medial femoral condyle and intercondylar region, there is also a large effusion . An incident report pertaining to R901's fall on 5/2/21 revealed the following: Incident Cause-(Registered Nurse (RN) F) tried to transfer pt from bed to wheelchair as per family request using EZ stand as per care plan. (Registered Nurse (RN) F) and (Licensed Practical Nurse (LPN) E) both present during the transfer. during transfer the sling slipping out, nurse called for extra help and assisted to place pt on the floor for safety. On 6/17/21 at approximately 4:09 p.m., Licensed Practical Nurse E (LPN E) was queried regarding R901's transfer in the EZ lift and subsequent fall on 5/2/21. LPN E indicated they heard Registered Nurse (RN) F (who was working as R901's nurse aide that day) call out for help and as they were walking to R901's room they saw RN F had already began lifting R901 off the bed with the EZ lift. LPN E indicated that as they were walking to the room, R901 was hanging on the sling, and they were unable to get a wheelchair under them and that RN F had to lower R901 to the ground. LPN E indicated that they had to call for help with other staff members and lifted R901 back into the bed with the Hoyer lift. LPN E was queried how an EZ lift transfer is used safely and they indicated that it is a two person transfer. LPN E was queried if they knew why RN F had already started to lift R901 off the bed before they were in position at the bedside to assist and guide in the transfer and they indicated they did not know. On 6/18/21 at approximately 11:14 a.m., RN F was queried regarding R901's transfer in the EZ lift and subsequent fall on 5/2/21. RN F indicated they had prepared R901 for the EZ lift transfer including putting on the sling and once that was completed, they asked LPN E to come in to watch because using the EZ lift required two people. RN F reported that they began lifting R901 off the bed when LPN E was walking into the room and that's when R901's sling slipped and they had to brace R901 with their legs and as they lowered R901 to the floor, R901's knees hit the floor first. RN F was queried if it was normal procedure to begin lifting a resident off the bed before the other staff member was at the bedside and in position to assist/guide with the transfer, and they indicated that it was not the normal procedure. RN F was queried why they did not wait for LPN E to be in position, and they indicated they did not know, but were trying to provide care to the resident. On 6/18/21 at approximately 12:10 p.m., during a conversation with the Director of Nursing (DON), the DON was queried regarding the procedure for utilizing the EZ lift. The DON indicated that the EZ lift is a mechanical left which requires two people to safely use. One person holds the remote control, and the other person stands next to the lift and guides the resident to ensure the resident is safe. The DON was queried if they were aware of the specifics of R901's transfer on 5/2/21 and they indicated they were not, just that 2 people were there. The DON was informed of the previous interviews with LPN E and RN F and indicated that RN F should have waited for LPN E to be in position before they started to lift R901. On 6/18/21 a facility document titled Mechanical Lift was reviewed and revealed the following: Procedure-1. Verify transfer assist needed per Kardex. Obtain additional assistance and needed equipment as indicated. Use of a mechanical lift requires a 2nd caregiver .STAND ASSIST MECHANICAL LIFT: Position sling around the patient's back so it is approximately two inches above the waistline .Position patient's arms outside the sling .Fasten safety belt around patient's waist . Position lift in front of the patient and lock wheels of lift. Assist the patient in placing his/her feet up on the platform of the lift . Fasten the clips of the sling to the lift .Using the hand control, slowly raise the patient to a standing position. If at any time the patient is unable to assist with the transfer and bear weight on lower extremities, return the patient to the sitting position on the chair or bed .Unlock the wheels and transport patient to chair, bed, or toilet .Position patient in front of destination. Do not lock wheels of lift .With the backs of the patient's knees touching the destination surface, slowly lower patient onto destination surface in an upright position. Keep control of lift to minimize movement and to ensure optimal positioning of patient .Unclasp sling from lift and remove safety belt from patient .

This citation pertains to intake #s: MI 379, MI 062 and MI 143. Based on interview and record review, the facility failed to promptly identify, assess, and implement treatment to prevent the development of a pressure ulcer for one (R711) of three residents reviewed for pressure ulcers, resulting in the development of an unstageable facility acquired pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture) and/or eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color; and may appear scab-like) in the wound bed) and the increased potential for delayed healing. Findings include: A complaint was submitted to the State Agency on 4/30/20 that alleged a resident developed bedsores (pressure ulcers) on the backside and scrotum while in the facility due to not being turned regularly, being left to sit in stool for hours and not having a trapeze (adaptive device secured to the bed to allow the resident to move self in the bed) to use the first week while in the facility to help with repositioning as the resident was able to use both upper arms. On 10/7/20 at 11:37 AM, a phone interview was conducted with the complainant who reported, .I got injured and became paraplegic when I was 25 (paralysis of the legs and lower body caused by spinal injury from a motor vehicle accident). I'm 57 now. It's (pressure ulcer development on sacrum) just traumatizing, I have home care coming in every day as I'm still dealing with the open area now .I should've been turned every two hours but that didn't happen. I should've had a trapeze to help myself move around but that was delayed. The reason I was there was a pressure ulcer on the right heel that had to be treated for [REDACTED]. I left as soon as I was done with the IV medication. A review of R711's clinical records revealed an admission into the facility on [DATE] and discharge to the community on 2/26/20. [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set (MDS) assessment dated [DATE] documented R711 had no behavior concerns, required extensive assistance of two people for bed mobility, transfers, hygiene and toilet use, was frequently incontinent of bowel, had an indwelling urinary catheter, was determined to have a pressure ulcer by clinical assessment and formal assessment instrument/tool, and had one unhealed stage four pressure ulcer that was present upon admission. A review of R711's Braden Scale (tool used to determine risk for pressure ulcer development) dated 1/23/20 had a score of 15.0 which indicated At Risk. A review of R711's admission nursing evaluation dated, 1/23/20, completed 1/24/2020 at 7:09 AM documented the resident was alert and oriented to situation, place, person and time, had clear speech, understood and was able to follow instructions, had a pleasant and cooperative mood and behavior, had a Peripherally inserted central catheter (PICC) to the right arm, had old wound with pink skin to the coccyx which noted Skin is intact, had no impairment to upper extremity range of motion, but had impairment on both sides of lower extremity range of motion and utilized a mechanical lift. The only identified open skin area was to the resident's right heel. A review of the physician ordered Daily Body Audit for Pressure every day shift for monitoring was to start on 1/24/20 through 2/26/20. This assessment was indicated as completed on the Medication Administration Record [REDACTED]. A review of R711's wound care orders for the sacrum/buttock area included: 1) An order on 2/12/20 through 2/18/20 read, Apply Triad Paste to sacral open area and cover with Foam Dressing every day shift for wound care. There was no progress note or nursing assessment to identify or indicate the description of the wound, or what other interventions were identified to prevent the worsening of this change in skin condition. 2) An order on 2/18/20 through 2/25/20 read, [MEDICATION NAME] Cream 1% Apply to Sacral/Bilateral Buttocks topically every day shift for Wound Care. 3) An order on 2/18/20 through 2/25/20 read, Sacral/Bilateral Buttock Care: 1.) Cleanse with NS (Normal Saline) 2.) [MEDICATION NAME] (thin layer) to open areas 3.) Triad to periwound 4.) Cover with a dry padded dressing, as needed for Wound care AND every day shift for Wound care. 4) A wound care order on 2/26/20 was not documented as administered and R711 discharged on [DATE]. Further review of R711's nursing progress notes revealed there was no documentation of any details of the resident's change in skin status to the sacrum/buttock area despite an order for [REDACTED]. The next notable documentation was not until the wound practitioner's note on 2/18/20. A review of R711's wound progress notes documented by (Nurse Practitioner/NP O) included: An entry for wound care on 1/31/20 and 2/4/20 identified wound care concerns for only the right heel pressure ulcer. An entry on 2/18/20 read, .Patient is being followed by ID (Infectious Disease) .Patient was also evaluated today for recurrent unavoidable sacral/bilateral buttock pressure ulcer unstageable that had been treated initially in 2018. Will recommend [MEDICATION NAME] / triad and dry padded dressing for antimicrobial/barrier and cushioning properties. Patient will follow up with (local hospital name) wound care clinic for hyperbaric therapy after his discharge from SAR (Sub-Acute Rehab). Due to multiple comorbidities including [MEDICAL CONDITION] wound healing may be delayed and future wound development is likely and unavoidable. Discussed importance of nutrition/hydration and frequent repositioning with wound healing .Wound 1 .Sacral/bilateral buttock. Type - Pressure .Unstageable .Length in cm (centimeters) - 11.9. Width in cm - 9.5 Depth in cm - 0.1 .Drainage Amount - Moderate. Drainage type - Serosanguineous . (Review of the available physician notes identified R711's past medical history documented a recurrent issue with pressure sore to the resident's heels, not the sacral/buttock area.) An entry on 2/25/20 read, .chronic right heel pressure ulcer stage 4 with osteo[DIAGNOSES REDACTED] that initially developed approximately 1-2 years ago .Patient also evaluated today for recurrent unavoidable sacra/bilateral buttock pressure ulcer unstageable that had been treated initially in 2018. 2/18/2020 sacral/coccyx xray was neg (negative) for osteo[DIAGNOSES REDACTED] .Wound 2 .Sacral. Type - Pressure .Length in cm - 13.5cm. Width in cm - 11.6cm. Depth in cm - 0.2cm . Serosanguineous . (Documentation of R711's past medical history by the attending physician and NP O both identify the right heel pressure ulcer since 2018. The sacral wound measurements on 2/25/20 show an increase (worsening) in size since 2/18/20.) A physician progress notes [REDACTED]. He has [MEDICAL CONDITION] and a foley catahter <sic> for [MEDICAL CONDITION] bladder Right heel .completing antibiotics tomorrow . There was no identification of the facility acquired sacral pressure ulcer in Physician Rs documentation or that there was a history of breakdown that was unavoidable. Review of the care plans revealed there was no care plan initiated/revised to include the change in R711's pressure ulcer to the sacral/buttock area. There were two care plans which addressed skin both initiated on 1/24/20 without any further revisions: 1) Open wound at right heel related to: pressure ulcer and 2) At risk for alteration in skin integrity related to: Hx (history of) pressure ulcers, impaired mobility, incontinence. Interventions included: Barrier cream to peri area/buttocks as needed, Encourage to reposition as needed; use assistive devices as needed, Observe skin condition with ADL (Activities of Daily Living) care daily; report abnormalities, and Provide preventative skin care routinely and prn (as needed). The facility acquired sacral wound had been identified by nursing staff on 2/12/20. Despite daily body audits being documented as completed, no other nursing staff identified any description of the wound, or what other interventions had been implemented to prevent the worsening of the pressure ulcer or to promote repositioning or offloading to the resident's sacral/buttock area. There was no documentation available for review or provided by the facility that the physician had documented clinical rationale of an unavoidable wound development until 13 days after R711's sacral/buttock area was identified as an unstageable pressure ulcer. On 10/8/20 at 11:30 AM, an interview was conducted with the Director of Nursing (DON). When queried about R711's pressure ulcers, the DON reported she was not in the position of DON at that time and might not be able to provide specific details. When queried about contacting NP O to discuss R711's wounds, the DON reported NP O was the wound NP at that time, but due to the pandemic was no longer coming to the facility. The DON was asked to review the available wound documentation for R711 and confirmed the identification of an open area identified by Licensed Practical Nurse (LPN N) on 2/12/20. The DON was asked about any description of the wound and indicated there should be documentation in the progress notes. Upon review of the progress notes, the DON reported there was no such documentation. When asked about the facility's process for documenting changes in skin conditions since daily body audits were documented as completed, the DON reported the nursing staff initialed that section of the medication administration records when body audits were done and further reported if there were changes, there should be corresponding progress notes. The DON confirmed that although documentation reflected the daily body audits were completed, there were no further progress notes from nursing that identified any changes in the resident's skin condition. The DON confirmed there was an x-ray done to rule out osteo[DIAGNOSES REDACTED] in the sacrum wound which was negative on 2/18/20. When asked about NP Os unavoidable note on 2/25/20, and how it was determined to be unavoidable when although there was identified history of previous breakdown which was noted as a healed (non-opened area) on admission, and if interventions had been identified and implemented timely such as timely incontinence care and interventions to assist with repositioning, why was the documentation did not identify a risk to that area on previous wound consultations on 1/31/20 and 2/4/20, the DON was unable to offer any further explanation. The DON was asked about the delay in the Wound NP O evaluating R711 (identified 2/12/20 and not seen until 2/18/20) and reported the wound consultant only came to the facility on ce a week. The DON was asked about the provision of a trapeze to R711's bed to assist with transfers and repositioning, the DON reported that therapy would make a recommendation and the facility would've implemented that same day. At that time, the DON reported she would attempt to locate any documentation regarding the trapeze provided for R711's bed. When asked if there was any other documentation that nursing had assessed/documented any skin areas such as shower/bath sheets, the DON reported those were kept on the nursing unit for about a year and would follow up to find that documentation for R711. On 10/8/20 at 2:40 PM, the DON provided one shower sheet dated 2/1/20 which indicated a bed bath had been provided to R711. The only skin alteration documented was on the heels. At that time, the DON acknowledged the concern regarding lack of documentation of additional shower/bathing sheets and reported We know as of 2/1/20 there was no open area. Some point between 2/1 and 2/12 he developed the wound (sacrum). On 10/8/20 at 2:44 PM, the current wound care nurse (Nurse M) was queried about R711's wound care from January to February 2020 and reported she was unable to offer any further explanation regarding R711's wounds as she was out on a medical leave during the time R711 was at the facility had not returned to work until 3/23/20. On 10/8/20 at 3:30 PM, the DON provided a therapy note which recommended a trapeze on 2/19/20 and reported Would've been put in place at that time. There is no actual work order for that. The DON was asked why the trapeze had not been implemented until 28 days after admission and reported she was unable to offer any further explanation. A review of the facility's Skin Practice Guide dated Issue Date: 01/2013 documented in part: .Patients with pressure ulcers have a head-to-toe skin evaluation completed daily by the licensed nurse to identify additional skin changes. Documentation of the evaluation is located in the Treatment Administration Record or progress note .Body positioning provides for pressure redistribution and can decrease pressure, friction and shear .Moist skin is more vulnerable to injury .those who develop new alterations are ideally evaluated by a qualified health professional .within 24-hours or as soon as practicable, after admission or new skin alteration identification .If a change in patient condition occurs, such as a deterioration in or development of new risk factors or skin alterations, the licensed nurse notifies the physician, wound team .and documents findings in the clinical record. The patient's plan of care is then updated to reflect the patient's current status and care needs. Communications with the physician, patient and family are documented in the clinical record .A member of the wound team evaluates the skin alteration and collaborates with the licensed nurse and physician .

This citation pertains to intake #s MI 3 and MI 2, MI 034, and #MI 138. This citation has three Deficient Practice Statements (DPS). DPS #1: Based on interview and record review, the facility failed to transfer a resident from their Geri-chair to the bed per plan of care for one resident (R#703), of three residents reviewed for accidents, resulting in a laceration and transfer to the hospital where the resident received 5 sutures. Findings include: On 10/8/20 a review of a facility reported incident file for R703 was reviewed and revealed a report that documented, .Investigation Summary/Actions Taken: On 2/29/20 resident (R703) sustained a left index finger skin tear which was discovered by his CENA (Certified Nurse Aide) after transferring the resident from his Geri chair to his bed. Nurse notified immediately, physician notified immediately, and the resident was ordered to have his finger assessed in the ER (emergency room ). The resident was sent for first aide <sic> to the hospital and returned immediately with 5 sutures. The aide stated that the resident's hand was bleeding after the transfer occurred . Continued review of the file documented the following, On 2/29/20, at approx. 8pm resident was observed in his Geri chair .Resident was observed by his CENA .as having no skin alteration to his left index finger. At approximately 845pm . Cena transferred the resident from his Geri Chair to bed without incident. (CENA, name redacted) immediately observed two droplets of blood on the Geri chair after transferring the resident and noticed that the resident's finger was bleeding and then informed the nurse, (Name redacted) that the aide noticed a cut on residents left index finger after he transferred him from his chair to the bed .The nurse notified the on-call Physician of the incident, ordered to send resident to the Hospital for further treatment .At approximately 12pm, the resident's sister reported to the facility to visit the resident, and stated to the resident's nurse (Name redacted) that she is filing a police report due to the resident sustaining a finger laceration .On 3/6/2020, the police came to the facility (Case # redacted), interviewed the DON (Director of Nursing), and a summary of the facility's investigation was briefed with the police officer .The facility ruled out abuse .the resident sustained [REDACTED]. A review of a written statement from Certified Nursing Aide (CNA) 'S' was conducted and read, .When I put him in bed I saw droplets of blood in chair so I look <sic> at his finger and I saw he has a cut, I don't know where the cut came from so I called the nurse. I transferred him by myself into the chair . The file further contained a document titled ONE-ON-ONE INSERVICE RECORD for CNA 'S' that indicated they had been given education on appropriate transferring from chair to bed. A review of R703's hospital record for the transfer to the emergency room was conducted and indicated R703 had sutures placed in a crisscross fashion over the laceration on his left index finger in order to approximate and close the wound. A review of R703's closed clinical record was conducted and revealed an admission date of [DATE] and a re-admission date of [DATE] with [DIAGNOSES REDACTED]. A review of R703's most recent Minimum Data Set (MDS) assessment dated [DATE] was conducted and revealed R703 had severe cognitive impairment, was non-ambulatory, required total assistance of two staff members for transferring, and had bilateral upper and lower extremity range of motion deficits. A review of R703's MDS assessment dated [DATE] (just prior to the incident on 2/29/20) was conducted and revealed that at the time of the incident R703 also required total assistance of two staff members for transferring. A review of R703's care plans was conducted and revealed a care plan for Activities of Daily Living with an intervention created on 11/13/18 that read, .Transfer 2 person Maxi lift with Blue sling . On 10/8/20 at 3:15 PM, an interview with CNA 'S' was conducted regarding the incident. CNA 'S' indicated R703 sustained a skin tear to his finger during the transfer from his Geri chair to the bed. When queried how CNA 'S' transferred R703, CNA 'S' indicated he transferred him by himself and did not use a mechanical lift. CNA 'S' indicated he transferred him manually with his own strength. A review of a facility provided policy titled, TRANSFER: BED-CHAIR/WHEELCHAIR dated 1/2011 was conducted and read, PURPOSE: To move safely from bed to chair or wheelchair and back again . It was noted the policy provided documented the steps in the procedure to transfer a resident but did not indicate staff should transfer the resident per their plan of care. DPS #2: Based on observation, interview and record review, the facility failed to ensure adequate supervision for a resident exhibiting exit seeking behaviors and consistent monitoring of a personal security alarm per plan of care for one (R701) of three residents reviewed for elopement risk, resulting in the increased potential for R701 to wander into other resident rooms and exit the facility while unsupervised. Findings include: Review of a complaint filed with the State Agency included allegations that R701 had eloped from the facility on 6/27/20. A review of R701's clinical record revealed an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) assessments dated 6/19/20 and 9/19/20, R701 had severely impaired cognition, exhibited no wandering behaviors during this assessment period of seven days, and required supervision of oner person with ambulation in the room and corridor. Further review of the clinical record included three Behavior Symptoms Assessment forms which included: On 8/1/19, .Exit Seeking .Wandering without intent and purpose .Unprovoked .Dementia or Alzheimer's .; On 6/29/20, .Identified Behavioral symptoms .Exit Seeking .Purposeful .looking for husband .; and on 9/1/20, .Exit Seeking .Wandering without intent or purpose .Unprovoked . A review of the incident/accident reports provided by the Administrator identified R701 had two recent elopements on 6/27/20 and 8/30/20. Review of R701's Medication Administration Records (MARs) from July to September 2020 revealed blank entries from 7/10/20 pm shift through 9/22/20 for the checking of placement and function of the resident's wander guard alarm to the right ankle. Review of R701's behavior care plans included: Wandering/Pacing/resident also has aggressive behavior .resident tends to go through roommates belongings and remove clothes. Pt (patient) wears a wanderguard ankle bracelet included a current intervention, initiated 6/27/2020 which read, 1:1 at all times r/t (related to) wandering. Exit Seeking touching exit door . which included an intervention initiated 8/2/19 that read, Check alert bracelet placement Q (every) shift and Functioning Q day and an intervention initiated 8/5/19 that read, Alert Bracelet (FYI-For Your Information). Review of the 10/7/20 day shift staff assignment sheet for the unit R701 resided on revealed Nurse F was assigned as the 1:1 caregiver for R701. On 10/7/20 at 1:30 PM, R701 was observed lying on the bed with an ankle bracelet type alarm to the right ankle. There was no staff observed in or near the room. There were no staff observed in the hallway. The resident's room was located close to an exit door which led to a parking lot and an apartment complex with woods/marsh area. Continued observation from 1:30 PM until 2:27 PM revealed there was no staff observed in or near R701's room. At 1:42 PM, R701 was observed up walking independently into the hallway and down towards the nursing station (near another exit door which had a driveway, embankment, and local busy road). On 10/7/20 at 3:10 PM, the Administrator was requested to provide any incident/accident reports for R701. When asked about 1:1 supervision, the Administrator reported R701 had an elopement on in June and was taken off 1:1 supervision in July and put back on again in September after another elopement. When queried about these incidents, the Administrator confirmed R701 had gotten outside two separate exit doors but had been redirected by staff after responding to the door alarms. On 10/7/20 at 4:02 PM, R701 was observed lying in bed, awake watching the door to the hallway without any staff observed in or near R701's room. On 10/7/20 at 4:06 PM, R701's assigned nurse (Nurse C) was queried about who was assigned to provide 1:1 supervision and reported, (name of Nurse F) was here until 2pm. At that time a binder for R701 was opened at the nursing station desk and contained several entries on a sheet titled 1 hour Checks. Further review of the entries documented, 1P - staff informed writer leaving. The next three entries 2P, 215P and 230P were noted as walking. When asked about this documentation, Nurse C reported that was for R701 who was supposed to have a one to one sitter due to wandering and history of elopements but currently did not. When asked about the three entries, Nurse C reported Unit Manager D was in the process of completing the documentation. On 10/7/20 at 4:11 PM, Unit Manager D who was in the process of assisting staff on another area of the unit was queried regarding the documentation in the binder and stated, (name of Nurse F) was here until 1pm and reported she was completing visual checks on R701 every 15 minutes. When asked to confirm whether Nurse F was here until 1:00 PM or 2:00 PM, Unit Manager D reported 1:00 PM. When queried about the lack of observation of 1:1 supervision since 1:30 PM, Unit Manager D reported that was not correct and had completed observation of R701 herself during this time. When queried about the conflicting statement in regard to direct observations, as well as observations of the resident wandering the hallway without any staff present, Unit Manager D offered no further explanation. When asked about the documentation in the binder, Unit Manager D reported she was in the process of completing. When asked what the facility's process was when 1:1 supervision was not able to be provided to ensure the safety of the residents, Unit Manager D reported, Typically if we don't have 1:1, we do 15 minute checks. When asked about when that documentation should be completed, Unit Manager D reported at the time of the observation. Unit Manager D confirmed that documentation had not been completed as such. On 10/7/20 at 4:20 PM, the Director of Nursing (DON) was queried about the facility's decision to remove R701 from 1:1 supervision in July (approximately 13 days following implementation of the 1:1 supervision) and reported, Usually (R701) would walk around, not actually exit seek. Figured change in mental status. Didn't go to door before. Normal behavior was to walk around. The second time it happened (8/30/20) we put (R701) back on 1:1 supervision. Things changed when husband came to facility. Needs to remain on 1:1 indefinitely. A review of the facility's Behavior Practice Guide dated Issue Date: 07/2015 documented in part: .When unsafe wandering or elopement risk has been identified, a Behavioral Symptoms User Defined Assessment (UDA) is completed in (name of electronic medical record program) .The personal security bracelet serves as an alert to the patient of safe boundary limits as an alert to staff if patient is close to an alarmed door .Bracelet placement is validated every shift. Bracelet functioning of the sensor is validated every day .Documentation is completed per center practices . DPS #3: Based on interview and record review, the facility failed to ensure adequate supervision assistance during bed mobility/incontinence care per plan of care to prevent a fall for one (R712) of three residents reviewed for falls, resulting in R712 falling from the bed when left unattended by staff and the increased potential for serious accident/injury. Findings include: A review of a complaint filed with the State Agency alleged the resident sustained [REDACTED]. A phone interview was completed with the complainant on 10/7/20 at 11:47 AM. At that time, the complainant reported R712 passed away on 8/27/20 while at the hospital. A review of R712's closed clinical record revealed an admission into the facility on [DATE], readmission on 7/24/20, and discharge to the hospital on [DATE]. [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) assessment dated [DATE], R712 was cognitively intact, weighed 275 pounds, was totally dependent upon two-person assistant for bed mobility, transfers, hygiene and toilet use, and had no falls during this assessment period. A review of R712's care plans included: An activities of daily living (ADL) care plan dated 8/23/19, revised 12/6/19 identified the following interventions: Ext (extensive assistance) x 2 (two people) with toileting bed pan please offer to use (added 12/6/19). two person assist with bed mobility (added 10/18/19). A risk for falls care plan dated 8/23/19, revised 4/27/20 identified the following interventions: 2 person mechanical lift full large sling for transfers (added 8/23/19, revised 11/25/19). Bed in low position (added 4/26/20). Educate CENA (Certified Nursing Assistant) on two person assist with bed mobility (added 4/27/20). A review of R712's incident/accident report dated 4/26/20 8:25 AM completed by Licensed Practical Nurse (LPN P) documented, in part: .During care patient was laying on her side, aide left room to get peri wipes patient fell Mild pain left leg .Skin tear left upper arm .Summary of Critical Information Obtained During Investigation: Patient stated that she is weak on left side and that is why she fell . A review of the nurse aide statement by CNA (Q) dated 4/26/20 documented, in part: Resident was receiving care was laying on her side I walked away too <sic> get wipes. When I came back to she was falling out of bed . A review of the nursing progress note dated 4/27/20 at 1:20 PM read, .on 4/26/2020 at 5:30 am, During patient's care patient was laying on her side when CENA left patient's room to get wipes and patient fell out of bed .patient was assisted back to bed by fire department. Intervention: Educate CENA on two person assist with bed mobility . On 10/8/20 at 8:36 AM, a phone interview was completed with CNA Q. When asked to recall the events regarding R712's fall on 4/26/20, CNA Q reported, I was giving her care and turned onto the side. Normally able to stay on side. We had a routine .I literally went a door and half down, she was rolling off the bed . When asked how the nursing assistants were aware of resident's transfer status, CNA Q reported there were monitors in the hall with that information. When asked to recall what R712's status was in regards to incontinence care and/or bed mobility prior to the fall, CNA Q reported, I'm pretty sure she should be a two person assist which is why I was working that day. No staff. When asked to recall if the bed may have been elevated since providing care to make it easier to change the resident's brief, CNA Q reported, It was at waist level, cause she's kinda heavy. When asked what follow-up had been provided by the facility following this incident, CNA Q stated, I think someone from Administration called me but that was it. On 10/8/20 at 10:45 AM, an interview was completed with the Director of Nursing (DON). When queried about R712's fall on 4/26/20, the DON reported the information was limited since she was on leave from the facility at that time. The DON further reported Unit Manager E was the nurse manager that provided education to CNA Q but no longer worked at the facility. The DON acknowledged the concern regarding the lack of required staff per plan of care at the time of the fall on 4/26/20.

This citation pertains to Intake MI 312 Based on interview and record review, the facility failed to provide timely assessment and monitoring of bowel status for one (R#702) of three residents reviewed for constipation, resulting in complications from constipation (fecal ball) and abdominal pain/tenderness. Findings include: On 12/17/19 at 10:00 AM, a phone interview was conducted with the complainant as a result of a concern for R#702. During the conversation, the complainant indicated R#702 had been a resident at the facility and was hospitalized with a bowel impaction. A record review was conducted on 12/17/19 and revealed R#702 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the initial Minimum Data Set (MDS) assessment dated [DATE], R#702 scored 6/15 on the Brief Interview of Mental Status (BIMS) exam indicating severely impaired cognition. The MDS assessment also indicated R#702 was incontinent of bowel and required the extensive assistance of staff for all activities of daily living. Review of R#702's care plan revealed a focus initiated 10/24/19 that read, Bowel Incontinence related [MEDICAL CONDITION](Cerebralvascular Accident 'Stroke') with interventions that included, Report changes in bowel movement frequency, consistency, control, etc. A Radiology Results Report dated 11/20/19 for R#702's sacrum/coccyx wound (buttocks) read in part, Conclusion: .Severe constipation. Correlate for fecal impaction . Review of R#702's 30 day Look Back for the Certified Nursing Assistants 'Task' revealed in question '4' that R#702 had daily Soft or Loose stool. Review of R#702's nursing progress notes revealed a note dated 11/21/19 by Licensed Practical Nurse (LPN) 'G' that read, radiology report was received n/o (new order) for suppository given one time only. Review of R#702's physician orders [REDACTED]. This medication is used for constipation. An additional order dated 11/21/19 read, (brand name) 5-325 MG ([MEDICATION NAME][MEDICATION NAME]) Give 1 tablet by mouth every 6 hours as needed for pain. This medication can cause constipation. An order dated 10/24/19 read, (brand name) 8.6-50 MG (Sennosides-[MEDICATION NAME] Sodium) Give 1 tablet by mouth two times a day. Review of R#702's clinical record revealed no follow-up tests after the suppository use on 11/21/19. Review of a NP (Nurse Practitioner) Progress Note dated 11/27/19 by NP 'P' read in part, .Change in bowel habits Severe constipation. Correlate for fecal impaction. Further review of R#702's physician orders [REDACTED]. Further note dated 11/28/2019 stated, in part, .All meds given .with prn med for pain .Patient did not eat her breakfast .patient family .very upset wanted (R#702) to go to the hospital Hospital per family request . Review of R#703's hospital records dated 11/28/19 read in part, Emergency Dept Notes . Abdominal: . Tenderness: There is generalized tenderness (highlighted in red) . Review of a hospital CT (computerized tomography) Scan of R#702's abdomen dated 11/28/19 read in part, Large amount of stool throughout the rectum with stool measuring up to 10 cm (centimeters) short axis. There is mild wall thickening of the inferior rectum with mild perirectal [MEDICAL CONDITION] changes posteriorly suggestive of mild associated proctitis . IMPRESSION: 1. Large rectal stool ball measuring up to 10 cm short axis with associated mild inferior rectal proctitis . Review of a hospital [MEDICATION NAME] consultation note dated 11/29/19 read in part, . * Constipation . Recommendation: - soap sud enemas twice daily until patient has a food <sic> BM (bowel movement) . Review of a hospital discharge summary dated 12/7/19 read in part, .Constipation, Resolved . -S/P (status [REDACTED]. On 12/17/19 at 1:58 PM, an interview was conducted and LPN 'E' was asked about the procedure for abnormal test results. LPN 'E' stated, The abnormal labs or reports go to the nurses. Then we call the doctor for orders. On 12/18/19 at 8:33 AM, a phone interview with LPN 'G' was conducted. During that interview, LPN 'G' was asked about the progress note written on 11/21/19 about a one time order for a suppository. LPN 'G' stated, I remember (R#702), but I don't remember any suppository, or an order for [REDACTED]. On 12/18/19 at 8:57 AM, an interview was conducted and NP 'P' was asked about R#702's radiology report dated 11/20/19 and why there were no orders until 11/27/19. NP 'P' stated, The constipation was an incidental finding. The main finding was the wound, so we rely on the nurse and aids to tell us if a resident is having constipation, pain or distention. When asked if the incidental finding was significant, NP 'P' stated, Yes, but (R#702) was already on (Sennosides-[MEDICATION NAME] Sodium) so [MEDICATION NAME] and a suppository were added. NP 'P' was asked how she found out about abnormal findings. NP 'P' stated, Usually the nurse calls. When I do rounds, I check the computer for the results. NP 'P' was asked if a person could have daily bowel movements with a fecal ball present. NP 'P' stated, Yes, loose or liquid stool can get around a fecal ball. When NP 'P' was asked what would happen if nothing was done to remove a fecal ball, NP 'P' indicated that the fecal ball would continue to get bigger and harder and cause a bowel impaction. On 12/18/19 at 9:16 AM, a phone interview with LPN 'Q' was conducted. During that interview, LPN 'Q' was asked about the suppository ordered on [DATE]. LPN 'Q' stated, I remember that. (R#702's family member) was concerned she was constipated. I gave (R#702) a suppository that was ordered. On 12/18/19 at 10:55 AM, an interview was conducted with the Director of Nursing (DON). The DON was queried about why only a one time order for a suppository had been done for week's time following R#702's abnormal radiology report. The DON stated, The report went to the nurse, then it was reviewed by the Unit Manager, then it went to the IDT (Interdisciplinary Team) meeting and we discussed it. When the DON was asked about the report saying 'corelate for impaction, the DON stated, We did correlate in the IDT meetings, (R#702) didn't have any symptoms like abdominal tenderness, she had bowel sounds and she was having daily bowel movements. When the DON was asked what changed a week later when R#702 was prescribed [MEDICATION NAME] and suppositories, the DON stated, R#702 had decreased appetite. On 12/18/19 at 11:26 AM, an interview was conducted with Registered Dietician (RD) 'N'. RN 'N' was asked about R#702's appetite. RD 'N' stated, (R#702) was started on supplements when she was admitted . She was getting them three times a day. When RD 'N' was asked if R#702's appetite had decreased, RN 'N' stated, (R#702) was a one to one assist with eating and usually ate most of her meals. It looks like there were times she ate less than all, but for the majority of the time, she ate it all. Review of a facility provided CARE PATH Gastrointestinal (GI) Symptoms flow sheet dated 2014 read in part, . Consider Contacting MD/NP/PA for orders (for further evaluation and management) - Abdominal X-ray . (arrow to) Evaluate Results - results of abdominal X-ray/ultrasound suggests ileus, obstruction, mass, or perforation . (arrow to) Notify MD/NP/P[NAME]

Based on observation, interview and record review the facility failed to implement physician ordered aftercare recommendations following Right hip hemiarthroplasty (hip surgery) stemming from a right femoral neck fracture and provide education to all staff members on the proper bed mobility, positioning, body alignment and transfer techniques for one resident (R#62) of three residents reviewed for accidents, resulting in three additional incidences of a dislocated right hip within a two month time span, pain and hospitilization. Findings include: On 9/23/19 at 9:22 AM, R#62 was observed lying in bed with their eyes closed. R#62 did open their eyes when spoken to, however responded in another language. On 9/24/19 at 11:57 AM, R#62 was observed resting in bed on their back. No response was received when prompted with verbal stimuli. On 9/25/19 at 3:46 PM, R#62 was observed with a fall risk band on the left wrist, laying on their back with heel protectors on both feet. A review of R#62's clinical record revealed the following: R#62 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set ((MDS) dated [DATE] documented No for a Brief Interview for Mental Status (BIMS) assessment due to resident is rarely/never understood. R#62 required a two person assist with bed mobility, transfers, dressing, toileting, personal hygiene and bathing. Further reivew of R#62's record revealed the following: On 5/12/19 at 5:58 PM, a nursing note documented Resident observed in (room number redacted) sitting on the floor. Resident is unable to verbalized <sic> what occurred. Resident assisted from the floor via two-person mechanical lift. Pt. (patient) Able to provide active ROM (Range of motion) to bilateral upper and lower ext. (extremities) No pain voiced or observed at this time. Daughters have been made aware in person. DR. (doctor) is aware. No new orders. No s/s (sign/symptoms) of injury found . A facility incident report was reviewed and documented in part, . Time of Incident: 5/12/19 . Description of incident: Resident was observed sitting upright on the floor, near a resident's bed . Corrective Action . Resident was encouraged to use wheelchair and offered toilet by on duty aide . On 6/12/19 at 9:06 AM, a late entry nursing note documented 6-11-19 1950 (7:50 PM), pt (patient) was observed lying on the floor in (hallway number redacted) hallway. Pt was alert and moving all extremities. Resident states pt (patient) was walking back to her room and fell . Vitals obtained. Pt assisted up with a hoyer lift and placed in bed. Nurse assessed pt (patient), no bruises, abrasion or skin tears noted. Pt grimacing when turned. Pt rubbing that right thigh. Nurse noted knee slightly red and warm. Hip warm to touch. Nurse spoke with (Doctor name redacted) On call Physician, STAT x-ray of the right knee, thigh and knee, Tylenol 650mg (milligram) q (every) 6hrs x 24hrs and to apply Ben-Gay patch to knee and thigh x1 were ordered. Nurse tried to notify family no VM (voicemail) and no answer. Pt trying to drift off to sleep. Call light within reach, bed lowest position and neuro checks started per protocol. On 6/12/19 at 11:30 AM, a physician note documented in part . seen for follow up of her abnormal X-ray results. She had a fall yesterday in the facility and hence X-rays were ordered. X-ray of the pelvis and hip revealed an acute displaced right femoral neck fracture. Upon encounter she is in the bed, language barrier present, upon asking if she had pain, she pointed to knee . Assessment/Plan: Dislocated right femoral neck fracture: Patient will be sent to ER (emergency room ) for evaluation of her right [MEDICAL CONDITION], will possibly need surgery. Nursing informed. Staff will call family and notify them about the transfer . An Orthopedic consultation report dated 7/12/19 documented in part, . Follow-up/Aftercare following Right hip hemiarthroplasty after right femoral neck fracture . Patient is having no pain and able to ambulate comfortably with assistance or walker. Stable implants/hardware on x-ray. Incision clean, dry, intact with no signs of infection . Recommendations- pain medication as needed/prescribed, posterior hip precautions: limit flexion of hip past 90 degrees, avoid adduction of right hip, avoid > (more than) 20 degrees of internal rotation of right hip when in flexion, weight bearing as tolerated, follow up in 3-4 months . An additional Orthopedic consultation report dated 7/12/19 at 1511 (3:11 PM), documented in part . Review of the radio graphs today reveal stable appearance of the right hemiarthroplasty with no evidence of hardware failure, hardware subsidence, hardware loosening . Continue hip precautions . On 7/14/19 at 12:44 PM, a nursing note documented, Resident difficult to arouse. No appetite. Resident family member at bedside and is requesting her mother to be sent out for observation .(Doctor name redacted) on call Physician called (Doctor name redacted) notified and order for resident to be sent out for observation Dx (diagnosis) Altered Mental Status. (Ambulance name redacted) Ambulance notified and will arrive by 1:15pm. On 7/17/19 at 6:34 PM, a nursing note documented Patient arrived to facility at 1730 (5:30 PM) transported by EMS (Emergency Medical Services) accompanied by daughter. Diagnosis: [REDACTED]. A Discharge Summary from the hospital dated 7/17/19 at 1354 (1:54 PM), documented in part, . Dislocation of internal right hip prosthesis . Seen by ortho in ED (Emergency Department), s/p (status [REDACTED]. On 8/22/19 at 12:27 PM, a nursing note documented Resident's on duty aide observed resident with pain due to facial grimacing and moaning in her right knee while dressing. On duty aide reported that resident's knee seemed out of alignment and had noticed it this morning during care. Nurse (writer) assessed right knee and confirmed that knee is out of alignment by observation. Nurse (writer) called MD to give report on change of condition. MD (Medical Doctor) ordered that resident be sent to (hospital name redacted) for emergency x-ray. EMS (Emergency Medical Services) arrived to facility to transport resident to (hospital name redacted) moments later. Resident's daughter followed along in her car to meet EMS (Emergency Medical Services) at emergency. All responsible parties notified of changes . An ED (Emergency Department) After Visit Summary dated 8/22/19 at 3:42 PM documented in part, . [DIAGNOSES REDACTED]. Your doctor will give you safety precautions to keep your hip centered in its socket during the healing period. Be sure to follow these precautions, Keep your knees and toes pointed forward when you sit in a chair walk or stand, Do not sit with your legs crossed, Do not bend at the waist more than 90 degrees. Be careful when moving in bed to keep your legs straight ahead as possible . Follow hip precautions to limit hip movement . An Orthopedic consultation dated 8/2/19 at 1622 (4:22 PM) documented in part, . The daughter states ever since the dislocation, her mother's activities have decreased, her walking has been difficult and she continues to not be herself . Review of the radiographs today reveal stable appearance of the right hip hemiarthroplasty with no evidence of hardware failure, hardware subsidence, hardware loosening . I reviewed the x-rays myself. I will have (doctor name redacted) review them as well . Continue posterior hip precautions . On 9/3/19 at 12:55 PM, a nursing note documented Resident assessed by M.D. (Medical Doctor) and writer, right hip inversion new order to transfer to hospital (hospital name redacted) via (ambulance name redacted) ambulance. On 9/3/19 at 1:39 PM, a physician note documented in part (Resident name redacted) is seen for follow up. Nurse has noticed (Resident name redacted) right leg internally rotated. (Resident name redacted) has dementia and is unable to provide any history. Her face is flushed. She did not have her knee immobilizer in place. She had right hip arthroplasty dislocation x 2 until now. She is confused at baseline, but no new behavioral problems. She needs assistance in her care and family feeds her meals . lying in bed, mild-mod distress by facial appearance . Extremities: right leg internally rotated at the knee joint . 1. Right hip hemiarthroplasty dislocation s/p closed reduction w (with) conscious sedation x 2: Recurrent dislocation currently. Will need ER (emergency room ) evaluation and treatment by ortho . An ED (Emergency Department) After Visit Summary dated 9/3/19 at 7:23 PM documented in part, . [DIAGNOSES REDACTED]. ED (Emergency Department) consult to Orthopedic Surgery . Your doctor will give you safety precautions to keep your hip centered in its socket during the healing period. Be sure to follow these precautions, Keep your knees and toes pointed forward when you sit in a chair walk or stand, Do not sit with your legs crossed, Do not bend at the waist more than 90 degrees. Be careful when moving in bed to keep your legs straight ahead as possible . Follow hip precautions to limit hip movement . On 9/24/19 at approximately 12:20 PM, CNA (Certified Nursing Assistant-name unknown) in the 700th hallway, was asked what the facility hip precautions were for R#62 and the CNA reviewed R#62's Kardex and could not provide an answer. A care plan titled The resident has R (right) [MEDICAL CONDITION] r/t (related to) fall (created 6/16/19) documented in part, . Total right hip precaution- posterior hip precaution. (initiated 7/17/19). However, the care plan doesn't reveal what the Total right hip precaution- posterior hip precaution interventions are for staff to implement. On 9/25/19 at 12:46 PM, The Director of Nursing (DON) was interviewed and queried why the Orthopedic doctor recommendations for R#62's hip precautions were not implemented, and asked how would the Certified Nursing Assistants (CNA's) and Nurses know how to position, transfer, provide changing of R#62's briefs or showers for R#62 if they weren't taught what the hip precautions are. DON was further queried if they knew that the failure to implement physician recommendations contributed to the multiple dislocations of R#62's right hip. The DON indicated facilty staff were adhearing with hip precautions and would provide documentation. On 9/25/19 at 3:23 PM, the DON stated, Your right, the CNA's and Nurses were not taught hip precautions (although it says it on her Kardex total right hip precaution- posterior hip precaution), moving forward we will have the therapy dept. train all of the the staff on hip precautions. A facility policy titled Falls Practice Guide (Issue Date: 12/2011) documented in part, . Upon the completion of evaluation the physician is notified and orders are documented, noted and implemented, as indicated . The patient's condition, response to interventions and subsequent care provided is documented in the patient's clinical record .

This citation has three deficient practices. Deficient Practice #1 Based on observation, interview, and record review, the facility failed to implement interventions and supervision for one resident, (R#63) of two residents reviewed for elopement, resulting in an Immediate Jeopardy when R#63, who exhibited exit seeking behaviors, and had previously eloped from the facility, exited the facility unattended and without knowledge of the staff. This had the likelihood to result in serious harm and or death. Findings include: The Immediate Jeopardy was identified on 7/31/18 at 11:30 AM, the Administrator was notified at 12:02 PM, and a plan of removal was requested to remove the immediacy. The immediacy was removed on 8/1/18 at approximately 11:30 AM., based on the facility's implementation of an acceptable plan of removal as verified on site by the survey team. Although the immediacy was removed, the facility's deficient practice was not corrected and remained an isolated incident that is not Immediate Jeopardy. On 7/30/18 at 10:14 AM, R#63 was observed in bed. R#63 had clear and rapid speech but the content of the conversation was non-sensical. It was observed at that time that R#63 had a staff member, Licensed Practical Nurse (LPN) 'BB' seated at the beside with her. LPN 'BB' was asked if R#63 required one-to-one supervision and LPN 'BB' indicated R#63 did require one-to-one supervision. On 7/30/18 at 11:29 AM, 3:42 PM, and 4:00 PM, a review of progress notes for R#63 was conducted. The notes revealed the following: 6/16/2018 at 8:42 PM, the note read, General Progress Note-Note text: patient exited facility from back door of courtyard 3 staff member heard door alarm and checked door. Patient was not sitting in her wheel chair in front of nursing station. writer came out of patient room and noted coworker standing out back. writer ran out side. staff noted patient in courtyard. On call and family member notified. 6/26/2018 at 6:37 AM, the note read, Skilled Nursing Note Text: Resident alert with confusion .Resident wanders while displaying exit seeking behaviors . 6/29/2018 at 6:55 AM, the note read, General Progress Note-Note Text: alert, pleasantly confused. received wandering down 700 hallway. keeps on going from room to room, looking for door to get out, asking where is grand river? is it close or far from here? . 6/30/2018 at 4:17 PM, the note read, Skilled Nursing Note Text: Patient wanders .she says she forgets where her room is .She is closely monitored by staff while up out of bed . 6/30/2018 at 11:45 PM, the note read, General Progress Note-Note Text: wandering into other residents rooms about courtyards, upsetting them, eating their personal items, in need of constant redirecting . 7/6/2018 at 8:17 AM, the note read, Skilled Nursing Note Text: Patient pleasantly confused, trying to get home. Fussing with her clothes . 7/15/2018 at 3:10 AM, the note read, General Progress Note-Note Text: resident up in the middle of the night roaming into other residents rooms rambling in their drawers redirected back to bedroom . 7/15/2018 at 9:01 AM, the note read, Skilled Nursing Note Text: Received resident up ambulating. All her belongings were packed and in the room next doors bathroom. Items placed back in residents room, she did not want them unpacked . 7/17/2018 at 6:57 PM, the note read, General Progress Note-Note Text: Resident observed going into resident's room (room number redacted) unwanted. Resident confused as to where her room is . 7/18/2018 at 8:06 AM, the note read, General Progress Note-Note Text: alert with confusion. received awake in the hallway last night. wandering to different rooms. would take out stuff from the rooms including trash. redirected and re-orientated . 7/18/2018 at 8:54 PM, the note read, Skilled Nursing Note Text: Resident wandered in and out of other residents rooms. Re-directable but she states she is confused and forgets where her room is. Orientated back to her room and sometimes its only a minute later she is back out of her room and lost again . 7/19/2018 at 7:59 PM, the note read, Restraint Note Text: continues to wander, pleasant and redirectable. Wanders into wrong rooms, she forgets where hers is . 7/20/2018 at 2:12 AM, the note read, General Progress Note- Note Text: wandering about courtyard this shift, redirected out of other residents rooms, at times resistance to redirection, found laying in (room number redacted) bed in the evening part of the shift . 7/24/2018 at 8:19 PM, the note read, Skilled Nursing Note Text: Resident found wandering in other residents room. Residents complaining of items being taken out of rooms. Resident found wearing another residents pajamas. Resident has increased confusion noted at this time . 7/29/2018 at 1:46 AM the note read, Skilled Nursing Note Text: Pt (patient) Elope today. Found in the parking lot. Incident Report completed. No apparent injuries. Family, Physician, and DON notified .One on One activated until Monday. Pt pleasantly confused, unable to re-focus her about her keys and going home. A review of R#63's clinical record was conducted on 7/30/18 at approximately 4:10 PM. The record revealed R#63 admitted to the facility on [DATE] with admission [DIAGNOSES REDACTED]. A review of R#63's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R#63 was cognitively intact, though many nursing notes reviewed had indicated R#63 was often confused. The MDS also indicated R#63 exhibited Wandering Presence and Frequency 1-3 days and the answer to the question, Does the wandering place the resident at significant risk of getting to a potentially dangerous place (e.g., stairs, outside of facility)? was marked Yes. The MDS further assessed R#63 as being ambulatory on the unit. A review of an assessment titled, Behavioral Symptoms Assessment-v4 completed on 6/24/18 (8 days after the elopement on 6/16/18) indicated R#63 had an Identified Behavioral Symptom of Exit Seeking. A review of R#63's care plan initiated 6/25/18 was conducted and read, Focus: Exit seeking/elopement risk (specify behaviors) related to: cognitive impairment. Goal: Will adapt to new environment. Interventions: ALERT BRACELET. Allow to vent feelings and/or frustration prn (as needed). Be aware that when patient has her purse and is persistent about looking for her keys She is at High Risk to Elope (intervention initiated 7/29/18), Calmly redirect to an appropriate area. Check alert bracelet placement Q (every) shift and Functioning Q Day . It was noted that the care plan did not include interventions that included increased supervision, and also revealed all but one intervention per the resident's plan of care were dated 6/25/18. On 7/30/18 at 5:00 PM, The facility's Administrator was queried regarding R#63's two successful elopements from the facility. The Administrator was asked what door R#63 eloped from on 7/28/18 and stated, The front door. At that time, a request for any investigations or incident reports regarding the elopements on 6/16/18 and 7/28/18 was made. On 7/31/18 at approximately 8:48 AM a second interview with the facility's Administrator was conducted. When asked about the first elopement on 6/16/18, the Administrator indicated he was aware of the incident. The Administrator stated, It was my understanding it was witnessed that she went out, referring to elopement on 6/16/18. When asked about the nursing note regarding the 6/16/18 elopement from the Courtyard 3 exit, the Administrator acknowledged that the note did not paint a clear picture of the incident and it needed to be explained. At that time, the Administrator was asked again for any investigation information for the elopement on 6/16/18 and stated, I was comfortable with staff telling me they saw it and didn't do an investigation. When queried what interventions were put in place after the first elopement on 6/16/18, the Administrator indicated they put an alert bracelet on R#63 that would sound alarms if she were too close to the doors or tried to exit the building. During the interview, the Administrator did provide an investigation for the second elopement that occurred on 7/28/18 and when asked to explain what happened said, The nurse overheard a resident say there was another resident outside. At the same time the alarm went off and (Nurse 'B') saw R#63 and exited the building to bring her back in. The Administrator was then queried about the function of the doors and who checks the alert bracelet system. It was explained that all doors were alarmed, only certain doors had the bracelet alert system attached to them and the Maintenance Supervisor tested their function. At that time, a request for a facility policy on elopement was made. On 7/31/18 at approximately 9:00 AM, A review of a facility provided document titled,Investigation Report was conducted. The document read, Summary of alleged incident: On 7/28/18 at approximately 745pm nurse (Nurse 'BB') overheard the alarm to the front lobby door, and at the same time the alarm sounded, another resident was able to see (R#63) waling <sic> on the sidewalk toward the parking lot, and stated, she's outside. (Nurse 'BB') also saw the resident outside and ran to the nearest door to exit the facility and return resident back inside the center and accompanied resident safely to her room . The resident stated to (Nurse 'BB') that she exited the front lobby door, stating, I can read the sign it says push the door and hold it for 15 seconds, and it will open. I was looking for my car. DON (Director of Nursing) and ADMIN (Administrator) notified, family and physician notified, and the facility began it's investigation. On 7/31/18 at 9:15 AM, a review of the facility's environment and alarm doors was conducted. During the review, The Maintenance Supervisor intentionally set off the alarm to an exit door between the 600 and 700 hallway. Staff on the 700 hallway were aware of the alarm being intentionally set off and did not respond; however; it took approximately 3 minutes before a staff member from the 600 hallway responded to the alarm. After staff responded, and the alarm cleared, Certified Nurse Aide (CNA) 'C' (who did not respond) was observed in the 600 hallway. The Maintenance Supervisor asked CNA 'C' if she heard the alarm, to which she said, No. During the tour of the Environment it was also noted that the layout of the building would not have allowed staff to see the front door from the nursing unit where R#63 resided. It was observed that there was a long corridor from the nursing unit to the lobby and in order to have exited through the front doors, R#63 would have to had to make a left turn around a corner and into the lobby that was not visible from the nursing unit. On 8/2/18 at 8:50 AM, an interview with LPN 'O' who was present the evening of 7/28/18 when R#63 eloped from the facility was conducted. LPN 'O' was asked to recount her recollection of the incident. LPN 'O' stated, I heard the alarm go off so I started running toward the front door. At that time, I heard the resident in (room number redacted) yell, (R#63) is outside! When I looked out (room number redacted) the window, I saw her walking on the sidewalk quite away's from the front door. I turned around to go out the other door that was closer to her (the door between the 600 and 700 unit) instead of the front door and I brought her back in. On 8/2/18 at 2:43 PM, a follow-up interview with the facility's Administrator was conducted regarding the facility's Quality Assurance program. During the interview, the Administrator indicated the facility would be looking at how they handle residents with elopement risks and how they investigate occurrences. On 8/2/18 at approximately 4:00 PM, a review of the facility provided document titled, Chapter 11 MISSING PATIENTS dated 5/2011 was reviewed. It was discovered the policy outlined steps and procedures the facility would take if it was discovered a resident was missing; however; the document did not address the assessment, care planning, and prevention of elopement. A review of second policy provided by the facility titled, Your Resident Rights with an effective date of (MONTH) 15, (YEAR) read, .8. Safe environment---The resident has a right to a safe, clean, comfortable homelike environment, including but not limited to receiving treatment and supports for daily living safely . The facility submitted the following acceptable plan including supporting documentation to remove the immediacy on 8/1/18: Immediate Corrective Action: 1. The cited resident no longer resided in the facility. 2. R#63 was observed outside of the building unattended and was redirected cooperatively back in to the facility. R#63 was assessed as having no injury or change in condition. Administrator and Director of Nursing notified, family and physician notified. 3. R#63 was placed on 1-1 supervision post incident. 4. R#63 sent to the hospital 7/31/18. Identification of other: 1. All residents currently resding in the facility were assessed for exit seeking behavior. Evidence of the assessments was documented on an auidt sheet. 2. Residents that were identified as exit seeking were reviewed and appropriate interventions were in place, care plans were updated. Systemic changes: 1. All exit doors in the facility were checked on 7/29/18 for proper functioning, no issues identified, all doors were alarming properly. 2. Staff were educated on proprer response to witnessing exit seeking behaivor, what exit seeking behavior is, and how to respond to code greens and door alarms. Staff were in-serviced on elopement policy and procedure and new protocol on 6-29-18. 3. New residents will be assessed upon admission and behaviors and interventions will be put in place. Monitoring: 1. Unit manager or designee will audit those residents who have been identified as exit seeking to validate intervetntions in place and patient not actively exit seeking 5 days a week for 4 weeks. 2. Code Greens to be completed weekly for 4 weeks to audit saff response to door alarms. 3. Audits will be given to the administrator and trended, then forwarded to the QA&A for additional reccommendations and review. Deficient Practice #2 Based on observation, interview, and record review, the facility failed to complete root cause analysis investigations for accidents and hazards for three residents (R#63, #21 and #91) of 12 residents reviewed for accidents and hazards, resulting in the liklihood for inappropriate care planning and additional accidents. Findings include: R#63 On 7/30/18 at 10:14 AM, R#63 was observed in bed. R#63 had clear and rapid speech but the content of the conversation was non-sensical. It was observed at that time that R#63 had a staff member, Licensed Practical Nurse (LPN) 'BB' seated at the beside with her. LPN 'BB' was asked if R#63 required one-to-one supervision and LPN 'BB' indicated R#63 did require one-to-one supervision. On 7/30/18 at 11:29 AM, 3:42 PM, and 4:00 PM, a review of progress notes for R#63 was conducted. The notes revealed the following: 6/16/2018 at 8:42 PM, the note read, General Progress Note-Note text: patient exited facility from back door of courtyard 3 staff member heard door alarm and checked door. Patient was not sitting in her wheel chair in front of nursing station. writer came our of patient room and noted coworker standing out back. writer ran out side. staff noted patient in courtyard. On call and family member notified. 7/29/2018 at 1:46 AM the note read, Skilled Nursing Note Text: Pt (patient) Elope today. Found in the parking lot. Incident Report completed. No apparent injuries. Family, Physician, and DON notified .One on One activated until Monday. Pt pleasantly confused, unable to re-focus her about her keys and going home. A review of R#63's clinical record was conducted on 7/30/18 at approximately 4:10 PM. The record revealed R#63 admitted to the facility on [DATE] with admission [DIAGNOSES REDACTED]. A review of R#63's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R#63 was cognitively intact, though many nursing notes reviewed had indicated R#63 was often confused. The MDS also indicated R#63 exhibited wandering 1-3 days, potentially placing the resident at a risk of getting into a dangerous place . in the behavioral section of the MDS assessment. On 7/30/18 at 5:00 PM, The facility's Administrator was queried regarding R#63's two successful elopements from the facility. At that time, a request for any investigations or incident reports regarding the elopements on 6/16/18 ant 7/28/18 was made. On 7/31/18 at approximately 8:48 AM, a second interview with the facility's Administrator was conducted. When asked about the elopement on 6/16/18, the Administrator indicated he was aware that she had an elopement from the facility prior to the one on 7/28/18. The Administrator went on to say, It was my understanding it was witnessed that she went out, referring to elopement on 6/16/18. When asked about his understanding and the nursing note for the event that did not indicate staff observed R#63 exit the building from the Courtyard 3 exit, the Administrator acknowledged that the note did not paint a clear picture of the incident and it needed to be explained. At that time, the Administrator was asked again for any investigation information for the elopement on 6/16/18 and stated, I was comfortable with staff telling me they saw it and didn't do an investigation. On 8/2/18 at 2:43 PM, a follow-up interview with the facility's Administrator was conducted regarding the facility's Quality Assurance program. During the interview, the Administrator indicated the facility would be looking at how they handle residents with elopement risks and how they investigate occurrences. R#21 On 7/30/18 at 11:49 a.m., R#21 was observed sitting in a wheelchair in the hallway. R#21 was unable to answer any questions, pleasantly confused, and stated she was waiting for someone. On 7/31/18 at 3:23 p.m., R#21 was observed in her room wearing an alarm bracelet on her ankle. When asked if she had any falls recently, R#21 stated, I tripped myself outside. I keep looking. I don't see anything. It healed . On 7/31/18 at 3:30 p.m., during an interview, when asked about R#21's fall history, CNA 'RR' stated, I'm new. I know she wanders and go in other people's room. On 8/1/18 at 8:02 a.m., a review of the clinical record revealed R#21 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Significant Change MDS dated [DATE] revealed R#21 was severely impaired for cognition and required extensive assistance with one-person physical assistance for bed mobility, transfer, and toilet use. The MDS revealed R#21 was not stable, and only able to stabilize with staff assistance. Further review of the MDS revealed R#21 had 2 or more falls with no injury, one fall with injury, and 1 fall with major injury. A review of R#21's care plans revealed the following: F[NAME]US: At risk for falls related to difficulty walking, muscle weakness related to dementia, [MEDICAL CONDITIONS], repeated falls/fall with fracture. GOALS: Minimize risk for falls. Decreasing number of falls. INTERVENTIONS: Areas near resident will be kept tidy and orderly. ALL: Assist resident to bathroom before and after meals At bedtime (resident name) will be assisted in putting away personal belongings before sleep. Encourage resident to wear her bathrobe at night time when out of bed instead of wrapping up in her blankets when she is ambulating Encourage Resident to wear slip resistant socks to bed. Encourage to transfer and change positions slowly. Ensure proper footwear, gripper socks or shoes. Have commonly used articles within easy reach Keep resident in close visual placement. One person assist with transfer wheelchair no walker One person assist with transfers Patient to get early breakfast tray Provide assist to transfer and ambulate as needed Remain (remind) resident she is in a wheelchair and is not able to ambulate unassisted. Room Change, change in environment. Verify (resident name) is sleeping comfortably throughout night shift. Offer to get up if awake On 8/1/18 at 10:45 a.m., a review of the facility's Incident Reports revealed R#21 had 21 incidents regarding falls and unknown injuries that occurred on the following dates: 9/1/17, 9/4/19, 9/15/17, 10/26/17, 11/30/17, 12/8/17, 1/12/18, 1/16/18, 2/4/18, 4/11/18, 4/17/18, 4/19/18, 4/21/18, 4/25/18 Incidents with injuries (skin tears and open area): 10/2/17 - small open area on right wrist, 11/5/17 - right forearm 2 skin tears, physician not notified, 4/18/18 - bleeding from back of head, resident transferred to the hospital, 4/30/18 - fall with no injury, physician not notified, 5/11/18 - skin alteration on left lower leg, 6/14/18 - skin alteration from wheelchair, 7/25/18 - open left lower leg skin alteration. On 8/2/18 at 12:35 p.m., an interview was conducted with the Interim Director of Nursing (DON). When queried about the assessment and needs for R#21's incidents and falls, the DON stated, I have been at the facility since 7/2/18. Fall assessment is part of the admission packet, care plan is initiated, and then individualized as we know the resident's needs. When fall occur, (I/A) in this facility, all incidents are not investigated. If there is an indication for it, then it is investigated. Since I've been here, I have the nurses call me, so that I can ask those pertinent questions. Looking for the root cause. We need to look at the processes. We have incident reports with no information. The staffing coordinator was not effective. R#91 On 7/30/18 at 9:44 AM, Resident #91 was observed sitting in the hall in a wheelchair. The Resident was alert, but unable to answer questions asked. On 7/31/18 at 12:52 PM a review of Resident # 91 clinical record indicated that the Resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #91's Minimum Data Set (MDS) assessment dated [DATE] documented that the Resident was severely cognitively impaired and required two person assist for transfers. A review of Resident #91's At risk for falls due to impaired balance/poor coordination (date initiated 6/15/18) documented, in part, the following interventions in place as of 6/15/18 2 person transfer with gait belt . encourage to transfer and change positions slowly .have commonly used articles within easy reach .provide assist to transfer and ambulate as needed .refer to the Therapy Plan of treatment Reinforce need to call for assistance . Continued review of the Resident's medical record documented a Patient Safety Note Text dated 6/22/18: Writer observed resident on the floor on his back in resident's room. Resident has no apparent injury, no c/o pain or discomfort. Writer and staff assisted resident to chair with hoyer lift . Further review revealed Hospital (name redacted) that documented the Resident suffered a small hematoma due to a fall in the Facility and remained in the Hospital through 7/4/18. Progress Note 7/4/28, .patient admitted with .acute subdermal hemotoma . A Facility Investigation and Accident Report dated 6/22/18 documented, in part, the following: Type: Fall without injury. Description of Accident: Writer observed resident on back. Was Resident taken to hospital? No. Corrective Action: Resident assisted to chair with the aide of a hoyer lift On 8/02/18 at 12:38 PM and interview and record review was conducted with the Director of Nursing (DON). The DON was queried as to the incident regarding Resident #91 and the I & A and investigation follow-up. The DON reported that all accidents are not always investigated. The DON reported that no further investigation was completed for the Resident. When queried as to how the Facility determined the cause of the Resident's fall, the DON stated, I started working at the Facility about a month ago. I agree that investigations need to be done in order to determine proper interventions. I think looking for a Route Cause is important and the Facility needs improvement, especially in the area of falls. If you don't search for the root cause, then it's difficult to determine. In the case of Resident #91, there is very little information provided and no investigation. On 8/2/18 at approximately 12:00 PM a review of the Facility Policy titled Falls Practice Guide (issue date 12/2011) was conducted and documented, in part, the following: Disclaimer: This booklet is considered a practice guide. The information included within this guide does not relieve a business unit or center of the obligation to comply with .federal and state regulations .Purpose: the purpose of the Falls Practice Guide is to describe a process of steps for identification of patient fall risk factors and interventions and systems that may be used to manage falls. Fall management focuses on minimizing fall risk factors and fall related injuries while continuing to promote the patients quality of life .Initial Evaluation: upon admission, review hospital discharge records, transfer sheets or other data regarding the patients history of risk factors .FYI .studies have shown that a patients risk of falling increases significantly as the number of risk factors increases .the risk for patient falls is potentially greater upon admission and within the first few days .Medical Care Initiative .decreasing the incidence of falls and potential fractures among patients is paramount .Initial Plan of Care .if upon completion of the Patient Admission .the patient is found to be at risk for falls or has a history of falls, the physician is contacted for orders Ongoing Management Strategies On the basis of the information obtained and analysis performed in the assessment and planning phases, the next step is to implement an organized approach for the management of the patients falls or fall risk factors .Change in Condition or Fall Occurrence an evaluation of the patient is completed timely following a fall or change in patient condition . Deficient Practice #3 Based on observation, interview, and record review, the facility failed to ensure an office containing a pot of hot coffee was locked and inaccessable to residents for one resident (R#7) of 12 residents reviewed for accidents and hazards, resulting in the liklihood of injury. Findings include: On 7/30/18 at 10:20 AM, R#7 was observed to propel her high back wheelchair into a small, unoccupied office on the 700 unit that is adjacent to the courtyard exit. It was observed that a metal pitcher for heating water or coffee was plugged into an electrical outlet and placed on the top shelf of a shelf unit. It was observed that the pitcher and the cord were within arms reach of R#7. R#7 was sitting in the doorway of the office and was observed shuffling items on one of the lower shelves. On 7/30/18 at 10:23 AM, Certified Nurse Aide (CNA) 'I' was observed to look out the courtyard door near the office R#7 was in. CNA 'I' was not observed to re-direct R#7 out of the office. On 7/30/18 at 10:25 AM, R#7 was removed from the office by Licensed Practical Nurse (LPN) 'T'. LPN 'T' was overheard to say, We need to lock this office as she re-directed R#7 away from the office. At that time, the exterior of the metal pitcher was felt and was noted to be hot to the touch. LPN 'T' was queried about who's office it was and indicated it was Unit Manager 'A's. On 8/1/18 11:18 AM, a review of R#7's clinical record revealed an admission date of [DATE] and re-admission date of [DATE] with [DIAGNOSES REDACTED]. A review of R#7's most recent completed quarterly Minimum Data Set (MDS) assessment indicated no assessment for cognition had been completed on 4/24/18 and the resident was independent for wheelchair mobility. A review of the previous MDS assessment completed 1/22/18 indicated severe cognitive impairment. A review of R#7's care plans for activities dated 10/18/16 read, pt. (patient) frequently wheels self around halls . On 8/1/18 11:30 AM, an interview with Unit Manager 'A' was conducted. Unit Manager 'A' indicated the office should have been closed and said, We got rid of the coffee pot, it won't be back in the building. On 8/2/18 at approximately 4:00 PM, a review of a facility provided policy titled, Your Resident Rights with an effective date of (MONTH) 15, (YEAR) read, .8. Safe environment---The resident has a right to a safe, clean, comfortable homelike environment, including but not limited to receiving treatment and supports for daily living safely .

This citation pertains to MI 554, MI 466, and MI 552: Based on observation, interview, and record review the facility failed to ensure residents were free from abuse for four (R#10, #13, #57, #331) of thirteen residents reviewed for abuse, resulting in actual abuse when R#10 slapped R#13 and R#57 assaulted R #331 causing scratches, bleeding, pain and a trip to the emergency room . Findings include: Residents #10 and #13: On [DATE] at 9:58 AM R#13 was queried in regards to his stay at the facility responded, I had one resident who slapped me in the face. Per R#13, a resident had slapped him in the face when he (R#13)had been coming from one hallway to another. R#13 explained the other resident had told him (R#13) to go into the television room. Per R#13 he had said no, and the other resident had slapped him. R#13 explained the incident had occurred over a month ago. On [DATE] at 12:52PM review of a progress note for R#13 dated [DATE] at 2:08PM revealed the following: Resident alert responsive able to make needs and wants known. All meds given by writer. @1240 Resident was sitting in the hallway and resident from (unit redacted) ask him to move he just look at her. Resident from (unit redacted) then roll up to him and slapped resident (unit redacted). This was witness by staff. Staff could not reach residents. Writer was passing meds staff notified her she then went and separated the two resident. Doctor and family member notified. Pain assessment done. I&A (incident and accident) complete. Writer took staff statement cause it was witness. Writer assess resident. No marks or redness observed on resident L (left) side of face. Resident denies pain at this time. Safety maintained. Review of a social services progress note dated [DATE] at 2:18PM documented the following: SSD (social services department) met with patient in Maple room to f/up (follow up) with recent slap from another female resident. Patient is A&Ox3 (alert and oriented to person, place, time). Patient presented with appropriate affect and congruent emotional display. Pt reports he is afraid of the other resident but feels safe at this facility as long as the female resident stays away from him and as long as facility is able to control the resident. SW (social work) assured pt that staff will do our best to keep them apart and the other resident away from him. He says that he felt good overall on today. SW discussed with and assisted in providing techniques to cope with his fear from other residents. Patient did not present with suicidal ideation, no intent and no distress noted. SW will continue to follow and provide supports. On [DATE] at 11:21 AM the clinical record for R#13 was reviewed and revealed the resident was admitted into the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Per review of the resident's MDS assessment dated 4XXX,[DATE] the resident scored 15 out of 15 on a brief interview for mental status exam, which indicated the resident was cognitively intact. On [DATE] at 6:01 PM review of facility reported incident documentation identified R#10 as the resident who had struck R#13. Per documentation of the facility reported incident (FRI) incident summary the following was documented: On [DATE] at 1pm, (R#10) slapped (R#13) in the face while passing by in her wheelchair. The incident was witnessed by the facility's laundry aide. The residents were immediately separated and the ADMIN (Administrator) and DON (Director of Nursing) were notified,. (R#13) was assessed as having no injury. The facility informed family and physician, and (R#10)was sent to the hospital for a psychiatric evaulation. The facility immediately began its investigation. There were no staff involved with the incident. On [DATE] at 6:10 PM a statement on behalf of R#13 dated [DATE] provided by the facility revealed the following: I was going down the hallway & I was going to go into my room And she was blocking the hallway to go to my room. And she told me to go to room where the TV was & I said no. And she slapped me. She slapped me on the left side of my face. It was (last name of R#10) On [DATE] at 8:06 AM the clinical record for R#10 was reviewed and revealed the resident had been admitted into the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's quarterly minimum data set (MDS) assessment did not reveal an assessment of the resident's cognition. Review of a progress note for R#10 dated [DATE] at 6:52PM (one month before the incident between R#10 and R#13) documented the following: Floor Nurse came to writer and stated this pt did hit another resident with her elbow. another CNA (Certified Nursing Assistant) was witness and stated that resident use her elbow and hit the other resident arm. Nurse separated both resident. Administrator was notified right away with the incident. and he said he will f/u (follow up) also he asked the other nurse on the floor to complete an incident report on the resident who got hit. Per a Mood and Behavior Progress note dated [DATE] at 3:57PM the following was documented: resident combative this shift, continues to strike at staff, continues attempting to bite staff, attempting to enter other residents rooms, states my furniture is in those rooms, redirected back to her room, currently up in w/c (wheelchair) wheeling self around unit, family notified of residents behavior, will continue to monitor On [DATE] at 9:37 AM review of a current plan of care for R#10 revealed the following: Verbal/physical agitation/aggression (hits/kicks/grabs with verbal aggressiveness/throwing cup off coffee at staff/cursing)related to:Cognitive impairment/dementia. On [DATE] at 9:39 AM review of a behavioral assessment for R#10 dated [DATE] documented the following: physical combativeness,agitation,irritability, or [MEDICAL CONDITION], unsafe impulsive behaviors, and nature of the behavioral disturbance-unprovoked. On [DATE] at 10:14am R#10 was observed in her room in a wheelchair, with a one on one staff member present in the resident's room. R#10 was queried as to who was present with her in her room, and responded that was her daughter. R#10 was queried as to where she was and responded that she was at her house. On [DATE] at 12:58 PM SW 'E' was queried as to how R#10's behaviors were managed, and responded that the resident had a one on one sitter, and explained the resident had a one on one sitter on and off. Per SW 'E' the sitter had previously been removed and then had to be reinstated. Per SW 'E' R#10 was petitioned out of the facility on [DATE] due to hitting a resident, and when R#10 returned the one on one sitter was reinstated. When queried as to the reason R#10 had a one on one sitter, SW 'E' responded it was related to aggressive behaviors and trying to get on the floor. SW 'E' explained, if anybody is in her (R#10's) space she will swing. SW 'E' explained that if the resident was unable to maneuver her wheelchair around or if she became stuck between two people then the resident would turn around and swing and hit them. SW 'E' reported that following the incident involving R#13 when the resident was triggered and agitated it did not matter who the person was, the resident would hit. Per SW 'E' when R#10 said no, she meant it. On [DATE] at 2:46 PM the Administrator, who functioned as the facility's Abuse Coordinator, was queried in regards to R#10, and responded that the resident required redirection and needed constant supervision. Per the Administrator R#10's one on one supervision had been previously discontinued with the plan to be to monitor the resident for behaviors, to provide close supervision for the resident, and to encourage/increase activities. Resident #57 and Resident #331 Resident #57 On [DATE] at 12:21 PM, Resident #57 was observed sitting in the large dining room. Resident #57's hair was unkempt, had dirt under the fingernails and his beard appeared scruffy and unshaven. Resident was alert, but confused when queried as to questions about life in the Facility. On [DATE] at approximately 10:28 AM a review of Resident #57's electronic medical record was conducted and revealed that the Resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the Residents Minimum Data Set (MDS) assessment dated [DATE] indicated that the Resident had a BIMS (brief interview for mental status) score of four (severely cognitively impaired), displayed physical behaviors towards others and required extensive assistance with personal hygiene, including bathing and showering. A review of Resident #57's behavior care plan documented that the Resident was at risk for behavior symptom .Resident hitting or becoming agitated with staff or caregivers/family. Resident attacking other residents (date initiated [DATE]- updated [DATE]). Continued review of the Resident's clinical record revealed, in part, the following progress notes: [DATE] 18:11 General Progress Note Text: Resident's wife was trying to wheel resident into the bathroom. Resident was agitated and was refusing to go into bathroom. Resident then hit his wife on the left side of face . Dr (name redacted) notified of incident. On call supervisor and DON notified of incident. (authored by Nurse DD) [DATE] 14:45 General Progress Note Text: Resident was hitting his wife in the activities room. Resident was removed from activities room and separated from wife. Dr. (name redacted) notified and Guardian (name redacted) Resident son (name redacted) called left message to call the facility. (authored by Nurse DD) [DATE] 14:50 General Progress Note Text: Resident was in the dining room with another resident witness by staff. Resident grab ahold of another resident's arm and shirt. Starting hitting resident. He would not let go of the other resident. Yelling Where is my knife. He was screaming let me get out of here, I need my knife. He starting grabbing the tables and tablet cloths as he was wheeling by. Then grabbing the vase and throwing it at a staff member. The vase scattered. Witness stated, he threw himself out of his wheelchair on the floor. Resident became combative and resistant to care. Staff unable to get resident off the floor because resident was kicking and swinging at staff. 911 called awaiting arrival. Administer of facility notified. On call supervision in house. Dr.(name redacted) notified order to transfer to hospital. (authored by Nurse DD) [DATE] 12:36 General Progress Note Note Text: Resident became combative when approached for morning medpass, resident spit on writers face, grabbed writer and punched writer in the arm multiple times, writer was able to remove self out of room pt safety maintained, on-call nurse called and made aware of incident and that resident did not have a sitter scheduled with him for dayshift as directed . On [DATE] at approximately 9:00 AM the Facility was asked to provide and Investigation and Accident ( I&A) Report pertaining to the incident involving Resident #57 on [DATE]. The Facility provided the requested documents and indicated that the Incident was reported to the State Agency. The I & A Investigation Report documented: Date of Incident [DATE] .Summary of Alleged Incident. Resident to Resident altercation resulting in minor injury occurred on [DATE] .the aggressor was hospitalized to rule out psychiatric ailments and returned within 24 hours and was placed on a ,[DATE]. Resident who was struck sustained redness to her face and superficial scratches to both arms Timeline of events .On [DATE] resident was attending activity with his wife and he became irritable .the activity assistant called for the nurse to separate him from his wife .resident left the activity willingly with the nurse who gave the resident a snack and seated the resident in the cafe while watching TV .after the resident finished his snack, he wheeled himself into the main dining room and became spontaneously agitated and wheeled to another resident (name redacted/#331) and started yelling, where's my knife and began holding the other resident's arms. At that time there were no other residents in the main dining room. The resident who was the victim yelled for help and the nurse witnessed (name redacted/R#57) holding onto resident (name redacted/R#57) arms. Assessed (Name redacted/R#331) as having a reddened face and superficial scratches to her arms and face. There were minor visible bit marks .however the skin was not broken .Both residents were sent to the hospital for further investigation . Resident #331 Resident #331 no longer resides in the Facility. On [DATE] a review of the Resident's clinical record documented that the Resident was originally admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the Resident MDS indicated that the Resident had a BIMS score of ,[DATE] (moderately intact) and required extensive one person assist for ADLs. Continued review of the Resident's clinical record revealed the following Progress Note: [DATE] 16:18 Skilled Nursing Note Text: Resident was sitting in the dining room watching out a window. Nurse was called to help by a visitor who heard her calling help. Nurse observed another resident holding her shirt and her right arm. Resident was yelling help. The other resident came up to her, he hit and scratched her on the right side of her face, neck and top of right shoulder by her neck. He bit her on her right wrist, bite marks were visible, skin was not broken. Patient removed from situation and kept with staff. Staff reassured patient she was safe now because she was scared and that he was not able to get to her . Ice packs placed on R (right) hand and R side of face and forehead. Pt was closing her right eye. Tylenol given for pain . MD notified. New order: Send to hospital for evaluation and x-rays Administrator notified. Police notified . Hospital Record: [DATE] R .presents to the emergency department via EMS (emergency medical services) with a chief complaint of assault at (name redacted) Nursing Home by another resident today. Per nursing note patient was in the dining hall when she was punched by a closed fist to the right side of her face. Patient states she does not know what happened but states she is here because she is bleeding everywhere. Patient further endorses pain everywhere. She denies falling .Final Impression: Traumatic injury of head, initial encounter, facial injury, initial encounter, Assault. [DATE] 12:20 Skilled Nursing Note Text: I heard back from the hospital RE; left ankle injury . c/o (complains of) pain upon arrival, so they did an xray. No FX(fracture) . [DATE] 16:23 note : [MEDICATION NAME] Tablet Give 650 mg by mouth every 6 hours as needed for pain c/o pain . repositioned, but still requested med . [DATE] 15:41 Social Services Note Text: Psychosocial/Wellness .visited with nurse while resident was sitting alone in main dining room looking out of the glass door. Resident reported that she is doing ok and that she feels better today but she is still sore over entire body . [DATE] 08:40 Social Services Note Text: Psychosocial/Wellness Visit-SW visited with resident at bedside. She was laying in bed. (name redacted asked hew how she was feeling, (name redacted) reported ok but still sore. SW asked resident did other resident choke her, she replied that she can't remember but she knows that her throat is sore. Resident and reported that she is doing ok and that she is not happy being in a facility but she does feel safe here at (name redacted) .validated her feelings and provided supports. On [DATE] at 10:50 AM, an interview and record review was conducted with the Administrator regarding the incident between Resident #57 and Resident #331. The Administrator reported that the incident did occur and that Resident #331, a hospice patient, expired in the beginning of July. When further queried as to the incident, the Administrator stated, Resident #57 had a history of [REDACTED]. The day of the incident he started to get agitated with his wife and was removed from the Activity room and placed in the lounge in front of the Nurses station and given a snack by Nurse DD. At some point he wheeled himself down to the main dining room. Resident #331 was sitting in the dining room alone and looking out of the window. A visitor reported to a staff member that she heard someone yelling for help in the dining room. Upon entering the dining room, Resident #57 was observed holding onto Resident #331's arm and shirt and would not the Resident go. Staff were able to separate the two residents and we sent Resident #331 to the Hospital for a full work-up and Resident #57 to the hospital for a psych evaluation. When queried as to why the Resident was not monitored following the incident with his wife, the Administrator stated, The nurse thought he had calmed down and she (the nurse) left him to perform care. Honestly, he did not have a history of being combative with other residents, just family and staff. He does have a history of [MEDICAL CONDITION] and something must have triggered the behavior. On [DATE] at 11:16 AM an interview was conducted with Nurse DD. Nurse DD was queried as to the incident between Resident #57 and Resident #331. Nurse DD stated, I was working that day and was told the Resident was agitated with his wife and I believe a CNA (certified nursing assistant) took him out of the activity room and brought him back to the nursing station. I gave him a snack and he appeared to calm down. I left to do medication pass. He wheeled himself down to the dining room. I did not see him. I just heard what happened after. When queried as to whether Resident #57 had a history of [REDACTED]. Honestly, I never would have left him alone if I thought he wasn't calmed down. When queried as to the distance from the lounge to the dining room, Nurse DD reported that it is a ways down the main hallway and stated, Resident #57 can wheel himself pretty fast. On [DATE] at 8:20 AM an interview and record review was conducted with Social Worker (SW) E. When queried as to the incident between Resident #57 and Resident #331, SW E stated, Resident #57 has been know to have on and off behavior issues, but no with other residents. He was know to get physically aggressive with his wife. When he was in the Activity room he became agitated with his wife and was removed from the room. I was told that he wheeled himself to the dining room. My understanding is that a visitor heard Resident #331 yelling for help and when staff entered the room, Resident #57 was grabbing onto Resident #331. She had scratches on her face and was sent to the hospital for a full workup. SW E was queried as to the implementations that were in place for Resident #57 prior given his behavior history, SW E stated, I know he had a history of [REDACTED]. In my opinion I believe the Nurse should have monitored him after the incident in the Activity room with his wife. He was left unattended and had to travel a long distance on his own from the lounge to the dining room. On [DATE] at approximately 3:00 PM a review of the Facility Policy titled Patient Protection Practice Guide(issue date ,[DATE]) was conducted and documented, in part, the following: The .(Guide) is an approach that uses the seven key components of an abuse intervention program to identify and prevent risk of abuse abuse is the willful infliction of injury .with resulting physical harm, pain or mental anguish .the most critical step toward detecting and preventing abuse is acknowledging that no one should be subjected to violent, abusive, humiliating .behavior .it is essential that center practices help prevent abuse, possible reoccurrence and respond actively to detect and prevent abuse .The intervention strategies for patients with dementia apply regardless of whether the individual is living in a nursing center. Specific additional behavioral and environmental interventions may be obtained from practitioners and other experts in the field to promote well-being, reduce frustration and anxiety, and minimize the potential for unpredictable catastrophic reactions and other negative outcomes of care .

Based on interview and record review, the facility failed to ensure that one resident (#619), of four residents reviewed for leave of absence approval, from a total sample of 30 residents, was not allowed to exit the facility unsupervised. Resident #619 left the building unsupervised on 2/6/17, obtained and filled a prescription for a narcotic medication. This deficient practice resulted in Immediate Jeopardy risk of harm related to taking opiate medication unknown to the facility and the risk posed by resulting respiratory depression in the presence of chronic respiratory disease. Two days later, Resident #619 was found with an altered level of consciousness and respiratory distress, which resulted in emergency hospitalization on [DATE].â Eurot The amendment addresses the residentâ Euro (Trademark)s risk for harm in taking opiate medication unknown to the facility and the risk posed by resulting respiratory depression in the presence of chronic respiratory disease. It also amends the level of consciousness of Resident #619 that was refuted by the facility. The Immediate Jeopardy was identified on 6/8/17. The Administrator was notified of the Immediate Jeopardy on 6/8/17. A plan to remove the immediacy was requested. The immediacy was removed on 6/8/17 based on the facility's implementation of an acceptable plan of removal as verified on-site by the survey team. Although the immediacy was removed, the facility's deficient practice was not corrected and remained isolated with actual harm that is immediate jeopardy. Findings include: A review of Resident #619's clinical record was reviewed on 6/7/17 at 1:30 PM and revealed that Resident #619 was originally admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment dated [DATE] revealed a 15 out of 15 BIMS (brief interview of mental status) score which indicated the resident was cognitively intact. On 6/7/17 at 1:00 PM, a review of the facility's document titled Incident Detail- Summary of Critical Information dated 4/20/17 was conducted. The Incident Detail documented: Resident #619 reported that she had gone to doctor's office previously to get prescriptions that she would fill and not tell the center about. On 2/6/17, Resident #619 had gone to doctor 'EE' and obtained a prescription for [MEDICATION NAME] sulfate 30 mg (milligram) tabs at a quantity of 180 tabs. She had the prescription filled and had taken 46 tablets within two days. On 2/8/17, Resident #619 was sent to the hospital unresponsive. The prescription bottle was found under the bed with 134 tablets in it. A review of Resident #619's care plan, date initiated 10/29/15, documented: Focus- At risk for behavior symptoms r/t (related to) mental illness as evidenced by manipulative behaviors, reporting of the allegations towards staff when upset, has narcotic dependency and history of obtaining medications not prescribed by the facility. Interventions: *Resident may leave the facility with either of her two sons. She cannot leave the facility with anyone else (date initiated 4/22/16). *Attempts to make physician appointments without her attending physician or the facility knowledge. Explain to resident she is able to see an outside physician as long as the referral is approved by her attending physician (date initiated 4/27/16). On 6/7/17 at 4:40 PM, an interview was conducted with the Administrator and Director of Nursing (DON). When queried regarding Resident # 619 and the incident that occurred on 2/6/17 and 2/8/17, the Administrator stated: She (referring to Resident #619) had a leave of absence and would take the bus to visit physicians. The Administrator indicated that the resident went on leave of absence with a friend on 2/6/17. The Administrator was queried further regarding the care plan which documented: Resident may leave the facility with either of her two sons. She cannot leave the facility with anyone else (date initiated 4/22/16). The Administrator indicated that the care plan had not been updated. The Administrator further explained that the guardian had allowed her to see a specialty doctor who would prescribe [MEDICATION NAME] sulfate. The Administrator indicated that on 2/6/17, the resident went on a leave of absence to this doctor and 2 days later Resident #619 was found unresponsive by staff. The Administrator said on the day she went to the hospital we found a bottle of pills under her bed. The Administrator presented an empty pill bottle dated 2/6/17 of the narcotic [MEDICATION NAME] sulfate that had been prescribed and filled for Resident #619 and indicated that the resident's guardian had advised her to destroy the medication that remained in the bottle. The label on the empty bottle documented: [MEDICATION NAME] 30 mg tabs. 1- 2 tablets p.o (by mouth) Q (every) 4 to 6 hours. QTN (quantity 180 tabs) which was prescribed by Physician 'EE'. On 6/8/17 at approximately 8:10 AM, the facility's Leave of Absence log for Resident #619 was reviewed. The Leave of Absence log included the following directions: Patient or authorized representative (guardian/responsible party/power of attorney for health care) reads and signs acknowledgement below in the presence of a witness that also signs the form. The Patient or Authorized Representative Signature on the log, was signed by Resident #619. The Witness Signature was left blank. The Leave of Absence log documented: Signing Out and Signing In Date: 2/6/17 Time: 10:20 and 12: 30 AM (under signing out) and noon and a second illegible time (under signing in). Signature of Patient or Person Accepting Responsibility for Patient- was signed by Resident #619. A telephone interview was conducted with Physician 'EE', hematology and oncology physician, on 6/8/17 at 9:08 AM. When queried regarding Resident #619, Physician 'EE' stated: She has been on [MEDICATION NAME] for a long time and followed by pain clinic. I've known her for over [AGE] years. She has had multiple fractures, has [MEDICAL CONDITION] and has had infections. I saw her on 2/2/17 and refilled it (prescription) on 2/2/17 (referring to the narcotic [MEDICATION NAME]). She may not have refilled til 2/6/17. Assumed she was being watched. Physician 'EE' also indicated that Resident #619 visited him on 3/2/17 and got another script for the narcotic medication [MEDICATION NAME] sulfate and that he had not seen the resident after this date. A review of an electronically signed order dated 1/19/17 at 1:30 AM by primary care physician 'DD' was conducted on 6/8/17 at 9:30 AM and documented: Patient may go LOA (leave of absence). The physician's orders [REDACTED]. A telephone interview was conducted with primary care physician 'DD' on 6/8/17 at 10:35 AM. When queried regarding Resident #619 and the incidents that occurred on 2/6/17 and 2/8/17, Physician 'DD' stated: She (referring to Resident #619) is not allowed to leave unaccompanied. She goes to different physicians' offices, to get scripts (referring to [MEDICATION NAME] sulfate). She cannot go see anyone without supervision. She has to be accompanied by someone. She has done this before. Physician 'DD' indicated that he had a physician that covers for him at the facility and stated: He (referring to colleague) knows her behavior. She is not allowed to leave unaccompanied. I would not give an order in January (referring to the 1/19/17 physician's orders [REDACTED]. Resident #619 required supervised leave of absences for years and stated: She is very manipulative. I had to assign a legal guardian. Primary care physician 'DD' explained that the guardian was assigned to Resident #619 in 2015. Primary care physician 'DD' stated: Yes, she is with it (referring to Resident #619's cognitive status) but not making appropriate decisions. We (referring to primary care physician and guardian) gave her supervision. On 6/8/17 at 12:00 PM, a review of the psychiatric note dated 2/20/17 was conducted. Resident #619 was referred for psychiatry consultation by physician 'DD'. The psychiatric note documented: Pt (patient) has been making accusations against staff, reported history of [MEDICAL CONDITION] disorder, asthma, Per history, she overdosed on [MEDICATION NAME]/ which is what landed her in the hospital. On 6/8/17 at 2:59 PM, a telephone interview was conducted with Resident #619's assigned Legal Guardians 'BB' and 'CC'. When queried regarding Resident #619 and the incident that occurred on 2/6/17 and 2/8/17, both Legal Guardians indicated that they were not contacted prior to the leave and had not approved a leave of absence for 2/6/17. Legal Guardian 'CC' stated: We were not told when the outside appointments were happening or occurred. I believe that she (referring to Resident #619) was making the appointments herself. That specific appointment (referring to office visit with Physician 'EE') needs a consent. We would approve for her to go with her sons on visit. A telephone interview was conducted with Nurse 'FF' on 6/8/17 at 3:17 PM. When queried regarding Resident #619 and the incident that occurred on 2/6/17 and 2/8/17, Nurse 'FF' stated: I don't remember or recall an order because there were issues with her before going on leave of absences and getting her own medications. I don't recall receiving an order from the primary care physician 'DD'. A review of the facility's policy and procedure titled Leave of Absence: Patient dated 3/2010 was conducted on 6/8/17 at 3:30 PM. The policy and procedure titled Leave of Absence: Patient documented: Purpose: To provide a system for notification and documentation of a patient's leave of absence from the center if authorized by the physician. Equipment: *Leave of Absence form *Log book for maintaining Leave of Absence forms for patients on a unit or floor Procedure: *Obtain physician permission for leave of absence from the center and communicate to patient/authorized representative (guardian/responsible party/power of attorney for health care) any restrictions or recommendations of the physician *Patient or authorized representative reads and signs acknowledgement on Leave of Absence form in the presence of a witness that also signs the form **If the patient cannot make own decisions and has an authorized representative, that individual signs the patient out of the center on the Leave of Absence form including current date, time and anticipated time of patient return --If an individual other than the patient's guardian/responsible party wishes to take the patient out of the center, the nursing staff must obtain permission from the authorized representative. The facility submitted the following acceptable plan including supporting documentation to remove the immediacy on 6/8/17: Date: 06/08/2017 This serves as Marvin and Betty Danto response to the Immediate Jeopardy that they received on 6/8/2017. The facility Quality Assessment and Assurance committee met on 6/8/2017 at 2:15 pm to resolve the alleged failure of the facility to ensure that one resident #619 who according to the attending physician should not have gone on a leave of absence without supervision, was allowed to exit the facility unsupervised on 2/6/17 and then obtained and filled a prescription for a narcotic medication and two days later was found unresponsive which required emergency hospitalization on [DATE]. As a result the following plan of correction has been developed. The following serves as the statement of abatement for Marvin and Betty Danto: #1- Cited resident no longer resides in facility. On 2/6/17, resident left facility for lunch with friend, returned the same day with no concerns/issues. 2/7/17 in A.M.- Nurse noted SOB, generalized [MEDICAL CONDITION], and low oxygen sats. Encouraged to deep breath, notified MD with new order for [MEDICATION NAME] and PRN oxygen. At 1908- Nurse noted patient still congested, Rales noted in bilat lung fields. Vital signs stable. 2/8/17- PRN nebulizers given, patient c/o SOB, head of bed elevated. Lungs sound with rales/wheezing, doctor notified with new order for Chest x-ray, stat [MEDICATION NAME] and the doctor stated would be in to see patient. At 1715 Physician seen patient and ordered patient to be sent out. Patient admitted to PPH with dx of acute [MEDICAL CONDITION], fever and anxiety. Returned to Marvin and Betty Danto on 2/14/17 with dx of acute [MEDICAL CONDITION], fever and anxiety. Patient transferred to hospital two more times for respiratory issues before discharging to a group home on 4/25/17 in stable condition. #2- All residents currently residing in the center has been audited to ensure M.D. orders are in place for LOA. Like residents are those who have an order for [REDACTED].# 5, 7,9,11,12,13,14,16,33,34,36,38,41,45,49,52,54,62,64,67,76,79,81,84,87,94,95,96,105, 106,107,108 Those residents have been reviewed to ensure they have not left the facility unsupervised. No concerns were noted. New admissions will be reviewed for MD orders for LOA and those residents that require supervision will not leave the facility unsupervised. #3- Licensed nurses will be educated on the LOA process to include residents with orders for supervised LOA are not to leave the facility unsupervised and must sign out for LOA with nurse in accordance to facility policy. 12/55 Nurses have been educated at this time. Licensed nursing staff will be educated prior to the start of working on the floor with residents. No licensed nursing staff worked prior to receiving the education. New licensed nursing staff hires will be educated prior to their first scheduled shift. #4- DON/Unit manager or designee will audit those residents with orders for LOA with supervision Daily for 4 weeks, then weekly for 2 mouths to ensure appropriate supervision provided when going on LOA. Administrator is responsible to ensure that compliance is attained and maintained. Audits will be reviewed and trended in QA&A committee. #5- Date of compliance 6/8/17

Based on observation, interview and record review, the facility failed to prevent an avoidable fall by failing to review the resident's needs care plan and failed to follow positioning procedures during care for one sampled resident (#701) out of three residents investigated for falls out of a total sample of three residents resulting in pain, anguish and injury. Findings include: Resident #701 was an eighty-seven year old female who was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Resident #701 was under the care of hospice. The resident no longer resided in the facility as she died approximately 30 minutes after the fall. On [DATE] at 9:00 AM, a record review of Resident #701's Minimum Data Set (MDS), dated [DATE], indicated Resident #701 was totally dependent on staff assistance with activities of daily living (ADLs)and needed to be fed by staff. In addition, Resident #701 had impairment to both of her upper extremities and lower extremities. She was incontinent (unable to control) of her bowels and had a Foley catheter as Resident #701 could not control her urination. On [DATE] at 9:15 AM, a record review of Resident #701's certified nursing assistant (CNA) careguide documented Resident #701 was a one person assist with bed mobility. On [DATE] at 9:30 AM, a record review of the Incident Report, dated [DATE], indicated in the documentation that the type of incident was Fall with serious injury. On [DATE] at 10:00 AM, a phone interview was done with Licensed Practical Nurse (LPN) G. According to LPN G, she was called into Resident #701's room by CNA B because the resident had fallen out of bed. LPN G stated Resident #701's legs were paralyzed and she had weakness in her right arm. In addition, LPN G stated Resident #701 could not have caught herself if she began falling out of bed. LPN G said that CNA B should have had another CNA with her because CNA B had not taken care of this resident before. LPN G indicated Resident #701 was conscious after the fall as she kept yelling for staff to get me up. On [DATE] at 12:00 PM, an interview was conducted with CNA B. In the interview, CNA B stated she was not sure if Resident #701 was a one or two person assist but CNA B provided care alone. CNA B said she was unaware Resident #701 was paralyzed. CNA B was suspended from the facility during the investigation. On [DATE] at 12:15 PM, are-enactment of Resident #701's fall was done with the alleged perpetrator CNA B and the Director of Nursing (DON) present. CNA B demonstrated how she elevated the bed approximately 3 feet from the floor in order to work comfortably. CNA B indicated she initially rolled the resident away from her onto Resident #701's right side to assess if Resident #701 needed to have her brief changed. CNA B then rolled Resident #701 onto her back and assembled her supplies. Once CNA B was ready to change Resident #701's brief, she rolled Resident 701 on her right side away from CNA B and moved Resident #701's left across her right leg. CNA B placed her right hand on Resident #701's left shoulder blade while she reached beneath Resident #701's right buttock to clean off feces (bowel movement). Resident #701 fell off the bed rolling from her right side and landing on her left side facing the bed. CNA B Left the room to get the nurse. CNA B did not check Resident #701's condition prior to getting the nurse. On [DATE] at 12:40 PM, an interview was conducted with Attending Physician (MD) A. MD A stated she had cared for Resident #701 for over ten years and was familiar with her medical conditions. According to MD A, Resident #701 had limitations as she had left sided paralysis and contractures (muscle and/or joint stiffness that restricts normal movement) to the right leg.According to MD A, Resident #701 fall on [DATE] was avoidable. On [DATE] at 1:05 PM, an interview was conducted with LPN C. She stated Resident #701 required total care with her ADLs because she could not do anything for herself. LPN C said Resident #701 could not have stopped herself from falling if she was on the edge of the bed. CNA C said Resident #701's fall was preventible because the CNA who cared for her should have rolled the resident towards herself not away from the CNA's body. On [DATE] at 1:30 PM, CNA F was interviewed. CNA F stated Resident #701's fall could have been prevented if the CNA had turned the resident towards the CNA because that the safest way to change her. On [DATE] at 1:45 PM, an interview was conducted with Registered Nurse (RN) E. She said Resident #701's fall was avoidable because the CNA should always roll the resident towards you and you always keep one hand on the resident. On [DATE] at 2:00 PM, an interview was conducted with the DON. When asked, the DON said This was an avoidable fall. On [DATE] at 2:15 PM, a record review of a document titled Bed Positioning, dated ,[DATE] and reviewed on /,[DATE], revealed the following information: the purpose of the document was to provide general guidelines in positioning of patients .for procedures . In the directions for turning a resident from their back onto their side, the document stated Reach across the patient and place one hand behind the shoulder and the other behind he hip and gently roll the patient toward you. According to the State Operations Manual (SOM), Avoidable Accident means that an accident occurred because the facility failed to identify environmental hazards and individual resident risk of an accident, including the need for supervision. ( )

Based on observation, interview and record review, the facility failed to ensure a resident was transferred with a two person assist based on her assessed needs for one resident (#502) of three residents reviewed for falls from a total of three sampled residents, resulting in a fall with a fractured femur. Findings Include: On 8/8/16 at 8:55 a.m., Resident #502 was observed in bed watching television. When asked if she recently had a fall and what happened, Resident #502 appeared to be confused and stated, No. At that time, Resident #502 was observed to have staples on the left side of her hip and down the left side of her thigh near the knee area. On 8/8/16 at 9:00 a.m., Physical Therapist C entered into Resident #502's room and stated, She doesn't remember about the fall. When asked if he was there to take Resident #502 to therapy, Physical Therapist C stated, No, therapy is performed in the room. The staples may be removed today when she goes to the doctor. I'm hoping they will change her to weight bearing as tolerated. Right now, we're using the Hoyer Lift for transfers. On 8/8/16 at 10:45 a.m., a review of the facility's Incident Report dated 7/23/16 at 7:00 p.m., documented the following: Location of Incident: Shower Room Description of Incident: Type: Fracture Resident observed leaving shower, hollering my leg, I can't move my leg . Physician notified? Yes . Date: 7/23/16 - 7:30 p.m. Was patient seen by a physician at the center? No Describe care and medications, if any, provided to patient following incident .: Norco given po (by mouth), ice applied to left knee, following ROM (Range of Motion) with complaint of severe pain, Stat x-ray Was patient taken to hospital? Yes . Date: 23-Jul-2016 - 9:30 p.m Describe cause of incident, if known: Cena (Certified Nursing Assistant) reports resident in shower room, holding on to railing with gait belt on, legs shaking, lowered to floor . Corrective Action taken following incident . Assisted x (times) 2 to chair. ROM with complaints of pain, X-ray Stat . According to the facility's Radiology Results Report dated 7/23/16 - 21:35 (9:35 p.m.) . Reason for study: Pain in Left Knee . Results: Periprosthetic fracture at the level of the femoral stem. Intramedullary rod identified proximally. The joint shows no dislocation. There is associated joint effusion. Conclusion: Acute metaphyseal fracture of the distal femur, new since September 7, 2015 . Further review of the hospital x-ray results on 7/24/16 at 5:27 a.m., documented DI (Distraction Index) Femur 2 or More View . On 8/8/16 at 11:15 a.m., a review of the clinical record revealed Resident #502 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #502 was severely impaired for cognitive/Decision-making, and required extensive assistance with two person physical assistance for transfer. The MDS documented bathing did not occur within that assessment period. According to the facility's fall assessment, Resident #502 had a fall on 8/24/15 at 18:30 (6:30 p.m.). The fall assessment documented impart as follows: .Physical Performance Limitations: Impaired balance during transitions, Gait Problem Medications: Antipsychotics, Cardiovascular Disease & Conditions: CHF/Pulmonary Edema, Other Dementia, Depression Documentation: Care plan initiated/revised: Yes A review of the facility's initial Fall Care Plan initiated/created 08/06/15, revealed Resident #502 was At risk for falls due to impaired balance/poor coordination, history of falls, potential medication side effects . Further review of the care plan initiated 08/06/15 documented Provide assist to transfer and ambulate as needed. RESOLVED 07/28/2016. Additionally, a care plan initiated/created on 07/25/2016 and revised on 07/28/16 documented two (2) person assist with transfers. On 8/8/16 at 12:50 p.m., during a telephone interview, when queried about Resident #502's fall on 7/23/16, Certified Nurse Assistant (CNA) D stated, I gave her a shower alone, I was trying to transfer her from the Geri-chair to the shower chair. The resident (#502) stood up and held onto the bar in the shower room. I had the gait belt around her. When I transferred her from the Geri-chair to the shower chair, I was trying to swing her to the shower chair. She started saying, 'I'm falling. I'm falling.' There was no chance to transfer her to the Geri-chair or shower chair. So, I had to lower her gently, and sit her down on the floor. I pulled the call light for help. I waited one minute, then I had to open up the door to call for help. I called for LPN E, and she called for CNA F to come help me, because she was in the middle of counting medication for change of shift. CNA F used the gait belt, picked up her (resident), and sat her in the shower chair. I gave her a shower, then pulled the call light for someone to help put her back in the Geri-chair. LPN E came to help put her back in the Geri-chair. I covered her, and LPN E took the resident back to her room. I cleaned up the shower room, and when I came out, I heard CNA F telling LPN E that the resident was crying and complaining that her leg hurts. On 8/8/16 at 1:55 p.m., during a telephone interview, when asked if Resident #502 was assessed after the fall, LPN E stated, I was counting narcotics with LPN G. CNA F was coming down the hall and I ask him to help CNA D. When CNA D opened the door, Resident #502 was screaming 'Get me off of the chair. Get me off of the chair. My leg hurt. I assisted CNA D to assist Resident #502 from the shower chair to the cardiac chair using a two person lift. I had one leg and arm and CNA D had one leg and arm. I thought Resident#502 was uncomfortable and we needed to get her off of the shower chair. LPN E further stated, When CNA F went to put Resident #502 into bed, he called me in the room to look at Resident #502's knee. I assessed her and found something was wrong with her leg. I went to call the doctor at 7:30 p.m., and an x-ray was ordered. The x-ray revealed Resident #502 had a fracture. On 8/8/16 at 3:05 p.m., during a telephone interview, when asked if LPN G or LPN D assessed Resident #502 after the fall in the shower room, LPN G stated, No, I didn't assess Resident#502 because CNA D said she had lower Resident #502 to the floor, and CNA F helped her to get Resident #502 in the shower chair. On 8/8/16 at 3:45 p.m., during an interview and review of the facility's policy titled Falls Practice Guide Flowchart dated 2011, when asked about the facility's policy and procedures for assessing residents after a fall, the DON stated, We assess everyone as a fall risk upon admission. We typically do a fall assessment at the time of the fall, but because Resident #502 went out, we would update her assessment when she returned. ( )

Based on observation, interview and record review, the facility failed to provide effective supervision to prevent falls for one (#815) of 14 reviewed for falls from a total sample of 20, resulting in multiple falls, including a fall with fracture. Findings include: On 5/1/14 at 9:05 A.M., resident #815 was observed in a low bed in the room. The resident was confused and did not respond to questionng. The resident had yellow, green and blue bruising accross both cheeks, the bridge of her nose, and her left jaw, and had a bluish green raised area in the center of the forehead. On 5/1/14 at 9:05 A.M., review of Resident #815's clinical record revealed documentation in the fall assessments that the Resident had fallen 16 times during the past 12 months, sustaining a fractured femur (broken hip) after a fall on 9/9/13, and had sustained facial bruising after a fall on 4/22/14. Review of Resident #815's clinical record revealed the following: A face sheet documented that Resident #815 was admitted into the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Minimum data set assessments dated 7/19/13, 10/23/13, and 4/23/14 revealed that Resident #815 had severely impaired cognition, impaired understanding and communication, needed extensive staff assistance for bed mobility and transfers to the wheelchair, did not walk, needed extensive assistance for eating, toileting and hygiene, had impaired balance was incontinent of bowel and bladder, had hearing and vision impairments and had fallen while in the facility during all three assessment lookback periods. A nursing care plan for Activities for Resident #815 documented, "language barrier. patient speaks only/fluent Russian." A care plan for Resident #815 for Activities of Daily Living (ADLS) initiated on 12/29/12, contained the following intervention dated 3/20/13, "toilet upon arising, before and after meals, bedtime, and as needed." A care plan for Resident #815 for "at Risk for falls", created 12/29/12, noted, "unsteady gait, impulsivity and poor safety awareness, Dementia, depression, anxiety, agitation/resistive to care", and contained the follwoing goals, "minimize risk of injury related to (R/T) falls, decreasinig number of falls, and minimize risk of falls." The falls care plan contained the following interentions (directions to staff), "do not leave resident unattended in bathroom or while in chair in room (dated 7/15/13), encourage to be in common area when up in wheelchair (dated 6/12/13), have commonly used articles within easy reach (dated 12/29/12), patient to be supervised during all meals, toileted before and after (dated 7/23/13), offer snacks before bed and if resident restless (dated 6/3/13), provide one to two man transfer (dated 1/3/13), recline gerichair when patient is not eating and close to nurse's station (created 1/5/14), staff to closely monitor patient and assist with ADLS (created 5/26/13)." On 5/2/14 at 11:00 A.M., Resident #815's clinical records and facility Incident and Accident Reports (I&A) were reviewed with the Director of Nursing (DON), who was also interviewed at this time. The following was revealed: Resident #815 fall assessments for 2013 through 2014, revealed no scores or numeric values. Whe queried, the DON stated, "we don't score falls risk." When queried about this, the DON stated that Resident #815's fall assements noted that the resident was at risk for falls, but when queried, was unable to state how the assessments documented whether the resident's risk was increasing or decreasing. Review of I&A for Resident #815 revealed the resident had fallen in the facility on 6/3/13 at 1:05 A.M., 6/12/13 at 9:00 A.M., 7/14/13 at 4:00 P.M., and then sustained a right hip fracture (broken hip) after a fall on 9/6/13 at 10:00 A.M. Review of the I&A for the fall on 9/6/13 revealed the following, "CNA observed patient standing up by her wheelchair and before she could get to her she took a few steps and fell to the floor and rolled to her side." The location was documented as "hallway". "cause of accident" was documented as, "patient is unsteady on her feet and does not and is unable to communicate her needs." A Nurse Practioner Progress note dated 9/10/13 documented, "had a fall last friday trying to get up from wheelchair (w/c). She has pain in the right lewer extremity and is positive for hip dislocation, x ray right hip is positive for fracture of the right intra trochanter (hip). Family meeting tonight to decide whether to send to (hospital) for surgical repair or maintain comfort measures with hospice care." A Progress note dated 9/14/13 documented, "decision made not to undergo surgical repair of right hip. Right lower extremity (leg) is shorter than left." Review of I&A for Resident #815, dated 10/06/13 at 5:30 A.M., revealed the resident was found on the floor mat on the left side of the bed, The resident sustaiend a , "skin tear noted 3 centimeters (cm) by 0.2 cm on the left side of her forehead and small hematoma (blood filled swelling)." A Progress note dated 10/6/13 documented, "fall with laceration of the left forehead." Review of an I&A dated 10/8/13 at 6:30 P.M., documented a fall from bed, noting, "Patient was not toileted prior to going to bed after dinner. One to one education with assigned staff. Review of "One On One Inservice records" dated 10/9/13 revealed the assigned certified nursing assistant (CNA) and nurse supervisor were both counseled about the failure to toilet Resident #815 per the care plan. Review of an I&A dated 10/16/13 at 9:00 A.M., revealed Resident #815 was found on the floor in the hallway next to the geri chair. The I&A documented, "skin tear to above right eye with moderate bleeding." The I&A investigation noted, "attempts to ambulate without regards to safety. Resident stated, I wanted water. Just give me the water." When queried about supervision provided to Resident #815, with documented confusion and attempts to ambulate despite having an unrepaired fractured hip, the DON stated, "We try to encourage residents at high risk for falls to stay in the common areas, such as the hallways or in the Maple dining room. Those areas are busy, so there is usually someone around to see them." When queried as to why there was no one available to respond to Resident #815's requests for water if there were staff in the area to monitor Resident #815 and provide assistance, there was no clear answer. The DON noted that the assisgned CNA was given a one to one counseling regarding leaving water and necessary items in reach, but supervision was not addressed. Review of I&A for Resident #815 noted additional falls on 12/19/13 at 2:30 P.M., and on 1/13/14 at 3:00 P.M.. The I&A on 1/13/14 at 3:00 P.M., documented, "Patient was onserved on the floor in the hallway, lying in front of her Gerichair. Patient often tries to get up and walk, and no longer has the ability to walk, She was trying to get out of bed earlier, when she was placed in her geri chair, she was able to get out and landed on the floor." When asked why Resident #815 was left without supervision despite frequent attempts to get out of bed and geri chair without assistance, the DON stated, "We've eliminated alarms and restraints. We try to look at the root cause of each fall, the reason the resident was trying to get up, and then care plan individualized interventions." The DON was unable to explain why this approach did not prevent Resident #815 from additional falls, or how this approach would work with advanced dementia and generalized agitation. Review of I&A for Resident #815 revealed falls from bed on 1/14/14 at 12:15 A.M., 2/12/14 at 2:15 A.M., and 2/21/14 at 11:30 A.M. The I&A dated 2/12/14 at 11:30 A.M., documented, "patient was trying to get out of bed, had to use the bathroom-patient has dementia and a language barrier, did not use the call light." When queried, the DON was unable to provide documentation to indicate whether the resident had been toileted after breakfast per care plan, or what kind of supervision was provided when the resident was in bed during the day. Review of I&A for Resident #815 revealed documentation the resident was, "observed on the floor in front of wheelchair" while in the Maple Dining Room. The I&A noted, "Due to Resident's decreased cognition, she does not recognize limitations." When asked what was done to assure Resident #815's safety because of this, the DON stated, "We place her in the Maple Dining Room, which is in direct view of a busy area of the unit." When asked how it protected Resident #815 to place her in the hallway or Maple dining room if no one was watching these areas, the DON stated that the facility had noticed that there was a problem with a high number of falls on that unit. Review of an I&A for Resident #815 documented additional falls on 4/1/14 at 12:39 A.M., and two falls on 4/22/14. The I&A dated 4/22/14 at 2:30 P.M., documented that Resident #815 was observed sitting on the footrest of her wheelchair, in her rom. When asked why the resident was not up in the common area per care plan, and how Resident #815 was supervised to prevent falls, if in the room in the wheelchair, the DON noted that the investigation documented that the resident had been at the nurse's station sitting in her chair, and could not explain the discrepency in documentation. The Investigation noted, the resident had been "figeting" when last checked. The I&A documented that Resident #815 sustained a "bruised limp on forehead" during the fall. THe DON did not explain why Resident #815 was not prevented from falling, but was found on the floor after the fall, if there were staff present at the nursing station to supervise her. The DON stated, "It's a busy area. Staff are constantly passing." The DON did not explain why Resident #815 was left alone if noted to be, "figeting." Review of an I&A for Resident #815, dated 4/22/14 at 6:53 P.M., documented that Resident #815 fell a second time on 4/22/14. sustaining, "hematoma in center of forehead with small skin tear approximately 0.8 by 0.2 cm, scant bleeding with bridge of nose discolored and slightly swollen." The I&A documented, "staff responded to a thud like sound and observed resident lying face down on the floor in front of her chair." It was unclear whether placing the resident in common areas provided sufficient supervision to prevent falls, when Resident #815 fell again without staff witnessing the fall, or being in close enough proximity to prevent a fall when the resident started to get up. Review of an I&A for Resident #815, dated 4/26/14 at 10:00 P.M., documented that Resident #815 was found on the floor next to the bed. The DON was unable to explain why, if the facility program of "root cause investigation into the cause of each fall, followed by targeted interventions aimed at preventing the root cause" was effective, why Resident #815 had 16 falls in one year with a fractured hip, lacerations and multiple instances of bruising. ( )

This citation pertains to intake number MI 795 Based on interview and record review, the facility failed to provide safe bed mobility assistance causing a fall from bed for one (#801) of four residents reviewed for falls from a total sample of five, resulting in hospitalization for a fracture of the left femur. Findings Include: Resident #801 was admitted into the facility on [DATE] and discharged to an acute care hospital on [DATE] for evaluation and treatment of [REDACTED]. Resident #801's [DIAGNOSES REDACTED]. Review of the closed electronic clinical record on 3/5/14 at 9:00 am revealed the following: Minimum data Set (MDS) assessments dated 5/8/13 and 11/19/13 documented Resident #801 required extensive assistance of two persons for transfers, toileting and bed mobility and total assistance of two persons for dressing and hygiene. The MDS documented the resident had functional impairment to upper and lower extremities on one side of the body. The at Risk for Falls Care Plan dated 12/12/13, documented Resident #801 was at risk of falls related to impaired balance/poor coordination, and CVA (stroke) and required total to extensive assistance with bed mobility and transfers. The ADL (Activities of Daily Living) Care Plan dated 1/8/14, documented Resident #801 required total to extensive assistance of one to two persons related to CVA with hemiparesis (weakness on one side of the body). According to the facility Incident Report dated 2/7/14 at 8:30 a.m., a CNA (Certified Nursing Assistant) later identified as Staff "A", reported, "During bed bath resident on her side and CNA turned to reach for draw sheet and brief and resident rolled out of bed. . . Resident assessed head to toe, no broken skin noted or discolorations. VS (vital signs) taken and Neuro checks started. + (positive) ROM (range of motion) all extremities, except left leg due to pain. . .corrective action: (safe position) resident was facing the opposite direction and not facing the CNA. One to one education with CNA. Nursing staff to be re-educated to roll patient towards care giver instead of away. . . STAT X-ray left hip and femur due to inability to do passive or active ROM (range of motion) to left leg." Further review of Resident #801's closed record revealed an X-ray result dated 2/7/2014, that documented, "Impression: A comminuted, displaced and angled fracture is seen in the intertochanteric region of the proximal left femur." On 3/5/14 at 11:25 a.m. CNA staff "A" was interviewed per phone regarding the incident for Resident #801. Staff "A" stated I was giving her a bed bath and rolled her over, I kept my hand on her hip and reached for the brief and linens and she rolled out of the bed. She was rolled away from me and was closer to the far edge of the bed than the middle. I have given her plenty of bed baths before and it was never a problem. I went and got the Nurse right away. Resident (#801) was making faces like she was in pain. The nurse assessed her and we got her back into bed." When queried staff "A" said she was providing care alone. When queried regarding her training for positioning, Staff "A" said she had received training to "roll the patient towards you." Staff "A" was asked if she was aware she was to roll the resident towards her prior to the incident with Resident #801 and she stated " Yes, but I have given her plenty of bed baths and it was never a problem." On 3/5/14 at 11:25 a.m. the Administrator was interviewed regarding the incident for Resident #801 and she said she interviewed the CNA (staff "A") and the CNA admitted the resident was rolled away from her when it happened. The Administrator said the resident was transferred to the hospital and did not return to the facility and the CNA was re-educated on rolling and safe positioning of residents. The facility policy titled "Bed positioning" was reviewed on 3/5/14 at approximately 12:00 p.m. and revealed the following: "Position patient on the side of the bed farthest from the caregiver so that when turned they are in the middle of the bed. . . Reach across the patient and place one hand behind the shoulder and the other behind the hip and gently roll the patient towards you." A review of CNA staff "A"s "Skills and Techniques Evaluation" sheet signed by staff "A" dated 5/28/13 documented she had evaluations that included "Positioning body alignment . . .turning and positioning . . .bed mobility/positioning . . . falls risk identification, interventions, prevention." ( )

This citation pertains to MI 471 and MI 984 Based on interview and record review, the facility failed to notify the physician of an acute change in condition in 1 of 8 sampled residents (#101) reviewed for an acute change of condition, in a total sample of 8 residents resulting in delayed treatment after Resident #101 was noted to have abnormal vital signs. Resident #101 subsequently died . Findings include: Review of the face sheet in the medical record dated [DATE] revealed Resident #101 was a [AGE] year old female admitted to the facility on [DATE]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #101 had no cognitive impairments and required extensive assistance with Activities of Daily Living (ADL's). Review of a Hospital's History and Physical record dated [DATE] revealed Resident #101's past medical history included hypertension (high blood pressure), [MEDICAL CONDITION] (low [MEDICAL CONDITION] hormone), history of [MEDICAL CONDITION] ([MEDICAL CONDITION], blood clot), Obesity, [MEDICAL CONDITION] disorder (Mental Illness), [DIAGNOSES REDACTED] (Mental Illness), Internal Vena Cava filter (IVC, a medical device implanted into the heart to prevent blood clots), and chronic low back pain. Review of a Hospital record dated [DATE] revealed Resident #101 had an extensive past medical history of [REDACTED]. The record revealed Resident #101 was admitted to the hospital for abdominal pain and distention, diarrhea, and dehydration. The record revealed Resident #101 had a colonoscopic decompression which showed a sigmoid volvulus (large bowel twist) with [MEDICAL CONDITION] (fluid) and possible ischemia (lack of blood supply) at the sigmoid colon. The record revealed Resident #101 had multiple comorbidities with recurrent sigmoid volvulus secondary to colonic motility disorder (bowel disorder). Review of a Hospital's Discharge Summary record dated [DATE] revealed Resident #101 had colectomy surgery (removal of a portion of the large colon) on [DATE] due to a sigmoid volvulus. The record revealed Resident #101's urine cultures were negative but Resident #101 complained of dysuria (painful urination) and was started on antibiotics for a Urinary Tract Infection [MEDICAL CONDITION]. According to Fundamentals of Nursing (Potter and Perry, 6 th edition, 2005), acceptable vital signs for adults include the following: Temperature: 96.8 degrees Farenheit to 100.4 degrees Farenheit; Pulse: ,[DATE] beats per minute; Respirations: ,[DATE] breathes per minute; average blood pressure: 120 (systolic)/80 (diastolic) mm Hg (millimeter of mercury, unit of pressure). According to Fundamentals of Nursing, [MEDICAL CONDITION] an abnormally elevated heart rate, above 100 beats per minute in adults. [MEDICAL CONDITION] is considered present when the systolic blood pressure falls to 90 mm Hg or below. [MEDICAL CONDITION] associated with pallor, skin mottling, clamminess, confusion, increased heart rate, or decrease urine output is life threatening and should be reported to a physician immediately. Review of the Facility's Interact Acute Change in Condition document (updated 2013) revealed the facility should notify the physician immediately if a resident's systolic blood pressure is below 90 mm Hg, resting pulse above 100 beats per minute, and/or oxygen saturation levels below 90%. Review of the Facility's Interact Implementation Guide (updated 2013) revealed if the resident has a change in status, then Licensed Practical Nurse (LPN)/Registered Nurse (RN) performs an evaluation on the resident, fills out the Situation, Background, Assessment, and Request (SBAR) form, and notifies the physician. Review of a progress note dated [DATE] at 8:01 AM and written by RN #7 revealed Resident #101 was "Alert with confusion, no distress noted, 2 person assist with ADLs and transfers, incontinent (of) bowel and bladder, kept clean per staff, scheduled meds (medication) given per orders, Pt (Resident #101) observed lethargic, non talking and drowsy most of the shift, VS (vital signs) ,[DATE] (blood pressure) P(pulse): 108 R(respirations): 22 O2(oxygen): 97.5ra (room air), will continue to monitor, bed low position and call light within reach. " In an interview on [DATE] at 11:26 AM, Director of Nursing (DON) #2 reported a SBAR form was not completed for Resident #101's abnormal vital signs on [DATE] at 8:01 AM. Review of a progress note dated [DATE] at 10:43 AM and written by RN #14 revealed "writer took report from offgoing nurse at 9:45 am. Nurse reports psO2 (oxygen level) was 89% on RA and 2L (liters) oxygen via n/c (nasal cannula) was applied. Writer went into room to check on patient and Code Blue called at 9:56 am cart retrieved and CPR (Cardiopulmonary Resuscitation) initiated by nurse and NP (Nurse Practitioner). 911 called. Patient unresponsive...10:15 am writer notified emergency contact (family member #15) change in patient condition and request family to come to facility ASAP (as soon as possible). 10:20 am (Physician #5) notified via phone." In an interview on [DATE] at 8:11 AM, RN #7 reported a blood pressure reading of ,[DATE] would be considered low and would have notified the physician and documented it in the progress notes. RN #7 reported he could not recall when he obtained Resident #101's vital signs and could not recall notifying the physician of Resident #101's low blood pressure reading on [DATE]. In an interview on [DATE] at 11:13 AM, Physician #6 reported she oversaw Resident #101's rehabilitation therapy for debility at the facility. Physician #6 reported she assessed Resident #101 on [DATE] and there were no new complaints or apparent problems noted. Physician #6 reported on [DATE], Resident #101 was sleepy but arousable, abdomen soft and non-tender, and pedal [MEDICAL CONDITION] was present with no calf tenderness. Physician #6 reported on [DATE], she had discharged Resident #101 from rehabilitation therapy. In an interview on [DATE] at 1:48 PM, Physician #5 was Resident #101's attending physician at the facility. Physician #5 reported Resident #101 was at risk for bowel obstruction due to adhesions (scar tissue) that form after colectomy surgery. Physician #5 reported a bowel obstruction usually would take awhile to develop but could develop within ,[DATE] hours. Physician #5 reported Resident #101 was stable when he assessed her on [DATE] and had cleared Resident #101 to be discharged home. Physician #5 reported he was not notified of Resident #101's low blood pressure reading on [DATE]. Physician #5 reported if he was notified of Resident #101 low blood pressure reading then he would have sent Resident #101 to the hospital for further evaluation and treatment. In an interview on [DATE] at 9:40 AM, DON #2 reported she was not employed with the facility when Resident #101 was in the facility. DON #2 reported if a resident presented with abnormal vital signs, then the physician should be notified and further assessments of the resident should be completed. DON #2 reported physician notification and assessments should be documented in the progress notes. Review of an Autopsy Report dated [DATE] revealed Resident #101 expired on [DATE] at approximately 9:45 AM at the facility. The report revealed Resident #101's abdomen was significantly protuberant and severe [MEDICAL CONDITION] was present on the ankles and feet. The report revealed the lower abdominal and inferior vena cava (heart) had a Greenfield Filter (IVC filter) with an almost obliterated lumen (loss of space) due to adhesions and fibrosis (scar tissue) of the intima (innermost layer of blood vessel) around the filter. The report revealed autopsy findings included a UTI with a significantly distended urinary bladder containing foul smelling urine and mottled kidneys, Obesity, and Focal Coronary [MEDICAL CONDITION] (hardening of the arteries). The report revealed Resident #101 died of an intestinal obstruction with complications including recent surgery for [REDACTED]. ( )

This citation pertains to MI 471 and MI 984 Based on interview and record review, the facility failed to provide care that met professional standards (immediately assess and monitor a resident with an acute change in condition and notify the physician of any abnormal vital signs) in 1 of 8 sampled residents (#101) reviewed for an acute change of condition, in a total sample of 8 residents resulting in delayed evaluation and treatment after Resident #101 was noted have abnormal vital signs. Resident #101 subsequently died . Findings include: Review of the face sheet in the medical record dated [DATE] revealed Resident #101 was a [AGE] year old female admitted to the facility on [DATE]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #101 had no cognitive impairments and required extensive assistance with Activities of Daily Living (ADL's). Review of a Hospital's History and Physical record dated [DATE] revealed Resident #101's past medical history included hypertension (high blood pressure), [MEDICAL CONDITION] (low [MEDICAL CONDITION] hormone), history of [MEDICAL CONDITION] ([MEDICAL CONDITION], blood clot), Obesity, [MEDICAL CONDITION] disorder (Mental Illness), [DIAGNOSES REDACTED] (Mental Illness), Internal Vena Cava filter (IVC, a medical device implanted into the heart to prevent blood clots), and chronic low back pain. Review of a Hospital record dated [DATE] revealed Resident #101 had an extensive past medical history of [REDACTED]. The record revealed Resident #101 was admitted to the hospital for abdominal pain and distention, diarrhea, and dehydration. The record revealed Resident #101 had a colonoscopic decompression which showed a sigmoid volvulus (large bowel twist) with [MEDICAL CONDITION] (fluid) and possible ischemia (lack of blood supply) at the sigmoid colon. The record revealed Resident #101 had multiple comorbidities with recurrent sigmoid volvulus secondary to colonic motility disorder (bowel disorder). Review of a Hospital's Discharge Summary record dated [DATE] revealed Resident #101 had colectomy surgery (removal of a portion of the large colon) on [DATE] due to a sigmoid volvulus. The record revealed Resident #101's urine cultures were negative but Resident #101 complained of dysuria (painful urination) and was started on antibiotics for a Urinary Tract Infection [MEDICAL CONDITION]. According to Fundamentals of Nursing (Potter and Perry, 6 th edition, 2005), acceptable vital signs for adults include the following: Temperature: 96.8 degrees Farenheit to 100.4 degrees Farenheit; Pulse: ,[DATE] beats per minute; Respirations: ,[DATE] breathes per minute; average blood pressure: 120 (systolic)/80 (diastolic) mm Hg (millimeter of mercury, unit of pressure). According to Fundamentals of Nursing, [MEDICAL CONDITION] an abnormally elevated heart rate, above 100 beats per minute in adults. [MEDICAL CONDITION] is considered present when the systolic blood pressure falls to 90 mm Hg or below. [MEDICAL CONDITION] associated with pallor, skin mottling, clamminess, confusion, increased heart rate, or decrease urine output is life threatening and should be reported to a physician immediately. Review of the Facility's Interact Acute Change in Condition document (updated 2013) revealed the facility should notify the physician immediately if a resident's systolic blood pressure is below 90 mm Hg, resting pulse above 100 beats per minute, and/or oxygen saturation levels below 90%. Review of the Facility's Interact Implementation Guide (updated 2013) revealed if the resident has a change in status, then Licensed Practical Nurse (LPN)/Registered Nurse (RN) performs an evaluation on the resident, fills out the Situation, Background, Assessment, and Request (SBAR) form, and notifies the physician. Review of a progress note dated [DATE] at 8:01 AM and written by RN #7 revealed Resident #101 was "Alert with confusion, no distress noted, 2 person assist with ADLs and transfers, incontinent (of) bowel and bladder, kept clean per staff, scheduled meds (medication) given per orders, Pt (Resident #101) observed lethargic, non talking and drowsy most of the shift, VS (vital signs) ,[DATE] (blood pressure) P(pulse): 108 R(respirations): 22 O2(oxygen): 97.5ra (room air), will continue to monitor, bed low position and call light within reach. " In an interview on [DATE] at 11:26 AM, Director of Nursing (DON) #2 reported a SBAR form was not completed for Resident #101's abnormal vital signs on [DATE] at 8:01 AM. Review of a progress note dated [DATE] at 10:43 AM and written by RN #14 revealed "writer took report from offgoing nurse at 9:45 am. Nurse reports psO2 (oxygen level) was 89% on RA and 2L (liters) oxygen via n/c (nasal cannula) was applied. Writer went into room to check on patient and Code Blue called at 9:56 am cart retrieved and CPR (Cardiopulmonary Resuscitation) initiated by nurse and NP (Nurse Practitioner). 911 called. Patient unresponsive...10:15 am writer notified emergency contact (family member #15) change in patient condition and request family to come to facility ASAP (as soon as possible). 10:20 am (Physician #5) notified via phone." In an interview on [DATE] at 8:11 AM, RN #7 reported a blood pressure reading of ,[DATE] would be considered low and would have notified the physician and documented it in the progress notes. RN #7 reported he could not recall when he obtained Resident #101's vital signs and could not recall notifying the physician of Resident #101's low blood pressure reading on [DATE]. In an interview on [DATE] at 11:13 AM, Physician #6 reported she oversaw Resident #101's rehabilitation therapy for debility at the facility. Physician #6 reported she assessed Resident #101 on [DATE] and there were no new complaints or apparent problems noted. Physician #6 reported on [DATE], Resident #101 was sleepy but arousable, abdomen soft and non-tender, and pedal [MEDICAL CONDITION] was present with no calf tenderness. Physician #6 reported on [DATE], she had discharged Resident #101 from rehabilitation therapy. In an interview on [DATE] at 1:48 PM, Physician #5 was Resident #101's attending physician at the facility. Physician #5 reported Resident #101 was at risk for bowel obstruction due to adhesions (scar tissue) that form after colectomy surgery. Physician #5 reported a bowel obstruction usually would take awhile to develop but could develop within ,[DATE] hours. Physician #5 reported Resident #101 was stable when he assessed her on [DATE] and had cleared Resident #101 to be discharged home. Physician #5 reported he was not notified of Resident #101's low blood pressure reading on [DATE]. Physician #5 reported if he was notified of Resident #101 low blood pressure reading then he would have sent Resident #101 to the hospital for further evaluation and treatment. In an interview on [DATE] at 9:40 AM, DON #2 reported she was not employed with the facility when Resident #101 was in the facility. DON #2 reported if a resident presented with abnormal vital signs, then the physician should be notified and further assessments of the resident should be completed. DON #2 reported physician notification and assessments should be documented in the progress notes. Review of an Autopsy Report dated [DATE] revealed Resident #101 expired on [DATE] at approximately 9:45 AM at the facility. The report revealed Resident #101's abdomen was significantly protuberant and severe [MEDICAL CONDITION] was present on the ankles and feet. The report revealed the lower abdominal and inferior vena cava (heart) had a Greenfield Filter (IVC filter) with an almost obliterated lumen (loss of space) due to adhesions and fibrosis (scar tissue) of the intima (innermost layer of blood vessel) around the filter. The report revealed autopsy findings included a UTI with a significantly distended urinary bladder containing foul smelling urine and mottled kidneys, Obesity, and Focal Coronary [MEDICAL CONDITION] (hardening of the arteries). The report revealed Resident #101 died of an intestinal obstruction with complications including recent surgery for [REDACTED]. ( )

This citation pertains to MI 471 and MI 984 Based on interview and record review, the facility failed to immediately assess and monitor a resident with an acute change in condition in 1 of 8 sampled residents (#101) reviewed for an acute change of condition, in a total sample of 8 residents resulting in a delay in treatment after Resident #101 was noted to have abnormal vital signs. Resident #101 subsequently died . Findings include: Review of the face sheet in the medical record dated [DATE] revealed Resident #101 was a [AGE] year old female admitted to the facility on [DATE]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #101 had no cognitive impairments and required extensive assistance with Activities of Daily Living (ADL's). Review of a Hospital's History and Physical record dated [DATE] revealed Resident #101's past medical history included hypertension (high blood pressure), [MEDICAL CONDITION] (low [MEDICAL CONDITION] hormone), history of [MEDICAL CONDITION] ([MEDICAL CONDITION], blood clot), Obesity, [MEDICAL CONDITION] disorder (Mental Illness), [DIAGNOSES REDACTED] (Mental Illness), Internal Vena Cava filter (IVC, a medical device implanted into the heart to prevent blood clots), and chronic low back pain. Review of a Hospital record dated [DATE] revealed Resident #101 had an extensive past medical history of [REDACTED]. The record revealed Resident #101 was admitted to the hospital for abdominal pain and distention, diarrhea, and dehydration. The record revealed Resident #101 had a colonoscopic decompression which showed a sigmoid volvulus (large bowel twist) with [MEDICAL CONDITION] (fluid) and possible ischemia (lack of blood supply) at the sigmoid colon. The record revealed Resident #101 had multiple comorbidities with recurrent sigmoid volvulus secondary to colonic motility disorder (bowel disorder). Review of a Hospital's Discharge Summary record dated [DATE] revealed Resident #101 had colectomy surgery (removal of a portion of the large colon) on [DATE] due to a sigmoid volvulus. The record revealed Resident #101's urine cultures were negative but Resident #101 complained of dysuria (painful urination) and was started on antibiotics for a Urinary Tract Infection [MEDICAL CONDITION]. According to Fundamentals of Nursing (Potter and Perry, 6 th edition, 2005), acceptable vital signs for adults include the following: Temperature: 96.8 degrees Farenheit to 100.4 degrees Farenheit; Pulse: ,[DATE] beats per minute; Respirations: ,[DATE] breathes per minute; average blood pressure: 120 (systolic)/80 (diastolic) mm Hg (millimeter of mercury, unit of pressure). According to Fundamentals of Nursing, [MEDICAL CONDITION] an abnormally elevated heart rate, above 100 beats per minute in adults. [MEDICAL CONDITION] is considered present when the systolic blood pressure falls to 90 mm Hg or below. [MEDICAL CONDITION] associated with pallor, skin mottling, clamminess, confusion, increased heart rate, or decrease urine output is life threatening and should be reported to a physician immediately. Review of the Facility's Interact Acute Change in Condition document (updated 2013) revealed the facility should notify the physician immediately if a resident's systolic blood pressure is below 90 mm Hg, resting pulse above 100 beats per minute, and/or oxygen saturation levels below 90%. Review of the Facility's Interact Implementation Guide (updated 2013) revealed if the resident has a change in status, then Licensed Practical Nurse (LPN)/Registered Nurse (RN) performs an evaluation on the resident, fills out the Situation, Background, Assessment, and Request (SBAR) form, and notifies the physician. Review of a progress note dated [DATE] at 8:01 AM and written by RN #7 revealed Resident #101 was "Alert with confusion, no distress noted, 2 person assist with ADLs and transfers, incontinent (of) bowel and bladder, kept clean per staff, scheduled meds (medication) given per orders, Pt (Resident #101) observed lethargic, non talking and drowsy most of the shift, VS (vital signs) ,[DATE] (blood pressure) P(pulse): 108 R(respirations): 22 O2(oxygen): 97.5ra (room air), will continue to monitor, bed low position and call light within reach. " In an interview on [DATE] at 11:26 AM, Director of Nursing (DON) #2 reported a SBAR form was not completed for Resident #101's abnormal vital signs on [DATE] at 8:01 AM. Review of a progress note dated [DATE] at 10:43 AM and written by RN #14 revealed "writer took report from offgoing nurse at 9:45 am. Nurse reports psO2 (oxygen level) was 89% on RA and 2L (liters) oxygen via n/c (nasal cannula) was applied. Writer went into room to check on patient and Code Blue called at 9:56 am cart retrieved and CPR (Cardiopulmonary Resuscitation) initiated by nurse and NP (Nurse Practitioner). 911 called. Patient unresponsive...10:15 am writer notified emergency contact (family member #15) change in patient condition and request family to come to facility ASAP (as soon as possible). 10:20 am (Physician #5) notified via phone." In an interview on [DATE] at 8:11 AM, RN #7 reported a blood pressure reading of ,[DATE] would be considered low and would have notified the physician and documented it in the progress notes. RN #7 reported he could not recall when he obtained Resident #101's vital signs and could not recall notifying the physician of Resident #101's low blood pressure reading on [DATE]. In an interview on [DATE] at 11:13 AM, Physician #6 reported she oversaw Resident #101's rehabilitation therapy for debility at the facility. Physician #6 reported she assessed Resident #101 on [DATE] and there were no new complaints or apparent problems noted. Physician #6 reported on [DATE], Resident #101 was sleepy but arousable, abdomen soft and non-tender, and pedal [MEDICAL CONDITION] was present with no calf tenderness. Physician #6 reported on [DATE], she had discharged Resident #101 from rehabilitation therapy. In an interview on [DATE] at 1:48 PM, Physician #5 was Resident #101's attending physician at the facility. Physician #5 reported Resident #101 was at risk for bowel obstruction due to adhesions (scar tissue) that form after colectomy surgery. Physician #5 reported a bowel obstruction usually would take awhile to develop but could develop within ,[DATE] hours. Physician #5 reported Resident #101 was stable when he assessed her on [DATE] and had cleared Resident #101 to be discharged home. Physician #5 reported he was not notified of Resident #101's low blood pressure reading on [DATE]. Physician #5 reported if he was notified of Resident #101 low blood pressure reading then he would have sent Resident #101 to the hospital for further evaluation and treatment. In an interview on [DATE] at 9:40 AM, DON #2 reported she was not employed with the facility when Resident #101 was in the facility. DON #2 reported if a resident presented with abnormal vital signs, then the physician should be notified and further assessments of the resident should be completed. DON #2 reported physician notification and assessments should be documented in the progress notes. Review of an Autopsy Report dated [DATE] revealed Resident #101 expired on [DATE] at approximately 9:45 AM at the facility. The report revealed Resident #101's abdomen was significantly protuberant and severe [MEDICAL CONDITION] was present on the ankles and feet. The report revealed the lower abdominal and inferior vena cava (heart) had a Greenfield Filter (IVC filter) with an almost obliterated lumen (loss of space) due to adhesions and fibrosis (scar tissue) of the intima (innermost layer of blood vessel) around the filter. The report revealed autopsy findings included a UTI with a significantly distended urinary bladder containing foul smelling urine and mottled kidneys, Obesity, and Focal Coronary [MEDICAL CONDITION] (hardening of the arteries). The report revealed Resident #101 died of an intestinal obstruction with complications including recent surgery for [REDACTED]. ( )

REFER TO INTAKE MI 406. BASED ON OBSERVATION, INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE AND APPROPRIATE SUPERVISION TO PREVENT ELOPEMENT FOR 1 (#101) OF 8 SAMPLED RESIDENTS IDENTIFIED AT RISK FOR ELOPEMENT IN A TOTAL OF 12 SAMPLED RESIDENTS, RESULTING IN IMMEDIATE JEOPARDY FOR RESIDENT #101, WHO WAS MISSING FROM THE FACILITY ON 7/4/12 FOR AN UNKNOWN PERIOD OF TIME, UNBEKNOWNST TO STAFF, BUT WAS THEN RETURNED TO THE FACILITY SHORTLY BEFORE 7:53 P.M. THIS DEFICIENT PRACTICE PLACED RESIDENT #101 AT HIGH RISK FOR PHYSICAL HARM OR DEATH. AS A RESULT OF THE FACILITY'S FAILURE TO SUPERVISE AND MONITOR PERSONS MOVING IN AND OUT THROUGH ALARMED DOORS, 7 OTHER RESIDENTS IDENTIFIED AS WANDERERS WERE PLACED AT HIGH RISK FOR ELOPEMENT, WHICH COULD RESULT IN PHYSICAL HARM OR DEATH. FINDINGS INCLUDE: RESIDENT #101, [AGE] years OLD, WAS admitted to the facility on [DATE], PER THE ADMITTING RECORD. ACCORDING TO THE 6/27/12 HISTORY & PHYSICAL REPORT, RESIDENT #101 HAD BEEN hospitalized for [REDACTED]. RESIDENT #101'S [DIAGNOSES REDACTED]. AS DOCUMENTED ON THE NURSING ADMISSIONS SCREEN, DATED 6/27/12, RESIDENT #101 HAD MODERATELY IMPAIRED COGNITION, AND POOR DECISION MAKING, WITH SUPERVISION REQUIRED. THE ASSESSMENT ALSO IDENTIFIED A HISTORY OF WANDERING, AND INDICATED THAT THE RESIDENT VERBALIZED A DESIRE TO EXIT THE FACILITY. RESIDENT #101 HAD A CARE PLAN FOR WANDERING INITIATED ON 6/27/12. THE CARE PLAN DOCUMENTED THE USE OF A SECURITY BRACELET (WANDERGUARD, A DEVICE THAT TRANSMITS A SIGNAL WHICH ACTIVATES AN ALARM WHEN THE SIGNAL IS RECEIVED, USUALLY AT A DOORWAY). A NURSE'S NOTE ON 6/27/12 DOCUMENTED THAT RESIDENT #101 "WANTED TO LEAVE THE FACILITY" AND A WANDERGUARD WAS PLACED ON HER LEFT ANKLE. A 6/28/12 NURSE'S NOTE DOCUMENTED THAT THE RESIDENT KEPT TRYING TO GO OUT EXIT DOORS STATING, "I NEED TO GO HOME AND FEED MY ANIMALS." ON 7/3/12, A NURSE'S NOTE DOCUMENTED THAT RESIDENT #101 "CONTINUED TO GET OUT OF BED SEVERAL TIMES TRYING TO LEAVE THE FACILITY." DURING AN INTERVIEW ON 7/12/12 AT 9:55 A.M., RESIDENT #101 COULD STATE HER NAME AND THE NAMES AND LOCATIONS OF A SON AND DAUGHTER. THE RESIDENT SAID SHE DID NOT LIVE AT THE FACILITY; SHE JUST VISITED. SHE SAID SHE DID NOT EAT IN THE FACILITY. THE RESIDENT SAID SHE ENJOYED TAKING CARE OF HER GARDEN AND TAKING WALKS IN THE EVENING. DURING A TELEPHONE INTERVIEW ON 7/12/12 AT 1:18 P.M., VISITOR #2 SAID THAT AN ALARM WAS SOUNDING AS SHE APPROACHED THE FRONT DOOR TO EXIT THE FACILITY ON 7/4/12. A "BLACK MALE IN SCRUBS" RESET THE ALARM AND ALLOWED THEM (VISITOR #2 AND OTHERS WITH VISITOR #2) TO LEAVE THE BUILDING. LOOKING OUTSIDE FROM INSIDE THE DOOR, VISITOR #2 SAID SHE OBSERVED A WOMAN (RESIDENT #101) ATTEMPTING TO GET INTO VISITOR #2'S CAR, WHICH WAS PARKED IN THE HANDICAPPED AREA. VISITOR #2 SAID A MALE VISITOR HAD LEFT THE BUILDING BEFORE THEM AND WAS TALKING TO THE WOMAN (RESIDENT #101). THE MALE VISITOR WENT BACK INSIDE TO NOTIFY THE STAFF THAT A RESIDENT WAS IN THE PARKING LOT TRYING TO GET INTO CARS. REGISTERED NURSE (RN) #7 WAS INTERVIEWED ON 7/13/12 AT 8:30 A.M. ABOUT RESIDENT #101'S ELOPEMENT ON 7/4/12. SHE SAID THAT A MALE VISITOR CAME IN AND TOLD HER (#7) THAT A RESIDENT WAS OUTSIDE IN THE PARKING LOT, TRYING TO GET INTO CARS. RN #7 SAID, "WE (NURSES) WERE COUNTING MEDICATIONS AT THE END OF THE 7 A.M. TO 7 P.M. SHIFT." RN #7 WENT OUTSIDE WITH LICENSED PRACTICAL NURSE (LPN) #3 AND ATTEMPTED TO BRING RESIDENT #101 BACK INSIDE THE FACILITY. RESIDENT #101 WOULD NOT WALK BACK INTO THE FACILITY, SO RN #7 WENT INSIDE THE FACILITY TO GET A WHEELCHAIR, WHILE LPN #3 REMAINED WITH RESIDENT #101. RN #7 SAID SHE DID NOT RECALL HEARING ANY DOOR OR WANDERGUARD ALARMS AT THE CHANGE OF SHIFT ON 7/4/12. SHE SAID SHE DID NOT KNOW IF THE WANDERGUARD ALARM SOUNDED WHEN SHE (#7) RETURNED THROUGH THE FRONT DOOR OF THE FACILITY WITH RESIDENT #101. LPN #3 WAS INTERVIEWED ON 7/13/12 AT 7:05 A.M. ABOUT THE ELOPEMENT OF RESIDENT #101 ON 7/4/12. LPN #3 SAID SHE (#3) ACCOMPANIED RN #7 TO THE PARKING AREA. SHE OBSERVED RESIDENT #101 IN THE HANDICAPPED AREA OF THE PARKING LOT, TRYING TO GET INTO CARS. VISITORS WERE WITH THE RESIDENT. RESIDENT #101 WAS ADAMANT THAT SHE WAS NOT GOING BACK INTO THE FACILITY. LPN #3 SAID SHE DID NOT RECALL HEARING A DOOR OR WANDERGUARD ALARM SOUND BEFORE OR AFTER SHIFT REPORT AT 7 P.M. SHE (#3) SAID SHE DID NOT KNOW IF THE WANDERGUARD ALARMED WHEN THEY (#3 AND #7) CAME BACK INTO THE FACILITY WITH RESIDENT #101 THROUGH THE FRONT DOOR. LPN #6 WAS INTERVIEWED ON 7/13/12 AT 8:20 A.M. ABOUT THE ELOPEMENT OF RESIDENT #101. LPN #6 SAID SHE HAD PUNCHED OUT AND WAS ON HER WAY OUT OF THE FACILITY, WHEN LPN #14 ASKED HER TO HELP LOOK FOR RESIDENT #101. ACCORDING TO HER (#6) TIME SHEET, LPN #6 PUNCHED OUT AT 7:46 P.M. ON 7/4/12. SHE SAID SHE DID NOT HEAR ANY ALARMS DURING OR AFTER CHANGE OF SHIFT REPORT. SHE SAID SHE CHECKED THE WANDERGUARD OF RESIDENT #101 EARLIER IN HER SHIFT, AND IT WAS WORKING. LPN #6 SAID SHE SAW RESIDENT #101 IN HER ROOM DURING REPORT, ALTHOUGH LPN #14 SAID REPORT HAD BEEN GIVEN IN THE DINING ROOM, MAKING IT IMPOSSIBLE FOR EITHER NURSE TO SEE THE RESIDENT. LPN #14 WAS INTERVIEWED AT 9:30 A.M. ON 7/13/12 BY PHONE. HE SAID HE WAS RECEIVING REPORT ON 7/4/12 FROM LPN #6, IN THE CAFE ACROSS FROM THE NURSE'S STATION, WHICH STARTED ABOUT 7:30 P.M., WHEN HE OVERHEARD STAFF TALKING ABOUT AN ELOPEMENT. HE SAID HE DID NOT HEAR A DOOR OR WANDERGUARD ALARM PRIOR TO OR DURING REPORT. LPN #14 SAID HE EXAMINED RESIDENT #101 AFTER SHE WAS RETURNED TO THE FACILITY. HE SAID THE RESIDENT'S VITAL SIGNS WERE NORMAL, THE RESIDENT WAS CALM BUT CONFUSED, AND THERE WAS NO INJURY OF ANY KIND. HE SAID THE WANDERGUARD WAS CHECKED AND FOUND TO BE FUNCTIONING APPROPRIATELY. CERTIFIED NURSING ASSISTANT (CNA) #12 WAS INTERVIEWED ON 7/16/12 AT 4 P.M. CNA #12 SAID SHE WAS ASSIGNED TO RESIDENT #101 DURING THE AFTERNOON SHIFT ON 7/4/12. SOMETIME AFTER DINNER, CNA #12 SAID RESIDENT #101 WENT INTO A ROOM TO PLAY CARDS WITH TWO OTHER RESIDENTS. ACCORDING TO CNA #12, SOMETIME BETWEEN 7:40 P.M. AND 7:45 P.M., THE TWO RESIDENTS WHO HAD BEEN PLAYING CARDS, ASKED CNA #12 FOR ASSISTANCE GETTING READY FOR BED. WHILE THE CNA WAS ASSISTING THE TWO RESIDENTS, SHE WAS NOTIFIED THAT RESIDENT #101 HAD ELOPED FROM THE FACILITY. THE CNA SAID THAT RESIDENT #101 HAD NEVER TRIED EXITING THE BUILDING BEFORE, ALTHOUGH NURSE'S NOTES HAD DOCUMENTED SEVERAL ATTEMPTS. CNA #12 SAID THE RESIDENT ALWAYS WORE A JACKET AND CARRIED A PURSE, WHICH MADE HER LOOK LIKE A VISITOR. THE CNA SAID SHE INITIALLY THOUGHT RESIDENT #101 WAS A VISITOR. OBSERVATIONS MADE ON 7/12/12, AT 9:30 A.M., DURING THE INITIAL TOUR OF THE FACILITY REVEALED THAT ALL FACILITY DOORS WERE ALARMED. FIVE OF THE FACILITY DOORS HAD ALARMS THAT WERE ACTIVATED BY THE WANDERGUARD. THE FRONT DOOR OF THE FACILITY WAS ALARMED AND ALSO HAD A WANDERGUARD-ACTIVATED ALARM. WHEN VISITOR #2 EXITED THE FACILITY THROUGH THE FRONT DOOR ON 7/4/12, THERE WAS NO STAFF PERSON IN THE OFFICE NEXT TO THE DOOR. DURING REGULAR BUSINESS HOURS, A STAFF PERSON WOULD ALLOW ENTRY/EXIT FOR VISITORS BECAUSE THE CODE WAS NOT DISPLAYED TO THE PUBLIC. ACCORDING TO MAINTENANCE SUPERVISOR #9, INTERVIEWED ON 7/13/12, AT 9:15 A.M., WHEN A STAFF PERSON WAS NOT AVAILABLE AT THE FRONT DOOR, AN ALARM WOULD SOUND AT THE COURTYARD ONE NURSE'S STATION. STAFF AT THAT NURSE'S STATION COULD SEE WHICH DOOR WAS ALARMING. STAFF COULD ALSO SEE THE PEOPLE ENTERING AND EXITING THE BUILDING. FACILITY STAFF COULD THEN ALLOW VISITORS TO ENTER/EXIT WITHOUT THE ALARM SOUNDING. ACCORDING TO THE MAINTENANCE SUPERVISOR, INTERVIEWED ON 7/13/12 AT 9:15 A.M., THE DOOR ALARM WOULD SOUND IF THE DOOR WAS OPEN MORE THAN 30 SECONDS. AT THAT TIME, SOMEONE WOULD HAVE TO GO TO THE DOOR AND RESET THE ALARM. ANYTIME A RESIDENT WITH A WANDERGUARD EXITED THROUGH THE DOOR, THE WANDERGUARD-ACTIVATED ALARM SHOULD SOUND, ACCORDING TO THE MAINTENANCE SUPERVISOR. THE WANDERGUARD-ACTIVATED ALARM HAD A DIFFERENT SOUND THAN THE DOOR ALARM. THE "BLACK MALE IN SCRUBS" WHO RESET THE ALARM FOR VISITOR #2 ON 7/4/12 AS SHE EXITED THE BUILDING WAS NEVER IDENTIFIED. MALE STAFF IN THE FACILITY AT THE TIME OF THE ELOPEMENT WERE IDENTIFIED AND INTERVIEWED. NO ONE admitted TO RESETTING THE ALARM. DIRECTOR OF CARE DELIVERY (DCD) #10, INTERVIEWED ON 7/12/12 AT 1:18 P.M., SAID FACILITY STAFF DID NOT WEAR BLACK SCRUBS. THE DCD SAID THE FACILITY COULD NOT DETERMINE THE IDENTITY OF THE BLACK MALE IN SCRUBS. LPN #3 WAS INTERVIEWED ON 7/13/12 AT 7:25 A.M. LPN #3 SAID THAT ON 7/4/12 THERE WERE MANY VISITORS IN THE FACILITY. AT 7 P.M., LICENSED STAFF WERE AT THE CHANGE OF SHIFT. THE LPN SAID IT WAS DIFFICULT TO HEAR EVERYTHING THAT WAS GOING ON BECAUSE THE UNIT WAS SO BUSY. ON 7/16/12 AT 9:10 A.M., THE ADMINISTRATOR WAS INFORMED OF THE IMMEDIATE JEOPARDY THAT BEGAN ON 7/4/12 AS A RESULT OF THE FACILITY'S FAILURE TO PREVENT THE ELOPEMENT AND ENSURE THE SAFETY FOR RESIDENT #101, AND PLACING 7 ADDITIONAL RESIDENTS AT HIGH RISK FOR ELOPEMENT AND THE RISK OF SERIOUS HARM, INJURY, OR DEATH. ON 7/17/12 THE SURVEYOR CONFIRMED THAT THE FACILITY HAD IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY ON 7/16/12. 1. ON 7/4/12, RESIDENT #101 WAS ASSISTED BACK TO THE BUILDING BY STAFF AND WAS ASSESSED FOR INJURY. RESIDENT #101'S SECURE BRACELET (WANDERGUARD BRACELET) WAS ASSESSED FOR FUNCTION AND PLACEMENT. THE RESIDENT WAS IMMEDIATELY PLACED ON A 1-TO-1 SUPERVISION AND REMAINED SO UNTIL HER DISCHARGE FROM THE FACILITY ON 7/13/12. THE RESIDENT'S CARE PLAN WAS REVISED AND A BEHAVIOR ASSESSMENT WAS COMPLETED BY THE DIRECTOR OF NURSING (DON) AND THE SOCIAL SERVICES DIRECTOR. 2. ON 7/4/12, A STAFF PERSON COMPLETED A SWEEP OF ALL DOORS TO ENSURE THAT THE ALARMS WERE FUNCTIONING. 3. ON 7/5/12, 125 RESIDENTS WERE ASSESSED FOR ELOPEMENT RISK. SIX RESIDENTS WERE IDENTIFIED AS "AT RISK" FOR ELOPEMENT. CARE PLANS, ASSESSMENTS, AND INTERVENTIONS WERE REVIEWED AND REVISED AS INDICATED BY THE SOCIAL SERVICE DIRECTOR. THEIR PERSONAL SECURE CARE BRACELETS (WANDERGUARD BRACELETS) WERE ASSESSED FOR PLACEMENT AND FUNCTION. NEW RESIDENTS WILL BE ASSESSED FOR ELOPEMENT RISK UPON ADMISSION USING THE NURSING ADMISSION EVALUATION WITH IMPLEMENTATION OF PREVENTATIVE INTERVENTIONS. CURRENT RESIDENTS ARE REASSESSED FOR ELOPEMENT RISK WITH A QUARTERLY COMPREHENSIVE ASSESSMENT, AND PREVENTATIVE MEASURES ARE PUT IN PLACE. 4. ON 7/4/12, THE ACTIVITY DIRECTOR COMPLETED A REVIEW OF "WATCH BINDERS" WHICH CONTAINED PICTURES AND INFORMATION OF THE RESIDENTS "AT RISK" FOR ELOPEMENT. WATCH BINDERS WERE PLACED AT EACH NURSING STATION, THE RECEPTIONIST DESK, AND THE EMPLOYEE BREAK ROOM. 5. IN-SERVICING ON CODE GREEN (CONDUCTING A HEAD COUNT), THE WANDER PATIENT PRACTICE GUIDE AND EMERGENCY MANAGEMENT MISSING PATIENT LOCATOR: FIRE ALARMS AND DOOR SAFETY WAS BEGUN ON 7/5/12. THE IN-SERVICING IS ON-GOING TO CAPTURE 100% OF EMPLOYEES. 6. ON 7/6/12, THE FRONT DOOR ALARM WAS RESET WITH A NEW CODE TO ENSURE THAT ONLY AUTHORIZED STAFF HAD KNOWLEDGE OF THE CODE. 7. IN-SERVICING TO ENSURE EGRESS CODES ARE NOT SHARED WITH VISITORS, VENDORS, OR FAMILY AND NOT TO RESET ALARMS WHEN THEY ARE UNABLE TO IDENTIFY WHO TRIGGERED THE ALARM WAS BEGUN ON 7/16/12. THE IN-SERVICING IS ON-GOING TO CAPTURE 100% OF EMPLOYEES. 8. AS OF 7/5/12, THE MAINTENANCE DIRECTOR/DESIGNEE WILL DO AT LEAST 5 DAILY AUDITS EACH WEEK TO ENSURE THAT THE DOORS ARE ARMED AND FUNCTIONING. FINDINGS AND TRENDS WILL BE SUBMITTED TO THE QA & A COMMITTEE. THE ADMINISTRATOR IS RESPONSIBLE FOR OBTAINING AND MAINTAINING COMPLIANCE. THE IMMEDIATE JEOPARDY (IJ) WHICH BEGAN ON 7/4/12 WAS REMOVED ON 7/16/12. THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF "ISOLATED" AND SEVERITY OF "NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY" UNTIL SUSTAINED COMPLIANCE CAN BE VERIFIED. ( ) ( )

THIS CITATION HAS MULTIPLE DEFICIENT PRACTICES. DEFICIENT PRACTICE #1. BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT ONE (#805) OF EIGHT RESIDENTS REVIEWED FOR FALLS, OUT OF A TOTAL OF 26 SAMPLED RESIDENTS WAS PROPERLY MONITORED DURING A TRANSFER, RESULTING IN A RESIDENT SUSTAINING A MINOR CLOSED HEAD INJURY AND LACERATIONS. FINDINGS INCLUDE: ON 4/24/12 AT APPROXIMATELY 10:00 AM, DURING THE INITIAL TOUR, RESIDENT #805 WAS OBSERVED SITTING IN HER WHEELCHAIR DOING HAND EXERCISES IN THE THERAPY ROOM. THE TAB ALARM WAS ATTACHED TO HER CLOTHING AND SHE HAD A STERI-STRIP ON HER FOREHEAD OVER THE RIGHT EYE BROW. ON 4/24/12 AT 2:50 PM, RESIDENT #805 WAS OBSERVED IN HER WHEELCHAIR IN HER ROOM ALONE. RESIDENT #805 WAS ASKED HOW SHE GOT THE WOUND ON HER FOREHEAD. RESIDENT #805 STATED, "OH THE BANDAGE ON MY FOREHEAD WAS PROBABLY FROM A FALL. THAT HAPPENS A LOT, OR I HIT MY HEAD." ON 4/25/12 AT 11:30 AM, A REVIEW OF THE ELECTRONIC MEDICAL RECORD REVEALED THAT RESIDENT #805 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE ADMISSION MINIMUM DATA SET (MDS), dated [DATE], INDICATED THAT RESIDENT #805 HAD MODERATELY IMPAIRED COGNITION, AND REQUIRED EXTENSIVE PHYSICAL ASSISTANCE WITH TRANSFERS AND AMBULATION. THE MDS FURTHER REVEALED THAT RESIDENT #805 HAD SUSTAINED A FALL. THE NURSING CARE PLAN, ENTITLED "AT RISK FOR FALLS", INITIATED 3/25/12, INDICATED THAT RESIDENT #805 HAD "IMPAIRED BALANCE/POOR COORDINATION, UNSTEADY GAIT, HISTORY OF FALLS". THE FALL CARE PLAN INTERVENTIONS WERE: -PROVIDE ASSISTANCE TO TRANSFER AND AMBULATE AS NEEDED -FALL MATS -LOW BED -PLACE RESIDENT IN COMMON AREA WHEN OUT OF BED ON 4/26/12 AT 9:10 AM, RESIDENT #805 WAS OBSERVED SITTING ALONE IN HER WHEELCHAIR IN HER ROOM EATING BREAKFAST. RESIDENT #805 WAS NOT IN A COMMON AREA, AND WAS UNSUPERVISED. ON 4/26/12 AT APPROXIMATELY 1:00 PM, A REVIEW OF THE INCIDENT REPORTS FOR RESIDENT #805 REVEALED THE FOLLOWING FALLS: 3/26/12 AT 4:30 AM, "SITTING ON THE FLOOR CLOSE TO BED, NO INJURY; PATIENT CONFUSED AND CLIMBED OUT OF BED WITHOUT ASSISTANCE. CORRECTIVE MEASURE: FLOOR MATS ON BOTH SIDES OF BED." 3/30/12 AT 2:00 AM, "OBSERVED ON THE FLOOR NEAR TOILET BY STAFF, DID NOT REMEMBER TO USE THE CALL LIGHT, NO INJURY. CORRECTIVE MEASURE: LOW BED..." 3/30/12 AT 7:15 AM, "ON FLOOR, SITTING ON BUTTOCKS IN FRONT OF THE WHEELCHAIR, ATTEMPTED TO AMBULATE TO RESTROOM. CORRECTIVE MEASURES: TOILET FREQUENTLY AND PLACE IN COMMON AREAS WHEN NOT IN THERAPY, IN BED OR WITH VISITORS." 4/5/12 AT 11:30 PM, "STAFF OBSERVED PATIENT AS SHE fell on TO THE FLOOR ON BUTTOCKS. SENSOR ALARM WAS SOUNDING, NOTED A 0.5 CENTIMETER (CM) X 0.5 CM SKIN TEAR ON LEFT ELBOW. PATIENT GOT UP TO GO THE BATHROOM SO ANXIOUSLY AND ON ARRIVAL OF THE STAFF TO HER ROOM SHE fell TO THE FLOOR. CORRECTIVE MEASURES: PSYCH CONSULT ORDERED FOR EVALUATION AND treatment of [REDACTED]. 4/15/12 AT 7:00 AM, "NURSE WAS ALERTED BY CERTIFIED NURSE AIDE (CNA ) TO PATIENT ROOM, AND ON ARRIVAL PATIENT WAS ON THE FLOOR LYING TO THE RIGHT SIDE OF (HER) BODY. CNA STATED THAT SHE ASSISTED HER TO THE BATHROOM, AND TRANSFERRED HER FROM THE WHEELCHAIR TO THE BED. AS SHE (RESIDENT #805) SAT DOWN ON THE BED, SHE LEANED FORWARD, LOST BALANCE AND fell FORWARD. SHE WAS NOTED WITH LACERATION TO HER RIGHT FOREHEAD OF 0.5 CM (CENTIMETERS) X 0.5 CM AND 2.5 CM X 0.5 CM. PATIENT WOUND DRESSING DONE AND MD (MEDICAL DOCTOR) ORDERED TO TRANSFER PATIENT TO HOSPITAL FOR EVALUATION. CORRECTIVE MEASURES: USE BEDPAN WHILE PATIENT IS ASLEEP FOR TOILETING." THE STATEMENT FROM CNA "J" DOCUMENTED, "WHILE I WAS IN THE ROOM ASSISTING PT. (PATIENT) FROM THE BATHROOM TO THE BED. PT LEANED FORWARD AND LOST BALANCE AND fell on TO THE FLOOR BEFORE I COULD CATCH..." NO ADDITIONAL INVESTIGATIVE INFORMATION WAS ATTACHED TO THE INCIDENT REPORT. A REVIEW OF THE DISCHARGE INSTRUCTIONS FROM A LOCAL HOSPITAL, DATED 4/15/12 (NO TIME INDICATED) DOCUMENTED, "CLOSED HEAD INJURY - MINOR, LACERATIONS MULTIPLE...PATIENT HAS DERMABOND/GLUE REPAIR TO THE RIGHT FOREHEAD PLEASE LEAVE STERI-STRIPS IN PLACE...PATIENT HAS A NODE OR AREAS SKIN TEAR TO THE RIGHT FOREARM PLEASE KEEP THIS AREA BANDAGE AT ALL TIMES...WAS REPAIRED WITH GLUE WITH STERI-STRIPS DO NOT REMOVE THE STERI-STRIPS UNTIL 7 DAYS..." ON 4/27/12 AT 9:20 AM, RESIDENT #805 WAS OBSERVED SITTING IN HER WHEELCHAIR IN HER ROOM. SHE WAS ALONE AND STATED SHE HAD TO GO TO THE BATHROOM. RESIDENT #805 HAD NOT BEEN PLACED IN A COMMON AREA FOR OBSERVATION. ON 4/27/12 AT 9:25 AM, DIRECTOR OF CARE DELIVERY (DCD) "B" WAS ASKED ABOUT RESIDENT #805'S 4/15/12 FALL. DCD "B" REVEALED THAT AS FAR AS SHE KNEW, RESIDENT #805 WENT TO SIT DOWN ON THE EDGE OF THE BED, LEANED FORWARD AND SUSTAINED A CUT OVER HER RIGHT EYE." DCD "B" WAS ASKED IF THERE WAS FURTHER INVESTIGATION SINCE STAFF WAS PRESENT AT THE TIME OF THE FALL. DCD "B" STATED, "I KNOW I SPOKE TO CNA "J" ABOUT IT. I THINK SHE SAID AT THE TIME SHE DIDN'T HAVE HER HANDS ON HER." AT 10:00 AM, CNA "J" STATED, "I WAS TRANSFERRING HER (RESIDENT #805) FROM THE WHEELCHAIR TO THE BED. AS I WAS TURNING HER AROUND TO SIT ON THE BED, SHE SAT ON THE BED AND WHILE I WAS GOING TO MOVE THE CHAIR, SHE LEANED FORWARD TO STAND UP AND fell on THE MATS THAT WERE THERE. SHE (RESIDENT #805) MOVED QUICKLY." CNA "J" REVEALED SHE HAD LEFT RESIDENT #805 SITTING ON THE EDGE OF THE BED WHILE SHE WALKED AROUND TO THE BACK OF THE WHEELCHAIR TO UNLOCK THE WHEELS AND PULL WHEELCHAIR BACKWARD SO SHE COULD SWING RESIDENT #805'S LEGS ONTO THE BED. ON 4/27/12 AT 10:15 AM, DCD "B" WAS ASKED IF CNA "J" HAD BEEN IN-SERVICED ON TRANSFERRING RESIDENTS AFTER THE INCIDENT. DCD "B" STATED, "NO, BUT I UNDERSTAND. I ASKED HER WHERE SHE WAS IN PROXIMITY TO THE RESIDENT. SHE TOLD ME SHE DIDN'T HAVE HER HANDS ON HER. I GUESS AT THAT TIME I SHOULD HAVE ASKED WHERE WERE YOU." DCD "B" WAS ASKED HOW THE CORRECTIVE MEASURES, "USE BEDPAN WHILE PATIENT IS ASLEEP FOR TOILETING" WAS APPLICABLE TO THE FALL. DCD "B" STATED, "THE NURSE FELT THAT SHE (RESIDENT #805) ATTEMPTED TO GET UP FREQUENTLY AT NIGHT, AND IF THEY OFFERED THE BEDPAN AT NIGHT IT WOULD REDUCE HER TIREDNESS DURING THE DAY." DCD "B" FURTHER REVEALED THAT IF RESIDENT #805 WAS UP AND AWAKE, SHE SHOULD BE IN A COMMON AREA WHERE SHE COULD BE WATCHED. ON 4/27/12 AT 12:00 PM, RESIDENT #805 WAS OBSERVED IN HER ROOM, SITTING IN HER WHEELCHAIR ALONE. RESIDENT #805 REVEALED SHE HAD TO GO TO THE BATHROOM. RESIDENT #805 WAS NOT IN A COMMON AREA, AND WAS UNSUPERVISED. ON 4/27/12, THE POLICY ON TRANSFERRING RESIDENTS WAS REQUESTED. PAGE ONE OF TWO OF THE POLICY ENTITLED "TRANSFER: BED-CHAIR/WHEELCHAIR", DATED 1/2011, WAS PRESENTED. IT FAILED TO DOCUMENT HOW STAFF SHOULD KEEP A RESIDENT SAFE DURING TRANSFERS. ( ) DEFICIENT PRACTICE #2. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO ENSURE SAFETY DEVICES WERE FUNCTIONING TO PREVENT FALLS FOR ONE (#815) OF EIGHT SAMPLED RESIDENT REVIEWED FOR FALLS IN A SAMPLE OF 26, RESULTING IN THE POTENTIAL FOR FALLS WITH INJURY. FINDINGS INCLUDE: ON 4/24/12 AT 11:50 A.M., OBSERVATION WAS MADE OF RESIDENT #815 SITTING IN A WHEELCHAIR, PROPELLING HERSELF DOWN THE HALLWAY BY GRABBING AND PULLING ONTO THE HANDRAILS IN THE HALLWAY TO HER BEDROOM. OBSERVATION WAS MADE OF A SENSOR PAD IN THE WHEELCHAIR THAT WAS NOTAATTACHED TO AN ALARM BOX. OBSERVATION REVEALED THERE WAS AN ALARM BOX ATTACHED TO A SENSOR PAD ON THE RESIDENT'S BED. ON 4/24/12 AT 12:00 NOON, STAFF NURSE "I" WAS WALKING DOWN THE HALLWAY AND WAS QUERIED REGARDING THE UNATTACHED ALARM BOX, AND RESIDENT #815'S ATTEMPT TO SELF TOILET. NURSE "I" STATED "WE DON'T HAVE ALARMS ANY MORE. I CAN FIND OUT IF SHE STILL HAS ALARMS." AT 12:15 A.M., STAFF NURSE "U" RESPONDED TO RESIDENT #815'S ROOM. NURSE "U" STATED THE WHEELCHAIR SEAT ALARM WAS SUPPOSED TO SOUND TO ALERT STAFF WHEN THE RESIDENT ATTEMPTED TO RISE WITHOUT ASSISTANCE. NURSE "U" WAS UNABLE TO EXPLAIN WHY THERE WAS NO ALARM BOX ATTACHED TO THE SENSOR PAD IN RESIDENT #815'S WHEELCHAIR. REVIEW OF RESIDENT #815'S CURRENT MEDICAL RECORD REVEALED THAT THE RESIDENT WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE ADMISSION MINIMUM DATA SET ASSESSMENT ((MDS) dated [DATE] DOCUMENTED THE RESIDENT HAD SEVERELY IMPAIRED COGNITION AND REQUIRED EXTENSIVE PHYSICAL ASSISTANCE FROM STAFF FOR TRANSFER, AMBULATION AND TOILETING. A NURSING CARE PLAN ENTITLED, "AT RISK FOR FALL DUE TO UNSTEADY GAIT (WALKING)", INITIATED 7/7/11 AND REVISED ON 11/15/11, INSTRUCTED STAFF TO "ENSURE THAT ALARM IS IN PLACE IN WHEELCHAIR/BED/GERICHAIR." A COPY OF THE FACILITY'S "FALLS PRACTICE GUIDE" POLICY WAS REQUESTED FROM THE FACILITY; BUT NOT RECEIVED BY THE END OF THE SURVEY. AN UNDATED "FALLS PRACTICE GUIDE FLOWCHART" WAS RECEIVED, BUT FAILED TO MENTION ENSURING SAFETY DEVICES WERE FUNCTIONAL. ( ) DEFICIENT PRACTICE #3. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE SAFE DISPOSAL OF AN ANTI-HYPERTENSIVE PATCH FOR ONE (#808) OF 26 SAMPLED RESIDENTS, RESULTING IN THE POTENTIAL FOR ACCIDENTAL INGESTION. FINDINGS INCLUDE: ON 4/24/12 AT 9:30 A.M., DURING THE INITIAL TOUR OF THE FACILITY, RESIDENT # 808'S GARBAGE CAN REVEALED AN UNFOLDED MEDICATION PATCH STUCK TO THE SIDE OF THE BASKET. NURSE "T" WAS QUERIED AS TO WHAT KIND OF PATCH IT WAS, AND STATED, "IT IS A CLONIDINE (ANTIHYPERTENSIVE, MEDICATION TO CONTROL BLOOD PRESSURE)PATCH." WHEN FURTHER QUERIED, SHE INDICATED IT BELONGED TO RESIDENT #808. RESIDENT #808'S MEDICAL RECORD WAS REVIEWED. HER FACE SHEET REVEALED THAT SHE WAS RE-admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. RESIDENT #808'S PHYSICIAN ORDERS [REDACTED]. ON 4/27/12 AT 10:45 A.M., NURSE "T" WAS QUERIED REGARDING DISPOSAL OF AN ANTI-HYPERTENSIVE PATCH, AND STATED, "THE CATAPRES PATCH (GENERIC CLONIDINE) IS NOT A NARCOTIC PATCH, SO IT CAN BE DISPOSED OF ANYWHERE." ON 4/27/12 AT 11:30 A.M., THE DIRECTOR OF NURSING (DON) WAS QUERIED REGARDING MEDICATION DISPOSAL. SHE STATED THAT "REGULAR MEDICATION AND CONTROLLED SUBSTANCE PATCHES WOULD BE DISCARDED IN THE SHARPS CONTAINER (LOCKED BOX FOR DISPOSAL OF USED NEEDLES), BUT A CATAPRES PATCH COULD BE DISCARDED IN THE GARBAGE CAN." THE POLICY AND PROCEDURE TITLED, "MEDICATION ADMINISTRATION: TRANSDERMAL DRUGS" DATED 3-2010 WAS REVIEWED AND DID NOT REFLECT A PROCEDURE FOR DISPOSAL OF AN ANTI-HYPERTENSIVE PATCH. PER THE MANUFACTURES RECOMMENDATION DATED 4/30/12 "USED CATAPRES PATCHES WILL CONTINUE TO CONTAIN LARGE AMOUNTS OF DRUG. IT IS THEREFORE IMPORTANT FOR YOU TO KEEP BOTH USED AND UNUSED PATCHES AWAY FROM CHILDREN AND PETS AND TO DISPOSE OF USED CATAPRES PATCHES PROPERLY. FOLLOWING THE USE OF A CATAPRES PATCH, FOLD THE ADHESIVE SIDE IN HALF AND DISCARD IT." ( )